June 19, 2017 at 10:25 am
Aaron CarrollLast year, Claire Caine Miller and I teamed up to write about the then-new AAP guidelines on infant sleep. Those guidelines recommended that infants sleep in the same room as their parents until they were one year of age. We took issue with that. New research backs us up! This is Healthcare Triage News.
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June 19, 2017 at 10:22 am Aaron CarrollI keep reading article after article about how Republican Senators are uncomfortable with the way that they are crafting their ACA repeal and replace bill. It’s too secretive. There’s no committee markup. It’s too fast. No one is listening. Many of them have no idea whatsoever is in the bill.
Correct me if I’m wrong, but they have 52 votes in the Senate. If just three of them would actually say this is a problem at the same time in the same place then it might mean that they could actually change this process. If just three of them said they wouldn’t vote for a bill created this way, then they’d have to do it in the more usual fashion.
Instead, there are a lot of opportunities for many more of them to voice their concerns individually, thus giving the appearance that there’s nothing they can do. They’re powerless alone.
Why someone in the media can’t point that out to them and ask them about it is beyond me. Why can’t we get three of them together and ask them?
June 16, 2017 at 9:26 am Aaron CarrollYou’ve probably already read a million thought pieces on how the Republican Senate AHCA bill is being written totally in secret, no one knows what’s in it, etc. So I’m not going to bother with that. But this exchange, in a revealing post over at Vox where reporters asked Republican Senators to explain their bill, has me losing my mind:
Tara Golshan, Vox: Generally, what are the big problems this bill is trying to solve?
John McCain: Almost all of them. They’re trying to get to 51 votes.
Tara Golshan: Policy-wise. What are the problems in the American health care system this is trying to solve — and is the bill doing that right now?
John McCain: Well, it’s whether you have full repeal, whether you have partial repeal, whether you have the basis of it. It’s spread all over.
Tara Golshan: But based on the specifics of the bill you have heard so far, is it solving the problems in the health care system?
John McCain: What I hear is that we have not reached consensus. That’s what everybody knows.
Tara Golshan: Right, but outside of getting the votes. From what you hear of the actual legislation being written is it solving the problems you see —
John McCain: It’s not being written. Because there’s no consensus.
Tara Golshan: But generally speaking, what are the big problems it is trying to solve?
John McCain: You name it. Everything from the Repeal caucus, which as you know they have made their views very clear — Rand Paul, etc. And then there are the others on the other side of the spectrum that just want to make minor changes to the present system. There’s not consensus.
Five times Tara Golshan (who deserves some sort of an award) asks Senator McCain what the bill is trying to do, what problems it’s trying to solve. FIVE TIMES. And, five times, Senator McCain can only discuss the difficulties of getting to 50 votes. Fifty Republican votes, mind you.
There’s literally no discussion of cost, of quality, of access. No mention of premiums or deductibles or even taxes. No concerns about anything even remotely related to healthcare at all.
I can’t tell if he didn’t want to answer, or if actual healthcare literally didn’t cross his mind. Some days I despair.
June 16, 2017 at 8:00 am Bill GardnerI recently argued that:
The drug overdose epidemic is a public health catastrophe in the same class as AIDS.
Arguably, it’s worse. Annual deaths by drug overdose are substantially higher than the worst year of the AIDS epidemic. The current very rapid increase in deaths by drug overdose shows no signs of slowing. Drug overdose is now the leading cause of death for Americans under 50. AIDS never achieved that.
If you measure the magnitude of an epidemic by the sum of the years of life lost by the victims, drug overdoses compete with cancer, not just AIDS. Many more Americans die of cancer (about 600,000) than drug overdose (an expected 60,000 in 2017). But more than half of cancer deaths occur in people 75 years or older (UK data). The average drug overdose victim dies in his or her early 40s and loses many more years of life.
Are we responding to the drug overdose epidemic in a way that is commensurate to these facts?
I don’t think the NIH is. The 2017 NIH Budget request slides presented by Director Francis Collins discussed:
These are all great things to do with federal dollars. But it’s remarkable that Collins did not mention drug or alcohol abuse or the current epidemic.
