Getting Patients to Think About Costs
By PAULINE W. CHEN, M.D.
A colleague and I recently got into a heated discussion over health care spending. It wasn’t that he disagreed with me about the need to rein in costs; but he said he was frustrated every time he tried to do so.
Earlier that week, for example, he had tried to avoid ordering a costly M.R.I. scan for a patient who had been suffering from headaches. After a thorough examination, my colleague was convinced the headaches were the result of stress.
But the patient was not.
“She wouldn’t leave until she got that M.R.I.,” my colleague said. Even after he had explained his conclusions several times, proposed a return visit in a month to reassess the situation and ran so far overtime that his office nurse knocked on the door to make sure nothing had gone awry, the patient continued to insist on getting the expensive study.
When my colleague finally invoked cost – telling the woman that while an M.R.I. might ferret out rare causes, it didn’t make sense to spend the enormous fee on something of such marginal benefit – the woman became belligerent. “She yelled that this was her head we were talking about,” he recalled. “And expensive tests like this were the reason she had health insurance.”
Face flushed, he paused to take a deep breath. “Yeah, I may be all for controlling costs,” he finally said. “But are our patients?”
According to a new study in the journal Health Affairs, his concern about patients may not be far off the mark.
A growing number of initiatives aimed at controlling spiraling health care costs have been championed in recent years, aiming to replace the current model in which doctors are reimbursed for every office visit, test or procedure performed. These programs range from pay-for-performance, where doctors can earn more money by meeting predetermined quality “goals” like controlling patients’ blood sugar or high blood pressure, to accountable care organizations, where clinicians and hospitals in partnership are paid a lump sum to cover all care.
Their uninspired monikers aside, all of these plans share one defining feature: doctors are to be the key agents of change. Whether linked with quality measures, bundled payments or satisfaction scores, it is the doctors’ behavior and choice of treatments that result in savings, goes the thinking.
Massachusetts waves off the Chicago Way as ObamaCare beckons
Imagine for a moment that you could take any one of your biggest debts — be it a home loan, credit card balance or student loan — and announce that (a.) you plan to never pay off this obligation, and (b.) you plan instead to have all of your neighbors dig into their own pockets and make good on this hefty IOU.
That’s essentially what the city of Chicago is considering as it hashes out a plan to potentially erase around $800 million in unfunded retiree health care liabilities. The vehicle that makes this potential trip possible is the Affordable Care Act, forever known as ObamaCare. The proverbial “neighbors” who could be left holding the bag are the nation’s taxpayers, from Boston to San Bernardino.
The prospect of a cash-strapped Chicago spreading its retiree health care liabilities thinner than a Downton Abbey plot is a disturbing scenario, given the hundreds of billions in additional unfunded liabilities owed by states, cities and towns throughout the country. Should Chicago go the easy route, it is foreseeable that most state and local governments would follow suit by effectively eliminating retiree health care benefits and pushing tens of thousands of former public workers into ObamaCare’s subsidized safety net. The hit to the national fisc would be astronomical.
Christie Says He’ll Take U.S. Money to Expand Medicaid
By KATE ZERNIKE
TRENTON — Gov. Chris Christie, one of the most strident Republican critics of President Obama’s health care overhaul, announced on Tuesday that he would accept federal money to expand the Medicaid program in New Jersey.
The expansion, which the governor described in his annual budget address to the Legislature, would provide health insurance to 104,000 of the poorest 1.3 million residents currently living without it, though some groups say the number could be higher.
Mr. Christie emphasized that it was a financial decision, not a philosophical shift; if New Jersey did not take the money, he said, the federal government would give it to other states.
“Let me be clear: I am no fan of the Affordable Care Act,” the governor said. “I think it is wrong for New Jersey and for America. I fought against it and believe, in the long run, it will not achieve what it promises. However, it is now the law of the land. I will make all my judgments as governor based on what is best for New Jerseyans.”
Mr. Christie’s budget speech, delivered less than a year before he will be up for re-election, at times sounded like a campaign pitch to the voters of this overwhelmingly Democratic state. Advocacy groups had lobbied hard for the Medicaid expansion, and Democrats in the Legislature applauded it.
But it also reflected Mr. Christie’s national ambitions and his continued push to present himself as a different kind of Republican — one who could teach Washington a thing or two about bipartisanship. He talked about how he had “turned Trenton upside down” in his first three years, ending what he described as the tax-and-spend ways of his Democratic predecessors. His proposed budget of $32.9 billion is an increase of about 4 percent over the one approved last year, but he emphasized that the state will spend less than it did in the 2008 fiscal year.
Accepting federal money for Medicaid, he said, would save the state $227 million in the fiscal year that begins in July. Earlier this month, the governor showed his opposition to the health care law when he declined to establish a state-run exchange to allow people to buy health insurance, insisting that the federal government would have to do it.
Our View: Federal health-care grant targets the right problem
The money to find new ways to pay for health care could change the system for the better.
