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The Practice of Medicine

Dr. Oz: Only a Third of Claims Backed by "Believable" Evidence?

His credentials are impressive: Vice-Chairman, Department of Surgery, Columbia University College of Physicians and Surgery; he has a long list of publications; and he holds three degrees from Ivy League Colleges. He’s also won a few Emmys and was one of the Time 100, The World’s 100 Most Influential People, in 2008.

Yet Dr. Oz, host of The Doctor Oz Show  since 2009 and The Doctors doesn’t do so well when it comes to fact checking. Following a June 2014 Senate subcommittee hearing in which he was taken to task for unsubstantiated claims made on his show, a group of Canadian researchers and physicians fact checked many claims he has made on his shows.

Researchers randomly selected 80 claims from each show and looked to see what evidence, if any, could back them up. Two team members conducted independent searches, spending up to an hour on each one. “In an attempt to be as fair as possible” to the shows, they wrote, they “used a relatively broad definition of support.” Still, only 21% of the recommendations on “The Dr. Oz Show” could be supported by what the researchers considered “believable” evidence. Another 11% were supported by “somewhat believable” evidence. Given that his shows’ viewership averages just under 3 million people per day, that’s a lot of people being exposed to a lot of apparently unsubstantiated medical advice.

Fewer People Taking Prescription Narcotics —but Abuse Remains a Problem, Study Suggests

Last week pharmacy benefits manager Express Scripts released a study of 6.8 million Americans who had at least one prescription for an opioid filled between 2009 and 2013. The findings? One piece of good news and a lot of red flags related to a medication that was involved in 16,000 overdoses in 2012 alone.

  • Nearly 60 % of patients taking the painkillers to treat long-term conditions were also being prescribed muscle relaxants or anti-anxiety drugs that could cause dangerous reactions.
  • Nearly one-third of patients were prescribed an opioid and a muscle relaxant in the same month, and around the same percentage were prescribed a muscle relaxant and an opioid at the same time.
  • About 8% of patients were taking all three types of drugs — a combination known as a “Houston cocktail,” which gives a heroinlike high — during the same period.
  • 27% were taking more than one opioid at a time, another hazardous combination.
  • Of the patients taking the mixtures, two-thirds were being prescribed the drugs by two or more doctors
  • Nearly 40% filled their prescriptions at more than one pharmacy.
  • Overall use of opioids had fallen, especially for people using them to treat short-term ailments.

“Not only are more people using these medications chronically, they are using them at higher doses than we would necessarily expect,” said Dr. Glen Stettin, a senior vice president at Express Scripts. “And they are using them in combinations for which there isn’t a lot of clinical justification.” Read more…

 

Rate of Health Spending Increases on the Decline

Much has been noted recently about a decrease in the growth of healthcare spending as announced by the Obama administration early this month.

“The pattern observed in recent years is not unique and is consistent with historical patterns,” Anne Martin of the Centers for Medicare & Medicaid Services said. The agency’s report noted: “The key question is whether health spending growth will accelerate once economic conditions improve significantly; historical evidence suggests that it will.”

Three recent pieces in The New York Times explore different aspects of what causes this decrease in growth rate and what it means for consumers and for the future (“Good News Inside the Health Spending Numbers,” “Health Spending Rises Only Modestly,” and “The Health-Cost Slowdown Isn’t Just About the Economy.”).

The medical system really is changing, which is why cost growth has been slow. But the changes aren’t guaranteed to continue. Some key points include:

  • Health spending in 2013 grew at the lowest rate since government officials started tracking it — back in 1960.
  • 2013 is the fourth consecutive year that health spending growth has kept pace with the growth in the overall domestic economy, suggesting something more durable than random.
  • The slowdown in health spending growth began in 2002 and has become more pronounced in recent years.
  • Spending by the federal Medicare program, private health insurance and people’s out-of-pocket expenditures all declined, suggesting that the savings were systemwide and not due to changes in just one kind of insurance.

 

Why Everything We Think We Know about Health Care Is Wrong

Catastrophic Care: Why Everything We Think We Know about Health Care Is Wrong – by David Goldhill

Review

By Brian L. Grant MD

MCN Talk regularly addresses — some would say obsesses about — the health care system in the US. David Goldhill in his book Catastrophic Care: Why Everything We Think We Know about Health Care Is Wrong has created a compelling and essential read for those who enjoy a sense of hopelessness and depression.

Affect and emotions aside, it is a must read for anyone who wishes to understand the scope of the irrational and out of control system of American health care and observe his views of how we may improve upon an out of control if not dire situation.

The book flowed from businessman, not health economist, Goldhill’s experiences with the death of his father in a hospital which he chronicled in an article in the Atlantic Monthly in September 2009. (Hint to those word-challenged readers: some Amazon reviewers suggest this lengthy article is a suitable surrogate to the much longer book).

Reading this with an open mind, it gives this writer pause and is tempering my enthusiasm for the ACA. Don’t get me wrong – I believe the ACA is superior to the system in place before, but that is saying very little. At core, Goldhill postulates and backs up with data and appropriate comparisons to the rest of world that health care, by our reliance on surrogates to pay for all aspects of care (insurance and government) has in place a series of perverse incentives, moral hazards and an absent marketplace that would work for much of the health care spend in improving quality, reducing utilization and curbing price.

