A 2018 JAMA summary of research says, "there is now independently corroborated evidence that the HRRP [hospital readmissions reduction program] was associated with increased postdischarge mortality among patients with heart failure and new evidence that the HRRP was associated with increased mortality among patients hospitalized for pneumonia. In light of these findings, it is incumbent upon Congress and CMS to initiate an expeditious reconsideration and revision of this policy."
There is also a 2017 summary in Modern Healthcare.
Correlation between Low Readmissions and High Death Rates
Heidenreich et al. pubmed.gov/20650356
(2010) Journal of the American College of Cardiology, 56(5), 362-368.
Gorodeski, et al. pubmed.gov/20647209
(2010) New England Journal of Medicine, 363(3), 297-298.
American Hospital Association aha.org/research/reports/tw/11sep-tw-readmissions.pdf
(2011) Trendwatch September 2011
Krumholz et al. pubmed.gov/23403683
(2013) Journal of the American Medical Association. 2013 Feb.13; 309(6): 587–593.
Gilman et al. pubmed.gov/25092831
(2014) Health Affairs, 33, no.8 (2014):1314-1322
A 2015 CDC study found higher death rates from heart failure after the readmission penalties started. Their data cover both hospitalized and non-hospitalized patients, so they include the effect of less hospital treatment for heart failure, driven by penalties.
A 2018 JAMA study found higher death rates after the readmission penalties started, primarily in heart failure patients, and to some extent in pneumonia patients treated in hospitals. The paper's findings are strong, but the summary hides those findings: The paper says, "45-Day Postadmission Mortality... HRRP announcement was significantly associated with an increase in mortality" but the summary says, "Given the study design and the lack of significant association of
the HRRP with mortality within 45 days of admission, further research is needed." Then they refuse to say what kind of research would be more conclusive than the research so far. I asked, "Would you support removing penalties for a large random sample of hospitals for 20 years? Something else?" and they were silent.
Deaths Caused by a Program to Avoid Readmissions:
Fan et al. pubmed.gov/22586006
(2012) Annals of Internal Medicine 2012 May 15; 156(10):673-83
Joynt et al. pubmed.gov/21325183
(2011) Journal of the American Medical Association. 2011 Feb 16;305(7):675-81
Rodriguez et al. pubmed.gov/21835285
(2011) American Heart Journal. 2011 Aug;162(2):254-261.e3
Joynt et al. pubmed.gov/23340629
(2013) Journal of the American Medical Association. 2013 Jan 23;309(4):342-3
Dr Ashish Jha, of Harvard's School of Public Health, told PBS, "If you look at, for instance, the U.S. News [and World Report] publishes its list of top 50 hospitals. Those hospitals tend to have very low infection rates, very low mortality rates, very low death rates. Guess what? They tend to have very high readmission rates, because they do such a good job of keeping their patients alive that many of them are readmitted."
Dr. Sunil Kripalani, of Vanderbilt University Medical Center told Fox News, "Among patients with heart failure, hospitals that have higher readmission rates actually have lower mortality rates. So, which would we rather have -- a hospital readmission or a death?"
Direct URL: drugs.globe1234.com
Patients can get independent information on drugs and medical devices from sites listed farther down on this page (many track your IP address; you can check their privacy statements).
A. This page is not about substance use disorders, but here are 2 resources
The sources in italics below cover medical devices, like pacemakers, artificial joints, lenses, etc. as well as drugs. FDA has a search box for US recalls of medical devices, and the press has an international list. Many devices have serious problems, and experts advise finding how many patients a device was tested on, how many times your doctor has installed it, and how it can be removed if necessary, before getting it implanted.
B. GENERAL SITES ON DRUGS AND MEDICAL DEVICES:
Advice from WorstPills.org, the first site below:
D. Electronic Prescriptions
There are two big problems when doctors send prescriptions to pharmacies electronically. This is more reliable than hand-written faxes, but:
Cancellation orders are crucial to correct mistakes and cancel refills. Patients can overdose when they keep getting the old medicine after the doctor orders a new one. Only a third of prescribers and 40% of pharmacies use software certified to handle cancellations, so less than a third of cancellations can go through. "Electronic health records allow prescribers to stop a prescription, but what many physicians may not realize is that in most cases that directive is not sent to any pharmacy," even though original prescriptions are reliably sent. Some doctors put cancellation orders in the notes of a new prescription, where many pharmacists will not see it.
