Tuesday, June 13, 2017

Elective but not

If you have ever religiously followed this blog (all one of you and by you I mean me) I loathe the Medical Industrial Complex.   As I get ready for "elective" surgery this next month I find myself battling the system in the ways that remind me that I chose this but really I didn't.  I have decaying teeth, a rotting mouth and in order to live the next 20 some years functionally I need implants.  Dentures are utterly nonfunctional and truly not something anyone should be using than other as a temporary measure.  Just go to YouTube and see all the testimonials about those struggling with teeth and dentures.

And as the Senate runs game plans around the repeal of Obamacare there are two elements missing in any replacement discussion - dental and vision care.  Gee ya think that your eyes and teeth don't affect health? Well then you must be an employee of the Federal Government.

The irony that the most progress and reduction in medical costs have been in the Plastic Surgery and Dental fields.  As they are not covered by Insurance and people still need it they are the two areas that you can find qualified and some not so much available to repair what nature did not nurture.

Nothing I am having done July 7th is covered by my dental insurance except for one extraction which I will have to fight for and even then only 80% is covered.  I cannot have any other treatments that year as I will then reach the maximum by policy that is covered annually.   Cleanings, routine maintenance and other needed care have stringent limits and is insufficient so I have two policies and even then I have massive out of pocket.  I have been told repeatedly that I should simply put the $100 bucks a month in a medical savings account to offset the costs instead as I would have a whopping $1200 dollars to cover thousands!  I can do math.  But if you also work around the policies you can get some coverage that may amount to more and with insurance you are seen in the same way you are with medical insurance, without it the Dentist can be very busy and not again override costs the way they can with insurance.  It is a weird game of bullshit and dice frankly.

I am grateful frankly that I have nothing else major and if this is the worst it gets for me in the last act of my life then I am good with it.

Every day I read another horrific article about the failures of the system to provide care. I am one such horrific story.   ProPublica which does an outstanding job documenting the multitude of problems in the Medical Industrial Complex did this story with The Atlantic about the fraud behind many of the methods and treatments surrounding cardiac care that costs millions, earns millions and puts people at risk.

Then this week a drug that miraculously cures Opioid addiction - was on the cover of the New York Times.   Vivitrol it sounds a little like a hard on drug but maybe that is the point - "Got a hard on for the hard stuff? Try Vivitrol instead!   Yes I always buy drugs on the Subway.  Whoops! I mean ones' advertised on them.   The drug doesn't but to the Inmates that are forced on the drug as human guinea pigs (bringing to mind other said experiments - Tuskegee anyone?)  And of course the Government approves this thanks to the endless lobbying and check writing that goes on to approve such junk science.  And Dr. Tom Price is a happy cheerleader for Big Pharma as we have come to know along with junk medicine but that doesn't stop our Government from putting a whack job quack in charge.

But you would think that Doctors care and they take that hypocritical oath and everything right? Right, they don't.


There’s No Magical Savings in Showing Prices to Doctors

Aaron E. Carroll
The New York Times

Physicians are often unaware of the cost of a test, drug or scan that they order for their patients. If they were better informed, would they make different choices?

Evidence shows that while this idea might make sense in theory, it doesn’t seem to bear out in practice.

A recent study published in JAMA Internal Medicine involved almost 100,000 patients, more than 140,000 hospital admissions and a random distribution of laboratory tests. During the electronic ordering process, half the tests were presented to doctors alongside fees. While the cost to the patient might vary, these Medicare-allowable fees were what was reimbursed to the hospital for the test or tests being considered. The other half of the tests were presented without such data.

The researchers suspected that in the group seeing the prices, there would be a decrease in the number of tests ordered each day per patient, and that spending on these tests would go down. This didn’t happen. Over the course of a year, there were no meaningful or consistent changes in ordering by the doctors; revealing the prices didn’t change what they did much at all.

This isn’t the first time a study like this found that showing prices to doctors doesn’t make a difference. Earlier this year, a study published in Pediatrics reported on a similar randomized controlled trial on physicians caring for children. In this case, doctors were randomized to one of three groups. The first group saw the median price of a test when they ordered it. The second saw both the price (often lower) when obtained within the current health care system and outside it. The third group saw no price at all.

Pediatric-focused clinicians showed no effect from price displays. Adult-focused clinicians actually ordered more tests when they saw the prices.

A similarly designed study of more than 1,200 clinicians in an accountable care organization published earlier this year also found no effects from telling physicians prices.

Some older studies have found that physicians might alter their behavior on individual tests, but in only five of the 27 they examined. Another found a small, but statistically significant, difference. Unfortunately, this study suffered from asymmetric randomization. Even before the intervention began, the tests chosen for the price-showing group were ordered more than three times as much as those chosen for the control group. More expensive tests appeared in the control group for some reason as well.

Of course, any one study has the potential to be an outlier or subject to limitations that might warrant skepticism. These can be minimized by looking at the body of evidence in systematic reviews.

One was published in 2015, and argued that in the majority of studies, giving physicians price information changes their ordering and prescribing behavior to lower the cost of care. A closer look, though, reveals that most of the studies in this analysis were more than a decade old. Many took place in other countries. And all were published before these latest, and largest, studies I discussed above. Another systematic review that looked at interventions focusing only on drug ordering found similar results, with similar caveats.

I should be clear: We have good reason to want to believe that interventions focusing on giving physicians information about the prices of the things they order should make a difference. In 2007, a systematic review demonstrated that doctors were ignorant of the costs of prescription drugs. They underestimated the prices of expensive drugs, overestimated the prices of inexpensive ones, and did not understand the extent of the difference in price between those considered cheap and those considered pricey. Another, published in 2015, explored 79 studies, 14 of which were randomized controlled trials, that suggested that physicians could be educated to deliver “high-value, cost-conscious care.”

But that education probably needs to be holistic. Flashing one point of data at a doctor does not get the job done; knowledge transmission needs to be accompanied by what this review called “reflective practice and a supportive environment.” Simply focusing on cost information may not be enough. The reasons that physicians order tests are more than financial, and efforts to influence their behavior most likely need to be more than informational.

Additionally, it may be that issues of price transparency need to involve more than one component of the health care system. While focusing solely on physicians, or on patients, might not work well, trying to work on both simultaneously might. It’s also possible that intervening solely on one procedure, test or drug at a time may not be as powerful as trying to influence spending on care over all.

Finally, trying to make physicians focus strictly on cost may be off base as well. Some care, even more expensive care, is worth it. What we really should attend to is value — the quality and impact relative to the cost. It is certainly harder to determine value than price, but that metric might make more of a difference to physicians, and to their patients.

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