What do we pay for and why

Both Patients and Hospitals Tend to Avoid Care that Costs More – One Health Plan in MA is Trying to Address This

By M2|2018-03-01T20:30:49+00:00March 1st, 2018|Evidence-Based Medicine, Health care spending, Health Plans, Hospitals, Insurance, Out-of-pocket spending, Uncategorized, What do we pay for and why|

Both Patients and Hospitals Tend to Avoid Care that Costs More – One Health Plan in MA is Trying to Address This

Despite evidence that cervical cancer is most effectively treated with brachytherapy (a form of radiation), Medicare reimbursement for a less effective treatment, external beam radiation, is higher, according to an article in Healthcare Finance News. Additionally, the delivery costs of brachytherapy in hospitals is greater than for external beam radiation.

The lower cost of delivery combined with higher Medicare reimbursement means external beam radiation is four times more profitable than brachytherapy for a hospital – despite being the less effective treatment.

The study by Kristine Bauer-Nilsen, University of Virginia School of Medicine, et al., published in Radiation Oncology, evaluated the delivery costs, using time-driven activity-based costing, and reimbursement for definitive radiation therapy for locally advanced cervical cancer.

Brachytherapy for locally advanced cervical cancer “ends up costing hospitals money because it takes 80-plus percent more physician personnel time to administer brachytherapy than it does to deliver the increasingly popular external beam radiation,” the article says. Even though it costs more for hospitals to provide brachytherapy than it does to provide external-beam radiation, the reimbursement doesn’t reflect the difference. Which in turn means, “the comparatively poor reimbursement rates may mean some hospitals simply don’t offer brachytherapy or commit physician time to it” as Jeff Lagasse, the author of the Healthcare Finance News piece succinctly concludes.

Businesses naturally do the things that pay them more. This study highlights how reimbursement has to change before health providers will change. “Value based care,” envisioned by policymakers mean the system as a whole only pays for health interventions that are valuable. But what is of value to the system is different than what is of value to a health care business, for example, a hospital or physician group.

Similarly, what a patient values, might be different from every other entity in the health care system. Just as financial incentives may drive hospitals’ choice of therapies, they also affect patients’ decision making when it comes to managing chronic conditions. Now, a health plan in Massachusetts is aiming to remove the financial incentives that lead patients to avoid needed care. In order to incentivize patients to “manage their conditions optimally and proactively,” Neighborhood Health Plan (NHP) is waiving out-of-pocket costs for chronic conditions.

The new comprehensive benefit design, called Care Complement, eliminates copays for 11 common prescription medications that treat conditions like high cholesterol, diabetes, high blood pressure, heart disease, and depression. The program also waives cost sharing associated with cardiac rehabilitation therapy and screenings to prevent diabetes complications, according to a recent AHIP (America’s Health Insurance Plans) blog.

“With certain chronic conditions, such as diabetes, there are often many recommended services to fully control the condition and reduce the risk of complications,” Dr. Anton Dodek, chief medical officer at NHP, says in the blog. “For diabetes, these recommendations include an annual routine eye exam, diabetic education, and nutritional counseling. Each of these office visits typically require a co-payment from the member, and can create a barrier to receiving care.”

The program also offers “affordable alternatives to opioids for chronic pain.” For example, it waives cost-sharing for medication-assisted therapies (MAT), as well as expenses for recovery coaches. And it gives physicians the resources needed to “help determine if their patients would benefit from alternative pain management treatments, such as physical therapy/occupational therapy sessions, chiropractic visits, and acupuncture visits.”

“By eliminating cost sharing, we hope that members will be encouraged to work with their doctors to manage their conditions optimally and proactively, which will result in healthier outcomes in the long run,” Dr. Dodek says.

Neighborhood Health Plan’s approach is exactly the kind of approach that we need more of; by adjusting financial incentives for patients to choose the most “valued” care for their chronic conditions, this plan is moving beyond looking at short-term costs, and instead is looking at the big picture. By helping patients with what they value – lower costs and higher quality – the health plan is likely to improve health outcomes in the long term.

Value based payment is harder than it looks. These examples shed light on what doesn’t work, and what does. Policymakers need to both copy success, and halt failure if they want to bend the cost curve.

