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The Practice of Medicine

Hearing Aid Prices Under Pressure From Consumer Electronics

Disruption is a common theme in business, including in health care. Disruptions displace incumbents and there are often losers. In this article, the focus is on the hearing aid industry, one where small electronic devices are typically priced in the thousands of dollars, despite their technology being less sophisticated and complex than the typical smart phone that does so much more, for so much less. Often such disparate prices are the result of a silo created by regulation – such that devices that amplify sound in a manner like hearing aids are euphemistically referenced as sound amplifiers for activities like bird watching. In the end, common sense and the desire of the market prevails, whether it is about online hearing aids or eyeglasses at a fraction of the price via current distribution channels, Uber vs. taxis, retail health clinics vs. hospital ERs, or online stores displacing main street.

Read the full New York Times article here.

Deductibles: A Significant Component of Health Insurance

Until recently, health insurance deductibles have proven to be quite a catch 22. On one hand, Americans would rather not have to pay a deductible or co-payment before receiving healthcare; however, it’s simultaneously impossible to ignore that deductibles have helped to make health insurance more affordable and, for some Americans, possible to have at all. Bernie Sanders recently released his proposed health care plan featuring the promise that no American would have to pay a deductible again. Although light on the details, this part of the plan would mean removing something that has been working its way into the health care market since the early 1990s. Deductibles can be significant for some when an average out-of-pocket cost of around $1000 required before coverage kicks in. This is something that has been tolerated due to the standing argument that it makes health care more affordable overall. But is this actually the case? The truth behind the purpose of deductibles is something we do not often get to see up front. The fact that most Americans can’t afford steep deductibles has been one reason to reassess the system but the main question now appears to be: Are deductibles actually helping with health care spending, or deterring it?

In this article featured in the New York Times, Michael Chernew, a professor of health policy at Harvard, stated “If you make something free, people will spend a lot on it.” Recent research is now supporting this idea as studies have shown that more required out-of-pocket costs may be responsible for a downturn in health care spending altogether. Researchers are now beginning to agree that high deductible plans are not what they have been thought to be in the past. Multiple randomized experiments are showing that over time, people who pay more health care bills out of their own paychecks choose to use less health care, while people who have everything covered by insurance tend to utilize healthcare more because they have insurance available. Another important factor is that in comparing these two groups of people, those who were choosing to receive less health care were no less healthy than those taking advantage of using more. What could this mean about the future of health care deductibles? No one is sure at this point. According to some health economists, including Michael Chernew, it may require “smarter” albeit more complicated forms of health insurance. These plans would utilize economic incentives to reduce unnecessary health care spending without deterring necessary care for patients.

We are interested to hear what you think about the possible new direction of health care and the role that deductibles and co-pays have. If you have a moment to read the more in depth New York Times article on this subject please leave us your thoughts in the comment section.

Tying Prices to Performance

by Jen Jenkins

For years, the government and private insurers have been attempting to make an important change in the reimbursement model under which doctors and hospitals operate. The fee-for-service system that is currently in place pays doctors and hospitals based on the sheer volume of tests that they perform and treatments that they ultimately prescribe.

It is quite baffling that a system like this was ever put into place because it by no means incorporates any incentive for ensuring the quality of patient treatment or overall outcomes. In fact, this system has led to a disconcerting trend of unnecessary testing and expendable costs. A change in the current model would mean rewards based on quality and better outcomes, not volume.

A similar shift in the reimbursement model may soon be evident in the drug and device manufacturing industry. Currently, the price of a drug or medical device is unrelated to its actual performance or quality of outcome for a particular patient. This has long been an unraveling problem (similar to that of doctor performance standards) wherein expensive drugs are not performing in the real world nearly as well as expected.

This issue also includes medical devices not working as anticipated; for example, a cardiac device that requires surgery to insert. Today you pay the price no matter what, but imagine being refunded completely if a drug or device did not work as your doctor promised. It’s slightly unfathomable based on the model we currently adhere to, but highly probable for the future of drug and medical device manufacturers.

