Category Archives: Access

Getting your teeth into health care

Posted by on October 27, 2013 Comments Off on Getting your teeth into health care

We all know the reasons for going to the dentist regularly:

  1. Early detection (cavities, gum disease, oral cancer, bruxism)
  2. Checking existing fillings for structural weakness or peripheral decay
  3. Review of oral health practices

These are dental reasons, but there are other reasons as well.

The relationship between dental health and other medical health is not a new concept, with studies going back to the 1980’s. For example, the statistical relationship between heart attacks and poor dental health was noted in a 1989 Finnish study.

Managed care organizations have a strong financial incentive to lower health care costs. Healthier members have lower medical costs, so improving the health of members is an attractive alternative to cutting benefits in order to lower costs.

Aetna has been a leader in “Dental-Medical Integration” (DMI) as an approach to that end.

A study in 2006 found significant relationships between treatment for gum disease ( a proxy for having gum disease) and higher medical costs for cardiovascular, cerebrovascular, and diabetic conditions, heart, stroke, and diabetes, respectively.

In 2009, Aetna reported considerable success in getting dental care for at risk members:

In 2008, nearly 67,000 medically at-risk members sought dental care after being enrolled in Aetna’s Dental Medical Integration program. At-risk members are identified as those with diabetes, heart disease and pregnant women who have not seen a dentist in 12 months or more.

A 2011 University of Pennsylvania study in collaboration with Cigna Dental established lower medical costs two years after periodontal (gum) treatment:

2011_UPa_Dental

Earlier this month Aetna reported:

  • Lowered their medical claim costs by an average of 17 percent
  • Improved diabetes control by 45 percent
  • Used 42 percent less major and basic dental services
  • Required 3.5 percent fewer hospital admissions year-over-year compared to a 5.4 percent increase for non-members

With the caveat that the Aetna programmed targeted individuals with particular diagnoses who had not seen a dentist in a year, we are nonetheless facing an important question:

Is it time to end the division between dental and medical insurance, treating health care for the mouth as a medical specialty like others, and dentists as medical specialists like others?

Competition, Cooperation, and Health Care

Posted by on October 14, 2013 Comments Off on Competition, Cooperation, and Health Care

Maybe it’s the days of endless government shutdown. Maybe it’s the days of endless rain.

Writing about any of it comes hard to me. I am uncharacteristically quiet and reflective.

We live in a society built on competition. The economic system creates wealth and rations scarce resources through competition. Democracy is a competition for the support of voters. And, no society is more sports-minded than we are, with giant arenas and stadiums for a variety of sports, each with millions of followers.

However, all of this competition occurs in the context of a society. A society implies certain shared values, a modicum of cooperation, and concern for other members of the society, if not for their own sakes, then for the sake of the society.

Consequently, a competitive society is one with built-in contradictions. At the extreme, economic competition results in great wealth, poorly distributed, and concentrated in the hands of the few. At the extreme, political competition, like sports competition, requires that victory trumps all ethical considerations, including the needs of the society or sport.

On the other extreme, a completely cooperative society, devoid of competition, sharing things equally, is unlikely to thrive. As our conservative friends point out, the incentives for wealth creation and technological progress based on expenditure are likely to be lacking. In addition, there will be free riders, people who wish to partake without producing.

The political and social pendulum in the United States often swings between competition and cooperation, between liberty and equality. At this point in time, it seems to me that we have swung a bit too far toward competition. We have a Congress that cares more about the next election and scoring political points than public policy; we have a Speaker, who should know better, but is more concerned about the challenge to his leadership than the American economy.