Every once in a while, we get some good news from Washington.
That was certainly the case last week, when the LePage administration announced that Maine would be one of only six states to get a federal grant to implement new programs to lower health care costs through reforming the ways we pay for services.
Maine will receive $33 million over the next 3½ years to expand its experiment with payment reform, including accountable care organizations, group practices that receive incentives to improve their patients' health instead of simply being paid for tests and procedures.
The model is designed to lower costs and improve outcomes at the same time. That's exactly the right place for the state and federal governments to be directing their efforts.
With all the strong words and posturing from Augusta and Washington, it's easy to lose sight of the fact that both capitols are struggling with the same issue.
A few weeks before our long-awaited trip to Italy in 2011, my husband, Jim, received a disconcerting phone call about one of the results of his annual physical. Jim’s PSA, a blood test that screens for early-stage prostate cancer, had been rising over the past couple of years. His internist was becoming concerned, and he suggested that Jim get another PSA when he returned from Europe.
I didn’t think much about this while we were away. I assumed my healthy, youthful husband, in his early 60s, couldn’t possibly be one of the almost 2.5 million American men living with prostate cancer. So I was surprised when the PSA test Jim had after our trip showed a continued increase. With this latest information, Jim’s internist thought it was time for him to see a urologist.
We made an appointment and unknowingly entered into the contentious arena of how to respond to potentially worrisome prostate cancer tests.
Originally used to track the progress of cancer treatment, the PSA test is now widely used to detect possible signs of early-stage prostate cancer. But it is an imperfect tool — so imperfect, in fact, that recently the U.S. Preventive Services Task Force, which is charged with tracking medical practices and treatments, said the test should no longer be part of routine standard of care.The test does more harm, through unnecessary surgery, than good, the group said. The recommendation, which reversed the task force’s previous position, has been extremely controversial, with many urologists, cancer doctors and prostate cancer survivors decrying it, saying the PSA test had saved lives.
All of this, though, was well in the future. For now, all we knew was that his PSA was elevated. The question was what to do. In trying to answer that, we felt as though we’d fallen down a medical rabbit hole.
— — —
The medical consensus has been that if the PSA number is above 4.0 and this is confirmed in a second test, a biopsy should be done. Clinicians also get concerned when the PSA number rises too quickly; a two-point rise — say, from 1.5 to 3.5 over a two- or three-year period — can be a red flag. My husband fell into the latter category. But as the urologist took great pains to tell us, the rise could mean nothing. Some men who have prostate cancer fall below 4.0, and others whose number is above 4.0 do not have cancer.
We found the doctor’s realistic assessment of the PSA reassuring, and we were sure he wouldn’t recommend a biopsy unless Jim’s third PSA, done through the urologist’s own lab, showed an increase. When the result came back, Jim’s PSA number had stabilized, but the doctor nonetheless recommended a biopsy. When Jim asked why, the doctor expressed concern about the PSA numbers and thought that a biopsy was warranted.
Missed diagnoses common in the doctor’s office
Posted Feb. 26, 2013, at 9:42 a.m.
Missed or wrong diagnoses are common in primary care and may put some patients at risk of serious complications, according to a U.S. study.
Mistakes in surgery and medication prescribing have been at the center of patient safety efforts, but researchers whose findings appeared in JAMA Internal Medicine said less attention has been paid to missed diagnoses in the doctor’s office.
Because of how common they are, those errors may lead to more patient injuries and deaths than other mistakes, according to David Newman-Toker from Johns Hopkins University School of Medicine in Baltimore, who co-wrote a commentary on the study.
“We have every reason to believe that diagnostic errors are a major, major public health problem,” Newman-Toker told Reuters Health. “You’re really talking about at least 150,000 people per year, deaths or disabilities that are resulting from this problem.”
For the study, researchers used electronic health records to track 190 diagnostic errors made during primary care visits at one of two healthcare facilities. In each of those cases, the misdiagnosed patient was hospitalized or turned up back at the office or emergency room within two weeks.
The study team found the type of missed diagnosis varied widely. Pneumonia, heart failure, kidney failure and cancer each accounted for between five and seven percent of conditions doctors initially diagnosed as something else.
Most diagnostic errors could have caused moderate or severe harm to the patient, the researchers determined. Of the 190 patients with diagnostic errors, 36 could potentially have had serious permanent damage and 27 could have died.
One of the difficulties in making an accurate diagnosis is that certain common symptoms, such as stomach ache or shortness of breath, could be signs of a range of illnesses, both serious and not, researchers said.
“If you look at the types of chief complaints that these things occur with, they’re fairly common chief complaints,” said Hardeep Singh, who led the study at the Houston VA Health Services Research and Development Center of Excellence.
“If somebody would come in with mild shortness of breath and a little bit of cough, people would think you might have bronchitis, you might have phlegm… and lo and behold they would come back two days later with heart failure,” he told Reuters Health.
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