Bringing Down the Costs of Medical Care

It is currently popular for government officials to single out the insurance companies for the rising cost of healthcare. Not that the insurers are without fault but the real reasons for cost increases are rarely addressed and therefore not appreciated. We are a country with an aging population (“old parts wear out”) and of many adverse behaviors (e.g., overweight, sedentary lifestyle, stress and 20% still smoke.) Combined, these are driving a rapid increase in chronic diseases such as diabetes type 2, cardiovascular disease including heart attacks, heart failure and strokes, high blood pressure, and cancer.

These are illnesses that, once developed, are usually with the individual for life, have a major impact on quality of life and are inherently expensive to treat. The Milken Institute did a comprehensive study of chronic diseases. Among their findings: 109 million Americans have a chronic illness now [that’s about one third of us!] and many have more than one for a total of 162 million. The costs of care today are about $275 million and the total economic costs are well over a trillion dollars per year in lost productivity, etc. They estimate that we are on a track for a 42% increase in these chronic diseases by 2023 (as a result of aging and behaviors,) not that long from now. And if we do nothing to change the way we care for these patients, the costs of medical care will be $790 billion and the total economic costs will be over 4 trillion dollars.

There are two things to do to reverse this trend. These are illnesses that by and large are caused by our behaviors or are the result of aging. We can’t stop aging. So, the first step is to have an active program in behavior modification. Easier said than done, of course but here are some principles. We need to individually accept responsibility for our own health. But we need to understand what we are doing and how it impacts us over the long term. Government can help here with educational programs, rules about school lunches, requiring restaurants to post calorie and fat contents, labeling food packages with a more realistic total calorie assumption (today packages imply that the average person needs a 2000 calorie diet) and other steps. Incentives, primarily monetary ones, can have a big impact. Incentives need to be large enough to be useful yet focused enough to drive toward the desired end. Our employer can help with wellness programs to assist us to stop smoking, loose weight, improve our nutrition or deal with stress more effectively. The incentive here can be asking the employee who is successful to pay a lower portion of their health insurance premium. Insurers can create incentives directly for following a healthier lifestyle by lowering premiums for those who don’t smoke or are at a reasonable weight.

The second major step is to ensure that those who do have a chronic illness get very good care coordination. Unfortunately, this is just not the case for most patients today. They end up with multiple doctors, each doing their own thing, excess specialist consultations, too many medications, unnecessary tests and procedures and sometimes even unneeded hospitalizations. This drives up the cost of care dramatically. When one has a primary care physician that takes the time to fully coordinate all the elements of care, the use of specialists declines as do tests, procedures and hospitalizations and drug therapy is well managed.

Unfortunately, most primary care physicians have too many patients under their care to allow adequate time for prevention sessions or the time needed for care coordination. They need to care for fewer patients meaning they will need to receive a higher fee for each visit and this must include a reasonable payment for preventive activities and coordination efforts. Added to this they need to be paid to take the time to respond to emails and to use other technologies that can keep the patient out of the office unless really necessary. Some docs are doing just this by limiting their practice to about 500 patients (rather than the usual 1200-1400) and charging a flat fee for all care for a year. Others are refusing to accept insurance, both commercial and Medicare, and instead are billing the patient just as a lawyer or accountant or other professional would. The billing includes time spend in prevention and coordination. These may well be the future of primary care reimbursement and a means to assist the patient to first prevent chronic illnesses from occurring and second to assist in good coordination of the care when one does develop.

But all of this raises critical questions. What should and what will government do to help us modify our behaviors? Will insurers be allowed and will they accept the responsibility of a two tiered premium pricing system? Will employers accept the added chore of developing wellness programs? Will physicians, even if they are offered adequate payments, actually spend the time needed for good prevention and good care coordination? And, most importantly, will we as citizens accept our responsibility to lead a reasonably healthy lifestyle?

Getting Nurse Staffing Right Is Critical – Patient Mortality Depends On It.

