Monday, August 7, 2017

The frustration of actually trying to get health care: the other meaning of access

I have written about the quality of care that people in the US receive, and about access to and the cost of care, but another very important issue is the actual process of obtaining appropriate care. This is a major source of frustration for patients and their families, and can drive anger against the system, against doctors, against insurers, against the government. People who experience this frustration and anger want it to change, and sometimes want to lash out, offering an opportunity to be intentionally misled by influential others for their political ends. The demonization of the Affordable Care Act (“Obamacare”) is a good example. Obamacare actually did lots of good things, starting with insuring tens of millions who did not previously have coverage; it also forbid insurers from charging more to those with pre-existing conditions, and allowed children to stay on their parents’ plans until they are 26. Actually, it did little or nothing bad, if the criterion is access to care. A few people saw increased premiums, mainly the healthy young and those who previously had such terrible policies that they were both cheap and essentially worthless. While the Republican congress tried to repeal it, it turned out that, surprise, people would be worse off without it.

On the other hand, frustration with the obstacles to obtaining appropriate care are real, every day, and in-your-face for patients and their families. I have recently been experiencing these from the perspective of the patient (or family) rather than that of the provider, as I work at getting care for my 92-year-old father. My experience with the provider perspective helps me to understand the situation from both sides, and hopefully to try to figure out which obstacles are rational and which are simply unnecessary.

Let me start by largely absolving any of my father’s individual providers; all those involved with him – physicians both general and specialist, physical therapists, and more recently the nurses, social workers, and nurse practitioners through the palliative care agency – are committed, caring and hard-working. They do their best to help him, to be available, to respond when a problem, minor or urgent, arises. However, there are obstacles in the way. Many services require a referral from a physician, from calling in prescriptions, to ordering lab tests or x-rays (and getting the results), to getting physical or occupational therapy, to enrolling in palliative care. While none of these individually may seem to be burdensome for the doctor, there can be many for any individual patient, multiplied by the number of patients a physician sees who need these services. While it is sometimes the specialist who makes such a referral or fills out such a form, it most often “rolls downhill” to the primary care provider. That provider has to have a very large number of patients to get by and make a living, so the phone messages and faxes and lab results pile up while s/he is spending all day actually seeing his/her patients. Rationalizing the delivery of care means trying to get nurses or other staff to deal with as many as possible, but lots of these require a doctor (or other licensed provider, such as a nurse practitioner) to interpret, approve, or sign off on.  And having more staff costs more money, and means (particularly for the primary care provider, whose reimbursement is much lower than for many specialists) having more patients. Thus, a vicious circle, often compared (from the provider’s point of view) to running on a hamster wheel; for patients, this often seems like obstructionism.

Of course, it often is obstructionism, but rarely on the part of the individual provider. The reason is, unsurprisingly, money. For the providers of care, or more usually the companies for which they work (whether for-profit or not), the issue is reimbursement by insurers, including Medicare and Medicaid. There are rules that must be followed, forms that must be filled out, referrals that must be signed, and procedures to go through, or payment will not be forthcoming. And then the provider, whether physician, nurse practitioner, physical therapist, pharmacist, or social worker, whether self-employed or working for a company, doesn’t get paid. And, depending on how often this occurs, will make less, fire staff, or go broke. In addition, insurance companies themselves often create obstacles to payment (such as the time-honored one of just refusing to pay the first time or two, because maybe the provider will give up), but this is more often true for costly surgeries than lower-cost preventive and treatment services. And sometimes the practices seem almost incomprehensible as in insurers requiring patients to use brand-name rather than generic drugs and thus have to pay more out of pocket (“Take the generic, patients are told. Until they are not”, NY Times, August 6, 2017); one word, not used in the article but clearly described: kickback.

To be fair, many of the rules that seem to be obstructions are not only about saving money; they are about both preventing fraud and even patient safety. There absolutely are major fraudsters out there, doctors and home-health companies and nursing homes and every sort of medical support provider (even hospitals), who try to and often succeed in bilking Medicare (and other insurers) out of millions of dollars in inappropriate (“do you want a scooter at no cost to you?” – but someone else is paying!) or truly fraudulent (there is no patient) care. In fact, some care, even if you want it, even if someone is willing to provide it (if they get paid), is not appropriate for you, or your family member. Medicare and other insurers do set criteria, and require that it be documented. This can actually be good, not only for all of us as taxpayers but for our health and safety.

But often it isn’t good. It sometimes makes care that is appropriate, evidence-based, and desired, hard to get. It takes a long time. It takes lots of phone calls, and hours on hold or waiting for calls back. It has messages lost in piles, or over the weekend. It should not happen, but it does. And it is frustrating. The “Triple Aim” guiding progressive health care has received a lot of attention. It is to deliver high-quality care in a cost effective manner that is satisfying to patients. To document the last, many hospitals, provider groups, and companies send out “patient satisfaction” surveys, which are at best cosmetic and at worst destructive. People don’t fill them out “right”; they tend to reflect an overall impression that leads people to mark each of the ostensibly-separate questions “great” or “terrible”. Also, in forming this global impression, folks understandably often overvalue the things that they can assess (like the quality of food or attractiveness of the facility) compared to things that they cannot (such as the actual quality of care). This is, by the way, where providing good customer service makes a big difference, and while some places are getting better, the medical care industry is generally weak in this critical area.

As in almost everything, those with the least get the least. The uninsured, the poorly insured, and the just poor, provide the least incentive to providers (getting paid) to meet their needs. Government regulations that require certain services for Medicare or Medicaid without paying for them result in greater strain on those providers who provide care to people in these groups. Many providers, especially in some fields or medical specialties or geographic areas, try to avoid them. They locate in wealthier neighborhood, don’t take folks who are uninsured (or on Medicaid, and sometimes even Medicare), or offer indulgent, wonderful “concierge” services for those who can pay a significant retainer. Thus works the “market” in health care. A terrible way to go.

A universal health insurance system won’t make all these problems go away; even with it, systems can still be poor, providers can be uncaring. But it will help a lot. Because everyone is covered, there is no “vendor lock”; the market can function well because people choose their providers based on service, not because they are forced to because they are locked in to a limited pool. Information flows between primary care and specialists and therapists and labs and imaging because if it doesn’t folks are free to take their business elsewhere. The way competition should work; competition on providing the best product and service.