In theory, this novel change sounds not only appealing but necessary. In reality, however, it becomes a bit complicated. What metric should be selected to measure performance and how will that metric be universally agreed upon? This is a question posed by a senior adviser from Analysis Group, a company that does consulting work for drug and device makers. Like with many other innovative implementations and changes in today’s society, new technology may need to play a role in this shift. However, drug companies want to be sure that patients are taking medications correctly and consistently while also adhering to other factors, such as specific diet or lifestyle changes, that are put into place by doctors. These components all play a role in the effectiveness of a drug. In response to this problem, technology company Qualcomm Life is currently working on a combination of software and sensors to monitor patients, a necessary part of making this change possible.

All obstacles currently in the way of making these changes a reality are seemingly practical ones and thus solvable. It is very likely that sooner than later we will see an inevitable change in which drug and device makers are sharing the risk where the outcome of the patient’s health is concerned.

Some examples of discussions and possible reasons for following the new model are highlighted in this Bloomberg Businessweek article.

The Vaccine War

by Angela Sams

Many of us likely saw or at least heard about the picture that Mark Zuckerberg, co-founder of Facebook, posted on the social media site recently. Though perhaps it appeared innocent on the surface, the photo of his two-month-old daughter getting vaccinated surely ruffled some feathers amongst the anti-vaccination community. A recent Time article discusses the fact that this isn’t the first public statement that Zuckerberg has made regarding vaccinations. He recently used Facebook to publicize a book called On Immunity, by Eula Bliss. “The science is completely clear: vaccinations work and are important for the health of everyone in our community,” he wrote.

Despite the fact that links between vaccines and autism have been discredited, there are still many who believe that vaccines are harmful. But what about the harm caused by unvaccinated individuals who are spreading diseases that were once a thing of the past? Indeed, if Zuckerberg wanted to, he could shut down the Facebook pages of the “antivaxxers.” This does not violate any First Amendment rights, due to the fact that Facebook is a private company.

Another article on the Time website discusses the dangers of “tolerating” those who refuse to vaccinate their children. Recently, at a school in Melbourne, Australia, approximately a quarter of the school’s student body contracted chicken pox. Only 73.2 % of the students had been vaccinated.  Apparently, the school does not require students to receive vaccinations, and instead wrote that “staff respects the right of every family to make choices about immunisation,” in a school newsletter back in May.

While tolerance is often a good thing, even called “the social and intellectual flexibility that allows a society to function at all,” at what cost does it come? Will our society eventually see a dangerous return of diseases that until recently have been kept at bay due to vaccines? The line has to be drawn somewhere, especially when the beliefs of certain individuals (despite the scientific facts) negatively impact those around them.

Measuring Medicine and Evaluating Education

by Jen Jenkins

The ability to measure quality in nearly every industry has proven to be a powerful and important component for success. In both healthcare and education, metrics and measurements are no less significant, but over time has this number gathering trend spun out of control?

According to Robert Wachter, a professor and chairman of the Department of Medicine at UC San Francisco and the author of this New York Times blog post, in healthcare and education “the focus on numbers has gone too far.” In medicine, the constant measuring that takes place has become more a matter of being included on a “top 100” or “best hospitals” list, rather than a chance to improve patient care. A significant amount of a doctor’s precious time is now being spent entering information into a computer system instead of having quality conversations with patients. A study done in 2013 found that during a 10-hour shift, emergency room doctors were clicking a mouse 4,000 times. That is an immense amount of time spent entering information and being away from patients, all in the name of producing numbers.

It’s true that spending time on metrics is not as much of an issue in industries where the focus and care of another person doesn’t possibly mean life or death.  The issue isn’t whether or not to get rid of measurement in healthcare–it does play an important role–but to instead scale it back. Allowing time for more research could help produce a better understanding of what to measure and ensure that what is being measured really matters in terms of the betterment of the industry. Overall, according to Robert Wachter, one should fully appreciate that measurement does place a burden on professionals in the medical field. We need to learn how to minimize that burden so that measuring for quality does not mean a decline in the actual quality of care that patients receive from doctors.

