ACP Internist Blog

Monday, June 24, 2019

Medical pricing transparency via non-transparent rule

Hidden in a 700-page draft regulation to improve patient's access to their electronic medical records is a proposal to require doctors, hospitals, and other health care providers to publicly reveal the prices they have negotiated with insurers. This rule, tied to the 21st Century Cures Act, would set the stage for eventually making prices publicly available. Although price transparency may be a good way to help lower medical costs, it's ironic that there is a lack of transparency when it comes to the proposed rule. I challenge you to read the Title, Summary, or Actions section and realize that it includes such a major change (hint: in the PDF document it's on page 7,513 of the Federal Register under Price Information).

On the face of it, making prices readily available sounds like a no-brainer, but I think it's more complicated than that, and there may be unforeseen consequences. The rule is long and complex, and I don't have the few days it would probably take me to really understand it, but let me play devil's advocate. Some of the comments posted say that medicine is the only industry that hides the cost. To a certain extent that's true, but this rule could go beyond just saying the price consumers pay. If you go to a restaurant they won't reveal how much they paid for the ingredients. If you book through a third-party website, they don't tell you how much, if any, they pay them for the referral. When you buy a car the dealer usually doesn't tell you if the automobile manufacturer is giving them a rebate. From the point of view of a business, the consumer shouldn't get to know their internal costs as that's secret competitive information.

What mitigates that argument is that the price of health care has gotten out of control. Despite being better educated about the matter than most, when it comes to getting healthcare for their own family I suspect most physicians struggle to understand their bills just like everyone else.

When it comes to pay, doctors are a commodity. For a given surgical procedure or office visit of a certain complexity, they are paid the same amount as mandated by Medicare or Medicaid, as negotiated with insurance companies, or their list price for the unfortunate cash patient. Just like any profession, some doctors are better than others. If you want to hire a top lawyer or an A list actor, you have to pay top dollar. But that's not so with much of healthcare. The price doesn't necessarily reflect the quality of the care.

Hospital systems mitigate that somewhat. They can negotiate higher prices with insurance companies and with large employers by demonstrating that they provide higher quality care and/or lower cost care, or because patient perceive them as providing superior care and they demand that that can get care from them. What will happen if the rule goes into effect and patients can easily compare prices? I don't know, but potentially they might choose the lowest cost without regard to quality. That could lead to systems competing on price, cutting corners to do so, and ultimately lowering quality.

The lowest price might actually not be the path to cost savings. Imagine two surgeons. One of them charges $5,000 for a knee replacement, and operates on 60% of the patients seen for knee arthritis, treating the rest successfully with injections and physical therapy, which on average costs $1,000. The other charges $7,000, and operates on 50% of the patients seen and treats the rest successfully with the same conservative measures. Besides the physician fee, the hospital system charges $10,000 for the surgery. In this example, treating 100 patients would cost $940,000 for the first surgeon, and $900,000 for second. So even though the second surgeon charges 40% more than the first, on average the doctor ends up being cheaper when it comes to managing knee arthritis.

I'm inclined to support more transparency in health care pricing, but I don't know how much of an impact it will have, and there may be unintended consequences.

Don't expect to see published prices anytime soon. Even if the proposal goes forward, following a public comment period that ends May 3, it's likely to be tied up in legal challenges for quite a while.

Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington. This post originally appeared on his blog, World's Best Site.
Friday, June 21, 2019

Things that bug me, telling me normal (CBC, BMP)

Dr. Rabih Geha's excellent post, “Every Piece of Data Matters,” at the online learning center Closler has stimulated much thought. He makes one important point that I would like to expand.

My mind finds it much harder to attach diagnostic significance to pertinent negatives. Even if their impact on a diagnostic hypothesis is equal, I find that a positive test result sways my reasoning more so than an equally impactful negative test.

My students and residents know that I want to hear the numbers. Sometimes normal is not normal. Sometimes seemingly normal gives clues.

The problem comes from our laboratory definition of normal. The lab uses large data sets to estimate a “normal” range. Sometimes the clinical condition says otherwise.

Several years ago I had a patient with an unknown “pneumonia” who was not improving. On examining his labs I noted that his creatinine has risen from 0.8 to 1.2. Both numbers were technically normal, but a 50% increase in creatinine should grab our attention. When we finally obtained a urinalysis, he had evidence of acute glomerulonephritis. The “pneumonia” was really GPA.

What is a normal platelet count? What is a normal WBC? How do we interpret a serum calcium if we do not know the serum albumin? What does it mean when the BUN is 2? What is the BUN/creatinine ratio and does that help us understand the patient's story?

The patient has a history of severe vomiting, but has a normal bicarbonate level. What is the anion gap? Does the computer flag an abnormal anion gap?

