Congrats to Dr. Bob Badgett on his coming retirement from KUSM-W

How Do You Know if Your Doctor Is Doing a Good Job?

We’ve spent a lot of ink in this blog discussing how difficult it is to measure quality in the various US healthcare systems. One large-scale effort to measure quality is the “Medicare Merit-based Incentive Payment System,” or MIPS. MIPS is a big deal for health systems. Quality isn’t just for professional pride. The MIPS program has a significant impact on the reimbursement received by U.S. physicians.

Some of the surveys or questions you’ve undoubtedly had to answer in doctors’ offices the last few years are undoubtedly tied to their efforts to improve their MIPS score. MIPS rates physicians based on measures in four categories:

1. Quality (30% weight), mostly in terms of clinical outcomes and patient experience. Doctors might be scored on the percentage of hypertensive patients who have their blood pressure controlled or the percentage of their patients who report a high level of satisfaction with their care.

2. Promoting interoperability (25% weight), how well a physician uses technology to improve the quality and efficiency of their care. Measures in this category might include the percentage of patients using the electronic health record (EHR) portal or how many prescriptions are sent to the pharmacy electronically.

3. Improvement activities (15% weight), how well a physician is working to improve her practice through activities like quality improvement programs.

4. Cost (30% weight), how much a physician’s care costs compared to his peers. Think: the number of seemingly unnecessary tests and procedures ordered.

Because the work that, say, a psychiatrist does is so different from the work a urologist does, doctors who participate in MIPS may choose six of a possible 257 performance measures to report, only one of which must be an “outcome measure,” such as hospital admission for a particular illness. The others can be “process measures” like rates of cancer screening. Docs are given a composite MIPS score between zero and 100. To avoid a “negative payment adjustment,” (that is, a reduced fee) physicians must score >75, which seems high to me unless I frame it as a solid “C” grade. Also, 86% of the docs in the sample achieved at least that score, indicating that they either are good at gaming the system or that the score isn’t terribly difficult to achieve.

In spite of the massive effort put into MIPS by regulators, docs, and health systems, it’s unclear whether the MIPS program really reflects the quality of care provided by participating physicians. To investigate, investigators analyzed 3.4 million patients treated in 2019 by 80,246 primary care physicians using Medicare datasets (paywall). They looked specifically at five “process measures” like rates of diabetic eye examinations and breast cancer screens and the “patient outcomes” of all-cause hospitalizations and emergency department visits.

They found that physicians with low MIPS scores (<30) had worse performance on three of the five process measures compared to those with high (>75) MIPS scores. Specifically, the low-scoring docs had lower rates of diabetic eye exams, HbA1c screening for diabetes, and mammography for breast cancer screening. However, the lower-performing docs had better rates of flu vaccination and tobacco screening. In the “patient outcomes,” there was no consistent association with MIPS scores: emergency department visits were lower (e.g., better) for those with low MIPS scores, while all-cause hospitalizations were higher (worse).

Overall, these inconsistent findings suggest that the MIPS program may not be an effective way of measuring and incentivizing quality improvement among U.S. physicians. The “patient outcomes,” which I think most of us would be most interested in, showed no clear association with MIPS scores. In addition, the study found that some physicians with low MIPS scores had very good composite outcomes, while others with high MIPS scores had poor outcomes. Like every correlative study, there were outliers. This suggests that there may be other, more nuanced, factors at play that are not captured by the MIPS program that influence a physician’s performance.

The study is recent enough that we don’t have peer-reviewed criticism or hypothesizing yet about the potential mechanism of MIPS failure. But a blog post from Cornell puts it this way: “…there is inadequate risk adjustment for physicians who care for more medically complex and socially vulnerable patients and that smaller, independent primary care practices have fewer resources to dedicate to quality reporting, leading to low MIPS scores.” So, sicker patients going to smaller, independent practices may drag down results. Put another, more frank, way from Dr. Amy Bond in the same blog post, “MIPS scores may reflect doctors’ ability to keep up with MIPS paperwork more than it reflects their clinical performance.” For our comrades in Human Resources, I suspect this criticism rings especially true.

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.

Publishing good science is the closest most of us get to immortality

First, a story about the last time I cried: a few weeks ago, I began to wonder how Dr. Susan Braithwaite, one of my professors from my endocrine fellowship at the University of North Carolina, was doing. I had asked her for a letter of reference in January of this year, 2022, because I was applying for a part-time job back at my medical school alma mater, the University of Kansas School of Medicine here in Wichita.

I emailed her to ask for the letter, which seems kind of strange and unprofessional except for the fact that she was a furious, enthusiastic emailer; during hospital rounds, she would go from floor to floor, opening computers and buzzing through her inbox to make sure no patient or physician had contacted her with critical information in the last fifteen minutes. In her immediate emailed response to my request, she mentioned she was having some health issues, but that she hoped to get back to work soon. She graciously agreed to write my letter of reference. It was promptly delivered to the Promotion and Tenure Committee at KUSM-W.

I got the job, and I wrote her an e-mail to thank her for her help. I offered to send her a physical, snail-mailed thank-you note, but I didn't know her physical address, and I don't think she was interested in giving it to me. In my thank-you email, I mentioned that I had used, and continue to use, her basal-bolus insulin titration algorithm that she, with an alliterative panache, published as “Five Steps to Freedom” on New Year’s Day in 2005. If you’re curious, here are the five steps:

But I’m getting ahead of myself. I promised a story about crying, not a story about blood sugars. A few weeks ago, after using the Five Steps algorithm for what must have been my 1,000th patient, I wondered how her health was holding up. So, I sent her a quick email.

I did not get an immediate response.

After a few days, I got a gmail nudge telling me that I had sent the email to Dr. Braithwaite five days earlier and asking, did I want to try again? I felt a wet, furry sense of dread. Instead of sending another email, I instinctively typed “Susan Braithwaite obituary” into Google and closed my eyes as I hit “enter.” Then I saw this:

And that’s when I cried. I cried for the reasons most of us cry when we encounter loss. I mostly cried for my guilt. I hadn’t reached out to her in January because I wanted to see how she was doing; I knew she’d taken a new job at Florida State, and I wasn’t curious enough to simply see how that was going for her. Nope. I reached out to ask a favor. And she gave it to me, even though she had maybe five months to live. It wasn’t even her first time doing me a favor. Once upon a time, she invited me to publish a letter with her in JAMA Internal Medicine, something I was underqualified to do. But she dragged me along, anyway, just like she helped hoist me into a new job at KUSM-W.

I also cried for the loss of such a beautiful, mathematical mind so dedicated to making the world a better place. But, in processing her loss, I thought of how many people will continue to benefit from her brief presence on Earth. She seemed to know her time was short, from the first moment I met her in 2006. She wouldn't talk to drug reps, a practice that I admired and now follow myself. I don’t think she saw them as a threat to her decision-making, the way some of us do. And there was no Sunshine Act back then, so she wasn’t protecting her reputation. I suspect she simply thought they were wasting her time. I wish I could say that she had endless time to spend with patients. Actually, I don’t. She didn’t have endless time to spend with patients. She had the exact amount of time it took to get an accurate history, do the proper exam, give advice, prescribe medications, and document the visit. She didn’t suffer through the rituals of the exam room that many of us believe make us better doctors. She refused, even, to type into the electronic health record. Instead, she would dictate a quick note in front of the patient, nodding to the patient to make sure she was getting the details right. Somehow (I really don’t know), the notes ended up in the EHR. They were shorter, more concise, and more useful than almost anyone else’s.

