What do we pay for and why

Same health care, different setting, but much higher costs

By M2|2019-04-25T20:36:11+00:00April 24th, 2019|Health care spending, Health Reform, Insurance, Medicare, Uncategorized, What do we pay for and why|

Same health care, different setting, but much higher costs

There is so much health care news happening right now, you may not have seen this, but different services cost different amounts, depending on where they were delivered. While this concept isn’t necessarily news to health care policy types, this latest data set and accompanying graphics make the issue clearer than ever and beg for a policy fix.

The Centers for Medicare & Medicaid Services (CMS) finalized the Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs Rule November 21, 2018, implementing site neutral payments for hospital outpatient clinic visits. The policy essentially reduces payments for services provided in outpatient settings to the same level as the payment made for the same service in a physician’s office.

However, the policy change applies only to Medicare, which covers less than 20% of the U.S. population. The commercially insured, for example, via employer-sponsored insurance and the individual and small group market, account for 56% of the population (see Charles Gaba, The Psychedelic Donut: Types of Coverage in the U.S.).

Wouldn’t a similar policy for people who receive health insurance outside of Medicare be a way to reduce costs?

Outpatient setting is always more expensive…

The Health Care Cost Institute compared a common set of services performed in physician’s offices and outpatient hospital settings and found “for this set of services, the average price was always higher in an outpatient setting than an office setting.”

Services that saw a significant change when provided in an office vs. an outpatient setting varied by service. Some of the bigger changes were for ultrasounds, upper airway endoscopies, and drug administration. For example, “in 2017, 45.9% of level 5 drug administration visits occurred in outpatient settings, compared to 23.4% in 2009.”

Not only did prices increase over time for both settings, the site differential for some of the visits was stunning.

We took the HCCI info and added a calculation of our own for a few of the visit types to show the percentage difference between the price of a visit in the office setting vs. outpatient setting, as shown in the table below.

It is also something that should be made transparent to patients. As mentioned in a recent , health care costs are rising and people are struggling to afford those costs. States are passing transparency bills left and right (hospital transparency, drug price transparency), even though it is unclear how “transparency” actually lowers costs. However, implementing site neutral payments for all payers (not just Medicare) is a more obvious, and more immediate, improvement to rising health care costs.

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We Pay for What We Value. Guess What We Value in the U.S. Health Care System?

By M2|2019-02-04T17:27:13+00:00February 1st, 2019|Health care spending, Health Care Trends, Hospitals, Insurance, Providers, Uncategorized, What do we pay for and why|

We Pay for What We Value. Guess What We Value in the U.S. Health Care System?

People often ask what the difference is between the United States and other health care systems. Health Affairs recently published a helpful piece focused on comparing costs entitled “It’s Still The Prices, Stupid: Why The US Spends So Much On Health Care, And A Tribute To Uwe Reinhardt” by Gerard F. Anderson of Johns Hopkins Bloomberg School of Public Health, Peter Hussey, a VP at RAND Corporation in Boston, and Varduhi Petrosyan, a professor and dean in the Turpanjian School of Public Health, American University of Armenia, in Yerevan. The article is an update of a similar one they published back in 2003, along with Uwe E. Reinhardt, who was the James Madison Professor of Political Economy at the Woodrow Wilson School of Public and International Affairs, Princeton University, until his death in November 2017. The authors compare the health care costs, accessibility, spending growth rates, and other fees in OECD countries.

Notably, there is no concise chart in the article, showing the side-by-side of this information – so we made one! We also calculated a multiple, to see how much more (or less, but usually more) the U.S. spends compared to the median of the OECD countries.

In the chart below, we tried to focus on the main categories of health care costs – health insurance administrative costs, hospital care, physician salaries, nurse salaries and pharmaceutical spending. Interestingly, the information needed for a comparison across countries and categories was not always available in the Health Affairs article. This highlights a pretty big problem with health care data – researchers often say that it’s hard to compare inputs across countries because of their different systems and economies, so they just don’t. This means we don’t actually know for sure how these costs compare to each other.

