Dr. Mike Merrill

Why are hospital prices so confusing?

A new law requires hospitals to post their prices online. The prices vary quite a bit. Why is this? 

The main reason, I think, is that in a hospital it is difficult to do cost accounting. "Cost accounting" is figuring out what it costs to do something inside an organization. 

Let's make my argument concrete. Let's say you're admitted with pneumonia. The hospital obviously has to charge for the nursing care. To simplify, let's say there's one nurse taking care of you for each 12-hour shift. How do we figure out how much of their time is spent on you? Minute to minute, this nurse could be walking from room to room, sitting down at a computer working on several different charts at once, talking to her supervisor about a problem, and pulling meds out of the medication room. Essentially they are taking care of multiple people during the same hour. It's hard to parse out that time. 

And then it's hard to predict how much of the hospital's resources will be used by any individual. Let's say you are in with the pneumonia, but you have chest pain, and a "rapid response" is called. About six people show up in your room within three minutes. One starts doing an EKG, another one checks your vital signs, another puts some different leads on your chest to watch your rhythm on the defibrillator, and another one starts recording the events as they unfold. The doctor arrives and orders a chest x-ray and some lab tests. The x-ray tech comes up from the basement and shoots the film. A nurse from another floor comes over to draw the blood. About 8 minutes have elapsed. This unforeseeable series of events goes on for maybe 25 minutes until the situation is figured out. How does the hospital account for all these resources in your bill? 

What about the cost of ensuring that the second-level backup generator works? Of ensuring that if the power goes out in the operating room, the first-level generator kicks in within three seconds? Of quality control on instrument sterilization? Of medications in the pharmacy that reach their expiration date and have to be discarded? 

I defy anyone to identify a business environment so complex and so regulated, and that provides so customized a service. 

 

Metrics are based on humanness

In healthcare, we understand that metrics have limits. So when we measure diabetes control, we know we're not seeing all of healthcare quality. It's only part of the picture. And we know that each number has a story behind it. For example, diabetes control in a disadvantaged population means something different than in a wealthy population. There are multiple factors underlying the number, and to understand it, we need to ask questions and have conversations. 

I like to say that "metrics are good, but thinking is indispensable."

Following are some interesting thoughts on metrics from Dr. David Shaywitz's December blog post at Forbes, and other stuff he points to. 

In Nobember 1984, when spreadsheets were permeating the business world, Steven Levy wrote a thoughtful essay in Harper's on how spreadsheets were transforming business thought. (The article's title was "A Spreadsheet Way of Knowledge," apparently an allusion to Carlos Castenada's book, The Teachings of Don Juan, a Yaqui Way of Knowledge, which is a highly mystical story of a Native American shaman):

• Measuring something makes it easy to ignore what is not measured. "The aspects that get emphasized are the ones easily embodied by numbers. ... Even a hostile takeover seems cut and dried, perfectly logical, in the world of spreadsheets. The spreadsheet user has no way of quantifying a corporate tradition or the misery of stockholders or whether the headaches of a drawn out takeover bid will ultimately harm the corporate climates of the firms involved."
• Spreadsheets and mathematical models are based on assumptions with highly variable reasonableness. "The accuracy of a spreadsheet model is dependent on the accuracy of the formulas that govern the relationships between various figures. These formulas are based on assumptions made by the model maker. An assumption might be an educated guess about a complicated cause-and-effect relationship. It might also be a wild guess, or a dishonestly optimistic view. ... People tend to forget that even the most elegantly crafted spreadsheet is a house of cards, ready to collapse at the first erroneous assumption "
• Spreadsheets are "a metaphor," and there are other kinds of metaphors apart from math.  

From Frank Pasquale of Yale Law School: 

• Don't let metrics be the only thing that tells you what is good: "There is an almost evangelical quality to [metric-driven] work, a passionate belief that older, intuition-driven decisions are a sinful relic of a fallen world…. [Metrics] colonize our own understandings of merit.”

From The Black Swan author Nassim Taleb: 

• Measurement "increases overconfidence": "Risk measurement and prediction —any prediction — has side effects of increasing risk-taking, even by those who know that they are not reliable. We have ample evidence of so called ‘anchoring’ in the calibration of decisions."

Please let me know what you think!

"Social determinants of health" are macroeconomic, not micro

There's a lot of work on "social determinants of health" that involves helping individual patients get the things they need: secure housing, food security, transportation. 

But the real message of the literature on social determinants is that factors larger than the individual - factors on a society level - affect individuals' health. And a corollary is that addressing these large-scale factors is likely to improve health for individuals. 

