Radiology price variation, the limits of virtual care, prevalence of mental health challenges, and rundown on current communicable diseases
October 28, 2022
Today, I’ll cover transparency data showing huge variations in the prices of imaging tests, a study showing that following up an emergency department visit with a virtual primary care visit wasn’t very effective at preventing returns to the emergency department, a survey showing how pervasive mental health issues are, and will review what employers need to know about the many different infectious diseases blaring from the headlines.
1. Huge variation in allowable prices for CT and MRI services
Researchers reported in Radiology that commercial insurance negotiated prices for 13 shoppable radiology services had enormous variation - not only within each hospital, but even among different health plans operated by the same medical carrier at the same hospital. The study is limited to hospitals that disclosed their prices on the platform Turquoise Health. The researchers found that variation was highest for services like MRI and CT scans that have high fixed costs.
Implications for employers:
- The U.S. system pricing system is remarkably opaque. Hospital transparency regulations are finally beginning to lift this veil on pricing, and insurance transparency rules should make it easier for technology companies to display prices.
- Studies show that patients are generally NOT effective at shopping even for “shoppable” services, but availability of prices could help carriers and employers fashion health plans that will “steer” more of their members to providers with lower unit cost.
2. Telehealth visits after emergency department discharges didn’t help prevent new emergency room visits or hospital admissions.
Emergency department (ED) utilization crept up in the decade before the pandemic. ED use plummeted in the early pandemic, but is now back up to pre-pandemic levels. Those who leave the ED with an appointment for a follow-up appointment generally are less likely to return to the ED. Researchers from UCLA report that those patients who had follow up visits with their primary care physicians via telemedicine were significantly more likely to return to the ED or get admitted compared to patients who had in-person PCP follow-up visits.
This study didn’t randomize patients, and those who had telemedicine follow-up on average were more likely to be younger and women. The higher rate of returning to the hospital remained after the researchers statistically adjusted for age and gender and illness acuity. It’s possible there were other differences between the two groups, including differences in home support or other services individuals may have tapped into.
Implication for employers:
- Virtual visits play an important role in increasing access (especially in mental health). This study shows we need to remain cautious and continue to study whether outcomes from these visits are equivalent to in-person visits.
3. More than half of adults say they have experienced a mental health crisis in their families
KFF, formerly the Kaiser Family Foundation, published results from the Mental Health in America survey it completed with CNN earlier this month, and found that 28% of respondents said a family member received inpatient mental health treatment, 21% reported a family member had a drug overdose requiring medical attention, and 16% said a family member had died by suicide. Twenty one percent of respondents reported that they had received mental health are in the last year. In a separate question, 27% said that they had not received mental health care or medications when they thought they might need it. Here is a link to the full survey results.
Source: KFF, 10/13/22 LINK
The polling researchers did not define “family,” but this gives us a sense of the pervasiveness of the mental health crisis. One in six reporting that someone in their family died by suicide might seem high, but suicide is in the top four causes of deaths for every age group from ages 10 to 44.
Implications for employers:
- Mental health continues to pose a challenge which has worsened since the beginning of the pandemic.
- The Surgeon General just released a report on workplace mental health and wellbeing. The report, which includes five case studies of organizations that have succeeded in better addressing the mental health needs of their employees, focuses on protecting workers from harm, providing connection and community, work-life harmony, and giving workers a sense of purpose and opportunities for growth.
- Employers should publicize the 988 crisis line for suicidal individuals
4. What employers should know now about the many different infectious diseases in the headlines
Even as pandemic restrictions have lifted and much travel has returned, we are inundated with reports of various infectious diseases in the US and around the world that could threaten our health over the coming months. Here’s a rundown:
a) COVID-19
Rates of COVID-19 infections remain high, and there are still over 25,000 in US hospitals and over 3,000 in ICUs with COVID. Deaths remain under 400 daily and continue to be concentrated in older adults. Yes, many of us who were vaccinated got infected - but the data that vaccines and boosters prevent infections remains robust.