He notes that unlike everything else in the economy, we rely upon insurance to pay for everything in health care, from the most routine to the most urgent. The surrogates are the customer and they are the problem, with primary customers – patients — being indifferent to cost and utilization, abrogating decision making and spending to others.

He illustrates that we conflate heath care with health, falsely and at our peril. When commenting on disparate health status of other countries he notes: “The reason Swedes, Japanese and Italians live so long isn’t their (very different) health care systems; it’s that they live like Swedes, Japanese and Italians…” Goldhill does not suggest that we do away with insurance, but that it be a true safety net for truly insurable and rare events, health crises that are “major, rare and unpredictable.” Vaccinations, routine exams, visits for the flu, contraception and the like, all affordable and predictable like a great deal of health care, would not fall under insurance but would be paid for by individuals of reasonable means.

He notes that the usual features of business and the marketplace, including competition, price comparison, and transparency, convenience and comfort, would quickly emerge when the surrogates are eliminated and buying decisions are made – in much the same way that we can dine out, vacation, obtain car repair or electronics – based upon providers who innovate and differentiate to receive our hard-earned dollars. He illustrates from his own experience the indecipherable nature of health care bills and the inefficiency of hospitals because there is no incentive to simplify and improve in the current system that is accountable to payers, not patients.

Goldhill demonstrates that the factors most impacting health are wealth, education and lifestyle, not access to health care. However, we focus on tests, procedures and other interventions that often do little and may harm, because that is where the money is. Most staggering is his illustration of how much the current system costs each of us in terms of real earnings in our lifetime.

He puts the lie to the concept that insurance is other people’s money. Thru payroll taxes both general and Medicare, employer spend, state taxes and other funds, our 18% of GDP currently spent on an inefficient health care system is money that is not going into paychecks and other more productive uses. When I was 13, we spent as a nation 5.8% of our GDP on health care. Today it is 17.6% and rising. Had health care only growth along with the GDP at the same rate over the past 45 years, we would each on average have more than $4,000 to spend annually each year, or $16,000 for a family of four.

Those who defend this increase on the basis of better technology and other factors should be reminded that the rules of economics and innovation generally work to reduce costs and increase quality at the same time. Witness the smartphone in our pockets that pack more computing power than those in the moon launches. We have seen a multi-thousand fold decrease in memory costs and gains in processing speeds and other features with major improvements in most technologies. Why not this same transformation in health care, which claims that technology and innovation is a driver for outsized cost increases?

Goldhill’s closing remarks in chapter 3 “The Disconnect” recaps his basic position: “Consumers don’t have enough information to be good consumers. But the agents we’ve designated to act on our behalf have proved to be worse. When it comes to regulating our health care system – providing real discipline on quality, excess, price and safety – there is no real surrogate. It’s a job that only we can do.”

The newer paperback version of the book is almost 400 annotated pages. Anyone in the business of providing care, overseeing, or paying for care – and perhaps the rest of us who receive care as patients would benefit from reading it.

Quick links:

Catastrophic Care: Why Everything We Think We Know about Health Care Is Wrong – by David Goldhill.

The New York Times Book Review: “Obamacare, How It Should Be Fixed.” David Goldhill’s response.

The Atlantic: “How American Health Care Killed My Father.”

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.”

Medicine still requires the vignette

In an era of systematic clinical research, medicine still requires the vignette, as explored in this opinion piece. The multiple comments are interesting as well, many with strong opinions which provide illumination into why patient stories are (still) so important and how they fit with a sound scientific approach to better treatment:

In addition to reminding us of the real and human part of practicing medicine, stories are great hypothesis generators. Evidence-based medicine is important, but no real evidence can be generated until a testable hypothesis is created. This is where vignettes play an important role. When we see an outcome, especially if it’s unexpected, it forces us to ask questions, which in turn lead to hypotheses.

With a Choice, Parents Opt for Cheaper Surgery

A study offers a compelling case for price transparency in helping reel in the nation’s health costs. As this New York Times article notes, a recent study looked at parental choices when faced with selecting between two different methods of routine, uncomplicated appendectomies for their children.

In the study two groups of parents were shown informational videos on the two different appendectomy procedures – open surgery or using a laparoscope. Laparoscopic surgery is the less invasive of the two, and was priced at $2,000 more. The videos were identical except that one included the price of the two procedures; the other did not.

Interestingly, by nearly a 2/3 margin the parents chose the less expensive though more invasive option. 90% of parents commented that they appreciated having the choice, suggesting that people given price information are more likely to choose the cheaper option.

The surgeon who conducted the study said the information from the hospital could be surprisingly hard for even surgeons to obtain because hospitals consider their price lists proprietary. Where else is the consumer not allowed to know the price, either with or without such choices to make?

He added, “Medicine is often regarded as this magical part of our economy where patients can’t make any choices.” But they can, and that can help hold down costs, he said, noting, “With a bit of information, I can choose my cellphone even though I don’t understand how it works.”

 

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?

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?

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.