Here’s to those who say “no”

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Comparing two patient visits

Every visit to a health practitioner is a story. Here’s the skeleton of how the story sometimes goes:

1. A patient makes a request for a specific test or treatment, often based on what he’s seen in advertisements or media. Take, for example, the time a perfectly ambulatory patient of mine saw a late-night TV ad for mobility scooters and asked me to prescribe one, since “Medicare [would] pay for it,” and since the patient found walking to be “exhausting.” 

2. The request is denied, hopefully for medically/economically sound reasons and not out of some peculiarity of the practitioner-patient relationship. What I mean here is that sometimes patients and doctors simply aren’t a good fit, and sometimes, strained relationship dynamics spill into decision-making. “Good” doctors allow this to happen less often than “bad” doctors, but I suspect no one ever quite gets to zero. I’ll leave the judgement of my “goodness” or “badness” to others. But in the case of my patient, with whom I had a very poor relationship (to my eye, largely because of near-constant requests like his request for the scooter), even though I had a good medical reason to deny the request (walking is good for you even if it makes you tired), my writing something to the effect of “over my dead body” in the chart probably betrayed my feelings.

3. The patient gives feedback of some kind. The relationship between patient requests and the doctor’s willingness to fulfill them has real, dollars-and-cents ramifications in that reimbursement is now sometimes tied to “patient satisfaction.” A study in JAMA Internal Medicine (paywall) found that about two-thirds(!) of visits involve a request for a specific test or treatment from the patient, and that 85%(!) of those requests are granted. But when requests are denied, patients report dramatically lower satisfaction. The effect is predictably strongest with requests for pain prescriptions or lab tests. The effect is almost nonexistent for stuff like antibiotics or x-rays. But back to our patient: maybe he complains to the office manager. Maybe he goes home and writes a scathing review on one of various doctor rating sites. (Advice to other medical professionals: don’t look these up. They hurt.) Patient Scooter chose to express his dissatisfaction not in writing, but by leaving a bowel movement on the floor in the elevator of the building. (I’m not making this up.)

4. Doctor uses that feedback to change his or her future performance/behavior. Or maybe he doesn’t, if the feedback is in the form of actual human excrement. (I did record the approximate size and quality of the stool in his chart.)

That story is not fair. It prioritizes the point of view of the medical professional. Here’s an alternate story, taken from a ProPublica piece a couple years ago:

1. A patient presents with a seemingly minor, but worrisome, finding: slight chest pressure that worsens when he exerts himself but gets better when he rests.

2. With the help of a non-invasive procedure, his primary care doctor and a cardiologist accurately diagnose the patient with “stable angina.” The cardiologist recommends a coronary angiogram—an x-ray of dye going through the vessels of the heart—with possible stenting of any narrowed arteries. “Stenting” is a procedure where a blocked artery is propped open with a tiny metal cage that is expanded in the vessel by the cardiologist. This high-intensity recommendation as a solution to a diagnosis the patient found only slightly troubling is not a surprise. Our instinct in medicine is not just to stand there, but to do something, even if we aren’t sure of its benefit. Doctors routinely overestimate the benefit of screening tests while underestimating harms, for example.

3. While the cardiologist is out of the room the patient looks up evidence on the effectiveness of stenting, such as this negative randomized trial from the Lancet (paywall), and concludes, many would say correctly, that it should not be first-line therapy for heart disease in most patients with stable angina who are not having a heart attack. Instead, the patient reads that aspirin, medications called beta-blockers, and cholesterol-lowering medications are first-line therapy.

4. The patient seeks a second opinion (we’re big fans of those at KBGH). Luckily for him, his second opinion comes from a cardiologist who is active in the RightCare Alliance, a coalition of patients and clinicians interested in bringing down the cost of medicine while potentially improving patient experiences. The second cardiologist agrees with the patient, who then loses weight, changes his diet, and experiences no more chest discomfort.

Here we have two stories, both of which had happy endings, at least in the evidence-based medicine sense. (Though the first ending was certainly not happy for the maintenance staff of my clinic.) But the journey to those endings was unnecessarily fraught. Patient One was convinced that he needed a device because of a slick ad by some unsavory device dealers. Patient Two, in addition to having “an inquiring mind and a smartphone,” in the words of David Epstein, lucked into seeing a cardiologist whose grasp of and willingness to follow evidence-based guidelines was superior to his peers. What ties these threads together? In a way, health literacy.

Enter health literacy

Health literacy is the capacity to process and understand basic health information in order to make good health decisions. High health literacy is associated with dramatic improvement in medical outcomes and a reduction in care costs. We’ve touched on it before at KBGH, and we even offer a health literacy product to members called Quizzify.

But what of the doctors’ poor decision making? What we call “health literacy” on the patient side, it could be said, we call “evidence-based medicine” on the physician side. Doctors are no longer reservoirs of information, as they once were; they don’t simply carry around information that their patients don’t have access to. The sum knowledge of medicine is far too deep and broad. Instead, doctors have transitioned into curators of medical information, sort of like librarians. And they’re expected to use their access to that information to make good decisions, ideally with the input of the patient, what we call “shared decision making.” But like anyone else, doctors’ decision making is influenced by outside forces. Doctors who own their own CT scanners, for example, are more likely than others to order CT scans. Other studies have shown that doctors who sell drugs to patients, like oncologists, are more likely to choose the more profitable drug more of the time. And simple human nature predicts that doctors who are able to “self-refer” for procedures, like cardiologists or surgeons who have the choice between low-paying patient education or high-paying procedures, will more often choose the procedure. This impulse, and the willingness of some people to pay for “doing something” may, in my opinion, explain some of the absurd, wasteful testing that gets done as part of executive physicals.

Health literacy in its classical definition is a way for patients to obtain and process health-related information. But in a broader sense—and I’m not trying to cast the patient-physician relationship as adversarial—health literacy can be thought of as the best way for a patient to defend herself from suboptimal decision making on the part of his doctor. After all, in the patient satisfaction study noted above, patients who were denied requested imaging studies or antibiotics were not significantly less satisfied. Why is this? An accompanying editorialist (paywall) notes that “Through Choosing Wisely and other campaigns to reduce low-value care, substantial attention has been devoted to preparing physicians to avoid frequently requested, low-value care such as these. We can train physicians to say no to other types of clinically inappropriate requests, while still reassuring patients and paying attention to their needs.”

Bringing it home

What we need, then, is a war with two fronts, manned by patients, doctors, employers, and payers who are willing to say “no.” (There I go with the adversarial language again). On one front, we continue to develop good health literacy in the general public, so that they can go to their doctor and ask for effective diagnostic and therapeutic strategies and decline tests or treatments they don’t think are in their best interest. But on the second front, we need to pay just as much attention to the “literacy” of physicians, employers, and payers, with the development of incentives that align with the well-being of the patient. One of the best ways to reduce low-value care, after all, is simply to stop paying for it.

Will technology save the aging primary care workforce?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

The issue we’re facing

The primary care physician workforce in Kansas–family doctors, internists, and pediatricians–is aging. Of the 1,976 primary care physicians in Kansas as of April 2020, 15.6 percent are already over 65, and 39.2 percent are over 55. The simple demographics of this are intimidating: even though they provide the most essential, cost-effective care in medicine, only 43 percent of practicing physicians in the U.S. are primary care providers, similar to the average of eleven Organization for Economic Cooperation and Development countries. But the fraction of graduating students entering primary care is steadily decreasing.  Even more ominously, older physicians are much more likely to be harmed by infectious diseases like SARS-CoV2, the causative virus behind COVID-19, adding to the inevitable workforce turnover caused by death. This all portends an uncertain future for primary care provision in many Kansas communities, since Kansas is already underserved relative to most other states at baseline.

As if that weren’t enough to worry about, physician skills appear to deteriorate over time. A 2017 study in the British Medical Journal found, for example, that elderly Medicare beneficiaries’ hospital adjusted 30-day mortality rates were 10.8% for physicians aged <40 and rose steadily to 12.1% for physicians aged ≥60, a 15% relative increase in risk for patients cared for by older doctors. Not only that, but costs of care were slightly higher among older physicians. This may not simply be due to age-related decline; it could be that younger doctors were trained in a way that improved their care. For example, “evidence-based medicine” is an integral part of medical training in the modern era. Older doctors who were not trained under this philosophy are demonstrably less likely to follow evidence-based care guidelines. This is hard for me to read. Statistically, I am likely a worse doctor than I was fifteen years ago. But I digress.

What can be done about this problem?

The Association of American of Medical Colleges, predictably, has argued for years that the solution is to train more physicians, by two mechanisms: first, the AAMC advocates for increasing the cap on Medicare funding that limits the number of residents at a given institution. Second, the AAMC supports greater incentives such as scholarships and loan repayment for primary care providers working in underserved areas. Examples of this are the Kansas Medical Student Loan Program, which pays for medical school for a limited number of students in return for an agreement to practice primary care in underserved areas in Kansas; and the Kansas Bridging Plan, which gives resident physicians additional funding during their training in exchange for a three-year commitment to practice in a rural community. On the federal level, the AAMC advocates for increased recruitment of international medical graduates, who already represent about a quarter of practicing physicians in America, through programs like the J-1 Visa Waiver program.

Others point toward increased use of non-physician practitioners like physician assistants (PAs) and advanced practice registered nurses (APRNs). This is clearly the preferred short-term option. PAs and APRNs require drastically less training than physicians, which eliminates the seven-year gap between policy and practice that we see in traditional medical training. And the health outcomes of patients seen by non-physician providers seem to be roughly equivalent to those of patients seen by doctors. Another British Medical Journal systematic review of randomized trials and observational studies–one of several such reviews in various journals, all with similar conclusions–concluded that “Patients are more satisfied with care from a nurse practitioner than from a doctor, with no difference in health outcomes.”

