Health Costs

Emergency helicopter transport can be pricey and, as recent reports of aircraft crashes show, potentially dangerous. Such downsides have sparked some concerns that transporting trauma patients by air may not be worth the risk. So researchers at Stanford set out to investigate how often medical helicopters needed to help save critically injured patients’ lives in order to be considered cost-effective when compared with ambulances.

Researchers published their findings (subscription required) online this month in the Annals of Emergency Medicine. My colleague explains their results in a release:

The researchers found that if an additional 1.6 percent of seriously injured patients survive after being transported by helicopter from the scene of injury to a level-1 or level-2 trauma center, then such transport should be considered cost-effective. In other words, if 90 percent of seriously injured trauma victims survive with the help of ground transport, 91.6 need to survive with the help of helicopter transport for it to be considered cost-effective.

The study… does not address whether most helicopter transport actually meets the additional 1.6 percent survivorship threshold.

“What we aimed to do is reduce the uncertainty about the factors that drive the cost-effective use of this important critical care resource,” said the study’s lead author, M. Kit Delgado, MD, MS, an instructor in the Division of Emergency Medicine. “The goal is to continue to save the lives of those who need air transport, but spare flight personnel the additional risks of flying - and patients with minor injuries the additional cost - when helicopter transport is not likely to be cost-effective.” (Helicopter medical services generally bill patients’ insurance providers directly, but patients may have to pay some of the bill out of pocket, or, if they’re uninsured, possibly all of it.)

The findings only apply to situations and locations where patients could be taken by both ambulance and helicopter to a trauma center. Researchers said that in scenarios where ground transportation to a trauma center wasn’t feasible, then transport by helicopter was preferable.

Photo by Brett Neilson

Medicaid, the federal health-insurance program for low-income individuals, is set to undergo a big expansion in 2014 as part of the implementation of the Affordable Care Act. That expansion is good news for the children of low-income adults who will be newly eligible for health insurance, according to an opinion piece published online yesterday in JAMA Pediatrics.

Under the current system, Medicaid and SCHIP health insurance cover a much larger proportion of low-income children than adults, with the result that many insured children have uninsured parents. While insuring kids is important, it isn’t always enough, say the authors of the new piece, who are from Indiana University and Boston University.

“Children with uninsured parents are significantly less likely to receive recommended health services, even if they themselves are covered,” they write.

However, because of the U.S. Supreme Court’s 2012 decision on the Affordable Care Act, states get to choose whether or not to expand Medicaid. (The Supreme Court ruled that the ACA’s Medicaid-expansion mandate was coercive.) This is where the story gets really interesting. The piece describes states’ financial concerns about Medicaid expansion - essentially, that it will be expensive to add people to the Medicaid rolls - but then elaborates on some of the financial factors that states turning down Medicaid expansion may not be considering:

…[O]verall, the cost of the Medicaid expansion to states would be less than 1% of their local gross state product. Others have illustrated that, because uncompensated care reimbursements will decrease under the ACA and because some individuals will shift from Medicaid coverage to coverage through the private exchanges, many states might actuallywind up saving money by accepting the expansion. Medicaid can also have a stimulative effect on the economy, leading to increased employment and revenues, and, once again, can increase the potential for overall savings for many states.

Refusing the expansion will also come at a cost to clinicians, offices, and hospitals. Disproportionate hospital share payments will be trimmed by the ACA, reducing a source of income to hospitals. If many citizens are denied Medicaid, then it is likely that they will remain uninsured. Providers that continue to care for them will do so at a significant loss. Although many complain that Medicaid reimbursements are too low, they are still better than nothing. Such a complaint also ignores the fact that reimbursements for primary care services (even those provided by subspecialists) will go up significantly under the ACA, starting this year.

The authors hope that some or all of the states that have announced they will not expand Medicaid will eventually decide the expansion would be beneficial for their low-income citizens, including parents and children, and for their overall financial picture.

Previously: Stanford economist Victor Fuchs: Affordable Care Act “just a start”, Roundtable of doctors discuss Affordable Care Act and Analysis: The Supreme Court upholds the health reform act (really)

Near the end of a woman’s pregnancy, obstetricians use ultrasound to check that the baby is poised to be born head-first. Since breech vaginal deliveries (with the feet or rear end first) are risky for both mom and child, many physicians opt to schedule a c-section if the baby isn’t head-down at the end of pregnancy.

However, before they take that step, doctors can perform a procedure called an external cephalic version (or simply “version”) to try to turn the baby. To do this, they push on the mother’s pregnant abdomen while carefully monitoring the baby with ultrasound. In the past, women were not given anesthesia during this procedure, but recent research has shown that administering anesthesia can make versions more successful, perhaps because the medications help to relax the women’s abdominal muscles and allow the physician to use less pressure. Unsurprisingly, moms who receive pain relief are also happier with the process than those who don’t.