Instead, she spent her time using her mathematical mind to examine dose responses to insulin at varying blood glucose levels and coming up with novel treatment algorithms for critically ill patients with diabetes. I'm guilty of showing her graphs of insulin-versus-blood glucose levels in presentations of my own and intentionally breezing over them to hide my own mathematical shortcomings. And, though I can’t prove it, I suspect that modern-day smart insulin pumps use similar mathematical logic to what she was able to casually draw up on conference room whiteboards. To get a taste of this, see her 2014 paper on “Multiplicative standard deviation for blood glucose.” Or a dozen others. Just enter “Braithwaite SS” into Pubmed. You’ll find that her dozens of publications are pragmatic and aimed, laser-like, at the immediate, demonstrable improvement of patient care.

Sigh… my point is, Susan Shapiro Braithwaite lives on. She did the hard work of inching the science of medical delivery ever so slightly forward. And, for those of us in the academic world, that’s as close as we can get to immortality.

Are We Witnessing the End of the Pharmacy Benefit Manager?

As much as we’d like to think that every player in the healthcare marketplace is an integral part of the team, contributing to the health and well-being of our employees and saving employers money, it’s becoming harder and harder to support the ongoing abuses of pharmacy benefit managers, or PBMs. I won’t rehash them here. You can find past opinions about them in other posts.

Two discoveries this week at KBGH make me wonder if we’re witnessing the end of the PBM model. First, in a (unfortunately paywalled) editorial in the New England Journal of Medicine, Leemore Dafny describes the business model of a new drug company called “Civica.” Civica was launched in 2018 by seven health care delivery systems and three philanthropies to address chronic shortages of generic drugs, like IV antibiotics and sedatives, that are essential to inpatient care. Civica has since grown to sell about 50 generic injectable drugs to more than 1,500 hospital members. Their newest venture is the production of three “biosimilar” insulins (aspart, lispro, and glargine, which you may know better by their brand names Humalog, Novolog, and Lantus) that make up about 80% of the insulin market.

Here’s the important part: Civica intends to make its insulins available to “all U.S. pharmacies at the same wholesale price and on identical terms.” Everybody gets the same price, and Civica won’t engage in the usual PBM “rebate” trickery. It will print wholesale prices and the manufacturer’s suggested retail price right on the packaging! That MSRP will represent more than an 80% reduction from prices we’re accustomed to paying through PBMs, who keep about 60% of our money as “rebates” and other chicanery. The MSRP for a pack of five insulin glargine (a.k.a. Lantus) pens will be $55. Dafny invites us to compare that to the usual list prices of $425 for Lantus, $404 for Semglee, and $148 for unbranded Semglee.

The second cloud on the horizon for the future of traditional PBMs is Mark Cuban’s online pharmacy CostPlusDrugs.com. Instead of eliminating the PBM, Cuban has simply made the pharmacy and the PBM one and the same, with fully transparent pricing.

I don’t think we can carve the gravestone for PBMs yet; they surely have new tricks up their sleeves, and I expect legal action to be part of their strategy to try to delay companies like Civica from acting too quickly. But the tradewinds against the old, predatory PBM model seem to be blowing harder and harder. “This plan is straightforward: sell a drug at cost and at the same price to all buyers,” says Dafny of Civica. If only other health services operated the same way.

Quick tip of the hat to Drs. Bob Badgett, MD, and Kevin Wissman, PharmD, at the University of Kansas School of Medicine-Wichita for alerting us to these.

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

How much of your care is planned?

Your doctor should be using “pre-visit” planning to make sure that your care is proactive, not purely reactive. Here’s how the American Medical Association says we should do it:

1. Your next visit should be set before you leave the clinic at your current visit. This should include scheduling any needed labs or x-rays. Unfortunately, not all electronic health records (EHRs) allow for proactive lab scheduling, so your doctor’s staff may need to use a look backward strategy, where a staff person orders labs according to a protocol based on your medications and diagnoses a few days before the next appointment. Regardless, you should have repeat labs and imaging available when your next appointment comes around.

2. Before your next appointment, someone from the clinic–often a nurse or MA–should contact other providers you may be seeing to get results of testing or treatments they may have performed. Ideally, copies of these results should be shared with you.

3. You should have the chance to check your status on preventive health between visits so you know what to ask your doctor about when you arrive at the next visit. This helps to identify “gaps in care,” like immunizations or screenings. Some clinics develop checklists like this one from Better Health While Aging. While this list is geared toward the primary care of aging patients, other providers like orthopedists, oncologists, or cardiologists may have specialty- or disease-specific checklists.

4. You should get a reminder of any upcoming visits, either by email, text, or phone call, at your preference.

5. A list of your current medications should be provided to you upon check-in so you can review the medication list for errors. This can be either a paper copy or a copy through the clinic’s “portal.”

6. A review of your medications may be paired with a pre-visit questionnaire to see if you have new medications, problems, or symptoms that can start to be evaluated even before the doctor sees you. Here’s an example from the American Academy of Family Physicians.

7. Your clinic’s staff and your doctor should hold a pre-clinic “huddle” to anticipate some of your needs and gaps in care so that the first time they consider these problems isn’t the moment you step into the lobby.

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 cost of medical care is poisoning us

According to Moore’s dictum (newly minted by me, although I’ve had the idea for a long time), appropriate medical care must meet one of three criteria: either it makes us feel better, it makes us live longer, or it saves us money. But these three criteria exist in a state of conflict. Chemotherapy certainly doesn’t make us feel better. It often causes hair loss, nausea, rashes, low blood counts, and other unseemly side effects, sometimes for months or years at a time. But we accept chemotherapy’s toxicity in exchange for a chance at a longer life. Ditto the discomfort and inconvenience of surgery. And some therapies that make us feel better in the short term may also shorten our lives (though, paradoxically, some hospice services may actually prolong life). 

Unfortunately, chemotherapy not only drains our energy level, but it is also likely to drain our bank account, and for modest life gains. New therapies for cancers often cost tens of thousands of dollars per month in exchange for an anticipated life prolongation of less than a year. That extra year may be precious, and I don’t mean to minimize it. But the cost adds up. For a drug costing ~$14,000 per month, a patient may have a copayment of ~$3,000 or more per month. Patients on Medicare, our national socialized medicine for elders, who are newly diagnosed with cancer incur out-of-pocket spending averaging 23.7 percent of their household income. Ten percent of Medicare folks with cancer have out-of-pocket spending equivalent to almost two-thirds of their household income. And for those of us not on Medicare, 40% of whom would not be able to find $400 in cash in an emergency, the cost is likely completely out of reach. So it’s no surprise that medical bankruptcy accounts for almost two-thirds of all U.S. family bankruptcy filings or that patients with cancer are 2.5 times as likely as non-cancer patients to file for bankruptcy. 

For many patients, this financial toxicity is as feared as the physical toxicity of the drugs themselves. One of my physician colleagues darkly refers to the medical-industrial complex as being in the business of “farming sick people for money.” Elements of cancer care seem to confirm his suspicions. Financial toxicity is a big enough problem that the National Cancer Institute devotes a section of its website to helping patients navigate it. 

We shouldn’t just care about the topic because of our humanitarian impulses. We should care about its second-order effects. Financial distress, or even the fear of it, is associated with delayed initiation of treatment, limited patient adherence to treatment, and abandonment of recommended treatment. This is horrifying, and it’s not limited to cancer care. Here’s a model of how it might play out in heart disease, where financial toxicity has similarly been linked to poor outcomes: 

Financial Toxicity in Atherosclerotic Cardiovascular Disease in the United States: Current State and Future Directions (nih.gov)

Many are calling for greater adoption of the Center for Medicare and Medicaid Innovation’s Oncology Care Model, which identifies care navigation and connection of patients to resources as core functions of medical practice. But in spite of research demonstrating clear value, not every practice has a care navigator because of the lack of a sustainable model for reimbursement.

