The Price of a Scar

October 17, 2014

CHW LogoIf we needed any more evidence that yes, cost matters to patients and families, a new study from Annals of Surgery should be a wake-up call.  Researchers from Primary Children’s Hospital in Utah approached the families of 100 children about to undergo surgery for acute appendicitis.  They were offered 2 options: the open procedure, or laparoscopic surgery.  Based on published evidence, they were told that the complication rates were similar, but that open appendectomy would result in a larger scar.  One half of the families were only given this clinical outcome information.  But the other half were also given information on the charges of the two different procedures: $2172 less for the open procedure.

We pediatric providers have long assumed that, when it comes to their children particularly for something serious or with potential lasting consequences, parents would always pick what was best.  Cost would be no object.  Well guess again.  In this study, among families not shown the charge information 35% of the time, while those who were aware of the charges chose the less expensive, bigger scar option 63% of the time.  Interestingly, this difference was independent of insurance type, deductible, or income.

I’m not suggesting that parents will take their kids to Walgreens for a heart transplant, or that many parents wouldn’t make extraordinary efforts to get what they think is best for their child.  But this study demonstrates that cost is a major factor.  When told the cost, they are willing to trade off some significant possible negatives – in this case, a larger permanent scar.  As one familiar member said, “Cost saving measures are a priority for me when it does not impact the safety of the patient.”  And this is an acute, potentially life-threatening condition, where the parents may weigh cost less due to the pressure of making a decision without time to really consider the alternatives or “comparison shop.”  Imagine how this might look for something completely elective like ear tubes.

A few important caveats.  First, the surgeons in this study could convincingly claim the complications would be expected to be similar because it would be the same team – surgeons, anesthesiologists, nurses, etc. – doing either procedure.  In the real world, parents need to choose between more dissimilar alternatives, such as a specialized children’s center with a full complement of sub-specialists vs. a lower volume community hospital with non-pediatric providers.  Second, parents were provided with the full cost of having the appendectomy: a bundled price for everything.  In reality, most people have a hard enough time finding out the price of each item or service used.  The move to price transparency can only work if hospitals and providers can show what the total cost to the family will be.  For example, our hospital has a reputation for being expensive, based on the price of some of our services.  But analyzing data reported to the state of Wisconsin, I was able to show that for children in the Milwaukee area, the least expensive average charge for an emergency department visit was at Children’s Hospital of Wisconsin!  I didn’t have the data to figure out why, but a very reasonable hypothesis based on other research on differences between general and pediatric EDs is that we do less testing and treatment than at other hospitals because of our greater expertise in dealing with children.  (I have long held that the key to being an excellent pediatric emergency physician is as much in knowing what not to do as what to do.)  Even if Children’s charges more (and I don’t know if this is actually true) for a CT scan of the head, a parent wanting to know the cost needs to understand that their child is far less likely to get one unnecessarily in our ED.

It’s all back to the value proposition.  People paying for health care – and increasingly that is families themselves – want a good outcome and good experience at a reasonable cost.  If we want to attract children to our hospital – and kids do deserve the best – we need to be able to demonstrate all parts of that value equation.  And what this Annals of Surgery study shows is that we can’t assume we know what parents will value.  Many of us would pay more for the smaller scar.  But what matters isn’t what we would do.  We can provide information, we can provide guidance; only the family can decide.


Common Ground  

October 14, 2014

CHW LogoFarmers vs. ranchers.  Jets vs. Sharks.  Arabs vs. Israelis.  Bourgeoisie vs. proletariat.  Packer fans vs. Viking fans.  Examples of seemingly unbridgeable gulfs abound in literature and life.  It’s sometimes difficult to picture these groups even talking to each other, much less connecting.  In the 1990s, books like Men Are From Mars, Women Are From Venus, and You Just Don’t Understand, popularized the notion that, because men and women see and process the world so differently, it creates inherent barriers to effective communication.  While criticized in some circles for over-generalization and stereotyping, the research behind these books supports the idea that differences in life experience can undermine meaningful dialogue and relationship-building between people.

New evidence shows that this is particularly true about class background.  In a series of studies, Stephanie Cote and Michael Kraus showed that interaction between people of different socioeconomic status were marked by verbal and non-verbal indications of lower degrees of engagement and emotional connection.

