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Government Policy

When Is Spoken Conversation not a Matter of Free Speech?

When it is “medical treatment,” apparently. According to a 2-1 decision this past summer by the United States Court of Appeals for the 11th Circuit. Specifically, everything a doctor says to a patient is “treatment,” not speech, and the government has broad authority to prohibit doctors from asking questions on particular topics.

As background, in 2011 the Florida Firearm Owners Privacy Act was passed, which threatens doctors with professional discipline if they ask patients whether they own guns or record the resulting information in a patient’s files when doing so is not “relevant” to a patient’s medical care. “Relevant” is not defined, and no provisions for establishing relevancy are outlined. The constitutionality of this Act was questioned and ultimately upheld by this summer’s Wollschlaeger v. Governor of Florida ruling.

Is the 2011 law necessary in any way? Opponents of Florida’s law, including the Brady Campaign to Prevent Gun Violence, believe the opposite, that asking patients about gun ownership is a legitimate means of promoting public health by giving doctors the opportunity to share firearms-safety tips. As this Times editorial notes, “the First Amendment generally doesn’t let the government outlaw the asking of annoying questions. Instead, people can refuse to answer or decline to associate with those who insist on asking such questions” and asks us to:

Imagine if tobacco companies successfully lobbied for a law that prohibited doctors from asking patients whether they smoke. Some doctors may want to know so they can conduct lung examinations, while others may just want to urge their patients to stop. But everyone should recognize that a law outlawing a simple question infringes on speech.

 

Deaf to Moore’s Law: The $6800 Hearing Aid Set, or the $475 One?

This Forbes article describes the applicability of Moore’s Law to health innovation and pricing. The author needed a hearing aid. He cited a teacher who had paid $6,800.00 for a pair of hearing aids. The writer had his own hearing loss and with some shopping, found an innovative source that sold him a hearing aid online for 7% the cost — $474.50 — delivered in 2 days via FedEx.

To be fair, the author notes that he does not know how his condition compared to that of the teacher.

We have seen similar disruptive changes in eyewear with Warby Parker and others selling prescription glasses for $100.00 or so, less than the cost of lenses alone in most outlets.

Must a set of hearing aids really cost thousands of dollars? Setting aside our lack of full information, we do know that they are a solid state electronic device, sold by the thousands and mass produced at some level. They would appear to filter and amplify sound, and be quite small.

Should a set of glasses cost hundreds of dollars? One has a piece of colored plastic in the form of a frame, and a piece of plastic bent to refract light. Both made by machines in bulk. There is a fashion aspect of the frames that to many buyers matters a great deal. Eyeglasses, unlike hearing aids, are worn by many billions of users world-wide, a number of whom own multiple pairs.

Compare a hearing aid to a smart phone. A top of the line Iphone without a carrier subsidy can be bought for $750.00. This device, like similar Android phones, is remarkable. Unlike the $5,000+ hearing aid, it is a full-fledged computer that computes, locates, calls, transmits, schedules, messages, photographs, shops, informs, and performs hundreds of other functions depending upon apps installed. One might reasonably assume that these devices are far more complex than a top of the line hearing aid. The price difference likely has more to do with scale, competition, buyer motivation, and other market factors.

Those who shop for eyeglasses and hearing aids are often paying out-of-pocket, and have a motivation to shop. Those selling such devices have a motivation to attract buyers with innovative delivery and pricing models. Can and should similar innovation be applied to high priced pharmaceuticals, medical devices, and medical procedures?

An Unsuitable Trajectory

MCNTalk reads Forbes. Mainly for great business articles but even for opinions, which are predictably free market and generally anti-government and Obama. That said, Forbes agrees that US Health care is high priced and advocates a consumer-driven solution. As we have opined elsewhere, consumer engagement that led to citizens shopping in a competitive market for care and coverage might have benefits.

Most startling is the reference to Swiss health care spending being 45% of the US levels. Having traveled in that marvelous country, one can’t credibly claim they are anything but more robust and wealthier per capita than the US. We deserve to understand and respond to such massive differences. Not having been to Singapore, where spending is said to be at 20% of US levels, this 5x spread is incomprehensible and we wonder if it is a typo or some major relevant facts are missing. Even Forbes agrees that things are way out of whack with our system’s cost.

As a thought experiment, imagine that rather than health care, the media reported that cars, smartphones and flat panel TVs cost twice or more as much in the US as they do in Switzerland. Since we pay ourselves for these goods, how much rhetoric and justification would we tolerate in explaining the differences? Or would we rather have a flurry of innovative efforts to ensure that US consumers are able to pay the same or less than others for similar products and services? The difference of course is who is paying. When employers or government pay, we the consumers basically have little reason to care. When on the other hand we have to pull out our own wallet, the impact and visibility is immediate. Unfortunately, the ACA and other reforms that don’t truly engage the consumer in feeling some pain or gain, have a basic flaw that impedes price competition. Furthermore, as many have pointed out, the ability to make an informed choice when it comes to complex health issues is questionable, not to mention the ability to shop when one is bleeding or in the process of an acute condition needing immediate intervention. Informed buying requires both the ability to have good information and enough time to decide.

