Monday, November 30, 2009

Health care price information

An article in the New York Times gives us hope that tools may be available for consumers to "act like consumers"when it comes to health care.

What does this mean?

In other areas of the economy and in our day to day lives, we spend enormous amounts of time shopping around.  We travel from store to store.  We read advertisements in the newspaper.  We listen to commercials on the radio.  Many read magazines like Consumer Reports or other related magazines.

All of this is in an effort to understand the attributes of the products we are buying and to understand the prices that we are being asked to pay and how these relate to our individual and family budgets.

In health care, it may still be difficult to understand all attributes of care--particularly when it comes to quality of care and whether and how the care is supposed to help us get better.  However, the article mentioned above describes an increasing number of tools that consumers can use to obtain information about prices and how an increasing number of medical care providers are willing to discuss prices.

GIven confusing language about prices and procedures this is just a first step in the process of preparing to act more like consumers and there has been evidence in the past suggesting that consumers find it difficult to make "informed choices" about what care is and is not absolutely necessary.  However, there is hope that we may find ways to consume like consumers in health care in the future.

Monday, November 23, 2009

Mandating insurance coverage of mammograms

So, in the week since the new recommendations on breast cancer screening there has been a lot of discussion.  There is an article in the Baltimore Sun today in which one of my colleagues was quoted.   This article discusses a number of things ranging from some using the entire discussion as a political issue (is this the start of rationing?) to the mention of the fact that many people know someone who was diagnosed with breast cancer in her 40s.

What I want to comment on directly is the following quote by Sen Barbara Mikulski (from Maryland)

"We've fought to make sure women have access to early detection and screening for breast cancer to help save lives while we are working on a cure," she wrote. "I believe that where data is conflicting, it is better to be safe than sorry."

She has proposed an amendment to the health care reform legislation that would guarantee access to regular mammograms to all women at age 40.

First, let me remind everyone that the USPSTF which made the recommendation did not actually consider economics at all.  

Second, let me remind everyone that there are a lot of things that can save lives.  If we paid for everything that could save lives for every person it would possibly help we'd be spending a lot more money on health care than we are already.  

If we as a society are willing to spend every cent for every service that might help someone, then we have to be prepared to spend more money.

Otherwise, we need some criteria to allocate resources.  Particularly resources that are either public or mandated.

One alternative would be to mandate coverage for those at high risk or for whom there is a clear medical justification.  Otherwise leave women who want to obtain a mammogram to pay for it themselves.  

Could this create two-tiered medicine?  Well, it could certainly contribute to that and we really already have two-tiered MEdicine in so many ways that it would not be "creating it".  It would simply be "adding to it".

As my colleague, Lisa Dubay, said in the article I referenced at the top, these types of discussions of what we are willing and able to pay for will not be easy but are ultimately necessary.

Tuesday, November 17, 2009

New Recommendation for Breast Cancer Screening

A new recommendation for breast cancer screening is in the news today.  The key is that mammography is no longer recommended for a woman aged 40-49 who has an average risk of breast cancer.  And, while it has received fewer headlines, a recommendation against teaching women to perform breast self-examinations.

The key result received a grade "C".  This means that "The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small."  USPSTF stands for United States Preventive Serivces Task Force.  Definitions of the grades of recommendations can be found here.

So what might a small net benefit mean?  It might be economic, although the USPSTF rarely makes economics a major consideration.  More directly, the USPSTF weighs benefits versus harms.  And the harms are from the potential for overtreatment.  Overtreatment also has potential high monetary costs. 

The interesting thing is that a recommendation remains to allow individual women and providers to decide whether an individual woman needs it.  This decision is supposed to be driven by clinical considerations.  What will be interesting to watch is whether payers change the incentives to receive mammography covered by insurance.  If insurance coverage is withdrawn except when there is a strict clinical justification, will women continue to get mammograms they have to pay for out of pocket.  It depends on how risk averse they are and how tight their budgets are.  It will be important to observe the changes in utilization over the next several years and to analyze how this affect women's health.

Monday, November 16, 2009

Electronic Medical Records

An article in Sunday’s New York Times, noted that to date there has been little demonstration of improvement in care or decrease in costs associated with the implementation of electronic medical records. The article does a good job of making a point about why this may be the case.

Simply put, not all hospitals that have implemented the new records have used them to their full extent. Any policy that is going to pour money into additional implementation of electronic medical records will not necessarily solve this problem. It is suggested at the close of the article, that a policy to encourage the implementation of such records should focus on providing incentives to make full use of such records. A key question is how to provide such incentives and whether policies can be used to provide such incentives.

Another reason for a lack of change may be that making any change when care is already “pretty good” is going to require a significant amount of resources. For example, the article points out that “In the heart failure category, for example, the hospitals with advanced electronic records met best-practice standards 87.8 percent of the time; those with basic computer records, 86.7 percent; and those without, 85.9 percent”. In short, while we would certainly like everyone to be at the highest quality standards, if the hospitals using no electronic medical records are already meeting best practice standards 86% of the time, there is not that much room for improvement.

Perhaps without a wholesale, system-wide improvement in the use of electronic medical records throughout the system, any change will be only marginal.