Think about the implications.  Many in the healthcare professions are at least in the middle class, while a large number of our patients and families are significantly less advantaged.  Does this interfere with our ability to bond with them, to empathize?  At times we have to admit it does.  Who hasn’t heard (and at times made) disparaging comments about “frequent flyers,” patients who are “non-compliant,” folks abusing the system?  This happens all too often.  Yet by and large, even those of us near the top of the economic ladder show amazing cognitive and emotional connection to those we care for.  How do we do it?

The answer, I think, comes from some of the same studies.  When participants were asked to interact with others of different background, their engagement and connectedness increased when they were first asked to identify points of commonality.  We see this when people of widely varying status come together in fellowship in places of worship (shared faith), or sports leagues or clubs (shared interests), or life-threatening emergencies (shared mortality and fate).  For us, I believe it is the kids, our value of purpose.  We caregivers and providers on the one hand, and families on the other, share an interest first and foremost in the child.  It’s when we forget that commonality that we fail to make a real connection, moving from curious to judgmental.

One of my favorite books, The Lemon Tree, tells the story of a Palestinian and an Israeli who bond over a shared love of a piece of property.  It shouldn’t be hard for each of us to try to find that one piece of common ground when we deal with families or colleagues who may be from such different circumstances that connecting is a challenge.  Even Packer and Viking fans can agree about the Bears.


Rolling Right Along

October 3, 2014

CHW LogoThe results are in, and Wisconsin is the winner! The 2014 National Bike Challenge just ended, and our state edged out last year’s winner, Nebraska, with over 7800 participants (including 40 from Children’s Hospital!) pedaling 3.9 million miles, of which 70% were for recreation and 30% were for transport.  That’s 1.3 million miles of commuting and errands that might otherwise have required a car.  In Wisconsin alone, we kept 3.6 million pounds of carbon dioxide out of the atmosphere.

The environmental impact is one of many reasons I and others choose to try to get around as much as possible on two wheels.  Much of the year it’s just nice to be outside, and it can be a really relaxing way to unwind at the end of the day.  Of course, it’s also a good way to get in some exercise while also doing something useful (spoken like a true multi-tasker).  The Wisconsin contingent burned a collective 213 million calories cycling during the five months of the challenge.  Just think of all the deep fried cheese curds we could eat afterward….

People are catching on.  I’ve noticed the bike racks here at the hospital getting more and more full.  Nationally, miles driven are down, and the number of people bicycling to work increased in 85 of the 100 largest metro areas between 2000 and 2010.  According to the Guardian, not only are individual workers recognizing the benefits and switching, but businesses are finding that promoting cycling actually improves their bottom line.  Businesses with access to protected bike lanes (such as you find everywhere in Denmark and the Netherlands) have higher sales per parking spot (car vs. bike); real estate values are higher; and workers are healthier.

Some recent local developments could make the picture even brighter for cyclists.  The city of Milwaukee has been adding bike lanes, and Wauwatosa, as part of a comprehensive cycling and pedestrian plan, is adding high-visibility green bike lanes to North Ave.  And we are finally catching up, albeit slowly, with the bike-sharing trend in many cities.  Bublr, a Milwaukee bike share start-up, currently has 10 stations around the city, with plans to increase that to 100.  (Several locations on the Milwaukee Regional Medical Center campus and in the village of Wauwatosa are being considered.)

Yes, I know winter will be here before we know it (or want it), but there’s still plenty of fall days left.  (And don’t rule out winter commuting.)  Give it a try.  We don’t want those Cornhuskers to catch us.


What’s the Value of Trainees?  

September 29, 2014

CHW LogoThere are two especially awkward phases of life for most physicians: adolescence and residency.  Both are sort of in-between states, where you are not quite what you left behind but not yet fully what you are moving toward.  Is a resident a learner or a worker?  Depends on who you ask, and the answer has changed over time.  For example, when I was a resident we belonged to a union (!) – the Committee of Interns and Residents (CIR).  Except the CIR wasn’t a true union, because we were considered students rather than employees, and therefore not able to unionize.  At the same time, we were able to continue to defer payments on student loans because we were still “in school.”  Since then, the National Labor Relations Board has ruled that residents are actually employees and therefore entitled to organize (the CIR is now affiliated with the SEIU), while the IRS has ruled similarly, and residents must begin making student loan payments.  Win some, lose some.

