By Nancy R. Kressin and Joshua M. Atz
In the end, my friend the veterinarian counseled me (N.R.K.), the answer was probably steroids, regardless of the diagnosis for my cat’s vomiting and weight loss. And in the end, the answer for my symptoms of gastroesophageal reflux disease was omeprazole. Yet the diagnostic path for each case varied substantially, in cost, risk, and time, although ultimately, the suggested approach for each was similar—a reasonably inexpensive, easily available medication to address the symptoms. While I recognize there was an array of “rule outs” in the background of each situation (some of which I was not privy to in the discussions described below), why was it so hard for this patient/client to negotiate her way to obtaining enough, but not too much, information to address these symptoms?
Patients are increasingly being encouraged to take an active role in understanding their physician’s thinking about diagnostic testing, to express their own preferences, and potentially decline or postpone tests with
limited value or excessive risks or costs. Yet it remains exceedingly difficult for even the most informed patient to do so. Let’s start at the beginning, with one person’s experiences, to illustrate this challenge.
Results from a $3000 intestinal biopsy for my cat wouldn’t provide information that would change the course of therapy, said my friend (J.M.A.), since there were two possible causes—inflammatory bowel disease or cancer—and he knew I wouldn’t be inclined to seek chemotherapy for my cat if the diagnosis was cancer. When I countered with this perspective to the veterinarian caring for my cat at the tertiary care veterinary hospital, she agreed, although the biopsy had sounded much more crucial when she had originally mentioned it. What if I hadn’t had a veterinarian friend to call? How many others would have unquestioningly paid the money to learn more—without changing the treatment on the other end, while needlessly inflicting additional suffering on the animal? When a diagnosis can be made (or the symptoms relieved) with an empirical trial of (relatively cheap) medication, and the patient/client prefers or is open to a more conservative approach via watchful waiting, why pursue further diagnostic workup? It appears that the forces of overdiagnosis in veterinary academic medical centers are similar to those in human academic medical centers—the technology is available, it needs to be used to pay for itself, trainees are eager to do procedures to gain experience, and the push to learn more, and to avoid missing a diagnosis—even when it may ultimately make no difference in the patient’s care—is an impetus to further testing.
As for me, I was no stranger to GERD, but the increased pain I was experiencing did not respond to once-a- day omeprazole. I had heard I could double the dose, so I did, taking two pills together each day, also making all the recommended lifestyle and dietary changes possible. After a few days, still experiencing pain, I made an appointment at my primary care physician’s office. In the meantime I read the American Gastroenterological Association guidelines supporting twice-a-day omeprazole, which I initiated. Two days later, I was feeling somewhat better, but I kept my appointment anyway, wanting to make sure I was on the right track. The clinician recommended I undergo endoscopy immediately. When I asked if it wouldn’t make sense to delay it for a few days to see if the revised omeprazole dosing—which seemed to be helping—would solve my problem, she still urged me to have it as soon as possible. It was not clear to me what her concerns
were, as we did not discuss the small risk of serious disease. Having such information would have helped me better understand, or protest, the suggested urgency of the procedure. I did as recommended and underwent endoscopy that week. The result? Hiatal hernia. The recommended therapy? Continue the omeprazole.
The cost difference between the two paths was thousands of dollars—the price of the cat’s steroids (<$10) vs the out-of-pocket cost to me for an endoscopy ($394), $3,566 to my insurer, plus the loss of a day’s work for me, half a day for my husband to accompany me, and the risks I incurred in undergoing endoscopy. The informational difference—at least to me, in hindsight—was not worth this cash or time outlay.
Why was I unable to negotiate a more conservative and less costly path for my own care? How could I, as a patient, have combated the forces driving the rush to diagnosis, or garnered more support for an empirical trial of medication to alleviate my symptoms and potentially illuminate their cause? Although I am a health services researcher and medical school faculty member and am aware of the issue of overdiagnosis—enough to question whether I really needed endoscopy immediately, or whether a few more days of watchful waiting with the changed medication dosing might suffice—I deferred to the clinician’s knowledge and experience, and scheduled the test, knowing my insurance would “cover it.” Had I realized in that moment that even with this coverage, several hundred dollars of out-of-pocket expenditures were in the offing, I may have protested further, but I didn’t have that information until after I underwent the procedure and received the insurance company’s “explanation of benefits.” There had been no discussion of the cost of the procedure with the clinician.