And, because we would all be in it together, in the same system, the most empowered will make sure it works for them, and thus, hopefully, for us all.

Thursday, July 20, 2017

The social mission of medical education: Admit different students

In his JAMA “Viewpoint” article, “Social Mission in Health Professions Education: Beyond Flexner”,[1] June 17, 2017, Fitzhugh Mullan makes a convincing case for medical schools to be committed to their social mission. He takes his definition from the “Beyond Flexner” website (, which says “Social mission is about making health not only better but fairer—more just, reliable, and universal”. He details what this means in terms of commitment to reducing health disparities, increasing access to healthcare in both rural and urban underserved communities, increasing diversity within the health professions. These serious issues have been identified for decades, but in fact the trend may be toward getting worse instead of better.

Mullan cites some examples of medical schools, primarily newer and “community based” schools, that are working toward these goals. These include Morehouse and Mercer (founded in an earlier wave of medical school expansion in 1975 and 1982 respectively), those of a more recent expansion in the 2000s (Florida International University and the AT Still Mesa Campus), and those yet to come (the merger of Geisinger Health System and Commonwealth University, Kaiser Permanente School). But he also talks about “mainstreaming”, the need for consciousness about, and implementation of, social mission to be a characteristic of all medical schools.

I believe that the most important measures of a health professions school’s social mission are its outputs. Using the 3 criteria identified by Mullan and colleagues in their seminal 2010 Annals of Internal Medicine article “The social mission of medical education: ranking the schools”,[2] we need to look at whether its graduates are more diverse, whether they practice in underserved areas, and whether they are more likely to be in primary care specialties. The 2010 article showed that some schools do better -- more often those that are public, newer, and not in the Northeast -- but the fact is that none is doing all that well.

The number of students entering primary care is a critical indicator because, based on national and international comparisons, a well-functioning health system should have 40-50% of physicians should be in primary care; the US is well below 30% and going down. Family medicine match rates are the most sensitive indicators of primary care production, because unlike internal medicine virtually all family physicians practice primary care, so a choice of this specialty means a commitment to primary care. In addition, it is the specialty most suited for practice in rural areas. Even if all schools consistently produced 50% primary care physicians, it would take at least a generation to get to that number for all physicians in practice, and we are far, far from this.

In 2012 John Delzell and I looked at 10 years of data (2002-2011) published annually on the family medicine match by the American Academy of Family Physicians (AAFP) documenting the number and percent of students from each medical school entering family medicine.[3] We found only a few schools that were relatively high in both number and percent, with the University of Minnesota and the University of Kansas far ahead of the rest. And yet even those schools do not produce primary care physicians at the 50% rate. In the most recent AAFP report, on 2015 graduates,[4] even the “socially conscious” schools cited by Mullan did not have very high numbers matching in family medicine:  Morehouse 8 (12.9%), Mercer 13 (13.8%), FIU 4 (5%). Minnesota, at 42 (18.2%) had the largest number in the nation, but still had 20 fewer than it did in 1999! In 1994, the Association of American Medical Colleges (AAMC) announced Project 3000 by 2000, aiming for 3000 minority medical students into US schools by the year 2000[5]. It failed. Today, in 2016-17, we are not only far from that number, but the percent of many minorities (especially African-American men) continues to drop.[6]

As in any process, the results of medical (and all health professions) education are affected by 3 sets of variables. Input variables are the students enrolled, process variables include the curriculum and overall experience of students during their education, and output variables are the expectations of what the income and life experience of a graduate is likely to be. While the last is probably the most important determinant, especially given the degree of debt with which students are graduating and the fact that many specialists can earn 2-3 (or more) times as much as a primary care physician, it is also the area that schools have the least ability to influence. As Mullan and colleagues have emphasized, medical schools can influence the process variables, including the school’s vision and mission, the teaching of social mission, determinants of health, disparities, and other areas in their classrooms and clinics, experiences for students to serve such as free clinics, and mentoring and role modeling by faculty. However, making these changes seem to be insufficient to overcome the negative influence of the output variables in terms of students choosing primary care and practice in underserved areas. At least for most of the students currently in medical school.

Which brings us to the input variable: who is admitted? Clearly, from the data cited above, medical schools are not taking appreciable numbers of students from underrepresented minority groups, from rural areas, or from lower socioeconomic groups, at least not in anything close to the proportion in the population. They take, on the whole, white (and Asian) students from well-to-do suburbs of large cities who, not coincidentally, went to the “best” public and private schools and have the highest grades and Medical College Admissions Test (MCAT) scores. The problem for the health of the American people is that the strongest predictor of where a medical student will practice is where they come from; minority students are far more likely to practice in minority neighborhoods, rural students are far more likely to practice in rural areas, and white upper middle class students from the suburbs are more likely to practice in the suburbs. These are the areas that already have enough physicians (and sometimes too many). In a real sense, a physician who enters practice in a non-underserved area in a non-shortage specialty is contributing little marginal benefit to the health of the American people. The imbalance of physicians practicing in health professions shortage areas (HPSAs) vs other areas is demonstrated in the attached table from Zhang, et al.[7]

Yes, our society must urgently address the “output variables” to ensure that students who choose primary care can earn a reasonable proportion of what other specialists do (some studies indicate that 70% of mean specialist income would be sufficient to eliminate that as a reason for not choosing primary care). Indeed, medical schools need to address the “process variables” by having explicit curricula on health disparities, social determinants of health, and community and preventive health, and ensure there is not a “hidden curriculum” mitigating against primary care. But they also urgently need to ensure that most of their admissions, not a token number, are students whose characteristics mean they are more likely to meet America’s healthcare needs. These include demographic characteristics, such as rural or minority origin and lower socioeconomic status of their family, and individual characteristics identified by past performance (not sentiments in an essay). This is primarily significant volunteer service, especially major commitments like the Peace Corps, Americorps, Teach for America, etc.

And, most importantly, these changes and programs must happen at all medical schools and for the bulk of the classes. The time for experiments and pilot programs is done. These efforts must be scaled up, to be, in Mullan’s word, “mainstreamed”. And now is not too soon.

