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Above the Fold

Which Is More Efficient: Employer-Sponsored Insurance or Medicaid?

Jul 13, 2017• 12

By SAURABH JHA, MD

An old disagreement between Uwe Reinhardt and Sally Pipes in Forbes is a teachable moment. There’s a dearth of confrontational debates in health policy and education is worse off for it.

Crux of the issue is the more efficient system: employer-sponsored insurance (ESI) or Medicaid. Sally Pipes, president of the market-leaning Pacific Research Institute, believes it is ESI. Employers spend 60% less than the government, per person: $3,430 versus $9,130, per person (according to the American Health Policy Institute). Seems like a no brainer.

Pipes credits “consumerist and market-friendly approaches to health insurance” for the efficiencies. She blames “fraud,” “improper payment,” and “waste” for problems in government-run components of health care.

But Uwe Reinhardt, economist at Princeton, counters that Medicaid appears inefficient because of the risk composition of its enrollees. Put simply, Medicaid recipients are sicker. Sicker patients use more health care resources. Econ 101.

The points of tension in their disagreement are instructive.

The Entertainment Presidency: A Primer For Health Care Professionals

Jul 11, 2017• 4

By RICHARD GUNDERMAN, MD and BENJAMIN GRAY, MD

Many physicians have expressed dismay at the conduct of US president Donald Trump. But whether colleagues find his politics objectionable or congenial, his conduct bold or vulgar, and the man himself an imbecile or a genius, it is important for healthcare professionals to understand that the Trump presidency is a predictable consequence of our times. In particular, it is an entirely natural outgrowth of the forms of media that characterize our age.

The Medium Becomes the Message

In 1964, media theorist Marshall McLuhan famously declared the medium the message. McLuhan argued that the consciousness of a people is more profoundly shaped by media themselves – for example, Gutenberg’s movable print, radio, or television – than by the content they convey. To understand the character of a presidency, McLuhan would argue, we need to shift our attention from specific policies to the media by which the president operates.

When candidates Abraham Lincoln and Stephen Douglas engaged in their famous 1858 debates for an Illinois Senate seat, broadcast media had not yet been invented, and the newspaper dominated. As print media, newspaper articles could examine a candidate’s position on an issue in great depth, and 19^th century debate audiences expected candidates to develop real arguments for their policies. As a result, each of the Lincoln-Douglas debates was formatted to last three hours.

Today’s media prefer sound bites. In fact, McLuhan argued that the medium of television operates “at the speed of light.” It permits “no continuity” and “no connection.” Instead, he said, with television, “It’s all just a surprise.” In contrast to the time Lincoln took to carefully craft his arguments, a television president might be expected to rely less on argument than on astonishment, not taking the time to trouble himself over non-sequiturs and contradictions.

Shopping For a Health Insurance Plan Again. Seriously?

Jul 10, 2017

By PAUL KECKLEY

On the golf course, my son Jason has an uncanny ability to hit any tree within earshot of his intended target line. It’s fait accompli in his book. And his reaction is always the same: “seriously!”

The same is his plight with health insurance. Though a self-employed healthy single male with a successful career and no need for government assistance in buying coverage, he just got this letter from his insurer:

“The last seven years within the health insurance market have led all of us to decisions we have never before considered. It has remained a very challenging environment as the debate over the 2010 Affordable Care Act (ACA) continues today.

At TRH Health Insurance Company, we have arrived at another critical decision point, which, unfortunately, will affect you. This letter (and the enclosed notification letter as required by the ACA) is our notice that we will not be offering plans in the non-subsidized marketplace in 2018. Your current plan remains effective through December 31, 2017.”

It’s the third time in five years he’s been dropped. Though paying his premiums dutifully and shrinking his coverage to reduce his monthly cost, his premium has increased more than 10% every year. And he’s healthy.

