JAMA Forum: What Near-Death Experience Can Tell Us About Medical Care

David Cutler, PhD (Image: Ted Grudzinski/AMA)In 2005, a survey was conducted examining how aggressively physicians treat patients near the end of life. Some 1500 primary care physicians and cardiologists were presented a scenario describing an 85-year-old man with severe congestive heart failure. The fictional patient was described as receiving maximal medications, using supplemental oxygen at home, and not being a candidate for surgery or other procedures to treat blockages in blood vessels to the heart. When the patient experiences worsening shortness of breath (a symptom of fluid accumulating in his lungs) and makes an office visit, increasing his supplemental oxygen makes him more comfortable.

The survey group was then asked “How often (always/almost always, most of the time, some of the time, rarely) would you arrange for each of the following?” The choices were

A. Allow the patient to return home and receive increased oxygen and increased diuretics (to remove excess fluid from the body)

B. Admit to the hospital (but not to the intensive care unit [ICU] or coronary care unit [CCU]) for aggressive removal of excess fluids

C. Admit to the ICU/CCU for intensive therapy and monitoring

D. Place a pulmonary artery catheter to assess the severity of heart failure and to optimize drug treatment

E. Recommend a pacemaker

F. Initiate or continue discussions about palliative care

Recently, the responses to this survey were analyzed by me, Ariel Stern, PhD; Jonathan Skinner, PhD; David Wennberg, MD, MPH. Although the data are nearly a decade old, there is no reason to think that answers today would be any different. Our analysis of these responses reveals the troubled state of American health care—as well as the possibilities.

Options A and B are less-intensive ways of managing the patient and each finds support in the literature. Three options—C, D, and E—are much more intensive but have no evidence to support them (they were not recommended in the guidelines then and are not recommended now). Option F, a palliative care discussion, is clearly warranted; half of patients like this die within a year. Thus, a physician following practice guidelines would be expected to choose A or B, plus F.

But the answers that physicians gave were far from these recommendations. One-quarter of physicians recommend 1 of the 3 most aggressive options. Only about half would likely have a palliative care discussion. Primary care physicians and cardiologists differ slightly in their answers, but not enormously so. Very aggressive treatments were supported by 22% of the primary care physicians and 28% of the cardiologists, while only 49% and 45% would have a palliative care discussion.


Cowboys vs Comforters

This issue has great import for medical spending. Based on the responses to our survey, we called the physicians who consistently advise aggressive end-of-life care not supported by guidelines “cowboys,” and those who would have a palliative care discussion “comforters.” A physician can be both a cowboy and a comforter, but empirically, few are.

Cowboys and comforters are not randomly distributed in the population, and medical spending reflects this. Medicare spending for end-of-life care is 60% more in an area where physicians are mostly cowboys than in one with few cowboys. An area full of comforters will spend 27% less. Generally, spending in this arena negatively tracks patient preferences. Patients routinely express a desire for comfort over aggressive care at the end of life.

What makes physicians become cowboys or comforters? Many physicians say that the fear of being sued for malpractice drives them to do too much. But our survey evidence does not support this theory. Although 41% of cardiologists report that they have sometimes or frequently done a cardiac catheterization because of malpractice fears, there is no correlation between the response to that question and being a cowboy. Nor is there a relation between physicians who report responding to patient expectations and being a cowboy. Some characteristics are correlated with not being a cowboy: those who are younger or who practice in larger groups are much less likely to be cowboys than other physicians.

In reality, I think there are 2 fundamental factors at work, and each is important for the future of medical care. First, although the evidence of what is appropriate may exist in guidelines and medical journals, nothing compels physicians to follow it. A cardiologist can believe he has better outcomes than the literature suggests. And if the issue comes up, “my patients are different” or “my outcomes are better” usually ends the conversation. These statements cannot be generally true or the literature would reflect that. But who can say if they are true for any particular physician?