[1] Mullan, F, Social Mission in Health Professions Education: Beyond Flexner, JAMA published online June 26, 2017. doi:10.1001/jama.2017.7286
[2] Mullan  F, Chen  C, Petterson  S, Kolsky  G, Spagnola  M.  The social mission of medical education: ranking the schools.  Ann Intern Med. 2010;152(12):804-811
[3]  Freeman J, Delzell J, Medical School Graduates Entering Family Medicine: Increasing the Overall Number, Fam Med 2012;44(9):613-4.
[4] Kozakowski S, Travis A, Bentley A, Fetter G, Entry of US Medical School Graduates Into Family Medicine Residencies: 2015–2016, Fam Med 2016;48(9):688-95, (online Table A).
[5] Nickens HW, Ready TP, Petersdorf RG, Project 3000 by 2000 -- Racial and Ethnic Diversity in U.S. Medical School, N Engl J Med 1994; 331:472-476August 18, 1994DOI: 10.1056/NEJM199408183310712
[7] Zhang X, Phillips RL, Bazemore AW, Dodoo MS, Petterson SM, Xierall I, Green LA, Physician Distribution and Access: Workforce Priorities, Am Fam Physician. 2008 May 15;77(10):1378.

Saturday, June 24, 2017

McConnell, the GOP and Trumpcare: We care about lowering taxes for the rich, not your health care!

First, let’s start with a reminder about how insurance works. Money (“premiums”) is collected from everyone, or as many people as possible, and when the bad thing happens (insurance is almost always about protecting against bad things, like car accidents, or fires, or death, or illness), the victims are compensated. If it pays out more than it collects, then the insurance company goes bankrupt and can no longer pay out. This works for all types of insurance, whether for-profit (as most is in the US), not-for-profit (like many health-insurance companies in other countries), or social insurance where everyone is a client and government is the insurer. Insurance companies, especially for-profit insurance companies, have to build in a profit margin as well. In addition, they prefer insure people who are at low risk of requiring payout, and not to insure or charge higher premiums to those who are at higher risk (e.g., younger drivers, for car insurance). This process is known as “underwriting”.

If an insurance company is forced to insure a lot of high-risk people (as they were under ACA) and can’t charge them really a lot (under ACA they could charge 3 times as much), they need a lot of low-risk people to pay premiums to be able to fund their probable payouts; thus the “individual mandate”. For social insurance, such as government financed health insurance programs (as in many other developed countries, or Medicare and Federal employee and military programs in the US), it is actually not necessary that more money come in from premiums than is paid out, because the government can (if it wishes) subsidize the loss from other funds. This is, of course, a political decision on how to allocate tax dollars and how many tax dollars to collect.

The Senate Republican leadership has made its position on this completely clear with its recently unveiled “health care” bill, the “Better Health Care Act” (BHCA). Crafted by Majority Leader McConnell and a small group of white men from a small group of places (for example, 2 senators each from Utah, Wyoming, and Texas). It will and should be called #Trumpcare; while the President didn’t write it, he has endorsed it and will sign it if it passes the Senate and the House reconciliation. It is clearly a tax-cut-for-the-wealthy bill that derives funding from the reduction (and sometimes elimination) of health care coverage for a very large percent of Americans; this is detailed by the NY Times’ Margot Sanger-Katz in “Shifting Dollars From Poor to Rich Is a Key Part of the Senate Health Bill”, June 22, 2017. The Times also has a piece by Sanger-Katz and Haeyoun Park that contains a clear listing of what will be cut from the ACA in order to fund these tax cuts, “How Senate Republicans plan to dismantle Obamacare”, summarized in the graphic. However, the details are important; even the parts of the ACA that the BHCA “keeps” are largely undercut by other parts of the bill. For example, it keeps the requirement that insurers must issue policies to people with pre-existing conditions (which can range from heart disease and cancer to endometriosis and broken bones and everything else), which is good. But it raises the amount that insurers can charge these people from 3 times as much under ACA to 5 times as much. This is a big deal, and a bad deal, for people with disabilities and for older people who are, (surprise!), much more likely to have pre-existing conditions.

While BHCA (Trumpcare) repeals the individual mandate, which will make some people happy (until they get sick) and the employer mandate (which will make employers happy), it also repeals the subsidies for out-of-pocket costs and decreases funding for subsidies to make policies on the exchanges affordable. The new bill would make either premiums or deductibles (or both) unaffordable for many Americans. It limits and sometimes eliminates the requirement that insurers provide “essential health benefits”, like preventive care and contraception, allows insurers to set annual and lifetime limits on how much they have to pay, and makes major negative changes to Medicaid. Medicaid is currently largely paid for by the federal government, 50%-80+% depending on the average state income, and 90-100% for people covered by Medicaid expansion. The “changes” include (gradually, so the impact won’t be seen for the 2018 election) cutting and capping the amount the federal government pays, shifting costs to the states, which often will not be able (or willing) to cover them.

This will affect a lot of people. Medicaid is now the largest insurer in the US, covering 69 million Americans, even though many states did not expand it under the ACA to cover poor adults. What it does is summarized in “How Medicaid works and who it covers” by Abby Goodnough and Kate Zernike. It covers, as seen in the accompanying chart, 79% of poor children (and more than a third of ALL children), 64% of nursing home patients (many of whom were middle class before the NH wiped out their savings!), 60% of children with disabilities, 49% of births, 30% of adults with disabilities. The people who will suffer from Medicaid cuts are old people in nursing homes, children, and disabled people (many of whom are able to stay in the community and even keep jobs rather than being in nursing homes because of this support). With the caps on lifetime benefits, it means, as Dr. Eve Shapiro points out in an Op-Ed in the Arizona Daily Star, that a premature baby on private insurance could exceed her lifetime limit on coverage before she even leaves the hospital”! And, with the right convergence of decisions by the state, the same could happen to an infant with Medicaid.

This is a big deal. Ideologues and pundits and politicians like to debate theoretical issue to see who scores the most points. They want to be the “most conservative”, the most “anti-abortion”, the most “pro-industry”, the most “anti-tax”. If they are articulate they may think that making their smarmy points makes them win. And I guess it does. Except the losers are not those on the other side of a debate podium, they are the majority of the American people, the politicians’ constituents, who don’t get treatments, don’t get diagnosed, do get sick and die. Lives, not ideologies, are at stake.

