- The Evidence Gap – The Pain May Be Real, but the Scan Is Deceiving – NYTimes.com – “It’s a concern, isn’t it?” said Dr. Jeffrey Jarvik, a professor of radiology and neurosurgery at the University of Washington. “We are trying to fix things that shouldn’t be fixed.”
Posts Tagged ‘costs’
The Evidence Gap – The Pain May Be Real, but the Scan Is Deceiving – NYTimes.com
December 17th, 2008 | Popularity: 11% 0 comments | Leave a replyNow Reading: “What’s the ROI on that scanner you just bought?” – Use of Medical Imaging in the United States
December 1st, 2008 | Popularity: 22% 0 comments | Leave a reply
The quote in the title of this post is the paraphrase of a conversation I have had more than a few times with someone who has asked me, “Ted, what’s the return on investment for web services for patients?” The answer I have usually gotten when I ask the question back is usually no answer.
Two papers just published in HealthAffairs provide a little more background for that conversation. The first is about the growth of the use of imaging technology in the United States. As you might expect, it is growing, and more with every new scanner put in operation.
To put things in better perspective, I created this graph from the data, showing the increase in the number of scans/beneficiary. In 2005, there were 547 CT scans per 1,000 Medicare beneficiary, or about 1 scan per 2 beneficiaries. What the article doesn’t mention is that the radiation load from a CT scan is high, anywhere to 15 – 100 times the dose of radiation from a chest X-ray. Medicare reimburses, on average $308 for a CT scan, $713 for an MRI.
A basic return on investment analysis is performed for abdominal aortic aneurysm (AAA) screening, which shows that as more people are screened using CT, less are screened using catheter angiography (which is more invasive). This is good, except, the reduction is less than 1:1, so there is overall expansion of screening to more people, and more procedures to fix AAA associated with this. The problem is that there isn’t data on whether this is overall a good thing or not from a cost/benefit perspective.
Because CT and MRI are a physician preference item, reimbursement and use is typically physician directed, which can create conflict (see Jaime Robinson’s paper in the same Health Affairs issue for more about this).
It’s interesting that the adoption curve of CT/MRI looks a lot like the adoption curve of personal health records in organizations that prioritize them, like Kaiser Permanente and Group Health Cooperative.
Currently, Medicare pays $0.00 per certified empowered/activated patient (potentially defined by more than 2 accesses to a comprehensive personal health record in 6 months).
So we know from this is example that it’s possible for health care to adopt technology. How can we recreate the magic of the CT/MRI adoption curve for something that’s patient directed? I have some ideas but want to see your comments first.
Now Reading: The value of ambulatory care measures: a review of clinical and financial impact from an employer/payer perspective
October 1st, 2008 | Popularity: 24% 0 comments | Leave a reply
The subtitle of this article might be, “what performance measures should employers be tracking and paying for in ambulatory care”
The article was passed to me by Sophia Chang, MD, at the California Healthcare Foundation, who has been advising and supporting on our Connectivity for Californians work, and is a nice economic study of 62 performance measures used in specialty recertifcation program and pay-for-performance initiatives.
The measures will look familiar to anyone who works in quality improvement – everything from blood pressure management, to retinal eye screening, all the way through to some measures that have less data associated with them, such as “plan of care for hypertension.” What the authors did was grade the evidence of effectiveness, add cost and benefit data based on meta-analyses and derive a “savings per patient” for each measure.
There are a few critical assumptions made, including full adherence to therapy (they used the term “compliance” which is no longer recommended), and most importantly, no quantification of indirect costs. In other words, this is not a study of presenteeism, only direct medical costs.
What came out near the top of measures with the most impressive savings profile? Hypertension management. Here’s the detailed analysis:
This study has a specific informative value in my mind – which is to encourage employers’ engagement around the performance measures that will likely result in a return on investment for them. This is not a call to action for the health system to reorient its priorities for maintaining community health. I think the idea is that if an employer has an interest in promoting efficient use of the health care dollars they spend on behalf of employees, an analysis like this provides an idea of where to start.
Incidentally, when I did the same analysis using my own literature review, but without the complex analysis employed here, I came to the exact same conclusion around hypertension, which surprised me. I thought I would become an expert in remote monitoring of congestive heart failure or coronary artery disease. The data led me a different way.
See what you think.
Report Anticipates Cost Savings From Online Health Care Services (how?)