0

Rising obesity rates indicate the need for improved insurance coverage of proven effective treatment options, both medical and surgical

By M2|2018-02-21T15:54:35+00:00February 21st, 2018|Health Care Trends, Health Plans, Insurance, Reimbursement, Uncategorized, What do we pay for and why|

Rising obesity rates indicate the need for improved insurance coverage of proven effective treatment options, both medical and surgical

Mortality improvements in the U.S. have declined relative to other wealthy countries, and a new study points to obesity as the culprit.

“Rising levels of body mass index [BMI] have prevented the United States from enjoying the full benefits of factors working to improve mortality,” according to study author Samuel Preston, professor of sociology at the University of Pennsylvania, et al. The study is published in the Proceedings of the National Academy of Sciences, as noted in a recent article in HealthDay.

In addition, according to the article, rising BMI has “reduced the annual rate of improvement in U.S. death rates between 1988 and 2011 by more than half a percentage point—equivalent to a 23% relative reduction in the rate of mortality decline—a large amount by international standards.”

“Heart disease deaths had declined consistently for nearly 40 years,” the article notes. “These declines have slowed or stopped altogether” and “rates of decline in cancer deaths have also slowed,” the article says. “At the same time, rates of obesity have been rising in the United States. From 1976 to 1980, 15 percent of Americans were obese. By 2014, 38 percent of Americans were classified as obese.”

The study’s researchers evaluated how much of the change in the death rate trend could be explained by rising BMI, and found that the increase in BMI reduced life expectancy by 0.9 years, almost 11 months, at age 40, and accounted for 186,000 excess deaths in 2011.

Despite rising obesity rates, another new study finds that many obese patients are not receiving antiobesity medications – and patients who are being prescribed medicines may be getting them because of provider bias. 80 percent are women, although obesity rates are similar for men and women in the U.S.

Fewer than 1 in 50 people in the U.S. eligible for antiobesity medications are receiving them, according to an evaluation of electronic records conducted by University of Colorado endocrinologist David Saxon, MD. Patients above a specific BMI threshold are eligible for weight-loss medication, but only 1.3% had received any prescription from 2009 to 2015, a recent Medscape article notes.

In addition, among patients who had received a prescription, 85% of the prescriptions were for phentermine, as opposed to newer agents. Primary care providers were most likely to prescribe these drugs.

Patients want “more information from their physicians about these medication options but there’s rarely the conversation,” Saxon says in the article. “Patients are probably more interested in them than the 1.3% who are receiving them.”

My friend and colleague, Scott Kahan, MD, is the director of the National Center for Weight and Wellness, and the medical director of Strategies To Overcome and Prevent (STOP) Obesity Alliance at George Washington University. Kahan explains that physicians historically have received little training in obesity management, and may hold misperceptions about obesity medications, including that they are unsafe, ineffective, or not well-studied.

“These misconceptions are likely a legacy of older medications that had lesser requirements for approval and were likely misused,” Kahan says. Another issue is lack of insurance coverage.

Yet another successful obesity treatment option is surgery. Two recent studies published in the Journal of the American Medical Association (JAMA) compared Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy in morbidly obese patients.

First, researchers at St. Claraspital in Basel, Switzerland, conducted a randomized trial of morbidly obese patients to determine whether there are differences between the two surgical options, in terms of weight loss, changes in comorbidities, increase in quality of life, and adverse events, as noted in an article in The Clinical Advisor. Excess BMI loss was not significantly different at 5 years: 61.1%, with sleeve gastrectomy vs 68.3% with RYGB.

In the second study, researchers in Finland also studied morbidly obese patients to examine the clinical equivalence of the two surgeries. The trial found the estimated mean percentage excess weight loss at 5 years was 49% with sleeve gastrectomy and 57% with RYGB, with no statistically significant difference in quality of life between groups and no treatment-related mortality. At 5 years, the overall morbidity rate was 19% and 26%.

In an accompanying editorial, David Arterburn, MD, MPH, and Anirban Gupta, MD, state that “these and other studies suggest that sleeve gastrectomy and bypass are overall quite similar in terms of their effects on weight and comorbid conditions through 5 years.” They also note that “these procedures may be associated with improved long-term survival compared with usual medical care. Overall, it seems that both procedures are excellent options for surgeons and patients to consider in the treatment of obesity.”

