Drone Pilots Found to Get Stress Disorders Much as Those in Combat Do

U.S. Air Force/Master Sgt. Steve Horton

Capt. Richard Koll, left, and Airman First Class Mike Eulo monitored a drone aircraft after launching it in Iraq.

The study affirms a growing body of research finding health hazards even for those piloting machines from bases far from actual combat zones.

“Though it might be thousands of miles from the battlefield, this work still involves tough stressors and has tough consequences for those crews,” said Peter W. Singer, a scholar at the Brookings Institution who has written extensively about drones. He was not involved in the new research.

That study, by the Armed Forces Health Surveillance Center, which analyzes health trends among military personnel, did not try to explain the sources of mental health problems among drone pilots.

But Air Force officials and independent experts have suggested several potential causes, among them witnessing combat violence on live video feeds, working in isolation or under inflexible shift hours, juggling the simultaneous demands of home life with combat operations and dealing with intense stress because of crew shortages.

“Remotely piloted aircraft pilots may stare at the same piece of ground for days,” said Jean Lin Otto, an epidemiologist who was a co-author of the study. “They witness the carnage. Manned aircraft pilots don’t do that. They get out of there as soon as possible.”

Dr. Otto said she had begun the study expecting that drone pilots would actually have a higher rate of mental health problems because of the unique pressures of their job.

Since 2008, the number of pilots of remotely piloted aircraft — the Air Force’s preferred term for drones — has grown fourfold, to nearly 1,300. The Air Force is now training more pilots for its drones than for its fighter jets and bombers combined. And by 2015, it expects to have more drone pilots than bomber pilots, although fighter pilots will remain a larger group.

Those figures do not include drones operated by the C.I.A. in counterterrorism operations over Pakistan, Yemen and other countries.

The Pentagon has begun taking steps to keep pace with the rapid expansion of drone operations. It recently created a new medal to honor troops involved in both drone warfare and cyberwarfare. And the Air Force has expanded access to chaplains and therapists for drone operators, said Col. William M. Tart, who commanded remotely piloted aircraft crews at Creech Air Force Base in Nevada.

The Air Force has also conducted research into the health issues of drone crew members. In a 2011 survey of nearly 840 drone operators, it found that 46 percent of Reaper and Predator pilots, and 48 percent of Global Hawk sensor operators, reported “high operational stress.” Those crews cited long hours and frequent shift changes as major causes.

That study found the stress among drone operators to be much higher than that reported by Air Force members in logistics or support jobs. But it did not compare the stress levels of the drone operators with those of traditional pilots.

The new study looked at the electronic health records of 709 drone pilots and 5,256 manned aircraft pilots between October 2003 and December 2011. Those records included information about clinical diagnoses by medical professionals and not just self-reported symptoms.

After analyzing diagnosis and treatment records, the researchers initially found that the drone pilots had higher incidence rates for 12 conditions, including anxiety disorder, depressive disorder, post-traumatic stress disorder, substance abuse and suicidal ideation.

But after the data were adjusted for age, number of deployments, time in service and history of previous mental health problems, the rates were similar, said Dr. Otto, who was scheduled to present her findings in Arizona on Saturday at a conference of the American College of Preventive Medicine.

The study also found that the incidence rates of mental heath problems among drone pilots spiked in 2009. Dr. Otto speculated that the increase might have been the result of intense pressure on pilots during the Iraq surge in the preceding years.

The study found that pilots of both manned and unmanned aircraft had lower rates of mental health problems than other Air Force personnel. But Dr. Otto conceded that her study might underestimate problems among both manned and unmanned aircraft pilots, who may feel pressure not to report mental health symptoms to doctors out of fears that they will be grounded.

She said she planned to conduct two follow-up studies: one that tries to compensate for possible underreporting of mental health problems by pilots and another that analyzes mental health issues among sensor operators, who control drone cameras while sitting next to the pilots.