You may notice the huge difference in per capita health insurance administrative costs. The fact that the U.S. spends almost 8 times as much as the median of OECD countries on health insurance administrative costs (and not actual health care) is rarely a focus of health system policy change, though it is well-known:

“The next-highest-spending country after the US (Switzerland) had administrative costs of only $280. In 2017 Steffie Woolhandler and David Himmelstein [Commonwealth Fund] estimated that the US would save about $617 billion (about 20% of its total health spending) if it moved to a single-payer system.”

We have written about standardizing a set of forms before. Maybe this is a good place to start addressing health care costs in the U.S.?

Another area of high cost in the U.S. compared to other countries is hospital and health care providers. According to the Health Affairs article, all of the inputs for hospital care – including “health care workers’ salaries, medical equipment, and pharmaceutical and other supplies – are much more expensive than in other countries.”

Why are health care provider costs higher in the U.S.? In part because the allocation of physicians in the U.S. is different from other OECD countries, and skews to more expensive care: the U.S. has the lowest percentage of general physicians relative to specialists of OECD countries.

Making changes seems as easy as the U.S. looking to a country that seems to have lower health care costs and “copying” what they do. But these researchers did this same analysis in 2003 based on 2000 data and now, nearly 20 years later, they found the relative rankings of the countries to be about the same for most indicators. Health care costs are different across countries because health care systems are different across countries. And of course, systems are different across countries because values are different.

Based on what the U.S. spends in different health care categories compared to other countries, we seem to really value health insurance administrative costs. Now we know.

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Here’s a health policy idea, let’s listen to patients

By M2|2019-01-24T15:19:50+00:00January 23rd, 2019|Health Care Trends, Innovation, Uncategorized, What do we pay for and why|

Here’s a health policy idea, let’s listen to patients

Earlier this month I was a presenter and leader of a panel session at the Washington State of Reform Health Policy Conference in Seattle titled, “A Policy Framework for New Medicine.” The other two panelists and I were asked to present our points-of-view about policy related to “personalized medicine, miracle drugs, and genome-specific therapies.” The other two panelists were gene therapy patients. Ashanthi DeSilva is the first person in the world to undergo an approved gene therapy, which she did at the age of 4 in 1990. Toby Willis was “the first adult to undergo the first gene therapy approved in the U.S. for treatment of an inherited disease,” in March 2018.

Gene therapy is a topic of particular interest to me, naturally because of the work that I do, but also because I wrote my thesis to complete an M.A. in Philosophy at Boston College on the ethical use of gene therapy, in 1994. Those were the early days of gene therapy as a practical treatment, and I encountered a great deal of resistance for my thesis proposal from the hallowed halls of the esteemed Jesuit institution. My advisors were just not convinced there was any real-world application for gene therapy, and therefore they didn’t see the value in developing a framework for navigating the ethical considerations that I was sure were on the cusp of driving innovative patient care. What an incredible experience for me, then, to meet the woman who had undergone the world’s first gene therapy trial as a young child in roughly the same time period that I was pushing for approval from the chair of the philosophy department to start a conversation on how to decide who should receive (and for what reasons) gene therapies.

Both Ms. DeSilva and Mr. Willis are remarkable people and they were able to shine a light on the policy problems that still exist decades after gene therapy was first used to treat a patient. For example, Ms. DeSilva must still argue with her insurance company to have her ancillary medications approved because they are subject to prior authorization requirements despite the fact that she needs them because of her primary diagnosis – and will likely need them for the rest of her life. Mr. Willis’s policy story focused on the core questions before the group: Should we pay for innovative treatment? For whom? Under what circumstances? And, of course, who should pay? Individuals? Employers? Insurers? Taxpayers?