With the slowing gains in life expectancy in the US linked to obesity, patients need their insurance plans to cover effective treatment options. If these options are going to be accessible for patients, insurers will need to have reasonable coverage and reimbursement policies in place; today, with FDA-approved drugs available to treat obesity and promising research showing that the sleeve and bypass surgeries are two excellent options, we need policies that encourage use of both drug and surgical approaches.

0

Innovation Series, Part 2: App for Substance Abuse Disorders

By M2|2018-01-10T22:28:15+00:00January 10th, 2018|Health Care Trends, Innovation, Uncategorized, What do we pay for and why|

Scientific Breakthroughs: From Gene Therapy to Creative New Approaches to Cancer Surgery, Patients Stand to Benefit Dramatically, But How Will We Pay For This Innovation?

Innovation Series, Part 2: App for Substance Abuse Disorders

From gene therapy to a “pen” that can detect cancerous tissue in 10 seconds, we live in a time of amazing scientific breakthroughs. Advances in technology and our understanding of the genetic basis of disease are resulting in a range of innovations that hold the promise of improving our approaches to treatment – including things like new treatment options for rare diseases and innovations that are more consumer friendly.

Last year, for example, the U.S. Food and Drug Administration (FDA) approved for marketing the first mobile application to help treat substance use disorders. Yes, there’s an app for that! Cognitive behavioral therapy (CBT) is a kind of talk therapy that is a proven treatment for a number of mental health and substance abuse disorders. The newly approved app, developed by Pear Therapeutics, essentially makes CBT digital. The app, called reSET®, is designed to be used in conjunction with counseling and would be prescribed as appropriate by a health care provider.

Digital therapeutics are a hot space for health care start-ups and Pear Technologies is leading the way. Founder and CEO of the company, Corey McCann told CNBC, “This is the moment for digital therapeutics.” While not yet available for sale in the U.S., the clinical data that led to FDA approval is promising. The trial included more than 500 patients with substance use disorder (SUD) over a 12-week period. The randomized trial compared intensive face-to-face counseling – a standard treatment for SUD – to reSET® combined with a reduced amount of face-to-face counseling. Of the patients using reSET® who were dependent on stimulants, marijuana, cocaine, or alcohol, nearly 60% were abstinent at the end of the study period, while just 30% of patients who received only the face-to-face counseling were abstinent.

Of note, data from the clinical studies indicated no side effects from the device. If a prescription digital therapy improves patient outcomes and has few or no side effects, should it be reimbursed at a higher rate than a competing intervention that is safe but has more side effects for the patient? Meeting the patient where she or he is seems obvious, and prescription digital therapeutics are another great example of innovation that is consumer-focused.

What do all of these new and potentially lifesaving innovations mean for the health care system? As with any innovation that offers new hope for patients, there will likely be high demand, but that will have to be considered in the context of limited resources. We are witnessing significant new innovations and scientific advancement; the usual questions of access and how to pay for it will be dramatically amplified in this modern era, given the unprecedented price tags.

0

Scientific Breakthroughs: From Gene Therapy to Creative New Approaches to Cancer Surgery, Patients Stand to Benefit Dramatically, But How Will We Pay For This Innovation?

By M2|2018-01-03T21:04:29+00:00January 3rd, 2018|Health Reform, Innovation, Reimbursement, Uncategorized, What do we pay for and why|

Innovation Series: Gene Therapy

Scientific Breakthroughs: From Gene Therapy to Creative New Approaches to Cancer Surgery, Patients Stand to Benefit Dramatically, But How Will We Pay For This Innovation?

From gene therapy to a “pen” that can detect cancerous tissue in 10 seconds, we live in a time of amazing scientific breakthroughs. Advances in technology and our understanding of the genetic basis of disease are resulting in a range of innovations that hold the promise of improving our approaches to treatment – including things like new treatment options for rare diseases and improving the likelihood of success of something like cancer surgery. As we kick off 2018, I wonder what great new innovations the year will bring?

As just one example of innovation, consider the field of gene therapy: early last year the FDA approved the first gene therapy, Novartis’ Kymriah (tisagenlecleucel)‎, bringing “hope to the 3,100 people under the age of 20 in the United States who are diagnosed each year with acute lymphoblastic leukemia,” as the pharmacy benefit manager (PBM) Express Scripts describes in a recent post on its web site. Kymriah is “customized for each individual, using genetically modified versions of the patient’s own immune cells to target and kill leukemia cells.”

