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Category: Health Policy

PCMH Fails Natural Experiment

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By AL LEWIS

flying cadeucii

Medical Homes Fail Yet Another “Natural Experiment”

Three “natural experiments,” three failures.  Such is the fate of patient-centered medical homes (PCMH), a well-intentioned but unsuccessful innovation now kept afloat by the interaction of promoter study design sleight-of-hand with customer innumeracy.

By way of review, a natural experiment is an experiment in which the design is outside the control of investigators, yet mimics an experiment.  The first two natural experiments below involve applying the intervention across entire states. The third involves a stimulus-response experiment in one specific community.

Statewide Natural Experiments: North Carolina and Vermont

In North Carolina, a statewide Medicaid PCMH was implemented years ago and steadily expanded until most Medicaid recipients belonged to one.  There was no reduction in relevant event rates (for ambulatory care-sensitive admissions) and costs increased. While the overall Medicaid budgets were routinely exceeded and that should have caused legislators to realize that something in their PCMH was amiss, Milliman fabricated data to pretend the PCMH program was a success.  Milliman got caught making up data (and ignoring other data that quite definitively invalidated its conclusion, and changed their story 180 degrees, a tacit admission that they lied.  And shortly thereafter (at least “shortly” by the standards of state government), North Carolina announced that it is abandoning this failed experiment.

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Does the ACA Actually Mandate Free Checkups?

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By CHRISTIAN GLASON

flying cadeucii“Where in the Affordable Care Act (ACA) does it mandate that every health insurance policy must include a free annual checkup?”

I posed this question to Al Lewis and Vik Khanna in the comments of their recent post entitled: The High Cost of Free Checkups, where they argue against the Affordable Care Act (ACA) provision that requires “free checkups for everyone.” They cite a recent New York Times Op-ed authored by ACA co-architect, Dr. Ezekiel Emanuel, that essentially debunks the link between annual checkups and overall health outcomes.  For Lewis and Khanna the solution is simple, we need to “remove the ACA provision that makes annual checkups automatically immune from deductibles and copays.” But for me there’s an enormous problem with their argument: The ACA doesn’t actually have any such provision.

After raising the issue in the comments section of the post, Mr. Lewis responded informing me that: “It’s definitely there” and “You’ll have to find it on your own, though — I unfortunately have to get back to my day job.” What Mr. Lewis doesn’t consider with his quick dismissal, is that I have already looked.  I’ve combed through the law and other policy guidance, rules and regs; searching for any mention of this required annual wellness exam, physical, visit, or any other linguistic derivative.  It doesn’t exist.

It turns out that while the law does require that an annual wellness visit be covered (sec. 4103. “Medicare coverage of annual wellness visit providing a personalized prevention plan”), this requirement is specific to Medicare beneficiaries and does not apply to individual or group plans. Beyond this particular section you won’t find any mention of a requirement within the ACA.

So what gives?  Lewis and Khanna aren’t the only ones who’ve mentioned this “free” Obamacare benefit. Even when researching this piece I had to engage in a lengthy discussion with a friend who is a healthcare policy advisor, unexpectedly defending my position. This claim has to be coming from somewhere, surely people smarter than me have gotten it right?

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Have Doctors Joined the Working Class?

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Marx und Engels Alexsander Platz Berlin

By Richard Gunderman, MD

On September 28, 1864, exactly 150 years ago this weekend, the first meeting of the International Workingmen’s Association (IWA) was convened at St. Martin’s Hall, London.  Among the attendees was a relatively obscure German journalist by the name of Karl Marx.  Though Marx did not speak during the meeting, he soon began playing a crucial role in the life of the organization, in part because he was assigned the task of drafting its founding documents.

The work of the IWA and Marx is increasingly relevant to the practice of medicine today, largely because of the rapidly shrinking percentage of US physicians who own their own practices.  This moves physicians into the category of what Marx and his associates called, “working people.”  According to data from the American Medical Association, in 1983 76% of physicians were self-employed, a number that had fallen in 2012 to 53%.  And the trend is accelerating.  It is estimated that in 2014, 3 in 4 newly hired physicians will go to work for hospitals and health systems.

To put this change in Marx’s terms, the rapid fall in physician self-employment means that a shrinking percentage of physicians own what he called the means of production.  In his view, this alienates workers – in this case physicians – from other physicians, themselves, the work they do, and from patients.  Whether we agree with Marx on every point, his writings on this topic provides a provocative perspective from which to survey the changing landscape of contemporary medicine.

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Halbig corpus interruptus

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By MATTHEW HOLT

In more stunning proof that America’s 18th century style governing process just doesn’t work, a subset of a regional Federal court ruled against part of Obamacare. The Halbig ruling is certain to be overturned by the full DC court and then probably will stay that way after it makes it’s way through the Supremes–at least Jonathan Cohn thinks so.

