<?xml version="1.0" encoding="UTF-8"?><rss version="2.0"
	xmlns:content="http://purl.org/rss/1.0/modules/content/"
	xmlns:wfw="http://wellformedweb.org/CommentAPI/"
	xmlns:dc="http://purl.org/dc/elements/1.1/"
	xmlns:atom="http://www.w3.org/2005/Atom"
	xmlns:sy="http://purl.org/rss/1.0/modules/syndication/"
	xmlns:slash="http://purl.org/rss/1.0/modules/slash/"
	>

<channel>
	<title>cost-effectiveness | American HealthScare</title>
	<atom:link href="https://www.healthscareonline.com/http:/www.healthscareonline.com/tag/cost-effectiveness/feed/" rel="self" type="application/rss+xml" />
	<link>https://www.healthscareonline.com</link>
	<description>How the healthcare industry&#039;s scare tactics have screwed up our economy -- and our future</description>
	<lastBuildDate>Sun, 28 Jan 2024 23:08:14 +0000</lastBuildDate>
	<language>en-US</language>
	<sy:updatePeriod>
	hourly	</sy:updatePeriod>
	<sy:updateFrequency>
	1	</sy:updateFrequency>
	<generator>https://wordpress.org/?v=6.7.1</generator>
	<item>
		<title>Primary Care Systems in the News &#8212; Do They Work?</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/primary-care-systems-in-the-news-do-they-work/</link>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Sun, 28 Jan 2024 23:08:12 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[ChenMed]]></category>
		<category><![CDATA[cost-effectiveness]]></category>
		<category><![CDATA[early detection]]></category>
		<category><![CDATA[family medicine]]></category>
		<category><![CDATA[family physicians]]></category>
		<category><![CDATA[Health Partners]]></category>
		<category><![CDATA[healthcare costs]]></category>
		<category><![CDATA[healthcare quality]]></category>
		<category><![CDATA[Iora]]></category>
		<category><![CDATA[Nuka]]></category>
		<category><![CDATA[payment reform]]></category>
		<category><![CDATA[prevention]]></category>
		<category><![CDATA[primary care]]></category>
		<guid isPermaLink="false">https://www.healthscareonline.com/?p=1469</guid>

					<description><![CDATA[<p>This is the second in a series of conversations I had with some open-minded colleagues who also deeply want to seen meaningful change in the U.S. healthcare system. The person I primarily responded to mentioned a chapter in Pursuing the Triple Aim. Here is what I wrote back to him: I was reminded how I was not super impressed with the Pursuing the Triple Aim book. Certainly, there are some good points in it, but each chapter also reads like a sales job from large healthcare systems. Rarely are these programs put to the test of peer review in the traditional medical literature. And sometimes when they are, they appear in some journals, which, in my opinion publishes too much stuff from commercial interests, such as Optum, or whoever Let’s take a look at some of the primary care programs and their claims more closely. In no particular order: The Nuka system This is one of the more transparent programs in the sense that their leaders have publicly spoken about their innovations, and their results have been published in the standard medical literature. Their leaders have talked about lots of aspects of the program: patients renamed customer-owners, inventing mini-pharmacy dispensaries for rural villages, [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/primary-care-systems-in-the-news-do-they-work/">Primary Care Systems in the News — Do They Work?</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>This is the second in a series of conversations I had with some open-minded colleagues who also deeply want to seen meaningful change in the U.S. healthcare system. The person I primarily responded to mentioned a chapter in Pursuing the Triple Aim. Here is what I wrote back to him:</p>



<p>I was reminded how I was not super impressed with the <em>Pursuing the Triple Aim</em> book. Certainly, there are some good points in it, but each chapter also reads like a sales job from large healthcare systems. Rarely are these programs put to the test of peer review in the traditional medical literature. And sometimes when they are, they appear in some journals, which, in my opinion publishes too much stuff from commercial interests, such as Optum, or whoever</p>



<p>Let’s take a look at some of the primary care programs and their claims more closely. In no particular order:</p>



<p>The Nuka system</p>



<p>This is one of the more transparent programs in the sense that their leaders have publicly spoken about their innovations, and their results have been published in the standard medical literature. Their leaders have talked about lots of aspects of the program: patients renamed customer-owners, inventing mini-pharmacy dispensaries for rural villages, using lots of tribal workforce for all job descriptions, and so on. Let’s look at two publications about Nuka that appeared in the mainstream medical literature.</p>



<p><a rel="noreferrer noopener" target="_blank" href="https://www.tandfonline.com/doi/abs/10.3402/ijch.v72i0.20960%40zich20.2013.72.issue-S2">One was a time series analysis</a>&nbsp;of medical record data that looked at time periods from transition to the new system, to PCMH implementation, to early PCMH adoption, to post PCMH implementation.&nbsp;In this study, they found a decrease in hospitalizations for unintentional injury or poisoning, and asthma. The heart failure hospitalizations were about the same. Hypertension admissions increased. The study was silent on conditions such as coronary artery disease, MIs, diabetes, DKA, etc. I assume this means there was no significant difference. It would have been easy enough to measure, but I acknowledge I’m speculating about this.</p>



<p>Notice that none of these positive outcomes have anything to do with OMT or other frameworks for Syndrome X care (blood pressure, diabetes, obesity, coronary artery disease, strokes, and so on). So, what explains the decrease in poisonings and asthma? They don’t talk about any specific asthma management plan. In a&nbsp;<a rel="noreferrer noopener" target="_blank" href="https://www.annfammed.org/content/11/Suppl_1/S41.short">similar article that also mentioned a decrease in emergency visits</a>&nbsp;for asthma and unintentional injuries, they included a qualitative component. In this section, they talk about improved access to primary care as the primary driver. One of the quotes was&nbsp;<em>I think emergency department visits have gone way down because it’s so much easier to see their primary care clinician.</em>&nbsp;They also mentioned getting nurses out of the specific disease management function (diabetes nurse, asthma nurse, etc.), and better support for primary care by the leadership.</p>



<p>I wish they would have drilled down the poisoning/injury numbers more. It should have been easy to count the number of lacerations, contusions, sprains, strains, and extremity fractures before and after full PCMH implementation. In other words, were injuries and poisonings down more because community health workers counseled young men to drink less and be safer, and the young men changed their behavior? Or did the total number of incidents not change much, but the custom-owners knew that their primary care center could see them reasonably fast, and they didn’t have to go to the ER. My guess is the latter, but it’s just a guess.</p>



<p>HealthPartners</p>



<p>Harvard Business School reported on HealthPartners diabetes management program in 2003 and calculated it only saved $75 per patient. The numbers you included in your email were from 2011, but I can’t find any information in the literature to support this. The problem with the HealthPartners report in Triple Aim is there is not enough detail to support the claims. It’s left to the reader to trust the numbers. I’ll talk about this more at the end.</p>



<p>Independent Health</p>



<p>In the same HBS report, they calculated that a diabetes program in the Independent Health Association “failed to find proof of substantial short-term medical cost savings attributable to the program.”</p>



<p>IDEAL program</p>



<p><a rel="noreferrer noopener" target="_blank" href="https://journals.lww.com/jphmp/Fulltext/2003/11001/Improving_Diabetes_Care_and_Outcomes__The.7.aspx?casa_token=vS4FGu2VvCEAAAAA:Xalij0KwzGqfPxFWzZ88S2mSP0Dy96wKAxUaK3eoBhRzXKzzf3IDU5FLNQn2DhNqTLJiOVe5lqs3_XlLYz3mur-g">IDEAL was a state-wide program in Minnesota</a>&nbsp;where the Department of Health and HealthPartners collaborated in traditional QI efforts. They showed a decrease in the average A1c and LDL cholesterol levels, but did not calculate costs.</p>



<p>Iora Health/ChenMed/and so on</p>



<p>These reports are hard to parse out because they are so emmeshed in the Medicare Advantage coding game that has been highly profitable to insurance companies and private equity. I’m in the camp that believes that more of the savings/profits in Medicare Advantage have come from coding games than actual improvements in care (I think the&nbsp;<a rel="noreferrer noopener" target="_blank" href="https://www.healthaffairs.org/content/forefront/emperor-still-has-no-clothes-response-halvorson-and-crane">Gillfilan/Berwick posts about this issue</a>&nbsp;are more believable than the opposing pieces). But given this complication, let’s press on and see what we can find.</p>



<p>Harvard Business Review has reported several times about Iora Health.&nbsp;<a rel="noreferrer noopener" target="_blank" href="https://hbr.org/2017/10/the-innovation-health-care-really-needs-help-people-manage-their-own-health">Let’s look at one published in 2017.</a>&nbsp;It states, “For example, an unpublished Iora study found that inpatient hospital admissions among a cohort of 1,176 Iora Medicare enrollees over an 18-month period decreased by 50%, emergency department visits decreased by 20%, and the total medical spend declined by 12%&nbsp;— this despite the cohort being sicker than average Medicare patients.” OK, it’s unpublished, but it could be true. I’m sure their primary audience was investors, so allow me a bit of scepticism here. Another big question in my mind is the statement the “cohort being sicker than average Medicare patients.” It’s really difficult to tell if this is real or a reflection of aggressive coding within the Medicare Advantage game. Let’s keep moving.</p>



<p>In&nbsp;<a rel="noreferrer noopener" target="_blank" href="https://hbr.org/2018/07/transforming-health-care-from-the-ground-up">another HBR report on Iora</a>, there is a section that talks up the health coaches (they take the patients shopping, for example), which is in line with OMT thinking, so I won’t repeat those critiques here. Further down is a statement that is just silly, “Under its capitation system, Iora makes money only if its patients stay healthy and thus require fewer tests and procedures.” More tests are ordered when a patient is under an aggressive screen-and-treat system vs. leaving well people alone.</p>



<p>Further down is where it gets meatier. The report states, “Iora saved money by contracting specialists as consultants to the primary care practice—essentially inviting cardiologists, nephrologists, and others to join the gig economy. When Fernandopulle asked the head of endocrinology at a top hospital what percentage of endocrine clinic patients could be managed by a primary care physician with a little expert advice by phone or e-mail, the answer was an astonishing 80%. A formal study of e-consultations by PCPs across 10 specialty areas, including neurology, rheumatology, dermatology, and nephrology, confirmed that on average, primary care physicians were able to address problems in those areas for 60% of patients.” Now we’re talking.</p>



<p>For context, just in case you didn’t already know, the corridor from Washington DC to Boston is the great sucking black hole of despair for family medicine. It is the most over-specialized part of the country with the fewest family physicians who are generally highly disrespected. This is where 3 of 4 Iora pilot sites were, the other being Las Vegas, which I assume is also not the most family medicine-friendly part of the country. (And of the groups were unions, which could have had very generous benefits that needed paring). Dr. Fernandopulle was probably a combination of lucky and smart that he was in Boston and focused his early efforts on that region. This result sounds exactly like one of the classic Starfield conclusions that 50% of visits to ologists are really primary care.</p>



<p>Savings that are generated from decreasing visits to ologists makes sense to me. The lowest hanging fruit in this domain is simply to reduce the number of touches to ologist care that add no value to the patient’s journey. The higher-hanging fruit is the difference in the cultures of the ologies and family medicine that also lead to more patient-centric and less aggressive testing and treating, but this is still accomplished if a patient is steered towards primary care as the easiest and most convenient place to access care.</p>



<p>I won’t list all the other articles about Iora here, but other themes are switching more prescriptions to generic, developing its own IT system, and again, the coaches and reducing ologist visits. I’ll just say here that I accept that the coaches are part of its success, but not in the way the typical article suggests. Hosting cooking classes is not the trick, it’s being quickly accessible if the patient has a concern. The coaches serve to increase access and act as information filters for the doctors.</p>