Behind it all are two ideologies that seem singularly unconcerned about any impact, other than how a position is measured against the yardstick of a belief system, a non-religious libertarianism allied with a particularly narrow version of Christianity, aligned together in opposition to government initiatives, despite their obvious contradictions. It is a characteristic of ideology and utopia, as Karl Mannheim called the narrow beliefs of the present and the future, that purity of belief surpasses any human need.
ideology and utopia

Combining these strong ideological commitments with the political system results in the political impasse we are experiencing. Closed belief systems can rationalize economic collapse as a necessary, ultimate good, so compromise is not only unnecessary from that perspective, but traitorous. As Eric Hoffer put it,

It is the true believer’s ability to “shut his eyes and stop his ears” to facts that do not deserve to be either seen or heard which is the source of his unequaled fortitude and constancy. He cannot be frightened by danger nor disheartened by obstacle nor baffled by contradictions because he denies their existence

So, the campaign against the program of our current President can pivot from health care to spending to entitlements, but is consistently against the President and his positions. When the economic consequences of the shutdown and the debt limit crisis are tallied, they will say, “See, we told you that the Affordable Care Act would destroy the economy.”

Politicians of all wings, parties and beliefs routinely employ spin–stretching the truth to make their points; however, at some point the distance from the truth is sufficient to call “spin” an outright falsehood. An example, in health care, was the charge that Obamacare mandated “death panels.” (Physicians routinely discuss end-of-life issues with their patients. The proposal was that they be reimbursed for the time so spent.)

As Mark Twain put it, “A lie can travel half way around the world while the truth is putting on its shoes.”

When confronted with an obvious falsehood or exaggeration, the honest person faces a dilemma: does the speaker/writer truly believe what is written, or is that person cynically exploiting the ignorance of others?

Here are some of the arguments about the Affordable Care Act that have been dragged into debate about fiscal policy, the Federal budget, and the US statutory debt limit.

  1. Congress has exempted itself from Obamacare.
    The fact is that Congressional employees will be shopping for health care on the exchanges rather than receiving employer-provided health care as would most businesses with a comparable number of employees. As employees, they will receive an employer contribution that reduces the monthly premium cost.
  2. Large enterprises have been made exempt from the mandate to provide coverage so individuals should be exempt as well.
    Large enterprises are still required to provide health insurance coverage for their employees as scheduled; however the Justice Department will not be imposing penalties immediately. Furthermore, the individual mandate is an entirely separate issue–it is the linchpin of eliminating denial of coverage for pre-existing conditions. Without it, no one would buy health insurance until they needed it, with the assurance that their health condition could not be denied.
  3. Health insurance premiums are going up because of Obamacare.
    With the exception of the past 3 years, health insurance premiums have been rising by double digit percentages each year. The rise slowed because of the deep recession we are emerging from. Health insurance premiums will continue to rise, largely driven by technology (MRIs are expensive), now that the recession is almost over. Furthermore, premiums may seem very high to individuals who have not been able to or been interested in purchasing insurance until now. Health insurance is expensive.
  4. Companies are letting full-time workers go and hiring part-time workers in their place.
    1. Many individuals choose part-time employment over full-time employment. So, the only concern should be involuntary part-time employment rather than all part-timers.
    2. There has generally been a rise in part-time employment during economic recessions. The recent recession is no different.
    3. Many new jobs are coming into the economy to help with Obamacare, as well as new hires in the private sector to meet the needs of the health care law mandates for preventive care and individual coverage.

      4. [It should be noted that individuals concerned about employment issues would never close the Federal government or permit it to be closed, since the loss of spending by Federal workers ripples through the labor market as business owners determine whether to take on new hires, and the lack of Federal issuance of permits in several areas e.g. a Vermont micro-brewery, adversely impacts employment.]

    And as I was reflecting upon the original conundrum, how to reconcile cooperation and competition, liberty and equality, while retaining the best of both, I came across a quotation from Milan Kundera,

    kundera

    “Too much faith is the worst ally. When you believe in something literally, through your faith you’ll turn it into something absurd. One who is a genuine adherent, if you like, of some political outlook, never takes its sophistries seriously, but only its practical aims, which are concealed beneath these sophistries. Political rhetoric and sophistries do not exist, after all, in order that they be believed; rather, they have to serve as a common and agreed upon alibi. Foolish people who take them in earnest sooner or later discover inconsistencies in them, begin to protest, and finish finally and infamously as heretics and apostates. No, too much faith never brings anything good…”

    The Roman playwright Terence wrote “Ne quid nimis,” alternatively translated as “Nothing in excess,” or “All things in moderation.”
    Terence

    Moderation isn’t sexy or attractive. It doesn’t cause the adrenaline rush of ideological combat. But, I think it is the medicine we need now.

