The “Shocking” Mammography Screening News

The U.S. Preventive Services Task Force (USPSTF) — a quasi-governmental, independent panel of experts in primary care and prevention charged with systematically reviewing the evidence of effectiveness and developing recommendations for preventive health services — just created a whole lot of hoopla by changing their mammography screening recommendations. They made the changes in an environment politically charged by the ongoing health care reform debate and raised the ire of some patient advocates.

The USPSTF is a trustworthy, conservative body that focuses on evidence, not politics. However, the decisions the USPSTF makes, certainly in this case, can have massive political implications. As a researcher who once studied the health screening and prevention needs of patients, I used the venerated guidelines set by the USPSTF as the criterion for assessing these needs. As a dermatologist, I’m familiar with USPSTF recommendations largely because of what they DON’T recommend: skin cancer screening.

Among dermatologists — doctors who see skin cancer every day — there is widespread support for skin cancer screening. The USPSTF, which focuses on scientific evidence, sees no proven net benefit and does not recommend routine skin cancer screening, much to the chagrin of most dermatologists. However, I trust their judgment. The USPSTF doesn’t support politically expedient skin cancer screening, because the evidence to support routine skin cancer screening is lacking.

The USPSTF has my trust, but many others don’t share that view. Listening to the debate over the change in mammography screening recommendations, I hear emotional and quasi-scientific rants about the horrors of the new mammography recommendation and how the lives of women are being totally discounted by the Task Force. I’m sure the Task Force carefully considered those lives. The specific evidence for how many lives are saved by routine mammography screening for women in the 40-50 year age range is roughly one life saved for every 2,000 women screened. And I am sure the USPSTF weighed that benefit against the risks of screening. What are those risks of screening? There are false positive tests that can result in morbidity and scarring from the resulting biopsies, as well as a profound emotional toll brought on by being told, “you have an abnormal mammogram.”

Those who view the changed USPSTF mammography screening recommendation through the lens of the health care reform debate magnify the noise surrounding the scientific controversy with allegations that a quasi-governmental body is deciding the future of women’s health and making recommendations to ration care away from women while callously ignoring the lives of our mothers, sisters and daughters who will die needlessly. They say this proves that the last thing we need now is more government involvement in American health care. I’m not so paranoid.

The Task Force didn’t ignore women’s lives. On the contrary, it carefully weighed the risks and benefits to women. The Task Force didn’t ration care. On the contrary, while the Task Force didn’t recommend routine mammography for women in their 40s, the Task Force did recommend that the decision to have mammography “should be an individual one and take into account patient context, including the patient’s values regarding specific benefits and harms.”

And that, to my ear, is a good thing. Patients should be empowered to make individual decisions based on the best evidence and on their own unique situations and preferences. The concept of patient-centered care and greater involvement of patients in their own health care underlies both the USPSTF recommendations and everything that I have advocated about patient satisfaction and feedback through DrScore.com.

Insulating Patients from the Cost Drives Prices Up

One of the great ironies of our health care system are copayment assistance programs.  Such programs seem like a wonderful way to help patients obtain access to modern medical treatments.  But as was pointed out in NPR’s This American Life show on health care reform, there’s a “dark side” to these programs.

Here’s how they work. Let’s say a company comes out with a new drug, and they set a price of $800 for a month’s supply. The insurer may cover much of the cost of the drug,  but because the drug is so much more expensive than other options, the insurer puts the drug on “tier 3,” requiring patients to pay 20 percent of the cost. In this example, that’s $160 per month, nearly $2,000 per year, which is a considerable sum of money. Some patients either can’t or won’t pay that much, so to help patients get better access to the drug, the company may offer a rebate or coupon program that cuts the cost of the co-payment from $160 to something far more affordable, perhaps just $10 or $20/month.

This sounds like a great way to help patients, but unfortunately, it is also a great way to game the system and keep the costs of drugs high. The purpose of co-payments is to create some incentive for patients to choose a lower cost product, but the co-payment assistance cards insulate patients from the cost of the drug, so they may choose the higher priced drug even though its benefits may be marginal in relation to the much higher cost. This allows the drug company to continue charging the insurer a very high price, and there is little pressure from the patient to provide lower costs drugs.

Insurers ask patients to pay for a part of the cost in order that patients consider the financial cost of using the biologic. If drug companies are permitted to eliminate the co-payment that insurers have in place, the drug company no longer has to compete on price.

A similar phenomenon happens when doctors see patients without charging co-payments for the visits. The doctor may feel that they are just being nice to patients by not charging the co-payment. But these co-payments have a central place in helping regulate patients’ use of doctors’ services. Doctors can reasonably see a patient without charging the patient (or the insurer) anything if the doctor wants to help the patient out. Taking payments from insurers without trying to collect the co-payment is somewhat dubious and sometimes illegal.