But with my cat, buoyed by coaching from my veterinarian friend and the up-front knowledge of a several thousand dollar cash outlay, I not only explored the value of the diagnostic tests with the veterinarian, but ultimately found that she agreed that having a diagnosis wouldn’t change the therapy, in the end.
My friend said that as a veterinarian in a small general practice, he is constantly considering the cost, the concern of pet owners to minimize their pet’s suffering, and the likely value of diagnostic testing, in part because few clients obtain health insurance for their animals, and most veterinary bills are paid out of pocket. Recent calls for human patients to have more financial “skin in the game” (with regard to health insurance reform) suggest that when diagnostic workups with little or no marginal value in the end are suggested, patients will question their physicians, physicians will become more conservative in their recommended testing, and costs for unnecessary diagnoses will decline. I do not believe it will be that simple.
Until patients are educated and emboldened (as I was by my veterinarian friend’s education and coaching, and by the knowledge about the potential effects on my pocketbook) to question the value of further testing, and until human health care clinicians include discussions of value with their diagnostic recommendations, it is hard to foresee how we can make similar progress in human medicine. Patients may be fearful that there is something seriously wrong that needs to be identified as soon as possible, they are often deferential to their clinicians’ greater knowledge of the (potentially scary) possibilities, and some patients want to be sure that everything possible is done for them, without recognizing the potential harms of diagnostic tests themselves, the risks of overdiagnosis, or the sometimes limited value in knowing the cause of symptoms in determining the course of therapy. Welch has suggested that patients ask, “Why are you suggesting this test?” “What is the accuracy of this test?” and “What will we do if the test is positive?” These are excellent suggestions, but patients’ wherewithal to ask these questions in the time-pressured, nerve-wracking, or upsetting setting of the clinical encounter may be severely restricted, especially for those with limited health literacy, English proficiency, or confidence. Patients need real-time information to help them ask informed questions. One possibility is that clinicians could share this information proactively, as diagnostic tests are recommended. However, as a researcher who has tried, with limited success, to increase physician-patient communication, I recognize that there are many challenges to doing so.
The advent of the Patient Centered Outcomes Research Institute’s research program may help patients obtain answers to questions like “What are my options and what are the potential benefits and harms of those options?” Perhaps the American Board of Internal Medicine Foundation’s Choosing Wisely campaign (in partnership with Consumer Reports and several physician specialty associations), which has identified and described a number of screening and diagnostic tests that have marginal value and real risks in some cases, can better attune both physicians and patients to such questions.1 Teaching medical students to “celebrate restraint” may help trainees learn to practice in a way that conserves resources and lessens overdiagnosis.
Until we can simultaneously embolden and educate patients, enhance clinician-patient communication, and change clinical diagnostic practice patterns to be more conservative (where clinically appropriate), overdiagnosis and unnecessary diagnosis will continue, costing individual patients, insurers, and our society more than we should spend. Maybe veterinarians can offer some suggestions to help us get there.
Read More: http://jama.jamanetwork.com/article.aspx?articleid=1555136
By Atul Gawande
If Camden, New Jersey, becomes the first American community to lower its medical costs, it will have a murder to thank. At nine-fifty on a February night in 2001, a twenty-two-year-old black man was shot while driving his Ford Taurus station wagon through a neighborhood on the edge of the Rutgers University campus. The victim lay motionless in the street beside the open door on the driver’s side, as if the car had ejected him. A neighborhood couple, a physical therapist and a volunteer firefighter, approached to see if they could help, but police waved them back.
“He’s not going to make it,” an officer reportedly told the physical therapist. “He’s pretty much dead.” She called a physician, Jeffrey Brenner, who lived a few doors up the street, and he ran to the scene with a stethoscope and a pocket ventilation mask. After some discussion, the police let him enter the crime scene and attend to the victim. Witnesses told the local newspaper that he was the first person to lay hands on the man.
“He was slightly overweight, turned on his side,” Brenner recalls. There was glass everywhere. Although the victim had been shot several times and many minutes had passed, his body felt warm. Brenner checked his neck for a carotid pulse. The man was alive. Brenner began the chest compressions and rescue breathing that should have been started long before. But the young man, who turned out to be a Rutgers student, died soon afterward.
The incident became a local scandal. The student’s injuries may not have been survivable, but the police couldn’t have known that. After the ambulance came, Brenner confronted one of the officers to ask why they hadn’t tried to rescue him.
