JustCare

Tag: Doctors

  • Why you should question your doctor’s orders

    Why you should question your doctor’s orders

    A new Pro Publica report explains how even when the data show that the best treatment for a health condition is exercise, a healthy diet and lifestyle changes, a large proportion of doctors continue to deliver medical treatments that are unnecessary, unhelpful and sometimes harmful. It’s well worth a thorough read. Here’s the big takeaway: When your doctor is proposing a new medication or an invasive procedure, it’s wise to question your doctor’s orders.

    What’s the problem? Doctors may not stay on top of the latest science, or they may not believe the new findings, or they may have a financial incentive to perform an unnecessary procedure. Doctors and patients also often focus on the purported benefits of a medication or procedure or see the treatment as at worst neutral, without giving adequate attention to its risks.

    How big is the problem? The problem is enormous, affecting millions of people and concerning a wide range of treatments. The report describes, among other things, the unnecessary and often risky implantation of stents in patients in stable condition who have not suffered heart attacks, the extensive prescribing of atenolol to prevent heart disease and stroke, when it has been shown not to do so, and the frequency of arthroscopic surgery to fix meniscus tears when physical therapy appears to be the appropriate treatment.

    The problem with stent implantations: Although stents have not been shown to prevent heart attacks in patients in stable condition who have not suffered a heart attack, it is still a very popular procedure for these patients. In one instance described in the report, a patient in his early 60’s who was suffering from heart pain went to an emergency clinic and was told that he needed an invasive procedure—a coronary angiogram–to determine whether he needed a stent implantation to unclog an artery. The man had not suffered a heart attack, and his heart was functioning normally.

    Rather than getting the procedure, the man sought out other opinions, only to learn that the data showed that stents for patients in stable condition do not prevent heart attacks nor do they extend the lives of patients. The safer and better treatment is a change in diet, weight loss and medication. But, hundreds of thousands of patients each year get stent implants, which are both unnecessary and can be a risky procedure.

    And, lest you believe the stent implantation does no harm, the report describes how a man recovering from treatment for Hodgkin’s lymphoma who was suffering from shortness of breath, received a stent implant—presumably to address his shortness of breath–he did not need. Then, when he needed a life-saving lung transplant, he couldn’t get it because the medications he was taking for the stent implant would cause a dangerous interaction. Before he could get off those medications, he ended up dying.

    The problem with atenolol, a beta blocker: After atenolol, a beta blocker, was found to lower blood pressure, it became a commonly prescribed medicine, particularly for older adults. What’s concerning is that after it was determined to not be effective in preventing heart attacks and stroke and in fact to increase the chances of stroke in older adults, it was prescribed to 2.6 million people with Medicare in 2014 alone. While each year fewer prescriptions for atenolol are written, the report indicates that it likely will be more than a decade before doctors stop prescribing it.

    The problem with arthroscopic partial meniscectomies (APMs): Though physical therapy has been found to be the effective treatment for people with torn menisci, patients with meniscus tears too often receive unnecessary and unhelpful arthroscopic surgery to repair the tears.

    What consumers can do: Because we have little or no medical expertise, questioning our doctors can be challenging. We may need to do our own research or to get a second or a third opinion. But, it can be well worth the time and effort.

    Here’s more from Just Care:

  • Beware of high doctor charges

    Beware of high doctor charges

    Gerard Anderson, Johns Hopkins Bloomberg School of Health, and Ge Bai, Johns Hopkins Carey Business School, conducted a national study to determine the extent to which doctors charge patients in excess of Medicare’s approved rates. They found a very wide charge variation among doctors, with doctors charging on average two and a half times the rate they accept from Medicare. If you have commercial insurance–including a private Medicare Advantage plan–and get out-of-network care, beware of high doctor charges.

    Specialties in which patients have little or no choice of physician had some of the highest excess charges. Anderson and Bai found that the median charge to uninsured and out-of-network patients for anesthesiologists was 5.8 times Medicare’s approved charge. Emergency doctors, radiologists and pathologists on average charged four or more times Medicare’s approved rates to these patients.