These sessions can sometimes be dry presentations where speakers do their thing without any regard for the audience. What happened at this session was different. It was a free flowing discussion that used the panelists as touchpoints, but drew out the expertise and ideas of audience members – including a health plan, a specialist provider, a policymaker, and pharmaceutical manufacturer. Some policy concepts offered were easily agreed upon, for example, trying to spread risk across a broader pool of people or spreading the costs of treatments over time. But I was the most impressed with the policy ideas offered by the patients in the room who were recipients of life-changing treatment. The ideas were at once simple, and nearly impossible. To close the session I asked the other panelists to give one recommendation for people in the audience to do when they left the room.

Ms. De Silva recommended that when thinking about health care policy, we should all try to think of someone besides ourselves.

Mr. Willis, who claimed not to be a policy expert, deftly explained what seems to be the core of the problem with the U.S health care system today. He said, “the system treats health plans as the customer, but I think patients should be the customer.”

So, as we begin an already busy health care policy 2019, I will be trying to heed this great advice. Maybe policymakers will, too.

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What gets prescribed and why: Opioids v. obesity meds

By M2|2018-12-06T18:37:08+00:00December 6th, 2018|Chronic pain, Evidence-Based Medicine, Health Care Trends, Insurance, Uncategorized, What do we pay for and why|

What gets prescribed and why: Opioids v. obesity meds

The U.S. health care system doesn’t always make sense. Sometimes, even when there is some logic to it, the reasons underpinning what gets prescribed by practitioners and covered by insurers are disappointing. Two pieces I read recently provide examples.

In one study, we learn that while primary care physicians are prescribing opioids less often, other specialists and nurse practitioners are prescribing them more often. Ultimately, opioid prescribing remains at a high level, despite known issues with misuse and abuse, and the availability of alternative pain treatments.

At the same time, while 40% of U.S. adults are obese, fewer than 2% of obese patients are offered medications for obesity, and ultimately “only about 1% of eligible patients fill a prescription for a weight loss medication.” Even when weight loss medications are prescribed, it is usually for a specific (fairly short) period of time, explained Dr. Caroline M. Apovian, a Professor of Medicine and Pediatrics, Department of Medicine, Section of Endocrinology at Boston University School of Medicine and the Director of Nutrition and Weight Management, Department of Endocrinology, Diabetes, and Nutrition, at Boston Medical Center, in an opinion piece in Medscape.

This is an example of what we like to call at M2: “what do we pay for and why?” If 40% of the public has a disease, why aren’t treatments prescribed and covered? Several chronic obesity management medications have been approved by the U.S. Food and Drug Administration (FDA) in the past few years, and have proven of efficacy of 5%-10% weight loss, but Dr. Apovian argues that “public perception of obesity as a matter of will power rather than a disease” is a key barrier to lower treatment rates for obesity.

The U.S. health care system doesn’t necessarily pay for what works, or the treatments people need. As with all policy decisions, there is a judgment about who deserves what, and who should pay for it. In the case of treating obesity with a prescription, Dr. Apovian succinctly explains the current policy stance: “If obesity is considered a moral failing, why treat it with a pill or surgery?”

What’s the hold up? Why do physicians not turn more frequently to the known effective treatments for obesity? Well, sometimes it is lack of proper training (discussed in our in April). Physicians have a lot to stay up to date on, and obesity treatments are often not prioritized despite the prevalence of comorbidities. As we discussed in a back in February, improved insurance coverage for proven effective weight loss treatments could help avoid expensive complications from obesity down the road and may improve quality of life. We suggest this is a better way to choose what is covered the current approach.

Pain affects a large number of people in the U.S. as well – more than 100 million adults. Nearly 40 million adults experience the highest levels of pain (category 3 or category 4), and there are more than 25 million adults who report chronic (daily) pain. Further, the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain is clear: “Opioids are not first-line or routine therapy for chronic pain.” Despite this clear recommendation, as the recent study confirms, opioids continue to be frequently prescribed for pain, even though there are less addictive alternatives available. These medications aren’t that expensive so are frequently covered by insurance.

The M2 blog, Coverage Drives Treatment: The Case of Pain explains how insurance companies seem to prefer to cover what is inexpensive, and perhaps less effective, at least when it comes to opioids for pain.

