Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Costs. Show all posts
Showing posts with label Costs. Show all posts

Sunday, February 25, 2024

Characteristics of Mental Health Specialists Who Shifted Their Practice Entirely to Telemedicine

Hailu, R., Huskamp, H. A., et al. (2024).
JAMA, 5(1), e234982. 

Introduction

The COVID-19 pandemic–related shift to telemedicine has been particularly prominent and sustained in mental health care. In 2021, more than one-third of mental health visits were conducted via telemedicine. While most mental health specialists have in-person and telemedicine visits, some have transitioned to fully virtual practice, perhaps for greater work-life flexibility (including avoiding commuting) and eliminating expenses of maintaining a physical clinic. The decision by some clinicians to practice only via telemedicine has gained importance due to Medicare’s upcoming requirement, effective in 2025, that patients have an annual in-person visit to receive telemedicine visits for mental illness and new requirements from some state Medicaid programs that clinicians offer in-person visits. We assessed the number and characteristics of mental health specialists who have shifted fully to telemedicine.

Discussion

In 2022, 13.0% of mental health specialists serving commercially insured or Medicare Advantage
enrollees had shifted to telemedicine only. Rates were higher among female clinicians and those
working in densely populated counties with higher real estate prices. A virtual-only practice allowing
clinicians to work from home may be more attractive to female clinicians, who report spending more
time on familial responsibilities, and those facing long commutes and higher office-space costs.
It is unclear how telemedicine-only clinicians will navigate new Medicare and Medicaid
requirements for in-person care. While clinicians and patients may prefer in-person care,
introducing in-person requirements for visits and prescribing could cause care interruptions,
particularly for conditions such as opioid use disorder.

Our analysis is limited to clinicians treating patients with commercial insurance or Medicare
Advantage and therefore may lack generalizability. We were also unable to determine where
clinicians physically practiced, particularly if they had transitioned to virtual-health companies. Given the shortage of mental health clinicians, future research should explore whether a virtual-only model
affects clinician burnout or workforce retention.

Wednesday, January 24, 2024

Salve Lucrum: The Existential Threat of Greed in US Health Care

Berwick DM.
JAMA. 2023;329(8):629–630.
doi:10.1001/jama.2023.0846

Here is an excerpt:

Particularly costly has been profiteering among insurance companies participating in the Medicare Advantage (MA) program. Originally intended to give Medicare beneficiaries the choice of access to well-managed care at lower cost, MA has mushroomed into a massive program, now about to cover more than 50% of all Medicare beneficiaries and costing far more per beneficiary than traditional Medicare ever has. By gaming Medicare risk codes and the ways in which comparative “benchmarks” are set for expected costs, MA plans have become by far the most profitable branches of large insurance companies. According to some health services research, MA will cost Medicare over $600 billion more in the next 8 years than would have been the case if the same enrollees had remained in traditional Medicare. Opinions differ about whether MA enrollees experience better care and outcomes than those in traditional Medicare, but the weight of evidence is that they do not.

Hospital pricing games are also widespread. Hospitals claim large operating losses, especially in the COVID pandemic period, but large systems sit on balance sheets with tens of billions of dollars in the bank or invested. Hospital prices for the top 37 infused cancer drugs averaged 86.2% higher per unit than in physician offices. A patient was billed $73 800 at the University of Chicago for 2 injections of Lupron depot, a treatment for prostate cancer, a drug available in the UK for $260 a dose. To drive up their own revenues, many hospitals serving wealthy populations take advantage of a federal subsidy program originally intended to reduce drug costs for people with low income.

Recent New York Times investigations have reported on nonprofit hospitals’ reducing and closing services in poor areas while opening new ones in wealthy suburbs and on their use of collection agencies for pursuing payment from patients with low income. The Massachusetts Health Policy Commission reported in 2022 that hospital prices and revenues increased during a decade at almost 4 times the rate of inflation.

Windfall profits also appear in salaries and benefits for many health care executives. Of the 10 highest paid among all corporate executives in the US in 2020, 3 were from Oak Street Health, and salary and benefits included, reportedly, $568 million for the chief executive officer (CEO). Executives in large hospital systems commonly have salaries and benefits of several million dollars a year. Some academic medical centers’ boards allow their CEO to serve for 6-figure stipends and multimillion-dollar stock options on outside company boards, including ones that supply products and services to the medical center.


My summary and warnings are here:

Greed is not good, especially in healthcare. This article outlines the concerning issue of greed pervading the US healthcare system. It argues that prioritizing profit over patient well-being has become widespread, impacting everything from drug companies to hospitals. The author contends that this greed is detrimental to both patients and the healthcare system as a whole. To address this, the article proposes solutions like fostering greater transparency and accountability, along with reevaluating how healthcare is financed.