The uncertainty carries over to the issue of federal funding for graduate medical education.  Currently Medicare, Medicaid, Veteran’s Affairs, and the states pay approximately $16 billion annually to hospitals to offset the cost of having residents and fellows.  Part of that covers the salaries and benefits of the trainees (direct GME), while the majority offsets the additional costs associated with medical training (indirect GME), such as lower productivity for supervising physicians, additional testing ordered by trainees, etc.  (I should note that this generally does not include pediatric residents and fellows, as children’s hospitals do not treat Medicare patients.  A separate, much smaller [$265 million] stream of Children’s Hospital GME funding is available, but unlike the Medicare money, it must be approved annually during the budget process.)

The rationale for this funding is that the training of physicians benefits society.  Teaching hospitals would have no financial incentive to train physicians who can, after all, go work anywhere when they are done.  Therefore, government should help pay for ensuring a supply of trained medical professionals.

Buried in a recent Institute of Medicine report on the state of graduate medical education, a small but notable group of health economists questioned that rationale.  They argue that residents provide a greater economic benefit to their hospitals than the salaries they receive; therefore, government GME funding is simply a subsidy of those hospitals.  The fact that most hospitals actually have more residents than they get funding for (the number was capped in the 1990s) is evidence that the hospitals must see them as a good investment.

If true, this might argue for using that $16 billion for other purposes, as those economists urge.  However, as I’ve already indicated, it’s not all that clear cut.  It is true that residents provide work that is of benefit to the hospitals that employ them as well as to the attending physician staff.  But much of this work takes the form of documenting and performing other tasks that can be – and in non-teaching hospitals, is – done by nurses or advanced practice providers.  And it isn’t clear that the work done by a resident provides more value than what could be done by these others, as the economists imply.  For one thing, residents rotate to different areas of the hospital each month, and often between hospitals.  There is a constant learning curve that in most cases sharply limits the benefit of the work compared with what you would get with a stable staff.  Moreover, the ratio of useful work increases with years of residency, but once residents enter their last (and most “productive”) year of training and really hit their stride, they leave.  In simple economic terms, most hospitals would actually be better off hiring non-residents for those tasks.

I do believe there is a unique value to a hospital of having physicians-in-training.  It’s not, as these economists argue, cheap labor.  Rather, it takes the form of the academic, intellectually challenging and stimulating environment that residents create.  It’s part of the reason I and many of my colleagues have always wanted to be at a teaching hospital.  That, however, is difficult to quantify.  In the current health care environment, with ever greater economic pressure, hospitals may be less willing to invest in such an intangible benefit without the GME funding.

Also, while it may be partly coincidental, teaching hospitals tend to be the care provider of last resort in a community.  The mission of caring for everyone regardless of ability to pay tends to go hand in hand with the education mission.  Part of the indirect cost of a teaching program is the large percentage of patients for whom the actual costs of care are not covered (Medicare, Medicaid, uninsured).  Yes, it’s a subsidy, but not for the bottom line of the hospital.  It’s a subsidy of the safety net we provide, masked as a subsidy for training future physicians.

There are certainly improvements we can make in the way GME is paid for.  For example, the program could do a better job of prioritizing undersupplied primary care fields (including pediatrics).  But arguing that GME funding is a form of corporate welfare for hospitals, and that the costs of training residents should be left to the marketplace, is not going to get us more of the right kinds of doctors, or better care for patients.


Picture This

September 22, 2014

CHW LogoA neurosurgeon, a minister, and a nurse walk into a bar…. (There’s no punch line, though I invite suggestions for a good joke.)  I’m willing to bet that in picturing the scenario the vast majority of you imagined two men and a woman.  I’d even go so far as to say that the woman was the nurse.  It’s an example of how our thinking is influenced by our most recent experiences.  If you work at Children’s Hospital of Wisconsin, the last nurse you met was very likely female, and the last neurosurgeon was certainly a male.  It is what is referred to in the psychology of decision making as the “availability heuristic”: when we make judgments without complete information, we tend to refer to our most recent experiences, relying on the information we have available by easy recall to fill in for the information that is missing.  (A heuristic is a mental shortcut – there are many types, this being just one.)  Not knowing the sex of the characters, I draw on the most recent prior information I have about the sex of a neurosurgeon or a nurse.