The interesting question is why these statements are rarely challenged. Sometimes, big systems do have these conversations, which may explain why there are fewer cowboys in hospital-based and group practices. Intermountain Healthcare in Utah is famous for the idea that internal standardization can lead to better care. Even today, though, Intermountain remains the exception.

Look behind the curtain, and one sees the importance of money. Standardization generally results in a greater reduction in overused services than an increase in underused services. Thus, in a fee-for-service system, standardization results in a revenue loss. Add to this the financial and psychic costs of physician profiling (to compare practice patterns) and standardization, and it is easy to see why even the largest systems avoid it.

As the payment system changes, this calculus will change as well. In an accountable care organization (ACO), money saved by avoiding unnecessary procedures becomes surplus to the organization. The same is true for organizations accepting a predetermined bundled payment for an episode of illness. There are more than 600 ACOs in the country today, and many hundreds of institutions are receiving bundled payments. Thus, internal analysis and standardization may become significantly more frequent.


Talking About Palliative Care

Why do only half of clinicians discuss palliative care for patients at the end of life? A likely reason is that such discussions are painful and physicians naturally wish to leave them to someone else. This choice may be easy to rationalize because so many physicians are involved in patient care near the end of life. The primary care physician can say that she is not an expert in severe congestive heart failure and hence the cardiologist needs to discuss options with the patient. The cardiologist can say that the primary care physician knows the patient better and is better equipped to have the palliative care discussion. Each is right, but the outcome is still bad.

Again, what is needed is a system for seeing that such discussions take place. At institutions such as Gundersen Lutheran in Wisconsin, end-of-life conversations are routine as people age and end-of-life spending is correspondingly lower. In other areas, the conversations are avoided. Not surprisingly, the Dartmouth Atlas shows enormous variation in end-of-life care spending across the country.

But there is cause for hope: if all physicians followed the guideline recommendations, end-of-life costs would decrease by one-third, and overall Medicare costs would decrease by 15%. This outcome can be achieved without rationing: gathering data, having discussions with colleagues and patients, and setting standards would do an enormous amount.

My suspicion is that much of health care is like the case of caring for the fictional 85-year-old with congestive heart failure. No one is trying to do the wrong thing, but the consequences of unstandardized and often excessive care is wasted money and unnecessary pain. Establishing the right systems, realigning payments, and pushing for the right care can accomplish far more than many think is possible.


About the author:

David M. Cutler, PhD, is the Otto Eckstein Professor of Applied Economics in the Department of Economics and Kennedy School of Government at Harvard University and a member of the Institute of Medicine. He served on the Council of Economic Advisers and the National Economic Council during the Clinton Administration and was senior health care advisor to Barack Obama’s presidential campaign. He also was involved in the debate over the Massachusetts health reform legislation discussed here and is a Commissioner on the state’s Health Policy Commission. Heis the author of the recently published The Quality Cure, and Your Money or Your Life (2004). He tweets at @cutler_econ.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



Author Insights: Legalizing Medical Marijuana May Reduce Opioid Deaths

Marcus A. Bachhuber, MD, a Robert Wood Johnson Foundation Clinical Scholar at the Philadelphia Veterans Affairs Medical Center, and colleagues found that states that legalize marijuana experience lower rates of opioid deaths, on average, compared with states that don’t allow medical marijuana. Image: University of Pennsylvania

Marcus A. Bachhuber, MD, a Robert Wood Johnson Foundation Clinical Scholar at the Philadelphia Veterans Affairs Medical Center, and colleagues found that states that legalize marijuana experience lower rates of opioid deaths, on average, compared with states that don’t allow medical marijuana. Image: University of Pennsylvania

Opioid-overdose deaths increased in states across the country between 1999 and 2010, but states that legalized medical marijuana saw less-steep increases than those without, according to a study published in JAMA Internal Medicine this week.

Growing use of prescription opioids over the past 2 decades to treat chronic pain has helped drive increasing rates of opioid overdoses. To help reduce the problem, state and federal governments have instituted prescription monitoring programs and drug safety plans and tightened restrictions on prescribing popular opioids. Some of these efforts have yielded reductions in opioid overdoses on a state level, but national rates continue to rise.