Sunday, September 17, 2023

The Plunging Number of Primary Care Physicians Reaches a Tipping Point.

Elisabeth Rosenthal
KFF Health News
Originally posted 8 September 23

Here are two excerpts:

The percentage of U.S. doctors in adult primary care has been declining for years and is now about 25% — a tipping point beyond which many Americans won’t be able to find a family doctor at all.

Already, more than 100 million Americans don’t have usual access to primary care, a number that has nearly doubled since 2014. One reason our coronavirus vaccination rates were low compared with those in countries such as China, France, and Japan could be because so many of us no longer regularly see a familiar doctor we trust.

Another telling statistic: In 1980, 62% of doctor’s visits for adults 65 and older were for primary care and 38% were for specialists, according to Michael L. Barnett, a health systems researcher and primary care doctor in the Harvard Medical School system. By 2013, that ratio had exactly flipped and has likely “only gotten worse,” he said, noting sadly: “We have a specialty-driven system. Primary care is seen as a thankless, undesirable backwater.” That’s “tragic,” in his words — studies show that a strong foundation of primary care yields better health outcomes overall, greater equity in health care access, and lower per capita health costs.

One explanation for the disappearing primary care doctor is financial. The payment structure in the U.S. health system has long rewarded surgeries and procedures while shortchanging the diagnostic, prescriptive, and preventive work that is the province of primary care. Furthermore, the traditionally independent doctors in this field have little power to negotiate sustainable payments with the mammoth insurers in the U.S. market.

Faced with this situation, many independent primary care doctors have sold their practices to health systems or commercial management chains (some private equity-owned) so that, today, three-quarters of doctors are now employees of those outfits.

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Some relatively simple solutions are available, if we care enough about supporting this foundational part of a good medical system. Hospitals and commercial groups could invest some of the money they earn by replacing hips and knees to support primary care staffing; giving these doctors more face time with their patients would be good for their customers’ health and loyalty if not (always) the bottom line.

Reimbursement for primary care visits could be increased to reflect their value — perhaps by enacting a national primary care fee schedule, so these doctors won’t have to butt heads with insurers. And policymakers could consider forgiving the medical school debt of doctors who choose primary care as a profession.

They deserve support that allows them to do what they were trained to do: diagnosing, treating, and getting to know their patients.


Here is my warning:

The number of primary care physicians in the US is declining, and this trend is reaching a tipping point. More than 100 million Americans don't have usual access to primary care, and this number has nearly doubled since 2014. This shortage of primary care physicians could have a negative impact on public health, as people without access to primary care are more likely to delay or forgo needed care.

Friday, December 16, 2022

How Bullying Manifests at Work — and How to Stop It

Ludmila N. Praslova, Ron Carucci, & Caroline Stokes
Harvard Business Review
Originally posted 4 NOV 22

While the organizational costs of incivility and toxicity are well documented, bullying at work is still a problem. An estimated 48.6 million Americans, or about 30% of the workforce, are bullied at work. In India, that percentage is reported to be as high as 46% or even 55%. In Germany, it’s a lower but non-negligible 17%. Yet bullying often receives little attention or effective action.

To maximize workplace health and well-being, it’s critical to create workplaces where all employees — regardless of their position — are safe. Systemic, organizational-level approaches can help prevent the harms associated with different types of bullying.

The term workplace bullying describes a wide range of behaviors, and this complexity makes addressing it difficult and often ineffective. Here, we’ll discuss the different types of bullying, the myths that prevent leaders from addressing it, and how organizations can effectively intervene and create a safer workplace.

The Different Types of Bullying

To develop more comprehensive systems of bullying prevention and support employees’ psychological well-being, leaders first need to be aware of the different types of bullying and how they show up. We’ve identified 15 different features of bullying, based on standard typologies of aggression, data from the Workplace Bullying Institute (WBI), and Ludmila’s 25+ years of research and practice focused on addressing workplace aggression, discrimination, and incivility to create healthy organizational cultures.

These 15 features can be mapped to some of the common archetypes of bullies. Take the “Screamer,” who is associated with yelling and fist-banging or the quieter but equally dangerous “Schemer” who uses Machiavellian plotting, gaslighting, and smear campaigns to strip others of resources or push them out. The Schemer doesn’t necessarily have a position of legitimate power and can present as a smiling and eager-to-help colleague or even an innocent-looking intern. While hostile motivation and overt tactics align with the Screamer bully archetype and instrumental, indirect, and covert bullying is typical of the Schemer, a bully can have multiple motives and use multiple tactics — consciously or unconsciously.