“The increasing use of remotely piloted aircraft for war fighting as well as humanitarian relief should prompt increased surveillance,” she said.

Read More..

Drone Pilots Found to Get Stress Disorders Much as Those in Combat Do

U.S. Air Force/Master Sgt. Steve Horton

Capt. Richard Koll, left, and Airman First Class Mike Eulo monitored a drone aircraft after launching it in Iraq.

The study affirms a growing body of research finding health hazards even for those piloting machines from bases far from actual combat zones.

“Though it might be thousands of miles from the battlefield, this work still involves tough stressors and has tough consequences for those crews,” said Peter W. Singer, a scholar at the Brookings Institution who has written extensively about drones. He was not involved in the new research.

That study, by the Armed Forces Health Surveillance Center, which analyzes health trends among military personnel, did not try to explain the sources of mental health problems among drone pilots.

But Air Force officials and independent experts have suggested several potential causes, among them witnessing combat violence on live video feeds, working in isolation or under inflexible shift hours, juggling the simultaneous demands of home life with combat operations and dealing with intense stress because of crew shortages.

“Remotely piloted aircraft pilots may stare at the same piece of ground for days,” said Jean Lin Otto, an epidemiologist who was a co-author of the study. “They witness the carnage. Manned aircraft pilots don’t do that. They get out of there as soon as possible.”

Dr. Otto said she had begun the study expecting that drone pilots would actually have a higher rate of mental health problems because of the unique pressures of their job.

Since 2008, the number of pilots of remotely piloted aircraft — the Air Force’s preferred term for drones — has grown fourfold, to nearly 1,300. The Air Force is now training more pilots for its drones than for its fighter jets and bombers combined. And by 2015, it expects to have more drone pilots than bomber pilots, although fighter pilots will remain a larger group.

Those figures do not include drones operated by the C.I.A. in counterterrorism operations over Pakistan, Yemen and other countries.

The Pentagon has begun taking steps to keep pace with the rapid expansion of drone operations. It recently created a new medal to honor troops involved in both drone warfare and cyberwarfare. And the Air Force has expanded access to chaplains and therapists for drone operators, said Col. William M. Tart, who commanded remotely piloted aircraft crews at Creech Air Force Base in Nevada.

The Air Force has also conducted research into the health issues of drone crew members. In a 2011 survey of nearly 840 drone operators, it found that 46 percent of Reaper and Predator pilots, and 48 percent of Global Hawk sensor operators, reported “high operational stress.” Those crews cited long hours and frequent shift changes as major causes.

That study found the stress among drone operators to be much higher than that reported by Air Force members in logistics or support jobs. But it did not compare the stress levels of the drone operators with those of traditional pilots.

The new study looked at the electronic health records of 709 drone pilots and 5,256 manned aircraft pilots between October 2003 and December 2011. Those records included information about clinical diagnoses by medical professionals and not just self-reported symptoms.

After analyzing diagnosis and treatment records, the researchers initially found that the drone pilots had higher incidence rates for 12 conditions, including anxiety disorder, depressive disorder, post-traumatic stress disorder, substance abuse and suicidal ideation.

But after the data were adjusted for age, number of deployments, time in service and history of previous mental health problems, the rates were similar, said Dr. Otto, who was scheduled to present her findings in Arizona on Saturday at a conference of the American College of Preventive Medicine.

The study also found that the incidence rates of mental heath problems among drone pilots spiked in 2009. Dr. Otto speculated that the increase might have been the result of intense pressure on pilots during the Iraq surge in the preceding years.

The study found that pilots of both manned and unmanned aircraft had lower rates of mental health problems than other Air Force personnel. But Dr. Otto conceded that her study might underestimate problems among both manned and unmanned aircraft pilots, who may feel pressure not to report mental health symptoms to doctors out of fears that they will be grounded.

She said she planned to conduct two follow-up studies: one that tries to compensate for possible underreporting of mental health problems by pilots and another that analyzes mental health issues among sensor operators, who control drone cameras while sitting next to the pilots.