“We didn’t want to dislodge the bullet,” he recalls the policeman saying. It was a ridiculous answer, a brushoff, and Brenner couldn’t let it go.
He was thirty-one years old at the time, a skinny, thick-bearded, soft-spoken family physician who had grown up in a bedroom suburb of Philadelphia. As a medical student at Robert Wood Johnson Medical School, in Piscataway, he had planned to become a neuroscientist. But he volunteered once a week in a free primary-care clinic for poor immigrants, and he found the work there more challenging than anything he was doing in the laboratory. The guy studying neuronal stem cells soon became the guy studying Spanish and training to become one of the few family physicians in his class. Once he completed his residency, in 1998, he joined the staff of a family-medicine practice in Camden. It was in a cheaply constructed, boxlike, one-story building on a desolate street of bars, car-repair shops, and empty lots. But he was young and eager to recapture the sense of purpose he’d felt volunteering at the clinic during medical school.
Few people shared his sense of possibility. Camden was in civic free fall, on its way to becoming one of the poorest, most crime-ridden cities in the nation. The local school system had gone into receivership. Corruption and mismanagement soon prompted a state takeover of the entire city. Just getting the sewage system to work could be a problem. The neglect of this anonymous shooting victim on Brenner’s street was another instance of a city that had given up, and Brenner was tired of wondering why it had to be that way.
If patients have a constitutional right to refuse medical treatment and die with dignity, do they also have a constitutional right to prematurely end their life to ensure a death with dignity? If they have a constitutional right to die with dignity, even if that means taking affirmative steps to hasten that death, do they have a constitutional right to be assisted by a physician? These questions and others will be explored in the upcoming session on Physician-Assisted Suicide, sponsored by the Health Policy Education Group (HPEG) on Friday, April 15, 2011 in GEB A103. The presentation includes TurningPoint questions, so please remember to bring your clickers! Hosted by Professor Carol Schwab.
As Congress reconvenes and the newly-minted Republican controlled House decides the direction it will take over the next year, health care will most certainly become a focus of conversation and legislation in the upcoming months. With the Republican party making promises to repeal the Patient Protection and Affordable Care Act (PPACA), the Democrats holding strong to their beliefs in health reform, and the public divided over their opinion of the health care bill, this promises to be in an interesting year for health policy legislation.
Also, in an effort to better explain the challenges the Patient Protection and Affordable Care Act faces, Anne Porter, the Southern Delegate for Legislative Affairs, has created a document highlighting the legal and funding challenges the bill will face in the future. Please make time to read this concise yet thorough summary.
I. Repeal of Health Law
II. Reversal on End-of-Life Care
III. Extra Reading
I. Repeal of Health Law
In the upcoming month, the House controlled Republican party will likely vote on a repeal of the health-care law. It is expected that the repeal will get through the House but will face a tougher challenge when encountering the Democrat-controlled Senate. Should the repeal get through the Senate, President Obama will most probably veto the legislation. Rep. Eric Cantor (R-Va.), the House majority leader stated, “Obamacare is a job killer for businesses small and large” and his party has vowed to “repeal and replace” the law. However, the Republican party has yet to offer a replacement to the PPACA or provide specifics as to how their bill will be different.
The Republicans, who ran on a platform that included repeal of the Patient Protection and Affordable Care Act during their successful election bids in November, believe repealing the bill will be a popular campaign. And while 54% of Americans oppose the law and 43% of Americans support it, the details are a little more complicated. Of the 54% of Americans that oppose the law, one-quarter of those individuals do not support the law because it is not liberal enough. So, in truth, only 37% of the American public opposes the law for attempting to create too much reform.
One of the more unpopular measures in the health-care law, the mandate that all individuals buy insurance, opposed by roughly 60% of Americans, will go into effect in 2014. However, in 2011, the health-care law is slated to eliminate the “doughnut hole“, increase Medicare reimbursement to physicians by 10%, and waive Medicare co-payments for valid preventive screening and treatment. The law will also continue popular programs such as extending insurance to children living at home up to age 26 and eliminate discrimination by insurance companies for previous medical conditions. Democrats are hoping Americans will like the popular programs more than they dislike the idea of being required to buy insurance, and in the end, they will back the bill.
