Tuesday, November 25, 2014

McKinsey Pegs Global Obesity Costs at $2 Trillion a Year

Today’s Managing Health Care Costs

Number is $2 trillion

McKinsey released a report late last week which stated that obesity is responsible for economic destruction almost equivalent to wars and cigarette smoking around the world.     The complete report is light on detail of how McKinsey calculated the full economic cost of obesity – but this includes
·         Medical costs
·         Loss of productivity
·         Premature death (that leads to loss of productivity)

McKinsey privately published this research – so there is no peer review and the  researchers have not disclosed a lot of information about how they calculated the total cost of obesity – or even how much of this is direct cost (like health care spending) and how much is indirect (like productivity).   Assertions of overall costs like this sometimes count the costs of all disease that might be associated with a risk factor, even if some of the disease might have occurred anyway in those without the risk factor.  For example, the CDC’s evaluation of the cost of preventable chronic disease historically included the costs of all breast cancer because it was screening sensitive – but we know that mammography does not save costs.

Most importantly, McKinsey researchers acknowledged that there isn’t a single silver bullet for obesity. 

Education and encouraging personal responsibility are necessary but
not sufficient—restructuring the context that shapes physical activity
and nutritional behavior is a vital part of any obesity program.

Let me rephrase this.  We need public health approaches here.  Not merely scolding or penalizing the obese. 

Here’s the McKinsey “prescription” for the multipronged approach to obesity. 


Some of the longer term public health approaches, such as active transport (making roads safer for walkers and bikers, and disincentivizing auto use), appear expensive per disability life year saved – but that’s likely because the costs are amortized over a short period of time, and non-BMI benefits (such as decreased global warming) are not considered.

McKinsey states that the highest level of evidence (sufficient) is available for weight management programs, surgery, and drug therapy.    For those with morbid obesity, I’d add that only surgery has been shown to be consistently effective.   McKinsey notes that there is “limited evidence for weight change” from parental education and workplace wellness programs.  We’re all hopeful that newer programs that incorporate activity monitors and app-based education could improve this – but measurement will be crucial.

Note that relying on willpower and scolding is not the answer – creating an environment where it’s easier to eat the right number of calories and exercise regularly is critical.   The fight against obesity will be a generational effort, and we should expect that as with cigarette cessation the benefits will start accruing years and decades from now.


Wednesday, November 19, 2014

There is no neutral way to pay physicians

Pamela Hartzband and her husband Jerome Groopman, two Boston physician-writers, have an op-ed in the New York Times Wednesday decrying “pay for performance.”  They see evil health insurance companies and employers paying physicians to use less expensive medications or to follow evidence-based practice.

They complain that evidence based guidelines are

…population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice.

I think there substantial theoretical reason to doubt that pay for performance would work – as simple extrinsic incentives rarely lead to sustainable change of complex behavior.    There is also substantial empiric evidence that Pay for Performance schemes don’t work.   There are almost no studies that show substantial change in physician practice based on pay for performance as it is deployed in the United States.

But Hartzband and Groopman are making another argument altogether  They are arguing that physicians should simply be paid to do whatever they decide to do-because medicine is too complicated for any outside party to judge whether their care is high value or low value.    Autonomy of the physician is supreme, and physicians will always act as effective agents for our patients.

There are worlds of problems with this argument.   I often argue against simple and inflexible payment rules that would force physicians to follow “evidence based practice” 100% of the time –because patients are complicated and studies aren’t available to cover every single element of each patient who presents to us.   But I have a hard time arguing that there is no problem with physicians who rarely follow evidence-based practice.   I’m not convinced paying them less will help change their practice- but  I want them paid less well as clinicians who are following evidence-based practice more.

I love Groopman’s writing – and especially his book “How Doctors Think.”  But this argument that we can't do better than straight fee for service drives me crazy.  If we believe in the beneficence of doctors –we should be confident that they will perform well (and honestly) regardless of how they’re paid. If we believe that doctors are evil, we should be fearful that they will perform poorly and based only on self-interest regardless of how they’re paid.   Doctors are human- somewhere between knights and knaves.