In his post, Robert Wachter goes on to explore this phenomenon of metrics and measurement in another industry where the cons may outweigh the pros. As in medicine, measurement in education comes at an expense. According to educators, that expense is actual learning and a loss of some important subjects that are not as easily measured by tests – examples include art, music, and physical education. Is a preoccupation with test scores really worth the demise of a well-rounded education?

Avedis Donabedian, a professor at the University of Michigan’s School of Public Health, had a surprising answer regarding the secret behind quality. After a lifetime spent in the field of quality measurement, this data-driven scientist said, “The secret of quality is love.” It’s clear that we cannot let the business side of either healthcare or education dissuade people from becoming doctors or educators; these are both fields that should be able to adopt measurement without losing the compassion and altruism that exists at their core.

Skin in the Game – Hospitalists Resisting Outsourcing

by Jen Jenkins

There was a time not long ago, circa the mid-1990s, when the term “hospitalist” did not exist. Doctors worked in hospitals only periodically, attending to their patients when necessary. It wasn’t until economic pressures and a push for efficiency in healthcare created “the hospitalist boom” that we started seeing doctors working in hospitals full-time. It became clear that having doctors based at every hospital was significantly better for both efficiency and for hospital profits. According to this article in the New York Times, the discipline grew rapidly from 2003-2011, jumping from 11,000 hospitalists nationwide to 50,000 respectively. Doctors began enjoying the additional time they were now afforded to spend with their patients and for a time hospitals were so happy with the advantages in efficiency that it all seemed too good to be true. And sure enough, the initial advantages began to wear off.  A huge consequence of the constantly changing healthcare market is the necessity for more and more efficiency. In yet another shift, doctors began having their quality time with patients limited due to a push for a focus on metrics, documentation, and hospital management.

Dr. Rajeev Alexander is a hospitalist at PeaceHealth Sacred Heart Medical Center in Springfield, OR. In his practice, Dr. Alexander believes in taking the time to go through every minute detail with his patients and he dislikes the style of medicine so carelessly flaunted in pop culture television. “Real life is all about the narrative,” he said. “It’s sitting down and talking about bowel movements with a 79-year-old woman for 45 minutes. It’s not that interesting, but that’s where it happens.” His method of treating patients happened to be negatively juxtaposed against the new direction his hospital wanted to take. In 2014, Sacred Heart announced that they planned on requesting bids to outsource their hospitalists to a management company. Outsourcing has recently become more popular across the country as hospitals realize it may be an excellent way for them to measure quality without being responsible for the complicated data collection that is involved. Working in our modern hospitals means being preoccupied with money constantly; this new shift was targeting that bottom line.

Here, the overarching problem for Dr. Alexander’s group is that hospitalists are not a “profit center” for hospitals. Dr. Alexander and his colleagues at Sacred Heart were outraged by the very idea of outsourcing, convinced that this would mean seeing many more patients per shift in the interest of profits. They did not want to lose their jobs by resisting this change but they also knew that it would be the patients that were significantly affected. Then, the idea of unionizing was brought up. It is rare, but there are hospitals around the country whose doctors are unionized, although no union is composed of a single group of specialists. Feeling increasingly bitter after seeing no better options, the group shed their doubts and held a union election. The decision to form a union was voted in overwhelmingly. They had won a battle but not the war. Although the industry has seen a retreat in outsourcing for the time being, that does not mean that hospitals aren’t still keen on getting more out of their doctors. Just how they do so, we shall continue to see.