    These findings underscore the plight of some patients in the health care marketplace, particularly the uninsured and people hospitalized, receiving out-of-network care unexpectedly. Many of these people lack choice of physicians or lack knowledge that their physician is out of network. And, they generally have no recourse. Just like drug companies with patented drugs, physicians treating the uninsured and out-of-network patients can charge whatever they please.

    To be clear, because the physician marketplace, for the most part, is not competitive, physicians generally command rates well in excess of Medicare’s rates from insurers. Insurers are largely unable to drive down provider charges to Medicare levels, which drives up premiums and deductibles for the insured patients. To rein in health care spending, we need to address this issue as well.

    Medicare Advantage plans come closest to negotiating rates akin to Medicare’s because of the competitive pressure the traditional Medicare program exerts on the market.

    Without a national database reflecting the amount physicians actually charge patients and how much patients pay, it’s impossible to know exactly what patients receiving out-of-network care and uninsured patients are paying for their care. But, the bigger issue is that even if we knew, it would not keep doctors from charging high rates whenever they can. The simplest way to drive these rates down is to expand Medicare, making it available to everyone without employer coverage and creating some competitive pressure in the marketplace.

    Here’s more from Just Care:

  • Which health plan should you choose if you’re ill?

    Which health plan should you choose if you’re ill?

    Which health plan should you choose if you’re ill? Given all the talk about competition in the health care marketplace, you’d think that Medicare and other health plans plans would be out there telling you that they offer the best doctors and hospitals at the best cost for people with specific conditions, e.g. cancer, stroke, or multiple chronic conditions. But, they do not.

    Commercial health plans, including Medicare Advantage plans for people with Medicare, make money on healthy people. They don’t want you to know about the quality of the costly care they offer, so they tell you very little about health outcomes for their patients with costly and complex conditions. If you Google, “best Medicare health plan for cancer patients,” see what comes up.

    And, to help keep the number cancer patients who enroll in their plans down, commercial health plans–for people with Medicare and working people–generally do not include the best cancer doctors or the best cancer hospitals, such as Memorial Sloan Kettering Cancer Center or M.D. Anderson, in their networks. Kaiser Health News reports that the Affordable Care Act health plans are not including specialty cancer centers in their networks and not covering out-of-network care.

    Of course, the data suggest that where you get your care can matter a lot, especially when you’re sick. One recent report showed that people who went to high quality hospitals after a heart attack lived nine to fourteen months longer than people who did not.

    What can you do to protect yourself?  As we explain in “Three reasons why you can’t pick a health plan that’s right for you,” If you are eligible for Medicare and can afford the upfront costs, consider enrolling in traditional Medicare with supplemental coverage. You may pay more for your coverage up front. But, if you end up needing costly care, it will likely save you money. And, traditional Medicare offers the greatest opportunity for coverage from the doctors and hospitals you want to use. If you go the commercial health plan route, here are two tips for choosing a health plan.

    Here’s more from Just Care: 

  • Traditional Medicare is changing

    Traditional Medicare is changing

    The New York Times reports that Medicare has finalized a new rule under which traditional Medicare is changing its provider payment system. The goal is to improve care for patients while reducing costs. Instead of paying doctors exclusively based on the number of services they perform, the “fee-for-service” model, traditional Medicare will adjust its payments based on what it deems to be the quality of care patients receive.

    MACRA, the Medicare Access and CHIP Reauthorization Act, signed into law by President Obama in 2015–with support from Congressman John Boehner and Congresswoman Nancy Pelosi–offers two new provider payment models, the Alternative Payment Model and the Merit-Based Incentive Payment System. For now, doctors will be able to choose between the models. Each model is supposed to reward doctors based on the quality of care they deliver and the savings they deliver to the health care system.

