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Constitutional Serendipity

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By David Boyle

Serendipity is not a word one usually associates with the present raucous debate over the “individual mandate” of the Patient Protection and Affordable Care Act. Democrats tend to support both the mandate and the PPACA, while Republicans tend to oppose both. However, this “between the devil and the deep blue sea” approach, whereby one makes a Hobson’s choice between being tyrannized by a government command to buy health insurance, or seeing no comprehensive health reform enacted in a country that needs it, is a false dichotomy, serendipitously enough.

The PPACA offers comprehensive reform, including welcoming features such as guaranteed issue of insurance regardless of preexisting medical conditions. However, the fact that the PPACA has valuable features doesn’t automatically legalize any possible measure designed to fund the Act, including coerced health insurance purchase. As former Vermont governor Howard Dean noted in August 2010 on MSNBC’s The Daily Rundown, Vermont enacted a successful state health care program without an individual mandate; Dean emphasized, “And people don’t like to be told what to do.” This latter factor is not negligible in a country with a statue in New York Harbor dedicated to liberty. (Perhaps this is why a June 9, 2011 CNN poll shows 54% of Americans opposed to the mandate, and other polls report similarly.)

Our American liberty has various constitutional and legal underpinnings which can defend people from the federal individual mandate, and maybe even from state individual mandates. As for Congress’ power to tax for the general welfare: taxes and penalties, such as the “Shared Responsibility Payment”, the PPACA financial penalty for refusal to buy health insurance, are not just interchangeable “economic incentives”.

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No Better Care, Thanks to Tort Reform

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By Charles M. Silver

In 2006, Dr. Howard Marcus wrote that Texas’ 2003 tort reform statute sparked an “amazing turnaround” in which doctors came to Texas in droves, instead of leaving the state as they had before. He was doubly wrong. Texas neither lost doctors before 2003 nor gained them especially quickly in subsequent years. In fact, according to statistics published by the Texas Department of State Health Services (TDSHS), the supply of active, direct patient care (DPC) doctors per capita grew faster from 1996 to 2002 than at any time after 2003. If the pre-reform growth rate had simply continued, Texas would have seven more DPC doctors per 100,000 residents than it does today.

Not only did pre-reform Texas outpace post-reform Texas; in the post-reform period Texas fell farther behind the average U.S. state. In 2002, Texas had 61 fewer DPC physicians per 100,000 residents than the average state. In 2010, Texas lagged the average state by a whopping 76.5 doctors per 100,000 residents, according to data published by the American Medical Association (AMA). Texas’ downward slide is also accelerating, meaning that Texas is falling behind the average state both farther and faster each year.

These statistics are public and well known. They can be found at TDSHS’s website and in a report Public Citizen published earlier this year. In view of this, it is shameful that Marcus, his colleagues at the Texas Alliance for Patient Access and Republican politicians continue to mislead. They are blatantly exploiting the ignorance of people who have better things to do than read up on the number of doctors in the State.

Marcus and his accomplices know about TDSHS’s numbers but have ignored them in all prior public statements I’ve found. They want to give glowing reports, so they focus on the number of new licenses granted by the Texas Medical Board (TMB) instead. TMB’s count of new licenses is misleading, however, because it ignores the number of doctors who leave the state, retire, die or stop seeing patients for other reasons. Suppose 100 calves were born into a herd of cattle that also lost 250 adult animals because of the heat and drought. The rancher who owned the herd would say he was down 150 head. Marcus and his buddies would say the herd grew by 100.

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Better Care in Texas Thanks to Tort Reform

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By Howard Marcus, MD

Thanks to the passage of lawsuit reforms, medical care is now more readily available in many Texas communities. For many patients, this change has been life-altering; for some, life-saving.

George Rodriguez walks today thanks to tort reform. Newly established Corpus Christi neurosurgeon Matthew Alexander urgently operated on Rodriguez’ spinal abscess, relieving the pressure on his spinal cord, and sparing him life in a wheel chair. Without the state’s lawsuit reforms, Dr. Alexander wouldn’t have relocated to Texas and Mr. Rodriguez would have been deprived access to emergency neurosurgery in Corpus Christi.

Cancer survivor Ruby Collins credits newly minted Brownwood urologist Daniel Alstatt with saving her life. Dr. Alstatt says he wouldn’t have moved there, were it not for tort reform.

Andrya Burciaga of McAllen, a complex patient with diabetes and hypertension, is a first-time mother, thanks in part to the expertise of obstetrician/fertility specialist Dr. Javier Cardenas. Again, if not for the passage of the reforms, Dr. Cardenas says he absolutely would not have returned to his hometown to practice medicine nor taken problem pregnancies such as Ms. Burciaga’s.

Because of reforms, more patients across Texas are getting the care they need, when they need it.