<p>In the interest of watching my word count, I’ll just say that the reports on ChenMed and the others sound very similar to me as Iora Health, so I’ll not comment about them in more detail. I’ll make one more quick semantic comment though. All of these articles say something like, “Iora works by keeping people healthy,” which isn’t true. People with heart failure aren’t healthy, their heart doesn’t pump well. People with diabetes aren’t healthy, their ability to regulate blood sugars is broken. A better way of thinking about this is that the doctors/teams help people live as well as possible given the cards they were dealt. But they’re patients are not perfectly “healthy.”</p>



<p>Wrap Up</p>



<p>The problem with all of these reports by mostly commercial entities is that they do not provide enough transparency and detail to really prove their case. For example, no report says this, “Before we started with working with some union, they were spending $X on blood pressure, diabetes, and cholesterol medicines; related tests (blood work, stress tests, etc.); ER visits total and disease-specific to syndrome X situations (chest pain, MI, stroke, etc.); hospital visits total and disease-specific; and other related big ticket items such as heart caths and such. We then spent $Y on more drugs, tests, coaches/dieticians/counselors, primary care, and so on over the next blah-blah years. At that point in the same population (understanding that all U.S. populations are mobile), we spent $Z on roughly the same list as $X. Therefore, the net spend or savings was whatever.”</p>



<p>Within this framework, there are still some spend traps to watch out for. A group could claim that their intervention results in lower A1c levels and lower costs per diabetic. Was the before/after group the same size (and likely horribly expensively managed, like a multi-ology model) or did the coaches go out and screen a bunch of people who felt fine, found more cases of diabetes, most of them controlled on just metformin, and thereby making the dollars and outcome results&nbsp;<em>per diabetic</em>&nbsp;look better?</p>



<p>Another trap would be something like a report not using established methods for reporting cost-effectiveness results, like taking the newly detected diabetics, and projecting future costs based on an overall average spend on diabetics, not a newly diagnosed patient with very mild disease. Another trap would be cherry-picking populations that have fewer minorities, low-income patients, and patients with significant mental illness or substance abuse challenges. And of course, throw in social determinant challenges (and no, no one has invented a way to correct for these, and mathematically, I don’t think it will ever happen). Another trap would be to take a group of insured patients in a region who likely are representative of their region, show that some intervention lowered the total spend, but did not disclose that this group had an exorbitant spend before, and now have a spend that is the same as other groups (In other words, there was plenty of fat to cut out, but nothing more fundamental about care delivery changed compared to other local options).</p>



<p>What about the Medicare Advantage population? Similar situation here, with slightly different accounting. For example, if Iora or whoever claims 15% overall decrease in total spend, was it that pre-Iora the total spend was $400 PMPM, then they did their thing, then the spend was $340 PMPM (not adding inflation in this example)? Or did Iora get in there, add lots of HCC codes, which then led to a new predicted spend of $500 PMPM, and they accomplished $425 which they claimed was a 15% reduction, when in fact it was an increase in the total spend? Again, I can’t find any report that divulges this level of detail. And if there is a report that looks like this example, I’d still like to see the detail I listed in the earlier example.</p>



<p>I suspect that some of the things Iora did are substantive, real, and reduced stupid healthcare expenses. One report said their doctors/teams take care of about 400-500 Medicare patients, vs. other approaches in the HMO era where they’d assign a family doc 800 or so patients. Remember that the fundamental Barbara Starfield, MD finding that geographic places with more family physicians (not internists, by the way) enjoy better health outcomes and lower costs. In the managed care era, no one ever tried to experimentally replicate this observational finding by merely loading up an area with family physicians and see what happens. In my view, if these ratios are true, then this is kind of what Iora did.</p>



<p>Good for them, and Nuka. All I ask is that we develop a deeper understanding of WHY total cost reductions happened. Except for patients with severe cases of common chronic diseases, it had nothing to do with wellness interventions, prevention, screening, or treating chronic diseases. It has everything to do with making access to primary care be the easiest way for a patient to access the system (side thought: I wonder if there are billboards on the highways in Iora cities that say, “The wait time to be seen at Iora Clinic is 10 minutes.” The ERs seem to think it drives business to them.). It has everything to do with specifically limiting access to ologists. It has everything to do with applying the unique culture of high-value family medicine to complex patient situations, where the unique medical decision making of family medicine becomes the “right” way to deliver care.</p>



<p>I very much appreciate the members of this group who know that we need more primary care in this country to achieve better outcomes at a lower cost. But if you keep prioritizing and incentivizing the wrong features and work functions of family medicine, you’ll continue to just make it worse.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/primary-care-systems-in-the-news-do-they-work/">Primary Care Systems in the News — Do They Work?</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
		
		
			</item>
		<item>
		<title>Misleading Conclusions on Outcomes of Cardiovascular Disease Chronic Care</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/misleading-conclusions-on-outcomes-of-cardiovascular-disease-chronic-care/</link>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Tue, 16 Jan 2024 04:52:39 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[cardiovascular disease]]></category>
		<category><![CDATA[chronic disease care]]></category>
		<category><![CDATA[cost-effectiveness]]></category>
		<category><![CDATA[diabetes]]></category>
		<category><![CDATA[family medicine]]></category>
		<category><![CDATA[family physicians]]></category>
		<category><![CDATA[healthcare costs]]></category>
		<category><![CDATA[high blood pressure]]></category>
		<category><![CDATA[prevention]]></category>
		<category><![CDATA[primary care]]></category>
		<category><![CDATA[Steno-2 study]]></category>
		<guid isPermaLink="false">https://www.healthscareonline.com/?p=1460</guid>

					<description><![CDATA[<p>I&#8217;m in an email group that is all in agreement that the U.S. healthcare system is exorbitantly expensive and needs reform. We come from wildly different backgrounds. The variety of perspectives is wonderful. However, a claim of some of the contributors is that aggressive medical therapy of cardiovascular disease (CVD) chronic disease care increases life expectancy by 8 years. This statement was based on a small Danish study called the Steno-2 trial, so let’s take a closer look at the Steno-2 trial. Efficacy of Steno-2 Approach This study randomized 160 patients into intensive vs. usual treatment groups, 80 in each arm. Usual care (for the majority of the trial) meant BP less than 160/95, hemoglobin A1c &#60; 7.5%, total cholesterol &#60; 250, no ACE inhibitor if the blood pressure was normal, and a few other minor targets; intensive care meant BP less than 140/85, hemoglobin A1c &#60; 6.5%, total cholesterol &#60; 190, and an ACE inhibitor even if the blood pressure was normal. Some of these numbers were lowered in the last 2 years of the 7.8-year primary study. This study generated several results papers. The first paper reported results 5.8 years after the study started. It found no difference in [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/misleading-conclusions-on-outcomes-of-cardiovascular-disease-chronic-care/">Misleading Conclusions on Outcomes of Cardiovascular Disease Chronic Care</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>I&#8217;m in an email group that is all in agreement that the U.S. healthcare system is exorbitantly expensive and needs reform. We come from wildly different backgrounds. The variety of perspectives is wonderful. However, a claim of some of the contributors is that aggressive medical therapy of cardiovascular disease (CVD) chronic disease care increases life expectancy by 8 years. This statement was based on a small Danish study called the Steno-2 trial, so let’s take a closer look at the Steno-2 trial.</p>



<p><em>Efficacy of Steno-2 Approach</em></p>



<p>This study randomized 160 patients into intensive vs. usual treatment groups, 80 in each arm. Usual care (for the majority of the trial) meant BP less than 160/95, hemoglobin A1c &lt; 7.5%, total cholesterol &lt; 250, no ACE inhibitor if the blood pressure was normal, and a few other minor targets; intensive care meant BP less than 140/85, hemoglobin A1c &lt; 6.5%, total cholesterol &lt; 190, and an ACE inhibitor even if the blood pressure was normal. Some of these numbers were lowered in the last 2 years of the 7.8-year primary study. This study generated several results papers.</p>



<p><a href="https://www.thelancet.com/journals/lancet/article/PIIS0140673698073681/fulltext" target="_blank" rel="noreferrer noopener">The first paper</a> reported results 5.8 years after the study started. It found no difference in mortality, therefore there was no difference in life expectancy. There were 2 deaths in the usual group; 4 deaths in the intensive group. 2 CVD deaths in the usual group; 3 CVD deaths in the intensive group.</p>



<p><a rel="noreferrer noopener" target="_blank" href="https://www.sciencedirect.com/science/article/abs/pii/S0026049503002130">The next paper</a>&nbsp;was the primary result paper, which reported results after 7.8 years of follow up. There was once again no difference in mortality between the groups, which means no difference in life expectancy. There were 15 total deaths in the usual group; 12 deaths in the intensive group. 7 CVD deaths in the usual group; 7 CVD deaths in the intensive&nbsp; group.</p>



<p>Now, pay attention to this, the experimental treatment differences were stopped and the usual care group was converted to intensive treatment.<a rel="noreferrer noopener" target="_blank" href="https://www.nejm.org/doi/full/10.1056/nejmoa0706245">&nbsp;The next paper</a>&nbsp;reported outcomes 13.3 years after the study started. There 40 total deaths in the usual group; 24 deaths in the intensive group. 19 CVD deaths in the usual group; 9 CVD deaths in the intensive&nbsp; group.</p>



<p><a rel="noreferrer noopener" target="_blank" href="https://link.springer.com/article/10.1007/s00125-016-4065-6">The last paper</a>&nbsp;in the STENO study reported outcomes 21 years after the study started and found a big difference in mortality, when the total number of participants was less than half of what the study started with. The authors claim that this finding results in an 8-year increase in life expectancy.</p>



<p>Let’s take a slightly different look at the outcomes. Here is a graph of each of the deaths in the reports.</p>



<figure class="wp-block-image"><img decoding="async" src="https://apis.mail.yahoo.com/ws/v3/mailboxes/@.id==VjN-fUqPAAJMMCpbqNaJuQjCcPtsH6WOXbovfifhTSaAWPJxdaWpzbRNoITvlMzMWG3tsdFKgbaBU0iQeGd8O0HeBA/messages/@.id==ABqSal8vpRO8ZZcxuwhJGJDoDLA/content/parts/@.id==2/thumbnail?appid=YMailNorrin&amp;downloadWhenThumbnailFails=true&amp;pid=2" alt="Inline image" title="Inline image"/></figure>



<figure class="wp-block-image size-full"><a href="https://www.healthscareonline.com/wp-content/uploads/2024/01/15-steno-overall-results.png"><img fetchpriority="high" decoding="async" width="581" height="341" src="https://www.healthscareonline.com/wp-content/uploads/2024/01/15-steno-overall-results.png" alt="" class="wp-image-1461" srcset="https://www.healthscareonline.com/wp-content/uploads/2024/01/15-steno-overall-results.png 581w, https://www.healthscareonline.com/wp-content/uploads/2024/01/15-steno-overall-results-300x176.png 300w, https://www.healthscareonline.com/wp-content/uploads/2024/01/15-steno-overall-results-102x60.png 102w" sizes="(max-width: 581px) 100vw, 581px" /></a></figure>



<p>OK, so far we have a very small study with a funky hitch in the outcomes. Is this hitch at 7.8 years expected? Let’s look at some classic studies in cholesterol treatment literature for starters.</p>