At the same time, a growing number of states have legalized medical marijuana. In states like Colorado, where medical marijuana has been legal since 2000, the primary reason for a physician to recommend medical marijuana is pain. Some of the other indications for prescribing medical marijuana include nausea from cancer chemotherapy and poor appetite and accompanying weight loss resulting from a chronic illness such as HIV infection.

Marcus A. Bachhuber, MD, a Robert Wood Johnson Foundation Clinical Scholar at the Philadelphia Veterans Affairs Medical Center, and his colleagues analyzed opioid overdose rates in states with or without legalized medical marijuana to see whether its availability to treat pain helps reduce opioid deaths. They found that while opioid overdose deaths have continued to increase in all states, states that permit prescribing medical marijuana had lower rates of opioid overdose deaths compared with those that do not.

Bachhuber discussed his results with news@JAMA.

news@JAMA: Why did you decide to do the study?

Dr Bachhuber: I’m a primary care physician and I’ve talked to many patients with chronic pain. In the past, I’ve had patients who said they’ve tried prescription opioid painkillers but the only thing that worked to reduce their pain was marijuana. So, my colleagues and I wondered whether people might be choosing to treat their pain with marijuana in states where this is legal, and if these states might see lower rates of painkiller overdoses or deaths.

news@JAMA: You found that the rates of opioid overdose were lower in states allowing medical marijuana. Can you explain what that means?

Dr Bachhuber: We found that rates of opioid overdose deaths have increased in all states. But in the years after the legalization of medical marijuana, states that did so had a rate that was 25% lower than what we’d expect to see in that state, given past trends and what was going on in the rest of the country.

news@JAMA: Why might making medical cannabis available reduce opioid overdose rates?

Dr Bachhuber: Going into the study, we hypothesized that patients with chronic pain might replace opioids with medical marijuana or supplement opioid medications with medical marijuana, allowing them to reduce their opioid dose. Alternatively, there is still a debate about whether medical marijuana might lead patients to use other drugs, so rates of opioid overdose might have increased. We thought there could be a change in either direction, and that’s why we decided to study it.

news@JAMA: Your study can’t prove that medical marijuana was the factor that reduced opioid overdoses. Might there be other explanations?

Dr Bachhuber: One of the limitations of our study is that we can’t identify, measure, and control for every factor that was different between the states and might be contributing to our results. If broader changes were happening in states that also implemented medical marijuana laws, such as changes in patterns of pain treatment or illicit drug use, those could be influencing our results and have nothing to do with medical marijuana. But, if medical marijuana laws are in fact reducing opioid overdose deaths, we would need studies following individuals over time to see how exactly these laws are shifting behavior.

news@JAMA: How much do we know about the use of opioids or marijuana for pain treatment?

Dr Bachhuber: Opioids are approved by the FDA for the treatment of pain; they have undergone randomized trials, but there is very little evidence for long-term use for more than a few months. Marijuana is still considered a Schedule I drug, meaning the FDA says there is no valid medical use. Because of this, there is not much research out there to help us understand the risks and benefits of medical marijuana, including what conditions could be successfully treated, which patients might benefit the most, and what the risks may be. Also, head-to-head studies of marijuana and opioids would be incredibly useful for clinical practice.

news@JAMA: What is the main take-home message from your study?

Dr Bachhuber: Our study provides evidence of a possible unexpected public health benefit of medical marijuana legalization. Medical marijuana may have other possible impacts on public health, and as more states enact these laws, it will be worth continuing to look at this issue.

Salk or Sabin? Using Both Polio Vaccines is Best, Study Reports

New research shows that the inactivated, injectable polio vaccine boosts mucosal immunity, making it an ideal tool to use with the oral vaccine to end poliovirus transmission. (Image: ©iStock.com/dina2001)

New research shows that the inactivated, injectable polio vaccine boosts mucosal immunity, making it an ideal tool to use with the oral vaccine to end poliovirus transmission. (Image: ©iStock.com/dina2001)

New research appears to have resolved a polio vaccine debate raging for more than 50 years: Is it more appropriate to use the oral, attenuated vaccine developed by Albert Sabin, MD, or the inactivated, injectable vaccine that Jonas Salk, MD, introduced?