A potential strategy that may meet the Oncology Care Model halfway is the use of “community health workers,” laypersons with an intimate knowledge of specific populations that may be served by a practice. If a doctor has a hard time connecting with recent Vietnamese immigrants in her practice, for example, a Vietnamese-speaking CHW who has knowledge of the religion and culture of the region from which the patients immigrated may be able to work with them on shared decision-making around things like transportation, diet, adherence to medications, and even end-of-life planning. 

[disclosure: the Kansas Business Group on Health has CDC funding related to increased adoption of community health workers]

Does your employee policy cover care navigation, or do you have personal experience with a community health worker? If so, we’d love to hear about it. If not, we’d love to help.

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.

When is the last time you taught your doctor something?

An average visit to a primary care doctor addresses about three primary complaints, like back pain, blood pressure, fatigue, cough, and the like. Each of those problems may have a pretty complex workup and therapeutic plan, so it is no surprise that people often leave their doctor’s office with a muddled idea of what they’re supposed to do next. Forty to eighty percent of what is discussed in doctor’s visits is forgotten immediately, and almost half of the information retained is incorrect. To fight this problem, Medicare (CMS) requires that doctors supply a summary of the visit on paper within three business days of the visit, but the summaries generated by many electronic health records are jumbled messes of computer-generated tech-speak gobbledygook. Some patients go so far as to secretly record medical visits, a practice that has been condemned by people within and outside the medical community. But, sensing an opportunity, clever apps to facilitate consensual recordings, like Abridge, have cropped up.

 But less tech-oriented doctors are interested in a more analog method called “teach-back.” You may know this better as how you make sure your teenagers have heard you when you ask them to mow the lawn; the phrase “repeat what I just said” may ring a bell. But don’t be insulted if your doctor uses the same technique with you. Entire websites and continuing medical education enterprises have been built on teaching it.

 Recently, investigators writing in the Journal of Primary Care & Community Health analyzed six years of data on 2,901 patients with diabetes from the Medical Expenditure Panel Survey (MEPS), a data collection of access, utilization, and payments for American patients. They were able to link the MEPS data to data on hospital inpatient stays. They specifically looked for two pieces of information about doctor visits: 1) did the patient receive medical instruction which was easy to understand, and 2) was the patient asked to describe how to follow the instructions given. If both answers were “yes,” the patient was designated as having had a “teach-back experience.”

 To determine the quality of the patient-doctor interaction that went along with these teach-backs, they looked for several questions that looked into patients’ perceptions of the provider’s listening, respect, time utilization, and the patient’s “global satisfaction.” And, if the survey data showed that the provider helped decide between treatment options and showed respect for the patient’s preference, “shared decision-making” was believed to have taken place.

 Finally, patients were asked about their perceived confidence in their diabetes treatment plan, and the likelihood of having complications (like eye, heart, or kidney problems) or hospitalization related to diabetes within two years was calculated.

 What the investigators found was encouraging. Patient teach-back experiences were associated with a lower risk of hospitalization, a higher perceived interaction quality with the provider, more shared decision-making, and a higher likelihood of lifestyle advice having been given. Patients who’d “taught back” to their provider were more confident in their treatment plan.

 So the next time you get a set of instructions from your doctor, take a second and ask her, “Let me repeat that back to you in my own words.” If she affirms that what you just said is true, you’re in good shape. If what you say back to her doesn’t quite match what she intended, you’ll both walk out of the visit having learned something.

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.

Still smoking? Let's game it out.

Do you remember learning about the asymptote in high school geometry? It’s that funny curve that gets closer and closer to a line through infinity, but never actually touches it. We say the curve “asymptotically” approaches zero.

Smokers are a little like this. As the rate of smoking asymptotically approaches zero, we are left with a population that is more and more “hardened” in its smoking habit. Around 70% of current smokers have no interest in quitting. So the smoking behaviors of the ~14% of people still smoking now are, person-for-person, harder to change than they were in the much larger fraction of the population who smoked five years ago. That is, as the population of smokers shrinks, it becomes ever harder to get the remaining smokers to stop. So most studies of smoking interventions like drugs, nicotine replacement, or therapy, ignore people who express little interest in quitting. Coordinators for most studies instead recruit people whose “readiness to change” is higher:

But a new study (paywall) takes this population of hardened smokers head-on with, of all things, a video game. Investigators recruited 433 smokers who reported they were not ready to quit. They randomized the smokers to get usual care with nicotine replacement therapy lozenges, or to get access to nicotine replacement therapy plus “Take a Break,” a 3-week mobile “game experience” that included 5 behavioral components: motivational messaging, challenge quizzes, brief abstinence goal setting, mobile health apps for cravings management (three “relaxation” apps were offered), and reward points for participation (in the form of gift cards).

To determine if the game had an effect, they looked at the time to their first quit attempt and tested carbon monoxide levels at 6 months to verify any claims of smoking cessation (smoking increases carbon monoxide levels in your blood, which, blech).

Apps are tricky because people tend to lose interest pretty quickly. Only about half of the game participants got through 100% of their daily challenge quizzes in the first week in the study. Roughly three-fourths set a brief abstinence goal of 1-2 days away from cigarettes, and 75% used the apps to manage their nicotine cravings. The game-treated participants set a sooner “time to quit,” and at six months, 18% (28 of 160) of game participants versus 10% (17 of 171) of nicotine replacement-only participants had carbon monoxide level–verified smoking cessation, roughly a doubling of the likelihood of smoking cessation once the fancy statistical analysis was done.

Those numbers look kind of sad, but remember that we’re talking about a very difficult population in the study, people who had expressed almost no interest in changing at the study’s onset. Through that lens, this is really a remarkable outcome, albeit in a small study. The best-performing clinics in the U.S. only get around 15% of their smokers to quit in any given year, and that is in a group of patients whose readiness to quit is undoubtedly higher than the population of this study.

As far as I can tell, the app isn’t available commercially yet. When “Take A Break” or its descendant products are available, though, we should think hard about using them. Smoking is still one of the leading causes of death, disability, and medical expenditures, so even a hefty price tag for such a product would be worth doubling the number of smokers who successfully quit in any six-month period.

As we’ve talked about before, we get pitched a lot of apps at KBGH. Do you have any positive experiences with skill-building or behavior change apps? If so, please share!

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.

Can the Biggest Loser solve our New Year’s Resolution?

Maybe, like me, you’re a couple of weeks into your New Year’s Resolution. I hope it’s going well. If your resolution centers on weight, let me suggest a strange source of motivation to continue. You may remember the dozen-year run of the NBC reality TV series The Biggest Loser. Contestants engaged in brutal exercise regimens and draconian calorie restriction (65%!) in an office-style weight loss competition, but only if your office manager trained under a third-world dictator and wore spandex. Through a 2022 prism, the show is horrifying, with its subtext that the value of the contestants as people was inextricably linked to their success in a crash diet and our knowledge that contestants abused diuretics for the sake of losing a few extra pounds for their public weigh-ins. The long-term weight-maintenance success rate of the contestants was, to put it mildly, not high.

So, I hope that any health-oriented 2022 resolutions bear little in common with The Biggest Loser. If you’re working on weight reduction, I hope you’ll focus more on the journey than the destination. But I also hope that we can all take a few lessons from the contest. A small number of contestants actually kept significant weight off after leaving the show, and a new analysis by Kevin Hall of NIH, maybe the most influential metabolic researcher in the world, looks at what may have led to their sustained success.