Eight years ago, Texas was in the throes of an epidemic of lawsuit abuse. High numbers of meritless lawsuits, combined with excessive awards, caused doctors’ medical liability rates to double within just four years. Non-profit nursing homes saw their rates jump 900% within that same time frame, while hospitals saw liability costs increase as much as 50% in one year. Roughly one in four doctors was sued every year while the vast majority of these suits and claims were closed without payment.

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A Vision for Health Care: Put the States in Charge

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By Victor M Sandler, MD

In an ideal world, all our doctors would have the wisdom of Marcus Welby, and all our nurses the compassion of Florence Nightingale. This medical world would be populated with doctors who all graduated No. 1 in their classes, who perform only necessary surgery — and without complications. These doctors would always wash their hands between patients to minimize the spread of infection. All medical research would be funded by nonprofit foundations to preclude bias. And, of course, all doctors would be salaried to avoid perverse incentives to do too much to too many.

Recently, the United States Preventive Services Task Force recommended against prostate-cancer screening, saying it doesn’t save lives overall and often leads to additional tests or treatments that do harm. Two years ago, the same task force, which is made up of nonfederal experts in primary care, recommended against screening mammography for women in their 40s.

What would Dr. Welby and Nurse Nightingale have said about the task force recommendations? I believe they would have endorsed them, because they are carefully researched and objective.

Yet both recommendations have been met with widespread protest. The task force has been accused of rationing — the dirtiest word in American medicine.

Why? Because a chasm separates the idealized world of American medical practice and our current reality.

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Obamacare Exchange Opposite of Free Market

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By Jack McHugh

As described here last week, the latest tack of Republican Obamacare “exchange” proponents is to characterize their “MIHealth Marketplace” as a positive good rather than a least-bad option among several bad choices.

They are even using labels like “conservative” and “free-market” to describe the entity whose main role will be to administer the billions of dollars of insurance subsidies the federal Patient Protection Act distributes.

The boosters are also trotting out the old canard that the exchange is merely a “Travelocity and Orbitz” for health insurance.

Those claims and labels were badly dented in a recent hearing of the House Health Policy Committee, where staffers from one of the corporations hoping to profit from exchange contracts presented a “Mandated State Exchange Functions” flow-chart.

If a health insurance “Travelocity and Orbitz” is all these politicians really want, they’re in luck, because such websites already exist. Better yet, they really are “free-market” services provided by private companies, with no role in administering Obamacare — go to www.ehealthinsurance.com or www.getinsured.com to see examples.

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CMS’ Opportunity: A Lawsuit Offers A Chance To Reform Physician Payment

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By BRIAN KLEPPER & DAVID KIBBE, MD

By mid-November, the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) must respond to the legal complaint filed in a Maryland federal court by six Augusta, Georgia family physicians.

These doctors are not asking for money, but for relief from the negative effects brought about by CMS’ twenty year reliance on the American Medical Association’s Relative Value Scale Update Committee (RUC) for valuing doctors’ work. They are asking CMS to enforce the Federal Advisory Committee Act(FACA), which requires that regulatory agencies shield themselves from undue special interest influence. In the process, they are asking CMS to rethink Medicare’s approach to physician payment, with a mind toward recognizing and valuing primary care’s ability to treat the whole patient within a larger system of care. They are asking CMS to develop payment policy that supports the needs of patients over those of professional groups.

In a sense, the suit reflects the larger concerns of America’s increasing unrest: a general frustration with a system rigged to benefit the few at the expense of the many, privatizing profits while socializing losses. It calls into question an incentive structure that has resulted in half or more of all health spending providing no utility and translating to exorbitant cost but debatable value. In other words, the case is accompanied by a sense that the system, as it is currently constituted, is failing the American people.

Any simple examination of medical services payment reveals the systematic under-valuing of primary care services relative to procedural services, the direct result of the RUC’s valuation process. For example, in an earlier Health Affairs Blog post we compared a 99214 moderately complex established office visit with a routine cataract extraction and intraocular lens implant. The first has all of medicine as it’s palette. The second is a highly refined, low risk, repetitive procedure that is valued, on an hourly basis, at 12.5 times the first.

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More Explanation of the Explanation of Benefits (EOB)

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By DAVID E. WILLIAMS

A few weeks ago I parsed an Explanation of Benefits (EOB) I received from Blue Cross Blue Shield of Massachusetts after a visit to Sports & Physical Therapy Associates, an excellent physical therapy center with 14 locations in Greater Boston. The post (What does an Explanation of Benefits (EOB) actually explain?) generated a number of comments and questions on the Health Business Blog itself and when it was cross-posted at KevinMD. In particular:

  • What would a cash paying patient be asked to pay?
  • How is the $225 in “charges” derived? Is it determined by Medicare?
  • Does the provider lose money on the Blue Cross contracted rate?

I’m not a billing expert so I sent an email to Sports & PT to ask them to respond directly. I was impressed with their informative and thorough response, which I am posting here with their permission.

Mr. Williams,

We would be happy to provide you with some insight into how insurance claims are processed.  Please find your questions with the corresponding answers below.

