Category Archives: Cost of care
Kathleen J. Mullen, PhD, is an alumna of the Robert Wood Johnson Foundation Scholars in Health Policy Research program, and an economist and associate director of the RAND Center for Disability Research at the nonprofit, nonpartisan RAND Corporation.
Dementia, a chronic disease characterized by significant impairment of cognitive functioning, afflicts 15 of every 100 Americans over age 70 – and it is their caregivers who are perhaps most familiar with the disease’s effects.
Family members are often the ones who find themselves navigating the complex system of nursing homes, in-home health care, and health insurance (Medicare, Medicaid, and private insurance), all while dealing with heartbreaking changes in the physical and mental functioning of their spouses, siblings, parents or grandparents. Indeed, my own family is struggling to sort through an overwhelming number of options and decisions to help ensure that my 86-year old grandmother receives the best available care now that she is unable to live without daily assistance.
For many families, a significant barrier to that best available care is cost: Caring for someone with dementia is extremely expensive. A recent RAND study, the results of which were published in the New England Journal of Medicine, offers some of the most comprehensive and credible estimates to date of the monetary costs of dementia in the United States. These costs include both out-of-pocket spending and spending by Medicare, Medicaid, and other third parties on nursing home and hospital stays, medical visits, outpatient surgery, home health care, special services (such as outpatient rehabilitation), prescription drugs, dental services, and other needs.
Ashok Reddy, MD, is a Robert Wood Johnson Foundation (RWJF) Clinical Scholar in residence at the University of Pennsylvania and a senior fellow at the Leonard Davis Institute of Health Economics. This is part of a series of essays, reprinted from the Leonard Davis Institute of Health Economics’ eMagazine, in which scholars who attended the recent AcademyHealth National Health Policy Conference reflect on the experience.
With the debate about the fiscal cliff and the sequester hanging so heavily over Washington, it was no surprise that congressional staffers at the AcademyHealth National Health Policy Conference seemed so exclusively focused on cutting health care spending. Some estimated that 30 percent of the $2.5 trillion spent on health care may provide little value; finding interventions that provide high-value care is a top priority that tends to obscure any other possibilities.
In this prevailing atmosphere of stark fiscal reality and gridlocked politics it can be hard to gain traction for the idea that investing in programs that prevent chronic diseases would ultimately decrease the costly long-term expenditures driven by those diseases. But that’s where traction is needed.
Take diabetes for instance. One estimate has the medical treatments for people with diabetes costing 2.4 times more than expenditures that would be incurred by the same group in the absence of diabetes. By preventing the development of diabetes in an individual you decrease the risk of heart attack, kidney failure and amputated extremities.
It is true that, so far, research in cost-effectiveness analyses has not shown that prevention reduces medical costs. Besides childhood vaccination and flu shots for the elderly, few health care services ‘save money.’ A 2010 Health Affairs article calculated that if 90 percent of the U.S. population used proven preventive services, it would save only 0.2 percent of health care spending.
-- Dr. Martin Luther King Jr., in a speech to the Medical Committee for Human Rights, 1966
Nalo Hamilton, PhD, RN, WHNP/ANP-BC, is an assistant professor of nursing at the University of California, Los Angeles School of Nursing; and Cheryl Woods Giscombé, PhD, RN, PMHNP-BC, is an assistant professor in the School of Nursing at the University of North Carolina at Chapel Hill. Both are Robert Wood Johnson Foundation Nurse Faculty Scholars.
The New Year has begun and for some 2013 marks a time of celebration and progress, while for others it is a time of uncertainty and despair. As we pause to remember the rich contributions of Dr. Martin Luther King, Jr., we should also reflect on how his legacy can be used to eliminate the health care disparities that so disturbingly affect the underserved and underrepresented in our nation today.
The World Health Organization has determined that geographic locale, ethnicity, education, environmental stress, and access to a health care system are social determinants of health and health inequities. These factors are influenced by the disparate distribution of resources, wealth, and power.
In the United States:
- African Americans, Hispanic Americans, and Native Americans have rates of diabetes that far exceed those in non-Hispanic whites.
- African American women are more likely to be diagnosed with advanced stage breast cancer compared to white women and have the highest rate of mortality.
- Native Americans report more alcohol consumption and binge drinking than other racial/ethnic groups.
- Hispanic males age 20 or younger have the highest prevalence of obesity compared to non-Hispanic whites and African Americans.
- African American men and women are more likely to die of cardiovascular disease than non-Hispanic whites.
- Infant mortality occurs in African Americans 1.5 to 3 times more than in other races or ethnicities.
Arthur Kellermann, MD, MPH, FACEP, holds the Paul O’Neill-Alcoa Chair in Policy Analysis at the nonprofit, nonpartisan RAND Corporation. He is an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program and the RWJF Health Policy Fellows program. This post is part of the "Health Care in 2013" series.
