
Doctors Slow to Adopt Tech Tools That Might Save Patients Money on Drugs - realshadow
https://www.npr.org/sections/health-shots/2019/07/05/738283044/doctors-slow-to-adopt-tech-tools-that-might-save-patients-money-on-drugs
======
skwb
I wonder how burdensome it is to even get the tool fully integrated into the
ehr. Like are the doctors not using it because it requires manual input of
drugs and insurance? Even then, the doctors aren’t necessarily getting paid
more for doing this extra work; it’s the payer (insurance) company that is
primarily benefiting.

To be clear, I am acutely aware of just how hard it is to get this sort of
thing working (MS in health Econ, phd in biomedical and clinical informatics).
Just keeping track of all the formularies seems like a pain just to to begin
with!

~~~
delfinom
Well due to the rise of EHR and other tech complexities, many doctors are just
joining mega-groups/networks that handle their IT just so they don't have to
deal things such as integration. The era of independent doctors is basically
coming to a very fast end.

Where I live, there are two competing networks of doctors now that have
basically absorbed thousands of doctors in the last 4 years with their signs
literally plastered everywhere now.

Yay because arguably it's the only way doctor offices are going to keep up
with ever changing tech. Nay because Americans are going to get fucked in the
ass even more by uncontrollable healthcare when the doctors networks become
cartels.

~~~
skwb
There's a certain chicken or egg among health economists for the role of
HITECH requirements resulting in consolidation [1, 2]. On one hand, these
HITECH requirements put additional technological reporting, which may be a
driver of consolidation (though this was in large part 'paid' for if you
adopted early). On the other hand, centralization of IT services can produce
economies of scale, especially if you're a small community hospital that has a
small community hospital budget (aka narrow). Hell, you even see the trend of
inter-UC health hosting the EHR instance for another UC [3].

In either case, the major role of healthcare consolidation has been to keep up
with insurance consolidation, which is to keep up with hospital consolidation,
and so on [4].

[1]. [https://www.hhs.gov/hipaa/for-professionals/special-
topics/h...](https://www.hhs.gov/hipaa/for-professionals/special-
topics/hitech-act-enforcement-interim-final-rule/index.html)

[2].
[https://www.healthaffairs.org/do/10.1377/hblog20190304.99820...](https://www.healthaffairs.org/do/10.1377/hblog20190304.998205/full/)

[3]. [https://cio.ucop.edu/making-epic-history-ucsd-and-uci-
health...](https://cio.ucop.edu/making-epic-history-ucsd-and-uci-health-share-
an-electronic-medical-records-system/)

[4].
[https://www.healthaffairs.org/doi/full/10.1377/hlthaff.22.6....](https://www.healthaffairs.org/doi/full/10.1377/hlthaff.22.6.77)

------
aladoc99
My experience with such a system has been that it would quote ridiculously
high prices for generic medications, so I'd simply tell patients their drug is
on the $4 list at WalMart. An information source that's unreliable is worse
than no information at all, since it poisons the well for competing systems.

------
dfeojm-zlib
America is slow to adopt collective, independent negotiating of medical,
hospital and prescription charges as happens in insurance,
Medicare/Medicaid/Tricare. Med4all would solve this, rather than hunting
around for big pharma "sales" and "promotions."

~~~
didgeoridoo
The US government is the “single payer” for defense contracts. How has that
worked out in terms of cost controls?

~~~
noir_lord
The NHS in the UK pays much lower prices for most drugs than the insurers do
(there are the odd egregious cases where a company take the piss, the
interesting thing is that we do actually fine them in a rare case of
consequences been applied) because simply put they are negotiating for 65
million consumers in one go, if the NHS price is high enough for them to make
a healthy profit per patient it is a no brainer.

The system requires numerous feedback loops and clinical overview (ours is
called NICE - National Institute of Clinical Excellence).

Is it perfect, no, few human things are.

Is it massively preferable to the _average_ healthcare situation for Americans
- hell yes it is.

I pay for my prescriptions which is £9 per drug per month (whatever the cost
to the NHS of that drug is), I take 3 drugs so that should be £27 per month
except they considered that case and I buy a NHS Pre-Payment Card which costs
me about £10 a month and covers me for any number of medications. [1]

So for £10 a month I get the routine medications I need to make my life not
just bearable but enjoyable which allows me to work.

So if costs controls in government are your concern the elect better people
with better systems.

Lest anyone think I'm all sunshine and roses on the NHS, it requires drastic
reformation (and they really really need to get rid of their 'internal market'
way of running) but the idea is as sound now as it was in 51 years ago (almost
to the day, it was founded July 5th 1948).