<p><a rel="noreferrer noopener" target="_blank" href="https://www.sciencedirect.com/science/article/abs/pii/S0140673694905665">The very first study of treating cholesterol with a statin was the 4S trial</a>. They enrolled a high-risk group of 4,444 patients who had survived an MI or who had proven coronary artery disease, and who had total cholesterol numbers between 210 and 310. Patients were given simvastatin or placebo. Here is the mortality outcome curve from that study. Notice the smooth even outcome over the duration of the study.</p>



<figure class="wp-block-image"><img decoding="async" src="https://apis.mail.yahoo.com/ws/v3/mailboxes/@.id==VjN-fUqPAAJMMCpbqNaJuQjCcPtsH6WOXbovfifhTSaAWPJxdaWpzbRNoITvlMzMWG3tsdFKgbaBU0iQeGd8O0HeBA/messages/@.id==ABqSal8vpRO8ZZcxuwhJGJDoDLA/content/parts/@.id==3/thumbnail?appid=YMailNorrin&amp;downloadWhenThumbnailFails=true&amp;pid=3" alt="Inline image" title="Inline image"/></figure>



<figure class="wp-block-image size-full"><a href="https://www.healthscareonline.com/wp-content/uploads/2024/01/4S-results.png"><img decoding="async" width="319" height="369" src="https://www.healthscareonline.com/wp-content/uploads/2024/01/4S-results.png" alt="" class="wp-image-1462" srcset="https://www.healthscareonline.com/wp-content/uploads/2024/01/4S-results.png 319w, https://www.healthscareonline.com/wp-content/uploads/2024/01/4S-results-259x300.png 259w, https://www.healthscareonline.com/wp-content/uploads/2024/01/4S-results-52x60.png 52w" sizes="(max-width: 319px) 100vw, 319px" /></a></figure>



<p>But what about patients without known coronary artery disease who had high cholesterol? <a href="https://www.nejm.org/doi/full/10.1056/nejm199511163332001" target="_blank" rel="noreferrer noopener">The WOSCoPS study was the first one to treat patients without known coronary disease</a>, so this more closely mirrors a typical primary care scenario. They enrolled 6,595 patients with a mean total cholesterol level of 272. Patients were given pravastatin or placebo. Here is the mortality and CVD outcome from that study.</p>



<figure class="wp-block-image"><img decoding="async" src="https://apis.mail.yahoo.com/ws/v3/mailboxes/@.id==VjN-fUqPAAJMMCpbqNaJuQjCcPtsH6WOXbovfifhTSaAWPJxdaWpzbRNoITvlMzMWG3tsdFKgbaBU0iQeGd8O0HeBA/messages/@.id==ABqSal8vpRO8ZZcxuwhJGJDoDLA/content/parts/@.id==4/thumbnail?appid=YMailNorrin&amp;downloadWhenThumbnailFails=true&amp;pid=4" alt="Inline image" title="Inline image"/></figure>



<figure class="wp-block-image size-full"><a href="https://www.healthscareonline.com/wp-content/uploads/2024/01/WOSCOPS-results.png"><img decoding="async" width="205" height="350" src="https://www.healthscareonline.com/wp-content/uploads/2024/01/WOSCOPS-results.png" alt="" class="wp-image-1463" srcset="https://www.healthscareonline.com/wp-content/uploads/2024/01/WOSCOPS-results.png 205w, https://www.healthscareonline.com/wp-content/uploads/2024/01/WOSCOPS-results-176x300.png 176w, https://www.healthscareonline.com/wp-content/uploads/2024/01/WOSCOPS-results-35x60.png 35w" sizes="(max-width: 205px) 100vw, 205px" /></a></figure>



<p>As you can see from these 2 landmark studies, a patient needs to take the medicine for about 6 to 18 months before any mortality improvement is seen. After that, the performance of the medicine is smooth and consistent for years after it was initiated.</p>



<p>What about the contribution of treating diabetes more aggressively? Let’s look at one of the longest randomized controlled trials ever completed, <a href="https://www.sciencedirect.com/science/article/abs/pii/S0140673698070196" target="_blank" rel="noreferrer noopener">the UK Prospective Diabetes Study (UKPDS).</a> In UKPDS, they randomized 3,642 patients newly diagnosed with type 2 diabetes into tight vs. loose control. The tight control group got oral medicines or insulin to keep their fasting sugars below 109. The loose group got meds if their fasting sugars were greater than 270. At the end of 10 years (though other arms of the trial went for greater than 20 years), the average hemoglobin A1c was 7.0% in the tight group and 7.9% in the looser group. The 2 graphs below show, on the left, the percent of patients who started dialysis; and on the right, total mortality. This study started in the late 1980s and some of the medications we have now weren’t available then, but you can see that the A1c levels are in line with excellent care here. You can also see that a tiny number of diabetics actually ever go on dialysis. You can also see that there is no mortality benefit for about 10 years, and then the effect after that is very small.</p>



<figure class="wp-block-image"><img decoding="async" src="https://apis.mail.yahoo.com/ws/v3/mailboxes/@.id==VjN-fUqPAAJMMCpbqNaJuQjCcPtsH6WOXbovfifhTSaAWPJxdaWpzbRNoITvlMzMWG3tsdFKgbaBU0iQeGd8O0HeBA/messages/@.id==ABqSal8vpRO8ZZcxuwhJGJDoDLA/content/parts/@.id==5/thumbnail?appid=YMailNorrin&amp;downloadWhenThumbnailFails=true&amp;pid=5" alt="Inline image" title="Inline image"/></figure>



<figure class="wp-block-image size-full"><a href="https://www.healthscareonline.com/wp-content/uploads/2024/01/UKPDS-results.png"><img loading="lazy" decoding="async" width="584" height="221" src="https://www.healthscareonline.com/wp-content/uploads/2024/01/UKPDS-results.png" alt="" class="wp-image-1464" srcset="https://www.healthscareonline.com/wp-content/uploads/2024/01/UKPDS-results.png 584w, https://www.healthscareonline.com/wp-content/uploads/2024/01/UKPDS-results-300x114.png 300w, https://www.healthscareonline.com/wp-content/uploads/2024/01/UKPDS-results-159x60.png 159w" sizes="auto, (max-width: 584px) 100vw, 584px" /></a></figure>



<p><a rel="noreferrer noopener" target="_blank" href="https://link.springer.com/article/10.1007/s00125-004-1527-z">Another UKPDS study</a>&nbsp;estimated that intense control would result in an increased life expectancy of 0.27 years over 16 years.</p>



<p>What about other studies of intensive glucose lowering?<a rel="noreferrer noopener" target="_blank" href="https://www.bmj.com/content/343/bmj.d4169.short">&nbsp;A meta-analysis of 11 trials</a>&nbsp;including 34,533 patients found no difference in mortality. Three years later,&nbsp;<a rel="noreferrer noopener" target="_blank" href="https://www.nejm.org/doi/full/10.1056/Nejmoa1006524">the ACCORD study</a>&nbsp;of 10,251 patients in the U.S. and Canada with diabetes and increased risk for CVD (prior evidence of CVD or multiple cardiovascular risk factors )&nbsp;were randomized into 2 different concurrent blocks of aggressive or usual treatment. Its conclusion read “intensive BP or intensive glycemia treatment alone improved major CVD outcomes, without additional benefit from combining the two. In the ACCORD lipid trial, neither intensive lipid nor glycemia treatment produced an overall benefit, but intensive glycemia treatment increased mortality.” There was no improvement in overall mortality, therefore no increase in life expectancy.</p>



<p>Next, you might wonder OK, I see the smooth performance for one treatment for coronary artery disease and diabetes, but Steno-2 used 4 medications. Are there other studies besides Steno-2 that have looked at this issue?&nbsp; Of course there are! Let’s look at them. I won’t mention every study ever done in this arena, but here are some of the biggies.</p>



<p><a rel="noreferrer noopener" target="_blank" href="https://ueaeprints.uea.ac.uk/id/eprint/68842/1/3003445.pdf">The ADDITION-Europe trial</a>&nbsp;randomized 3,055 patients in 3 European countries who were newly diagnosed with type 2 diabetes. Patients were randomized into intensive management vs. usual care according to the 3 countries national guidelines. “Intensive” meant more medications and more available counseling to achieve lower targets for A1c (&lt;7.0%), blood pressure (&lt;135/85), and total cholesterol (&lt;174). After 5 years, “clinically important improvements in cardiovascular risk factors” were achieved in the intensive group. There was no difference in mortality, CVD risk, or first CVD event.</p>



<figure class="wp-block-image"><img decoding="async" src="https://apis.mail.yahoo.com/ws/v3/mailboxes/@.id==VjN-fUqPAAJMMCpbqNaJuQjCcPtsH6WOXbovfifhTSaAWPJxdaWpzbRNoITvlMzMWG3tsdFKgbaBU0iQeGd8O0HeBA/messages/@.id==ABqSal8vpRO8ZZcxuwhJGJDoDLA/content/parts/@.id==7/thumbnail?appid=YMailNorrin&amp;downloadWhenThumbnailFails=true&amp;pid=7" alt="Inline image" title="Inline image"/></figure>



<figure class="wp-block-image size-full"><a href="https://www.healthscareonline.com/wp-content/uploads/2024/01/ADDITION-results.png"><img loading="lazy" decoding="async" width="608" height="388" src="https://www.healthscareonline.com/wp-content/uploads/2024/01/ADDITION-results.png" alt="" class="wp-image-1465" srcset="https://www.healthscareonline.com/wp-content/uploads/2024/01/ADDITION-results.png 608w, https://www.healthscareonline.com/wp-content/uploads/2024/01/ADDITION-results-300x191.png 300w, https://www.healthscareonline.com/wp-content/uploads/2024/01/ADDITION-results-80x50.png 80w, https://www.healthscareonline.com/wp-content/uploads/2024/01/ADDITION-results-94x60.png 94w, https://www.healthscareonline.com/wp-content/uploads/2024/01/ADDITION-results-163x103.png 163w" sizes="auto, (max-width: 608px) 100vw, 608px" /></a></figure>



<p>There is another set of studies that have a similar spirit of comprehensive CVD care called “polypill” studies. They typically contain 4 or 5 medications in once-daily pills such as statins, diuretics, beta blockers, ACE inhibitors, and aspirin. A meta-analysis of 6 polypill trials covering 24,266 patients that measured overall mortality calculated an 11% decrease that was barely statistically significant. Typical follow-up lengths for these kind of studies are about 5 years. Here is the forest plot from that study.</p>



<figure class="wp-block-image"><img decoding="async" src="https://apis.mail.yahoo.com/ws/v3/mailboxes/@.id==VjN-fUqPAAJMMCpbqNaJuQjCcPtsH6WOXbovfifhTSaAWPJxdaWpzbRNoITvlMzMWG3tsdFKgbaBU0iQeGd8O0HeBA/messages/@.id==ABqSal8vpRO8ZZcxuwhJGJDoDLA/content/parts/@.id==6/thumbnail?appid=YMailNorrin&amp;downloadWhenThumbnailFails=true&amp;pid=6" alt="Inline image" title="Inline image"/></figure>



<figure class="wp-block-image size-full"><a href="https://www.healthscareonline.com/wp-content/uploads/2024/01/Polypill-results.png"><img loading="lazy" decoding="async" width="623" height="411" src="https://www.healthscareonline.com/wp-content/uploads/2024/01/Polypill-results.png" alt="" class="wp-image-1466" srcset="https://www.healthscareonline.com/wp-content/uploads/2024/01/Polypill-results.png 623w, https://www.healthscareonline.com/wp-content/uploads/2024/01/Polypill-results-300x198.png 300w, https://www.healthscareonline.com/wp-content/uploads/2024/01/Polypill-results-91x60.png 91w" sizes="auto, (max-width: 623px) 100vw, 623px" /></a></figure>



