Vol. 69 June 15, 2012 How to Avoid the “R” Word.

June 15, 2012


“We make those decisions all the time. The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open.” –Donald Berwick, MD

When infinite demand exists for finite resources certain decisions have to be made by those responsible for distribution of the resources. It is called “rationing“.  And that is what is causing all the palaver about reducing medical care costs. Who decides, how do they decide, and how do the decisions get implemented? “Rationing” has become the political lighting rod of that discussion and any politician or candidate (or even Director-designee of CMS) that does not successfully avoid its use is at great political peril.

A recent thoughtful essay in the NEJM advances the case for substituting “avoidance of waste” for the “R” word. (1) Since 30% of our medical care costs go to tests, treatments, drugs, and medical devices that in truth result in no patient benefit (2), the author argues that, at least, we should first eliminate the non-beneficial expenses. Consumer Reports in cooperation with American Board of Internal Medicine and 16 other medical specialty societies has recently published its list of non-beneficial medical activities for us to avoid. They call the campaign “Choosing Wisely”.

Since many very expensive items can be categorized as new technology, the author also argues for a more rigorous standard for the approval of new technology. New technology currently needs ONLY to prove that is safe and that is better than a placebo. There is NO requirement that it show that it has better outcomes than existing technology. This is true for drugs, PET scanners, linear accelerators, organ and bone marrow transplants, cardiac surgery, and all the different kinds of heart vessel stents. Highly technical, complex, and expensive gene treatment (“personalized medical therapy”) is just now peeking at us around the corner.

If a standard of improved outcome for new technology were in place, how would it be implemented? The ACA established the Center for Comparative Effectiveness Research within CMS to gather comparative outcome data and make recommendations, but the ACA also explicitly denies the CMS the authority to use such recommendations in setting Medicare reimbursement rates!

For example, in the very same issue of the NEJM there is an elegant multi-center study that leads to the implementation questions for a less dramatic, not-quite-so-emotionally-laden, but much more common condition than heart transplants and exotic “savior” cancer drugs; urinary incontinence in women. This study showed beyond a doubt that urodynamic testing results on women who go to a urologist because of urinary stress incontinence had no effect on the outcome of the surgery. The surgery is successful 69-72% of the time whether the urodynamic testing is done or NOT. In other words, the clinical judgement of the urologist in the office is enough to indicate who is likely to benefit from the surgery.

The urodynamic testing, with it’s charge in the U.S. of $640-$1503 depending on the insurance company and region, adds no benefit. The article’s authors (all 34 of them) flatly state that urodynamic testing for women presenting with stress incontinence should not be done. (the same conclusion made by NICE, National Institute for Health and Clinical Excellence, in the U.K. in 2006). The article does list four specific instances where urodynamic testing might prove helpful; 1) patients with previous surgery for incontinence, 2) presence of neurological disease, 3) patients planning more extensive pelvic-organ relapse corrective surgery, and 4) urge-predominant incontinence rather than stress-incontinence. All of these definable situations can be documented in the medical record for the few patients who have them.

How could such a reasonable, well-founded recommendation to reduce costs without compromising quality be implemented?

1) Medicare could refuse to reimburse for urodynamic tests in uncomplicated stress incontinence patients. This is without doubt the most direct way to save these costs. Private insurance would soon follow suit after the political and medical backlash quieted down (urodynamic studies are almost always done in the urologist’s office and can represent a significant revenue stream to the office). Current ACA language explicitly prohibits this action.

2) ACO’s could implement a practice guideline recommending avoidance of urodynamic testing before usual stress continence surgery. Any resulting cost savings could be shared by all the physicians in that ACO. Urologists would receive a portion of the savings to offset their revenue loss, and they in turn could ask the other specialties in the ACO, “What have you done for us lately, so that we can share in some of your cost savings”.

3) Physician leaders in the urological specialty and academic centers could support educational efforts to inform their members of the non-benefits of urodynamic testing for most patients and wait for its use to fade away under the weight of replicating, confirming studies, and editorial comments.