    Moderation in politics, moderation in spending, moderation in punditry. Here’s to moderation!!

The US health care debate

Posted by on October 3, 2013 Comments Off on The US health care debate

Writing about the political dance in Washington, DC is not a pleasant task. I intend to skirt around the edges of it. It is marginally about health care and largely about the relative power of the two major US political parties.US_capitol

Nonetheless, since it has brought the Obama health care plan back to the top of the national political agenda, it is worth recalling some basics.

First, the principle of insurance is that a catastrophic risk is spread across as many people as possible making advanced contributions so that funds are pooled and available to any individual suffering that risk. For example, individuals buying life insurance at a young age receive a favorable premium rate and are likely to contribute for a long time, much longer than the time it would take to accumulate the death benefit, but for those individuals not so fortunate, the monies are there in a pooled risk fund to be distributed to the family of someone who dies prematurely. The risk of an expensive illness with accompanying medical costs is similar.

Second, millions of Americans have not had health insurance. Some of those are young, feel invulnerable and do not want health insurance. Others have pre-existing health impairments and have been refused health insurance. Still others do not receive insurance through their employers and cannot afford it on their own.

Third, there are negative consequences to our society for these uninsured:

  1. Those without insurance still must be treated when they get ill or have a motor vehicle accident.
  2. The young, less likely to be net expenses to a pooled risk fund, need to be part of the contributors under the principle of insurance
  3. Those denied insurance because of pre-existing conditions need to be saved from bankruptcy, and the hospitals need to be protected from having to serve them at no cost.
  4. Those who do not have insurance through their employers, who could not afford individual insurance policies, require a means to participate.

Fourth, the Patient Protection and Affordable Care Act (PPACA), commonly known as “Obamacare,” is an honest attempt to address those concerns, as well as reining in the ever-rising costs of medical care.

Fifth, the term “socialized medicine” is easily bandied by politicians, but there are two distinct areas of government involvement in health delivery that can more accurately be called “socialized medicine,” and “socialized insurance.” The US has both. Socialized medicine occurs when the government provides access to healthcare either directly through government clinics or through social insurance used in government health facilities. In that case, the health care providers are government employees. Foreign examples are the National Health Service of the United Kingdom. NHS-logoIn the US the system of hospitals under the Department of Veterans Affairs (VA). Socialized insurance is when the government supplies health insurance but the healthcare practitioners are not government employees. Medicare is socialized insurance, as are the national health systems of Canada, France, Italy, and Germany. There are advocates for socialized insurance in the United States, under the banners “Medicare for All” and “Single-Payer.” There is no recognizable group that favors socialized medicine in the US–NONE.

Sixth, Obamacare is neither socialized medicine nor socialized insurance, because all of the providers are private, and all of the insurers are private. An early proposal to include a “public option” form of insurance was dropped. It is not surprising that Obamacare is completely privatized–it is a proposal in concept by that most conservative think tank, the Heritage Foundation. (More recently, it has taken a further turn to the Right by engaging former SC Senator Jim DeMint as President; however, it has always been quite conservative.) Its proposal was adopted, supported, and implemented by the Republican governor of Massachusetts Mitt Romney. The theory was that the accelerating costs of healthcare could be addressed by a market system, and the government assumed the role of creating the market or even playing field for the insurance companies to compete for business.

Seventh, the individual mandate, which draws a lot of the political fire, was part of the original Heritage plan by Stuart Butler in a 1989 paper, and of the Romney plan. It is essential to the effectiveness of the system in two major ways:

  1. It makes the younger, healthier citizens participants, with the benefit of their consuming less than they contribute but not being a burden when struck by accidents or rare illness.
  2. More importantly, it makes possible the elimination of pre-existing conditions. If pre-existing conditions could not prevent obtaining insurance, no one would buy insurance until contracting an illness, and would then be assured of acceptance. Because the insurance would have to cover the illness, with no reserve built up, with no spreading of risk across the entire population per the insurance principle, the insurance would be nearly unaffordable with the premiums set at the level of the average illness since it would have to cover the risk. Pregnancy benefits are often rated that way in insurance policies since the benefits being paid are nearly assured.

