health policy


Dartmouth Study Looks At When Doctors And Patients Clash Over ‘Unnecessary’ Care

A new Dartmouth study looked at whether or not doctors' actions are influenced by an interest in controlling health care costs. (Alex Proimos/Flickr)

A new Dartmouth study looked at whether or not doctors’ actions are influenced by an interest in controlling health care costs. (Alex Proimos/Flickr)

What happens when you want a test that your doctor thinks won’t help? Has a national campaign against high-cost, low-value care helped physicians have these tough conversations? And what drives doctors to provide care that they don’t think a patient needs?

These are the sorts of questions that researchers at the Dartmouth Institute for Health Policy and Clinical Practice sought to answer in a new study that came out Tuesday. The researchers surveyed clinicians at Atrius Health, Massachusetts’ largest outpatient care provider, with over a million patients, to determine what drives physicians to order tests they don’t think are in a patient’s best interest, and whether doctors were interested in controlling costs.

While nearly all doctors (96.8 percent) in the survey agreed that they should “limit unnecessary tests,” one in three thought that it was “unfair” to ask physicians to consider cost, and nearly one in three (30.7 percent) thought there was too much emphasis on cost. Primary care doctors were more likely to report being pressured by patients to order unnecessary tests, while surgeons were more likely to be concerned about malpractice.

Dr. Tom Sequist, one of the study’s authors, said in an interview that the researchers found a big gap between physicians’ desire to limit costly and low-value care, and their ability to do so.

“The thing that strikes me the most about this study is that over 90 percent of physicians said they were interested in reducing unnecessary cost, but only a third said they understood the role of cost in the system,” Sequist said. “It’s like saying, ‘I’m really interested in physics, but I have no idea how physics works.’ ” Continue reading

Economist Heidi Williams, Genius Award Winner, On Invisible Drug Industry Incentives

Last week, as she was sitting in her office at MIT, 34-year-old economist Heidi Williams got an unexpected phone call. It was from the John D. and Catherine T. MacArthur Foundation, telling her that she had just been awarded a so-called “Genius Award” — a no-strings-attached $625,000 grant that celebrates “the creative potential” of its fellows.

Williams, an assistant professor of economics at MIT, researches how invisible economic incentives affect the kind of cures that the medical industry produces. Her research has found that researchers are more likely to develop cures for late-stage cancer patients than early-stage patients, for instance, and that intellectual property law can limit innovation in genome research.

Radio Boston’s Anthony Brooks spoke with Williams about her research and her award (the interview airs in an upcoming show). Their conversation, edited:

AB: Tell us how you got the news about this award, and your reaction to it.

HW: I got a phone call from an area code that I recognized as a Chicago number. And I was just completely speechless when I answered the phone and talked to them. I’m very early in my career, and I was just completely overwhelmed to hear that I had received a fellowship.

Talk to me about these invisible economic incentives that affect the cures that the medical industry produces. Can you explain how this works?

Researchers working on drug treatments often come up with a lot of ideas, but if you talk to them, many of those ideas just never reach patients. Sometimes you hear anecdotes about the reason why those products never got developed — because of misaligned incentives in the patent systems or because of misaligned incentives in the policy system more generally. I try to explain why some promising scientific leads never get developed into new drugs or medical technologies that consumers or patients actually have access to.

Why are there incentives for late-stage cancer treatment for example, but few for early-stage cancer, or even cancer prevention? What incentives control that?

When new drugs come to market in the U.S., they need to show the U.S. government evidence that the drugs are safe and effective by showing evidence that the drug improves survival. When you need to show that a drug improves survival for patients that are very sick and will die relatively quickly, you can show that in a randomized clinical trial much more quickly than if you need to show evidence that a drug improves the survival of patients that have a longer life expectancy.

Longer clinical trials take more time and cost more money, but also, biotech and pharmaceutical companies almost always file for patent protection before they start their clinical trials. And so every additional amount of time that they’re spending in clinical trials is less time that they have for their patent to actually be generating profits for them once their drug is on the market. Continue reading

What Makes Berwick Run: Spurned Medicare Chief Seeks To Lead Massachusetts

Dr. Donald Berwick (Jesse Costa/WBUR)

Dr. Donald Berwick (Jesse Costa/WBUR)

Dr. Don Berwick — pediatrician, health care improvement guru, Anglophile, Obamacare booster — has a really, really great bedside manner. He leans in; he listens. He’s deeply thoughtful about seemingly intractable problems (Medicaid expansion, for instance, or the way doctors get paid) without being alarming. In short, he’s the guy you want in the exam room when your kid falls off the jungle gym.

And if you live in Massachusetts, he wants to be your governor.

