Unbiased Analysis of Today's Healthcare Issues

Quality of Life and Prospect Theory

Written By: Jason Shafrin - Jul• 07•16

Prospect theory states that individuals view transactions relative to a fixed reference point.  Individuals are risk averse for gains (i.e., they would prefer $10 for sure over a 50/50 of winning $0 or $20) but risk loving over losses (i.e., they would prefer a 50/50 ‘lottery’ of losing $0 or $20 over a sure loss of $10.  But are findings for individual preferences for monetary outcomes relevant for patient preferences over quality of life states?

This is the question examined by Attema et al. (2016) using a survey methodology.  They find that:

…health is a fundamentally different commodity than money, with a positive correlation between concavity for gains and for losses. Instead, ‘diminishing sensitivity’ or reflection at the individual level, with a positive correlation between concavity of utility for gains and convexity for losses,is often found in the monetary domain.

Hmmm….that is pretty confusing. Can you give me an example?

For example, people mayevaluate a loss of $11,000 as similar to a loss of $10,000, since the additional loss of $1000 is not perceived as making much of a difference in the context of an already large loss. However, the difference between $1000 and $2000 is perceived as large.

This makes sense.  If you are buying a care, a $500 increase in the price of a $30,000 care seems small, but a friend asking for a $500 loan seems very large.

How is health different?

In the health domain, with 60% as reference point, convexity would mean that a loss from 60% to 40% of QoL would be perceived as much“larger” than a loss from 40% to 20%. We observed the opposite in our experiments: the loss from 60% to 40% was perceived as smaller than the loss from 40% to 20%.

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Paging Dr. Watson

Written By: Jason Shafrin - Jul• 06•16

In the future, will your recommended cancer treatment be decided by a computer?  That is what IBM hopes with the launch of their Watson for Genomics project.  CNET reports:

Typically, finding the appropriate treatment for a specific patient means sequencing his or her genome — the complete DNA structure packed into a single cell — finding mutations and then getting a team of seasoned doctors in a room to decide the best options. Watson can do it in less than three minutes…

Watson for Genomics will take on the data-intensive task of searching through sequenced DNA of patients from the Veterans Affairs Department, finding mutations and scanning medical literature to pinpoint the therapeutic treatments that would work best. The program promises to identify customized regimens for 10,000 US veterans during the next two years.

However, patient treatment preferences are likely to vary.  One drug may be more effective but have serious side effects, another may be less effective but fewer side effects.  It is unclear how Watson would take into account these patient preferences.

Thus, a more likely solution is that a Watson-physician team will present treatment options to patients. Physicians will not be replaced, their role will just change.

The pros and cons of retail clinics

Written By: Jason Shafrin - Jul• 05•16

Aaron Caroll does a nice job summarizing these viewpoints in his article in the N.Y. Times’ Upshot:

Researchers for a study published in the American Journal of Medical Quality talked to patients who sought out care at retail clinics. Patients who had a primary care physician, but still went to a retail clinic, did so because their primary care doctors were not available in a timely manner. A quarter of them said that if the retail clinic weren’t available, they’d go to the emergency room.

It’s understandable why physicians’ groups might be opposed to retail clinics. Above and beyond the obvious economic loss when a patient goes elsewhere, many primary care physicians correctly point out that retail clinics often lack the knowledge and experience that come from continuity of care…The American Academy of Pediatrics, the American Academy of Family Physicians and The American Medical Association have all released policy statements or guidelines that oppose, or at least advise, that use of retail clinics be restricted.

Are the doctors right?  On average, the clinics do a pretty good job according to a study by Mehrotra et al. (2009).

Overall costs of care for episodes initiated at retail clinics were substantially lower than those of matched episodes initiated at physician offices, urgent care centers, and emergency departments ($110 vs. $166, $156, and $570, respectively; P < 0.001 for each comparison). Prescription costs were similar in retail clinics, physician offices, and urgent care centers ($21, $21, and $22), as were aggregate quality scores (63.6%, 61.0%, and 62.6%) and patient’s receipt of preventive care (14.5%, 14.2%, and 13.7%) (P > 0.05 vs. retail clinics).

Carroll rightly points out, however, that retail clinics may increase health care cost.  Although cost per visit are lower for retail clinics, they are much more convenient than a doctors visit and are likely to induce more visits.  This is not  a bad thing if patients were forgoing care because physician office’s inconvenient hours were a barrier.

Fourth of July

Written By: Jason Shafrin - Jul• 03•16

Happy Fourth of July weekend.  For Americans, the Fourth of July means celebrating with BBQ, fireworks, friends and family.  But being safe is important as well.

As the U.S. Consumer Product Safety Commission reports, in 2014 there were 11 deaths and more than 10,000 injuries from fireworks that resulted in an ER visit.

Not only is your physical health at risk, but your financial health may also be at risk.  The Connecticut Post reports that:

fireworks affect two different policies – your homeowner’s insurance policy and your health insurance policy. Injuries to yourself or your family are going to be covered by your health care policy. Damages to property and injuries to others will be covered under separate sections of your homeowner’s policy.