But there’s a wrinkle: Some physicians have worried about the additional expense of using anesthesia for versions, since the anesthesiologist’s time and the drugs used come with costs. Researchers from Stanford and Lucile Packard Children’s Hospital decided to address this conundrum by analyzing whether the additional cost of anesthesia was offset by the savings from enabling more vaginal deliveries and avoiding some cesareans.

In our press release, Brendan Carvalho, MD, the lead author of the new research, explained the findings:

“[O]ur work shows that it doesn’t add significant costs, and most likely reduces overall costs because more women can avoid cesareans.”

…

The study found that using anesthesia increased average success rates of version procedures from 38 percent to 60 percent. Because it led to fewer cesareans, use of anesthesia also decreased the total cost of delivery by an average of $276; the range of cost differences estimated by the model extended from a $720 savings to a $112 additional cost.

Looking at the question of cost-effectiveness in a different way, the success rates of versions had to be improved at least 11 percent with anesthesia for the cost of the anesthesia to be negated, the researchers calculated.

So far, Carvalho said, Packard Children’s is one of only a few Bay Area hospitals offering anesthesia for versions. But he hopes his team’s findings will encourage more physicians to consider the practice, since it’s good for both mothers’ well-being and hospitals’ bottom lines.

Previously: Should midwives take on risky deliveries?
Photo by Trevor Bair

Heart disease is the primary cause of death for the more than 20 million people in the United States with chronic kidney disease (CKD). For kidney patients who have secondary diagnoses of coronary artery disease or diabetes, which puts them at particularly high risk of heart attack or stroke, the cholesterol-lowering drugs statins are routinely prescribed.

But for the remainder of patients with chronic kidney disease, it’s unclear whether statin treatment is either cost effective or medically prudent. A Stanford study published today in the Journal of the American College of Cardiology sheds some light on the issue.

…At very low prices, generic statins are cost-effective in nearly all patients with chronic kidney disease

“We did a cost-effectiveness analysis weighing the potential benefits in patients with chronic kidney disease and hypertension,” first author Kevin Erickson, MD, a Stanford nephrologist, recently explained to me. “We essentially show that at very low prices, generic statins are cost-effective in nearly all patients with chronic kidney disease, but at average retail prices they are only cost-effective in patients with kidney disease who have higher cardiovascular risk.”

The study also indicates that adverse side effects of these drugs, including muscle-related toxicity, and potential diabetes and memory loss, should be taken into consideration by clinicians when determining treatment options. “While statins reduce absolute [cardiovascular disease] risk in patients with CKD, increased risk of rhabdomyolysis, and competing risks associated with progressive CKD, partly offset these gains,” Erickson and his co-authors cautioned in the paper.

Previously: Wider statin use may be cost-effective way to prevent heart attacks

Congratulations are in order for two Bay Area journalists: Writer Lisa Krieger and photographer Dai Sugano have won a health journalism award for the “Cost of Dying” series that ran in the San Jose Mercury News last year. The project was prompted by something very personal - the illness and death of Krieger’s elderly father - and is summarized nicely by the Association of Health Care Journalists, the organization that gave out the awards:

At the center of Krieger’s unflinching account of her father’s last days is an uncomfortable question: “Just because it’s possible to prolong a life, should we?”

Hundreds of readers wrote in to thank Krieger for sharing her story and going beyond the “death panel” rhetoric that so often stifles honest discussion of end-of-life concerns. Her work demonstrates that reporters can sometimes tell the story from an unusual perspective – their own – and touch readers in a different way than would be possible with more traditional coverage.

Sheri Fink, MD, PhD, a Stanford medical alumna, also won an award from the AHCJ in the beat writing category. Fink is currently penning an article on Hurricane Sandy for the next issue of Stanford Medicine magazine.

Previously: On a mission to transform end-of-life care and Is $618,616 too much to (try to) save a life?
Via Covering Health

Earlier this month, close to 200 heavy-hitters in academics, government and the private sector assembled at Stanford to discuss health-research policy. The ultimate goal of the event, which was co-hosted by Stanford’s Clinical Excellence Research Center and the White House Office of Science and Technology Policy, was to help guide the White House in developing policy changes to improve health care and its affordability.

As reported by my colleague yesterday, recommendations that emerged from the day-long summit included:

• Leveraging information within electronic medical records by creating incentives for health-care providers and insurers to make privacy-protected patient data widely and easily accessible to researchers.
• Creating more flexible research funding categories and regulatory “safe havens” that encourage the testing of unconventional health-care delivery innovations.
• Stimulating commercial investments in cost-saving medical devices by linking insurance reimbursement levels to the incremental value they deliver.
• Reinventing patient consent forms to be more relevant to new ways of safely conducting medical research, such as analyses of previously collected biological specimens or of health-care quality improvement programs.

I like the way participant Mark Hlatky, MD, a professor of health services research and of medicine at Stanford, put it: “While there is no single silver bullet for our inefficient health-care system, this event suggested a number of ideas that could synergize such that the whole will be greater than the sum of the parts.”

Previously: Making health care better and more affordable, Stanford expert urges physicians to take the high road in slowing health care spending, How can we slow growth of U.S. health-care spending? and New Stanford center to address inefficient health care delivery

Stanford’s Clinical Excellence Research Center, which we’ve previously written about on Scope, was the focus of a recent edition of Minnesota Public Radio’s The Daily Circuit. As reporter Kerri Miller describes it, the center is “taking on some of the toughest quandaries in health care,” and its work was prompted by director Arnold Milstein, MD, asking himself “why the care for cancer, and kidney disease, and morbid obesity is often so expensive, too often not as effective as it should be, and frequently so difficult for the patients who are going through it.” Take a listen to find out how he and colleagues are trying to change that.

Previously: Stanford expert urges physicians to take the high road in slowing health care spending, Uncommon hero: A young oncologist fights for more humane cancer care, Innovative Stanford clinic to support chronic care patients and New Stanford center to address inefficient health care delivery

“All men are created equal” may be the guiding legal principle for citizens of the United States, but not when it comes to health care coverage and outcomes, says Victor Fuchs, PhD, one of the nation’s foremost health economists and the Henry J. Kaiser Jr. Professor, Emeritus, at Stanford.

In a Viewpoint published today in the Journal of the American Medical Association, Fuchs provides a history lesson on how and why the U.S. health care system spends more than double on per-person health expenditures than other advanced nations, and he offers some strategies for controlling future costs.

“This is the best short piece on U.S. health care that I’ve ever seen,” Howard Bauchner, MD, editor-in-chief of JAMA, told me.

Beginning today, the Affordable Care Act expands the number of Americans receiving preventive care, providing new federal funding to state Medicaid programs that choose to cover preventive services. It also requires that states pay primary care physicians no less than 100 percent of Medicare payment rates for primary care services.

While the health-care reforms mandated in the act include some provisions to motivate health-care providers to become more efficient, less fragmented and more accountable, it doesn’t include revenue sources for all its new services. Fuchs says, “More comprehensive reforms are necessary to avoid financial disaster.”

According to Fuchs, there are three fundamental differences in the U.S. system — driven by its history — that make it difficult for the U.S. to adopt a less costly government-financed health care system. There is a distrust of large government that began when America broke away from the strong-armed British Empire. There is a reluctance to redistribute wealth across all citizens, in part because of the country’s cultural diversity. And there are “choke points” in the U.S. political system — such as the cost of election campaigns and the Senate filibuster — that give deep-pocketed special interest groups the upper hand in preventing sweeping reforms.

As a new Congress returns to work with health care reform high on its new year’s resolutions, Fuchs’ editorial provides a starting point, grounded in history, for a new round of negotiations.

Previously: Study: If Americans better understood the Affordable Care Act, they would like it more, Does the Affordable Care Act address our health-cost problem?, Stanford economist Victor Fuchs: Affordable Care Act “just a start” and An expert’s historical view of health care costs

From Dec. 24 to Jan. 7, Scope will be on a limited holiday publishing schedule. During that time, it may also take longer than usual for comments to be approved.

With rising health care costs threatening U.S. global competitiveness, Arnold Milstein, MD, urges physicians to focus their efforts on more efficient and effective ways of practicing medicine, rather than lobbying Congress to protect their incomes.

Milstein lays out this “urgent choice” in this perspective piece published yesterday online in the New England Journal of Medicine.

I’ve been following Milstein’s efforts to build the Stanford Clinical Excellence Research Center for the last two years, and I’m impressed with the progress that he and his graduate research fellows have made in designing better, more efficient ways to deliver medical care. His overarching philosophy is summed up here:

U.S. health care needs to adopt new work methods, outlined in the Institute of Medicine’s vision for a learning health system. Such methods would enable clinicians and health care managers to more rapidly improve value by continuously examining current clinical workflows, management tools from other service industries, burgeoning databases, and advances in applied sciences (especially health psychology and information, communication, and materials technologies). They could then use the insights gained to design and test innovations for better fulfilling patients’ health goals with less spending and rapidly scaling successful innovations.

By adopting these new technologies and methods, Milstein predicts that physicians’ short-term income drops will be replaced with new income-generating opportunities. For example, with Internet-based video and instant translation services, physicians will soon be about to export their expertise to rapidly developing countries facing physician shortages.

He ends the editorial with a quote from Sir William Osler, the father of modern medicine:

Medical care must be provided with the utmost efficiency. To do less is a disservice to those we treat, and an injustice to those we might have treated.

Which path will physicians choose?

Previously: How can we slow growth of U.S. health-care spending?, When it comes to health-care spending, U.S. is “on a different planet” and U.S. health-care costs rising faster than abroad

Speaking of Longreads, I just learned that an article from Stanford Medicine made last week’s list of Top 5 Longreads of the Week. In case you haven’t yet seen it, Kris Newby’s piece focuses on a group of Stanford physicians aiming to make health care better and more affordable.

Previously: Uncommon hero: A young oncologist fights for more humane cancer care and New Stanford center to address inefficient health care delivery