Head on over to the Health Systems Ed Blog and give it a read. Here’s the link!
The state of Iowa is about to conduct a bold experiment by putting everyone in Medicaid and the Children’s Health Insurance Program (known here as HAWK-I) into private managed care plans. There was a recent story on the subject by Iowa Public Radio’s Clay Masters, which ran on NPR’s All Things Considered and was also featured in the Kaiser Health News. In full disclosure, yours truly was interviewed for the piece, and was rewarded with a small quote towards the end of the story. I share it here with you not only for the obvious purpose of shameless academic self-promotion, but also because it is a very important story that offers a foretaste of what may be soon to come in your own state, as more and more states consider ways to relieve the pressure that Medicaid puts on their budget.
We’re officially into summer, and Hank Stern hosts the latest edition of the Health Wonk Review, with a theme of Hot Summer Nights, Cool Summer Drinks. I encourage you to beat the heat by reading his wonderful piece, which summarizes some of the best health policy blogging of the past two weeks.
You may recall that about 3 weeks ago, I wrote a piece on this blog in honor of my Dad and in support of a novel and important charity to fund prostate cancer research at Duke University called Give 1 For Dad. If you missed that piece, I urge you to read it here.
The charity was founded by Sam Poley, whose father, Neil, had metastatic prostate cancer. I’ve actually never met Sam or his father. I know Sam’s wife, Stephanie, from my time at the University of North Carolina. I learned of the Give 1 For Dad charity through Facebook. I visited the website, watched the video Sam posted, and found myself moved by the cause and the concept. So I did the least I could do in support: I gave a donation and I wrote my blog post urging anyone who read it to do the same. I made an appeal echoing Sam’s own–to consider what our Dads mean to us and to give accordingly.
At last count, the charity had raised just $19,000. On the one hand, that’s fantastic–it’s nearly halfway to the amount that needs to be raised for the project to begin enrolling and treating patients with cancer. On the other hand, it’s disappointing that much more hasn’t been raised already. This week, when you go out for a dinner and drop $50 or $100 without a thought, you should think again. Could you, perhaps, sacrifice on that one meal? You needn’t go without. Just scale back. Make a conscious decision to say that, rather than a fancy meal out, we’ll stay in, or order off the value menu. Take the difference and give it to the cause of Give 1 For Dad.
You may think, “Oh, I intend to give, I’ll do it next week, or the week after, or at the end of the month when I get paid.” Friends, I urge you to do it today. Time matters. People are sick now who might benefit. People will get sick tomorrow and the next day. Sadly, for some, it is now too late. Neil Poley–Sam’s father–passed away on July 4th. Yet it is not too late for those others–known to us or unknown–whom we might help through a modicum of charitable sacrifice. Indeed, to honor Mr. Poley’s memory, the family has asked for donations to Give 1 For Dad. This blog post is, once more, echoing that call in hopes of disseminating it to a wider audience. Martin Luther King, Jr. reminded us that “It may well be that we will have to repent…for the appalling silence and indifference of the good people…” I’m not asking you to give until it hurts. I’m merely asking you to give something in the hopes that it might ameliorate the hurts of others.
For reasons unknown to me, my email address ended up on a list that landed in the hands of the makers of “a meal and snack measuring tool” called “PortionMate.” I was contacted with an email that seemed more or less targeted at individuals who run healthcare facilities–or perhaps for dieticians and other providers to use with their patients. However, as I do not run such a facility and my students do not count as patients, it seemed I was not their target demographic. Nevertheless, the content on their website seemed interesting, so I emailed them back. I told them about this blog, and said that if they’d send me a set of the measuring rings–more on that in a moment–I’d be willing to write up a review on my blog. Now, it’s not exactly the type of health policy and health services research content that you typically find here, but if people would eat better, and lose weight, it would go farther in improving health outcomes than most anything we have achieved through policy of late.