My favorite quote about physician payment is from James Robinson of UC Berkeley:

There are many mechanisms for paying physicians; some are good and some are bad. The three worst are fee-for-service, capitation, and salary.  Fee for service rewards the provision of inappropriate services, the fraudulent upcoding of visits and the churning of “ping pong” referrals among specialists. 

Capitation rewards the denial of appropriate services, the dumping of the chronically ill, and a narrow scope of practice that refers out every time-consuming patient.  Salary undermines productivity, condones on-the-job leisure, and fosters a bureaucratic mentality in which every procedure is someone else’s problem.

Hartzband and Groopman are worried about the corrupting effect of incentive payments to improve quality (or patient experience, or cost-efficiency).   But they aren’t worried about the corrupting influence of fee for service payments.  An insurance company encouraging the use of a more cost effective drug – TERRIBLE!  A urologist prescribing more expensive radiation therapy when it increasestake-home pay by a factor of 2?  Not really a consideration, I guess.

There is no neutral way to pay physicians.   There is simply not a “best” way.  What we’re doing now doesn’t work well – and we should support legitimate efforts to better tie physician payments to quality and population health.

Value Based Payments Can Disadvantage Safety Net Providers

Guest Post by Kimberly S.G. Chang, MD (HSPH’15) Mongan Commonwealth Fund Fellow in Minority Health Policy 

I find myself reflecting on the state of provider reimbursement, and the shift from fee-for-service payments to value-based payments.  With admirable intention, policymakers seek to establish pay-for-performance (P4P) bundling reimbursement, with provider payments inextricably linked to clinical outcome measures of their patients, attempting to control inflationary health care costs.  In a nutshell: if a doctor has healthier patients, then she will get paid more – attributing the health of the patient directly to the care of the physician.

As a family physician with twelve years providing care to an extremely vulnerable population at a federally qualified health center (FQHC) in Oakland (71% live under the federal poverty level, 98% are uninsured or publicly-insured, 71% do not speak English), I’ve always been proud of the care my colleagues and I provided to our patients.  More recently, though, I’ve been quite scared of the P4P shift: not because we don’t bring our A-game and don’t provide exceptional care with limited resources (we do!), but because my patients’ clinical outcomes will be judged against those who have more resources (social and economic) at their disposal, and this contest will ultimately end up punishing those who serve the vulnerable - by paying less to agencies serving patients who need additional resources the most. 

I fear that the Federally Qualified Health Centers (FHQCs) are at a severe disadvantage in this contest of clinical outcomes.  It’s like a having an underfunded public school in the inner city competing in a debate in Latin against Andover.  Or a twenty-student school from a rural area playing lacrosse against Exeter. I fear that providers serving the socioeconomically dispossessed will be financially penalized for caring for the most vulnerable populations and subsequently further marginalizing and widening health disparities, in the shift towards P4P.

There are ways to mitigate the uneven playing field when it comes to P4P and value-based reimbursements.  One of them is reimbursing providers for providing enabling services: services which allow, or enable, a patient to see a doctor, such as interpretation, case management, transportation, insurance eligibility counseling, and health education.  There are several research studies which aim to show how providing enabling services yields improved health outcomes.  I am hopeful that these enabling services, which attempt to attenuate the social determinants of health and barriers to care, will be reimbursed in the future.  FQHCs provide these services – bearing the cost on their own. 

Risk adjustment, not only for clinically complex patients, but also for sociodemographically complex patients, would be an amazing gift.  The National Quality Forum Report on Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors highlights the research behind such a move. 

Tuesday, November 18, 2014

Hospice Associated with Better Deaths and Lower Costs

Today’s Managing Health Care Costs
Number is 5.3

There’s been a long debate about whether hospice referrals actually save money – or whether hospices serve those who are more at peace with (or resigned to) death,  – leading to apparent cost “savings” which are not caused by hospice at all.

News reports of abuses at for-profit hospice organizations, largely in the South, have raised eyebrows, and helped decrease support for hospice in general

My clinical experience with non-profit hospices in Massachusetts is that they provided invaluable care for my dying patients and their families, including help with grieving after the death of a loved one.

