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Is the Fact that I Am a Woman Considered a Pre-Existing Condition?

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By Maggie Mahar

The male body has long been considered the “standard” for health care coverage. Having a woman’s body is seen as an expensive anomaly, and women pay dearly for being different.

When they buy their own health insurance in the individual market, women must lay out an extra $1 billion a year, simply because they are women. Some argue that this is fair: after all, a woman could become pregnant, and labor and delivery are costly.

But the truth is that, even when maternity benefits are excluded, one-third of all health plans charge women at least 30 percent more, according to a report released just last month by the National Women’s Law Center.

In 36 states, “92 percent of best-selling plans charge 40-year-old women more than 40-year-old men,” the Center reports, and “only 3 percent of these plans cover maternity services … One plan in South Dakota charges a woman $1252.80 more a year than a 40-year-old man for the same coverage.”

Today, less than half of American women can obtain affordable insurance through a job, which explains why millions buy their own insurance in the individual market. In that market, just 14 states ban gender rating:  California, Colorado, Maine, Massachusetts, Minnesota, Montana, New Hampshire, New Mexico, New Jersey, New York, North Dakota, Oregon, Vermont, and Washington.

Pricing based on gender also plagues the small group market, where insurers frequently jack up premiums if a small or mid-size business employs too many women. This means that many of these employers just can not afford to offer insurance. Only 17 states address the problem.

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You Have to Break Some Eggs If You Want to Make an Omelet

By David Dranove

In my last blog I explained how at one time our nation’s healthcare budget was relatively small and our economy was robust, so that economic growth could accommodate rising health spending and still allow us to spend more on other goods and services. Today our healthcare budget is huge and growing, while our economy stagnates. Economic growth is barely enough to pay for rising healthcare spending, with little left over to buy more of anything else. In the next few blogs I will explore our options for cutting health spending. To the extent that economic theory and empirical evidence allows, I will also discuss the likely consequences. It should come as no surprise to say that all of these options entail some risks. But if we are to avoid putting all our eggs in the healthcare basket, then we must decide which risks are worth taking.

A simple fact of accounting guides my analysis: If we want to spend less money on medical services, then we either (a) pay lower prices for the services we buy, (b) substitute away from high price services in favor of lower priced alternatives, or (c) purchase fewer services. There are no other options. Moreover, we can do these things either by government fiat or through markets and incentives. In this blog I explore options (a) and (b), mainly focusing on Medicare.

The Affordable Care Act calls for substantial reductions in Medicare fees, providing the largest anticipated cost savings in the ACA. (Private insurers relied on market forces to reduce provider fees in the 1990s, only to see providers gain the upper hand and sharply increase fees in the 2000s.) It is clear that the federal government has the power to reduce Medicare fees, but should it? What are the consequences?

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The PED Question

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By Andrew Blecher, MD


I am a fan of the Olympic Games and look forward to them every four years.   I was an All-American sprinter myself, having competed against some Olympic medalists, and have a special interest in Track and Field. This is the perfect example of a sport that doesn’t get so much exposure outside of the Summer Olympics, so the events become a stage for athletes in these fields to shine in the rarer-than-usual limelight. The 2012 Olympic Games are underway and as a former athlete and fan, I am looking forward to some amazing performances.

But I am also a sports medicine physician and have treated many elite level athletes, including Olympic Champions. This adds an additional perspective for me as an onlooker- layered within a former athlete, fan, and doctor-and one that I have a hard time coming to grips with. The 2012 Olympic Games are underway and I am looking forward to some amazing performances. The question is, will I believe them?

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Why Medical Management Will Re-Emerge

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By Brian Klepper

Several years ago I had dinner with a woman who had served in the late 1990s as the national Chief Medical Officer of a major health plan. At the time, she said, she had developed a strategic initiative that called for abandoning the plan’s utilization review and medical management efforts, which had produced heartburn and a backlash among both physicians and patients. Instead, the idea was to retrospectively analyze utilization to identify unnecessary care.