The answer, based on a study published online today in Science, is that using both is best.

“This study has really revolutionized our understanding of inactivated polio vaccine and how it can fit within the global eradication program to help get this finished as quickly as possible,” coauthor Bruce Aylward, MD, MPH, the World Health Organization’s (WHO) assistant director-general of polio, emergencies and country collaboration, said during a press briefing.

Sabin’s oral formulation became the vaccine of choice in global eradication efforts because it induces superior mucosal immunity, is easy to administer, and costs less. Local immunity at mucosal surfaces such as those lining the gastrointestinal, respiratory, and urogenital tracts is important because they’re major entryways for viruses and other pathogens to enter the body.

However, the oral vaccine also has drawbacks. Mucosal immunity wanes over time, so multiple doses are necessary. Revaccination can be difficult or impossible in conflict zones such as Afghanistan, Nigeria, and Pakistan, where poliovirus remains endemic.

Also, the virus used to make the oral vaccine is weakened but still alive. It can be shed in feces, which increases local, national, and international transmission risks. On very rare occasions it can cause polio in the person who is vaccinated.

Scientists already knew that the inactivated vaccine prevented paralytic polio disease by spurring antibody production. But they weren’t certain about its role in mucosal immunity. So an international research team led by Hamid Jafari, MD, director for polio operations and research at WHO, enrolled nearly 1000 children in a clinical study to determine whether the inactivated vaccine boosts mucosal immunity. The trial took place in the Uttar Pradesh state of northern India, a longtime stronghold for the virus.

Children in the trial already had received multiple doses of oral vaccine as part of immunization programs. For the trial, they randomly received 1 dose of inactivated or oral vaccine, or no vaccine. Four weeks later, all the children received a 1-dose challenge with oral vaccine. At 3 follow-up periods during the next 2 weeks, the investigators measured poliovirus excretion in their stool—a sign of being infectious.

Compared with the control group, children who received the inactivated vaccine excreted anywhere from 39% to 76% less virus in their stool, depending on poliovirus type and children’s age. Older children excreted more virus than younger children. Only the older children who received oral vaccine excreted significantly less virus than controls.

“Giving inactivated polio vaccine makes people very, very less infectious,” Jafari said during the press briefing.

Since 1988, global eradication efforts have reduced polio cases by 99%. But Jafari said that effort now is at a crossroads. Endemic polio is confined to unstable regions that often are inaccessible to outsiders. “Yet the virus in these areas persists with incredible tenacity and threatens the increasingly vulnerable populations in polio-free countries with a weak or conflict-affected health system,” he noted.

“Inactivated polio vaccine will be a powerful additional tool in our arsenal to fight this disease in these remaining areas,” Aylward added.

The Global Polio Eradication Initiative’s strategic “endgame” plan calls for the introduction of inactivated polio vaccine by the end of 2015 in countries now using only the oral vaccine. “Both vaccines complement one another and should be used to interrupt the final chains of transmission to obtain a polio-free world in the most rapid and effective way possible,” coauthor Roland Sutter, MD, the WHO’s coordinator for research and product development, polio operations and research, said during the briefing.


JAMA Forum: Tackling the Ebola Epidemic

Lawrence Gostin, JD

Lawrence Gostin, JD

The Ebola virus epidemic in West Africa is now out of control, but it shouldn’t have come to this. Ebola virus disease (EVD) is a preventable disease, but the current epidemic is challenging efforts to contain it. Previous outbreaks that have occurred since the virus was first detected in 1976 have been confined to rural areas. This time, EVD has reached the urban landscape, with people and animals congregating together. Extensive travel across land borders and by air is furthering its spread.

