Doctors bring in a lot of money for hospitals

https://www.axios.com/newsletters/axios-vitals-f3febfe2-1e33-46ad-993e-dc47d3fa3638.html

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Doctors are generating a lot of revenue for hospitals — much more than those doctors receive in salary, according to a recent survey by physician staffing firm Merritt Hawkins.

Why it matters: It’s easy to see why hospitals view acquiring physician practices as a lucrative opportunity — which hospitals are doing at a rapid pace.

  • “This is [a] good reminder that doctors are the gateway to the rest of the health care system. It’s doctors that make the decisions about whether people get admitted to the hospital, or get a lab test, scan, or prescription,” the Kaiser Family Foundation’s Larry Levitt said.

Go deeper: A recent survey by the American Medical Association found that for the first time ever, the U.S. has more physicians who work as employees than those who run their own practice.

https://www.merritthawkins.com/uploadedFiles/MerrittHawkins_RevenueSurvey_2019.pdf

https://www.axios.com/doctors-hospital-employees-independent-practices-7f91e1b6-aab3-452b-8204-98e0884c359c.html

 

 

 

 

 

Reforming U.S. Healthcare: Even Research Statistics Are Rigged

https://fixushealthcare.blog/2019/04/13/reforming-u-s-healthcare-even-research-statistics-are-rigged/

Slide1

To paraphrase Elizabeth Barrett Browning, How do I rig thee? Let me count the ways.

Even research statistics are all too often rigged, according to a commentary in this month’s Journal of the A.M.A.  These rigged statistics are being applied to clinical studies of new drugs, devices, and treatments to put them just far enough over the line of “significance” to win Food and Drug Administration approval.

And to win big dollar profits for research companies and the researchers themselves – my claim, not the Journal’s.

This goes beyond what Mark Twain called “lies, damned lies, and statistics.” Twain was referring to “spinning” legitimate statistics to show results in a favorable light.

But Stanford’s John P. A. Ioannidis MD, ScD, calls out statisticians-for-hire for actually cherry-picking, distorting, and manipulating post-hoc the statistical analyses themselves in scientific publications, in the service of Big Pharma.

Ioannidis’s Observations

Here are some of his observations:

  • Some policy makers have an exaggerated sense of certainty about research results based simply of a P-value less than 0.05 (P-value is a statistical construct that estimates the probability that an observed difference between the study group and control group is a true difference rather than a coincidental difference caused by random factors alone.)
  • Some policy makers hype results based on statistical differences that are technically correct but weak at best
  • Some policy makers focus on “statistical significance” only and fail to consider “clinical significance” as well as other practical considerations when interpreting study results
  • “Some fields that claim to work with large, actionable effects (eg, nutritional epidemiology) may simply have larger, uncontrolled biases.” That is, just because a study appears to have a robust statistical effect does not mean the conclusion is iron-clad. An observed difference might have another hidden explanation that contradicts the study conclusion.
  • “Absent pre-specified rules, most research designs and analyses have enough leeway to manipulate the data and hack the results to claim important signals.”
  • “Studies have shown that unless an analysis is prespecified, analytical choice (eg, different adjustments for covariates in nonrandomized studies) may allow obtaining a wide range of results.”
  • “In a recent survey completed by 390 consulting statisticians, a large percentage perceived that they had received inappropriate requests from investigators to analyze data in ways that obtain desirable results.”
  • “Passing the threshold of “statistical significance” … such as P < .05 is typically too easy…”
  • “Clinical, monetary, and other considerations may often have more importance than statistical findings.”

Ioannidis’s Solution

Dr. Ioannidis’s offers a solution to keep honest statisticians honest:  Require researchers to post in advance, such as at ClinicalTrials.gov, not only the overall research design but also detailed descriptions of

  • numbers of subjects to be studied (since cohort size affects the “power” of the statistical analysis)
  • which statistical methodologies will be used
  • advance definition of subgroups designated for separate analysis
  • specification of the threshold for statistical significance (choice of P value)
  • criteria for altering statistical methods in the face of unexpected problems occurring during the course of a study
  • plans to post raw data for all to see and analyze.

Comment:

Prestigious medical journals could adopt Ioannidis’s solutions without waiting for comprehensive reform of the whole health system. But the Journal’s surfacing of issues around abuse of research statistics illustrates the extent to which that system has fallen under the pall of profits, the depth to which the system has been rigged, and the degree to which Hippocratically-pledged professionals have been coopted. And this means that the full weight of our society, government and nation will be needed to fix it.

