Health Business Blog

Managed Care Matters hosts the latest edition of the Health Wonk Review, focusing on implementation of health reform. It’s a well organized collection of posts from the wonkosphere.

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Oncology is the area where the health care cost conundrum is coming into sharpest focus. Theoretically, who wouldn’t spend whatever it takes to cure a life-threatening disease? And yet practically the costs of new treatments are so high, and the improvements usually modest enough, that when it comes right down to it costs are becoming a real issue for patients and doctors.

An interesting article by Scott R. Berry et al. in the Journal of Clinical Oncology (Continental Divide? The Attitudes of US and Canadian Oncologists on the Costs, Cost Effectiveness, and Health Policies Associated With New Cancer Drugs) explores the attitudes of US and Canadian oncologists. From a survey of hundreds of oncologists they conclude that views of the two countries’ oncologists are similar, despite the fact that Canadians practice in a system where some chemotherapy drugs are not covered due to their cost, while in US society as a whole it is taboo to even talk about cost effectiveness or “rationing.”

A few highlights from the article:

On cost-effectiveness

• 84% of US and 80% of Canadian oncologists agree that,”Patient ‘out of pocket’ costs currently influence my decisions regarding which cancer treatments to recommend for my patients.” (Note that while there is little out-of-pocket spend in Canadian health care in general, patients do have to pay for certain drugs that aren’t covered)
• 67% of US and 52% of Canadian oncologists say, “Every patient should have access to effective cancer treatments regardless of their cost.” Note that even in the US this means one-third of physicians think costs should be a deciding factor
• 58% of US and 75% of Canadian oncologists agree that, “Every patient should have access to effective cancer treatments only if the treatments provide ‘good value for money’ or are cost effective.” And yet only 42% of US and 49% of Canadian oncologists said they were well prepared to interpret and use cost-effectiveness information for treatment decisions

On policy issues

• 57% of US and 68% of Canadian oncologists favored price controls for cancer drugs by Medicare
• 80% of US and 69% of Canadian oncologists thought there should be more use of cost-effectiveness data in coverage and payment decisions. (The lower number for Canadians is probably due to the fact that cost-effectiveness information is already used for this purpose)
• 79% of US and 85% of Canadian oncologists want more government research on comparative effectiveness of cancer drugs

Many ideological foes of health reform and comparative effectiveness research think that all would be well if decisions were left up to doctors and their patients. But oncologists already take costs into account and favor cost-effectiveness research, so life (and death) might not actually change much.

In my opinion we should support more and higher quality comparative effectiveness research, then train doctors and patients to interpret and act on it.

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Although I’m upset at continued inflation of health insurance premiums in Massachusetts, I’m proud that the state has brought many more people into coverage since health reform was passed in 2006. We have the lowest rate of uninsurance in the US and have made strong progress in enrolling even hard-to-reach people. Two new reports sponsored by the Robert Wood Johnson Foundation assess the characteristics of the remaining uninsured and evaluate the role of special provisions in bringing young adults into coverage.

Massachusetts Health Reform in 2008: Who are the Remaining Uninsured Adults? identifies the groups that are more likely to lack coverage. They are:

• Male, young, and single
• Racial/ethnic minorities and non-citizens
• Unable to speak English well or very well
• Living in a household in which there was no adult able to speak English well or very well

These results aren’t terribly surprising, but they do underscore the need to focus on targeted interventions and outreach because broad-based messages and programs will have an uneven effect. These findings have implications for Massachusetts, but also for Federal efforts under PPACA. They are also likely to figure into debates on immigration policy.

As discussed in The Importance of Young Adult Provisions in Massachusetts’ Health Reform, Massachusetts did recognize at the outset that young adults would be hard to reach. Two provisions were included in health reform to encourage them to enroll:

• Eligibility for dependent coverage was increased from age 19 to 26
• A Young Adult Plan (YAP) was created that provided access to narrower benefits and higher cost sharing

According to the paper, the percentage of young adults lacking insurance coverage dropped by 61 percent over two years, whereas other comparison groups within Massachusetts (older adults, older minority adults and older childless adults) showed drops of 38 to 49 percent. In New York, by comparison, there was essentially no change in coverage levels within these groups during the same time period.

