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Health Costs

Health Costs, Health Policy, In the News

Is “Big Med” the future of health care?

The current special issue of the Journal of the American Medical Association takes the history and vitals of the U.S. health-care system’s finances. And, as NPR’s Shots blog reports, experts conclude that the cost of “drugs, hospital stays, doctors and bureaucracy” – rather than the number of diagnostic tests ordered or the size of the aging Baby Boomer population – accounts for over 90 percent of spending increases on health care since 2000.

What’s the prognosis? Maybe the large and concentrated market power of “Big Med,” says the Shots piece, borrowing the term from a JAMA analysis. But, like big airlines, the consolidation of services into fewer large bodies could produce better efficiency and safety while leading to a loss of quality in the consumer experience.

Previously: Making health care better and more affordableThe history of U.S. health care in about 1,000 words, An expert’s historical view of health care costs, Stanford expert urges physicians to take the high road in slowing health care spending and Does the Affordable Care Act address our health-cost problem?

Health Costs, Medicine and Society, Orthopedics, Research

How much for those healthy knees?

How much for those healthy knees?

hurt kneeWhat’s the cost of healthy, functional knees for life? Priceless, you might say, especially if yours feel achy or injured. But rehabilitation after a major injury, such as an anterior cruciate ligament (ACL), can be expensive, and results after surgery vary.

A recent study published in the Journal of Bone and Joint Surgery has examined the cost-effectiveness and quality-of-life impact of surgery to repair an ACL tear in relation to the price of the procedure, versus rehabilitation without surgery. Researchers found the average lifetime societal benefit of having ACL reconstruction surgery to be $50,000 per patient – or $10.1 billion across the U.S., which reports approximately 200,000 ACL tears annually.

This price includes not only money that would have been spent on rehabilitation and future injury repair, but also comparative lost wages and disability payments after surgery versus non-surgical rehabilitation. It also considers the patient’s ability to live with high function, low levels of pain and minimal risk of developing knee osteoarthritis.

From the study:

In the short to intermediate term, ACL reconstruction was both less costly (a cost reduction of $4503) and more effective (a [quality-adjusted life years - QALY] gain of 0.18) compared with rehabilitation. In the long term, the mean lifetime cost to society for a typical patient undergoing ACL reconstruction was $38,121 compared with $88,538 for rehabilitation. ACL reconstruction resulted in a mean incremental cost savings of $50,417 while providing an incremental QALY gain of 0.72 compared with rehabilitation. Effectiveness gains were driven by the higher probability of an unstable knee and associated lower utility in the rehabilitation group. Results were most sensitive to the rate of knee instability after initial rehabilitation.

Previously: Study shows men, rather than women, may be more prone to ACL injuries, Stanford study shows protein bath may rev up sluggish bone-forming cells andIron-supplement-slurping stem cells can be transplanted, then tracked to make sure they’re making new knees
Via Medical News Today
Photo by Carolyn Tiry

Chronic Disease, Health Costs, In the News, Patient Care, Stanford News

Focusing on the whole person to treat chronic disease – and cut costs

Focusing on the whole person to treat chronic disease - and cut costs

Yesterday’s Marketplace on NPR offered a look at the new – and cost-effective – way some doctors are treating chronic illness. Among those featured in the segment was Alan Glaseroff, MD, co-director of Stanford Coordinated Care:

“[Our] work begins by asking the question, ‘Why wouldn’t a person with a chronic condition do everything in their power to live long and feel well?’” he says. “And generally there is sort of a subtext, ‘What is wrong with this person, they are not listening to me.’”

At his clinic, Glaseroff sees 160 privately insured patients, who racked up $58,000 a year, on average, in medical bills before he began treating them.

Glaseroff directs his team to focus first on what matters to a patient like dancing at his daughter’s wedding, for instance. Then they deal with the fact that the patient is diabetic and smokes three packs a day.

Glaseroff says his approach has helped shave 20 percent off his patient’s medical costs. He says if the model succeeds in other states, “It will be a huge step forward.”

Previously: Innovative Stanford clinic to support chronic care patients

Health Costs, Health Disparities, Public Health, Rural Health

“Mountain Dew mouth” rots teeth, costs taxpayers

"Mountain Dew mouth" rots teeth, costs taxpayers

1527462651_903a291406“Blecch! Ew! Sheesh! I’ll take a crab juice,” replied a thirsty Homer Simpson to a vendor’s alternative offer of Mountain Dew. I side with Homer on most issues, including this one. But whatever you think of the taste, you’d be hard-pressed to argue in favor of the soft drink’s nutritional value.