[1] [https://apps.nhsbsa.nhs.uk/ppc-
online/patient.do](https://apps.nhsbsa.nhs.uk/ppc-online/patient.do)

~~~
rayiner
> Is it massively preferable to the average healthcare situation for Americans
> - hell yes it is.

Your _average_ American has employer-paid health insurance, which covers most
of their costs. According to the OECD, average out-of-pocket healthcare
expenditure in the U.S. is $1,370, versus $629 in the U.K.
[https://data.oecd.org/healthres/health-
spending.htm](https://data.oecd.org/healthres/health-spending.htm). Keep in
mind that median household disposable (post-tax) income in the U.S. is
$45,000, versus $29,000 in the U.K.

~~~
stevekemp2
Sure, but there are obvious cases which turn these averages into really
different personal-stories.

One case is the obvious cost of having a child in America, even with insurance
some people pay thousands of dollars.

~~~
rayiner
"The american system is bad for the poor or unlucky" is a very different
argument than "the american system is bad for the average person."

The difference in median disposable income between the U.S. and the U.K. is
stunning: almost $17,000. Even after you factor in things like student loan
debt (averaging $220/month for the minority of people who have student loans
at all) and out-of-pocket healthcare expenses and premiums (a few thousand a
year on average, versus maybe a thousand or so in other OECD countries), the
median American household is coming out way ahead.

~~~
noir_lord
Child mortality rates in the US 5.9 per 1000, In the UK 3.8. [1]

> Two-thirds of people who file for bankruptcy cite medical issues as a key
> contributor to their financial downfall. [2]

United Kingdom suicide rate per 100,000 7.5, United States 13.8 [3]

United States Murder Rate per 100,000 5.35, United Kingdom 1.2 [4]

More to life than money I guess, also your $17,000 is accounting for income
distribution, at first glance that looks good but while our income
distribution is pretty bad, the US is positively Dickensian.

No jingoism intended here, we get a lot wrong and other countries straight up
kick our arse (Spain's infant mortality rate is half ours at 2.0 for example
amongst major European countries) but that just means we should be looking to
improve.

[1] [https://data.oecd.org/healthstat/infant-mortality-
rates.htm](https://data.oecd.org/healthstat/infant-mortality-rates.htm)

[2] [https://www.cnbc.com/2019/02/11/this-is-the-real-reason-
most...](https://www.cnbc.com/2019/02/11/this-is-the-real-reason-most-
americans-file-for-bankruptcy.html)

[3] [https://data.oecd.org/healthstat/suicide-
rates.htm#indicator...](https://data.oecd.org/healthstat/suicide-
rates.htm#indicator-chart)

[4]
[https://en.wikipedia.org/wiki/List_of_countries_by_intention...](https://en.wikipedia.org/wiki/List_of_countries_by_intentional_homicide_rate)

~~~
rayiner
On infant mortality statistics, at least part of the difference is that the US
reports that figure rigorously, while other countries do not necessarily do
so: [https://www.nationalreview.com/2011/09/infant-mortality-
dece...](https://www.nationalreview.com/2011/09/infant-mortality-deceptive-
statistic-scott-w-atlas).

As to income distribution: that’s the OECD’s estimate of the median household.
So it’s not being skewed up by super-rich households.

As to bankruptcies, less than 0.5% of households file for bankruptcy in a
given year.

As to homicide or suicide rate: again, that affects a tiny minority.
Meanwhile, the much higher income affects 60-70% of the whole population.

The U.K. is a society where you’ve lowered the median to lift up the floor.
That’s one way to do it. And I don’t even disagree with you that the US should
do more in that regard. But if you support an expanded welfare state (and I
do), it’s dishonest to sell that policy to people by pretending that the
average person is going to be better off. Unless they place a very high value
on security (avoiding low probability outcomes like medical bankruptcy) over
material comfort, they’re going to be worse off.

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DataDrivenMD
They lost me at "might."

You'd be hard-pressed to find many docs (myself included) who are champing at
the bit to adopt an informational resource with knowledge gaps.

~~~
jchw
I don't understand. The article is about a pricing tool. The "might" is that
it can't give useful price information for all kinds of insurance. It doesn't
seem all that horrific that it might not be able to give useful pricing
information for every single patient...?

~~~
elliekelly
Doctors schedules are already tight as it is and I’m not sure what benefit
there is to the doctor to spend the precious extra minutes looking to see
whether they might be able to save their patients some money before
prescribing a drug.

~~~
paganel
Because by saving the patient that sum of money said patient will maybe have
enough funds to come visit said doctor for a second time (or a 3rd, or a 4th),
instead of postponing the visit for financial reasons.