The question is when do we stop debating and engage in the truly tough decisions that will send us in the right direction. We are not optimistic because any system that represents almost 20% of our GDP will not give up turf easily. For the US health spend to approach benchmarks of other industrialized and healthy economies would displace many jobs, institutions, revenue streams, and profits.

The Impact of Community Health Workers: Cutting Re-Admissions and Creating Healthier Communities

Community health workers can support, guide and encourage patients to manage their health over the long term. Many poor countries use CHWs on an enormous scale. This is a crucial role in a country where vast numbers of people are sick with chronic lifestyle-related diseases. Doctors can’t help patients change their behavior in the 15 minutes they spend with each patient. But community health workers can.

In the United States, in 2010, researchers from the University of Pennsylvania began interviewing patients who lived in high-poverty neighborhoods about what they saw as barriers that kept them from getting health care, and kept them sick. Those responses — from long interviews with 115 patients — became the basis of the Penn Center and IMPaCT, which stands for “individualized management for patient-centered targets.”

The Penn Center is one of several new models hospitals are trying to make CHW programs sustainable. Another is program is Grand-Aides. Unlike the Penn CHWs, Grand-Aides don’t help with social or logistical issues. They are nurse extenders who get hundreds of hours of medical training. Each patient visit is supervised in real time by phone by a nurse, who makes all the decisions. A pilot at two pediatric Medicaid sites in Texas showed that the program cut readmissions by at least two-thirds. Learn more…

$1,600 for a Diaper Rash Treatment?

Alarmed by a rapid increase in spending on compounded drugs, like a $1,600 baby balm, insurers and others are acting to control their use.

Drug compounding involves a pharmacist making medicines for a patient who cannot be helped by mass-manufactured drugs. Compounded drugs do not require FDA approval, though Congress recently has moved to enact regulatory legislation. They might be used when a patients is allergic to an ingredient in a commercial product, or a patient needs a liquid formulation of a medication rather than it being in pill form.

Pharmacy benefit managers say there is scant evidence that these combinations of ingredients are safe or any more effective than conventional drugs. Express Scripts, the largest PMB, has said it will stop paying for more than 1,000 ingredients used in compounding, cutting spending by its health plan clients on such medicines by 95 percent. It said such spending had grown to $171 million in the first quarter of this year from $28 million in the first quarter of 2012.

When Posting Baby Photos Became Illegal

Though no identifiers such as names or contact information are included, it is illegal for doctors and midwives to post photos of the babies of their patients on their office wall, though this has been a common practice since not long after the advent of photography.

Under HIPAA (the Health Insurance Portability and Accountability Act), baby photos are a type of protected health information, no less than a medical chart, birth date or Social Security number, according to the Department of Health and Human Services. Even if a parent sends in the photo, it is considered private unless the parent also sends written authorization for its posting, which almost no one does. A thoughtful piece in The New York Times mulls over this and is worth the read for those involved with protecting health information. The comments are thought-provoking as well, such as this one:

“Yes, the HIPAA privacy rules do forbid public displays of baby pictures. That’s perhaps too bad, but it’s not life threatening.

“The real problem with the HIPAA privacy regulations is that while they do address a real issue – the use and often abuse of private medical information for non-medical purposes (for example marketing), the rules have brought about a much more serious problem: the frequent inavailability to legitimate health care providers of important medical information regarding patients, information these doctors (and other providers) need to make urgent, life saving, medical decisions.

“The HIPAA rules and data security requirements are well intentioned, but complex and difficult to implement, and the penalties for non-compliance severe. In the real world it’s hard for the custodians of medical data (such as hospitals) to prohibit unauthorized access, while at the same time permitting it for care providers with a real need to know. And sometimes medical care suffers as a result. The security requirements can be particularly troublesome, as it’s hard with present technology to implement data security that is both secure and functional.

“HIPAA regulations will probably some day find the right balance. But we’re not there yet. And medical care is sometimes shortchanged as a result.”

Certainly the IME and peer review industry has been impacted in recent years, as has the larger world of health care and insurance, with ongoing focus and concerns on maintaining data security, to where it is a cornerstone of providing quality services to claimants. As this reader notes, it is important to remember what the purpose of these industries is—providing for the health of the patient—and to ensure our procedures all work to this end.

The Happiness Calculation for Smokers

How do you quantify happiness levels? The question has relates to a longstanding requirement — first codified under the Clinton administration — that every set of federal regulations with more than a $100 million effect on the economy needs an analysis to prevent the adoption of regulations with high costs and low benefits.

