Tuesday, December 1, 2015

We Could Eradicate Hepatitis C. But We Have to Test and Treat Prisoners

Today’s Managing Health Care Costs Number is 11,730

The headline in Kaiser Health News  is “Testing For Hepatitis C In Prisons Could Save Many Lives On The Outside.”

…testing all prison inmates for hepatitis C—and treating them when appropriate—is extremely cost-effective. Using an “opt-out” system—testing each prisoner as a matter of course unless he specifically declines—could prevent between 10,900 and 12,700 new hepatitis C infections, most of which would occur in the community after infected prisoners returned home. The study also found the testing and treatment would lead to a significant decrease in the number of liver transplants, cases of liver cancer, and other liver-related deaths in the community.

The KHN reporter adds in the concluding paragraph:

“Cost effective” is not the same as cost saving: “It means something will cost additional money, but it’s worth spending…”


The study was in the November 24 issue of Annals of Internal Medicine, and projects that such screening would cost about  $1.15 billion in the first year – and progressively less over time.  Nine out of ten prevented cases of Hepatitis C would be outside of prison, as most prisoners eventually leave prison and provide a reservoir for infection of the general population.   The simulation is robust – and incorporated likely pharmacy discounts and used a 3% discount rate.   It projected that 10 years of screening would prevent 11,730 deaths.

The authors included a chart (below) showing infections and costs prevented – but relegated the costs incurred to a table. I’ve put them in the graphic above.  You can see that the expense of treatment is much more than the cost savings.

We absolutely should pay for screening and treatment of Hepatitis C in prisons.   Incarceration should not  lead to a lifetime of disability and sickness nor be a death sentence. We have the chance to make Hepatitis C a rare disease – and we will fail to do this if we don’t test and treat prisoners.  Thousands will unnecessarily die, and many more will have quality adjusted life years ripped away from them.  Most of the victims will not be prisoners.

Prisons worried about the cost of hepatitis treatment even before the new expensive (tolerable and effective) medications became available.  The current system of relying on states to fund this care is simply not going to work.  We need a national fund for Hepatitis C treatment – much as we “nationalized” end stage renal disease care by making those on dialysis eligible for Medicare.   

We have the potential to eradicate a deadly virus, one that kills more Americans each year than HIV.   The cost per quality adjusted life year is less than $30,000.  It’s cruel and sad that we seem unlikely to take the necessary action.

Graphic of prevented infections and costs from the Annals of Internal Medicine article.  

Monday, November 30, 2015

Solutions to Gun Deaths that the NRA Would Not Oppose.

Today’s Managing Health Care Costs Number is 5,947

Highly public shootings, like the (terrorist) attack on Planned Parenthood in Colorado Springs on Friday, make many of us think of the public health imperative of decreasing gun deaths.  It seems there is news of a mass shooting almost daily – and these shootings have a powerful narrative force.  They happen in places (malls, colleges, clinics) where we have been – and they are random.  The victims of these shootings could easily be us or our loved ones or our friends.

Propublica published a powerful piece this weekend pointing out that our approach to pushing gun control as a response to these tragic shootings is focused on these shootings where victims are often white.  But these types of shootings represent a small fraction of that ~12,000 homicides in the US each year.  Half of the victims of these homicides (5947 in 2012) are black males, who represent just 6% of the population.  

We are missing the opportunity to spend trifling sums of money to implement community programs that have been shown to substantially reduce the number of young black men murdered each year.   The Propublica article focuses on the Boston Ceasefire program.  

Under Ceasefire, police teamed up with community leaders to identify the young men most at risk of shooting someone or being shot, talked to them directly about the risks they faced, offered them support, and promised a tough crackdown on the groups that continued shooting. In Boston, the city that developed Ceasefire, the average monthly number of youth homicides dropped by 63 percent in the two years after it was launched.

Ceasefire programs have dramatically reduced the rate of gun-related homicides in 7 of the 8 cities where this has been implemented. The cost is not zero – it’s a few hundred thousand dollars a city.  Hiring a competent and street-wise manager is key, as is support from the police, politicians and the community.  The programs require continual tending – even the much ballyhooed Boston program ended when its police lead was promoted.

