Center your care on a PCP

If you’ve been to a Kansas Business Group on Health meeting in the last couple of years, you know already that American health care is beset by “low-value” care. We spend inordinate amounts of money doing “executive physicals” that offer almost no benefit. We pay for expensive back surgeries that are sometimes no better, and often worse, than physical therapy. We fail to substitute cheaper generic or bioequivalent drugs for more expensive drugs in spite of evidence that the less expensive drugs work just as well. All these low-value services account for between $75 billion and $100 billion in annual U.S. health care spending. In a $3.5 trillion health care economy, that seems like a rounding error. But it’s a big number! $100 billion is an extra $300 per year on health care per American.

 What do most of these sins against our collective pocketbooks have in common? They mostly happen in specialist offices, not at the hands of primary care providers (PCPs). We’ve extolled the virtues of primary care often here at KBGH (although not necessarily the “annual check-up”). We’ve long known that primary care is the most cost-effective place to get your care. This was reinforced just last week in a new study looking at the sources of low value care.

 The investigators analyzed Medicare Part B claims from a 20% random sample of beneficiaries enrolled between 2007 and 2014. They excluded anyone in a given year who could not be linked to a PCP in the data, and they defined “low value services” as 31 services by various clinical guidelines:

Annals of Internal Medicine

When they looked at who ordered the low-value services, they found that PCPs accounted for a tiny fraction, 14.5%. But since many of the services you see above are not routinely done by PCPs, they looked further and found another 19.8% were performed or ordered by doctors to whom the patient was referred by the PCP, and another 5.6% was done by physicians to whom the patient had been referred by the PCP in the past.

The remaining 60.2% of low-value spending was “for services performed or ordered by a physician to whom the PCP never referred the beneficiary.” That is, almost two-thirds of the low-value spending was by physicians the PCP likely didn’t even know the patient was seeing! It’s possible the patient Googled “chest pain,” or answered a billboard for another service. The data doesn’t say.

This hurts me as a specialist physician. I wonder how many of the 31 low-value care items I’ve over-utilized in my career. Several of the items on the list, from certain thyroid tests to tests of vitamin D and parathyroid hormone, were right down my alley as an endocrine specialist. If it matters, the worst-offending non-primary care specialties for low-value spending were cardiology (27.3%), ambulatory surgical centers (8.9%), internal medicine (7.0%), orthopedic surgery (4.9%), and gastroenterology (4.8%). No endocrinology on that list. Whew!

All this isn’t to say that people don’t benefit from seeing more than one doctor. We’ve reviewed the myriad benefits of second opinions in past posts. But I do think that it reinforces the need for all of us to have a primary care physician directing our care. More than 84 percent of Americans have had contact with a health care professional in the past year, but only about half of those visits were to primary care offices, and only 75% of Americans have a primary care physician, a number that is declining over time.

None of us want to be accused of erecting barriers to good care. But I believe that adopting policies that encourage the use of primary care over, or ahead of, other services will be good for both the health of your employees and the bottom line of your company.

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 Robots Are Coming, Part 2

Last week we tiptoed up to some of the problems that increasing automation in health care may uncover. This week let’s talk briefly about proposed FDA action to address them.

FDA approvals of automated and artificially intelligent health care platforms have been accelerating, and in the flurry of activity that accompanies all Presidential transfers of power, the outgoing Trump administration had controversially proposed waiving much of the regulatory oversight of medical artificial intelligence tools. With a new administration in place, the original WhiteHouse.gov link I’d originally included in this post no longer exists, and the FDA has pivoted hard in the other direction, releasing a new five-part action plan laying out its efforts to regulate products that incorporate “Artificial Intelligence/Machine Learning (AI/ML)-Based Software as a Medical Device (SaMD).” Let’s go through them one at a time:

1. One of the big challenges in regulating artificial intelligence is that an AI program is, by definition, not a static product the way a drug or a physical device is. Once the FDA approves a drug, we know that we’ll be dispensed the same drug ten years from now that we’ll get today.

   But artificial intelligence learns over time. So as the dataset that a software platform “learns from” grows, the interpretation of that data by the program may change. We call this process of gradual improvement through multiple steps an “iterative” process. So the FDA has expressed an expectation that manufacturers and the FDA be able to transparently monitor performance through this iterative process in hopes of maximizing safety while allowing the gradual change and improvement of the platform.

2. When you go to an ATM you have the expectation that you can put any bank card into the ATM and check your bank balance, even if your ATM card was issued from a different bank than the machine. When you put a CD into a CD player, you know it will play, regardless of whether the machine is a Sony or a Panasonic. But this isn’t true of every device. Electronic health records are notoriously finicky about what data they can exchange, for example. So the FDA has asked manufacturers to use “Good Machine Learning Practice (GMLP)” to “encourage harmonization of the development of programs through consensus standards efforts.” These include harmonization of data management, feature extraction, training, interpretability, evaluation, security, and documentation standards.

3. Many artificial intelligence/machine learning platforms are trained on existing datasets. The patients who contributed their data were real, but the data is now so divorced from any living creature that it is easy to think of it in hard, mathematical terms rather than as attached to a real, living person who had thoughts, feelings, emotions, and parents. So the FDA has asked that manufacturers take a “patient centered” approach to how these technologies interact with people. What this precisely means is still under discussion, but broadly it seems to mean transparency to users (that is, you’ll know when your data is being used, and you’ll know when a machine is helping make decisions in your care), usability (meaning the operation of the software won’t be a mystery), equity (everyone gets a fair shake at representation within the software’s training dataset, for example), trust, and accountability.

4. The machines we build carry our biases. You may have read about bias in software used in sentencing for convicted criminals. The software was meant to reduce bias in sentencing, but since it was trained on a dataset that displayed the bias of past sentencing, the software itself was biased against certain groups of people. Or you may have seen news of this in facial recognition algorithms, which only become adept at recognizing faces when intentionally exposed to diverse faces. A good example of a similar phenomenon in medicine is a tool developed to predict knee pain in patients with osteoarthritis. A commonly used tool built on data from mostly white, British patients was found to be less accurate than a similar tool that was trained on data that included more Black and low-income patients. The new, more diversely trained model roughly doubled the likelihood that an evaluated Black patient would be considered eligible for surgery. With this in mind, the FDA has pledged to “evaluate and address algorithmic bias and to promote algorithm robustness,” specifically as it relates to race, ethnicity, and socioeconomic status, to avoid biases present in the health care system from seeping into algorithms.

5. Since many currently commercially available AI and machine learning products were approved based on their performance with historical datasets, not based on prospective testing on real patients the way a drug or another device would have historically been, we don’t know for certain how they’ll do in the real, nitty-gritty care of patients. But even with the traditional model of drug testing prior to approval, a need for post-approval testing is not unprecedented. Roughly a fifth of medications prescribed, for example, are used “off-label,” meaning they’re used for something other than the purpose for which the FDA originally approved them. Gabapentin, for example, is frequently used for pain relief, but it’s FDA approvals are only for seizure disorder and for a specific type of pain syndrome called “postherpetic neuralgia.” With this in mind, the FDA has pledged to monitor “Real-World Performance.” This not only allows the FDA to monitor the performance of the device in terms of accuracy of its recommendations, but it allows the FDA to monitor just exactly how the devices are being used. As far as I can tell, real-world performance data monitoring at this point is voluntary but encouraged. Depending on how well this voluntary system works, FDA intends to develop a framework for any mandatory prospective reporting in the future.

 Will any of this solidify public and physician trust in artificial intelligence? I don’t know. My hunch is that trust on the physician side will hinge more on the positive or negative effect of AI on clinics’ bottom line. And public trust of technology seems to depend more on convenience than on the good or ill intentions of the company. Few of us complain about Google, for example, because even though Google knows a lot about us it makes certain parts of our lives, like the composition of this blog post on Google Docs, better.

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 Robots Are Coming, Part 1

We are mostly techno-optimists here at KBGH. We have talked about the possibility of technology saving the aging primary care workforce by augmenting their skills in certain areas. But if you are a techno-pessimist, you might think more in terms of what automation or robots will do to certain jobs, the way factory automation has decreased the availability of jobs in manufacturing. (Or you may worry about safety because of bias in machines or a Tom Selleck-Runaway style robot rebellion. Great movie with Wichita native Kirstie Alley. I digress.)

My training is in endocrinology and metabolism, disorders of the finely tuned feedback loops of chemical messengers in the body. About half of most endocrinologists’ practices is the care of diabetes mellitus, a collection of metabolic defects that cause excess sugar to build up in the blood and cause blindness, kidney disease, and nerve damage, among other devastating problems. When I was in training in the mid-aughts, a big part of my day was spent managing insulin pumps, small pager-sized devices worn by some diabetic patients that deliver precise doses of insulin to meet their dietary and exercise patterns. My job was to observe blood glucose levels the patients took from fingersticks and coach patients on how to change their pump settings. For all their sophistication, insulin pumps were still pretty manual.

In the last few years, though, a new type of insulin pump has emerged. We call them “closed-loop” devices because, when paired with an implanted sensor that constantly tracks the patient’s blood sugar levels, the pumps can make adjustments to insulin infusion rates without the wearer even being involved. For now, the automation in the devices is mostly confined to rates of insulin infusion when the wearer is not eating or exercising. But pumps that can detect food intake and activity and make rapid adjustments are just around the corner. Insulin pumps will eventually use artificial intelligence, complex intelligence uninvolved with messy human emotionality or consciousness, to make adjustments in the background that are seemingly unrelated to our traditional understanding of diet, exercise, or adherence to therapy. Accidentally load your insulin pump with insulin that is slightly out of date and less potent than last week’s supply? The machine may detect it and adjust your rates of infusion to make up the difference. Have a family tragedy that increases your stress hormone levels, causing blood sugars to spike? The insulin pump’s “brain” may be able to detect this and bring your sugars back to normal without your input or recognition.