    But, there’s a lot of skepticism about how well these models can possibly work. The Health Care Blog’s Kip Sullivan makes a compelling argument that “measuring cost and quality accurately at the individual doctor level is not possible.” Sometimes results are outside the doctor’s control and other times it’s impossible to attribute a good or bad outcome to a particular doctor when multiple doctors are involved. Sullivan calls MACRA “an unworkable mess.”

    How will the Centers for Medicare and Medicaid Services attribute a fair rating to the cost and quality of services of a particular doctor?What if patients have multiple chronic conditions that make it hard to treat their illness? Will doctors avoid them so as not to hurt their ratings?  Notwithstanding the challenges of answering these questions in a fair manner, change is afoot.

    Medicare expects that as many as 120,000 doctors will accept the Alternative Payment Model that requires them to be part of an Accountable Care Organization (ACO) or other health care group rewarded financially for keeping people healthy. These doctors can benefit from cost savings if their patients have good health outcomes. It also requires the doctors to report quality measures and use electronic medical records. It’s worth noting here that ACOs to date are at best saving a tiny amount of money and have mixed quality results.

    Up to 640,000 doctors are expected to participate in the Merit-Based Incentive Payment System. They will not take as much risk as doctors who participate in the Alternative Payment System. But, they will also be rewarded financially based on their performance and will be accountable for the quality of care they provide.

    Another 380,000 or so doctors will not participate in these new payment systems because they see too few Medicare patients. The CMS chief said that about half of doctors in small practices, with fewer than 10 doctors, will not participate.

    Here’s more from Just Care:

  • Four ways Congress could weaken Medicare

    Four ways Congress could weaken Medicare

    Much like Social Security, Americans across the political spectrum prize Medicare. Medicare provides the anchor for their health security if they are over 65 or have a disability and offers peace of mind to their families. People love Medicare—a government health insurance program—even though they don’t love government. But, Republicans in Congress want to transform Medicare as we know it, turn it into a voucher program, even though it would mean shifting more costs to older adults, people with disabilities and their families.

    Here are four ways Congressional leaders could weaken Medicare if Trump becomes President.

    1. Republicans in Congress want to privatize Medicare and turn it into a defined contribution program. They want to give people with Medicare a voucher that contributes to some of the cost of their health care coverage and make them pay the rest. Congress could limit the amount of the voucher from one year to the next, shifting more costs to people with Medicare. They want to move Medicare from a defined benefit program covering all the care people need, to a defined contribution program. Sometimes they call this “premium support.” But, whatever you call it, it would inevitably mean forcing people to pay more for their health care. Commercial insurers likely would have few constraints on the premiums, deductibles and copays they charged, and people with Medicare would be left largely on their own to afford them.
    2. Republicans in Congress want to do away with traditional Medicare. Seven out of ten people with Medicare still opt for traditional Medicare because it gives them the wide choice of doctors and hospitals anywhere in the country and the ease of access that they value. It is also extremely cost-effective, spending only two percent of its budget on administrative costs. And, it has done a far better job of reining costs than Medicare Advantage plans, offered by commercial insurers; at the same time, it has helped ensure the Medicare Advantage plans keep their costs in check to remain competitive. Moreover, the federal government is able to drive improvements to the health care system through traditional Medicare. Regardless, Republicans in Congress want to eliminate traditional Medicare, reducing people’s access to doctors and hospitals and driving up health care costs.
    3. Republicans in Congress want to means-test Medicare even further. Like Social Security, Medicare is an earned benefit. People contribute to Medicare throughout their working life. Medicare covers people in America over 65 and people with disabilities who have paid in, regardless of their health or wealth. Already, Congress has passed a law forcing about six percent of people with Medicare—individuals with incomes over $85,000 and couples with incomes over $170, 000—to pay more for Medicare. Republicans in Congress want to increase premiums for middle-class and wealthier Americans even further threatening Medicare’s affordability. Also, the more that these individuals are asked to pay for Medicare, the more Congress positions Medicare as a welfare program and erodes support for Medicare.
    4. Republicans in Congress want to raise the age of Medicare eligibility. People eligible for Medicare based on age can enroll when they are 65. Republican leaders want to raise the age at which people can enroll in Medicare to 67. Many Americans depend upon Medicare to provide them with health care coverage once they lose their employer coverage. While they can enroll in the state health insurance exchanges, the state exchanges provide neither the broad choice of doctors and hospitals nor the continuity of care that Medicare offers. Easy access to doctors and hospitals as well as continuity of care are especially important for older adults who use three times more health care than people under 65.
  • The VA health system: Best in class and under fire