Tuesday, November 10, 2009

ER Waiting Times

Here is an interesting Baltimore Sun web blog piece that picked up on an article in the Archives of Internal Medicine.  The key point is that ER waiting times are getting longer.  Many people who present to ERs are not seen in the recommended time from when the present.  People are receiving poor quality of care as a result.

Is this news?  Not particularly.

Is this all the fault of the hospitals?  No.  Many patients are using the ER for reasons that may not be truly emergency situations.  The incentives for them to go elsewhere (from limited medical care provider office hours, to a lack of insurance for medical care provider office visits, to a lack of time off from work) are limited.  Perhaps we could do things to change the incentives as part of health care reform--covering urgent care clinics would help.

However, let us also consider the supply side.  With a relatively fixed physical plant, what we may be seeing are diseconomies of scale.  In other words, as the output grows, the efficiency with which the visits are being produced decreases.  As the ER's operate within a fixed space to serve a growing number of patients, the providers who are attempting to provide the care find themselves unable to provide the care as efficiently.  Sometimes having more patients come through can actually be associated with a decreased average cost per patient.  At some levels this can lead to greater specialization and provide opportunities for useful coordination.  However, we are seeing the costs increase as the individuals stay longer and the coordination of skills and personnel needed is more difficult when the organization is basically at capacity.

We will likely continue to see the time for and cost of ER visits increase until we provide greater incentives for patients to obtain  non-emergency care elsewhere.

Thursday, November 5, 2009

Medical spas

In yesterday's New York Times there was an article about medical spas.  The article is subtitled: "let the buyer beware".  This is a general premise in economics.  People should be responsible for their own choices (consumer sovereignty).  In other markets we let people make their own choices.  In medical care (particularly with respect to elective procedures outside traditional medical care settings) we may need more regulated markets than exist at present.

Just this morning, my wife asked my son to make sure that some DVDs he had ordered through my wife's eBay account were acceptable.  She was then going to post feedback for the seller.  With eBay everyone is expected to post good or bad feedback so that other potential buyers and sellers working with that individual in the future have all the information they need to determine whether they want to engage the person in a market transaction.  If a person takes the chance despite poor feedback and finds no way to get their money after a bad transaction, they are out some money.  But it is usually just money.

If a person makes a decision to undertake a medical procedure, he may be risking his life.  In the article it mentions a liposuction that lead to a death.  The key is whether consumers understand all the potential consequences of a procedure and judge how a particular provider's expertise (or lack of expertise) affects the likelihood of negative potential consequences.  Unless consumers learn more about the poor consequences and likelihood of these, the government should take at least some role in regulating the market and making more information available for consumer participants in the market.  This is what is being debated in several states as described by the article.

Wednesday, November 4, 2009

More on Obesity

So, there is a new report from some of my colleagues at the Johns Hopkins Bloomberg School of Public Health that suggests that teenagers overweight and obesity issues may not be due to a lack of physical activity.  Once again, detailed in the School's news feed.

The findings suggest that teens may actually be watching less TV rather than more.  It does not mean that they are spending less time in front of some kind of screen (computers and personal digital devices still offer many distractions).  The findings, however, suggest that there have not been huge changes in the amount of physical activity.

So, what does this mean?  Well, if we are assessing the cost-effectiveness of alternative ways of reducing overweight and obesity among teens, this does give us some insight.  While both increasing activity and reducing caloric intake are likely to be bring down weight, the key is that what has changed in recent years may have more to do with caloric intake than with activity.  It is not necessarily easy to change things "back to the way they were" but it may be easier (and require fewer resources) to change things back than to achieve new levels of activity or lower levels of caloric intake.  While I have made some comments in passing that encouraging physical activity may be a cost-effective way to achieve weight control among children, this may not be the case.  Or it is at least likely that efforts to control caloric intake would be more cost-effective.

Monday, November 2, 2009

What Does it All Mean?

In Sunday's New York Times, there was an article entitled, "Changing Numbers Make Meaning Even More Elusive".  One key take away message from this article is that when we are trying to understanding the health care reform efforts, simply looking at the numbers that are part of the headlines is probably no better than taking what you see in a television commercial about a product as all the information you need to make a decision about whether the purchase the product.  And, the numbers in the headlines don't seem to last very long.


First, there are many aspects of this discussion that are not part of the main discussion.  The article gives an example of higher Medicaid payments that were part of the stimulus package in the first year of the Obama administration being continued.  These are not part of the health care reform discussion directly but add over $20 billion and may help to ameliorate concerns about other aspects of the bill.

Second, as the proposals become more clear and people have a chance to assess all the incentives we come to a better understanding of what would happen.  The article describes the expected response to incentives.  The public plan that is under the most direct discussion at the moment will not be able to impose Medicare payment levels but will have to negotiate rates with providers.  This will not necessarily save any money and make the premiums lower as private insurers already do this.  And private insurers have an incentive to maximize profits rather than just to break even.  So, private insurers may actually be better at this.

Additionally, the public plan may attract people who have historically had difficulty getting private insurance.  These people tend to be sicker.  Maybe there will be savings in administrative costs.

So, of three possible differences: one may hold down premiums, one is likely to make no difference, and one is likely to increase premiums.  What may be apolitically viable plan that encourages market behavior will not likely help to achieve the goal of more affordable insurance for those who do not have insurance at present.