Now Viewing: Cost of care

What’s Keeping the Cardiac Polypill off the Market?

Jul 3, 2014, 10:05 AM, Posted by Sheree Crute

Lisa Ranson Lisa Ranson

No matter how busy Lisa Ranson’s morning gets, somewhere between preparing breakfast and suiting up for work or play, she takes the first cluster of eight pills that protect her from a family legacy of heart disease so powerful she had bypass surgery at 34.

Even at that young age, she was no stranger to daily prescription regimens. Growing up, she watched her dad struggle. These days they compare notes. “He’s survived two heart attacks, had bypass surgery, and he has a pacemaker,” Ranson says.

An avid walker who treks three and a half miles most days near her home in the small town of Dunbar, W.Va., Ranson is now 51 and in great shape. But her healthy lifestyle is no match for her genetic inheritance—she is one of 34 million people living with hypercholesterolemia.

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Choosing Wisely: Intensifying the Spotlight On Health Care of Dubious Value

Apr 30, 2014, 8:52 AM, Posted by Susan Dentzer

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“If you study the kinds of decisions that people make, and the outcomes of those decisions, you’ll find that humanity doesn’t have a particularly impressive track record,” write the brothers Chip and Dan Heath in their masterful book Decisive. Invoking research from psychology and behavioral economics, the Heath brothers demonstrate how people often make decisions by looking at what’s in the “spotlight”—the information immediately before them, sparse as it may be.

But what’s in that spotlight “will rarely be everything we need to make a good decision,” the Heaths counsel. To choose wisely, we need to broaden our focus, or “shift the light.”

That’s especially true in health care, where the consequences of any decision, poorly made or not, may be life or death.

Enter Choosing Wisely, a program that shifts the spotlight onto many of the tests and treatments that both providers and patients should question, if not abandon completely.

(Editor's note: On May 2, 2014, RWJF held a First Friday GoogleHangout to explore how Choosing Wiselysprang from critical examination of the overuse of medical care in the United States—and how it’s changing how care is delivered in communities. Watch an archived version of the Hangout, above.)

This two-year old campaign, launched in 2012 by the American Board of Internal Medicine Foundation, has identified more than 250 tests and procedures that warrant scrutiny because they are ineffective, unnecessary, unsupported by evidence, or possibly harmful. Even so, physicians and other clinicians perform them regularly, and patients sometimes request them.

Fifty-four of the nation’s premier medical specialty societies have joined the Choosing Wisely effort, and most of these have contributed to their own lists of questionable care. This week, three non-physician groups will also sign on to the campaign. Among the categories of dubious care identified on various societies’ “top five” lists are these:

  • Excessive imaging: CT or MRI scans for low back pain shouldn’t be ordered within the first six weeks of treating a patient, unless there are severe neurological symptoms, while patients with minor head injuries shouldn’t routinely get a head CT unless they have a skull fracture or are bleeding. Excessive scans expose patients to radiation that increases their lifetime risk of cancer.
  • Unnecessary medications: Antibiotics are not effective against viruses and should not be prescribed for viral illnesses such as sinus infections or bronchitis, particularly in children. But doctors say they frequently feel pressured to write these prescriptions by anxious parents.
  • Superfluous screening or diagnostic tests: Patients with no symptoms of heart disease and are at low risk of developing it are still frequently subjected to electrocardiograms when they get routine physical exams, despite evidence that this routine screening doesn’t improve patient outcomes. By the same token, hospitalized patients may have their blood drawn countless times for costly diagnostic testing that often yield little useful information, and can contribute to anemia.

The Robert Wood Johnson Foundation is supporting Choosing Wisely with a $2.5 million grant to extend the influence of these lists beyond medical specialty societies and into communities. State medical societies in Texas, Oregon, Minnesota, Tennessee, Washington, and Massachusetts have undertaken steps to promote the lists, including developing continuing medical education courses for doctors. So have ten regional health collaboratives, such as Maine Quality Counts and the Washington Health Alliance outside Seattle (both are among RWJF’s Aligning Forces For Quality communities as well).

Consumer Reports and AARP are among organizations that have taken the lead in publicizing the lists for consumers. All told, these efforts have reached an estimated 170,000 or more physicians and 16 million-plus consumers. There’s even a Wikipedia page for the campaign, with the lists of tests and procedures curated by a “Wikipedian” in residence.

