NEW @ THCB PRESS: Surviving Workplace Wellness. Spring 2014. Al Lewis and Vik Khanna. e-book edition. # LIGHTHOUSE Healthcare. Illuminated.

Medicaid

Avik Roy has done the unthinkable. In a recent op-ed title he used “conservative’s case” and “universal healthcare” in the same sentence. And bridged these disparate words by the preposition for.

Spoiler alert: Roy has asked Republicans to embrace universal healthcare.

The Twitterverse is abuzz. An angry Gary P. Jackson, a self-affirmed conservative, tweeted:

“there is NEVER a conservative case for Marxism….especially Universal healthcare.”

Stated differently, universal healthcare is the worst form of Marxism except for all other forms of Marxism.

Thus far Roy has not been asked to produce his birth certificate, which is just as well. Roy, a prolific Forbes columnist and a scholar at the Manhattan Institute, was healthcare policy adviser to Mitt Romney. He is not a cheerleader of the Affordable Care Act.

There are things one may disagree with Roy. However, his short treatise, How Medicaid Fails the Poor, was impressive, as it deftly dealt with Medicaid’s structural problems. That a right-of-center policy analyst would write a book with that title is one of the many ironies I am now accustomed to encountering (the other delicious irony was the love of Cadillac health plans by unions).

In The Washington Examiner and National Review Online, Roy urges conservatives to acknowledge and embrace universal healthcare, in no uncertain terms:

“…[conservatives] have to agree that universal coverage is a morally worthy goal.”

The arguments put forward by Roy are pure common sense. No one objects to public education as “socialized education.”  If conservatives are afraid that universal healthcare means big government, government is already heavily involved in healthcare.

And not just Medicare, which a certain tea party placard asked the government to keep its hands off!
Continue reading “The Conservative’s Faustian Fear”

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“Extraordinary claims require extraordinary evidence,” said Carl Sagan.

The claim that health insurance improves health outcomes is hardly ground breaking. Studying whether insurance affects health status is like wondering whether three meals a day lead to a higher muscle mass than total starvation.

Well that’s what I thought. Until I read the study on Oregon’s Medicaid program by Baicker and colleagues in the NEJM earlier this year and, more recently, Avik Roy’s short treatise “How Medicaid Fails the Poor”.

Baicker et al found that Medicaid enrollees fared no better in terms of health outcomes than those without insurance. That is, no insurance no difference.

The study is an exemplar of policy research laced with regression equations, control of known confounders and clear separation of variables. There is only so much rigor social science can achieve compared to the physical sciences. Yet this is about as good a study as is possible.

The one thing the study did not lack was sample size. It’s useful to bear in mind sample size. Large effects do not need a large sample size to show statistical significance. Conversely, if study with a large sample size does not show even a modest effect, it means that the effect probably does not exist.

There are several interpretations of the Medicaid study, interpretations inevitably shaped by one’s political inclination. The ever consistent Paul Krugman, consistent in his Samsonian defense of government programs against philistines and pagans, extolled critics of Medicaid as “nuts” and asked, presumably rhetorically, “Medicaid is cheaper than private insurance. So where is the downside?”

Unlike Krugman I am not a Nobel laureate and am about as likely to win a Nobel Prize as I am of playing the next James Bond, so it’s possible that I am missing something blatantly obvious.  Could the downside of a government program paying physicians, on average 52 cents, and as low as 29 cents, for every dollar paid by private insurance in a multiple payer system be access?

Indeed, it’s darn impossible for patients on Medicaid to see a new physician.  As Avik Roy explains “…massive fallacy at the heart of Medicaid….It’s the idea that health insurance equals healthcare”.

But wait. It gets better.

I am accustomed to US healthcare throwing more plot twisters than Hercule Poirot’s sleuth work. But one I least expected was that patients on Medicaid do worse than patients with no insurance (risk-adjusted, almost). I am not going to be that remorseless logician, which John Maynard Keynes warned us about, who starting with one mistake can end up in Bedlam, and argue that if you are for Medicaid that is morally equivalent to sanctioning mass murder. Rather, I ask how it is possible that possessing Medicaid makes you worse off than no insurance whatsoever.

To some extent this may artifactually appear so because poverty correlates with ill health, and studies that show Medicaid patients faring worse than uninsured, cannot totally control for social determinants of health.

Continue reading “How Can Patients on Medicaid Possibly Be Worse Off than Those Who Don’t Have Insurance?”

