Via You Had One Job:
This is a hard question. And answers (explicit and implicit) vary. My JAMA Forum post elaborates.
Paying for value is all the rage in health care, and recently the spotlight has been brightest on prescription drugs. It’s hard to argue with the notion that how much we pay for a drug should be related to the value it provides. Hard to argue, that is, until you try to pin down whose value counts, what value means, or how much to pay for it.
Caution is advised. Research shows they aren’t very good.
A few years ago, doctors from the Mayo Clinic tested the wisdom of online health advice. Their conclusion: It’s risky. According to their study, going online for health advice is more likely to result in getting no advice or incomplete advice than the right advice.
No site they examined listed all the necessary symptoms so that a user could obtain an accurate triage — whether to rush to the emergency room, call the doctor or treat the condition at home. A third of the sites did not list any of the key symptoms. Among sites that checked any critical symptoms, four in 10 provided no triage advice.
Even when online symptom checkers suggest diagnoses, they can suggest so many of them that patients are unlikely to be able to deduce which diagnosis is most likely. One study found that older adults could find the correct diagnosis of an illness only half the time using Google or WebMD.
Rather than searching the internet, what about using a symptom-checking app you may have loaded on your smartphone or tablet? Such apps — some from trusted institutions like Harvard Medical School or the Mayo Clinic, among many others — are specifically designed to provide fingertip access to diagnostic and triage advice. Yet they are not regulated for safety or accuracy.
Last year, researchers from Harvard Medical School and the RAND Corporation assessed the diagnostic and triage accuracy of 23 of the most popular symptom-checkers, some with tens of millions of users. They found that only one-third listed the correct diagnosis first, half got it among the top three suggestions, and 58 percent included the correct diagnosis among the top 20 suggestions.
Diagnostic abilities were better for those problems reasonably treated at home, for which the top diagnosis was correct 40 percent of the time, or for those that are more common, for which the top diagnosis was correct 38 percent of the time.
Tested apps gave correct triage advice 58 percent of the time, and at a higher rate for more serious problems requiring urgent care. One reason is that symptom checkers tend to be risk-averse. They’re biased toward advising patients to seek professional care even when self-care is appropriate. Some of the apps tested always advise professional care, even for conditions that don’t warrant it.
Though it’s far less convenient, talking to a medical professional may be a more likely route to accurate medical advice than using the internet or apps. But how much more likely depends whether you talk to a nurse by phone or see a doctor in person.
A 2012 systematic review found that most telephone triage services provided accurate advice over two-thirds of the time. A study of pediatric abdominal pain found phone triage accuracy of 61 percent. Another put it at 69 percent. However, the services have also been faulted for increasing visits and driving too many people to emergency departments with overly cautious advice.
Though apps may be in roughly the same range as phone consultations for triage accuracy, they are poor substitutes for consulting a doctor in person. Studies find physician diagnostic error rates to be much lower than that of apps, though still in the 10 to 15 percent range by some estimates (others put it as low as 5 percent).
Seeing a doctor in person takes a lot of time and, for some, costs a lot of money. So it’s understandable that people will turn to more efficient ways, like using websites, apps and the phone. But, as they do so, they should not (yet) presume greater accuracy.
The following published in JAMA yesterday, all free/ungated:
- United States Health Care Reform: Progress to Date and Next Steps, by Barack Obama
- The Affordable Care Act and the Future of US Health Care, by Howard Bauchner
- US Health Care Reform: Cost Containment and Improvement in Quality, by Peter R. Orszag
- The Future of the Affordable Care Act: Reassessment and Revision, by Stuart M. Butler
- The Past and Future of the Affordable Care Act, by Jonathan Skinner and Amitabh Chandra
Do not overlook the following systematic review from HSR, which is
, unfortunately, notalso free/ungated:
- Key Provisions of the Patient Protection and Affordable Care Act (ACA): A Systematic Review and Presentation of Early Research Findings, by Michael T. French, Jenny Homer, Gulcin Gumus, and Lucas Hickling
What is this post about? Look here.
Aaron and I have been posting on the AcademyHealth blog about how we turn academic papers into interesting blog posts. We’ve already posted on how we read papers and how we decide what to write about. Our third post, now live, covers how we make blog posts interesting.
- Providers shifting to higher-end CT scanners, Modern Healthcare
What is this post about? Look here.
The following originally appeared on The Upshot (copyright 2016, The New York Times Company).
A $30,000 price tag for cancer drug therapy that extends life only a few weeks is understandably alarming. But a $2,000 price tag for all childhood vaccines — credited with eradicating smallpox, preventing a million or more cases of other diseases and averting thousands of deaths each year — is a bargain. In fact, the price of childhood vaccines may be too low for our own good because it contributes to shortages.
Vaccine shortages have popped up in the United States many times over the past 50 years. In 2001, eight of 11 recommended childhood vaccines were unavailable or in short supply. A recently published study by the economist David Ridley and other Duke University researchers found that between 2004 and 2014, an average of nearly three out of 22 vaccines were in short supply in the United States. In 2007, one-third of vaccines were. (Looking globally, limited vaccine supplies hampered the response to a recent yellow fever outbreak that began in Angola and spread elsewhere.)
Vaccine prices have gone up over the years, in large part because of newer vaccines that command higher prices. The number of recommended vaccine doses has also increased, which pushes up the overall cost of full vaccination. Still, vaccines are inexpensive relative to their value. A typical dose costs $50 and, apart from an annual flu shot, only a few doses are required over a lifetime. According to the Duke study, vaccines with lower prices were more likely to be in short supply than those with higher prices. There were no shortages of vaccines with a price per dose above $75.
Low prices are implicated in vaccine shortages, just as they are for other injectable drugs delivered in hospitals and doctors’ offices. Generic injectables used for patients with serious illnesses and in emergencies also have low prices that contribute to shortages. But vaccines, unlike such injectables, are not generic. Vaccines are brand biologics (large-molecule, protein-based drugs made by living organisms, not by chemical processes), which normally command very high prices. So why are their prices low instead of high?
Vaccine prices are held down by government programs, which extendvaccinations to millions of children who might not otherwise get them. Federal and state programs buy more than half of childhood vaccine doses at a discount. The largest federal vaccine program — Vaccines for Children— may adjust prices within a year, but only downward, and it constrains changes in what it pays for some vaccines to below the overall inflation rate. Though the program keeps a six-month backup supply of vaccines on hand, the average shortage lasts three times that long, according to the Duke study.
Commercial market vaccine prices are higher than government ones, but not by enough to prevent shortages.
Low prices and concentrated buying power in government programs have pushed redundancy out of the market. There are only a few vaccine manufacturers, and some vaccines — including those for measles, mumps, rubella, varicella and shingles — are produced by just one. With little excess capacity, when a manufacturer experiences a problem requiring a shutdown, vaccine production falls below needed levels, causing a shortage. It can take years and close to a billion dollars to bring a new vaccine to the market, hardly a recipe for rapidly addressing a shortage.
“Manufacturers won’t invest in extra production capacity when prices are too low,” Mr. Ridley said.
Vaccines are among the most cost-effective treatments ever developed. Though most medical treatments don’t save money, vaccines do — preventing many diseases that would cost more to treat and allowing millions of people to live longer and more productive lives. Several studies have found that at even at 10 times their cost, vaccines would still save money.
We probably don’t need to raise vaccine prices by a factor of 10 to promote new vaccine investment and stabilize supply. According to one study, a doubling in price would incentivize new vaccine research, development and production.
For drugs as valuable as vaccines, that might be a price worth paying.