<p><em>Cost-Effectiveness of CVD treatment</em></p>



<p><a rel="noreferrer noopener" target="_blank" href="https://diabetesjournals.org/care/article/31/8/1510/28536/Cost-Effectiveness-of-Intensified-Versus">The Steno-2 authors actually published a cost-effectiveness analysis</a>, so let’s take a look at what they calculated.</p>



<p>They used a standard approach of a Markov analysis to incorporate risk and event data. They based their model on the first 8 years of treatment. So there is the first funny thing. The Steno-2 study found no difference in CVD deaths or overall mortality at 7.8 years. Yet they state in the paper that there was a 1.9 year difference in undiscounted life expectancy. How can there be a difference in life expectancy if there was no difference in mortality? There can’t be, but let’s press on.</p>



<p>They say that the discounted difference in life expectancy was 1.0 years. They appropriately estimated that the treatment costs on the front end increase to pay for more drugs and clinic visits; and they also included in their model savings from future CVD events. The way they reported out the incremental cost-effectiveness ratios (ICERs) was a little strange, but the bottom line is that they estimated the primary ICER outcome as 2,538 Euros per quality-adjusted life year (QALYs, the standard outcome of the medical cost-effectiveness literature).</p>



<p>In case you missed the point, even the Steno-2 authors, using exaggerated projections of 8-year outcomes from a tiny study, still calculated that aggressive preventive treatment DOES NOT SAVE MONEY.</p>



<p><em>Summary</em></p>



<p>The Steno-2 study was a single outlier study with mortality results that are biologically implausible and contained less than 5% of the subjects than just one of the classic landmark trials in this literature; and less than 1% of the subjects in published meta-analyses.</p>



<p>All of the standard large trials in this literature find that patients have to take their medicines for 6-18 months before any real effect is seen. Then, the results are smooth and consistent over the life of the randomized trial. In the Steno-2 study, there was absolutely no difference in outcomes over 7.8 years, then a massive jump in deaths in the “control group” AFTER they were put on the intensive treatment. This means that the intensive treatment killed people!! (I’m being a little facetious here. There is a 99% chance the long-term Steno-2 outcome was nothing more than a statistical fluke. It happens all the time in small randomized controlled trials. If you want to learn more about this phenomenon,&nbsp;<a rel="noreferrer noopener" target="_blank" href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0020124&amp;xid=17259,15700019,15700186,15700190,15700248">here is a paper by John Iaonnidis, MD</a>, who is one of the gurus of evidence-based medicine.)</p>



<p><em>Take home points</em></p>



<p>Here is what you need to know about preventing cardiovascular disease in primary care.</p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;It helps a little. A better way of thinking about this is that treating high blood pressure, high cholesterol, and diabetes DELAYS heart attacks and deaths more than it PREVENTS heart attacks and deaths.</p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;The magnitude of the benefit for high-risk people is on the order of a few months of increased life-expectancy per chronic disease to maybe a year-ish.</p>



<p>o&nbsp;&nbsp;&nbsp;Actually,&nbsp; the Steno-2 cost-effectiveness study supports this statement. It treated diabetics with pre-existing kidney damage, which is a fairly high-risk group. It calculated an increase in discounted life expectancy of 1 year over 8 years of treatment. If it treated 3 different conditions and the outcomes were additive, then this works out to be about 3-4 months of life expectancy per disease.</p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;The magnitude of benefit for low-risk people is on the order of a few weeks of life expectancy per chronic disease.&nbsp; Low-risk could mean the patient is relatively young, 20s – 40s roughly. It could also mean the patient has a mild case of the chronic disease: barely elevated blood pressure easily treated with one common drug, for example.</p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;There are a few exceptions in really high-risk patients with bad versions of the common chronic diseases, but treating any of the common CVD prevention chronic diseases DOES NOT LOWER THE TOTAL COST OF CARE.&nbsp; In this arena, medical economics realities are like most other economic realities—BETTER OUCOMES COST MORE.</p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Therefore, the Starfield-type findings that places with more family docs and fewer ologists enjoy better outcomes at a lower cost CANNOT BE EXPLAINED BY MORE CVD-RISK CHRONIC DISEASE CARE.</p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;And therefore, any efforts to “support” primary care in helping lower the total cost of care by beating on the family physicians to do more chronic disease care set them up to fail.</p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Real efforts to use primary care to attempt to reduce healthcare costs must identify and support a completely different set of constructs such as</p>



<p>o&nbsp;&nbsp;&nbsp;Comfort with uncertainty in medical decision making (and an overall comfort with death)</p>



<p>o&nbsp;&nbsp;&nbsp;Providing actual comprehensive care of nearly 2,000 symptoms and diagnoses</p>



<p>o&nbsp;&nbsp;&nbsp;Incentivizing as few referrals to ologists as possible</p>



<p>o   Real continuity of family physician to patient (not team to patient)</p>



<p>o&nbsp;&nbsp;&nbsp;Decreased emphasis on team-based care (I&#8217;ll talk more about this in the next post)</p>



<p>o&nbsp;&nbsp;&nbsp;Incentivizing family physicians to cover more patient responsibilities outside of 8-5 M-F.</p>



<p>o&nbsp;&nbsp;&nbsp;Incentivizing family physicians to have primary care responsibility for their own patients in the hospital</p>



<p>o&nbsp;&nbsp;&nbsp;Abandon the CPT billing system for family medicine.</p>



<p>o&nbsp;&nbsp;&nbsp;Creating micro-environments where the easiest thing for a patient to do when he/she has a concern is call or visit their family physician (as opposed to going to urgent care or the ER). This means that a live human actually is paid to answer the call, which means the practice is paid enough to pay for these humans. To achieve this, the family physicians must have slack in their work systems. Each of their days need enough of them present to handle surge capacity. Part of the justification for high charges in the ER is this concept. This payment concept needs to move to the primary care arena.</p>



<p>o&nbsp;&nbsp;&nbsp;Finding patients who are also comfortable with uncertainty and who are willing to make sacrifices for the good of the healthcare system.</p>



<p>OK, that’s a lot to digest. I’ll post part 2 of this discussion in about a week.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/misleading-conclusions-on-outcomes-of-cardiovascular-disease-chronic-care/">Misleading Conclusions on Outcomes of Cardiovascular Disease Chronic Care</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
		
		
			</item>
		<item>
		<title>The Micro-Economics of Healthcare &#8212; Older Diabetes Treatments</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-micro-economics-of-healthcare-older-diabetes-treatments/</link>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Thu, 13 Oct 2022 02:02:33 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[cost-effectiveness]]></category>
		<category><![CDATA[diabetes]]></category>
		<category><![CDATA[healthcare costs]]></category>
		<category><![CDATA[insulin]]></category>
		<category><![CDATA[metformin]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=1439</guid>

					<description><![CDATA[<p>The topic today is some of the older diabetes treatments. I’ll cover some of the newer agents–jardiance, ozempic, trulicity, and so on–next month. The cost-effectiveness literature covers individual drugs and overall goals such as “intensive glucose control” or “goal of normoglycemia.” Before I get into the details, I will try to explain the overall findings this way. What is the most likely cause of death for a poorly controlled diabetic? A heart attack. What is the most likely cause of death for a well-controlled diabetic? A heart attack. Our U.S. language on chronic disease and outcomes is at best imprecise, and at worst, just wrong. When common chronic diseases are appropriately treated, they don’t PREVENT death, they DELAY death. From a policy perspective, each healthcare system must decide how much it’s willing to pay for an extra number of weeks of life expectancy. If a new drug for diabetes or any other chronic disease costs too much, according to that country’s cut-offs, they don’t buy the drug. This is the main reason the U.S. has twice as many adults on statins as any European country. The U.S. has no such cut-off. In fact, Medicare is prohibited from considering cost in [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-micro-economics-of-healthcare-older-diabetes-treatments/">The Micro-Economics of Healthcare — Older Diabetes Treatments</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>The topic today is some of the older diabetes treatments. I’ll cover some of the newer agents–jardiance, ozempic, trulicity, and so on–next month.</p>



<p>The cost-effectiveness literature covers individual drugs and overall goals such as “intensive glucose control” or “goal of normoglycemia.”</p>



<p>Before I get into the details, I will try to explain the overall findings this way. What is the most likely cause of death for a poorly controlled diabetic? A heart attack. What is the most likely cause of death for a well-controlled diabetic? A heart attack.</p>



<p>Our U.S. language on chronic disease and outcomes is at best imprecise, and at worst, just wrong. When common chronic diseases are appropriately treated, they don’t PREVENT death, they DELAY death. From a policy perspective, each healthcare system must decide how much it’s willing to pay for an extra number of weeks of life expectancy. If a new drug for diabetes or any other chronic disease costs too much, according to that country’s cut-offs, they don’t buy the drug. This is the main reason the U.S. has twice as many adults on statins as any European country.</p>



<p>The U.S. has no such cut-off. In fact, Medicare is prohibited from considering cost in its coverage determinations.</p>



<p>OK, let’s look at a couple of these cost-effectiveness studies in more detail.</p>



<p><a href="https://care.diabetesjournals.org/content/20/5/735.abstract" target="_blank" rel="noopener" title="">A study from 1997</a> using 1994 dollars compared a goal of “normoglycemia,” defined as a hemoglobin A1c of 7.2% vs. 10%, using several medicines including insulin. Of course, they didn’t assume insulin would cost $300/vial. They assumed it would cost a little over $1,000 per year, but the other pills (metformin when it was new to the U.S. and glyburide) would be about $3,000/year. Of course, the costs have changed. There were other modest assumptions about cost such as a case of severe hypoglycemia costing $268.</p>



<p>They estimated that the life expectancy would increase by 1.3 years. They calculated that the incremental cost-effectiveness ratio (ICER) was ~$16,000/QALY. Not too bad, but not cost saving.</p>



<p>Here is a similar study:</p>



<p><a href="https://care.diabetesjournals.org/content/29/2/259.short" target="_blank" rel="noopener" title="">Generic “intensive glucose control” </a>&#8212; $78,000/QALY</p>



<p>As you might imagine, there is an extensive literature on single agents, almost always funded by the drug manufacturer. Meta-analyses of this literature has found what you probably expect: drug company-funded studies are more likely to calculate lower ICERs. Trying to find valid U.S.-based studies can actually be a little tedious. The literature is full of studies that sound like, “The cost-effectiveness of of thiazolidinedione added to metformin in poorly controlled patients with diabetes in Slovenia.” Of course, their cost estimates are, legitimately, much lower than the U.S. Here is a sampling of single agent studies using U.S. costs, if possible.</p>



<p></p>



<p><a href="https://link.springer.com/article/10.2165/00019053-200624001-00003" target="_blank" rel="noopener" title="Thiazolidinedione in the UK">Thiazolidinedione in the UK</a> &#8212; £16,000/QALY</p>



<p><a href="https://pubmed.ncbi.nlm.nih.gov/20056950/" target="_blank" rel="noopener" title="">Sitagliptin vs. glyburide as a second-line agent on top of metformin</a> &#8212; $169,500/QALY (BTW, calculates an increase of 1 ½ months of life expectancy)</p>



<p><a href="https://link.springer.com/article/10.1007/BF02849895" target="_blank" rel="noopener" title="">Insulin detemir </a>&#8212; $4,000-$7,000/QALY</p>



<p></p>



<p><a href="https://link.springer.com/article/10.2165/00019053-200725030-00007" target="_blank" rel="noopener" title="Insulin glargine vs. NPH in Canada ">Insulin glargine vs. NPH in Canada </a>&#8212; $8,000/QALY</p>