Getting the appropriate votes to repeal the health care law could also be challenging because the PPACA is partly seen as a budget saving bill. The non-partisan Congressional Budget Office (CBO) on 1/6 concluded that repealing the law would increase the national debt by about $230 billion from 2012 to 2021 due to the elimination of cost-saving measures included in the PPACA. However, the House Budget Committee Chairman, Paul Ryan (R-Wis), said those savings are phony, accusing Democrats of having used “smoke and mirrors” to produce the numbers.
II. Reversal on End-of Life-Care Reimbursement
In November, the Obama administration revised the health care bill to include Medicare reimbursement for end-of-life care, including advance directives, in which patients could indicate whether they want to forgo or receive aggressive life-sustaining treatment. This topic was originally introduced in the 2008 Medicare Improvement for Providers Act with bipartisan support within the House and Senate. In the 2008 Act, end of life planning would be reimbursed only once as part of Medicare’s Initial Preventive Physical Examination. The revision by the health care bill would have allowed reimbursement to occur annually with the intention of encouraging physicians to continue having end of life discussions with their patients.
However, on 1/4, the administration reversed its stance and took out the rule citing procedural reasons for the change and to allow stakeholders to have an adequate opportunity to comment on the bill. Despite the administration’s stance, the press points out that this change likely occurred out of political motive. With the Republican party fast approaching a vote to repeal the PPACA, Democrats likely did not want to readdress this sensitive issue. Medicare coverage for voluntary end-of-life planning was part of the original House version of the health reform legislation in 2009, but it was dropped after Sarah Palin and other Republicans began referring to it as “death panels” where government would be deciding the fate of vulnerable seniors. Those charges were later debunked by several non-partisan fact-checking groups who saw end of life discussions an important part of the physician’s interaction with the patient.
Physicians may still continue to have end of life discussions with their patients. However, they will continue to not be reimbursed by Medicare for their efforts.
III. Extra Reading
The GOP’s Risky Best to Repeal HealthCare Reform – Salon
Beyond Repeal – The Future of Healthcare Reform – NEJM
Medicaid Bonuses to Reward States for Insuring More Children – NY Times
Your OSR Legislative Affairs Team
Anne Porter, Southern Region
Elizabeth Davlantes, Central Region
William Stevens, Western Region
Frank Bauer, Northeast Region
Nathan Copeland, National Delegate
An ACO is a group of health care providers (health system model) that accept accountability for the provision of patient care across the continuum of care through different settings, including outpatient, inpatient and postacute care.
In 2011, health care delivery is being pushed to create a “seamless” integrated system of care, and ACOs are being touted as the solution. By grouping a diversity of health care providers, such as a hospital, primary care physicians and specialists, ACOs aim to create a cohesive, clinically integrated framework, encourage accountability and create incentives and rewards to providers who focus on coordinating the overall scope of patient care.
Unlike the current, fragmented model, the ACO is designed to enable and encourage health care providers to take greater responsibility for controlling the growth of health care costs for a given population of patients.
Simultaneously, ACOs aim to improve patient care quality.
With more than 50% of the population dealing with a chronic condition, the former approach to providing episodic care and treatment is no longer the most appropriate. Health care delivery needs to address chronic care management and clinical integration when comorbidities exist. Care needs to be coordinated and managed. Patients also need to be engaged and must take responsibility for their overall health care and treatments. This means communication and collaboration need to exist among all stakeholders — patients, providers, hospitals, the community and health insurance plans. Then, a “team approach” in which all provider staff plays a role needs to be adopted. Providers should also work with the patient to make him/her accountable for his/her own care. Getting providers to this point is known as practice transformation.
The ACO model is intended to encourage participating primary care physicians, specialists and hospitals to work collaboratively to ensure the care they deliver is well-coordinated and designed to benefit patients and reduce waste. It involves prevention, wellness and episodic care through organized systems of care to keep people out of the hospital. To do so effectively, hospitals and physicians have to psychologically and culturally come to grips with making a profit margin based on appropriate utilization that produces savings through managing the expense side of the profit-and-loss statement rather than the revenue side.
Effective primary care delivery is at the core of the ACO structure, and the overall practice transformation falls into three, interrelated themes: pay for performance, patient-centered medical home and practice re-engineering. Combined, these initiatives form the basis of practice transformation and, ultimately, clinical integration. This is the end state that payers, employers and regulators are pushing for with regard to health care delivery systems.