A blog post by Health Affairs points out this distinction nicely. 

Things that truly affect social-level function: building a grocery store in a "food desert," improving the safety a neighborhood, providing a low-cost gym, creating affordable housing, and creating a new employer that offers good jobs.  

Unfortunately, truly addressing social determinants requires large-scale intervention. The market by itself cannot be counted on solve the problem because, after all, poor people don't have money.  That leaves government, and in today's political climate, government action on almost anything is problematic. 

Eventually, we will collectively discover that having disadvantaged environments in our midst is bad for everyone, and that individual responsibility cannot solve all problems in an interconnected world. 

 

Three cuban professors define socialism (short videos), and other notes from a visit to Havana

My wife Melanie and I enjoy learning things while traveling. For example we had some great private tours from Ph.D.'s through Context Travel in Rome last year. I can't express how much the non-stop lecturing and question-answering added to our visit. 

This year, on a lark, we booked a cruise (our first - it was actually OK), and decided on one that goes to Havana for two days. In the spirit of learning, we bought a few "experiences" through Airbnb, rather than just doing the cruise ship tours. 

Our first tour was with Leo, an economist, and Cesar, a historian. We went through the history of Cuba, the revolutions, the complicated and difficult relationship with the USA, the partnership with the USSR, and the difficult times when the USSR fell apart (the "Special Period" of austerity). Again, I can't express how enriching these hours were. For something to share with you, I made two brief videos, asking our hosts to define "socialism":

 

At the end of the tour, I told Leo I wanted to learn about central planning, and he said, "I can get you a visit with the University's chief of central planning tonight." 

Wow. 

Another few hours of fascinating conversation. I asked him the same question about socialism: 

What really struck me, talking to these guys, is how much what they said aligns with what I have heard/read economists say in the USA. For example, they understand that a planned economy cannot satisfy everyone's needs, and that a separate economy, using market forces, will occur - whether explicitly or hidden (i.e.,black market). They acknowledge that the tradeoff of a rigidly planned economy is lack of efficiency. For example, for an entire month last year, there was no toilet paper in Cuba. (Of course, part of the difficulty is the trade embargoes, which make it difficult to find trading partners.)

The one difference in their thought was the primacy of the goal of making sure everyone is OK, that everyone benefits in some way from changes. Especially, as they integrate into the world economy, they are intent on ensuring that no one gets hurt. They seek to protect the poorest. "In Cuba, it is difficult to die" - you will not starve, you will have a place to live, you will have health care. I swear you could feel it on the street, even in the poorest neighborhoods - I never felt that desperate anger you can feel sometimes in the USA. There was resentment of inequality, to be sure, but never that sense of "it's me against you." 

We also spent some time in the Museum of the Revolution, documenting the events of the late 1950s and early 1960s. It's fascinating that the revolution was not intended to create a socialist state, but to push away USA-domination. The revolution was "as green as a palm leaf," Castro said - i.e., not "red". The embrace of socialism and the alliance with the USSR came a few years later, after the Bay of Pigs cemented Cuba's opinion that the USA was not to be trusted. They had to turn to someone else for help, and there weren't too many options then. 

 

At the art museum (Museo de Bellas Artes Cubano) you could see politics everywhere - anti-capitalist most notably. Some of it was a bit heavy-handed, as in "Heaven and Earth" by Marcelo Pogolotti, 1934: 

 

Havana itself was tremendously safe, but it looked like a war zone. Buildings falling apart, streets with huge holes, broken down cars. No capital. Here's a banyan tree growing on top of a building: 

 

But there are construction cranes elsewhere. It will be truly interesting to see how the country changes over the next few decades, and especially interesting to see how the government tries to protect the poorest during the process. After all - consider the huge death rates during the "shock therapy" doctrine in Russia during the 1990s. Cuba's ideology would not tolerate such a thing. 

 

 

This is $1 million of the drug Eyelea

Eyelea is used to treat macular degeneration, a disease of the eye. This is about 500 vials of it, so about $2,000 a dose. There is a generic available, Avastin, that costs about $80 a dose. 

This is a stack that a Buffalo ophthalmologist made using the empty vials he accumulated over about two years. 

Here's what you can do with $1 million: 

• You could hire 20 substance abuse counselors for a year. 
• You could completely immunize 1,000 children. 
• You could feed 300,000 meals to homeless people.
• You could house 200 homeless people for a year. 
• It's 50,000 bags of groceries. 
• It's Head Start for 200 kids for a year. 
• It would cure 50 people of Hepatitis C.
• It's prenatal care for 1,000 babies. 

 

Merry Christmas. 

