Atul Gawande, associate professor of surgery and public health at Harvard and one of our most prolific contemporary physician-writers, adapts his New Yorker piece [full text of the article The Hotspotters] surveying innovative attempts to lower healthcare costs by better serving those patients with greatest need to a 13 minute PBS FRONTLINE report focused on one such program, the Camden Coalition of Healthcare Providers in Camden, New Jersey, led by Dr. Jeffrey Brenner, that is having unprecedented success.
- FRONTLINE: Doctor Hotspot (full report) (milkandcookies.com)
- The emerging liberal doctor majority (salon.com)
You have insurance and, supposedly, it covers your medicines. However, you still get stuck with a portion of the bill that the insurance company calls a “copay.” In some cases these copays can run more than $150/ month per medication (e.g. Enbrel). If you are on more than one of these expensive, branded medications the copays can really add up. What are your options?
1. Generic alternative. Always ask your doc if there is a reasonable generic alternative. This is always the best option for you in the long run. However, if there truly is no generic medication that comes close, then check into either (or both) of the next two options.
2. Drug specific copay programs. These programs are run by the manufacturers of the drugs, aka Big Pharma (BP). Usually, these discounts are given to all patients, regardless of income. But make no mistake, it is a way for BP to circumvent your insurance company’s cost control mechanism for prescriptions. By picking up part or all of the cost of your copay, BP trying to make their product more attractive to you and to your physician. But when the manufacturer stops offering the copay discount programs you will be back to square one. However, if according to your doctor, you must be on one of these drugs, then by all means, take advantage of the savings while they last. In the case of Enbrel, the Enbrel Support Card Program picked up the tab for six months worth of copays. To find out more info on whether such a program exists for your medication, there are many websites out there, including the manufacturer’s site.
However, I found the following two websites particularly useful:
Internetdrugscoupons.com This website shows you all available drugs that have coupons, copay and otherwise, associated with them. It’s an ugly little site, and ignore the annoying ads for a prescription savings card. But it couldn’t be simpler to use. And all the coupons I clicked on were still valid- so it seems like the folks behind it keep it up to date. According to the mission statement on the website “[The founder] assembled this database of drug coupons to make it easy for people like my elderly parents to save money on their medications.”
RxAssist.org This is a super slick website that allows you to look up your medicines, albeit individually, to see what deals are offered. When you see a deal you click on the medicine and you are directed to the manufacturer’s website. According to the About section of the website, RxAssist.org was established in 1999 with funding from The Robert Wood Johnson Foundation.
3. Disease specific copay programs. There are many organizations that offer patients with specific diseases, such as cancer and HIV/AIDS, assistance with their prescription copays. These programs often require financial ability-to-pay information from you to qualify for assistance. Disease Specific Copay Programs is a very comprehensive list of copay and other assistance programs compiled by a BP-funded site called Partnership for Prescription Assistance, aka PPArx.org.
Leslie Ramirez is an internal medicine physician and founder of Leslie’s List, which provides information that enables all patients, but especially the uninsured and underinsured, to find more affordable medications and health care services.
- Copay Cards: Don’t Throw The Baby Out With The Bathwater (georgevanantwerp.com)
- Short Survey On Copay Cards (georgevanantwerp.com)
- Institute of Medicine Recommendations Released; Birth Control Could Become a Copay-Free Preventive Service (womenshealthnews.wordpress.com)
- Prescription Med Prices Set to Plummet (abcnews.go.com)
Health services researchers who studied controversial aspects of Medicare spending and quality of patient care received a prestigious award yesterday from the nation’s largest health services research professional association….
…The Article of the Year Award recognized two companion studies by Silber and Kaestner: “Aggressive Treatment Style and Surgical Outcomes,”*** published in the December 2010 issue of the journal Health Services Research, and “Evidence on the Efficacy of Inpatient Spending on Medicare Patients,” ***published the same month in The Milbank Quarterly.