 

Why the Age of Your Doctor May Matter

by Angela Sams

If you need some sort of serious medical procedure done or find yourself in the hospital for another reason, you would probably want the best, most experienced doctor, right? To the contrary, a recent New York Times op-ed article by Dr. Ezekiel Emanuel indicates that the opposite may be true. The article explores a recent research paper published in JAMA Internal Medicine, which analyzed ten years of data regarding hospital admissions. The research shows “that patients with acute, life-threatening cardiac conditions did better when the senior cardiologists were out of town.” This was the case at what are considered “the best hospitals in the United States, our academic teaching hospitals.” When the top senior cardiologists were absent, patients’ mortality was decreased by approximately one third. Furthermore, patients whose heart conditions are treated in a teaching hospital rather than a community hospital generally fare much better.

One would think that an older, more experienced doctor would be more adept at treating patients, but Dr. Ezekiel poses the idea that younger doctors are still fresh from training and may be better at clinical treatment, whereas older doctors are better at the research side of medicine. Senior doctors may also be more likely to try more interventions. The data in this recent paper, along with other recent studies, seem to indicate that less is better in terms of healthcare. It’s important to remember that with each new test or treatment comes the potential for side effects or something going wrong.

Perhaps doctors should be required to give patients information about a potential procedure and prevent over-medication by attempting to discontinue medications annually. Dr. Ezekiel suggests that patients can also become involved in their own care by asking four simple questions before a procedure:

  • What difference will it make, and will the test results change the treatment approach?
  • How much will this treatment improve the prolongation of my life and reduce the problem?
  • How likely and severe are the side effects?
  • Is this a teaching hospital?

Patients have a right to be as involved as possible in their care. And, while it may make a doctor uncomfortable to be asked such questions, if they truly have the best interest of the patient at heart, they will be more than happy to answer.

Could you be Paying for Someone Else’s Prescription?

by Angela Sams

You get what you pay for, right? Not necessarily. Whether Americans realize it or not, they may in fact be paying $124 or more for the expensive prescriptions of a neighbor, a family member, or a complete stranger!

A recent op-ed article in the New York Times discusses a drug that “is a new class of cholesterol-lowering agents called PCSK9 inhibitors” as an example of a medicine that may result in higher insurance premiums for all of us. This new inhibitor, just approved by the FDA in July, is thought to reduce bad cholesterol (LDL) by up to 60 percent more than a placebo. And, though there is no solid proof that the drug (and others like it) can prevent heart attacks, strokes, and deaths caused by heart disease, researchers are still optimistic.

So what’s the problem with a drug that could potentially improve quality and length of life? The hefty price tag. The companies who create these drugs have disclosed that a prescription will cost more than $14,000 per year, per patient. Multiply this by the number of years that a patient must take that drug, and the number quickly becomes unfathomable. Those costs will then fall to insurers, and eventually trickle down to the rest of us. Policymakers and academics have a couple of proposals that could help save patients money, “such as separating out deductible limits for drugs from deductibles from other health benefits and limiting co-pays for these drugs to $100 to $250.” However, this won’t get rid of the fact that the drugs cost a certain price. That price must still be paid, even if it falls to the insurance company.

Here is where the idea of value comes into play. Are we really getting what we pay for? And how is one to determine the value of a particular medicine? Other items in our economy (think cars, phones, or TVs) are purchased by consumers, depending on whether or not that consumer thinks it’s a good “value.” In the case of medicine, value could potentially be determined by measuring the improved quality of life it gives to patients. Since we are all affected by the rising costs of these prescriptions, it is up to us as a society to determine the value of these medications, and how much they are worth, monetarily.

Transforming Big Medicine

by Jen Jenkins

When this fascinating article by surgeon and public-health researcher Atul Gawande made an appearance in the New Yorker, it posed a very interesting question: Does healthcare need a makeover similar to what casual-dining, big-chain restaurants have done? Gawande juxtaposes the medical and restaurant industries, using the Cheesecake Factory as an example. Although, for obvious reasons, the two industries are incredibly different, they both still seek a similar goal of delivering “a range of services to millions of people at a reasonable cost and with a consistent level of quality.”