Caveats: Although more than 200 articles have been written about aspects of the campaign in medical journals, there is as yet little hard evidence that is has reduced superfluous care. A recent perspective in the New England Journal of Medicine noted that the specialty societies’ lists “vary widely in terms of their potential impact on care and spending”—and suggests that some societies omitted lucrative elective procedures, such as knee replacement surgery, that also aren’t appropriate for many patients.

The bottom line: As a nation, we need to shine a spotlight on an even broader range of questionable health care in the future. But for now, the Choosing Wisely campaign is illuminating plenty of “care” that we can clearly pass up with impunity as we pursue our real objective:  better health.

 

ACOG Issues New Guidelines to Curb Overuse of C-Sections

Feb 27, 2014, 5:27 PM, Posted by Tara Oakman

Tara Oakman Tara Oakman

While I knew that having children would turn my world upside down, I assumed that this transition would be more metaphorical than literal. Ha! Moments before I was discharged from a Maryland hospital a few days after my twins were delivered by c-section, the ground shook violently. My husband had just left the hospital room to get the car, so I was alone with two newborns and a painful surgical wound. All I could think was ... “This is an earthquake! I have two babies. And I can’t move!

One of the scariest parts of the experience was that I couldn’t respond to my maternal instinct to quickly pick up and protect my babies because I had just had major abdominal surgery. Granted, managing in an earthquake is not a common part of recovery from a C-section, but there can be many other dangerous complications that occur more frequently, such as infection, emergency hysterectomy or heavy blood loss. It can also lead to greater difficulty with breastfeeding. C-sections are also very costly, even if there are no major complications. They are much more expensive than vaginal delivery.

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Health Policy Wit or Wit-Out Consumer Input

Dec 13, 2013, 10:56 AM, Posted by David Adler

CU RWJF Meeting Consumer advocates brainstorm about rising health care costs.

Whether you’re a Philadelphia native, a visitor, or just a cheesesteak aficionado, you need to know how to order. When you get to the front of the line at one of Philadelphia’s long-established cheesesteak stands you order your sandwich wit or wit-out. Either with onions or without. Whatever you do, don’t stand at the window and first think about this important decision. Let’s just say it won’t end well. But, as much as I love cheesesteaks (in moderation of course) this is not the most important wit or wit out decision we have to make as a country.

The decision we really need to make is how we want our health policy decisions made. You can have it wit or wit out consumer input. At a recent meeting on health care costs sponsored by the Robert Wood Johnson Foundation and Consumers Union, my colleague Anne Weiss drove this point home.

I’m paraphrasing a bit, but the gist of her remarks (and indeed of the meeting) was that efforts to contain spending and to get more value out of our health care system are going to come about with or without consumer input. She wants it to proceed with it. In other words, Anne’s ordering her health care value steak wit. I second her choice. Personally I think it’s ridiculous to eat a cheesesteak without onions, and I think it’s equally problematic to address health care costs without consumer input.

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Five Takeaways from the National Transparency Summit: An Issue Whose Time Has Come

Dec 9, 2013, 4:33 PM, Posted by Susan Dentzer

RWJF Senior Health Policy Adviser Susan Dentzer RWJF Senior Health Policy Adviser Susan Dentzer
  1. Transparency is an idea whose time has come—in large part because U.S. consumers are feeling so much pain from higher health costs. Health economists have long noted that U.S. health care prices are out of whack and that hospital chargemasters are nonsensical. Recent media coverage of these phenomena has captured widespread attention, perhaps because consumers are being hit so hard in the pocketbook. Since 2000, rising prices of hospital charges, professional services, drugs, devices and administrative costs, are responsible for 91 percent of the increases in health spending. Meanwhile, consumers’ out-of-pocket spending on health care, estimated at $329 billion this year, is projected to rise to $411 billion in 2020—a 25 percent increase. Almost three in five workers in small firms, and one in three workers in larger firms, are in a health plan with a deductible of at least $1,000 for single coverage, and in 2012, nearly one of five U.S. adults was contacted by a collection agency over unpaid medical bills.

    It’s well established that much of this money is being spent on health care of questionable value. With so much of their money—and their well-being—now at stake, “People are going to impose transparency on the health care industry,” predicted Leah Binder, a conference participant who heads the Leapfrog Group.