And this is just the tip of the iceberg in terms of medical technology. Already “decision support systems,” like the alert your doctor gets through her electronic health record to make sure you get your cancer screenings, show small, persistent improvements in overall care. And as we touched on in previous blog posts, robots have proved themselves to be superior to humans in a range of medical tasks, from finding diabetic eye disease to detecting bleeding in brains on CT scans.

All this will require a cultural shift. Often patients express frustration at having “only seen the PA” when they have gone to the doctor, in spite of ample evidence that physicians’ assistants and nurse practitioners provide excellent care, sometimes exceeding the quality of care of physicians in trials. Our culture currently places value on face-to-face time with the physician. And Americans are anxious about the potential safety of driverless cars in spite of the fact that human-driven cars currently kill more than 30,000 people a year. So how will we respond to robots guiding certain potentially high-risk parts of our care like insulin adjustment or detection of bleeding in radiology studies? Maybe we will give them the same brush-off we sometimes give PAs. Or maybe we will accept their input the way we have accepted advertising algorithms from Facebook and Google. It is completely possible that medical professionals will resent medical robots the way we resent automation for taking away factory jobs. To tiptoe into these ideas we will talk about a potential regulatory framework next week.

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.

Is your bedroom the new hospital?

In his book “Home Game: an Accidental Guide to Fatherhood,” author Michael Lewis tells the story of his infant son’s admission to the hospital for a lung infection with respiratory syncytial virus, commonly known as “RSV.” His son requires oxygen during his stay but gets no other treatment: no antibiotics, no steroids, no ventilator. Michael speculates that the only reason his kid was admitted was so that nurses and doctors could check on him daily in case he got worse and needed to be intubated. And so, feeling the burn of a lost night’s sleep for both himself and his son, Michael stages a minor protest to allow his son to rest. He meets every potential visitor to the room at the door and demands to know their purpose. Nurses are mostly let in. But if the visitor is a resident or medical student “checking in,” for example, he gives them an update on his son’s respiratory rate and oxygen level and shoos them away. After a couple days his son improves and is discharged home.

As of the writing of this blog post roughly 130,000 Americans are hospitalized with COVID-19, up from ~96,000 at the beginning of December, resulting in more than a third of America’s hospitals operating at at least 90 percent capacity. Some of those inpatients are like Michael Lewis’s son: they’ve been admitted because of frailty or a combination of risk factors (age, other diseases, etc.) that put them at higher risk of death, and the primary treatments they are receiving are oxygen and steroid medications that could theoretically be delivered at home.

Like telemedicine, our very idea of the purpose of hospitalization may be morphing under the pressure of a viral pandemic, prompting changes that have been smoldering for decades. CMS is exploring ways to increase hospital capacity during the COVID-19 surge. We can’t solve this problem by building new hospitals. That takes time (at least outside of China), and hospital beds are needed in relatively small numbers in the US (compared to places like Germany) when viral pandemics aren’t raging uncontrollably. CMS is instead encouraging hospitals to be more aggressive in deciding who can be cared for at home in a program they call, unimaginatively, the “Acute Hospital Care At Home” program, a waiver allowing qualifying health systems to provide hospital-level care at patients’ homes for more than 60 conditions, including common reasons for admission like asthma, congestive heart failure, and pneumonia. You can’t be “admitted” to your own bedroom via telemedicine; you have to be transferred from an in-person emergency department or traditional inpatient hospital bed after an in-person evaluation by a physician. And surgical care clearly needs to be done in the traditional setting, at least for now.

Some companies, having anticipated this need, are marketing equipment or even using artificial intelligence-based systems for monitoring “hospitalized” patients at home. And it seems to work. “Hospital at home” may be marginally better than traditional hospitalization: a study in the Annals of Internal Medicine showed that with one home hospital program, only 7% of patients had to be readmitted to the hospital within 30 days of discharge, compared to 23% of inpatients in traditional care, and the average cost of care of home was 38% lower than care in the hospital.

So the next time you’re on your way to the hospital (heaven forbid), be sure to keep your choice in the back of your mind before you hit the door: would you rather be cared for in the hospital, or would you rather convalesce in the comfort of your own bed?

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.

Is it time to re-think sick leave?

When I was a medical resident, saucy attending physicians, wanting to impress on us the importance of our work, said things like “If we’re not rounding with you, we better be rounding on you,” meaning that in order to justify missing hospital rounds we better be sick enough to need hospitalization ourselves. So it was no surprise that I once saw a residency classmate work through a night call shift with obvious symptoms of acute influenza.

In the COVID-19 era, working with patients through a febrile illness seems as dated as smoking indoors or driving without a seatbelt. But America remains one of the few developed countries that does not guarantee universal access to paid sick leave for all workers. Twenty-seven percent of all US employees and 17 percent of all US full-time employees cannot take paid sick leave. Congress tried to address this, albeit temporarily, with the Families First Coronavirus Response Act (FFCRA), which was passed on April 1, 2020 and expired on December 31, 2020. 

As a reminder, FFCRA said that employers with up to 500 employees must cover, with exceptions:

• Up to 80 hours paid sick leave at usual pay if the employee was quarantined and/or experiencing COVID-19 symptoms

• Up to 80 hours paid sick leave at two-thirds usual pay if the employee was caring for someone else in quarantine

• Up to 10 weeks of paid expanded family and medical leave at two-thirds usual pay if the employee was unable to work due to caring for a child whose school or child care provider was closed or unavailable for reasons related to COVID-19

About a quarter of US companies affected by the law used it in its lifespan; employers with 500 or more employees already overwhelmingly offer paid sick leave. FFCRA’s passage set up a “natural experiment” (we’ve talked about these before): in some states like Kansas without pre-existing laws around sick leave, workers gained the right to take paid sick leave. These were treated by researchers as the “treatment group.” Their change in COVID-19 rates were compared to changes in workers in twelve states and the District of Columbia who already had access to paid sick leave before FFCRA, the “control group.” Investigators were able to use baseline levels of infection in the few weeks before passage of the law as a baseline. 

The results? States where employees gained new access to paid sick leave had a “statistically significant decrease of approximately 400 fewer confirmed new cases per state per day relative to the pre-FFCRA period and to states that had already enacted sick pay mandates before enactment of the FFCRA.” The authors estimate that this translated into about one prevented case per day per 1,300 newly covered workers.

Given COVID-19’s roughly 2% mortality rate, 400 cases fewer per day could equals as many as eight lives per state per day saved by a simple administrative decision. This is completely in line with previous research showing that paid sick leave induces employees with contagious infections like influenza to take sick leave, thus reducing influenza activity during non-COVID-19 times.

Besides the obvious humanistic angle, is this cost effective? After all, COVID-19 hospitalizations are expensive. I tried to muddle through some math to see how much each saved life cost, but I don’t trust my numbers. So instead I’ll ask you: if you’re an employer with fewer than 500 employees, how did FFCRA affect you and your bottom line?

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.

Refusing COVID Vaccination Is Morally Indefensible

Imagine for a moment that you are stuck on an island with a few dozen other people. The island has a spring that serves as its only source of fresh drinking water. By some stroke of luck, the island also has a safe, secure, sanitary porta potty that sits a couple hundred feet from the freshwater spring (humor me; you saw Cast Away). You and the other strandees have collectively decided that the porta potty is safe and that it is open and free for everyone on the island to use.

In spite of this astonishingly lucky set of circumstances, a fellow desert-islander named Chuck tells the group that he’s philosophically opposed to using the portable toilet and that the only comfortable place for him to have a bowel movement is on a stump a few feet away from the freshwater spring. Chuck is not differently abled. There are no poisonous plants or insects in the area of the toilet. He has no history of an allergic reaction to the toilet seat in the porta potty. Everyone points out to Chuck that by doing this he will endanger the lives of everyone else through contamination of their drinking water with his feces. An epidemiologist in the group (again, what a stroke of luck!) calculates that by continuing to defecate near the spring, Chuck will give between two and three people a diarrheal illness, and given the tenuous nutritional situation on the island, one of them may die. Chuck is unconvinced, and continues to use the spring as his private latrine.

Now imagine that a vaccine to a virus that is currently the number one cause of death in the United States is available for free. It appears safe. It cannot give you the virus, as it contains no intact virus. By getting the vaccine you will drop your chance of illness by more than 90%. More importantly, you may well save someone else’s life by getting it, just as Chuck might save the health of his island-mates by pooping in the toilet. That vaccine, obviously, is one of the newly available vaccines against SARS-CoV-2, the virus that causes COVID-19.

Given this, we can only conclude that anyone who has access to COVID-19 vaccination and for whom vaccination is not medically contraindicated has a moral obligation to undergo vaccination in order to contribute to herd immunity. The end. It is a classic utilitarian problem: unless the individual cost of being vaccinated is so high that it outweighs the expected negative effect on the aggregate wellbeing of others, we are obligated to be vaccinated. And if you think a possible mild fever for two days outweighs the current death rate of more than 3,000 people per day in the United States, we operate in different moral universes.

This calculation applies not only to the elderly, whose COVID-19 infection fatality rate may be more than 10%, but to the youngest people approved to get the vaccine (sixteen year-olds) who have an infection fatality rate of less than 0.01%. Because the spread of the virus, often asymptomatically, among young people is the single biggest threat to the health and life of the elderly. Fortunately, since SARS-CoV-2 is not as easily transmissible as extremely contagious viruses like measles, and since the vaccines are extremely effective, the number of vaccinated people needed to achieve “herd immunity” is smaller than some other vaccinations: probably around 75-85%. But we’re operating on the razor’s edge right now: our drinking water-contaminating friend Chuck is the 16% of the population who still state they will refuse a COVID-19 vaccine.