An article in this past week’s JAMA will reignite this argument.   Researchers looked at medical claims of over 86,000 Medicare beneficiaries in 2011 who had poor prognosis cancer. They excluded those who received “cancer-directed” therapy (11% of the nonhospice group and 1% of the hospice group) – which should have partially corrected for the selection bias for less care among the hospice group. They matched groups for age, cancer, and time until death – leaving about 18,000 in both the hospice and the nonhospice groups.

The article doesn’t resolve the question of whether hospice saves money – since the selection between the hospice and nonhospice group invariably includes some differences that are poorly measured and impossible to remove by patient matching.  It’s striking that the average duration of hospice care was only 11 days- a shockingly low number.

It certainly looks like hospice care is associated with much less intervention, far fewer hospital deaths, and more of the kind of care that most of us would like around our deaths. The risk of dying in the hospital was 5.3 times higher in the nonhospice group.   Any result that showed that hospice wasn’t more expensive should be considered a victory for the hospice movement.

Thursday, November 13, 2014

Insomnia is Expensive

Today’s Managing Health Care Costs

Number is $92 billion

Guest Post by Stefanie Kraus,  Harvard School of Public Health (MPH 2015)

How many hours do you sleep during the week? For most Americans the answer is: “not nearly enough!” Health experts tell me to sleep more. I wonder if they have two terms papers due on the same day. I’ll try and sleep more on the weekend, which they tell me is equally bad. Sound familiar?

Estimates put the prevalence of chronic insomnia in the United States at up to 30% or higher. According to researchers at Harvard Medical School, insomnia is associated with many organic and affective disorders such as obesity, diabetes, depression, and heart disease.  Insomnia is associated with direct health care costs close to $92 billion annually and even more if we consider indirect costs such as lost worker productivity.   

Many of us are desperate for sleep. We pop Ambien to try and get our minds to distress and our bodies to sleep on the harried schedule that our work life demands. The insomnia drug market in this country alone approaches 32 billion dollars annually. Yet, prescription sleeping pills have potential serious side effects such as driving while sleeping and are not generally effective in improving sleep quality. We also try to keep ourselves awake during the day by guzzling energy drinks. Sales of energy drinks in the United States increased by 6.7% in 2013 – approaching 9.7 billion dollars. All that caffeine causes even more sleep problems.

A recent study in the Journal of Clinical Sleep Medicine found that even brief cognitive behavioral therapy for insomnia significantly lowered projected direct and indirect health care costs. How much more could we lower costs if we changed our norms to allow for adequate sleep in a real and meaningful way? Societies that promote adequate sleep as a cultural norm may have lower rates of morbidity and mortality attributable to sleep deprivation. Emphasis on material gain, educational, and work status leave us toiling long hours at a great sacrifice to sleep and ultimately health. The term papers for school and the projects for work are more pressing. 

As a result of morbidity and mortality linked to sleep deprivation, we utilize more healthcare and increase health expenditures. Educating the public about the dangers of sleep deprivation is inadequate where societal norms value productivity over sleep.   

Changing social norms is one of the most potent, yet underutilized, health interventions. Instead of promoting sleeping pills, we could pursue legislation that would limit the number of hours an employee can be required to work. Instead of requiring employees to be at work at a specific hour, we can provide flexible working days to account for differences in sleep patterns. 

Instead of students guzzling energy drinks to stay awake during class, we can reduce the work load to resemble a more traditional work week.

I would rather have an environment that lets me sleep more rather than handing me a discounted sleeping pill. Wouldn’t you?

Wednesday, November 12, 2014

Emergency Departments: Come Get Your CT Here!

Today’s Managing Health Care Costs

Number is 162%

Emergency Departments continue their rapacious increased utilization of virtually all kinds of imaging tests – making decrease in emergency department use even more critical to health plans wishing to control overall health care costs.

Researchers at Thomas Jefferson University looked at Medicare ED imaging utilization statistics from 2002 and 2012-  and discovered that the rate of CT, MRI, and noncardiac ultrasounds skyrocketed over that decade.  The only imaging modality where utilization decreased was nuclear medicine – which reflects substantial changes in clinical practice.  This isn’t substitution -  the utilization of plane radiographs went up too.   Link  Harvard Link

One in 7 imaging studies done on Medicare beneficiaries in 2012 was done in an emergency room (14%).