The authors also concluded that the special provisions for young adults in Massachusetts made a difference in that group’s enrollment.

PPACA contains similar young adult provisions to the Massachusetts law. It’s good to know there is some evidence that they will have the intended effect.

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Late last month, like clockwork the dreaded thick white envelope arrived from Blue Cross Blue Shield of Massachusetts, announcing the health insurance rate increases for the year starting September 1, 2010 for my small business. I took a deep breath and opened the envelope, looking for the inevitable double digit premium increase. So I was surprised to see that the proposed increase was just 3.4 percent –well over the rate of inflation but the smallest increase we’ve ever seen, by a long shot.

My lucky day, I thought. But then I read the cover letter:

IMPORTANT: Except for some PPO plans, these are interim rates in effect until the Division of Insurance has completed its review of our 2010 rate requests. Final rates may be higher than interim rates.

Finally I remembered. My firm is actually one of those small businesses that was affected by the recent spat between the health insurers and the Patrick Administration, and this was my prize.

Today a new letter arrived, entitled “Your New, Final Rates.”

Guess what?

The new premium represents an increase of 12.8 percent, which is a lot lower than Blue Cross probably hoped for, but still awfully high. Our family rate –for fairly dumbed down HMO coverage with high deductibles and co-pays– is $18,000 per year. Put another way, that’s $2000 more than a minimum wage worker in Massachusetts would earn if they worked 40 hours a week for 50 weeks.

The settlement allowed BCBS to raise rates by 0.4 to 12.9 percent. Just our luck we were at the top end of the range. BCBS had wanted to raise rates by 1.7 to 22.6 percent, and I’m sure we would have been at the top end of that range. Probably will be next year, too.

I’m not too happy with BCBS about this, but there’s plenty of blame to go around. I hope the silver lining is a genuine focus on costs over the coming year or two.

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I’ve known for a while that falls are a big problem, especially for the elderly. Some elderly relatives and acquaintances of mine sustained falls that started them down a path of medical trouble and –in some cases– death. A new report, The Burden of Falls in Wisconsin sheds some light on the role of falls in that state. Some key findings:

• Fall are the leading cause of injury-related death in Wisconsin; higher than car crashes and suicides
• 87 percent of fall-related deaths occur among those 65 and older
• 55 percent of falls the cause death occur at home
• 40 percent of those admitted to a nursing home had a fall within the month prior to admission

The American Academy of Orthopaedic Surgeons has good information about how to prevent falls. I’m hoping to speak to one of their spokesmen soon.

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Evan Falchuk is President and COO of Best Doctors, an employee benefit company that provides members with access to world-class medical experts who review their diagnosis and treatment plan. It’s used by people facing serious medical problems who want additional expertise brought to bear.

In this podcast interview, Evan holds forth on health care reform, health information technology, social media, quality ratings sites, patient navigation, and the role of Best Doctors.

I first interviewed Evan back in 2008. Since then he’s started a blog of his own.

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David Williams interviews Best Doctors' Evan Falchuk Play Now | Play in Popup | Download

Insurance Writer hosts the latest edition of the Cavalcade of Risk blog carnival, featuring risk-related posts on medical, financial, workers comp and general topics.

And don’t forget to check out the singing dog!

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In June I posted Opening our eyes to pro-anorexia and pro-bulimia websites, to alert parents and pediatricians to the existence of an online world of eating disorder websites. Some of the sites include tips and tricks to hide one’s condition from others. I received a number of emails after that post; some were happy I’d shared the info, others felt I’d unfairly slighted the pro-ana sites (by lumping them with pro-anorexia sites), and others thought I’d done a disservice by linking to some of the sites.