This was at the height of anti-managed care fervor. A popular movie at the time, As Good As It Gets, cast Helen Hunt as the mother of a sick kid. When someone mentioned an HMO, Ms. Hunt’s character let fly a flurry of expletives. America’s theater audiences exploded in applause.

Apparently, the health plan’s senior management team bought into cutting back on medical management but saw no need for retrospective review. After all, if the health plan abandoned actions against inappropriate services, utilization and cost would explode. Fully insured health plans make a percentage of total expenditures, so more services, appropriate or not, meant the plan’s profits would increase.

And that’s how it played out. Virtually all health plans followed suit, dismantling the aggressive medical management that had been managed care’s core mechanism in driving appropriateness. In the years following 1998, health plan premium inflation grew significantly, for a short period reaching 5.5 times general inflation, but averaging 4 times general inflation through today. Medical management became all but a lost, or at least a scarce, discipline in American health care, which is its status now.
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Needle Exchange Programs Vital In Fight Against AIDS

By Lord Norman Fowler

In 1986, British Prime Minister Margaret Thatcher’s special cabinet committee on AIDS made a fundamentally important decision which changed the course of the emerging HIV epidemic in the UK. In spite of some vocal opposition, it decided there should be clean needle exchanges for injecting drug users (IDUs) to prevent the spread of HIV.

The opposition to that move has been echoed in the years that followed — not least in the United States. Government-financed needle exchanges would condone crime, the critics claimed. It would encourage drug use and give entirely the wrong message to the public.

The experience of the last quarter of century has disproved those fears. There is no question that needle exchanges and drug substitution have reduced HIV: only 2% of new infections in Britain now come through that route. The policy has neither encouraged drug taking nor crime. Similar reports come from other nations that have adopted this approach.
 
Tragically, not all nations have followed such a lead. Nearly half of the countries with epidemics concentrated among IDUs have no needle and syringe programs at all according to UNAIDS. The result is the further spread of HIV and an increasing death toll — only four of every 100 people who inject and are eligible for treatment get antiretroviral (ARV) drugs.

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‘Help Wanted’ For Medicaid Expansion

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By John H. Schumann, MD

Despite its complexities and its politics, I support the Affordable Care Act (aka “Obamacare”).  As I’ve written elsewhere, I think it would be both morally and economically wrong for Governor Fallin and the Oklahoma legislature to opt out of the ACA’s vast Medicaid expansion – a position shared by Oklahoma Policy Institute.  So if Oklahoma does the right thing and opts to expand Medicaid for adults with incomes at or below 133 percent of the federal poverty level, what will happen?

Oklahoma faces a serious shortage of primary care access. The Oklahoma Health Care Authority, the agency in charge of administering Medicaid, recently compiled county-by-county maps, color-coded to classify areas of severe physician shortage based on presumptive levels of Medicaid expansion.  At a glance, these maps reveal something we already know: rural areas are hurting for physicians and populous counties seem to have more capacity.  In my opinion, however, the maps don’t paint a full picture of the eventual shortfall.Continue reading…

Doctors, Patients, or Insurers? Who Will Shape Health Care?

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By Davis Liu, MD

At a conference for America’s Health Insurance Plans, Gladwell argued that patients or consumers have been unable to be more empowered because doctors, as the intermediary, held the power of knowledge much the same way chauffeurs did for the early days of the automobile and Xerox technicians did in the early days of photocopying. A person was needed to guide and assist the individual to get the job done. At some point, however, the technology became simpler. People began to drive their own cars and make their own photocopies. The mystique of the chauffeur and technician was lifted. Now everyone could drive. Everyone could make photocopies.

Is it possible that for health care and the health care system, which for many people is a system they interact with rarely and in an area (health / illness) where the uncertainty and stakes many be too “high”, that individuals willingly  defer the responsibility to someone else? Gladwell hints that might be a possibility:

“A key step in any kind of technological transition is the acceptance of a temporary deficit in performance at the beginning in exchange for something else,” said Gladwell. That something else can eventually include increased convenience and lower cost. He offered a number of examples, including the shift to digital cameras where early pictures were not as good as film and the advent of the digital compression of music, which he contends has made the quality of music worse….

