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Health Policy

The Private Practice Oncologist, a Vanishing Breed

In the northwest we are lucky indeed to be home to the Seattle Cancer Care Alliance; the SCCA is a world class center that unites doctors from Fred Hutchinson Research Center, UW Medicine, and Seattle Children’s Hospital. But what if someone wanted to seek treatment or even just an opinion elsewhere in Seattle? As it turns out, there’s only one independent oncology group in Western Washington now.

It’s not just in the Northwest where independent oncology groups are disappearing. The Community Oncology Alliance, an advocacy group for independent practices, said that since 2008, 544 of 1,447 such groups were purchased by or entered contractual relationships with hospitals; another 313 closed and 395 reported they were in tough financial straits.

This is tied to reimbursement schedules for chemotherapy drugs: cancer centers, as opposed to private groups, participate in a federal program that lets them purchase these drugs for about half what private practice doctors pay. When a doctor is affiliated with a hospital or research center, though, patients end up paying, out of pocket, an average $134 more per dose for the most commonly used cancer drugs, according to a report by IMS Health, a health care information company. So while cancer centers pay less, they charge more.

Thus far health care economists say they have little data on how the costs and profits from selling chemotherapy drugs are affecting patient care. The cost of chemotherapy drugs has increased tremendously in the past decade, however, resulting in more out-of-pocket expenses for those even with comprehensive insurance coverage and tremendous expenses for those without coverage. With drug manufacturers promoting individual drugs through aggressive marketing techniques (as an example in this New York Times article, Celgene, in a recent email about its drug Abraxane, told one doctor who had bought 50 vials that he could get a rebate of $647.51 by buying 68 vials. If he bought 175 vials he’d get $1,831.93), the effects of this combined set of circumstances — increased cost of drugs, tiered reimbursements, fewer private practice alternatives — the best treatment options may not be the prevailing care options for some cancer patients.

While individual oncologists deny choosing treatments that provide them with the greatest profit, Dr. Kanti Rai, a cancer specialist at North Shore-Long Island Jewish Cancer Center, said it would be foolish to believe financial considerations never influence doctors’ choices of drugs. “Sometimes hidden in such choices — and many times not so hidden — are considerations of what also might be financially more profitable,” he said.

Dr. Peter Eisenberg, in private practice in Marin County in Northern California, summed it up: “The disgrace is that we have to treat people differently depending on how much money they’ve got.”

Addressing the Obesity/Cancer Link: What Will We Learn From China?

It has long been known that excess weight is a major health risk, but until recently cancer hadn’t been a major part of the obesity/health discussion. A recent British study of 5.24 million people, however, looked at the occurrence of 22 different cancers and their association with body mass index (BMI), a measure of weight/body size and type.

The study concluded that when adjusted for factors like age and smoking, a higher BMI was associated with a large increase in risk of cancers of the uterus, kidney, gallbladder, and liver, and smaller risk increases for at least six other types of cancer.

What’s Your Fitness Age?

It’s not news that longevity is tied in part of how fit we are. What is new is a study from researchers at the Norwegian University of Science and Technology which examined data from more than 55,000 Norwegian adults who had completed extensive health questionnaires beginning in the 1980s. The scientists used the volunteers’ answers to estimate each person’s VO2max and “fitness age.”

According to the study’s authors, the results suggest that fitness age may predict a person’s risk of early death better than some traditional risk factors like being overweight, having high cholesterol levels or blood pressure, and smoking. There’s also a link directly to a short test to find your own fitness age, with exercise suggestions.

Thankfully, fitness age can be altered, said Ulrik Wisloff, professor at the K.G. Jebsen Center for Exercise in Medicine at The Norwegian University of Science and Technology, who led the study. His advice if your fitness age exceeds your chronological years or is not as low as you would like? “Just exercise.”

Gotten Your Flu Shot Yet?