Now it is being applied to the government’s new tobacco regulations proposed this past April, specifically to a cost-benefit calculation which assumes that the benefits from reducing smoking — fewer early deaths and diseases of the lungs and heart — have to be discounted by 70 percent to offset the loss in pleasure that smokers suffer when they give up their habit.

Is this a problem? Well, yes, according to many, as the proposed regulations could water down the agency’s ability to regulate tobacco products. If the formula for assessing costs and benefits remains unchanged in the final version of the regulations, it could set a dangerous precedent that would constrain public-policy making for years to come.

“This is the single biggest obstacle facing the F.D.A. in executing the job Congress gave it,” said Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, an advocacy group. “There’s no way the F.D.A. can do its job if this is applied.”

An F.D.A. spokeswoman, Jennifer Haliski, said that there was “still a great deal of uncertainty” surrounding the calculation, and that the agency was helping fund research to explore the issue. So far the Food and Drug Administration has received at least 69,000 public comments on the new regulations, some quite high profile. Earlier this month a group of economists, including one Nobel Prize winner, weighed in, asking that the calculation be changed before the ruling takes effect. Read more…

What Happens When Hospitals Buy Clinics?

One thing that happens is that the prices increase for services at these clinics. According to hospitals, one reason is that because hospitals (unlike individual doctors) must maintain 24-hour emergency room coverage and cannot turn away patients, they need to raise revenue elsewhere to help absorb this expense. Thus hospitals charge higher rates for many items than do private practices. Nationally, hospitals are buying more and more clinics, where they are also charging higher rates.

As the Affordable Care Act attempts to steer people away from pricey inpatient admissions, hospitals have begun buying up doctors’ offices in hopes of increasing their revenue and market share. The number of oncology practices owned by hospitals, for instance, increased by 24 percent from 2011 to 2012.

Cancer drugs often double in price when hospital systems charge for them. A treatment of Herceptin, a breast cancer drug, costs private insurers $2,740 when used in an independent clinic and $5,350 in a hospital outpatient setting, according to an analysis of 2012 claims by PricewaterhouseCoopers’ Health Research Institute. The price of Avastin increased from $6,620 to $14,100 when used in a hospital setting, the Health Research Institute says.

In some instances conflicts have arisen between insurance companies and hospitals over how much to pay for treatment. In one case, the insurer says reverting to lower payments for roughly 20,000 Pennsylvania chemotherapy patients should $200 million a year.

Steven Weiss, spokesman for the American Cancer Society’s Cancer Action Network, said in an e-mail. “For years, patients have paid different prices for the same procedure or drug, depending on where they are treated,” he said, and “long-standing trends like this one continue to threaten patient access to lifesaving care.” Read more…

Trying to Bring Down Oz

Concerned with the public health impact of Dr. Mehmet Oz’s health advice, in 2013 University of Rochester medical student Benjamin Mazur asked state and national medical associations to take action. However, though for over a hundred years the federal government has passed legislation and created agencies to prevent consumers from being deceived or harmed by “bad medicine,” the situation is a complicated one. For instance, though the Federal Trade Commission has the legal authority to prosecute people who mislead and injure consumers, they can’t do anything about Oz since he’s not actually selling the products he talks about.

With regard to his concerns, Mazur noted: “I’m definitely not the only one.”  Sen. Claire McCaskill, for instance, told Dr. Oz during a Capital Hill hearing: “The scientific community is almost monolithic against you in terms of the efficacy of…three products that you called miracles.”

Mazur explains his concerns:

This issue was brought up by a number of physicians I worked with during my family medicine clerkship. We had all of this first-hand experience with patients who really liked his show and trusted him quite a bit. [Dr. Oz] would give advice that was really not great or it had no medical basis. It might sound harmless when you talk about things like herbal pills or supplements. But when the physicians’ advice conflicted with Oz, the patients would believe Oz.

Mazur is not entirely anti-Oz, of course; as he explains, “I would probably say that he does have the health interest of his viewers in mind. But in the long term, undermining good science and the relationship patients have with their current physicians is probably doing much more harm than good. If they’re not going to listen to advice from physicians—who are providing good, evidence-based advice—if they’re going to listen to other doctors on the show, it’s going to do more harm than good.” Read more…

Opioid Deaths Drop in Florida as the State Cracks Down

Prior postings have decried deaths and abuse in prescribing of opiates. Florida was the poster child of abuse, with strip mall featuring “pain clinics” where patients from other states would fly into to receive bogus prescriptions.

The sheer number of prescriptions nationwide has helped drive abuse in the United States. In 2012, more than 259 million prescriptions for pain pills were dispensed, federal researchers said, enough for every American adult to get a bottle of them. For the past decade, more than 20,000 Americans have died each year from prescription pain pill overdose.

As this article and associated editorial demonstrate, change is possible. Florida and other states have made a good start in curbing abuse. Lives have been saved in the process. There is more to be done in curbing the misuse of opiates for chronic pain. Opioid painkillers are dangerously overprescribed, but Florida has shown how states can confront this problem.