“The increasing use of remotely piloted aircraft for war fighting as well as humanitarian relief should prompt increased surveillance,” she said.

Read More..

In a Slight Shift, North Korea Widens Internet Access, but Just for Visitors

HONG KONG — North Korea will finally allow Internet searches on mobile devices. But if you’re a North Korean, you’re out of luck — only foreigners will get this privilege.

Cracking the door open slightly to wider Internet use, the government will allow a company called Koryolink to give foreigners access to 3G mobile Internet service by next Friday, according to The Associated Press, which has a bureau in the North.

The North Korean police state is famously cloistered, a means for the government to keep news of the world from its impoverished people. Only the most elite North Koreans have been allowed access to the Internet, and even they are watched. And although many North Koreans are allowed to have cellphones, sanctioned phones cannot call outside the country.

Foreigners were only recently allowed to use cellphones in the country. Previously, most had to surrender their phones with customs agents.

But it is unlikely that the small opening will compromise the North’s tight control of its people; the relatively few foreigners who travel to North Korea — a group that includes tourists and occasional journalists — are assigned government minders.

The decision, announced Friday, to allow foreigners Internet access comes a month after Google’s chairman, Eric E. Schmidt, visited Pyongyang, the North’s capital. While there he prodded officials on allowing Internet access, noting how easy it would be to set up through the expanding 3G network of Koryolink, a joint venture of North Korean and Egyptian telecommunications corporations. Presumably, Mr. Schmidt’s appeal was directed at giving North Koreans such capability.

“As the world becomes increasingly connected, their decision to be virtually isolated is very much going to affect their physical world, their economic growth and so forth,” Mr. Schmidt told reporters following his visit. “We made that alternative very, very clear.”

North Koreans will get some benefit from the 3G service, as they will be allowed to text and make video calls, The Associated Press said. They can also view newspaper reports — but the news service mentioned only one source: Rodong Sinmun, the North’s main Communist Party newspaper.

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Italy Set to Vote for a New Parliament

ROME — As Italian voters head to the polls on Sunday and Monday to elect a new Parliament and three regional governments, the prevailing mood is one of anger and disillusionment.

The fledgling, anti-establishment parties that campaigned on promises of radical change could benefit from the voters’ discontent, but the lack of a clear winner could also leave Italy mired in uncertainty.

“Italians feel frustration, anger, but also some hope for renewal,” said Nicola Piepoli, who runs a polling company. They are frustrated, he said, because their taxes are rising but they see no improvements in their “economic and social life,” and they are angry because candidates did not address “concrete problems” during the campaign, focusing instead on “futile, absurd things.”

“But many still hope for some change,” Mr. Piepoli added, explaining the growing support for populists like the comedian Beppe Grillo and his Five Star Movement, and for smaller parties like Civil Revolution, led by Antonio Ingroia, a former prosecutor, and Act to Stop the Decline, a movement guided by Oscar Giannino, a journalist.

Mostly though, the mood is dark among Italians fed up with protracted political scandals and disinclined to believe election promises because they are so rarely fulfilled.

(On Friday, former Prime Minister Silvio Berlusconi, campaigning to return to office, made a new promise: he said that if he won, he would personally refund an unpopular property tax paid by Italians in 2012. “I will take four billion euros of my own fortune and give it to Italians,” he said on television, a pledge of about $5.3 billion.)

“There’s no one to vote for, and if I went to the polls I’d choose the least-worst candidate, so I prefer not to vote,” said Concetta Rossi, a recruiter for hotel employees in Rome. “It’s never been this bad.”

The center-left Democratic Party, led by Pier Luigi Bersani, a low-key former industry minister, is expected to place first but is unlikely to win enough seats to govern without a coalition. The centrist movement backing the current prime minister, Mario Monti, is a possible ally, but even together they might not prevail in the Senate because the electoral law allocates seats based on regional votes. Lombardy and Sicily, where polls suggest that the right is strong, are crucial.