But think about what the Halbig ruling is about. Its proponents say that when Congress (well, just the Senate actually as it was their version of the bill that passed) designed the ACA, they wanted states only to run exchanges and only people buying via states to get subsidies. But that they also wanted a Federal exchange for those states that couldn’t or (as it turned out) wouldn’t create their own. But apparently they meant that subsidies wouldn’t be available on the Federal exchange. That would just sail through Logic 101 at any high school. Well only if the teacher was asleep, as apparently most Senators were.

Now two judges interpret what was written down to imply that subsidies should only be available on state exchanges–even though logic, basic common sense and fairness would dictate that if we’re going to subsidize health insurance we should do it for everyone regardless of geography.

Don’t forget that in the House version of the bill there was only a Federal exchange. Continue reading…

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

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By Saurabh Jha, MD

“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.

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The Email I Want to Send To Our Tech Guys But Keep Deleting…

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By Shirie Leng, MD

Dear Tech Guys:

So today I’m doing anesthesia for colonoscopies and upper GI scopes. Nowadays we have three board-certified anesthesiologists doing anesthesia for GI procedures every single day at my institution. I’ll probably do 8 cases today. I will sign into a computer or electronically sign something 32 times. I have to type my user name and password into 3 different systems 24 times. I’m doing essentially the same thing with each case, but each case has to have the same information entered separately. I have to do these things, but my department also pays four full-time masters-level trained nurses to enter patient information and medical histories into the computer system, sometimes transcribed from a different computer system. Ironically, I will also generate about 50 pages of paper, since the computer record has to be printed out. Twice.

No wonder almost everyone I know hates electronic medical records! I don’t know anything about computers, and I don’t know what systems other hospitals have. I may be dreaming of a world that doesn’t exist or that world is here and I haven’t heard about it. Nevertheless, here’s my wish list for a system that doctors would actually want to use:

1. Eliminate the User Names and Passords: You can’t tell me that in this day of retinal scans and hand-held computers that there isn’t a better way to secure data. What if each person had their own iPad that you only have to sign into ONCE a day that automatically signs your charts. If you’re worried about people leaving them sitting around use a retinal scan or fingerprint instant recognition system.

2. Eliminate the Paper: If you’re going to have full-time people entering data for you, why print it out? It’s on the computer for anyone to access.

3. All Data Systems Must Be Compatible: You can’t have patient data entered in one place that doesn’t automatically import into another place. If my anesthesia record can’t talk to the hospital OMR, I have to RE-TYPE everything in, which is completely ridiculous.

4. Everybody Has to Use the Same System: Everybody, state-wide. Right now, electronic records from a nearby hospital are not available at my hospital, even though the two hospitals are right across the street from each other.

5. Don’t Make Me Turn the Page All the important information about a patient should be on the first page you open when you look up a patient. I shouldn’t have to click six different tabs. Specific to anesthesia, all the relevant data about the patient including what medications they have received during the case should be automatically displayed on the screen when you start a case. Specific to primary care, all the latest labs and data, recent appointments with specialists, current med list and anything else the doctor wants to see commonly should be right on the first screen.

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Why Should We Cover People Who Don’t Take Care of Themselves?

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By JOE FLOWER

One of the most common ideas in the whole healthcare financing discussion is a moral one. Why, people say, should my taxes and my healthcare premiums go to take care of the huge medical problems of people who don’t take care of themselves? As one commenter on THCB put it: “…self inflicted injuries to not be covered at all, ideally. If someone drinks their liver away I don’t think we should all have to buy them a new one. Same for smoking.”

This is a common idea, one that seems logical and right on the surface. But there are four assumptions built into it, all four of which have problems:

1) That the “self-inflicted injuries” that people commonly identify (smoking, drinking, other addictions, obesity) actually are major predictors of cost.
2) That we can clearly differentiate “self-inflicted injuries” from other medical problems
3) That to the extent that they are actually “self-inflicted,” the patient could just stop doing them if they just had enough gumption, or enough something.
4) That if our goal is to cut unnecessary medical costs, refusing medical coverage would cut costs.

But each of these four is problematic.
1) The best predictors of medical costs are not smoking, drinking, or obesity, but depression and stress. (“Association Between Health Risks and Medical Expenditures“) So trying to dis-insure “self-inflicted injuries” might miss the target of lowering healthcare costs.

