What does real disaster preparedness look like?

This is a re-print of commentary from a past Kansas Business Group on Health newsletter.

“Preppers,” those reality-TV characters always gearing up for The End Of The World, have a bad reputation: they’re kooky extremists praying for the government to fail, we think, or they’re the victims of end-of-days preachers stocking their bomb shelters with beans, rice, and ammunition. But the COVID-19 pandemic has given me a different perspective. Modern disasters don’t fit into the mold described by Mad Max movies, paranoiac end-of-days prophecies, or Hank Williams, Jr.’s “A Country Boy Can Survive.” Instead, modern disasters are likely the slow-motion, smoldering problems we’re seeing now: economic decline, a continuously threatening viral illness, and the seeming impending failure of institutions.

How do we prepare ourselves and our employees for this kind of disaster? After a Sunday evening deep-dive into disaster preparation that I’m not completely proud of (but not really ashamed of, either), I’m convinced hoarding dry goods won’t cut it. I see two big items crucial to disaster preparedness that many of us neglect (credit to ThePrepared.com):

First, guard yourself against financial difficulties. As Neal Gabler pointed out in a viral article in The Atlantic a few years ago, roughly half of Americans cannot scrape together $400 in an emergency without using credit cards. So before you or your employees buy emergency potable water containers for your basement, work on building a solid financial foundation. Companies like Tally will help employees get credit card debt under control. Most personal finance sites, like Robinhood, eTrade, and dozens of others now offer commission-free trading now to help put away even small amounts of monthly income for a future rainy day. You can consider making any retirement savings at your company “opt-out” rather than “opt-in,” a strategy that has been shown to radically increase savings rates. Consider a workshop for employees on end-of-life planning. It doesn’t have to be morbid. Make it clear that people with advance directives and wills have less end-of-life anxiety. Financial wellness is inexorably intertwined with physical wellness. As we’ve said before on the KBGH blog: given the high stakes of illness in this country, your doctor may be your real financial planner.

Second, get your physical and mental health to a point where you can handle the physical and emotional demands of an emergency. Ask yourself and your employees, can you walk far enough to get to the grocery store and back in case of a fuel crisis? Can you keep your mind clear under stress? Do you have addictions that will cripple you in case of a catastrophe? If the answer to any of those is “maybe,” now is the best time to start working on them. We should all work to make sure we have the strength to navigate our homes, our work, and our environment without the benefit of motorized transportation, elevators, and automatic doors. Encourage employees to start taking longer and longer walks from home to see if they can get to the grocery store or their kids’ school without a car. Encourage taking the stairs as often as possible (some companies even run the elevators purposely slowly to encourage this). Encourage employees to work to know that, if they fall, they can easily get back up and moving. If someone is not confident in his mind’s ability to handle undue stress, make sure they have the ability to see a mental health professional to learn coping skills for another crisis or to work toward being addiction-free.

It’s fine to indulge yourself in a binge-watch of Doomsday Preppers. But as you watch, pay attention to whether their strategies apply to you. You probably don’t need a gas mask. But you definitely need to be able to carry your grandkids up a flight of stairs and to write a check for $400 on short notice.

Wearing a Mask is an Act of Service

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

From February to October of 2002 father and son John Allen Muhammad and Lee Boyd Malvo killed more than a dozen people and injured several more on a crime spree that started in Tacoma, Washington and ended in an orgy of indiscriminate violence in and around Washington, D.C. The media devoted enormous time and resources to the shootings. Once it was clear the attacks were the work of a serial killer, on-air coverage often lasted for hours after each attack.

The attacks naturally caused a huge amount of public apprehension in the D.C. area. People at gas stations began walking rapidly around their cars in order to make themselves harder targets. Many gas stations hung tarps around fuel pumps to block the view of potential snipers. People attempted to buy gas at the National Naval Medical Center, as they felt safer inside the guarded fence of a military installation. Senate pages got a police escort to and from the United States Capitol every day and were confined to their residence hall except for work activities. Schools cancelled field trips and outdoor sports, and some schools hired additional security officers and changed after-school pick-up procedures in order to minimize the amount of time children spent in the open.

People began wearing bulletproof vests.

Imagine the public reaction if the scale of the D.C. sniper attacks were much, much larger. What if, instead of a dozen or so deaths over nine months, one to two thousand Americans were dying daily in the crosshairs of snipers. Imagine that elders, especially those with medical conditions, were the primary target of the snipers simply because they were easier to kill.

What would be our response to this internal threat? Would we hole up for a month, wait for the death rate from terrorist attacks to plateau, and then largely go about our business? No. I suspect we would devote billions or even trillions of dollars to identifying members of the group, arresting them, and prosecuting them. We would use sophisticated methods to track their movement.

And we would wear bulletproof vests.

You may have figured out where I’m going with this. My analogy is pretty transparent. After the sacrifice of ten weeks of social distancing (which may have prevented 60 million infections and many thousands of deaths), we’re all naturally tired. But a rogue agent known as SARS-CoV-2 is on the move in America and still killing thousands of people per day through not gunshot wounds, but from a disease called COVID-19. We’re not in a second wave of infection; we’re not even out of the first wave yet:

The virus doesn’t kill by gunshot. It kills by airborne transmission and infection of people’s lungs.

Our bulletproof vests are masks. And we should be wearing them.

I know it’s hard to keep up with changing advice. Under the assumption that all masks worn would be medical grade the CDC originally advised against wearing them to avoid shortages. So did I. But the evidence has become very convincing that even cloth masks--our “bulletproof vests”--don’t just protect us. They protect those around us, too. One study showed that if even 60-70 percent of Americans consistently wore masks, and those masks were at least 60-70 percent effective at preventing disease transmission, we would crush the reproductive rate of the virus. The goal of any strategy in infection prevention is to get the number of people infected in turn by each infected person, the “Re,” down to less than 1.0:

Proceedings of the Royal Society A

Watch the rate of infection fall as the rate of mask wearing increases and the rate of effectiveness of the masks increases! The bidirectional effect of masking shines light on a more important point: protecting against coronavirus, whether by being careful with social distancing, by handwashing, or by mask wearing, is an act of service, just like getting vaccinated for other infectious diseases. We can only do so much to protect ourselves; most of our work should be in protecting one another. Two hairstylists in Missouri, who saw hundreds of clients after being unknowingly infected themselves, appear to have infected zero clients because of their faithful facemask use.

So in that regard, COVID-19 is not like a serial killer. COVID-19 is like HIV. Where sex is the dangerous activity (along with shared needles), being indoors with other people is the dangerous activity with COVID-19. Ninety-seven percent of “superspreading events” are indoors. I like Linsey Marr’s analogy about how COVID-19 is like cigarette smoking. Imagine everyone smokes but you. She said, “The denser the smoke, the more likely it is to affect you. It’s the same with this virus: The more of it you inhale, the more likely you are to get sick.” So if everyone around you smoked, you would stay out of crowded spaces that would be quickly filled with smoke. You would try to stand as far from the smokers as you could. If you could open a window to clear some of the smoke, you would. And if you were forced to be in a crowded space you would wear a mask to filter the smoke. 

I’ve had a chance now to see several workplaces’ policies around COVID-19 safety. And they’re pretty good! But we need to encourage our employees to follow those same safety rules outside the office. Ninety percent of Americans report frequently wearing masks. I cannot help but believe that there is a flaw in that data. My recent masked trips to the grocery store in which a small minority of people were wearing them tells me the true number is much smaller than that.

I know it can seem like a performance to wear a mask in public when you may not even know a person who’s been affected by COVID-19. But this shouldn’t be about virtue signaling. Defeating a global disease requires global effort. Protect the people around you. If you’re outdoors alone, you don’t need to mask up. But if you’re in a crowd where you can’t stay six feet from other people, or if you’re indoors with people you don’t live with, for heaven’s sake, wear a mask.

We Need to Support Black Doctors

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

The stark differences in health outcomes

We should never reduce any population of people to a set of statistics. Every one of those “statistics” has a story. But here are a few numbers that should get our attention:

African-Americans have a rate of COVID-19 that is three times higher than the infection rate of the population as a whole. Even worse, the risk of death of an African-American person with COVID-19 far exceeds that of other racial groups. While people of white, Latinx, and Asian descent have death rates that all fall between 20 and 23 deaths per 100,000 people, African-Americans have suffered a death rate more than twice as high: 50.3 deaths per 100,000 people. About one out of every 2,000 black people in America have already died of COVID-19. Let me repeat that: one two-thousandth of African Americans are already dead. From one disease. A similar death rate among white people would have resulted in almost 100,000 deaths just in that ethnic group so far. And sadly, Kansas has the highest racial disparity of any of the 41 states reporting such data.

But the damage is not limited to viral illnesses. Americans in general have lives about three years shorter than citizens of peer countries like those in Western Europe.

African-American men have a life expectancy that is, in turn, almost five years shorter than the American average. This means that an African-American man loses the better part of a decade in life expectancy compared to an average western European citizen.

And almost all of this difference is due to heart disease deaths, the risk of which is readily modifiable with solid, basic medical care.

What are the reasons for this disparity?

The basic medical care of black people is neglected for multiple reasons in our country, including a well-deserved historic lack of trust in the medical system by black people. Remember that in the Tuskegee Syphilis Experiment the U.S. Public Health Service intentionally and secretly withheld treatment from a group of black men with syphilis from 1932 to 1972 to study the “natural history” of the disease, jeopardizing the health of the men and any future partners. 1972!

A second problem is a dearth of black physicians, starting in training. African-Americans are tragically underrepresented in medical school. While African-Americans make up 13.4% of the American population, they make up only 7.3% of medical students. This disparity, while slowly shrinking over time, has real consequences. Patients may do better when cared for by someone who looks like they do. A 2018 randomized trial found that black men had far better outcomes when cared for by black doctors: rates of screening for hypertension, diabetes, high cholesterol, and obesity went up markedly in men with black doctors, by more than 25% in some cases. The difference appeared to be due to improved communication. Patients were simply more likely to bring up other health problems when assigned to a black doctor. Interestingly, uptake of “invasive” screenings—tests involving probing or a blood draw–increased only for the group assigned a black doctor. This would seem to reinforce the idea that trust, long missing with the medical establishment, is a vital part of the doctor-patient relationship. And the cultural knowledge imparted by someone from your own community can be priceless, something we have found in our CDC work on community health workers.