For the past year, Mr. Bersani, a former Communist who has played up his Catholic upbringing, has supported Mr. Monti’s reformist agenda, though sometimes grudgingly. He has backed Mr. Monti’s commitments to the European Union for greater fiscal responsibility, but would review policies that might have hurt workers and retirees.

Investors and economic analysts have their own concerns about the potential instability that could emerge in the absence of a strong government.

In its 15 months in office, Mr. Monti’s technocratic government tried to pass much-needed reforms, but it failed to stimulate the economic growth required to pull Italy out of a persistent recession. On Friday, the European Commission said in its winter forecast that Italy’s economy would shrink by 1 percent in 2013, double its November estimate.

Gains made by anti-establishment parties, including the Five Star Movement, could stall Mr. Monti’s overhauls, and a strong showing by the center-right party led by Mr. Berlusconi could derail the austerity measures meant to keep Italy on a fiscally responsible track.

“The fear remains that the general election produces a significant no-confidence vote on the current austerity plan and the need to reform further,” Raj Badiani, an economist with IHS Global Insight, wrote in a research report last week. “Without the prospect of a stable coalition government with a credible reform agenda, Italy could be forced to reconstruct a technocratic government to keep the markets at bay.”

Alessandro Amadori, the director of Coesis, which conducts marketing and opinion polls, said the “emotional mapping” of Italy highlighted the population’s “disenchantment and rage,” and even its resignation. “People don’t think that much will change. They hope for a sign, but they don’t have high expectations.”

Mr. Amadori added: “These elections will probably mark a moment of transition, rather than long-term change. Italians are looking for something that will shake things up, but what will emerge, we still don’t know.”

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Common Sense: Mindful of Bubbles as Deal-Making Boom Begins

Warren E. Buffett has teamed up with 3G Capital to buy the venerable H. J. Heinz Company for $23 billion. But the famed value investor isn’t exactly buying low: when the deal was announced on Valentine’s Day, Heinz shares were trading at a record high of nearly $61. Had Mr. Buffett and his partners bought a year ago, shares were selling for $53, a 13 percent discount.

Mr. Buffett is hardly the only buyer pursuing deals now that the stock market is hitting levels last seen in 2007. The Wilshire 5000 index recently set a record, and the Dow Jones industrial average has pierced 14,000 several times in the last three weeks.

Thomson Reuters reports that during the first two months of 2013 there have been over a thousand deals valued at almost $163 billion in total. That’s more than double the amount for the same months in 2012. If this blistering pace continues, merger and buyout deals could surpass $2 trillion in 2013, far more than the $1.57 trillion in 2007.

We all know what happened after that. From its peak in October 2007, the Standard & Poor’s 500-stock index plunged 56 percent.

“Buy low and sell high” is probably the most common adage in investing. So why do so many highly paid chief executives of acquiring companies persist in doing the opposite?

Mr. Buffett, it should be said, may be the exception that proves the rule, since he’s been among the few willing to make big deals when stocks are cheap.

His company, Berkshire Hathaway, completed a $34 billion purchase of Burlington Northern in November 2009, when the S.& P. 500 hit an 11-year low. It surely ranks as one of the best deals ever, since stocks generally, and railroad stocks in particular, have surged since then.

Mr. Buffett kept busy throughout the downturn, buying profitable stakes in Goldman Sachs and General Electric in the depths of 2008 while also bolstering investor confidence.

But even Mr. Buffett can get swept up in a deal-making frenzy. He called his 2007 investment in the Texas utility TXU bonds a “huge mistake” and “unforced error.” The $45 billion TXU buyout, led by Kohlberg Kravis Roberts, a veteran deal maker and buyout firm, still ranks as the biggest leveraged buyout ever — and may turn out to be one of the worst.