Eighth, there is the issue of affordability. Enterprises with over 50 employees are required to provide insurance. Most already do, but these employers are a very small segment of the workforce, perhaps 10 percent. The rest of us are self-employed or employed by smaller enterprises. If they already provide health insurance that is fine, but under the individual mandate, if they do not, then anyone working there including the executives will have to fulfill the mandate by finding insurance on the exchanges, and by shopping for the level of coverage at a premium they can afford. Both affordability and insuring the young are addressed in part by requiring adults to be eligible until age 26 for insurance under their parents’ plan.

For those at the bottom of the pay scale, those who do not qualify for Medicaid, which can have very stringent asset limitations (in California, for example, having funds over $2,000 disqualifies one from Medi-Cal), those often called “the working poor” may be eligible for government subsidies. In addition, the federal government is offering states financial incentives to expand the Medicaid program to cover more of the working poor.

Finally, there is the issue of what is health insurance coverage? If we want to require people to buy it, we need to be able to say what is and what is not acceptable coverage, to avoid individuals and businesses buying something so minimal that it complies with the law but does not address the problem of access to health care. An individual buying a policy hat pays $100 daily for hospital care has not really bought insurance. So, the government through implementing regulations has stipulated what a minimum policy contains. This has raised issues of conscience for those who do not believe in one or more aspects of medical science as applied to health care.

The religious reservations are well-known in the United States. Among them are a preference for Christian Science practitioners among Christian Scientists, an avoidance of blood transfusions among Jehovah’s Witnesses, rejection of birth control measures among Catholics, as well as rejection of pharmaceutical and surgical interventions to prevent or abort a pregnancy among numerous denominations. The law has allowed a religious exemption for churches. The point of contention has been for practitioners who participate in commerce and do not wish to compromise their religious beliefs by providing the means for something they consider murder. From a public policy view, the problem is multiple:

  1. Recognizing that right by owners of businesses and organizations may deny access to some of their employees who feel equally strongly that obtaining those treatments is their right.
  2. Recognizing those rights by one group implies, under equal protection, recognizing such objections by all groups and individuals. That places the government in the powerful and unwelcome position of determining which religious beliefs are legitimate and entitled to protection, an intrusion into religion that most Americans would find offensive.
  3. Recognizing that right with respect to abortion, would open the possibility of recognizing objections to all forms of insurance. A business owner might claim religious exemption to providing any insurance, undermining the public purpose of the law.

In order to address these concerns, the law limits religious exemptions to religious institutions, such as places of worship. There are pending court cases that may change the way this challenge is addressed in order to comply with First Amendment considerations.

One theory of American government is that the states act as laboratories for the society and the nation, trying approaches, which, if successful, can be generalized. That has occurred here, with Massachusetts providing the laboratory. As the national experiment is just beginning, it is too early to tell whether the proponents or opponents of Obamacare have correctly analyzed its impact and future. Five years from now, it will be much clearer. I look forward to seeing that day and looking around to see what worked and what did not, what needs changing, what has been correctly changed, and what has not. I have often thought that politics is America’s most engaging indoor sport, and, at this moment, Obamacare is at center court.

Patriotism and Healthcare

Posted by on August 5, 2013 Comments Off on Patriotism and Healthcare

The furthest left button on my car radio is tuned to C-SPAN radio. It could easily be tuned to National Public Radio if I lived elsewhere.

As I have long been curious about public policy issues, it is a matter of course for me to see what is playing when I start my car engine.

On Wednesday July 24, I heard an interview with Jim McDermott on the implementation of the Patient Protection and Affordable Care Act (PPACA) or Obamacare.

Jim McDermott is a partisan Democrat, who has represented the Seventh District of Washington since 1989. He mixes it up with the Republicans on numerous occasions, actively participating in the partisan back and forth that is national politics in the US. Part of his presentation that day were partisan talking points that we are accustomed to hearing from public office holders of both major parties.