The increased rate of screening demonstrated in this study could have huge health implications. The investigators tried to estimate the effect of having more black doctors in the population as a whole and found that even a modest increase could reduce the black-white gap in heart disease mortality by 19%, and the and the overall black-white gap in male life expectancy by 8%.

Efforts are being made to attack this problem from the start. After all, the lack of black trainees isn’t simply the result of fewer black kids wanting to be doctors. Quite the contrary. Locally, the Medical Society of Sedgwick County sends member physicians every year to talk to high school students about the process of applying for and completing medical training. Nationally, the American Medical Association has a program called “Doctors Back to School” to facilitate physicians of color visiting grade schools to encourage minority students to consider careers in medicine. Kids cannot be what they cannot see, as the platitude goes.

But the real impediment to getting more black doctors probably lies in greater systemic reform of the type that is being aggressively advocated for nationwide. We need to see this as a failure of the system, not a failure of individual people. As you watch protests unfold nationally and locally, I hope your view of them changes when you see them through this lens.

Are you a positive deviant?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

How do we know we’re doing a good job? We’ve touched on it in past blog posts. It can be harder to determine than we give it credit for. One strategy we’ve come across in our work on CDC grants is to look for “positive deviance”. We look for microcosms of success within clinics, and then we try to learn from them and diffuse their methods throughout the clinic. With the help of Dr. Bob Badgett from the University of Kansas School of Medicine-Wichita, we have implemented processes in clinics in a few steps:

First, after deciding what outcome we want to measure, we benchmark what others are doing. If we use blood pressure control as an example, we can look at HEDIS data for national benchmarks, which showed that nationally in 2018 61% of commercially-insured patients with hypertension had good control, versus 59% in Medicaid HMOs and 69% in Medicare PPOs.

Next, we look at both individual and team performances in clinics. Let’s pretend that we are interested in the care of patients with high blood pressure at Moore Endocrinology, Inc. We would build a proprietary report to run through Moore Endocrinology Inc’s electronic health record (EHR) that would tell us the blood pressures of every patient seen by every doctor in the clinic and chart them out, like this fictional clinic team:

Most providers cluster around the vertical line that indicates the average rate of control of ~75% (pretty good compared to the national benchmarks). But look at providers 2 and 50. Their rates of control are significantly higher than the others on their team, at 87% and 88%. They are the positive deviants. We don’t just look at providers individually; positive deviants can be broken out into provider teams, and in the case of teaching clinics, even attending physicians (think Dr. Cox and Dr. Kelso on Scrubs). We don’t pay any attention to the negative deviants. All our efforts are put toward finding the people doing unusually well and helping others get to their level.

Next, we look at more granular data within the EHR to get insights into whether or not blood pressure drug regimens were altered appropriately whenever a patient presented with an uncontrolled blood pressure. For example, if a patient’s blood pressure was uncontrolled, did the provider change the dose of a medication, add another medication, or do something to encourage improved medication adherence on the part of the patient, like changing to a cheaper med, offering advice on pill boxes or alarms, or changing to longer-term prescriptions?

Then, with the consent of the providers in the clinic, we meet in small groups and do focused, structured group interviews to determine the practice habits of everyone, without revealing who in the group is the positive deviant, not even to that provider personally. And we find fascinating things. It’s possible that the positive deviant uses a different drug titration strategy than her peers. More likely, she’s encouraging patients to check more blood pressures at home. Maybe she utilizes the medical assistants on her team in an innovative way, such as coaching patients on adherence or proactively reaching out to patients who’ve historically had poor blood pressure control.

Finally, we work with the clinic to determine what clinic-wide changes can be implemented to make everyone else’s practice look more like the positive deviant’s.

The purpose of this blog post isn’t to pat ourselves on the back for a clever strategy in working with clinics. It’s to introduce this idea to you, someone involved with the health and health care insurance coverage of a population of employees.

If your business is a member of the Kansas Business Group on Health you should have received a request to complete a benchmarking survey over the last few weeks. What we’re trying to accomplish with the survey is much like what we’re doing with clinics. We want to find out which of our members is doing certain things particularly well. For example, perhaps Business X has a particularly low rate of spending on drugs; they’re a positive deviant. Without revealing who that business is, we would like to work with that business and other members of the Group to see what Business X is doing to keep costs down. Then we can work with other members of the Group to adopt similar strategies. It’s a team-based approach to take those little microcosms of success and let everyone else learn from them.

So if your business hasn’t had a chance to fill out the survey yet, please go to our website and fill it out (it won’t take more than 10 minutes to complete). Even if you aren’t yet a member of the KBGH, we still encourage you to complete it as it would be helpful to see what you’re doing. The survey will be kept completely anonymous on an organization level, and the data will only be provided in aggregate.

If you have any questions or comments, please contact us!

Which of your employees can return to work – and when?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

In a perspective piece in this week’s New England Journal of Medicine, Dr. Marc Larochelle proposes a three-component strategy for returning to work: 1) a framework for counseling patients about the risks posed by continuing to work, 2) urgent policy changes to ensure financial protections for people who are kept out of work, and 3) a data-driven plan for safe re-entry into the workforce.

Let’s go through his framework for work-related risk first. He summarizes it with this diagram:

New England Journal of Medicine

The occupational risk on the vertical y-axis is defined by OSHA standards. The horizontal x-axis is based on age and the presence of high-risk chronic conditions identified by the CDC, like diabetes and heart disease.

How this could work

Let’s consider a couple hypothetical employees to see how this rubric might work: “Matt” is a 65 year-old man with no chronic medical problems who takes no medications other than an occasional ibuprofen for joint pain. By the CDC risk stratification rubric, then, he is at high-risk based on his age alone. Matt works as a radiology technician with no direct patient contact, but he is within six feet of patients with confirmed or suspected SARS-CoV-2 infections daily. By the OSHA standard, then, he is at high, but not “very high,” risk. Regardless, by the proposed Larochelle risk stratification above, Matt would be category “C” and should not go back to work.

“Shelley” is a 25 year-old woman with a history of type 1 diabetes complicated by neuropathy and kidney disease. So she is medium-risk in spite of her complex medical history, in spite of her young age. She works in a retail setting in Wichita, a city with currently relatively modest levels of community transmission. Therefore her occupational risk would be considered “medium.” This would put her in category “A,” in which Dr. Larochelle recommends that she be able to return to work, albeit likely with fastidious use of personal protective equipment (PPE).

But beyond a strategy to determine the safety of the workplace, we owe it to people of elevated risk, even those working in risky jobs, to work on two additional goals: first, we should conceive strategies to allow people to live a dignified life without hardship while away from work. This is largely a policy position we can support through elected officials at the state and federal level.

Second, we owe it to high-risk people to develop strategies to allow them to eventually return to their jobs, preferably even before the risk of those jobs drops due to decreased community prevalence of the virus. In a widely read piece in The Atlantic a couple weeks ago, Dr. Julia Marcus analogized our current predicament to the HIV/AIDS epidemic of the 1980s and 1990s. It would have been easy, in theory, to stop HIV cold in its tracks: people just needed to stop having sex. But people like having sex, just like they like going to work and eating at restaurants and watching baseball. So public health officials were forced to come up with alternative, innovative strategies like promoting condom use.

Similarly, COVID-19 could be stopped cold, much as Mongolia has accomplished, by instituting strict limits on social interactions. But we’re at a point of quarantine fatigue in which further efforts at social distancing in the immediate future are likely to be met with resistance. And a vaccine is months, if not years, away. This is where testing comes in, especially in regard to risk stratifying people for return to work and social interaction.

The role of testing

In listening or watching the news on testing, you are likely to think that risk is binary: a positive swab test means you have COVID-19, and a negative test means you don’t. Likewise, one might believe, a positive IgG antibody test means that you’re immune to COVID-19, and a negative antibody test means you’re still at risk. But neither of these assertions are true. The “positive predictive” value of a test, meaning the likelihood of a positive test predicting the presence of an actual disease state, depends on the “pre-test probability.” So a person who lives in a community with low prevalence of COVID-19 and has had no known exposure to someone with the disease is unlikely to have immunity, regardless of what her antibody test says. Even with a test that is 90% sensitive and 95% specific, that person likely has only about a 25% chance of having immunity.

This doesn’t only apply to infectious disease testing, by the way, and testing for other conditions has real implications for your employees. It is popular for doctors to routinely check the thyroid blood tests of patients as part of routine medical testing. It is not uncommon for mildly abnormal results of such testing to result in the patient being put on thyroid hormone for life. But mildly abnormal thyroid blood testing in someone who feels well and has no physical signs of thyroid disease does not mean that person has a thyroid problem. It only means the person has about a one in three chance of having a thyroid problem. As with COVID-19 antibody testing, the initial abnormal test result should prompt additional evaluation, not a definitive diagnosis.

So what do we do with the results of COVID-19 antibody testing? CDC suggests that we use them to “risk stratify” people on a population level, not as a marker to indicate safe return to the workplace.

Instead, we should aggressively use nasal testing for the virus itself to determine the status of people with exposure to persons with known or suspected COVID-19, much as we’ve discussed in the past.

Transparency is Trust

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

In 1963, Stanford economist Kenneth Arrow published the landmark paper “Uncertainty and the Welfare Economics of Medical Care.” He argued presciently that health care was an unfair system in which to bargain due to “asymmetric information.” The doctors, hospitals, and nurses simply know more than the patients, and this imbalance in information keeps the patient from being able to comparison shop or argue for fairer prices. If a doctor tells you you need a stent in your heart, after all, don’t you need it?

Equip patients with information and they usually make the right choice

There is data to suggest that patients, when given the right information to work with in a digestible way, make responsible decisions in health care purchasing. My favorite study on the topic looked at parents of children with appendicitis. Parents were randomized to see one of two videos: one group of parents saw a video that simply went over the difference between old-fashioned “open” surgery to remove the appendix and newer laparoscopic surgery that uses small “keyhole” incisions to put a camera and small instruments into the abdomen to remove the diseased organ. The video seen by the other half of parents explained the differences in the surgeries but also explained the price difference between the techniques (laparoscopic surgery is more expensive). Both videos stated that patient outcomes are similar with either procedure.