But long-term, if the skills of physicians like me decline with age, we can be certain the skills of other providers fall as well. How do we ensure that quality care continues to be delivered over the lifespan of the practitioner?

Automation may be the answer

Let’s look at my specialty, endocrinology. Six years ago, when I left full-time practice, the management of blood glucose levels was mostly an intuitive art/science, driven mostly by the experience of the physician-patient dyad. But in the last few years we’ve seen the emergence of “smart” glucometers that quadruple the likelihood of of a patient controlling their blood sugars while reducing their risk of dangerous low blood sugars. We’ve seen the development of automated insulin devices in the hospital that outperform conventional treatment of blood glucose levels. The FDA approved an artificial intelligence-based device to scan and diagnose the eyes of diabetic patients with diabetic eye changes (the most frequent complication of diabetes) without even having an ophthalmologist or optometrist involved. Newer, even more innovative, devices are in development, such as an app that can allegedly detect the presence of lung disease by the sound of a patient’s cough.

Some of these devices will pan out in the long run, while others won’t. But even a conservative projection is cause for optimism. It is not unreasonable to predict that practitioners with far less training than physicians will have the tools and skills to provide very competent care–elements of both primary care and specialty care–in the near future. Technology must be carefully monitored by humans, but its abilities do not decline with age. On the contrary, a given technology’s performance today is the worst that it will likely ever be. Best Buy will sell faster computers next month than it does today, and faster yet a year from now. And automated devices aren’t resistant to delivering evidence-based care; it is programmed in. I welcome the Rise of the Robots.

Primary care is being crowded out

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

The next time you have a minor injury or get sick, will you call your primary care doctor to get a same-day appointment, or will you go to the local urgent care? Now may seem like a strange time to even be asking the question, since many patients aren’t taking the chance on either one. Patient volumes in medicine are down 50% or more as people practice social distancing and hospitals and surgery centers cancel elective procedures. But eventually we all need care. And a recent study in the Annals of Internal Medicine (paywall) found that when we seek that care we’re increasingly likely to seek it from urgent care centers.

Multiple investigators from Harvard, Mount Sinai, and the University of Pittsburgh looked at deidentified claims data for adults aged 18-64 years from a single commercial insurer (they didn’t reveal which one) between January 1, 2008, and December 31, 2016 to determine the rate of primary care visits per 100 member-years. By cleverly using CMS place-of-service codes, National Provider IDs, tax identification numbers, and CPT codes, they were able to further categorize visits as having taken place in a purely outpatient office, the emergency department, an urgent care, a retail clinic, or a commercial telemedicine visit.

What they found was bad news for primary care doctors and, if you believe that primary care saves money and improves outcomes, as most policy makers do, bad news for the people paying for healthcare, like employers. Primary care visit rates declined 24.2% in the eight years of the study, from 169.5 visits per 100 member-years in 2008 to 134.3 in 2016. The proportion of insured patients with no medical visits at all in a given year went up, from 26.1% to 32.5%, as did the proportion with no visits to a PCP in a given year (from 38.1% to 46.4%). This trend held even when gynecologists were re-classified as PCPs, since some women get the bulk of their care from their gynecologist.

An optimist might venture that the population was just healthier in 2016 than it was in 2008. And in patients that had no chronic diagnoses the drop in PCP visits was higher. But overall the insured group did not get healthier or sicker over the time of the study.

So where did the care go? To “alternative settings.” Urgent care visit rates almost doubled, from 4.4 visits per 100 member-years in 2008 to 8.0 in 2016. Retail clinic visit rates more than tripled, from 0.83 visits per 100 member-years in 2008 to 3.0 in 2016. Commercial telemedicine visit rates rose a spectacular 500%, from 0.003 visits per 100 member-years in 2008 to 1.6 in 2016.

The authors posited three possible explanations for this: First, patients may be less likely to seek primary care if they are younger and healthier and comfortable with online self-care or a secure message with a nurse or other non-physician provider when a minor acute need, like conjunctivitis, arises.

Second, those increasing financial barriers such as increased deductibles and co-pays may influence care more than we have previously thought. The average out-of-pocket cost of a visit increased from $29.70 in 2008 to $39.10 per visit in 2016 for “problem-based” visits (that is, visits meant to address a specific complaint). And over the time of the study more PCP visits became subject to a deductible (from 9.2% of visits in 2008 to 25.2% of visits in 2016). The decline in PCP visits in this study was largest in low-income communities. Using some clever economic calculations the authors estimated that this may have explained about a quarter of the decline in PCP use.

But third, and most powerfully, patients appear to simply be replacing PCP visits with visits to specialists and alternative settings. Even though the proportion of patients visiting specialists did not change, many patients saw multiple specialists. And the increase of 9 visits per 100 member-years to alternative settings offset about a quarter of the PCP visit decline. This may well have been a matter of convenience. As we’ve discussed before in this blog, the average physician visit takes more than two hours. Traditional primary care settings are known for their inefficient or inflexible scheduling practices. One study found that patients are so frustrated by scheduling practices that they think nothing of blowing off visits, leading to high no-show rates in the clinic. Visits to alternative venues may simply be more convenient not only in getting a generic appointment, but in getting an appointment after-hours so that no work is missed.

If the convenience argument is correct, doctors may be able to get some of that patient population back by employing “open access” scheduling. In this system, same-day appointments are almost always available. The day’s schedule isn’t full of appointments made weeks or months ago. The doctors preferentially schedule follow-up appointments in the morning, but fill much of their afternoon schedule as the day goes on. Somewhat famously, this is how a Kaiser Permanente clinic in Sacramento reduced their wait for an appointment from 55 days to one day. But the system requires some sacrifice on the part of the doctor, which may be a tough sell in a system where PCPs are already losing market share. Open patient slots, after all, are potentially lost money. It also may require some sacrifice on the part of the system. Open-access scheduling is generally thought to require doctors to carry smaller “patient panels” than they traditionally do, which may in turn lead to a need to train more physicians.

For larger employers there may be other fixes, such as on-site clinics. And with the increased adoption of telemedicine into traditional practices, we may see more patients using that option instead of going to the ER or to urgent care.

If your business has found a way to incentivize increased use of primary care, rather than ever-expanding use of urgent cares and emergency rooms, let us know.

Social distancing doesn’t cause recessions – pandemics do

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

We’re almost a month into social distancing in our collective effort to reduce the spread of COVID-19. It’s working; models indicate we’ve likely already prevented hundreds of thousands of deaths. But the economic effects of social distancing are tough. Though we haven’t met the official definition of a recession yet, simply because we haven’t been at this long enough, no one doubts that we are in a recession, if not an outright depression. The 22 million unemployment claims in the U.S. since early March are at levels that dwarf even the 2008 Great Recession.

So, naturally, even though public support for continued social distancing remains high, we’re hearing calls from some to relax restrictions. Small protests have broken out in Ohio and other places. Politicians are clearly spooked by the impending decision on when to “re-open the economy,” as some call it. And even though it is easy to make fun of some of their responses to questioning, the decision to relax social distancing in the hopefully near future will clearly be based on some combination of instinct and data. The best data we have on the topic seems to come from more than 100 years ago, during the 1918 influenza epidemic.

Economists Sergio Correia and Stephan Luck of the Federal Reserve and Emil Verner from MIT recently tried to apply lessons learned from the 1918 “non-pharmacologic interventions” for influenza (what we’re calling “social distancing”) like closures of schools, theaters, and churches; restriction on public gatherings and funerals; quarantine of suspected cases; and restricted business hours, to our current situation.

They came to two conclusions: First, areas that were more severely affected by the 1918 Flu Pandemic saw a “sharp and persistent decline” in economic activity. This is no surprise. We’ve seen the devastation COVID-19 has wrought in northern Italy and New York City. Second, the economists concluded that early and extensive use of non-pharmacologic interventions like social distancing had no independent adverse effect on local economic outcomes. Rather, cities that intervened earlier and more aggressively experienced a relative increase in real economic activity after the pandemic was over compared to other cities.

In other words, these three economists concluded that it was not social distancing that caused the most economic pain in 1918. It was the disease.

You can see the relationship between non-pharmacologic interventions and economic activity in the figure below. The green dots are cities with early, aggressive social distancing. The red dots are cities with late or low-intensity social distancing. The vertical axis is the change in employment over the four years before and one year after the pandemic. The horizontal axis is the mortality rate. What the best-fit line shows is that cities that intervened early and aggressively not only experienced more economic growth over time, but also, in most cases, had far lower mortality rates.

The United States is not a manufacturing economy today like it was 100 years ago, and these numbers look primarily at manufacturing output, which fell 18% during the influenza pandemic. The U.S. is primarily a service economy now. If that strikes you as a weakness of their analysis, the authors also looked at bank assets over the same time period, according to the intensity of the non-pharmacologic intervention (left; [e]), and the speed of the intervention (right; [f]):

 The cities that intervened earliest and most aggressively were much more likely to experience an increase in wealth through the time of the influenza pandemic.

What lessons can we learn from 1918? We need to take the long view. Social distancing hurts now. Unemployment of 25% or even 30% is unprecedented in the last century, and we need strong actions by federal, state, and local governments, along with good work from charities and non-profit organizations, to get us through the hardest part of this pandemic. But we need to be very, very careful about when we relax social distancing. Many projections, like this one from Morgan Stanley, are already taking into account a “second wave” of infections this fall:

 That second wave of infections is likely avoidable if we do the right thing now.