  2. Consumers and patients deserve to know far more about the costs and quality of care, but unless the two are linked, the public may continue with its longstanding delusion that the more expensive the care, the better the quality. Francois de Brantes, executive director of the Health Care Incentives Improvement Institute, noted that this widespread consumer misapprehension constitutes a “perverse incentive” for providers to continue to raise prices. Meanwhile, evidence of poor quality abounds. Martin Makary, a Johns Hopkins University physician and author of Unaccountable: What Hospitals Won’t Tell You And How Transparency Can Revolutionize Health Care, reminded the conference that preventable adverse events in hospitals are now the nation’s third leading cause of death annually. Many highly esteemed medical centers that end up routinely on “best hospital” lists don’t make the Joint Commission’s tally of top performers on basic quality and safety measures.

    Conference speakers agreed that there’s a pronounced need to combat these trends by developing more and better quality measures—especially those capturing care outcomes, and in particular, the outcomes that are most important to patients. Providers’ scores on these measures should then be funneled to purchasers and the public. “When consumers can really start to see that this hospital is better than this other hospital, or this doctor is better than that doctor, they will start to move,” said Bill Kramer, executive director for national health Policy at the Pacific Business Group on Health.

    Promising prototypes of the platforms that could communicate such information include winners of the RWJF Hospital Price Transparency Challenge—for example, Consumer Reports’ Hospital Adviser: Hip & Knee, which combines hospital quality rankings with Medicare cost data to help consumers pinpoint high value institutions where they could obtain surgery.

  3. Fostering greater transparency will be a long process, but there could be relatively quick “wins.” Many contracts between health insurers and providers contain “gag clauses” that bar both parties from disclosing claims data or prices paid for care. The clauses appear to serve both parties’ interests—helping to protect health plans’ proprietary interests in the provider networks they’ve established, and providers’ desire not to disclose how little they are willing to be paid. California has outlawed such clauses in health plan contracts, and many conference attendees agreed that other states should follow suit.

    What’s more, a total of 16 states have set up mandatory or voluntary all-payer claims data bases (APCDs) to pool statewide data on diagnoses, procedures, care locations, and provider payments. Conference participants agreed that more states should enact mandatory APCD’s, or use the regulatory authority in state insurance laws to compel insurers to issue payment and pricing data, as was done in Rhode Island.   More states could also follow the lead of Maine Quality Counts, the private, independent nonprofit organization that leads the RWJF-sponsored Aligning Forces for Quality coalition in the state, and which has aggregated health plan data for purchasers, consumers and providers to promote transparency on quality and cost.

  4. Transparency in the hands of consumers could be powerful—but in the hands of providers, even more so. Health care providers themselves often lack information about the quality and costs of their care. In particular, transparency can focus attention on the extreme amount of variation among providers in the care they provide. Glenn Steele, president and CEO of Geisinger Health System, described how Geisinger’s physicians came together to define “best practices” across a dozen hospital episodes of care, including heart bypasses, hip replacements, and gastric bypass surgery. As physicians in the system adhered to these guidelines, spending fell, by 20 percent  because doctors narrowed the indications for which they agreed that the procedures were warranted, and 15 percent by reducing unnecessary variation.
  5. Transparency is a necessary but insufficient tool for health system transformation. Openness about price and quality alone is “not going to be enough” to achieve the goals of the Triple Aim, observed Steven Brill, whose Time magazine article in March 2013 gave renewed focus to the issue. Payment reforms and “culture change” that shift providers from a volume-based to-value-based approaches remain critical. What’s more, consumers need to have health insurance benefit designs beyond high-deductible health plans that encourage them to make wise choices, such as “value-based” benefits” that help nudge them toward cost-effective care delivered by low-cost, high quality providers. Others at the conference warned that regulators must stay attuned to unintended consequences of health system transformation, such as the consolidation of health care providers that could lead to attempts to jack up prices.

    In the end, “We don’t win the game until the care gets better,” observed Jay Want, CEO of WantHealthcare. The nation also must ensure “that the transparency we seek will serve to change the way we think about health and wellness,” said RWJF president and CEO Risa Lavizzo-Mourey. “We need to use our skills, our imagination, our influence, and, yes, our hearts, to transform our nation into one that considers being healthy part of what it means to be an American.”

    To that end, transparency about the choices we face as a nation on the costs and quality of health and health care can give our society a critical lens to look within.

“An Educated Consumer is Our Best Customer:” Four Things to Know About Transparency In Health Care Prices, Costs and Quality

Nov 26, 2013, 10:14 AM, Posted by Susan Dentzer

Watch our December 6, 2013, FirstFriday Google+ Hangout archive on transparency in health care.

Panic about high health insurance premiums. Fears about high-cost health-care providers being cut out of health plan networks. Worries that the health plans now available through health insurance exchanges won’t cover the care that patients need.