Gene therapies “are administered once, unlike nearly all other medications that are repeatedly taken over time,” Express Scripts notes. “And therein lies the challenge.”

The promise of gene therapy comes with a “dramatically higher price;” for example, Kymriah is priced at $475,000. Not only is this price significantly higher than more traditional types of drugs – it’s also much higher than other specialty drugs, the PBM says.

Paying for these types of breakthroughs will present challenges. “Pharmaceutical companies have a single opportunity per patient to get paid,” and “many gene therapies target extremely rare diseases, so there aren’t many patients to share the cost drug makers require to justify the expense of research, development and commercialization. The result is very high price tags,” Express Scripts says.

“The health care system isn’t set up for this type of economic model. Thus, making these therapies available to patients “requires novel collaboration,” the company says. A “new payment model” is needed, and Express Scripts is working with drug companies, policymakers, patient groups and payers on “innovative approaches to make gene therapies accessible for patients.”

For example, value-based contracting can “ensure that payers and patients aren’t on the hook when a treatment isn’t effective. Consultations involving pharma companies and payers can help set appropriate prices.” And “discussions with policymakers can help set an appropriate regulatory framework.”

“Ultimately…gene therapies will require payment and patient care systems which are as novel as the medications themselves,” Express Scripts says. “Ideas on the table include paying for a treatment over time, establishing insurer risk pools and financing one-time payments. A successful model must address patients who change insurers or employers, and tracking their health outcomes over time to ensure payments aren’t being made if the treatment stops being effective.”

What do all of these new and potentially lifesaving innovations mean for the health care system? As with any innovation that offers new hope for patients, there will likely be high demand, but that will have to be considered in the context of limited resources. We are witnessing significant new innovations and scientific advancement; the usual questions of access and how to pay for it will be dramatically amplified in this modern era, given the unprecedented price tags. Particularly in the case of gene therapy, this may require new types of conversations and collaborations between drug developers, payers and patients, along with new payment approaches.

0

Policy Making from a Chinese Menu

By M2|2017-11-28T01:59:48+00:00November 27th, 2017|Health care spending, Health Reform, Uncategorized, What do we pay for and why|

Policy Making from a Chinese Menu

The dueling Congressional tax plans are the latest exhibit in policy making by Chinese menu. Instead of thinking through issues and starting with the core question of: What problem are we trying to solve? –both the House and Senate have engaged in choosing their favorite items from a menu with no coherent point of view about why those singular items might come together to form a whole policy.

Merriam-Webster dictionary defines policy as “a definite course or method of action selected from among alternatives and in light of given conditions to guide and determine present and future decisions.” Choosing eggrolls, spicy kung pao chicken, house fried rice, and vegetable lo-mein for dinner is a definite course of action from among alternatives in light of the given condition that you are hungry. It might even guide future decisions not to have Chinese food for a couple days because you are ready to move on to steak or spaghetti.

I was formally trained in philosophy and debate. Clients engage my firm to think through policy issues. I’m essentially paid to argue, but not like a lawyer, more like a philosopher. We are well aware of the trade-offs policy decisions entail. Argumentation is the art of thinking through those trade-offs. The stasis theory is ingrained in my thinking and approach to issues, even now as I work with corporate clients on business issues and run my own business. Developed by the Ancient Greeks, honed by the Romans, and used for centuries hence, the four core questions of stasis theory are those most of us were taught regarding how to think about problems.

When faced with an issue, we ask: First, what are the facts, or, is there really a problem? Second, what kind of problem is it? Third, how serious is this problem, who is affected, what are the costs of solving the problem? Fourth, and finally, we ask, should we take action, who should we include in solving the problem, and what needs to happen to solve the problem?

As you can see with the fourth question, policy questions often begin with a “should” – at least in concept. Should local tax dollars be used to build parks? Should individuals be required to have automobile insurance? How should free speech be weighed against public safety? There is a method being used to determine present and future decisions. Stepping through the core questions of the stasis theory helps us as individuals, communities, and as a society think about alternatives to solving a problem, and be clear-minded about what we are not choosing, as much as what we are choosing to do.