Short cuts like this evolved as a way for our minds to function more efficiently.  When asked “Think of a common man’s name that starts with P,” it is far easier for me to conjure up the last man with that name that I interacted with (Peter) than to call up in my mind the complete list of men’s names beginning with P (Paul, Philip, Patrick, Pedro, Pradeep, etc.) and thinking about how many people have each of them.  In many circumstances, the availability heuristic works well and allows us to act on incomplete information.

You could argue that it’s simply a matter of playing the odds.  In the US, the majority of neurosurgeons and ministers are men, and the majority of nurses are women.  But research shows that we actually are not all that good at thinking statistically, and that playing the odds is often trumped by recent experience.  When recent experience is not representative of reality, this mental shortcut leads to bias.  For example, we recently had a patient in the ED who had just arrived from Liberia with high fever and upper respiratory symptoms.  Which is the most likely diagnosis: a) malaria, b) a cold, c) Ebola?  If Ebola even crossed your mind then you are displaying the availability bias; a cold is several orders of magnitude more likely based on actual prevalence.

Non-representative recent experience can steer us wrong in many ways.  It’s a common problem in medical diagnostic decision making, especially among non-experts.  I remember as a fellow seeing a teen with severe abdominal pain, to the point that he was irrational.  I had recently read about acute intermittent porphyria, which can cause abdominal pain and altered mental status, and promptly ordered a urine porphobilinogen level to test for it.  Never mind that it has an incidence of around 1 in 50,000.  Not only was I wrong, it delayed me from treating his pain and making the actual diagnosis (kidney stone, incidence about 1 in 10, though less common in teens).  I suspect the availability bias explains a good deal of the higher cost of care provided by medical trainees.  The first time a resident sees someone with a rare illness, they start to evaluate more patients for that problem.  It’s also a culprit in driving some utilization by patients.  When the media run sensational reports about uncommon conditions, people overestimate their risk and often seek unnecessary medical care.

The availability heuristic also leads to broader bias in society.  For instance, young blacks are arrested for marijuana possession at much higher rates than young whites, despite having a similar frequency of drug use.  Blacks thus have higher rates of incarceration, and news stories about drug arrests are much more likely to feature African-Americans.  As a result, people (both blacks and whites) overestimate the proportion of criminals that are black.  In one study, 60% of viewers of a crime story without a picture of the suspect falsely recalled seeing one, and 70% believed that the suspect was African-American.  After all, the last news story they saw about crime was likely to have featured a black suspect: availability bias.  Similarly, low income individuals are more likely to be prosecuted for child abuse, leading us to believe – incorrectly – that those who are more well off are unlikely to maltreat their children, and potentially missing an opportunity to intervene when necessary.

There are many examples of how our use of this mental shortcut can lead us not only to misrepresent how common or uncommon something is across a group, but also to misapply the most readily recalled information about groups to individuals.  Even when the most recent image is truly representative (e.g., most nurses at Children’s are female), it may not apply to a given individual.  (Just ask any of the 3 male nurses I worked with in the ED yesterday!)

The availability heuristic is just one of the filters we all see the world through.  Like other filters, it’s not necessarily either good or bad, but it is something to be aware of.  When we make a snap judgment without having all the information, we need to be aware that we are overly influenced by our most recent experience and by the way things are portrayed – correctly or not – in society at large, and be willing to reshape our initial image as we get more information.  And while some people cry “political correctness” when we use gender-neutral language or multiracial images, a non-biased environment is an important way to make our mental images more accurate.  I know more than a few women neurosurgeons, female ministers, and male nurses who would appreciate it.


Relax, This Won’t Hurt

September 12, 2014

CHW LogoI’m overdue for one of the rituals of middle age in 21st century America: the screening colonoscopy.  Now this may have been a rationalization, but just after my doctor referred me for one, I changed employers, and therefore insurance plans (moving into a high-deductible plan), so I needed to see what the coverage would be.  Of course, it’s taken me 2 years to do it.  Can’t read the fine print too carefully, I always say.

