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.

How to Get Your Employees to Take Advantage of Price Transparency

In the KBGH Book Club we’ve gone through the “What’s wrong with this situation?” phase, and we’re just entering the “What can we do about this?” phase. A solution that is proposed again and again in this book and in the benefits world in general for controlling costs in medical care is price transparency.

In theory price transparency works like this: since most of the medical care that we receive is non-urgent, we should have time to compare prices. So if only the price of, say, an elective knee MRI at several locations was published on a website, we could simply compare the different radiology practices, choose the lowest price, and go to that practice for our MRI. There is some evidence to support that this works. My favorite study, which I wrote about in a previous blog post, showed that parents choosing a treatment for their child’s appendicitis still mostly chose the cheaper option when they were given cost information, even though it affected their insurance payment more than their out of pocket cost.

Because of this, and because of an Executive Order President Trump signed on October 29, 2020, CMS and the Departments of Labor and Treasury have issued a final rule that will, for the first time, require most private health insurance plans to do two things:

1. They will have to provide personalized cost-sharing information to patients.

2. They will have to publicly report negotiated prices for specific health care services through an online tool. The tool initially will be required to have the ability to compare rates and out-of-pocket expenses for 500 of the most common labs, visit codes, and procedures (deadline January 1, 2023). Starting January 1, 2024, these tools must report this cost information for all health care services. Legal challenges to these rules will undoubtedly continue (not everyone believes, as we do at KBGH, that transparency = trust). But barring a truly explosive set of judicial rulings, we can expect a great deal more price transparency moving forward than what we have now.

Unfortunately, as Jeffrey Kullgren and Mark Fendrick note in a recent editorial (paywall), transparency tools have not yet been shown to reduce overall spending, even when patients are paying pre-deductible prices, when they should be most sensitive to prices. Multiple phenomena may account for this. Patients may simply have too many choices (the old “too much jam” phenomenon). Some patients may assume that less expensive options are of lower quality. Patients may simply not know when more than one option is available. Kullgren and Fendrick make several suggestions on how to make the new price transparency rule work:

1. Make sure employees know that health care services are “shoppable.” We’ll all have to sell patients on the idea that the information is “trustworthy, reliable, and worth using,” as the authors say. This will mean working with our insurance partners to make sure those things are true. Relying simply on the fantasyland “chargemaster” prices for hospital services, for example, will undoubtedly make employees skeptical or cynical about the process.

2. Many employees will need guidance on how to best use the transparency information. A specific example given by Kullgren and Fendrick is direction on when prices could be most helpful. Planning a knee replacement in a few weeks or months, for example, is a good use of pricing information. Trying to price shop after a diagnosis of a potentially life-threatening cancer requiring urgent treatment, though, is clearly not a good practice, in spite of what my favorite parents-cheaping-out-on-their-sick-kids study above may say.

3. On the provider side, we need to continue moving away from fee-for-service reimbursement models and toward quality-driven, alternative payment models. Much of this movement is happening on the public side in Medicare and Medicaid. On the employer side, a move toward more direct contracting with providers could be a good way to accomplish this.

4. Employers need to work with professional societies (like the Medical Society of Sedgwick County, with whom KBGH is allied) to continue to advocate that cost containment is a core professional responsibility of modern medical providers. Integrating cost information into the medical record like the Veteran’s Administration does for drug pricing may be a good practice.

5. We need to pressure different health systems to adopt electronic health record interoperability standards so that, when patients use price information to seek services at alternate facilities, their care won’t be fragmented between doctors that can’t access the same information.

How do you propose we nudge our employees toward taking advantage of price transparency moving forward? We’d love to hear your ideas!

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.

Here’s to those who say “no”

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

Comparing two patient visits

Every visit to a health practitioner is a story. Here’s the skeleton of how the story sometimes goes:

1. A patient makes a request for a specific test or treatment, often based on what he’s seen in advertisements or media. Take, for example, the time a perfectly ambulatory patient of mine saw a late-night TV ad for mobility scooters and asked me to prescribe one, since “Medicare [would] pay for it,” and since the patient found walking to be “exhausting.” 

2. The request is denied, hopefully for medically/economically sound reasons and not out of some peculiarity of the practitioner-patient relationship. What I mean here is that sometimes patients and doctors simply aren’t a good fit, and sometimes, strained relationship dynamics spill into decision-making. “Good” doctors allow this to happen less often than “bad” doctors, but I suspect no one ever quite gets to zero. I’ll leave the judgement of my “goodness” or “badness” to others. But in the case of my patient, with whom I had a very poor relationship (to my eye, largely because of near-constant requests like his request for the scooter), even though I had a good medical reason to deny the request (walking is good for you even if it makes you tired), my writing something to the effect of “over my dead body” in the chart probably betrayed my feelings.

