Abolishing Mammography Screening Programs? A View from the Swiss Medical Board
Nikola Biller-Andorno, M.D., Ph.D., and Peter Jüni, M.D.
April 16, 2014DOI: 10.1056/NEJMp1401875
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In January 2013, the Swiss Medical Board, an independent health technology assessment initiative under the auspices of the Conference of Health Ministers of the Swiss Cantons, the Swiss Medical Association, and the Swiss Academy of Medical Sciences, was mandated to prepare a review of mammography screening. The two of us, a medical ethicist and a clinical epidemiologist, were members of the expert panel that appraised the evidence and its implications. The other members were a clinical pharmacologist, an oncologic surgeon, a nurse scientist, a lawyer, and a health economist. As we embarked on the project, we were aware of the controversies that have surrounded mammography screening for the past 10 to 15 years. When we reviewed the available evidence and contemplated its implications in detail, however, we became increasingly concerned.
First, we noticed that the ongoing debate was based on a series of reanalyses of the same, predominantly outdated trials. The first trial started more than 50 years ago in New York City and the last trial in 1991 in the United Kingdom.1 None of these trials were initiated in the era of modern breast-cancer treatment, which has dramatically improved the prognosis of women with breast cancer. Could the modest benefit of mammography screening in terms of breast-cancer mortality that was shown in trials initiated between 1963 and 1991 still be detected in a trial conducted today?
Second, we were struck by how nonobvious it was that the benefits of mammography screening outweighed the harms. The relative risk reduction of approximately 20% in breast-cancer mortality associated with mammography that is currently described by most expert panels2 came at the price of a considerable diagnostic cascade, with repeat mammography, subsequent biopsies, and overdiagnosis of breast cancers — cancers that would never have become clinically apparent. The recently published extended follow-up of the Canadian National Breast Screening Study is likely to provide reliable estimates of the extent of overdiagnosis. After 25 years of follow-up, it found that 106 of 484 screen-detected cancers (21.9%) were overdiagnosed.3 This means that 106 of the 44,925 healthy women in the screening group were diagnosed with and treated for breast cancer unnecessarily, which resulted in needless surgical interventions, radiotherapy, chemotherapy, or some combination of these therapies. In addition, a Cochrane review of 10 trials involving more than 600,000 women showed there was no evidence suggesting an effect of mammography screening on overall mortality.1 In the best case, the small reduction in breast-cancer deaths was attenuated by deaths from other causes. In the worst case, the reduction was canceled out by deaths caused by coexisting conditions or by the harms of screening and associated overtreatment. Did the available evidence, taken together, indicate that mammography screening indeed benefits women?
Third, we were disconcerted by the pronounced discrepancy between women’s perceptions of the benefits of mammography screening and the benefits to be expected in reality. The figureU.S. Women’s Perceptions of the Effects of Mammography Screening on Breast-Cancer Mortality as Compared with the Actual Effects. shows the numbers of 50-year-old women in the United States expected to be alive, to die from breast cancer, or to die from other causes if they are invited to undergo regular mammography every 2 years over a 10-year period, as compared with women who do not undergo mammography. The numbers in Panel A are derived from a survey about U.S. women’s perceptions,4 in which 717 of 1003 women (71.5%) said they believed that mammography reduced the risk of breast-cancer deaths by at least half, and 723 women (72.1%) thought that at least 80 deaths would be prevented per 1000 women who were invited for screening. The numbers in Panel B reflect the most likely scenarios according to available trials1-3: a relative risk reduction of 20% and prevention of 1 breast-cancer death. The data for Switzerland, reported in the same study, show similarly overly optimistic expectations. How can women make an informed decision if they overestimate the benefit of mammography so grossly?
The Swiss Medical Board’s report was made public on February 2, 2014 (www.medical-board.ch). It acknowledged that systematic mammography screening might prevent about one death attributed to breast cancer for every 1000 women screened, even though there was no evidence to suggest that overall mortality was affected. At the same time, it emphasized the harm — in particular, false positive test results and the risk of overdiagnosis. For every breast-cancer death prevented in U.S. women over a 10-year course of annual screening beginning at 50 years of age, 490 to 670 women are likely to have a false positive mammogram with repeat examination; 70 to 100, an unnecessary biopsy; and 3 to 14, an overdiagnosed breast cancer that would never have become clinically apparent.5 The board therefore recommended that no new systematic mammography screening programs be introduced and that a time limit be placed on existing programs. In addition, it stipulated that the quality of all forms of mammography screening should be evaluated and that clear and balanced information should be provided to women regarding the benefits and harms of screening.