This paper, nor this blog post, have been peer reviewed. We at KBGH would love to know your thoughts on how and when we should modify social distancing for COVID-19.

When can your employees return to work?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

As of the writing of this post, Kansas has 1,106 confirmed cases of COVID-19, enough cases that either you or someone you know likely knows an infected person. This, in turn, means many of us have been potentially exposed. Given the need for certain “critical infrastructure” workers to return to work after an exposure, CDC has released new interim guidance on returning to work. Keep in mind: this interim guidance does not apply to people who have been diagnosed with COVID-19; it applies only to people who have been exposed to someone with COVID-19 without proper personal protective equipment but has not been diagnosed with the disease.

In short, the CDC guidance statement says that exposed critical infrastructure workers—sixteen categories including law enforcement, 911 call center employees, fusion center employees, hazardous material responders, janitorial and custodial staff, and vendors in food, agriculture, critical manufacturing, informational technology, transportation, energy, and government facilities—can continue to work as long as certain conditions are met:

• Employees’ temperatures should be taken and symptoms assessed before work resumes

• Employees should regularly self-monitor for fever or symptoms, and if employees develop symptoms, they should not work

• A face mask should be worn for 14 days since the most recent exposure, although there is evidence to support more widespread use, and this is reflected in a second CDC recommendation

• Employees should maintain six feet of separation from one another if possible

• Work spaces, particularly commonly touched areas, should be regularly cleaned and disinfected

If you are unsure whether your workforce belongs to a category within critical infrastructure, guidance can be found on the website of the Cybersecurity and Infrastructure Security Agency within the Department of Homeland Security.

If you or an employee has been infected and was symptomatic (that is, not an asymptomatic carrier), CDC recommends one of two strategies to determine when to discontinue isolation and potentially return to work. Keep in mind these strategies take into account only the potential transmissibility of the virus and not the physical wellness of the infected patient. That is to say, just because someone is no longer contagious may not mean she is well enough to return to work:

1. A time-based, non-test-based strategy:

Persons with symptomatic COVID-19 who able to care for themselves at home may discontinue isolation if they meet all three of these conditions:

• At least 7 days have passed since their symptoms first appeared and

• At least 3 days (72 hours) have passed since their fever went away (without the use of fever-reducing medications like ibuprofen or acetaminophen) and

• Their respiratory symptoms (e.g., cough, shortness of breath) have improved

2. A simplified test-based strategy:

Kansas still has a catastrophic lack of testing capacity, but if a patient is able to get re-tested, they may discontinue isolation if:

• Fever has gone away (without the use of fever-reducing medications like ibuprofen or acetaminophen) and

• Respiratory symptoms (e.g., cough, shortness of breath) have improved and

• Two nasal swab specimens collected 24 hours apart are resulted negative.

To end the post on a positive note, the current statewide strategy of social distancing appears to be working. Kansas is on pace for peak resource use on April 20, but we are not expected to exceed our statewide ICU or hospital resources.

Please be safe and remember that we encourage you to check to make sure these recommendations are up to date before using them, since we learn more every day, and recommendations are changing fast. Be sure to check out and share Quizzify’s quizzes on coronavirus with your employees, which are reviewed by physicians at the Harvard Medical School. The quizzes are a fun and interactive way to learn about the virus, and they are continually updated as new information becomes available. If you have specific questions, please don’t hesitate to contact us.

Mental Health Treatment: The Tale of Two Employees

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

You probably know someone like Juanita. Juanita feels so anxious at her job as a delivery driver that she is starting to miss work and perform poorly. She goes to her primary care doctor, who prescribes a medication to help reduce her anxiety and tells Juanita it will take two to three weeks to feel a benefit. Juanita asks if anyone like a counselor or therapist is available to see in the meantime, while she’s waiting for the medication to work. Her doc tells her that the clinic has no behavioral health providers on-site. Furthermore, unbeknownst to Juanita, her insurance policy doesn’t cover therapy sessions very well, and tele-behavioral health may not be covered at all. Juanita decides to seek out a mental health provider on her own. She calls several offices, but because of increased recent demand for mental health services, no one has an appointment available in the next three weeks. Juanita ends up on a waiting list and eventually has a good, albeit expensive, experience at her first visit and feels better. When she asks her primary care doctor and her therapist how much better she should expect to feel after her second visit, though, they can’t give a straightforward answer. They tell her this kind of improvement is hard to measure. They are, however, very careful to screen her for risk of suicide or self-harm.

Marcus works at a different company with a different philosophy toward mental health. When he begins to feel so anxious at his job as a warehouse supervisor that he worries his performance is suffering, he visits his primary care doctor, who prescribes a medication to help reduce his anxiety. His doctor tells him it will take two to three weeks to feel better, just as Juanita’s doctor did. But at his first visit, the doctor rates Marcus’s anxiety with an instrument called the Hamilton Anxiety Scale. He also schedules Marcus for a next-day visit with a licensed specialist clinical social worker (LSCSW) who the clinic contracts with to do tele-behavioral health consults, one of several options in Marcus’s network. The doctor tells Marcus that the LSCSW will work with him on “strength-based” strategies to take advantage of Marcus’s natural skills and talents as a starting point to address his anxiety. Marcus’s benefits package covers the LSCSW’s services just as it would cover any other medical treatment. After two months of visits with the LSCSW and careful medical management by his doctor, who is in frequent contact with the LSCSW, Marcus’s score on the Hamilton Anxiety Scale has declined from an initial score of 24 to a persistent score of 8, indicating likely remission of his anxiety.

The contrast between these two patients’ experiences are obvious in a high-level, qualitative sense. But they have very specific differences: Marcus was cared for in a network with an adequate number of providers, all of whom are in collaborative practice with Marcus’s primary care doctor. Telemedicine under Marcus’s employee plan is covered at the same reimbursement level as in-person visits, and behavioral health is reimbursed at the same rates as other medical care. And Marcus’s doctor and social worker objectively measured Marcus’s state of mental health in order to judge whether or not he was getting better.

These five characteristics–network adequacy, coverage of telehealth, payor parity, measurement-based care, and collaborative care between medical and mental health providers–are but a few of the marks of good access to mental health care. But they are the specific domains that the Kansas Business Group on Health is attempting to improve here in Kansas through a project with the National Alliance of Healthcare Purchaser Coalitions called the Path Forward. We’ve touched on this topic in past blog posts specifically regarding substance abuse. But since we’ve found ourselves in the teeth of a viral pandemic that is probably going to get worse before it gets better, we thought it was important to reinforce what we’re working on around mental health. The scope of this pandemic is not only physical in nature, but also impacts our mental health. There are resources available that KBGH can help you with for you or your employees.  If you have specific questions, please reach out to us. We have a number of resources available. We do not know how long the effects of this virus will last, but we know that the impact is far reaching.

Is social distancing...bringing us closer together?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

If you’ve read as much as I have in the last few days about the COVID-19 pandemic, you’ve probably come across ominous-sounding warnings about social isolation or loneliness as a result of social distancing, our preferred short-term strategy to prevent the spread of the SARS-CoV-2 virus. Social isolation is the physical state of being alone, while loneliness is the feeling you get when your social interactions don’t meet your expectations; you can feel lonely in the middle of a crowded room, but you’re only socially isolated when you’re, well, socially isolated.

But both are bad for you. A 2017 systematic review showed that social isolation was associated with a 29% increased risk of death, while subjective loneliness was associated with a near-identical 26% increase in mortality. For perspective, a second meta-analysis in 2010 showed that “…by the time half of a hypothetical sample of 100 people has died, there will be five more people alive with stronger social relationships than people with weaker social relationships.”

As we have ramped up social distancing there has been legitimate fear that we would exacerbate the already-high rates of social isolation and loneliness, especially in elderly people. While it’s too early to say if that’s happening, I’ve been pleasantly surprised at my own experience. Just yesterday this meme came across my phone:

I found it so true. Now that many of us (but not healthcare workers, first responders, food delivery people, restaurant workers, mail carriers, or a hundred other “essential service” professionals and workers) are stuck at home during the day, it seems that we’re finding new strength and resilience just from getting out and moving in our neighborhoods and green space. I’ve talked to more neighbors on walks in the last three days than I had in the last three months, and not just because of warmer weather. Could it be that COVID-19 has begun a small restoration of what physician sociologist Nicholas Christakis calls the “social suite”: love, friendship, cooperation, and teaching, all from six feet away?

The evidence of increased investment in the social contract isn’t limited to the streets in my neighborhood. Young people are volunteering in large numbers to do things like deliver meals. So many retired doctors have offered to re-enter the workforce–at significant personal risk, considering many of their ages–that the Kansas State Board of Healing Arts has begun issuing emergency short-term licenses, and KAMMCO is issuing short-term liability insurance. Manufacturers in cycling, my favorite sport, are pivoting away from bike gear and toward the production of personal protective equipment. Congress is operating at a rare, near-normal level of functionality to give financial relief to millions of people (now if we could only get more testing resources). And I know that many of the readers of this blog, be they human resources professionals, insurance brokers, health administrators, or others, are working steadfastly to save as many jobs at their companies as they can in the face of an impending global economic catastrophe.

While you’re working hard on those things, don’t forget to work on these, too:

1. Look for ways to have “conversation-centric” interactions with people. Talk on the phone. Skype or FaceTime. Talk to people from your porch or from the street. As former Surgeon General Vivek Murthy says, “Smiling at someone–eye contact–is an act of service.”