Years ago, while still in training, I went to see a dentist for a regular check-up and to address a minor problem. It was a very rainy day, and I was able to get in right away due to a cancellation. Understanding that I was a student, the dentist offered me a very reasonable, low price for his services. Upon finding out that I was insured, he said I didn’t need to worry about the bill at all, and that he would happily take care of everything directly with the insurer. Almost certainly, he billed the insurer far more than he offered to bill me directly. Insurance doesn’t just insulate the purchasers of services from the cost of the service; the doctors who provide the service have little compunction about charging unseen, third party insurance corporations whatever the doctor can, while many doctors wouldn’t directly charge the patient such a high price.

A Look at Why Medical Care Costs So Much

The issues raised in the This American Life program on health care reform resonated with me as they are common issues in my practice. As a dermatologist, one of the most common problems my patients have is psoriasis, a red, scaly rash that can affect different parts of the skin. These spots on the skin are caused by inflammation; in other words, they are caused by an overactive immune system. When psoriasis is particularly severe, the inflammation causes internal problems. Psoriasis is associated with arthritis, heart disease and depression.

Psoriasis can help us better understand the costs in our health care system. A patient with relatively mild psoriasis (a few red, scaly spots on the elbows and knees) has several options for treatment, the first being a high-potency topical cortisone medication, which typically clears up the spots if the patient uses it regularly. The topical cortisone medicines are reasonably safe; however, with persistent long-term use, cortisone medicines can cause some thinning of the skin. 

• The high potency topical corticosteroids have been around a long time. Generic versions are available in creams and ointments and can be purchased for only a few dollars a tube; however, they can be messy.
• If patients prefer less mess, they can choose newer formulations of topical corticosteroids, including a spray or foam. These are easier to use but significantly more expensive, costing $100 to $200 per container.
• Patients also have the option of a vitamin D cream or ointment. These drugs are considerably more expensive than generic topical cortisones, but have fewer long-term side effects. One company developed a combination cortisone/vitamin D ointment that contains both products. While this is a convenient way to get the benefit of both drugs at once, a large tube of the medication can cost $800 or more.

The newer options may perform better on a patient’s psoriasis than the first, but patients tend to choose the drug based on the type of insurance they have: 

• If patients are uninsured, have no prescription benefit or have a high co-payment for medications, they will often choose one of the low cost, generic topical cortisone medications.
• If patients have good prescription coverage as part of their insurance, they may choose a branded cortisone medication. I had one patient who had terrific drug coverage in their insurance plan. When offered the choice of a low-cost generic cortisone, the less messy/more costly high strength cortisone in the spray, and the highest cost combination cortisone/vitamin D medication, the patient said, “Doc, give me the spray and the combination drug. I’ll try them both and see which I like better. My insurance covers the cost of my medications.”

The cost of medical care doesn’t follow the rules of cost that apply to most consumer goods because the people who consume the medical care aren’t the ones directly paying for it. If well insured patients are given a choice between a $10 drug that may work reasonably well and a $10,000 drug that might work 10 percent better, the patient is quite likely to choose the $10,000 drug. That kind of thing doesn’t happen at a place like Best Buy. People won’t pay a 100 times higher price for a computer that offers just 10 percent more RAM or a camera that has 10 percent more pixels.

If people were paying for care out of their own pockets, they wouldn’t buy $50 aspirin pills in the hospital —they would pay for less expensive products that met their needs. They would search for the best deals on medical care. Providers of services would be forced to compete on price, and the price of health care services would drop, making care more affordable for everyone.

There are people who argue that medical care is inherently different from other services we purchase, that we need health insurance companies to make decisions for us and to pay for things that we can’t afford. Certainly the growth in the cost of health care is different from other goods, but much of the high cost is caused by health insurance, not solved by health insurance.

Yes, there are emergencies and complexities that make purchasing health care somewhat different from purchasing other products. But it isn’t completely different — there are non-health care emergencies and other incredibly complex products and services that we purchase regularly.

The difference is that when we buy those products with our money, our tendency to search out low prices and only pay for those things that are worth the price. 

Rational Discourse Found on NPR

National Public Radio’s “This American Life” is a wonderful program, and I was excited to see that they were going to cover health care reform in two episodes. I downloaded them as podcasts — you can too at http://www.thisamericanlife.org/Radio_Archive.aspx, episodes 391 and 392.  

Last Saturday, I finally had a chance to listen to Part Two while driving home from a medical meeting. This episode of “This American Life” provides the clearest and most rational explanation of the high cost of health care that I’ve heard on any medium. The show was well balanced toward insurance companies, doctors and drug companies, yet it made clear how our system is screwed up and how it got that way.  If you get the chance, listen to this program. You will come away better educated on the whole debate.

