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How To Bend The Cost Curve In Healthcare

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President Obama has stressed the importance of “bending the cost curve” in order to put the brakes on galloping health care expenses that total 2.5 trillion dollars a year and are increasing at 6% a year. The fastest way to do this is shockingly simple: carefully explain to patients the known risks and benefits of procedures.

Dr. Elliott S. Fisher, Director of Dartmouth’s Center for Health Policy Research, estimates that thirty to forty percent of elective procedures are unnecessary. This includes elective angioplasty ($16,000), spinal fusion ($22,300), knee replacement ($14,400), and hip replacement ($15,700).

And it’s not just costly procedures that are ballooning our health tab; the annual price for diagnostic imaging studies such at CT’s and MRI’s is about 100 billion dollars, roughly 35% of which is estimated to be wasted.

A prime example of an overused procedure is angioplasty, which opens up clogged arteries in the heart.  Over a million are performed every year in the United States.  Most patients believe it will prevent a heart attack and prolong life.  But that’s only true if the procedure is performed when a patient is actually showing signs of a heart attack.  In elective cases which, according to the American College of Cardiology’s National Cardiovascular Data Registry, account for 37% of angioplasties, it has not been shown either to prevent heart attack or prolong life.  For a segment that aired last June on the CBS Evening News with Katie Couric, cardiologist Dr. Steven Nissen of the Cleveland Clinic told me, “Cardiovascular interventional procedures are big money makers for hospitals and for practitioners.” For a lot of doctors, “it’s tough to walk away from that.”

Our fee-for-service payment system certainly creates perverse incentives for doctors, a major reason for the spiraling cost of health care.  But there is another factor that is more insidious: the reluctance of physicians to accept new evidence about the medicine they practice.  For example, doctors have been taught for many years that an open artery is always better than a closed one.  Despite convincing data showing that this simply isn’t true, many physicians remain unconvinced and refuse to change their behavior.

When I interviewed President Obama about health care in July, I asked him about unnecessary elective angioplasties and the friction between what a physician believes to be true and what is supported by evidence-based medicine.  He replied, “I have enormous faith in doctors. I think they always want to do the right thing for patients. But I also think, if we’re honest, doctors, right now, have disincentives to making the better choices in the situations you talked about. If you are getting paid more for the angioplasty, then that subconsciously even might make you think the angioplasty is the better route to take. And so if we’re reimbursing the physician not on the basis of how many procedures you’re performing but rather how are you caring for the patient overall – what are the outcomes – then I think you start seeing some different choices.”

Trying to figure out which medical interventions actually work is the whole point of the so-called “comparative effectiveness” studies for which Congress has budgeted 1.1 billion dollars.  There has already been good progress in this kind of research.  Aside from data showing that elective angioplasties don’t save lives, a recent study found that vertebroplasty, a common procedure to treat pain from back fractures, was no better than a placebo treatment with a shot to temporarily numb the area.

Ultimately, insurers will try to change behavior by refusing to cover services that have performed poorly in comparative effectiveness research.  That strategy will likely take years to implement and will be complicated by the fact that medicine is both an art and a science and will never be able to be reduced to perfectly predictable algorithms.  Clinical judgment and even what has recently become a  politically incorrect term – intuition – will always play an important role.

So how do we save billions starting now?  By doctors and patients agreeing to discuss carefully whether procedures and tests are worth it.

This will have to involve consent forms.  A review of hundreds of these forms at more than 150 hospitals found them to be of “limited value.“ They are loaded with confusing language, often omit specific risks and benefits, and are generally not well explained by doctors.  Patients often sign the forms minutes before a procedure without even reading them.  Experts such as Dr. Fisher say that 30-40% of unnecessary procedures could be eliminated through proper informed consent – what is increasing being called “informed patient choice” to emphasize that doing the suggested procedure is not a foregone conclusion.

Gerry O’Connor, PhD, Associate Dean for Health Policy and Clinical Practice at the Dartmouth Hitchcock Medical Center, has implemented a pilot program that personalizes the consent process.  In the case of angioplasty, the physician  collects detailed medical information about a patient, then searches a database of angiogram results to estimate individual risks and benefits by finding out what happened to similar patients who had the same procedure. ”It’s not generic,” he told me. “It’s for people like you.  If we get that right, we’ll create a better informed consent.”

Ultimately, electronic medical records will connect with electronic medical knowledge, including comparative effectiveness results, to give doctors and patients information – so-called “decision support” – at the moment a test or procedure is electronically ordered.  But until then, and starting immediately, doctors and patients can try the low-tech solution of setting aside enough time to weigh adequately the pros and cons of medical options – not just for procedures but for other treatments and diagnostic studies.  Of course, this is more easily said than done in a system that reimburses far better for doing things to patients than for communicating with them.  That must change.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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