Confounding situations like this are when we understand why an overhaul of the health care system is appealing to some. It would be an incredible opportunity to step back and create a new system that approaches all situations – obesity, pain, everything – from the perspective of longer term effectiveness. Ultimately this would reduce health care system costs overall, as less time (and money) would be spent covering up symptoms of something that is likely to cause greater expense down the road.

But in order to do this, we’d have to face who we think deserves what kind of care. These decisions are baked in to the system we have and rarely discussed. 2019 is around the corner. Should we start this conversation in the new year?

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Avoidable ED visits – what does “avoidable” mean and what can we do about this issue?

By M2|2018-07-10T18:48:57+00:00July 9th, 2018|Evidence-Based Medicine, Hospitals, Uncategorized, What do we pay for and why|

Avoidable ED visits – what does “avoidable” mean and what can we do about this issue?

An employer group in Massachusetts is coming together to reduce avoidable emergency department (ED) visits, in large part because they claim ED visits are a key driver of health care costs in the Commonwealth. According to the coalition, “ED visits can be five times more expensive than primary care or urgent care visits.” Not only are ED visits expensive compared to other health care services, the coalition cites a Massachusetts Health Policy Commission estimate of $300-350 million in annual costs, in total, just for commercially insured people in Massachusetts.

While this seems laudable, it turns out there’s a big difference of opinion about the definition of “avoidable ED visit.” The coalition’s statement claims studies show more than 40% of ED visits are avoidable. Some of the most common conditions for avoidable ED visits, accordingly to this employer group, include acid reflux, allergies, back pain, bronchitis, sinusitis, stomach pain, and urinary tract infections. At first glance, these maladies don’t seem like they need to be treated in an emergent setting.

At issue is the definition of “avoidable.” According to the American College of Emergency Physicians (ACEP) only 3.3% of ED visits are avoidable. In a study based on data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for years 2005 to 2011, Renee Hsia, MD, MSc, of the Department of Emergency Medicine at the University of California, San Francisco, found many of the visits to EDs that are classified as “avoidable,” such as those listed above, also involve either mental health or dental issues.

Dr. Hsia argues, “This suggests a lack of access to health care rather than intentional inappropriate use is driving many of these ‘avoidable’ visits. These patients come to the ER because they need help and literally have no place else to go.”

So, are more than 40% of ED visits avoidable or is it less than 5%? This is a fairly big difference. In ACEP’s view, the entire concept of “avoidable ED visits” should be questioned. “Despite a relentless campaign by the insurance industry to mislead policymakers and the public into believing that many ER visits are avoidable, the facts say otherwise,” said Becky Parker, MD, FACEP, the president of the American College of Emergency Physicians (ACEP). “Most patients who are in the emergency department belong there and insurers should cover those visits. The myths about ‘unnecessary’ ER visits are just that – myths.”

It seems essential to know more about why people are going to the ED for health issues that don’t fall into the category of: I was taken to the ED in an ambulance because I was unconscious, or my friend drove me after I sliced off my finger…The Massachusetts Health Policy Commission has been gathering all sorts of data the past few years, and below is the chart they have published on avoidable ED use.

As the chart shows, nearly 70% of “avoidable ED visits” happen between 8am and 8pm. This is probably not the typical idea that people have in their minds about when “avoidable ED” visits occur. So based on Massachusetts data showing the majority of avoidable ED visits happening during daytime hours, it seems more likely that the ACEP point of view is correct: Maybe these visits really do indicate access to care problems more than patient choice – which possibly could be changed simply by improved education.

The Health Commission chart is accompanied by some analysis from the 2014 Massachusetts Health Insurance Survey. In the survey, of the respondents who had been to the ED in the past year, “over half said they had done so because they could not get a timely appointment with their usual source of care.” Ideas to address this lack of access include encouraging patients to seek care at retail clinics or urgent care centers, encouraging providers to expand office hours, making hotlines and telehealth more available, and “granting Nurse Practitioners full practice authority.”

