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Anish Koka, MD

@anish_koka

Mar 25

The Cost Conundrum was an article written in 2007 in the New Yorker by famed surgeon and author, Atul Gawande that sought to explain the high cost of American medical care.

It was inspired by data from a health policy researcher from Dartmouth named Eliot Fisher. Fisher’s group had mapped Medicare spending of every county in the U.S.

McAllen, Texas had the distinction of having the second highest per capita Medicare spending in the country, and it was this town Gawande traveled to, to write his article.

Gawande, an academic surgeon from one of the elite medical centers in America wrote with some distaste of a two filled with strip malls with small independent private practices dotting the landscape that were making handsome profits by billing fee for service Medicare to the max.

Gawande provided a stark contrast to this low value, profit driven care by traveling to a high value, low cost county — the Mayo Clinic.

A visit to a surgeon’s clinic at the Mayo Clinic told the story of an hour long discussion with a patient followed by a cardiologist materializing within 15minutes from another floor to help ready a patient for surgery the next day.

How did they do this?

Gawande’s words :

“..decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially possible.
No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.”

The answer to the health care cost problem lay in this elegant article. The plan as initially forwarded by Eliot Fisher from Dartmouth and now gracing the pages of the New Yorker was to create “Accountable Care Organizations” in the image of the Mayo Clinic.

Convert McAllen, Tx to Rochester, MN and the nations problems would be solved.

As a young medical trainee reading his article, I was sold.

But I never stopped to think of how Mayo was operating in this manner. How could a surgeon at Mayo afford to spend a whole hour with a patient? How exactly does a cardiologist have time to run down in the middle of the day to discuss a complicated patient? If the cardiologist doesn’t bill the consultation, how is the cardiologist being paid?

1/x

Gawande never provided these details, and more importantly no one of any importance asked these questions.

“The Cost Conundrum” was required reading for the framers of the ACA, and so health care was reimagined and jiggered to make winners out of large health care systems. Cuts from CMS targeted private practice reimbursement. Regulations that required reporting of practices through an electronic health record were applied. The incentives quickly melted away to become penalties. Private practitioners faced a choice : accept the lump of coal or join a hospital. Most fled to hospitals, dotting the landscape with soup to nuts health care systems and realizing the dream Gawande had written about.

Except, Gawande and his adoring readers (that would include me) had been hoodwinked. The secret sauce for this high value care being provided to patients by the very best in the field wasn’t in the Medicare data that Eliot Fisher’s group in Dartmouth had put out. The drunk looking for keys under the lamp post doesn’t find his keys for a reason. The keys in this case was where no one was looking – payments from private insurers.

2/x

Just down the road from where I grew up, another group of researchers at Carnegie Mellon University published a paper based on claims data from private insurers that showed a much more complex landscape than the Eliot Fisher data had presented.

The dollars paid by private companies was multiple of what was paid by medicare. A knee MRI paid by private insurers was $1331, Medicare paid $353. Even more startling was how Rochester, MN ranked relative to its peers in per capita cost.

While Rochester, MN was a bargain when it came to Medicare spending per beneficiary, it was one of the most expensive markets when it came to private spending per beneficiary. The other large vertically integrated health systems (Grand Junction, CO – La Crosse, WI) that Gawande had highlighted? Also some of the most expensive on the private market.

Apparently, creating large integrated health system created a monopoly that could effectively name its price for the services it was rendering. Medicare gets to set its prices – the private insurers have to negotiate with providers. The fewer health systems in a county, the higher the prices negotiated. THIS is what was paying for one hour patient visits with a surgeons and made Cardiologists materialize out of thin air. The idea that any of these large health systems were low cost was a myth.