2) Trying to decide what is “self-inflicted” and what is not presents a major problem. A friend has a lifelong condition that gives him excruciating pain. He has struggled manfully (and successfully) against addiction to booze and painkillers to ameliorate his pain. He has always felt bitter toward his father because his father was addicted to booze and painkillers. He recently realized that his condition is genetic, and guessing from some symptoms he observed, realized that his father was fighting the same excruciating pain. His attitude toward his late father changed instantly.

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The bleak state of the (health care) economy

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By MATTHEW HOLT

Health care spending increased at 3.9%, its slowest rate for decades in 2010 following a slowdown in 2009. Merill Goozner has the play by play but it’s clear that the numbers are starting to reflect what Jeff Goldsmith said in his keynote at Health 2.0 last year.–even the health care industry can not grow geometrically forever.

But there’s something hiding in these data. Recently I gave an update for a talk that I’d given 15 years before at the Oregon Medical Association. I reviewed the 2010 year forecast I did for IFTF in 1997 and I was struck by how in our scenarios we had overestimated the per capita spend on health care, but underestimated its share of GDP. That meant while overall health spending didn’t grow as fast over the decade as we’d forecast, the economy grew much slower. And of course the big jumps in health care as share of GDP that we saw in 1991-4 and 2007-9 came when the economy tanked

As we enter the 7th year of our lost decade with the stock market starting to predict a double dip recession, and real unemployment in the high teens, we face the prospect of getting to 20% of the GDP going to health care via not a boom in spending brought on by the ACA or a rich economy making rational choices, but by default. Of course these days the loonies in the Tea Party are reminding us of  the other meaning of the word default!

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The Most Commonsensical And Hopeless Reform Idea Ever

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By MICHAEL MILLENSON

The way that Michael Long and Sandeep Green Vaswami want to change hospital care may well rank as both the most commonsensical and most hopeless health reform proposal ever. The real question is whether they can show the same tenacity in pursuing their goal as an elderly Jewish woman from Munster, Ind., who has invested nearly two decades in a similar effort.

What the two men are advocating is simple: hospitals should offer the same level of professional staffing and patient care on weekends as during the rest of the week. They should do this, the two men write in the Health Affairs blog, because trying to cram seven days of care into five leads to a cascade of problems that harm and even kill patients. It also costs a lot of money.

That’s the commonsense part. The hopeless part is that Long and Vaswami, both affiliated with the Institute for Healthcare Optimization, seem to believe that doctors, nurses and hospital execs will read their article and then spontaneously volunteer to work the weekend shift.

American hospitals are complex entities, but at heart they remain the doctor’s workshop, dependent upon the goodwill of physicians who admit and care for patients. Maintaining that goodwill requires treading carefully. For instance, telling a neurosurgeon, “You’re working Wednesday through Sunday this week” would rank high on the list of what a friend of mine calls a “career-limiting event.”

Long and Vaswami are aware they’re tampering with long-standing tradition, but as justification they offer a disturbing catalog of the effect of care controlled by the calendar.

To begin with, bunching scheduled admissions in midweek often overwhelms the staff, leading to “significant” increased risk of patient death or admission to the Intensive Care Unit. Filled beds force emergency rooms to discharge patients to “inappropriate care locations,” with the hospital relying on specialized teams to ride to the rescue “when patients deteriorate because of inadequate care.” At the same time, “medically appropriate transfers … may also be delayed or rejected.”

And that’s when hospitals are operating normally. Patients admitted over the weekend face an increased risk “because critical diagnostic or therapeutic modalities are not available,” while patients staying over the weekend experience “delays at best and deterioration in clinical condition at worst.”

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FDA Should Add a Comparative Effectiveness Arm to Final Trials

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By MERRILL GOOZNER

The Food and Drug Administration’s Prescription Drug User Fee Act is up for reauthorization next year, and so is the consumer and drug industry face-off over the contentious issue of comparative effectiveness research (CER). Consumers, patients and some physicians are demanding that CER be required of all new drugs coming to market when there are already FDA-approved therapies for the same condition. They say it will give payers and patients immediate feedback on the relative worth of the latest drugs, which are always more pricey than what preceded them, especially if the older drugs are coming off patent.

Industry opposes including CER arms in final efficacy trials. The companies claim it will place additional costs on the already expensive new drug development process; provide inadequate information for actually divining the relative worth of two competing therapies; and dissuade companies from investing in follow-on drug research, which can turn up drugs that are significantly better than older drugs.

The American Enterprise Institute’s Scott Gottlieb, who served in the FDA during the Bush administration, this week offered a lengthy brief in support of the industry position. Unfortunately, he sets up a straw man in order to knock down what could be a very effective tool for lowering the cost of medicine. It behooves industry leaders to ignore his advice, and to ignore the bleating of their marketing departments’ incessant demand for follow-on drugs.

 

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