As the GOP Senate leadership weighs its options in moving toward a Repeal of the Affordable Care Act and its replacement, their greatest political risk is the potential that up to 22 million will lose their insurance coverage per the Congressional Budget Office’ most recent score. They have bet their political calculus on stories like Jason’s, one of 18 million in the individual insurance market whose premiums have skyrocketed. More than 8 million of these get a subsidy to buy their policy because their incomes fall below 400% of the federal poverty level. Those subsidies are likely to go away. For the rest, like Jason, it’s a crap shoot. Individual insurance plans that feature less coverage, narrow networks, high premiums, high out of pocket costs and the high likelihood the underwriter will cancel the policy the next year is standard fare. Or, they just choose to go without.

Join Our Free Webinar About Advancements and Challenges in Patient Matching

Jul 10, 2017

By JILL MERRIGAN

Join Health 2.0’s Matthew Holt and Indu Subaiya in discussion with Adam Culbertson, Innovator-In Residence, HIMSS; Abel Kho, Associate Professor of Medicine and Preventive Medicine in the Feinberg School of Medicine at Northwestern University; and Tom Leary, VP of Government Relations, HIMSS. We’ll be talking about the challenges, such as technical and political hurdles to matching patients. Additionally, hear about current projects underway to advance this challenging problem.

The BCRA Is An Improvement Over Obamacare. Here’s Why..

Jul 10, 2017• 48

ANISH KOKA, MD

Dr. Jha writes on these pages in typically stirring fashion about his views on the recent health care kerfuffle and rightly so fingers what the real focus of our efforts should be: Cost. He ends by slaying both sides because of their refusal to confront the hospital chargemonster – the fee schedule hospitals make that remarkably only really applies to the uninsured.

Unfortunately, the solution proposed ensures hospital fee schedules for the uninsured are no greater than Medicare reimbursements, which is far from perfect. Consider that the Medicare reimbursement for a stent placed to an ischemic limb is in the range of $15,000. While this makes for a less daunting bill for the uninsured, in reality for the vast majority of folks that are uninsured $15,000 is about as far away as $150,000.

But my major disagreement with the good Dr. Jha relates not to his attempt to slay the chargemaster, but his underappreciation for the attempts made in the GOP bill to control health care spending. A conservative mantra about the why of health care costs focuses on the existence of deep pocketed third party payers that make costs opaque to patients. Attempting to have patients understand what they’re being charged has been conservative dogma, and there are a number of studies that suggest patients with health saving accounts are more cost conscious when they interact with the health care system. Dr. Jha glosses over this important point – This is the Republican attempt to bend the cost curve! And at least to this physician who’s lived through the last eight years, a plan that has a considerably greater chance of success than any number of failed acronyms designed so far by enlightened theorists from the Acela corridor.

HSA chart

The policy experts are hard to convince about HSAs, and point to the above chart as evidence of the uselessness of HSAs.

Should Doctors and Nurses Be Patient Activists?

Jul 9, 2017• 24

By DANIELLE OFRI, MD

When the eminent physician Dr Cliff Cleveland wrote his memoir about his years in medical practice, he entitled his book, “Sacred Space.” Yes, it’s a bit sentimental, but he pays rightful homage to the idea that that relationship between patients and their doctors and nurses is something exceedingly precious. Medical professionals appropriately go out of their way to keep that space neutral, private and nonjudgmental, because patients are often at their most vulnerable.

A patient of mine recently told me about a genital symptom that was bothering her. She’d had it for two years, but had been too embarrassed to bring it up. We had to build up our trust bit by bit, until she felt comfortable revealing it to me. Happily, it was something easily treatable. It’s situations like these that remind me how critical it is to protect this space.

Like most doctors and nurses, I try to keep the outside world firmly outside the exam room. I don’t talk about politics, religion, money, or sports. I don’t even gripe about the mayor. Most medical professonals avoid political activism for the same reason. But could that reticence be harmful to our patients?

I grappled with this over the past few weeks, as the House passed its American Health Care Act and then the Senate put forth its Better Care Reconciliation Act. As one detail after another was revealed, I began to worry about my patients. The cuts to Medicaid would do real damage to them. I had a number of fragile patients in mind who could die if their care was disrupted.