One of the major challenges in weight reduction is that we all gravitate toward a weight “set point” that is determined fairly early in life. When we lose a lot of weight, a la The Biggest Loser contestants, our resting metabolic rate–the calories we burn just to breathe, think, and live–slows significantly, and it becomes ever harder for us to keep weight off as our physiology inevitably pushes us back toward that set point. Investigators call this “metabolic adaptation.”

Distressingly, Hall found that six years after the competition ended, former contestants who maintained a very meaningful 12% weight reduction still exhibited a ~500 kcal/day metabolic adaptation. That is, their bodies burned 500 calories per day less at rest than they had prior to their weight reduction. And, paradoxically, the people who had the highest levels of physical activity (i.e., those who continued to burn the most energy through exercise) had the largest reductions in basal metabolic rate even though they were also the group who kept off the most weight. We can only conclude that physical activity not only burns extra calories but may have an effect on appetite. Other mechanisms are possible as well. It’s a big unknown.

Regardless of the uncertainty, this is even more evidence that we should focus more on the process of healthy living than we do on any individual measure, like body weight, waist circumference, or pant size. As we’ve said before, patients who enter programs like the Diabetes Prevention Program are often surprised at how little their weight is mentioned in class compared to, say, their daily activity levels. As you struggle with your resolution this year, consider altering your strategy if things get tough. Instead of saying “I’m going to lose five pounds this month,” consider process-based SMART objectives, like eating at least five servings of fruits and vegetables daily, taking a tablespoon of psyllium husk daily, and at least 30 minutes a day of real physical activity.

And if you’re interested in promoting this kind of strategy to your employees through resources like the Diabetes Prevention Program, please let us know.

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.

No, your doctor doesn't know what that medication will cost you, either

In seven years of working on CDC grants focusing on improved care of metabolic diseases like diabetes and high cholesterol, I’ve come to think that two broad factors determine the success or failure of chronic disease management. First, doctors must overcome clinical inertia, the phenomenon in which the doctor and the patient follow the easier path in the encounter and generally leave things as they are rather than stop, start, or adjust therapy when indicated. As many as 85% of visits for high blood pressure are affected by clinical inertia, meaning that medications are not adjusted when the patient’s blood pressure, symptoms, or labs indicate that they should be.

Second, patients who are prescribed therapy must adhere to it. Only about a third of patients two years removed from a diagnosis of heart disease are still taking their cholesterol medications, for example, and only about two-thirds of patients with hypertension take their blood pressure medications on any given day.

One of the most significant predictors of medication adherence is cost. High-deductible plans, the old Medicare “donut hole,” high copays, and expensive branded medications have all been linked to lower adherence rates. One potential solution to this problem is good coaching by the physician and better choice of drugs at the bedside, driven by the physician’s intimate knowledge of medication costs. But do doctors really have a grasp on medication costs? A recent study (paywall) suggests, to no one’s surprise, that they do not.

Investigators sent a survey to 900 outpatient physicians (300 each of primary care, gastroenterology, and rheumatology). A mix of 374 responded. The survey contained a hypothetical vignette in which a patient was prescribed a new drug that cost $1000/month without insurance. A summary of the fictional patient’s private insurance information was provided, including her deductible, coinsurance rate, copay, and out-of-pocket maximum. Doctors were asked to estimate the drug’s out-of-pocket cost at four time points in a theoretical year as the patient’s cost-sharing changed due to other medical expenses.

Overall, 52% of physicians could accurately estimate costs before her deductible was met, 62% accurately used coinsurance information, 61% accurately used copay information, and 57% accurately estimated costs once she met her out-of-pocket maximum. (This performance actually exceeded my expectations. Prior to my exit from daily clinical medicine and entree into the benefits game, I think I would have failed most of these tests.) But only 21% of respondents answered all four questions correctly. The docs’ ability to estimate out-of-pocket costs was not associated with their specialty, attitudes toward cost conversations, or other clinic characteristics.

We need to acknowledge that this is a feature of the system, not a bug. Doctors are not trained to be HR professionals. They’re forced into the role. To quote Malcolm Gladwell:

I don’t understand, given the constraints physicians have in doing their job and the paperwork demanded of them, why people want to be physicians. I think we've made it very, very difficult for them to perform their job. I think that’s a shame. My principal concern is the amount of time and attention spent worrying about the business side. You don’t train someone for all of those years of medical school and residency, particularly people who want to help others optimize their physical and psychological health, and then have them run a claims-processing operation for insurance companies.

Many people in the health care industry want the system to stay complex and opaque. That’s why large groups like the AMA and AHA are fighting some of the rules that have come about in the past couple of years. But I hope that your instincts match mine. We have myriad reasons to simplify insurance coverage, but I’ll start with two:

First, by reducing cost and administrative burden, we can make patients more likely to adhere to helpful therapy.

Second, if we can make the system more efficient by eliminating administrative complexity, we can leave doctors, nurses, pharmacists, allied health professionals, mental health professionals, dieticians, and others the brain power to do the work they were trained to do.

We hope you have a happy holiday season!

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 If You Could Write Your Own Doctor's Note?

The process is mostly invisible to us when we see our doctors, but the documentation of a patient visit–the recording of the visit’s findings and the doctor’s recommendations–takes about twice as much time as the visit itself. This is because of the way American health care is reimbursed. The more complex the visit, the more complicated the note, and the more the doctor gets paid. As a result, American clinic notes are about four times the length of clinic notes in other developed countries:

Annals of Internal Medicine

Add in the complexity of navigating electronic health records (EHRs), and you have a recipe for physician burnout and patient dissatisfaction. That patient dissatisfaction only compounds when the patient doesn’t believe the note accurately reflects the visit or is outright offended by the content. To get around this, many doctors have resorted to having “scribes” in the exam room, a workaround that seems crude by 21st-century standards but which is generally viewed neutrally or favorably by patients.

But what if we’re overlooking a vast resource in the generation of a comprehensive, accurate clinical record? As we’ve blogged about before, patients now have a legal right to see their medical records free of charge, thanks to the 21st Century Cares Act. Is it possible that we, the patients, could write much of our clinical notes ourselves?

A new study suggests that contributing to your own medical record may not only make you happier but may help your doctor as well. And, if the study’s findings on engagement during clinic visits are to be believed, it may actually make you healthier (although the study is careful not to jump to that conclusion).

Here’s how it went: before visits with their primary care practitioner, a patient portal asked patients in several clinics to submit an unstructured “interval history” of what had happened since their last visit, up to 2000 words (How have you been since your last visit?). Patients were also asked to set an up-to-300-word agenda for the encounter (What are the most important things you would like to discuss at your visit? [list up to 3]). The EHR invited practitioners to incorporate patient submissions into visit notes.

Only about nine percent of visits had patient-generated data at the end of the pilot, but those who did resulted in happy patients. More than 80 percent of patients found the questions “not difficult” to answer, and over 92 percent thought sending answers before the visit was a “good idea.” Most importantly, 68.8 percent thought that submitting responses to the questions helped them prepare for the visit.

Seventy percent of physicians in the study reported that they “usually” or “always” incorporated the responses into visit notes, and almost 90 percent said that the pre-visit information either saved time or was time-neutral for the visit’s length, presumably including documentation time.