When the government is involved, it is essential that reasoning for choices is clear. Lawrence O. Gostin, a Professor at Georgetown Law, explains, “government should justify interventions because, almost invariably, they intrude on individual rights and interests and incur economic costs.”

Commentators and tax experts are writing and speaking about the winners and losers in the tax cut passed by the House this week and the Senate bill under consideration, so if you are following the issue, you have a pretty good idea of what is in the proposals. What we have very little idea of is why. Is there really a problem? What kind of problem is it?

Will lowering the corporate tax rate for large companies fix this problem? Will raising the tax rate for small businesses who are accountants, dentists, or consultants fix this problem? Is raising the deficit an acceptable cost of solving the problem?

During this holiday season, as families and friends gather, I would ask anyone who is willing to engage in a discussion that asks as many of the four questions above as possible. Like the health bills that passed, but eventually failed to become law earlier this year, the tax proposals before us are a result of Chinese menu-style policy making. A definite course of action is being selected, but without much input or thoughtfulness about what problems we are trying to solve, the costs of solving the problem, and whether the solutions will actually work.

If we want coherent policy, that is, policy that addresses a clearly defined problem and is likely to produce the desired outcome, we need to discuss amongst ourselves, and then engage with our representatives. We elected them but they still need to know how we want them to solve these problems. Discuss, argue, engage – better policy is on us.

0

Anthem Steers Members Away from Hospitals for MRIs, CT Scans, in Favor of Freestanding Facilities

By M2|2017-11-12T22:41:42+00:00November 10th, 2017|Health care spending, Hospitals, Insurance, Uncategorized, What do we pay for and why|

Anthem Steers Members Away from Hospitals for MRIs, CT Scans, in Favor of Freestanding Facilities

Anthem is expanding its recently launched program that cuts hospital outpatient payments for MRIs and CT scans in order to steer patients toward freestanding facilities that provide these imaging services at lower cost. The program began in July with four states, and is now growing to include a total of nine states, including Colorado, New York, and Ohio.

Under its Imaging Clinical Site of Care program, Anthem no longer pays hospitals in the affected states for outpatient imaging services for MRIs or CT scans. Imaging is a large part of hospital revenue, and Anthem said it costs more to have the service done in a hospital outpatient setting than at a freestanding facility, according to a recent article in Healthcare Finance.

According to Anthem, imaging services can be just as safely provided in a lower cost, free-standing center as in a hospital outpatient setting. The cost for MRIs and CT scans can vary from $350 to $2,000 as Anthem noted when it began educating members about their options related to imaging services in 2010.

Anthem is willing to share the cost-savings with its members. In cases where it is not medically necessary to receive services from a hospital, consumers who go to a freestanding facility can save close to $1,000 out-of-pocket for some imaging services for those who have not met their deductible, and up to $200 for those whose plans require only a copay, the article notes, based on Anthem data.

Helping patients understand cost differences and sharing savings from changing the site of care is important as a recent report in Health Affairs, notes many consumers do not make any attempt to compare prices for health care services. “Most survey respondents said they didn’t comparison shop or even ask how much they would owe in copayments or other cost-sharing expenses before they turned up for an appointment.”

With a large insurer such as Anthem leading the way, other private insurers may follow suit on reimbursement for imaging services. “Hospitals need to recognize they are competing in a market already delivering on convenience, quality and affordability,” Anthem spokesperson Lori McLaughlin said.

Similar moves have been made on the public payer side as well.

Under Medicare, procedures performed in the hospital outpatient department are paid at a higher rate under the hospital outpatient prospective payment system compared to freestanding clinics, which are paid on the Medicare physician fee schedule. In July 2017, the Centers for Medicare & Medicaid (CMS) said it plans to continue implementing reductions to the outpatient prospective payment system spending in CY 2018, as it had begun in CY 2017. CMS estimated it would save approximately $500 million in 2017 by reimbursing services provided at certain outpatient provider-based departments at 50% of the Outpatient Prospective Payment System; this percentage is proposed to change to 25% in CY 2018.

This is a great example of the kind of approach that’s needed to lower health care costs. As I’ve noted in prior blogs (for example, here), we get what we pay for. If we want to move the needle on costs, we need a lot more of this type of approach, incentivizing patients to take advantage of lower cost, high quality alternatives to the way things have traditionally been done.