The report caused an uproar and was emphatically rejected by a number of Swiss cancer experts and organizations, some of which called the conclusions “unethical.” One of the main arguments used against it was that it contradicted the global consensus of leading experts in the field — a criticism that made us appreciate our unprejudiced perspective resulting from our lack of exposure to past consensus-building efforts by specialists in breast-cancer screening. Another argument was that the report unsettled women, but we wonder how to avoid unsettling women, given the available evidence.
The Swiss Medical Board is nongovernmental, and its recommendations are not legally binding. Therefore, it is unclear whether the report will have any effect on the policies in our country. Although Switzerland is a small country, there are notable differences among regions, with the French- and Italian-speaking cantons being much more in favor of screening programs than the German-speaking cantons — a finding suggesting that cultural factors need to be taken into account. Eleven of the 26 Swiss cantons have systematic mammography screening programs for women 50 years of age or older; two of these programs were introduced only last year. One German-speaking canton, Uri, is reconsidering its decision to start a mammography screening program in light of the board’s recommendations. Participation in existing programs ranges from 30 to 60% — variation that can be partially explained by the coexistence of opportunistic screening offered by physicians in private practice. At least three quarters of all Swiss women 50 years of age or older have had a mammogram at least once in their life. Health insurers are required to cover mammography as part of systematic screening programs or within the framework of diagnostic workups of potential breast disease.
It is easy to promote mammography screening if the majority of women believe that it prevents or reduces the risk of getting breast cancer and saves many lives through early detection of aggressive tumors.4 We would be in favor of mammography screening if these beliefs were valid. Unfortunately, they are not, and we believe that women need to be told so. From an ethical perspective, a public health program that does not clearly produce more benefits than harms is hard to justify. Providing clear, unbiased information, promoting appropriate care, and preventing overdiagnosis and overtreatment would be a better choice.
The views expressed in this article are those of the authors and do not necessarily reflect those of all members of the expert panel of the Swiss Medical Board.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
This article was published on April 16, 2014, at NEJM.org.
SOURCE INFORMATION
From the Institute of Biomedical Ethics, University of Zurich, Zurich (N.B.-A.), and the Institute of Social and Preventive Medicine and Clinical Trials Unit Bern, Department of Clinical Research, University of Bern, Bern (P.J.) — both in Switzerland; and the Division of Medical Ethics, Department of Global Health and Social Medicine, Harvard Medical School, Boston (N.B.-A.). Dr. Biller-Andorno is a member of the expert panel of the Swiss Medical Board; Dr. Jüni was a member of the panel until August 30, 2013.
Thomas Frieden has a scary job. As director of the Centers for Disease Control and Prevention, he gets the call when infections begin defeating all known antibiotics, or Ebola resurfaces, or overdoses from prescription opiates begin skyrocketing.
Meanwhile, I’m the kind of person who won’t even go see movies about disease outbreaks. So when I sat down with Frieden recently, I asked him the question hypochondriacs need to know: What has all this data taught him to fear? What does he tell his family to do differently?
His answer was borderline dull:
Very little is different really. It’s basic. Wash your hands regularly. Get regular physical activity. Eat foods you love that are healthy. That’s one of the things that’s so challenging. Take physical activity as an example. You don’t have to have much, 30 minutes a day. Doing that, which can be three 10-minute walks, is going to make a huge difference in your life. You’ll feel better even if you don’t lose an ounce. You will be much less likely to have high blood pressure, high cholesterol, cancer, arthritis, depression. You’ll sleep better. And it doesn’t cost a cent.
There’s a lot a of things that can be done that are not very difficult and can make a really big difference. Of course, get your shots, get vaccination, get a flu shot every year and see the doctor regularly and if you have a problem make sure to get follow up.
The broader point — which came up again and again in our interview — is that the main threats to health aren’t spectacular. People die from heart disease, car accidents, and tobacco a lot more often than they’re killed by Ebola, terrorism, and heroin.
The CDC Director’s reply reminded me of Michael Pollan’s famous, commonsense triplet about diet: “Eat food. Not too much. Mostly plants.” I asked whether Frieden had similarly concise advice. He did.
“Eat right. Get physical activity. Don’t smoke. Alcohol in moderation. Spend time with friends.”
Unlike a lot of health treatments, weird diets, and fancy exercise regimes you’ll read about, this advice is backed up by reams of rock-solid evidence — and following it costs next to nothing.
