Comparative Effectiveness

The New England Journal of Medicine just published a great article about physician stewardship as it relates to medical spending. The piece, called "Cents and Sensitivity—Teaching Physicians to Think about Costs," discusses whether or not we should be training physicians to consider the bills patients will face when making decisions about what treatment to choose. (Aaron Carroll’s treatment of this piece is here.) The authors propose that teaching physicians to be more cost-conscious will increase their capacity to care for the whole patient, not just their symptoms:

"Whether it’s lack of time, fear of “missing something,” or simple ignorance, the incentives to do more often overwhelm our impulse to use resources wisely. Now some educational reformers are offering us an added ethical incentive. Put simply, helping a patient become well enough to climb the stairs to his apartment is meaningless if our care leaves him unable to afford that apartment. Protecting our patients from financial ruin is fundamental to doing no harm."

We agree that overtreatment is a problem, and we applaud the NEJM for addressing it. It says a lot about how far we have come from even five years ago when everyone was thumping their chests and talking about how we have “the best healthcare in the world.” But we believe that there’s an even greater reason to address the topic of overtreatment: because it is dangerous. Starting with the Institute of Medicine’s 1999 report, “To Err is Human,” the research has continued to demonstrate that more does not always mean better. 

So yes, physicians should consider what patients can afford, but even before that, physicians need to realize that doing nothing is often safer than putting patients at risk with treatments that don’t work. Fiscal responsibility—making sure we aren’t sending Grandpa Frank from the ICU to the poor house—will be the natural consequence.

Austin Frakt tweeted a news release from AcademyHealth this afternoon that brought painful flashbacks to the health policy world.

The House Appropriations Committee has released its proposed 2013 budget for the Departments of Labor, Health and Human Services and Education, in which it "terminates" the Agency for Healthcare Research and Quality (AHRQ). The budget proposal also cuts $150 million from PCORI's funding source, and prohibits any federal agency covered by the committee's jurisdiction from performing patient-centered outcomes research with other funds.

The proposal is, quite simply, insane. It's a direct attack on the only federal agency that produces research on the health care sector and the delivery system--research that is crucial to any effort to reduce unnecessary care, improve patient safety, and curb the increase in healthcare spending.

This budget marks a return to the bad old days, when Congress stood up against science and killed the Agency for Health Care Policy and Research. It's not clear whether this is just dangerous political posturing that will die on the House floor or in the Senate, or if it's dangerous political posturing that might actually pass, but either way we'll be watching the story and keeping you posted. In the meantime, The Incidental Economist is collecting stories about AHRQ funding of valuable (or not-so-valuable) projects.

This program has received funding from AHRQ in the past, including funding for the Avoiding Avoidable Care meeting. That funding has not colored our perspective on this--we would be ardent supporters of the Agency and of evidence-based medicine regardless.

Here's our wrap-up of last week's articles by our own Shannnon Brownlee and Joe Colucci:

Letting Big Pharma Review Its Own Drugs — What Could Go Wrong? (The Atlantic Health Channel):

Earlier this month GlaxoSmithKline agreed to pay a record breaking $3 billion fine for a slew of criminal and civil violations. But is a fine really enough? In a piece in The Atlantic, Shannon Brownlee and Joe Colucci argue that we need to stop letting drug companies track the post-market safety of their drugs and establish an external automatic review system. 

12 Ways Health Care Could Be Improved If the House Wanted to Hold More Than Symbolic Votes (The Atlantic Politics Channel):

In the wake of the House's 33rd vote to repeal/defund Obamacare, Joe and Shannon propose a list of 12 things the House could have done to make a better use of tax payers' dollars and actually improve health care. In the article in The Atlantic the proposals range from enacting a less intrusive mandate to funding after school programs to teach kids how to cook. Any of them would have worked better than another "symbolic vote."

Why The ‘Best’ Hospitals Might Also Be The Most Dangerous (TIME Ideas):

We've all seen them—the U.S. News Rankings of everything from colleges to cars. How do their hospital rankings look? In her latest article for TIME, Shannon argues that, based on new rankings by Consumer Reports, many top-name hospitals fail to measure up in terms of safety. Hospital rankings would be a lot more useful if they considered how medical care affects most patients, not whether a hospital performs some cutting-edge procedure on three patients per year.

The Supreme Court will soon pass down their decision on the most hotly-contested and highly influential policy decisions in recent years:  the Affordable Care Act (ACA).  As CNN has put it, this is "an issue that affects every American."  If fully implemented, the ACA is projected to extend coverage to millions of Americans—a huge victory for universal coverage advocates.  It has also received opposition from those who claim that it represents an unprecedented intrusion of government into the free market.  But free market lovers also have reasons to cross their fingers that the ACA will be upheld in its entirety.  Here's why:

1.  The ACA is market friendly: The ACA is among the most market driven universal health care proposals that has, to date, been tried in other universal health care systems around the world—beat only, perhaps, by the Swiss model.   Ezra Klein shares this view:  “I think conservatives would be smart to embrace the Affordable Care Act structure…giving private insurance a central role in those markets and leaving us with a health system that looks more like Switzerland than like Canada.”  

