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Health Costs, In the News, Mental Health, Research, Stanford News

Exploring the costs and deaths associated with workplace stress

Exploring the costs and deaths associated with workplace stress

6273248505_43d0b56424_oMany of us know that a stressful job or work environment can be hard on our physical and mental health. But what is less known – and less studied – is how work-related stress translates into deaths and dollars spent on health care. According to new research, work-related stress may be linked to more than 120,000 deaths per year and about $190 billion in health-care costs in the United States alone.

In a study submitted to Management Science, former Stanford doctoral student Joel Goh, PhD, and Stanford professors Jeffrey Pfeffer, PhD, and Stefanos A. Zenios, PhD, reviewed 228 studies to explore the relationships between ten common sources of workplace stress, mortality and healthcare expenses in the U.S.

The researchers found that a lack of health insurance and job insecurity were among the top stressors linked to poor physical and emotional health. From a recent Stanford Business story:

Job insecurity increased the odds of reporting poor health by 50%, while long work hours increased mortality by almost 20%. Additionally, highly demanding jobs raised the odds of a physician-diagnosed illness by 35%.

“The deaths are comparable to the fourth- and fifth-largest causes of death in the country — heart disease and accidents,” says Zenios, a professor of operations, information, and technology. “It’s more than deaths from diabetes, Alzheimer’s, or influenza.”

Perhaps the most surprising result, the researchers explain, was the strong effect of psychological stressors on overall health:

Employees who reported that their work demands prevented them from meeting their family obligations or vice versa were 90% more likely to self-report poor physical health, the researchers note. And employees who perceive their workplaces as being unfair are about 50% more likely to develop a physician-diagnosed condition.

The researchers acknowledge that the study has some limitations. For example, they were unable to make strong causal links between work-related stress, mortality and health-care expenses; and they only examined 10 sources of stress. The importance of the study, Pfeffer explains, is that it draws attention to the need to create positive work environments where people feel good about themselves and their work.

Previously: How the stress of our “always on” culture can impact performance, health and happinessStudy finds happy employees are 12 percent more productiveWorkplace stress and how it influences health and How work stress affects wellness, health-care costs
Photo by Bernard Goldbach

Aging, Health Costs, Medicine and Society, Ophthalmology, Research, Stanford News

Factors driving prescription decisions for macular degeneration complex – and costly

Factors driving prescription decisions for macular degeneration complex - and costly

5197694152_fbbfe73c21_zFor the last decade or so of her life, my grandma was basically blind. Her eyes, like those of many seniors, suffered from macular degeneration, a progressive disorder that affects the macula, a small spot near center of the retina critical for clear vision.

She lived her last years in a nursing home in Iowa and I honestly don’t know what drugs, if any, she took for this condition, much less how much they cost.

But multiplied by millions (macular degeneration is the most common cause of visual impairment in older adults), the costs are a big deal. That’s why Stanford researchers set out to understand why doctors would prescribe one drug, ranibizumab (let’s call it r) at a cost of $2,000 a dose over bevacizumab (b), which runs $50 a dose.

They published their findings in Health Affairs today.

Both drugs are equally effective and have similarly severe side effects. And, according to a 2011 report, if all Medicare doctors had prescribed b rather than r in 2011, the system would have saved $1.1 billion.

Stanford researchers hypothesized that Medicare physicians — who face a financial incentive to prescribe more expensive drugs — would be more inclined to prescribe r than Veterans Affairs physicians, who don’t have the same incentive.

Instead, as health economist Kate Bundorf, PhD, told me, it’s much more complex.

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Health Costs, Medicine and Society, Medicine X, Technology

The power of social media: How one man uses it to help amputees get prosthetics

The power of social media: How one man uses it to help amputees get prosthetics

Stanford’s Medicine X is a catalyst for new ideas about the future of medicine and health care. This new series, called The Engaged Patient, provides a forum for some of the patients who have participated in or are affiliated with the program. The latest installment comes from Medicine X ePatient Joe Riffe.

Allie - smallWe’re all familiar with social media. We spend our days updating our Facebook statuses, tweeting our latest attempt at being funny, or using Instagram to show off our last meal. Social media is an excellent way to connect with friends and family; some people have even gained celebrity status all through the social-media movement. Social media has sparked revolutions as well. The Occupy Wall Street Movement, for example, was largely driven by the power of a hashtag.