I think this has the potential not only to spread out the burden of documentation (something that seems unfair to patients who already pay outrageously high prices for their health care) but to bring the doctor’s goals for a visit more in line with the patient’s. The setting of the agenda for a visit is a sneaky cross-current interfering with the conversation and examination in the exam room. I’ve had patients deny that I’d ever informed them of their thyroid cancer diagnosis, even after multiple visits, surgeries, and treatment with radioactive iodine. I can only guess that this was due to some combination of my own shortcomings and the patient’s distraction by other issues during the visit. And most doctors have had patients slip in covert requests for tranquilizers or narcotics at the end of a visit, only after discussing several other items–an average of three, and rising–during the scheduled time. Such short-circuited behavior, intentional or not, tends to sabotage the entire therapeutic relationship.

To make self-documentation really work, though, it stands to reason that increased healthcare literacy (“the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions”) is a prerequisite. Most Americans are not health literate, but research indicates that people can become so if given the proper tools. One tool we offer at KBGH is Quizzify, a gamified method for increasing patients’ knowledge of health care and their ability to make critical decisions. If you’re interested in learning more, let us know!

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.

63% of What You Pay for Insulin Pays for Something Other Than Insulin

A landmark study (paywall) landed on our doorsteps last week not with a thunderous crash, as it should have, but with a gentle thud. Investigators from UCLA’s School of Public Policy published a cross-sectional analysis of where money paid for insulin actually went in the years 2014-2018.

An accompanying editorial (also paywalled) aptly describes the methodology of this research paper as “daunting,” given the difficulty in getting information in such an opaque marketplace. The investigators had to compile data on 32 separate insulin products from The SSR Health Rx Brand Pricing Data Tool, a commercial pharmacy claims database, CMS records, individual state Medicaid and drug transparency reports, and public filings of participant companies, including not only drug manufacturers, but drug wholesalers, pharmacies, pharmacy benefit managers (PBMs), and insurance companies themselves. Their methodology was complex enough that I’m not sure I completely understand it, and I’m confident I can’t pass it on to you in less than 800 words. So I’m going to get down to the nitty-gritty. First, here is their helpful schematic on the flow of money in the drug pipeline, which I found to be as good as about any explanation I’ve come across:

JAMA Health Forum

You can see that the key breakdowns in this complicated flow of goods and services are at points (2) and (7), where kickbacks from the manufacturer to the PBM (also known as “rebates”) are paid to move a drug up the formulary and where the PBM subsequently passes a share of those rebates on to the benefit plan.

Between 2014 and 2018, the average list price of the 32 insulin products rose 40.1% (inflation over the same period was 5.96%). So the list price of insulin rose eight times as fast as the list price of, say, dishwashers.

At the same time, though, the average net price paid to manufacturers fell by 33.0%. So, for example, Eli Lilly, the oldest insulin manufacturer in the United States, got $69.71 of every $100 spent on its insulin products in 2014. By 2018, they were getting only $46.73 out of every $100 spent.

Similarly, the share going to health plans (as those sneaky “rebates”) fell by 24.7%, and the share of expenditures retained by drug wholesalers increased by 74.7%, from $4.63 to $8.09, although the absolute costs were obviously low in comparison to others in the chain.

Reader, prepare your body for the coming rage (I recommend some light stretching and some John Tesh on the stereo). The share of insulin expenditures going to PBMs from 2014 to 2018 rose 154.6%, from $5.64 to $14.36 of every $100 spent. And the share retained by pharmacies increased by 228.8%, from $6.21 to $20.42.

If you can still read through all the red mist, let me reiterate this: Let’s say that you and your diabetic employee together pay ~$115 to insurance company X in December. Insurance Company X will then take its allowed Medical Loss Ratio of ~$15 and spend the remaining $100 on insulin. Of that $100, the breakdown of who gets what is below:

• Manufacturer: $46.73

• Wholesaler: $8.09

• Pharmacy: $20.42

• PBM: $14.36

• Health insurer: $10.40

Here’s the same information in graphical form, which is helpful to see the change over time:

JAMA Health Forum

Understand that about a quarter of people on insulin–your employees–report routinely skipping doses because of insulin’s tremendous expense. While those people are very likely shortening their lives because they can’t afford their drugs, PBMs, pharmacies, and to lesser extent wholesalers, are taking ever-greater shares of the money that you and your employees pay for the insulin, all while stiffing the manufacturer. I don’t mean to let the manufacturers off the hook; the pharmaceutical industry is the most profitable industry in America by a healthy margin. But we need to recognize that every participant in the distribution system for insulin, from the manufacturer to the PBM to the pharmacy, shares some of the blame for the astronomical increase in price that we’ve experienced over the last decade or more.

Outside of breaking out the pitchforks and torches, what can be done about this problem? A lot, we believe. As we’ve outlined before, you can look at your PBM contract to make sure you have access to your data, that you are allowed to access underlying contracts of your PBM, and that you can get out of your contract in a reasonable amount of time. With that information in hand, you can challenge new clinical approvals for low-impact drugs added to your formulary. You can even buy generics directly from the manufacturer. And, if you’re a member of KBGH, you could immediately cut pharmaceutical costs even without uncomfortable conversations with your PBM by working with our Right Rx program.

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.

Focus on the Process, Not the Outcome

Imagine, if you dare, that you are Kansas City Chiefs Head Coach Andy Reid. Fresh off two Super Bowls (and almost a third), your team now sits at 3 wins and 4 losses after a blowout defeat in which you scored zero touchdowns. You could indulge in self-pity and just listen to radio talking heads conjecture on your anticipated win-loss record come Thanksgiving.

But if your Andy Reid cosplay is true to form, I’d bet dollars-to-donuts that, instead of focusing on that intermediate outcome, you’d spend the next practice working on the process to make a better outcome more likely: fundamental skills like making sure players line up in the proper formation, know their assignments, and use sound technique in blocking, tackling, throwing, and catching. I’d bet you would want to make sure your players take care of nagging injuries.

Let’s think about the ultimate goals of medical care through this process-oriented lens. As we’ve outlined before, every medical test or treatment should aim to accomplish at least one of the following goals:

1. It makes the patient feel better.

2. If it does not make the patient feel better, the test or treatment should make the patient live longer.

3. Finally, if a test or treatment makes no difference in how the patient feels and makes no difference in how long the patient lives, it should at the very least save money.

If a diagnostic or therapeutic strategy can’t be proven to cause #1, 2, or 3, it isn’t worth pursuing. In this framing, weight loss is a winner: it clearly meets criterion #1. Not only does weight loss increase one’s self-esteem come bikini season (at least according to literally every magazine cover I’ve ever seen in the checkout aisle of a supermarket), it reduces the risk of multiple potentially debilitating chronic diseases, and it eases joint pain. And, as has been repeatedly shown by programs such as the Diabetes Prevention Program, which we push hard at KBGH as part of our work with CDC and KDHE, weight loss saves money (criterion #3). But in terms of #2, life prolongation, weight loss has historically fallen short. And prolonging life is maybe the thing doctors are most proud of, given our 40-year extension of life expectancy in the developed world in the last century or so.

This is a paradox.

An excellent review published this week took on this paradox head-on and concluded that interventions for obesity would be more effective at preventing early death if they focused less on weight loss and more on increasing physical activity and improving fitness levels. That is, talk less about the outcome of a reduced body weight in six or twelve months, and talk more about the physical activity that will help the patient get there:

iScience

As you can see above, for any given weight, you’re less than half as likely to die of any cause if you’re cardiovascularly “fit” than if you’re not cardiovascularly fit (the word “unfit” seems a little pejorative here, but maybe that’s just me).