Why aren’t we focused on this epidemic? It’s the same problem that plagued the early years of AIDS. The victims were stigmatized and those not in their families or neighbourhoods didn’t take their deaths seriously.
Turning the tide on AIDS required that we rethink our values, not just our virology. Now it’s time to rethink how we feel about the people suffering from drug and alcohol problems.
June 15, 2017 at 10:00 am Aaron CarrollCystic fibrosis is an inherited disorder that affects the lungs, pancreas, intestines and other organs. A genetic mutation leads to secretory glands that don’t work well; lungs can get clogged with thick mucus; the pancreas can become plugged up; and the gut can fail to absorb enough nutrients.
It has no cure. Over the last few decades, though, we have developed medications, diets and treatments for depredations of the disease. Care has improved so much that people with cystic fibrosis are living on average into their 40s in the United States. In Canada, however, they are living into their 50s. That’s the topic of this week’s Healthcare Triage.
This episode was adapted from a column I wrote for the Upshot. Links to reading and further references can be found there.
June 15, 2017 at 9:15 am Aaron CarrollThe following originally appeared on The Upshot (copyright 2017, The New York Times Company).
Physicians are often unaware of the cost of a test, drug or scan that they order for their patients. If they were better informed, would they make different choices?
Evidence shows that while this idea might make sense in theory, it doesn’t seem to bear out in practice.
A recent study published in JAMA Internal Medicine involved almost 100,000 patients, more than 140,000 hospital admissions and a random distribution of laboratory tests. During the electronic ordering process, half the tests were presented to doctors alongside fees. While the cost to the patient might vary, these Medicare-allowable fees were what was reimbursed to the hospital for the test or tests being considered. The other half of the tests were presented without such data.
The researchers suspected that in the group seeing the prices, there would be a decrease in the number of tests ordered each day per patient, and that spending on these tests would go down. This didn’t happen. Over the course of a year, there were no meaningful or consistent changes in ordering by the doctors; revealing the prices didn’t change what they did much at all.
This isn’t the first time a study like this found that showing prices to doctors doesn’t make a difference. Earlier this year, a study published in Pediatricsreported on a similar randomized controlled trial on physicians caring for children. In this case, doctors were randomized to one of three groups. The first group saw the median price of a test when they ordered it. The second saw both the price (often lower) when obtained within the current health care system and outside it. The third group saw no price at all.
Pediatric-focused clinicians showed no effect from price displays. Adult-focused clinicians actually ordered more tests when they saw the prices.
A similarly designed study of more than 1,200 clinicians in an accountable care organization published earlier this year also found no effects from telling physicians prices.
Some older studies have found that physicians might alter their behavior on individual tests, but in only five of the 27 they examined. Another found a small, but statistically significant, difference. Unfortunately, this study suffered from asymmetric randomization. Even before the intervention began, the tests chosen for the price-showing group were ordered more than three times as much as those chosen for the control group. More expensive tests appeared in the control group for some reason as well.
Of course, any one study has the potential to be an outlier or subject to limitations that might warrant skepticism. These can be minimized by looking at the body of evidence in systematic reviews.
One was published in 2015, and argued that in the majority of studies, giving physicians price information changes their ordering and prescribing behavior to lower the cost of care. A closer look, though, reveals that most of the studies in this analysis were more than a decade old. Many took place in other countries. And all were published before these latest, and largest, studies I discussed above. Another systematic review that looked at interventions focusing only on drug ordering found similar results, with similar caveats.
I should be clear: We have good reason to want to believe that interventions focusing on giving physicians information about the prices of the things they order should make a difference. In 2007, a systematic review demonstrated that doctors were ignorant of the costs of prescription drugs. They underestimated the prices of expensive drugs, overestimated the prices of inexpensive ones, and did not understand the extent of the difference in price between those considered cheap and those considered pricey. Another, published in 2015, explored 79 studies, 14 of which were randomized controlled trials, that suggested that physicians could be educated to deliver “high-value, cost-conscious care.”