This American Life covered another approach that has proven successful at reducing gang violence. The crime-ridden city of Richmond California inaugurated an Office of Neighborhood Safety – which identified that 17 young men were responsible for 70% of all the crime in the city – a city that had 42 homicides in 2006 before the program started. The intervention – they paid these young men between $300 and $1000 a month to be law-abiding.  This is not nearly as much as they could make dealing drugs –but enough to lower the murder rate by 2/3. 80% of the participants in this program have not had an arrest – a wild success.

These programs cost little for every life saved, and they would not likely face the withering opposition of the NRA.   But still they have not been aggressively promoted by the Obama administration. The funds the Obama administration requested have been slashed by Congress.

In medicine, as in life, we often focus on events with narrative arc – an epidemic of Ebola, or the devastation of brain cancer.  These are important – but sometimes a small investment in social services can save a huge number of lives.   In this case, as the Propublica article emphasizes, the lives saved would be black lives.   Funding these programs is part of how we need to show that black lives really do matter.

Wednesday, November 25, 2015

CA Spine Surgeons Admit Illegal Pay for Referrals

Today’s Managing Health Care Costs Number is $580 million

Another case of the medical system behaving badly.  

The former chief financial officer of a Long Beach, California, hospital, two orthopedic surgeons, a chiropractor and a health care marketer have been charged with illegally referring more than 4,000 patients for spinal surgeries and generating more than $580 million in fraudulently submitted bills during an eight-year period    Source

Back injuries are terrible – and spinal surgery is occasionally helpful –but often leads to lingering disability and trouble. Many estimate that between 1/3 and ½ of spinal surgery that is performed in the US should not have been performed.  

It’s exasperating that there are physicians or a hospital that were paying for referrals.   All are apparently pleading guilty and will serve jail time.

Atul Gawande had a great description of a second opinion service that saved a WalMart employee from unnecessary back surgery in the New Yorker this May. 

Rural Critical Access Hospital Fights for Life

Today’s Managing Health Care Costs Number is 25

KQED reported earlier this week about the efforts to keep Mendicino Coast District Hospital (MCDH) in Fort Bragg California from closing its doors.

Mendocino is a 25 bed rural acute care hospital.   It lost $3.2 million on $43.7 million in net operating revenue in FY 2013.  It employs about 215 FTEs (245 for the health system overall, which includes 25-30 at a community health system).  Of note the system has an exceptionally high cost of fringe benefits (about 38% of total employee compensation; most health care systems are under 30%).

On one hand, Mendocino Coast District Hospital sounds like a dismal place to get medical care.  Here’s a description from the KQED reporter:

It’s like stepping back into 1971. The main patient floor is lined with painted cinder-block corridors and drab brown carpets. The smell of Salisbury steak spills out of patient rooms.

The hospital gets a single star in either in-hospital or 30 days post hospital quality in five of ten measures of clinical care according to HealthGrades.  (Single star is “worse than expected” in a five star scale). The hospital scores below national averages on all ten measures of patient experience, and it’s less than half as effective at giving appropriate surgical antibiotics as national averages

On the other hand, the nearest hospital is 35 miles away –and Mendocino Coast District Hospital is one of the few good employers left in Fort Bragg.  It’s no surprise that the residents of the town are fighting to keep their hospital open.

MCDH faces a number of existential challenges.  The rural population is dwindling, leading to decreased demand.   Federal funding for critical need hospitals, which are paid based on ‘cost’ rather than bundled payment by admissions (DRGs) like other hospitals, has decreased.   Recruiting physicians to a decrepit hospital hours from a big city is getting tougher, and the average age of physicians is probably increasing. The hospital has had 4 CEOs in the last year, and the leadership physicians are squabbling, to put it politely.  The current facility needs to be rebuilt to meet California’s new earthquake code, and there is no endowment to tap.

The CEO and CFO want to raise revenue, and the leadership physicians want to cut (administrative) costs.  Increasing charges for the few people covered by private insurance doesn’t seem like a likely way to become a viable business. The hospital will probably have to reconfigure its (generous) benefits and slim down further even if the county increases its subsidies.