The parents who saw the video with the charge estimate were 1.8 times as likely to choose the open procedure. In fact, the effect of simply stating the charges in the video reduced the average price of the surgery from $10,477 to $9,949, a difference of $528, since more parents chose the open procedure when presented with good data. And more than a quarter of the parents choosing the open procedure said cost was the primary factor in their decision-making! This point is worth restating: parents, when confronted with a surgical choice in an emergency situation that, if handled incorrectly, could harm their own child, still took cost into account in their decision-making.

Things we’d hoped would work… but didn’t.

Many hoped the internet would solve the knowledge gap in medicine and empower patients. After all, in the business of buying and selling cars, some argue that information asymmetry is long-gone. If I were to buy a new Chevy Bolt today, I would simply choose my desired features on Edmunds.com, print the price sheet, and offer to pay my dealer a price in the ballpark of what Edmunds suggested was fair. But in spite of efforts from companies like Castlight, CashMD, and others, we haven’t seen a big dent in healthcare costs due to transparency alone. Some of this is due to the fact that doctors themselves–outside of the radical transparency of many Direct Primary Care physicians–aren’t always privy to the price of tests, drugs, or even their own services. And even those DPC doctors can’t necessarily share other outcomes we’re interested in, like rates of screening for cancer and metabolic diseases, mortality rates, and other quality indicators.

So the government has tried to step in. The Trump administration released an executive order in fall of 2019 requiring that by 2021 all hospitals must publish their “standard charges” online in a machine-readable format so that other software can begin to compare prices. This is a good start, but it is unlikely to work. Those “standard charges” are, in most cases, “chargemaster” prices that have little bearing on reality. Medicare, for example, pays about 31% of the chargemaster price. Second, patients mostly care about out-of-pocket payments, not insurance payments. To have an idea of their own liability, patients need the “bundled price” for the entire episode, which chargemaster prices do not provide. Instead, the chargemaster prices are for individual charges for materials and procedures

What CAN we do?

But we can’t just throw our hands up in frustration. As employers we should control what we can control. We can control state and federal policy as voters, but our power may be better wielded locally. We’ve pointed out previously in this blog that a lack of transparency was one of the big drivers of health care costs. That transparency extends beyond the operating room, exam room, or pharmacy. It reaches into the relationship between you and your partners, such as your broker, your PBM, and medical providers you may directly contract with. A good first step, if you weren’t able to attend our recent webinar with Dave Chase of Health Rosetta, is to ask for those partners to disclose all their revenue streams. Their undisclosed revenue streams may surprise you. Once everyone’s revenue is transparent, we believe that partners can work together in a more trusting relationship, to the benefit of both parties.

Note: KBGH works with Team IBX to introduce transparency in the insurance RFP process, but Team IBX was not involved in the writing and did not influence this post.

No one is padding numbers to increase COVID-19 case counts

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

I’ve heard a few times over the past couple weeks that hospitals are padding their case counts of COVID-19 patients in order to increase revenue. This is transparently, obviously false, as we’ll get into later. But before we wade into that, let’s take this chance for a quick review of how hospitals and doctors get paid for the care of patients.

The history and process for how physicians are paid

Once upon a time, billing for medical care was very informal. Hospitals and doctors largely set individual, almost artisanal, rates for each patient according to a “sliding scale” of what the patient was expected to be able to pay. Poor patients paid less, and wealthier patients paid more.

Once medical insurance became common, insurance companies, including Medicare, attempted to hold physicians and hospitals to the standard of  “customary, prevailing, and reasonable charges.” Unsurprisingly, this loose standard led to steadily inflated billing, so much so that the passage of Medicare is arguably what vaulted physicians from middle-class professionals into the upper reaches of national income. As early as 1970, congressional testimony referred to federal insurance as the “Goose that laid the golden egg” for physicians and hospitals.

Through a series of reforms in the 1970s, ‘80s, and ‘90s, billing for medical care became much more standardized (and in part led to the administrative bloat that is now the number one source of waste in American health care). Nearly every diagnostic or therapeutic procedure performed by a medical professional is now captured by a “Current Procedural Terminology” (CPT) code. For example, your dermatologist codes a “2029F” for a skin exam. A cardiothoracic surgeon codes a “33945” for a heart transplant. A routine, but fairly comprehensive new visit to a primary care doctor is coded a “99204.” All these codes are reimbursed according to the complexity of the task, taking into account the amount of time a procedure is expected to take, the amount of resources like syringes and protective equipment expected to be consumed, and the skill or level of training required to provide the service.

Hospitals themselves bill not according to CPT codes, but rather according to Diagnosis related groups (DRGs), which were introduced in the 1980s. DRGs are meant to make sure that reimbursement account for the severity and mix of the type of patients the hospital treats, and thus the resources that the hospital needs to treat those patients. For example, someone who presented with fever, cough, and a density on their chest x-ray, and who tested positive for COVID-19, would be coded a discharge diagnosis of “J12.81” for “pneumonia due to SARS-related coronavirus.” If that same patient needed ventilator support during her hospitalization, though, she would be coded “J96.01” for “Acute respiratory failure with hypoxia,” which pays in the ballpark of $54,000 (about three times as much as a COVID-related diagnosis). The additional payment is meant to pay for the increased duration of the visit and the increased intensity of treatment, since patients on ventilators are typically cared for by a single, specialized nurse, a respiratory therapist, a pulmonary physician, and others.

Our healthcare system has some inherent issues

The purpose of this post is not to defend current medical coding and billing. Our system is bizarre by almost any developed country’s standard. Take the way payment is determined for those CPT codes. The American Medical Association owns the Relative Value Scale Update Committee, or “RUC,” which is tasked with updating physician payment for those roughly 4,000 CPT codes. The RUC is powerful. It ultimately guides about 70% of all physician payment in the United States. Most of its 31 members are assigned by professional societies like the American College of Radiology and the American Society of Plastic Surgeons. Therefore, primary care doctors, the most cost-effective and crucial part of the health care workforce, make up only a tiny fraction of the committee. So the natural momentum of the committee is to steadily increase the payment for specialty care, while keeping reimbursement for routine care relatively flat. And the committee arguably works with faulty data. RUC recommendations are based on survey results of only about 2% of physicians, updated only every 5-20 years. Perhaps because of this, estimates of the time it takes to complete a given procedure—a vital component in calculating the complexity of care—are notoriously inaccurate.

In spite of these limitations, RUC recommendations are accepted without change by CMS more than 90% of the time, and commercial insurers largely base their payments on a multiple of the CMS charge as a baseline for negotiations with individual health systems.

Even though doctors can largely set their own rates without competition or pushback, they don’t get off scot-free. Because coding of routine visits is tied directly to the “complexity” of the patient, documentation requirements dictate that the average physician note in the U.S. is four times the length (paywall) of notes in peer countries. This is why you may have found notes from your doctor so long, repetitive, and bewildering. To make this worse, the advent of electronic health records has led to “chart bloat,” a phenomenon in which notes, thanks to cut-and-paste and other features, lead to an illusion of complexity and thus increased charges.

DRG rates, at least, are set by a slightly more predictable, scientific method. This isn’t to say that some gamesmanship doesn’t go into hospital billing; every physician in America has been coached on billing for the exact level of sickness of her patients at some point in her career.  The words, “Don’t bill a uroseptic patient for a simple UTI” still ring in my ears from residency.

So does this mean the number of COVID-19 cases are being inflated?

In spite of these faults, there is no evidence that we’re over-attributing illness to COVID-19. We are still under-testing compared to most of our peer countries, and this is reflected in the mortality data we’re seeing.  The “background” mortality rate in America is about 2.8 million deaths per year, with a little more than half of those deaths from cardiovascular disease and cancer. Deaths are seasonal and pretty steady year-over-year. But right now we’re seeing an excess mortality rate that is roughly double what COVID-19 accounts for. That is, only about half of observed excess premature deaths are in people diagnosed with COVID-19. So if anything, we are under-attributing deaths to COVID-19. After all, a patient who dies of a heart attack brought on by low oxygen levels and sticky blood due to an undiagnosed case of COVID-19 was still killed by COVID-19.

What about those increased payments for COVID-19 patients? It is true that hospitals make about 20% more for a patient infected with SARS-CoV-2. This is the result of the $100 billion slice of the federal stimulus passed in March that is allocated to hospitals. Why did hospitals get their own cut? Because volumes in hospitals are down by more than half as elective procedures like hip replacements and cardiac catheterizations—the lifeblood of hospital systems, for better or for worse—have been delayed or cancelled. Here is Harvard data on ambulatory visit volume through mid-April:

As a result, health care jobs—long considered “recession-proof,” are going away. Almost 43,000 health care jobs were lost in March alone. Health care is such a giant part of the American economy—a stunning $3.5 trillion per year, good for almost a fifth of gross domestic product, again, for better or for worse—that this reduction in health service delivery is thought to account for about half of our current loss of GDP. That’s why you hear our current financial predicament being referred to as a “health care-led recession.”

So if COVID-19 is a huge conspiracy to allow doctors, nurses, and hospitals to make extra money, it isn’t a very good one. 

Here’s to those who say “no”

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Comparing two patient visits

Every visit to a health practitioner is a story. Here’s the skeleton of how the story sometimes goes:

1. A patient makes a request for a specific test or treatment, often based on what he’s seen in advertisements or media. Take, for example, the time a perfectly ambulatory patient of mine saw a late-night TV ad for mobility scooters and asked me to prescribe one, since “Medicare [would] pay for it,” and since the patient found walking to be “exhausting.” 

2. The request is denied, hopefully for medically/economically sound reasons and not out of some peculiarity of the practitioner-patient relationship. What I mean here is that sometimes patients and doctors simply aren’t a good fit, and sometimes, strained relationship dynamics spill into decision-making. “Good” doctors allow this to happen less often than “bad” doctors, but I suspect no one ever quite gets to zero. I’ll leave the judgement of my “goodness” or “badness” to others. But in the case of my patient, with whom I had a very poor relationship (to my eye, largely because of near-constant requests like his request for the scooter), even though I had a good medical reason to deny the request (walking is good for you even if it makes you tired), my writing something to the effect of “over my dead body” in the chart probably betrayed my feelings.

3. The patient gives feedback of some kind. The relationship between patient requests and the doctor’s willingness to fulfill them has real, dollars-and-cents ramifications in that reimbursement is now sometimes tied to “patient satisfaction.” A study in JAMA Internal Medicine (paywall) found that about two-thirds(!) of visits involve a request for a specific test or treatment from the patient, and that 85%(!) of those requests are granted. But when requests are denied, patients report dramatically lower satisfaction. The effect is predictably strongest with requests for pain prescriptions or lab tests. The effect is almost nonexistent for stuff like antibiotics or x-rays. But back to our patient: maybe he complains to the office manager. Maybe he goes home and writes a scathing review on one of various doctor rating sites. (Advice to other medical professionals: don’t look these up. They hurt.) Patient Scooter chose to express his dissatisfaction not in writing, but by leaving a bowel movement on the floor in the elevator of the building. (I’m not making this up.)

4. Doctor uses that feedback to change his or her future performance/behavior. Or maybe he doesn’t, if the feedback is in the form of actual human excrement. (I did record the approximate size and quality of the stool in his chart.)

That story is not fair. It prioritizes the point of view of the medical professional. Here’s an alternate story, taken from a ProPublica piece a couple years ago:

1. A patient presents with a seemingly minor, but worrisome, finding: slight chest pressure that worsens when he exerts himself but gets better when he rests.

2. With the help of a non-invasive procedure, his primary care doctor and a cardiologist accurately diagnose the patient with “stable angina.” The cardiologist recommends a coronary angiogram—an x-ray of dye going through the vessels of the heart—with possible stenting of any narrowed arteries. “Stenting” is a procedure where a blocked artery is propped open with a tiny metal cage that is expanded in the vessel by the cardiologist. This high-intensity recommendation as a solution to a diagnosis the patient found only slightly troubling is not a surprise. Our instinct in medicine is not just to stand there, but to do something, even if we aren’t sure of its benefit. Doctors routinely overestimate the benefit of screening tests while underestimating harms, for example.

3. While the cardiologist is out of the room the patient looks up evidence on the effectiveness of stenting, such as this negative randomized trial from the Lancet (paywall), and concludes, many would say correctly, that it should not be first-line therapy for heart disease in most patients with stable angina who are not having a heart attack. Instead, the patient reads that aspirin, medications called beta-blockers, and cholesterol-lowering medications are first-line therapy.

4. The patient seeks a second opinion (we’re big fans of those at KBGH). Luckily for him, his second opinion comes from a cardiologist who is active in the RightCare Alliance, a coalition of patients and clinicians interested in bringing down the cost of medicine while potentially improving patient experiences. The second cardiologist agrees with the patient, who then loses weight, changes his diet, and experiences no more chest discomfort.

Here we have two stories, both of which had happy endings, at least in the evidence-based medicine sense. (Though the first ending was certainly not happy for the maintenance staff of my clinic.) But the journey to those endings was unnecessarily fraught. Patient One was convinced that he needed a device because of a slick ad by some unsavory device dealers. Patient Two, in addition to having “an inquiring mind and a smartphone,” in the words of David Epstein, lucked into seeing a cardiologist whose grasp of and willingness to follow evidence-based guidelines was superior to his peers. What ties these threads together? In a way, health literacy.

Enter health literacy

Health literacy is the capacity to process and understand basic health information in order to make good health decisions. High health literacy is associated with dramatic improvement in medical outcomes and a reduction in care costs. We’ve touched on it before at KBGH, and we even offer a health literacy product to members called Quizzify.

But what of the doctors’ poor decision making? What we call “health literacy” on the patient side, it could be said, we call “evidence-based medicine” on the physician side. Doctors are no longer reservoirs of information, as they once were; they don’t simply carry around information that their patients don’t have access to. The sum knowledge of medicine is far too deep and broad. Instead, doctors have transitioned into curators of medical information, sort of like librarians. And they’re expected to use their access to that information to make good decisions, ideally with the input of the patient, what we call “shared decision making.” But like anyone else, doctors’ decision making is influenced by outside forces. Doctors who own their own CT scanners, for example, are more likely than others to order CT scans. Other studies have shown that doctors who sell drugs to patients, like oncologists, are more likely to choose the more profitable drug more of the time. And simple human nature predicts that doctors who are able to “self-refer” for procedures, like cardiologists or surgeons who have the choice between low-paying patient education or high-paying procedures, will more often choose the procedure. This impulse, and the willingness of some people to pay for “doing something” may, in my opinion, explain some of the absurd, wasteful testing that gets done as part of executive physicals.

Health literacy in its classical definition is a way for patients to obtain and process health-related information. But in a broader sense—and I’m not trying to cast the patient-physician relationship as adversarial—health literacy can be thought of as the best way for a patient to defend herself from suboptimal decision making on the part of his doctor. After all, in the patient satisfaction study noted above, patients who were denied requested imaging studies or antibiotics were not significantly less satisfied. Why is this? An accompanying editorialist (paywall) notes that “Through Choosing Wisely and other campaigns to reduce low-value care, substantial attention has been devoted to preparing physicians to avoid frequently requested, low-value care such as these. We can train physicians to say no to other types of clinically inappropriate requests, while still reassuring patients and paying attention to their needs.”

Bringing it home

What we need, then, is a war with two fronts, manned by patients, doctors, employers, and payers who are willing to say “no.” (There I go with the adversarial language again). On one front, we continue to develop good health literacy in the general public, so that they can go to their doctor and ask for effective diagnostic and therapeutic strategies and decline tests or treatments they don’t think are in their best interest. But on the second front, we need to pay just as much attention to the “literacy” of physicians, employers, and payers, with the development of incentives that align with the well-being of the patient. One of the best ways to reduce low-value care, after all, is simply to stop paying for it.

Will technology save the aging primary care workforce?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

The issue we’re facing

The primary care physician workforce in Kansas–family doctors, internists, and pediatricians–is aging. Of the 1,976 primary care physicians in Kansas as of April 2020, 15.6 percent are already over 65, and 39.2 percent are over 55. The simple demographics of this are intimidating: even though they provide the most essential, cost-effective care in medicine, only 43 percent of practicing physicians in the U.S. are primary care providers, similar to the average of eleven Organization for Economic Cooperation and Development countries. But the fraction of graduating students entering primary care is steadily decreasing.  Even more ominously, older physicians are much more likely to be harmed by infectious diseases like SARS-CoV2, the causative virus behind COVID-19, adding to the inevitable workforce turnover caused by death. This all portends an uncertain future for primary care provision in many Kansas communities, since Kansas is already underserved relative to most other states at baseline.

As if that weren’t enough to worry about, physician skills appear to deteriorate over time. A 2017 study in the British Medical Journal found, for example, that elderly Medicare beneficiaries’ hospital adjusted 30-day mortality rates were 10.8% for physicians aged <40 and rose steadily to 12.1% for physicians aged ≥60, a 15% relative increase in risk for patients cared for by older doctors. Not only that, but costs of care were slightly higher among older physicians. This may not simply be due to age-related decline; it could be that younger doctors were trained in a way that improved their care. For example, “evidence-based medicine” is an integral part of medical training in the modern era. Older doctors who were not trained under this philosophy are demonstrably less likely to follow evidence-based care guidelines. This is hard for me to read. Statistically, I am likely a worse doctor than I was fifteen years ago. But I digress.

What can be done about this problem?

The Association of American of Medical Colleges, predictably, has argued for years that the solution is to train more physicians, by two mechanisms: first, the AAMC advocates for increasing the cap on Medicare funding that limits the number of residents at a given institution. Second, the AAMC supports greater incentives such as scholarships and loan repayment for primary care providers working in underserved areas. Examples of this are the Kansas Medical Student Loan Program, which pays for medical school for a limited number of students in return for an agreement to practice primary care in underserved areas in Kansas; and the Kansas Bridging Plan, which gives resident physicians additional funding during their training in exchange for a three-year commitment to practice in a rural community. On the federal level, the AAMC advocates for increased recruitment of international medical graduates, who already represent about a quarter of practicing physicians in America, through programs like the J-1 Visa Waiver program.

Others point toward increased use of non-physician practitioners like physician assistants (PAs) and advanced practice registered nurses (APRNs). This is clearly the preferred short-term option. PAs and APRNs require drastically less training than physicians, which eliminates the seven-year gap between policy and practice that we see in traditional medical training. And the health outcomes of patients seen by non-physician providers seem to be roughly equivalent to those of patients seen by doctors. Another British Medical Journal systematic review of randomized trials and observational studies–one of several such reviews in various journals, all with similar conclusions–concluded that “Patients are more satisfied with care from a nurse practitioner than from a doctor, with no difference in health outcomes.”

But long-term, if the skills of physicians like me decline with age, we can be certain the skills of other providers fall as well. How do we ensure that quality care continues to be delivered over the lifespan of the practitioner?

Automation may be the answer

Let’s look at my specialty, endocrinology. Six years ago, when I left full-time practice, the management of blood glucose levels was mostly an intuitive art/science, driven mostly by the experience of the physician-patient dyad. But in the last few years we’ve seen the emergence of “smart” glucometers that quadruple the likelihood of of a patient controlling their blood sugars while reducing their risk of dangerous low blood sugars. We’ve seen the development of automated insulin devices in the hospital that outperform conventional treatment of blood glucose levels. The FDA approved an artificial intelligence-based device to scan and diagnose the eyes of diabetic patients with diabetic eye changes (the most frequent complication of diabetes) without even having an ophthalmologist or optometrist involved. Newer, even more innovative, devices are in development, such as an app that can allegedly detect the presence of lung disease by the sound of a patient’s cough.

Some of these devices will pan out in the long run, while others won’t. But even a conservative projection is cause for optimism. It is not unreasonable to predict that practitioners with far less training than physicians will have the tools and skills to provide very competent care–elements of both primary care and specialty care–in the near future. Technology must be carefully monitored by humans, but its abilities do not decline with age. On the contrary, a given technology’s performance today is the worst that it will likely ever be. Best Buy will sell faster computers next month than it does today, and faster yet a year from now. And automated devices aren’t resistant to delivering evidence-based care; it is programmed in. I welcome the Rise of the Robots.

Primary care is being crowded out

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

The next time you have a minor injury or get sick, will you call your primary care doctor to get a same-day appointment, or will you go to the local urgent care? Now may seem like a strange time to even be asking the question, since many patients aren’t taking the chance on either one. Patient volumes in medicine are down 50% or more as people practice social distancing and hospitals and surgery centers cancel elective procedures. But eventually we all need care. And a recent study in the Annals of Internal Medicine (paywall) found that when we seek that care we’re increasingly likely to seek it from urgent care centers.

Multiple investigators from Harvard, Mount Sinai, and the University of Pittsburgh looked at deidentified claims data for adults aged 18-64 years from a single commercial insurer (they didn’t reveal which one) between January 1, 2008, and December 31, 2016 to determine the rate of primary care visits per 100 member-years. By cleverly using CMS place-of-service codes, National Provider IDs, tax identification numbers, and CPT codes, they were able to further categorize visits as having taken place in a purely outpatient office, the emergency department, an urgent care, a retail clinic, or a commercial telemedicine visit.

What they found was bad news for primary care doctors and, if you believe that primary care saves money and improves outcomes, as most policy makers do, bad news for the people paying for healthcare, like employers. Primary care visit rates declined 24.2% in the eight years of the study, from 169.5 visits per 100 member-years in 2008 to 134.3 in 2016. The proportion of insured patients with no medical visits at all in a given year went up, from 26.1% to 32.5%, as did the proportion with no visits to a PCP in a given year (from 38.1% to 46.4%). This trend held even when gynecologists were re-classified as PCPs, since some women get the bulk of their care from their gynecologist.

An optimist might venture that the population was just healthier in 2016 than it was in 2008. And in patients that had no chronic diagnoses the drop in PCP visits was higher. But overall the insured group did not get healthier or sicker over the time of the study.

So where did the care go? To “alternative settings.” Urgent care visit rates almost doubled, from 4.4 visits per 100 member-years in 2008 to 8.0 in 2016. Retail clinic visit rates more than tripled, from 0.83 visits per 100 member-years in 2008 to 3.0 in 2016. Commercial telemedicine visit rates rose a spectacular 500%, from 0.003 visits per 100 member-years in 2008 to 1.6 in 2016.

The authors posited three possible explanations for this: First, patients may be less likely to seek primary care if they are younger and healthier and comfortable with online self-care or a secure message with a nurse or other non-physician provider when a minor acute need, like conjunctivitis, arises.

Second, those increasing financial barriers such as increased deductibles and co-pays may influence care more than we have previously thought. The average out-of-pocket cost of a visit increased from $29.70 in 2008 to $39.10 per visit in 2016 for “problem-based” visits (that is, visits meant to address a specific complaint). And over the time of the study more PCP visits became subject to a deductible (from 9.2% of visits in 2008 to 25.2% of visits in 2016). The decline in PCP visits in this study was largest in low-income communities. Using some clever economic calculations the authors estimated that this may have explained about a quarter of the decline in PCP use.

But third, and most powerfully, patients appear to simply be replacing PCP visits with visits to specialists and alternative settings. Even though the proportion of patients visiting specialists did not change, many patients saw multiple specialists. And the increase of 9 visits per 100 member-years to alternative settings offset about a quarter of the PCP visit decline. This may well have been a matter of convenience. As we’ve discussed before in this blog, the average physician visit takes more than two hours. Traditional primary care settings are known for their inefficient or inflexible scheduling practices. One study found that patients are so frustrated by scheduling practices that they think nothing of blowing off visits, leading to high no-show rates in the clinic. Visits to alternative venues may simply be more convenient not only in getting a generic appointment, but in getting an appointment after-hours so that no work is missed.

If the convenience argument is correct, doctors may be able to get some of that patient population back by employing “open access” scheduling. In this system, same-day appointments are almost always available. The day’s schedule isn’t full of appointments made weeks or months ago. The doctors preferentially schedule follow-up appointments in the morning, but fill much of their afternoon schedule as the day goes on. Somewhat famously, this is how a Kaiser Permanente clinic in Sacramento reduced their wait for an appointment from 55 days to one day. But the system requires some sacrifice on the part of the doctor, which may be a tough sell in a system where PCPs are already losing market share. Open patient slots, after all, are potentially lost money. It also may require some sacrifice on the part of the system. Open-access scheduling is generally thought to require doctors to carry smaller “patient panels” than they traditionally do, which may in turn lead to a need to train more physicians.

For larger employers there may be other fixes, such as on-site clinics. And with the increased adoption of telemedicine into traditional practices, we may see more patients using that option instead of going to the ER or to urgent care.

If your business has found a way to incentivize increased use of primary care, rather than ever-expanding use of urgent cares and emergency rooms, let us know.

Social distancing doesn’t cause recessions – pandemics do

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

We’re almost a month into social distancing in our collective effort to reduce the spread of COVID-19. It’s working; models indicate we’ve likely already prevented hundreds of thousands of deaths. But the economic effects of social distancing are tough. Though we haven’t met the official definition of a recession yet, simply because we haven’t been at this long enough, no one doubts that we are in a recession, if not an outright depression. The 22 million unemployment claims in the U.S. since early March are at levels that dwarf even the 2008 Great Recession.

So, naturally, even though public support for continued social distancing remains high, we’re hearing calls from some to relax restrictions. Small protests have broken out in Ohio and other places. Politicians are clearly spooked by the impending decision on when to “re-open the economy,” as some call it. And even though it is easy to make fun of some of their responses to questioning, the decision to relax social distancing in the hopefully near future will clearly be based on some combination of instinct and data. The best data we have on the topic seems to come from more than 100 years ago, during the 1918 influenza epidemic.

Economists Sergio Correia and Stephan Luck of the Federal Reserve and Emil Verner from MIT recently tried to apply lessons learned from the 1918 “non-pharmacologic interventions” for influenza (what we’re calling “social distancing”) like closures of schools, theaters, and churches; restriction on public gatherings and funerals; quarantine of suspected cases; and restricted business hours, to our current situation.

They came to two conclusions: First, areas that were more severely affected by the 1918 Flu Pandemic saw a “sharp and persistent decline” in economic activity. This is no surprise. We’ve seen the devastation COVID-19 has wrought in northern Italy and New York City. Second, the economists concluded that early and extensive use of non-pharmacologic interventions like social distancing had no independent adverse effect on local economic outcomes. Rather, cities that intervened earlier and more aggressively experienced a relative increase in real economic activity after the pandemic was over compared to other cities.

In other words, these three economists concluded that it was not social distancing that caused the most economic pain in 1918. It was the disease.

You can see the relationship between non-pharmacologic interventions and economic activity in the figure below. The green dots are cities with early, aggressive social distancing. The red dots are cities with late or low-intensity social distancing. The vertical axis is the change in employment over the four years before and one year after the pandemic. The horizontal axis is the mortality rate. What the best-fit line shows is that cities that intervened early and aggressively not only experienced more economic growth over time, but also, in most cases, had far lower mortality rates.

The United States is not a manufacturing economy today like it was 100 years ago, and these numbers look primarily at manufacturing output, which fell 18% during the influenza pandemic. The U.S. is primarily a service economy now. If that strikes you as a weakness of their analysis, the authors also looked at bank assets over the same time period, according to the intensity of the non-pharmacologic intervention (left; [e]), and the speed of the intervention (right; [f]):

 The cities that intervened earliest and most aggressively were much more likely to experience an increase in wealth through the time of the influenza pandemic.

What lessons can we learn from 1918? We need to take the long view. Social distancing hurts now. Unemployment of 25% or even 30% is unprecedented in the last century, and we need strong actions by federal, state, and local governments, along with good work from charities and non-profit organizations, to get us through the hardest part of this pandemic. But we need to be very, very careful about when we relax social distancing. Many projections, like this one from Morgan Stanley, are already taking into account a “second wave” of infections this fall:

 That second wave of infections is likely avoidable if we do the right thing now.

This paper, nor this blog post, have been peer reviewed. We at KBGH would love to know your thoughts on how and when we should modify social distancing for COVID-19.

When can your employees return to work?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

As of the writing of this post, Kansas has 1,106 confirmed cases of COVID-19, enough cases that either you or someone you know likely knows an infected person. This, in turn, means many of us have been potentially exposed. Given the need for certain “critical infrastructure” workers to return to work after an exposure, CDC has released new interim guidance on returning to work. Keep in mind: this interim guidance does not apply to people who have been diagnosed with COVID-19; it applies only to people who have been exposed to someone with COVID-19 without proper personal protective equipment but has not been diagnosed with the disease.

In short, the CDC guidance statement says that exposed critical infrastructure workers—sixteen categories including law enforcement, 911 call center employees, fusion center employees, hazardous material responders, janitorial and custodial staff, and vendors in food, agriculture, critical manufacturing, informational technology, transportation, energy, and government facilities—can continue to work as long as certain conditions are met:

• Employees’ temperatures should be taken and symptoms assessed before work resumes

• Employees should regularly self-monitor for fever or symptoms, and if employees develop symptoms, they should not work

• A face mask should be worn for 14 days since the most recent exposure, although there is evidence to support more widespread use, and this is reflected in a second CDC recommendation

• Employees should maintain six feet of separation from one another if possible

• Work spaces, particularly commonly touched areas, should be regularly cleaned and disinfected

If you are unsure whether your workforce belongs to a category within critical infrastructure, guidance can be found on the website of the Cybersecurity and Infrastructure Security Agency within the Department of Homeland Security.

If you or an employee has been infected and was symptomatic (that is, not an asymptomatic carrier), CDC recommends one of two strategies to determine when to discontinue isolation and potentially return to work. Keep in mind these strategies take into account only the potential transmissibility of the virus and not the physical wellness of the infected patient. That is to say, just because someone is no longer contagious may not mean she is well enough to return to work:

1. A time-based, non-test-based strategy:

Persons with symptomatic COVID-19 who able to care for themselves at home may discontinue isolation if they meet all three of these conditions:

• At least 7 days have passed since their symptoms first appeared and

• At least 3 days (72 hours) have passed since their fever went away (without the use of fever-reducing medications like ibuprofen or acetaminophen) and

• Their respiratory symptoms (e.g., cough, shortness of breath) have improved

2. A simplified test-based strategy:

Kansas still has a catastrophic lack of testing capacity, but if a patient is able to get re-tested, they may discontinue isolation if:

• Fever has gone away (without the use of fever-reducing medications like ibuprofen or acetaminophen) and

• Respiratory symptoms (e.g., cough, shortness of breath) have improved and

• Two nasal swab specimens collected 24 hours apart are resulted negative.

To end the post on a positive note, the current statewide strategy of social distancing appears to be working. Kansas is on pace for peak resource use on April 20, but we are not expected to exceed our statewide ICU or hospital resources.

Please be safe and remember that we encourage you to check to make sure these recommendations are up to date before using them, since we learn more every day, and recommendations are changing fast. Be sure to check out and share Quizzify’s quizzes on coronavirus with your employees, which are reviewed by physicians at the Harvard Medical School. The quizzes are a fun and interactive way to learn about the virus, and they are continually updated as new information becomes available. If you have specific questions, please don’t hesitate to contact us.

Mental Health Treatment: The Tale of Two Employees

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

You probably know someone like Juanita. Juanita feels so anxious at her job as a delivery driver that she is starting to miss work and perform poorly. She goes to her primary care doctor, who prescribes a medication to help reduce her anxiety and tells Juanita it will take two to three weeks to feel a benefit. Juanita asks if anyone like a counselor or therapist is available to see in the meantime, while she’s waiting for the medication to work. Her doc tells her that the clinic has no behavioral health providers on-site. Furthermore, unbeknownst to Juanita, her insurance policy doesn’t cover therapy sessions very well, and tele-behavioral health may not be covered at all. Juanita decides to seek out a mental health provider on her own. She calls several offices, but because of increased recent demand for mental health services, no one has an appointment available in the next three weeks. Juanita ends up on a waiting list and eventually has a good, albeit expensive, experience at her first visit and feels better. When she asks her primary care doctor and her therapist how much better she should expect to feel after her second visit, though, they can’t give a straightforward answer. They tell her this kind of improvement is hard to measure. They are, however, very careful to screen her for risk of suicide or self-harm.

Marcus works at a different company with a different philosophy toward mental health. When he begins to feel so anxious at his job as a warehouse supervisor that he worries his performance is suffering, he visits his primary care doctor, who prescribes a medication to help reduce his anxiety. His doctor tells him it will take two to three weeks to feel better, just as Juanita’s doctor did. But at his first visit, the doctor rates Marcus’s anxiety with an instrument called the Hamilton Anxiety Scale. He also schedules Marcus for a next-day visit with a licensed specialist clinical social worker (LSCSW) who the clinic contracts with to do tele-behavioral health consults, one of several options in Marcus’s network. The doctor tells Marcus that the LSCSW will work with him on “strength-based” strategies to take advantage of Marcus’s natural skills and talents as a starting point to address his anxiety. Marcus’s benefits package covers the LSCSW’s services just as it would cover any other medical treatment. After two months of visits with the LSCSW and careful medical management by his doctor, who is in frequent contact with the LSCSW, Marcus’s score on the Hamilton Anxiety Scale has declined from an initial score of 24 to a persistent score of 8, indicating likely remission of his anxiety.

The contrast between these two patients’ experiences are obvious in a high-level, qualitative sense. But they have very specific differences: Marcus was cared for in a network with an adequate number of providers, all of whom are in collaborative practice with Marcus’s primary care doctor. Telemedicine under Marcus’s employee plan is covered at the same reimbursement level as in-person visits, and behavioral health is reimbursed at the same rates as other medical care. And Marcus’s doctor and social worker objectively measured Marcus’s state of mental health in order to judge whether or not he was getting better.

These five characteristics–network adequacy, coverage of telehealth, payor parity, measurement-based care, and collaborative care between medical and mental health providers–are but a few of the marks of good access to mental health care. But they are the specific domains that the Kansas Business Group on Health is attempting to improve here in Kansas through a project with the National Alliance of Healthcare Purchaser Coalitions called the Path Forward. We’ve touched on this topic in past blog posts specifically regarding substance abuse. But since we’ve found ourselves in the teeth of a viral pandemic that is probably going to get worse before it gets better, we thought it was important to reinforce what we’re working on around mental health. The scope of this pandemic is not only physical in nature, but also impacts our mental health. There are resources available that KBGH can help you with for you or your employees.  If you have specific questions, please reach out to us. We have a number of resources available. We do not know how long the effects of this virus will last, but we know that the impact is far reaching.

Is social distancing...bringing us closer together?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

If you’ve read as much as I have in the last few days about the COVID-19 pandemic, you’ve probably come across ominous-sounding warnings about social isolation or loneliness as a result of social distancing, our preferred short-term strategy to prevent the spread of the SARS-CoV-2 virus. Social isolation is the physical state of being alone, while loneliness is the feeling you get when your social interactions don’t meet your expectations; you can feel lonely in the middle of a crowded room, but you’re only socially isolated when you’re, well, socially isolated.

But both are bad for you. A 2017 systematic review showed that social isolation was associated with a 29% increased risk of death, while subjective loneliness was associated with a near-identical 26% increase in mortality. For perspective, a second meta-analysis in 2010 showed that “…by the time half of a hypothetical sample of 100 people has died, there will be five more people alive with stronger social relationships than people with weaker social relationships.”

As we have ramped up social distancing there has been legitimate fear that we would exacerbate the already-high rates of social isolation and loneliness, especially in elderly people. While it’s too early to say if that’s happening, I’ve been pleasantly surprised at my own experience. Just yesterday this meme came across my phone:

I found it so true. Now that many of us (but not healthcare workers, first responders, food delivery people, restaurant workers, mail carriers, or a hundred other “essential service” professionals and workers) are stuck at home during the day, it seems that we’re finding new strength and resilience just from getting out and moving in our neighborhoods and green space. I’ve talked to more neighbors on walks in the last three days than I had in the last three months, and not just because of warmer weather. Could it be that COVID-19 has begun a small restoration of what physician sociologist Nicholas Christakis calls the “social suite”: love, friendship, cooperation, and teaching, all from six feet away?

The evidence of increased investment in the social contract isn’t limited to the streets in my neighborhood. Young people are volunteering in large numbers to do things like deliver meals. So many retired doctors have offered to re-enter the workforce–at significant personal risk, considering many of their ages–that the Kansas State Board of Healing Arts has begun issuing emergency short-term licenses, and KAMMCO is issuing short-term liability insurance. Manufacturers in cycling, my favorite sport, are pivoting away from bike gear and toward the production of personal protective equipment. Congress is operating at a rare, near-normal level of functionality to give financial relief to millions of people (now if we could only get more testing resources). And I know that many of the readers of this blog, be they human resources professionals, insurance brokers, health administrators, or others, are working steadfastly to save as many jobs at their companies as they can in the face of an impending global economic catastrophe.

While you’re working hard on those things, don’t forget to work on these, too:

1. Look for ways to have “conversation-centric” interactions with people. Talk on the phone. Skype or FaceTime. Talk to people from your porch or from the street. As former Surgeon General Vivek Murthy says, “Smiling at someone–eye contact–is an act of service.”

2. Let kids around you continue to have unstructured play time with friends. Just keep them apart. Let them run around, ride bikes, and throw sand. Don’t let them wrestle or share toys.

3. If you’re still going to work, synchronize your coffee breaks with someone else. Common socializing like this has been definitively shown to be more restorative than snacking or emailing. If you can do it outside, even better.

4. Take time to express gratitude to others. Expression of gratitude is one of the most common indicators of life satisfaction in the US.

5. Volunteer. Organizational volunteering has been shown to be associated with a 24% reduction in mortality risk.

6. If you’re lucky enough to have some money to donate, do it. Spending money on others makes us far happier than spending it on ourselves.

COVID-19 is changing telemedicine for the better

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

I’m typing this while on voluntary quarantine at the recommendation of the Kansas Department of Health and Environment because of a recent trip to Orange County, Florida. But like many of you, I’m managing to stay busy at home. One of the things I’m doing is providing “peer-to-peer” consultation to other doctors through a platform called RubiconMD [disclaimer: they pay me for the work, but not for advertising or testimony]. Doctors who subscribe to RubiconMD can forward me labs, imaging, and chart notes for patients with tricky hormonal and metabolic problems, and I type a recommendation back to them, potentially saving the trouble and expense of an in-person visit. These so-called “store-and-forward consults,” or “e-consults,” are one form of telemedicine, and they have proven effective enough–saving ~$500 per patient per year in one study–that they are now covered by Medicare.

The more well-known form of telemedicine in which practitioners and patients interact through a screen is referred to as “real-time” telemedicine. Other than the fact that the patient connects to the practitioner through a secure internet platform, telemedicine visits look a lot like traditional in-person medical visits: someone on the patient’s end (the “originating site,” in telemedicine parlance) collects vital signs, the doctor or other practitioner conducts an interview and, with the help of the ubiquitous high-resolution cameras on modern devices and a few on-site gadgets, performs a physical examination. Then the practitioner bills for the encounter as she would any other visit, albeit with a modifier attached to the billing to indicate that the visit was done remotely.

The average patient seen in-person at a physician office spends 121 minutes on the visit: 37 minutes traveling, 64 minutes waiting, and 20 minutes with the doctor. So if you think the idea of skipping the waiting line (not to mention all the coughing and touching) at your doctor’s office is attractive, you’re not alone. Telemedicine visits have a roughly 90% patient satisfaction rate. Kaiser Permanente has seen more patients via telemedicine than in-person since 2017. Local telehealth provider Freestate Healthcare and national providers Access Physicians and Eagle Telemedicine, among others, provide remote physician services at several rural hospitals with no doctors physically on site. In our work with CDC grants around diabetes prevention, we are running a trial of Omada, a virtual diabetes prevention program, to reduce the risk of high-risk patients developing diabetes. More than half of medical schools now offer required or elective training in telehealth to improve trainees’ “webside manner.”

And telemedicine has a growing body of evidence to support its use beyond reduced wait times and patient satisfaction. The Veterans Administration has found that telemedicine use corresponds to a 59% reduction in inpatient bed days and a 31% reduction in hospital admissions.

In spite of this rosy picture, the growth of telemedicine has been slowed by a regulatory system that is not designed for rapid change. Medicare, for example, has historically enforced a “site of service” requirement for telemedicine, meaning that patients seen via telemedicine still needed to travel to a hospital or doctor’s office to get linked to the distant telemedicine practitioner. Medicare has also mandated that patients must be located in a “health professional shortage area,” meaning that patients in areas with more physicians were ineligible to receive care via telemedicine, even if it was difficult for them to travel, and even if they had a highly communicable disease. Laws have mandated that the treating physician be licensed in the state where the patient was located, meaning a doctor licensed only in Kansas couldn’t historically see a patient in Oklahoma. And federal regulators have long restricted the technology that can be used for the interface. You couldn’t simply Skype or FaceTime your doctor, since those platforms were not compliant with the Health Insurance Portability and Accountability Act (HIPAA). This is not, on its face, an unreasonable policy; health data is valuable, so it is not hard to imagine it being the target of hackers.

There has been movement on this in the last year. Medicare Advantage plans began covering telemedicine visits from home earlier this year. But the current coronavirus pandemic is forcing faster changes, probably for the better. This week Centers for Medicare and Medicaid Services (CMS) suspended site-of-service requirements and state licensure requirements for telemedicine, and the Office for Civil Rights at Health and Human Services (HHS) announced that it would waive potential penalties for using lower-security forms of video communication for telemedicine. That is, any live video chat software is acceptable for now. This means that, at least in the short term, you can Skype or FaceTime your doctor (although we still recommend a more secure platform if your doctor can offer one). And you can do it from home. This policy is extending to other insurance carriers as well. I called Aetna, who informed me that they are allowing all visits (with the usual rules on copays and deductibles) to be performed via telemedicine for the next 90 days.

...once people get a taste of life with more easy access to telemedicine, I can’t imagine them going back.

If you or your company want to seek out such secure platforms, encourage patients to talk to their doctors about starting telemedicine visits. We at the Kansas Business Group on Health believe that care continuity is important. Urgent care centers and emergency departments have an important role to play, but encouraging patients to see their own doctors, rather than unaffiliated urgent care practitioners or cash-only telemedicine companies like Teledoc, is good for patients’ care and good for your bottom line. Freestate, Zoom, Doxy, VSee, and many other HIPAA compliant platforms are available to your employees’ doctors. They should consider asking specifically about any platform’s use of business associate agreements (BAAs) to certify there are safeguards against data breaches. Even though FaceTime is now technically allowed to be used as a telemedicine platform, for example, Apple will not sign a BAA. But Skype for Business, again for example, will.

I guess if you are the type of person who tries to find the bright side of things, this blog post is for you. This is just one way that COVID-19 is going to change medicine long-term. For the next few months, telemedicine access will become what its proponents have advocated for for years: a broad-based, broadly covered service that can be provided in the patient’s home on widely available, inexpensive software platforms. This is important not only in the context of a worldwide viral pandemic. It is important because once people get a taste of life with more easy access to telemedicine, I can’t imagine them going back.

Is it time to retire the handshake?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Last Sunday at my church the congregation turned, as we always do, to greet one another. The pastor had a runny nose, but she repeatedly reassured all of us that it was from allergies, not an infection. I, too, was experiencing some rhinorrhea, mine exercise-induced from a hard bike ride that morning in the cool air. But as people started to reach for my hand I couldn’t block the results of an experiment from my mind. Bill Bryson wrote about it in his book “The Body: A Guide for Occupants.” The Mythbusters later re-created it. In the experiments, a confederate wore a device in his nose to a party. The device imitated a runny nose: it dripped at 60 mL per hour, roughly the same rate as someone with a viral cold. The fluid was clear, but fluoresced under black light so that investigators could track it later. The partygoers—who were unaware this was happening—went about their business, and at the end of the night everyone was examined with a black light to see where the fake, fluorescent snot ended up. Not surprisingly, everyone at both parties ended up covered in it. In the Mythbusters version, even people who had been instructed to “act like germophobes” had demonstrable contamination with the fluid. The one exception? A woman who had refused to shake hands with the drippy confederate.

With this information roiling around inside my head I ducked out of the sanctuary and into the bathroom. I washed my hands for twenty seconds and returned to my seat. With a worldwide viral pandemic unfolding, I wondered, is it time to retire the handshake?

I asked around. One of my medical school classmates told me he attends church with a lawyer who asks for a fist bump instead of a handshake. My neighbor, a realtor, told me that handshakes are such an integral part of the ceremony of his work that he can’t imagine changing. (Ironically, he was diagnosed with influenza A last week. Don’t worry. He’s doing fine)

So I dove into the literature. In spite of mountains of evidence that our hands are filthy, we are very into shaking hands: 78% of patients want their physician to shake their hand, and docs and patients shake hands 83% of the time. But maybe there’s a middle ground. Dr. Leonard Mermel from Brown University (paywall) points out that studies have shown that alternate practices of greeting, such as fist bumps and high-fives(!), decrease the transfer of organisms from one person to another by 50-90%. And some clinical sites have gone so far as to ban handshakes (paywall), comparing the challenge of the discontinuation of the handshake in clinics to the change in smoking practices among doctors in the 1950s and 1960s.

The handshake is a powerful signal. It can bring adversaries together in a moment of shared respect. It can give unequal parties a moment of balance and equity. It can help a person quickly project that she is trustworthy, confident, and prepared. But it can also transmit a stunning number of organisms from one person to another in a short amount of time.

So for this winter or the COVID-19 pandemic, whichever ends first, let’s fist bump instead.

One of your employees is likely to get coronavirus disease. What should you know about it ahead of time?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Let’s get the semantics out of the way. “Viruses” are little more than small packaged strands of genetic material—DNA or RNA—that invade cells and trick those cells into reproducing the virus. The duplicates of the virus take up too much space inside an infected cell, and the cell ruptures like a balloon. This is how tissue damage occurs, like the sore throat you get with many respiratory viruses. Most viruses infect other organisms, ranging from bacteria to mammals and birds, and are harmless to humans. You can find hundreds of harmless viruses in a few ounces of seawater, for example.

But sometimes viruses cross over from other hosts to infect humans. We call such infections “zoonotic.” Coronaviruses are a family of RNA viruses similar in many ways to influenza. They are called “corona” viruses because of their “crown” of spiky proteins. Four common coronaviruses—229E, NL63, OC43, and HKU1—have long been known to infect humans. They cause colds. We’ve seen outbreaks of two other coronaviruses in the last couple decades. Severe Acute Respiratory Syndrome (SARS) was transmitted to humans from civet cats. Middle East Respiratory Syndrome (MERS) came from camels. The novel coronavirus discovered in 2019 in Wuhan, China, the seventh known coronavirus to infect humans, is likely either from bats or pangolins, those scaly mammals that look like a cross between a raccoon and a lizard.

The newly discovered virus is now officially known as “SARS-CoV-2,” short for “severe acute respiratory syndrome coronavirus 2.” The disease that SARS-CoV-2 causes is officially known as “COVID-19,” short for “coronavirus disease 2019.” But for the sake of conversation, let’s use “COVID-19” for the next 800 words.

By contrast, COVID-19 seems only slightly more contagious than a generic influenza strain, with an r0 so far between two and three. It is also a fairly middling organism, mortality-wise: it has a current observed mortality rate of two percent, a number which will probably decrease over time.

The identification and naming of the virus and the work already done toward producing a vaccine is a testament to the advancement of science. We have accomplished all this in the time it took to even identify H5N1 23 years ago. But in spite of this, we are unlikely to be able to contain the virus. Since the original index case of presumed bat-to-human or pangolin-to-human transmission, COVID-19 has proven able to be transmitted directly from human to human. We measure the human-to-human contagiousness of a virus by a statistic called r0 (pronounced “R naught”). The r0 is complex to calculate, but it ultimately reflects the number of other people a person with an infection can be expected to, in turn, infect. Some viruses have an astonishingly high r0. A person with measles, for example, can be expected to infect between twelve and eighteen others. HIV’s r0 is 4.3.

By contrast, COVID-19 seems only slightly more contagious than a generic influenza strain, with an r0 so far between two and three. It is also a fairly middling organism, mortality-wise: it has a current observed mortality rate of two percent, a number which will probably decrease over time. A particularly bad influenza virus has a mortality rate of 20 percent (as in the 1918 Spanish flu, which may have in fact originated in Kansas) or even 60 percent, as observed in Asian Avian Influenza A (H5N1). But the fact that COVID-19 kills few of its victims has the paradoxical effect of increasing its transmission. Those H5N1 patients either died quickly or got so ill so quickly that they could be isolated right away, so only a few hundred people eventually died. As Dr. James Hamblin writes in the Atlantic this week, “…much ‘milder’ flu viruses, by contrast, kill fewer than 0.1 percent of people they infect, on average, but are responsible for hundreds of thousands of deaths every year.”

So even with the quarantine of hundreds of millions of people in China and elsewhere, COVID-19 cases are now in dozens of countries, including the United States. We’ve now seen the first case of likely “community-acquired” COVID-19 in the U.S. Epidemiologist Dr. Mark Lipsitch told James Hamblin that, eventually, 40 to 70 percent of the world’s population will become infected, likely resulting in flu and cold seasons being slightly worse in intensity and slightly more diverse, virus-wise.

What do we tell our employees, then? The news is fast-moving, and I’ve already revised this blog post twice in two days before posting, so nothing mentioned here should be considered irrefutable. But the fundamentals of disease containment are well-established, they’re not sexy, and they don’t differ for COVID-19 at this point compared to other infections. If you get sick, CDC recommends that you:

1. Stay home except to get medical care.

2. Separate yourself within the home from others, including pets.

3. Wear a facemask if you’re forced to be around others, including pets.

4. Cover your coughs and sneezes.

5. Don’t touch your eyes or nose.

6. Wash your hands for at least 20 seconds with soap and water. If you can’t get to soap and water, use a hand sanitizer with at least 60% alcohol. THIS IS LIKELY THE BEST PIECE OF ADVICE WE HAVE.

7. Don’t share household items.

8. Clean all your “high-touch” surfaces, like counters and doorknobs, daily.

9. Once you are free from fever without using medications, free from symptoms including cough, and have had two negative sputum tests, CDC says you can be released from isolation.

If you’re around someone who is sick, CDC’s advice is the same: help the patient with basic needs to allow him or her to stay home, like groceries; monitor his symptoms, and if he’s getting sicker call his doctor; and wear a facemask and gloves when you interact or do laundry.

For businesses, CDC has similar interim guidance:

1. Encourage sick employees to stay home.

2. Separate and send home sick or coughing employees right away.

3. Encourage good hand hygiene and cough/sneeze etiquette.

4. Clean surfaces often.

5. Check CDC Traveler’s Health Notices before traveling.

And for heaven’s sake, if you haven’t already had a vaccination against influenza, get one now. It is not too late. You are still far, far more likely to get sick or die from influenza than from COVID-19; influenza causes between 12,000 and 61,000 deaths per year in the United States, yet we can’t get much more than about 50% of people to get immunized in any given year.

