2012 Potpourri III

An article in Health Affairs finds that cost controls implemented by Medicaid programs to limit inappropriate and expensive use of second-generation antipsychotics actually led to use of all such medicines.  The authors studied utilization management strategies used in thirty states between 1999 and 2008.  The strategies included step therapy, quantity limits and prior authorization.  The states with these limits, especially prior authorization, had a 14% rise in use of second-generation antipsychotics versus 19% in states that didn’t use such methods.  In addition, overall dispensing of antipyschotics was down.  This might reflect quality issues, so the authors suggest further research to examine outcomes.    (HA Article)

The latest American Hospital Association fact sheet on uncompensated care suggests that in 2010 the cost was $39.3 billion, up very slightly from 2009, and was 5.8% of overall expenses, down slightly from 6.0% in 2009.  The number has waivered around that 6% level for almost two decades, so while the absolute amount is growing, it doesn’t appear that the overall burden of such care on hospitals is increasing.  Uncompensated care consists of both charity care and bad debt.  Since many hospitals, especially not-for-profit hospitals, make very good profits and pay high management salaries, it doesn’t really seem like an undue burden.     (AHA Fact Sheet)

Telemedicine has great promise for improving quality and lowering costs.  A study in the Archives of Dermatology examined outcomes for 1500 patients who were evaluated by interactive teledermatology at an academic medical center.  The teledermatology consults resulted in changes in diagnosis in 70% of patients and in management of their care in 98%.   More than 68% of the patients who had more than one teledermatology visit showed clinical improvement.  The study strongly suggests the value of having access to specialty expertise.   (Derm. Study)

Another Health Affairs article examines the effect of cuts in reimbursement for an osteoporosis test.   The test, dual energy x-ray absorptiometry of the central skelton, is considered the gold standard, but is expensive.  So Medicare decided to make it less so, at least for Medicare, and by 2010 had reduced payments by 56% compared to 2007.  But testing use also dropped dramatically, which the authors suggest led to around 12,000 fractures that might have prevented from diagnosis and treatment.  Congress has provided temporary relief from the cuts, which the authors suggest should be extended.   (HA Article)

An article in the Annals of Family Medicine looks at the association between a person’s primary care and their mortality risk, testing the hypothesis that better access to primary care leads to reduced overall mortality.  The authors looked at Medicare Expenditure Panel Survey data from 2000-05 for people aged 18 to 90.  These people self-reported characteristics of their primary care and the researchers created a score related to the primary care attributes and linked that to the likelihood of death.    As expected, those persons who reported access to primary care with a higher score had a lower likelihood of mortality.    (Annals Article)

A Viewpoint in the Journal of the American Medical Association looks at where the cost savings can come from in the US health system.  As the commentary notes, the US is spending $2.6 trillion on health care, growing at a rate faster than GDP or inflation, and it is not likely that all that money is well-spent.  The reform law targets a number of areas for cost-savings.  The author suggests that $52 billion a year in reductions is needed just to keep health spending in line with GDP growth, so any proposal which doesn’t amount to at least that much isn’t worth considering.  The author rejects malpractice reform, limiting insurance company profits, increasing drug re-importation or generic use and stopping spending on expensive premies on these grounds, even though collectively the savings are pretty good.  The author suggest focusing on the high-cost, chronic disease patients.  Duh.   (JAMA Article)