Welcome to the rollout of Obamacare....right?

Actually, with the exception of the new health insurance exchanges, all of the phenomena described above have a long history. Similar concerns were voiced loudly in the late 1980s and 1990s, when “managed care” in health insurance became a dominant force on the health care and health insurance landscape.

What’s amazing to people who lived through both of these eras—then and now—is how little has changed.  

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When it Comes to Health Care, We’ve Been Living in the Land of Oz for Too Long

Sep 6, 2013, 4:30 PM, Posted by Tara Oakman

Cost Report April 2013

“Pay no attention to the man behind the curtain! The Great and Powerful Oz has spoken!” 

In some ways, our health care system has traditionally functioned much like the fantastic land of Oz depicted in one of my favorite movies.  Consumers and purchasers are expected to be passive consumers, doing what they are told and paying whatever price is levied based on a high degree of trust and limited information. This model seems increasingly ridiculous. We now face an urgent need to improve the quality and efficiency of our health care system.

But to do that, we need information, a lot of information. Health professionals, purchasers, consumers—basically anyone who comes in contact with health care—need timely, accurate, comprehensive information on cost and quality if they are to make smart decisions. Without such information, not even a wizard could do the trick. But right now, such information is usually unavailable, or, when it is accessible, too often indecipherable. In fact, the Institute of Medicine estimates that $105 billion is wasted every year in the U.S. because of a lack of competition and excessive price variations in health care, and a lack of information on the price of health care services plays a large role in this waste.

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Carrots, Sticks, or Something Else? Motivating Doctors to Transform Health Care

Aug 14, 2013, 2:14 PM, Posted by Susan Dentzer

craigsammitforumedited Craig Sammit, MD, president and CEO of Dean Health System, and Holly Humphrey, MD, dean for Medical Education at the University of Chicago Pritzker School of Medicine

An old joke has it that the doctor’s pen is the costliest technology in medicine, since money typically flows where physicians’ prescriptions and other orders decide that it should go. As a result, influencing these decisions is key to achieving the Triple Aim of better health and health care at lower cost.

But what’s more likely to influence doctors: external factors, such as bonuses for improving the quality of care, or internal factors, such as appealing to their sense of altruism or satisfaction with their work?  In other words, carrots, sticks, or something altogether different—what Daniel H. Pink, author of Drive, calls “our innate human need to direct our own lives, to learn and create new things, and to do better by ourselves and our world”?

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New Role for Health Care Providers: ‘Hot-Spotting’ Unhealthy Communities?

Jun 28, 2013, 9:21 AM, Posted by Susan Dentzer

In his now legendary approach to urban medicine, physician and Robert Wood Johnson Foundation grantee Jeffrey Brenner, MD, pioneered the technique of hot spotting—making block-by-block maps of Camden, N.J., examining residents’ hospital costs and identifying the handful of patients who cycled in and out of those institutions and racked up stratospheric medical bills.

What if America’s hospitals and health systems used similar techniques to identify the nation’s poorest and least healthy communities—and then teamed up with local community development organizations to set them on a path to better health?

David Fleming, a physician who directs Seattle’s public health department, made that pitch recently to members of the Foundation’s Commission to Build a Healthier America. National health reform, he said at the panel’s June 19 Washington meeting, affords an opportunity to nudge health care providers to reach outside their facilities to hot spot areas in need of health improvement. “The solutions to health in this country lie beyond the walls of the clinic and in our communities,” Fleming argued.

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This Year’s Health Care Transformation Oscar Goes To…

Jun 17, 2013, 3:55 PM, Posted by Mike Painter

A doctor reviews information with a patient.

For an actor—let’s call her Jennifer for discussion purposes—who suddenly has a big award-winning breakthrough—there is nothing sudden about her success.  Jennifer’s accolades come to her not by accident but rather after years of below-the-radar hard work, striving and struggle.  That same principle applies to seeming sudden success in other fields—say, health care.  In fact, today let’s go crazy and salute some breakthrough health care actors.  Health care is transforming before our very eyes. 

Hang onto your hats, because it’s changing from one predominantly focused on churning out more services and procedures to one relentlessly driving the right care at the right time at the best price. 

That’s not happening all by itself. That slowly accelerating transformation could seem sudden—or spontaneous.  It might seem like it’s happening effortlessly—almost by magic.  Nothing, of course, could be further from the truth.  Trust me— there is a bunch of struggling, starving transformation artists who have been working years for this moment—like the great people at the Consumer-Purchaser Disclosure Project.

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