Many free market advocates point to the fact that our current insurance structure is the problem—patients are shielded from the costs of their medical care, so market forces don't play into their choices.  The ACA will, to some extent, level the playing field in that area.  The creation of state insurance exchanges, with minimum coverage requirements, demystify the health care shopping process, allowing patients to compare apples to apples and buy a plan based on the best value.  Unlike systems in other countries, where government officials negotiate prices, this will force insurance companies to compete for your business, pushing them to provide the best service at the cheapest price.  As Austin Frakt puts it, "That's, essentially, competitive bidding."   The ACA allows the private markets to stay in the game, increases competition, and buys us more time to tinker with free market solutions to escalating costs.

2.  Inaction will kill us:  Inaction—the very thing that the anti-ACA legal case claimed the government is trying to regulate—is the thing that will bring us down.  The rising cost of health care is unsustainable and represents, according to the bipartisan Social Security Advisory Board, "perhaps the most significant threat to the long-term economic security of workers and retirees."  If something isn't done, we will be spending one of every five dollars on health care by 2020.  Imagine the jobs that could be created if we weren't paying so much to the health care system!  (And no: more health care jobs are not always a good thing!)

Some sort of major health system reform is coming in the next decade or two, regardless of how the Supreme Court rules.  As a nation we will soon come to the point when we have to decide if we want to keep spending a fifth (or a fourth? a third?!) of our paychecks on health care. We can either willingly enter the realm of 21st century health insurance (like the rest of our industrialized buddies), or we can have our tattered economic carcass dragged there when our ever-burgeoning health care costs squash other economic activity.  Fast forward fifty years to when more than a third of our GDP--one third of all economic activity--goes to pay for health care.  At that point, public and market pressure will force the government to move to contain costs, and it's hard to imagine they'll do anything 'market friendly.'  Then will free market advocates look back, longingly, to a time when we could have had a health care system with maximum free market involvement?  

We are waiting with bated breath to see how the court will rule.  Regardless of what happens, one group will bemoan the end of the world and another will throw a party.  Free market advocates should think twice about where they would be most comfortable.

In case you missed it, the FDA came out with new rules last week to limit the use of antibiotics in farm animals. While at first glance this might seem unrelated to health issues in humans, it actually matters quite a lot. The connection works like this: the indiscriminate use of antibiotics to produce the food we eat contributes to the creation of antibiotic-resistant disease strains. When humans then get infected with these strains, antibiotics are ineffective at treating the new strains, thus posing a fairly significant public health risk.

This risk is not insubstantial. According to the New York Times, “at least two million people are sickened and an estimated 99,000 die every year from hospital-acquired infections, the majority of which result from such resistant strains.” Further, the use of antibiotics for farm animals is not an isolated occurrence – as Ezra Klein pointed out in the Wonkbook newsletter this week, “70 percent of the antibiotics used in this country – 70 percent! – go into livestock production.” The director general of the WHO, Margaret Chan, has warned that the overuse of antibiotics could “end medicine as we know it.”

So the overuse of antibiotics is bad for humans, bad for public health, and leads to up to $40 billion of avoidable care costs per year. It should be pointed out that many doubt the efficacy of the new rules, but even with these concerns, it’s a welcome first step towards reducing improper antibiotic use in farm animals and reducing avoidable care costs for those humans among us.

Some would argue that $40 billion might not seem much compared to the overall costs of health care, estimated at $2.6 trillion dollars in 2010 alone. That's barely over one percent of medical spending--but one percent matters! (It meets Zeke Emanuel's threshhold, at least.) The fact is, the medical spending problem is enormous, and we need small, common-sense changes in addition to large-scale payment and delivery-system reform if we want to make a difference.

Over at The New Yorker, David Sedaris has an amusing piece on his experiences with “socialized medicine.” It’s worth a read – if not for the humor, then for its helpful illustrations of concepts directly relevant to health policy.

Take, for example, this section:

The time before that, I was lying in bed and found a lump on my right side, just below my rib cage. It was like a devilled egg tucked beneath my skin. Cancer, I thought. A phone call and twenty minutes later, I was stretched out on the examining table with my shirt raised.

“Oh, that’s nothing,” the doctor said. “A little fatty tumor. Dogs get them all the time.”

I thought of other things dogs have that I don’t want: Dewclaws, for example. Hookworms.

“Can I have it removed?”

“I guess you could, but why would you want to?”

He made me feel vain and frivolous for even thinking about it. “You’re right,” I told him. “I’ll just pull my bathing suit up a little higher.”

While certainly a humorous tale, there are also several relevant kernels of truth for health policy. Most people wouldn’t blame Mr. Sedaris for wanting the tumor out – it seems, after all, a perfectly logical reaction for a patient. Notice his doctor’s response, however: “why would you want to?”

