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The article gives an introductory example of a patient that was referred to two different cardiologists, both of whom wanted to do an angiogram. The article doe

by Gatsky 10y ago

The article gives an introductory example of a patient that was referred to two different cardiologists, both of whom wanted to do an angiogram. The article doesn't mention of course that the cardiologists get paid per angiogram performed. The remuneration per unit time for seeing the patient in clinic and carefully discussing the options and evidence is drastically less than just doing the angiogram. Some cardiologists will also have a target number of angiograms they need to perform every year specified by arrangements with the angiogram facility. So although it is widely known that doing angiograms and inserting stens in patients with stable coronary artery disease is a waste of time, perverse incentives in a fee for service model result in these outcomes. As such it isn't a good example of evidence-free medicine. In Australian public hospitals, the cardiologists are paid the same salary regardless of whether they do zero or 1000 angiograms a year. They are very happy not to do unnecessary angiograms in line with the current evidence. If anything, this introductory example shows that a health system needs to be set up to facilitate and encourage evidence-based practice. Otherwise this article rehashes many points about clinical trials and interpreting medical evidence, without a really coherent theme, except maybe to (yet again) criticise doctors. Things have improved in the last 10 - 15 years. Clinical trials come under more scrutiny, trial pre-registration has become more common (although not strictly enforced), health systems gather more and more data about patient outcomes outside of clinical trials and manipulative marketing practices by pharmaceutical companies have been curtailed drastically. In my opinion, the challenges for evidenced based medicine in the next decade are: 1. Getting some decent data about nutrition. There are really remarkably few useful things we can say about how nutrition relates to health. 2. Reducing unnecessary interventions towards the end of life in an ageing population. Healthcare and healthcare research is not well suited to de-escalating care. 3. Transitioning from a one-size-fits-all approach doing clinical trials in 1000s of undifferentiated patients, to collecting 1000s of data points about each individual patient (blood and metabolic variables, genome sequencing, immune profiling, microbiome etc) and using that data to get them healthy and keep them that way. Needless to say, the difficulties in doing this will make doing a randomised controlled trial look like a walk in the park. 4. Fighting pseudo-scientific diagnostic tests and treatments. Examples of this are everywhere - Theranos, gene therapy clinics in undisclosed locations in South America, quantified self services that have no proven health benefits, virtually every supplement ever sold, multivitamins... 5. Fighting the politicisation of health care. This is a very worrying trend that can easily render all our scientific efforts irrelevant - eg anti-vaxxers, far-right intolerance of harm minimisation measures like abortion and decriminalising drug use.

Hnrobert42 10y ago
6. Studies on how to most effectively treat people with non-invasive treatments. "Take this pill once a day" has a far higher compliance rate than "exercise more." I am thinking of the example mentioned in "The Power of Habit" where one group of knee surgery patients was given a brochure about post-surgery treatment, like PT, exercise, etc. The other was give the same brochure with blank pages to write out a specific plan for following the recommendations. Of course, the second group fared much better.
atourgates 10y ago
The system is also rigged against cost-savings from small providers. My wife is an ophthalmologist in private practice. Recently, we were looking at the economics of buying a laser to do a common treatment for patients with glaucoma, called a Selective Laser Trabeculoplasty (SLT). Even with a decent understanding of medical reimbursement models in the United States, I was still kind of shocked by what I found. The laser to perform the procedure costs about $30,000 to purchase. The Medicare allowable for a physician performing the procedure in a standalone surgery center is about $315. There's really no reason that the procedure needs to be performed in a surgery center, and Medicare does let the physician bill about $30 more if they bought a laser for their office, and performed the procedure there. But, at an increase of $30/procedure, you'd have to be doing a ton of SLTs to make buying your own laser financially attractive vs. just using the local surgery center's. Where things get crazy, is in terms of facility fees. If a physician performs an SLT procedure at an ambulatory surgery center, the physician's medicare allowable is about $315, and the surgery center can bill a separate facility fee of about $290, making the total procedure cost medicare just over $600. If my wife's practice were bought by a hospital tomorrow, and they brought an SLT into her office, every time she performed an SLT in the exact same office that was now hospital owned, they'd be able to bill the $315 physician fee, plus a "hospital outpatient department" (HOPD) facility fee of $443, bringing the total cost of the procedure to over $750. So, to recap the total costs to medicare: Physician does the procedure in their privately owned medical practice: $345 Physician does the procedure in a surgery center: $600 Physician does the procedure in a hospital-owned medical practice: $750 You want to know why independent medical providers are getting bought up by hospitals and large health systems at an alarming rate? That's why. Because for doing the exact same thing, they get paid by medicare and private insurance companies (whose rates are largely based off of medicare reimbursement rates) 2x what a provider can on their own. You hear a lot in the healthcare market about the efficiencies of scale, and how large integrated healthcare organizations are doing amazing things. You don't hear a lot about the potential for independent practitioners to reduce costs, but it's absolutely there, and largely ignored. That said, medicare is (or at least was under the ACA) moving toward a "pay for performance" model, where instead of getting paid more for doing more angiograms, cardiologists will get paid more for keeping their patients from needing angiograms in the first place. There are still plenty of issues, but I think broadly that's the right direction for healthcare reimbursement to be going.

by Gatsky 10y ago

Hnrobert42 10y ago

6. Studies on how to most effectively treat people with non-invasive treatments. "Take this pill once a day" has a far higher compliance rate than "exercise more." I am thinking of the example mentioned in "The Power of Habit" where one group of knee surgery patients was given a brochure about post-surgery treatment, like PT, exercise, etc. The other was give the same brochure with blank pages to write out a specific plan for following the recommendations. Of course, the second group fared much better.

atourgates 10y ago

The system is also rigged against cost-savings from small providers. My wife is an ophthalmologist in private practice. Recently, we were looking at the economics of buying a laser to do a common treatment for patients with glaucoma, called a Selective Laser Trabeculoplasty (SLT). Even with a decent understanding of medical reimbursement models in the United States, I was still kind of shocked by what I found. The laser to perform the procedure costs about $30,000 to purchase. The Medicare allowable for a physician performing the procedure in a standalone surgery center is about $315. There's really no reason that the procedure needs to be performed in a surgery center, and Medicare does let the physician bill about $30 more if they bought a laser for their office, and performed the procedure there. But, at an increase of $30/procedure, you'd have to be doing a ton of SLTs to make buying your own laser financially attractive vs. just using the local surgery center's. Where things get crazy, is in terms of facility fees. If a physician performs an SLT procedure at an ambulatory surgery center, the physician's medicare allowable is about $315, and the surgery center can bill a separate facility fee of about $290, making the total procedure cost medicare just over $600. If my wife's practice were bought by a hospital tomorrow, and they brought an SLT into her office, every time she performed an SLT in the exact same office that was now hospital owned, they'd be able to bill the $315 physician fee, plus a "hospital outpatient department" (HOPD) facility fee of $443, bringing the total cost of the procedure to over $750. So, to recap the total costs to medicare: Physician does the procedure in their privately owned medical practice: $345 Physician does the procedure in a surgery center: $600 Physician does the procedure in a hospital-owned medical practice: $750 You want to know why independent medical providers are getting bought up by hospitals and large health systems at an alarming rate? That's why. Because for doing the exact same thing, they get paid by medicare and private insurance companies (whose rates are largely based off of medicare reimbursement rates) 2x what a provider can on their own. You hear a lot in the healthcare market about the efficiencies of scale, and how large integrated healthcare organizations are doing amazing things. You don't hear a lot about the potential for independent practitioners to reduce costs, but it's absolutely there, and largely ignored. That said, medicare is (or at least was under the ACA) moving toward a "pay for performance" model, where instead of getting paid more for doing more angiograms, cardiologists will get paid more for keeping their patients from needing angiograms in the first place. There are still plenty of issues, but I think broadly that's the right direction for healthcare reimbursement to be going.