When I was the CEO of a large academic hospital we were constantly concerned to properly balance nurse staffing. More staff than needed meant wasted money and too little staffing risked lesser quality care and nurse disharmony and even resignations. But adjusting the staffing levels of multiple units, each with differing patient types and needs was a major effort and easily thwarted by rapidly varying census numbers, patient admissions and transfers to other units, nurse shortages, and many other factors. In retrospect it is remarkable that it worked as well as it did. But the risk management group was ever concerned that if the staff levels were too thin it was possible that adverse events could occur.

Now there is a new study reported in this week’s New England Journal of Medicine that links deficiencies in nurse staffing with increases in patient mortality. The investigators evaluated an unnamed academic hospital with a strong record of high quality and lower than expected patient mortality. They looked shift by shift and noted whether that shift was at targeted levels based on patient acuity, over or under. They also looked at the level of patient turnover during each shift. Quoting from the article, “In an institution with a history of success in meeting staffing levels and with a level of patient mortality that was substantially below that predicted by its case mix, we found that the risk of death increased with increasing exposure to shifts in which RN hours were 8 hours or more below target staffing levels or there was high turnover. We estimate that the risk of death increased by 2% for each below target shift and 4% for each high turnover shift to which the patient was exposed.” [Italics mine]

The take away message to me is that hospital executives and boards need to be sure that they are managing nurse shift decisions carefully. In any hospital, personnel constitute about 60% or more of expenses and nurses represent about one half of that so the dollars are not inconsequential and need to be managed appropriately. Clearly, “appropriately” also means assuring that each unit has the necessary complement of registered nurses on each shift. From the article, “Our findings suggest that nurse staffing models that facilitate shift to shift decisions on the basis of an alignment of staffing with patients needs and the census are an important component of the delivery of care.” It also means that hospitals need to look at their approach to transferring patients from unit to unit. Often times this is necessary such as movement of an unstable patient to an ICU. But this study makes the point that excess transfers can be detrimental to patient welfare and may require more than the usual staff numbers. “Our results suggest that both target and actual staffing should be adjusted to account for the effect of turnover on patient outcomes.”
How a hospital aligns its nurse staffing is an important element of quality in addition to cost management. Getting staffing right is critical. When it is correct, mortality will be lower. Further, although not measured, if mortality came down in this study, it is fairly safe to assume that other quality measures were improved as well.

Surviving Cancer As A Teenager – It’s Not Just The Treatments

When Clarissa was 13 she entered Johns Hopkins Hospital to be treated for relapsed acute leukemia knowing full well that she had only a 40% chance of survival. Today she is 16 and in excellent health. But it took 2 ½ years of incredibly rigorous treatments to get there. Equally importantly it meant riding an emotional roller coaster for her and her parents.

Clarissa had been treated for leukemia when she was 2 and had been fine for a decade when the relapse occurred. She found there was not much available to read about coping with the emotional issues that come with a cancer diagnosis during the teenage years nor was there a support group of teens who had faced the same challenges. Consider that a teen wants to be more and more independent but that is just impossible when you now need your parents even more than ever and must depend on doctors and nurses for life itself. Teens are focused on their appearance but what if you have no hair and an intravenous catheter sticking out from your skin – pretty hard to hide. Friends want to be friends but don’t know whether to visit or not and when they do they find you wearing a mask to protect against infection and must shun the instinct to hug. These and other issues surfaced over her two and one half years of treatment, years in which she spent much of the time in the hospital and lost well over a year of school, again much of that to avoid contact with infection while her immune system was at its lowest. With the help of at home tutoring, she kept up with her assignments and now is back in school with her classmates, getting good grades and enjoying the life of a high school student while thinking about college and the future.

Clarissa persevered and now wants to help other teens who develop cancer to cope with what lies ahead. She has started a blog, gives frequent talks and plans to write a book on coping later this year.

A friend of mine, a twenty five year survivor of adult leukemia, told me after reading her first blog entry: “Wow! I am sitting at my desk with tears in my eyes - she is so beautiful - inside and out. So brave - so inspiring. I am coming up on 25 years and have no courage compared to this young woman.”

If you know a teen ager with cancer, I encourage you to direct them to Clarissa’s blog at http://www.teen-cancer.com/

Palliative Care Teams – A Big Improvement in Quality of Life

During the healthcare reform debate there was the unfortunate reference to “death panels.” No such thing was ever in the proposals but it meant that an important part of medical care was set aside as too “toxic” to discuss. But end of life counseling is very important. Indeed it is good to have realistic discussions at the beginning of a serious illness; indeed it is only fair to the patient and the patient’s family.


Palliative care (I don’t like the term; it seems to imply only end of life care and so I prefer “supportive care”) is designed to achieve the best possible quality of care and the least suffering possible. This is not limited to pain management but also to psychosocial support, spiritual needs, the treatment of any symptoms, and assistance or at least support for decision making. It might be a complicated pain management program or a simple cup of tea in the afternoon to talk over important issues. Ideally it uses a team approach including physicians, nurses, social workers, psychologists, chaplains and others all working together. Palliative care teams have demonstrated their value in improving care and, interestingly, substantially reducing medical care costs.

There was a recent report of a controlled trail of palliative care. 151 patients with lung cancer entered a randomized trial when they first came to be treated in a thoracic oncology practice. It compared standard care to the same care plus a palliative care team. The results were clear that palliative care added to the patients’ quality of life; reduced the frequency of depression, the number of hospital days and even extended the survival by 2.7 months.

My experience, and others report the same, is that many physicians are uncomfortable with palliative care and tend not to refer their patients or if they do, not until very late in the patients’ course. Perhaps it gets at the deep inner concern that they do not want to be seen as “giving up” on the patient and perhaps it even forces them to admit that they cannot always cure every patient. Whatever, it is unfortunate because many people who could benefit from early referral to the palliative care team are not getting that benefit. Most large hospitals now have such teams; it behooves the patient or family to ask about them.

Protocol Medicine – It Is Time For Doctors To Recognize Their Value

We hear that doctors do not like “protocol medicine” – they do not want to follow a “cookbook” when every patient is different. It is not a good understanding of the issues.

Some years ago when I worked in a branch of he National Cancer Institute and then the University of Maryland Cancer Center, we admitted many patients with acute leukemia. The treatment approach including the necessary special tests to obtain, chemotherapy drugs, steps to prevent infection, prevent kidney problems, etc was complicated. So I wrote out a set of admission orders, had them typed up, xeroxed and kept at the nurses’ station. When a new patient was admitted, the physician took one of those order sheets and either accepted each individual order or made changes. But the doctor now would not forget something important such as a drug, its dose or the number of times per day. This worked much better than depending on memory yet any specific order could be eliminated or modified as needed for the individual patient. This was not a “cookbook” but rather an improvement in both safety and quality.

Peter Pronovost and colleagues from the Johns Hopkins Bloomberg School of Public Health have worked on designing similar protocols for ICU patients for those needing the insertion of a central intravenous catheter to reduce the frequency of hospital acquired infections. This is basic stuff like gown and glove, use a disinfectant on the skin, use sterile materials, etc. It works; the infection rate falls by 60% if the guidelines are followed. Indeed in the Michigan hospitals where the technique was evaluated, the rate dropped to zero.

Remarkably, many doctors at hospitals across the country rebel at having those steps to follow using the same argument of “protocol medicine.” And equally remarkably, most hospital executives are hesitant to insist. They will need to become more assertive and physicians must accept the new standards. It is a matter of rights and responsibilities.

If physicians want the public (and elected representatives) to be supportive of malpractice tort reform, they will first have to accept “protocol or “cookbook” or “checklist” approaches that are tried and proven to improve quality and safety.

The Incidence Of Kidney Failure Due To Diabetes Is Down – But We Should Not Be Pleased

Diabetes mellitus is the most common cause of kidney failure that progresses to end stage renal disease (ESRD,) meaning that the person requires dialysis or kidney transplant. ESRD is chronic and life long, is complicated to treat, has a major negative effect on quality of life and the costs are high.


So it was good news when the Centers of Disease Control reported that the incidence of ESRD among diabetics had declined by about 35% over the ten years ending in 2007. The reasons for the decline are not known but a few assumptions seem reasonable. More and more patients now keep good control of their blood sugar with careful monitoring and many also keep their blood pressure under control with anti-hypertensive medications. Further, it has been shown that angiotensin-converting enzyme inhibitors (or ACE inhibitors) and angiotensin-receptor blockers (or ARBs) slow the decline of kidney function in those with diabetes and early kidney failure. It is believed that as many as 80% of these patients are taking ACE or ARBs – a good thing. All of these may be the factors that have led to this decline of diabetes to kidney failure; or there may be others as yet not appreciated.

But the news really is not so good. The decline in kidney failure incidence was offset by a much increased absolute number of individuals with diabetes developing kidney failure. Why? Because there are so many more individuals developing diabetes now than just a decade ago – so there are more people at risk of and therefore developing kidney failure.

We can be pleased that secondary prevention approaches are slowing the onset of kidney failure among those with diabetes but we should be aghast that so many of our fellow citizens are setting themselves up for a high risk of diabetes as a result of obesity.

The message - the real need is to accelerate efforts to stop the epidemic of obesity (excess consumption of not very nutritious food compounded with a sedentary lifestyle, including in adolescents.) Obesity is the primary culprit leasing to the rapidly rising number of individuals with diabetes.

The Shingles (Herpes Zoster) Vaccine Really Works But Many Older Folks Don’t Receive It - They Should

Herpes zoster (or shingles) is caused by the same virus that causes chicken pox. Zoster increases in incidence with advancing age. It is estimated that over 1 million Americans get shingles annually with the resulting acute discomfort and often chronic pain thereafter. A vaccine was introduced by Merck in 2006; the initial studies of 38,546 patients indicated that it reduced the incidence by about 50% and for those who still got shingles, the severity was lessened substantially. But acceptance of the vaccine has been slow. It seems that this is due to a combination of lack of knowledge that it is available and is effective; failure of physicians to inform their patients; and a fairly high cost of about $200, often not covered by insurance.


A new study was reported in JAMA January 12, 2011. Kaiser Permanente, Southern California and Centers for Disease Control and Prevention investigators evaluated 75,761 Kaiser members who had no underlying immunological disorder and who had been vaccinated between January, 2007 and December 2009. These were compared to a control group of 227,283 age matched members who had not been vaccinated.

Among the unvaccinated individuals, this study showed that, as anticipated, shingles incidence goes up with age from - 60-64 years of age (9.7 infections per 1000 person years) to over age 80 (17.3 per 1000 person years).

Vaccination reduced the frequency by about 50% from a total of 13.0 per 1000 person years to 6.4 per 1000 person years. This halving of incidence was found at all age intervals, indicating that the vaccine works as well in the very elderly as in “younger” individuals. The incidence of zoster was steady over time. For example, at one year, slightly more that 1% of the unvaccinated individuals had developed zoster compared to less that 0.05% in the vaccinated group; at two years the numbers were about 2 ½ % and 1%, respectively. During the time of patient follow-up, this can be stated as one case of herpes zoster was prevented with each 71 vaccinated. However, since the follow up was only about 1 ½ years for most individuals and since it is estimated that beginning at age 60 a person has a 20% lifetime risk of zoster, it is my presumption that it actually takes many fewer individuals vaccinated to prevent one episode of zoster over the rest of one’s life.

Not part of this study, the original Merck investigation demonstrated that many older people do not respond well to the vaccine with increases in antibody production. This finding is consistent with many others that those over 60 years of age respond much less well than do those who are younger. This raises the question as to whether it would be useful to measure antibody production after vaccination to determine who has and who has not responded well. Perhaps those who do not should get a second vaccination. This is an important issue for all vaccines in older people. The same occurs with influenza vaccine which is why, this year, the dose for older people was doubled. But perhaps there are other approaches as well to improving the response rates for those at increased risk in their older years who respond less well to vaccines.

The study makes clear that this vaccine is effective, including for those over 80 years of age where the incidence is the highest. Given the implications of herpes zoster in immediate and longer term suffering and the attendant costs, I believe this is a vaccine that essentially everyone over the age of 60 (other than immunocompromised individuals) should receive. Insurance should pay for it just as with the influenza vaccine.

Even if paid for out of pocket, it is worth it. Patients need to ask for it and doctors need to encourage it.