So there it is: in less than 15 words, the US official who probably knows better than anyone else what might kill you explains how to protect yourself.
I created this conceptual infographic illustrating the increasing health benefits achievable with digital health with the great team at Misfit Wearables. You can download a high-resolution version by clicking on the image.
References:
Number of people sequenced
“250,000 human genomes will be fully sequenced by the end of 2012, 1 million by 2013, and 5 million by 2014″ -Topol, Eric (2011-12-02). The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care (p. 102). Perseus Books Group. Kindle Edition.
Also, compliments of Story of Digital Health strategic partner nuviun, there’s this interactive diagram of the digital health landscape…
PCMHs and ACOs are complementary approaches to improving care delivery. Medical homes require strong links to specialists and hospitals, while ACOs—which are accountable for the full continuum of health services—require a strong grounding in primary care. The authors suggest the following payment approaches to promote integration of PCMHs and ACOs:
ACO contracts could include dedicated payments to support enhanced primary care services.
ACOs could invest in PCMHs by hiring more primary care providers, expanding office hours, developing information technology and care coordination infrastructure, supporting coaching and learning collaboratives, and dedicating resources to urgent care.
ACOs could align physician performance and resource allocation to support PCMHs. For example, measures of care coordination and communication could be considered when assessing physician performance. Primary care physicians could be paid according to the size and complexity of their patient panels, and specialists could be given incentives to work with medical homes.
Structuring Payment to Medical Homes After the Affordable Care Act
April 7, 2014
Authors: Samuel T. Edwards, Melinda K. Abrams, Richard J. Baron, Robert A. Berenson, Eugene C. Rich, Gary E. Rosenthal, Meredith B. Rosenthal, and Bruce E. Landon Journal: Journal of General Internal Medicine, published online April 1, 2014 Contact: Bruce E. Landon, M.D., M.B.A., Harvard Medical School, landon@hcp.med.harvard.edu Summary Writers: Martha Hostetter Access to full article: View Article
The Issue
The patient-centered medical home (PCMH) model aims to transform primary care practice through the use of multidisciplinary teams and a shift from “reactive visit-based care to proactive population health management.” Currently, medical home providers are reimbursed with a blend of fee-for-service payments and additional compensation for services provided outside of office visits, including care coordination. Writing in the Journal of General Internal Medicine, Harvard Medical School’s Samuel T. Edwards, M.D., and colleagues consider how the PCMH payment model could evolve to keep pace with health care payment reforms launched by the Affordable Care Act, most notably the “shared savings” approach used by many accountable care organizations (ACOs).
What the Study Found
PCMHs and ACOs are complementary approaches to improving care delivery. Medical homes require strong links to specialists and hospitals, while ACOs—which are accountable for the full continuum of health services—require a strong grounding in primary care. The authors suggest the following payment approaches to promote integration of PCMHs and ACOs:
ACO contracts could include dedicated payments to support enhanced primary care services.
ACOs could invest in PCMHs by hiring more primary care providers, expanding office hours, developing information technology and care coordination infrastructure, supporting coaching and learning collaboratives, and dedicating resources to urgent care.
ACOs could align physician performance and resource allocation to support PCMHs. For example, measures of care coordination and communication could be considered when assessing physician performance. Primary care physicians could be paid according to the size and complexity of their patient panels, and specialists could be given incentives to work with medical homes.
Conclusions
As a promising model of care delivery, the PCMH “can serve as a lynchpin of ACOs,” the authors say. For their part, ACOs will need to support this model within their organizations.
Citation
S. T. Edwards, M. K. Abrams, R. J. Baron et al., “Structuring Payment to Medical Homes After the Affordable Care Act,” Journal of General Internal Medicine, published online April 1, 2014.
Authors: Jeph Herrin, Justin St. Andre, Kevin Kenward, Maulik S. Joshi, Anne-Marie J. Audet, and Stephen C. Hines Journal: Health Services Research, published online April 9, 2014 Contact: Jeph Herrin, Ph.D., Division of Cardiology, Yale University School of Medicine, jeph.herrin@yale.edu Summary Writers: Deborah Lorber Access to full article: View Article
“The current readmission reduction program that aims to penalize hospitals whose readmissions are above a certain threshold may not be appropriate.”
Synopsis
A majority of the variation seen in U.S. hospitals’ readmission rates for heart attack, heart failure, and pneumonia can be attributed to hospitals’ location, rather than to the quality of care provided in individual hospitals. Community factors most strongly associated with lower hospital readmission rates include more general practitioners and fewer specialists per capita and the presence of high-quality nursing home care.