The county will vote on whether to raise taxes to keep its hospital afloat in fall, 2016.  It will be a terrible blow to the community if this hospital closes – but it might be that funding primary and specialty care and transportation to better equipped hospitals in neighboring towns would be a better investment than keeping this facility open.   

Thursday, November 19, 2015

Schwartz Center Highlights Compassionate Care

I joined about 2000 others at the annual Kenneth Schwartz Center for Compassionate HealthCare dinner last night.  Kenneth Schwartz was a health care lawyer who died at age 40 of lung cancer in 1995.    He was a tireless advocate for compassionate care – and worried openly that efforts to lower health care costs would interfere with how much time physicians got to spend with their patients.  He published a seminal article, “A Patient’s Story” in the Boston Globe.   Creation of the Schwartz Center is one of his legacies.

The Schwartz Center helps hospitals and other care organizations establish Schwartz Rounds to discuss cases where there was opportunity for a higher level of compassion – much as traditional “morbidity and mortality” rounds allow clinicians to reflect on how care could have been improved.  Schwartz rounds are now held in  375 hospitals in the US and 120 in the United Kingdom.  The cases discussed usually represent missed opportunities.   Compassionate care isn’t important only for the dying – one of the physicians at my table talked about a Schwartz Rounds topic of children who are hospitalized during the holidays

The annual dinner is an opportunity for storytelling – narrative helps really. The dinner featured a middle school lacrosse player diagnosed with glioblastoma.  She was supported by her friends, her family, and a nurse who has since bonded with the family.    Medical care couldn’t save her life, but what she wanted from what was left of her life was to remain a full member of her middle school community.   She achieved that.  

Atul Gawande talked about the importance of asking patients what they really want.  He told the heartbreaking story of a dying woman whose only wish was that she could bring her grandchild to Disney World.   Unfortunately her caregivers asked this question when her disease had progressed too far.   A few months earlier she could have had her wish.  She died in the hospital two days later.   Here’s a link to the Frontline film based on Atul’s book, Being Mortal.

The Schwartz Center honors one compassionate caregiver each year – and this year is the first that the Center sought nominations from across the country.  The award was given to a pediatrician who runs the palliative program at the University of Mississippi.  He told of an infant who died of meningitis – and how he felt impotent as a physician, but the family was grateful for his empathic tears.  He also reported that when he attended a child’s funeral, the funeral director told him that he was the first physician he had ever seen at the graveside.

I’m pretty sure compassionate care means we’ll spend less in the medical system – less on futile interventions, and less on care people really don’t want.  There is good evidence that improved communication lowers the risk of malpractice action.  Giving providers “room” to be compassionate, especially enough time, can be a challenge as we try to constrain health care cost increases – but we must not inhibit clinicians from displaying their natural empathy.   

Compassionate care is what all of us want – whether we are close to death, or even when we feel that our mortality is far away. The Schwartz Center rounds have helped increase compassionate care given by thousands of providers, and the awards have helped shine the light on providers who serve as a model to us all.

Addendum The NPR Hidden Brain podcast has a 20 minute segment on compassion from late October that’s worth a listen.   Turns out that being compassionate isn’t just good for the beneficiaries of compassion  -- it actually leads to increased happiness for the person showing compassion. A virtuous cycle indeed. 

The managing health care cost number will return with the next post. 

Tuesday, November 17, 2015

New Cholesterol Medications Could Cost Half as Much as All Primary Care Visits

Today’s Managing Health Care Costs Number is $124

Kevin Schulman and colleagues wrote last month in the New England Journal that the cost of the new PCSK9 inhibitors, injectable biologic drugs that dramatically lower LDL (bad) cholesterol, could be huge.

We estimated the magnitude of additional costs per beneficiary in a typical insurance pool by applying a 25% reduction (negotiated discount, cost sharing, or both) to the list price of alirocumab, accounting for the estimated $600 in savings due to fewer cardiovascular events, and varying clinical criteria for use of these therapies. If 5% of the estimated 27% of U.S. adults 40 to 64 years of age who have high LDL cholesterol levels were eligible for a PCSK9 inhibitor, annual insurance premiums would increase by $124 for every person in the insurance pool.

