Reducing unnecessary care: On Wednesday April 4, nine physician societies, together with the ABIM Foundation and Consumer Reports, released a list of 45 procedures or tests (5 per specialty) that are overused and adding to soaring healthcare costs as part of a new educational initiative called Choosing Widely. Another 8 specialty boards are preparing lists of relevant tests their members should be more judicious about ordering. Once again it’s a reminder that there’s growing support for the idea that in certain areas of healthcare it’s critical to embrace a “less is more” mentality. Among the tests garnering extra scrutiny: CT scans for chronic sinusitis, dual energy X-ray scans for osteoporosis in women younger than 65, and MRIs to evaluate lower-back pain.
But given the grievous nature of cancer, it’s the recommendations by the American Society of Clinical Oncology that could prove most controversial, especially guidance to avoid chemotherapy use in advanced cancer patients who are unlikely to benefit. As Sharon Begley of Reuters reports, ASCO’s recommendations were driven by medical considerations, but, importantly, cost was also a major factor. The NYT suggests doctors will be more likely to embrace the notion of doing less since the guidelines come directly from physician groups (as opposed to a government sponsored organization like the US Preventive Services Task Force).
Maybe, but one thing that would help: changing the reimbursement structure away from fee-for-service so that physicians are compensated for their cognitive skills. In the current environment, physicians are paid more for doing more, noted Lee Newcomer, SVP of Oncology, Women’s Health and Genetics at UnitedHealthcare, in a recent Value & Innovation sponsored webinar. Indeed, that disconnect is one of the reasons United instituted an episode-of-care pilot at 5 practices in 2010 that pays doctors a separate case management fee when treating breast, lung, and colon cancer patients. In early 2012 the program was further enlarged to include a sixth group, with data about the program’s performance (in terms of cost-savings, quality, and end-of-life care) due out sometime later this year. –Ellen Licking
- Doctor panels urge fewer routine tests (NYT).
- Doctors seek to end 5 cancer tests, treatments (Reuters).
- More on the Choosing Wisely Campaign.
More controversy tied to Provenge: As the first therapeutic cancer vaccine to reach the market, Dendreon’s prostate cancer vaccine Provenge has been plagued with more downs than ups. After weathering an initial FDA rejection (2007), a national coverage decision (2011) and a lackluster launch, Dendreon’s newly revamped management team must tackle yet another hurdle that seems likely to impact drug adoption: charges that pivotal data were misinterpreted. Indeed a major paper published recently in the Journal of the National Cancer Institute questions whether the costly vaccine extends overall survival, hypothesizing instead that the placebo used to treat control patients may actually have been harmful.
Provenge is a custom product, generated by extracting a patient’s white blood cells and engineering them with a specific antigen such that when they are given back to the individual, the modified cells trigger the immune system to produce T-cells to kill the prostate cancer cells. Thing is, in multiple studies, administration of Provenge hasn’t resulted in shrinkage of primary tumors or secondary metastases, an event you’d expect if the immune system had been reactivated. Another conundrum: after-the-fact statistical analysis (always tricky) showed that the increased life expectancy took place only in the patient population that was older than 65, while the younger men showed no improvement. This finding is surprising because it’s well known that the immune system weakens with age, yet Provenge’s observed response is most effective in those with the weakest immune systems.
The JNCI paper makes a controversial suggestion: the placebo group may have been compromised. Perhaps the weaker immune systems of the older men were unable to handle the removal and subsequent transfusion of white blood cells. While this hypothesis has yet to be tested rigorously, the implications for Dendreon couldn’t be worse. The publication of strong data associated with the much cheaper Zytiga [HB1] in the pre-chemotherapeutic setting are already a burden Dendreon’s new commercial chief must solve, and nearly a dozen new therapies are now in Phase III, including other cancer vaccines that are easier to manufacture, and could theoretically be priced more cheaply. – HB
- Click here to access the JCNI paper.
- For coverage by the Chicago Tribune see here.
- A Reuters story on the topic is here.