Some good news on the vaccination front: the World Health Organization (WHO) welcomes the approval by Swissmedic, the Swiss regulatory authority for therapeutic products, for a trial with an experimental Ebola vaccine at the Lausanne University Hospital. This marks the latest step towards bringing safe and effective Ebola vaccines for testing and implementation as quickly as possible. The goal is to produce millions of doses of two experimental Ebola vaccines by the end of 2015.

That’s incredible news; as of last Friday the U.S. Center for Disease Control was reporting a total of 10,141 report cases worldwide, with 5,692 confirmed by testing and 4,922 deaths so far.

Closer to home, there are plenty of alarming health situations to worry about over which we have much more control. During the 2013-2014 flu season, for instance, only 46% of Americans received their flu shot, even though it kills about 3,000 people in this country in a good year, nearly 50,000 in a bad one. Flu shots don’t provide immunization against every strain of flu, but they greatly decrease the likelihood of contracting the flu and the severity of the flu should one become ill. So, as New York Times op ed piece asks:

Do me a favor. Turn away from the ceaseless media coverage of Ebola in Texas — the interviews with the Dallas nurse’s neighbors, the hand-wringing over her pooch, the instructions on protective medical gear — and answer this: Have you had your flu shot? Are you planning on one?

 

Today’s high deductibles, tomorrow’s bad debt

Increasingly Americans are paying higher and higher co-pays and deductibles on their health insurance. According to the Kaiser Family Foundation,  41% of Americans who receive health care coverage through their work have deductibles of at least $1,000, up from 10 % in 2006. And for 7 million new enrollees in Obamacare plans, the average deductible in the most popular “silver” tier of coverage is $2,267.

Higher deductibles can be quite appealing to those with choices among health plans, as they generally have lower premiums than low-deductible plans. That’s fine when you don’t get sick or need coverage. However, with fewer than half of American households having three months worth of expenses in savings, these larger deductibles can quickly lead to financial crises.  The situation is compounded by the complicated nature of insurance language: Only 14 percent of insured adults correctly understand insurance jargon such as deductibles, coinsurance, copays, and out-of-pocket maximums, according to a 2013 study published in the Journal of Health Economics.

To deal with this, hospitals are more and more frequently asking patients for payment up front. The figures, as with any numbers related to US health care expense, are astronomical: hospitals’ total cost of uncompensated care reached $46 billion in 2012.

This can actually be good news for patients: some hospitals offer discounts for paying early. Making payment arrangements is not exactly foremost on someone’s mind as they are facing hospitalization, but pre-negotiating a payment schedule sometimes allows for a lower or no interest rate and allows patients to avoid sliding into debt. For hospitals, identifying those with payment challenges can help, says Richard Gundling of the Healthcare Financial Management Association. “For both the patient and the facility,” he says, “trying to collect a debt that can’t be paid just wastes everybody’s time.”

 

 

A Surprise $117,000 Medical Bill

I dropped my jaw as I read this article in the Sunday New York Times, front page. On the one hand, it is above outrageous. On the other hand, this is not news. It is normal life in American health care. I did wonder if the $116,862 that Anthem Blue Cross Blue Shield paid to Dr. Mu had an extra digit added by accident. But I know that the New York Times would have corrected such an error. Even at $11,000 the amount would have been excessive.

There is so much to relish in terms of excesses in this article. Excesses in fees, excesses in treatment (note Dr. Deyo’s comments on the high rate of spinal surgery in the US compared to elsewhere), and excesses in bizarre and improper behavior by an insurance company (who paid this sort of bill and uses its “high costs” as a justification for future rate increases).

If this article does not suggest that the current system is more than broken, what is?

A Doctor’s Malaise, and a Profession’s

Brian L. Grant MD

Reading the NY Times Review of this book leaves one with their own sense of malaise, whether they are a doctor or a patient. The anecdotes shared reflect the reality for many physicians and health care workers. This writer recalls a number of years ago, refusing to sign off on routine admit orders for a patient who had no need for $5.00 multivitamin tablets that could be purchased at a drug store for a hundredth the cost (not that they were needed at all from a clinical or nutritional standpoint), I was called in to “meet” with the hospital administrator, a non-clinician, who was clearly irritated with my decision, and the general comment that I was going to do what was clinically appropriate and was not concerned with his cost and profit issues. Thankfully I was not an employee of the hospital, or that may have been my last day.