“You always see a lot of M.& A. activity when the market is overvalued,” Matthew Rhodes-Kropf, an associate professor at Harvard Business School who has studied the phenomenon and also advises private equity and venture capital firms. “Of course, you only know a market peak with benefit of hindsight. But when you look back, you’ll see a lot of M.& A. activity.”

One reason is that there has to be two sides to every deal, and, “When prices are low, sellers don’t want to sell,” Professor Rhodes-Kropf said. “They know their stock will go up with even modest growth. All they have to do is hang on.”

The same thing happened after the recent real estate crash, when owners withdrew their homes from the market rather than sell at fire-sale prices, and the number of transactions plunged.

Conversely, as stock prices rise, some executives start to worry about their ability to meet investors’ growth expectations and whether their stocks are getting overvalued, Professor Rhodes-Kropf said. A merger or buyout may provide an attractive option, both for the seller, who can cash in at a premium, and the buyer, who gets immediate revenue gains and may benefit from the growth prospects at the newly acquired company.

Professor Rhodes-Kropf’s research suggests that mergers and buyouts occur disproportionally in overvalued industries and overvalued companies.

Still, that doesn’t explain why so many mergers and buyouts occur when the stock market is as overvalued as it turned out to be in both 2000 and 2007. You’d expect sellers to be plentiful, but not buyers.

Stephen A. Schwarzman, chairman and chief executive of Blackstone Group, one of Wall Street’s best-known and most successful deal makers, told me this week that early in the merger cycle: “You typically buy companies that are in the same industry or where there’s a fit. Those deals tend to be smart, pretty reasonable, and they usually work.”

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Question Mark: Acne Common in Baby Boomers Too

Pimples are no surprise on babies and teenagers, but boomers?

You no longer have to gaze over a school lunchroom, hoping to find a seat at a socially acceptable table. You don’t rush to get home at night before your junior license driving restrictions kick in. And you men no longer have to worry that your voice will skip an octave without warning.

But if adolescence is over, what is that horrid protuberance staring at you in the mirror from the middle of your forehead? Some speak of papules, pustules and nodules, but we will use the technical term: zit. That thing on your forehead now is the same thing that was there back in high school, or at least a close relative. Same as it ever was (cue “Once in a Lifetime”).

We get more than the occasional complaint here from baby boomers who want to know about this aging body part or that. So you would think people would be happy with any emblem of youth — even if it is sore and angry-looking and threatening to erupt at any second. But oddly, there are those who are not happy to see pimples again, and some have asked for an explanation.

Acne occurs when the follicles that connect the pores of the skin to oil glands become clogged with a mixture of hair, oils and skin cells, and bacteria in the plug causes swelling, experts say. A pimple grows as the plug breaks down.

According to the American Academy of Dermatology, a growing number of women in their 30s, 40s, 50s and even beyond are seeking treatment for acne. Middle-age men are also susceptible to breakouts, but less so, experts say.

In some cases, people suffer from acne that began in their teenage years and never really went away. Others had problems when they were younger and then enjoyed decades of mostly clear skin. Still others never had much of the way of pimples until they were older.

Whichever the case, the explanation for adult acne is likely to be the same as it is for acne found in teenagers and, for that matter, newborns: hormonal changes. “We know that all acne is hormonally driven and hormonally sensitive,” said Dr. Bethanee J. Schlosser, an assistant professor of dermatology at Northwestern.

Among baby boomers, the approach of menopause may result in a drop in estrogen, a hormone that can help keep pimples from forming, and increased levels of androgens, the male hormone. Women who stop taking birth control pills may also see a drop in their estrogen levels.

Debate remains over what role diet plays in acne. Some experts say that foods once thought to cause pimples, like chocolate, are probably not a problem. Still, while sugar itself is no longer believed to contribute to acne, some doctors think that foods with a high glycemic index – meaning they quickly elevate glucose in the body — might. White bread and sweetened cereals are examples. And for all ages, stress has also been found to play a role.