Reducing unnecessary health care costs is a common goal across individuals, families, employers, and governments. The Massachusetts Employer-Led Coalition to Reduce Health Care Costs zeroes in on “avoidable ED visits,” listing a focus on four levers for impact:

Employee engagement
Data and measurement
Multi-sector collaboration
Policy advocacy

We often focus on what works, and it seems notable that the Commonwealth has a range of data showing expanding access to a broader range of providers (by changing scope of practice laws and reimbursing more convenient types of care) seems highly likely to reduce “avoidable ED visits.” As more specificity is put forth by the coalition, time will tell whether their policy solutions match the problem.

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Proof Point: Addressing Social Determinants of Health Reduces ED and Hospital Visits, and Reduces Costs

By M2|2018-05-23T16:53:35+00:00May 23rd, 2018|Evidence-Based Medicine, Health Care Trends, Hospitals, Providers, Social Determinants of Health, Uncategorized, What do we pay for and why|

Proof Point: Addressing Social Determinants of Health Reduces ED and Hospital Visits, and Reduces Costs

Just a couple weeks ago, I about social determinants of health (SDH), so I was intrigued to come across this recent study in Health Affairs showing that improved access to care and a consideration of SDH can lower emergency room use and inpatient hospitalizations, and reduce costs.

A health clinic in Dallas, the Baylor Scott & White Health and Wellness Center (we’ve also highlighted before), partnered with the Dallas Parks and Recreation Department to create a primary care clinic in a rec center in an underserved Dallas community. The public-private partnership offers clinical services such as routine primary care, regardless of the person’s ability to pay. But it also offers access to other health-supporting interventions. For example, the partnership provides access to programs that help community members participate in physical activity and get healthy food.

Community health workers are also a component of the approach. Patients often need help navigating both the health care system and support programs, for example, free exercise classes at the rec center. Community health workers assist patients with that navigation in a culturally relevant way for the Dallas center. Local churches – more than 25 of them – provide an additional level of support by increasing awareness of the health clinic/rec center offerings and availability of community health workers.

The clinic “exemplifies the integration of social determinants of health within a population health strategy,” according to the study by David Wesson, President, Baylor Scott & White Health and Wellness Center, and his colleagues.

While increasing access to both clinical health care services and health-supporting programs, such as those offered by rec centers, is worthy goal on its own, to health policy wonks the added proof point of cost savings due to a population based approach that integrates SDH is just as exciting.

The study examined emergency department (ED) and inpatient care use for 12 months after initiation of the program. People who used the center’s services experienced a reduction in ED use of 21.4% and a reduction in inpatient care use of 36.7%, with an average cost decrease of 34.5% and 54.4%, respectively. All of these are notable proof points: “These data support the use of population health strategies to reduce the use of emergency services,” the authors conclude.

The Baylor Scott White/Dallas Recreation Center partnership is a great example of how improving access to health care and addressing the social determinants of health can have a positive impact on both health outcomes as well as costs, by reducing expensive types of care such as emergency and inpatient services. We are still building the evidence-base, but this study shows taking a holistic approach to patient care, including addressing the social determinants of health such as culture and language, can help achieve what everyone wants: improved health and lower costs.

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Want to Fix the Opioid Crisis? First, Think Structurally

By M2|2018-05-17T16:49:16+00:00May 17th, 2018|Chronic pain, Evidence-Based Medicine, Insurance, Public Health, Social Determinants of Health, Uncategorized, What do we pay for and why|

Want to Fix the Opioid Crisis? First, Think Structurally

I am often asked to come up with creative ways to address various health care problems. When I was asked by a client a few years ago to come up with some ideas to address the opioid crisis, I dove in to the latest academic literature, news reports, and books (if you haven’t read it yet, and are interested in the bigger picture of opioids, check out Dreamland by Sam Quinones). Thousands of pages later, I came to what seemed an obvious conclusion: opioid misuse and abuse is not a singular crisis, but the effect of a huge set of policy decisions that have occurred over years.