It is hard to feel sorry for colleagues on an economic basis, as physicians are hardly on the bottom rungs of the US economic ladder. But one is more likely to enjoy a waterfront home as an MBA or entrepreneur than an employed physician. The lack of autonomy driven by a seizing of power by payers, drug companies, and non-medical managers is perhaps what drives physician malaise. Medicine is not your father’s profession any longer. Not only is your doctor more likely than ever to be a mother now, but the economic realities of health care have substantially changed. The smartest people in the health care room are as likely to be the investors and non-medical managers who ably control distribution and access. And as has been discussed before in these pages, the lack of market dynamics in a system where the ultimate consumer – the patient — is generally buying without paying, abets a system where abuses like unneeded treatments, consultations, and tests can take place.

Today the new IPhone comes out to great fanfare. It will be expensive relative to most phones. Some will decide they must have it, but many will stick with what they currently have in their pockets – whether a current IPhone or another brand. If phones were paid for by “phone insurance,” many would decide that this latest version is the only acceptable option and that it is unjust and unfair for their carrier to deny them this phone. And of course Apple would determine that their phone will be priced at a much higher rate reflecting the perceived necessity of it and lack of market constraint and competitive drivers like we see in many a medical device, drug, procedure or study.

The saddest part is that while nobody has ever died or been hurt from too nice a piece of consumer electronics (unless they were mugged to get at it), many a patient has been harmed from unneeded care and medical intervention. And society is harmed from way too much money being spent in the health care sector, driven as much by overconsumption as by high prices.

Thoughtful physicians and health practitioners are saddened and disheartened when they conclude that much of what they do lacks value relative to the cost and actual impact. They realize that they are part of a system driven by excesses and motivated by behaviors on the part of colleagues, hospitals and companies that are less than admirable in many cases; and driven on self-interest rather than the physical and economic well-being of patients and society. The ideals that still drive many to enter health care are challenged regularly, leading to a disconnect between one’s self-identity and reality. This can give way to depression, cynicism, or concession. On the other hand there still remain many in medicine who have found ways to do what they love, while serving others with integrity and pride.

Emergence of the Trauma Industry

This article from The New York Times focuses on a particular criminal ex-cop. But reference is made to many other defendants involved in this particular crime, of “feigning mental illness” and invoking the 9-11 attacks as a source of psychological scarring. These crimes did not take place in a vacuum. They occurred in a social context where the defendants, many sworn officers, believed they could get away with it, and likely saw themselves as damaged and entitled.

The experience of trauma and even the development of a diagnosis such as Post Traumatic Stress Disorder does not correlate with a person being damaged or disabled. Trauma is part of the human condition, and in most cases the victims adjust, move on, and support themselves and their families – at times with the help of some therapy. Men and women have gone to war, and returned to productive civilian lives. A bureaucracy of entitlement for compensation and pensions based upon ones experiences, rather than one’s actual impairment, did not exist.

Only in recent years have we observed an emergence of a trauma industry, where both individuals and clinicians all too frequently appear to correlate an unfortunate experience or experiences with damage. The ability to obtain compensation likely has driven this process and outcome.

Those who die in performing their jobs or who sustain serious injury warrant eternal respect and honor. What of those who ride on the coat-tails of dramatic news, and do their sometimes unpleasant and highly stressful jobs? Has the human condition and the nature of trauma and war changed fundamentally in the past couple decades to explain or justify the increased level of diagnoses and compensation for trauma-related experiences?

The article reflects some who were caught. In the culture of cynical entitlement that appears to be reflected in the article, what remains unrecognized? Does one really believe that this case and the Long Island Railroad abuses cover and resolve the core issues?

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…