They agreed, and within a week or two, I got a kit delivered to my door. I should also disclose that, other than the free kit, I was not compensated in any way for writing this review. Consider it a public service.
The basic idea behind PortionMate is that we have no idea what appropriate serving sizes should look like. Sure, we can read the side of the package, but as comedian Brian Regan jokes about ice cream, some guy probably put “1/2 cup” on the container as a joke, but now it’s already packed on all the trucks and it’s going out like that. In other words, we don’t adhere very closely to the serving sizes on the nutrition labels. To make it easier for us, you’ll often hear guidelines like “Eat a serving meat the size of the palm of your hand.” The problem with that, of course, is that we all have differently sized hands. PortionMate basically takes this concept and standardizes it, using a series of 6 differently colored and differently sized rings (see below).
As laid out clearly in the accompanying booklet, the green ring is roughly 1 cup, and is for fruits and vegetables. The yellow ring is 3/4 cup, and is for cereal and fruit. The orange ring is 1/2 cup, and is for fruits, vegetables, cereal, and beans. The blue ring is 1/3 cup, and is for cooked grains and starchy vegetables. The red ring is about 3 ounces, and is used for measuring protein (i.e., meats). Finally, the purple ring is about 1 ounce, and is used for measuring nuts, seeds, dried fruits, and cheese. As you can see from my little experiment, however, it is very important to use the correct ring for the correct food type. Sadly, while the chocolate chip cookie fits easily within the red ring, I don’t think this is a correct use of the product, and none of the rings are allocated for use with sweets (if you exclude fruit). That, as far as I’m concerned, is a flaw in the product.
My other main issue with this product is that I don’t see how it adds much value. For example, I’ve used the MyFitnessPal app to keep a food diary, and it pulls in all of the actual nutritional information from everything I eat. All I have to do is make sure to measure the serving size. So, for example, it is easier for me to pour cereal into a measuring cup and then dump it into the bowl–and likewise for the milk–than it is for me to use the yellow ring. On top of that, not all cereal serving sizes are 3/4 cup. Some are 1 cup. So I’d have to remember when to use the yellow ring and when to use the green ring. But the biggest problem is that there’s no bottom in the ring. Of course, if there were, it would be a measuring cup.
That said, I think that it could be a useful tool for gauging portion size of things like steaks, that aren’t as easily measured. Sure, you can go off the weight, but fitting it inside the ring is easier. The same might be true for other foods that I can’t think of right now off the top of my head. The bottom line? There is nothing “wrong” with this measuring tool. Indeed, it might even work well for you. I think the point might be to train you what proper serving sizes of various foods look like. And, in that respect, if used consistently, I think it would work very well. I, however, will continue to use measuring cups, and iPhone apps.
It’s widely known that it costs a lot more to live in some parts of the country than others. Off the top of your head, you can probably name New York, San Francisco, and Washington, D.C. as examples of cities where it is extremely expensive to live. Of course, that’s just the tip of the iceberg. It’s not like Boston, Chicago, or Los Angeles are particularly cheap. Generally speaking, big cities are more expensive. A large part of that is likely supply and demand. When a bunch of people want to live somewhere, and the amount of habitable space is finite, the cost of that space goes up, and that tends to drive up the costs of everything else in turn. But this also happens on a slightly more macro scale. That is, some regions of the country are more expensive than other regions of the country. For example, the coasts typically have higher costs of living than inland areas, and the northeast and west parts of the country tend to be more expensive than the south or midwest.
In a recent Health Affairs paper, Brendan Saloner and colleagues report the results of an experiment in which a group of actors pretended to be uninsured and made phone calls to attempt to schedule a new patient primary care appointment and find out what it would cost. As the title of their article gives away right from the start, the “average price was $160.” That’s not a particularly shocking number to most of us who have a sense of health care charges, but for the uninsured individual who’s not insulated from those costs, that’s a lot of money to pay to see the doctor for what might amount to about 12 to 15 minutes’ worth of a visit.