Except, of course, it is about ideology. This is made clear in “A debate that shows what each party cares about” by Neil Irwin the Times. No one, certainly not a senator who has to run for re-election, wants to say that they are about making it harder or impossible for many (often the majority) of their constituents to be able to access health care, or to pay for it, or to get the treatments and therapies they need. But make no mistake: every senator who votes for this bill is saying exactly that, that they value tax cuts for the most privileged above basic health care for the rest of us. “This plan will improve the affordability of health insurance,” lied Sen. McConnell in a recent opinion piece in the Cincinnati paper.

Yes, “Mr. McConnell has always taken pride in protecting his members.” And his donors. It is too bad that he has no interest in protecting the rest of us.

Sunday, June 18, 2017

US Health Rankings remain low and #Trumpcare will make them worse!

On many occasions this blog has made the point that, despite frequently-repeated claims that the US has “the best healthcare in the world”, we do not. This point is also made by dozens of other sources, recently including Kaiser Health News (KHN) editor-in-chief Elisabeth Rosenthal in her book “American Sickness”. In my book, “Health, Medicine and Justice: Designing a fair and equitable health care system”, and in many lectures I have given to physicians and students, I have cited the “37th in the world”  ranking the US achieved in the comprehensive World Health Organization (WHO) report of 2000. The report’s Table 10, available as a pdf at that site, indeed lists the US as #37 in Overall Performance, just below Costa Rica and just above Slovenia. On an equally telling scale, Performance on Health Level (measured by Disability-Adjusted Life Expectancy, DALE) the US ranked #72, between Argentina and Bhutan. When many US news media led their stories with “Just ahead of Slovenia!”, the Slovenian ambassador took exception, noting that his country was working hard to improve their people's health status.

But, as I also pointed out in my lectures, this table is old, based on 1997 data, and I use it because it is the last time that WHO released such rankings. I supplement it with newer data, such as the Commonwealth Fund’s “Mirror, Mirror on the Wall” from 2014. This compares fewer countries, albeit appropriate, developed, wealthy, OECD countries. In this study, the US also ranks last overall and in many subscales; I have published this graphic before as well.  

Now, we have new rankings to refer to, the Bloomberg Global HealthIndex from 2017. It would be nice to be able to say that the US had moved up from the 2000 WHO report, but now, at #34 (and still just behind Costa Rica) the change is really insignificant. Slovenia, it might be noted, has moved up, to #27, so maybe their efforts are paying off!

Given the recalcitrance of US health status to improvement, it is obviously important to look at the ”why” as well as the “what could be done?”. This is especially now, given that these ranking do not yet reflect any negative impact that may happen through the repeal of the Affordable Care Act (ACA) and its replacement by a a Republican plan (#Trumpcare). The contents of the bill that the Senate is currently working on, and which Majority Leader McConnell hopes to bring to a vote by July 4, remain secret not only to the public but also, apparently, to many or most senators. Therefore, the bill passed by the House of Representatives, the American Health Care Act (AHCA) remains our best guide to what the final plan may look like.

And it is not encouraging; the Congressional Budget Office (CBO) estimates that 23 million Americans willlose health insurance, about equally from loss of Medicaid expansion and from  cuts to support for the health insurance exchanges set up by ACA. This will unquestionably mean that the overall health status of Americans will go down, both in absolute terms and relative to other nations. Without health insurance, people will not access health care, especially for prevention and “minor” problems (or problems that are not really minor but so far not, or minimally, symptomatic). This means that by the time that their health is so bad that they seek care, they are less likely to survive or do well, and also that the cost of their care will be far higher. This is not a plan to most efficiently use healthcare dollars to maximize the health of the American people.

So what is going on? In a recent blog post (“Pre-existing conditions and profit-taking: the causes of our healthcare problems, May 29, 2017)  I wrote “The AHCA is basically a tax-cut-for-the-1% bill, with the money coming from the health care coverage for the rest of us.” That is true, but the question that still needs to be answered is “why”? Ultimately, it is a question of values: if the goal was to have the best possible health status for the American people, rich or poor, white or black, native born or immigrant, rural or urban, this would not be the system that we have and #Trumpcare would be designed to fix the problems with the ACA, not to exacerbate them. President Trump and the GOP have emphasized, in the campaign and since, that for many the ACA has not made insurance accessible because the premiums are too high. This is a good point, and a solution would be great; unfortunately, the AHCA would make them higher, and price out far more people. The values of the Republican leadership are clearly to maximize tax cuts and other financial benefits to the richest American people and corporations, and this AHCA will do. The perpetrators are not among those at the margins; even those congresspersons and pundits who are not truly wealthy have outstanding health insurance for life, and are certain that they will not be in the marginalized group, and that they will be able to access the “best health care in the world”.

Of course, even when you have great insurance and access to “everything”, it is not always better. Sometimes if you are too well-insured you get too much care, tests and procedures and drugs that can put you at risk of harm. And even in the “best” facilities things don’t always go well – medical errors are common, communication can be poor, and even when there are no screwups bad things can happen. Donald Berwick, head of the Institute for Healthcare Improvement (IHI), and former interim head of the Center for Medicare and Medicaid Services (CMS) talks about the US perhaps having the best “rescue care” in the world. But even that is not so good; many IHI initiatives are focused on changing that system to work better, including improvement capability, patient safety, and population health. Anyone who has been sick, or in the hospital, or had a close friend or relative in such a situation recently, can testify to the failings of our health care delivery system even for the well-insured.

So the situation in the US was not good up until now, and will almost certainly get worse with #Trumpcare. Many of the people who will suffer most are those who voted for the President and the GOP members of Congress. Maybe they think that the bad things will not happen to them and their families, but only to “others”.  But they will, and we need to move up in the rankings, to be closer to other OECD countries.

Maybe the solution for the US is not to mimic France, or Italy, or Canada. But whatever the solution is, it has to pass the empiric “does it make our people’s health better?” test. And clearly #Trumpcare will not.

