Kevin R. Riggs

Why Is There No Generic Insulin? Historical Origins of a Modern Problem

Six million U.S. patients with diabetes take insulin, which was discovered in 1921 — yet is available only in brand-name forms. The reasons why an agent discovered almost 100 years ago is still unavailable as a low-priced generic have implications for policy and practice.

Overcoming Barriers to Discussing Out-of-Pocket Costs With Patients

Increased cost sharing, in the forms of higher co-payments, deductibles, and yearly maximums, has been advocated to encourage patients to become smarter consumers and thus to reduce the overall cost of medical care. High out-of-pocket costs, however, can cause care to be delayed or foregone and can lead to financial distress and even bankruptcy. Some argue that physicians should be more cognizant of their patients’ out-of-pocket costs, not for the sake of society but for the sake of the patient.1 In our view, physicians have an ethical duty, at a minimum, to discuss out-of-pocket costs with patients in the same way that they would discuss the adverse effects of a treatment.2 But when physicians actually begin to consider out-of-pocket costs as part of clinical decision making, the challenges can seem overwhelming. We examine potential barriers to discussing out-of-pocket costs with patients and provide guidance on how physicians can overcome these barriers.

Providing Price Displays for Physicians: Which Price Is Right?

Price transparency is gaining momentum as one way to address the cost crisis in U.S. health care. Attention frequently focuses on patients’ awareness of prices.1 Less attention has been given to initiatives designed to increase physicians’ awareness. Recent research demonstrates that displaying prices to physicians reduces expenditures2,3 and is well-received by physicians.3 Price displays are also being used to teach cost-consciousness in medical education.4 However, prices are notoriously variable, and “price” can have multiple potential meanings (e.g., cost of service provision, cost plus profit, charges, or expected reimbursement, among others). To illustrate, consider three general sources that might be considered for displaying the “price” of certain tests (Table). In this example, potential displayed amounts vary as much as tenfold. Table Examples of possible prices (rounded to the nearest dollar) Which “price” is right? Implementing price displays requires more than knowing only whether doing so effectively decreases expenditures. In this Viewpoint we suggest that several ethical values should be considered to guide the design and implementation of providing price displays to physicians. While recognizing its sometimes ambiguous use in this context, we refer simply to “price” throughout; our goal is to offer ethical clarity on choosing an amount to display.

Effect of Prescription Drug Coupons on Statin Utilization and Expenditures: A Retrospective Cohort Study

Drug coupons are widely used, but their effects are not well understood.

Navigating Ethical Tensions in High-Value Care Education

Enthusiasm for high-value care is increasing throughout health care, including in the education of medical students, residents, and fellows.1 Until recently, there were few examples of educational programs that equipped future physicians with the tools required to practice high-value care or even consider the cost of care they deliver. In fact, future physicians were encouraged to provide care that could be considered as quite the opposite—academia often instilled excess over restraint, celebrating trainees who generated (and tested for) the broadest differential diagnosis. Because physicians who train in high-spending regions subsequently provide more costly care than those who train in low-spending ones,2 medical school and residency are critical times to teach high-value care. Despite the enthusiasm, inherent to the concept of value are potential ethical tensions between patient and societal interests, and different approaches to increasing value may be controversial. In this Viewpoint, we describe this tension in the context of highvalue care education and suggest that physicians’ primary commitment to patient welfare and the process

Can Appealing to Patient Altruism Reduce Overuse of Health Care Services? An Experimental Survey

BackgroundA challenge to reducing overuse of health services is communicating recommendations against unnecessary health services to patients. The predominant approach has been to highlight the limited benefit and potential harm of such services for that patient, but the prudent use of health resources can also benefit others. Whether appealing to patient altruism can reduce overuse is unknown.ObjectiveTo determine whether altruistic appeals reduce hypothetical requests for overused services and affect physician ratings.DesignExperimental survey using hypothetical vignettes describing three overused health services (antibiotics for acute sinusitis, imaging for acute low back pain, and annual exams for healthy adults).ParticipantsU.S. adults recruited from Research Now, an online panel of individuals compensated for performing academic and marketing research surveys.InterventionsIn the control version of the vignettes, the physician’s rationale for recommending against the service was the minimal benefit and potential for harm. In the altruism version, the rationale additionally included potential benefit to others by forgoing that service.Main MeasuresDifferences in requests for overused services and physician ratings between participants randomized to the control and altruism versions of the vignettes.Key ResultsA total of 1001 participants were included in the final analyses. There were no significant differences in requests for overused services for any of the clinical scenarios (P values ranged from 0.183 to 0.547). Physician ratings were lower in the altruism version for the acute sinusitis (6.68 vs. 7.03, P = 0.012) and back pain scenarios (6.14 vs. 6.83, P < 0.001), and marginally lower for the healthy adult scenario (5.27 vs. 5.57, P = 0.084).ConclusionsIn this experimental survey, altruistic appeals delivered by physicians did not reduce requests for overused services, and resulted in more negative physician ratings. Further studies are warranted to determine whether alternative methods of appealing to patient altruism can reduce overuse.