<p>For all of these treatments, the micro-economics of healthcare are most similar to everything else in micro-economics: better outcomes cost more. How much each country is willing to spend to squeeze out a few more weeks of life expectancy is up to each country. The U.S. is unwilling to set cost limits. That’s one of the main reasons why we have the exorbitantly expensive system we have.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-micro-economics-of-healthcare-older-diabetes-treatments/">The Micro-Economics of Healthcare — Older Diabetes Treatments</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
		
		
			</item>
		<item>
		<title>Micro-Economics of Healthcare – Screening and Preventing Diabetes</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/micro-economics-of-healthcare-screening-and-preventing-diabetes/</link>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Sun, 11 Sep 2022 21:22:03 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[cost-effectiveness]]></category>
		<category><![CDATA[diabetes]]></category>
		<category><![CDATA[prevention]]></category>
		<category><![CDATA[screening]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=1436</guid>

					<description><![CDATA[<p>Since diabetes was the disease that started me on this journey, I’ll get into it now. I’ll break this huge issue into smaller posts. Since I went into great detail about the methods of the literature with the hypertension post, I’ll keep these shorter. Screening for and preventing diabetes does not save money. There are a number of published cost-effectiveness analyses on these topics. A nice review appeared in Diabetes Care in 2010. The general pattern is that the higher the risk for diabetes in a patient population, the more cost-effective the screening is. For high-risk patients, the ICER could be in the $3,000/QALY range. For lower-risk patients, or those with limited life expectancy, it can be over $1,000,000/QALY. To prevent diabetes in high-risk patients, there is a similar pattern. These studies are one step past screening costs and assume the high-risk patient just showed up. Interventions could include interventions from lifestyle counseling to metformin treatment, in high-risk patients with pre-diabetes or impaired glucose tolerance. The range of ICERs is large, very dependent on assumptions about the underlying risk of the patient, cost assumptions, long-term outcomes, and so on. More optimistic studies in higher-risk patients calculate ICERs in the low [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/micro-economics-of-healthcare-screening-and-preventing-diabetes/">Micro-Economics of Healthcare – Screening and Preventing Diabetes</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>Since diabetes was the disease that started me on this journey, I’ll get into it now. I’ll break this huge issue into smaller posts. Since I went into great detail about the methods of the literature with the hypertension post, I’ll keep these shorter.</p>



<p>Screening for and preventing diabetes does not save money. There are a number of published cost-effectiveness analyses on these topics. <a href="https://diabetesjournals.org/care/article/33/8/1872/39197/Cost-Effectiveness-of-Interventions-to-Prevent-and" target="_blank" rel="noopener">A nice review appeared in Diabetes Care in 2010.</a></p>



<p>The general pattern is that the higher the risk for diabetes in a patient population, the more cost-effective the screening is. For high-risk patients, the ICER could be in the $3,000/QALY range. For lower-risk patients, or those with limited life expectancy, it can be over $1,000,000/QALY.</p>



<p>To prevent diabetes in high-risk patients, there is a similar pattern. These studies are one step past screening costs and assume the high-risk patient just showed up. Interventions could include interventions from lifestyle counseling to metformin treatment, in high-risk patients with pre-diabetes or impaired glucose tolerance. The range of ICERs is large, very dependent on assumptions about the underlying risk of the patient, cost assumptions, long-term outcomes, and so on. More optimistic studies in higher-risk patients calculate ICERs in the low thousands/QALY. On the other end of the spectrum, the ICER could be over $100,000/QALY.</p>



<p>For screening’s impact on mortality, the highest assumption in <a href="https://jamanetwork.com/journals/jama/article-abstract/188201" target="_blank" rel="noopener">one of the major studies </a>for increased life expectancy was 1.5 months in 25-34-year-olds. For prevention through treatment, <a href="https://www.acpjournals.org/doi/abs/10.7326/0003-4819-143-4-200508160-00006" target="_blank" rel="noopener">an overall estimate </a>for increased life expectancy in adults with impaired glucose tolerance was 3 months.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/micro-economics-of-healthcare-screening-and-preventing-diabetes/">Micro-Economics of Healthcare – Screening and Preventing Diabetes</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
		
		
			</item>
		<item>
		<title>The Micro-Economics of Healthcare: Hypertension</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-micro-economics-of-healthcare-hypertension/</link>
					<comments>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-micro-economics-of-healthcare-hypertension/#comments</comments>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Wed, 31 Aug 2022 04:14:49 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[cost-effectiveness]]></category>
		<category><![CDATA[healthcare costs]]></category>
		<category><![CDATA[hypertension]]></category>
		<category><![CDATA[micro-economics]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=1432</guid>

					<description><![CDATA[<p>I&#8217;m on an email group whose members are heavy into the money side of healthcare. They are fighting back against our exorbitantly expensive healthcare system. The members of this group know a lot about the macro-economics of healthcare—overall spend, spend by major categories, some cross-national comparisons—and the finance of healthcare—carve-outs, loss ratios, those god-awful PBMs, and so on. But they don’t understand the micro-economics of healthcare. My trigger was this statement: I wonder if any any of the group know of good quality $ data on the cost savings to health plans from diabetes chronic care programs, &#160;So, linking HbA1c improvement (clinical) tp hard cost savings for health plans (which is their only interest). We all know that story. Improving A1Cs across a population of diabetics does not lower healthcare costs, in the short term or the long term. This group’s grand muse, Al, has told you that chronic disease costs are not as big a driver of the overall spend as other conditions, but that message does not seem to be taking hold of the collective consciousness. I am determined to teach open-minded people the micro-economic realities of healthcare. This science is 47 years old. The July 31, 1975 [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-micro-economics-of-healthcare-hypertension/">The Micro-Economics of Healthcare: Hypertension</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>I&#8217;m on an email group whose members are heavy into the money side of healthcare. They are fighting back against our exorbitantly expensive healthcare system. The members of this group know a lot about the macro-economics of healthcare—overall spend, spend by major categories, some cross-national comparisons—and the finance of healthcare—carve-outs, loss ratios, those god-awful PBMs, and so on.</p>



<p>But they don’t understand the micro-economics of healthcare. My trigger was this statement:</p>



<p><em>I wonder if any any of the group know of good quality $ data on the cost savings to health plans from diabetes chronic care programs, &nbsp;So, linking HbA1c improvement (clinical) tp hard cost savings for health plans (which is their only interest). We all know that story.</em></p>



<p>Improving A1Cs across a population of diabetics does not lower healthcare costs, in the short term or the long term. This group’s grand muse, Al, has told you that chronic disease costs are not as big a driver of the overall spend as other conditions, but that message does not seem to be taking hold of the collective consciousness.</p>



<p>I am determined to teach open-minded people the micro-economic realities of healthcare.</p>



<p>This science is 47 years old. The July 31, 1975 issue of NEJM is where this began. I will back up all my assertions with links to articles from the standard peer-reviewed medical literature. This is not only a U.S. science. These approaches are the basis for the coverage decisions of every other major developed country in the world. The National Institute for Health and Care Excellence (NICE) in the UK is the most transparent about how they decide what they’ll pay for healthcare interventions, but all other countries have an agency with a similar mission. In contrast, it is illegal for U.S. Medicare to consider cost-effectiveness in its coverage determinations.</p>



<p>There are many facets to the chronic care of diabetes so it’s a little more complicated than other chronic diseases. I’ll start with a simpler disease, hypertension. I’ll cover diabetes in later posts, if Brian approves of course.</p>



<p>The methodology for these cost-effectiveness studies were standardized in 1996. An update appeared in 2016—in a book called Cost-Effectiveness in Health and Medicine. I won’t get into the deep weeds on methodology, unless people have questions. The outcome of a cost-effectiveness analysis study is the incremental cost-effectiveness ratio (ICER). The unit of measurement of an ICER is the dollars spent/saved per quality-adjusted life year (QALY).</p>



<p>The cost trade-off for all chronic diseases is that there are costs on the front end for services like doctors’ visits, tests, and medications that may or may not pay off with lower treatment costs decades later. For hypertension in particular, the associated bad diseases of heart attacks and strokes may not appear for 50 years.</p>



<p>One of the disconnects I’ve observed in people who don’t understand the inputs and outputs of chronic disease care is that they over-estimate the incidence of the long-term outcomes and the effectiveness of treatments. Just because you have high blood pressure that is well treated on medication does not mean you will never have a stroke or heart attack.</p>



<p>Here’s the evidence:</p>



<p>One of the earliest comprehensive cost-effectiveness analyses was in a 1990 Annals of Internal Medicine study. <a href="about:blank">https://www.acpjournals.org/doi/abs/10.7326/0003-4819-112-3-192</a> One of the authors was Harold Sox, MD, who was one of the early leaders of the evidence-based medicine movement. They concluded that “the absolute benefits of screening are quite small. Under our base-case assumptions, the average screenee (someone screened once for hypertension) can expect to save between 1 and 20 days of quality-adjusted life.” This study assumed about 20% of the screened population would have hypertension, so the increased life expectancy per hypertensive patient would be about 5 days to 3 months. The ICER for a 40-year-old man was $16,280/QALY, for a 40-year-old woman $23,216.</p>



<p>These positive numbers mean that the cost of the screening and treatment outweighed future savings. Therefore, this service increases the total cost of care over the short term and the long term.</p>



<p>In the same year in JAMA, a study looked at the ICERs for different drug class treatments over a lifetime of treatment. <a href="about:blank">https://jamanetwork.com/journals/jama/article-abstract/380290</a>. They calculated the total costs and outcomes for the U.S. population with hypertension. For the cheapest drug, propranolol, the total cost of therapy was $85.8 billion, the cost of saved events was $39.7 billion, for a net increase in costs of $46.1 billion. This resulted in a cost per year of life saved of $10,900. More expensive drugs had higher ICERs. They did not quality adjust in this study.</p>



<p>There have been studies is specific sub-populations. This one is from the UKPDS type 2 diabetes study.</p>



<p><a href="about:blank">https://pubmed.ncbi.nlm.nih.gov/9732339/</a> They compared tight blood pressure control (&lt;180/105) vs. loose control (&lt;150/85). Life expectancy improved by 9.7 months, 5 if future events are discounted at 6%. They found treating hypertension in diabetics to be relatively inexpensive, but not cost saving at £1049/QALY. Diabetics are more effected by the vascular damage of hypertension than non-diabetics, therefore one would expect that treatment would have a larger effect on life expectancy and would therefore be more cost-effective.</p>



<p>Some studies looked at cost-effectiveness in a slightly different way. This study looked at the net cost per coronary event prevented. <a href="about:blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC286247/</a>. It didn’t explicitly report change in life expectancy. It calculated the cost to prevent a coronary event was $18,300 for “intensive antihypertensive” treatment.</p>



<p>The treatment of hypertension doesn’t have to be just pills. This study looked at the added value of case management in vulnerable populations. <a href="about:blank">https://pubmed.ncbi.nlm.nih.gov/29239999/</a>. It estimated an increased life expectancy of .04 QALYs at a cost of $52,850/QALY.</p>



<p>This 2011 study appropriately pointed out that some of the cost-effectiveness studies for hypertension assumed brand drug pricing and estimated that the true cost-effectiveness was better at generic prices.</p>



<p><a href="about:blank">https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010.0431</a>. It calculated $52,983/QALY with brand-name drug and $7,753/QALY for generic. Again, there the total cost goes up with treatment.</p>



<p>There are a few dissenting studies.</p>



<p>In 1977, there was a study published before the first consensus statement on cost-effectiveness methodology was published that found a very high impact of treating hypertension.</p>