The authors don’t list what studies were performed for what indications, but do reference the Choosing Wisely guidelines, which advise against a number of imaging studies likely commonly ordered in EDs including:
·         Imaging for headaches without risk factors for structural problems
·         Imaging for suspected lung blood clots in patients with low pre-test probability
·         CT for appendicitis in children (ultrasound is preferred first)
·         Images for syncope (fainting) with normal neurologic examination
We suffer from an information bias – we’d rather do an unnecessary test than erroneously skip doing a test that has any tiny chance of helping a patient.  This might be augmented by fear of litigation (rational or irrational).  We discount the likelihood that our patients will be hurt by a medically questionable tests – forgetting how much harm can come from a false positive test, and we underestimate the likelihood of false positive tests in those with low pretest probabilities.

The problem is especially acute for ED physicians, who don’t benefit from a longitudinal relationship with patients, and thus aren’t confident that if a problem is overlooked the patient will return with “no harm done.  Patients who had terrible diagnoses are seared into their memories.  Imaging tests can help smooth patient flow –and in some instances help physicians feel comfortable discharging patients after shorter observation periods.

There’s one more issue.   CT Scans are generally located adjacent to EDs – and there’s good evidence that ready access leads to increased utilization. 

There are some potential answers to this increase in imaging tests. We currently pay too much for these – lower fee for service payments or better yet bundled payments would help convince hospitals to discourage unnecessary imaging.  High deductible health plans which often have emergency department coinsurance instead of copayments could also lower utilization – but will substantially raise out of pocket costs.  Leadership in the emergency medicine community could help, but the ready access, the cognitive bias toward testing, and existing culture all predispose to increasing overutilization.

CT Scans 
(note that these decreased in 2011 due to coding changes - not utilization decreases)
 MRI and nuclear medicine scans 
 Plain radiographs
 Noncardiac Ultrasounds 
All numbers are expressed per 1000 medicare beneficiaries - the denominator is not ED visits.  

Monday, November 10, 2014

Thyroid Cancer in South Korea: Epidemic of Screening

Today’s Managing Health Care Costs

Number is 40,000

Quick – do you know of anyone who has thyroid cancer?

If you live in South Korea – you probably do. 

You might think perhaps there’s been an environmental change that has led to an epidemic of thyroid cancer in South Korea – maybe you’d even think about the North Korean nuclear tests and wonder whether there was any relationship.

There’s not. The epidemic of thyroid cancer in South Korea is an epidemic of diagnosis.  The cancers were probably always there – and many of them caused little harm.  The rate of thyroid cancer mortality –with all of this extra diagnosis, hasn’t even budged. 

Researchers reported on this epidemic in this past week’s New England Journal of Medicine.   

All this extra diagnosis has its cost, and harms those who are screened. From the authors:

Thyroid cancer is now the most common type of cancer diagnosed in South Korea. More than 40,000 people in the country were diagnosed with the disease in 2011 — a figure that is more than 100 times the number of people who die from thyroid cancer, which for the past decade has been between 300 and 400 each year. Virtually all the people diagnosed with thyroid cancer are treated: roughly two thirds undergo radical thyroidectomy, and one third undergo subtotal thyroidectomy…

Thyroid-cancer surgery has substantial consequences for patients. Most must receive lifelong thyroid-replacement therapy, and a few have complications from the procedure. An analysis of insurance claims for more than 15,000 Koreans who underwent surgery showed that 11% had hypoparathyroidism and 2% had vocal-cord paralysis

It makes intuitive sense that better screening should improve social welfare.  Who wouldn’t want their cancer diagnosed earlier?   But it turns out that screening programs can sometimes increase costs  and complications without increasing life expectancy.  There is much “subclinical” thyroid cancer that would never hurt patients.  Finding it, on the other hand, is associated with both cost and harm.   

There is enough data here to say that it’s clinically obvious that screening for thyroid cancer is harmful. But there’s already an entire ecosystem around thyroid cancer diagnosis and treatment in South Korea – and I wouldn’t be surprised if the screening epidemic takes many years to subside.

This shows that the likelihood of being diagnosed with thyroid cancer is highly correlated with higher penetration of screening.