The Issue
Readmission to the hospital shortly after discharge has been recognized as an indicator of poor health system coordination. Since 2009, the Centers for Medicare and Medicaid Services has been publicly reporting 30-day readmission rates for heart attack, heart failure, and pneumonia. And in 2013, Medicare began linking payments to hospitals to how well they perform on these measures, leading hospitals to focus on improving their rates. Previous studies have looked for relationships between readmission rates and hospital characteristics, like size or teaching status, or patient-level factors, like race or health literacy. This article, supported by The Commonwealth Fund, looks at the association between readmission rates and local community characteristics.
Key Findings
Almost 60 percent of the variation in U.S. hospital readmission rates can be explained by the county where a hospital is located. Individual hospital performance accounts for only two-fifths of the variation for the three conditions examined.
Having high percentages of residents who are Medicare beneficiaries, are unemployed, or have never been married is associated with higher hospital readmission rates. However, an area’s designation as a “retirement destination” was associated with lower rates—a possible reflection of higher socioeconomic status among the Medicare population and a community geared toward caring for older people.
Higher numbers of general practitioners per capita were associated with lower readmission rates, while higher numbers of specialists were associated with higher readmission rates.
In counties where nursing home quality was higher (as measured by multiple indicators), readmissions were lower.
Addressing the Problem
If community factors explain a substantial amount of the variation in hospital readmission rates, then programs that penalize hospitals with readmission rates above a certain threshold may not be appropriate, the authors say. Other initiatives might be more effective, such as the Affordable Care Act’s Community-Based Care Transitions Program, which allows community-based organizations to receive a bundled payment that covers the costs of services needed to help patients transition from hospital to home.
About the Study
The authors examined all hospitals with publicly reported 30-day readmission rates for patients with acute myocardial infarction, heart failure, or pneumonia who were discharged between July 1, 2007, and June 30, 2010. Readmissions data were then linked with publicly available county data from the Area Resource File, the U.S. Census, Nursing Home Compare, and the Neilsen PopFacts data set. The final sample included 4,073 hospitals.
The Bottom Line
Population characteristics at the county level explain a large portion of the variation in hospital readmission rates for certain major medical conditions. Instead of strictly penalizing hospitals for exceeding certain thresholds, policymakers should focus on programs that help patients transition from hospital to home.
Citation
J. Herrin, J. St. Andre, K. Kenward et al., “Community Factors and Hospital Readmission Rates,” Health Services Research, published online April 9, 2014.
“Whenever you put information out there, creativity and innovation flourish,” she said. “This is going to be such a giant leap forward in terms of what we’re doing in health care today, what works, what doesn’t work and what it should cost.” But for that to happen “there needs to be some “pretty powerful computing and some savvy tech gurus to help slice and dice this information in meaningful ways for consumers”
New York is sponsoring a contest — the Health Innovation Challenge — that asks the tech-savvy, including coders and developers, to put health data to use keeping costs down, increasing quality and improving efficiency. Winners receive cash, and their ideas will be put to work in the state government.
Shah said releasing the data — and allowing researchers, entrepreneurs and consumers to dig into it — could “democratize” health care in a way that has already happened with the way people buy cars or plane tickets: It will allow them to compare cost and quality.
Instead of making decisions based on quality, people tend to pick their providers based on where their doctor recommends they should go, and that might mean where she did her residency or a specialist whom she plays golf with, he said. New data may allow people to comparison shop for medical care.
While Shah acknowledged a “special” relationship between a patient and a doctor that includes treatment plans and communication in ways that won’t be picked up in data, a colonoscopy should be the same everywhere.
Rather than taking doctors’ recommendations, entrepreneurs will take data, repackage it and show people which hospitals have the longest average stays, which charge the most for a procedure, and which have the highest infection rates.
“Often, we find that high quality equals lower costs,” he said. That’s because the most cost-effective procedures tend to be the ones where patients receive proper medications, do not have to be treated for hospital-based infections, and where providers work as a team to make sure quality measures are met.
As more people — or their employers — choose low-premium, high-deductible plans, the cost of a knee surgery or an imaging scan becomes more important to the consumer than when insurance covered everything.
WASHINGTON — As the government moves toward more medical “transparency” by releasing a slew of new data— including Medicare provider payment data last week — entrepreneurs are creating new products to help consumers use the data to choose quality, lower-cost care.