Monday, May 29, 2017

Pre-existing conditions and profit-taking: the causes of our healthcare problems

Elisabeth Rosenthal, the editor-in-chief of Kaiser Health News and author of “An American Sickness” (discussed in this blog on April 15, 2017, United Airlines, health care, and a system designed to privilege the powerful) has an op-ed in her old newspaper, the New York Times, on May 29, 2017 titled “We all have pre-existing conditions”. That is a good and accurate title, but a little different from the print title “The cost of pre-existing conditions”.  That cost is high, to the people with those conditions, and less obviously, to the overall society. This includes their families and friends, of course, but also their employers. When a potentially treatable condition excludes you from having health insurance, you are less likely to get it treated, and more likely to get sick and miss work. The spectrum of conditions that insurance companies used in the pre-ACA era to exclude people was broad. Rosenthal notes specific examples including having had an abnormal Pap smear, a history of being on anti-depressants, a history of taking thyroid medication, and being on post-menopausal hormone treatment. Of course, once you are excluded and have no insurance, you don’t seek care for other conditions either, either pre-existing or those that develop later or might have not been recognized. Not only could insurers exclude you for having a pre-existing condition, but there was no regulation of what or how significant that condition had to be. We have heard stories of people being denied treatment for cancer because, on signing up, they had “failed to report” a pre-existing history of treatment for things as minor as an ingrown toenail or acne!

The ACA, also known as Obamacare, changed that. It eliminated the ability of insurance companies to exclude people based on their pre-existing conditions, thus rendering moot the question of what conditions could be excluded. It also prevented those insurance companies from charging more money to people with those pre-existing conditions by requiring “community rating”; they had to set their rates based upon the overall actuarial risk of the entire community in which they sell insurance. The same principle is why those of us who receive our health insurance via employers, especially large employers, usually have lower rates for better coverage – because the risk pool is everyone who works for that company, and while many are sick, many more are younger and healthier (after all, this excludes all the people who are not working). Thus, the requirement that the individual policies sold under ACA had to be based on the community rating was critical for many Americans to be able to get even close to affordable health insurance.

For many, the cost on the individual marketplace was still too high. For those whose pre-existing conditions had previously made them unable to get insurance, it was often still a boon. For those who were younger and healthier, though, who had had cheaper policies or gone without coverage altogether, they now had to pay more. After all, community rating means an average, so those at lower risk will pay more than they would have with individual rating, and certainly more than with no insurance since the ACA had the “individual mandate” requiring them to get coverage. The bigger problem is that in some geographic areas, many (or most or in some cases all) insurers decided that the benefit of offering insurance (i.e., making money) was not worth the risk of paying out for actual medical care. This is especially true in rural areas, where low population density and a higher proportion of older and therefore sicker people make for a poor risk/return ratio.

The problem, of course, for those younger and healthier people who chose to forgo coverage or, after the individual mandate, to buy the cheapest and crappiest policies, is that they can get sick. They can discover that they have cancer, whatever their age. Or get into a car accident, requiring many surgeries and long treatment and rehabilitation (did they have car insurance?). Or be burned in a fire started by smoking (did they have homeowner’s insurance? Did they opt to not pay the higher premiums that they can legally be charged for being smokers?) Or they can have a premature baby that needs treatment in a neonatal ICU.  Or, particularly for the older group who knew they had a problem like hypertension, diabetes, or arthritis but were hoping they’d stay relatively asymptomatic, they can have a downturn – have a stroke or a heart attack or a serious infection or pain so bad that they can no longer work. And then they find that the “affordable” (i.e., crappy) health insurance that they bought is almost as bad as none.

So we have a conundrum. To work, health insurance has to include everyone, the sick as well as the healthy. But the healthy, especially those with lower incomes, don’t want to pay what seems to be the unfairly high rates that they have to in order for the whole system to be fair. The older and less healthy may want health insurance, but still be dissuaded by the high premiums. The sick need the coverage, but again, without the healthier paying in, the cost for them is too high, and results in either their being unable to afford it or the insurers being unwilling to cover them even if it means leaving an entire market.

Let’s look at some facts:
1.      The US spends more on health care than any other county, by far.
2.      The US has, on a population basis, worse health outcomes than most other developed countries, far worse than many.

This is the true conundrum. How can we pay so much for so little? It is because we pay an enormous percent of our “health care” expenses for drug company (and drug “middlemen”, pharmacy benefits managers) profits, insurance company profits, and income for for-profit and function-like-for-profit non-profit hospitals. As documented by Eric Lipton and Katie Thomas in the May 29, 2017 Times (“Drug lobbyists’ battle cry over prices: blame the others”), there is plenty of blame to go around! In addition, the percent that is actually spent on health care on treatments (and sometimes cures) is primarily for far advanced disease, not prevention and early diagnosis and treatment. We spend almost nothing on public health and prevention.

We keep telling ourselves lies (our healthcare system is the best in the world, the ACA is the problem, drug companies need to charge so much because they spend so much on research and development, etc.) but fewer and fewer of us are believing it. Many of the people who are worst affected voted for Donald Trump and for Republican congressmen who have devised the AHCA (American Health Care Act) that will “solve” the problem by essentially eliminating health insurance coverage for 23 million Americans, 14 million in the first year alone, according to estimates by the non-partisan Congressional Budget Office (CBO). The AHCA is basically a tax-cut-for-the-1% bill, with the money coming from the health care coverage for the rest of us.

Is there any way out of this conundrum? Yes. We have the money, obviously; we are spending it. Fifty percent of health care spending is already government, 60% if you include the lost taxes from the employer portion of health insurance. We make the community being rated everyone in the US. We all have one health plan. We are all covered. We all get all necessary services. We don’t lose coverage by leaving or jobs for any reason, from family needs to an entrepreneurial start-up. The old and vulnerable among us are covered and have their needs met, and the healthy among us win by staying healthy and having coverage when we need it. We pay for it by eliminating the profit centers, and not by cutting taxes on the wealthiest of us.

It can be done. It has been done. In every other developed country. We have the resources to do it here. We must need to stand up to the entrenched and powerful profiteers.

Sunday, May 21, 2017

Cancer, cost, hope, and the responsibility of physicians

The headline on a recent article by Marilynn Marchione of the Associated Press, as featured in the Arizona Daily Star, is “Few doctors discuss cancer costs with patients, study finds”, and that about covers it. The actual study previewed in the article, which will be presented at the American Society for Clinical Oncology (ASCO) conference in Chicago in June, was led by Dr. Rahma Warsame of Mayo Clinic. It recorded clinical encounters at three cancer sites (Mayo, USC, and LA County) and discovered that the often extraordinarily high cost of cancer care was not usually discussed; discussion happened in just 151 of 529 visits, and in only 45 of those cases, less than 1/3, was the issue brought up by the doctor rather than the patient.