Physicians' Dual Agency, Stewardship, and Marginally Beneficial Care

The high cost of health care in the United States is commonly called a crisis. Nearly everyone agrees that physicians—by virtue of their prescription pens or, increasingly, their mouse clicks—shoul...

Surgeons’ views on preoperative medical evaluation: a qualitative study

BackgroundThere is substantial variation in the practice of preoperative medical evaluation (PME) and limited evidence for its benefit, which raises concerns about overuse. Surgeons have a unique role in this multidisciplinary practice. The objective of this qualitative study was to explore surgeons’ practices and their beliefs about PME.MethodsWe conducted of semi-structured interviews with 18 surgeons in Baltimore, Maryland. Surgeons were purposively sampled to maximize diversity in terms of practice type (academic vs. private practice), surgical specialty, gender, and experience level. General topics included surgeons’ current PME practices, perceived benefits and harms of PME, the surgical risk assessment, and potential improvements and barriers to change. Interviews were audio-recorded and transcribed. Transcripts were analyzed using content analysis to identify themes, which are presented as assertions. Transcripts were re-analyzed to identify supporting and opposing instances of each assertion.ResultsA total of 15 themes emerged. There was wide variation in surgeons’ described PME practices. Surgeons believed that PME improves surgical outcomes, but not all patients benefit. Surgeons were cognizant of the financial cost of the current system and the potential inconvenience that additional tests and office visits pose to patients. Surgeons believed that PME has minimal to no risk and that a normal PME is reassuring to them and patients. Surgeons were confident in their ability to assess surgical risk, and risk assessment by non-surgeons rarely affected their surgical decision-making. Hospital and anesthesiology requirements were a major driver of surgeons’ PME practices. Surgeons did not receive much training on PME but perceived their practices to be similar to their colleagues. Surgeons believed that PME provides malpractice protection, welcomed standardization, and perceived there to be inadequate evidence to significantly change their current practice.ConclusionsViews of surgeons should be considered in future research on and reforms to the PME process.

Prevalence and Cost of Office Visits Prior to Colonoscopy for Colon Cancer Screening.

This study uses employer-sponsored private insurance claims data to determine the proportion of colonoscopies for colon cancer screening and polyp surveillance that were preceded by office visits and the associated insurance payments for those visits between 2010 and 2013.

Discordant Thymectomy in Identical Twins Concordant for Myasthenia Gravis

BACKGROUND Thymectomy is standard therapy fornonthymomatousmyasthenia gravis despite the absence of randomized clinical trials (1). Myasthenia gravis is uncommonly reported in monozygous twins; disease concordance occurs in approximately one third of such identical twin pairs; and treatment for myasthenia gravis, when described,is usually concordant in identical twin pairs (2). OBJECTIVE To report an 11-year clinical course of a pair of identical twins concordant for generalized acetylcholine receptor antibody–positive nonthymomatous myasthenia gravis in whom only 1 was treated with extended transsternal thymectomy. CASE REPORT Twin A was a 19-year-old white woman who presented with an 8-week history of intermittent leg weakness, causing her to fall during activities, such as climbing stairs. On examination,she had moderately severe fatigable proximal muscle weakness and ptosis. Her weakness improved with intravenous edrophonium administration.Initial binding acetylcholine receptor antibody titer was 1.22 nmol/L (normal value, 0.03 nmol/L). Repetitive 2-Hz nerve(median, ulnar, and facial) stimulation studies demonstrated up to a 16% decremental response. Chest computed tomography showed residual thymic tissue without thymoma. An extended transsternal thymectomy was performed 11 weeks after the onset of symptoms.