When students present, I expect to hear the numbers. When reading MKSAP questions or reading (or listening to) Human Diagnosis Project cases, too often labs are reported as normal. Yet the numbers may still provide some value.

So here is my call for presenting the numbers and let me decide if they provide information. Perhaps I can teach the team something from these labs. But let me decide if the numbers are actually normal. Please!

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.
Thursday, June 20, 2019

Density of breasts, clarity of decisions

My dear friend and esteemed colleague, Dr. Nancy Cappello, passed away this past year, far too soon. The short version of that story is that Nancy died of the very late consequences of delayed diagnosis and treatment of her breast cancer. That delay resulted from the imaging challenges with dense breast tissue. The longer arc of that narrative is a tale of arduous challenge for Nancy and her loved ones, and a story of courage, inspiration, altruism, and beauty. A great tale, just not this one.

This one is about a recent commentary in JAMA on the topic of dense breast tissue, and what to do about it in clinical practice. The authors, who cite the work of Dr. Cappello prominently, focus more on the density of medical decisions than that of breasts. They note that breast density may indeed confound the interpretation of mammograms, but seem to argue that want of needed research confounds medical decisions even more so.

Specifically, the piece argues that we have no trials randomizing women with dense breasts to standard versus enhanced screening protocols, proving that the latter reliably enhance outcomes and save lives. They reassert as well the long-recognized liability of breast cancer screening: to find the cancer that should be treated, there is an unavoidable toll in false alarms, resulting in anxiety, biopsies, and potential complications that would never have occurred without screening.

This is not an argument against screening, but it is a valid reminder that medical screening is a literal case of “looking for trouble.” The goal is to find established trouble early, and dispatch it effectively. But the more figurative meaning of blundering into adversity also pertains. Cancer screening is never perfect, and can fail in either direction, failing to find cancer when it's there, indicating it is there when it is not. Both represent their own version of trouble.

Arguably the graver trouble, and the variety that ultimately cost my friend Nancy her life, is the false negative. The mammographic signs of early breast cancer are obscured by dense breast tissue, and the result in Nancy's case and far too many others, is the proverbial “clean bill of health” when a cancer that should be in plain sight is in fact hiding on a hard-to-read mammogram. The damage this does is self-evident: screening fails to fulfill its one objective of finding cancer early, and instead the cancer progresses before being detected. The chance to treat early and minimize the toll is lost.

But while less grave, the trouble in the other direction is vastly more prevalent. False positives occur when the various anomalies of normal tissue are mistakenly interpreted as potential signs of cancer. This risk, too, is elevated with dense breast tissue. Over a decade of screening, half or more of all women will experience a false positive mammogram. While arguably just a “false alarm,” and sometimes readily proved to be just that, these false positives are far from benign. As noted, they are at best a source of transient but significant anxiety. They are often the reason for involved and invasive testing, which is in turn a potential source of complications, and future mammograms made even harder to interpret reliably.

The trade-offs between false positive and false negative risks are not avoidable, but they are manageable. Managing them well includes gauging the individual risk for breast cancer in the first place, based on family history, lifestyle, biomarkers, and genetic markers. It extends to the screening interval (i.e., yearly, more often, or less) and choice of screening modality (e.g., standard mammography, tomosynthesis, thermography, ultrasound, etc.).

My aim here is not to advise you or the women in your life directly on the “right” answer. My aim is to reaffirm Nancy Cappello's righteous message: that decision should be made together by well-informed doctor and patient, and insurance, all insurance, should cover as a matter of routine every reasonable variant on the theme of such decision-making.

The well-informed doctor will have read the commentary in JAMA, and the studies cited in it; will be aware of the new research coming out on the topic routinely. The well-informed patient will know, because she has been told, whether she is among the nearly 50% of all women with dense breast tissue, whether or not her mammograms pose interpretive challenges. She will know her relative risk for breast cancer.

So yes, there are densities in the decision making regarding dense breast tissue and cancer screening. Those will only be fully transilluminated by careful research, and considered interpretation of the results directed at the greatest net good, least net harm.

But in the interim, that imperative, least net harm, prevails. It is the oft-cited (if incorrectly attributed) prime directive of the medical profession: primum non nocere. First, do no harm.

We lack the science, art, and aptitudes to avoid harm completely, but we are duty bound to minimize it. It is harmful to provide test results that impart doubt and worry rather than confidence and reassurance. It is harmful to limit options when we have the option of empowering patients with informed choices.

Nancy and her work did not espouse enhanced, costly screening for all. She pursued, relentlessly, the right to relevant screening for all, the right to options curated to personal circumstance, with insurance coverage reliably assured for the approaches doctor and patient agree are warranted. Nancy's efforts to expand access to information about, and options for, dense breast tissue cancer screening to all women rest not on recondite decisions, but rather the cornerstones of medical ethics.