In a recent commentary in the American Journal of Public Health, author Nabarun Dasgupta of the University of North Carolina, Chapel Hill, and colleagues are blunt – “The structural and social determinants of health framework is widely understood to be critical in responding to public health challenges. Until we adopt this framework, we will continue to fail in our efforts to turn the tide of the opioid crisis.”

Using a structural framework to analyze causes of the opioid crisis generates “an alternate hypothesis…that an environment that increasingly promotes obesity coupled with widespread opioid use may be the underlying drivers of increasing White middle-class mortality,” the authors point out. “Complex interconnections between obesity, disability, chronic pain, depression, and substance use have not been adequately explored.” Also, suicides “may be undercounted among overdose deaths,” they say. “Under both frameworks, social distress is a likely upstream explanatory factor.”

In order to “turn the tide” on the opioid crisis, the authors urge a focus on patient suffering, tied to things like social disadvantage, isolation, and pain. However, one of the challenges is that the U.S. health care system is “unprepared to meet the demands elucidated by a structural factors analysis.”

Again, seems obvious, but still bears repeating: the health care delivery system is not built to deal with structural problems.

Addressing these types of factors requires “meaningful clinical attention that is difficult to deliver in high-throughput primary care.” Indeed, the current “institutional, legal, and insurance architecture have robbed clinicians of time and incentives to continue care for these patients,” the authors say.

Incorporating social determinants of health (SDH) into care plans also highlights the need to “integrate clinical care with efforts to improve patients’ structural environment,” the commentary says. While the commentary authors recommend, “Training health care providers in ‘structural competency’” as promising, as the system scales up “partnerships that begin to address upstream structural factors such as economic opportunity, social cohesion, racial disadvantage, and life satisfaction,” I’m not as inclined to think health provider training alone will suffice. When I was first taught the basic premises of SDH and structural thinking as a young graduate student, the discipline was already decades old.

Knowing the importance of SDH is not enough. Until the evidence base is deeper, it is difficult to get payers to reimburse such as activities. (See next week’s blog for a great example though!)

Thinking structurally is not so difficult to learn, but acting structurally is extremely difficult. Still, the opioid crisis – like so many health care conundrums – can’t be solved without it. Let’s get to it.

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Paying to Address Social Determinants of Health: Medicare Advantage to Offer “Supplemental Benefits”

By M2|2018-05-07T14:32:50+00:00May 4th, 2018|Health care spending, Health Care Trends, Medicare, Social Determinants of Health, Uncategorized, What do we pay for and why|

Paying to Address Social Determinants of Health: Medicare Advantage to Offer “Supplemental Benefits”

CMS recently announced it will change its policy regarding Medicare Advantage plans and the scope of “supplemental benefits” these plans may offer. As of the 2019 plan year, CMS says it is reinterpreting existing law and expanding the options that Medicare Advantage plans may offer to enrollees.

In the past, CMS has not allowed an item or service to be eligible as a supplemental benefit – an additional benefit beyond the standard benefits under traditional Medicare – “if the primary purpose includes daily maintenance,” the agency says.

However, in the 2019 final Call Letter for Medicare Advantage, CMS says the policy change will “expand the scope of the primarily health-related supplemental benefit standard” to allow benefits used to “diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization.”

Items and services under this expanded scope could include things like “air conditioners for people with asthma, healthy groceries, rides to medical appointments and home-delivered meals,” a recent article in Kaiser Health News notes.

Transportation, different food options, and items such as grab bars in bathrooms might be covered options now. While a physician’s order or prescription is not necessary, the new benefits must still be “medically appropriate” and recommended by a licensed health care provider.

While public health types (me included) often focus on explaining what a social determinant of health is and how it could be addressed in order to improve health equity, this policy change is significant in that it attaches payment to interventions – even if they are not clinical – that could lead to improved health.

Separately, the most recent federal budget agreement lifts the annual caps on the amount Medicare pays for physical, occupational, or speech therapy, and streamlines the medical review process. This policy change will apply to both traditional Medicare and Medicare Advantage enrollees.