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If you wanted to know what doctors thought about money and medical practice, including plumber envy, you’d read American Medical News(AMN). That’s the biweekly newspaper the American Medical Association just announced it’s shutting down.

Unlike JAMA, in which doctors appear as white-coated scientists, AMN focused on practical and political issues, not least of which was the bottom line. For outsiders, that’s provided a fascinating window into the House of Medicine.

Take, for instance, the sensitive topic of plumber envy. A 1955 AMA report I discovered during research on a book I wrote some years ago lamented physicians’ “consistent preoccupation with their economic insecurity,” including envious comparisons to “what plumbers make for house calls.”

Flash forward to 1967. Thanks to most patients now enjoying private or public health insurance, doctors’ incomes have improved substantially. The pages of AMN include advertisements for Cadillacs and convention hotels (Miami Beach is “Vacationland USA”). However, one man’s income is another man’s expenses, and complaints about rising medical costs have surged. When AFL-CIO president George Meany joins the chorus of carping, an AMN headline asks, “How about plumbing?”

If today’s doctors have finally piped down about plumbers ­– an electronic search of AMN archives back to 2004 produced no plumbing references – it may be because the average plumber earned about $51,830 in 2011, according to the Bureau of Labor Statistics, while the average general internist earned $183,170. Meanwhile, the AMN ads for cars ­were long ago replaced by ads for drugs, where influencing a doctor’s choice can drive millions or billions in revenue.

Unsurprisingly, the issue of rising medical costs and its causes has been a persistent theme in AMN since its launch in 1958. (For my book research, I pored through its indexes and old issues.) While AMN ran articles with titles like, “Medicine Called ‘Best Bargain Ever,’” the AMA leadership knew health cost unhappiness was not a psychosomatic disorder.

Continue reading “What the Death of American Medical News Says About the Future of American Medicine”

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“Half of primary care physicians in survey would leave medicine … if they had an alternative.” — CNN, November 2008

“Doctors are increasingly leaving the Medicare program given its unpredictable funding.” – ForbesJanuary 2013

Doctors, it seems, love medicine so much … that they’re always threatening to quit.

In some cases, it’s all in how the question is asked. (Because of methodology, several eye-catching surveys have since been discredited.)

But physicians’ mounting frustration is a very real problem, one that gets to the heart of how health care is delivered and paid for. Is the Affordable Care Act helping or hurting? The evidence is mixed.

Doctors’ Thoughts on Medicare: Not as Dire as Originally Reported

The Wall Street Journal last month portrayed physician unhappiness with Medicare as a burning issue, with a cover story that detailed why many more doctors are opting out of the program.

And yes, the number of doctors saying no to Medicare has proportionately risen quite a bit — from 3,700 doctors in 2009 to 9,539 in 2012. (And in some cases, Obamacare has been a convenient scapegoat.)

But that’s only part of the story.

What the Journal didn’t report is that, per CMS, the number of physicians who agreed to accept Medicare patients continues to grow year-over-year, from 705,568 in 2012 to 735,041 in 2013.

Continue reading “Why Reports of the Death of Physician Participation in Medicare May Be Greatly Exaggerated”

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I am known in the disease management and wellness fields as a naysayer, critic, curmudgeon, and/or traitor…and those are only the nouns that are allowed to be blogged across state lines.  This is because I am driven not by wishful thinking but rather by data.  The data usually goes the wrong way, and all I do is write down what happened.  Then the vendors blame me for being negative — sort of like blaming the thermometer because the room is too hot — because they can’t execute a program.

However, the nonprofit Iowa Chronic Care Consortium (ICCC) apparently can execute a program.  They reduced total diabetes events by 6% in the rural counties they targeted.  This success supports a hypothesis that in rural (presumably underserved) areas, disease management fulfills a critical clinical gap:  it provides enough basic support that otherwise would not be provided even to those who actively seek it to reduce near-term complications and exacerbations.