2. Let kids around you continue to have unstructured play time with friends. Just keep them apart. Let them run around, ride bikes, and throw sand. Don’t let them wrestle or share toys.

3. If you’re still going to work, synchronize your coffee breaks with someone else. Common socializing like this has been definitively shown to be more restorative than snacking or emailing. If you can do it outside, even better.

4. Take time to express gratitude to others. Expression of gratitude is one of the most common indicators of life satisfaction in the US.

5. Volunteer. Organizational volunteering has been shown to be associated with a 24% reduction in mortality risk.

6. If you’re lucky enough to have some money to donate, do it. Spending money on others makes us far happier than spending it on ourselves.

COVID-19 is changing telemedicine for the better

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

I’m typing this while on voluntary quarantine at the recommendation of the Kansas Department of Health and Environment because of a recent trip to Orange County, Florida. But like many of you, I’m managing to stay busy at home. One of the things I’m doing is providing “peer-to-peer” consultation to other doctors through a platform called RubiconMD [disclaimer: they pay me for the work, but not for advertising or testimony]. Doctors who subscribe to RubiconMD can forward me labs, imaging, and chart notes for patients with tricky hormonal and metabolic problems, and I type a recommendation back to them, potentially saving the trouble and expense of an in-person visit. These so-called “store-and-forward consults,” or “e-consults,” are one form of telemedicine, and they have proven effective enough–saving ~$500 per patient per year in one study–that they are now covered by Medicare.

The more well-known form of telemedicine in which practitioners and patients interact through a screen is referred to as “real-time” telemedicine. Other than the fact that the patient connects to the practitioner through a secure internet platform, telemedicine visits look a lot like traditional in-person medical visits: someone on the patient’s end (the “originating site,” in telemedicine parlance) collects vital signs, the doctor or other practitioner conducts an interview and, with the help of the ubiquitous high-resolution cameras on modern devices and a few on-site gadgets, performs a physical examination. Then the practitioner bills for the encounter as she would any other visit, albeit with a modifier attached to the billing to indicate that the visit was done remotely.

The average patient seen in-person at a physician office spends 121 minutes on the visit: 37 minutes traveling, 64 minutes waiting, and 20 minutes with the doctor. So if you think the idea of skipping the waiting line (not to mention all the coughing and touching) at your doctor’s office is attractive, you’re not alone. Telemedicine visits have a roughly 90% patient satisfaction rate. Kaiser Permanente has seen more patients via telemedicine than in-person since 2017. Local telehealth provider Freestate Healthcare and national providers Access Physicians and Eagle Telemedicine, among others, provide remote physician services at several rural hospitals with no doctors physically on site. In our work with CDC grants around diabetes prevention, we are running a trial of Omada, a virtual diabetes prevention program, to reduce the risk of high-risk patients developing diabetes. More than half of medical schools now offer required or elective training in telehealth to improve trainees’ “webside manner.”

And telemedicine has a growing body of evidence to support its use beyond reduced wait times and patient satisfaction. The Veterans Administration has found that telemedicine use corresponds to a 59% reduction in inpatient bed days and a 31% reduction in hospital admissions.

In spite of this rosy picture, the growth of telemedicine has been slowed by a regulatory system that is not designed for rapid change. Medicare, for example, has historically enforced a “site of service” requirement for telemedicine, meaning that patients seen via telemedicine still needed to travel to a hospital or doctor’s office to get linked to the distant telemedicine practitioner. Medicare has also mandated that patients must be located in a “health professional shortage area,” meaning that patients in areas with more physicians were ineligible to receive care via telemedicine, even if it was difficult for them to travel, and even if they had a highly communicable disease. Laws have mandated that the treating physician be licensed in the state where the patient was located, meaning a doctor licensed only in Kansas couldn’t historically see a patient in Oklahoma. And federal regulators have long restricted the technology that can be used for the interface. You couldn’t simply Skype or FaceTime your doctor, since those platforms were not compliant with the Health Insurance Portability and Accountability Act (HIPAA). This is not, on its face, an unreasonable policy; health data is valuable, so it is not hard to imagine it being the target of hackers.

There has been movement on this in the last year. Medicare Advantage plans began covering telemedicine visits from home earlier this year. But the current coronavirus pandemic is forcing faster changes, probably for the better. This week Centers for Medicare and Medicaid Services (CMS) suspended site-of-service requirements and state licensure requirements for telemedicine, and the Office for Civil Rights at Health and Human Services (HHS) announced that it would waive potential penalties for using lower-security forms of video communication for telemedicine. That is, any live video chat software is acceptable for now. This means that, at least in the short term, you can Skype or FaceTime your doctor (although we still recommend a more secure platform if your doctor can offer one). And you can do it from home. This policy is extending to other insurance carriers as well. I called Aetna, who informed me that they are allowing all visits (with the usual rules on copays and deductibles) to be performed via telemedicine for the next 90 days.

...once people get a taste of life with more easy access to telemedicine, I can’t imagine them going back.

If you or your company want to seek out such secure platforms, encourage patients to talk to their doctors about starting telemedicine visits. We at the Kansas Business Group on Health believe that care continuity is important. Urgent care centers and emergency departments have an important role to play, but encouraging patients to see their own doctors, rather than unaffiliated urgent care practitioners or cash-only telemedicine companies like Teledoc, is good for patients’ care and good for your bottom line. Freestate, Zoom, Doxy, VSee, and many other HIPAA compliant platforms are available to your employees’ doctors. They should consider asking specifically about any platform’s use of business associate agreements (BAAs) to certify there are safeguards against data breaches. Even though FaceTime is now technically allowed to be used as a telemedicine platform, for example, Apple will not sign a BAA. But Skype for Business, again for example, will.

I guess if you are the type of person who tries to find the bright side of things, this blog post is for you. This is just one way that COVID-19 is going to change medicine long-term. For the next few months, telemedicine access will become what its proponents have advocated for for years: a broad-based, broadly covered service that can be provided in the patient’s home on widely available, inexpensive software platforms. This is important not only in the context of a worldwide viral pandemic. It is important because once people get a taste of life with more easy access to telemedicine, I can’t imagine them going back.

Coronavirus “Dos” and “Don'ts”

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH. Beware that this post was originally written on March 12, 2020, so some of the recommendations have changed. For example, stay away from your gym, if it’s even still open:

Do: Wash your hands as often as you think of it. Soap and water is best, but alcohol-based hand sanitizer is okay, too. Don’t forget to wash your hand towels as well.

Don’t: Buy facemasks. Those are needed by sick people and medical professionals.

Do: Cover your coughs and sneezes. Use the vampire method.

Don’t: Spit on the sidewalk.

Do: Work from home if you can. Microsoft, Zoom, Google, and others are now offering free work-from-home software.

Don’t: Work from your Starbuck’s “home.”

Do: Go somewhere isolated by yourself or with your immediate household members if you need a vacation.

Don’t: Go on a cruise or get on an airplane.

Do: Wipe down surfaces, knobs, and pulls with a surface cleaner or a dilute bleach solution. Don’t forget to clean your phone and your keyboard.

Don’t: Hoard alcohol cleanser or wipes.

Do: Greet your neighbors and friends in these uncertain times.

Don’t: Shake their hands.

Do: Consider salary advances or other monies to help your employees over childcare and other costs if quarantines go into effect.

Don’t: Just tell employees to “go home.”

Do: Get exercise.

Don’t: Go to the gym during peak hours.

Do: Postpone weddings, parties, and other social gatherings.

Don’t: Succumb to social pressure to hold or attend events that seem risky.

Do: Isolate yourself if you get sick.

Don’t: Allow a couple weeks of social distancing to turn into social isolation.

Do: Watch out for symptoms of a cough or cold.

Don’t: Neglect your other health issues, like hypertension, diabetes, or, especially, heart and lung disease.

Do: Pay attention to reputable sources of news on COVID-19. The Atlantic, Wall Street Journal, Seattle Times, Miami Herald, Toronto Star, Stat, Dallas Morning News, Medium, New York Times, The Guardian, and several medical journals like JAMA and the New England Journal of Medicine have dropped their paywalls for coronavirus related coverage.

Don’t: Panic. Let’s flatten the curve.

Is it time to retire the handshake?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Last Sunday at my church the congregation turned, as we always do, to greet one another. The pastor had a runny nose, but she repeatedly reassured all of us that it was from allergies, not an infection. I, too, was experiencing some rhinorrhea, mine exercise-induced from a hard bike ride that morning in the cool air. But as people started to reach for my hand I couldn’t block the results of an experiment from my mind. Bill Bryson wrote about it in his book “The Body: A Guide for Occupants.” The Mythbusters later re-created it. In the experiments, a confederate wore a device in his nose to a party. The device imitated a runny nose: it dripped at 60 mL per hour, roughly the same rate as someone with a viral cold. The fluid was clear, but fluoresced under black light so that investigators could track it later. The partygoers—who were unaware this was happening—went about their business, and at the end of the night everyone was examined with a black light to see where the fake, fluorescent snot ended up. Not surprisingly, everyone at both parties ended up covered in it. In the Mythbusters version, even people who had been instructed to “act like germophobes” had demonstrable contamination with the fluid. The one exception? A woman who had refused to shake hands with the drippy confederate.

With this information roiling around inside my head I ducked out of the sanctuary and into the bathroom. I washed my hands for twenty seconds and returned to my seat. With a worldwide viral pandemic unfolding, I wondered, is it time to retire the handshake?