Why Ebola Is Out of Control

The most affected countries—Guinea, Liberia, and Sierra Leone (with recent spread to Nigeria, which currently has a dozen cases)—are ranked lowest in global development and do not have the basic infrastructure to contain the Ebola epidemic. Even with international help, it will take at least 6 months to bring the crisis under control, according to Médecins Sans Frontières/Doctors Without Borders. For now, Ebola is spreading unchecked because of such factors as fragile health systems in resource-poor countries, cultural practices, and deep-seated distrust.

Broken Health Systems

Being treated or working in a hospital in affected states is hazardous. Health professionals are the most susceptible: they typically care for infected patients without personal protective equipment and infection controls; they lack training in differential diagnosis of and treatment for EVD; and they are underpaid. Patients, too, perceive that hospitals in the affected countries are unsafe places that offer little effective treatment. Consequently, patients with Ebola-type symptoms stay away, and those who need treatment for myriad health problems—from AIDS and malaria to cancer and heart disease—remain untreated in the community.

The persistence of traditional burial and other cultural practices in West Africa also make it more difficult to contain Ebola. Loved ones come in close contact with the deceased, including ritual touching and bathing. Burial practices create the conditions for transmitting EVD, which then can be spread throughout the community. Another practice, consuming bush meat, which might include animals that are reservoirs for Ebola virus, is a traditional source of food, especially for poor Africans, providing life-sustaining protein. Women, as the traditional caregivers, are more likely to contract the virus than men.

Further challenging attempts to contain the spread of Ebola are common misperceptions, such as the belief that aid workers from medical groups were spreading the disease. Public education has been neglected and governments have curtailed accurate news reporting about the crisis. Epidemic control requires trust and an informed public, so risk communication is fundamental to controlling Ebola’s spread.

Ethical Issues

Also related to the issue of trust has been the use of scarce experimental therapies. More than 20 Ebola outbreaks have erupted in sub-Saharan Africa, yet the world was unprepared for the current tragedy, with no licensed vaccines or treatments. (This lack of readiness would not have surprised Albert Camus. As he wrote in The Plague, “Everybody knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down on our heads.”)

An experimental drug called ZMapp, which has neither been proven effective nor tested for safety in humans, was available in scarce amounts and was administered to 2 US aid workers and, reportedly, to a Spanish priest. The last remaining doses have now been delivered to West Africa, but the initial perceived preference given to white foreign workers fueled a sense of injustice. Although selecting who should get the untested treatment is an agonizing choice, it’s my opinion that priority should be given to African health workers, who die of Ebola in far greater numbers than do foreign workers. In any case, it is vital that allocation decisions be made fairly and transparently. The decision to treat the foreign workers was made behind closed doors without community consultation. Going forward, high-resource countries should create public-private partnerships to ramp up development and rigorous evaluation of vaccines and treatments.

Militarization of a Disease

Adding to the distrust that hinders attempts to control the epidemic is local populations’ fear not only of Ebola but also of the militarization of the disease. Countries have erected cordons sanitaires (guarded lines preventing anyone from leaving), but are using ancient methods to enforce the quarantine. In West African hot spots, armed troops have established blockades, closed roads, and banned travel beyond the guarded perimeter.

As a result, the populace is finding it hard to obtain food and other basic necessities. Targeted travel restrictions may be necessary, but there is a smarter way to go about them, through humane care and incentives. Governments should provide people with nourishing food, health care, and psychosocial support. Transmission hot zones can’t be ignored, but neither can the needs and human rights of communities.

What Can Be Done Now? A “Health Systems Fund”

Fragile health systems are at the root of the problem, and bolstering them is a key to fighting Ebola and preventing another uncontrolled outbreak. Affected countries are unprepared for Ebola’s complexities; they are unable to provide all their people basic health services, much less the requirements of an Ebola response, including full body protective gear, specially trained health workers, isolation units, and advanced laboratory capacity with higher biosafety capabilities. Building strong health systems would rebuild the most basic community asset: trust. Looking ahead, the international community should mobilize to provide sustainable funding scalable to needs.