This third option is often how our practice patterns currently change, but it is a slow process as shown by our continued discussions of the comparative benefits of open heart surgery or various vascular stents. That this “revelation” about the non-benefits of urodynamic testing has been around since 2006, but still warrants an article published in a 2012 NEJM is another clue about the pace of change. Given the inevitability of rationing and the moral repugnance of doing so with broad-brush budget caps monitored by bureaucrats, arbitrary decisions by non-accountable insurance companies, price-based decisions by for-profit drug companies, age-based discrimination, or by economic or social class classifications, we can only hope that we can find a better way.

Comparative Effectiveness Research under the ACA could develop evidence-based standards to be implemented by ACOs of high quality, cost-conscious physicians who would then share in the savings resulting from their hard work of changing practice patterns appropriately. Otherwise, we may have to settle with our current system of “muddling through” and try to be patient with the plodding pace of change as we watch the treasury run dry.

It might help if we did replace “rationing” with “avoidance of waste”, but I don’t hold out too much hope for that. It will take more than one article and a less insipid term to capture our imagination.

In my next blog on July 1, I will describe how to avoid the “F” word.

Refererces:
1. “From an Ethics of Rationing to an Ethics of Waste Avoidance”, Howard Brody, M.D.,Ph.D; NEJM 366;21 May 24, 2012: p. 1949
2. “The Implications fo Regional Variations in Medicare Spending”, Wenneberg et al., Ann Intern Med 2003;138: p. 288
3. “A Randomized Trial of Urodynamic Testing before Stress-Incontinence Surgery”, Nager et al., NEJM 366;21 May 24, 2012: p.1987


Vol. 64 April 1, 2012 Breaking Medical News

April 1, 2012

FDA APPROVES VIAGRATOR

The Food and Drug Administration announced yesterday approval of the new drug, Viagrator, a combination of Viagra and Lipitor. Pfizer has been seeking lost revenues since Lipitor’s patent expired,and the demographics of the users of Viagra and Lipitor are almost identical. Combining the two into one capsule is a slam dunk. Viagrator will still carry a warning about the need to call a doctor if effects last for more than 4 hours, but new information that a double-cheese omelet can reverse it will be added.

Pfizer is searching for an appropriate celebrity to serve as a symbol of both sexual prowess and high cholesterol to promote its new product. Industry sources report that Newt Gingrich is the leading candidate, but doubt that a contract can be signed before November.

MEDICARE TO AWARD “FREQUENT FLYER POINTS”

In Medicare’s quest to become more like Visa with single swipe payments, timely and understandable statements, and better fraud protection Medicare has announced its own frequent flyer reward points program. Each Medicare dollar spent on medical care will earn points for the patient that can be redeemed for other medical services. The rewards menu is quite complicated. For example, 4 MRI’s earn you enough points for a colonoscopy. Points from 6 EKGs can be redeemed for a week’s supply of Inderal or nitroglycerine. The medical device rewards catalog includes a CPAP machine after 8 visits to a pulmonologist. a walker after 2 visits to an orthopedist or 4 visits to a neurologist, and a high-seat toilet after the second hip or knee replacement.

The AMA has come out strongly against the use of Medicare reward points for travel to other countries for surgery, and the American Society of Plastic Surgeons has refused to participate in the rewards program at all. They are still mostly “cash up-front”. Efforts by the Obama administration to use the program as a Medicare cost-cutter by deducting points for inappropriate care (for example, after 4 visits to an ER in 6 months you would LOSE 200 points) have been rejected by Congress so far.

FREE PIZZA FOR BIRTH CONTROL

A new twist to the current controversy about paying for abortion and birth control pills was recently put into the other side of the intercourse equation. An enterprising group of urologists is offering a free pizza if you get a vasectomy in March. The free pizza is touted to help you recover post-operatively as you watch March Madness on the tube. I wonder what you could get for a tubal ligation? … an Easter dinner for 6?

BLUE CROSS TO MANDATE FITNESS CLUB MEMBERSHIP

Some Blue Cross/Blue Shield policyholders recently received a notice that in 2012 the healthcare insurer will reimburse up to $150 for fees in health fitness clubs or structured weight loss programs for its subscribers. The response was so positive that BC/BS’s initial caution quickly turned to such enthusiasm that BC/BS plans to make fitness club membership MANDATORY for its subscribers on July 1,2012.

Acturarial analysis suggested that members needing walking assistance devices, specially modified automobiles, or wheelchairs be excluded from this requirement. This suggestion was ignored when AARP pointed out that many “thousands and thousands of AARP members” used canes. Legal counsel expressed concern in today’s environment about potential law suits against this “individual mandate”. BC/BS officials dismissed the concern with “Hey, it’s not like we’re mandating that everyone eat broccoli!