<p><a href="about:blank">https://www.nejm.org/doi/10.1056/NEJM197703312961307</a>. They calculated an increased life expectancy for treating hypertension of 2.3 to 5.0 years for women, 1.4 to 8.1 for men. As you can see from the other examples, this is the clear outlier on the effectiveness of treating hypertension. In spite of this huge estimated positive impact of treatment, they estimated no cost savings.</p>



<p>For some reason, the CDC wrote 2 studies that found small savings. In 2002, the CDC published a study in JAMA that calculated the ICER for “intensified hypertension control” in type 2 diabetics as cost saving. It decreased the total spend by about 2%. <a href="about:blank">https://pubmed.ncbi.nlm.nih.gov/12020335/</a></p>



<p>The CDC also published an estimate of the benefit of “Intensified hypertension control” based on UKPDS study findings. This is odd given that the British researchers who conducted the UKPDS trial found that treating hypertension at British drug and clinic prices didn’t cost much, but it was not cost saving.</p>



<p><a href="about:blank">https://pubmed.ncbi.nlm.nih.gov/12020335/</a>. The CDC estimated that “intensified hypertension control” increased life expectancy by 0.40 to 0.47 QALYs and was cost saving.</p>



<p>I’ll finish with a 2015 study in NEJM that asked the question, “what if we magically found all untreated people with hypertension in the U.S. and treated them (in other words, no costs for outreach and clinic visits to find these people)?” <a href="about:blank">Cost-Effectiveness of Hypertension Therapy According to 2014 Guidelines | NEJM</a>. Their results were more nuanced. They estimated that treating hypertension was cost-saving for men and women ages 60-74, and cost saving for men with more severe hypertension (&gt;160/100) at ages 33-74. For women with more severe disease, the cost was $26,000/QALY ages 33-44, but cost saving for other ages. For men and women with an untreated pressure of &gt;140/90, the overall ICER for men was $40,000/QALY, for women it ranged from $7,000 to $181,000/QALY. And remember, these cost estimates are biased low because they did not add costs that would be required to discover these people to treat them.</p>



<p>Now let’s dig a little deeper into their estimates. For men, they assumed that 2.4 million new cases of stage 1 hypertension in males ages 35-59 would be discovered and treated. The number of CVD events in this population would decrease from 195,000 to 179,000 (8% decrease) over 10 years, CVD deaths from 49,100 to 46,200 (6% decrease), CVD costs from $32.5 billion to $31.9 billion (2% decrease), and QALYS from 44,162 to 44,187 (.05% increase).&nbsp; For females, the numbers are CVD events 101,000 to 100,000 (1% decrease), CVD deaths 20,600 to 20,400 (1% decrease), CVD costs $20.3 billion to $20.2 billion (.4% increase), and QALYs 44,995 to 44,998 (.01% increase).</p>



<p>Summary</p>



<p>The overall summary of 40+ years of cost-effectiveness studies of hypertension treatment is that it helps patients a little from slightly fewer heart attacks and strokes, and increases the total cost of healthcare. It increases life expectancy in higher-risk patients by less than a year, a few weeks to a few months in lower risk patients.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-micro-economics-of-healthcare-hypertension/">The Micro-Economics of Healthcare: Hypertension</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
					<wfw:commentRss>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-micro-economics-of-healthcare-hypertension/feed/</wfw:commentRss>
			<slash:comments>1</slash:comments>
		
		
			</item>
		<item>
		<title>Family Physician Work Administrators Never See</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/family-physician-work-administrators-never-see/</link>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Thu, 24 Feb 2022 16:53:54 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[cost-effectiveness]]></category>
		<category><![CDATA[family medicine]]></category>
		<category><![CDATA[family physicians]]></category>
		<category><![CDATA[payment reform]]></category>
		<category><![CDATA[physician payment]]></category>
		<category><![CDATA[primary care]]></category>
		<guid isPermaLink="false">https://www.healthscareonline.com/?p=1425</guid>

					<description><![CDATA[<p>A very smart person in the healthcare benefits space wrote that family physicians can&#8217;t influence much the top 25 most costly DRGs in hospitals. Here was my response: There are many reasons this isn&#8217;t true. But it&#8217;s understandable that a benefits or administrative person would have no inkling of this, because in many cases there is no way for the administrator to see what&#8217;s happening on the ground. In the interest of not repeating my points too much, I took the top 10 from the list you referenced and commented below: ·&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;Major joint replacement o&#160;&#160;&#160;Family docs talk their patients out of unnecessary surgery, inject joints with steroids (which usually more delays the inevitable, to be perfectly honest), and send people to PT instead of the cutters. o&#160;&#160;&#160;This is invisible to plan administrators and benefits people because there are no CPT codes to report this work of talking patients out of procedures. ·&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;Vaginal delivery o&#160;&#160;&#160;Family docs prescribe birth control to their female patients, including placing IUDs and Nexplanons. o&#160;&#160;&#160;BTW, the fertility rate in the US is rapidly dropping. I’m sure it’s more caused by larger social and economic forces than healthcare system forces. ·&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;Spinal fusion o&#160;&#160;&#160;Family docs talk their patients out [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/family-physician-work-administrators-never-see/">Family Physician Work Administrators Never See</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>A very smart person in the healthcare benefits space wrote that family physicians can&#8217;t influence much the top 25 most costly DRGs in hospitals. Here was my response:</p>



<p>There are many reasons this isn&#8217;t true. But it&#8217;s understandable that a benefits or administrative person would have no inkling of this, because in many cases there is no way for the administrator to see what&#8217;s happening on the ground. In the interest of not repeating my points too much, I took the top 10 from the list you referenced and commented below:</p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Major joint replacement</p>



<p>o&nbsp;&nbsp;&nbsp;Family docs talk their patients out of unnecessary surgery, inject joints with steroids (which usually more delays the inevitable, to be perfectly honest), and send people to PT instead of the cutters.</p>



<p>o&nbsp;&nbsp;&nbsp;This is invisible to plan administrators and benefits people because there are no CPT codes to report this work of talking patients out of procedures.</p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Vaginal delivery</p>



<p>o&nbsp;&nbsp;&nbsp;Family docs prescribe birth control to their female patients, including placing IUDs and Nexplanons.</p>



<p>o&nbsp;&nbsp;&nbsp;BTW, the fertility rate in the US is rapidly dropping. I’m sure it’s more caused by larger social and economic forces than healthcare system forces.</p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Spinal fusion</p>



<p>o&nbsp;&nbsp;&nbsp;Family docs talk their patients out of unnecessary surgery, and send people to PT instead of the cutters. They also send them to pain management types, though the evidence for that is pretty weak. A lot of the family docs’ work is in getting the patient to more humbly accept that they will have pain the rest of their life and that there is no magic technology to change that.</p>



<p>o&nbsp;&nbsp;&nbsp;This is invisible to plan administrators and benefits people because there are no CPT codes to report this work.</p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Ecmo or trach with mechanical ventilation 96+ hours.</p>



<p>o&nbsp;&nbsp;&nbsp;Maybe some small effects by family docs talking to really sick multi-morbid patients into palliative approaches, both in the hospital after the severe physiologic insult and before they get this bad in their clinics.</p>



<p>o&nbsp;&nbsp;&nbsp;This is invisible to plan administrators and benefits people because the family docs are not fairly paid for this work.</p>



<p>§&nbsp;&nbsp;There is a CPT code for advance care planning, but it doesn’t pay well and its documentation requirements are burdensome. I’m also not sure how many insurance companies actually pay the code.</p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Extreme immaturity, neonate</p>



<p>o&nbsp;&nbsp;&nbsp;Family docs who provide prenatal care may be able to help this rate, a little.o&nbsp;&nbsp;&nbsp;The overwhelming bigotry in the U.S. against family docs delivering babies and providing prenatal care&nbsp;impacts their ability to do a whole lot about this diagnosis.</p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Cesarean section</p>



<p>o&nbsp;&nbsp;&nbsp;See vaginal delivery.</p>



<p>o&nbsp;&nbsp;&nbsp;There is evidence that family physicians care for pregnant patients with more social determinant challenges, but have lower C-section rates.</p>



<p>o&nbsp;&nbsp;&nbsp;<a rel="noreferrer noopener" target="_blank" href="https://www.jabfm.org/content/34/1/181.abstract">https://www.jabfm.org/content/34/1/181.abstract</a></p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Cardiovascular procedures with stent</p>



<p>o&nbsp;&nbsp;&nbsp;Family docs make a small dent in this by treating their high-risk patients with statins, and so on.</p>



<p>o&nbsp;&nbsp;&nbsp;Family docs manage chest pain in their office, when appropriate, and don’t tell every patient with chest pain to go to the ER.</p>



<p>§&nbsp;&nbsp;Especially the more confident, comprehensive family docs. I acknowledge that a lot of family docs lack confidence, especially those who were trained in traditional academic settings. In medical school and their family medicine residencies, they are told by the other ologists that they are too stupid to care for sick patients. Unfortunately, many believe it.</p>



<p>o&nbsp;&nbsp;&nbsp;Family docs treat patients with severe refractory disease by suggesting palliative approaches.</p>



<p>o&nbsp;&nbsp;&nbsp;The 2<sup>nd</sup>&nbsp;and 3<sup>rd</sup>&nbsp;bullet points are invisible to plan administrators and benefits people because there are no CPT codes to report this work.</p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Psychoses</p>



<p>o&nbsp;&nbsp;&nbsp;Family docs care for more mental illness than the psychiatrists. They manage these conditions in their offices and don’t tell every patient having a bad day to go to the psychiatric ER.</p>



<p>o&nbsp;&nbsp;&nbsp;Their ability to manage these complex patients is hampered by a general CPT coding and payment system that devalues mental health care, especially those with both psychiatric and organic medical disease. Those are easily the hardest patients to care for. It is never easy to sort out which symptoms are organic vs. psychiatric. But family physicians often reassure patients in nebulous situations without ordering scans from head to toe and chem 2000 panels.</p>



<p>o&nbsp;&nbsp;&nbsp;This is invisible to plan administrators and benefits people because there are no CPT codes to report this work or these judgement calls. We don’t get paid to not do stuff to people.</p>



<p>·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Septicemia or severe sepsis w/o mechanical ventilation</p>



<p>o&nbsp;&nbsp;&nbsp;Some of the family docs who work in hospitals might be able to impact this a bit, mostly by not over diagnosing sepsis. The challenge here is that the DRGs for the hospitals are so rigged to incentivize the diagnosis.</p>



<p>o   There are meta-analyses that basically conclude that the only thing that really changes the outcomes in sepsis is starting antibiotics for the underlying cause ASAP. Family docs might make a bit of an impact here by seeing a sick patient in their office who really needs to go to a hospital and starting antibiotics in their office.</p>



<p>A lot of health benefits people think they understand primary care and its contributions to the health care system &#8212; and how things could be better &#8212; but they don&#8217;t fully. It&#8217;s not entirely their fault. If the payers have given us no mechanism to describe the valuable work we do, how would they know? And where is the AAFP doing anything to tell this story to major employers, insurance companies, and policy makers?</p>



<p>If family medicine won&#8217;t grow a spine and tell its story more effectively, then its clear that no one else will step in and do it for them.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/family-physician-work-administrators-never-see/">Family Physician Work Administrators Never See</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
		
		
			</item>
		<item>
		<title>In Defense of Dying For the Economy</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/in-defense-of-dying-for-the-economy/</link>
					<comments>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/in-defense-of-dying-for-the-economy/#comments</comments>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Thu, 09 Apr 2020 03:38:11 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[artificial life support]]></category>
		<category><![CDATA[cost-effectiveness]]></category>
		<category><![CDATA[Covid-19]]></category>
		<category><![CDATA[healthcare costs]]></category>
		<category><![CDATA[healthcare outcomes]]></category>
		<category><![CDATA[life expectancy]]></category>
		<category><![CDATA[mechanical ventilation]]></category>
		<category><![CDATA[rule of rescue]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=1385</guid>