I asked around. One of my medical school classmates told me he attends church with a lawyer who asks for a fist bump instead of a handshake. My neighbor, a realtor, told me that handshakes are such an integral part of the ceremony of his work that he can’t imagine changing. (Ironically, he was diagnosed with influenza A last week. Don’t worry. He’s doing fine)

So I dove into the literature. In spite of mountains of evidence that our hands are filthy, we are very into shaking hands: 78% of patients want their physician to shake their hand, and docs and patients shake hands 83% of the time. But maybe there’s a middle ground. Dr. Leonard Mermel from Brown University (paywall) points out that studies have shown that alternate practices of greeting, such as fist bumps and high-fives(!), decrease the transfer of organisms from one person to another by 50-90%. And some clinical sites have gone so far as to ban handshakes (paywall), comparing the challenge of the discontinuation of the handshake in clinics to the change in smoking practices among doctors in the 1950s and 1960s.

The handshake is a powerful signal. It can bring adversaries together in a moment of shared respect. It can give unequal parties a moment of balance and equity. It can help a person quickly project that she is trustworthy, confident, and prepared. But it can also transmit a stunning number of organisms from one person to another in a short amount of time.

So for this winter or the COVID-19 pandemic, whichever ends first, let’s fist bump instead.

One of your employees is likely to get coronavirus disease. What should you know about it ahead of time?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Let’s get the semantics out of the way. “Viruses” are little more than small packaged strands of genetic material—DNA or RNA—that invade cells and trick those cells into reproducing the virus. The duplicates of the virus take up too much space inside an infected cell, and the cell ruptures like a balloon. This is how tissue damage occurs, like the sore throat you get with many respiratory viruses. Most viruses infect other organisms, ranging from bacteria to mammals and birds, and are harmless to humans. You can find hundreds of harmless viruses in a few ounces of seawater, for example.

But sometimes viruses cross over from other hosts to infect humans. We call such infections “zoonotic.” Coronaviruses are a family of RNA viruses similar in many ways to influenza. They are called “corona” viruses because of their “crown” of spiky proteins. Four common coronaviruses—229E, NL63, OC43, and HKU1—have long been known to infect humans. They cause colds. We’ve seen outbreaks of two other coronaviruses in the last couple decades. Severe Acute Respiratory Syndrome (SARS) was transmitted to humans from civet cats. Middle East Respiratory Syndrome (MERS) came from camels. The novel coronavirus discovered in 2019 in Wuhan, China, the seventh known coronavirus to infect humans, is likely either from bats or pangolins, those scaly mammals that look like a cross between a raccoon and a lizard.

The newly discovered virus is now officially known as “SARS-CoV-2,” short for “severe acute respiratory syndrome coronavirus 2.” The disease that SARS-CoV-2 causes is officially known as “COVID-19,” short for “coronavirus disease 2019.” But for the sake of conversation, let’s use “COVID-19” for the next 800 words.

By contrast, COVID-19 seems only slightly more contagious than a generic influenza strain, with an r0 so far between two and three. It is also a fairly middling organism, mortality-wise: it has a current observed mortality rate of two percent, a number which will probably decrease over time.

The identification and naming of the virus and the work already done toward producing a vaccine is a testament to the advancement of science. We have accomplished all this in the time it took to even identify H5N1 23 years ago. But in spite of this, we are unlikely to be able to contain the virus. Since the original index case of presumed bat-to-human or pangolin-to-human transmission, COVID-19 has proven able to be transmitted directly from human to human. We measure the human-to-human contagiousness of a virus by a statistic called r0 (pronounced “R naught”). The r0 is complex to calculate, but it ultimately reflects the number of other people a person with an infection can be expected to, in turn, infect. Some viruses have an astonishingly high r0. A person with measles, for example, can be expected to infect between twelve and eighteen others. HIV’s r0 is 4.3.

By contrast, COVID-19 seems only slightly more contagious than a generic influenza strain, with an r0 so far between two and three. It is also a fairly middling organism, mortality-wise: it has a current observed mortality rate of two percent, a number which will probably decrease over time. A particularly bad influenza virus has a mortality rate of 20 percent (as in the 1918 Spanish flu, which may have in fact originated in Kansas) or even 60 percent, as observed in Asian Avian Influenza A (H5N1). But the fact that COVID-19 kills few of its victims has the paradoxical effect of increasing its transmission. Those H5N1 patients either died quickly or got so ill so quickly that they could be isolated right away, so only a few hundred people eventually died. As Dr. James Hamblin writes in the Atlantic this week, “…much ‘milder’ flu viruses, by contrast, kill fewer than 0.1 percent of people they infect, on average, but are responsible for hundreds of thousands of deaths every year.”

So even with the quarantine of hundreds of millions of people in China and elsewhere, COVID-19 cases are now in dozens of countries, including the United States. We’ve now seen the first case of likely “community-acquired” COVID-19 in the U.S. Epidemiologist Dr. Mark Lipsitch told James Hamblin that, eventually, 40 to 70 percent of the world’s population will become infected, likely resulting in flu and cold seasons being slightly worse in intensity and slightly more diverse, virus-wise.

What do we tell our employees, then? The news is fast-moving, and I’ve already revised this blog post twice in two days before posting, so nothing mentioned here should be considered irrefutable. But the fundamentals of disease containment are well-established, they’re not sexy, and they don’t differ for COVID-19 at this point compared to other infections. If you get sick, CDC recommends that you:

1. Stay home except to get medical care.

2. Separate yourself within the home from others, including pets.

3. Wear a facemask if you’re forced to be around others, including pets.

4. Cover your coughs and sneezes.

5. Don’t touch your eyes or nose.

6. Wash your hands for at least 20 seconds with soap and water. If you can’t get to soap and water, use a hand sanitizer with at least 60% alcohol. THIS IS LIKELY THE BEST PIECE OF ADVICE WE HAVE.

7. Don’t share household items.

8. Clean all your “high-touch” surfaces, like counters and doorknobs, daily.

9. Once you are free from fever without using medications, free from symptoms including cough, and have had two negative sputum tests, CDC says you can be released from isolation.

If you’re around someone who is sick, CDC’s advice is the same: help the patient with basic needs to allow him or her to stay home, like groceries; monitor his symptoms, and if he’s getting sicker call his doctor; and wear a facemask and gloves when you interact or do laundry.

For businesses, CDC has similar interim guidance:

1. Encourage sick employees to stay home.

2. Separate and send home sick or coughing employees right away.

3. Encourage good hand hygiene and cough/sneeze etiquette.

4. Clean surfaces often.

5. Check CDC Traveler’s Health Notices before traveling.

And for heaven’s sake, if you haven’t already had a vaccination against influenza, get one now. It is not too late. You are still far, far more likely to get sick or die from influenza than from COVID-19; influenza causes between 12,000 and 61,000 deaths per year in the United States, yet we can’t get much more than about 50% of people to get immunized in any given year.

The biosimilars are coming! (and that’s a good thing)

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Most drugs on the market are made the same way you made new compounds in chemistry lab in high school or college: by putting molecules or elements together in a solution and adjusting the temperature, pressure, pH, and other inputs to encourage the elements to combine in a specific way. So if an enterprising high-schooler were to discover a way to produce pure, uncontaminated aspirin in her garage, we could be confident that it would have the same effect as aspirin produced by Bayer.

And generics—unbranded versions of name-brand drugs—really do work to drive down the cost of medications. A 2017 study in the New England Journal of Medicine found that for a drug with a single manufacturer, generic and brand-name prices were roughly the same. But for a drug with three manufacturers, the generic price was only 60% of the brand-name price. So it’s no surprise that 90 percent of drugs used in America are generic.

But newer drugs—and some old ones like insulin—are not synthesized from scratch. Because of their complexity, we have to trick bacteria into making them—as with insulins—or we have to isolate them from living organisms where they naturally occur. We call such large-molecule drugs “biologics,” and instead of calling copies “generics,” we call copies of these drugs “biosimilars.” (As a side note, the first bacteria-produced “recombinant” human insulin ever to be given to a human was injected right here in Wichita by Dr. Richard Guthrie.)

When we make a biosimilar drug to match a biologic drug, the new drug is not necessarily atom-for-atom identical to the brand-name drug. The FDA allows the new drug to be slightly different as long as “no clinically meaningful differences” are noted between the original drug and the biosimilar drug in terms of safety, purity, or potency. This obviously requires more study than what would be required for our garage-produced aspirin. This means a lot of work, much of it in human subjects. Because of this difference, biologics have long operated under a different set of rules than “small-molecule” drugs. Whereas old-fashioned drugs are granted a 20 year patent from the date of application, after which it is relatively straightforward for another company to start producing a generic version, biologics are subject to a kind of natural immunity to generic competition that’s made worse by bad behavior on the part of the reference drugs’ manufacturers, misinformation campaigns, and close-but-not-quite-similar clinical outcomes.

The result has been that, while biosimilar drugs are common in western Europe, their use has been very limited in America. As such, Americans have long assumed that we paid far more for biologic drugs than our peer countries have.

A new study proves this out. Pharmacists and physicians from the University of Pittsburgh looked at the price of the only four biosimilars on the market by December 2018 (white blood cell-producing filgrastim [Neupogen®] and pegfilgrastim [Neulasta®], immunosuppressive drug infliximab [Remicade®], and insulin glargine [Lantus®]) over time. Their findings were striking. From 2007 through 2018 the cost of each of these medications went up by ~5-14% per year. At the time of introduction of a biosimilar (or two years ahead of time in the cases of glargine and infliximab) the cost of the medications immediately plummeted: −7.7% for filgrastim, −7.4% for pegfilgrastim, −13.6% for infliximab, and −23.5% for glargine.