If you have a known severe allergic reaction to a prior vaccine, then you should probably wait to be vaccinated against SARS-CoV-2. But true allergic reactions to vaccines are unusual. By my back-of-the envelope count, only three people out of many tens of thousands already vaccinated have reported allergic reactions.

So please get vaccinated as soon as you can. And please encourage your employees to get vaccinated. It is our only path out of the sticky mess we’ve been in since March.

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.

Amazon is a pharmacy now. Is that a good thing?

Amazon is now in the pharmacy business

Amazon announced just before Thanksgiving that it was entering the pharmacy business. On its face, this is a good thing. Amazon has grown so large that it is a de facto arm of the federal government, and it is incorporated as much as utility companies into many of our lives. The move isn’t sudden; some analysts have framed this as a natural extension of their 2018 purchase of PillPack, a pharmacy service to coordinate, organize, and deliver prefilled medication containers. So we can be confident Amazon will offer efficient, seamless delivery and good prices, two things that are often missing from our experience in American health care. It’s no surprise, then, that the announcement was catastrophic to the stock price of several pharmacies whose shares fell by a tenth or more. GoodRx, a quasi-pharmacy benefit manager (PBM) designed for discounts for uninsured and underinsured patients, lost a fifth of its value.

How it works

Amazon Prime customers will get medications delivered for free within two days. They’ll also qualify for discounts of up to 80 percent off generics and up to 40 percent off brand-name drugs. (some have pointed out that people who can’t afford Prime will be cut out of these offerings, an example of a systemic problem in American health care that Amazon won’t or can’t fix)

I did a quick road-test of Amazon Pharmacy today. The interface is, as one would expect, pretty intuitive and slick. If nothing else, Amazon has mastered simplicity. Just by seeing my routine demographics and the last four digits of my social security number Amazon was able to find my insurance information automatically, a task which I can tell you from both the physician side and the patient side is not easy. Then, after entering medications I currently take, I was given the option of transferring those prescriptions from my current pharmacy. I did not do this (my commitment to this project only goes so far), but it looked like the process would have been seamless on my end. I do not know what nightmarish snarl of paperwork it may have generated for my existing pharmacy or my doctor, though.

Allegedly, were I to have gone ahead and tried to check out, I would have been shown two prices: one with my insurance benefits, and one with my Prime discount. I would have chosen my preferred price, and the medication would have been delivered within two days. It remains to be seen how Amazon Pharmacy would handle one-off prescriptions for an infection or injury, although their same-day delivery in cities and by drone aircraft point toward that being a future feature.

Where do pharmacists fit in?

But the practice of pharmacy is more than the cheap, reliable delivery of medications. We at KBGH see pharmacists not as people who take pills out of a big bottle and put them into a small bottle to sell to you, but as highly trained medical professionals [note: KBGH has CDC funding to promote, among other things, team-based patient care including pharmacists]. Pharmacists’ training is toward the upper end of medical professional training in terms of time and testing requirements. After a minimum of two years of undergraduate classes with strict prerequisites (and some schools require additional coursework), pharmacists since 2000 have universally completed a Doctor of Pharmacy (Pharm.D.) degree, a four-year professional degree program which makes them eligible for licensure by their state Board of Pharmacy. The Pharm.D. degree is often followed by one or two years of a postgraduate residency program to increase the pharmacist’s depth of knowledge in a specific area of focus like inpatient care or chronic disease management. Pharmacists interested in research may do fellowship training beyond residency.

Pharmacists, like physicians, utilize “extenders” and technologies to increase their capacity. This theoretically allows pharmacists to spend more time on direct patient care roles like providing evidence-based medication recommendations, monitoring therapeutic responses to drugs like anticoagulants and blood pressure medications, and reconciling medications as patients transition from one care setting to another.

Pharmacists are capable of contributing to extraordinary patient outcomes. A meta-analysis of randomized trials, for example, showed that pharmacist + physician dyads are much more effective than physicians alone in treating patients’ cardiovascular risk factors. Teams with pharmacists had patients with blood pressures 8.1 mmHg lower, bad cholesterol levels 13.4 mg/L lower, and a 23 percent lower likelihood of smoking:

Some pharmacists, in collaboration with other practitioners, offer testing for high blood pressure, infections like strep throat, and markers of chronic disease management like cholesterol and blood sugar levels. In 2015 the State of Kansas authorized the creation and use of “Collaborative Practice Agreements” between pharmacists and physicians for patient care. Amazon Pharmacy has promised to try to virtually recreate the “counter conversation” with the pharmacist that many people desire, so while it is hard to see Amazon tiptoeing into the collaborative practice water any time soon, it is not impossible to imagine long-term. Amazon already offers telemedicine to its employees. Expect telemedicine for the rest of us next. And expect those telemedicine providers to work with Amazon Pharmacy somehow as the company learns what it takes to provide more comprehensive physician-pharmacy services. Maybe PillPack’s existing expertise in counseling will translate into more traditional brick-and-mortar pharmacy-style interactions. With time, it seems inevitable that Amazon will be labeled a preferred pharmacy for most health insurance plans. After that, it will surely follow CVS’s lead and become or acquire a PBM.

Staying out of stores is unquestionably safer in the COVID-19 age, a system-delivered advantage for Amazon. So if your employees begin using Amazon Pharmacy I’d make sure they know some basics, like that if they opt not to use their insurance but instead just take the Amazon Prime discount, their purchase may not count toward their health insurance deductible.

But for now, for complex patients with complex medication regimens that include potentially dangerous, potentially interfering drugs, the use of a community pharmacy familiar with your employees seems the most prudent course. Many community pharmacies already offer delivery and PillPack-like services designed for ease of drug administration, all with a more recognizable over-the-counter pharmacist interface. Grocery stores adapted when Amazon bought Whole Foods, and I would expect pharmacies to do the same.

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.

American Healthcare Primer, Part Two: Private Insurance

This is part two of a series on American healthcare. It may make more sense if you start with Part One.  As with Part One, much of this information comes from Ezekiel Emanuel’s Which Country Has the World’s Best Health Care?

 Where does money come from?

Of the United States’ about 325 million people, around 180 million are covered by employer-sponsored health insurance, accounting for approximately 20% of health care spending. Employees pay on average 18% of the cost of their premiums for individual plans and 31% the cost of their premium for family plans, equivalent to about one-third of median income. Employers pay the remainder of the premiums as a form of tax-exempt reimbursement. To some extent, employer contributions to insurance are taken from wages; it is widely acknowledged that employees would make more if their employers were not covering their health insurance.

More than half of employer-sponsored insurance prices are determined by insurance brokers working on commission. This system incentivizes brokers to negotiate higher rates. Some brokers are now working in other models like “pass-through” in order to minimize that incentive.

Another 22 million people purchase health insurance individually, 11 million of those through “exchanges” set up by the ACA. Eight million people receive insurance subsidies that were once paid for by the federal government. But after the recent discontinuation of these federal subsidies, insurers–still required by law to provide subsidies–were forced to increase premiums on non-subsidized patients in order to cover the cost. Overall, individuals pay for about 28% of all health care spending.

Roughly 28 million Americans, most of them between the ages of 20 and 40, have no health insurance. A small number of uninsured patients receive care through subscriptions to physician practices in a growing model called “Direct Primary Care.”

Where does the money go?

As with public insurance, hospitals consume about a third of spending. In most private insurance, both individual and employer-sponsored, payments to hospitals and physicians are negotiated individually and tend to be roughly two to three times rates paid by Medicare.

Like in public insurance, hospitalizations are covered according to “Diagnosis-Related Groups” (DRGs), fixed, pre-specified amounts paid according to the diagnosis codes attached to the hospitalization. Unlike public insurance, the rates paid for any given DRG can differ by many multiples. The highest rate a given hospital receives from any payer for a given DRG is known as the “charge master” price, and it tends to be exorbitant; when you hear about sixteen-dollar Tylenol or similarly absurd prices on the evening news, it is the charge master price that is being cited. Medicare rates are roughly 31% of the charge master rate.

Physician payments, as in public insurance, consume about 20%, of all health care spending. Commercial insurers base their payments on a multiple of the CMS Physician Fee Schedule.

Pharmaceuticals consume about 17%, of all health care spending and are considered the first- or second-most egregious source of excess spending (behind administrative complexity) in the American health care system. Pharmaceutical prices are not set solely by drug companies. Pharmacy benefit managers, or PBMs, are companies that manage prescription drug benefits for commercial health plans and self-insured employer plans, along with public insurers. PBMs have three revenue sources: supply chain fees paid for the work of managing the benefit plan, which is uncontroversial; “Spread pricing,” a controversial tactic in which the PBM keeps the difference between manufacturer and insurer prices for a drug; and manufacturer rebates, in which a fraction of the cost of the drug to the consumer is transmitted back to the PBM so that the manufacturer’s product can obtain preferred formulary placement over the products of competitors. Rebates have grown in magnitude out of proportion to the health care economy. Insulin has a typical rebate of 66%, for example. As such, revenues of PBMs exceed even those of the pharmaceutical companies with whom they negotiate. In 2017, Express Scripts’ revenue was roughly $100 billion. Pfizer’s revenue was $52 billion.

Outpatient pharmaceuticals are typically covered according to a tiered pharmacy benefits plan, with Tier 1 generic drugs costing ~$10/month, Tier 2 preferred branded drugs costing ~$35/month, Tier 3 non-preferred branded drugs costing ~$70/month, and Tier 4 specialty drugs often being covered under a “coinsurance” model of ~25% patient payment.