As an indicator of aggressive care, Silber and Kaestner used the Dartmouth Index, a prominent set of measures of inpatient spending on elderly patients. In studying over 5 million Medicare admissions for various surgeries between 2000 and 2005, they found that surgical patients in hospitals with a more aggressive treatment style were less likely to die within 30 days of admission compared to patients in less aggressive hospitals. They also found that this benefit was stable, persisting after the 30-day mark. …
- A promising way to control health costs (money.cnn.com)
- Fewer Medicare Patients Being Hospitalized for Heart Problems (insurance.zocdoc.com)
- Medicare premiums, saving Medicare and more; keep on eye on the real concerns (quinnscommentary.com)
Poor childhood health caused by environmental factors, such as air pollution and exposure to toxic chemicals, cost the United States $76.6 billion in 2008, according to authors of a new study in the May issue of Health Affairs. This price tag represents a dramatic increase in recent years, rising from 2.8 percent of total health care costs in 1997 to 3.5 percent in 2008…
Researchers used recent data to estimate the number of environmentally induced conditions in children and then calculated the annual cost for direct medical care and indirect costs, such as lost productivity resulting from parents’ caring for sick children. They found that the aggregate cost of environmental illness in children was $76.6 billion in 2008 dollars.
The study provides an update to an analysis of 1997 data that documented $54.9 billion in annual costs of environmentally contributable childhood diseases in the United States. In comparing the two studies, researchers found that diminished exposure to lead and reductions in costs for asthma care were offset by diseases newly identified as environmentally induced, including attention deficit disorder,[Editor Flahiff's note: see above map] and the added burden of mercury exposure. This toxic metal, from contaminated fish and coal-fired power plants, can harm the developing brain and is associated with intellectual disability.
Key findings from the study:
- Lead poisoning cost $50.9 billion
- Autism cost $7.9 billion
- Intellectual disability cost $5.4 billion
- Exposure to mercury (methyl mercury) cost $5.1 billion
- Attention deficit hyperactivity disorder cost $5.0 billion
- Asthma cost $2.2 billion
- Childhood cancer cost $95.0 million
- US must strengthen efforts to restrict chemicals that threaten health, say researchers (scienceblog.com)
- Asthma Rates on the Rise in U.S. (webmd.com)
- Protect our kids from toxic mercury (cnn.com)
- US must strengthen efforts to restrict chemicals that threaten health, say researchers (medicalxpress.com)
HCUP On-line Tutorial Series
From the AHRQ (Agency for Healthcare Research and Quality) press release
HCUP Offers New Online Tutorial Series’ Modules
AHRQ is pleased to announce the release of a new module and an updated re-release of a favorite in the HCUP Online Tutorial Series. These online trainings are designed to provide data users with information about HCUP data and tools, as well as training on technical methods for conducting research using HCUP datasets.
- The all-new Calculating Standard Error tutorial is designed to help users determine the precision of the estimates they produce from the HCUP nationwide databases. Users will learn two methods for calculating standard errors for estimates produced from the HCUP nationwide databases.
- The newly revised HCUP Overview Course is a helpful introduction to HCUP for new users. The original course has been updated to include the latest additions to the HCUP family of databases and tools, including the Nationwide emergency Department Sample.
- HCUP Facts and Figures: Statistics on Hospital-based Care in the United States (jflahiff.wordpress.com)
- New Analysis Illustrates the Hidden Burden of Atrial Fibrillation on Healthcare Spending and Resources in Each State (prnewswire.com)
- AHRQ News And Numbers: Medication Side Effects, Injuries, Up Dramatically (jflahiff.wordpress.com)
- New Tab: Tutorials (tinysewingempire.wordpress.com)
Experts today challenge the view that popular drugs to prevent disease – like statins and antihypertensives to prevent heart disease andstroke, or bisphosphonates to prevent fractures - represent value for money.
In a paper published on bmj.com[full text] today, Teppo Järvinen and colleagues argue that the benefits seen when these drugs are tested in clinical trials may not apply in the real world.
They argue that value for money in real life clinical practice is likely to be much lower than in a clinical trial, where patients are carefully selected and receive special attention from dedicated staff. “This gap between the ideal and clinical circumstances raises the question of how well our most widely used preventive drugs work in real life,” they write. ….
…although there are claims that important preventive drugs such as statins, antihypertensives, and bisphosphonates are cost effective, there are no valid data on the effectiveness, and particularly the cost effectiveness, in usual clinical care,” they say.