Something else caught my attention. McDermott pointed to a change in our view of the obligations of citizens to the Republic and to our society. Since the end of the military draft, wars have been fought with minimal inconvenience to the civilian population, engendering an atomistic individualism, all of us isolated and alone sharing a space and looking out for ourselves.

Here is how he put it at the 8:48 minute mark of C-Span’s National Journal on July 24,2013:

It’s a much larger problem than just healthcare. When we ended the draft in 1975, we said to all young people in this country you have no responsibility for your country. You are an individual. You can live in any way you want. You don’t owe anything to your country. So we raised a whole generation, actually two generations of people who do not see themselves as responsible for their neighbor. We have young people who figure if I get hurt, if I am on my motorcycle and get into an accident, they will take me down to the emergency room, they’ll patch me up. I will not have money to pay for it, but somebody will pay for it and everybody in society who has health insurance is paying an extra $1000 a year for these kids who refuse to anticipate that something might happen to them. Young people get cancer, young people have skiing accidents, young people have all kinds of problems and they just act as though somebody else will take care of it. That’s not right. Part of the bill says you have the responsibility to pay for the possibility that you may be . . . “We require them with automobiles. We do not let people drive without auto insurance. It’s not your problem because someone else will pay for it. We say you have to have auto insurance.

Were it not for the partisan wrangling on Capitol Hill, are these not conservative values of individual responsibility and citizenship that all but the most ideological acolyte of Ayn Rand could agree to?

Plato addressed similar questions in his dialogue: Crito. Socrates had been condemned to death. His friend Crito attempted to convince him to flee into exile rather than accept that penalty. As part of a lengthy discourse about law and society, Socrates responded by imagining an argument with laws of the society:

Then the laws will say: ‘Consider, Socrates, if we are speaking truly that in your present attempt you are going to do us an injury. For, having brought you into the world, and nurtured and educated you, and given you and every other citizen a share in every good which we had to give, we further proclaim to any Athenian by the liberty which we allow him, that if he does not like us when he has become of age and has seen the ways of the city, and made our acquaintance, he may go where he pleases and take his goods with him. None of us laws will forbid him or interfere with him. Any one who does not like us and the city, and who wants to emigrate to a colony or to any other city, may go where he likes, retaining his property. But he who has experience of the manner in which we order justice and administer the state, and still remains, has entered into an implied contract that he will do as we command him. And he who disobeys us is, as we maintain, thrice wrong: first, because in disobeying us he is disobeying his parents; secondly, because we are the authors of his education; thirdly, because he has made an agreement with us that he will duly obey our commands; and he neither obeys them nor convinces us that our commands are unjust; and we do not rudely impose them, but give him the alternative of obeying or convincing us;–that is what we offer, and he does neither.

In order to uphold his agreement with his society, Socrates chose to accept its death sentence rather than flee. We are not faced with such stark choices in 21st Century America. We have on occasion leaders and laws preferred by others, but we agree in our democratic contract to accept them, so long as we retain the right to speak out against them and to elect different representatives on a regular basis. Such is our obligation to respect Obamacare, which is the law of the land.

We do not have to go out on a battlefield shouldering a weapon to be patriotic. We do not even need a war or an enemy or an adversary to be patriotic. It can be sufficiently patriotic to respect the laws, particularly those that assign us social responsibility, for like Socrates, we have accepted all the bounty of this society, and it would demean us not to accept the accompanying responsibilities.

PTSD: Military and Civilians

Posted by on July 1, 2013 Comments Off on PTSD: Military and Civilians

As I was surfing my car’s radio dial for some music–not much luck at the time–I heard a DJ defending his decision to discuss PTSD in the military. I guess some other listeners had been unsuccessful in finding music but found a serious discussion of trauma and war on a music show unacceptable.

What used to be called “shell shock” or “battle fatigue,” has the medical diagnosis of Post Traumatic Stress Disorder (PTSD). It is the kind of thing that got General George Patton in trouble, when he slapped a soldier suffering from it.

In many areas of brain disorder (ADHD, bi-polar, OCD, and PTSD), we can now provide a medical diagnosis rather than a moral diagnosis. Suffering from one of these disorders is no more evidence of moral shortcomings than diabetes, heart disease, or cancer–just different organs involved.