The Turning Point

Since the very inception of DrScore, the company has been represented at the annual conference of the Medical Group Management Association (MGMA), an enormous meeting of medical practice managers from across the country. Each year we purchase a booth in order to promote our patient satisfaction survey service to doctors and practice managers.

I enjoy the MGMA conference. It is a great opportunity to meet many people who appreciate the importance of patient satisfaction. And meeting attendees have always been extraordinarily receptive to what DrScore offers: an easy, low-cost way to get detailed feedback from patients, document quality and provide a basis for enhancing the quality of medical care.

But this year marked a real turning point in how DrScore was perceived at MGMA. In years past, health care providers were interested in the service, but tended to remain loyal to the old-fashioned paper-and-pencil survey as a way of getting feedback. That seems to have changed in 2009. It looks like the Internet has become so ubiquitous that Web-based collection of patient feedback (with all its advantages and lesser expense) is what doctors are looking for.

This change in perception marked a turning point for me, too. DrScore has achieved what I and my team intended it to: a free service for patients that allows them to rate their experience with doctors and look up doctor ratings, and a physician-endorsed tool that doctors use to obtain valuable feedback from their patients in order to improve their medical practice.

Miscommunication — It Happens to Everyone

My interview with the People’s Pharmacy radio program was broadcast on October 10. Visit (http://www.peoplespharmacy.com/2009/10/10/743-saving-your-skin/)

I thought the program, which was focused mostly on dermatology, went well. I was also able to speak on some other issues about which I have a lot of passion — in particular, patient satisfaction.

Unfortunately, I did not communicate one of my points very clearly, and a physician who had been listening to the show felt that I had insulted family physicians and posted a comment on the People’s Pharmacy Web site. Because I have enormous respect for family physicians and other primary care doctors, I felt terrible about the misunderstanding. But I greatly appreciate that the doctor wrote to me and to the show to let me know his feelings. It gave me an opportunity to respond to him and others, clarifying what I meant. More importantly, the feedback made me realize that in future radio programs I need to be more clear and explicit in letting listeners know exactly what I mean.

Ironically, this is the same kind of communication problem that doctors and patients —and everyone else — face day in and day out. At least in medicine we have one solution: give patients clear, written directions describing the diagnosis and treatment plan. But doctors, like everyone else, often don’t hear themselves and think they have communicated clearly when they have not. That is why it is so important for patients to help doctors by giving them the feedback about their communication style. I’ve said it many times: Feedback helps doctors do what they want to do most, which is to give their patients great medical care.

The Myth of the ‘Evil’ Empire: Insurers, Drug Companies and Malpractice Lawyers Aren’t So Bad

Everyone has their own theories about what is causing the high rises in the cost of health care. Today I want to talk about one of my favorites: insurance companies.

Many people say that there isn’t enough competition in the insurance market. There’s plenty of competition already. There are more health insurance companies, options and plans than there are companies making many of the high-quality, low-cost consumer goods sold at Best Buy. People may argue that one insurer controls a certain market; however, I don’t believe that more competition among insurers will help solve the problem.

I heard one talk show host claim that being a “for-profit” insurance company means a company’s goal is just to make money. For-profit companies have multi-faceted goals. FedEx is a for-profit company whose mission is to deliver packages quickly. Canon is a for-profit company that makes great cameras. Apple is a for-profit company that makes great, easy-to-use computers. Disney is a for-profit company that gives people a magically great experience. Don’t be fooled into thinking that because a health insurance company is “for profit” that its only reason to exist is to make money or that its “for-profit” status underlies the high cost of medical care.

High salaries for executives at health insurance companies aren’t the heart of the health care crisis either. I must say that seeing some of the ridiculously high salaries makes me sick (being naturally envious may be part of my thinking there). Some of the salary figures seem unconscionable. But even if those salaries are somehow unfair, they aren’t the problem underlying the U.S. health care crisis. The combined value of all the health insurance companies’ top executives’ pay probably doesn’t add up to more than a small percentage of annual health care spending — perhaps less. There’s high executive pay in many industries. The heads of Microsoft, FedEx, Apple and Disney probably do very well; however, those industries provide great quality and affordable prices. No insurance is needed to purchase products or services from those industries.

So if we have plenty of competition, and the insurers aren’t inherently “evil,” why is the U.S. health care system broken? Why are we spending so much for medical care with no end in sight to the increases in cost? Why is the cost of medical care so different than the costs of so many other goods that we buy?

Insurers are a problem, but it’s not for the reasons you think. The way our insurance system is set up actually creates an obstacle to a consumer-driven health care market that would help drive down costs. Unlike other products that we buy ourselves, consumers generally do not pay for medical care directly. Instead, the insurer pays the medical bills, which insulates us from the price of the medical care we use.

How do we create consumers who are more cost-conscious about purchasing health care? That’s a topic for another blog after we explore more about the “evil” drug companies and lawyers.