0

Employers sending patients to top-performing providers with bargain prices for routine surgeries

By M2|2017-11-01T19:11:22+00:00October 31st, 2017|Health care spending, Hospitals, Uncategorized, What do we pay for and why|

Employers sending patients to top-performing providers with bargain prices for routine surgeries

In the face of high hospital bills, lack of local competition, and wild variations in surgical costs among different providers, some employers are responding by steering patients toward high-quality, bargain-priced providers. While this is happening primarily among some large private employers, a “handful” of public employers are also taking these steps, according to a recent article in Kaiser Health News.

Employers are striking deals for bundled payments for routine surgeries, with one fixed price covering tests, physician fees, and hospital charges; in some cases, the best-quality, lowest-cost provider is out of town. In addition, the providers are on the hook financially if any complications arise, the article notes.

Cost is not the only factor; the company also makes its choices based on quality, including data on complications and readmissions. “Not all surgeons are equal,” Carrum CEO Sachin Jain says in the article.

As an example, the article notes that Santa Barbara County is among about 400 employers on the west coast working with Carrum Health, a company that negotiates the bundled prices.

While the Santa Barbara County bundled payment program is voluntary for covered employees, the county has saved “nearly 50 percent on four surgery cases” since starting its program last year, the article says.

The article profiles one patient who received an all-expenses-paid trip to a luxury resort, over a thousand dollars in spending money, and a personal concierge during her stay in San Diego. The county provides further incentives to covered employees to participate in the program by waiving copays and deductibles.

However, “it was money well spent,” the article notes. Sending the patient 250 miles away for knee replacement surgery saved Santa Barbara County $30,000.

“If that doesn’t speak to the inefficiencies in our health care system, I don’t know what does,” Andreas Pyper, assistant director of human resources for Santa Barbara County, says in the piece. “It’s almost like buying a Toyota Corolla for $50,000 and then going to San Diego to buy the same Corolla for $16,000. How long would the more expensive Toyota dealership last?”

Some companies have gone so far as to send patients overseas for cheaper care, but most employers favor a more regional approach, according to the article. Local physicians are still relied upon for follow-up care.

For some hospitals, the advantages of offering deep discounts include that “they get patients they otherwise would never see and are paid in full right after the patient is discharged, avoiding the onerous billing and collections process,” the article says.

Some hospitals also have the financial capacity to offer such sharply reduced prices; “most hospitals significantly mark up their commercial rates for orthopedic procedures and cardiac surgeries to compensate for lower government reimbursements,” Michael Bark, assistant vice president of payer relations at Scripps Health, an integrated health system, says.

This is another great example of how it is possible to drive lower-cost, higher-quality care. We need more leaders, whether payers or employers, to take these kinds of steps to reimburse for increased value in health care services. As I’ve said in previous blogs such as , we get what we pay for; the more we direct our reimbursement dollars toward high-value care, the more we’ll get. The interesting thing in this case is that it’s employers who are demanding high value; with 50% of Americans receiving their insurance through their employers, if employers start demanding this type of approach, we might see change.

0

Patients Like It and Physicians are Interested – Why Isn’t Telehealth Flourishing?

By M2|2017-10-08T11:39:21+00:00June 21st, 2017|Health Care Trends, telehealth, Uncategorized, What do we pay for and why|

Patients Like It and Physicians are Interested – Why Isn’t Telehealth Flourishing?

Most people don’t really like going to the doctor. But at least some studies are showing people are more comfortable when the “going to” part of seeing a doctor is taken out of the equation.

Telehealth is defined as the use of medical information exchanged from one location to another via electronic communications to improve a patient’s health.

So how do patients view telehealth? In a recent study of patient experiences following video visits with their primary care physicians, all 19 patients interviewed reported overall satisfaction with the video visits. Most reported being interested in continuing use of video visits as an alternative to in-person visits.

Convenience and decreased costs were the main benefits cited. Some of the patients reported feeling more comfortable with video visits and preferred to receive serious news via video visits, as they could be “in their own supportive environment.”

But are physicians routinely offering telehealth visits to their patients?

In family practice, the answer is no; only 15% of family physicians had used telehealth services during 2014, according to a recent study published in the Journal of the American Board of Family Medicine.