One message to acne sufferers has not changed over the years. Your mother was right: don’t pop it! It can cause scarring.

Questions about aging? E-mail boomerwhy@nytimes.com

Booming: Living Through the Middle Ages offers news and commentary about baby boomers, anchored by Michael Winerip. You can follow Booming via RSS here or visit nytimes.com/booming. You can reach us by e-mail at booming@nytimes.com.

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IHT Rendezvous: North Korea Widens Internet Access, but Just for Visitors

HONG KONG — North Korea will finally allow Internet searches on mobile devices and laptops. But if you’re a North Korean, you’re out of luck — only foreigners will get this privilege.

Cracking the door open slightly to wider Internet use, the government will allow a company called Koryolink to give foreigners access to 3G mobile Internet service by March 1, The Associated Press reported.

The decision, announced Friday, comes a month after Google’s chairman, Eric E. Schmidt, visited Pyongyang and prodded officials on allowing Internet access, noting how easy it would be to set up through Koryolink’s expanding 3G network. Presumably, his appeal was directed at giving North Koreans such capability.

“As the world becomes increasingly connected, their decision to be virtually isolated is very much going to affect their physical world, their economic growth and so forth,” Mr. Schmidt told reporters after arriving at Beijing International Airport following his visit to North Korea. “We made that alternative very, very clear.”

Foreigners were only recently allowed to use cellphones in the country. Previously, they had to surrender their phones with customs agents.

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DealBook: Carlyle's Profit Fell in 4th Quarter as Growth Slowed

11:18 a.m. | Updated Most of the publicly traded private equity giants proudly reported glowing fourth-quarter earnings.

The Carlyle Group isn’t one of them.

On Thursday, the alternative investment giant disclosed a 28 percent drop in fourth-quarter profit from the period a year earlier, as the growth of its portfolio companies slowed. That sent the company’s stock down more than 8 percent by midmorning, to $33.70.

Carlyle reported fourth-quarter profit of $182 million, expressed as economic net income, compared with $254 million in the year-earlier period. That amounts to 47 cents per unit. Analysts surveyed by Capital IQ had expected about 66 cents per unit, on average.

And Carlyle’s distributable earnings, a measure the firm prefers because it tracks actual payouts to its limited partners, fell 24 percent, to $188 million. Using generally accepted accounting principles, Carlyle earned $12 million in net income.

The results fall short of those of rivals like the Blackstone Group and Kohlberg Kravis Roberts. Private equity firms in general have gained from improvements in the markets, which have lifted the valuations of their portfolios and bolstered their core business of buying and selling companies.

Carlyle attributed the decline in economic net income to a smaller appreciation in the value of its portfolio. It reported a 4 percent gain for the quarter, compared with a 7 percent increase in the period a year earlier.

The decision to delay reaping carried interest from its latest mainstay fund, Carlyle Partners V, weighed on distributable earnings. The company opted to hold off, given the relative freshness of the fund and the influx of new investments like the buyouts of the TCW Group and Getty Images.

Carlyle highlighted its strong fund-raising and gains from selling investments. The firm raised $4.6 billion in new money for the quarter and $14 billion for the year, compared with a total of $6.6 billion raised in all of 2011. It generated $6.8 billion in realized proceeds for the quarter and $18.7 billion for the year, compared with $17.6 billion in 2011.

“We had another excellent year,” David M. Rubenstein, one of Carlyle’s co-chief executives, said in a statement. “Our performance over the past two years was marked by steady, continuous progress across our business.”

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Well: Getting Patients to Think About Costs

A colleague and I recently got into a heated discussion over health care spending. It wasn’t that he disagreed with me about the need to rein in costs; but he said he was frustrated every time he tried to do so.

Earlier that week, for example, he had tried to avoid ordering a costly M.R.I. scan for a patient who had been suffering from headaches. After a thorough examination, my colleague was convinced the headaches were the result of stress.