NEW APPS TO BE UNVEILED AT SEXTECH-HACKATHON

Now that sexting has become prevalent, what’s next? Well, we are in a capitalistic society that rewards entrepreneurs, so you guessed it, a one-day California conference to develop apps for it. Why not unleash, and even incentivize, the most creative, innovative minds of our society to help us deal with “unmentionables”?

The call is out to….“design an app to solve the challenge of providing honest, real-time, private data from youth and young adults about “unmentionable” activities, like sexual behavior, substance use, sadness, and relationship drama to researchers and program experts who work with youth.”

The reason to do this is that…“the health field has been trying to prevent the most common adolescent and young adult health problems since time began: sexually transmitted diseases, depression, substance abuse and dating violence. By the age of 25, more than 90% of young adults will have experienced more than one of these problems, and for some youth, the consequences will be lifelong (infertility, homelessness, brain injuries, etc.).”

“It’s almost impossible to know what works in terms of prevention efforts, as health researchers rely on survey answers given by youth after the fact with questions such as: How many times did you use a condom for sex in the last six months? Now, really, who remembers?”

“We want to put the best and brightest minds in tech behind the solution. We want an app where young people are enticed and excited to share their Unmentionable data – data about the whos, whats, wheres and whens of their risk behaviors – in the moment or soon after.”

Interested? Too bad, it’s already over. March 31 in San Francisco.

HAPPY APRIL FOOLS DAY…or NOT!


Vol. 53 October 15, 2011 The Heart of the Matter

October 14, 2011

Imagine that you are over 65 years old and you have a failing heart. Your doctor tells you that you are at “maximum medical treatment” and are not eligible for a heart transplant because of your age and other medical conditions.  Then the doctor mentions that a pump could be implanted in your body to help your heart pump more blood; a left ventricular assist device or LVAD.

Imagine a small device put into your chest during open heart surgery that could help you pump enough blood around so that some of your old energy would return and you could resume some, but not all, of your usual activities.

Imagine that Medicare would pay for the operation, device, and medical follow-up. Then try to imagine what the $228,039,342 Medicare paid for about 1500 of these operations would look like if spread out on a table in hundred-dollar bills.

Imagine what it would be like to be one of the 55% (815) of patients who survived the operation and left the hospital alive after receiving this pump. Imagine how even happier you would be if you were one of the 43%  (350) discharged alive who was still alive 2 years later. Imagine your relief when Medicare pays the average $1,000 a day hospital rate for the 56% of pump recipients who have to be rehospitalized at least once in the 6 months after implantation.

Imagine your perplexing thoughts when a statistician tells you that your life extension cost about $60,057 “per quality-adjusted life-year”.

Imagine that your psyche and your family can handle the burdens of multiple medical visits, utter dependence on the infallibility of a medical device, 24/7 family care and vigilance, strict adherence to medication regimens, worries about medical and financial complications, and alteration of body image perceptions that can lead to depression and anxiety.

Imagine how your life might actually end. If you turn off the pump it is suicide. If your doctor or family member turns off the pump it is either euthanasia, assisted suicide, or ethical withdrawal of therapy depending on the status of your permission (and maybe the State you are in).  Perhaps you will develop a new fatal condition from which you will die with the pump running. Imagine if you lived long enough to require a pump replacement.

Imagine that part of the pre-operative process before the pump is implanted is a detailed discussion with your physician (and your family hopefully) about how and when YOU would want the pump turned off.

NOW … IMAGINE THAT YOU ARE DICK CHENEY. *

Then imagine how a “rationing” process to cut medical care costs under Medicare might work in this situation.

Imagine how it might work if you were the patient rather than Mr. Cheney.

Blogs have already appeared making the argument that Steve Jobs would not have lived his “extra” two years with a liver transplant under U.K. or Canadian health systems.