Despite this dearth of data, they point out that the majority of clinical guidelines and recommendations for preventive drug therapy rest on these claims.
The authors argue that before claims on cost effectiveness can be used to guide treatment policies and practices, it should be adequately proven by testing in a real-world setting. …
- Clinical Trials: Crafting the Label (biostrategics.wordpress.com)
- Prescriptions – Good or Bad? (georgevanantwerp.com)
- Regulatory requirements: differences or similarities between FDA and EMA? (sopwriting.wordpress.com)
- Generics Dominate Scripts in 2010
In 2010, generics captured 78% of the total market share for prescriptions, up from 63% in 2006
- Dietary Calcium And Supplements Recommended Instead Of Bone-Building Meds (Medical News Today, May 3, 2011)
- Statins and bone drugs ‘not cost effective’ (telegraph.co.uk)
Adverse drug events costly to health care system: Vancouver Coastal Health-UBC research
Emergency department physicians call for screening tools
Patients who suffer an adverse medical event arising from the use or misuse of medications are more costly to the health care system than other emergency department (ED) patients, say physicians and research scientists at Vancouver General Hospital and UBC. Their research, the first to examine the health outcomes and cost of patient care for patients presenting to the ED with adverse drug events, is published today in the Annals of Emergency Medicine.***
The research team, led by Dr. Corinne Hohl, emergency physician at Vancouver General Hospital and research scientist with the Centre for Clinical Epidemiology and Evaluation at Vancouver Coastal Health and the University of British Columbia, studied the health outcomes of patients who had presented to the emergency department with an adverse drug event and compared them to patients who presented for other reasons.
An adverse drug event is an unwanted and unintended medical event related to the use of medications.
After adjustment for baseline differences between patient groups, researchers found no difference in the mortality rate of the patients they studied, but those presenting with an adverse drug event had a 50% greater risk of spending additional days in hospital, as well as a 20 % higher rate of outpatient health care needs. The team followed 1,000 emergency department patients from Vancouver General Hospital for six months.
This new research builds on a 2008 study, published in the Canadian Medical Journal, which showed more than one in nine emergency department visits are due to medication-related problems.
“What we are finding is that these incidents are common and costly, both in terms of patient health and utilization of health care dollars,” says Dr. Corinne Hohl. “We also know that these events are hard for physicians to recognize, and that nearly 70 percent of these incidents are preventable.”
In BC alone, hospital emergency departments treat an estimated 210,000 patients each year for adverse drug events. The most common reasons for them are adverse drug reactions or side effects to medication, non adherence, and the wrong or suboptimal use of medication. The research team estimates that the cost of treating these patients is 90% greater than the cost of treating other patients after adjustment for differences in baseline characteristics. The added cost could be as much as $49 million annually.
The research team has been developing screening tools to better assist health care providers in the emergency department in recognizing patients at high risk for adverse drug events, as well as developing an evaluation platform that will help inform prescribing practices for physicians in the community
“We anticipate the development of a screening tool will be able to increase the recognition rate of these adverse drug events from 60 to over 90 percent, and we will be able to treat the patient effectively and rapidly, improving his or her care,” says Dr. Hohl.
“Right now we spend a lot of time trying to diagnose what is wrong with the patient, yet often miss the fact that there is a medication-related problem. This means that patients often go home still on a medication which may be causing harm.” We are also using the data from this research project to help develop a new drug evaluation platform to inform prescribing practices for physicians in the community. The hope is to prevent many of these adverse events from even taking place.”###
Funding support for this research is through Vancouver Coastal Health Research Institute, the Michael Smith Foundation for Health Research, and the Department of Surgery at the University of British Columbia.