Caroline mediated a situation that illustrates both conscious and unconscious dynamics. At the reception to celebrate Ewa’s* national-level achievement award, Harper, her coworker, spent most of the time talking about her own accomplishments, then took the stage to congratulate herself on mentoring Ewa and letting her take “ownership” of their collective work. But there had been no mentorship or collective work. After overtly and directly putting Ewa down and (perhaps unconsciously) attempting to elevate herself, Harper didn’t stop. She “accidentally” removed Ewa from crucial information distribution lists — an act of indirect, covert sabotage.  

In another example, Ludmila encountered a mixed-motive, mixed-tactic situation. Charles, a manager with a strong xenophobic sentiment, regularly berated Noor, a work visa holder, behind closed doors — an act of hostile and direct bullying. Motivated by a desire to take over the high-stakes, high-visibility projects Noor had built, Charles also engaged in indirect, covert bullying by falsifying performance records to make a case for her dismissal.

Thursday, November 18, 2021

Ethics Pays: Summary for Businesses

Ethicalsystems.org
September 2021

Is good ethics good for business? Crime and sleazy behavior sometimes pay off handsomely. People would not do such things if they didn’t think they were more profitable than the alternatives.

But let us make two distinctions right up front. First, let us contrast individual employees with companies. Of course, it can benefit individual employees to lie, cheat, and steal when they can get away with it. But these benefits usually come at the expense of the firm and its shareholders, so leaders and managers should work very hard to design ethical systems that will discourage such self-serving behavior (known as the “principal-agent problem”).

The harder question is whether ethical violations committed by the firm or for the firm’s benefit are profitable. Cheating customers, avoiding taxes, circumventing costly regulations, and undermining competitors can all directly increase shareholder value.

And here we must make the second distinction: short-term vs. long-term. Of course, bad ethics can be extremely profitable in the short run. Business is a complex web of relationships, and it is easy to increase revenues or decrease costs by exploiting some of those relationships. But what happens in the long run?

Customers are happy and confident in knowing they’re dealing with an honest company. Ethical companies retain the bulk of their employees for the long-term, which reduces costs associated with turnover. Investors have peace of mind when they invest in companies that display good ethics because they feel assured that their funds are protected. Good ethics keep share prices high and protect businesses from takeovers.

Culture has a tremendous influence on ethics and its application in a business setting. A corporation’s ability to deliver ethical value is dependent on the state of its culture. The culture of a company influences the moral judgment of employees and stakeholders. Companies that work to create a strong ethical culture motivate everyone to speak and act with honesty and integrity. Companies that portray strong ethics attract customers to their products and services, and are far more likely to manage their negative environmental and social externalities well.

Sunday, September 19, 2021

How Does Cost-Effectiveness Analysis Inform Health Care Decisions?

David D. Kim & Anirban Basu
AMA J Ethics. 2021;23(8):E639-647. 
doi: 10.1001/amajethics.2021.639.

Abstract

Cost-effectiveness analysis (CEA) provides a formal assessment of trade-offs involving benefits, harms, and costs inherent in alternative options. CEA has been increasingly used to inform public and private organizations’ reimbursement decisions, benefit designs, and price negotiations worldwide. Despite the lack of centralized efforts to promote CEA in the United States, the demand for CEA is growing. This article briefly reviews the history of CEA in the United States, highlights advances in practice guidelines, and discusses CEA’s ethical challenges. It also offers a way forward to inform health care decisions.

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Ethical Considerations

There have been a few criticisms on ethical grounds of CEA’s use for decision making. These include (1) controversies associated with the use of QALYs, (2) distributive justice, and (3) incomplete valuation. We discuss each of them in detail here. However, it is worth pointing out that cost-effectiveness evidence is only one of many factors considered in resource allocation decisions. We have found that none of the international HTA bodies bases its decisions solely on cost-effectiveness evidence. Therefore, much of CEA’s criticisms, fair or not, can be addressed through deliberative processes.

QALYs. The lower health utility, or health-related quality of life, assigned to patients with worse health (because of more severe disease, disability, age, and so on) raises distributional issues in using QALYs for resource allocation decisions. For example, because patients with disabilities have a lower overall health utility weight, any extension of their lives by reducing the health burden from one disease “would not generate as many QALYs as a similar extension of life for otherwise healthy people.” This distributional limitation arises because of the multiplicative nature of QALYs, which are a product of life-years and health utility weight. Consequently, the National Council on Disability has strongly denounced the use of QALYs.