This result will likely produce its own unanticipated consequence: because many people now believe (thanks, ironically, to some of my own past work) that disease management doesn’t produce savings, there will be widespread skepticism about the validity of this study.  Quite the opposite:  this “natural experiment” is as close to pristine as one could hope for in population health, for five reasons:

  1. There was no participation/self-selection bias because outcomes were measured on all Iowa Medicaid members.
  2. The program was offered in some Iowa counties but not others, so there was no eligibility or benefits design bias, Medicaid being a statewide program.
  3. The program encompassed only one chronic condition (diabetes) rather than all five common chronic conditions normally managed together (asthma, CAD, CHF, and COPD being the other four).   Since all five conditions were tracked concurrently, whatever confounders affected the event rate in one of those conditions should have affected all of them.   And event rates in the four other conditions did indeed move together in both the control and study counties.   Just not diabetes.
  4. The data was collected exactly the same manner by the same (unaffiliated) analysts using exactly the same database so there is no inter-rater reliability issue.
  5. Both groups contained hundreds of thousands of person-years and thousands of events.

As one who has reviewed another high-profile “natural experiment,” North Carolina Medicaid, and found that the financial outcomes were the reverse of what the state’s consultants originally claimed (incorrectly, as they later acknowledged by changing their answer), I can also say that natural experiments in population health don’t harbor some as-yet-unidentified confounder that causes the study population to outperform the control population.

Continue reading “Stop the Presses: A Disease Management Program Worked”

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Oct. 1, 2013 is a focus of increasing anxiety in this country. That’s the date when enrollments begin for the federally run health insurance exchanges, created under the Affordable Care Act (ACA). No one really knows what to expect, but it could be far worse than advertised —and for a reason that has more to do with the federal deficit than health care.

What’s anticipated is unsettling enough. President Obama speaks of inevitable “glitches and bumps” in the implementation. Senate Finance Committee Chairman Max Baucus (D-Mont.) sees the possibility of “a huge train wreck” if the public isn’t adequately educated and prepared. Supporters of the ACA, especially Democrats in the Congress, are nervous about taking the blame if the exchanges don’t unfold as intended.

All these worries are legitimate. The American people, already burdened by a numbingly complex, inefficient and inequitable tax system, now wonder if an increasingly government-run health care system will follow suit. Many are concerned that some employers will dump their current health care plans and pay the relatively modest fine. There’s also worry that young people will opt out of the exchanges (preferring to pay the small penalty), leaving the exchanges with a disproportionately older and sicker pool. Then there’s the very real uncertainty surrounding the ACA’s ultimate cost — illustrated by the impact of Medicare alone, which the Office of the Chief Actuary of Medicare estimates could cost cost $10 trillion more than claimed.

Amid all these concerns and speculations, almost no attention is being paid to the opportunity that the ACA’s insurance exchanges could represent for state and local governments’ retiree health care programs. It’s time to think about it because the consequences could be far-reaching.

States in a deep hole

We already know that many state and local governments are in a financial hole that keeps getting deeper. A newly released report by the U.S. Government Accountability Office (GAO) makes clear that, absent significant reforms, the fiscal picture for most state and local governments will steadily worsen through 2060. A main cause, in addition to Medicaid, is the cost of health care for state and local government retirees. These largely unfunded obligations are similar to the pressures on the federal government to fulfill its unrealistic Medicare promises.

Continue reading “When Retiree Benefits and Obamacare Collide”

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Much has already been written about the Oregon Medicaid study that just came out in the New England Journal of Medicine. Unfortunately, the vast majority is reflex, rather than reflection.  The study seems to serve as a Rorschach test of sorts, confirming people’s biases about whether Medicaid is “good” or “bad”.

The proponents of Medicaid point to all the ways in which Medicaid seems to help those who were enrolled – and the critics point to all the ways in which it didn’t.  But, if we take a step back to read the study carefully and think about what it teaches us, there is a lot to learn.

Here is a brief, and inadequate, summary (you should really read the study):  In 2008, Oregon used a lottery system to give a set of uninsured people access to Medicaid.  This essentially gave Kate Baicker and her colleagues a natural experiment to study the effects of being on Medicaid.

Those who won the lottery and gained access were compared to a control group who participated in the lottery but weren’t selected.  Opportunities to conduct such an experiment are rare and represent the gold standard for studying the effect of anything (e.g. Medicaid) on anything (like health outcomes).

