2011 Potpourri XXVIII

A survey of almost 350 physicians indicated that the almost 21,000 doctors employed by the federal government are much less likely to practice defensive medicine due to malpractice suit fears than are physicians working in the private sector.  Only 48% of government doctors said they engage in defensive medicine while, depending on the survey, 70% to 90%  of private physicians do so.   For doctors who had worked in both environments, most of them said they did it more often in the private sector.  A separate survey has shown that US physicians engage in excess delivery of services to avoid malpractice far more than international doctors.  Although it is pretty clear that defensive medicine has huge costs, don’t hold your breath waiting for reform, since tort lawyers are huge political contributors.   (Jackson Release)

In a shocking development, the trade association for medical device manufacturers, AdvaMed, has acknowledged that medical device prices have risen rapidly and are a contributor to runaway health spending.  Oh, never mind, that’s not what the study said; it claims that medical device prices have been very stable and are actually quite low.   We hate to be cynics (not really) but these kinds of industry reports might have more credibility if they showed real transparency and, for example, described gross and net margins for devices, which we know from public company reports are amazingly high.  Device manufacturers have unfortunately also often followed the path of drug companies and encouraged inappropriate use of their products.  The study claims that from 1989 to 2009 medical device prices increased at an average annual rate of only 1%.  Unfortunately the methodology is particularly non-real worldy, with dubious sources and no description of weighting for example.  What would have been useful is to see what consumers and payers actually paid for medical devices over time.  We have a feeling those prices have been going up at more than 1% a year.   (AdvaMed Study)

The ehealth Initiative released some information from its recent survey of health information exchanges, which are a core part of the great plan to have everyone’s health information zipping around to providers and payers.  The survey covers 255 HIEs in various stages of development and operation.  Many have solved some technical issues, primarily around ensuring interoperability, but most perceive they continue to have a lot of technology challenges.  Building a sustainable revenue model is a major issue, as is coming to grips with privacy and security concerns.  A core value HIEs will need to offer to sustain provider interest is helping with meaningful use requirements.  The overall picture appears to be one of very inconsistent development and a real patchwork of HIEs as opposed to a truly national network.   (HIE Survey)

A little noticed CMS release could have a big impact on drug pricing.  Evaluating reimbursement for Medicaid and Medicare has been difficult, especially since AWP became discredited.  It is very hard to ascertain what retail or mail pharmacies actually pay for the drugs they dispense to consumers and what consumers, especially self-pay patients, pay for their drugs.  CMS has hired a vendor to develop  a database and ultimately a monthly survey of retail pharmacy prices, which can be used by Medicaid and other payers, and more importantly, a database of the actual ingredient acquisition cost for those pharmacies.  This would facilitate an emerging move, at least by some Medicaid programs, to pay on the basis of acquisition cost.  Good luck figuring out what that really is after discounts, rebates, etc., but any information would create more transparency and could impact both pharmacy and drug company revenues as payers start to whittle away at pricing.   (CMS Release)

A study in the Annals of Internal Medicine discusses an esoteric aspect of health research–metabias, and in particular bias resulting from inclusion of single versus multi-center trials.  You want to be able to believe that the results from clinical trials and other research reflect real-world experience, but there are variety of sources of potential error or bias in all research.  Understanding the potential sources of bias allows for correcting designs of future research and to some extent, compensating for them in interpreting results.   This study found that single-center randomized clinical trials consistently showed greater treatment effects than did multi-center ones, meaning that results from such trials should be viewed more cautiously.     (Annals Article)