3. The patient gives feedback of some kind. The relationship between patient requests and the doctor’s willingness to fulfill them has real, dollars-and-cents ramifications in that reimbursement is now sometimes tied to “patient satisfaction.” A study in JAMA Internal Medicine (paywall) found that about two-thirds(!) of visits involve a request for a specific test or treatment from the patient, and that 85%(!) of those requests are granted. But when requests are denied, patients report dramatically lower satisfaction. The effect is predictably strongest with requests for pain prescriptions or lab tests. The effect is almost nonexistent for stuff like antibiotics or x-rays. But back to our patient: maybe he complains to the office manager. Maybe he goes home and writes a scathing review on one of various doctor rating sites. (Advice to other medical professionals: don’t look these up. They hurt.) Patient Scooter chose to express his dissatisfaction not in writing, but by leaving a bowel movement on the floor in the elevator of the building. (I’m not making this up.)

4. Doctor uses that feedback to change his or her future performance/behavior. Or maybe he doesn’t, if the feedback is in the form of actual human excrement. (I did record the approximate size and quality of the stool in his chart.)

That story is not fair. It prioritizes the point of view of the medical professional. Here’s an alternate story, taken from a ProPublica piece a couple years ago:

1. A patient presents with a seemingly minor, but worrisome, finding: slight chest pressure that worsens when he exerts himself but gets better when he rests.

2. With the help of a non-invasive procedure, his primary care doctor and a cardiologist accurately diagnose the patient with “stable angina.” The cardiologist recommends a coronary angiogram—an x-ray of dye going through the vessels of the heart—with possible stenting of any narrowed arteries. “Stenting” is a procedure where a blocked artery is propped open with a tiny metal cage that is expanded in the vessel by the cardiologist. This high-intensity recommendation as a solution to a diagnosis the patient found only slightly troubling is not a surprise. Our instinct in medicine is not just to stand there, but to do something, even if we aren’t sure of its benefit. Doctors routinely overestimate the benefit of screening tests while underestimating harms, for example.

3. While the cardiologist is out of the room the patient looks up evidence on the effectiveness of stenting, such as this negative randomized trial from the Lancet (paywall), and concludes, many would say correctly, that it should not be first-line therapy for heart disease in most patients with stable angina who are not having a heart attack. Instead, the patient reads that aspirin, medications called beta-blockers, and cholesterol-lowering medications are first-line therapy.

4. The patient seeks a second opinion (we’re big fans of those at KBGH). Luckily for him, his second opinion comes from a cardiologist who is active in the RightCare Alliance, a coalition of patients and clinicians interested in bringing down the cost of medicine while potentially improving patient experiences. The second cardiologist agrees with the patient, who then loses weight, changes his diet, and experiences no more chest discomfort.

Here we have two stories, both of which had happy endings, at least in the evidence-based medicine sense. (Though the first ending was certainly not happy for the maintenance staff of my clinic.) But the journey to those endings was unnecessarily fraught. Patient One was convinced that he needed a device because of a slick ad by some unsavory device dealers. Patient Two, in addition to having “an inquiring mind and a smartphone,” in the words of David Epstein, lucked into seeing a cardiologist whose grasp of and willingness to follow evidence-based guidelines was superior to his peers. What ties these threads together? In a way, health literacy.

Enter health literacy

Health literacy is the capacity to process and understand basic health information in order to make good health decisions. High health literacy is associated with dramatic improvement in medical outcomes and a reduction in care costs. We’ve touched on it before at KBGH, and we even offer a health literacy product to members called Quizzify.

But what of the doctors’ poor decision making? What we call “health literacy” on the patient side, it could be said, we call “evidence-based medicine” on the physician side. Doctors are no longer reservoirs of information, as they once were; they don’t simply carry around information that their patients don’t have access to. The sum knowledge of medicine is far too deep and broad. Instead, doctors have transitioned into curators of medical information, sort of like librarians. And they’re expected to use their access to that information to make good decisions, ideally with the input of the patient, what we call “shared decision making.” But like anyone else, doctors’ decision making is influenced by outside forces. Doctors who own their own CT scanners, for example, are more likely than others to order CT scans. Other studies have shown that doctors who sell drugs to patients, like oncologists, are more likely to choose the more profitable drug more of the time. And simple human nature predicts that doctors who are able to “self-refer” for procedures, like cardiologists or surgeons who have the choice between low-paying patient education or high-paying procedures, will more often choose the procedure. This impulse, and the willingness of some people to pay for “doing something” may, in my opinion, explain some of the absurd, wasteful testing that gets done as part of executive physicals.