The PSA test sounds so innocent.

It's possible to hurt a patient with a lab test. It's an innocent enough thing to order, but the downstream effects may not be useful at all. The test is done, it leads to an inconclusive result, further testing is done, maybe a referral, and eventually a treatment occurs that shouldn't have happened in the first place. Maybe there is a complication.

PSA testing may be an example. We know prostate cancer is overdiagnosed, such that many men are diagnosed who never would have suffered or died of the disease if nothing was done.

As part of the Choosing Wisely campaign, professional societies recommend caution with PSA tests: 

• The American College of Preventive Medicine says, "Don’t routinely perform PSA-based screening for prostate cancer." 1,000 men need to be screened to save one life, and false positives and suffering are much more likely for any individual than being saved by the test. Obviously, your threshold for testing should be adjusted for risk factors like family history.
• The American Academy of Family Physicians generally agrees, but notes that "whether [the] potentially small benefit in mortality outweighs the potential harms is dependent on the values and preferences of individual men," so shared decision-making should be used.
• The American Society of Clinical Oncology says that there is no mortality benefit of PSA screening, so especially with men expected to live less than 10 years, don't screen.

There are some great resources for shared decision-making on the web and in book form. See, for example, the book Cancer Screening Decisions.

The Choosing Wisely campaign encourages specialty societies to identify tests and treatments of questionable value - things that should cause us to pause and think.

"Have a conversation, not a test."

Source: Cancer Research UK / Wikimedia Commons

Is coronary angiography overused in Western New York?

Coronary angiography is the "gold-standard" test for coronary disease. It's considered the final word on whether or not you have it. It involves threading a catheter to the arteries that supply the heart. A liquid that x-rays don't penetrate is injected into the blood, and so with an x-ray (really fluoroscopy, a continuous x-ray image over a few seconds) you can see the exact shape of the coronary arteries.

 

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5143685/ (image creators do not endorse opinions in this post)

Multiple specialty societies caution against its overuse. For example, as noted on the Choosing Wisely website, the Society for Cardiovascular Angiography and Interventions says: "Avoid coronary angiography to assess risk in asymptomatic patients with no evidence of ischemia or other abnormalities on adequate non-invasive testing." That is, if a patient has no symptoms and no evidence of coronary disease on testing, try not to do an angiogram. 

And yet there is evidence that, at least in the past, angiograms have been overused. A 2014 study of a database of angiograms in New York State in 2010 and 2011 found that 25% of them did not appear to be justified, based on established criteria.

In medical culture, there is a place for going outside guidelines. Providers are taught from the beginning to treat the individual patient according to the circumstances. "Guidelines are great, but there is no substitute for thinking," as I used to tell my students and residents. 

I must say that after talking with a cardiologist recently, it sounds like this old information about NY state angiograms has been taken to heart by the community, and things have changed. And yet, given the structure of our health care system, with its financial incentives to do procedures, all the malpractice risk, and patients' and providers' desire for certainty, excess testing still occurs. 

At Independent Health, we have access to claims data from the entire region. Claims data only reflects information sent to us with a request for payment. And yet it is somewhat useful in determining disease and treatment patterns on the ground. We put claims data through the Milliman Waste Calculator, which is the industry standard in assessing whether certain care might not have been necessary. The calculator has been used, for example, in Washington state, and has generated media reports. 

When we looked at coronary angiography, the calculator identified 860 coronary angiograms that may have been inappropriate during the first half of 2018. The logic the calculator used can be summed up  as: "patients who had an angiogram but did not have a significant heart condition or a positive stress test." If anyone would like a more granular look at the logic, please contact me. 

What does this mean? It depends on your tolerance of uncertainty and risk.

Let's take the perspective that the guidelines are clear dividing lines between what should and should not be done. Even if the calculator is highly inaccurate, and only a fraction of the 860 angiograms did not meet guidelines and were unnecessary, that still means that patients were put at risk of stroke or cardiac complication for no reason. I think that putting someone at unnecessary risk is harming them. 

But we can take the other perspective, that the cardiologists, assessing risk on the ground, based on experience and a multitude of details, made generally good decisions and only subjected patients to that procedure if the benefits of the information obtained clearly seemed to outweigh the risks. In that case, who is it that carefully assesses whether the cardiologist, in this subjective matter, has judged reasonably? And that he or she has carefully set aside the financial incentive, the malpractice risk, any pressure from the patient to "find an answer," and their own personal biases toward knowing what's going on? It's not me, I'll tell you that. 

And that's probably why gravitate toward the guidelines. 