Physician telehealth users differed from nonusers in many ways. They were more likely to be located in a rural setting (26 percent vs. 15 percent), to use an electronic health record (97 percent vs. 92 percent), and to work in a practice with at least 6 family physicians (40 percent vs. 29 percent). In addition, telehealth users were less likely to work in a privately owned practice and to provide general primary care to their patients.

Physician telehealth users were also less likely to report at least one barrier to providing telehealth services in their office than nonusers. Lack of training and reimbursement were the most common barriers identified by both users and nonusers.

“If telehealth services are to have a major impact in the primary care setting, more physicians will need to become experienced in the use of these services,” the authors conclude, noting that many of the barriers to wider adoption “are amenable to policy modifications.”

“One suggestion for overcoming the training barrier is for family medicine residency programs to ensure that graduating residents are offered opportunities to use telehealth services. To address issues of reimbursement, governmental and private payers could engage in outreach efforts to increase awareness of their current allowed payments for telehealth and either expand the types of telehealth services currently eligible for payment or develop new ways to reimburse telehealth services,” the authors say.

The bottom line is that “uptake in the United States has occurred most rapidly where reimbursement is favorable,” according to the authors of recent study in The Annals of Family Medicine. Notably, Medicare reimburses for telehealth specifically in areas where there are health care professional shortages and for specific approved services, the study says.

As far as patient preferences, the study participants “repeatedly cited reduced costs as an important benefit of video visits,” the authors note.

As part of a pilot program evaluated in this study, patients were not required to pay a co-pay for their video visits. “While this likely contributed to participants’ opinions of the cost benefits, patients also noted that they saved transportation costs and were absent from work for less time,” the authors say.

“Further work is needed to identify the full range of patient cost considerations related to telehealth, they state. “Cost issues have important implications for practices and health systems incorporating telehealth into care models, as they are likely to impact patient satisfaction and uptake of virtual services.”

If it is cheaper to the patient, and it provides high-quality care that the patient is satisfied with, why wouldn’t we reimburse for it?

0

Are we giving the wrong advice on fitness and obesity?

By M2|2017-10-08T11:51:04+00:00June 2nd, 2017|Uncategorized, What do we pay for and why|

Are we giving the wrong advice on fitness and obesity?

What if there was a health care intervention that could save the U.S. health care system more than $300 billion? It would at least be worth hearing about, right?

Researchers estimate that obesity raises annual medical costs by more than $3,500 per obese individual. Thus, public health professionals and policy makers have sought to lower obesity rates.

The real issue is that obesity is a significant risk factor for expensive and life-threatening diseases, such as diabetes and cardiovascular disease. Heart disease is the #1 cause of death in the U.S. for both men and women, and more than half of the deaths due to heart disease are men, according to statistics issued by the CDC. Heart disease deaths vary by geography though. As this map shows, from 2008-2010, death rates due to heart disease were highest in the South and lowest in the West.

Source: CDC

There are many common risk factors for heart disease. For example, high blood pressure, high cholesterol, and smoking are key risk factors for heart disease. About half of Americans (47%) have at least one of these three risk factors, the CDC says. Several other medical conditions and lifestyle choices can also put people at a higher risk for heart disease, including:

• Diabetes
• Overweight and obesity
• Poor diet
• Physical inactivity
• Excessive alcohol use

This means that most public health education is generalized to say things like “You should improve your lifestyle,” in order to decrease your risk for the #1 killer – heart disease.

However, new research says the advice should be much more specific.

“I think one of the reasons for failure of public health initiatives in modifying lifestyle behavior is giving a blanket message of improving lifestyle, which includes healthy eating, exercising, not smoking, and a bunch of other factors,” Ambarish Pandey, University of Texas Southwestern Medical Center, Dallas told Medscape.

In a study published in JACC: Heart Failure in April 2017, Pandey and colleagues evaluated nearly 20,000 people for more than six years; as expected, they found that people who were overweight or obese were more likely to have the traditional cardiovascular disease risk factors noted above. These individuals were also likely to have lower cardiorespiratory fitness (CRF).

The researchers also found that CRF accounted for 47% of the risk of heart-failure hospitalization associated with increased BMI. “These findings highlight the importance of CRF in mediating BMI-associated heart failure risk,” they conclude.