Alternatives to QALYs have been proposed. The Institute for Clinical and Economic Review has started using the equal value of life-years gained metric, a modified version of the equal value of life (EVL) metric, to supplement QALYs. In EVL calculations, any life-year gained is valued at a weight of 1 QALY, irrespective of individuals’ health status during the extra year. EVL, however, “has had limited traction among academics and decision-making bodies” because it undervalues interventions that extend life-years by the same amount as other interventions but that substantially improve quality of life. More recently, a health-years-in-total metric was proposed to overcome the limitations of both QALYs and EVL, but more work is needed to fully understand its theoretical foundations.

Sunday, November 29, 2020

Freerolls and binds: making policy when information is missing

Duke, A. & Sunstein, C.
(2020). Behavioural Public Policy, 1-22. 

Abstract

When policymakers focus on costs and benefits, they often find that hard questions become easy – as, for example, when the benefits clearly exceed the costs, or when the costs clearly exceed the benefits. In some cases, however, benefits or costs are difficult to quantify, perhaps because of limitations in scientific knowledge. In extreme cases, policymakers are proceeding in circumstances of uncertainty rather than risk, in the sense that they cannot assign probabilities to various outcomes. We suggest that in difficult cases in which important information is absent, it is useful for policymakers to consider a concept from poker: ‘freerolls.’ A freeroll exists when choosers can lose nothing from selecting an option but stand to gain something (whose magnitude may itself be unknown). In some cases, people display ‘freeroll neglect.’ In terms of social justice, John Rawls’ defense of the difference principle is grounded in the idea that, behind the veil of ignorance, choosers have a freeroll. In terms of regulatory policy, one of the most promising defenses of the Precautionary Principle sees it as a kind of freeroll. Some responses to climate change, pandemics and financial crises can be seen as near-freerolls. Freerolls and near-freerolls must be distinguished from cases involving cumulatively high costs and also from faux freerolls, which can be found when the costs of an option are real and significant, but not visible. ‘Binds’ are the mirror-image of freerolls; they involve options from which people are guaranteed to lose something (of uncertain magnitude). Some regulatory options are binds, and there are faux binds as well.

From the Conclusion

In ordinary life, people may be asked whether they want a freeroll, in the form of a good or opportunity from which they will lose nothing, but from which they gain something of value, when the magnitude of the gain cannot be specified. The gain might take the form of the elimination of a risk. More commonly, people are given near-freerolls, because they have to pay something for the option. Often what they have to pay is very low, which makes the deal a good one. The central point here is an asymmetry in what people know. They know the costs, while they have large epistemic gaps with respect to the potential gains. People often fall prey to ‘freeroll neglect.’ When this is so, they do not see pure or near-freerolls; they seek missing information before choosing among options, even though they have no need to do so.

Freerolls are mirrored by binds, in which people are given an option from which they can only lose, even though they do not know how much they might lose. To know that binds are undesirable, the chooser need not have full knowledge about the range of possible downside outcomes. Nor need the chooser know anything about the shape of the distribution of those outcomes.

Tuesday, September 29, 2020

Do We Listen to Advice Just Because We Paid for It? The Impact of Cost of Advice on Its Use

Gino, F. (2008). 
Organizational Behavior and Human 
Decision Processes, 107(2), 234–245. 

Abstract

When facing a decision, people often rely on advice received from others. Previous studies have shown that people tend to discount others' opinions. Yet, such discounting varies according to several factors. This paper isolates one of these factors: the cost of advice. Specifically, three experiments investigate whether the cost of advice, independent of its quality, affects how people use advice. The studies use the Judge-Advisor System (JAS) to investigate whether people value advice from others more when it costs money than when it is free, and examine the psychological processes that could account for this effect. The results show that people use paid advice significantly more than free advice and suggest that this effect is due to the same forces that have been documented in the literature to explain the sunk costs fallacy. Implications for circumstances under which people value others' opinions are discussed.

From the Discussion

Many of the decisions people make on a daily basis result from weighing their own opinions with advice from other sources. The present work explored one factor that might affect the use of advice: advice cost. In particular, the initial hypothesis was that, independent of its quality, people would weigh advice significantly more when it costs money than when it is free. This hypothesis was tested in three experiments requiring participants to answer questions about US history with or without advice from others.  The results of the studies show that participants relied more heavily on advice when it cost money than when it was free. The results also suggest that this paid-advice effect is due to the same forces that have been documented in the literature to explain prior instances of the sunk costs fallacy.  