Soda has a bad reputation for being high in empty calories that contribute to some of the nation’s public-health problems, such as obesity and diabetes. NPR’s The Salt blog reports today on a phenomenon widespread in Appalachia of rotting teeth owing to frequent consumption of soda. The incidence is called “Mountain Dew mouth” – “after the region’s favorite drink,” which was invented in Tennessee, the piece notes.

Public-health advocates point out a burden of cost imposed by the Dew, which can be acquired with food stamps (now called the Supplemental Nutrition Assistance Program). Greater access to the drink and limited availability of dental care contribute to “Mountain Dew mouth,” which is reinforced by cultural issues in the area.

From the piece:

Many people don’t trust the well water in their homes because of pollution concerns and probably drink more soda because of it, [Priscilla Harris, JD, an associate professor at the Appalachian College of Law], says. She’s received a grant from the Robert Wood Johnson Foundation to study the problem.

And there’s another reason why soda mouth is so pervasive in Appalachia, Harris says: the region’s distinct culture of sipping soda constantly throughout the day. Singer adds, “Here in West Virginia, you see people carrying around bottles of Mountain Dew all the time — even at a public health conference.”

The article reports statistics about the region’s rate of tooth decay as 26 percent for pre-schoolers, and tooth extraction because of decay or erosion as 15 percent for 18- to 24-year-olds. In West Virginia, Centers for Disease Control and Prevention numbers show 67 percent of residents age 65 and over having lost six or more teeth from tooth decay or gum disease.

Previously: Sugar intake, diabetes and kids: Q&A with a pediatric obesity expert and Dental health a major problem for many
Photo by uberculture

Ask Stanford Med, Health Costs, Research, Stanford News

What’s the going rate? Examining variations in private payments to physicians

What's the going rate? Examining variations in private payments to physicians

In this photo taken Tuesday, Sept. 2, 2009, University Muslim Medical Association Community Clinic family medicine physician Linh Vuong, right, checks vital signs of high school student Ericka Millan,15, at the UMMA Community Clinic in Los Angeles.  American Muslims want to ensure that they can fulfill "zakat," or obligatory charitable religious giving, following zakat pledge by President Barack Obama. (AP Photo/Damian Dovarganes)When a U.S. physician sees a patient – either for a routine visit or to administer some sort of treatment – there’s a good chance she’ll be paid a different amount for her work than another doctor doing the same thing one state, or perhaps even one county, away. Variation in the amounts that private insurers pay physicians is a known phenomenon, but extensive research on the practice – and the factors that account for such variation - has been lacking.

To better understand these differences in payments, Stanford health-policy experts Laurence Baker, PhD, and M. Kate Bundorf, MBA, MPH, PhD, teamed up with an Indiana University–Purdue University researcher to comb through more than 41 million insurance claims for four kinds of services: office visits with established patients, office visits with new patients, office consultations, and preventive visits with established patients. What they found was that physicians at the high-end of payments received were generally paid more than twice than what physicians at the low end were paid for the same service. They also found that the variation couldn’t be explained by patients’ and physicians’ characteristics – things like the age and sex of the patient, the physician’s specialty, and whether the doctor was a “network provider” – but that about one third of the variation was associated with the geographic area of the practice.

To find out more about the study, which was published online yesterday in Health Affairs, I contacted Baker. He answers my questions below.

Were you surprised by what you found?

Sort of. Some news reports have highlighted variations in health-care bills, so we were ready for some variations. But since we were looking at services that are quite common and pretty consistent from place to place, we weren’t expecting to find very big variations, which is what we got.

The other thing that’s interesting is the amount of variation that isn’t explainable by the things we looked at. I had expected a lot of it would be explainable, but most of it isn’t. This is another indication of the complexity of the health care system and the lack of understanding we have of the factors that determine prices.

Did you expect geography to be more of or less of a factor?

I had expected more. Geography is a proxy for many things – such as the costs in different areas, the competitiveness of areas, the preferences of the population and doctors. These could all influence prices. I had thought these would play a bigger role than what we found. But there’s a chance that these things still do, but in ways that are specific to individual doctors or groups, so that we need to do more work to fully measure them.

Why is a better understanding of price variation important?