“I think our study shows that we could target low fitness and exercise more aggressively and more tactically than BMI or body weight and encourage people to exercise more,” Pandey said. “Obviously a higher BMI is bad and lower BMI is better, at least at the normal range, but I think focusing more on fitness and exercise and focusing more on the level of physical activity may be the greater goal in the near future to better improve the risk of cardiovascular diseases.”

Of course, there are many problems with reducing cardiovascular risk by advising people to exercise more, and maybe even helping them do so, not the least of which is that it is not a medical intervention. In other words, no physician or other health care provider gets paid to recommend it.

Who should pay to help people exercise more? Should employers pay for your gym membership or P90X® workout videos? When a person moves from a low level of fitness to a moderate level of fitness – which is the most beneficial in terms of reducing cardiovascular risk – who should get credit in a world moving to value-based payment?

Changing what we pay for in health care will in turn change what interventions are delivered.

That is much more easily said than done, however, if interventions that work are not delivered by the medical professionals who get paid by health insurers or other third-party payers, such as federal and state governments.

Another solution would be to pay physicians to conduct these interventions. Why shouldn’t a medical professional get paid to do what works?

0

Light Health Care Users: Most Americans Use Few Health Care Resources and Have Low Out-of-Pocket Spending

By M2|2017-10-09T01:49:05+00:00May 23rd, 2017|Health care spending, Health Care Trends, Insurance, Out-of-pocket spending, Uncategorized, What do we pay for and why|

Light Health Care Users: Most Americans Use Few Health Care Resources and Have Low Out-of-Pocket Spending

Every day we read news coverage focused on rapidly rising health care costs, but a seldom-reported part of the story is how very few people are responsible for those costs.

A study of health care costs from 1977 to 2014 shows that over the length of the study period, the top 1 percent of the health care using population consistently cost the system more than the bottom 75 percent. Just 1 percent of the population, in fact, accounts for nearly a third of medical spending.

The study, published in the April 2017 issue of Health Affairs, finds that “most Americans use few health care resources and have low out-of-pocket spending.”

In addition, more than 93 percent of these light spenders (those in the bottom half of the population) believe they have received “all needed care in a timely manner,” and the light spending by the majority of the population “has remained almost unchanged during the thirty-seven-year period.”

This light spending has also remained “unchanged since the inception of the Affordable Care Act (ACA),” as a Medscape article on the study notes.

These findings matter because most health care policy discussions focus on spending at the population level – in other words, on the 1 to 5% of the U.S. population that incurs significant medical costs. That isn’t how individuals think of health spending, however. Most of us think of what we as individuals, or perhaps our family, spends on health care.

Insurance, by design, must include many non-users, so to speak, in order to work. Most of us buy home insurance or car insurance and never use it. That is, we make payments to an insurer in the form of premiums, but we typically don’t have car accidents and don’t have house break-ins or fires. Similarly, most people don’t have much in the way of medical spending.

But if too many light spenders don’t buy insurance, the price of insurance increases for everyone. And in fact, that is what happens.

This chart from the April 2017 Health Affairs article shows that the highest spenders are the most likely to be on public insurance – think Medicaid for the severely disabled – and light spenders are the most likely to be uninsured – they don’t think they need it, and they probably don’t for years and years – until something catastrophic happens.

In terms of out-of-pocket spending, for light spenders in 2014 this figure was just $75 on average, which is less than the $94 (in adjusted 2014 dollars) spent in 1977, the authors find. On the other hand, high spenders averaged $1,096 in out-of-pocket costs. And 50% of light spenders had no spending at all (not including health insurance premiums, if they were insured), whereas only 6.1% of high spenders had none.

As we continue to think about how to improve or change health care insurance, delivery, and payment in the U.S., it is important to remember how few people actually interact with the health care system every year. Even for people buying health insurance, a large proportion of people spend little on actual health care services, and that has remained stable for decades.

This makes some complaints about the Affordable Care Act a little easier to understand. As the study explains, light spenders “as a group are unlikely to receive substantial short term benefits from the Affordable Care Act.”

The question is, what is insurance for? We probably shouldn’t design the entire U.S. health care system for people who don’t need care. But the subtle lines of who pays more, the sick or the well, the old or the young, are something we still need to work out.

0