But that education probably needs to be holistic. Flashing one point of data at a doctor does not get the job done; knowledge transmission needs to be accompanied by what this review called “reflective practice and a supportive environment.” Simply focusing on cost information may not be enough. The reasons that physicians order tests are more than financial, and efforts to influence their behavior most likely need to be more than informational.
Additionally, it may be that issues of price transparency need to involve more than one component of the health care system. While focusing solely on physicians, or on patients, might not work well, trying to work on both simultaneously might. It’s also possible that intervening solely on one procedure, test or drug at a time may not be as powerful as trying to influence spending on care over all.
Finally, trying to make physicians focus strictly on cost may be off base as well. Some care, even more expensive care, is worth it. What we really should attend to is value — the quality and impact relative to the cost. It is certainly harder to determine value than price, but that metric might make more of a difference to physicians, and to their patients.
June 15, 2017 at 8:55 am Aaron CarrollI’m human; I can admit when I’ve screwed up. I took on more than I can handle these last few months, and that’s seriously cut into my blogging. The good news is that things are lightening up at the end of this month, and I plan a triumphant return in July.
In the meantime, go read this “Medicine and Society” essay in the NEJM by Louise Aronson Debra Malina. Best graf:
Those structural inequalities might lead a Martian who landed in the United States today and saw our health care system to conclude that we prefer treatment to prevention, that our bones and skin matter more to us than our children or sanity, that patient benefit is not a prerequisite for approved use of treatments or procedures, that drugs always work better than exercise, that doctors treat computers not people, that death is avoidable with the right care, that hospitals are the best place to be sick, and that we value avoiding wrinkles or warts more than we do hearing, chewing, or walking.
The whole thing is worth your time.
June 13, 2017 at 7:00 am Austin FraktIt was at the 2009 AcademyHealth Annual Research Meeting in Chicago that I learned about accountable care organizations (ACOs). The day after leaving the meeting, I was already concerned:
[I]f the U.S. health care system moves toward an ACO model we will see greater provider consolidation, all other things being equal. Provider groups’ greater market power to negotiate higher payments will be a countervailing force against the promise of the ACO model to provide higher quality care at lower cost.
I have not been alone in harboring this reservation about ACOs. For years, I and others have viewed ACOs as one of several legal and regulatory motivations for provider consolidation. The logic goes like this: the ACO model encourages the provision of more coordinated care for a population of patients. In addition, it rewards provider organizations for higher quality and lower costs. Historically, all of these are have been justifications for provider consolidation, including the horizontal integration of hospitals, the horizontal integration of physician practices, and the vertical integration of hospitals and physician groups.
But, a recent paper by Hannah Neprash, Michael Chernew and J. Michael McWilliams suggests this logic may be flawed. By comparing changes in provider consolidation from 2008–2010 to 2011–2013 between markets with higher versus lower Medicare ACO penetration (as measured in 2014), they found no evidence of a change in the trend toward consolidation associated with ACO adoption.
The chart, just below, summarizes the main findings. Though vertical integration of physicians with hospitals (left panel) and physician group size (right panel) both increased over the study period, the rate of growth for both was identical across quartiles of 2014 ACO penetration. Here, ACO penetration is measured at the metropolitan statistical level as the proportion of Medicare beneficiaries attributed to an ACO.
Many other measures assessed by the authors — changes in physician market concentration, hospital market
concentration, and commercial health care prices — are consistent with the hypothesis that the Medicare ACO model did not encourage consolidation. However, mean physician group size grew more rapidly for physicians participating in an ACO, relative to physicians who did not.
From this evidence, it seems I was (and others were) wrong to blame ACOs for consolidation of health care providers … maybe.
But, the authors also found an increase in hospital mergers after the Affordable Care Act became law alongside an inverse relationship between hospital market concentration and ACO penetration. This leads to a different hypothesis about how ACOs might influence market concentration after all:
These findings suggest that new payment models may have triggered some consolidation as a defensive reaction to the threat these models could pose, rather than as a way to achieve efficiencies in response to the new incentives. Hospitals and specialists in particular might consolidate both horizontally and vertically to achieve sufficient market share to resist payer pressure to enter risk contracts or weaken ACOs’ ability to exploit competition in hospital and specialty markets, to compel reductions in prices and service volume.