But the patient was not.

“She wouldn’t leave until she got that M.R.I.,” my colleague said. Even after he had explained his conclusions several times, proposed a return visit in a month to reassess the situation and ran so far overtime that his office nurse knocked on the door to make sure nothing had gone awry, the patient continued to insist on getting the expensive study.

When my colleague finally evoked cost – telling the woman that while an M.R.I. might ferret out rare causes, it didn’t make sense to spend the enormous fee on something of such marginal benefit – the woman became belligerent. “She yelled that this was her head we were talking about,” he recalled. “And expensive tests like this were the reason she had health insurance.”

Face flushed, he paused to take a deep breath. “Yeah, I may be all for controlling costs,” he finally said. “But are our patients?”

According to a new study in the journal Health Affairs, his concern about patients may not be far off the mark.

A growing number of initiatives aimed at controlling spiraling health care costs have been championed in recent years, aiming to replace the current model in which doctors are reimbursed for every office visit, test or procedure performed. These programs range from pay-for-performance, where doctors can earn more money by meeting predetermined quality “goals” like controlling patients’ blood sugar or high blood pressure, to accountable care organizations, where clinicians and hospitals in partnership are paid a lump sum to cover all care.

Their uninspired monikers aside, all of these plans share one defining feature: doctors are to be the key agents of change. Whether linked with quality measures, bundled payments or satisfaction scores, it is the doctors’ behavior and choice of treatments that result in savings, goes the thinking.

But as the new study reveals, doctors need to take into account more than just symptoms and diseases when deciding what to prescribe and offer. They must also consider their patients’ opinions and willingness to be cost conscious when it comes to their own care.

The researchers conducted more than 20 patient focus groups and asked the participants to imagine themselves with various symptoms and a choice of diagnostic and treatment options that varied only slightly in effectiveness but significantly in cost. They were asked, for example, to choose between an M.R.I. or a CT scan for a severe long-standing headache, with the M.R.I. being much more expensive but also more likely to catch some extremely rare problems.

When it came to their own treatment, “patients for the most part did not want cost to play any role in decision-making,” said Dr. Susan Dorr Goold, one of the study authors and a professor of internal medicine and health management and policy at the University of Michigan in Ann Arbor. Most did not want their doctors to take expenditures into account, and many made it clear that they would ask for the significantly more expensive medications, procedures or diagnostic studies, even if those options were only slightly better than the cheaper alternatives. “That puts doctors, whose primary responsibility is to their individual patients, in a very difficult position.”

A majority of the participants refused to consider the expenses borne by insurers or by society as a whole when making their choices. Some doubted that one individual’s efforts would have any real overall impact and so gave up considering cost-savings altogether. Others said they would go out of their way to choose the more expensive options, viewing such decisions as acts of defiance and a kind of well-deserved “payback” after years of paying insurance premiums.

Underlying all of these comments was the belief that cost was synonymous with quality. Even when the focus group leaders reminded participants that the differences between proposed options were nearly negligible, participants continued to choose the more expensive options as if it were beyond question that they must be more efficacious or foolproof.

The study’s findings are disheartening. But Dr. Goold and her co-investigators believe that public beliefs and attitudes about cost and quality can be changed. They cite the dramatic transformation in attitudes about end-of-life care as an example of how initiatives to improve understanding can lead people to make higher quality and more cost-effective decisions, like choosing hospices over hospitals.

“We need to begin to talk about these issues in a way that doesn’t turn it into a discussion pitting money against life, and we need to find ways of getting people to think about not spending money on things that offer marginal benefit” Dr. Goold said. “Because it’s going to be tough otherwise trying to implement any cost-saving measures, if patients don’t accept them.”

Read More..

Well: Getting Patients to Think About Costs

A colleague and I recently got into a heated discussion over health care spending. It wasn’t that he disagreed with me about the need to rein in costs; but he said he was frustrated every time he tried to do so.