As of Jan. 1, Medicare beneficiaries will be eligible for therapy indefinitely as long as their provider confirms their need for therapy and they continue to meet other requirements. Also, under a 2013 court settlement, enrollees will not lose coverage “simply because they have a chronic disease that doesn’t get better,” KHN says.

In an interview with KHN, Judith Stein, executive director, Center for Medicare Advocacy, said, “Put those two things together and it means that if the care is ordered by a doctor and it is medically necessary to have a skilled person provide the services to maintain the patient’s condition, prevent or slow decline, there is not an arbitrary limit on how long or how much Medicare will pay for that.”

These are innovative moves on CMS’s part; they show the agency recognizes the need for a more holistic approach to health care for Medicare enrollees and that it’s willing to address the social determinants of health, such as the impact of the home environment on a patient’s health.

CMS is now moving beyond purely “medical” treatments for Medicare Advantage enrollees and addressing broader aspects of health. We get what we pay for, and by covering different types of care, CMS is encouraging actions that may lead to improved health outcomes and avoidance of some preventable health events for patients.

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An Alternative to Opioids? Other Interventions Show Significant Improvements in Pain and Physical Function For Disadvantaged Populations

By M2|2018-04-10T19:27:24+00:00April 10th, 2018|Chronic pain, Evidence-Based Medicine, Health Disparities, Insurance, Social Determinants of Health, Uncategorized, What do we pay for and why|

An Alternative to Opioids? Other Interventions Show Significant Improvements in Pain and Physical Function For Disadvantaged Populations

Pain is a common, yet difficult to treat condition; it is one of the top reasons people go to the doctor. Opioids are commonly prescribed to treat pain; opioids are quite effective but addictive. The use of cognitive behavioral therapy (CBT) is known to be efficacious in addressing chronic pain; however, its benefit in disadvantaged populations is not well understood.

To help shed light on this question, a team led by Beverly Thorn, University of Alabama, conducted a study to evaluate the efficacy of literacy-adapted and simplified group CBT versus group pain education (EDU) versus usual care.

The randomized controlled trial enrolled 290 adults with chronic pain symptoms. Most had incomes at or below the poverty level, and about one-third read below a fifth grade level. Many participants were taking opioids at the beginning of the study.

Both the CBT and EDU were delivered in ten weekly 90-minute group sessions. Participants in all three groups reported their pain levels and physical functioning via questionnaires at baseline, ten weeks, and six months.

The study, funded by the Patient-Centered Outcomes Research Institute and published in the Annals of Internal Medicine, found that patients in the CBT and EDU groups had greater decreases in pain intensity scores between baseline and post-treatment than participants receiving usual care.

However, while treatment gains were still present in the EDU group at six-month follow-up, these gains were not maintained in the CBT group, Thorn, et al., say.

Regarding the secondary outcome of physical function, those in the CBT and EDU interventions had greater post-treatment improvement than patients who received usual care; this progress was maintained at six-month follow-up. Changes in depression, another secondary outcome, did not differ between either the CBT or EDU group and those receiving usual care, the researchers state.

This study highlights the fact that when done correctly, i.e., when materials are adjusted and tailored to a patient’s reading level, there are non-opioid interventions like behavioral therapy and education that work. While it is probably easier to prescribe opioids for pain, given the increasing severity of the opioid addiction epidemic, insurers really should consider these effective alternative treatments which positively impact pain. Why NOT prescribe effective, non-addictive treatment whenever possible?

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Interoperability – all that’s old is new again

By M2|2018-03-08T16:02:41+00:00March 7th, 2018|EHRs, Health Care Trends, Health Information Technology, Hospitals, Uncategorized, What do we pay for and why|

Interoperability – all that’s old is new again

For some of us in health care policy, 2018 so far is the year of testing just how good our filing systems are. All that is old is new again and ideas to “fix the U.S. health care system” from years ago are popping back up. This week “interoperability” is the hot topic, in part because Seema Verma, Administrator of the Centers for Medicare & Medicaid Services (CMS), made a big announcement at the Healthcare Information and Management Systems Society (HIMSS) annual conference, saying interoperability would again be a focus of the federal government. She made three big announcements really, but today we are focused on Verma’s announcement that CMS will be overhauling the “Electronic Health Record (EHR) Incentive Programs to refocus the programs on interoperability and to reduce the time and cost required of providers to comply with the programs’ requirements.” Not surprisingly, when she mentioned the burdens on health providers of meeting meaningful use requirements and that CMS would be changing those requirements, the full ballroom broke into applause.