The timing of this information is good. The dam on biosimilars is breaking. Dozens of biosimilar drugs have been approved in the last two years. So as you work with your pharmacy benefit manager to design your drug benefit, make sure that biosimilars are covered for your most expensive biologic agents. This may be harder than you think; abusive contracting practices are some of the obstacles biosimilars face in getting into wide use. However, the benefit to your bottom line will be substantial if you’re able to successfully integrate biosimilars into your pharmacy benefit.

Is 98.6 a lie?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics—but rarely hotter than today’s topic—that might affect employers or employees. This is a reprint of a blog post from KBGH:

If I were to ask a grade-schooler what a normal blood pressure is, I doubt he could tell me 120/80 mmHg. Nor could he tell me that a normal pulse is somewhere between 60 and 100 beats per minute, nor could he tell me that a normal body mass index is less than 25.0 kg/m2. But if I asked that same kid what a normal body temperature is, I bet he would blurt out “ninety-eight point six” before I could even finish the question. It’s printed into our brains, like “1776” or “three strikes.” That number—98.6—comes from an 1851 study by Carl Reinhold Wunderlich, a German physician who studied over a million temperature readings in over 25,000 patients to settle on 37° Celsius (98.6° Farenheit) as the “normal” body temperature, and 38°C (100.4°F) as a fever.

But the thermometer was still a fairly primitive technology in 1851. Daniel Farenheit had only invented his version in 1717, and by the time of Wunderlich’s study thermometers were still mostly found in academic centers. It took a solid twenty minutes to get a reliable reading. Not only that, but Wunderlich was studying a population that was simply sicker on average than modern people are. His patients, even those who reported good health, were more likely to have elevated body temperatures due to inflammation, bad teeth, or smoldering infections with tuberculosis or other horrifying diseases. And nobody had air conditioning.

So in the modern era, when thermometers are ubiquitous and their technology mundane, maybe it should not surprise us that the dogma of 98.6 is now in doubt.

As infectious disease physician Richard T. Ellison III writes in the New England Journal of Medicine Journal Watch (paywall), more recent studies show an average temperature of 97.9°F (36.6°C). But even that number is not rock-solid. Our body temperatures appear to change with age. To reach this conclusion, researchers looked at almost 700,000 temperature measurements from three sources: Union Army Civil War veterans from 1862 to 1930, National Health and Nutrition Examination Survey I (NHANES I) subjects from 1971–1975, and the Stanford Translational Research Integrated Database (STRIDE) cohort from 2007–2017. They found that across all three studies, body temperature progressively decreased with age, equivalent to -0.003°C to -0.0043°C (-0.005°F to -0.0077°F) per year. This means that a 10-year old with a body temperature of 97.9°F could be expected to have a body temperature of only 97.6°F—a full degree Farenheit lower than our old standard!—by the time she is seventy.

Not only did the new analysis of these old studies show that body temperature declines with age, it showed that body temperatures have declined with time. That is, temperatures recorded in the 1970s were lower than in the 1860s through 1930s, and temperatures recorded from 2007 through 2017 were lower than those in the 1970s. Again, this is probably because of reduced inflammation as infectious diseases became less common and because of the gradual adoption of air conditioning. If your mind isn’t already swimming, the study also found that body temperatures change with the time of day, the body weight of the patient, and even with race and sex.

Does this mean that your doctor’s office is lying to you when they tell you your body temperature? Are the infrared thermometers being used in airports to detect people infected with corona virus a fiction? Your answer depends on what we are trying to detect with the elevated temperature. Our old friend 98.6°F does now appear to be a figment of our collective nostalgia. But the Centers for Disease Control and the World Health Organization, who both are most interested in detecting potentially sick people early in their disease, still stick to a fever definition of 38°C (100.4°F). Some have argued that this number should be lowered to 99.9°F or even 99.5°F to increase the sensitivity of finding sick people. The Infectious Disease Society of America, whose emphasis is more on the care of ill patients in critical care and hospital settings, uses the same definition of 38°C (100.4°F), though, albeit with the caveat that the temperature of 100.4°F must be maintained for at least an hour, or the patient must have a single value over 101.0°F.

All this is to say that nothing in medicine is simple. Humans are complex creatures living in a dynamic environment, and as much as we like to define simple, neat cutoffs for “abnormal,” sometimes it just isn’t possible. So the next time your doctor’s office tells you that your body temperature is “normal,” take all this into account. Is it normal in the Wunderlich sense, in that it’s near 98.6°F? Or is it normal in the context of the A/C in her office, your age, your sex, your race, your living in the 2020s, and the state of your teeth?

Wait…Can you really modify your hospital Consent and Financial Agreement?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Dr. Marty Makary, general surgeon at Johns Hopkins who is more famous for his research on health costs and value, tells a riveting story of hospital billing (no, really!) in his book The Price We Pay: What Broke American Health Care–and How to Fix It (pages 167-170). A friend named Dina becomes ill while visiting Marty. When the two of them arrive at the emergency room, she is informed that the ER is “out of network” for her insurance. After some salty language on both sides, both sides agree she can be treated in the ER anyway. But prior to treatment Dina (with Marty’s help) asks for a physical copy of the hospital’s Consent and Financial Agreement form (Dr. Makary calls it the “battlefield consent form”), rather than automatically signing the form on the iPad that is brought to the room. Dina crosses out the clause on the paper agreement that states she would “sign away her financial life” (Dr. Makary’s words) before seeing any bill.

Dina has a minor surgical procedure, recovers, and eventually receives a $60,000 out-of-network bill. Marty shows her what her insurance would have paid had the hospital been in-network using Healthcarebluebook.com: about $12,000, or one-fifth the out-of-network bill. After getting Dina’s consent and requesting an itemized bill, Marty calls the hospital and offers $12,000 to settle the bill, which is refused. He explains to the hospital that Dina has no contractual obligation to pay because she struck out the clause in the contract saying she’d pay whatever they charged. Marty adds that legally the hospital is prohibited from using collection agencies to hurt her credit if she does not pay. The hospital director immediately offers to settle for $30,000, then $25,000, then $19,000.

Marty sticks to his original offer of $12,000, and the bill eventually gets sent to collections. When the collections agency calls, Dina asks them to send her a copy of the Consent and Financial Agreement, the form on which she’d deleted the section indicating her obligation to pay. The collection agency never calls back, and Dina eventually makes a $5,000 donation to the hospital’s fundraising drive, earning a plaque on the wall.

This is, shall we say, a novel way to deal with surprise medical bills. But it has some high-profile proponents. Al Lewis, Harvard-trained attorney and famous skeptic of worksite wellness, told Dr. Makary’s story on his blog. He went so far as to suggest making a card for your employees to carry and has even produced a template. He suggests the card say something to the effect of, “I consent to appropriate treatment and (including applicable insurance payments) to be responsible for reasonable charges, up to 2 times the Medicare rate.”

Needless to say, one party’s idea of “reasonable” can differ radically from another’s. Al says that reasonable charges can be “settled by binding arbitration using the New York law as a model. That law, based on Major League Baseball binding arbitration rules, is well-accepted and has generally been successful at curbing abuses.” [Disclosure: KBGH has a financial relationship with Quizzify not related to medical billing, but rather for health literacy training]

So. Is this a real strategy that at-risk patients could use? It seems under-handed. But some (most) would say that the entire system of surprise out-of-network payments in health care is under-handed, especially when the agreements are, as some have argued, signed under duress. Al Lewis’s website deftly says “Legally, we can’t guarantee this will work. But we know the alternative—signing whatever they put in front of you—carries the risk of much higher bills, and more chance of inappropriate treatment.”

And that’s what we say, too. The Kansas Business Group on Health is not endorsing this practice. We simply want our members to be aware of its growing use by frustrated, scared patients.

Want more productive employees? Give them cleaner air

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

In late 2015 a massive gas leak broke loose in the Aliso Canyon oilfield near Los Angeles. The gas leak turned out to be a bit of a false alarm from the Los Angeles Unified School District’s perspective, but due to parental concerns the School District and the Southern California Gas company installed improved, high-performance air filters in every classroom, office, and common area in the eighteen schools within five miles of the gas leak at the end of January 2016.

Ironically, by the time the filters were installed three months after detection of the gas leak, the excess methane from the gas well was into the upper atmosphere and not directly affecting the health of the students. The quality of the air in the Porter Ranch area of the San Fernando Valley where the gas leak happened is quite good by California standards, and the air inside the schools met criteria set forth by the Clean Indoor Air Act.

But an enterprising economist took advantage of the new air filters—which reduced whatever pollution was present in the schools by roughly 90%–to conduct an observational study we call a “natural experiment.” He compared standardized test scores before and the two years after the air filter installation in schools that got air filters to scores in schools that were just outside the five-mile radius and which did not get air filters. He controlled for all the usual “confounders” that investigators try to rule out as hidden causes, like demographics and ZIP code that might indicate exposure to different learning environments or levels of air pollution at home.

They’re equivalent to the effect of decreasing class size by a third or switching students to charter schools.

In following the students over time he found that math scores went up by 0.20 standard deviations and English scores went up by 0.18 standard deviations. The effect was durable over time. That is, the benefit of the cleaner air didn’t go away. These numbers are huge. They’re equivalent to the effect of decreasing class size by a third or switching students to charter schools. And at roughly $1,000 per classroom per year, new air filters are a tiny fraction of the cost of either of those interventions.

What does this have to do with your workplace? The effect does not seem to be limited to schools. As Matthew Iglesias points out, similar results have been seen in several other settings, including farm workers, baseball umpires, and packing plant workers.