The article suggested several reasons for this. One was that the visits were short, 15 minutes at USC and LA County (about typical, though, across the country), and 30 minutes at Mayo. Another was that doctors are trained to diagnose and recommend treatment rather than to focus on the cost. A third is that the doctors themselves might not know the costs of the treatment. And, for a combination of both of those reasons, they might be uncomfortable talking about the cost. Given that these treatments can easily cost $100,000 a year or more, this is not fair to patients. While good insurance might cover the cost, not everyone has good insurance. In addition to the uninsured, many more people have crappy insurance plans with poor benefits and lifetime caps that are easily exceeded with the cost of cancer care. For most of these folks, the answer is go broke and bankrupt, or die without treatment. From a health point of view, this is not a desirable state of affairs. From a medical point of view of trying to do the best for a patient, it is an abrogation of the obligation to provide the best care. From a moral point of view, it is reprehensible. From some points of view, however, it must be ok, because this is the situation we are in, and it is not by accident. And that is tremendously distressing.

But who would have such a despicable point of view? We can start with the organizations that make money from such care. Of course, this includes the very clinical oncologists who are the members of the ASCO, but they are the least of the beneficiaries. Indeed, I feel comfortable saying that most oncologists would enthusiastically welcome lower costs for chemotherapy. The biggest winners are the drug manufacturers, who charge fantastic amounts for these drugs, and the hospitals and “cancer centers” that provide them. A large part of this profit comes from the reimbursement from insurance companies, which, in addition to paying the cost of the drug, also pay an fee to the hospital for administering the drug that is, frankly, exorbitant and far more than is paid for comparable work in provision of most other care. Indeed, this is why there is such an apparent explosion of cancer centers. It is not because of the explosion of cancer; it is because they are big profit centers and every hospital wants their own to try to lure cancer patients (those who are well-insured, it goes without saying) away from their competitors. And, in a step back from my confidence in the patient-centeredness of oncologists, those groups of oncologists who own independent cancer centers outside of hospitals, and make lots of money on it.

Why would insurers pay such high prices? Medicare pays a pretty high “administration fee”, and most private insurers reimburse at multiples of Medicare. Also, insurers can just raise their rates to cover these costs, especially if they value (as in “appreciate the clout because of the number of patients they control”) the relationship with a particular hospital, cancer center, or health system as described in Elisabeth Rosenthal’s “An American Sickness” and discussed in my blog post “United Airlines, health care, and a system designed to privilege the powerful” (April 15, 2017).

Students learn very little about the cost of care in medical school. There are beginning to be some courses that introduce cost-consciousness, but they are uncommon and limited, although even residents and students have access to smartphone information, through apps such as ePocrates®, that provides information about drugs, and often cost.  But is true that these doctors do not know the cost of the care that they are providing? Certainly while the clinical oncologist may not know the exact dollar amount, they know that it is a lot. And it is irresponsible to not discuss this with patients, to help them understand what they are getting into when they start treatment.

Drugs are only one component of the cost of care; a huge one in cancer, but radiation therapy can be even more. As I have discussed before, the real problem is that no one knows what anything actually costs. Yes, hospitals have “charge masters”, but they are not only dense and hard to find (especially for patients) but not that relevant; these charges are adjusted dramatically depending upon insurance. Medicare is unique in that it sets the amounts that it will pay (a lot for chemotherapy), but other insurers pay varying amounts depending upon the contracts that they have arranged with the hospital. Thus we have the irony (which I discussed in “Integrated Health Systems and Cost: The Price is the thing!”,December 20, 2015) that smaller cities with large integrated health systems have some of the lowest costs for Medicare (because they can create efficiencies) but some of the highest costs for private insurers (because they “own” the market and can charge more).

The real issue is that people should be able to get the care that they need and is medically indicated and has evidence to back its effectiveness without going broke. Physicians can no longer hide behind the first half of that sentence, saying “I recommended the care that they need and is evidence-based” (although certainly their recommendations should always be evidence-based!) without considering the cost. On the other hand, the health system of the US should ensure that everyone is covered for necessary care. One way of having enough money to do this is not providing unnecessary, evidence-free care to some people just because they or their insurance will pay for it.

This also means that people should not expect it. As horrific as it is for you or a loved one to be dying of cancer, it is unreasonable to expect that experimental, hopeful, or completely wishful-thinking treatments would or should be paid for by someone else, and it is generally a bad idea to try to pay for them yourself since they won’t work. Some years back, my friend was dying of an aggressive cancer. A bone marrow transplant failed. The genetics of his cancer were such that it was destined to fail. The cancer center (arguably the “best” place in the US for his type of cancer) offered him the opportunity for a second transplant, but the insurance company rightly refused to pay. His family cashed in his entire retirement to pay. Predictably, the transplant failed, and his family was left without any savings. The doctors knew that it would almost certainly fail, and should have known what it would cost, and thus not recommended it. An agnostic stance on cost is unacceptable.

The media coverage of the ACA and the Republican repeal plan makes clear that there are many people who do not want to pay for insurance coverage when they are healthy, but want everything taken care of when they or their family are sick. Then they get desperate and might spend the last of their savings on treatments that will not work, whether quack drugs like laetrile or futile attempts offered by the medical community, such as happened to my friend. It is the responsibility of doctors to know the cost of treatments they recommend and discuss this with their patients, and to not offer ineffective treatments. It is wise for patients also to ask for this, although many are unempowered and intimidated by the medical system.

But if we all pay in when we can and benefit when we need it, the system would work. It’s called single payer, or Medicare for all. Unfortunately, our system, with or without ACA, is nowhere close.

Sunday, May 14, 2017

Contraception, women's health and dignity, teens, and stupid legislators

A bill before the Maine legislature would allow women to obtain a year’s worth of oral contraceptives at a time, rather than the previous 3-month limit. This is a good thing, as argued by its sponsors and supporters. Women typically take oral contraceptives for long periods of time, and the requirement that they return to refill their prescriptions every 3 months is at best an inconvenience and at worst a burden. It is a burden women should not have. Indeed, there is no good reason to require a prescription for oral contraceptives at all.

This does not mean that there are no reasons put forward by opponents; if there were none, there would be no opponents. Overall, the opposing arguments fall into 3 categories: money, control, and wacko paranoia. If women only have to fill prescriptions once a year there will be fewer prescriptions being filled, which could be a small hit to pharmacies. The bigger objection is from insurers, as addressed in an article in the Portland Press-Herald of April 19, who worry that it could become a “mandate” for coverage with no cost share for other contraceptives, particularly those that are more expensive for insurers.