The cost of advice affected the degree to which participants used advice but did not affect the value gained by following advice. In the studies, advice came from another participant who was randomly chosen on a question-by-question basis. On average, advisors were as equally informed or knowledgeable as judges. In fact, individuals who were history experts could not participate in the studies. Moreover, participants had no opportunity to assess the accuracy of advisors’ estimates. Nor had they the opportunity to assess the accuracy of their own estimates, as no performance feedback was provided. When advice cost money, participants weighed their personal opinions less than others’. When advice was free, they instead weighed their personal opinions more than others’.

Thursday, May 21, 2020

The Difference Ethical Leadership Can Make in a Pandemic

Caterina Bulgarlla
ethicalsystems.org
Originally posted May 2, 2020

Here is an excerpt:

Since the personal costs of social isolation also depend on the behavior of others, the growing clamors to reopen the economy create a twofold risk. On the one hand, a rushed reopening may lead to new contagion; on the other, it may blunt the progress that has already been made toward mitigation. Not only can more people get sick, but many others—especially, lower-risk groups like the young—may start reevaluating whether it makes sense to sacrifice themselves in the absence of a shared strategy toward controlling the spread.

Self-sacrifice becomes less of a hard choice when everybody does his/her part. In the presence of a genuinely shared effort, not only are the costs of isolation more fairly spread, but it’s easier to appreciate that one’s personal interest is aligned with everyone else’s. Furthermore, if people consistently cooperate and shelter-in-place, progress toward mitigation is more likely to unfold in a steady and linear fashion, potentially creating a positive-feedback loop for all to see.

Ultimately, whether people cooperate or not has more to do with how they weigh the costs and benefits of cooperation than the objective value of those costs and benefits. Uncertainty—such as the uncertainty of whether one’s personal sacrifices truly matter—may lead people to view cooperation as a more costly choice, but trust may increase its value. Similarly, if the choice to cooperate is framed in terms of what one can gain—such as in “stay home to avoid getting sick”—rather than in terms of how every contribution is critical for the common good, people may act more selfishly.

For example, some may start pitting the risk of getting sick against the risk of economic loss and choose to risk infection. In contrast, if people are forced to evaluate whether they bear responsibility for the life of others, they may feel compelled to cooperate. When it comes to these types of dilemmas, cooperation is less likely to manifest if the decisions to be made are framed in business terms rather than in ethical ones.

The info is here.

Wednesday, March 25, 2020

What Should Health Care Organizations Do to Reduce Billing Fraud and Abuse?

K. Drabiak and J. Wolfson
AMA J Ethics. 2020;22(3):E221-231.
doi: 10.1001/amajethics.2020.221.

Abstract

Whether physicians are being trained or encouraged to commit fraud within corporatized organizational cultures through contractual incentives (or mandates) to optimize billing and process more patients is unknown. What is known is that upcoding and misrepresentation of clinical information (fraud) costs more than $100 billion annually and can result in unnecessary procedures and prescriptions. This article proposes fraud mitigation strategies that combine organizational cultural enhancements and deployment of transparent compliance and risk management systems that rely on front-end data analytics.

Fraud in Health Care

Growth in corporatization and profitization in medicine, insurance company payment rules, and government regulation have fed natural proclivities, even among physicians, to optimize profits and reimbursements (Florida Department of Health, oral communication, September 2019). According to the most recent Health Care Fraud and Abuse Control Program Annual Report, in one case a management company “pressured and incentivized” dentists to meet specific production goals through a system that disciplined “unproductive” dentists and awarded cash bonuses tied to the revenue from procedures—including many allegedly medically unnecessary services—they performed. This has come at a price: escalating costs, fraud and abuse, medically unnecessary services, adverse effects on patient safety, and physician burnout.

Breaking the cycle of bad behaviors that are induced in part by financial incentives speaks to core ethical issues in the practice of medicine that can be addressed through a combination of organizational and cultural enhancements and more transparent practice-based compliance and risk management systems that rely on front-end data analytics designed to identify, flag, and focus investigations on fraud and abuse at the practice site. Here, we discuss types of health care fraud and their impact on health care costs and patient safety, how this behavior is incentivized and justified within current and evolving medical practice settings, and a 2-pronged strategy for mitigating this behavior.

The info is here.

Friday, March 13, 2020

When Medical Debt Collectors Decide Who Gets Arrested

Lizzie Presser
Propublica.org
Originally posted 16 Oct 19

Here is an excerpt:

Across the country, thousands of people are jailed each year for failing to appear in court for unpaid bills, in arrangements set up much like this one. The practice spread in the wake of the recession as collectors found judges willing to use their broad powers of contempt to wield the threat of arrest. Judges have issued warrants for people who owe money to landlords and payday lenders, who never paid off furniture, or day care fees, or federal student loans. Some debtors who have been arrested owed as little as $28.