Patients Should Control Their Data. Yes, but…

The CMS administrator also announced a new initiative, “MyHealthEData – to empower patients by giving them control of their healthcare data, and allowing it to follow them through their healthcare journey.” It may seem obvious that patients should have electronic access to, and full control of, their health records, but the government does seem to need to intervene in order to get this information released from government agencies and payers, as well as from private health insurers and providers. Susan Morse (@SusanJMorse), who covered the HIMSS Conference for Healthcare IT News, explains that part of the issue is hospitals involved in data blocking. Verma told conference goers CMS would be strengthening requirements for providers to stop the practice: “It’s not acceptable to limit patient records or prevent them from seeing their complete history outside of (that) health system,” she said.

Data blocking may not be the primary barrier to patient control of their health care data, however. The March 2018 American Hospital Association Trendwatch: Sharing Health Information for Treatment shows hospitals and health systems have rapidly improved electronic sharing of clinical/summary care records over the past several years as the AHA Trendwatch chart below shows.

Can (Will?) Health Providers Use Patient Data?

Interoperability at its core means information can move back and forth between the various entities that have it. That could be from provider to provider, from plan to provider, provider to patient, etc. The fact sheet explaining the Trump Administration MyHealthEData Initiative Putting Patients at the Center of the U.S. Healthcare System mentions one of the goals of the effort is:

“Reducing Duplicative Testing – Provider systems typically do not share patients’ data, which can lead to duplicative tests when a patient goes to see a different provider. This increases costs and can lead to patient inconvenience or even harm. CMS is studying the extent and impact of duplicate testing, and will identify ways to reduce the incidence of unnecessary duplicate testing.”

In a study published in 2010, (all that’s old is new again…) in the Journal of the American Medical Informatics Association titled, “A Preliminary Look at Duplicate Testing Associated With Lack of Electronic Health Record Interoperability For Transferred Patients,” found approximately 20% of patients had non-clinically indicated duplicate testing resulting in added costs to the system. The study authors continued, “The most common setting for duplicate testing identified in the current study happened on admission from an outpatient clinic site. Patients from outpatient clinic transfer to hospital admission via several paths, including entrance via hospital admitting services or directly to the inpatient ward, either escorted or unescorted by hospital clinical staff.”

However, while hospitals and health systems have improved their sharing of clinical summaries with outside entities, the same AHA Trendwatch shows much slower progress in integrating information from outside sources. As the chart (from AHA Trendwatch) below shows, 65% of hospitals and health systems are either not able or not routinely able to integrate external information electronically.

Giving patients access to all of their health care data electronically is no doubt important. However, it is not sufficient to improve care or reduce costs, even for something as simple as avoiding non-clinically indicated duplicate testing. Achieving interoperability will also require payment incentives to change. As this blog has pointed out in other instances, money matters and you avoid what you have to pay for. Electronic health data vendors can still charge providers for building interfaces that help disparate systems “talk” and can charge providers to move data. Keith Aldinger, MD, an internist who practices in Houston, Texas wrote for Medical Economics in late 2017, physicians have “been assessed financial penalties for not attesting to meaningful use and yet the IT industry gets a pass.” His idea for improving interoperability is to put health IT vendors on the hook: “They should not be allowed to charge one cent for transferring information and any attempt to do so should elicit a financial penalty.”

All that’s old is new again. We still have to figure out how to get health care data moving in ways that improve health care for patients. Interoperability, you’re hot again. Let’s hope you do better this time around.

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