$124 is more than half as much as we pay for all primary care office visits!

The insurance pool of those with employer sponsored health insurance is about  49% of the population – or 159 million.   This means the cost of these medications could be almost $20 billion.    This doesn’t count the cost of PCSK9s for the Medicare population, where prevalence of hypercholesterolemia is higher.  

Note that the potential savings if these medications eliminated ALL heart attacks entirely is accounted for in these figures.   Even if these drugs are highly effective, they are priced at far more than their value.   The Institute for Clinical and Economic Review (ICER) estimated the value of these drugs at between $3600 and $4800 annually – as opposed to the $14,000 list price.

The most recent JAMA predicts four decision errors likely to lead to vast overprescribing of  PCSK9 medications

1.     We will start diagnosing more people with intolerance to statins.  These people will then be candidates for PCSK9 inhibitors.   Muscle aches with statins are common -  and most who suffer from these could simply try a different statin or even try the same statin again.   Statin intolerance should be a rare reason for PCSK9 use – and then only in patients at very high risk of cardiovascular disease. 
2.     We’ll return to LDL targets – and many people won’t be able to achieve these with statins.  These targets are likely to be chosen without nearly enough attention to “number needed to harm.”
3.     PCSK9 inhibitors will be prescribed for statin “failure,” even though it’s hard to define “failure” for meds which lower (but cannot eliminate) risk. 
4.      PCSK9 inhibitors will be prescribed for nonadherence to statins.  The new drugs are injected every week or two weeks – as opposed to taken orally daily. Keep in mind that statin adherence rates were 27% (!) in the control group of a recent study.

There is a long history of physicians warmly embracing heavily-marketed new drugs and new technologies.   There is every reason to believe this new class of drugs will be overused. At best, this will buy us better outcomes at an exceptionally high price.  At worst, we’ll discover that these drugs have unexpected side effects and we will have spent unnecessary billions of dollars and diminished health care quality.

Friday, November 13, 2015

Physician and Patient Incentives to Lower Cholesterol Have Tiny Impact

Today’s Managing Health Care Costs Number is 12

University of Pennsylvania researchers published a carefully designed study in JAMA this week assessing the efficacy of patient and physician incentives to lower LDL and improve adherence to statin medications. The study was big (1500 patients), well designed, and lost no patients to followup over 15 months.   The incentives were meaningful – over $1000 per patient for physicians and patients who participated.

The results are sobering.

There was statistically better adherence (measured by electronic pill bottle caps that track opening) for those patients randomized to both physician and patient incentives.  However, this difference was small – and not likely to be clinically significant.  The cost was large – if all patients and physicians participating in this research in the group with incentives for physicians and patients and achieved adherence goals, the cost would have been over $2 million.   That doesn’t count the considerable administrative costs of the program, including the electronic pill bottle caps, tracking, and incentive fulfillment. On average, this would have led to decreases in LDL of just 12 mg/dl compared to the control group.    

The most striking finding to me is the low rate of medication adherence in all groups.    Adherence was taking medication as prescribed 80% of the time;  only 1 in four of the control group achieved this, and only 4 in 10 with physician and patient incentives were assessed as adherent.

It’s also especially disappointing that patient incentives alone didn’t nudge LDL levels down at all compared to the control group.   Patients control whether or not they take their meds – and it would be nice to be able to aim interventions squarely at them rather than at physicians. 

We should keep on trying various incentive programs to influence the behavior of patients and physicians.  We should measure the results carefully, as Asch and colleagues did here, since real life results are not always what we’d expect.   Extrinsic incentives are most likely to work when they are awarded quickly for simple activities (like patients taking a pill), as opposed to when they are awarded later complex behaviors without clearly visible outcomes (like physicians encouraging patient adherence).  

For all of human behavior, intrinsic motivation is all important.

Adherence by Group Assignment 

LDL Level by Group Assignment