Now Viewing: Health Care Cost and Value

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 Watch an archived version of the Hangout, above.)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.

 

How Can Health Systems Effectively Serve Minority Communities? Shift the Cost-Access-Quality Axis.

Apr 29, 2014, 10:30 AM

To mark National Minority Health Month, the Human Capital Blog asked several Robert Wood Johnson Foundation (RWJF) scholars to respond to questions about improving health care for all. In this post, Italo M. Brown, MPH, a rising fourth-year medical student at Meharry Medical College, responds to the question, “What are the challenges, needs, or opportunities for health systems to effectively serve minority communities?” Brown holds a BS from Morehouse College and an MPH from Boston University, School of Public Health. He is an alumnus of the Health Policy Scholars Program at the RWJF Center for Health Policy at Meharry Medical College.

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In our domestic health care system, we nurture the drive to improve patient outcomes, and apply evidence-based knowledge to solve contemporary health care challenges. Yet, studies have demonstrated that minorities are disproportionately affected by chronic conditions, and on average are less likely to receive ongoing care/management of their comorbidities. In addition, public health experts have asserted that social determinants of health (e.g., education level, family income, social capital) directly impact the minority community, and effectively convolute the pathway to care. 

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Heavy Workloads for Hospitalists Correlate to Longer Patient Stays

Apr 9, 2014, 9:00 AM

When workloads increase for hospitalists—the physicians who care exclusively for hospitalized patients—length of stay (LOS) and costs increase, too, according to a study published by JAMA Internal Medicine.

Researchers at Christiana Care Health System, a large academic community hospital system in Delaware, analyzed 20,241 inpatient admissions for 13,916 patients over a three-year period. Hospitalists had an average of 15.5 patient encounters per day, and LOS increased from 5.5 to 7.5 days as workloads increased at hospitals with occupancies under 75 percent.

Each additional patient seen by hospitalists increased costs by $262, although increasing workload did not affect outcomes such as mortality, 30-day readmission rates, and patient satisfaction.

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What's Next Health: Designing an Elegant Health Care Process

Mar 20, 2014, 8:00 AM, Posted by Pioneer Blog Team

Jay Parkinson, founder of Sherpaa Jay Parkinson, founder of Sherpaa

Each month, What’s Next Health talks with leading thinkers with big ideas about the future of health and health care. Recently, we talked with Jay Parkinson, founder of Sherpaa, who challenged us to consider what a more "beautifully designed" health care system might look like. As you'll read in his post below, Jay’s trying to do just that through his work at Sherpaa. (Jay’s opinions are not necessarily those of the Robert Wood Johnson Foundation.)

By Jay Parkinson

Everything great comes from an elegantly designed process. Just think of all of the experiences we love and use on a daily basis. Consider the iPhone. Apple re-imagined what a phone, or rather, a tiny computer in your pocket, could be and created a revolutionary device. Steve Jobs designed not only the interface that changed computing forever, but Tim Cook designed the manufacturing and material sourcing processes that enabled them to produce a remarkably complicated device at a relatively inexpensive price. They understood that, in order to deliver an exceptional user experience, they had to design the entire process, from the interface to the factory.

Health care was never designed. It just happened, revolving mostly around doctors’ needs and wants, in a culture that strongly believed “doctor knows best.” But our culture changed with the democratization of health information and other industries quickly evolved, raising consumers’ expectations of what health care could and should be.

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ACOG Issues New Guidelines to Curb Overuse of C-Sections

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

Tara Oakman holding her twin babies. 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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Physician Compensation Patterns Pose Challenges to Efforts to Incentivize Changes in How Care Is Delivered

Feb 25, 2014, 9:00 AM

Salary is the most common type of compensation for physicians in non-solo practice settings, many of whom are paid through a blend of methods, according to a new American Medical Association (AMA) Policy Research Perspectives report that says it provides a “rare glimpse” into how non-solo physicians are paid.

Just over 53 percent of non-solo physicians reported that all or most of their compensation came from salary, while nearly 32 percent said all or most of their compensation was based on personal productivity. The report points out that this breakdown “suggests that it may be difficult to align practice-level incentives that encourage judicious use of resources with physician-level incentives that do not.”

Ideally, the report says, financial and other incentives would encourage physicians to make the best care decisions possible for patients, providing them “the right care, in the right place, and at the right time,” but current incentives often do not encourage that approach.

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A Year of Dramatic Increase in Insurance Coverage

Jan 27, 2014, 9:00 AM

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2014 marks the start of coverage for those who are newly insured via the health insurance exchanges. In general, healthy behaviors and lifestyle are probably the most important inputs to health, especially for those of us free of serious chronic conditions. But for those of us who are sick, quality health care and access to drugs is crucial for health and happiness. We will soon know to what extent the health insurance exchanges have overcome their implementation problems and have connected previously uninsured Americans to health care.
 
When markets for health insurance work efficiently, they can deliver access to crucial health services to those who need and want them most. Unfortunately, free, unregulated markets for health insurance rarely function efficiently. The market failures in health care have long been noted by economists, most famously by Nobel Prize winner Kenneth Arrow, MA, PhD. In my view, one the most important changes that the Affordable Care Act (ACA) brings with it is an attempt to address and correct market failures via the exchanges.

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Health Policy Wit or Wit-Out Consumer Input

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

Consumers Union RWJF Health Care Cost Conference for Advocates 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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Can Our Positive Health Assets Cut Health Costs?

Dec 12, 2013, 12:30 PM, Posted by Pioneer Blog Team

A female patient gets an allergy checkup in a doctor's office.

By Eric Kim

What if scientists could develop simple, low cost interventions that enhance health and reduce healthcare costs? What if these interventions also increased psychological well-being and were inherently enjoyable for people to perform? These questions are particularly relevant now, as we are constantly reminded of our nation’s rising healthcare costs.

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RWJF Pioneering Ideas Podcast: Episode 2 | Pitch Day, Payment Reform & Behavior Change

Dec 11, 2013, 8:00 AM, Posted by Pioneer Blog Team

Please note that this podcast player might not work in some versions of Internet Explorer. Please view this page in another browser, such as Chrome, Firefox or Safari. You may also access the episode via SoundCloud.

RWJF's Pioneering Ideas Podcast is on iTunes! Don’t miss an episode—click to subscribe.

Welcome to episode two of our podcast. This time we kick things off with our new Mailbag segment, in which Senior Program Officer Paul Tarini answers questions from listeners (time stamp: 1:12). Next, in a conversation with Assistant Vice President of Research and Evaluation and former Pioneer Team Director Brian Quinn, social scientist, innovator, teacher and recent What’s Next Health guest BJ Fogg talks about the need to help people understand how behavior works so they can be more effective in changing their own behavior (4:34). Then we listen in on RWJF’s first-ever Pitch Day, emceed by the Foundation’s Entrepreneur-in-Residence, Thomas Goetz, and featuring judges like angel investor Esther Dyson and NPR science correspondent Shankar Vedantam (8:10). Finally, Senior Program Officer and physician Mike Painter shares a personal story and a plea for getting the human motivators right in health care (16:11). This episode is hosted by program associate (and former TV broadcaster) Christine Nieves.

We hope you enjoy listening, and we hope you learn something; we certainly did. And there’s more to learn: Share your thoughts and ideas in the comments section below, as well as any questions that you’d like us to answer in a future episode.

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