October 1st, 2008 | Popularity: 15% 0 comments | Leave a replyReport Anticipates Cost Savings From Online Health Care Services – iHealthBeat – This sounds promising; however, like other estimates of cost-savings of health information technology, a careful examination of the methodology is necessary. Unfortunately, I cannot find the actual study online, but I did e-mail the folks at Milliman to see if I could examine it. if anyone else has (legal) access to it or has reviewed it, please feel free to post a comment.
update 10/09/08: I contacted Milliman and this report is not available for public review. If I am in a situation to review it, I will repost that information here. In the meantime, I am going to reserve judgement on the use of this study’s findings for future work. The conclusions certainly seem compelling, so I hope to get the opportunity to review it.
Stepping Through a Patient’s Experience with Hypertension: Setting Rates and Negotiating Benefits
August 14th, 2008 | Popularity: 38% 0 comments | Leave a replyThis is fourth of a multi-part series on a patient’s experience managing a chronic condition, in this case hypertension. A diagnosis has been made, and our patient has hopefully followed up and has hopefully been maintained on appropriate therapy (there is a 1 in 3 chance that this is happening). Now it is time for our patient’s health care sponsor (such as his employer) to review the health care benefit.
Click on the image to see it larger size
Patient Story (Frydman)
There is no patient story in this phase. At some point during the year, our patient’s employer will discuss provided health care coverage with a health plan or plan(s) who have set rates for coverage in the coming year. On the diagram, there’s no red dot indicating the presence of data because in many (most?) cases there is not a lot of data to guide this conversation. Many health plans have claims data, to show how many services and what types have been paid for throughout the year. They may not have data about the effectiveness of those services. For example, they may not know what percent of office visits for high blood pressure showed effective control. On the employers’ part, they may not have much data, either. If they are self-insured, they may have similar levels of claims data, but not measures of performance.
Even in health care organizations with advanced electronic medical records, the determination of “% patients with appropriate blood pressure control” may not be done in an automated fashion – a random selection of charts may be used to come up with this percentage. The electronic health record may facilitate the selection and review of charts, but nothing more. This is dependent on the health care environment being studied.
(If there are health plan and providers who would like to inform this part of the story, comments are open)
Clinical and Public Health pearls (Houston-Miller and Eytan)
- High blood pressure is one of the most costly conditions for employers, more than cancer, diabetes, heart disease, and behavioral health conditions. This does not take into account that hypertension is responsible for a significant amount of morbidity among patients with heart disease and diabetes. This post shows the costs of each. The first graph shows the cost per person with the condition. When you average the costs across an entire employed population, the large numbers of patients with hypertension escalates the cost of this condition above all others. For those people interested in the cost profile of chronic conditions to employers, The Center for Studying Health System Change hosted a forum where expert Ron Goetzel, Ph.D. provided an updated look at the data. It is compelling.
- Fewer than 10% of the cases of undetected or uncontrolled hypertension could be associated with lack of health care use. In other words, health plans and employers are already paying for this current state. It does not exist because patients are not getting enough health care.
Comment
Where is the data? and What’s Missing? In this case, there isn’t much data in the conversation. The conversation is around use of services, and in that setting, an assumption is typically made that more services is better. The result is that these stakeholders cannot engage at their potential to ensure that services are as effective as possible.
It is possible that a patient or provider may share data about the effectiveness of their blood pressure control services which are being purchased and paid for by employer and health plan respectively. Blood pressure control is already a HEDIS measure, and is a development Pay for Performance measure in California in 2009.
Next post, the yearly checkback, completing the cycle. Comments welcomed, of course
Stepping Through a Patient’s Experience with Hypertension: Making the Diagnosis
August 6th, 2008 | Popularity: 42% 16 commentsThis is second of a multi-part series on a patient’s experience managing a chronic condition, in this case hypertension. We’re now past the discovery that something may be wrong, and at follow up with a personal physician. Recall that 1/3 of patients do not make it this far.
Click on the image to see it larger size
Patient Story (Frydman)
I was convinced that the HBP was just a temporary event due to stress and that by the time I had it checked by my friend the problem was gone. The measurements showed that I was completely mistaken. For the first time I was faced with the possibility that I was not really in control with a health problem. Even after a couple of measurements and a strong admonition from my friend to take every day the medicines he prescribed, I was still inclined to deny the reality of the problem. I remember telling myself: ” even if the problem is there to stay I can still afford to wait another 6 months before I become a compliant patient.” And I kept being this stupid and stubborn patient for another 1 1/2 year.