More than half of the debt in collections stems from medical care, which, unlike most other debt, is often taken on without a choice or an understanding of the costs. Since the Affordable Care Act of 2010, prices for medical services have ballooned; insurers have nearly tripled deductibles — the amount a person pays before their coverage kicks in — and raised premiums and copays, as well. As a result, tens of millions of people without adequate coverage are expected to pay larger portions of their rising bills.

The sickest patients are often the most indebted, and they’re not exempt from arrest. In Indiana, a cancer patient was hauled away from home in her pajamas in front of her three children; too weak to climb the stairs to the women’s area of the jail, she spent the night in a men’s mental health unit where an inmate smeared feces on the wall. In Utah, a man who had ignored orders to appear over an unpaid ambulance bill told friends he would rather die than go to jail; the day he was arrested, he snuck poison into the cell and ended his life.

The info is here.

Thursday, March 5, 2020

Ethical concerns with online direct-to-consumer pharmaceutical companies

Curtis H, Milner J
Journal of Medical Ethics 
2020;46:168-171.

Abstract

In recent years, online direct-to-consumer pharmaceutical companies have been created as an alternative method for individuals to get prescription medications. While these companies have noble aims to provide easier, more cost-effective access to medication, the fact that these companies both issue prescriptions (via entirely online medical reviews that can have no direct contact between physician and patient) as well as distribute and ship medications creates multiple ethical concerns. This paper aims to explore two in particular. First, this model creates conflicts of interest for the physicians hired by these companies to write prescriptions. Second, the lack of direct contact from physicians may be harmful to prospective patients. After analysing these issues, this paper argues that there ought to be further consideration for regulation and oversight for these companies.

The info is here.

Tuesday, February 18, 2020

Can an Evidence-Based Approach Improve the Patient-Physician Relationship?

A. S. Cifu, A. Lembo, & A. M. Davis
JAMA. 2020;323(1):31-32.
doi:10.1001/jama.2019.19427

Here is an excerpt:

Through these steps, the research team identified potentially useful clinical approaches that were perceived to contribute to physician “presence,” defined by the authors as a purposeful practice of “awareness, focus, and attention with the intent to understand and connect with patients.”

These practices were rated by patients and clinicians on their likely effects and feasibility in practice. A Delphi process was used to condense 13 preliminary practices into 5 final recommendations, which were (1) prepare with intention, (2) listen intently and completely, (3) agree on what matters most, (4) connect with the patient’s story, and (5) explore emotional cues. Each of these practices is complex, and the authors provide detailed explanations, including narrative examples and links to outcomes, that are summarized in the article and included in more detail in the online supplemental material.

If implemented in practice, these 5 practices suggested by Zulman and colleagues are likely to enhance patient-physician relationships, which ideally could help improve physician satisfaction and well-being, reduce physician frustration, improve clinical outcomes, and reduce health care costs.

Importantly, the authors also call for system-level interventions to create an environment for the implementation of these practices.

Although the patient-physician interaction is at the core of most physicians’ activities and has led to an entire genre of literature and television programs, very little is actually known about what makes for an effective relationship.

The info is here.

Tuesday, February 11, 2020

The Americans dying because they can't afford medical care

Michael Sainato
theguardian.com
Originally posted 7 Jan 2020

Here is an excerpt:

Finley is one of millions of Americans who avoid medical treatment due to the costs every year.

A December 2019 poll conducted by Gallup found 25% of Americans say they or a family member have delayed medical treatment for a serious illness due to the costs of care, and an additional 8% report delaying medical treatment for less serious illnesses. A study conducted by the American Cancer Society in May 2019 found 56% of adults in America report having at least one medical financial hardship, and researchers warned the problem is likely to worsen unless action is taken.

Dr Robin Yabroff, lead author of the American Cancer Society study, said last month’s Gallup poll finding that 25% of Americans were delaying care was “consistent with numerous other studies documenting that many in the United States have trouble paying medical bills”.

US spends the most on healthcare

Despite millions of Americans delaying medical treatment due to the costs, the US still spends the most on healthcare of any developed nation in the world, while covering fewer people and achieving worse overall health outcomes. A 2017 analysis found the United States ranks 24th globally in achieving health goals set by the United Nations. In 2018, $3.65tn was spent on healthcare in the United States, and these costs are projected to grow at an annual rate of 5.5% over the next decade.

The info is here.