PTSD results from a shock or trauma–perhaps war is the most common and severe emotional trauma. I regret to note that having a volunteer army has resulted in the unintended consequence of making troops expendable to the civilian population. Now, we think nothing of sending them into combat with minimal reason or provocation, as they are volunteers, while we are in no way inconvenienced by doing so–no rationing, no higher war taxes, zilch.

As a result, we have decade-long wars (2 at last count in recent years) that cannot help but create PTSD along with other casualties of confict. And, of course, we need to make sure those needs are met along with the amputations and prostheses that the civilian population associates with war. The Veterans Administration (VA) maintains a National PTSD Center, and I have no idea how good the programs are, but they can be found by consulting the VA PTSD Locator

A related point, however, is that civilians as well as military are subject to the traumas that trigger PTSD. As the National Institute for Mental Health notes:

PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes.

While our primary concern may be with the direct effects (psychological and emotional) of PTSD, just this week an Emory University study of identical twin Vietnam War veterans found that risk of heart attacks was more than doubled in those with a history of PTSD.

Mental illness or brain disorders of any type require considerable investment of resources, professional and financial, to address. As a society we have dragged behind on this–mental health parity laws at the state level commonly had loopholes for high financial impact. There is a federal law in place, but it is not clear how effective it is. Change is occurring, but slowly.

Just within the past week, we learned that the California Department of Managed Health Care had imposed the second largest fine ever on Kaiser Permanente for failure to provide long term mental health care.

This country was founded by emptying Europe’s jails, and has been populated by escapees from prisons and hospitals around the world, along with other immigrants. As a nation, we have our share of people with “issues.” Some of the benefit has come from their creativity and willingness to challenge frontiers; however, in the 21st Century we need to help those folks adjust to what passes for civilization. Our veterans deserve it, but so do a lot of civilians, too. Let’s work to see they receive the necessary services–having mentally stable neighbors and colleagues improves life for all of us.

Are we making progress or falling behind?

Posted by on May 27, 2013 Comments Off on Are we making progress or falling behind?

In health care we don’t need to look far for bad news. In the past week, I have read:

  1. The prevalence of diabetes has increases 75 percent from the early nineties to the late naughts. A more extensive discussion (may require free Medscape subscription registration) is at New Statistics Shed Light on ‘Worrisome’ Diabetes Epidemic
  2. Leapfrog Hospital Safety Scores ‘Depressing’
  3. Study finds jump in ER-related admissions

And certainly we could include partisan bickering in Washington among politicians more focused on the next election than any meaningful policy debate or measures.

However, the simple fact is that none of this matters. We have no choice. If we do not adequately address our health care needs, then we will no survive as individuals or as a society.

If that premise, the premise of this blog, is correct, then we must assure access to healthcare for everyone. We must get the public health epidemics of obesity, diabetes, and gun violence, among others, under control.

On this Memorial Day, as we reflect on how many Americans have given up their lives at a young age to protect the American experiment, let us consider our debt to them: we owe it to them to insure that our society does not fail and that individuals not on battlefields do not give up their lives at a young age because they ate too much or someone bought a gun out of fear.

We are Americans: we do not accept failure in ourselves. The rest is trivial distraction.

How Do We Implement What Works?

Posted by on April 29, 2013 Comments Off on How Do We Implement What Works?

Medicare is abandoning the one experimental program that works. So claims Ezra Klein of the Washington Post in “If this was a pill, you’d do anything to get it.”

Klein describes a program by Healthy Quality Partners (HQP) where nurses make home visits to geriatric patients with chronic illnesses. It has been subsidized by Medicare as an experiment, in which some randomly chosen patients receive the intervention while some do not. The results have been better outcomes at lower cost to Medicare per the article as well as a study published last July.

Let’s assume that the claims are true: better outcomes and lower costs. How do we take an experiment, and by definition experiments have a beginning and an end, and generalize it into practice?

There are numerous possibilities:

First, we could do what the article implies: provide more government funds to Healthy Quality Partners, instructing them to expand the experiment operationally beyond the 1,736 members in Pennsylvania. I am assuming that maintaining indefinitely a small-scale experiment that works makes no sense–onward and upward.