Beyond the profit motive, some entrepreneurs hope to use the data to keep costs down on new medical products they create, help the government suss out fraud or unusual activity, and to persuade doctors to use the best practices gathered from their peers — something that was difficult to do when pricing information was not available.
“I think this data transparency is one of the major keys to transformation of the entire health care system,” said Robert Grajewski, president of Edison Nation Medical, a group that works to remove barriers for getting medical devices to the market. “In health care, it’s very confusing to know what the pricing is, not just for the device, but for the overall procedure. This helps us have a benchmark that needs to be achieved or overcome to improve care and overcome costs.”
The provider payment data released by the Centers for Medicare & Medicaid Services has Grajewski looking at why prices are higher for one doctor over another, why a doctor might choose a brand name over a generic medication, and why a doctor might choose surgery over physical therapy. The data became available after a court order lifted an injunction sought by the American Medical Association had been in place since 1979.
Grajewski isn’t the only one. Mercom Capital Group released a report Monday that found venture capital funding for health care information technology hit $858 million in the first quarter of this year. That includes $398 million in 103 new deals for consumer-focused technology, such as mobile apps.
“We’ve been tracking these numbers since 2010, and this quarter was the biggest number ever,” said Raj Prabhu, Mercom’s CEO. “$858 million is a huge number — in 2010, I don’t think we saw $200 million.”
Much of the momentum is coming from inventors who hope to create shopping applications that allow consumers to compare prices and outcomes on their smart devices. These include apps such as GoodRX, which allows consumers to compare medication prices at different pharmacies; NerdWallet Health, which allows people to compare hospital prices by locations; and an app from Consumer Reports that lets people compare prices for hip and knee replacements.
“Ever since the government started releasing data, this has been great for these kinds of companies to turn into useful applications,” Prabhu said.
“Every person is a health care consumer,” he said. “It’s so massive — nobody wants to miss the boat.”
Ceci Connolly, managing director of PWC’s Health Research Institute, said she expects the data to ultimately help the health care industry itself.
“Whenever you put information out there, creativity and innovation flourish,” she said. “This is going to be such a giant leap forward in terms of what we’re doing in health care today, what works, what doesn’t work and what it should cost.”
But for that to happen, there needs to be some “pretty powerful computing and some savvy tech gurus to help slice and dice this information in meaningful ways for consumers,” she said. Someone could use the CMS data to look at trends in hip surgeries: Is it much higher for one hospital than at others? A consumer might reconsider whether he actually needs surgery from a particular doctor. Or are there relatively few hip surgeries at the local hospital? The consumer might consider going to a doctor who performs a lot of hip surgeries.
Someone else might take the CMS data and compare it to CMS’s Five-Star Quality Rating System data, Connolly said.
“The whole promise of big data is not just any one data set, but it’s the way you can bring them together and analyze them across many,” she said.
New York is sponsoring a contest — the Health Innovation Challenge — that asks the tech-savvy, including coders and developers, to put health data to use keeping costs down, increasing quality and improving efficiency. Winners receive cash, and their ideas will be put to work in the state government.
It comes after the launch of the state’s transparency project, Open.NY.gov, which features data that state agencies have been ordered to catalog for the public.
“For a long time, the medical establishment has talked about patient-centered care,” New York State Department of Health Commissioner Nirav R. Shah. “But largely, it’s still been about hospital-centered care, doctor-centered care.”
Shah said releasing the data — and allowing researchers, entrepreneurs and consumers to dig into it — could “democratize” health care in a way that has already happened with the way people buy cars or plane tickets: It will allow them to compare cost and quality.
Instead of making decisions based on quality, people tend to pick their providers based on where their doctor recommends they should go, and that might mean where she did her residency or a specialist whom she plays golf with, he said. New data may allow people to comparison shop for medical care.
While Shah acknowledged a “special” relationship between a patient and a doctor that includes treatment plans and communication in ways that won’t be picked up in data, a colonoscopy should be the same everywhere.
Rather than taking doctors’ recommendations, entrepreneurs will take data, repackage it and show people which hospitals have the longest average stays, which charge the most for a procedure, and which have the highest infection rates.
“Often, we find that high quality equals lower costs,” he said. That’s because the most cost-effective procedures tend to be the ones where patients receive proper medications, do not have to be treated for hospital-based infections, and where providers work as a team to make sure quality measures are met.
As more people — or their employers — choose low-premium, high-deductible plans, the cost of a knee surgery or an imaging scan becomes more important to the consumer than when insurance covered everything.