Control is a big and insidious issue. The idea that women are incapable of making their own decisions, particularly with regard to their reproductive systems, is as outrageous as it is persistent. For generations women have fought and often won struggles to be considered legally as “people” (implicit definition: men); to have the vote, to own property, to divorce. But no area has been as fraught with (yes, “fraught” requires a preposition!) opposition as the entire area of women’s reproduction. From before the time of Margaret Sanger, every source of pressure – religious, economic, and legal – has been brought to bear against the idea that women should have control of their own bodies and particularly their reproduction. The struggle continues; abortion rights are the most vulnerable today, but as the opposition to the Maine bill illustrates, contraceptive rights are scarcely secure.

Even among the biggest supporters of contraception, there can be poor decisions. Nearly 20 years ago I sat on a Planned Parenthood advisory board, and many of its members were surprised that I strongly opposed a requirement that women have a Pap smear before receiving a contraceptive prescription. The logic of those who supported it was that the inducement of receiving contraceptives would encourage women to get their Pap, which was then recommended. My position was that the negative incentive of the Pap (and associated pelvic examination, see below) would keep women, especially young women and teens, from getting their contraceptives, and thus likely increase unwanted pregnancies. I am sure that that Planned Parenthood, and other contraceptive providers, no longer have such a requirement. Indeed, we no longer recommend Pap smears for women under the age of 21, and for others, they are recommended only every 3 years. Regarding the screening pelvic examination, it simply violates the first criterion for a screening test – there must be condition that can be screened for in an asymptomatic person. This has led the American College of Physicians, having reviewed the evidence, to recommend against it, while the US Preventive Services Task Force (USPSTF) somewhat incomprehensibly, gives it an “I” (evidence is insufficient to recommend for or against) recommendation. This is summarized in a recent review from the Agency for Health Research and Quality (AHRQ). The American College of Obstetricians and Gynecologists still basically advocates it, although it suggests the decision be made individually between the woman and her doctor, no real change from when I discussed it on July 3, 2014 (”The screening pelvic examination: not annual, not ever”).

Being a major provider of contraception does not save PP from the wrath of Congressional Republicans; indeed, while abortion is the flaming tip of the spear of conservative opposition, the right’s opposition to PP is also against those that do not do abortions, but mainly provide contraception and other women’s health services. The good news is that the GOP may be unable to attach defunding PP to the “health” bill (Obamacare repeal) because it is being done at a budget resolution. You might think that providing contraception would be seen as a good thing, since fewer unwanted pregnancies would lead to fewer abortions, but this is not their logic. [I think that they are, basically, anti-sex, at least that practiced by others, as demonstrated by all the patently false claims we hear constantly in school-based clinics that prescribing contraception will “encourage” sex.]

Of course, it does not. Hormones encourage sex, yes. Social pressure encourages sex, for sure. But not contraceptives; what they do is prevent pregnancy. Amazing. And if the whole campaign against PP, as well as opposition to allowing a year’s worth of OCPs, is grounded in a mindset that wants to control women, the issue for young women (and their partners) is far worse. They are seen as not only women, but immature and incapable of making wise decisions. There is some basis for the idea that they are immature, as parents know; the brain is not fully developed until at least the mid-20s and the last part to develop is the ability to make “executive decisions” – taking the information that you have, looking at it completely and objectively, and making a smart choice.  This is why teens and young adults make poor decisions in driving and, conversely, make the best soldiers.

But this is not a justification for restricting access to contraceptives, condoms, or other health services that might prevent bad outcomes. Because teens make not make the most mature decisions, and often regret them later, it doesn’t mean that they won’t make them. So we need to make it as easy as possible for them to not have long-lasting negative consequences, like STIs and unintended pregnancy. There need to be as few barriers as possible for young people to not get (or make another) pregnant, to not get preventable sexually-transmitted infections (STIs). These would include making oral contraceptives over the counter, making condoms in front of the counter, and preferably free. Should a young woman (or man) come to a clinic for care, invite them in, see them quickly, meet their needs. For goodness sake, don’t make it hard, don’t send them somewhere else to register as they’ll walk out the door!

The editorial in the New York Times, May 13, 2017, “The health care bill’s insults to women”, documents the degree to which women in rural and underserved areas, where more than half of PP’s clinics are, will lose if Medicaid doesn’t cover services at PP. It notes that in 105 counties, PP is the only provider of reproductive health services. The editorial starts with insensitive “sophomoric” quotes from several congressmen and senators, including one from Kansas Sen. Pat Roberts that “I wouldn’t want to lose my mammograms!”. Sen. Roberts would be well advised to identify which of the areas in Kansas, particularly in the very rural “Big First” district he once represented as a congressman, would be among those losing services. A lot, actually, especially since one OB/Gyn from Great Bend is now busy representing the district in Congress. Of course, Dr. Roger “the poor just don’t want health care” Marshall probably didn’t take care of many underserved folks.

This is not the way to go. Our goal must be to increase health as much as possible, not to create obstacles to it.

Saturday, April 15, 2017

United Airlines, health care, and a system designed to privilege the powerful

The spectacle of Chicago Department of Aviation security officers beating and dragging a passenger off of a United Airlines flight was recorded by other passengers and quickly went viral on the Internet, generating outrage across the country (and internationally, particularly in China, where the fact that the passenger was Asian was a source of fury). A series of statements from United and its CEO, Oscar Muñoz escalated from tone-deaf explanation (essentially “well, we told him to get off first”) to most recently apparent contrition, saying it should never, ever, happen to anyone and that United would never, ever, have local police board its planes to take off a legitimate, paying customer.

It is unlikely that this too-little too-late response is going to appease anyone, and it is profoundly to be hoped that United suffers severe financial repercussions; the passenger, who suffered a broken nose and lost teeth, almost certainly will sue. It is not clear how to make this happen to the Chicago Aviation Department. The fury of the public is almost certainly increased by the personal experience of (coach) airline passengers. It also is not limited to either United or to airline travel, as Helaine Olen articulately describes in her NY Times op-ed “United Airlines is not alone”, on April 12, 2017. Ms. Olen goes through the list of issues that were raised by this incident, including not only the concerns about racism (would it have been worse if he were black?), but about the militarization of our police response to relatively minor issues. Although the officers involved were from Aviation Security and not the Police Department, it is understandable that a friend from Chicago posted the question “Was anyone surprised that the Chicago PD used such violence?” on Facebook, given that department’s history of “overreaction” and use of military-type tactics.

