Category Archives: #karan

Friday News Dump: Wonkbites

by Karan Chhabra

Happy Friday!

  1. Docs and dollars: This one’s a twofer. The first is a hotly-discussed NEJM paper showing that urologists (not radiation oncologists, as we’ve covered earlier) owning a stake in radiation therapy equipment tend to recommend that equipment more often than docs without an ownership stake. The second is a less-publicized government report showing that surgeons with a stake in device distributors also recommend those devices more than other surgeons. This shouldn’t surprise anyone — doctors are human, after all. The Stark laws designed to prevent physician self-referral, for some reason, make an exception for the IMRT conflict-of-interest in the first paper. And I don’t think any legislation foresaw the physician-owned-distributorships in the second article.
  2. Is Mass. going to shake up health policy again? Massachusetts, a laboratory for experiments that make their way into federal health policy, is now in very early discussions of a single-payer system. Of course, no one’s dethroning private insurance companies just yet, but there is a bill circulating to create a public insurance option that may attract some interest. The sponsors are interested in single-payer for no other (stated) reason than its potential to reduce costs—the state’s next big challenge now that it has widely expanded insurance.
  3. Consolation prize: The healthcare.gov launch was an abject failure. (Hopefully with a Duke/Advisory Board alum in charge of the cleanup, we’ll see some good news.) Interestingly though, the data services hub—which worried insiders the most, as we’ve covered before—is actually working quite well. It has the important, though unglamorous job of synthesizing information across multiple federal databases and verifying applicants’ information to prevent fraud. And it has done just that for most people who’ve made it through the website’s dysfunctional front end.
  4. Icing out the family jewelsBecause there’s nothing a man’s injured nether regions need less than freezer burn.

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Karan is a student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

Why hospitals aren’t cutting costs nearly as much as they could (in one chart)

by Karan Chhabra

The more you read about healthcare delivery, the easier it is to get discouraged about slaying the healthcare cost monster. Absent huge and damaging price cuts, there aren’t a ton of quick fixes. But as you get closer to clinical care, patterns of waste emerge. Those seeing patients every day know them best. But it probably takes a push to get them questioning the dogmas of their practice. Enter this paper (gated) on a cost reduction project from UCSF’s neurosurgery residents, prompted by a hospitalwide incentive program for residents:

OBJECT: Given economic limitations and burgeoning health care costs, there is a need to minimize unnecessary diagnostic laboratory tests.

METHODS: The authors studied whether a financial incentive program for trainees could lead to fewer unnecessary laboratory tests in neurosurgical patients in a large, 600-bed academic hospital setting. The authors identified 5 laboratory tests that ranked in the top 13 of the most frequently ordered during the 2010–2011 fiscal year, yet were least likely to be abnormal or influence patient management.

RESULTS: In a single year of study, there was a 47% reduction in testing of serum total calcium, ionized calcium, chloride, magnesium, and phosphorus. This reduction led to a savings of $1.7 million in billable charges to health care payers and $75,000 of direct costs to the medical center. In addition, there were no significant negative changes in the quality of care delivered, as recorded in a number of metrics, showing that this cost savings did not negatively impact patient care.

CONCLUSIONS: Engaging physician trainees in quality improvement can be successfully achieved by financial incentives. Through the resident-led quality improvement incentive program, neurosurgical trainees successfully reduced unnecessary laboratory tests, resulting in significant cost savings to both the medical center and the health care system. Similar programs that engage trainees could improve the value of care being provided at other academic medical centers.

In a nutshell, each year UCSF offers its residents about $400 each if they can achieve the goals of a quality improvement project that they design and execute. Their neurosurgery house staff, working with their hospitalist service, found that certain lab tests they ordered rarely affected their plan of care. So they designed a protocol describing exactly when those tests ought to be used, advertised the protocol and the incentives, and within a year cut those tests’ use by 47%–without compromising their patients’ quality of care. Considering that it’s just one service with just 18 residents, the cost savings are staggering:

ucsf cost savings

Amazing results. But think about who really won here. The hospital saved $75,000 in lab costs. The payers saved $1.7 million in billable charges. There’s almost no comparison. That $1.7M is actually a loss to UCSF, because if they’d billed it, they would have gotten much (if not all) of it back as revenue. Think about that for a second, because it’s key to understanding much of what’s wrong with American healthcare: this amazing project, which saves gobs of money without hurting patients, probably causes UCSF immediate financial harm.

UCSF is not the VA, or Kaiser Permanente, or the British NHS. It has just one ACO contract for San Francisco city employees, so it’s not a true accountable care model either. For organizations like UCSF–in this sense, for the vast majority of American hospitals—if they don’t do something, they can’t bill for it. Which means they don’t get paid.

Fortunately, UCSF is a forward-thinking institution. I’m sure its leaders are looking to the future and realizing that they’ll have to encourage many more of these projects to make it through the decades ahead. UCSF is an academic institution, too, where quality improvement competitions serve a valuable educational purpose. But let’s not forget what reality is like for the hospital down the street hawking its proton beam facility to patients with prostate cancer. When they save the system money, they lose.

We have reason to believe this will change. As episodic bundling and accountable care spread across the country, hospitals’ incentives will come closer to encouraging what the system needs as a whole. But we need to make sure these progressive payment models aren’t confined to Medicare, and are embraced by enough payers to bring hospitals to the tipping point where lower charges actually are a financial win. Till that happens, feel-good stories like UCSF’s will remain just that.