    The VA health system: Best in class and under fire

    Some might say with good reason that the Veterans’ Health Administration or the “VA” health system is best in class–indeed, Phillip Longman, senior editor at the Washington Monthly, has written extensively about the VA, calling it “The best care anywhere.” The VA offers a national health care system with the government owning most of its care facilities and employing its 311,000 doctors and other staff. What makes the VA system so good and why is it under fire?

    The VA system is the largest health care system in the U.S., covering 6.7 million veterans through a network of about 150 hospitals and more than 800 outpatient clinics. Different veterans are eligible for different levels of coverage, with veterans who were engaged in combat eligible to get the highest level of coverage. The VA does not charge a premium for coverage, but depending upon the nature of their service and injuries, veterans may pay copays. Copays tend to be low for veterans who sustained serious injuries while on active duty and are unable to find employment. Copays can be quite high for other veterans.

    The VA has been praised as a model for delivery of integrated care for people with complex and costly conditions. Doctors employed by the VA can rely on an electronic medical record system that allows them to coordinate care; they use data to drive good health care outcomes. Not surprisingly, the VA gets high marks on quality relative to the private sector. And, its doctors have the expertise needed to treat a population of people with very serious conditions.  Just one example of the V.A.’s expertise–a 2005 fall-prevention program has led to many fewer veterans falling and getting a hip fracture. By contrast, most hospitals don’t provide guidance to discharged patients who were hospitalized for a hip fracture resulting from a fall, let alone collect follow-up data.

    But, at the same time, the VA, like all health care systems in the U.S., is experiencing a doctor shortage. It has too few doctors and other providers to treat the growing pool of veterans, including both aging Vietnam War veterans and younger Iraq and Afghanistan veterans–and wait times to see primary care doctors are excessive. A 2014 report by the VA Office of the Inspector General documents the issues.  And, an April 2016 GAO report finds that wait times for primary and specialty care continue to be a serious concern and that the VA appointment scheduling policy needs upgrading.

    To address long waits for care, just a few weeks ago, a bi-partisan Congressional Commission has made a series of recommendations. Not surprisingly, the conservatives on the Commission, along with outsiders like the Koch brothers and Donald Trump, would like to privatize the VA over the next two decades. Veterans are strongly opposed.

    The Commission made many recommendations around infrastructure. Its biggest recommendation was to establish a new VHA Care System, expanding the pool of doctors and hospitals treating veterans with additional health care providers, from both government and the private sector. However, back in 2014 to address the long waits for care, Congress passed the Choice Act, which allowed veterans coverage for care from private doctors in certain situations. While this may sound good in theory, it did not work in practice. Indeed, wait times increased.

    For sure, more doctors and hospitals are needed to treat veterans. But, why would relying on the private sector be a solution now, when it did not work back in 2014? We all experience long wait times to see doctors. Moreover, most primary care doctors outside the VA are not trained to treat war veterans And, commercial care brings with it large out-of-pocket costs. As Philip Longman says, “Offering unlimited, unmanaged choice of doctors and treatments would not only lead to dangerously fragmented care, it would also cost so much that in the real world, it would be a political non-starter and thus limit choice.”

    There are other ways to reduce wait times for treatment. Some propose that the VA allow nurses with special expertise to practice without supervision from doctors, which is already permitted in 20 states. Or, as Longman proposes, in places where it lacks capacity, the VA could identify and contract with skilled outside doctors in an integrated fashion that allowed these providers to use the same electronic medical system as the VA doctors.