He said: “this is very dangerous. We do not want you to experience a catastrophic event. Therefore you must be treated”
For some reason, that is NOT the message that makes me understand that I really must be treated. There is clearly a missing piece in the way the doc is interacting with me, his friend. By spending maybe 3 to 5 minutes explaining the rational behind the proposed treatment he would have transformed the interaction from – he is forcing me to change – to – I understand why I must change
I was supposed to go back but I didn’t do it. During a business trip I did try checking my BP with a home tool a few times and every time the BP was well within the norms, helping me be even more in denial. But then the next time I went to my friend’s office the data still showed clear HBP. Go figure!
Clinical and Public Health pearls (Houston-Miller)
- Hypertension is the #1 reason for physician office visits in the United States (9.7% of all visits)
- 20 % of patients diagnosed with high blood pressure do not actually have it; it is falsely elevated in the doctor’s office (called “white coat hypertension”). This results in unnecessary (and costly) treatment.
- 10 % of patients measured with normal blood pressure in the doctor’s office actually have high blood pressure (called “masked hypertension”)
- In recognition of the above, many health plans and Medicare reimburse for “Ambulatory Blood Pressure Monitoring” (CPT Code: 93784), which is a 24-hour, round-the-clock, blood pressure measurement. This type of measurement is typically a research tool and not used in clinical practice. There is no reimbursement for home monitoring currently.
- The average of 2 home blood pressure readings is more predictive of mortality than screening blood pressures taken by nurses and technicians
- 32 – 53 % of patients stop their medications by the end of the first year
- A patient like this is considered “high risk” because he is male and likely to have another condition (such as high cholesterol)
Comment
Where is the data? The diagram and patient’s experience illustrate the fact that the information related to the diagnosis and treatment is typically localized to the provider, and not the patient. When a diagnosis is made, lab studies and medicines are ordered, and the patient’s health plan will receive a claim for the office visit. The patient is typically instructed to come back to the doctor’s office for reassessment, rather than doing self-assessments, and the patient is usually not given a treatment plan, or access to blood pressure and other data generated in the visit.
What’s missing? As in the previous vignette, the patient is without information regarding the significance of the condition, or resources to learn more / compare with other patients’ experiences. In my own searching, I have found limited social networking resources online for blood pressure management, relative to other conditions such as diabetes. This is beginning to change, though, as more organizations, such as the American Heart Association, become active in promoting self-management and personal health records.
Tomorrow, ongoing management and maintenance of blood pressure control. Comments welcomed, of course.
Milliman Medical Index – Milliman’s fourth annual study of average medical spending for a typical American family of four
June 6th, 2008 | Popularity: 22% 0 comments | Leave a reply- Milliman Medical Index – Average family of four at $15,609 medical costs / year. Employee share is up 10 %, the highest cost share is for pharmaceuticals, at 27 %. This ties to the Connectivity for Californians work, because it’s a reminder I need to look up total patient costs for hypertension management.
Conservative vs aggressive Medical Care: Consumer Reports
June 6th, 2008 | Popularity: 23% 0 comments | Leave a reply- Aggressive medical care, conservative vs aggressive – Nice XPlane (xplane.com – one of my favorite design groups) produced images of regional differences in health care costs, from Consumer Reports. It's helpful to see this group champion appropriate care for patients.
Now Reading: Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring
May 27th, 2008 | Popularity: 27% 1 comment
Pickering, Thomas G., Nancy Houston Miller, Gbenga Ogedegbe, Lawrence R. Krakoff, Nancy T. Artinian, and David Goff. “Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring. A Joint Scientific Statement From the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association.” Hypertension (May 22, 2008).
As we have been planning a multi-stakeholder pilot to demonstrate improved management of chronic conditions by Californians, this paper was just published, which adds compelling information to the discussion. Talk about interesting timing.
The paper is a compendium of research and information to date on the value of home blood pressure monitoring, which has not been previously integrated into the clinical practice of improving blood pressure control. The impact of poor control is reiterated: high blood pressure as accountable for 27% of total CVD events in women and 37% in men.
Useful Facts
- 35% of hypertensive patients check their BP once a week, 64% of patients own a monitor.
- Arm monitors appear to still be the best choice through validation studies.
- There is often “poor” agreement between patient reported readings and readings stored in the monitors’ memory, with one study showing up to a 20% error rate.
- Patients are at risk for over-diagnosis (“white coat hypertension”) up to 20% of the time, and under-diagnosis (“masked hypertension”) up to 10 % of the time, resulting in over/unnecessary treatment, or undertreatment.
- Blood pressures measured outside of the doctor’s office in many cases is superior in predicting which patients are at risk for organ damage.