This power is also accessible to patients to start a David versus Goliath type war. I use the power of social media to help amputees get prosthetics, and in this piece I’ll tell you two of these stories. The first is about Allie; the second is a recent story about my own battle to get a prosthetic.

I met Allie in the hospital after a mutual friend asked me to meet her and her family to show them that being an amputee doesn’t mean you can’t live the life you want to live. I immediately connected with Allie. I wanted to be her mentor; she the Luke to my Obi Wan. Allie didn’t have insurance at that time, and I couldn’t stand the thought of this young girl, just starting her life, not having access to the best prosthetics available. I explained to her that with the right prosthetic, anything is possible.

A local prosthetic company had gotten to Allie before the prosthetist I use was able to meet with her and her family. They convinced the family that due to Allie’s lack of insurance she would have to settle for the best prosthetic she could afford – and not the best available like she deserved. Allie suffered on this prosthetic for months. The ill-fitting socket and knee didn’t suit the lifestyle of an active 20-year old.

After nearly a year of suffering, Allie found herself with insurance and made her way to the prosthetist I use. He quickly saw the need for her to have access to the best technology available and had his team start creating a prosthetic for her.

There are many hoops to jump through when trying to get a prosthetic leg. The biggest obstacle is that advanced technology comes with a hefty price tag. Luckily, the office she goes to now knows how to get through these hoops fairly quickly.

Allie made it though this process fairly quickly and received a letter from her insurance company promising to pay for the advanced prosthetic. Then, they began the stall tactic. They waited months, delaying the payment required to order the prosthetic that Allie so desperately needed.

That was when I came in. With one tweet – just one tweet – I was able to expedite the payment for her prosthetic limb. Why does this company prevent amputees from returning to their lives by approving high-quality prosthetics then not paying for them, I wrote to my hundreds of followers. A few days later I was greeted on Facebook by the photo above: Allie with her new leg.

Unadulterated joy!

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Health Costs, Pain, Public Health, Research

Study examines trends in headache management among physicians

Study examines trends in headache management among physicians

4175034274_63cd0d4a7c_zAn estimated 12 percent, or 36 million Americans, suffer from migraines, resulting in an economic loss of $31 billion each year due to lost productivity, medical expenses and absenteeism.

Making lifestyle changes, such as exercising regularly, getting adequate sleep, reducing stress and cutting food triggers from your diet, have been shown (.pdf) to be effective ways to manage headache symptoms. But research recently published in the Journal of General Internal Medicine shows that physicians are increasingly ordering medical tests and providing referrals to specialists instead of offering counseling to patients on how changing their behavior could relieve their pain. Medical News Today reports:

The study, which analyzed an estimated 144 million patient visits, found a persistent overuse of low-value, high-cost services such as advanced imaging, as well as prescriptions of opioids and barbiturates. In contrast, the study found clinician counseling declined from 23.5 percent to 18.5 percent between 1999 and 2010.

The use of acetaminophen and non-steroidal anti-inflammatory drugs like ibuprofen for migraine remained stable at approximately 16 percent of the medications. Meanwhile, the use of anti-migraine medications such as triptans and ergot alkaloids rose from 9.8 percent to 15.4 percent. Encouragingly, guideline-recommended preventive therapies – including anti-convulsants, anti-depressants, beta blockers and calcium channel blockers – rose from 8.5 percent to 15.9 percent.

Unlike with the treatment of back pain, researchers found no increase in the use of opioids or barbiturates, whose usage should be discouraged, although they were used in 18 percent of the cases reviewed.

Researchers also found a significant increase in advanced imaging such as CT scans and MRIs, from 6.7 percent of visits in 1999 to 13.9 percent in 2010. The use of imaging appeared to rise more rapidly among patients with acute symptoms, compared to those with chronic headache.

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Health Costs, Health Policy, Patient Care, Research

Medicare payment reform shown to cut costs and improve patient care

Medicare payment reform shown to cut costs and improve patient care

PT got Margie practicing on crutches, including going up and down a step.A few years back, the Centers for Medicare and Medicaid Services (CMS) made a straightforward change: No longer would it pay for easily preventable conditions that develop in the hospital. A care-team fails to help ambulate a patient following a hip or knee surgery and the patient develops deep-vein thrombosis? Unfortunate for the patient and unfortunate for the hospita, which now has to absorb the cost of that care.