    Longman sees the VA as our opportunity to move the U.S. towards a better, more cost-effective health care system. In his words, “The VA model of care, with its emphasis on integration, prevention, and evidence-based, cost-effective care, is also in the forefront of where the rest of the U.S. health care needs to go. If we lose the VA, the cause of real healthcare delivery system reform will be set back by at least another generation, with incalculably dire consequences health and finances of the American population.” Of course, moving towards a VA system for all threatens Aetna, Blue Cross and UnitedHealthcare among other big stakeholders in our health care system. And, that’s precisely why the VA system is at risk.

    Here’s more from Just Care:

     

  • Should you care whether doctors take money from pharmaceutical and medical device companies?

    Should you care whether doctors take money from pharmaceutical and medical device companies?

    A recent Pro Publica report finds that doctors at for-profit and southern hospitals are more likely to take money from pharmaceutical companies and medical device companies. What does that mean about the hospitals at which these doctors work? And, why should you care?

    In prior Just Care posts based on earlier Pro Publica research, we’ve explained that some doctors take tens or even hundreds of thousands of dollars in money and gifts from pharmaceutical and medical device companies. You can learn about your doctors’ relationship with these industries here.  We’ve also explained that doctors who accept gifts from industry, even free lunches, are more likely to prescribe the products to which the gifts were linked.

    The question we should care about is whether the doctors who accept industry gifts and use these products are acting in the best interest of their patients. Or, are they conflicted, prescribing drugs and using products on their patients that are more expensive and deliver less value?

    Overall, two out of three doctors take money and gifts from the drug and device companies. In some states, an even higher proportion of doctors take money from these companies. In New Jersey, Pro Publica found that eight out of ten doctors took money and gifts from these companies. And, in Louisiana, Mississippi, Florida, South Carolina and Alabama, more than three out of four doctors accepted drug and device company money and gifts.

    The rate of acceptance appears to turn in part on whether states have had policies in place requiring public disclosure of gifts, policies that predate federal disclosure requirements. In some hospitals, three of ten doctors or fewer accept fees and perks from the drug and device industries. Vermont has the lowest rate, at fewer than one in five doctors.  In Minnesota, three of ten doctors accept fees. And in Maine and Massachusetts, fewer than half do.

    Not surprisingly, hospitals that have rules banning drug and device company reps from meeting with doctors in their hospitals to promote a drug or device have the lowest rates of gift acceptances by doctors. Kaiser Permanente has such a ban. Since 2014, Kaiser staff may not accept anything of value from industry. “Our intent was to disrupt the strategy of using what industry calls ‘food, friendship and flattery’ to develop relationships with prescribers and influence the choice of drugs, the choice of devices, implants, things like that,” said Dr. Sharon Levine, an executive vice president of the Permanente Federation.

    Pro Publica also found some instances in which a small proportion of hospital doctors took money or gifts but that those doctors accepted large gifts.

    There is no consensus as to when it is appropriate for doctors to take money or gifts and, if it is, how much is too much. And, we don’t understand the degree to which these gifts are driving up health care costs or hurting patients. Based on the amount of money the pharmaceutical and medical device companies invest in building and maintaining these relationships, we can be sure it’s helping their bottom lines.

    Here’s more from Just Care:

  • Practice of medicine more stressful than ever

    Practice of medicine more stressful than ever

    Most of us are finding it increasingly hard to get a doctor’s appointment. So, it’s no surprise that a new survey of doctors by InCrowd suggests that doctors are finding it increasingly hard to keep up with demand. They have so much pressure on their time; the practice of medicine is more stressful than ever.

    If we are to address the shortage of doctors effectively, we not only need to need to expand medical school classes and residency positions, we need to find ways to make the practice of medicine, particularly primary care medicine, more rewarding.

    More than half of the doctors surveyed (57 percent) said that they had personally experienced burnout, including emotional exhaustion, a low sense of personal accomplishment and a lack of enthusiasm for work.