At the time of the writing of this post I cannot find real-time numbers for Wichita’s level of 2.5 micrometer air pollution (PM2.5), the most important number for health. But the air in the San Fernando Valley from this study compares roughly to that in Topeka and Kansas City, KS, both of which have shown a PM2.5 density of roughly 35-65 mcg/m3 in the last 24 hours, indicating that workers in urban Kansas settings may benefit just as much as school kids in Los Angeles.

Others have tried unsuccessfully, due to ongoing litigation, to determine exactly which filters were installed in the schools. But a press release indicates that the filters were likely Blueair’s 503, 550E, 555EB, 603, 650E, and Pro XL models, which all use “electrostatic and mechanical filtration to remove 99.97% of harmful particles from the air, down to 0.1 microns in size.” So if you’re considering this step in your workplace, these seem to be the appropriate specifications to aim for. You’ll make your employees healthier, and you may find you make them more productive.

For First-Rate Care, Seek Second Opinions

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Imagine that tomorrow as you brush your teeth you notice a small lump in your neck. You see your doctor, who diagnoses a nodule on your thyroid gland. She sends you immediately to a surgeon who tells you that you need to have your thyroid gland removed. A thyroidectomy is a big operation, and this is all moving so fast, and you’ve crossed that gauzy boundary from “person” to “patient” in a matter of days. What do you do?

Many of us would seek a second opinion, one of the most time-honored rituals in medicine. A patient, unsure of the accuracy of a diagnosis or the veracity of a treatment plan seeks a second physician to confirm or refute the findings or recommendations of the first physician.

Do second opinions work?

Second opinions—whether they’re a matter of a second radiologist or pathologist reviewing images or slides or an endocrinologist reviewing the case above—have a demonstrable impact on the care delivered to a patient. A commonly cited number is that 30 percent of patients can expect their diagnosis or treatment plan to change with a second opinion, but I’m unable to find the original source of that number. A 2014 systematic review in Mayo Clinic Proceedings, though, found that between 10 and 62 percent of second opinions yield a “major change in the diagnosis, treatment, or prognosis” of a patient.

So it is no surprise that surveys have found that nearly one in five patients who saw a doctor in the past year sought a second opinion, and more than half of patients who are cancer survivors sought a second opinion at some point during their cancer care.

It just makes financial sense: an insurer—or you, the employer, if you’re self-insured—would rather not pay for a $5,000 thyroidectomy when a second consultation and thyroid ultrasound, which cumulatively cost only a few hundred dollars and which likely leaves your neck unscarred, would suffice. 

Second opinions appear to help the mental health of patients, not just the accuracy of their diagnoses. An Australian study found that the opinion of a second oncologist gave more than half of cancer patients greater confidence in their diagnosis and treatment plan. A study of neurology patients found that patients were most satisfied with the amount of information and emotional support provided by the neurologist offering the second opinion.

Do insurance providers pay for them?

The majority of insurance plans cover second opinions. It just makes financial sense: an insurer—or you, the employer, if you’re self-insured—would rather not pay for a $5,000 thyroidectomy when a second consultation and thyroid ultrasound, which cumulatively cost only a few hundred dollars and which likely leaves your neck unscarred, would suffice.

Medicare covers second opinions if “a doctor recommends that you have surgery or a major diagnostic or therapeutic procedure,” and if the opinions of the first two physicians differ, will cover a third opinion. And many state Medicaid programs have or have had mandatory “Second Surgical Opinion Programs,” which require patients to obtain a second opinion before surgery as a condition of their coverage.

In Kansas, Medicaid managed care providers Sunflower, United Healthcare, and Aetna all cover second opinions. However, some managed care plans and HMOs do not cover second opinions. Some states, including California and New York, have laws that guarantee HMO members the right to a second opinion. Kansas, to our knowledge, does not have such a law.

Some self-insured employers such as Wal-Mart have taken the leap to insist that their employees go to “Centers of Excellence” for all high-risk procedures like spine surgery and bariatric surgery. The purpose of these trips is not just to get the procedure done; Wal-Mart and others want to know if the procedure is necessary in the first place.

What can employers do to help?

Startups have emerged to help with this process. The telemedicine company 2nd.md advertises heavily on the internet, but we are unaware of the quality of their care or their costs. Docpanel.com provides radiology-specific second opinions. The company best known to me is Grand Rounds, a company which now serves primarily in care coordination, but whose focus was once the connection of patients with specialists to confirm and explain high-burden diagnoses. [disclosure: I once interviewed for a contract position at Grand Rounds, but I have no relationship with the company]

But there is likely no need to go directly to a new vendor. Check with your insurance provider or third-party administrator to confirm that your employees have access to second opinions, and educate your employees about their options. The Patient Advocate Foundation has a brief handout that may be helpful. A delicate balance must be struck: it is usually a mistake to interfere in the relationship between a patient and a trusted practitioner (see our prior post on HyVee and stem cells). It is not a mistake in the slightest, though, to give patients the opportunity to seek out additional opinions in case of uncertain diagnoses or complex treatment plans. The first doctor’s feelings may be bruised in some cases; I’ve been on both ends of that relationship. That’s okay. Those hurt feelings may be the cost of doing business for getting a more accurate diagnosis, a more up-to-date therapy plan, or a more realistic prognosis. And those can potentially have real health benefits to your employees and real dollars-and-cents benefits to your bottom line.

Should Specialists Be Paid Fee-For-Service?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

How did the fee-for-service model originate?

Once upon a time, legends say, if you could not afford to pay your doctor cash, you could pay him with commodities like grain, chickens, Brussels sprouts, or milk. Whatever goods or currency were exchanged, we called this model “fee for service.” For decades it has been the dominant model in American medicine, and it defines the patient-doctor interaction as fundamentally transactional: the doctor gets something in return for the advice/diagnostics/prescription/procedure she provides you. So historically the way to increase your income as a doctor was to simply increase volume: the more patients you saw, the more money you made.

Quality was generally measured, if at all, by the likelihood of a patient returning to see the doctor. In cases of possible patient harm, doctors tried to hold one another accountable by reviewing peers’ cases and participating in meetings such as “Morbidity and Mortality” (M & M) conferences to catch obvious errors. Working within a model that so rewarded quantity of care over quality of care, it comes as no surprise that doctors may miss half of indicated care, and that somewhere between a fifth and a third of the care that doctors provide may not be indicated at all.

A move towards quality over quantity

We are gradually moving away from “fee for service.” With the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), a rare bipartisan bill, doctors can earn significant bonuses or incur significant penalties from Medicare by meeting or failing to meet certain benchmarks of quality of care.

We’ve long experimented with capitated Medicare Advantage plans that seek to incentivize private insurers to find cost savings and quality opportunities. And around half of payments from private insurers are now thought to be tied to some degree of value-based payment, or “pay for performance.” The goal of this change is to incentivize not just quantity of care, but quality as well.

We’ve even seen a modest rise in doctors operating outside the insurance system in so-called “Direct Primary Care” practices. These doctors ask for a modest recurring fee—usually $50-$100 per month—in exchange for unlimited access, with the underlying assumption that by limiting their patient panels (in part by eliminating administrative overhead), quality will inherently rise.

Should specialists be paid fee-for-service?

It was in this line of thinking that investigators recently undertook an examination of costs associated with specialty care in Canada. Canadian specialist physicians seeing patients with diabetes and chronic kidney disease can be paid under an American-style fee for service system, or they can be salaried with potential benefits tied to the quality of care they provide. *Disclosure: Justin Moore, MD, is a diabetes specialist by training*

Researchers compared the costs and quality of care associated with each one, and the results were surprising: diabetic patients were 12% more likely to have a hospital admission or an emergency department visit for a diabetes-related condition if they were seen by a salaried physician rather than a fee-for-service physician, although the difference was not quite statistically significant (1.63 admissions or visits per 1000 patient-days in salaried docs vs 1.47 in fee-for-service docs).

A lazy interpretation of this might lead you to believe that the salaried physicians, having their paycheck guaranteed, simply didn’t see the patients in clinic frequently enough. But the researchers actually found the opposite: patients seen by salaried docs had 13% higher rates of follow-up visits and procedures (and their associated costs) than the fee-for-service docs, although again, the numbers didn’t quite reach statistical significance (1.74 visits per 1000 patient-days in the salaried docs vs 1.54 visits in the fee-for-service docs).

From this data–admittedly in a Canadian system that differs in many important ways from our own–editorialists concluded that “It would appear that salary-based payment does not have the same association with reduced quantity of care provided for specialist physicians who treat chronic diseases as it does in some primary care settings.”

The lesson to be taken from this study seems to be, as it so often is, that we should proceed with caution. While primary care may be in some ways best delivered in a salaried model, for now a fee-for-service payment model may remain preferable in specialty care. When designing your benefits, or when thinking of innovative ways to contain costs in your high-utilizing employees, this might be worth keeping in mind.

Is “Social Media Hygiene” The Next Frontier In Workplace Wellness?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Social media takes up an inordinate amount of our time. A recent report by Activate Consulting found that, when multitasking with consumer internet and media activities are accounted for, the new “normal” day is 31.5 hours:

The amount of time we spend on these platforms is not likely to go down. According to that same Activate Consulting report, the number of social media networks an average person participates in is projected to almost double in the next four years, from 5.8 to 10.2 per user.

And in spite of snarky comments—many of them, yes, on social media—about the habits of millennials or Generation Z, it is Gen X workers in their forties and fifties who are the heaviest social media users, at almost seven hours per week, rising about 17 minutes per year.