It seems obvious, yet slightly disturbing, that this approach would be successful. In my idealized worldview, all patients are treated the same, regardless of who’s picking up the tab.

But when you change the financial incentives, change happens. Stanford health economist Jay Bhattacharya, MD, PhD, and health economist Risha Gidwani,DrPH, who is affiliated with the VA and Stanford, found the prevalence of two preventable conditions – deep-vein thrombosis and pulmonary embolisms – for patients with a recent hip or knee surgery dropped after Medicare stopped paying. The study was published today in the Journal of General Internal Medicine.

From our press release on the work:

When CMS stopped paying for treating deep-vein thromboses and pulmonary embolisms, the incidence of those conditions after hip or knee replacement surgery dropped 35 percent in the Medicare population, Gidwani said. In the younger, non-Medicare population, the incidence of these two conditions increased, although they also decreased in the patients over age 65 who had private insurers. There are more than 1 million hip or knee replacements performed in the United States each year, and over 60 percent of them are paid for by Medicare.

“We have a win-win,” Gidwani told me. “We have patients who are avoiding adverse events while Medicare saves money.”

Previously: Beyond Berwick brouhaha: Medicare chief another step to health-care reform, Experts discuss high costs of health-care — and what it will take to change the system and Competition keeps health-care costs low, Stanford study finds
Photo by Dave & Margie Hill

Health Costs, Health Policy, Patient Care, Research

Spotting stellar primary care practices, Stanford study identifies 10 practices that lead to excellence

Spotting stellar primary care practices, Stanford study identifies 10 practices that lead to excellence

crutches-538883_1280Many of us know first-hand that expensive, substandard health care abounds in America. The problem has been analyzed and bemoaned, measured and critiqued. Solutions, bright spots and success stories are less abundant—in fact they are downright rare. That’s why recent findings from a partnership between Stanford’s Clinical Excellence Research Center and the Peterson Center on Healthcare, a new organization that aims to improve health care in the United States, are so exciting. Bucking current theories, researchers found that independent, primary care medical practices can provide superior care while saving money. And, they identified 10 principles these practices embrace, which distinguish them from their peers.

I had the chance to speak with CERC Director Arnold Milstein, MD, about the Stanford-based project:

What exactly did you do?

We examined the performance of more than 15,000 primary care practices looking for “positive outliers” or practices that provide excellent care at a lower cost. This is the first  systematic comparison of its kind and we weren’t sure we’d be able to discern any differences. But we did. We found a substantial difference in measures of quality and the total annual amount of health care spending between sites. Then, we arranged for  observers (independent physicians) to visit these offices to understand what was different about care delivery at sites associated with less spending and high quality scores.  They discovered 10 distinguishing features of successful health-care practices that were present much more frequently in these positive outlier practices than in other offices. There are some major differences in how they deliver care.

What were some these features? Did any surprise you?

About two-thirds align with current national initiatives such as Choosing Wisely and the Patient Centered Medical Home, but about one-third are new ideas.

The 10 features are not abstract ideas, they are tangible and therefore more easily transferable. For example, the higher-performing sites are ‘always on’ — patients can reach the care team quickly 24/7. I use the word ‘care teams’ because I’m not referring to physicians only. These teams include nurses, nurse practitioners, medical assistants and/or office managers, developed  to the highest of their abilities. These teams often treat conditions in a gray zone between primary care and specialist care. They follow up with their patients when a case is referred to a specialist. They check in with patients to ensure they are able to follow self-care recommendations.  Their work station is shared, so they can learn from each other. These teams adhere to systems to deliver care — choosing individual tests and treatments carefully. Distribution of revenues among physicians is not  solely based on service volume. Finally, these practices invest much less in office rent and costly testing hardware.


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Cardiovascular Medicine, Chronic Disease, Health Costs, Research, Stanford News

Home health-care treatments for lymphedema patients cut costs and improve care

Home health-care treatments for lymphedema patients cut costs and improve care

Lymphedema, an incurable chronic illness that involves severe swelling of the limbs, is frequently ignored, often misdiagnosed and under treated. Now a study by a Stanford researcher, who has for years worked to change this, illustrates how the use of home health-care treatment can help. The research appears today in PLOS ONE.