For the first month of my medicine internship at the University of Washington, I was assigned to Seattle’s VA Hospital. I was stunned to learn that my attending physician would be Paul Beeson, widely regarded at the time as one of the giants of American medicine. [i] At an age when most doctors are enjoying their retirement, Dr. Beeson was still doing what he loved best—caring for patients and teaching.
I have forgotten most of the clinical pearls Dr. Beeson taught that month. But one that still stands out is the way he questioned the need for every lab test, x-ray and treatment my team ordered. “Why do you want that?” he’d ask. “What will you do with the result?” Throughout the month, he urged us to forego interventions that offered little benefit to our patients, but exposed them to potential side effects or complications. His message was clear. Do only what’s needed, not more.
Today, we need Dr. Beeson’s message more than ever before. In the three decades since I trained under him, America’s health care system has grown so large, it claims a bigger share of the gross domestic product than American manufacturing or wholesale and retail trade. [ii] As a result, the federal government spends more on health care than national defense and international security assistance. In several states, health care is crowding out spending for education. In the past decade, health care cost growth has wiped out the hard-won earnings of middle-class families. [iii]
Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows and grantees. Some recent examples:
Following the announcement of the 2012 RWJF Community Health Leaders, many media outlets have covered the awardees. Among them: Kay Branch, MA, in the Anchorage Daily News, Ifeanyi Anne Nwabukwu, RN, BSN, in the Washington Informer, and Fred Brason in the Winston-Salem Journal.
A 2004 Community Health Leader also was in the news: Rabbi Elimelech Goldberg was named one of People Magazine’s “Heroes Among Us” for his work with Kids Kicking Cancer, a nonprofit that uses martial arts therapy to empower young cancer patients and help them manage pain.
RWJF Physician Faculty Scholar Deverick J. Anderson, MD, MPH, and colleagues conducted a single-center pilot study that finds ultraviolet light kills more than 90 percent of pathogens, when hospital rooms are flooded with the light from a robotic device. "We are now performing a study to determine if use of the device can actually prevent patients from acquiring these infections in the hospital," Anderson told MedPage Today. The findings were presented at the IDWeek 2012 conference.
Ruchi S. Gupta, MD, MPH, also a Physician Faculty Scholar, did a Q&A with the Chicago Tribune offering guidance for parents of children with food allergies, especially on Halloween. Read a post Gupta wrote for the RWJF Human Capital Blog about her professional—and personal—experience with child food allergies.
The Robert Wood Johnson Foundation Human Capital Blog is asking diverse experts: What is and isn’t working in health professions education today, and what changes are needed to prepare a high-functioning health and health care workforce that can meet the country’s current and emerging needs? Today’s post is by Mitesh Patel, MD, MBA, a Robert Wood Johnson Foundation Clinical Scholar and senior fellow at the Leonard Davis Institute for Health Economics at the University of Pennsylvania, a member of the AAIM-ACP High-Value, Cost-Conscious Care Curriculum Development Committee, and a practicing physician at the Philadelphia Veteran Affairs Medical Center. He is also the author of Clinical Wards Secrets, a guide for medical students transitioning from the classroom to hospital wards.
Health care costs continue to escalate. Concurrently, the amount of published medical research has increased 10-fold over the last decade. Each of these changes combined with recent health care reform has led to a rapidly evolving health care system. Unfortunately, medical education has been unable to keep pace with these changes.
Health care professionals find themselves searching for ways to deliver better value for their patients. They are looking for an opportunity to become a part of the solution to stemming the rising costs while still providing high-quality, evidence-based care.
The American College of Physicians (ACP), the Accreditation Council for Graduate Medical Education (ACGME), and the Medicare Payment Advisory Commission (MedPAC) have each recognized these deficits among the health care workforce. They’ve called for a restructuring of medical education to address these issues. However, teaching hospitals and medical educators lack a common strategy to accomplish this daunting task. To address these issues, my research team and I studied approaches to transforming medical education to help prepare providers to assess and deliver value-based care for their patients.
To better prepare a high-functioning health and health care workforce, we must start by gaining a better understanding of the problem. In 2009, we published the first study that shed light on this issue on a national scale. We found that among U.S. medical students, less than half felt they were appropriately trained in topics relating to the practice of medicine such as medical economics. In addition, we found that a higher intensity curriculum in health care systems resulted in a payoff, not a tradeoff.
The Robert Wood Johnson Foundation (RWJF), NPR and the Harvard School of Public Health commissioned a poll to better understand Americans’ experiences and attitudes related to the cost and quality of their medical care. Released on May 21st, Sick in America found that many Americans who experienced a serious illness or injury in the past 12 months are concerned about the financial costs of medical care, and struggle to ensure that their care is appropriate. Nearly nine in ten respondents (87 percent) think the cost of care is a serious problem for the country.
In addition to surveying the public, the poll examined sick Americans’ experiences and perceptions. “Sick Americans” (27 percent of adults surveyed) were defined as those who said they had a serious illness, medical condition, injury, or disability requiring a lot of medical care or who had been hospitalized overnight in the past 12 months. A quarter of sick Americans said a doctor, nurse, or other health professional did not provide all the needed information about their treatment or prescriptions – or they had to see multiple medical professionals, and no single doctor understood or kept track of all the different aspects of their medical issues and treatments (23 percent). Three in 10 hospitalized Americans said there was poor communication among the doctors, nurses, and other health care professionals involved in their care.
In addition, 34 percent of patients who were hospitalized for at least one night in the past year said “nurses weren’t available when needed or didn't respond quickly to requests for help.”
To learn more, NPR published a call-out to nurses on its Facebook page. It was a non-scientific way to gather information, NPR notes, but the response from nurses was significant. “We received hundreds of responses and read them all: piles of stories about nurses feeling overworked, getting no breaks, no lunches and barely enough time to go to the bathroom. Even worse, many nurses say breaks and lunchtimes are figured into their salaries and deducted, whether they take them or not,” NPR reported on Morning Edition.
The poll also found that consumers see a shortage of nurses and physicians as one of the problems with the quality of health care in the country today. Of the one-third of total respondents who were asked about major reasons for quality problem, 35 percent identified “not enough doctors or nurses in hospitals or medical offices” as a major problem.
Americans visited their doctors less often and took fewer medications in 2011, according to a study released this month by the IMS Institute for Healthcare Informatics. The likely cause: financial pressures.
“The Use of Medicines in the United States: Review of 2011” finds the total number of physician office visits declined 4.7 percent in 2011, the fourth decline in five years. Non-emergency room hospital admissions also declined slightly (by 0.1 percent), but emergency room admissions increased (7.4 percent), “the possible result of continued high levels of uninsured patients associated with long-term unemployment,” the study says.
It also finds changes in medication utilization. While seniors remained the largest users of medications, their use of retail prescriptions fell by 3.1 percent. Young people, age 19 to25, however, increased their prescription use by 2 percent. They were the only age group to increase their drug utilization in 2011, perhaps as a result of the provision of the Affordable Care Act that allows them to stay on their parents’ health insurance until age 26.
The drop in per-capita use of prescriptions may be due in part to combination pills and 90-day, rather than 30-day, prescriptions, American Medical News reports, but “researchers believe strained finances are the most significant factor.”
“The end of the recession has not delivered recovery to many people,” Michael Kleinrock, director of research development at IMS and the primary author of the study, told American Medical News. “Patients are spreading out repeat visits and self-medicating with over-the-counter drugs.”
Read a news release about the study.
Read the American Medical News story.
An appendectomy in California could cost anywhere from $1,500 to more than $180,000, even at the same hospital or within the same county, according to a study led by RWJF Physician Faculty Scholar Renee Y. Hsia, MD, MSc. The study, published this week in the Archives of Internal Medicine, found wide variations in fees for the routine procedure, about one-third of which could not be explained even after reviewing all the cases and accounting for individual health variations.
“We expected to see variations of two or three times the amount, but this is ridiculous,” Hsia told the New York Times. “There’s no rhyme or reason for how patients are charged or how hospitals come up with charges… There’s no other industry where you get charged 100 times the same amount, or 121 times, for the same product.”
Read a post Hsia wrote for the RWJF Human Capital Blog about ambulance diversion and emergency department crowding.
Human Capital News Roundup: Rising Medicare expenses, community-based health care, breast cancer prevention and more.
Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program site director Ana Diez Roux, MD, PhD, MPH, and RWJF Interdisciplinary Nursing Quality Research Initiative (INQRI) co-investigator Christopher Ruhm, PhD, were cited in a Bloomberg column by former Office of Management and Budget director Peter Orszag. The research of both investigators shows, counter-intuitively, that life expectancy rises during periods of economic downturn.
Dawn Alley, PhD, an alumna of the Health & Society Scholars program, is the lead author of a study that finds that obesity—and the chronic conditions that often come with it—are a major contributor to the growth in Medicare expenses. Each obese beneficiary adds an additional $149 a year to Medicare, Reuters reports.
An assessment tool used by the federal government to determine if a community health center is functioning as a “patient-centered medical home” may not accurately reflect the quality of the diabetes care the health center provides, according to a study led by RWJF Clinical Scholar Robin Clarke, MD. The researchers found no significant relationship between passing the assessment and the quality of diabetes care provided, Cardiovascular Business reports. Health Canal also reported on the findings.