					<description><![CDATA[<p>The Texas Lieutenant Governor, Dan Patrick, was recently lambasted by much of the press for his comments in an interview he did on the Fox network. He said that he is 69 years old and he was willing to take the chance that he could be infected from the COVID-19 virus and die from it in order to protect the economy from public health measures such as shutting down non-essential businesses. New York&#8217;s governor Cuomo responded that his elderly parents did not agree. Let&#8217;s remember that Lt. Gov. Patrick was a radio and television talk show host before he was elected. It&#8217;s just in his nature to speak in dramatic terms. But what Lt. Gov. Patrick said actually represents a difficult truth. We have a choice in this country of how we react to COVID-19 and how that choice impacts the economy. Unfortunately, we must talk about lives and dollars in the same sentence. I read an economic study recently where economists modeled different projections of the spread of COVID-19 and how it would affect the economy. It was a commissioned study that I was asked to review from another state, so I can&#8217;t share the details. The gist of [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/in-defense-of-dying-for-the-economy/">In Defense of Dying For the Economy</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>The Texas Lieutenant Governor, Dan Patrick, <a href="https://www.usatoday.com/story/news/nation/2020/03/24/covid-19-texas-official-suggests-elderly-willing-die-economy/2905990001/" class="aioseop-link">was recently lambasted by much of the press</a> for his comments in an interview he did on the Fox network. He said that he is 69 years old and he was willing to take the chance that he could be infected from the COVID-19 virus and die from it in order to protect the economy from public health measures such as shutting down non-essential businesses. New York&#8217;s governor Cuomo responded that his elderly parents did not agree.</p>



<p>Let&#8217;s remember that Lt. Gov. Patrick was a radio and television talk show host before he was elected. It&#8217;s just in his nature to speak in dramatic terms.</p>



<p>But what Lt. Gov. Patrick said actually represents a difficult truth. We have a choice in this country of how we react to COVID-19 and how that choice impacts the economy. Unfortunately, we must talk about lives and dollars in the same sentence.</p>



<p>I read an economic study recently where economists modeled different projections of the spread of COVID-19 and how it would affect the economy. It was a commissioned study that I was asked to review from another state, so I can&#8217;t share the details. The gist of the study was that if the virus was allowed to spread rapidly there would be hundreds of thousands of deaths quickly, maybe up to 2 million, but the hit on the economy would be brief and short lived. If we flatten the curve, and as I&#8217;m sure everybody has heard that concept a dozen times by now, then the deaths are minimized but the recession is deep and wide.</p>



<p>What is the total hit to the U.S. economy of the COVID-19 pandemic? All the reports I reviewed estimated a GDP contraction of about 3%-6% for 2-3 years. <a href="https://www.kpmg.us/content/dam/global/pdfs/2020/CoronaVirus_04_01_20_MiniChartBook_Final2.pdf" class="aioseop-link">A report from KPMG</a> estimated the Federal Reserve will add about $6 trillion to its balance sheet, so let’s go with that number for now.</p>



<p>What are they doing in other developed countries? Italy and Spain were hit early and hard. They did not have much time or capacity to think about much of anything other than just trying to cope with the crisis. As hospitals become overwhelmed in Italy, <a href="https://www.theatlantic.com/ideas/archive/2020/03/who-gets-hospital-bed/607807/" class="aioseop-link">ICU doctors there disconnected patients on ventilators</a> who had been on the machines for a few days, but were getting worse. Presumably, they used some judgements about which patients to leave on a few more days based on factors such as age and comorbidities. Their justification was that other patients were deteriorating and needed the vents also, but were more likely to survive.</p>



<p>In Britain, Prime Minister Boris Johnson has sounded a little more American than usual, before he went to the ICU at least, talking about expanding ventilator capacity and saving lives, without much suggestion of accepting limits or acknowledging scarce resources.</p>



<p>Worldwide, even in countries with the most advanced ICU technologies, it looks like the <a href="https://www.npr.org/sections/health-shots/2020/04/02/826105278/ventilators-are-no-panacea-for-critically-ill-covid-19-patients" class="aioseop-link">death rate for people who become so sick </a>with COVID-19 they require mechanical ventilation is about 50%. And if the worst of the surge is about to happen in a few weeks, then all of the efforts of non-traditional vent companies to make new vents will mostly be too little/too late, as it <a href="https://www.vox.com/recode/2020/3/20/21186749/ventilators-coronavirus-covid-19-elon-musk" class="aioseop-link">usually takes 2-3 years to invent, test, and approve a new vent model.</a> Even with many regulations and expectations of testing eased, the surge of vents won’t likely materialize until the summer, well past the worst of the surge of cases.</p>



<p>So what is the cost per year of life saved with the choices we have made in the US? This is a very difficult number to even estimate, because there are still so many unknowns. Let’s assume the total hit to the U.S. economy is $6 trillion. For this money, let’s assume that the curve is flattened and one million lives are extended because they didn’t catch COVID and die. This means that it costs roughly $6 million to extend a life.</p>



<p>80% of people dying from COVID-19 are greater than 65 years, and most of those are older than 80. Let’s assume the average age of death is 75. The average life expectancy of a 75-year old in the U.S. is about 10 years. Therefore we are spending about $600,000 per year of life saved.</p>



<p>There was an <a href="https://www.ncbi.nlm.nih.gov/pubmed/3645228" class="aioseop-link">article that was published in 1986</a> that coined the term “rule of rescue.” In a nutshell, the paper observed that people are more willing to spend money on a visible death then an invisible or seemingly random death. For example, people are more likely to support a very expensive chemotherapy for cancer that would not extend a life very much over public health measures that would extend a lot more years of life at a lower average cost per year. This principle is clearly playing out in this pandemic. The ethical question is whether it is defensible that the recognized life extended has more value than the hidden life. Most would say no, but acknowledge the difficult psychology of the situation.</p>



<p>Let me say, as I always do in situations where we must talk about difficult tradeoffs, that the cut-off point of where to spend money and where to say “we simply can&#8217;t afford it,” is not my place nor any other physicians.</p>



<p>But other developed countries are willing to make these difficult trade-off decisions. As a recent example, the UK National Health Service (NHS) refused to pay for advanced cystic fibrosis drugs, because the manufacturer, Vertex, charged too much (per NHS/NICE guidelines). After over 18 months of negotiation, Vertex agreed to lower its price and gave other concessions. Of course the actual price is shrouded in secrecy, but commentators estimate that the <a href="https://www.bmj.com/content/367/bmj.l6206" class="aioseop-link">NHS will spend a little more than £10,000 (about $12,500 U.S.) per year for these drugs,</a> compared to <a href="https://www.atsjournals.org/doi/full/10.1164/rccm.201507-1428ED" class="aioseop-link">about $258,000 per year in the U.S. </a>(This estimate might be a little high because of the all of the PBM rebate games). Undoubtedly over that 18 months, people in the UK with cystic fibrosis died who might have lived longer if they had access to the improved treatment. But the NHS refused to buy the drug that was too expensive, because it has a budget and has to live within certain limits to preserve resources for other aspects of the economy.</p>



<p>And what does this increase of the Federal Reserve’s balance sheet really mean? This is more debt that will be placed squarely on the shoulders of our children and grandchildren. Once the economy gets back on its feet will we raise taxes on ourselves to payback the massive loan to ourselves? That’s laughable.</p>



<p>The tiny glimmer of hope Lt. Gov. Patrick&#8217;s comments can give us, is that he showed it is actually possible for a U.S. politician to talk about lives and dollars of economic impact in the same sentence. When this pandemic finally plays itself out, which I suspect will actually take several years with several recurrent surges, I hope that this brief display of courage to face facts, state transparency of thought, and demonstrate an eyes-open understanding of difficult tradeoffs in health and economic choices, means that we might actually have some of these difficult conversations in the future without completely emotionally melting down.</p>



<p>A boy can dream.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/in-defense-of-dying-for-the-economy/">In Defense of Dying For the Economy</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
					<wfw:commentRss>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/in-defense-of-dying-for-the-economy/feed/</wfw:commentRss>
			<slash:comments>2</slash:comments>
		
		
			</item>
		<item>
		<title>The Worst Corporate Wellness Story Ever</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-worst-corporate-wellness-story-ever/</link>
					<comments>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-worst-corporate-wellness-story-ever/#comments</comments>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Mon, 22 Jul 2019 02:38:05 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[cost-effectiveness]]></category>
		<category><![CDATA[mammograms]]></category>
		<category><![CDATA[mammography]]></category>
		<category><![CDATA[worksite wellness]]></category>
		<category><![CDATA[Yale]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=1360</guid>

					<description><![CDATA[<p>My thanks to Al Lewis of quizzify.com for bringing this story to my attention. It seems that a 57-year-old woman who had a history of a double mastectomy for breast cancer was told by her employer that she had to get her annual screening mammogram or she would be fined each month she didn&#8217;t. She was fined $25 per week, according to her complaint, which equaled the amount this single mother was paying for her kid&#8217;s books. She was contacted several times by the health plan and advised that she receive the required mammogram. She would be fined $25 per week until she did. As if this isn&#8217;t bad enough &#8212; I can just hear this poor woman trying to explain to the young caller from the wellness plan why it made no sense that she get a mammogram (just in case a few readers don&#8217;t fully understand, a double mastectomy means she had both of her breasts cut off. There was nothing left to scan) &#8212; who was her employer? Yale University. Yep, that one. Yale is now being sued for this and other complaints about its wellness program. It&#8217;s wellness vendor was apparently Healthmine. It also seems apparent [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-worst-corporate-wellness-story-ever/">The Worst Corporate Wellness Story Ever</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>My thanks to Al Lewis of quizzify.com for bringing <a href="https://dismgmt.wordpress.com/2019/07/17/the-worst-wellness-story-of-all-time-harassing-a-double-mastectomy-patient-to-get-a-mammogram/">this story to my attention.</a></p>



<p>It seems that a 57-year-old woman who had a history of a double mastectomy for breast cancer was told by her employer that she had to get her annual screening mammogram or she would be fined each month she didn&#8217;t. She was fined $25 per week, according to her complaint, which equaled the amount this single mother was paying for her kid&#8217;s books.</p>



<p>She was contacted several times by the health plan and advised that she receive the required mammogram. She would be fined $25 per week until she did.</p>



<p>As if this isn&#8217;t bad enough &#8212; I can just hear this poor woman trying to explain to the young caller from the wellness plan why it made no sense that she get a mammogram (just in case a few readers don&#8217;t fully understand, a double mastectomy means she had both of her breasts cut off. There was nothing left to scan) &#8212; who was her employer?</p>



<p>Yale University.  Yep, that one. Yale is <a href="https://www.wnpr.org/post/union-workers-file-civil-action-lawsuit-against-yale-over-employee-wellness-program">now being sued for this and other complaints about its wellness program.</a> It&#8217;s wellness vendor was apparently Healthmine. It also seems apparent that no one at Yale or Healthmine understands that doing more mammograms increase the total cost of healthcare, and therefore insurance costs. <a href="https://academic.oup.com/jnci/article/98/11/774/2521606">Here is one example of a cost-effectiveness analysis of mammograms.</a></p>



<p>If Yale doesn&#8217;t understand the stupidities of simplistic algorithmic approaches to healthcare, I guess I should be more understanding of companies that make cars or sell other stuff. </p>