Turns out, I’m not atypical.  A study in Medical Care looked at people who were switched from an HMO to a high-deductible health plan (HDHP).  Compared with those who stayed in the HMO, people in the HDHP tended to use fewer low acuity services (such as non-urgent ER visits).  Interestingly, women had similar rates of use for medium- to-high acuity services, while men reduced their use across all levels of acuity.  It appears that women are better health consumers than men, wisely saving resources for services that are more necessary.  Men are either just cheap, or looking for an excuse not to go to the doctor.

There are many myths and uncertainties surrounding HDHPs.  More and more Americans are enrolled in them – including an increasing share of employees at Children’s Hospital of Wisconsin – so it’s worth addressing a couple of those.  First, preventive care (including, if it’s coded right by the provider, screening colonoscopies) is generally covered at 100% and not subject to cost-sharing.  So don’t skimp on the check-up and vaccines; you’ve already paid for them through your premium.  Second, research has shown that for most people, HDHPs lead to more rational use of health resources (that is, avoiding unnecessary treatment while preserving needed treatment), with no worse health outcomes compared with forms of insurance that do not require the patient to bear as much of the cost.  There is an important exception: the RAND Health Insurance Experiment showed that lower income people deferred both needed and unneeded care similarly, and had some worse health outcomes associated with that.  (And maybe stubborn men, as well.)  That said, making good choices requires some guidance.  It’s not necessarily easy for people without medical training to distinguish low-value services from those that are necessary.  A key principle is to ask questions.  Is a brand name drug necessary, or would a generic do?  Or what about no medication at all – would the condition get better on its own?  How will doing a diagnostic test change what the provider will recommend in terms of treatment?  There are many sources of information on line, many of which are of dubious quality.  A particularly reputable one is Choosing Wisely, where you can find recommendations from the leading medical professional organizations about services that are generally agreed to be low value.

When used well, high deductible plans are nothing to be afraid of, and may have the potential to decrease costs with as good or better outcomes.  I guess the same is true of colonoscopy….


It Takes a Village

September 5, 2014

CHW LogoMy older son spent the first year and a half of his life in Falls Church, VA.  Based on data from the Robert Wood Johnson Foundation, his life expectancy is 83 years. (Don’t worry, buddy – they go fast but you have plenty left.)  But if he had been born three Metro stops away, in Washington, DC, his life expectancy would be 7 years shorter.  The situation is even more striking in New Orleans, where the difference in life expectancy across the metro area is 25 years.  As an article in Health Affairs put it, Zip code is more important than genetic code when it comes to health.

It’s easy to write this off.  Different communities, different people.  While there are undoubtedly differences in population between neighborhoods – including racial and ethnic differences that may include a genetic component – the strongest association is with poverty.  Poor people have worse health regardless of their race or culture.  Moreover, a 2011 study published in the New England Journal of Medicine showed that when people who began in a poor neighborhood were randomly assigned to receive housing vouchers allowing them to relocate, those who moved to low-poverty areas subsequently had lower rates of obesity (19% lower) and diabetes (22% lower) than those who either stayed or moved to another high-poverty area.  It appears the real estate people are right: it’s all about location, location, location.

The exact factors about a neighborhood that lead to adverse health impacts are unclear.  Possibilities include: physical infrastructure (e.g., parks, sidewalks, safe streets) that allows and promotes physical activity; access to healthy food; low crime and attractive environment that decrease chronically elevated levels of stress hormones.

As an organization committed to making the children in Wisconsin the healthiest in the nation, Children’s Hospital recognizes that we can’t simply provide excellent health care.  We must partner to influence all the other determinants of a child’s health, including the state of their community.   A recent article in the New York Times highlighted a Philadelphia program of community health workers: individuals from target communities, hired by a health system and trained to work with other families in those communities to address health needs and connect with needed resources.  This is very similar to Children’s’ own community health navigator program in three neighborhoods in central Milwaukee.  Health Partners, an integrated health system in the Twin Cities, has adopted what it calls a “community business model,” whereby they invest in activities and partnerships that are designed to improve all of the modifiable determinants of health, not just medical care.

Kids on the near north side of Milwaukee deserve to have the same life expectancy as those in Wauwatosa.  To get there, it truly takes a village.


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