The thing I found most interesting, though, was the geographic variation in prices they identified. While they report both the mean and the median costs in their paper, I’m going to focus here on the median costs, because that figure isn’t affected by outliers in the way that the mean can be. The authors investigate the cost of new patient appointments in 10 different states: Arkansas, Georgia, Iowa, Illinois, Massachusetts, Montana, New Jersey, Pennsylvania, Oregon, and Texas. While that’s just a sample of the country, it does a decent job at capturing the various regions of the United States.
I grew curious about how the median cost for a new primary care appointment compared to the cost-of-living in each state. Now, it’s not really fair to look at the overall cost-of-living, because there’s variation within that figure. For example, while city A and city B may cost more than city C, it could be because the cost of housing is much higher in city A than city C, while the cost of transportation and health care are higher in city B than city C. Fortunately, I found a cost-of-living calculator that helped me look specifically at health care costs. The calculator gives each city a score for health care costs that are standardized to a national average value, which equals 100. Thus, a city with a score less than 100 has cheaper health care than the national average, and a city with a score more than 100 has more expensive health care than the national average.
Because I had to pick a city from each of the 10 states that the study included, I went with the state capitals. Now, that poses an issue in that some state capitals are major cities (e.g., Atlanta, Boston) while others are not (e.g., Harrisburg, Salem). So, please, recognize that this is a very back of the envelope approach to looking at this issue that is not without its limitations. Still, doing that, this is how the capitals of the 10 states rank in order from most expensive to least expensive health care (again 100 is the national average):
- Boston, MA 126.6
- Salem, OR 117.7
- Helena, MT 103.6
- Atlanta, GA 102.6
- Springfield, IL 101.8
- Trenton, NJ 101.8
- Austin, TX 100.6
- Harrisburg, PA 91.5
- Little Rock, AR 87.1
- Des Moines, IA 84.7
Okay. So now the question is: How does this translate into the median costs identified in the study? Well, ignoring population weighting and the like, the average score across our 10 capital cities is 101.8, which corresponds to the median primary care visit cost of $125 identified in the study. To scale this down to a national average, we multiply by 98.2% and find that the median national cost of a primary care visit for an uninsured patient is expected to be $123 (I rounded up). We can then figure out the expected cost for each of our cities and compare it to the actual cost identified by the researchers. This is what we find:
- Boston, MA Expected: $156 Actual: $150
- Salem, OR Expected: $145 Actual: $195
- Helena, MT Expected: $127 Actual: $150
- Atlanta, GA Expected: $126 Actual: $126
- Springfield, IL Expected: $125 Actual: $125
- Trenton, NJ Expected: $125 Actual: $125
- Austin, TX Expected: $124 Actual: $125
- Harrisburg, PA Expected: $113 Actual: $125
- Little Rock, AR Expected: $107 Actual: $120
- Des Moines, IA Expected: $104 Actual: $143
So, costs are pretty much what we’d expect in Boston, Atlanta, Springfield, Trenton, and Austin. In fact, Boston is the only place where the actual cost was less than expected. It seems that the actual cost doesn’t go below $120, so places like Harrisburg and Little Rock end up costing a little bit more than expected. Helena also costs about 20% more than expected. But the big shocks are Salem and Des Moines. While Salem is expected to be the second-most expensive, it is actually the most expensive by far–a whopping 30% more costly than the next most expensive locale, Boston. And, at the other end of the spectrum, Des Moines is expected to be the cheapest of all, but it is actually the fourth most expensive on the list. That said, I reiterate that these actual numbers are from a sample within the state and do not necessarily represent the cities as I’m interpreting it here. Nevertheless, it demonstrates that variation in health care costs don’t even necessarily reflect the differences in health care costs we know to exist. That is, there’s variation on top of the variation. Just one of the many reasons why it can be so difficult for people to navigate the health care system, particularly if they’re uninsured.