This crisis represents a manifest failing of the international community, particularly its wealthier members, which ought to have been generous in supporting surveillance and response capacities obligatory under the International Health Regulations (IHR). The World Health Organization (WHO), the World Bank, and the United States Agency for International Development, among others, have made notable pledges of support. But what the region needs now is an assurance that these funds will be ample and sustainable.

To address this need, I propose an emergency, and then an enduring, “Health Systems Fund” administered by WHO (with participation of local governments and civil society) and supported by high-resource countries. Considering the funding needs, an immediate (emergency) down payment of $200 million is needed for the affected countries and their at-risk neighbors. The money should be spent to strengthen health systems. Building on recent pledges of support, these additional funds could reward and motivate frontline health workers, ensure humane conditions in communities subjected to cordon sanitaire, and establish surveillance and response preparedness.

This fund would be surprisingly affordable, with this initial installment of funding representing only 1% of international health assistance. Growing the fund over time into a multibillion dollar funding channel for lower-income countries would finally make it possible to mobilize the resources envisioned in the IHR, as well as the growing global commitments to universal health coverage. Eventually, the fund might be merged with the Global Fund to Fight AIDS, Tuberculosis and Malaria into a new Global Fund for Health.

It is in all states’ interests to contain health hazards that may eventually travel to their shores. But beyond self-interest are the imperatives of health and social justice: a humanitarian response that would actually work, now and for the long term.


About the author: Lawrence O. Gostin, JD, is University Professor and Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, and Director of the World Health Organization Collaborating Center on Public Health Law and Human Rights. His most recent book is Global Health Law (Harvard University Press).

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



Using Antipsychotics for Elderly Patients Boosts Kidney Risks

Using antipsychotic drugs to treat older patients with dementia increases the risk of kidney injury, a new study found. (Image: JAMA, ©AMA)

Using antipsychotic drugs to treat older patients with dementia increases the risk of kidney injury, a new study found. (Image: JAMA, ©AMA)

Older adults treated with atypical antipsychotics are at increased risk of kidney injury, according to a study published today in the Annals of Internal Medicine. The findings add to previous evidence that this class of drugs is risky for older adults.

Although atypical antipsychotics are commonly prescribed for older adults to treat agitation and other behavioral symptoms of dementia, the US Food and Drug Administration has not approved the drug for this purpose. In fact, since 2005 the agency has warned that use of these drugs to treat older adults with dementia was associated with a 2-fold increased risk of death. An agency analysis of 17 placebo-controlled trials found the risk of death among patients with dementia taking olanzapine, aripiprazole, risperidone, or quetiapine was 4.5% compared with 2.6% among those taking a placebo.

Use of atypical antipsychotics is associated with a range of adverse effects, including hypotension, pneumonia, heart attack, and the breakdown of muscle tissue, that may contribute to kidney injury. But the extent of the potential kidney risk was unclear, so Y. Joseph Hwang, MSc, of the London Health Sciences Centre in Ontario, Canada, and colleagues conducted a cohort study comparing 97 777 patients aged 65 years or older receiving a new atypical antipsychotic prescription with 97 777 matched controls to assess the risk of kidney injury within 90 days. Patients who received an atypical antipsychotic medication were more likely to be hospitalized with a kidney injury. Use of the medication was also associated with low blood pressure, urine retention, and death.

In addition, the researchers looked at a subgroup of patients with creatinine levels available (a measure of kidney function). They found the absolute risk of hospitalization for kidney injury was about 2% higher in the treated group (5.46% vs 3.34%).

The authors conclude that the study adds to evidence that use of atypical antipsychotics in elderly patients should not be taken lightly.

“The drugs should be used only after other approaches have been exhausted; when prescribed, patients must warned about potential adverse events,” they wrote.

They recommend careful monitoring of blood pressure, creatinine levels, and other potential signs of kidney problems in older patients receiving atypical antipsychotics. Physicians treating older patients with kidney injury should consider these medications a potential cause and stop use of the drugs if possible, they wrote.