Primary care physicians should look to achieve patient-centered medical home designation; those primary care providers that have acquired patient-centered medical home designation/accreditation will be in a preferred position in becoming part of an ACO. In addition, a primary care provider should evaluate its processes through a LEAN process review, which involves breaking down the process into component steps and validating that each step is necessary and the most efficient.
Practice transformation is not limited to primary care providers. Specialists need to enhance their roles with primary care providers through coordination of care and rationalization of treatments. Additionally, specialists need to create outcome documentation that details the effectiveness of treatment. This outcomes report card will need to be shared with interested parties.
The federal government is promoting ACO development and has a number of demonstrations underway. While large hospital systems are looking to create ACO structures, the government wants to see other entities take the lead. Overall, the spectrum-of-care models need to reflect a demonstration of clinical integration. Because the savings to be shared are achieved by eliminating unnecessary expenses and improving overall patient quality, the ACO model seeks to focus providers’ attention on areas of health care delivery that are fragmented, inefficient and inconvenient for patients. Under the new ACO system, a bundled price is paid to the ACO for all health care services. The ACO then decides individual component payments to its member providers.
While the ACO health care model seems to be a significant change in the way health care delivery is currently provided and there are sure to be financial and professional obstacles, once implemented, the ACO should result in better care for the patient, improved payment for the provider and less frustration for everyone. In the midst of the change, practices that have streamlined care delivery and have adopted “best practices” are in the prime position to adapt to the new environment. These practices will be looked to by others for replication.
- Mark Dengler is the President of Research & Marketing Strategies (RMS), a full-service marketing and market research firm located at 15 East Genesee Street (Suite 210) in Baldwinsville. RMS Healthcare, a division of RMS, offers focused, health care-specific consulting and research services to health care clients. Call Dengler at (315) 635-9802 or 1-866-567-5422, or e-mail MarkD@RMSresults.com to see how RMS can help you.
On November 29th, HPEG hosted a lecture by Dr. David Mirvis, current faculty member of Harvard’s School of Public Health and retired faculty member of UTHSC’s Department of Preventative Medicine. Dr. Mirvis lectured on “What is Health Anyway?”, a topic that sought to broaden the definition of health care and health policy from beyond just the traditional view of health being defined by access to care.
For further information, check out Nicole Lurie’s article “What the Federal Government Can Do About the Nonmedical Determinants of Health” (Health Affairs, Volume 21, Number 2). In this piece, Lurie expounds upon the fact that “the acute health care delivery system contributes proportionally less to health when compared with environment and behavior” and explores how other sectors can become engaged in the health policy conversation.
“The Case for More Active Policy Attention to Health Promotion” by McGinnis, Williams-Russo and Knickman (Health Affairs, Volume 21, Number 2) more concretely outlines what the non-acute health delivery determinants to health care are and explains why so little has been spent on programs that promote health.
On Monday, September 20th, 2010, Professor Carol Schwab, director of UTHSC’s Medical/Legal Education, will speak on the issues of palliative care and pain management. Professor Schwab’s lecture will provide excellent insight for those seeking a legal and medical perspective on these topics. Please join us Monday, September 20th at noon in GEB A103 for an interesting and interactive session.
The following articles highlight the history and current issues of the healthcare state. Some articles must be accessed via the UTHSC Library website with your appropriate login information.
Historical perspective: Atul Gawande, Getting There from Here
The System: Gary Claxton, How Private Insurance Works
End of Life Care: Atul Gawande, Letting Go
Issues confronting the healthcare state:
- Cost: Atul Gawande, The Cost Conundrum
- Cost: Reed Abelson, “A Health Insurer Pays More To Save“
- Quality: Stephen Campbell and David Reeves, “Effects of Pay for Performance on the Quality of Primary Care in New England”, NEJM 2009; 361: 368-378.; Seth Glickman, Fang-Shu Ou and Elizabeth DeLong, “Pay for Perfomance, Quality of Care and Outcomes in Acute Myocardial Infarction”, JAMA 2007; 297(21): 2373-2380.
- Access: Leif Hasse, A New Deal for Health: How to Cover Everyone and Get Medical Costs Under Control
- Overtesting: Lindsey Tanner, “Fear of Malpractice Drives Overtesting“
Arguments for reform
- Support for a National Health System: Elise Gould, Consumer-Driven Health Care is a False Promise
- Support for Evidence Based Medicine: David Leonhardt, Making Healthcare Better
- Support for a Free Market Healthcare State: Michael Cannon, Yes Mr. President, a Free Market can Fix Healthcare