Only 20 million Americans have had the bivalent boosters so far, which are targeted to the current dominant strain (BA.5), which has a similar spike protein to BQ.1 and BQ.1.1 which are rising in frequency. All those ages 5 and up who have had the primary series at least two months ago should get the booster - don’t wait! Those who recently recovered from COVID-19 can wait until three months after their recovery.
The White House just released a two-page playbook for how businesses can protect their workers at this time. Suggestions include on-site vaccinations, paid time off for vaccinations, communication about other treatment like oral antiviral pills, and a focus on improving indoor air quality at the workplace.
b) Influenza
All signs are pointing to a rough influenza season. Again, the best approach is to get vaccinated, and the time to get vaccinated is now. Many employers are running flu shot clinics, and most employers cover influenza vaccines with no member cost at both pharmacies or physician offices to make this as convenient as possible. In the early pandemic, infection with influenza and COVID-19 simultaneously led to worse outcomes.
Companies can encourage hand washing, and efforts to increase indoor ventilation can lower risk. Masks provide protection against influenza, too.
c) RSV
Rates of infection with RSV, also called respiratory syncytial virus, are now spiking in much of the United States. This illness largely impacts infants and the elderly and can be life-threatening for premature babies and those with compromised immune systems.
High-risk infants can receive a protective monthly monoclonal antibody (palivizumab) infusion during RSV season. Unfortunately, this drug is exceptionally expensive and supplies are limited. It is currently recommended only for preterm infants born at less than 29 weeks during their first year of life and premature infants who have severe chronic heart or lung disease. A clinical trial is underway for a promising vaccine for high risk adults.
Employers could see increased medical costs due to this spike in RSV cases, and more employee time away from work taking care of sick children and addressing childcare issues when there has been an outbreak in a preschool.
The combination of the respiratory viruses RSV, influenza, and SARS CoV2 (which causes COVID-19) have been dubbed the “tripledemic,” and patients who are infected with more than one of these at the same time are at higher risk of poor outcomes.
d) Monkeypox
New cases continue to decline, and vaccination is becoming more readily available. Monkeypox generally requires skin-to-skin contact, so risk of workplace transmission remains very low. Although the vast majority of cases are in men who have sex with men, there have also been cases in women and children. Those at risk for monkeypox can receive the Jynneos vaccine through some providers; each state health department has epidemiologists who can answer employer questions, and can provide a list of vaccination sites. Here is a link to a crowdsourced vaccine locator.
e) Ebola
There have now been over 100 cases of Ebola in Uganda, including in Kampala, the country’s capital. Ebola is highly contagious through exposure to bodily fluids and is associated with high mortality rates (25-90%). There is currently no pharmacologic treatment for the species causing the outbreak in East Africa, and epidemiologists fear that Ebola will continue to spread further. An trial of an experimental vaccine will likely be started in the coming weeks.
Symptoms of Ebola (fever, chills, headache, fatigue, vomiting, diarrhea, loss of appetite, and rash) sometimes appear three weeks after exposure, and the US now requires travelers who have been in Uganda in the previous 21 days to be routed to one of five airports for screening before entry. The U.S. does not require any quarantine period prior to entry. There are no reported cases outside of Uganda at this time, so Ebola is likely to have no impact on the vast majority of employers.
f) Fungal Infections
The Wall Street Journal recently reported on “deadly fungi.” Fungal infections have traditionally been a serious risk for immune suppressed patients. Some fungal infections are prevalent in a larger geographic area, likely due to the changing climate. That, combined with some strains of fungus resistant to currently available therapies, means that some individuals, even those without severe underlying disease, have been infected with infections which are harder to treat.
This will likely not cause a widespread impact on employee health or employer cost of care in the near term.
Hope that all have a good and safe weekend, and a Happy Halloween.
Jeff