Second, we could change the reimbursement scheme at Medicare to provide reimbursement for such services so that anyone in the country could create a similar program with the financial incentive of knowing that Medicare would reimburse the services.

Here is how that second possibility has developed:

The Clinical Procedure Terminology (CPT) codes were created and are owned by the American Medical Association. Recently Medicare adopted additional CPTs for coding reimbursement for coordination of care services.

Care Coordination CPTs

A statement by the American Nurses Association (ANA) is enthusiastic about the addition of the codes. Note: the ANA participates on the AMA CPT and RVU Update Committee.

ANA Care Coordination

Eileen Shannon Carlson RN, JD of the ANA points out that it is rare for CPTs to be adopted that only apply to nurses, as do two of chronic care coordination additions.

To be fair, the new codes only reimburse care coordination after a hospitalization and for a short period of time, why the HQP initiative addressed the needs of the elderly with chronic conditions. Nonetheless, I can imagine the next step being a protocol to target care coordination for the elderly independent of a hospitalization. Contrary to much in the popular press, government programs are very aware of spending dollars and getting value in return, so they limit risk by taking baby steps in developing programs.

Ezra Klein may well be correct, or he might be underestimating the challenge of turning a large ship, particularly when the upfront costs of such a turn may be prohibitive. What do you think?

Does the US face a shortage of primary care physicians? Part IV

Posted by on April 22, 2013 Comments Off on Does the US face a shortage of primary care physicians? Part IV

We showed it exists. We show that one proposed solution probably won’t help without extensive micro-managing: conditioning receipt of new residencies on service in under-served areas, e.g. service in the National Health Service Corps.

What else can be done?

First, we can make alterations in the practice of primary care by physicians in the United States.

Peter Ubel makes this argument, suggesting that primary care physicians adopt the model of anesthesiologists supervising nurse anesthetists. He argues that the advantages of having more non-physicians offering care under the supervision of a physician are:

  1. More non-physicians doing routine primary care frees physicians from routine.
  2. Such a practice could see more patients per hour, improving physician compensation in primary care
  3. The model would improve primary care, as it is not physicians but primary care that is in shortage.

A recent article in Health Affairs adds the element of telemedicine to changes in primary care, long distance diagnosis and supervision of non-physicians through the use of technology.

Second, we can move more of primary care to non-physicians.

The second proposal takes the first one step further: allow nurse practitioners and physician assistants to practice independently of physicians. Peter Ubel is a physician, so his proposal in part reflects his background.

Consider this: we allow paramedics operating in a moving vehicle to make life-saving decisions but do not permit nurse practitioners to prescribe or refuse to prescribe an antibiotic with a supervising physician.

Paramedics and emergency medical technicians have a scope of practice that they know. There is no reason for nurse practitioners and physician assistants not to have a similar scope of practice clearly defined for when they are operating independently of a physician–such a scope might be slightly different than when a physician is involved.

The scope of practice of health care professionals is at the state level. In Texas bills are under consideration to make it easier for nurse practitioners to locate supervising physicians. In Connecticut bills have proposed permitting nurse practitioners to operate independently.

Third, we can make it easier for foreign physicians to practice primary care in this country.

A study at the University of Virginia is skeptical of the additional residency requirements for foreign-trained physicians.

All physicians must pass the three sections of the US Medical Licensing exam. It is a good test: there are no statistical differences in patient outcomes or complaints to medical boards between foreign and domestic-trained physicians. The proposal is to permit those passing the exam to compete for residencies on an equal footing, regardless of the location of their medical school.

If the problem is as dire as the AAMC and US Senators have suggested, then we should use all of these approaches to be sure the problem is addressed. At the worst we will have too many primary care providers, improving our health and lowering costs through an abundance of supply.

Does the US face a shortage of primary care physicians? Part III

Posted by on April 15, 2013 Comments Off on Does the US face a shortage of primary care physicians? Part III

We have seen that there is a physician shortage, but it is confined to primary care–the number of specialists relative to the population has expanded.