Medical ethics are about “where you draw the line”. Remember that in the beginning of this scenario your doctor said you were “ineligible” for a heart transplant. That was a drawn line, a rationing decision. Our current dilemma and sometimes heated discussion is really about WHO draws the line. (Medicare, Medicaid, private insurance or pharmaceutical company, Congress, professional specialty societies, health care lobbyists, medical ethics committees, Comparative Effectiveness Research in the U.S., NICE in the U.K., individual physicians and patients, or God)

*shamelessly copied from Matthew McConaughey’s dramatic closing speech to the jury
saving Samuel L. Jackson’s life in A Time To Kill  by John Grisham.

References;
Journal of Medical Ethics, Spring 2011, Vol.18, issue 2, published by Lahey Clinic; LVADs as destination therapy: difficult ethical decisions.

Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System, Daniel Callahan, 2009, Princeton  University Press


Vol. 52 October 1, 2011 Medical Costs of Prisons, Medicare Cost Projections

October 1, 2011

Please excuse the September 15th hiatus. The cyber-devils made my website go down and it took a
while for my consultant to diagnose the problem between the website host and the domain registry.
It was more like “Who’s On First” then “Tinker to Evers to Chance”.

.

.
25% of all Americans with HIV, 33% of Americans with hepatitis C, and 33% of all heroin users spend some time in prison. (1)

U.S. has 5% of the world’s population and 25% of the world’s prisoners. That was 2.8 million prisoners in January 2008.

40% of federal inmates have mental disorders which is 4X the rate in the general population. If you count all types of jails, the number peaks at 60%. The largest facilities housing psychiatric patients in the U.S. are jails. 7% of inmates receive mental health treatment while incarcerated.

Released prisoners are 129 times more likely to die of a drug overdose within 2 weeks of release then the general population. Most are uninsured. They are terminated by Medicaid upon incarceration and are ineligible to re-enroll upon release in most states. The Affordable Care Act permits former prisoners to receive health care coverage.

State correctional spending is the fastest-growing sector of government spending other than Medicare.

Rhode Island spends an average of $41,346 per year per inmate. That jumps to $109,026 per year per inmate for maximum security inmates. Massachusett’s average annual cost per inmate is closer to $46,000.

The $5.6 TRILLION surplus projection in 1995 that turned into a $6.2 TRILLION deficit projection was spurred in part by the $272 BILLION prescription drug coverage (Part D) and the $1.9 TRILLION tax cuts passed during George Bush’s administration (plus a couple of wars, of course). (2)

The savings in Medicare costs projected by “health care system redesign” and changes in coverage and/or benefits will have their first real effect in 2022. “People say you can’t solve the deficit problem without dealing with health care, but you can’t solve the near-term deficit problem by dealing with health care either.” (3)

Under Rep. Ryan’s proposal, if you are under 55 years old you will pay $12,500 out-of-pocket for your health care  while the government will spend $8,000  in 2022 . Under current policy that cost to you would be $6,250 with the government paying $8,500.

$500 BILLION has already been cut from Medicare costs by reducing payments to Medicare Advantage plans (HMO-like plans that studies showed did not reduce medical costs for enrollees) and to acute care hospitals (Helps explain all the recent public scrambling for “policy reviews” and pleas for help coming from many urban acute care hospitals in most states.)

Medicare is projected to consume 6% of the GDP (Gross Domestic Product) in 2035. Raising the eligibility age for Medicare from 65 to 67 in 2014 would reduce Medicare costs only about 0.4% of that 2035 GDP. (5)

If you are 65 years old today you paid an average of $150,000 in Medicare and Social Security taxes over your lifetime and will receive about $350,000 in retirement benefits. A 46-year-old under current policy will pay over $200,000 in Medicare and Social Security taxes and will receive over $500,000 in retirement benefits. (6) Hence, all the discussion about higher premiums for the affluent, restrictions on gold-plated Medigap plans, and increases in co-insurance and deductible amounts.

My Conclusions:
1. It seems to cost more to consider drug addiction a crime than to treat it as a medical disorder.
2. Medical technology will continue to improve and cost more, so be prepared to pay more taxes and/or higher premiums for your health care insurance at any age.

References:
1. Medicine and the Epidemic of Incarceration in the United States, NEJM 362;22 June 2, 2011, Rich et al
2. Money, Pat Regnier and Amanda Gengler, October 2011, p.107-115
3. Henry Aaron, economist, Brookings Institute, ibid
4. Kaiser Family Foundation, Congressional Budget Office, ibid
5. Congressional Budget Office, ibid
6. Urban Institute, ibid


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