Monday, December 30, 2019

23 and Baby

Tanya Lewis
nature.com
Originally posted 4 Dec 19

Here are two excerpts:

Proponents say that genetic testing of newborns can help diagnose a life-threatening childhood-onset disease in urgent cases and could dramatically increase the number of genetic conditions all babies are screened for at birth, enabling earlier diagnosis and treatment. It could also inform parents of conditions they could pass on to future children or of their own risk of adult-onset diseases. Genetic testing could detect hundreds or even thousands of diseases, an order of magnitude more than current heel-stick blood tests—which all babies born in the U.S. undergo at birth—or confirm results from such a test.

But others caution that genetic tests may do more harm than good. They could miss some diseases that heel-stick testing can detect and produce false positives for others, causing anxiety and leading to unnecessary follow-up testing. Sequencing children’s DNA also raises issues of consent and the prospect of genetic discrimination.

Regardless of these concerns, newborn genetic testing is already here, and it is likely to become only more common. But is the technology sophisticated enough to be truly useful for most babies? And are families—and society—ready for that information?

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Then there’s the issue of privacy. If the child’s genetic information is stored on file, who has access to it? If the information becomes public, it could lead to discrimination by employers or insurance companies. The Genetic Information Nondiscrimination Act (GINA), passed in 2008, prohibits such discrimination. But GINA does not apply to employers with fewer than 15 employees and does not cover insurance for long-term care, life or disability. It also does not apply to people employed and insured by the military’s Tricare system, such as Rylan Gorby. When his son’s genome was sequenced, researchers also obtained permission to sequence Rylan’s genome, to determine if he was a carrier for the rare hemoglobin condition. Because it manifests itself only in childhood, Gorby decided taking the test was worth the risk of possible discrimination.

The info is here.

Tuesday, December 10, 2019

Medicare for All: Would It Work? And Who Would Pay?

Ezekiel (Zeke) Emanuel
Podcast - Wharton
Originally posted 12 Nov 19

Here is an excerpt:

“If you want to control costs, there are at least three main areas you have to look at: drug costs, hospital costs to the private sector, and administrative costs,” he said. “All of them are out of whack. All of them are ballooned.”

On drug costs, for example, it is not clear if that would be achieved through negotiations with drug companies or by the government setting a price ceiling, Emanuel said. He suggested a way out: “We should have negotiations informed by value-based pricing,” he said. “How much health benefit does the drug give? The more the health benefit, the higher the price of the drug. But we do need to have caps.”

Emanuel also faulted Warren’s idea to limit payments to hospitals at 110% of Medicare rates as unwise. He suggested 120% of Medicare rates, adding that it would “probably have no real pushback from most of the health policy people, especially if you do have a reduction in administrative costs and a reduction in drug costs.” he said.

Emanuel pointed to a recent Rand Corporation study which showed that on average, private health plans pay more than 240% of Medicare rates for hospital services. “That seems way out of whack,” he said. “There are a lot of hospital monopolies, and consolidation has led to price increases – not quality increases as claimed. We do have to rein in hospital prices.” The big question is how that could be achieved, which may include placing a cap on those prices, he added.

On reining in administrative costs, Emanuel saw hope. He noted that the private sector spends an average of 12% on administrative costs, and he blamed that on insurance companies and employers wanting to design their own employee health plans. He suggested a set of five or 10 standardized plans from which employers could choose, adding that common health plans work well in countries like the Netherlands, Germany and Switzerland. Japan has 1,600 insurance companies, but standardized health plans and a centralized clearinghouse helps keep administrative costs low, he added.

The info is here.

Thursday, November 14, 2019

Assessing risk, automating racism

Embedded ImageRuha Benjamin
Science  25 Oct 2019:
Vol. 366, Issue 6464, pp. 421-422

Here is an excerpt:

Practically speaking, their finding means that if two people have the same risk score that indicates they do not need to be enrolled in a “high-risk management program,” the health of the Black patient is likely much worse than that of their White counterpart. According to Obermeyer et al., if the predictive tool were recalibrated to actual needs on the basis of the number and severity of active chronic illnesses, then twice as many Black patients would be identified for intervention. Notably, the researchers went well beyond the algorithm developers by constructing a more fine-grained measure of health outcomes, by extracting and cleaning data from electronic health records to determine the severity, not just the number, of conditions. Crucially, they found that so long as the tool remains effective at predicting costs, the outputs will continue to be racially biased by design, even as they may not explicitly attempt to take race into account. For this reason, Obermeyer et al. engage the literature on “problem formulation,” which illustrates that depending on how one defines the problem to be solved—whether to lower health care costs or to increase access to care—the outcomes will vary considerably.