**Not at Web Site as of this posting
- Enhancing medication safety with computerized alerts (physorg.com)
- Americans and Canadians get different drug information online: UBC study (eurekalert.org)
Homeless people without enough to eat are more likely to be hospitalized
Mass. General study is first to document association between food, use of health services
Homeless people who do not get enough to eat use hospitals and emergency rooms at very high rates, according to a new study. One in four respondents to a nationwide survey reported not getting enough to eat, a proportion six times higher than in the general population, and more than two thirds of those had recently gone without eating for a whole day. The report will appear in the Journal of General Internal Medicine and has been released online.***
“The study is the first to highlight the association between food insufficiency and health care use in a national sample of homeless adults,” says lead author Travis P. Baggett, MD, MPH, of the Massachusetts General Hospital (MGH) General Medicine Division. “Our results suggest a need to better understand and address the social determinants of health and health-care-seeking behavior,”
Baggett and a team of investigators at MGH and the Boston Health Care for the Homeless Program analyzed survey data from 966 adult respondents to the 2003 nationwide Health Care for the Homeless User Survey. They found that homeless people who did not have enough to eat had a higher risk of being hospitalized in a medical or psychiatric unit than did those with enough to eat and also were more likely to be frequent users of emergency rooms. Neither relationship could be explained by individual differences in illness. Nearly half of the hungry homeless had been hospitalized in the preceding year and close to one-third had used an emergency room four or more times in the same year.
Baggett explains the study was sparked by his clinical experience caring for homeless individuals. “Homeless patients with inadequate food may have difficulty managing their health conditions or taking their medications. They may postpone routine health care until the need is urgent and may even use emergency rooms as a source of food. Whether expanding food services for the very poor would ameliorate this problem is uncertain, but it begs further study.” Baggett is an instructor in Medicine at Harvard Medical School.
From the January 31, 2011 Reuters news item by Genevra Pittman
NEW YORK (Reuters Health) — Hospitals that spend more money treating patients with acute illnesses may be better at keeping those patients alive, suggests a new study.
The finding is in line with recent research, but it challenges an assumption held by many policymakers that hospitals can be forced to spend less without significant consequences for patient health.
“The traditional literature on spending is that quality isn’t higher (in hospitals that spend more),” said Mary Beth Landrum, who studies health care policy at Harvard Medical School and did not participate in the research. But, “when you start looking at specific groups of patients, you may actually find that there is some benefit for some of the increased spending,” she told Reuters Health.
The current study included people treated for heart attack, heart failure, stroke, hip fracture, pneumonia and serious stomach bleeding. Researchers led by Dr. John Romley of the University of Southern California looked at records for more than 2.5 million of these patients admitted to California hospitals during the years 1999 through 2008.
Romley’s team calculated how likely the patients were to survive their hospital stay, then compared those numbers to how much money the hospitals typically spent to treat the conditions in question.
For each of the six conditions, they found the highest-spending hospitals spent more than three times as much as the lowest-spenders.
Those hospitals ranking in the bottom-fifth for expenditures on heart failure and hip fracture, for instance, averaged $5,100 caring for a heart failure patient and $8,000 treating a hip fracture. The top-fifth-spending hospitals for the same conditions averaged $19,000 on a heart failure patient and $29,000 on one with hip fracture.
For each of the conditions examined higher spending was also linked to higher patient survival.
Patients treated at the highest-spending hospitals for heart failure, for example, had a 25 percent smaller chance of dying while they were there than patients treated at lowest-spending hospitals.
During the second half of the study (2004 to 2008) the mortality differences seen with high or low spending on hip fracture patients were extremely small, but overall the researchers say the numbers show money does seem to make a difference in survival.
If all patients in the study who were treated at the lowest-spending hospitals had instead been treated at the highest-spending facilities, the authors calculated that about 18,000 fewer people would have died during the first half of the study, and 14,000 fewer during the second half.
What exactly high-spending hospitals are doing to save lives is not completely clear.
Previous research suggests hospitals that spend more money don’t have fewer complications during care — they may just be more prepared to notice and address complications quickly, said Dr. Amber Barnato, who studies end-of-life care at the University of Pittsburgh and was not involved in the current study.
“There must be something about paying close attention, which might mean more staff, more eyes on the patients,” Barnato told Reuters Health. In addition, she said, “there might be a greater willingness to do intensive things to rescue someone, like put them on a breathing machine (or) put them in the (intensive care unit).”
The findings, published in the Annals of Internal Medicine,*** are in line with a few recent studies, including one showing that hospitals where heart failure is treated frequently give better care but also spend more money per patient than hospitals that treat the condition less frequently.