In a story I wrote on the study, Stanley Rockson, MD, a leading expert on lymph disorders, explains that one of the major challenges to improving care for lymphedema patients is that home care is poorly reimbursed by third-party payers. Rockson and colleagues set out to examine the cost effects of the use of one of these home-care therapeutics called a compression device to reduce swelling.

This is clearly a compelling argument for increased coverage of compression devices and similar home-care devices to reduce costs

By examining the health-care claims from a national private health insurer from 2007 to 2013, researchers found that patients who used these compression devices reduced annual health-care costs from $62,190 to $50,000. As Rockson explains in a press release, “Total health-care costs for these patients are very high, but can be profoundly reduced with treatment intervention, in this case a compression device. This is clearly a compelling argument for increased coverage of similar home-care devices to reduce costs.”

Rockson, who both researches lymphedema and treats patients with the disorder, has worked over the years to educate both the public and health-care professionals about this “hidden” disease. As a reporter who covers his research, he has also helped educate me – and in my piece I describe both the cause of the disease and available treatments:

Lymphedema is most commonly caused by the removal of or damage to lymph nodes as a part of cancer treatment. It results from a blockage in the lymphatic system, which is part of the immune system. The blockage prevents lymph fluid from draining well, and the fluid buildup leads to swelling, which can be painful and debilitating. These symptoms can be controlled with various treatments, including treatments done at home and outpatient physical therapy. Home treatments for lymphedema include manual lymphatic massage, multilayer bandaging techniques and application of various compressive garments to reduce tissue fluid.

I’ve written several other stories about Rockson’s work on lymphedema over the years. One such piece, published in 2009, helps bring a greater understanding to the disease by describing how it impacted one patient. Hearing firsthand from a patient about what it’s actually like to live with lymphedema day-in and day-out makes the ongoing search for better treatments and possible cures all the more pressing:

Julie Karbo fights a battle every day to keep her lymphedema under control. Every night she hooks her arm up to a portable pump to help drain away fluids. Every day she wears compression sleeves to keep the swelling down. She limits the number of groceries she carries into the house to make sure she doesn’t put undue strain on the affected arm, and keeps a close watch for any possible infection-causing scratches or spider bites.

“A bee sting or a spider bite can lead to a very serious infection,” says Karbo, 49, a high-tech public relations executive and single mother of two in the Bay Area, who—unlike many lymphedema patients—never had cancer. “It’s something that greatly impacts the way you live your life.”

Previously: New blood test could bring lymphedema detection (and treatment) into the 21st century and New Stanford registry to track lymphedema in breast cancer patients

Global Health, Health Costs, Health Disparities, Stanford News

Stanford undergrad works to redistribute unused medications and reduce health-care costs

Stanford undergrad works to redistribute unused medications and reduce health-care costs

1Sanchay Gupta arrived at Stanford with a strong interest in income inequality. In 2013, he spent two weeks of his summer vacation in Guatemala exploring issues of global chronic underdevelopment as part of an intensive field research internship sponsored by the Freeman Spogli Institute for International Studies. While on the trip, he shadowed Stanford doctors in ad-hoc rural clinics serving the indigenous communities and got a firsthand look at the country’s rural health-care system. He also interviewed patients about how their health status affected their family’s welfare while conducting field research.

Among the patients he interviewed was a father of nine children who made his living carrying firewood. One day the man injured himself carrying a particularly heavy load and was declared unfit for work. Seemingly overnight, the family income drastically fell below $3 a day and the father could no longer afford to see a doctor for treatment. But until he received proper medical care, there was no way that he could recover from his injury and resume supporting his family.

“It was during my time in these community settings that I witnessed how disparities in access to medical care can perpetuate inequality,” said Gupta, who was recently named one of the “15 incredibly impressive students at Stanford” by Business Insider. “As a result, I became really interested in how solving issues of inequality could break the cyclical theme of poverty.”

At the same time, Gupta was  fostering a vested interest in the fate of America’s health-care system. He had taken a few courses on U.S. health policy and strategies for health-care delivery innovation, and the experiences sparked a desire to get involved in efforts to eliminate costly inefficiencies within the health-care sector.

In looking for opportunities to get involved in helping reduce inefficiencies in health care, he learned about Supporting Initiatives to Redistribute Unused Medicine (SIRUM), a non-profit launched by Stanford students that engages with health-facility donors, converting their regulated medicine destruction process into medicine donation.