More research is needed to engender new and better breast cancer screening methods. More research is needed to define the optimal screening protocol for dense breast tissue in general, and across the range of personal risk categories. But until or unless research refines our understanding, Nancy's way, the way of informed, personalized decision making, remains the right way. That decision to me seems perfectly clear.

David L. Katz, MD, FACP, MPH is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his Linked In page.
Monday, June 17, 2019

The silent epidemic affecting all our hospitals

There's a huge problem we have right now affecting our nation's hospitals. It's not a disease you've ever heard of before, or something that cutting edge research or treatments are going to solve. It's a seemingly simple issue that has been lacking in every single hospital I've ever worked in, whether it be a large academic teaching hospital or a small rural medical center. It's rarely talked about, but endemic nevertheless. I'm hereby going to assign it a name:

“Sinking in bed syndrome”

What on earth is it you may ask? Well, the scenario goes something like this. A patient, usually elderly, is admitted to hospital with an acute medical illness. During the first few days of treatment, they are basically lying in bed while receiving all their treatments. They get more and more sunk into their bed, becoming weaker and weaker at the same time (even though their actual illness is improving). As they recover, they find it more difficult to get up out of bed and start walking again. The longer they are in bed, the more difficult it will be. Muscles have become tense and joints are stiffer. Because of this deconditioned state, recovery will be prolonged and patients will spend longer getting back to their baseline state.

All hospital-based doctors see this type of scenario unfold on a weekly basis. Sadly, lots of these patients actually report having quite reasonable and independent function prior to their admission. Of course, they have been unwell, and their illness itself will set them back. But having seen how we leave patients “sinking” in their bed for days at a time, I'm of the firm belief that keeping them in this state really sets them back even more.

In short,we just need to get them up much sooner. Unfortunately, it's not in our systemic culture to do that, and in almost all places I've worked, I sometimes need to plead just to get our patients up out of bed to the chair simply to make sure they are not lying down flat all the time. Sometimes sadly, it's family members who are the ones voicing their concern to me that their loved ones have become weak and need to sit up and walk more. It's a shame too, that many healthcare institutions only think of getting physical therapy involved when discharging from the hospital is imminent when actually it should be done much sooner.

Only a few decades ago, the culture was to keep patients who were sick in the hospital on complete bed rest for an extraordinarily long amount of time. Patients having heart attacks would be kept in and observed for several weeks. We now know that such a prolonged hospitalization is not only unnecessary, but also very bad for our patients.

So why do we not get our patients up sooner? I believe it's not a question of laziness or lack of resources. Nurses and nurses' aides are the most hardworking people I've ever encountered, and most nurses are aware that it's good to get patients up and moving. However, in the haze and hustle of a hospital admission—with intravenous lines, telemetry monitors, strong medications and constant tests—we lose sight of the simple little things that can make an enormous difference. In my experience, patients even just look so much better sitting up in a chair as opposed to lying in the bed!

So here's what the world of health care should really push for: A National Ambulate the Patient Week. This should involve:

 Education for all healthcare professionals about the importance of ambulation. Physicians should be encouraged to write “OUT OF BED TO CHAIR AT LEAST THREE TIMES DAILY” as an order for nearly all hospitalized patients as soon as they can, usually from hospital day 2. With that order should be an assumption to “ENCOURAGE AMBULATION”, either with or without assistance depending on the circumstance

 Invest in more physical therapy services and also dedicated PT-aides, also known as “walkers or mobility aides,” to get people up and moving early

 Administrative oversight from charge nurses and unit supervisors to raise a red flag when they see a patient who potentially has “sinking in bed syndrome”

 Posters around hospitals encouraging early ambulation and walks around the hospital floor

 More comfortable chairs! This may sound rudimentary, but a common complaint I hear everywhere is that hospital chairs are very uncomfortable. However much they are purportedly designed for hospitalized patients, just glancing at them and testing them out myself—I'm very skeptical about how comfortable patients can feel sitting in them. I get the same feedback from relatives who test them out. If healthy people don't feel comfortable in any given place, how on earth do we expect sick people to?

There are certain departments that are actually already very good at mobilizing their patients. One such example is orthopedics, where surgeons are almost obsessive about getting people up as early as possible after hip or knee surgery. If they can do it, so can everyone else.

Richard Asher, the British endocrinologist and forward-thinker from the early part of the twentieth century once said: ”Look at the patient lying long in bed. What a pathetic picture he makes! The blood clotting in his veins, the lime draining from his bones, the scybala stacking up in his colon, the flesh rotting from his seat, the urine leaking from his distended bladder and the spirit evaporating from his soul.”

That quote was from 1947. I will leave it to your imagination to think what scybala is!

Seventy years later, while we are not as bad as we were in the 1930s and 1940s, we can still do a lot better. So let's make it a national priority get all our hospitalized patients up and moving earlier. Starting from today.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.