This isn’t necessarily new news. We’ve known for a long time that the things that happen in doctors’ offices that truly prolong life are surprisingly limited. But they’re powerful, and physical activity promotion is right there with cholesterol management, blood pressure control, and smoking cessation in terms of its potential to make people live longer. Physical activity reduces your risk of death from any cause by about 23% in a given period of time. Focusing on the process of being active daily achieves the outcome–the outcome we’re all ultimately most interested in–of a reduced risk of death, even without taking into account weight reduction.

Journal of the American Medical Association

This approach of process-over-outcomes and health at any size is provocative, but it is gaining steam. We’ll hear several speakers address the topic at the upcoming KBGH-sponsored Live Well with Diabetes Day of Discovery Event. Just as Andy Reid is surely telling his players to focus on their skills and decision making and not on their wins and losses, those speakers will likely tell us to start paying more attention to physical activity and food choices and less attention to the scale.

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.

Precision Medicine and Me

In case you missed our excellent discussion on precision oncology with Dr. Fred Schnell and Dr. Quoc Truong this week, we thought we’d review what precision medicine means for the future care of your covered lives.

Had you been diagnosed with, for example, lung cancer ten years ago, your oncologist would have acted primarily on the visual description of the tumor under the microscope as reported by the pathologist. They would have described the tumor as either a “small cell” carcinoma (arising from “neuroendocrine” tissue), an “adenocarcinoma” (arising from glandular tissue) or a “squamous cell” carcinoma (arising from skin-like cells). Then your oncologist, depending on the size of the tumor and its spread outside the lungs to places like liver or bone, would have prescribed a regimen of chemotherapy and possibly radiation based on which broad category your tumor fit into. The chemotherapy and radiation would have had “toxicity” that limited its dose: things like nausea, a rash, low blood counts, or fever. You and your oncologist would have crossed your fingers and hoped for a tumor response.

If you were to be diagnosed now, though, as Drs. Schnell and Truong outlined, you would ideally have two crucial tests done before you ever received treatment. The first would be a “whole-genome” scan of the tumor’s DNA for specific mutations that might affect its response to specific drugs. One that was mentioned yesterday was a mutation in the epithelial growth factor gene. The second test would be another whole-genome test, this time from your blood, to see if you had any predisposition to cancer that might affect your response or your family’s risk for cancer. This would not only help you but would help your family members adopt early detection practices if you were to be found to carry an abnormal gene. The most famous of these genes, unrelated to lung cancer, are probably the “BRCA” mutations that increase the risk of breast and ovarian cancers.

Based on those tests, you would not necessarily receive the blunt, toxic chemotherapy that you would have ten years ago. You may receive one of those drugs, but the testing might indicate that you’d be a better candidate for much more precise, directed therapy, such as a drug that specifically targets the epithelial growth factor receptor or another gene mutation.

This genetic testing is not cheap. Whole-genome testing may run into the $3,000 or higher range. But given the astonishing cost of cancer chemotherapy and radiation, paying for this testing upfront seems to be a reasonable gamble if it means a less toxic, more precise, and potentially more effective therapy for a malignancy. We would love to explore this topic with you further. If you haven’t had a chance to dial into one of our oncology modules, please feel free to reach out, and we’ll get you signed up!

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.

Discipline is freedom

Spend even a little bit of time in the literature and blogosphere surrounding productivity culture, and you’ll read that “discipline is freedom.” Writers almost always attribute it to Aristotle, but he probably never said it, at least not in the context in which it is usually applied. And I know it sounds like what a dystopian government would print above the entryway into a forced labor camp. But its softer interpretation has some merit in medicine. Let me explain.

Many investigators frame the regulation of medicine according to scope. “Macroscopic” regulation, they say, comes in the form of payer policy, some of the things that Matt, Shelley, and I rant about in this post almost weekly.

“Microscopic” regulation, though, is where our notion of discipline may apply. It refers to things like safety initiatives and professional practice guidelines at the institutional and clinician levels. Take the “hemoglobin A1c” level, the nearly ubiquitous marker of diabetes control. If your personal physician adheres to the American Association of Clinical Endocrinologists’ guideline on diabetes, for example, he might treat you to a goal hemoglobin A1c level of ⩽6.5% for your diabetes. But if someone else’s doctor is a member of the American College of Physicians, she might aim for a more relaxed number for an A1c goal, like 7-8%.

A physician group seeing your employees should be able to defend their treatment target. I promise that they obsess over it in training and in evidence-based medicine conferences. But maybe more importantly, regardless of the physician’s treatment goal, he or she should be able to articulate how they intend for the patient to get there. Medicine now has a substantial body of evidence proving that structured treatment algorithms tend to outperform artisanal, patient-centered, off-the-cuff physician recommendations at the bedside. Sticking to diabetes as our example, we know that nurses and diabetes educators, following rules set by endocrinologists, tend to perform at least as well as doctors in getting patients’ A1c levels down to an acceptable range. We know that nurses outperform doctors in the treatment of gout when given a set of rules to follow. And in maybe the most famous example of this, we know that medical assistants operating in systems that give them rules and resources for the care of patients with high blood pressures perform astonishingly well (paywall), with control rates exceeding almost every other practice in the world.

The “discipline” here is the willingness of the nurses and medical assistants to follow rules set out for them by the care team. The “freedom” is the doctors’ ability in these systems to work as doctors. Instead of getting bogged down in the thick of therapeutic inertia, the doctors can focus on what they were really trained to do: diagnosing tricky cases, developing good relationships with patients and other providers, and designing treatment plans for the fraction of patients whose disease states don’t neatly fall into one of the algorithms.

Have you experienced any protocol-based care, such as chemotherapy, diabetes treatment, or management of things like gout or hypertension? We’d love to know 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.

Wear the Right Uniform for the Job

A couple of weeks ago, while I was driving to the office supply store over lunch, I saw a cyclist riding toward me on the busy four-lane road. I’m very enthusiastic about active transportation, including cycling, so like many drivers, I tend to slow down and use caution around cyclists just in case they are skittish in traffic. As I approached this cyclist, though, I could see that he was wearing a helmet and a moisture-wicking shirt. His bike was kitted out with pannier bags and a headlight. His “uniform” indicated that he was no amateur bike commuter. He had clearly done this before. I waved as I passed, and I watched in the rear-view mirror as he switched lanes, signaled, and make an expert left turn behind me.

The encounter got me thinking about the value of a uniform, and that got me reflecting on the pandemic. I’m not the snappiest dresser even on my best days, but all the time at home in front of a computer screen has allowed for some pretty cavalier choices in clothing, especially from the waist down. Eighteen months in, I’ve found generally positive effects to wearing a work “uniform” of my own, mostly consisting of reasonable pants and a collared shirt. First, putting on the uniform signals to me that the day has begun, like James Joyce’s white coat signaled the beginning of his writing day (I promise this is the last time I’ll compare myself to Joyce in this blog post). The donning of a uniform is one of my strategies, along with Cal Newport’s “shut down” ritual, that helps me separate my workday from my leisure day.

Second, a uniform gives the appearance, even through Zoom or Microsoft Teams, that I mean business, much like donning a white coat does in patient-care settings. White coats, originally adopted by doctors to indicate that they were adherents to science, have been linked to improved patient perception in certain situations, in spite of the fact that infrequently laundered white coats are also potentially dangerous sources of infection in hospitals. One of my extended family members has a corporate job in which professional appearance is still very valued, and her strict dress code for her team, even for people in virtual meetings, has drawn praise from coworkers and clients. That’s not to say this can’t be taken to an extreme. In the 1990s, when the national dress code had been relaxing for decades, a friend of mine worked as a computer programmer for Ross Perot. Even though he spent his day isolated in a cubicle and rarely spoke to another employee in person, he was expected to wear a black, blue, brown, or grey suit, starched shirt, tie, and shined shoes to work every day. Needless to say, he found another job. And NBA all-timer Bill Russell famously retired early from basketball after deciding (and I’m paraphrasing) that he was tired of being a grown man wearing shorts playing a children’s game.