Kids breathe easy with lower co-pays: Yet more data supporting the advantages of keeping drug co-pays low: according to a study published on March 28 in the Journal of the American Medical Association, parents don’t fill their children’s asthma medication as frequently as recommended when insurance companies increase co-pay fees. The ten-year study analyzed the insurance claims for almost 9,000 children prescribed new medicines to treat their asthma. For asthmatic kids between five and eighteen, higher co-pay costs were tied to about three more days without treatment compared to those with lower co-pay costs. Similarly, about 2.4% of kids in the higher co-pay group were hospitalized in the first year as opposed to 1.7% in the lower cost group. When the price of medications and hospitalization were added up, there was no reported difference in total asthma costs between the two co-pay groups because the increased hospitalizations made up for any savings payers incurred on drugs. The lessons of the report are twofold and complicated: on the one hand, there is evidence again that higher co-pays have negative effects on prescription adherence – for sure, lowering medication costs will somewhat reduce hospitalizations. On the other hand, because the difference in prescription adherence between the two groups was small, the data suggest simply cutting co-pays won’t significantly improve consumer adherence, meaning additional strategies will be required. One avenue many payers are betting on: new patient engagement tools, especially mobile tools that help track behaviors.-HB
Pay-for-Performance remains controversial: We all know that a large part of current healthcare policy is focused on tying financial incentives to performance, rather than services, cutting unnecessary costs and improving patient outcomes. A new study published on March 30 in the New England Journal of Medicine might send some policy makers back to the drawing board. The Centers for Medicare and Medicaid Services (CMS) recently completed a 6-year outcomes-based research study of pay-for-performance hospitals through the Premier Hospital Quality Incentive Demonstration (HQID). The idea is reasonable: financial incentives for better care should promote improvement in the quality of care and, in theory, lead to better patient outcomes. Here’s the sticking point: while there were data supporting Premier HQID’s ability to significantly improve quality of care, they didn’t show a reduction in patient mortality during the study period. While some say the study casts doubt on a central tenet of the healthcare law, CMS noted in a statement that the Premier HQID was an “effort under the last Administration, separate from the value-based purchasing model that we’re implementing into Medicare’s hospital payment system.” The value-based purchasing model covers a broader range of hospitals and includes incentives for improvements in quality metrics beyond mortality rates. Nor should the observed quality improvements be underestimated: the Premier alliance estimated the project saved the lives of 8,500 heart attack patients over five years alone. –HB
- Read the full study from the New England Journal of Medicine here.
- Read more from Kaiser Health News.
- For more on the Premier health alliance report on HQID click here.
SCOTUS and healthcare reform: what to read now. Three days of intense oral arguments on the constitutionality of the Accountable Care Act in the Supreme Court added to March Madness this year. At its crux, the ongoing debate centers around three key questions. First, does the individual mandate fall within the constitution’s commerce clause? Second, must the entire health-care law fall if the individual mandate is found unconstitutional or is this provision severable? And third, does the requirement for states to expand their Medicaid programs in compliance with the law overburden the states beyond federal authority? Now that the pointed repartee, the garbled defense of the mandate, and the disparagement of cruciferous vegetables have ended, let the strategizing and prognosticating begin. How will Justice Kennedy and Chief Justice Roberts vote?
For the record, President Obama remains confident the mandate will hold. Meantime, Wall Street reacted positively to the publicized hearings sending the share prices of major payers like Aetna, UnitedHealthGroup, Humana, and WellPoint up 2% to 5% in the wake of the hearings. Indeed, Wall Street appears to be betting the ACA will either be upheld as written or completely struck down come June. It’s the compromise position – the one in which the individual mandate is abolished but the other insurance regulations remain that is more problematic for payers. The fear is it would result in healthy people dropping their coverage, meaning those with insurance are statistically sicker and more expensive to treat, a recipe for soaring premiums.
That’s a bad recipe for big for-profit hospitals too (but so is outright repeal of the law), notes Moody’s. In a report issued April 4 they predict partial or total repeal of healthcare reform will squeeze for profit-hospitals as costs associated with treating patients financially unable to pay their bills increase.
What alternatives might Democrats and President Obama propose if the Supreme Court repeals the individual mandate in June? Some like Paul Starr of Princeton have recommended adopting the so-called German Provision, in which individuals threatened by the mandate can opt out but must then wait five years before they can qualify for guaranteed insurance that doesn’t include pre-existing conditions. But the only real answer for which there is consensus; crafting a just-in-case Plan B is a top priority. EL & HB
- Transcript from SCOTUS oral arguments
- Wall Street Thinks It Knows The Future of Obamacare, via The Atlantic.
- The constitutionality of the mandate (LA Times Op-Ed).
- A December 2011 New Republic Article looks at alternatives to the individual mandate.
- Moody’s issues a report on hospitals in the wake of an ACA repeal.
Image courtesy of flickrer waferboard via creative commons.