Youth Suicide Linked With Economic Downturns

Mass job layoffs increase the risk of suicide among adolescent girls and black youths, according to a new study. (Image:©iStock.com/bugphai)

Mass job layoffs increase the risk of suicide among adolescent girls and black youths, according to a new study. (Image:©iStock.com/bugphai)

The news earlier this week of actor-comedian Robin Williams’s death drew attention to increased suicides among middle-aged men. But a study released today focuses on another group vulnerable to suicide: teens living in areas where statewide job layoffs have occurred.

In their study, researchers from Duke University’s Sanford School of Public Policy in Durham, North Carolina, noted that economic downturns are known to increase adult suicides. The effect on adolescents, however, isn’t as clear.

“The relationships between changes in economic circumstances and the suicide-related behaviors of adolescents have received relatively little attention,” the researchers wrote in today’s online release in the American Journal of Public Health.

To gain a better understanding, the researchers analyzed data on adolescent suicide from 403 457 youths with a mean age of 16 years who participated in the Youth Risk Behavior Survey from 1997 to 2009. They explored responses to questions asking the youths whether, in the previous 12 months, they had seriously considered attempting suicide, made a plan for how they would try to take their own life, or actually attempted suicide.

The researchers also examined Bureau of Labor Statistics reports on mass layoffs for each state and the District of Columbia. Mass layoffs were defined as affecting more than 50 workers.

Overall, 16.3% of youths included in the analysis considered suicide, 12.6% made suicide plans, and 8.5% attempted suicide. The analysis showed that statewide job losses increased suicide-related behaviors among all girls and black adolescents in the study. Boys and white or Hispanic youths weren’t affected.

Among girls, 20.3% considered, 15% planned, and 10.4% attempted suicide. Among black youths, 13.9% considered, 11.2% planned, and 9.5% attempted suicide. The researchers reported that when 1% of a state’s working-age population lost jobs, the likelihood that girls and black youths would consider, plan, or attempt suicide increased by 2% to 3%. The increases were statistically significant, with the exception of girls’ suicide attempts.

By controlling for variables such as poverty rate and overall unemployment, lead author Anna Gassman-Pines, PhD, said job loss wasn’t a proxy for states’ other economic problems. “Instead, [job loss] represented a meaningful economic shock, which led to changes in girls’ and black adolescents’ suicide-related behaviors,” she said in a statement.

Gassman-Pines and her colleagues noted that suicide is the third leading cause of death among youths and young adults aged 10 to 24 years, claiming 4600 lives annually. Another 157 000 in that age group are treated annually for self-inflicted injuries.

JAMA Forum: Much Ado About Narrow Networks

Andrew Bindman, MD

Andrew Bindman, MD

The bumpy rollout of the health insurance coverage expansion by the Affordable Care Act (ACA) through private insurance exchanges ultimately exceeded enrollment expectations. The question is no longer whether the public will embrace these new health insurance marketplaces, but whether individuals are happy with their ability to use their new plans to access care.

In several states, there are concerns that the networks of physicians available through health plans sold in insurance exchanges are sometimes too narrow, limiting access to care and disrupting long-standing patient-physician relationships for some enrollees. The concern has surfaced mainly in the form of anecdotes, with no reliable estimate of how many individuals are negatively affected. But physician organizations have been quick to ring the alarm bell on behalf of patients and, presumably, their own self-interests.

Cost-cutting Déjà vu?

There is a striking familiarity about this concern that harkens back to the 1990s, when consumers pushed back against attempts by managed care organizations to limit their choice of physicians. In response, many health plans redirected their cost-cutting efforts away from narrow networks and focused instead on limiting benefits and finding ways to keep high-cost patients from joining their plans.

The regulatory requirements within the ACA have removed these cost-saving maneuvers by standardizing the essential benefits health plans must provide and by eliminating opportunities for health plans to select against high-cost patients. With these options constrained, it is perhaps not surprising that health plans would once again turn to narrow physician networks as a means to control costs.