Finally, some evidence indicates that a proper uniform may actually improve performance. One of my high school cross country teammates often did his long weekend “base mileage” runs in jeans, and it completely freaked me out. On top of the obvious chafing issues, I could not handle the thought of just rolling out of a tractor cab on Saturday evening and loping off down a dirt road. I needed the ceremony of changing out of work clothes into shorts to help me transition. While sports apparel companies loudly tout the benefits of “moisture wicking,” breathability, compression, and aerodynamics, studies show that simply wearing an appropriate uniform, or even a good luck charm, for a sporting activity may improve performance, presumably because of psychological effects like focus and confidence.

So, even if you’re a borderline slob like me, here’s my advice as a licensed medical professional, for whatever it’s worth: wear the clothes and equipment that match your tasks for the day. If you’re going to the Oscars, wear a ball gown or tuxedo. If you’re exercising, wear whatever clothes are appropriate for the sport. And if you’re employed in knowledge work like I am, wear what you would wear to the office, even if your day will be spent at your own dining room table. You’ll feel better and perform 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.

Diabetes screening comes for the millenials

When I was a junior medical school faculty member, we spent a lot of time talking about the special educational needs of the Millenial generation. At the time, as a proud Gen Xer myself, Millenials seemed so...distant. But now the oldest millennials are 40(!), and the youngest are 25. As the age of Millenials has risen, so have rates of obesity and diabetes. About one in three Americans now has “prediabetes,” meaning a blood glucose level that is abnormally high but not high enough to be declared diabetes mellitus. Around ten percent of Americans are currently diabetic, and the rate of diabetes in people under age 20 has gone up a staggering 95% in the last twenty years (paywall).

So, inevitably, these streams have crossed, and the United States Preventive Services Task Force, or USPSTF, has now reduced the recommended age to screen for diabetes down from ages 40-70 to ages 35-70, starting smack dab in the middle of the Millenial bracket. They recommend we repeat the screening every third year. The screening recommendation applies only to people with a body mass index of 25.0 kg/m2 or above, but that is still a huge population, more than 40 percent of Americans by some estimates. And the guideline recommends considering even earlier screening for “...American Indians, Black people, Hispanics and other groups with ”overweight or obesity with “disproportionately high diabetes rates.”

The purpose of screening people for diabetes and prediabetes, typically with a fasting blood test, is not to simply attach a hurtful label to someone; it is to find people whose progression from prediabetes to diabetes, which normally proceeds at a rate of ~5-15% per year, can be slowed or halted with lifestyle changes or medications. The most tried-and-true program to accomplish this is the National Diabetes Prevention Program, or DPP, a one-year behavior change program conducted by peer coaches in-person or virtually. The USPSTF “found evidence that medical interventions for newly diagnosed diabetes have a moderate benefit in reducing diabetes-related deaths and heart attacks over a span of 10 to 20 years.” But the most compelling reason for screening for and preventing diabetes may be monetary savings. In addition to being the seventh leading cause of death in the United States, diabetes is an astonishingly expensive disease. The American Diabetes Association estimates that the cost of caring for a person with diabetes is roughly 2.3 times the cost of caring for the average person without diabetes. Diabetes accounts for about one in seven dollars spent in the American medical system. At a cost of around $500 for a year of the DPP, then, with one in seven participants subsequently avoiding a diagnosis of diabetes, it is no surprise that diabetes screening and the DPP are wildly cost-effective. And that is without taking into account that people enrolled in the DPP have lower rates of absenteeism and a reduced need for blood pressure and cholesterol medications.

We at KBGH so believe in the DPP that we’ve offered two employers funding for pilot programs. If you’re interested in exploring offering the DPP as a medical benefit, please reach out to us!

[disclaimer: KBGH receives CDC and KDHE funding in part for increased detection and prevention of type 2 diabetes]

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.

Should we punish people for inappropriate emergency room visits?

On a Saturday morning in November 2016, I woke up with a high fever and a frozen, excruciatingly painful right shoulder. I have a primary care doctor that I trust and like, but she, like most primary care docs, doesn’t work Saturdays. But I’m in the extremely privileged position of being married to a primary care physician (albeit not my primary care physician because that would be weird). My wife examined my shoulder, tsk-tsked my fever, and drove me to her clinic. One of her colleagues in the sports medicine department who happened to be in the building did a quick ultrasound of my shoulder and saw a possible effusion, or excess fluid, in the joint space, and recommended I be admitted to the hospital for a possible “septic joint,” the unglamorous medical terminology for pus in the joint space.

To make a four-day story short, I was admitted through the emergency department, went to surgery, had the shoulder drained, was seen by an infectious disease specialist who ruled out infection, continued to have fevers for a few more days, and left the hospital without a diagnosis, like around 15-20 percent of patients. But my fevers eventually subsided, and I healed up with the help of physical therapy. The problem hasn’t recurred.

I subject you to this story because I’m curious whether a modern insurance company would have considered my emergency department visit “appropriate.” I was clearly in distress. But to this day I have no diagnosis to explain my symptoms, and I can only assume that I would have eventually returned to my baseline state of health had I sweated out my fevers at home and taken over-the-counter pain medications for my shoulder.

But that’s all hindsight. My presentation really was worrisome for a septic joint, and when a patient presents with that diagnosis, we have maybe 24 hours to offer treatment before the infection causes irreversible damage.

United Healthcare, the largest health insurance company in America, decided a few months ago to start vetting emergency room bills, with the possibility of not covering a claim if the reason for the visit was not eventually deemed an emergency. Unsurprisingly, this caused an uproar not only among patients but understandably among doctors and hospitals as well. The doctors and hospitals don’t control who comes in the door, after all. They just take care of whoever walks in and try to cover the fixed costs of having a functioning 24/7 clinic open to the public. And as inefficient as emergency care can be, discouraging it could have the unintended consequence of diverting people away from needed care, and most patients already have a strong disincentive for ED use because of high-deductible plans and cost-sharing. And contrary to popular belief and the policy direction of many employers, Americans don’t actually overutilize care in comparison to patients in peer countries. So United Healthcare ultimately announced it would delay (but not abandon) implementing the new policy until after the COVID-19 pandemic has passed. (Anthem attempted a similar policy several years ago, but it is still tied up in litigation.)

On the other hand, though, it is generally accepted that the ED is a more expensive care environment than, say, a primary care doctor’s office. So if unnecessary ED visits could instead be diverted toward primary care visits, United Healthcare could save money and theoretically pass those savings on to everyone in the form of lower premiums.

So I was really interested to see Dylan Matthews’ analysis of the role of excess emergency department use in driving up healthcare costs. I cannot find a good link to his article; I got it via an email newsletter. So I’m going to do my best to outline his findings without committing outright plagiarism.

In short, Matthews found in speaking to a half-dozen healthcare finance experts from Harvard, Rutgers, and other institutions, that there is no evidence that reducing emergency department visits explicitly to save money actually works. This is, according to the experts, because rates of ED utilization have actually been steady for the last several years, and have actually dropped during and post-COVID-19. The problem with the ED, like with most of American medicine, is not utilization, but cost. And implementing a post-hoc vetting process like United Healthcare is proposing makes vulnerable patients the middle man in an astonishingly complex transaction. Some studies, like this one from 2017, show that incentives can provoke a small diversion toward primary care and way from the ED, but total costs don’t decline because the inpatient cost of the ED visit is simply shunted toward increased outpatient utilization. My personal caveat to this finding is that primary care is generally cost-effective in the long run, and that early intervention in the primary care setting is likely to lead to better outcomes. Short-term studies like the 2017 paper above don’t have the duration to detect this.