<p></p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-worst-corporate-wellness-story-ever/">The Worst Corporate Wellness Story Ever</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
					<wfw:commentRss>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-worst-corporate-wellness-story-ever/feed/</wfw:commentRss>
			<slash:comments>2</slash:comments>
		
		
			</item>
		<item>
		<title>The Mildly Effective Flu Shot</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-mildly-effective-flu-shot/</link>
					<comments>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-mildly-effective-flu-shot/#comments</comments>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Sat, 29 Sep 2018 15:57:25 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[cost-effectiveness]]></category>
		<category><![CDATA[flu shot]]></category>
		<category><![CDATA[influenza vaccine]]></category>
		<category><![CDATA[mortality]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=1318</guid>

					<description><![CDATA[<p>Flu season is about to be upon us. I’ve written about this before, but it’s been a few years, so I thought I’d update some of the evidence (with my thanks to Juan Gervas, MD for compiling a nice list of relevant studies). This, in the face of the recent CDC proclamation that 80,000 people died of the flu last season. The implication is, of course, that everyone must get their flu shot. How effective is the flu shot? There are different ways to measure this. The CDC reported that the shot has been effective in reducing outpatient visits for the flu by about 40% in the last few years. But this is a relative decrease. What are the absolute numbers? A Cochrane review of 52 trials over 40 years found that the absolute decrease went from 2.3% to 0.9% of adults who caught the flu, or 1.4% total (NNT 71). There was no evidence that the vaccine reduces missed days from work, hospitalizations, or deaths. Similar results were found in a separate review of the vaccine in children. How many people in the U.S. die of the flu each year? The CDC historically states that around 30-40,000 people die each [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-mildly-effective-flu-shot/">The Mildly Effective Flu Shot</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>Flu season is about to be upon us. <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/humility-and-the-flu/">I’ve written about this before</a>, but it’s been a few years, so I thought I’d update some of the evidence (with my thanks to Juan Gervas, MD for compiling a nice list of relevant studies). This, in the face of the recent CDC proclamation that 80,000 people died of the flu last season. The implication is, of course, that everyone must get their flu shot.</p>
<p>How effective is the flu shot?</p>
<p>There are different ways to measure this. <a href="https://www.cdc.gov/flu/professionals/vaccination/effectiveness-studies.htm"><u>The CDC reported</u></a> that the shot has been effective in reducing outpatient visits for the flu by about 40% in the last few years. But this is a relative decrease. What are the absolute numbers? <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001269.pub6/full"><u>A Cochrane review</u></a> of 52 trials over 40 years found that the absolute decrease went from 2.3% to 0.9% of adults who caught the flu, or 1.4% total (NNT 71). There was no evidence that the vaccine reduces missed days from work, hospitalizations, or deaths. Similar results were found in a separate review of the vaccine in children.</p>
<p>How many people in the U.S. die of the flu each year?</p>
<p>The CDC historically states that around 30-40,000 people die each year from the flu, but this is clearly exaggerated. <a href="https://community.cochrane.org/news/why-have-three-long-running-cochrane-reviews-influenza-vaccines-been-stabilised"><u>A review of actual death certificates</u></a> found that the actual number was closer to 1,000. A paper discussed in the next section came to a similar conclusion. One of the contributing factors to the exaggeration is that an observed increase in chronic disease deaths is attributed to the flu. <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1702090"><u>A recent study in NEJM</u></a> for the first time, to my knowledge, actually got flu titers in hospitalized adults to try to prove causality. They found an increased risk of myocardial infarctions in people with confirmed respiratory infections, but not deaths, and RSV and other viruses were also implicated. I believe this is the first study that more proves that an increase in exacerbations in some non-respiratory chronic diseases is likely caused by the flu.</p>
<p>Do flu shots save lives?</p>
<p>Basically, no. There have been several reviews of this over the years. The above-mentioned Cochrane reviews in adults and children are 2 of them. <a href="https://jamanetwork.com/journals/jama/fullarticle/2585966"><u>A review in JAMA</u></a> of infectious disease mortality found a non-significant increase in flu mortality from 1980 to 2014, a period of greatly increased uptake of the flu vaccine. It also points out that the overall number of flu deaths is great exaggerated (see Table in article). Of the 17.3/100,000 mortality rate of pneumonia and flu, only 1.4/100,000 were from the actual flu virus.</p>
<p>Is the flu vaccine cost-effective?</p>
<p>It entirely depends on the assumptions used to do the analysis. <a href="https://www.ncbi.nlm.nih.gov/pubmed/20008759"><u>A cost-effectiveness analysis (CEA) published in the Annals of Internal Medicine</u></a> concluded that flu shots save money. However, their model assumed a population of 8.3 million people and that the number of lives saved would be between 1,468 and 2,051 in one year.  As I described previously, studies of all U.S. death certificates identify around 1,000 with flu listed as the cause of death, so it is apparent that these authors used the mostly wildly optimistic assumptions of the effectiveness of the vaccine.</p>
<p><u><a href="https://www.valueinhealthjournal.com/article/S1098-3015(11)01402-1/pdf">Another study</a> </u>made similar assumptions about the efficacy of the vaccine, assuming that the vaccine prevented deaths in 2-7% of the non-elderly population and 16% of the elderly population (if I’m interpreting their table correctly). Therefore, the vaccine was estimated to be cost-saving.</p>
<p><a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0022308"><u>Another study</u></a> found that the vaccine was cost saving for high-risk groups and had an incremental cost-effectiveness ratio (ICER) of $8,000-$52,000 for other patient groups. They assumed a vaccine effectiveness of 60%-69%. They did not explicitly state their assumptions about deaths, though it appears they assumed that if the vaccine was effective for 60-69% of people, then they didn’t die. Both of these assumptions are contradicted by the other lines of evidence already discussed.</p>
<p>Other findings:</p>
<p>The effect of health care workers forced to get flu shots on decreasing patient harm is greatly exaggerated: <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0163586">https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0163586</a></p>
<p>The flu vaccine becomes less effective with repeated vaccinations and does not prevent household transmission of the flu virus: <a href="https://academic.oup.com/cid/article/56/10/1363/404283">https://academic.oup.com/cid/article/56/10/1363/404283</a></p>
<p>There was an increased risk of developing narcolepsy in Northern European countries from receiving a flu shot, by a factor of 5-14 fold in children and 2-7 fold in adults. The overall risk was estimated to be about 1 in 18,000 vaccinated people. This may be related to a single batch from one manufacturer. <a href="https://www.sciencedirect.com/science/article/pii/S1087079217300011">https://www.sciencedirect.com/science/article/pii/S1087079217300011</a></p>
<p>Other systematic reviews have pointed out the large gap between the public policy enthusiasm for widespread flu vaccination vs. the evidence of its actual effectiveness: <a href="https://www.bmj.com/content/333/7574/912">https://www.bmj.com/content/333/7574/912</a></p>
<p>Conclusions</p>
<p>Because there are no good RCTs of flu vaccination, the truth is no one knows how effective the flu shot is or how cost-effective it is. Using probably wildly optimistic assumptions of the effectiveness of the vaccine to prevent deaths, it may actually save money. On the other extreme, it could have a very high ICER if the only real benefit is a 40% drop in office visits for the flu, with no lives saved.</p>
<p>The other truth is that we’ll probably never know, because no politician would ever have the courage, in the U.S. at least, to call out this potentially large waste of national resources and pay for a proper study.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-mildly-effective-flu-shot/">The Mildly Effective Flu Shot</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
					<wfw:commentRss>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-mildly-effective-flu-shot/feed/</wfw:commentRss>
			<slash:comments>2</slash:comments>
		
		
			</item>
		<item>
		<title>The Power of Comprehensive Family Medicine</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-power-of-comprehensive-family-medicine/</link>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Mon, 08 Jun 2015 04:03:34 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[comprehensive care]]></category>
		<category><![CDATA[cost of care]]></category>
		<category><![CDATA[cost-effectiveness]]></category>
		<category><![CDATA[family medcine]]></category>
		<category><![CDATA[family physicians]]></category>
		<category><![CDATA[healthcare costs]]></category>
		<category><![CDATA[Medicare]]></category>
		<category><![CDATA[procedures]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=1085</guid>

					<description><![CDATA[<p>Hello again!  I haven&#8217;t written anything in a while. No big worries. I moved recently (same town, same neighborhood), but the remodel of the new house has been a mis-adventure and I&#8217;ve been living out of boxes and breathing dust for over a month. Things are kind of finally settling down. So back on track: I assume many of you have seen this, but it&#8217;s so important I thought I&#8217;d pile on. Researchers from the Graham Center writing in the Annals of Family Medicine report on a more extensive analysis of the interaction between characteristics of family physicians and the associated cost of care with their patients. The primary issue was comprehensiveness of care provided by the studied family physicians, which was defined by 2 different scales. One included major service categories such as hospital care, ER care, maternity care, pain management, etc. The other scale got into more detail listing more specific service locations, procedures, and office analytic capabilities. NOWHERE ON THESE SCALES WERE ANY OF THE CLASSIC MEASURES OF THE PCMH, ESPECIALLY AS DEFINED BY THE NCQA!! The population examined was Medicare beneficiaries. The costs were for part A and part B. The bottom line was &#8212; as [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-power-of-comprehensive-family-medicine/">The Power of Comprehensive Family Medicine</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>Hello again!  I haven&#8217;t written anything in a while. No big worries. I moved recently (same town, same neighborhood), but the remodel of the new house has been a mis-adventure and I&#8217;ve been living out of boxes and breathing dust for over a month. Things are kind of finally settling down. So back on track:</p>
<p>I assume many of you have seen this, but it&#8217;s so important I thought I&#8217;d pile on. Researchers from the Graham Center writing in the Annals of Family Medicine <a href="http://annfammed.org/content/13/3/206.full"><span style="text-decoration: underline;">report on a more extensive analysis</span> </a>of the interaction between characteristics of family physicians and the associated cost of care with their patients.</p>
<p>The primary issue was comprehensiveness of care provided by the studied family physicians, which was defined by 2 different scales. One included major service categories such as hospital care, ER care, maternity care, pain management, etc. The other scale got into more detail listing more specific service locations, procedures, and office analytic capabilities. NOWHERE ON THESE SCALES WERE ANY OF THE CLASSIC MEASURES OF THE PCMH, ESPECIALLY AS DEFINED BY THE NCQA!!</p>
<p>The population examined was Medicare beneficiaries. The costs were for part A and part B.</p>
<p>The bottom line was &#8212; as they had found in a previous study &#8212; that there was a very significant correlation between the comprehensiveness of care and reduced total costs of care. The most comprehensive sub-group of family physicians had TEN PERCENT LOWER total cost of care than the least comprehensive group.</p>
<p>To put this in perspective, the most successful ACOs have only lowered the cost of care by one percent or so. The majority have not even &#8220;bent the cost curve&#8221; (in other words, just slowed down medical inflation). The moderately successful ACOs have merely lowered the annual inflation rate.</p>
<p>This study did not measure quality of care, but I have 2 caveats. One is that the Starfield meta-analysis and others have consistently found that population health is improved in places with more family physicians. Two is that the more time marches on the more I think the quality family physician care is nearly unmeasurable. There are too many exceptions, caveats, and factors beyond the family physician&#8217;s control.</p>
<p>Tell your family. Tell your neighbors. Tell your colleagues. Comprehensive family physician care is the best single answer to bring down exorbitant costs of the U.S. healthcare system!</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/the-power-of-comprehensive-family-medicine/">The Power of Comprehensive Family Medicine</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
		
		
			</item>
	</channel>
</rss>