    This feeling of burnout has potentially serious effects on patient safety and quality of care; it may also affect the number of people who go into medicine. Almost six in ten doctors surveyed said that they were unsure whether they would recommend a career in medicine to a family member or knew they would not do so.

    In addition to time pressures, doctors felt that completing electronic medical records was a big stressor. Almost three out of four primary care and emergency room doctors surveyed said that the facilities in which they worked were not addressing physician burnout effectively.

    Two hundred doctors were surveyed. Each had been in practice for ten or more years, and, overall, the doctors had been in practice an average of 17 years.

    According to a new report by Merritt Hawkins, the doctor shortage in primary care is leading to a large increase in their starting salaries. They are seeing double digit increases. The starting salary for family medicine is up 13 percent to $225,000.

    Here’s more from Just Care:

  • Why traditional Medicare remains so popular

    Why traditional Medicare remains so popular

    Uwe Reinhardt, PhD, writes Why Many Medicare Beneficiaries Cling to an Allegedly Worse Deal in JAMA Forum earlier this month. In a nutshell, he argues that traditional Medicare remains so popular because it offers people the choice of doctors and hospitals they want.

    Reinhardt points out that the government spends more per person for Medicare Advantage enrollees (people enrolled in a commercial insurance plan that offers Medicare benefits) than on traditional Medicare. In addition, because Medicare Advantage plans generally rely on networks that restrict access to doctors and hospitals, they can offer seemingly more benefits and lower out-of-pocket costs to their enrollees than are available to people in traditional Medicare. But, still only 3 in 10 people with Medicare choose to enroll in one of these plans.

    Most older adults, says Reinhardt, like the freedom of choice available through traditional Medicare exclusively. People value the ability to see almost any doctor and use virtually all hospitals and other health care facilities anywhere in the country. Indeed, the U.S. Government Accountability Office issued a report in September 2015 addressing concerns raised about the narrow networks in many Medicare Advantage plans that can limit access to needed care.  It recommended greater oversight of these plans.

    Reinhardt also posits that people trust the government more than the commercial Medicare Advantage plans. People value traditional Medicare for the same reason they value Social Security–it is “an always faithful and reliable companion.” In sharp contrast the commercial insurers that offer Medicare Advantage are nothing more than “ephemeral companions.”

    Medicare Advantage plans can morph and change at any time. The insurer who offers the Medicare Advantage plan can change many terms of the agreement whenever it wishes. Doctors and hospitals can move in and out of the network throughout the year, changing the network and undermining continuity of care. And benefits, copays and deductibles can change from year to year. Protocols for accessing care can also change. In addition, the Medicare Advantage plan can stop offering coverage altogether or the insurer offering the coverage could be bought by another insurer who changes the rules.

    Here’s more from Just Care:

  • Doctors influenced by drug company money

    Doctors influenced by drug company money

    Behavioral psychologists will tell you that none of us are immune from influence both explicit and subtle. Notwithstanding, we’d like to believe that we are free agents. A recent Pro Publica analysis finds evidence to suggest that doctors are influenced by drug company money and gifts.

    Not surprisingly, the drug and device companies spend billions on doctors and hospitals. The Centers for Medicare and Medicaid Services has a database that tracks these dollars by doctor and hospital. In 2014 alone, CMS data reveals that drug and medical device companies spent $6.5 billion on doctors and hospitals.

    Pro Publica found that doctors who take money or gifts from the drug and medical device companies tend to prescribe more brand-name drugs than those who do not–two to three times more.  Pro Publica further found that the more money the doctors take, the more brand-name prescription drugs they prescribe, notwithstanding the availability of lower-cost generic alternatives.

    For example, internists who do not take drug or device money prescribe brand-name prescription drugs 20 percent of the time. Internists who take $5,000 or more prescribe brand-name drugs 30 percent of the time–50 percent more often!

    Pro Publica could not show that doctors who took money from a particular company prescribed more of that company’s drugs.

    Pro Publica
    Pro Publica

    Here’s more from Just Care on drug companies and prescription drugs: