HCR -- Top Five Ways to Improve Care & Reduce Costs (Updated)

By John Ballard

Go to the link to read the reasons. (Naomi Freundlich at Maggie Mahar's place.)
Here they are for three specialties.

Top 5 Internal Medicine

• Lower Back Pain: Don�t do imaging for lower back pain within the first 6 weeks unless red flags are present.


• Screening: Don�t obtain blood chemistry panels (eg, basic metabolic panel) or urinalyses for screening in healthy adults who don�t have symptoms.


• EKGs: Don�t order annual EKGs or any other cardiac screening for low-risk patients without symptoms.


• Cholesterol Lowering Drugs: Use only generic statins when initiating lipid-lowering drug therapy.


• Bone Density: Don�t use DEXA (bone density) screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors.

Top 5 Pediatrics

• Throat Infections: Don�t prescribe antibiotics for pharyngitis (sore throat) unless the patient tests positive for streptococcus (Strep throat). [According to an article in Time, �Most cases of sore throat are viral, yet antibiotics are prescribed more than half the time, contributing to drug resistance and high costs.�


• Head Injuries: Don�t obtain diagnostic images for minor head injuries without loss of consciousness or other risk factors [The risks of radiation exposure for kids far outweigh any benefits of scanning otherwise]


• Fluid in the Middle Ear: Don�t refer otitis media with effusion early in the course of the problem. [Again, most ear infections are viral and will go away on their own without antibiotics.]


• Cold Medications: Advise patients not to use cough and cold medications. [Recent studies have shown that these medications have no benefit and parents often use incorrect dosages, leading to harmful side-effects.]


• Asthma: Use inhaled corticosteroids (a steroid medication) to control asthma appropriately.

Top 5 Family Medicine

• Lower Back Pain: Don�t do imaging for lower back pain within the first 6 weeks unless red flags are present.


• Sinusitis: Don�t routinely prescribe antibiotics for acute mild to moderate sinusitis (inflammation of the sinuses) unless symptoms � which must include purulent (full of pus) nasal secretions AND maxillary (upper jaw bone) pain or facial or dental tenderness to percussion � last for 7 days OR symptoms worsen after initial clinical improvement. [The Time piece notes; �Despite the fact that most sinusitis is caused by a viral infection, antibiotics are still prescribed in more than 80% of outpatient cases. That adds up: each year sinusitis results in 16 million office visits and $5.8 billion in costs, even though viral infections will clear on their own.�]


• EKGs: Don�t order annual EKGs or any other cardiac screening for low-risk patients without symptoms.


• Pap smears: Don�t perform Pap tests on patients younger than 21 years or in women have had a hysterectomy for benign disease.


• Bone scans: Don�t use DEXA (bone density) screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors.

~~~~~~~~~~~~~~~~~~~~~~~~~~~

Last week a couple of cancer specialists published recommendations in the New England Journal of Medicine. Interested readers are welcome to check out the whole piece, but thanks to Merrill Goozner here is their list of five for quick reference.

Top 5 Cancer

• Only use testing and imaging where �benefit has been shown�;


• Limit second-line and third-line treatments to metastatic cancer to sequential monotherapies for most solid tumors. �Patients will live just as long but will avoid toxic effects. . . Society will benefit from cost reductions associated with less chemotherapy, fewer supportive drugs, and fewer toxicity-associated hospitalizations��;


• Don�t give chemotherapy to people when their cancer has made them so weak that a positive response is highly unlikely;


• Lower chemo doses to eliminate the routine use of drugs that replace the white blood cells destroyed by toxic chemo drugs; and


• Stop treating patients if they haven�t responded to three different drug regimens � unless they are enrolled in a clinical trial actually testing the fourth regimen.

Goozner couldn't resist anticipating how the Wall Street Journal and others opponents of reform will react to these (or any) "top five" ways to improve outcomes at lower costs.

Now, here�s my top five list of how the editorial page of the Wall Street Journal will respond to this call for rationing based on science and common sense:

• It�s rationing that abrogates physician autonomy;
  


•  It�s rationing that prevents individual choice in evaluating the trade-offs between benefits and risks;
  


• It�s rationing that denies very ill patients hope;
  


•  It�s rationing that puts cost ahead of best practices; and
  


• Did I mention that it�s rationing?
  

And as far as end-of-life counseling is concerned, we�ve already heard right-wing politicians crying �death panels.�

~~~~~~~~~~~~~~~~~~~~~~~

A seriously stupid public discussion continues as the Ryan/GOP plan gets tossed around like a football, I need to make a fairly simple point. If the private sector/insurance industry is as good at controlling costs as many claim, then why have the premiums for Medicare Part B Medigap policies not gone down?

Medicare does not set prices. The prices charged for medical procedures, devices and medicine are set by the providers. (Read private sector) Medicare determines how much of the price to reimburse. MEDICARE DOES NOT SET THE PRICES. Get it?

The argument that "doctors are dropping Medicare patients because Medicare rates are going down" is seriously misleading. Medicare dollars are tax dollars, folks. When Medicare rates go down it's because fewer tax dollars are being paid out. Complainers cannot have it both ways: if Medicare rates go up, then so, too, must the amount of taxes being collected for that purpose.

Private doctors who no longer accept Medicare are doing so because they want to charge more. Anyone who wants to patronize them and can afford their rates is perfectly free to do so.
Medicare tax dollars are still available to all providers IF THEY CHOOSE TO ACCEPT THEM, but when they make the choice to stop accepting Medicare those patients who can still afford to use their services are free to do so. No one is stopping them if they can afford the higher rates those doctors will charge.

It's the American way. It's called FEE FOR SERVICE.
It's like buying coffee.
If you want Starbucks or Caribou, prepare to pay the price.
Otherwise, get a McCafe or brew your own.