Together such studies challenge the assumption that much of hospital spending is inefficient and that hospitals could perform just as well with smaller budgets, researchers say.
That debate has been an important part of the controversy surrounding new health care reform legislation, which will cut back Medicare spending on hospitals, Romley noted.
“If the results are real … that would suggest these reductions across the board in hospital spending might lead to worse outcomes for some patients,” Romley told Reuters Health. That doesn’t mean cuts wouldn’t still be cost-effective, if money elsewhere could better improve public health. But, he added, “it is important to understand the trade-offs.”
The new findings need to become part of the national debate on how best to allocate money to protect the health of the general population — but they don’t change the fact that health care funding isn’t in unlimited supply, Barnato said.
Even if patients with serious illnesses such as the ones examined in the current study do make it out of the hospital alive, many die within a year, and some of the money used on end-of-life care might save more lives if it was used to address preventable childhood diseases or obesity, for example, she said.
“A hospital that spends more money can have slightly better quality or safety,” Barnato explained, “and that spending might still not result in better population health.”
***For suggestions on how to get this article for free or at low cost, click here
Finding Low Cost Mental Health Care (written for teens)
In addition to school counselors, these options were presented, as well as how to get help in a crisis, how to get financial assistance, what to do if you don’t want your parents to know you are seeking mental health help, and prescription assistance
- Local mental health centers and clinics. These groups are funded by federal and state governments so they charge less than you might pay a private therapist. Search online for “mental health services” and the name of the county or city where you live. Or, go to the website for the National Association of Free Clinics. The U.S. Department of Health and Human Services’Health Resources and Services Administration also provides a list of federally funded clinics by state.
(Note: By clicking either of these links, you will be leaving the TeensHealth site.)
One thing to keep in mind: Not every mental health clinic will fit your needs. Some might not work with people your age. For example, a clinic might specialize in veterans or kids with developmental disabilities. It’s still worth a call, though. Even if a clinic can’t help you, the people who work there might recommend someone who can.
- Hospitals. Call your local hospitals and ask what kinds of mental health services they offer — and at what price. Teaching hospitals, where doctors are trained, often provide low- or no-cost services.
- Colleges and universities. If a college in your area offers graduate degrees in psychology or social work, the students might run free or low-cost clinics as part of their training.
- On-campus health services. If you’re in college or about to start, find out what kind of counseling and therapy your school offers and at what cost. Ask if they offer financial assistance for students.
- Employee Assistance Programs (EAPs). These free programs provide professional therapists to evaluate people for mental health conditions and offer short-term counseling. Not everyone has access to this benefit: EAPs are run through workplaces, so you (or your parents) need to work for an employer that offers this type of program.
- Private therapists. Ask trusted friends and adults who they’d recommend, then call to see if they offer a “sliding fee scale” (this means they charge based on how much you can afford to pay). Some psychologists even offer certain services for free, if necessary. You can find a therapist in your area by going to the website for your state’s psychological association or to the site for the American Psychological Association (APA). To qualify for low-cost services, you may need to prove financial need. If you still live at home, that could mean getting parents or guardians involved in filling out paperwork. But your therapist will keep everything confidential.
Additional Mental Health resources, especially for teens
- Teen Health – Your Mind has links to many articles written for teens in areas as Parents, Feeling Sad, Mental Health, Feelings and Emotions, Body Image, Families, Friends, and Dealing with Problems
- Teen Mental Health (MedlinePlus) has links to Web pages about treatment, specific conditions (as cutting), patient handouts, and more
(DOI 10.1377/hlthaff.25.1.57©2006 Project HOPE–The People-to-People Health Foundation, Inc.)
ABSTRACT:Although Americans and foreigners alike tend to think of the U.S. healthcare system as being a“market-driven”system, the prices actually paid for health care goods and services in that system remain remarkably opaque. This paper describes howUS hospitals now price their services to the various third party payers and self paying patients and how that system would have to be changed to accomodate the increasingly popular concept of consumer directed health care. ”[HealthAffairs25, no. 1(2006): 57–69]
An August 18, 2010 blog post by David Williams (posted in Kevin MD.com)
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 in the Journal of Clinical Oncology 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:
- 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.