- It appears that more study is needed regarding the effectiveness of home blood pressure monitoring to guide treatment and ultimately support better control. As far as I can tell, none of the studies mentioned here assess the impact of coupling improved patient-health system communication (eg secure messaging with physicians or health system) with home blood pressure monitoring.*
- Medicare currently reimburses ambulatory (24 hour) blood pressure monitoring for patients with suspected white coat hypertension, and this monitoring has been shown to be cost-effective in reducing unnecessary treatment.
- Of extreme interest in our planning, this paper refers to studies assessing patient attitudes toward home monitoring, which appear favorable, but maybe less so when out of pocket expense is required – this is a follow-up/countermeasure item.
Conclusion
Beyond information about the value of home blood pressure monitoring, there are suggested protocols for integrating this monitoring into practice. This seems like a great springboard to integrate this into patient access to their own clinical information, along with potential connections to the health system and other patients.
Based on the information presented, there seems to be a case for employing “connected” blood pressure monitoring for accurate diagnosis of blood pressure and response to treatment. Given that Medicare already reimburses ambulatory blood pressure monitoring for white coat hypertension, there may also be a case to extend, as a pilot, reimbursement for home monitoring for diagnosis and initial management of blood pressure outside of physician visits. This ties well to the data that most patients with high blood pressure are insured and seeing physicians, with only 35% control, making this approach a worthy alternative.
From a biological plausibility perspective, it makes sense that measuring an ongoing physiological state (average blood pressure throughout the day) in its native environment, over time, has a likelihood of being more accurate than a few point measurements done outside of the environment where people live and work (the doctor’s office).
The opportunity for the proposed project here is to integrate the benefits of home monitoring with a sustainable workflow inside and outside of the health system, using technology available today, to improve patient and family involvement in their care. Of interest, the Agency for Healthcare Quality and Research is promoting the idea of patient involvement in care as a quality and safety improvement strategy for patients. This work could extend the strategy to more stakeholders, including employers and the health system itself.
Conflict of Interest Analysis
I think this should be part of a review of any paper, given the information being published about sponsored research (here’s some examples).
The lead author has a significant relationship with device maker Omron, and has received speakers fees from pharmaceutical manufacturer Boerhinger-Ingelheim and Omron. Another author has received speaker’s fees from Merck and serves in a consultant/advisory board capacity for Pfizer and CV Therapeutics.
There was discussion previously about support to the American Heart Association by device makers.
These associations could result in over-exhuberant promotion of home blood pressure monitoring devices and treatment (i.e. it’s unlikely that a device manufacturer would have an interest in less devices being sold), and need to be taken into account when reviewing this piece. This might be reflected especially in areas where the data is/was equivocal about benefits, yet conclusions are framed in the positive or hopeful.
One of the issues in the discussion of device/medication promotion is that new treatments are compared to placebo instead of to current practice. The information presented here compares the treatment of interest to current practice, which has room for improvement. With that in mind, I think the information here is contributory to the work we’re considering and will be used to update the A3 accordingly.
A Disclosure of My Own
I should point out that I assisted in the planning of the Group Health blood pressure study mentioned above from an operations/informatics perspective, and was not funded under the grant and am not a co-author of that study, which is not connected to this work. I am currently funded by the California Healthcare Foundation.
Comments welcome, of course.
AHA – Trendwatch – Absenteeism and Presenteeism in the Workplace
May 22nd, 2008 | Popularity: 18% 0 comments | Leave a reply- AHA – Trendwatch – Absenteeism and Presenteeism in the Workplace – The American Hospital Association also weighs in on lost productivity due to chronic illness. Their analysis is based on the Goetzel 2004 paper
Health and Productivity Among U.S. Workers
May 22nd, 2008 | Popularity: 17% 0 comments | Leave a reply- Health and Productivity Among U.S. Workers – Another analysis of the impact on productivity on illness. This is more general, and also refers to the Goetzel study published in 2004
Hypertension, Health 2.0, and Indirect Costs, Now it’s Getting Interesting
May 20th, 2008 | Popularity: 41% 1 commentIn my fielding of this data to various people, this part of the analysis has been by far the most controversial. Let’s first start with indirect costs added on top of direct costs, from the societal perspective, just for California. By indirect costs, we mean lost time from work (absence and short term disability), presenteeism (impairment while at work, to avoid being absent), and caregiving (21 million working men and women are caregivers in the US)
The indirect cost data is only for employed persons reporting the condition, which means it is a subset of the population (doesn’t include indirect costs for the non-employed, doesn’t include costs for the undiagnosed). The graph above is therefore a little bit off, because the medical cost is for all people, productivity costs just for employment related losses.