The format of medicine delivery in America is changing. Instead of community-based hospitals, there are now large conglomerates formed between hospitals and clinics; physicians who were once self-employed or working in small private-practice settings are now predominantly joining said conglomerates. In Gawande’s comparison to the big-chain restaurant industry, health systems have turned into chains and physicians have become employees.  Hospitals and medical groups used to pose mainly as landlords. Now, due to health-care reforms, they have taken a radical interest in how physicians conduct their business. Why? Clinical performance is becoming linked to financial rewards and can mean the difference between hospitals keeping or losing tens of millions of dollars. Unfortunately, this shift has not necessarily meant an improvement in the way healthcare is delivered on a mass scale.

“Good medicine cannot be reduced to a recipe”

In the article, Dr. Gawande does a spectacular job of bringing a typical Cheesecake Factory kitchen to life. You feel as if you are there as he describes the different roles, the precision, and the necessary steps to bring a food order from the menu, to plate, to table. Also fascinating is the forecasting models he describes. In order to have an almost psychic-worthy accuracy for purchasing groceries to avoid spoilage and food waste, chain restaurants have developed forecasting models using computer analytics. “Chain production requires control, and they’d figured out how to achieve it on a mass scale.” The medical industry, although it has taken on a similar format, has had a difficult time finding a way to obtain similar control and have it trickle down.

Dr. John Wright is among those attempting to inspire change. Following something very similar to this “Cheesecake Factory model” as Dr. Gawande calls it, Dr. Wright began researching what the best people in the industry are doing and how, then he standardized it. Now he is attempting to get the rest of the industry to follow suit. Unlike the Cheesecake Factory, there are certainly many more components that must be woven in and, when exercised, it is much more difficult to persuade clinicians to follow a standardized plan, whereas restaurant employees do it without question. To articulate this process, Dr. Gawande shares a story of his mother’s knee replacement and working with Dr. Wright’s team, who did exactly as what is described above; something called “systematic care.” The results were outstanding in the case of Dr. Gawande’s mother, all due to having someone (Dr. Wright) responsible for the total experience of care, including the costs and the results.

There will always be those who are skeptical of change, yet slow transformation seems almost unavoidable. Dr. Gawande believes that reinventing medical care could produce hundreds of innovations; most significantly, a way to put someone in charge of overseeing the healthcare process from start to finish and ensuring that it is “coherent, coordinated, and affordable.” The Cheesecake Factory model is a very interesting one and, according to Gawande, possibly the best prospect for change in medicine.

Restoring Sight to the Poor

by Angela Sams

Can you imagine a life without sight? Those who are blind face many challenges on a daily basis—challenges that probably don’t even occur to those who can see. Enter Dr. Sanduk Ruit, a Nepali ophthalmologist who is on a mission to help the blind see, using a procedure called the “Nepal Method.” A recent article in the New York Times delves into his miraculous work.

Living blind in a country that is poor presents its own unique challenges, as access to healthcare may not even be an option. Dr. Ruit is pushing past these barriers by offering a cataract microsurgery to patients for only $25. It is a technique that he developed, and it is now being taught to medical students in the United States.

For the powerful impact the microsurgery has on its recipient, you would think it wouldn’t be so simple. That could not be further from the truth. The entire process takes about five minutes, and involves removing the cataract on a patient’s eye and replacing it with a new lens. A procedure that was once seen as something that could only be done with expensive machines, Dr. Ruit’s procedure is just as effective. The big difference is that it is much more affordable.

The cure for blindness extends beyond Nepal. A charity called the Himalayan Cataract Project helps ensure that other countries such as Ethiopia and Ghana can also benefit. The charity was started by Dr. Geoffrey Tabin, another eye specialist who has been working next to Dr. Ruit in Nepal.

In addition to removing the cataracts of the blind, Dr. Ruit founded the Tilganga Institute of Ophthalmology, which includes “hospitals, outreach clinics and training programs and an eye bank, using fees from better-off patients to support impoverished ones.” Approximately 30,000 patients will receive eye surgery from the institute annually.

It seems that the success in Nepal is just the beginning of something great. Stories such as this give us reason to believe that blindness can eventually be eradicated, one eye at a time.