In addition, there is a geographical factor that is beyond the scope of this blog: are the physicians, primary care and others, distributed to provide coverage of those in need, or are they concentrated geographically so that they are adequate in numbers but inadequate in dispersion? Huang and Finegold believe 44 million Americans will be living in places where the demand for physicians exceeds supply by more than 5 percent, 7 million where the deficit will exceed 10 percent.

The American Association of Medical Colleges (AAMC) advocates lifting the cap on Medicare-financed medical residencies imposed by the Balanced Budget Act of 1997. Senator Charles Schumer (D-NY) has introduced the Resident Physician Shortage Act to increase the number of residencies by 15,000 over the next several years. He is particularly concerned about the absence of physicians in the more rural–and colder–upstate New York. His argument is that the shortage is driven by retirements. Aside: New York appears to have more medical schools (12) than any other state (7 next highest).

However, if the problem is really primary care, will simply increasing residencies address the problem? The following chart from the Washington Post is cause for optimism or pessimism, depending upon how you look at it. The number of residents choosing family practice residencies has declined precipitously since 1998, followed by an upturn, which may be brief or long-lived.

Family Practice Residencies

Consequently, the AAMC, as does Schumer, stresses that retirement will affect specialties as well as primary care.

AAMC Specialty Shortage

The question of adequate numbers of medical residencies is actually a separate, though indirectly related, question than the adequacy of the physician supply. According to Peter Ubel, who supplies the following graph from Karen Sliff of the Washington Post. The source of the data is the AAMC, which is why it is so difficult to get at the truth of an issue in Washington: the providers of information have an interest in actions taken on that information.

Resident Positions

So, let us grant that it is probably reasonable, although not necessarily essential, to increase the number of financed medical residencies; however, it is fair that those residents take responsibility for part of the cost to us of providing them, and that such obligation be forgiven if they are willing to serve rural populations for 5 years? My support for increasing residencies is conditional on them going where the need is, not where specialists find the big bucks.

Next time, we will finish this series by looking at other approaches of providing care to a growing population.

Does the US face a shortage of primary care physicians? Part II

Posted by on April 8, 2013 Comments Off on Does the US face a shortage of primary care physicians? Part II

In the first act I left a gun on the wall. I questioned whether there was a physician shortage in the US.

The rule of drama is that a gun on the wall in the first act has to be used later in the play. Let’s look at the US physician shortage.

We want to determine: is there really a shortage? what is the nature of the shortage? if there is a shortage, do the measures proposed address that shortage?

The AAMC claims that the shortage has resulted from the cap on Medicare-funded residencies implemented under the Balanced Budget Act of 1997.

I wanted to find a time series on the number of physicians from 1997 to the present. It may be that the AAMC and AMA have such a series but it would be time-consuming, even if possible, to get hold of those figures.

Consequently I went to the Bureau of Labor Statistics (BLS) for physician employment and to the US Census Bureau for population figures. Also, the BLS changed the way it classified and calculated numbers of health care practitioners. The BLS has confirmed to me that the physician totals for 1999-2003 do not exist, although some sub-totals do.

First, I compared the number of physicians to the US population. I simply divided the number of physicians by the population and multiplied by 1000 to get physicians per 1000 population, yielding this graph:

Physicians Per 1000 2004_2012

Now that does not look like a physician shortage–indeed, it looks like we may have a physician surplus with the growth in the number of physicians outstripping population growth.

So, I looked a bit further. I grouped pediatricians, general internists, and family practice physicians, calling them “Primary Care.” Then, I produced this graph, indexing them to 2004 being 100 so we could see the relative growth.

Physicians Indexed 2004_2012

It is clear that while the total number of physicians has grown faster than the population, the number of primary care physicians has trailed.

Since we have the sub-categories going back to 1999, just after the Balanced Budget Amendment of 1997 was passed, here is the indexed comparison:

PCP to US Population 1999_2012

While the number of Primary Care Physicians kept pace with the population from 2004 through 2007, it has generally fallen short of population growth.

The challenge then is: how do we allocate resources to increase the number of physicians in primary care without those funds being diverted to creation of even more specialists?