Dental and vision care

Private insurers cover dental and vision at varying rates. Most patients have supplemental insurance for this purpose.

Long-term care

Private insurers do not, for the most part, cover long-term care, and long-term care insurance is rare, with only 0.5% of employers offering it. Fewer than 10% of employees nationally have long-term care insurance, in spite of the ~$90,000 annual cost of nursing home care and projected steep rise in need in the next few decades.

Administrative complexity

The United States has much higher administrative cost and complexity than peer countries, owing to a patchwork of private insurance plans with few harmonized features. Overall overhead is 8%, but this rises to 14% if private insurance-related activity is included. Ten other wealthy countries average 3% overhead. We spend roughly four times what Canada spends on administrative overhead, for example. The $812 billion per year we spend on administrative overhead exceeds the entire budget of Medicare.

What do we get from our health care spend?

Medical innovation, at least in terms of new drugs, therapies, and surgeries, is quite high in the United States. America is first in the world in clinical trials, number one (by far) in Nobel Laureates in Medicine, number one in medical patents awarded.

That said, health outcomes in the United States generally lag behind peer countries. We have far more uninsured patients. We have the highest maternal and infant mortality rates in the developed world and the lowest life expectancy. We are in the bottom third of developed countries in happiness.

Our excess costs are not related to utilization of medical services, but rather to inflated prices. All excess cost of pharmaceuticals in America is due to higher prices than in other countries, not increased use. Rates of hospitalization and the length of stay of those hospitalizations are lower in American than in most peer countries.

Pre-pandemic, Bloomberg rated American health care as 35th best in the world, between Costa Rica and Bahrain. In 2000 the World Health Organization ranked the United States 37th (again, ironically, just behind Costa Rica).

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.

American Healthcare Primer, Part One: Public Insurance

With the pending transition in Presidential administrations and a historic pandemic killing more than 1,300 Americans daily, we are in for a lot of health care policy talk over the next few months. To refresh our fund of knowledge about American health care, we at KBGH have decided to outline the big features over a series of posts. Much of this comes from Ezekiel Emanuel’s excellent Which Country Has the World’s Best Health Care?

Contrary to popular media, there is no “American Health Care System.” Instead, we have a patchwork of independent and overlapping systems, each with its own problems, bright spots, and idiosyncrasies. This week we’ll cover public insurance.

What do we spend on health care?

The United States spends more than $3.5 trillion annually on health care, equivalent to about 18% of gross domestic product, accounting for almost $11,000 per person. This is roughly double the per-capita average of Organization for Economic Cooperation and Development (OECD) peer countries like Japan and western Europe.

Where does money come from?

Roughly 45% of American health care is publicly financed: 28% federally and 17% by state and local governments. Medicare costs almost $600 billion per year, or 2.9% of gross domestic product (GDP), and covers 55 million senior and disabled Americans. Medicare Part A, covering hospitalizations, is funded by a 1.45% payroll tax from employers along with a 1.45% payroll tax from employees (plus another 0.9% payroll tax for individuals earning >$125,000 or couples earning >$200,000 annually).

Optional Medicare part B, covering physician visits, is financed by income-linked premiums averaging ~$130 per month for people who elect for the coverage. The premium covers ~25% of the cost, and the federal government covers the remaining 75%.

Medicare part C, or “Medicare Advantage,” can charge enrollees additional premiums.

Medicare part D is paid for by premiums paid by elderly beneficiaries and by other general governmental tax revenue.

Medicaid and the Children’s Health Insurance Program (CHIP) collectively cover 65 million mostly poor patients along with certain blind and disabled persons. Some beneficiaries are “dual-eligible,” meaning they are also covered by Medicare. The federal government pays ~57% of the cost of traditional Medicaid as the “Federal Medicaid Assistance Percentage,” while states cover the other ~43%. Medicaid accounts for 1.9% of GDP, or roughly $400 billion per year from the federal government. In many states Medicaid is the single largest fraction of the state budget. In expanded Medicaid under the ACA, in which Kansas does not participate, 90% of the cost is borne by the federal government with 10% borne by the state to cover patients whose income falls up to 138% the federal poverty line.

Kansas uses a “managed” form of Medicaid in which Medicaid is facilitated through third-party payers (Sunflower Health Plan, UnitedHealthcare Community Plan of Kansas, and Aetna Better Health of Kansas).

In Kansas MediKan covers adults with disabilities who do not qualify for Medicaid but whose applications for federal disability are being reviewed by the Social Security Administration. MediKan covers a scope of services similar to that covered by Medicaid, but with additional restrictions and limitations.

CHIP provides health insurance for children whose parents make too much to qualify for Medicaid but whose private health insurance does not allow them to get their children insured. CHIP is not open-ended like Medicaid, but is rather a block grant system varying slightly by state. The federal government pays 72% of the cost up to a year’s maximum allotment, and the State provides the remaining 28%.

The Veterans Health Administration (VA) covers 9 million former military service members. 2.2 million people of Native American descent are insured through the Indian Health Service (IHS). 9.4 million active-duty military and their families are covered through Tricare.

Where does the money go?

About 85% of health care spending is for chronic conditions like diabetes, hypertension, chronic obstructive pulmonary disease, and high cholesterol. About a third of patients with a chronic medical illness also have a comorbid psychiatric disease like depression or anxiety. This is thought to increase the cost of care of those patients by 60% or more.

Hospitals consume about $1.1 trillion, or 33%, of all health care spending

Medicare Part A covers hospitalizations. Hospitalizations are covered according to “Diagnosis-Related Groups” (DRGs), fixed, pre-specified amounts paid according to the diagnosis codes attached to the hospitalization. Medicare’s DRG rates are set by the federal government. Medicare does not negotiate DRG payments; hospitals may take them or leave them. But Medicare does adjust the base DRG rate via special payments to rural and other hospitals, via “Disproportionate Share Hospital” payments to hospitals who provide a large volume of uncompensated care, and via two forms of additional payment to hospitals who provide graduate medical education to resident physicians.

Hospitalizations in Medicaid are covered according to DRGs, with prices set by the states.

The VA owns its own hospitals.

Physician payments consume about $700 billion, or 20%, of all health care spending

American physicians are well-paid: primary care doctors like family physicians, pediatricians, and internists make an average of $223,000 annually, and specialists make an average of $329,000, though that number is inflated by the relatively large salaries of proceduralists like cardiologists and orthopedic surgeons who make roughly five times what peers in other developed countries earn.

Nurse practitioners make an average of $105,000 per year.

Public insurance payments to physicians differ markedly by specialty. Pediatricians make a large fraction of their income from Medicaid, since more than a third of American children are on Medicaid at any given point. Cardiologists, who treat a predominantly elderly population, make the majority of their income from Medicare.

The DRG payment mentioned above does not cover physician costs in either public or private insurance; physician services are billed separately under “Common Procedural Terminology” (CPT) codes. Most ambulatory and inpatient physician payments are still fee-for-service, with “Relative Value Units” (RVUs) converted by each insurer. The purpose of RVUs is to create a common metric to measure physician services based on the time, skill, and intensity of physician work along with practice expenses and malpractice premiums. One RVU via Medicare is worth about $36. After conversion, that $36 becomes about $56 for an office visit and about $77 for a gallbladder surgery (procedural skills are generally more valued than medical skills in the system).

The Relative Value Scale Update Committee (RUC), a 31-physician panel owned and organized by the American Medical Association, assists the Centers for Medicare and Medicaid Services (CMS) with assigning and updating RVUs. The RUC guides ~70% of all physician payment in the United States, equal to an estimated $500 billion each year. Its recommendations are made based on survey results of only about two percent of physicians updated only every 5-20 years, but RUC recommendations are accepted without change by CMS more than 90% of the time.

Physician payments are still mostly fee-for-service with RVUs converted by the federal government, but alternative payments models developed through The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), like capitation, bundled payments, and global budgets, are growing in utilization, currently making up about a third of all payments.

Medicaid physician payments are mostly fee-for-service with an RVU conversion set at the state level, but managed Medicaid providers are experimenting with “capitated” payments, in which a lump sum payment is paid to the physician to encourage reduced overall spending.

The VA and IHS employ their own physicians on salary.

Pharmaceuticals consume about $500 billion, or 17%, of all health care spending.

Drug prices in the United States are 56% higher than in peer European countries and represent our single biggest source of excess health care spending. Americans make up only 4% of the world’s population, but we account for almost 80% of pharmaceutical revenue. Pharma companies point to spending on research and development, but those budgets are dwarfed by advertising budgets. Pharmaceutical and health product manufacturers account for 7.3% of all lobbying money spent in the US, while no other sector accounts for more than five percent. Pharma is by a large margin the most profitable business sector in America.

Of the 17% of the health care budget consumed by drugs, 10% is in the outpatient setting and 7% is in hospitals, nursing homes, or doctors’ offices.

Some drugs, though, are not sold through pharmacies, but through physician offices as part of the “buy-and-bill” system. The most prominent example is cancer chemotherapeutics. Medicare caps physicians at billing six percent higher than the average wholesale price. This incentivizes physicians to use more expensive drugs to generate higher payments.

Medicare part D pays for pharmaceuticals. It is forbidden by law from directly negotiating drug prices, but is allowed do negotiate indirectly through a pharmacy benefit manager (PBM). Pharmacy benefit managers create formularies and negotiate prices in both private insurance and in Medicare. They may limit drug choices in all but six categories: immunosuppressants (as might be used in autoimmune diseases or organ transplants), antidepressants, antipsychotics, seizure medications, HIV medications, and cancer drugs.

Medicaid covers drugs on formularies determined at the state level, usually with a nominal co-payment of a few dollars per prescription.

The VA and IHS, unlike other public health insurers, are free to negotiate their own prices on pharmaceuticals. The VA by law gets at least a 24% discount from the manufacturer’s average retail price outside the federal government. Outpatient drugs are available with a copay of $5 for generics, and many vets are eligible for free prescription medications.

Dental and vision care

Medicare does not cover dental care, but some Medicare Advantage plans do.

Medicaid covers dental care for children. Coverage for adults varies by state.

Long-term care

Medicare covers part of 100 days per illness of long-term “skilled nursing care” as long as the care is triggered by a hospitalization of at least three days related to the illness needing long-term care. Coverage declines from 100% of the first 20 days down to $167/day for the remaining 80 days.

Medicaid is the primary payer for long-term care in the US, covering 62% of nursing home care and 50% of all long-term care nationally. In order for Medicaid to pay, patients must have no more than $2,000 in assets, excluding their car and a home valued up to $552,000; and require assistance with “personal care” like bathing and dressing. Medicaid requires a “look back” of five years to insure that assets have not simply been transferred to others.

What do we get from our health care spend?

Outcomes in Medicare tend to be slightly better than outcomes in private insurance. Outcomes in Medicaid tend to be slightly worse, probably owing to social determinants of health. For example, In commercial HMOs in 2018 the rate of hypertension control was 61.3% and in commercial PPOs 48.8%. Medicare rates of control were 58.9% in HMOs and 68.8% in PPOs. The Medicaid HMO rate of control was 58.9%.

After Thanksgiving we’ll talk about private insurance. Have a great holiday!

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.

Why You Should be Glad CMS Now Covers More Ambulatory Blood Pressure Monitoring

CMS covers more ambulatory blood pressure measurements now. Wait! Before you fall asleep–this is a bigger deal than you think.

Of all medical interventions available to physicians taking care of adults, blood pressure control may have the largest potential impact on lives saved. Since more than a third of Americans have hypertension, every 10 percent increase in controlled blood pressures nationwide would save something like 14,000 lives per year. And right now, less than half of people with hypertension have a well-controlled blood pressure. Going from 50% control to 90% control could be expected to save almost 60,000 lives per year. Part of the problem with getting there, though, is that measuring a blood pressure accurately is astonishingly hard. Some of this is due to obvious errors by the measurer: using the wrong size cuff, taking the measurement over clothes, and talking to you while they inflate the cuff, for example.

But some of the error is less predictable. A clever recent study (paywall) found that when participants in the SPRINT study, a large trial of very intensive blood pressure control, were seen by their own doctors during the study but outside the study protocol, their blood pressures differed markedly from the blood pressures obtained by the fastidious measurement techniques of the protocol. People in the “intensive” control group, in whom investigators were aiming for a blood pressure <120 mmHg, had a routine blood pressure at their own doctors’ offices that was 7.3 mmHg higher. People in the standard control group who were aiming for a blood pressure <140 mmHg had an average difference of 4.6 mmHg between their study blood pressure and their routine blood pressure.

Unfortunately, your own doctor may not be able to put in the time or workflow that it takes to get a study-quality blood pressure. She may not be able to let you rest for 5 minutes before a reading, or she may not invest in automated blood pressure cuffs. She may not have the time to average the results of three separate readings. But what your doctor could do is prescribe “ambulatory blood pressure monitoring,” or ABPM. ABPM is a technique by which you wear a device at home that periodically monitors your blood pressure, even at night, without any input from you. Then it sends the results to your doctor. Because the device is unaffected by the technique and timing issues above, it is considered the gold standard for the diagnosis of hypertension. But it has been historically very hard to get insurance companies to pay for. Getting payment required documenting a high likelihood of “white coat hypertension,” that is, a blood pressure in the doctor’s office that was consistently higher than blood pressures obtained outside the office on more than one occasion. People with “masked hypertension,” whose blood pressures outside the office may have been substantially higher than those measured at the doctor, were excluded.

A recent rule change by Centers for Medicare and Medicaid Services (CMS), though, allows expanded use of ABPM not only for suspected white coat hypertension, but also for masked hypertension. Since CMS is the bellwether for other insurers’ behavior, we can surely expect private insurers to follow.

So check your blood pressures at home. Or go to your local fire station or EMS. They can check your blood pressure 24/7/365 for free, and they know what they’re doing. See the image below to locate all the EMS and Fired Department stations in Sedgwick County, or download your own copy here. There is also an area where you can track your out-of-clinic blood pressures to report back to your physician.

If your home readings don’t match what you’re getting from your doctor’s office, ask your doctor about doing ambulatory blood pressure monitoring. Better yet, encourage your employees to ask about it.

Note: the Kansas Business Group on Health receives CDC funding to improve the detection and care of high blood pressures. But we believe in it either way.

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.

What's a Year of Life Worth?

Determining the value of treatment

You’ve probably heard the term “cost-effectiveness” thrown around in regard to medical treatments. In this blog we’ve made the case that much of the testing in “executive physicals” isn’t cost-effective, for example; we argued that the weird little tests that some executives get simply aren’t worth the money because they haven’t been shown to improve quality of life nor quantity of life, a measure we bundle into “quality-adjusted life years” or QALYs (pronounced “quollys”). But we’re not just picking on C-suite folks. When any new treatment, like a new pacemaker, costs more per QALY gained than the theoretical care its high cost displaces, like routine blood pressure treatment lost due to the extra cost resulting in nurses being laid off, the health of the population suffers.

Historically, even though the Centers for Medicare and Medicaid Services (CMS) have explicitly avoided setting policy according to cost-effectiveness for fear of rationing care, we’ve used Medicare’s payment for dialysis as an “apocryphal” benchmark. A year of dialysis in the early 1990s cost about $50,000. And without dialysis a person with end-stage renal disease will quickly die. So, the argument went, a year of human life must be worth about $50,000 and any new drug, therapy, or surgical procedure should cost no more than $50,000 for every resulting additional QALY. By this argument, a chemotherapy drug that adds five years to your life should cost no more than ~$250,000.

Other ways to use this model

This model based on precedent is far from the only way people have tried to define cost-effectiveness. A 2019 mathematical model found that Americans with an income of $50,000 should be willing to pay $100,000 for one additional year of ideal health. An extrapolation of patients in the United Kingdom’s National Health Service–where cost-effectiveness is tracked extraordinarily tightly–estimated that Americans would be willing to pay between $24,823 and $40,112 per QALY gained. A somewhat similar analysis comparing US health expenditures to other countries estimated $60,475 to $97,851 per additional year of life.

In an attempt to define a more home-grown, objective, US-specific threshold for cost effectiveness, David Vanness, James Lomas, and Hanna Ahn recently published a simulation to determine the number of people in a model population of 100,000 individuals resembling the US population who would lose insurance because of a $100 premium increase (1.6%, or $10,000,000 total for the population). They used 2019 premiums from the ACA marketplace as their baseline, and they were able to estimate insurance loss from historical data on coverage losses from the ACA Marketplace.

Next, using a study of mortality reduction observed with ACA Medicaid expansion, they were able to deduce the number of deaths among the newly uninsured in a year. To account for loss of quality of life among the survivors (since QALYs account for both quantity and quality of life), they benchmarked to a study on health-related quality of life by year of age.

Then the investigators ran a simulation with these “givens” 50,000 times. Here’s what they found: for each additional $10,000,000 in health expenditures passed through to patients as premium increases (remember, the equivalent of $100 per person, or a 1.6% increase), roughly 1,860 of the 100,000 simulated patients became uninsured. This resulted in five additional deaths, 81 QALYs lost due to death, and 15 QALYs lost due to illness.

So a new treatment costing the theoretical American population of 100,000 people $10,000,000 would need to increase QALYs by 96 to avoid reducing the overall health of the population. $10,000,000 divided by 96 equals $104,000 per QALY, about double the apocryphal $50,000 per QALY estimated by Medicare’s dialysis coverage.

What do you think? This is a question far better suited to the Halloween season we just left than to the Thanksgiving season we’re entering, but it’s a question we all have to ask ourselves: Is $104,000 per year a reasonable threshold for insurance companies to use in deciding on coverage of new drugs, tests, or services? Are you an Ebenezer Scrooge, unwilling to pay even $50,000 per year of life? Or are you a spendthrift, willing to pay more?

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.

Are ICHRAs Trouble for Low-Income Workers?

Losing any part of your health coverage is bad news right now, when the United States has just recorded its highest-ever new caseload of COVID-19. So depending on how you’re covering the health care needs of your lower-income employees, news out of the United Hospital Fund last week, brought to our attention from Modern Healthcare (paywall), may be especially alarming.

The UHF reported Friday that low-income workers who buy their health insurance through “individual coverage health reimbursement arrangements,” or ICHRAs, could lose ACA premium subsidies or lose their eligibility for free or low-cost coverage.

How do ICHRAs work?

ICHRAs, which became available in January of 2020 (probably too late for your most recent open enrollment periods), were designed with the intention to allow employer groups to establish “monthly allowances” for individual employees who could then submit their medical expenses back to their employers for reimbursement on a tax-free basis. The intention was to encourage employees to seek care on the individual market, and then reimburse the employees for some or all of their expenses. Employers offering ICHRAs have broad discretion over what is reimbursed, and how much; employers can choose whether to provide allowances for individuals or individuals and their families. They can offer different allowances based on workers’ ages, they can decide exactly what expenses can be reimbursed (premiums, cost sharing, or both), and the employers can decide whether or not to roll over unspent amounts from one year to the next.

What this could mean

Unfortunately, the downstream effect of this could be that “… some workers could also forfeit premium subsidies through the ACA or lose eligibility for free or low-cost coverage…comprehensive group coverage [could be] replaced with an ICHRA, which could mean benefit reductions and narrower provider networks,” as Peter Newell, director of UHF’s Health Insurance Project and author of the report, said. The report offers a theoretical to illustrate this:

In lower-cost Erie County, New York (Buffalo), workers with incomes of $48,000 would pay more for coverage with a minimum affordable ICHRA and without ACA tax credits than they would under straightforward employer coverage. Workers making ~$24,000 would lose eligibility for the $20-per-month Essential Plan, and to obtain comparable coverage it would cost them more than $700 per month, a net loss of $680 per month. The only workers who would clearly benefit from an ICHRA in such an environment would be those making more than ~$50,000 annually, who would be ineligible for ACA premium subsidies.

Potential solutions

To correct this, the UHF recommended three changes at the Federal level (either congressional or regulatory): First, they recommend allowing low-income workers to opt out of ICHRAs without an affordability test. Second, the UHF recommends that individuals participating in ICHRAs be allowed to keep their ACA tax credit if they’re eligible for both, regardless of income. And third, the authors recommend the government discourage employers from replacing employer-sponsored plans with ICHRAs through new regulations. Given the enthusiasm of the current Presidential administration for ICHRAs (along with short-term limited duration insurance and association health plans), this third recommendation seems completely dependent on the results of the November 3 election. But your company’s decision on ICHRAs is not dependent on the election at all. If you have low-wage employees who have had success or problems with individual coverage health reimbursement arrangements, we’d love to hear your experience.

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.

Ho Ho How to Avoid Holiday Weight Gain (Encore)

You can already see it coming: the weight we all gain over the holidays is as predictable as the weight we try to take off for the summer. A few years ago researchers used WiFi-enabled “smart scales” whose buyers were aware that their weights would be used for research to track the weights of American, German, and Japanese subjects for one year. The scales are important: people frequently misreport their weight, or they change their diets when they know they’ll have to report somewhere to be weighed. By having the scale in their house and wirelessly communicating with the database, the investigators hoped to reduce this bias. For any given holiday the researchers compared the maximum weight at no more than 10 days after the start of the holiday to the weight that was measured 10 days before the holiday.

The results? In all three countries, the participants’ weight rose in the 10 days after Christmas Day, compared with the 10 days before Christmas (+0.4% in the U.S., +0.6% in Germany, and +0.5% in Japan). The raw amount of weight gained wasn’t large: only 1.3 pounds for an average American. But the researchers pointed out that since the population of this study—people who spent ~$150 on a scale—is probably wealthier and more motivated toward weight loss than average, the results of the study probably underestimate the effect on the general population. For example, the average worker gains 2-3 pounds per year (half of that between Halloween and New Year’s Day, naturally) and weights in this study had gone down to pre-holiday levels within six months or so.

So: what can we do to help our employees prevent this weight gain in the first place?

An interesting answer comes from two groups of researchers who elected to try a “weight prevention” approach rather than a traditional weight loss approach. First, investigators at the University of Georgia developed a program they called Holiday Survivor for state employees. Participants were divided into teams and were instructed by a worksite wellness professional on self-monitoring and regular weigh-ins from the end of October to mid-January. Efforts were put toward increased awareness of food intake and physical activity through self-monitoring, but the program was geared not toward teaching new knowledge, but instead to build social support for positive behaviors. Each team of four employees received points for participating in weekly program activities like a healthy potluck, a 5 km run/walk, or “lunch and learns,” and for completing weigh-ins. Individual participants also received points on two occasions for providing proof of food logs (not the logs themselves). In early January a prize ceremony was held to celebrate team and individual achievements.

In spite of the emphasis on weight maintenance, the employees lost an average of 4.4 pounds (from 196.7 in October to 192.3 pounds in January).

A second group of investigators in the U.K. randomized workers in a variety of jobs to either get a pamphlet on the dangers of holiday weight gain (without dietary advice) or to get instruction on recording their weight at least twice weekly (ideally daily), ten tips for weight management, and pictorial information about the physical activity calorie equivalent (PACE) of holiday foods and drinks (that is, information such as “13 minutes of running for a can of sugared soda”). The goal was for participants to gain no more than ~1 pound of their baseline weight.

Over the holiday season the group getting the pamphlet alone gained on average 0.8 pounds, while those weighing frequently, getting tips on weight management, and informed of the PACE of holiday foods lost 0.27 pounds.

The Kansas Business Group on Health generally takes a prosaic view of traditional worksite wellness practices. We tend to believe that true health is hard to define and harder to measure, and that improvements in health are rarely as simple as old-fashioned carrot-and-stick rewards or punishment. But this strategy of proactively engaging employees to manage a known occupational hazard (the holiday season) is novel and promising. If any members have had similar luck we’d love to hear about your strategies!

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.

Use a Checklist for Your Checklists

I’m a big fan of physician-author Dr. Atul Gawande. Like, a big fan. Want evidence? Once upon a time the screen background of my phone was a picture of my wife and I with Dr. Gawande:

Just me, Atul, and Dr. Tracy Williams. No big deal. Eat your heart out on that plaid jacket, Pete Campbell.

My screen background is now a picture of my kids at a bike race (I’ve grown). Recently, and not because of garden-variety celebrity worship, I’ve been re-reading some of his 2009 book The Checklist Manifesto. I highly recommend it, and I thought I would share some of the lessons of the book that might especially resonate in the Time of Remote Work Due to COVID.

Gawande is careful to craft a message that a true checklist to help us accomplish involved tasks is not like your grocery list. It’s more like a catalyst to action, meant to free people up rather than restrict them. To help us write checklists that meet these needs, he recommends a “Checklist for checklists,” of sorts. Here are the parts that I find especially useful:

1. Try to define what kind of problem are you trying to solve. Is it fairly simple, like baking a cake? Is it complicated, like launching a rocket, where many, many things can go wrong? Or is it complex, like raising a child, where the inputs into the problem and the child’s response to them are constantly changing?

2. With the complexity of the problem in mind, what kind of list do you need? Some lists are more oriented toward “doing,” like baking that cake, while others are more oriented toward “reviewing,” like the pre-flight checklists in airplanes.

3. What kind of items do you need? Some checklists, like building an addition to your home, will require mostly actions. Other checklists, like preparing for a recurring meeting, are mostly communications.

4. Remove any items you assume list users will just do without prompting. In the process of compiling this I’ve deleted bullet points around identifying decision points and defining the problem. You already know to do those.

5. Identify the critical items and keep them. Consider emphasizing them by highlighting or installing alerts, such as on your phone if it’s a personal list, or on a poster or any software package the task needs in order to run if the list is shared among many, such as in the clinics we at KBGH work in.

6. Leave room for judgement. No one wants to sit through a meeting where the food for the office Christmas party (remember those?) is debated for an hour. Leave someone with a budget and any attendees’ life-threatening food allergies and see how she does.

7. Simplify the language if possible.

8. If the checklist is shared, adjust the order and layout for clarity if possible.

9. For checklists that have dire consequences, like the aviation checklists above or the preoperative checklists pioneered by Dr. Gawande, trial the list in real-world situations if possible before it goes into daily use.

10. Gather feedback from every potential user and refine the list based on that feedback. Dr. Gawande’s surgical checklist wasn’t just written and reviewed by surgeons. It was reviewed and modified by everyone involved in the care of the patient, from the orderly wheeling her into the room to the surgeon and anesthesiologist to the circulating nurses.

11. Maintain the list over time to keep up with its context. Checklists and clinic protocols require care and feeding just like your pets.

12. Treat the list as a tool, not as a religious tome. We at KBGH are fans of the care guidelines developed and used within the Kaiser health systems, such as this one for hypertension care (scroll to the bottom). But we know that a small number of patients will not be well-served by that care algorithm. That’s why doctors and nurses are trained to think critically.

13. Diffuse the list. Make sure it is available to everyone who may need it. That may mean posting it online.

Do you use checklists for complex tasks in your workplace? Let us know!

When will I get the coronavirus vaccine?

The importance of vaccine development and deployment is hard to overstate

About 700,000 Americans have died of HIV, ever. As of the writing of this blog post, roughly 210,000 Americans have died of COVID-19 in about seven months. And that number probably underestimates the real death rate by a quarter (paywall).

After a very eventful week for COVID-19, some good news is poking up through the weeds. We’re close enough to getting one or more functional vaccines that we need to start thinking about how to distribute those vaccines. The National Academies of Sciences, Engineering, and Medicine, in response to a request from NIH and CDC, formed a committee to “assist policymakers in the U.S. and global health communities in planning for equitable allocation of vaccines against COVID-19.” Their report, authored by Emory University’s Dr. William H. Foege and 17 other members, is now available for free download. Some highlights:

First, the committee recommends that shots be free of charge to all, and that efforts to distribute them should focus on disadvantaged areas to “remedy” racial health disparities. The report further suggests CDC hold back 10% or so of the vaccine in reserve for use in “hot spots” identified through the Social Vulnerability Index, a tool that uses 15 Census data points on race, poverty, crowded housing, and other factors to estimate risk in natural disasters. Look at the figure below to get a sense of this:

https://www.medrxiv.org/content/medrxiv/early/2020/07/06/2020.07.04.20146084.full.pdf

Don’t worry about the text, which I know is hard to read. Look at how the green and gold counties on the left figure, which represent high-risk areas in the Social Vulnerability Index, line up with the red counties in the figure on the right, which represent the highest per-capita mortality rates. You’ll notice a pretty neat fit.

But beyond those broad measures, the guidance of the NAS committee is that immunization should be implemented in “waves.” See which one you fit into:

Wave One

When vaccines and supplies are expected to be scarce, they recommend the first doses should go to high-risk health care workers in hospitals and nursing homes and to those providing home care. First responders also would be in this group, along with anyone who works in a hospital or clinic, from clerks through janitorial staff. This is because, somewhat counter-intuitively, models show that vaccinating the workers will save more lives than vaccinating the residents.

Wave Two

This wave would come at an undetermined time related to the successful production and deployment of vaccine doses, which would include older residents of nursing homes and other crowded facilities, along with people of all ages with high-risk health conditions. The report lists cancer, chronic kidney disease, and obesity among possibilities, but does not commit to a full list of conditions that should be included.

Later Waves

Subsequent waves would vaccinate teachers, child care workers, workers in essential industries (which may vary state-to-state, since even though Federal health officials have the final say on distributing the 300 million vaccine doses the government is buying under Operation Warp Speed, state and local health departments will decide many details), people living in homeless shelters, group homes, prisons, and other facilities, since like nursing home residents, they can’t simply isolate themselves if they’re infected..

Everyone else—healthy children, young adults, etc.—are recommended to wait until vaccine supplies increase. The AP reports that “Many health experts predict a vaccine won’t be widely available to all Americans until mid-to-late next year.”

So this is where we review the fact that a vaccine won’t be magical. It’s worth emphasizing that the vaccine will add to, not replace, present efforts. Let’s assume that the best vaccine is 70 percent effective. By the standard we’re accustomed to with influenza vaccination that’s pretty good. That means that if 330 million Americans receive the vaccine, 99 million will be left vulnerable. And we still don’t know how long the vaccine will protect us; it could be months or it could be years. You’ll likely need to take multiple doses for maximum effect. So alas, the practices of social distancing of some sort and masking in crowded places aren’t going anywhere soon. But that caveat aside, there may be a vaccine-tinted light at the end of a very long tunnel.

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 was a reprint of a blog post from KBGH.

Delphi for High Value Care

Can the Oracle of Delphi move us toward more high-value care?

Have you ever been in a meeting in which important decisions seemed to be made by or for the loudest voices in the room, even when you had a hunch that the secret consensus of the room was not in favor of the decision? If so, then you’ve been in a situation where the Delphi method would have helped.

In ancient Greece, Pythia was the high priestess of the Temple of Apollo. She was informally known as the “Oracle of Delphi.” The Oracle was consulted about important decisions throughout the ancient classical world, and her opinion was considered so valuable that Delphi was considered the center of the world. (I consider Byers, Kansas, my childhood home, the center of the world, but that fact has more to do with my robust self-esteem than it does with geographic fact or fiction.)

In modern times–the 1950s–the Delphi name was applied to a decision-making or forecasting strategy pioneered by the RAND corporation, a famous nonprofit policy think tank. (R ANd D; “research and development.” Get it?) Except this time, the decision was not to be made by an all-knowing oracle, but by the carefully considered and anonymous consensus of the group. They called it the Delphi method, and it is my favorite way to keep louder or more senior voices from always getting their way in meetings or organizations.

Here’s how it works:

• A panel of “experts” is convened, usually virtually or remotely, ideally with a diverse background but some technical expertise regarding the question at hand.

• Each expert is asked to make an anonymous judgement or prediction regarding the question(s).

• The participants remain anonymous, even through the completion of the final report, so that those who are more senior, more vocal, or more reputable cannot dominate the decision-making. (computers have obviously made Delphi much, much easier to facilitate than it once was)

This anonymity is also meant to free participants from any embarrassment about admitting error and to prevent the “bandwagon effect,” in which faddish ideas can become popular.

The experts’ initial answers to survey questions are collected, and irrelevant content is filtered out by a panel director. Then the survey and its answers are cycled back through the group so that others can revise their own opinions or forecasts. This process continues with a goal of gradually working toward consensus:

Wikipedia

This works for more than just complex decisions

Delphi has been adapted into “Wideband Delphi,” a technique in Scrum project management in which team members repeatedly, and anonymously, estimate the amount of time or work a project will take until they reach consensus. Then their wisdom is measured against the real-life velocity of the project to inform future estimates.

This is all prologue to what I really want to write about today, which is a solution for “guideline bloat.” Medicine, like many complex fields and like the field you likely work in, be it engineering, human resources, or accounting, continually develops and refines guidelines for use as tools to guide the screening for and care of specific illnesses. But medicine has a problem: there are too many guidelines, and they tend to encourage more care, not less. A well-known study estimated that a single primary care doc providing nothing but USPSTF screening and prevention recommendations for an everyday practice would need most of the day just for those, assuming no sick people ever came in the door. But an average primary care physician doesn’t just see people for screening and prevention, as you know. The average patient she sees has more than three problems or complaints.

So calls have come to prioritize guideline use, and some are saying that Delphi is the way to do it. In the last few weeks we’ve seen a demonstration (paywall) of how that might work. A team of investigators from several medical schools reviewed guidelines from the years 2011 through 2016 to identify “potential deintensification recommendations” in primary care medicine. That is, how can we take unnecessary care away from patients instead of adding more diagnostic work and potentially unnecessary therapies? They came up with about 50 possible recommendations and then reconfigured them to generate recommendations that 1) were actionable and measurable, and that 2) explicitly defined the deintensification action and which patients it might apply to. Then they convened a Delphi expert panel to review their synthesized evidence and judge the potential recommendations. The final work product of the panel was intoxicating if, like me, you’re the kind of person that believes that good medicine involves stopping as many treatments as you start. Here’s an example.

The original, pared-down guideline on colon cancer screening that was fed to the group of experts looked like this:

JAMA Internal Medicine

That’s a mouthful. But after a few runs through the Delphi machine, that word salad was chopped down to this:

JAMA Internal Medicine

That may still seem awkward and wordy if you’re not completely comfortable with medical jargon (FOBT is “fecal occult blood testing,” and FIT is “fecal immunochemical testing.” Enjoy your lunch). But to translate English to English, it just says that, in an average population, we should not repeat colon cancer screening very often unless past attempts at screening have been thwarted by too much poop in the patient’s colon for the doctor to be able to see through the colonoscopy camera. In other words, the health care system should not foot the bill for too-frequent cancer screening.

Two editorialists (paywall) write enthusiastically about the prospects for this kind of thinking about low-value care when low-value care is “driven by clinician behavior and a disjointed US health care system that pays for doing more, necessary or not.”

So two recommendations this week, neither of which have been run through a Delphi panel: 1) You should be using Delphi in your company if you’re not, especially if you have powerful voices that tend to dominate decision making. And 2) we should all be thinking about systematic ways like this to reduce the amount of low-value care being delivered by our healthcare system and paid for by our companies.

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 was a reprint of a blog post from KBGH.

Is the Broker Model Broken?

If you ever squirm through the seeping underbelly of dastardly health insurance tactics like we do here at KBGH, you may have seen this report from The Hill last week outlining some alleged underhanded tactics being used by health insurance brokers.

The tl;dr (too long; didn’t read) version of the story is that the Government Accountability Office (GAO) performed an undercover audit of insurance brokers to determine if companies selling health plans exempt from the Affordable Care Act coverage requirements were being honest about the limitations of those plans. After all, ACA non-compliant plans tend to be cheaper, but they also tend not to cover preexisting conditions.

Out of 31 undercover phone calls to representatives in Alabama, Florida, Kansas, Pennsylvania, and Wyoming, during which GAO agents posed as customers looking for health insurance that covered their preexisting conditions like diabetes or cancer, about a quarter of the time (eight calls) sales representatives engaged in “potentially deceptive marketing practices.” Examples included:

1. Representatives telling the undercover agents that preexisting conditions would be covered, even when the agents claimed conditions that were explicitly excluded by the plan in question.

2. Representatives refusing to provide documentation of coverage prior to enrollment.

3. Representatives implying or asserting that the customer was being enrolled in a comprehensive insurance plan rather than, for example, a health care sharing ministry or membership in an association with a bundle of limited benefit plans.

4. Representatives suggesting that no other coverage was available.

5. Representatives intentionally falsifying the caller’s health status on the application.

 Examples of call recordings are available online.

In spite of its shades of its Dateline NBC-esque qualities, this doesn’t seem to have been a showy, “gotcha” operation. The investigation was requested by Democratic senators Robert P. Casey and Debbie Stabenow as a follow up on an investigative report on misleading online ads for non-ACA plans. But the GAO is a nonpartisan organization. The Hill, which reported the story, is well-known as a centrist or even center-right publication. And as Katie Kieth points out in Health Affairs, this isn’t even the first report of its kind. Many other instances of this kind of behavior have been documented.

What does this mean for you, the employer?

This news alone may not be very relevant to your company’s health coverage. After all, these agents were posing as individuals seeking a non-ACA compliant plan. If you’re in Human Resources this is very unlikely to represent your interactions with a brokerage or the greater health insurance industry. But this isn’t the first time the insurance brokerage industry has been stung recently. In early 2019 a Propublica piece showed that brokers working on commissions–usually three to six percent of the premium–routinely increased the cost of benefits to companies. This isn’t a personality flaw in the broker agents; it’s a feature of a flawed system.

To my knowledge no one has been able to mount a significant defense against these allegations. To the contrary: the 2019 Propublica piece led to senators calling for disclosure of perks and fees paid to brokers, a position enthusiastically supported by Michael Thompson, the president and CEO of the National Alliance of Healthcare Purchaser Coalitions, of which KBGH is a member.

What you can do to protect yourself

KBGH believes that brokers can be a vital part of the health insurance marketplace. Health coverage is confusing, and it is worth good money to make sure your company is getting the best value for its health care dollar. Ideally, we would like to see all brokerages work on a fee basis and take no commission off your premiums, since that commission perversely incentivizes the broker to increase your health coverage costs. To make this easy, Health Rosetta has created a “Benefits Advisor Compensation Disclosure Form” that you can download for free to use with your broker.

But at the very least, we believe in transparency. Your broker should be able to disclose all the ways it is making money off its work with you up front. If your broker refuses to do that, we recommend that you find a new broker.

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 was a reprint of a blog post from KBGH.

Why Six Feet?

“We should all stand six feet apart to prevent the spread of COVID-19.” If you haven’t had that hammered into your head since March, let me be the hammer that takes the last lick at the nail.

Where did that number come from?

Six feet seems arbitrary. Why not five feet? Why not ten feet? In the August 25 issue of the British Medical Journal, “BMJ” for short, a few authors take us on a journey six feet long (or two meters, if you’re in one of the all-but-three countries that has switched from imperial to metric measurement; or two metres if you’re a true pedant).

The two-meter rule has a long history. Scientists in the 19th century, shortly after the very invention of germ theory, placed culture plates around patients who were then asked to cough or sneeze. Then the scientists could culture out whatever bugs landed on the plates. Most of the plates more than 1-2 meters from the test subject failed to grow anything scary. So, two meters became the default distance.

As cameras got better in the 1940s, visual representation of sneezes became possible:

Gross backlit sneeze snapshot brought to you by Wikipedia

One experiment showed that only 10% of droplets traveled as far as 5 ½ feet. So even though 10% of sneezers were able to eject harmful bacteria up to 9 ½ feet away, the two-meter rule was cemented. Unfortunately for hard-core two-meter adherents, recent studies have failed to fully support these original conclusions. Eight out of the ten studies included in a recent systematic review, for example, showed large numbers of respiratory droplets landing beyond 2 meters for particles up to 60 micrometers, a particle size large enough to contain thousands of copies of SARS CoV-2, although not small enough to deposit those viruses into your lungs.

Dragon breath-like eight-meter sneeze plume brought to you by Lydia Bourouiba via Wikipedia

What do we do with this information?

Not to pat my family on the back, but you do the same thing we did this weekend. You pretend that everyone in the world is a smoker, and you protect yourself from the imaginary PM2.5-rich smoke by wearing a mask and keeping your distance. On a shopping trip this past weekend, my wife and I ran into an acquaintance and talked with her, indoors, for several minutes. In our minds, she was actively smoking: we did not shake hands, hug, or get closer than a few feet, and everyone wore a mask.

Two days later, that person tested positive for COVID-19.

I’m going to be careful and self-isolate myself for a couple of weeks just in case; I’m fortunate that my work allows it fairly easily. But for the most part I feel safe because we were all masked, including the infected person, and we stayed relatively physically distant. Because as the authors of this review noted, the risk of transmission, even with prolonged exposure, is relatively low if everyone is masked and the environment is reasonably well-ventilated:

British Medical Journal

As we mentioned in a previous blog post, for example, two Missouri hairstylists who unknowingly exposed hundreds of people to the virus appear to have infected zero clients because of their fastidious facemask use.

So six feet isn’t magical. But it’s still a reasonable number, especially combined with good ventilation and good adherence to masking. The next time you see me, if I keep my distance and don’t shake your hand, it isn’t personal. It’s epidemiology.

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 was a reprint of a blog post from KBGH.

It’s Time For Your Flu Vaccine. Seriously.

With nighttime temperatures forecasted in the 40s next week, it’s no surprise that the time for influenza vaccination is upon us. And since this year’s seasonal flu coincides with an ongoing COVID-19 pandemic that is worse in America than in almost any other developed country, and because influenza vaccination will save lives and reduce symptoms that might be confused with COVID-19, CDC has details on new recommendations for vaccination. Here are the highlights of new information about the flu shot:

• Everyone aged 6 months and above should receive the influenza vaccine.

• Anticipate about two weeks from immunization to protection from the influenza virus.

• The timing of your shot isn’t critical. The duration of immunity from a flu shot is about four months, so the CDC recommends immunization before Halloween if possible in order to provide maximum protection through the heart of the flu season.

• Expect the vaccine to cut your risk of infection by about half, give or take:

• As always, the composition of the seasonal influenza vaccine is an educated guess based on trends in detected circulating viruses. The vaccine historically includes either three (“trivalent”) or four (“quadrivalent”) strains of virus. Each influenza A virus expresses a version of a sugary protein called hemagglutinin, or “H,” and a version of an enzyme called neuraminidase, or “N.” This year, in case you’re interested, trivalent egg-based vaccines contain:

  • Influenza A/Guangdong-Maonan/SWL1536/2019 (H1N1)pdm09 (a version of the virus implicated in the 2009 H1N1 Pandemic)

  • Influenza A/Hong Kong/2671/2019 (H3N2)

  • B/Washington/02/2019 (B/Victoria; a strain that accounted for the vast majority of influenza B infections last year)

• Quadrivalent (four-component) egg-based vaccines contain those three viruses in addition to influenza B/Phuket/3073/2013(Yamagata)

• Non-egg-based vaccines contain:

  • A different H1N1 called influenza A/Hawaii/70/2019(H1N1)pdm09

  • A different H3N2 called A/Hong Kong/45/2019(H3N2)

  • The same B/Washington/02/2019(B/Victoria)

  • The same B/Phuket/3073/2013(Yamagata)

• As you can tell, many versions of the influenza vaccine are available (and two new versions for folks aged 65 and up were recently approved), but the most important choice is not which vaccine to receive, but whether to get vaccinated. If you have questions about which vaccine is best for you, we encourage that you talk to your doctor or other health care professional.

• Common reasons to avoid a flu vaccination are having a fever that day, allergies to certain foods or ingredients like eggs or latex, or a previous serious reaction like swelling or seizure. Feeling a little sore after last year’s injection is not a reason to skip this year’s.

• Because remember: It is impossible to get influenza from the vaccination. The influenza vaccine contains only small amounts of either a protein that stimulates the immune system or an inactivated virus that is not capable of infecting anyone. In randomized, blinded trials (paywall) where some people got flu shots and others got only saline placebo shots, the only differences in symptoms was increased soreness in the arm and redness at the injection site in those people who got a flu shot. There were no differences between the groups in body aches, fever, cough, runny nose, or sore throat.

• In related news, since rates of routine childhood immunization have fallen during the pandemic, new rules from the Department of Health and Human Services now state that pharmacists nationwide will be able to administer routine childhood vaccines–that is, FDA-approved vaccines recommended by the CDC’s Advisory Committee on Immunization Practices for youth ages 3 to 18–during the COVID-19 pandemic. Needless to say, this is controversial.

For other questions about influenza vaccination, contact us or go to www.cdc.gov/flu/. Now go get your shot!

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 was a reprint of a blog post from KBGH.

What is the value of a mask?

For various reasons the rate of infection in Kansas is back on the way up, and it’s bound to get worse as the weather cools and we all spend more time indoors together.

 As businesspeople, we want to see a return on our investment. But what if the investment we make isn’t in our business or in the stock market, but in our health, and specifically in COVID-19 protection? An analysis from Goldman Sachs recently tried to answer this very question.

How do masks affect usage, case rate, and fatality?

The investigators estimated that the “Effective Lockdown Index, or “ELI,” a statistic of their own that takes into account a combination of official social mobility restrictions and actual social distancing data, took away about 17% from American gross domestic product (GDP) between January and April this year.

Then they looked at data from multiple sources to make a couple big conclusions:

First, mask mandates immediately increase the number of people who mask by about 25%. This seems reasonable and in line with our local experience when the Sedgwick County and City of Wichita emergency orders went into place. (It’s also worth remembering on a national level that Florida and Texas, two of the most-affected states, still don’t have statewide mask mandates).

Second, mask mandates are associated with large reductions in cases and deaths from COVID-19:

Again, this is largely in line with the change seen in Kansas counties with mask mandates versus counties without mask mandates. So using some further reasonable assumptions and fancy statistical methods, the Goldman Sachs folks determined that a national mandate would cause a 15 percent rise in the share of the population that wears masks, which would in turn reduce the daily growth of cases by about one percent.

Gauging the economic impact of wearing a mask

With those numbers in their pockets, the investigators went back to their “ELI” to determine what fraction of the economy would be affected by another March/April-style lockdown:

They determined that another lockdown similar to this past spring’s would cost just short of 5% of total economic activity. As we said last spring, pandemic viruses cause recessions. Then authors writing in The Economist simply divided that share of GDP by the number of people who would start wearing masks under a mandate and came up with a value for mask wearing. They calculated that one American wearing a mask for one day prevents a fall in GDP of $56.14, or about double the initial fine that you would get in Wichita for being a recalcitrant mask non-wearer. As the authors of the Economist piece said, “Not bad for something that you can buy for about 50 cents apiece.” Clearly they’re not taking into account my designer taste in facial covering, but I digress.

 It’s tough to overstate how huge this potential cost savings is. For reference, doubling smoking cessation counseling services, as we covered in a previous blog post, returns about $215 per employee over ten years, the equivalent of about $0.06 per day. I’ll admit that’s not a fair comparison, since we’re comparing the benefit to the employer in the case of smoking cessation versus the benefit to the national economy in mask-wearing. But I think my point is made.

 I’m lucky to live in a mask-mandated city inside a mask-mandated county. But for the rest of us, if we want our businesses to stay open, and if we cannot count on mandates or enforcement at the city, county, state, or federal levels, we need to mandate mask use from our employees ourselves.

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 was a reprint of a blog post from KBGH.