Narrow networks can reduce a health plan’s cost by reducing access to high-cost services and by directing patients to physicians who accept lower payments in return for promises of higher volume. There would appear to be obvious potential for savings, as the recently released Medicare physician payment data revealed marked variation in the intensity of services and payment amounts to physicians; fewer than 2% of physicians generated 24% of the total payments. If plans are able to avoid these sorts of high-cost physicians, who are disproportionately clustered in a few specialties, there is the potential for real savings. How much might plans save by using a selective process to prevent high-cost physicians into their networks? Estimates vary, with some suggesting it could be as high as 25% of costs.

The outcry associated with narrow networks might be more muted if it were clear that networks were excluding only extreme high-cost outlier physicians and including physicians of similar or better quality who could provide the same services. Patients are particularly interested in having their regular source of primary care available through a plan’s network—and when that’s not the case, it raises concerns about the quality of all of the available physicians.

The lack of transparency about how plans decide who is in the network and who is excluded undermines the patients’ and physicians’ confidence in the process. What’s more, during the initial rollout of insurance exchanges, many of the participating plans provided consumers with misleading information about their physician networks. As a result, many individuals signed up for a plan that they believed would include their regular physician, only to find out afterwards that that was not the case.

Strength in Numbers

Physicians are attempting to outflank plans’ attempts to form narrow networks by forming groups with significant market control. By negotiating as a large group, physicians hope to prevent plans from being able to select among them to create narrow networks at lower rates. To further reinforce their position, physician organizations are encouraging legislators to pass “any willing provider” laws that would require plans to contract with any qualified physician.

Although these strategies maximize the potential for access, they provide high-cost physicians with a safe haven to continue practice as usual, which could undermine the effectiveness of health plans to control costs. What is needed are clear ground rules for how and when health plans should be allowed to narrow their networks, rules that would balance the competing interests of preserving access and quality while allowing for some cost controls. Health insurance exchanges might be a good place for establishing these rules, particularly in states where the exchange has already positioned itself as an active purchaser working on behalf of consumers.

Standards are needed for physician network adequacy, just as there have been standards established for different levels of insurance coverage (bronze, silver, gold, and platinum tiers). Such standards should address the number of physicians by specialty categories that are available on a population and geographic basis for the plan. For example, there are some rudimentary federal standards for the number of primary care and specialist physicians needed on a population basis that were derived from data in integrated health plans. These could be updated and perhaps modified to take the population’s health risk, geographic barriers, and other priorities into consideration when applying to the health plans in a particular state.

Out-of-pocket Costs

There should also be a routine assessment made of how a plan’s network affects out-of-pocket costs for its enrollees. Plans with overly narrow networks are likely to have more patients receiving care outside of the network, care that incurs higher out-of-pocket costs. Including these patient costs in the assessment of the actuarial value of a plan would result in a more honest valuation of a plan in an insurance exchange.

Insurers should also be required to be transparent in how they decide which physicians are included or excluded from a plan’s network. Physicians and consumers should be able to see the data on costs, quality, and other factors used to make network decisions so that there is both a shared understanding of how physicians are being evaluated and an opportunity to identify and correct erroneous information. If the decision is based on the performance of the physician’s group as opposed to the specific performance of the physician, that should be made explicit as well. Ideally, insurers would disseminate a clear set of performance standards that would let physicians and consumers know what physicians in a plan are expected to achieve in terms of access, costs, and quality in order to be a part of the plan’s network.

In the end, patients will decide if they are willing to accept narrow networks as a means of lowering health care costs. Although this approach failed in the 1990s, plans may have few alternatives as a means to control costs this time around. Faced with narrow networks or steep increases in premiums, patients may be willing to give up some amount of choice, particularly if they can be convinced that their plan is excluding physicians who are the true high-cost outliers and not the patients’ relatively low-cost primary care physicians.


About the author: Andrew Bindman, MD, is Professor of Medicine, Health Policy, Epidemiology and Biostatistics at University of California San Francisco (UCSF). He is the founder and Director of the University of California Medicaid Research Institute, a multicampus research program that supports the translation of research into policy.

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