Health literacy in its classical definition is a way for patients to obtain and process health-related information. But in a broader sense—and I’m not trying to cast the patient-physician relationship as adversarial—health literacy can be thought of as the best way for a patient to defend herself from suboptimal decision making on the part of his doctor. After all, in the patient satisfaction study noted above, patients who were denied requested imaging studies or antibiotics were not significantly less satisfied. Why is this? An accompanying editorialist (paywall) notes that “Through Choosing Wisely and other campaigns to reduce low-value care, substantial attention has been devoted to preparing physicians to avoid frequently requested, low-value care such as these. We can train physicians to say no to other types of clinically inappropriate requests, while still reassuring patients and paying attention to their needs.”

Bringing it home

What we need, then, is a war with two fronts, manned by patients, doctors, employers, and payers who are willing to say “no.” (There I go with the adversarial language again). On one front, we continue to develop good health literacy in the general public, so that they can go to their doctor and ask for effective diagnostic and therapeutic strategies and decline tests or treatments they don’t think are in their best interest. But on the second front, we need to pay just as much attention to the “literacy” of physicians, employers, and payers, with the development of incentives that align with the well-being of the patient. One of the best ways to reduce low-value care, after all, is simply to stop paying for it.

Examining Executive Physicals

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:

Fifteen years ago it was common to see parked semi trucks with CT scanners in the trailer, advertising “whole-body CT scans” as a preventive measure. Thankfully the trend eventually petered out. I can’t find reliable information on why the practice died. It’s possible that the worried segment of the population simply all had their CTs done, and no one else was willing to pay. But from a medical safety perspective, I hope the practice died because people–patients, regulators, or others–decided that the risk of “false positive” tests, with their necessary biopsies and follow-up testing, all of which carries its own risk, was not justified by the small chance of finding a potentially treatable abnormality. Or people simply decided they didn’t want the relatively large radiation dose (a whole-body CT exposes a person to ~15 mSv radiation, roughly a tenth of the exposure of Hiroshima survivors).

But the practice of whole-body CT scans lives on in the tiny corner of the market known as “executive physicals.”

In a recent paper in JAMA, Deborah Korenstein, Maha Mamoor, and Peter Bach used a combination of internet searching and phone calls to identify highly ranked hospitals offering executive physicals. Executive physicals at these prestigious institutions routinely offered:

• Electrocardiograms (USPSTF grade D or I for low-risk patients)

• Chest x-rays (not addressed at all by the USPSTF, but not generally paid for by any insurance company in asymptomatic patients)

• Pulmonary function testing (USPSTF grade D for asymptomatic patients), and

• You guessed it: whole-body CT scans.

Unnecessary testing has downsides

The unnecessary testing of anyone–let alone your most highly-paid employees–is a three-headed spear. First, the exams themselves are expensive: around $5,000 each. Second, much of the testing that is unsupported by evidence is likely a waste of money, as we’ve discussed in a previous post, especially since your highly paid professionals are likely to outlive your other employees based on their income alone. But maybe more important is the potential real harm done by unnecessary testing.

A well-known example of this comes from South Korea. That country’s national health insurance program initiated an aggressive cancer screening program in 1999 that screened for breast, cervical, colon, gastric, and liver cancers, mostly free of charge. With certain cancers this is a potentially good idea, even though cancer screening doesn’t seem to make people live longer as a whole. But patients in South Korea were frequently offered thyroid cancer screening with neck ultrasound as an optional add-on for a modest cash price.

By 2011, the rate of thyroid cancer diagnoses in South Korea had jumped 15-fold. This was not because of a new toxin in South Korean drinking water or because of radiation exposure. The entire increase was due to the new detection and diagnosis of “papillary” thyroid cancers that were too small and slow-growing to be felt on physical examination, but were easily detected with ultrasound testing. Because they were small and slow-growing the cancers were also unlikely to ever kill the patients in whom they were discovered.

So what was the downside? All the surgeries to remove cancerous thyroids had consequences (in addition to the surgery’s ~$5,000 cost). In addition to thousands of people who now needed to be on a daily thyroid hormone pill for life, South Korean patients experienced a huge increase in common complications of the surgery: two percent experienced permanent hoarseness due to paralysis of one of the vocal cords, and a whopping eleven percent now needed to take high-potency vitamin D and high-dose calcium multiple times a day for the rest of their lives to prevent muscle cramping because of damage to the calcium-controlling parathyroid glands that lie next to the thyroid.

This might be acceptable if a significant number of years were added to patients’ lives as a result of this. But that has not happened. A person in South Korea has the exact same (very small) chance of dying of thyroid cancer now as she did before this movement. That is to say, all this testing had only downside; there was no upside.

So the next time your company is negotiating the health benefits of its executives it might be worth asking what evidence supports any additional testing offered to C-suite folks. It may cost more than you think.

Health literacy is not just important for C-suite individuals.  Considering that only 12% of Americans having proficient health literacy, and that health-illiterate people spend 80% more on healthcare than their health-literate counterparts, it’s crucial to educate your employees!  The Kansas Business Group on Health offers discounts on resources to educate you employees on how to be better consumers of healthcare.