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Karan is a student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

Friday News Dump: Wonkbites

by Karan Chhabra

We couldn’t keep up this silent protest of the government shutdown forever. So we’re back online with Wonkbites, this time protesting by ignoring all news shutdown-related:

  1. Who wants Obamacare? If only we knew. Amid the fanfare over the October 1 “launch” of Obamacare, many have been wondering how many people actually signed up for insurance through those exchanges. We know there were glitches and we know there were a ton of pageviews, but neither of those tells us how many people are actually being helped. In this article, Dan Diamond steps back from the scrum and tells us all there is to know at this point.
  2. Obamacare means no copays for preventive services. Or so we thought. But some doctors are still charging copays for preventive services, and it sounds fishy. The article doesn’t quantify how many, or if it’s because of misunderstanding rather than outright deception. It also mentions that some patients are getting hit with copays because their insurance plans are grandfathered-in, or because they got “curative” services in a visit that was meant to be preventive. But again, without knowing the magnitude of the problem, it’s hard to know whether to sound the alarms.
  3. Medicaid policy or USPS bailout?  The blogosphere is full of debates on Arkansas’ plan to move Medicaid to the private insurance exchanges (we’re no exception). It seems like the patients couldn’t care less about the controversy. When the state sent short letters to 132,000 eligible households, they got a whopping 55,400 responses back in the mail. Though I’m mostly impressed that many people still use the mail, it’s also refreshing to see patients put their own care before political debates. (Is the same thing happening on the Obamacare exchanges?)
  4. Poopin’ pills: For better or for worse, we’re on a bit of a streak covering progress in fecal transplantation. So we’ll keep it up with this story on poop pills, with promising results against the nasty intestinal infections increasingly treated with fecal transplants. I don’t want to be a buzzkill by pointing out that these pills actually make you eat the poop, whereas regular transplants go up the other way… but it’s food for thought (no pun intended).
  5. We’re not snobs, we’re just more socially perceptive than youA new, well-designed study in Science forced people to read different types of writing, and then tested subjects’ empathy and social skills using well-validated measures. It found that heavy, “literary” fiction improved empathy scores, even more than “pop” literature and nonfiction. So if English majors seem like pretentious oafs it’s not their fault—they’re just more socially skilled, obviously.

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Karan is a student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

Friday News Dump: Wonkbites

by Karan Chhabra

The NFL season opener might wait for rain, but Wonkbites won’t.

  1. Doc fix’s on sale! After so many years of gridlock, why the sudden interest in passing a “doc fix” that would repeal the SGR? This interview points to a surprisingly favorable rating from the CBO that makes a doc fix seem cheaper this year than anytime in the recent past.
  2. Hitting the heartlandState opt-outs from Medicaid expansion will disproportionately affect Americans in rural areas, according to a health economist at a recent conference. The converse is also true: city-dwellers meeting criteria for Medicaid expansion live disproportionately in states going ahead with the expansion. Perhaps it’s nothing more than a red state/blue state divide, but the politics of Medicaid expansion appear to exacerbate already-significant gaps between rural and urban healthcare.
  3. Great Expectations: The latest volley in the rate shock debate revolves around a new Kaiser Family Foundation study saying insurance premiums actually won’t rise as much as previously expected. But expected is key—it’s not that rates will decline across the board, but that they’re not going to rise as much as we once thought.
  4. Comparing apples to oranges: An apple a day keeps the doctor away, but a cantaloupe might not. Or at least that’s the thrust of a new study connecting specific fruits to the risk of developing type II diabetes. Blueberries, grapes, and apples came out healthiest, with cantaloupes and fruit juice the worst. Though it controlled for a slew of confounders, it’s still just an observational study—so take the results with a grain of [something that doesn’t add yet another food cliche to this blurb].
  5. As long as the doc isn’t me, enjoy this list of 14 ways to drive your doctor crazy during a physical. I can attest that they’re 100% effective.

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Karan is a student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

Friday News Dump: Wonkbites

by Karan Chhabra

Does anyone still say TGIF anymore? If not, they should, because on Friday there are Wonkbites.

  1. Put your drug in a box…  A new paper suggests the FDA’s ominous “black box warnings” may not influence doctors as much as one might think, and that financial incentives are actually more powerful than the FDA’s edicts. When a black box warning was issued for drugs used in anemic dialysis patients, their use didn’t stop much at all. But when Medicare unwound an incentive that paid more for higher doses, their use dropped precipitously. The pen may be mightier than the sword, but once again the wallet is mightier than them all.
  2. Pocket protectors: If you’ve been sucked into the mess that was this week’s Obamacare-delay-gloom-and-doom story, take a deep breath and read this article clarifying what has actually changed (hint: not everything).
  3. Tightening the leash: A watchdog group within HHS has recommended tightening criteria for being named a Critical Access Hospital, a designation formerly reserved for isolated providers that has since ballooned to about one in four hospitals nationwide. The proposal is simple—merely that HHS ensures each hospital is actually the sole provider within a geographic area—but the politics are challenging, as the article rightly mentions. Months ago Dr. Ashish Jha  proposed a similar change, but suggested it’s secondary in importance to making sure those hospitals are delivering high-quality care.
  4. Must be the money: It costs between $350M and $5B to develop a new drug–any new drug—and the costs have been getting worse each decade. This article explains why, and how it matters. A teaser: “There’s one factor that, as much as anything else, determines how many medicines are invented, what diseases they treat, and, to an extent, what price patients must pay for them: the cost of inventing and developing a new drug, a cost driven by the uncomfortable fact than 95% of the experimental medicines that are studied in humans fail to be both effective and safe.”
  5. What’s in a name? If you’ve ever wondered why generic drugs have such weird names, here’s your answer.

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Karan is a student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.