This weekend, have fun and be safe.

Friday Links

Written By: Jason Shafrin - Jun• 30•16

After 190 failed tries…

Written By: Jason Shafrin - Jun• 29•16

Why are pharmaceuticals so expensive?  One reasons is that there is a lot of research that goes into developing a drug.  Most of that research results in drugs that don’t work.  One example is the search for Alzheimer’s treatment.  As Bloomberg reports:

Drug companies have long focused on a different protein called amyloid that clumps in the brains of Alzheimer’s patients and is thought to trigger the disease. Companies have poured billions into amyloid-blocking drugs with little success. In 2010, Eli Lilly halted trials of semagacestat after patients on the drug deteriorated more quickly than those on a placebo. In 2012, Pfizer and Johnson & Johnson released results of large trials that showed their amyloid treatment didn’t slow progression of the disease. All told, at least 190 Alzheimer’s drugs have failed in human trials, according to Bernard Munos, a senior fellow at FasterCures, a health nonprofit.

Clearly, Alzheimer’s is one of the most important diseases where treatments have largely failed.  Incentivizing innovation–through higher drug prices, prizes, the patent system, basic research funding, and other avenues–is key to ensure that the fight for effective Alzheimer’s treatments continues.

Measuring Quality in Cancer Care

Written By: Jason Shafrin - Jun• 28•16

Identifying high-quality, cancer care is a laudable goal.  However, a recent article by Alvarnas (2016) says the way many are trying to measure quality of cancer care currently is inadequate.  Specifically:

  1. Quality and value are multidimensional, but the narrow focus of many quality measures undermines their effectiveness and meaningfulness. (Porter 2010)
  2. Quality and value measures are all too often based upon isolated care transactions, rather than based upon the continuum-of-care model that is an essential part of effective cancer care.(Porter 2010)
  3. Few quality/cost/value measures include risk as part of their formulation or expression. (Spinks 2011, CIBMR 2016)
  4. Electronic Health Records do not facilitate capture or assessment of key outcomes data.(Klumpp 2013)
  5. Few quality measures are linked to care strategy, healthcare facility/provider strategic planning, or the development of more effective care systems.(Porter and Lee 2015)
  6. Our measures for assessing patient-reported outcomes are weak, and rarely measure those things which matter most to patients.(Johnson 2016, de Boer et al. 2008)

So what’s the alternative to administrative quality measurement?  Porter and Lee 2015 recommend the following:

The failure to prioritize value improvement in health care delivery and to measure value has slowed innovation, led to ill-advised cost containment, and encouraged micromanagement of physicians’ practices, which imposes substantial costs of its own. Aligning reimbursement with value in this way rewards providers for efficiency in achieving good outcomes while creating accountability for substandard care.

That sounds like a better vision to me.

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Brexit = upheaval for drug makers

Written By: Jason Shafrin - Jun• 27•16

Will the European Medicines Agency (EMA) need to re-located after Brexit? According to a Reuters story, the answer is yes.

The EMA is a London-based organization that approves treatments for all EU countries. As the UK leaves the EU, however, EMA is expected to have to relocate. 600 individuals work for EMA.

More important is how Brexit would affect patients.

Although Britain could continue to take part in the EMA system if it remains in the European Economic Area, like Norway, many of those supporting its exit from the EU oppose that option.

As a result, British patients could move to the back of the queue for new medicines as companies prioritize the larger EU market, and some medicines could be left in regulatory limbo.

Where will EMA go?  Healthcare officials in Sweden, Denmark, Italy and Germany have expressed interest in hosting EMA, but EMA’s future destiation–or if any move at all will be needed–is still influx.

Doctors with Borders

Written By: Jason Shafrin - Jun• 26•16

Although I believe that a lot of the pundits claims of economic downturns due to the Brexit are overblown, there are clearly many uncertainties to resolve.  The Telegraph reports on how Brexit will affect doctors working in the UK.

As a result of the country’s decision to leave the EU, health regulators may have to change the way information about medics is shared across European borders when concerns are raised about doctors or nurses.

At present, there are European directives on sharing disciplinary records and fitness to practise hearings.

Niall Dickson, chief executive of the General Medical Council, said: “Withdrawing from Europe will have implications for the way that we regulate doctors but we understand that the vote to leave the EU will have no impact on the registration status of any doctor already on the register.

“We will now explore how doctors from the EU will be granted access to the UK medical register and how any concerns about those doctors will be shared between us and other countries.

“We will also seek to understand the implications for UK doctors wishing to work in the EU once the UK is no longer a member state.”

Will the cost of health care rise in the UK due to an inability to hire less expensive foreign physicians and health workers. Perhaps, but my guess is that the effect is fairly modest, especially after immigration rules within the UK have been ironed out.

Links

Written By: Jason Shafrin - Jun• 24•16