The last time you probably heard about Berwick, a Democrat, he was being lambasted by certain (Republican) members of the U.S. Senate who vowed to block his confirmation as President Barack Obama’s designated Administrator of the Centers for Medicare and Medicaid Services. Berwick served as the head of CMS for 17 months, and then, with regret but little discernible bitterness, he returned home to Newton, Mass., and decided to run for governor. (Before heading CMS Berwick served as the director of the Institute for Healthcare Improvement, a nonprofit in Cambridge.)

We spoke with Berwick mostly about health care on his way to more far-ranging interview on Radio Boston. In a 30-minute discussion, Berwick talked about the “majestic” Affordable Care Act and compared re-inventing health care to throwing a hat over a very tall wall and climbing over to retrieve it. Here, edited, is some of our (very long) interview:

So, overall, how is your campaign going?

I’m thrilled by how things are going. Of course, people are interested in health care, it’s a very big issue for our country and our state. We have to get this right. I keep saying the truth, which is that the eyes of the country are on Massachusetts. We’re, what, five years ahead of the country in broadening coverage. Health care is a human right in the state now, and you can’t say that in any other state, and that’s what began in 2006. So we’re kind of pioneers for the country. Now, in order to make that possible, we have to reform health care.

Health care has to meet people’s needs better, at lower cost, without harming anyone, but by making health care better, that’s the best way to improve, to contain costs. That’s the journey we’re on, since the cost containment enterprise is now started, and everyone’s watching, everyone’s watching. Continue reading

Mass. Study: Savings ‘Spillover’ From Blue Cross Global Plan

(401(K) 2012/flickr)

(401(K) 2012/flickr)

Health wonk alert: If you can define an ACO (Accountable Care Organization) and know a little bit about the AQC (a pioneering global payment experiment by Blue Cross Blue Shield of Massachusetts), then read on.

There’s evidence from a study just out in JAMA that when doctors change the way they care for one group of patients (as with the AQC), there is a spillover benefit for other patients (in this case, Medicare).

Dr. Michael McWilliams says doctors who were part of the AQC, but weren’t being paid through a global budget for their Medicare patients, still cut Medicare spending by 3.4%.

He says the savings “would suggest that providers aren’t just targeting changing, but are changing their processes of care in a more systemic way such that the value of care they deliver to all patients is higher.”

That claim is harder to prove if you look at the quality of care Medicare members received as compared to patients in the Blue Cross ACQ.  McWilliams found some spillover to quality improvements.  Doctors provided fewer unnecessary MRIs for back pain and more consistent cholesterol testing.  But other “quality measures” such as reducing readmissions or preventable hospitalizations did not migrate from Blue Cross to Medicare members.

In Massachusetts, these findings may not have much practical effect for patients.  Most residents on Medicare have moved into one of the Pioneer ACOs, where doctors have incentives to spend money more wisely and boost preventive care. But it’s an interesting finding given that a lot of doctors talk about feeling ‘”schizophrenic” when they have to manage some patients who are on global budgets and others who are not, who are still fee for service.

For the nation, McWilliams says the findings show that contracts like the AQC have the “potential to foster systemic changes in care delivery.” From the press release on the study: Continue reading

New Scrutiny Of Hospitals By State Health Commission

WBUR’s Martha Bebinger reports that hospitals looking to expand or change what they do are under new scrutiny starting today:

The state’s Health Policy Commission adopted guidelines today that apply to providers with revenue of at least $25 million a year. These hospitals or other providers must notify the commission when they propose a merger, affiliation or acquisition that would increase their revenue by $10 million or more. Hospitals that seek to merge or affiliate with insurance companies must also report their plans.

Tall Chris/flickr

Tall Chris/flickr

Several commission members objected to the guidelines because they do not require providers to tell the commission when they are closing units or facilities. The commission is expected to consider adding closures at a later date.

Commission members says more scrutiny is needed in this time of rapid hospital mergers and acquisitions because when hospital networks grow they often get more expensive.

“Our role is to examine those consolidations and say, will this lead to higher prices or will this lead to better quality and care coordination,” said Commission Director David Seltz.

Evidence on the pros and cons of hospital changes will be public for the first time in Massachusetts but the commission does not have the authority to block changes it finds are not worthwhile. The commission can forward any recommendations to the state Attorney General for possible action.

Blogger: ‘Health Care Reform Gangnam Style’

Has any media phenomenon ever gone as global as Psy’s Gangnam Style rap video? (Besides the bible, I mean.) It was at an astronomical 878,054,797 views on YouTube when last I looked, leaving Michael Jackson’s “Thriller” far, far back in the ancient dust.