When a patient first comes to our clinics, we provide them our Policy Disclosure document.  I think you will find it valuable in understanding the relationship between patient and provider, patient and insurance carrier, and lastly, provider and insurance carrier.  Here is the first paragraph:

“Sports and Physical Therapy Associates (SPTA) is pleased to participate in your health care and we look forward to establishing a lasting relationship as your physical therapy provider. As part of this relationship, we wish to establish our expectations of your financial responsibility as outlined in our Financial Policy. Letting you know in advance of our Financial Policy allows for a good flow of communication and enables us to better satisfy you. Your medical insurance is a contract between you and your insurance company; we are not a party to that contract. We can often help with providing information about your benefits, but you are primarily responsible for knowing what type of coverage you have and for any charges that you have incurred as a patient with us. Please review and sign the following Financial Policy prior to your first visit.”

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Are Health Apps the Cure for Anything That Ails You?

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By ROCHELLE SHARPE

With about 9,000 consumer health apps currently available in the iTunes store, it seems like almost all smart phone users can download their way to better health these days.

The store offers a mindboggling array of creative apps, including ones that calculate calories burned during exercise, create soundtracks to help people fall asleep, and display pictures that can elicit memories from Alzheimer’s patients. If the store doesn’t offer something for what ails you now, it probably will soon. The selections will proliferate within the next year, with an additional 4,000 consumer apps expected by next summer, industry experts say.

But all this innovation creates a bewildering set of problems. It’s hard to figure out what apps are available, let alone which work best. Health apps may have the potential to dramatically improve people’s lives, but those based on misleading or bogus information can cause serious harm.

“Apple isn’t testing apps for their scientific validity,” said Dan Cohen, a social worker who has reviewed apps for their effectiveness.

Given the stakes, it’s no surprise that the government is starting to regulate these smart phone applications. Just last month, the Federal Trade Commission brought its first cases against the makers of two health apps. Each claimed to cure acne with colored lights emitted from cell phones.

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Federal Debt, Student Loans and the Physician Workforce

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By Ian Metzler and John G. Meara MD

As of June last year, Americans now owe more in student debt than they do in credit card debt. Student borrowers are winning the dangerous debt race as both amounts hurtle toward the $1 trillion marker, student debt rose by over 500% since 1999 (1). To put this in perspective, student debt has increased at nearly double the rate of inflation seen in the housing bubble that caused the recent financial crisis. There are foreboding similarities between real estate and education. Until 2008, it was assumed that both commodities would unfailingly rise in value and that the market was far from saturated. However, the number of unemployed college graduates is rising and a recent report found that two out of five student loan borrowers were delinquent on their payments at some point in the first 5 years of their loan (2). Moreover, unlike credit card or mortgage debt, student debt is not diffusible through bankruptcy, it stays with borrowers for life.

Despite this unstable situation, in August 2011 Congress passed the Budget Control Act that will abolish subsidies from a pillar of education finance—the Federal Direct Stafford loan. Although undergraduates with the loan will continue to receive subsidies, graduate students will start accruing interest while still in school. With the skyrocketing costs of higher education and the increasing time it is taking post-grads to pay off their loans, this amount adds up quickly. For example, a medical student who matriculates in 2012 and receives the unsubsidized Stafford loan for all four years of her schooling will graduate with $5000 more in debt than a medical student who graduated this year, all resulting from interest charges that accrued while she was studying full time. It often takes medical students 10 years or more to repay all their debt, and in that time interest will continue to add up so that she actually pays $10,000 just for the interest on that single, federally-provided loan. In total, $18 billion is being passed off onto graduate students over the next ten years (3) The removal of subsidies is a subtle step but it sends a strong message. If the federal government continues to retract its commitment to financially support higher education, it risks three major effects: exaggerating the student debt crisis, inhibiting diversity in higher education and discouraging the pursuit of non-profit or socially responsible careers.

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Gmail offline–not as easy as using toothpaste

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Tonight I’m getting on an 18 hour flight with no WiFi, so this morning I spent 20 minutes trying and failing to first download, then to open, then re-find the Offline Gmail app from Google. Which has changed since it was part of Gears a while back and now only works on Chrome–too much consternation from those who’d been using it the old way (as I did on an older computer). Except it doesn’t work. Or at least I can’t find it to make it work–I cant even find the place to find the apps I’ve downloaded from the Chrome store (yes, it’s the only one I’ve downloaded). This wouldn’t merit a mention on THCB until I read in a NY Times article about educating children without computers. In it is this priceless quote about computer technology from Alan Eagle, a senior Google employee who sends his kids to a school with no computers in it: “It’s supereasy. It’s like learning to use toothpaste,” Mr. Eagle said. “At Google and all these places, we make technology as brain-dead easy to use as possible. There’s no reason why kids can’t figure it out when they get older.” And that arrogance is the reason why Google will eventually fade. Clearly Mr Eagle has never used the Chrome App for offline Gmail. But perhaps he’ll come round to my house and help me find it!