In this guest post, Angela E. Gambrel Lackey, a 45-year-old woman on a journey of recovery from anorexia, shares her personal perspective on pro-ana. The post first appeared on her blog, Leaving ED.

—-

The Lies of Proana
by Angela E. Gambrel Lackey

My mind feels as if it were split in two by anorexia. Part of me is pulled toward eating less and losing weight. The pursuit of thinness feels so strong, ready to pull me under. But is it really being thin that I want? I don’t think so.

People say I am too thin now; losing more pounds feels rather pointless and yet . . . I look at pictures of those who are young and thin; fake photos to draw me in and trap me. I will never look like that. It is a lie. I won’t tiptoe between raindrops nor walk across snow-covered fields with nary a footprint.

The Lies of Proana

Il Faut Souffrir Pour Etre Belle
(One must suffer to be beautiful)

Welcome to the world of fantasy
Where slender young women
float through life
untouched by the ravages
of their starving bodies
and
wasted minds.

Did I ever believe any of this? Do I still? Is my mind torn in two? As I struggle to eat, both believing I need to lose weight and then seeing the truth, I wonder whose mind is it, anyway? Who is in control here and am I that easily manipulated? Or am I sometimes drawn toward this fantasy world because I find it too hard to escape the reality of anorexia? I wonder …

It is so easy to believe the lies of proana. The women pictured look flawless — smooth, delicate skin, slender bodies and glossy smooth hair. Who could resist the allure of these images?

Proana says all you have to do is not eat. Of course, not every one of these websites actually say you must starve to achieve this imaginary life. Starvation is sometimes just a whisper behind the positive posts of eating less and exercising more; of ways to avoid food and how much better you will feel the less you eat.

Some proana sites go further, trying to make starvation sound virtuous; a state to aspire to:

“Starvation is fulfilling.
Colors become brighter, sounds sharper,
odors so much more savory . . .“

LIES! I wish I could reach through the website where I found that and shake the person, yelling You are starving, that’s why things seem different and strange. Starving!!! Lies which help perpetuate the downward spiral of so many women. More fulfilling??? I remember in some of my worst restrictive times I would suddenly get an urge to snatch food from someone eating in front of me. The smells and imagined taste almost were too much. And yet part of me was (is?) susceptible to this and it scares me.

The other, healthier part of me wants to break free of anorexia forever. I am tired. Tired of counting calories. Tired of worrying about every single bite I put in my mouth. Tired of fighting with my mind all the time. I struggle to maintain some semblance of a normal life and at each turn, crouching in every corner is anorexia.

Tired of thinking about a life without my husband, a life without love and joy.

The anxiety is the worst. I wake up afraid of everything. Having sex with my husband. Food. Getting out of bed. The fear that I will amount to nothing. Eating. Not eating. Facing the day. Taking a shower and deciding what clothes to wear. Completing assignments.

Nothing is untouched by anxiety. Nothing.

The other day my husband told me he was leaving unless I made a real effort toward recovery. I thought I was. I was thinking about what I needed to do, writing about it, trying to work through the fear of eating and gaining weight.

I felt I was making an effort. I was thinking about it; doesn’t that count for something? Of course, I also was talking about not gaining anymore weight and possibly losing more. I feel fine, I said. Why can’t I stay the way I am? Why can’t I just accept I have anorexia and live with it. I could give up treatment and let things happen,

What did I expect? For David to say, sure that’s fine, being under one hundred pounds is perfectly okay by me?

I’m such an idiot sometimes. I cried more that night than ever before . . .  I promised to do better and I do truly want recovery. It’s just so hard and I’m not as strong as people seem to think.

Last night, I told my doctor I want one of two things — either anorexia to kill me or to be free. Anorexia nervosa purgatory just isn’t working for me.