Take Action

Now, take action.

 

 

 

Segment 3 – Healthcare Reform Successes & Failures

Segment 3 – Healthcare Reform Successes & Failures

Slide15

In Segment 2, we looked at the history of medical care in the U.S. until 1965, the year Congress enacted Medicare and Medicaid.

In Segment 3 we will look at reform movements, starting with Medicare and Medicaid. We will look at why later reforms failed and where that leaves us now.

By the early 1960s, nearly all employees were covered by Blue Cross/Blue Shield.

But problems emerged. First, low-wage workers were often not covered by their small businesses, and elderly retirees were not covered. Costs were going up because pre-paid insurance increased patient demand for services. Harry Truman had proposed national health insurance after he surprisingly was re-elected in 1948. But the AMA launched a multi-million-dollar publicity campaign to deride the plan as “Communism” and “socialized medicine.” Truman’s public insurance plan failed.

The next attempt at reform was successful – the 1965 passage of Medicare and Medicaid. Lyndon Johnson succeeded because coverage targeted the uninsured poor-and- elderly, leaving the rest of the private for-profit health system unaffected.

Senator Teddy Kennedy tried in 1971 to extend Johnson’s success to build a single-payer system, and won support from President Nixon. But this plan was derailed by the Watergate scandal.

The next attempt came from Bill and Hillary Clinton. After Clinton took office in 1992, Hillary and expert panels devised a plan for universal coverage including essential benefits and pre-existing conditions with mandated employer insurance and expanded Medicaid. This plan failed because the insurance industry launched a stinging publicity campaign featuring a down-home couple named “Harry and Louise.” Americans also balked at the tax increases needed to fund it.

The Clinton’s failure made it necessary to find another solution to rising costs. Managed care, which had first appeared in 1973, became that solution. And it did work, slowing growth to under 6%. But around the year 2000 came a backlash over mammograms and so-called “drive-by” deliveries, which undermined the ability of managed care to control costs.

What do we make of this history? Here are the main take-aways that help us understand our present health system. First, there has always been a tension between the profit motive in the free marketplace and a health promotion motive. Second, Americans have given special treatments to the health industry in return for medical advances. And third, powerful vested interests (doctors, hospitals, insurance, drug companies) have often used polemics and ideological arguments to defend their favored status, not necessarily actual health outcome data.

Slide09

So, this leaves the US with the largest, most expensive healthcare system in the world. In 2011 shown here it took in payments of 2.7 trillion dollars, mostly private insurance, Medicare, Medicaid and out-of-pocket. The figure for 2015 was 3.2 trillion dollars, representing 1/6 of the entire economy of the entire Gross Domestic Product. Government’s share of payments was almost 50% in 2016.

Slide10

This graph shows the dollars spent in 2011 – mostly on hospitals, doctors, drugs, long-term care. Remember that 25% of this pie graph actually goes to administrative costs, not medical services.

Slide11

In defense of U.S. healthcare, in 2012 then-House-Speaker John Boehner and then Senate Minority Leader Mitch McConnell famously said, “the U.S. has the finest health care system in the world,” and further that “wealthy foreigners flock to the U.S. because of its cutting edge facilities.”

2017-10-13-boehner-mcconnell.png

However, the World Health Organization rates the U.S. 15th in performance (life expectancy and delays in care), and only 37th in overall attainment (including financial and service fairness).

In 2015 the Kaiser Foundation compared the US with 10 other developed countries. Here are their results showing areas in which US is better, equal or lacking.

Here are the Commonwealth Fund’s 20-11 rankings – US is in the middle of the pack for most areas but dead last on several others and overall rank.

Slide14Source: http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

What about “foreigners flocking-for-care”? This pertains to highly specialized treatments available only in certain centers such as Mayo, Cleveland Clinic or Hopkins. Some centers in Florida and Texas do market to wealthy foreigners, who pay the full charge in cash, not discounted insurance rates like the rest or us. Boehner and McConnell pointed to Canadians coming to Michigan hospitals, but the Commonwealth study found that Canada is worst in timeliness and 10th worst overall, just ahead of the US in 11th place, so not surprising.

The further truth is that, according to Centers for Disease Control, 3/4 million Americans go abroad each year for medical treatments, such as for holistic care or dental care, but mostly seeking lower cost.

In the next Segment we will talk about cost, namely how the rising cost of healthcare is affecting our economy, our politics, our society – and some say our very existence.

I’ll see you then.