Price variations could signal important problems with the functioning of health-care markets. Large price variations for similar services normally only exist where someone in a market has a lot of power to dictate prices, which is often a problem for consumers. Price variations can also exist for reasons we’d be less concerned about – for example, if some providers are much higher in quality than others. But knowing about the existence and patterns of price variations can guide us to examine areas that we may need to work on to improve the system.

Informing patients about price variations can also be important. Some patients – for example, the uninsured – can end up paying widely different prices for the same services. If they have more information, they’ll perhaps be better able to manage their health-care experiences and bills.

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Aging, Chronic Disease, Health Costs, Medicine and Literature

Examining end-of-life practices and Katy Butler’s “Knocking on Heaven’s Door”

How long is too long to hang on when the end of life calls? Abraham Verghese, MD, Stanford physician and best-selling author, discusses the emotional and financial costs of extended end-of-life care in a New York Times book review of Katy Butler’s “Knocking on Heaven’s Door.” In the book, Butler details the drawn-out descent of her father after a stroke and sheds light on the unseen hardships of caring for the slowly dying, both for families of the ill and hired home workers.

From the review:

Butler finds that the health care system — and society — seem quite unprepared for a patient like her father. Had he received a diagnosis of a terminal illness, the family would have been supported by a Medicare-funded hospice team.

“But there is no public ceremony to commemorate a stroke that blasts your brain utterly, and no common word to describe the ambiguous state of a wife who has lost her husband and become his nurse.”

The review compares the sometimes six-figure cost of an end-of-life ICU stay to a home health-care worker’s salary, which Butler describes as typically “immorally low.”

Verghese writes:

My hope is that this book might goad the public into pressuring their elected representatives to further transform health care from its present crisis-driven, reimbursement-driven model, to one that truly cares for the patient and the family.

Previously: A conversation guide for doctors to help facilitate discussions about end-of-life careHow a Stanford physician became a leading advocate for palliative care, Honoring an exploration of the “cost of dying”, Exploring the psychological trauma facing some caregivers and Is $618,616 too much to (try to) save a life?

Health Costs, Health Disparities, Health Policy, In the News, Obesity, Public Health, Science Policy

Can food stamps help lighten America’s obesity epidemic?

shopping_12from SNAPIn a recent article in New Scientist, Peter Aldhous discussed several issues related to the Supplemental Nutrition Assistance Program, commonly referred to as food stamps. Noting that “because junk food is cheaper than fruit and vegetables, poverty and obesity tend to go hand-in-hand,” he offered several ways in which the program could be used to lower obesity and malnutrition rates among food stamp users. Here are some examples of the “economic carrots and sticks” he mentions in his piece:

One simple idea is to give the benefits every two weeks, rather than monthly. This would smooth out a cycle in which people load up on high-calorie food when the payments come in, then go hungry towards the end of the month – a pattern known to cause weight gain…

But most attention is focused on efforts to provide incentives to buy fruit and vegetables, or restrict purchases of junk food. A pilot project delivered promising results last month. Over 14 months to December 2012, 7500 households receiving food stamps in Hampden, Massachusetts, were given an extra 30 cents for every dollar spent on fruit and vegetables. Surveys run four to six months into the study show that their consumption of fruit and vegetables was 25 per cent higher than for people on regular food stamps.

Sanjay Basu of Stanford University in California has studied how changes in food prices affect what people put in their shopping baskets. His work suggests that banning food-stamp purchases of unhealthy foods, or increasing their price, should be even more effective…

If the food stamp program could be used to improve the diet of food stamp users, Aldhause writes, it could pave the way “for using taxes and subsidies to nudge the nation as a whole towards a healthier relationship with food.”

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: More evidence that boosting Americans’ physical activity alone won’t solve the obesity epidemicLucile Packard joins forces with Ravenswood School District to feed families during the summer breakFood stamps and sodas: Stanford pediatrician weighs inFood stamp use shows scope of child poverty and Denmark’s “fat tax” aims at life expectancy – not just waistlines
Photo by United States Department of Agriculture

Cancer, Cardiovascular Medicine, Health Costs, Health Policy, Surgery

Check the map – medical procedure rates vary widely across California

Check the map - medical procedure rates vary widely across California

While many patients may think “doctor knows best” when choosing between different medical procedures, a new study from the California HealthCare Foundation found that some of these decisions may be driven more by local physician preferences rather than clinical evidence.

In some California counties, the local rates of elective procedures are dramatically higher than neighboring areas. For example, a man newly diagnosed with prostate cancer who lives in Tracy, Calif., is 479 percent more likely to undergo internal radiation, i.e., brachytherapy, than the state average. (Click on the map above for rates in other counties.)