In other words, if a doctor prescribes me a $1000 medicine instead of a $500
one, and a visit to said doctor costs $500, I might not visit him a second
time because I've already paid $1000 for the medicine and I don't have enough
money for my health anymore. Not visiting your doctor when you need it (for
whatever reasons) is bad for the patient.

~~~
elliekelly
That’s not a very strong incentive. I’m not really sure that’s an incentive at
all. Most doctors have more than enough appointments. Their schedules are
_overbooked_.

But even if doctors who needed more patient bookings could attract those
bookings by saving patients money then logic would follow that doctors who
have room in their schedule would consistently use the app from the article.
Yet most doctors aren’t using it at all.

So even if your premise is correct I think you’re greatly overestimating the
surplus supply of doctors appointments and underestimating how steep/inelastic
the demand curve is for healthcare.

Mostly unrelated, is saying “surplus supply” redundant? I can’t decide.

------
doctorpangloss
"Doctors Slow to Use Some Startup's Thing That My New York Party Acquaintance
Asked Me To Talk About"

~~~
fenomas
What is this in reference to? There's nothing similar in the article.

~~~
Ice_cream_suit
Think...

Puff pieces are a dime a dozen.

------
hereme888
"Doctors slow to..." Implies all doctors. Then the article begins with an
emotional story about one patient. Statistical facts don't come from an
emotional argument. That's what politicians and marketers do.

What's more likely: that the hardest working, highest average IQ professionals
are slow to adopt something that would help them save their patient's lives?
Or that the writer of the article is biased and exaggerating things?

~~~
logicchains
>the hardest working, highest average IQ professionals are slow to adopt
something that would help them save their patient's lives?

This is already the case with checklists, which are proven to save lives but
resisted by many doctors: [https://www.newscientist.com/article/2090554-not-
all-surgeon...](https://www.newscientist.com/article/2090554-not-all-surgeons-
follow-checklists-that-prevent-bad-mistakes/) . In my limited experience with
doctors a non-insignificant proportion seem to care more about their own ego
than saving lives (the kind of people who would bring up their own IQ in a
discussion).

Medical error is apparently the third largest cause of death in the US
([https://www.cnbc.com/2018/02/22/medical-errors-third-
leading...](https://www.cnbc.com/2018/02/22/medical-errors-third-leading-
cause-of-death-in-america.html)), and surgical checklists have been shown to
reduce error rates by 40%:
[https://www.theguardian.com/society/2009/jan/14/health](https://www.theguardian.com/society/2009/jan/14/health).
In any other profession it would be completely unacceptable to refuse to use a
technique like checklists on the grounds that "I don't make silly mistakes";
imagine if an engineer working on safety-critical equipment said "My code
doesn't need any testing because I don't make mistakes".

~~~
carlmr
I use checklists extensively, however I'm wondering if mandatory checklists
would have the same effect.

I have checklists for holiday packing with different sub checklists for beach,
ski, etc vacation.

At work there are checklists for code review that I personally find don't
help. Why? I didn't make that checklist myself. It's a checklist basically
containing every mistake anyone ever made that could have or should have been
caught in review.

This leads to a checklist of hundreds of Well-d'uhs, because a lot of people
make many silly mistakes.

I have a personal review checklist with the things I often forget. I think
checklists only work if they're full of pertinent information, and for many
professions I think that depends on the person using the checklist and whether
they're motivated to use it or obliged to.

~~~
logicchains
I worked at a company that used mandatory checklists for some operational
roles, they definitely cut down on the number of mistakes (at least the
mistakes the checklist was crafted to address). It made people more
accountable: whereas previously a certain mistake might be human error
(unavoidable), if it still happened after the checklist then either somebody
didn't fill out the checklist (and could be punished for negligence) or lied
by checking a box on checklist without actually doing the thing (and could be
severely punished for dishonesty). This motivated people to thoroughly check
the things.

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gscott
Walmart, Target and some others have lists of low prices drugs for common
conditions.

[https://www.walmart.com/cp/$4-prescriptions/1078664](https://www.walmart.com/cp/$4-prescriptions/1078664)

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darawk
That's because they have no incentive to, and for the most part, neither do
their patients.

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travisoneill1
The industry is medieval. I had to get a CT scan in the ER while traveling
once and the only way the medical records office could communicate to get the
scan was fax or email, and they sent me the images by mailing a CD (in 2018)!

~~~
geezerjay
What's wrong with using email to communicate with the medical records office?

And as CT scans are private information, why would you assume it would be Ok
to make them available through a public server and send them over the
internet?

~~~
lotsofpulp
I think they typo’d “mail” and wrote “email” unintentionally. Or at least
that’s the only way their post makes sense to me.

~~~
travisoneill1
yes

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dsfyu404ed
Why would they be fast? It's not their money. The incentive is not there.
Meanwhile on the other side switching anything is work. Of course it doesn't
get done super quick.