3/x

Read 5 tweets

Anish Koka, MD

@anish_koka

Nov 21, 2024

Thread on Medicare Advantage denials

1. MA denies an MRI to follow up / characterize a suspicious adrenal mass seen on a CT

2. MA denies a walker to a 76 year old polio survivor because he received a cane in the past 5 years

3. MA denies radiation treatment to a patient with a pancreatic tumor because no prior authorization had been submitted (it had been submitted)

Read 7 tweets

Anish Koka, MD

@anish_koka

Mar 23, 2024

Comments / summary on Pfizer subclinical myocarditis study

Overall really confusing

Group 1: 1487 total randomized to Pfizer vs placebo, troponin done at baseline, post usual dose (30mg)

Group 2 : Broken into 2 bc EUA for 12-15 arrived during trial, so majority of 12-15 unblinded and took Pfizer vaccine
🧵

Troponin tested pre and post vaccine dose.

Rather than show individual baseline troponin and rise after placebo vs drug , results shown in summary format, so cannot track individual rise In tn

1st study eligibility criteria is Pts who had received 2 or 3 doses of Pfizer > 4 months prior.

I assume patients who had myocarditis with 1st 2 doses are not rushing to enroll in this trial

Read 8 tweets

Anish Koka, MD

@anish_koka

Mar 8, 2024

Ok. So my summary on the @Change_HC @Optum @UHC cyberattack debacle.

TL,DR : Govt. regulation creates billion dollar revenue streams for large corporations. Regulatory capture by large organizations means a healthcare system that is incredibly susceptible to single points of failure, and most of the players in the space have no clue/ don't really care!

🧵

Feb 21, 2024, cyberhackers compromise @Change_HC (formerly Emdeon, acquired a few years prior by @UHC for $13billion).

@Change_HC is the largest medical clearing house that takes electronic claims generated by hospitals and doctors offices , scrubs them, and puts them in a format that insurance companies accept. Insurance companies process claims, and make payments to hospitals and doctors.

The first reaction of @Change_HC is to disconnect from all of its clients, which means, no medical claims are processed to be delivered to insurance companies.

Change HC / United then proceeds to say absolutely nothing of substance for the next 2 weeks with regards to any timeline of coming back online

Read 15 tweets

Anish Koka, MD

@anish_koka

Oct 2, 2023

https://twitter.com/ichudov/status/1708534667261972962

If you have a deep seated fear of COVID you will instinctually seize on any study that confirms that bias.

If you fear the vaccines, you instinctually will want to believe data that confirms that bias.

Neither approach will get you close to the truth

🧵

https://twitter.com/ichudov/status/1708534667261972962

If the goal is truth, then the real bias everyone should lean into is against the academic-peer-review industrial complex that spends most of its time generating data that doesn’t replicate and then exacerbates the problem with hyperbolic conclusions

“If the only tool you have is a hammer, you tend to see every problem as a nail.”

Academia is full of people who have spent 20 years becoming masters of a particular domain that usually has no practical, real world application.

Read 14 tweets

Anish Koka, MD

@anish_koka

Sep 30, 2023

The coverage of this wildly speculative paper linking sars-cov2 is much worse than the actual paper is.

To give you a flavor.

The study is based on 8 autopsies of patients with a diagnosis of COVID.

Let’s take Patient 1.

🧵

59 year old black man with a history of CAD.

He was admitted to the hospital 3 times before dying.

Hospitalizations 1 was with a clot in his lungs. His only treatment was heparin and xarelto. This means he didn’t present with a COVID pneumonia.

Hospitalization 2 was listed for heart failure. His ejection fraction was 40-45%. He spent 5 days in the hospital. He was still COVID positive.

Hospitalization 3 was with an acute heart attack. A circumflex artery occlusion associated with rupture of a component of the mitral valve — the papillary muscle. He was now COVID negative. He died of the heart attack and resultant heart failure, I assume.

The authors of this study took coronary artery tissue and looked for evidence of sars-cov2

They show representative samples of tissue in their main figure. They do not , even in their supplement, show all tissue sampled and stained.

The presence of sars-cov2 rna In patients who were infected by itself doesn’t mean much, but researchers probed tissue for the antisense strand of the S gene (S antisense), which is only produced during viral replication.

Read 10 tweets

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