The biosimilars are coming! (and that’s a good thing)

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Most drugs on the market are made the same way you made new compounds in chemistry lab in high school or college: by putting molecules or elements together in a solution and adjusting the temperature, pressure, pH, and other inputs to encourage the elements to combine in a specific way. So if an enterprising high-schooler were to discover a way to produce pure, uncontaminated aspirin in her garage, we could be confident that it would have the same effect as aspirin produced by Bayer.

And generics—unbranded versions of name-brand drugs—really do work to drive down the cost of medications. A 2017 study in the New England Journal of Medicine found that for a drug with a single manufacturer, generic and brand-name prices were roughly the same. But for a drug with three manufacturers, the generic price was only 60% of the brand-name price. So it’s no surprise that 90 percent of drugs used in America are generic.

But newer drugs—and some old ones like insulin—are not synthesized from scratch. Because of their complexity, we have to trick bacteria into making them—as with insulins—or we have to isolate them from living organisms where they naturally occur. We call such large-molecule drugs “biologics,” and instead of calling copies “generics,” we call copies of these drugs “biosimilars.” (As a side note, the first bacteria-produced “recombinant” human insulin ever to be given to a human was injected right here in Wichita by Dr. Richard Guthrie.)

When we make a biosimilar drug to match a biologic drug, the new drug is not necessarily atom-for-atom identical to the brand-name drug. The FDA allows the new drug to be slightly different as long as “no clinically meaningful differences” are noted between the original drug and the biosimilar drug in terms of safety, purity, or potency. This obviously requires more study than what would be required for our garage-produced aspirin. This means a lot of work, much of it in human subjects. Because of this difference, biologics have long operated under a different set of rules than “small-molecule” drugs. Whereas old-fashioned drugs are granted a 20 year patent from the date of application, after which it is relatively straightforward for another company to start producing a generic version, biologics are subject to a kind of natural immunity to generic competition that’s made worse by bad behavior on the part of the reference drugs’ manufacturers, misinformation campaigns, and close-but-not-quite-similar clinical outcomes.

The result has been that, while biosimilar drugs are common in western Europe, their use has been very limited in America. As such, Americans have long assumed that we paid far more for biologic drugs than our peer countries have.

A new study proves this out. Pharmacists and physicians from the University of Pittsburgh looked at the price of the only four biosimilars on the market by December 2018 (white blood cell-producing filgrastim [Neupogen®] and pegfilgrastim [Neulasta®], immunosuppressive drug infliximab [Remicade®], and insulin glargine [Lantus®]) over time. Their findings were striking. From 2007 through 2018 the cost of each of these medications went up by ~5-14% per year. At the time of introduction of a biosimilar (or two years ahead of time in the cases of glargine and infliximab) the cost of the medications immediately plummeted: −7.7% for filgrastim, −7.4% for pegfilgrastim, −13.6% for infliximab, and −23.5% for glargine.

The timing of this information is good. The dam on biosimilars is breaking. Dozens of biosimilar drugs have been approved in the last two years. So as you work with your pharmacy benefit manager to design your drug benefit, make sure that biosimilars are covered for your most expensive biologic agents. This may be harder than you think; abusive contracting practices are some of the obstacles biosimilars face in getting into wide use. However, the benefit to your bottom line will be substantial if you’re able to successfully integrate biosimilars into your pharmacy benefit.

Is 98.6 a lie?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics—but rarely hotter than today’s topic—that might affect employers or employees. This is a reprint of a blog post from KBGH:

If I were to ask a grade-schooler what a normal blood pressure is, I doubt he could tell me 120/80 mmHg. Nor could he tell me that a normal pulse is somewhere between 60 and 100 beats per minute, nor could he tell me that a normal body mass index is less than 25.0 kg/m2. But if I asked that same kid what a normal body temperature is, I bet he would blurt out “ninety-eight point six” before I could even finish the question. It’s printed into our brains, like “1776” or “three strikes.” That number—98.6—comes from an 1851 study by Carl Reinhold Wunderlich, a German physician who studied over a million temperature readings in over 25,000 patients to settle on 37° Celsius (98.6° Farenheit) as the “normal” body temperature, and 38°C (100.4°F) as a fever.

But the thermometer was still a fairly primitive technology in 1851. Daniel Farenheit had only invented his version in 1717, and by the time of Wunderlich’s study thermometers were still mostly found in academic centers. It took a solid twenty minutes to get a reliable reading. Not only that, but Wunderlich was studying a population that was simply sicker on average than modern people are. His patients, even those who reported good health, were more likely to have elevated body temperatures due to inflammation, bad teeth, or smoldering infections with tuberculosis or other horrifying diseases. And nobody had air conditioning.

So in the modern era, when thermometers are ubiquitous and their technology mundane, maybe it should not surprise us that the dogma of 98.6 is now in doubt.

As infectious disease physician Richard T. Ellison III writes in the New England Journal of Medicine Journal Watch (paywall), more recent studies show an average temperature of 97.9°F (36.6°C). But even that number is not rock-solid. Our body temperatures appear to change with age. To reach this conclusion, researchers looked at almost 700,000 temperature measurements from three sources: Union Army Civil War veterans from 1862 to 1930, National Health and Nutrition Examination Survey I (NHANES I) subjects from 1971–1975, and the Stanford Translational Research Integrated Database (STRIDE) cohort from 2007–2017. They found that across all three studies, body temperature progressively decreased with age, equivalent to -0.003°C to -0.0043°C (-0.005°F to -0.0077°F) per year. This means that a 10-year old with a body temperature of 97.9°F could be expected to have a body temperature of only 97.6°F—a full degree Farenheit lower than our old standard!—by the time she is seventy.

Not only did the new analysis of these old studies show that body temperature declines with age, it showed that body temperatures have declined with time. That is, temperatures recorded in the 1970s were lower than in the 1860s through 1930s, and temperatures recorded from 2007 through 2017 were lower than those in the 1970s. Again, this is probably because of reduced inflammation as infectious diseases became less common and because of the gradual adoption of air conditioning. If your mind isn’t already swimming, the study also found that body temperatures change with the time of day, the body weight of the patient, and even with race and sex.

Does this mean that your doctor’s office is lying to you when they tell you your body temperature? Are the infrared thermometers being used in airports to detect people infected with corona virus a fiction? Your answer depends on what we are trying to detect with the elevated temperature. Our old friend 98.6°F does now appear to be a figment of our collective nostalgia. But the Centers for Disease Control and the World Health Organization, who both are most interested in detecting potentially sick people early in their disease, still stick to a fever definition of 38°C (100.4°F). Some have argued that this number should be lowered to 99.9°F or even 99.5°F to increase the sensitivity of finding sick people. The Infectious Disease Society of America, whose emphasis is more on the care of ill patients in critical care and hospital settings, uses the same definition of 38°C (100.4°F), though, albeit with the caveat that the temperature of 100.4°F must be maintained for at least an hour, or the patient must have a single value over 101.0°F.

All this is to say that nothing in medicine is simple. Humans are complex creatures living in a dynamic environment, and as much as we like to define simple, neat cutoffs for “abnormal,” sometimes it just isn’t possible. So the next time your doctor’s office tells you that your body temperature is “normal,” take all this into account. Is it normal in the Wunderlich sense, in that it’s near 98.6°F? Or is it normal in the context of the A/C in her office, your age, your sex, your race, your living in the 2020s, and the state of your teeth?

Wait…Can you really modify your hospital Consent and Financial Agreement?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Dr. Marty Makary, general surgeon at Johns Hopkins who is more famous for his research on health costs and value, tells a riveting story of hospital billing (no, really!) in his book The Price We Pay: What Broke American Health Care–and How to Fix It (pages 167-170). A friend named Dina becomes ill while visiting Marty. When the two of them arrive at the emergency room, she is informed that the ER is “out of network” for her insurance. After some salty language on both sides, both sides agree she can be treated in the ER anyway. But prior to treatment Dina (with Marty’s help) asks for a physical copy of the hospital’s Consent and Financial Agreement form (Dr. Makary calls it the “battlefield consent form”), rather than automatically signing the form on the iPad that is brought to the room. Dina crosses out the clause on the paper agreement that states she would “sign away her financial life” (Dr. Makary’s words) before seeing any bill.

Dina has a minor surgical procedure, recovers, and eventually receives a $60,000 out-of-network bill. Marty shows her what her insurance would have paid had the hospital been in-network using Healthcarebluebook.com: about $12,000, or one-fifth the out-of-network bill. After getting Dina’s consent and requesting an itemized bill, Marty calls the hospital and offers $12,000 to settle the bill, which is refused. He explains to the hospital that Dina has no contractual obligation to pay because she struck out the clause in the contract saying she’d pay whatever they charged. Marty adds that legally the hospital is prohibited from using collection agencies to hurt her credit if she does not pay. The hospital director immediately offers to settle for $30,000, then $25,000, then $19,000.

Marty sticks to his original offer of $12,000, and the bill eventually gets sent to collections. When the collections agency calls, Dina asks them to send her a copy of the Consent and Financial Agreement, the form on which she’d deleted the section indicating her obligation to pay. The collection agency never calls back, and Dina eventually makes a $5,000 donation to the hospital’s fundraising drive, earning a plaque on the wall.

This is, shall we say, a novel way to deal with surprise medical bills. But it has some high-profile proponents. Al Lewis, Harvard-trained attorney and famous skeptic of worksite wellness, told Dr. Makary’s story on his blog. He went so far as to suggest making a card for your employees to carry and has even produced a template. He suggests the card say something to the effect of, “I consent to appropriate treatment and (including applicable insurance payments) to be responsible for reasonable charges, up to 2 times the Medicare rate.”

Needless to say, one party’s idea of “reasonable” can differ radically from another’s. Al says that reasonable charges can be “settled by binding arbitration using the New York law as a model. That law, based on Major League Baseball binding arbitration rules, is well-accepted and has generally been successful at curbing abuses.” [Disclosure: KBGH has a financial relationship with Quizzify not related to medical billing, but rather for health literacy training]

So. Is this a real strategy that at-risk patients could use? It seems under-handed. But some (most) would say that the entire system of surprise out-of-network payments in health care is under-handed, especially when the agreements are, as some have argued, signed under duress. Al Lewis’s website deftly says “Legally, we can’t guarantee this will work. But we know the alternative—signing whatever they put in front of you—carries the risk of much higher bills, and more chance of inappropriate treatment.”

And that’s what we say, too. The Kansas Business Group on Health is not endorsing this practice. We simply want our members to be aware of its growing use by frustrated, scared patients.