UHC and Anthem will presumably, sooner or later, get these policies going, and that will kick off a natural experiment that eventually tells us whether the policies do what they’re intended to do--decrease cost by decreasing ED use--or whether patients are harmed. What we unequivocally know is that the policies will lead to patients trying to decide if their problem is really an emergency. Is that chest pain because of your extra fries at supper, or is it a heart attack? Is that shoulder pain and fever a mystery that will never kill you, or do you really have a septic joint? It’s too early to predict what the effect of this will be. In the meantime, though, as we’ve mentioned many times before, the best way to optimize your employees’ care is to make sure they have good, low-cost access to a primary care practitioner.

We hope that insurance companies and other players in the health care marketplace can come up with more innovative ways to control cost, like addressing the outrageous prices charged for services compared to other countries, and spare patients the task of being their own health care providers and worse, small-claims adjusters.

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.

Could Internet Access Make Your Employees Healthier?

Reader, you’re about to read a post that is decidedly pro-internet. Like Nixon in China, we at KBGH feel we have particularly powerful priors to make this pro-internet argument. We’ve posted in the past on the potential ill health effects of social media, which, along with Amazon commerce, is maybe the leading driver of internet activity in 2021. And we freely acknowledge all the other bad things that come with internet use, like leaky personal data, mean anonymous messages, poor interoperability of electronic health records, and the general time-suck of streaming services. So we’re not coming from a magical internet land of digital butterflies and rainbows when we tell you that access to the internet is good.

With access to the internet, you can see pictures of your grandkids now, for almost free. You can push a few buttons, drive to the airport, and fly, float, or bus anywhere in the world. We gaze in wonder at the seemingly impossible tasks made possible by internet connectivity and its associated computing power, like the recent news of AlphaFold2 (part of Google/Alphabet’s DeepMind) outdoing legions of human biologists by solving the problem of protein folding and publicly releasing 350,000 protein structure predictions, more than double the number that have been determined in all of human history by traditional methods, and including nearly every protein expressed in the human body. We all have access to our doctors’ notes now, thanks to the internet.

So the internet is increasingly seen not as a luxury, but as a utility, like electricity or city water. Access to cheap electricity undoubtedly increases your risk of being electrocuted. But it also increases your likelihood of having heat in the winter. We take the bad with the good. And a new tool from the Agency for Healthcare Research and Quality shows that access to the internet, in spite of all its flaws, may be valuable to your health. The effect is so powerful that many believe that internet access–which 25 million Americans lack–should be considered a “social determinant of health,” just like income or education level.

The new tool looks at years 2014 to 2018 and shows that internet access, both in terms of broadband and internet-connected devices, is unequally distributed. In the darkest blue counties, between 22% and 62% (!) of homes have no computing devices:

Here is Kansas, with data from Sedgwick County:

The darkest blue counties align closely with counties with the highest poverty rates and highest levels of chronic disease. People on Medicaid and Medicare make up about two-thirds of those without home internet, and around a fifth of Americans under the poverty line lack internet. So a skeptic might say that the lack of internet access is just a proxy for poverty. But other studies show an independent effect, even after controlling for income and other determinants of health. It does not take a huge leap of the imagination to see how internet access may improve health outcomes, given our recent history of a global pandemic and forced entry into telemedicine. And with more social distancing likely on the horizon this fall (*gentle reminder: update your vaccines*), we are likely to get another heapin’ helpin’ of telemedicine as 2021 turns into 2022. But the benefit of internet access likely extends far beyond simple access to a physician. Less than 20% of health outcomes are directly attributable to the care of a physician and his care team, after all.

We don’t know the exact mechanism by which internet access may improve health outcomes. Caregivers may have more informal access to health information. It may give people access to their physician’s electronic health record portal. It may simply lead to more economic opportunities, like the gig economy. Regardless, we believe that it may be helpful to determine which of your employees lack home internet access. For those that do, it may be beneficial to their health to assist them in getting access. I can’t find any good studies of specific strategies, but off the top of my head, we could make sure access to broadband is widely available at the workplace so that they can take advantage of breaks in the day. We could instruct employees on local sources of free broadband like the public library. We could coach them on using publicly available apps like WiFi Maps or the Facebook mobile app to find wifi hotspots (and coach them on the potential data insecurity of public wifi while we’re at it; this is not an endorsement of WiFi Maps, and Lord knows it’s not an endorsement of Facebook). If any of your employees are taking continuing education courses, there is a chance the course vendor or institution offers free internet access for the duration of the course.

Has your company taken steps to increase broadband access? What potential interventions have we overlooked? We’d love to hear from you.

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 are the steps to productivity?

I’ve been a fan of Cal Newport, the epically productive lifehacker and computer science professor, since I read his book Deep Work in 2017 (and promptly deleted my social media). He recently channeled Dave Ramsey’s “Baby Steps” for a responsible financial life in his podcast to create a preliminary list of steps to gain mastery over professional productivity. . Here they are, in my own words:

https://mythinkpond.com/post/2020-12-05-managing-your-time/

1. Begin daily time block planning (see above). This is the organization of your day into blocks of time so that every minute of your day has a job, even if that job is getting rest or going for a walk. Not coincidentally, Newport has a planner he sells (and which I’ve used) for this very purpose, although a cheap notebook works just as well.

2. Set up task boards for each of your professional roles. On each task board, keep track of the obligations for those roles and the status of each obligation. He recommends a column for this week’s work, a column for “ambiguous/needs clarified,” a column for each major project you’re working on, a column for “waiting to hear back,” Newport uses Trello for this, a software I’ve never managed to get the hang of, but a physical board would work as well as long as you do most of your work in one location like an office. He also mentions Flow and Asana.

3. “Full capture” your day. He means that, at the end of the day, every professional obligation for the day is out of your head and recorded in a trusted system so that it won’t be ignored or forgotten moving forward. He says he got this from David Allen’s Getting Things Done, which I’ve never read. Newport says that a beginner’s “trusted system” should consist of their email inbox, their calendar, and their task board (see above). He recommends having a box to check at the end of the day that indicates this step has been done. Big on ceremony, that Cal Newport.

4. Develop a weekly plan, based on your calendar and your task boards. Look at the whole picture, start blocking out time for big projects you know are going to take time, just so people can’t interrupt those time blocks with meeting requests. Come up with a “productivity heuristic” for the week, like devoting 30 minutes each morning to handling questions from clients, come hell or high water. When you time block plan every day, use the weekly plan to guide what you’re spending your time on.

5. Develop a strategic plan. Part one is the vision for your professional life, where you’d like to be in five years and how you plan to get there. Part two is your vision for the upcoming quarter. Your weekly plan is influenced by the strategic plan in the same way that your time block planning is influenced by your weekly plan.

6. Automate and eliminate. This is the process of tweaking your work-life by putting in place systems and guidelines to streamline, reduce context switching, and get unnecessary jobs off your plate, like committee assignments you don’t feel are productive. He stresses that the elimination step has to come after you’ve developed professional credibility in other ways. So he recommends saving the automate and eliminate steps for after steps 1-5 have been mastered.

7. Go for it. This one is a little cheesy, maybe in the tradition of self-helpers. Once you’ve implemented all these philosophies, take advantage of your new powers to take really ambitious swings.