Now, a different look at the data, which averages costs across the entire employee population, from the employer perspective.
This is different because it takes into account prevalence, and spreads that cost over all employees, whether they report the condition or not. My explanation for the different way this data looks is that the medical cost per person for hypertensive employees is far less than for heart disease, but there are many more hypertensive patients in a population. In the employee samples used to derive this data, there’s a factor of 2 difference compared to heart disease (12.4 % vs 6.4 %).
The sources for this data are the same as previous charts (formatted for Zotero, below).
I have already been asked, “Ted, how can high blood pressure cause presenteeism at all?” and I welcome the skepticism. I reviewed the study below, which defined the term for our profession, and it includes a combination of employee studies, some done quite well, that ask about employee impairment and absences due to multiple conditions. This includes things like side effects of medications (which are a cornerstone of hypertension therapy). Questions, based on the study, were things like whether an employee performance was reduced by ‘losing concentration, repeating a job, working more slowly than usual, feeling fatigued, or generally “doing nothing”‘. The authors specifically chose tools that measured multiple conditions at once, so that comparisons could be made.
One novel study worth mentioning specifically is one by Bank One, that used administrative and computerized productivity records of its employees to explicitly measure productivity losses, in addition to using a health risk appraisal and claims data to come up with estimates. For hypertension, the estimate was 0.4 % in this one, which was right in the middle.
Based on my reading of the paper, I am accepting the methodology as supportive. As a student of LEAN, though, I know that the facts are best obtained on the factory floor, so my next interest is in working with an employer, and ultimately and employee, who experiences these conditions first hand. And I do mean on the factory floor, rather than the health system.
After creating this post, I realized that my A3 (coming next) has one inaccuracy. Fixing that, posting it soon.
1. An Unhealthy America: The Economic Burden of Chronic Disease: California. Take a look at the methodology here.
2. Goetzel, Ron Z, Stacey R Long, Ronald J Ozminkowski, Kevin Hawkins, Shaohung Wang, and Wendy Lynch. “Health, absence, disability, and presenteeism cost estimates of certain physical and mental health conditions affecting U.S. employers.” Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 46, no. 4 (April 2004): 398-412.
Comment away, this can only improve with input.
More on Hypertenstion and Health 2.0 : Costs
May 19th, 2008 | Popularity: 20% 2 comments
Continuing on the case for connecting Californians, here is a look at the direct costs of hypertension (high blood pressure). There are several sources for cost data, the sources I used here typically rely on the Medical Expenditure Panel Survey (MEPS). The references are below.
The first chart shows things from a societal perspective, for California residents, the cost per person reporting the condition. It does not include costs for people who do not report the condition.
The second chart shows things from an employer’s perspective, and is calculated differently – it is the total cost of the condition spread across the entire employee base, per year. On this one, you’ll note that the prevalence of hypertension makes it formidable from an employer’s perspective relative to the other chronic conditions.
There’s a whole lot more to be said about this, but I’ll keep it brief and open things up for comments.
Additional cost estimate (not charted): $US 1,131 direct medical expenditures, prescriptions > 50 % of expenditures
Next, a profile of indirect costs.
Sources (Zotero format):
First Chart
1. An Unhealthy America: The Economic Burden of Chronic Disease: California. Take a look at the methodology here.
Second Chart
2. Goetzel, Ron Z, Stacey R Long, Ronald J Ozminkowski, Kevin Hawkins, Shaohung Wang, and Wendy Lynch. “Health, absence, disability, and presenteeism cost estimates of certain physical and mental health conditions affecting U.S. employers.” Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 46, no. 4 (April 2004): 398-412.
Additional Estimate
3. Balu, Sanjeev, and Joseph Thomas. “Incremental expenditure of treating hypertension in the United States.” American journal of hypertension : journal of the American Society of Hypertension 19, no. 8 (August 2006): 810-6.
Update: Physician Impact on Healthcare Finances
March 5th, 2008 | Popularity: 16% 0 comments | Leave a reply
Catlin A, Cowan C, Hartman M, Heffler S, the National Health Expenditure Accounts Team. National Health Spending In 2006: A Year Of Change For Prescription Drugs [Internet]. Health Aff. 2008 Jan 1;27(1):14-29. [cited 2008 Mar 5 ]
Reducing waste in our health care system is important. The latest data shows that 83 cents of every health care dollar spent is spent by physicians. Making the systems that carry out these orders efficient is a good goal; working with physicians at the point the orders are written (or typed) is also important.