Nearly one-third of patients don’t fill first-time prescriptions and many say concerns about costs are a key reason for their non-compliance. At the same time, an estimated $5 billion of unused and unexpired prescriptions drugs are destroyed in the United States annually. To address these problems, SIRUM has developed an online platform that allows medical facilities, manufacturers, wholesalers and pharmacies to donate unused drugs instead of destroying them.

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Health Costs, Health Policy, Patient Care, Stanford News

A call for medical malpractice reform

Golden Lady Justice, Bruges, BelgiumA new report in the Journal of the American Medical Association offers a look at the current decline in medical malpractice suits and makes some predictions about their future. The authors include two Stanford faculty, Michelle Mello, JD, PhD, and David Studdert, LLB, ScD, who both have joint appointments at the School of Medicine and the School of Law.

Using national databases, the researchers found that the paid claims against doctors decreased between 2002 and 2013. Rates decreased by an average of 6.3 percent for medical doctors (MDs) and 5.3 percent for doctors of osteopathy (DOs). The amount of an average paid claim peaked in 2007 at $218,400, but had gone down a bit as of 2013. A post on the Stanford Law School’s blog explains why this may be a good time for policy-makers to consider reforms in the medical liability system:

“After years of turbulence, the medical liability environment has calmed,” said Mello. “Although many aspects of the malpractice system are dysfunctional, causing angst for physicians, the cost of malpractice claims and insurance have been stable for the last few years and the number of claims has been declining.”

She added, “Usually, attention is only focused on reform during ‘malpractice crises,’ but highly charged political environments are not conducive to cool-headed policy decisions. This current period of calm is a good time to be thinking about reforms that could improve our medical liability system.”

In their piece, the authors describe seven different novel approaches to medical malpractice reform, including one that encourages medical institutions and providers to communicate with complaining patients and find resolutions that might include payouts to patients before they file suit.

The paper also includes some predictions about the trends that will be important for medical liability policy in the coming decade. The authors assert that traditional tort reforms “will never deliver,” but the previously mentioned communication-and-resolution programs are likely to expand, as will “safe harbor” laws that protect clinicians and their institutions if they can show they are following a prescribed course of clinical treatment. Other trends include the increasing consolidation of health care within hospitals and large health systems. These large entities are likely to use their growing size to influence the liability system.

More ominously, authors note that liability insurance crises have happened in regular cycles since the system was expanded in the 1960s, and warn that another is imminent. They conclude their report by saying:

Action now to reduce the amplitude of the next medical liability cycle is both prudent and feasible. Further testing of nontraditional reforms, followed by wider implementation of those that work, holds the most promise. Prospects for permanent improvement in the medical liability climate depend on it.

Photo by Emmanuel Hybrechts

Events, Health Costs, Health Policy, In the News, Medicine and Society, Stanford News

Experts discuss high costs of health-care – and what it will take to change the system

Experts discuss high costs of health-care - and what it will take to change the system

4386861133_5e79734a6f_zNew York Times reporter Elisabeth Rosenthal, MD, visited Stanford this week for a Health Policy Forum, “Can we put a price on good health? Controlling the cost of health care,” with Stanford health-policy researcher Doug Owens, MD.

Those who attended looking for answers, easy fixes, or a master villain were out of luck. Instead, attendees gained insight into a convoluted system that all agree is broken, yet no one has the total power, or know-how, to fix. Here’s Rosenthal:

The issues and the problems are so diffuse… There’s the tendency to be very reductionist – ‘Oh, it’s the hospital, it’s the insurance companies, it’s pharma’… We’re all so codependent and it’s all so intertwined.

Finances dictate what we do and the incentives are so powerful. The message to patients is that we’re responsible too.

So that complimentary coffee you might get in a hospital lobby? Not actually free, Rosenthal said. She knows: While reporting for the well-known series “Paying Till It Hurts” she has talked to scores of patients and doctors and insurance representatives and policy-makers.

The main problems with the American health-care system are cost, quality and access, Owens said. The Affordable Care Act improved access, yet did little to lower costs or improve quality, he said.

And costs will continue to escalate if all the players remain most responsive to economic pressures, Rosenthal said. “Physicians feel like their income is being squeezed. Hospitals are better prepared to push back, and hospitals and physicians are looking to recoup some of that lost income in other ways. What’s lost in that very real tug of war is that patients are held hostage in the middle. That’s what’s distressing,” she said.

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