Then I had an — epiphany? A revelation? Maybe a word from God, I don’t know. I suddenly thought, What if I just stopped worrying and started eating like a normal person? What would happen? Would I literally explode? Would it kill me? Or would I start becoming the person I was, only better?

I think of the past and dream of the future, thinking of the possibility of a rich and normal life . . .

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When I was just learning about the health care industry a couple decades back I remember being surprised by a few fairly basic things: drug companies actually conduct the clinical trials that lead to approval of their own drugs (I guess I assumed it was a neutral third party), the profit motive drives what treatments patients receive, and people’s preferences for drug formulations varied by country. Americans liked pills, Italians injections (often performed by mom at home) and the French were into suppositories.

So I read with interest Patches for Pain Relief Take Hold in the U.S. in today’s Wall Street Journal. Pain patches still represent less than 3 percent of the pain market in the US, but they’re starting to grow. Meanwhile in Japan pain patches are much more mainstream. With concerns about liver and stomach damage from aspirin and other pain relievers that pass through the digestive system, it sounds like the approach makes some sense, especially for localized pain:

“In general, topical approaches cause less in the way of systemic effects,” says Knox Todd, a professor of emergency medicine at the Albert Einstein College of Medicine in New York. Many of his patients “swear by” patches as a way to treat minor to moderate pain, he says.

Doctors say patches reduce the risk of overdosing because it’s more difficult for people to take too many at once. They can be removed when the pain stops—unlike pills, which, once swallowed, can’t be undone. And because the medicine in patches is localized, they are less likely to clash with other drugs, Dr. Todd said.

I don’t know whether this shift in the US market is a result of Japanese cultural influence. I kind of doubt it. But it is a good sign that best practices from other parts of the world are making their way around this direction. But I don’t think we’ll be following the French anytime soon by taking suppositories for sore throats.

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I’m impressed that the Boston Globe printed a number of insightful letters in response to its Mistakes that matter article, which discussed the case of two patients whose prostate cancer biopsies got mixed up. (One had cancer, the other didn’t. The one without cancer got surgery as a result of the mixup, the one with cancer had delayed treatment and possibly negative consequences as a result.)

Two of the four letters are from patients who were tested for cancer. The best is one from Irving Sacks of Peabody, documenting how he searched widely for alternative treatments after being diagnosed with cancer of the esophagus. In the end he found out from a medical center in California that he had another condition –not cancer– and didn’t need the proposed surgery to remove his esophagus. He says (and I concur):

When confronted with a life-threatening medical assessment, do not rely on a single diagnosis, and, when getting a second opinion, go outside the network, even to another city.

Edgar Dworsky of Somerville wasn’t persuaded that he had prostate cancer after the first pathologist said the slides were “suspicious for cancer,” so he took the same slides to another pathologist who said he “definitely” had prostate cancer and a third who said the slides were “highly suspicious for prostate cancer.” Based on that set of findings he’s decided he doesn’t (yet) have prostate cancer and has embarked on a program of watchful waiting rather than active treatment. At least from what he’s written it’s a little hard to follow his logic but for his sake I hope he’s right.

Arthur Rosenthal of Salem points to a New England Journal of Medicine article (Mortality Results from a Random Prostate-Cancer Screening Trial) that showed screening didn’t make it less likely that those tested would die from cancer. As Rosenthal points out, screening may not save you from dying from cancer but it can induce worry by making you think you do have cancer. I agree with that.

Finally, Dr. Donald Ross, past president of the Massachusetts Society of Pathologists, but writing on his own behalf, says the problem is profit-driven corporate labs. Unlike hospital-based practices such as his, which he asserts follow precautions to avoid mix-ups, such labs drive through so much volume that they increase workload and lead to errors. I’m willing to keep an open mind on Ross’s point, but he doesn’t cite evidence showing lower error rates. I’m also unconvinced that profit-seeking companies are any more interested in revenue than independent physicians.

In any case I’m glad to see the Globe provide so much information on the practical challenges in getting the right diagnosis.

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