Thursday
Sep222016

I Really Wish You Wouldn't Do That

By Kim Bellard, September 22, 2016

Digital rectal exams (DREs) typify much of what's wrong with our health care system.  Men dread going to go get them, and -- oh, by the way – they apparently don't actually provide much value. By the same token, routine pelvic exams for healthy women also don't have any proven value either.

The recent conclusions about DREs come from a new study.  One of the researchers, Dr. Ryan Terlecki, declared: "The evidence suggests that in most cases, it is time to abandon the digital rectal exam (DRE).  Our findings will likely be welcomed by patients and doctors alike."

The study actually questioned doing DREs when PSA tests were available, but it's not as if PSA tests themselves have unquestioned value.  Even the American Urological Association came out a few years ago against routine PSA tests, citing the number of false positives and resulting unnecessary treatments.

Indeed, the value of even treating the cancer that DREs and PSAs are trying to detect -- prostate cancer -- has come under new scrutiny.  A new study tracked prostate cancer patients for ten years, and found "no significant difference" in mortality between those getting surgery, radiation, or simple active monitoring.

The surgery and radiation, on the other hand, had some unwelcome side effects.  Forty-six percent of men who had their prostate removed were wearing adult diapers six months later, and impotence was reported in 88% of surgical patients and 78% of radiation patients.

As for the pelvic exam, about three-fourths of preventive visits to OB-GYNs include them, over 60 million visits annually.  They're not very good at either identifying or ruling out ovarian cancer, and the asymptomatic conditions they can detect don't have much data to indicate that treating them early offers any advantage to simply waiting for symptoms.

Or take mammograms.  Mammograms are uncomfortable, have significant false positive/over-diagnosis rates, and costs us something like $4b annually in unnecessary costs, yet remain the "gold standard."

Then there is everyone's favorite test -- colonoscopies.  Only about two-thirds of us are getting them as often as recommended, and over a quarter of us have never had one.  There are other alternatives, including a "virtual" colonoscopy and now even a pill version of it, but neither has done much to displace the traditional colonoscopy.  And all of those options still require what many regard as the worst part of the procedure, the prep cleansing.

The final example is what researchers recently called an "epidemic" of thyroid cancer, which they attributed to overdiagnosis. In fact, according to the researchers: "The majority of the overdiagnosed thyroid cancer cases undergo total thyroidectomy and frequently other harmful treatments, without proven benefits in terms of improved survival."  Not only that, once they've had the surgery, most patients will have to take thyroid hormones the rest of their lives.

All of these examples happen to relate to cancer, although there certainly are similar examples with other diseases/conditions (e.g., appendectomy versus antibiotics for uncomplicated appendicitis).

Two conclusions:

1.  If we're going to have unpleasant things done to us, they better be based on facts

2.  We should do everything we can to make unpleasant things, well, less unpleasant:

Let's get right on those.

 

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

 

 

Thursday
Sep152016

Workplace family monthly health premiums rise to $1,512; deductibles up 12% in 2016

By Claire Thayer, September 15, 2016

In 2016, employer-sponsored health insurance covered half of the non-elderly population.  For the 18th year in a row,  the Kaiser Family Foundation & Health Research & Educational Trust (HRET) published findings from its annual survey of employers reflecting trends of employer sponsored health benefits on premiums, employee cost-sharing, wellness programs and employer opinions in the 2016 Employer Health Benefits Survey.  Here are a few highlights:

  • The average premium for single coverage in 2016 is $536 per month, or $6,435 per year.
  • The average premium for family coverage is $1,512 per month or $18,142 per year
  • The $18,142 average family premium in 2016 is 20% higher than the average family premium in 2011 and 58% higher than the average family premium in 2006
  • Among those with a general annual deductible for family coverage, the percentages of covered workers with an average aggregate general annual deductible are 61% for workers in HMOs, 64% for workers in PPOs, and 77% for workers in POS plans
  • The share of covered workers in plans with a general annual deductible has increased significantly over time: from 55% in 2006, to 74% in 2011, to 83% in 2016, as have the average deductible amounts for covered workers in plans with deductibles: from $584 in 2006, to $991 in 2011, to $1,478 in 2016
  • Eighty-three percent of firms offering health benefits in 2016 offer only one type of health plan. Large firms are more likely to offer more than one plan type than small firms (53% vs. 16%)
  • Enrollment remains highest in PPO plans, covering just under half of covered workers, followed by HDHP/SOs, HMO plans, POS plans, and conventional plans.
  • Forty-eight percent of covered workers are enrolled in PPOs, followed by HDHP/SOs (29%), HMOs (15%), POS plans (9%), and conventional plans (< 1%)
  • Nearly all (more than 99%) covered workers work at a firm that provides prescription drug coverage in their largest health plan.
  • Sixty-one percent of covered workers are in a self-funded health plan.
  • Twenty-four percent of large firms (200 or more workers) that offer health benefits to their employees offer retiree coverage in 2016, similar to recent years.
  • Among large firms that have a health risk assessment, 54% offer an incentive to employees to complete the assessment

Says KFF President and CEO Drew Altman, “We’re seeing premiums rising at historically slow rates, which helps workers and employers alike, but it’s made possible in part by the more rapid rise in the deductibles workers must pay.”