The original source of the Milliman waste calculator logic on this topic is here: https://bit.ly/2SQRunP

 

Screening tests may not make sense from the individual's perspective

There's a big difference between how doctors traditionally think about screening and how patients should think about it. 

Let's say I'm a doctor, and I'm considering all my patients as a group. I have 1,000 men that I'm trying to save from prostate cancer. That's about this many guys: 

Source: NYS Archives

I know that if I do PSA screening on all of them, I will save one from dying of prostate cancer. So it seems like a good idea to me, and I start the screening, and do this for 11 years.  (The following is based on the book Cancer Screening Decisions by R.N. Adler, 2018.)

890 of these men will never have prostate cancer. 780 have negative tests. 100 men have positive PSA testing, and then have biopsies. 32 men have complications of the biopsy. 66 men get prostate cancer, diagnosed either from the screening or symptoms. So OK, I have a bunch of testing in this population, and 32 men have complications from the biopsy, but overall I'm saving one life, so that seems worth it. 

Now let's imagine I'm one of the men in the picture. What are the chances I'm going to be the one person saved by the test? Well, literally it's 1 in 1,000. Let's say I worry about it and I want to get the testing anyway. What is the price of the bet that I'll be that 1 in 1,000? PSA testing for 11 years, and a 1 in 10 chance I'll have a biopsy, and if I have a biopsy, a chance that I'll have a major complication like an infection. 

I can tell you that many men, after this discussion, will decide not to have the test. 

There are decision tools out there now that help providers have conversations with patients about this exact problem: identifying the risks and benefits of screening for individual patients. These tools increase patient knowledge and increase their ability to accurately assess risk. 

 

 

Yeah, I'm diabetic and my sugar gets low sometimes. No big deal, right?

Actually it can be a pretty big deal, especially if you are older and you've had diabetes for a while.

Hypoglycemia causes anxiety, tremors and sweating. In more severe cases, you can get confused, lose consciousness, have a seizure, or even die. Think about driving and having all that sneak up on you. Or if you're asleep and don't wake up. 

It's actually not that uncommon. In medical training, we learn that if a patient is found confused or unresponsive, one of the first things to do is check their blood sugar, or just give them some sugar through an IV. 

Considering the risk, the American Geriatrics Society says that for older adults, the benefit of tight glucose control might not be worth it if you're getting hypoglycemia. They suggest hemoglobin A1C goals of 7.0 to 7.5% if you are healthy and have a long life expectancy, 7.5 to 8.0% if your life expectancy is less than 10 years, and 8.0 to 9.0% if you have multiple medical problems and a shorter life expectancy. 

You should discuss your exact goals with your doctor. But you should also know that tighter control of blood sugar is not necessarily better overall. It's another example of "more is not always better" in medicine.

 

 

 

 

Better medical tests: "normal" becomes "disease"

Human beings are smart, and we keep inventing new things. In medicine, that means more and better tests to analyze us in increasingly sophisticated ways. This trend will continue, so we need to get used to it, and be smart about it. 

Sometimes when tests get better, they are able to identify more subtle things. For example, years ago we would diagnose a pulmonary embolus ("PE," a blood clot in the lungs) mostly by using a ventilation/perfusion scan, which gives a rough idea as to whether a large chunk of lung has a blood clot in it. We know that if there is a large clot, the patient needs to be anticoagulated with warfarin, for at least a few months. 

Then we began diagnosing PE's with CT scans. This was an improvement, because they are easier to do, can be done on less stable patients, and give a clearer picture. On a CT angiogram, you can actually see the clot. The following picture shows a really bad one, called a "saddle PE," that stretches across both pulmonary arteries.

(Source:  https://commons.wikimedia.org/w/index.php?curid=53722435). In a CT scan, dark means less dense and white means dense. A dense "dye" is injected into the blood to make it appear lighter. The dye does not go into the clot, so now you can tell where one ends and the other begins.

These days, CT scans are becoming increasingly excellent, to the point where very small clots can be viewed in the lung. But there is a question whether these small clots are as dangerous as the big ones, and whether the patient actually needs anticoagulation. It's currently controversial. 

There are other potential examples of conditions being overdiagnosed by improved testing: heart attack, breast cancer and lung cancer, for example. 

Does this mean we should stop testing? No! Medical care is quite good and quite helpful, overall. We just need to be careful. 

One answer to the problem of new technology is to do different kinds of research. A new technology that sees subtler things should make us stop and ask ourselves if this is still disease. And in fact, these are the questions that researchers are asking now. 

While we wait for the scientific consensus to evolve, it's important to ask questions and weigh what we know of risks and benefits.