We Agree on One Thing

The health care system in the United States is nothing short of amazing. We are capable of extraordinary technologic feats, treating previously fatal ailments and peering unobtrusively into the depths of the human body.

It is an amazing system, but that doesn’t mean it’s not broken. That is something that Republicans, Democrats, Independents, Libertarians and most everyone else can agree on.

Why is it broken? Let me list a few reasons:

• The costs of this amazing system are just too high and continue to grow.
• The high cost means that if a person is not incredibly wealthy or well insured, then he or she is not going to have good access to medical care.
• People who are insured can lose that insurance, sometimes just by changing their jobs or perhaps sometimes just by becoming ill.
• People who are already sick with a condition often can’t get coverage for that condition.
• Sometimes people who are covered by insurance aren’t covered well enough to make their medical needs affordable.

So while everyone agrees that something needs to be done to fix the system, that’s where the agreement and civil discourse stop. We seem to be stuck because no one will agree on exactly WHAT causes the failure in the current health care system.

Doctors Who Don’t Want to be Rated

The other day I received an e-mail from a physician who did not want to be included in the DrScore database of physicians that can be rated online. This physician wanted to be removed immediately and was quite passionate in her demand.

I have come to realize that there are some doctors who absolutely don’t want to be rated on the Internet. Their position may be firm because they simply fear a poor rating. More likely, however, it’s an issue of control.

Doctors tend to be incredibly hardworking, bright, driven people. (I am a doctor, and I am biased.) They like to be in charge and able to do what needs to be done to take care of their patients without interference from outside entities. But that is not the world we live in today — regulatory and insurance barriers make it harder for us to focus only on what we think is the best course of treatment for the patient. Throw in the World Wide Web and the ability for patients to get on there and tell use what they think, and WHOA! Everything seems out of control

But the fact is, the Internet is here to stay. Trying to stop patients from getting online and rating doctors is like trying to hold back the tide to preserve the row of beach cottages. It simply isn’t a sound strategy, and the doctors will continue to get battered. The better solution? Get a representative rating.

Doctors have VERY LITTLE TO FEAR from representative online ratings. The more representative the rating, the better doctors are going to look. Of the doctors with 20 or more ratings on DrScore, the average rating is about 9.3 out of 10!

As a physician and a believer in good customer service — from the parking lot to the friendly staff to the time spent with the doctor — I want to encourage doctors to stop fearing the ratings process and, instead, take control of it. Ask ALL your patients to go online and give you feedback, whether it is positive or negative. Hearing those positive comments from patients makes doctors feel really good about what we’re doing. Specific positive comments about particular aspects of our practices let us reward and reinforce the good people and systems in our medical practices. And then, remember, the negative comments are true gifts. They help direct us to become better at what we do.

With regards to the doctor who wanted to be removed from the DrScore database, my answer is simply this: DrScore will not inhibit patients from giving their doctors feedback. DrScore welcomes information from doctors to help us update our database of physicians and their professional contact information. But we will only remove a doctor’s name from the database if the doctor is no longer practicing medicine.

Seven Suggestions for Improving Patient Satisfaction

I am often asked to speak to physician groups about how to improve patient satisfaction. Here are a few tips free of charge. 

1. Make improving patient satisfaction a fundamental goal of the practice. Providing health care that is technically good (giving the patient the right diagnosis and treatment) is critical (of course), But if you provide this kind of care without paying attention to other aspects of the patient experience, the patient may not feel satisfied. It’s sort of like if Disney World offering the world’s fastest roller coaster (technically great), but didn’t work to ensure that the roller coaster experience was also magical!
2. The importance of patient satisfaction must come from the physicians first. The physician has to be the leader. If the physician isn’t focused on patient satisfaction, the staff won’t be either.
3. Appearances count. Make every aspect of the office inviting and friendly. Does the office need new paint or furniture? Would flowers or coffee help make your patients sense how much you care about them?
4. Above all else, if you can, remove (or reduce the prominence of) signs at the check-in window that suggest that all you care about is money. Instead, put up a sign that says what you really think, something like, “We appreciate the trust you put in us, and we strive to give you the best possible medical care.”
5. Learn from other successful service organizations. Many stores sell well made clothing, but what makes Nordstrom special is its attention to customer satisfaction.
6. Be on time, as much as possible. You know that when you are kept waiting, you feel disrespected and uncared for. Leaving patients feeling that way is bad for patient satisfaction, bad for trust in the doctor, bad for compliance, and bad for malpractice risk.
7. Ask for feedback. Feedback will let you know where you stand and how to improve. Asking for feedback also communicates to your patients that you care about them, respect them and value their opinions. 

I want to hear about some successful strategies your physician practice has employed to improve customer service. Please email me, and I will share tips in future blogs.