But Olen’s main point is that this event (if not necessarily the attendant violence) reflects the vast disparity in treatment provided, not only by United and other airlines but across our society, of people in different socioeconomic situations. She goes through the multiple enhancements to the first class cabins (sleepable seats with Saks 5th Avenue bedding, better meals, etc.) and compares them to the growing level of discomforts and indignities inflicted on coach passengers, with no food, increased crowding, baggage fees, and the like. The crowding is worse than on a bus, and Greyhound doesn’t charge for baggage. Full-fare first class passengers are a big profit center, but most people in first class are not the 1%ers who can pay these fares, they are business travelers whose companies have bought coach tickets and upgraded to first based on miles earned through an airlines loyalty program. And airlines love that, because it means they will keep flying with them. The rest of us, tough. And don’t believe that they “need” to stay so lean; Olen notes that United made $2.3 Billion in profit last year.

Olen also makes the connection to health, observing that
In a study published in 2014, Martin Gilens at Princeton University and Benjamin Page at Northwestern University found government policy and actions rarely reflected majority sentiment, but instead favored corporate interests and the wealthiest Americans. When congressional Republicans offered up a health insurance reform package earlier this year that would have covered fewer people than the Affordable Care Act, Representative Jason Chaffetz, Republican of Utah, initially defended it by claiming Americans needed to choose between spending on necessary medical care or buying an iPhone. Meantime, the fabled 1 percent would have received an average tax cut totaling $37,000 if the legislation were fully enacted.

And if anyone doubts that this is how the health system functions (although I doubt that many readers of this blog do), I recommend the new book “An American Sickness: how healthcare became big business and how you can take it back”, by Elisabeth Rosenthal (Penguin Random House, 2017). Rosenthal, a former New York Times reporter whose fantastic series “Paying till it hurts” ran in the Times a couple of years ago, is now the editor-in-chief of Kaiser Health News. I have cited her reporting frequently in this blog and in my 2015 book “Health, Medicine and Justice: designing a fair and equitable healthcare system” (Copernicus Healthcare). Indeed, “An American Sickness” overlaps considerably with my book, but is by a much better-known figure, and hopefully will be widely read. Rosenthal, a physician, pulls few punches in this work, saying unequivocally that the US health system is designed and functions to maximize the income and profit of providers (especially hospitals), insurance companies, and pharmaceutical and device manufacturers. (An excellent review of the book by Jacob Hacker, Professor of Political Science at Yale, can be found here.) Rosenthal identifies the ten “Economic rules of the dysfunctional medical market” (which I have reproduced in the figure); all are important but #10, “Prices will rise to whatever the market will bear” is particularly critical, and reflects that the health system bears little or no relationship to a true market, and does not play by Adam Smith’s rules.

(E. Rosenthal, “An American Sickness”)

1.      More treatment is always better. Default to the most expensive option.
2.      A lifetime of treatment is preferable to a cure.
3.      Amenities and marketing matter more than good care.
4.      As technologies age, prices can rise rather than fall.
5.      There is no free choice. Patients are stuck. And they’re stuck with buying American.
6.      More competitors vying for business doesn’t mean better prices; it can drive prices up, not down.
7.      Economies of scale don’t translate to lower prices. With their market power, big providers can simply demand more.
8.      There is no such thing as a fixed price for a procedure or test. And the uninsured pay the highest prices of all.
9.      There are no standards for billing. There’s money to be made in billing for anything and everything.
10.   Prices will rise to whatever the market will bear.

Rosenthal supports each of these rules with data and examples. Regarding rules #8 and #9, in an NPR interview with Terry Gross on “Fresh Air” ,she emphasizes the importance of getting an itemized bill from the hospital and going through it line by line, citing a person who found $70,000 in outpatient surgery charges for an inpatient hospitalization, and others billed for circumcisions their newborn sons did not have. But it is not always easy; in the book she tells of a person who demanded an itemized bill rather than the one she received, where the total of $45,000 was simply labeled “Miscellaneous”! The hospital never sent it, despite it being her legal right, but did send her to a collection agency! Rosenthal says we would never tolerate shopping at a supermarket with no prices where they just sent us a $2000 bill every week. We should not tolerate this in healthcare.  Every single service must have a listed, easily accessible public price. It may be fine to discount it for some insurers, and even more for some than for others, but the list price must be as clear as we expect it to be for anything else that we buy.

I learned some things from Rosenthal that had not even occurred to me; for example, the ACA’s 85% limit on “medical loss ratio” (i.e., the percent of premiums that insurers actually have to spend on medical care) ironically helps encourage them to be willing to pay higher prices to providers. Why would they pay $130,000 for a treatment that cost $19,000 only 15 blocks south (the opening example in the book)? Well, they get to keep 15%. And 15% of a bigger number is more in their pockets. And they just pass on the cost as higher premiums! Rosenthal discusses an important conservative health economist who is known for saying the high cost of US healthcare is overblown, but (amazingly) sings a very different tune when confronting the hospital bill for his father!

“Dysfunctional” is the wrong word for our health non-system. It functions just fine to make lots of money for the biggest corporate (including ostensibly “non-profit”) players. For the rest of us, it doesn’t always provide the best, or even adequate care, and it drains our individual and collective pockets, significantly contributing to individual bankruptcies and bad health outcomes when folks go without care. It also results in governments at federal, state, and local levels not having funds for other social programs that might actually improve health more.

Yes, we can change it but it will require resolve and a lot of work, because the opponents of change are rich, powerful, and entrenched. We cannot accept any excuses from our bought-off politicians or “pragmatists” who are the ones who suffer the least. We are least able to fight when we are sick and need care, just as we are least able to object to our conditions when we have a ticket and are on a plane bound for where we need to go. But just as we can fight the latter, we can fight the former; the social media response to United is an example of a good start.

But it is going to take more than a good start to get the thieves and profiteers out of healthcare, and get a system that benefits us all. It is going to take a long fight with a lot of hard work. Up for it?

Total Pageviews