To make this data more useful to medical consumers, the study authors published an online interactive map that allows Californians to quickly determine if their region performs elective procedures at disproportionately higher rates than the rest of the state.

“We’re hoping these maps can push along conversations about how to improve health-care delivery,” said Laurence Baker, PhD, a consultant on this study and a professor of health research and policy at Stanford. “One thing that is often important is better communication between patients and doctors, particularly in cases where patients can have different preferences. Getting this information out there might help some conversations happen that could lead to better treatment decisions and health outcomes.”

This new version of the procedure map adds breast cancer, prostate cancer, and spine procedure rates and expanded data to include Medicare patients and younger populations enrolled in commercial plans, Medicaid patients, and the uninsured.

Previously: Heart bypass or angioplasty? There’s an app for thatNew breast cancer finding suggests limiting surgery and Ask Stanford Med: Answers to your questions on prostate cancer and the latest research

Cardiovascular Medicine, Health and Fitness, Health Costs, Research, Stanford News

Simple, inexpensive tool helps predict mortality risks

Simple, inexpensive tool helps predict mortality risks

A short survey that asks patients to assess their walking ability could be helpful in predicting a person’s risk of cardiovascular disease, as well as mortality risks from any cause. That’s according to a Stanford study recently published online in the journal Circulation.

The Walking Impairment Questionnaire, also known as the WIQ, is currently used to predict risks of peripheral artery disease, a narrowing of the arteries that causes limited circulation to the limbs. The authors of this new study wanted to see if the WIQ, which can be filled out by patients while waiting for their doctor appointments, might be helpful in predicting other health risks.

“A 70-year-old patient’s ability to walk six minutes is a great predictor of cardiovascular risks,” said Kevin Nead, a Stanford medical student and the first author of the study. “But most people are seen in 15-minute doctor visits. They’re not going to be doing a walking test.” Perhaps, he reasoned, a subjective test like this 17-question survey could be used instead.

Nead and his colleagues, who examined questionnaire results from more than 1,700 patients, found that the use of the WIQ alone successfully predicted cardiovascular outcomes. In addition, when the survey was used in conjunction with other common clinical tests such as blood pressure measurements and blood tests, it significantly improved the ability to predict mortality not just from cardiovascular disease but from any cause.

“In an era of increasing expense for medical costs, this work suggests that the WIQ, an extremely simple and economical tool, may significantly improve our ability to prognosticate risk,” Nead told me.

Photo by timparkinson

Emergency Medicine, Health Costs, Public Health, Research, Stanford News

Comparing the cost-effectiveness of helicopter transport and ambulances for trauma victims

Comparing the cost-effectiveness of helicopter transport and ambulances for trauma victims

Emergency helicopter transport can be pricey and, as recent reports of aircraft crashes show, potentially dangerous. Such downsides have sparked some concerns that transporting trauma patients by air may not be worth the risk. So researchers at Stanford set out to investigate how often medical helicopters needed to help save critically injured patients’ lives in order to be considered cost-effective when compared with ambulances.

Researchers published their findings (subscription required) online this month in the Annals of Emergency Medicine. My colleague explains their results in a release:

The researchers found that if an additional 1.6 percent of seriously injured patients survive after being transported by helicopter from the scene of injury to a level-1 or level-2 trauma center, then such transport should be considered cost-effective. In other words, if 90 percent of seriously injured trauma victims survive with the help of ground transport, 91.6 need to survive with the help of helicopter transport for it to be considered cost-effective.

The study… does not address whether most helicopter transport actually meets the additional 1.6 percent survivorship threshold.

“What we aimed to do is reduce the uncertainty about the factors that drive the cost-effective use of this important critical care resource,” said the study’s lead author, M. Kit Delgado, MD, MS, an instructor in the Division of Emergency Medicine. “The goal is to continue to save the lives of those who need air transport, but spare flight personnel the additional risks of flying – and patients with minor injuries the additional cost – when helicopter transport is not likely to be cost-effective.” (Helicopter medical services generally bill patients’ insurance providers directly, but patients may have to pay some of the bill out of pocket, or, if they’re uninsured, possibly all of it.)

The findings only apply to situations and locations where patients could be taken by both ambulance and helicopter to a trauma center. Researchers said that in scenarios where ground transportation to a trauma center wasn’t feasible, then transport by helicopter was preferable.

Photo by Brett Neilson

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