The doctor in this story could easily have said, “You’re right: let’s get it removed right away!” Mr. Sedaris, not knowing any better, would probably have gone right along with the program, and the harmless tumor would have been removed. Taken in aggregate, however, these decisions can generate significant costs without corresponding positive health returns. Sure, Mr. Sedaris would be able to wear his bathing suit as he likes, but the French government – or whoever insures his care – would have borne the cost for this convenience.

Similar situations occur every day in the US, with distinctly different results. Patients seem to expect care from their physicians, and doing nothing can seem like the exact opposite of care – despite the fact that it might often be the more prudent medical decision. Removing the harmless tumor or performing an unnecessary MRI  may not be worth the cost, and poses the risk that Mr. Sedaris might contract an infection or have some other complication. In aggregate, such care accounts for a not-insignificant chunk of America’s health care costs.

American medicine, therefore, might do well to take note of Mr. Sedaris’ cautionary – if humorous – tale, and start getting the country used to the idea that we might all be better of if doctors provided less care instead of more. If that means we all might have to pull our bathing suits up a little higher in support for Mr. Sedaris and his fatty tumor, so be it. 

If you missed the broadcast (and our live-tweeting!) this morning, be sure to check out the great discussion of Choosing Wisely, unnecessary care, and what patients and providers can do about it on the Diane Rehm show this morning! The panel included our program director, Shannon Brownlee, Dr Christine Cassel of the ABIM Foundation, Dr. Eric Topol of Scripps Health, and Dr. Ranit Mishori of the Georgetown University School of Medicine.

The panel was well-informed and willing to admit the strengths and weaknesses of the Choosing Wisely program. They all agreed that patients can't fix overtreatment on their own--doctors have to take responsibility for making evidence-based recommendations, and for considering whether test results have any real clinical consequences. In cases where a test doesn't provide any useful or consequential information, the responsible thing to do is skip the test. They also agreed that the problem goes beyond fear of malpractice lawsuits--overtreatment and unnecessary care comes from a culture of "more medical care is better," and the financial incentives that go along with that assumption.

There's a lot more in the program: check it out! And don't forget to look at the website for the Avoiding Avoidable Care conference, coming up later this month!

Yesterday, the ABIM Foundation's Choosing Wisely initiative released a list of 45 medical procedures in nine specialties that doctors shouldn't use, and that patients should know are not necessary. The procedures include a variety of treatments, screening tests, and diagnostic tests, including: MRI and CT scans for low back pain without red flags; cardiac imaging tests for patients with chest pain and low risk of complications; brain imaging for a simple headache; and curative treatment for cancer patients when there's no reason to think the treatments will work.  All of the recommendations are based on solid medical evidence that the procedures harm patients, provide no benefit, or provide extremely small benefits at very high costs.

It's remarkable that the ABIM Foundation was able to pull together panels of people in all of these specialties (allergy, asthma, and immunology, family medicine, cardiology, general internal medicine, radiology, gastroenterology, clinical oncology,  nephrology, and nuclear cardiology) who were willing to agree that these treatments and tests are not beneficial to patients. It speaks to the strength of the evidence against performing useless treatments.

Dr. Vikas Saini, a cardiologist and president of the Lown Cardiovascular Research Foundation, has more commentary over at his blog:

"The truth is, guidelines and appropriate use criteria are used sparingly in practice. Occasionally, in a tough case. But there is such a guideline explosion, you need a guideline for the guidelines.  I don’t blame practicing clinicians when they ignore them. If we are to tackle this problem seriously, what we need of our doctors needs to be baked into their (our) daily cognitive frames, habits, and attitudes."

Take a look at the whole post--it's definitely worth a read.

We'll certainly be covering this initiative as it continues--there are another eight or more specialty societies preparing lists now, for release this fall,  including hospice and palliative care, geriatrics, and hospital medicine. Be sure to check out the website for the Avoiding Avoidable Care conference, as well (avoidablecare.org)--we'll be talking about a lot of the same issues!

Shannon Brownlee's most recent TIME Ideas op-ed is up, and it tackles one of the most-repeated ideas in health care: If we give patients a financial stake in choosing less expensive care, and provide good information about which providers are cheaper than others, we'll end up with higher-value care. (After all, it works in lots of other markets--we don't have a crisis of spiraling iPad costs and lower-than-expected outcomes.) Brownlee's piece gets to the heart of why price transparency doesn't go far enough, though:

"So why do I still have no idea which lens to choose? Because I still need more information. All I know about this lens is what the slick brochure from the manufacturer is telling me. But how safe is the more expensive lens? What are the long-term effects? Can I get a new lens put in if it goes bad? That kind of information just doesn’t exist — as it doesn’t for many medical procedures."

You can read the rest of the article here: http://ideas.time.com/2012/02/27/can-you-comparison-shop-for-surgery/#ixzz1ncfvpkNU