So of course I had to read a post called Health Care Reform Gangnam Style when I saw it on The Health Care Blog (thanks to Its very fun concept: A start-up called Rap Genius crowdsources translations of rap lyrics that most of us are not gangsterish enough to understand. But what we really need, blogger Lisa Suennen writes, is translations of impenetrable “healthcare speak:”

You may think Nelly’s lyrics are opaque, but have you ever seen an Explanation of Benefits from your insurance company? Makes the “30 down at the bottom, 30 more at the top” phrasing downright obvious compared to trying to make sense of what was billed vs. allowed vs. paid vs. subject to the deductible vs. amount left for the patient to pay.

It may be cool to understand rap lyrics, particularly if you are a 45 year old white dude with two kids, a golden retriever and a Honda Accord, but lets keep it real, yo (defined as: be realistic): we are living in a healthcare world that is rapidly turning into a retail market out of the emerging ashes of what was previously the domain solely of the healthcare wonkery. More than ever it is becoming downright essential for actual humans to understand the “rap” (crap?) that the healthcare world turns out. Continue reading

KHN: Everything You Want To Know About Paul Ryan And Health Policy

Paul Ryan (Talk Radio News Service/flickr)

Paul Ryan addresses the Republican National Convention tonight. Ahead of the speech, Kaiser Health News offers a clear primer detailing Ryan’s positions on a range of health policy matters, from national health reform (repeal it) to retooling Medicare (use vouchers) to funding for Planned Parenthood (end it).

Here’s a snippet of KHN’s analysis of Ryan’s health reform philosophy:

Supports repeal of much of the 2010 health law, including the Independent Payment Advisory Board, Medicaid expansion, subsidies and the individual mandate. However, his House-passed budget plan included many of the Medicare trims that are now hot-button items in the campaign. Ryan has said that those Medicare cuts, totaling $716 billion, are included in his budget because they are part of the budgetary baseline.
Throughout his career and most recently in the Roadmap for America’s Future, supported market-based reforms such as interstate insurance purchasing and the creation of association health plans, as well as efforts to decouple health coverage from the workplace, including removing tax incentives for employer-sponsored insurance and providing tax credits to individuals to purchase their own insurance.
Backed a 2009 proposal – the Patients’ Choice Act – which emphasized proposals such as health promotion and disease prevention and included, among other provisions, state-based health exchanges, protections against pre-existing condition exclusions as well as insurance denials based on age or health status, and expanded health savings accounts.

But Will The Cost-Cutting Bills Really Save Money?

It may not rank at the tippy-top of the titillation scale, but this thoughtful discussion about reining in health care costs featuring Brian Rosman of Health Care For All, and Joshua Archambault of The Pioneer Institute, covers some key issues in the House and Senate cost-cutting proposals now pending in the Legislature.

The plans are estimated to save about $150 billion over 15 years, but Archambault calls the proposals “faith-based initiatives,” when it comes to savings projections. That’s because he says it remains unclear if the new focus on prevention and wellness and the new payment models will actually save money.

“If we change the way we pay for health care and if we change the way we deliver health care, will we save money?” Archambault asks in the CommonWealth magazine “Face to Face” video conversation. He says there’s really no proof that these models will lead inexorably to savings. Continue reading

Q&A: When A Health Wonk Runs For Office

Christine Barber

The little news item caught my eye: A health policy analyst was running for alderman in Somerville.

A member of Health Wonk Nation seeking public office! That’s unusual, isn’t it? (Though you’d think so many of them would be driven crazy by the irrational aspects of our health care system that they’d get into politics out of desperation.)

I wondered how an analyst’s deep knowledge of the Byzantine ins and outs of the system might play out at political-platform time. So today I asked the candidate, Christine Barber. She’s a senior policy analyst at the nonprofit Community Catalyst, and used to be a research analyst on the legislature’s Committee on Health Care Financing.

Q: Does your platform in your run for office include any planks on health care?

Yes and no. I’m running for ward alderman to represent my neighborhood, which is Winter Hill and Ten Hills in Somerville. I’ve spent my career working on health care coverage, typically at the state and national levels because that’s where it’s typically regulated. A lot of the improvements to cutting costs, improving quality, improving access — a lot of those really need to happen at least at the state level and in some cases the national level.

That said, I think there’s some work we do at the municipal level that is as critically important, but more in the public-health realm than the health coverage realm.

A few things that are important to me that I think can be improved in my neighborhood are:
— Food access and nutrition: Access to vegetables and fresh foods, preferably local foods
— Public transportation: We’re slated for the green line extension but while we wait, we need to rethink our bus service.
— Rethinking bicycle access: We don’t have good bike lanes. Overall, we need to be thinking of other ways to get where we’re going because air quality in Somerville is consistently poor.
–Encouraging the overall health of our residents.
–Keeping our streets safe: Children walk to school every day; making sure they’re safe on their travels, and making sure crime is down and that people feel safe. Obviously that affects their health and wellbeing.

Q: Are there any ways your deep understanding of health care issues affects what you want to do in office? Continue reading