Two years after enrollment, Baicker and colleagues examined what happened to people who got Medicaid versus those who remained uninsured.  There are six main findings from the study.  Compared to people who did not receive Medicaid coverage:

  1. People with Medicaid used more healthcare services – more doctor visits, more medications and even a few more ER visits and hospitalizations, though these last two were not statistically significant.
  2. People with Medicaid were more likely to get lots of tests – some of them probably good (cholesterol screening, Pap smears, mammograms) and some of them, probably bad (PSA tests).
  3. People with Medicaid, therefore, not surprisingly, spent more money on healthcare overall.
  4. Continue reading “Misunderstanding Oregon”

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For a large and growing number of us with meager or no coverage, health care is the ultimate “gotcha.” Events conspire, we receive care and then are on the hook for a car- or house-sized bill. There are few alternatives except going without or going broke.

Steven Brill’s recent Time cover story clearly detailed the predatory health care pricing that has been ruinous for many rank-and-file Americans. In Brill’s report, a key mechanism, the hospital chargemaster, with pricing “devoid of any calculation related to cost,” facilitated US health care’s rise to become the nation’s largest and wealthiest industry. His recommendations, like Medicare for all with price controls, seem sensible and compelling.But efforts to implement Brill’s ideas, on their own, would likely fail, just as many others have, because he does not fully acknowledge the deeper roots of health care’s power.

Continue reading “Why Only Business Can Save America From Health Care”

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It has become accepted economic wisdom, uttered with deadpan certainty by policy pundits and budget scolds on both sides of the aisle, that the only way to get control over America’s looming deficits is to “reform entitlements.”

But the accepted wisdom is wrong.

Start with the statistics Republicans trot out at the slightest provocation — federal budget data showing a huge spike in direct payments to individuals since the start of 2009, shooting up by almost $600 billion, a 32 percent increase.

And Census data showing 49 percent of Americans living in homes where at least one person is collecting a federal benefit – food stamps, unemployment insurance, worker’s compensation, or subsidized housing — up from 44 percent in 2008.

But these expenditures aren’t driving the federal budget deficit in future years. They’re temporary. The reason for the spike is Americans got clobbered in 2008 with the worst economic catastrophe since the Great Depression. They and their families have needed whatever helping hands they could get.

If anything, America’s safety nets have been too small and shot through with holes. That’s why the number and percentage of Americans in poverty has increased dramatically, including 22 percent of our children.

What about Social Security and Medicare (along with Medicare’s poor step-child, Medicaid)?
Continue reading “The Hoax of Entitlement Reform”

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Things have been crazy.  It’s much, much more difficult to build a new practice than I expected.  I opened up sign-up for my patients, getting less of a response than expected.  This, along with some questions from prospective patients has made it clear that there is still confusion on the part of potential patients.  So here is a Q and A I sent as a newsletter (and will use when marketing the practice).

About My New Practice

Q. Why did I do this?

A.  I get to be a doctor again (perhaps for the first time).  I got tired of giving patients care that wasn’t as good as it could be.  I got tired of working for a system that pays more for bad care than for good.  I got tired of forcing patients to come in for care I could’ve given over the phone.  I got tired of giving time that should be for my patients to following arduous regulations.  I got tired of medical records not meant for actual patient care, but instead for compliance with ridiculous government rules.  Making this change gives me the one thing our system doesn’t want to pay for: time devoted for the good of my patients.

Q. How can I afford to do this?

A. I have greatly decreased my overhead by not accepting insurance and keeping my charges simple.  My goal is to have 1000 patients paying the monthly fee, which will limit the number of staff I need to hire.

Q. When will it open?

A.  My office will open in January, 2013, but the exact date is still not set.  I had initially hoped to be already seeing patients, but things always are harder than they seem.

Q.  What makes this better for patients?

A.  The main advantage is that I am finally able to give them the care they deserve: care that is not hurried, not distracted by the ridiculous complexity of the health care system, and not driven by the need to see people in person to give care.  This means:

  1. I don’t ever have to “force” people to come to the office to answer questions.  This means that I will let people stay at home (or work) for most of the care for which I would have required an office visit in the past.
  2. I will be able to give time people deserve to really handle their problems
  3. I won’t have to stay busy to pay the bills, so I can take care of problems when they happen (or when they are still small), rather than having to make people wait to get answers
  4. Patients won’t get the run-around.  They will get answers.
  5. I won’t wait for patients to contact me to give them care.  I will regularly review their records to make sure care is up to date.
  6. I will help my patients get good care from the rest of the system.  Avoiding hospitalizations, emergency room visits, unnecessary tests, and unnecessary drugs takes time; I will have the time to do this for my patients.  This should more than make up for my monthly fee.

Continue reading “Questions and Answers”

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