All this virtual communication may be bad for us. Studies that are now several years old show that the more Facebook you use, the worse you are likely to feel. As anyone who has ever been accidentally pulled into an email argument that could have been solved with a single two-minute face-to-face conversation can tell you, in email and on social media in particular, we may abandon social norms in response to feedback from other users, since the algorithms that drive the platforms reward content that is highly emotionally charged. Tweets that use the greatest amount of moral-emotional language are the most likely to be retweeted or liked. Facebook posts that display not only disagreement, but indignant disagreement, are more likely to be liked or shared.

Why is this?

Researchers believe that virtual conversations lack the “advanced analogue cues” that in-person, video, or phone conversations have. Without clues like body language, tone of voice, and facial expressions, we have a hard time discerning the true intent or meaning behind innocuous statements.

What can be done?

A randomized trial by Stanford investigators showed that people who were paid to deactivate their Facebook accounts—as compared to people paid to continue their usual activity—were happier and reported increased well-being, decreased political polarization, and increased time spent with friends and family. And, presumably because of the drug-like effect of social media platforms, people who were paid to discontinue Facebook experienced apprehension at re-starting, just as a former smoker may be nervous about going outside around other smokers at break time.

But because of the strong network effect of social media, asking employees to cancel their accounts is probably unrealistic. Instead, we should look for healthier ways to use the platforms. After sifting through the mainstream medical literature, here are some of our tips:

1. Encourage your employees to use social media as a bridge to in-person connection and real experiences, preferably outdoors and definitely away from screens. Using social media this way to connect to other people you’ve lost touch with may even have profound professional benefits.

2. Create this bridge to in-person connection by changing the way you approach social media. Do not seek “likes.” Do not like other people’s posts, even though that may seem rude at first. Instead of passively scrolling through your Twitter, Instagram, or Facebook feed and hitting the “like” button, intentionally reach out to people. One study found that even one week of increased composed, directed social media posts to friends and family increased happiness. Another study compared this strategy to simply “liking” or sharing posts on Facebook. People who received targeted, composed messages from friends or family felt better; those who simply got “likes,” status updates, or shared posts experienced no change.

3. Encourage employees to enforce “sacred spaces” where no devices are used, in order to reclaim conversation and non-verbal advanced analog cues. At home this may mean the kitchen, the dining room, and the bedroom, since even the presence of a device on the table may alter conversations, and looking at bright screens before bed can disrupt sleep (to say nothing of sex). As technology researcher Sherri Turkle famously said, “The greatest favor you can do to your sister, mother, lover, professor, student, is put away your phone.”

4. While you’re at it, encourage employees to delete all social media apps from their phones and use social media only on a device they have to seek out, like a desktop computer. If that seems too severe a step, encourage them to go to their phone’s settings and kill notifications from all social media.

Are there strategies you’ve tried, either at home or in the workplace?  We’d love to hear them!

Your Doctor Is Your Real Financial Planner

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

The last time you spoke to your financial planner, I suspect the first question she asked you was some version of “Where would you like to be in ten years?” Or twenty, or thirty. Maybe you told her that you wanted to have your house paid off, or to be out of debt, or to be retired, or to have enough savings to send your kids to college.

The last time you went to the doctor, though, I’m willing to bet your conversation was more…retrospective. Medical students are taught to use open-ended questions to initiate a visit, so he probably asked something like “What brings you in today?” And if you’re like most people your answer wasn’t “I want to make sure I’m happier and healthier ten years from now than I am today.” Instead you probably led with whatever complaint was bothering you that day: a rash, a sore joint, shortness of breath. This doesn’t mean you were doing it wrong. Doctors exist to relieve suffering, after all. The Hippocratic Oath states in part that “I will apply, for the benefit of the sick, all measures which are required.”

``Where would you like to be in ten years?`` isn't just a question that should come from your financial planner. It should come from your doctor, too.

But if you’ll allow the slight stretching of a metaphor, what if your interactions with your health care professional sounded more like your conversations with your financial professional? Because the person that is most in charge of your financial future may not be your financial advisor. It’s more likely your doctor. Here are some hard truths at the intersection of medicine and finance:

• Illness and injury are the number one cause of bankruptcy in the United States, contributing to almost two-thirds of cases.

• The risk of illness goes up as income falls, and more than two-thirds of Americans with incomes below $40,000 say they could not scrape together $400 in an emergency.

• Medical debt is the number one reason to get a call from a collection agency, and a sixth of Americans have an unpaid medical bill on a credit card.

• One-third of cancer patients have to ask friends or family for money to finance their treatments.

• Health insurance does not necessarily protect against catastrophic loss of savings if you get sick: the ACA, for all its good, did little to reduce medical bankruptcies.

• And the expense of medical treatment may actually make outcomes worse. Filing for bankruptcy is associated with a 79% increase in the risk of death in patients with cancer.

So “Where would you like to be in ten years?” isn’t just a question that should come from your financial planner. It should come from your doctor, too.

What if we applied a financial planning rubric to health and wellness? Once the shock wore off from your doctor asking you where you wanted to be in ten years, what would you say? If you were diabetic, you might first answer that you wanted to avoid the complications of diabetes: you wanted to keep your vision, you wanted to keep all your toes, and you wanted to avoid having to go on dialysis for kidney failure. These are all perfectly good answers, but they suffer from low expectations. They’re a little like telling your financial advisor that you want to avoid bankruptcy and avoid having the bank repossess your house.

What if you were more ambitious? What if you said that, in addition to all those, you wanted to run a 5k with your granddaughter, or dance at your son’s wedding without being out of breath? What if you said you wanted to be able to carry your infant grandson up and down stairs without fearing a fall? Fortunately, just as the best financial strategies tend to be simple, the best health strategies are simple, too. Just as the financial advisor would hopefully come up with a plan to start putting money away, your doctor would work with you to make a shared decision on how to get to the last dance at that wedding a few years from now. The financial advisor might tell you to maximize deposits into tax-deferred annuities, while the doc might work with you to start scheduling “deposits” of physical activity. Just as your financial advisor might tell you to knock off the daily trips to Starbucks, your doc might tell you to knock off the bright screens in your eyes for an hour or two before bed (and, hopefully, would tell you to take it easy on the #PSL).

The next time you have a meeting with employees about their health benefits, ask them what they think of this philosophy. After all, the Hippocratic Oath also says, “I will prevent disease whenever I can, for prevention is preferable to cure.” And more powerfully, “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability.”  Also remember that as an employer, you have the opportunity to help your employees stay healthy by offering real food at work instead of processed foods, providing a wellness program in a box, or by helping to shape the environment in which your employees live.

A Big Reason Why American Health Care is so Expensive

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

How much health care gets wasted?

Recently, researchers from insurance company Humana and the University of Pittsburgh published a review of sources of and current levels of waste in the US health care system. They estimated that waste in the current system amounts to roughly a quarter of all health care spending: $760 billion to $935 billion annually. This waste was accounted for in six “domains”:

1. Failure of care delivery. This is waste that comes from the lack of adoption of best care practices, like patient safety initiatives.

2. Failure of care coordination. Think of patients being re-admitted to the hospital because of a gap in the system that held up their home health care, or unnecessary emergency department visits.

3. Overtreatment or low-value care. If you’ve ever received an antibiotic for what was almost definitely a viral upper respiratory tract infection, this applies to you. Somewhere between one fifth and one third of all health care delivered does nothing to improve the health of the recipient.

4. Pricing failure. Because of the perversity of the US health care system, with its lack of transparency and effective markets, we simply pay more for everything in medicine—from doctors to nurses to MRI scans—than people pay in other countries.

5. Fraud and abuse.

6. Administrative complexity. This is the result of inefficient and misguided rules. As a physician, the example of this that is closest to mind is the paperwork that accompanies prior authorization requests, which is different for almost every insurance company. It takes a lot of manpower to navigate the complexities of a system in which dozens of insurance policies within a practice all have different rules and procedures for payment.

Which of these domains was the biggest offender? Which one is responsible for the biggest chunk of that $760-935 billion annual bill for waste?

Administrative complexity

And it wasn’t particularly close: administrative complexity was thought to account for about $265 billion of waste in and of itself. Number two was pricing failure at $240 billion, and in third place was failure of care delivery at $165 billion.

The authors of the review helpfully scoured the medical literature looking for solutions and potential savings from each of the domains, and they found some interesting nuggets. Integration of behavioral and physical health, for example, was thought to have the potential for $31.5-58.1 billion dollars in savings annually in reducing failures of care delivery. Insurer-based pricing interventions, such as the State of Maryland’s All-Payer Model, were thought to be worth $31.4-41.2 billion annually.

But, you must be thinking, what about that juicy slice of savings from administrative complexity, the biggest cause of medical waste of all? If you scroll through the article to that row, you see this:

What does this mean, “Not Applicable”? This means that, in a thorough review of the existing medical literature, the authors of this review could not find a single example of a high-quality study looking at the effect of an intervention to decrease administrative complexity.

I understand if you need to pause reading in order to flip your desk.

Now understand: this does not imply that no efforts are being made to reduce complexity. The American College of Physicians, one of the largest professional organizations in medicine, has championed a reduction in administrative tasks in health care for several years now. Other organizations have advocated for using artificial intelligence to approve or deny prior authorization requests on first pass without the doctor even needing to submit a form.

But to date, none of these efforts has produced a high-quality paper showing compelling cost reduction. And most of these efforts have taken place in the patient care milieu. We’re curious if any employers have encountered or experimented with ways to reduce administrative waste. If you have a good story, please share it with us.