Health systems like the Veterans Health Administration and Kaiser Permanente can cancel electronically, where prescriber and pharmacy are in the same organization. Otherwise only 5 pharmacy chains accept e-cancellations (CancelRx):
No other chain is certified for e-cancellation, such as Walgreens ($57 billion of US prescriptions) and Walmart ($19 billion). Consumer Reports unfortunately recommends Costco and Sam's Club for price (uncertified), Walgreens for its apps (uncertified), and supermarket chains for convenience (only Kroger's is certified). CR should know better.
Doctors can cancel electronically only if their software is certified under "CancelRx". Out of 954 systems, only 156 are marked as certified, and usually only the latest updates. If your doctor is part of a large group, you can ask the group to ensure its software gets certified and updated. Individual doctors have little control. CancelRx is getting more widespread, but the sponsor, Surescripts, is not willing to say how many doctors or pharmacies use it.
Automatic refills are even more dangerous. When pharmacies call patients to say, "Your prescription is ready," patients and callers do not know whether the doctor recently ordered it or it is a zombie renewal. Costco, CVS, RiteAid and Walgreens encourage patients to sign up for automatic refills, so patients at Costco and Walgreens (two which lack e-cancellations) can get undesired medicine for long periods, thinking their doctor ordered it.
Prior authorization for prescriptions is a system where an insurer tells a pharmacy that a doctor needs to send the insurer detailed information and get the insurer's approval for the prescription. Insurers tell pharmacies, not doctors or patients, when prior authorization is needed, and pharmacies say they have no obligation to tell doctors, though they have the forms and information which the doctor needs, and no one else does. A Massachusetts court says pharmacies must tell doctors, and a doctor says the entire circuitous system of prior authorization for drugs kills patients.
F. Cost and Number of Prescriptions, Overall, and for Each Doctor
Dr. David Belk has clear data on wholesale (NADAC) and retail costs of generic and branded drugs (from GoodRx) and what drives the costs.
Drug stores in half the states are not allowed to volunteer to you that the cash price is less than your co-pay, but the other half of states have laws letting them tell you. You can always ask anyway.
Drugs are distributed to retail pharmacies primarily by three companies: AmerisourceBergen, Cardinal, and McKesson, which have paid small fines, relative to their revenue, for not reporting excessive deliveries of opioids.
You can find the number of drug prescriptions from each doctor and costs for Medicare patients in at least 2 places, described below. For non-Medicare prices see above.
ProPublica has Medicare Part D cost for each drug: number of prescriptions and total spending. You can get separate totals for US and each state, so you can get average cost per prescription, and for each doctor who prescribed a drug 50 or more times in 2013.
Medicare itself has more complete Part D data. The US and state summary files (bottom of the link) show for each drug: the number of beneficiaries as well as prescriptions and spending, so you can get average per beneficiary (total during a year), as well as per prescription for each drug.
Medicare's detailed files show number of days prescribed, so you can get average cost of a daily dose, as well as each doctor who prescribed a drug 11 or more times in 2013. This info is in 23 million records, without state or US summaries. However you can get good state and national estimates by opening any of their 36 spreadsheets (divided by last name of prescriber) and getting averages there. The average costs do not vary much by last name of prescriber. (Tips for working with large spreadsheets)
Some doctors and drugs typically have 30-day or 90-day prescriptions, which may be renewed all year. Their averages include the cost for each whole long prescription (30 or 90 days). Docs & drugs with shorter prescriptions only include that lower cost. Medicare's focus seems to be on cutting total costs, not cost per dose.
ProPublica's methodology says it has "retail cost" for these prescriptions.
Medicare's fact sheet gives more detail, saying it includes,
After seeing which drugs a doctor prescribes, you can find drug safety and effectiveness from the sources at the top of the page.
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