 

More info:

  • Summary of findings is here
  • Entire report with over 200 exhibits in 14 different sections is here
  • News release is here
  • Health Affairs article is here

 

Friday
Sep092016

Uber, Lyft and Healthcare

By Clive Riddle, September 9, 2016

Bruce Japson, in his Forbes article earlier this summer - On-Demand Health's Growth Second Only To Uber And Lyft, that "investment in on-demand health services is projected to reach $1 billion in 2017 with Teladoc and rival telehealth firm American Well joining the likes of Uber and Lyft in the top 10 most funded on-demand companies, according to the most recent tally by consulting giant Accenture ACN -1.02%. Investment in on-demand health was just $200 million in 2014."

While Bruce was talking about valuations of on demand companies, it is most interesting that on a different level, the paths of healthcare and on demand ride services are converging.

Just this week, CareMore Health System touted their recent collaboration with Lyft that “Improves Access to Care, Reduces Transportation Cost and Wait Times” according to results from a pilot study of their Medicare Advantage beneficiaries that was just published in the Journal of the American Medical Association (JAMA),  in the article, “Nonemergency Medical Transportation: Delivering Care in the Era of Lyft and Uber

CareMore notes that “individuals using the service are now waiting an average of just nine minutes to be taken to or from their medical appointment” and that “average per-ride costs have been reduced by more than 30 percent (from $31.54 to $21.32). Satisfaction with the new program, which covers beneficiaries in selected areas of southern California, exceeded 80 percent.” CareMore plans to continue the program and potentially expand to markets beyond California.

Earlier this year, MedStar Health, the largest not-for-profit healthcare system in Maryland and the Washington, D.C., region, and Uber announced a collaboration “to give patients a new option for ensuring they can get to and from healthcare appointments. Patients who miss appointments or have to reschedule at the last minute frequently cite transportation as a factor.”

The Advisory Board, writing about in July, in their article “A surging trend: Uber, Lyft have hospitals rethinking patient access” reported that “other hospitals quickly became interested in MedStar's model, said Michael Ruiz, chief digital officer for MedStar. ‘We probably had 50 different systems across the country reach out to us and ask us 'How did you do it?’’ Several other hospitals have formed partnerships with Uber this year, including New Jersey-based Hackensack UMC and Florida-based Sarasota Memorial Hospital.”

How many years off are we from driverless Uber and Lyft cars picking us up for our healthcare visits?

Tuesday
Aug302016

High Drug Prices, Complexity of Drug Development and What the Market Will Bear

By Claire Thayer, August 30, 2016

The escalating cost of prescription drugs is of concern for all of us and impact stakeholders all across the health continuum: patients, payers, providers, as well as policy makers.   A recent Consumer Reports study, Is There a Cure for High Drug Prices?, offers these 5 reasons drug costs are ballooning:

  • Reason #1: Drug Companies Can Charge Whatever Price They Want
  • Reason #2: Insurance Companies Are Also Charging You More
  • Reason #3: Old Drugs Are Reformulated as Costly ‘New’ Drugs
  • Reason #4: Generic Drug Shortages Can Trigger Massive Price Increases
  • Reason #5: Specialty Drugs Are Costing All of Us

This week, the Journal of the American Medical Association (JAMA) released an in-depth article, The High Cost of Prescription Drugs in the United States, which explores literature from January 2005 to July 2016 for sources of drug prices in the U.S., justification and consequences of high prices and possible solutions.  The authors conclude that “high drug prices are the result of the increasing cost and complexity of drug development but also arise in large part from the approach the United States has taken to the granting of government-protected monopolies to drug manufacturers, combined with restriction of price negotiation at a level not observed in other industrialized nations.”

Among overall study findings:

  • In 2013, per capita spending on prescription drugs was $858 compared with an average of $400 for 19 other industrialized nations.
  • In the United States, prescription medications now comprise an estimated 17% of overall personal health care services.
  • The most important factor that allows manufacturers to set high drug prices is market exclusivity, protected by monopoly rights awarded upon Food and Drug Administration approval and by patents.
  • The availability of generic drugs after this exclusivity period is the main means of reducing prices in the United States, but access to them may be delayed by numerous business and legal strategies.
  • The primary counterweight against excessive pricing during market exclusivity is the negotiating power of the payer, which is currently constrained by several factors, including the requirement that most government drug payment plans cover nearly all products.
  • Another key contributor to drug spending is physician prescribing choices when comparable alternatives are available at different costs.
  • Although prices are often justified by the high cost of drug development, there is no evidence of an association between research and development costs and prices; rather, prescription drugs are priced in the United States primarily on the basis of what the market will bear.
Friday
Aug262016

EpiPens By The Numbers

by Clive Riddle, August 26, 2016

Without wading into the policy, prognostication, editorial or other narrative issues surrounding Mylan’s EpiPen pricing controversy, here simply is a collection of selected relevant data compiled related to all that is Mylan EpiPen: