June 2011

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MRIs, Back Surgery and Primary Care

June 30, 2011 in Physician Compensation, Specialists, Supply of Medical Services | No comments

Do MRIs increase the liklihood a patient receives back surgery?

“Orthopedists and primary care physicians who begin billing for the performance of MRI procedures, rather than referring patients outside of their practice for MRI, appear to change their practice patterns such that they use more MRI for their patients with low back pain. These increases in MRI use appear to lead to increases in low back surgery receipt and health care spending among patients of orthopedic surgeons, but not of primary care physicians.”

What is it about patients who see primary care physicians that makes them less likely to get back surgery. I can think of a number of reasons:

  • Financial Incentives: Primary care physicians would not be the ones performing the surgery and thus have no financial incentive to favor surgery over rehabiliation.  Orthopedists who self-refer the surgery stand to gain thousands of dollars from this decision.
  • Provider Selection. Doctors who decide to become primary care physicians may favor less invasive treatment.
  • Patient Selection. Patients who visit primary care physicians may favor less invasive treatment. Or, patients who visit primary care physicians may be more likely to have lower income and less generous insurance coverage, and thus may be more likely not to opt for the back surgery.

Source

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CoR + Wednesday Links

June 29, 2011 in Carnivals, Current Events | No comments

…and of course this week’s Cavalcade of Risk is up at Workers’ Comp Insider.

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Biases

June 28, 2011 in Econometrics | No comments

All economists are familiar with the problem of selection bias.  In non-randomized samples, patients may choose to be in either the treatment or control group based on factors which are also related to the outcome of interest.  Even if researchers can design a study that fully controls for selection bias, robust studies must also account for other biases.  These include:

  • Recall bias: Patients in one group have better or worse memory of a given event.  If one wishes to compare changes in income for individual who received certain workforce training, individuals who participated in the program may be more or less likely to inflate their income levels over time.
  • Interviewer bias: If new data is being collected and researchers use separate interviewers for the treatment and control groups, if one interviewer systematically over/understates the interviewee responses, the study results will be biased.
  • Observation bias: This problem is particularly problematic for medical studies.  Observation bias occurs when physicians (or patients) are more likely to detect a disease.  Thus, a study identifying how pollution affected disease rates may underestimate the impact of the pollution if those affected are less likely to detect any disease than those who are not.  For instance, if poor individuals are more likely to drink polluted water than rich individuals, but also less likely to go to the doctor, the disease incidence from polluted water would be underreported and the causal impact of water pollution would be underestimated.

Outside of purely statistical biases, the research community at large may suffer from other biases as well.  These include:

  • Funding bias: Researcher bias towards interpreting quantitative results in favor of the entity which funded their study.
  • Status quo bias: Survey respondents may base their opinions closer to the status quo or researchers can interpret their results in a fashion more likely to coincide with the existing academic literature.
  • Publication Bias: tendency of researchers, editors, and pharmaceutical companies to handle the reporting of experimental results that are positive (i.e. showing a significant finding) differently from results that are negative (i.e. supporting the null hypothesis) or inconclusive, leading to bias in the overall published literature.
  • Hindsight bias: is the inclination to see events that have already occurred as being more predictable than they were before they took place

 

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Access to health insurance ≠ Access to health care.

June 27, 2011 in Health Insurance, Health Reform, Public Policy | 3 comments

Is the Massachusetts health reform a success?  Yes and no.

In terms of increasing access to health care, it has been an unqualified success.  According to the Economist, only1.9% of Massachusetts residents were uninsured in 2010.

Massachusetts’ health reform has not been able to offer universal access to health care or to constrain costs. “ One in five working-age adults say they have trouble finding a doctor who will see them…Spending on MassHealth, the programme for the poor, rose 40% between 2006 and 2010….average monthly premiums rose by 12% between 2006 and 2008. True, a higher share of firms now offer coverage, but they are also shifting costs for that coverage to employees”

Massachusetts is trying to legislatively block health premium increases.  Reducing health insurance cost, however, will likely drive down provider reimbursement and either increase cost sharing or decrease access to health care.

The key takeaway from this post is the following: “Access to health insurance does not guarantee access to health care.”

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Medicare Dashboards

June 24, 2011 in HC Statistics, Medicare | 2 comments

For which drugs does Medicare spend the most money?  For which inpatient hospital treatments does Medicare have the highest expenses.  CMS’s new Dashboards provide an easy to use source to access these high level summary statistics.  You can find this information here:

For instance, some results from the Prescription Drug Benefit Dashboard include:

Drug Class 2008 Drug Cost ($)
ANTIHYPERLIPIDEMICS $6,165,831,884
ANTIPSYCHOTICS/ANTIMANIC AGENTS $5,698,011,103
ANTIDIABETICS $4,688,777,238
ULCER DRUGS $4,411,792,980
ANTIHYPERTENSIVES $4,177,531,157
ANTIASTHMATIC AND BRONCHODILATOR AGENTS $3,598,966,726
ANTICONVULSANTS $3,288,116,849
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS – MISC. $3,112,790,209
ANTIDEPRESSANTS $2,835,474,451
ANALGESICS – OPIOID $2,578,161,329

 

Drug Class 2008 Drug Cost ($)
LIPITOR $2,397,843,000
PLAVIX $2,305,145,585
NEXIUM $1,487,052,730
SEROQUEL $1,462,338,499
ARICEPT $1,326,144,339
ZYPREXA $1,229,061,198
ADVAIR DISKUS $1,213,298,009
ACTOS $1,062,975,107
PREVACID $848,394,558
ABILIFY $837,090,968

More publicly available government statistics can also be found at Data.gov.

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Stanley Cup HWR

June 23, 2011 in Carnivals | No comments

Boston Health News has posted the latest Health Wonk Review, subtitled Hockey, hoodlums and hot rod angels.  Check it out!

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Health Reform in the UK

June 23, 2011 in Current Events, International Health Care Systems | No comments

Health Reform in the U.S. means more government involvement in health care.  More public insurance (expanding Medicaid), more government intervention in the insurance market (health exchanges), and government being a driving force for innovation (the Center for Medicare and Medicaid Innovation).

In the UK on the other hand, “Health Reform” means more privatization, not less.  As reported in the Economist,

“Last year the government produced a two-part blueprint for reforming the NHS. One part was a bid to introduce more choice and competition, by enabling private and voluntary providers to treat more NHS patients. That should not have been controversial: along with the cash it hurled at the service, Tony Blair’s government began to transform it from a publicly run monopoly to a state-funded market, in which both public and private hospitals treat NHS patients—the sort of system that exists in much of the rest of Europe. Until Gordon Brown took over and dampened reform, it was starting to have an impact: according to research by the London School of Economics into post-operative heart care, giving patients choice led to productivity increases that saved around 300 lives a year.”

These changes, however, may never come to pass.  For instance, an attempt to “…transfer more control over budgets and the commissioning of care to family doctors (GPs)” was stopped in its tracks.  The scheme is now voluntary.

Nevertheless, I can make three key observations.

  • The U.S. is moving more towards government-run health care and the U.K. is moving towards private provision of health care services.
  • Despite this trend, the NHS still wields significantly more control over the health care system than any American agency.
  • Finally, no country is completely happy with their health care system.

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Wednesday Links

June 22, 2011 in Current Events | 1 comment

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Egypt: Six Months Later

June 21, 2011 in Current Events, Regulation | 1 comment

A lot has changed since I last visited Egypt in early January and since the protests in Midan Tahrir in mid-January.  According to Marketplace, one thing that hasn’t changed is the incredible amount of bureaucracy which still exists in the country.

So here’s the crux, according to Ragui Assaad, a fellow at the Economic Research Forum in Cairo: Too many business-minded Egyptians look at the hassle, the heartache, and sheer waste of time involved and decide not to register their business.

RAGUI ASSAAD: Many people simply cannot afford to do these things and so avoid them altogether and remain under the radar.

Assaad says you can call it the “black market” or you can call it the “informal” economy.

ASSAAD: This is the issue of informality. Informality is not that people don’t want to pay taxes. Informality is that people cannot afford the very high transaction costs that it takes to deal with the bureaucracy in any way.

As I recommended in an earlier post, a funny, heart-wrenching read which details how the common Egyptian cab driver deals with many challenges–including government bureaucracy–is the book Taxi by Khaled Al Khamissi.  In addition to increasing the level of freedom Egyptians have available to them, reducing these high transaction costs is one of the keys to improving the quality of life in Cairo and the rest of Egypt.

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Maximizing utility for end-of-life care

June 20, 2011 in Hospitals, Nursing Homes | 1 comment

Hospitals in Sacramento were concerned about the large number of nusring home transfers to its facility.  Were many of these tranfers unnecessary? Did patients with little chance of recovery benefit from these hospital stays?

To reduce end-of-life tranfers to hospitals from nursing homes, 3 Sacramento-area hospital systems and 18 nursing homes instuted the Preparing Residents for End-of-Life Plans and Respecting Endof-Life Decisions (PREPARED) project.  In the project, the hospital systems provided clinician educators with expertise in end-of-life care to work part of their time each week in nursing homes. The PREPARED intervention included provided advance care planning (ACP) education to patients as well as nursing home staff and administrators.

The study found that the initiative decreased hospitalization rates, increased nursing home as the the site of death, and improved perceptions of quality of care by family members.

How do family members perceive quality of care? The study shows that family members prefer the more intimate setting of a nursing home to a hospital, but this preference is likely conditional on a fixed death date.  By this I mean that if a family knew there loved one would die with certainty on a given date, the nursing home would be the preferred setting. If hospital care could extend the patient’s life, however, (i.e., more realistically not conditioning on death date) then family members may prefer to send their loved one to the hospital even though it is a less intimate setting.  A lot of these preferences may have to do with provider education. Providers who tell family members that their loved one has a chance (albiet small) of recover may be more likely to go the hospital route than those whose providers tell them there is basically no chance of recovery.

Further, most people would rather commit an error of commission than omission.  For instance, by not sending a loved one to the hospital, family members may feel guilt that they didn’t do all they could to save the patient.  However, sending the loved one to the hospital has its own risks (hospital acquired infections, complications, medical errors), but it seems that generally family members feel less guilty about death due hospital-related care.

Thus, although the study shows that family members are more satisfied when their loved one dies in a nursing home compared to a hospital, I do not believe that this is strong evidence of a long-term trend towards less hospitalization of terminally ill patients.

Source: Kathy Glasmire and Kathleen Kerr. Be Prepared: Reducing Nursing Home Transfers Near End of Life. CHCF, March 2011.

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