Saturday, July 13, 2019

The Worst Patients in the World

David Freedman
The Atlantic - July 2019 Issue

Here are two excerpts:

Recriminations tend to focus on how Americans pay for health care, and on our hospitals and physicians. Surely if we could just import Singapore’s or Switzerland’s health-care system to our nation, the logic goes, we’d get those countries’ lower costs and better results. Surely, some might add, a program like Medicare for All would help by discouraging high-cost, ineffective treatments.

But lost in these discussions is, well, us. We ought to consider the possibility that if we exported Americans to those other countries, their systems might end up with our costs and outcomes. That although Americans (rightly, in my opinion) love the idea of Medicare for All, they would rebel at its reality. In other words, we need to ask: Could the problem with the American health-care system lie not only with the American system but with American patients?

(cut)

American patients’ flagrant disregard for routine care is another problem. Take the failure to stick to prescribed drugs, one more bad behavior in which American patients lead the world. The estimated per capita cost of drug noncompliance is up to three times as high in the U.S. as in the European Union. And when Americans go to the doctor, they are more likely than people in other countries to head to expensive specialists. A British Medical Journal study found that U.S. patients end up with specialty referrals at more than twice the rate of U.K. patients. They also end up in the ER more often, at enormous cost. According to another study, this one of chronic migraine sufferers, 42 percent of U.S. respondents had visited an emergency department for their headaches, versus 14 percent of U.K. respondents.

Finally, the U.S. stands out as a place where death, even for the very aged, tends to be fought tooth and nail, and not cheaply. “In the U.K., Canada, and many other countries, death is seen as inevitable,” Somava Saha said. “In the U.S., death is seen as optional. When [people] become sick near the end of their lives, they have faith in what a heroic health-care system will accomplish for them.”

The info is here.

Thursday, December 27, 2018

You Snooze, You Lose: Insurers Make The Old Adage Literally True

Justin Volz
ProPublica
Originally published November 21, 2018

Here is an excerpt:

In fact, faced with the popularity of CPAPs, which can cost $400 to $800, and their need for replacement filters, face masks and hoses, health insurers have deployed a host of tactics that can make the therapy more expensive or even price it out of reach.

Patients have been required to rent CPAPs at rates that total much more than the retail price of the devices, or they’ve discovered that the supplies would be substantially cheaper if they didn’t have insurance at all.

Experts who study health care costs say insurers’ CPAP strategies are part of the industry’s playbook of shifting the costs of widely used therapies, devices and tests to unsuspecting patients.

“The doctors and providers are not in control of medicine anymore,” said Harry Lawrence, owner of Advanced Oxy-Med Services, a New York company that provides CPAP supplies. “It’s strictly the insurance companies. They call the shots.”

Insurers say their concerns are legitimate. The masks and hoses can be cumbersome and noisy, and studies show that about third of patients don’t use their CPAPs as directed.

But the companies’ practices have spawned lawsuits and concerns by some doctors who say that policies that restrict access to the machines could have serious, or even deadly, consequences for patients with severe conditions. And privacy experts worry that data collected by insurers could be used to discriminate against patients or raise their costs.

The info is here.

Sunday, November 11, 2018

Nine risk management lessons for practitioners.

Taube, Daniel O.,Scroppo, Joe,Zelechoski, Amanda D.
Practice Innovations, Oct 04 , 2018

Abstract

Risk management is an essential skill for professionals and is important throughout the course of their careers. Effective risk management blends a utilitarian focus on the potential costs and benefits of particular courses of action, with a solid foundation in ethical principles. Awareness of particularly risk-laden circumstances and practical strategies can promote safer and more effective practice. This article reviews nine situations and their associated lessons, illustrated by case examples. These situations emerged from our experience as risk management consultants who have listened to and assisted many practitioners in addressing the challenges they face on a day-to-day basis. The lessons include a focus on obtaining consent, setting boundaries, flexibility, attention to clinician affect, differentiating the clinician’s own values and needs from those of the client, awareness of the limits of competence, maintaining adequate legal knowledge, keeping good records, and routine consultation. We highlight issues and approaches to consider in these types of cases that minimize risks of adverse outcomes and enhance good practice.

The info is here.

Here is a portion of the article:

Being aware of basic legal parameters can help clinicians to avoid making errors in this complex arena. Yet clinicians are not usually lawyers and tend to have only limited legal knowledge. This gives rise to a risk of assuming more mastery than one may have.

Indeed, research suggests that a range of professionals, including psychotherapists, overestimate their capabilities and competencies, even in areas in which they have received substantial training (Creed, Wolk, Feinberg, Evans, & Beck, 2016; Lipsett, Harris, & Downing, 2011; Mathieson, Barnfield, & Beaumont, 2009; Walfish, McAlister, O’Donnell, & Lambert, 2012).