An interesting observation – unintended consequence of non-universal healthcare?: As consumers are being asked to pay more, so they’re trying to become better health-care shoppers.
states have passed transparency laws
medicare has started to dump raw service cost data
private firms are developing their own transparency tools
a report recommends:
total estimated price
out-of-pocket costs
patient safety and clinical outcome data
“Care providers, employers and health plans have negotiated rates, which isn’t necessarily something they want out in the public. They warn making those negotiations publicly could actually discourage negotiations for lower prices — naturally, there are conflictingopinions on this point.”
Price transparency stinks in health care. Here’s how the industry wants to change that.
By Jason Millman Updated: April 16
There’s been much written in the past year about just how hard it is to get a simple price for a basic health-care procedure. The industry has heard the rumblings, and now it’s responding.
About two dozen industry stakeholders, including main lobbying groups for hospitals and health insurers, this morning are issuing new recommendations for how they can provide the cost of health-care services to patients.
The focus on health-care price transparency — discussed in Steven Brill’s 26,000-word opus on medical bills for Time last year — has intensified, not surprisingly, as people are picking up more of the tab for their health care. Employers are shifting more costs onto their workers, and many new health plans under Obamacare feature high out-of-pocket costs.
The health care-industry has some serious catching up to do on the transparency front. States have passed their own health price transparency laws, Medicare has started to dump raw data on the cost of services and what doctors get paid, and private firms have developed their own transparency tools.
“We need to own this as an industry. We need to step up,” said Joseph Fifer, president and CEO of the Healthcare Financial Management Association, who coordinated the group issuing the report this morning. The stakeholder group includes hospitals, consumer advocates, doctors and health systems.
Their recommendations delineate who in the health-care system should be responsible for providing pricing information and what kind of information to provide depending on a person’s insurance status. Just getting the different stakeholders on the same page was difficult enough in the past, said Rich Umbdenstock, president and CEO of the American Hospital Association.
“We couldn’t agree on whose role was what. We were using terms differently,” he said.
The report’s major recommendations include how to provide patients with:
the total estimated price of the service
a clear indication of whether the provider is in-network or where to find an in-network provider
a patient’s out-of-pocket costs
and other relevant information, like patient safety scores and clinical outcomes.
“I think that the focus now, unlike three years ago when it was on access, the focus is about affordability,” said Karen Ignagni, president and CEO of America’s Health Insurance Plans. “What are the prices being charged? It leads consumers to want to know, ‘How do I evaluate all that?'”
To give a sense of just how murky health pricing can be, one of the group’s recommendations is for providers to offer uninsured patients their estimated cost for a standard procedure and to make clear how complications could increase the price. You would think that shouldn’t be too hard — there’s no insurer to deal with, no contracts to consult.
But previous research points out just how difficult it can be to get the price for a basic, uncomplicated procedure. In a study published this past December, researchers found that just three out of 20 hospitals could say how much an uninsured person should expect to pay for a simple test measuring heartbeat rate.
The group’s recommendations also touches on limits to transparency and the “unintended consequences” of too much data being public. Care providers, employers and health plans have negotiated rates, which isn’t necessarily something they want out in the public. They warn making those negotiations publicly could actually discourage negotiations for lower prices — naturally, there are conflictingopinions on this point.
The report nods to other ways at achieving transparency. For example, it talks about “reference pricing” in self-funded employer health plans, in which employers limit what they’ll pay for an employee’s health-care services — thus setting the reference price.
“The employer communicates to employees a list of the providers who have agreed to accept the reference price (or less) for their services. If an employee chooses a provider who has not accepted the reference price, the employee is responsible for the amount the provider charges above the reference price,” the report reads, noting that Safeway grocery stores implemented a successful pilot program that expanded a few years ago.
Perhaps what’s most significant about these recommendations is the stakeholders’ acknowledgement that the health-care market is changing. Consumers are being asked to pay more, so they’re trying to become better health-care shoppers
AHIP’s Ignagni said most insurers already provide cost calculator tools and quality data on their Web sites. Providers, said the AHA’s Umbdenstock, need to be more accommodating to patients’ price-sensitivity.
“‘We can’t answer your question’ may have worked in the past, but it doesn’t fly any longer,” said Mark Rukavina, principal with Community Health Advisors and a report contributor. “This [report] basically lays out the principles for creating a new response to the question.”
Jason Millmancovers all things health policy, with a focus on Obamacare implementation. He previously covered health policy for Politico. He is an unapologetic fan of the New York Yankees and Giants, though the Nationals and Teddy Roosevelt hold a small place in his heart. He’s on Twitter.