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What We Talk About When We Talk About Nursing Shortages

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By David Glenn


Not so long ago, the air was filled with dire warnings of an impending nursing shortage. By 2020, according to one widely-cited analysis, demand might exceed supply by as many as 800,000 nurses.

That analysis was made in good faith, and it was based on not-crazy extrapolations from thirty years’ worth of economic data.

But in many local labor markets in 2012, there’s no sign of a shortage. In fact, in some regions there’s evidence of a glut. A few months ago, the California Institute for Nursing & Health Care announced that 43 percent of people who received nursing degrees in California and 2010 and 2011 were not working as nurses.

I’m going to try to make some dimly-informed comments about the nursing labor market in the next few posts. But first, a few words about what it means to say that there is (or isn’t) a nursing shortage.

In this context, “nursing shortage” is used in an unsentimental labor-economics sense. A nursing shortage exists when employers are actively trying to hire additional nurses but are rubbing against supply constraints, as evidenced by:

rapidly rising wages
mandatory overtime
heavy use of temporary “agency” nurses to fill gaps on units
a greater-than-usual willingness to hire nurses with little experience or limited training
new investments in nurse-replacing technology
desperate 3 am phone calls from hospital administrators to college presidents, begging them to launch new nursing programs

To say that there is no nursing shortage today is not to say that all hospital units are adequately staffed for patient safety and decent quality of care. There is plenty of reason to believe that patients would be better off if hospitals invested in stronger nurse-patient ratios.

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For America’s “Best Hospitals,” Reputation Doesn’t Hold as Much Weight

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By Molly Gamble

U.S. News and World Report has released its annual lists of the best hospitals in America, but this year the rankings were based more on performance data and less on reputation.

U.S. News and World Report began rating hospitals in 1990 when clinical data comparing hospital performance didn’t exist, according to a blog post written by Avery Comarow, senior writer and health rankings editor for U.S. News. As a result, the first editions of the list were solely based on the hospitals’ reputations. The media outlet began turning away from reputation-based rankings in 1993 when it added mortality, nurse staffing and other objective measures that reflected patient care.

That focus on performance data has continued to grow. In fact, for 12 of the 16 specialties in the latest edition of Best Hospitals, more than 65 percent of a hospital’s ranking depends largely on clinical data, most of which is from the federal government. Hospitals in the four remaining specialties — ophthalmology, psychiatry, rehabilitation and rheumatology — are ranked solely by their reputation among specialists.

U.S. News says it took steps to strengthen its reputational rankings this year, including a modification that reduced the likelihood of hospitals with the highest number of physician nominations to “bob toward the top” of rankings. As a result, this “took some of the juice out of high reputational scores” and placed more emphasis on objective, clinical data. The media outlet said some hospitals that made it to the top may not have any reputational score at all — their inclusion is based wholly on clinical performance.

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Clinical Trials for Beginners

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By Judy Stone, MD

Have you ever wondered about what goes on behind the scenes—how new drugs are magically produced and brought forth? We’ll continue to take the mystery out of clinical research and drug development and to provide background information so that both patients and physicians can make more informed decisions about whether they wish to participate in clinical trials or not.

Why care?

To develop a medicine, from the time of discovery of the chemical until it reaches your drug store, takes an average of 12-15 years and the participation of thousands of volunteers in the process of clinical trials (Fig 1).

Very few people participate in clinical trials—it is even less than 5% for patients with cancer—due to lack of awareness or knowledge about the process. We’ll go into detail about how drugs are developed in later posts.

An inadequate number of volunteers is one of the major bottlenecks in drug development, delaying the product’s release and usefulness to the public. Of course, many people may suffer or even die during this wait, if they have an illness that is not yet otherwise treatable. So if you want new medicines, learn about—and decide if you wish to participate in—the process. I have, as a volunteer subject, researcher, and advocate.Continue reading…

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