Earlier that week, for example, he had tried to avoid ordering a costly M.R.I. scan for a patient who had been suffering from headaches. After a thorough examination, my colleague was convinced the headaches were the result of stress.

But the patient was not.

“She wouldn’t leave until she got that M.R.I.,” my colleague said. Even after he had explained his conclusions several times, proposed a return visit in a month to reassess the situation and ran so far overtime that his office nurse knocked on the door to make sure nothing had gone awry, the patient continued to insist on getting the expensive study.

When my colleague finally evoked cost – telling the woman that while an M.R.I. might ferret out rare causes, it didn’t make sense to spend the enormous fee on something of such marginal benefit – the woman became belligerent. “She yelled that this was her head we were talking about,” he recalled. “And expensive tests like this were the reason she had health insurance.”

Face flushed, he paused to take a deep breath. “Yeah, I may be all for controlling costs,” he finally said. “But are our patients?”

According to a new study in the journal Health Affairs, his concern about patients may not be far off the mark.

A growing number of initiatives aimed at controlling spiraling health care costs have been championed in recent years, aiming to replace the current model in which doctors are reimbursed for every office visit, test or procedure performed. These programs range from pay-for-performance, where doctors can earn more money by meeting predetermined quality “goals” like controlling patients’ blood sugar or high blood pressure, to accountable care organizations, where clinicians and hospitals in partnership are paid a lump sum to cover all care.

Their uninspired monikers aside, all of these plans share one defining feature: doctors are to be the key agents of change. Whether linked with quality measures, bundled payments or satisfaction scores, it is the doctors’ behavior and choice of treatments that result in savings, goes the thinking.

But as the new study reveals, doctors need to take into account more than just symptoms and diseases when deciding what to prescribe and offer. They must also consider their patients’ opinions and willingness to be cost conscious when it comes to their own care.

The researchers conducted more than 20 patient focus groups and asked the participants to imagine themselves with various symptoms and a choice of diagnostic and treatment options that varied only slightly in effectiveness but significantly in cost. They were asked, for example, to choose between an M.R.I. or a CT scan for a severe long-standing headache, with the M.R.I. being much more expensive but also more likely to catch some extremely rare problems.

When it came to their own treatment, “patients for the most part did not want cost to play any role in decision-making,” said Dr. Susan Dorr Goold, one of the study authors and a professor of internal medicine and health management and policy at the University of Michigan in Ann Arbor. Most did not want their doctors to take expenditures into account, and many made it clear that they would ask for the significantly more expensive medications, procedures or diagnostic studies, even if those options were only slightly better than the cheaper alternatives. “That puts doctors, whose primary responsibility is to their individual patients, in a very difficult position.”

A majority of the participants refused to consider the expenses borne by insurers or by society as a whole when making their choices. Some doubted that one individual’s efforts would have any real overall impact and so gave up considering cost-savings altogether. Others said they would go out of their way to choose the more expensive options, viewing such decisions as acts of defiance and a kind of well-deserved “payback” after years of paying insurance premiums.

Underlying all of these comments was the belief that cost was synonymous with quality. Even when the focus group leaders reminded participants that the differences between proposed options were nearly negligible, participants continued to choose the more expensive options as if it were beyond question that they must be more efficacious or foolproof.

The study’s findings are disheartening. But Dr. Goold and her co-investigators believe that public beliefs and attitudes about cost and quality can be changed. They cite the dramatic transformation in attitudes about end-of-life care as an example of how initiatives to improve understanding can lead people to make higher quality and more cost-effective decisions, like choosing hospices over hospitals.

“We need to begin to talk about these issues in a way that doesn’t turn it into a discussion pitting money against life, and we need to find ways of getting people to think about not spending money on things that offer marginal benefit” Dr. Goold said. “Because it’s going to be tough otherwise trying to implement any cost-saving measures, if patients don’t accept them.”

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