It takes a close read to understand what the authors are saying here. It’s not necessarily about Medicare ACOs, but about ACOs more generally (including commercial market ACOs). They’re saying that providers might consolidate to resist this broader ACO movement and/or its implications for pressure on prices and volume. However, it’s a reasonable hypothesis that commercial market ACO presence is correlated with Medicare ACO presence across markets. Therefore, observations of relationships between consolidation and Medicare ACO penetration may also be valid for informing inferences about broader relationships involving commercial market ACOs as well.
The upshot is that maybe the ACO model is influencing consolidation, just not in the way I and others had thought. Rather than consolidating to support the ACO model, providers may be doing so as a defense against it. It’s too soon to know for sure. More work needs to be done to gather evidence to support or refute this alternative hypothesis.
June 12, 2017 at 8:00 am Bill GardnerAlexander Burns and Jennifer Medina report in The New York Times that
At rallies and in town hall meetings, and in a collection of blue-state legislatures, liberal Democrats have pressed lawmakers, with growing impatience, to support the creation of a single-payer system, in which the state or federal government would supplant private health insurance with a program of public coverage.
I support universal health insurance: I voted with my feet to work in Canada. When the office of an outspoken New England legislator asked me for comments on the text of a single-payer bill, I was glad to give them.
My question is: How do advocates plan to build a coalition that could pass single-payer?
I’m not talking about the current weakness of the Democratic Party. Let’s assume a future in which the Democrats have recaptured the presidency and the Congress. Let’s assume that Republican health care policies are supported by only about 1 in 5 Americans, as is the case today.
The problem is that even in these circumstances, I fear that many Americans will judge the risk of a financial loss in a transition to single payer to be greater than the benefit they are likely to receive from single payer.
Consider that 49% of Americans have health coverage through their employer (7% have non-group coverage, 36% have public insurance, and 9% are uninsured). These employees aren’t getting health insurance for free. They pay for their insurance benefit through foregone wages. But it often looks to them like they are getting insurance for small premiums, if not for free. If they have to pay for their insurance through increased taxes, many will likely perceive that they have suffered a net loss.
Moreover, some people would suffer an actual loss in a transition from employer-supplied health insurance to single-payer. In theory, we might expect an employee’s compensation would rise enough to cover the tax costs of single-payer, but that won’t happen for everyone. Some people will be net losers.
In part, this is because a universal care system will, by design, help equalise access to health care. Suppose we tried to do this through a scheme that held total health care spending constant. Then making access more equal would require redistributing some health care resources from the haves to the have-nots. That might be just, but the haves would hate it. And they vote.
Alternatively, we could bring the care of the underserved up to the standard of the well-served. This will require increased health care spending and an even larger increase in taxes. Most of those taxes would come from the affluent. The affluent already have good insurance, so they gain little from single payer. Again, the haves are net losers.
As I see it, there won’t be a sustainable US single-payer system unless we can make American health care more efficient. Efficient enough so that you can level the have-nots up to health care standard of the haves without increasing spending. There are theories — or at least stories — about how to do this. Single payer would reduce administrative costs. A single insurer would have great power to knock down the prices charged by manufacturers, hospitals, doctors, and nurses. Either course will involve political warfare against powerful industries.
There is a counterargument against my pessimism. Other developed countries have single-payer (or other forms of) universal health care. If, Canada did it, why can’t the US make the same transition?
However, the US may have missed the window when establishing a single-payer system would have been comparatively easy. The Canadian transition began in Saskatchewan in 1947. Saskatchewan farmers were largely uninsured and had nothing to lose in the transition to public insurance.
So my question for single-payer advocates is, where do the votes come from?
June 9, 2017 at 3:21 pm Aaron CarrollThe guidelines for screening for prostate cancer have changed. Again! And that’s ok! The USPSTF is hard at work. This is Healthcare Triage News.
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