What would I do, I asked myself, if I started to notice a dangerous side effect of a medication that my patients were taking. The answer, of course, is easy. And it wouldn’t even be a question; it would be an obligation. If I see a threat to my patients’ health, it’s in my job description to speak up.

Repeal and Replace. Repeal and Replace. Repeal …

Jul 9, 2017• 5

By BRIAN JOONDEPH, MD

Repeal and replace. Simple enough on the campaign trail. We heard this promise in 2010, when voters gave the House to Republicans. We heard it again in 2012, when voters gave them the Senate. Despite controlling Congress, Obamacare remained the law of the land. Candidate Donald Trump, along with most Republican members of Congress, promised repeal and replace last year.

Republicans now have their largest electoral majority in nearly a century, and repeal and replace is spinning its wheels, like an old Pontiac stuck in the snow.

Some think a grand bill is still possible, particularly Senate majority leader Mitch McConnell. Others are skeptical. Senators Rand Paul and Mike Lee favor a two-pronged approach: repeal first then repeal later. Herein lies the problem. Republicans can’t agree on anything.

Democrats had no such problem in 2010 when they passed Obamacare. The Bernie coalition didn’t get a single-payer plan as they wanted. Some wanted higher Medicaid reimbursement for their states, as in the “Cornhusker Kickback.” But they came together and passed Obamacare, each Democrat getting most but not all of what he wanted.

Beyond “Repeal and Replace”

Jul 5, 2017• 8

BY DANIEL STONE, MD

The toxic polarization of Washington politics might lead even the most stubborn optimist to abandon any hope for bipartisanship on healthcare. Despite endemic pessimism, the flagging efforts to forge a Republican consensus on “repeal and replace” might set the stage for overdue efforts at compromise. Congress will be tempted to move on to more promising areas such as tax reform and infrastructure funding. That temptation should be resisted. The threat to the nation posed by the current state of American healthcare calls for Congress to resurrect the long lost spirit of bold bipartisanship.

Before considering opportunities for compromise, the obstacles confronting the GOP reform efforts are worth considering. Republicans face the same stubborn reality that confronted the framers of the Affordable Care Act (ACA): Expensive services cannot be covered by cheap insurance. The cost of U.S. healthcare has simply priced low income and even middle income individuals out of health insurance. Without subsides, they get left behind. The Congressional Budget Office’s estimated that the Ryan plan would result in 24 million losing coverage underscored the political divide: Confronted with unmanageable healthcare costs, most Republicans would opt to reduce public expense whereas Democrats plus a handful of Republican moderates prefer more extensive coverage. The effort of the GOP leadership to split the difference by preserving some residual subsidies and the structures supporting them—“Obamacare light”—remains unacceptable to many on the right. No clear middle ground has yet emerged.

Believe Them the First Time

Jul 5, 2017• 10

By NIRAN AL-AGBA, MD

I remember the first time someone threatened to kill me. It was my day off, so I was not in the clinic that day; a Children’s Hospital specialty group was working there instead, and after a staff member called the police, she notified me. A father had walked in saying he wanted to kill me for “taking his children away from him.” Wracking my brain as to this man’s identity, I drew a blank.

The police found him in a local park a short time later and judged him to be “harmless.” Somehow, I did not share their reassuring sentiment. I figured out who the man was, tracked down his mother, and promptly explained the situation. She provided a recent photograph so my staff could be trained to recognize him and contact the authorities the moment he entered our building. That photograph still hangs in our “Most Wanted” section of my front office, amongst other pictures which have been added. Occasionally, I request an updated picture to make sure we are keeping our office environment safe.

The second time a parent threatened my life was over the phone.

I was taking call on the weekend for a group of pediatricians. One of them had evaluated a child for a finger injury and had not quite done their due diligence. It sounded infected and in need of repair as the father described its appearance over the phone. I recommended he take his daughter to the local Emergency Room. He threatened to stab me instead. I called to warn the ER staff and then notified the other practice. The response was less than vigorous from my call partners, “you must have done something to upset him.” Their reaction astonished me; “blame the victim” is an unacceptable response to a colleague in this situation.