Monthly Archives: May 2010

Memorial Day

Memorial Day is often considered the kick-off to summer–backyard barbecues, pool parties, trips to the beach–but let us never forget the ultimate sacrifice our nation’s service men and women have  made to allow us these simple pleasures.

The blog will be back tomorrow.

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Posted by on May 31, 2010 in Uncategorized


Economist Article Explores Future of Health Reform

A commentary piece appearing in last week’s issue of The Economist takes a look at the future of health reform including efforts to overturn the law as we head closer and closer to the mid-term elections. It’s well written and worth a read. Ordinarily, I’d have more to say, but I’ve been (and remain) extremely busy and tired. So, enjoy the article and have a fantastic weekend. Just don’t do anything that you’ll try to repeal later.

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Posted by on May 28, 2010 in Uncategorized


Take A Wonk On the Wild Side

Ladies and gentlemen, the latest edition of the Health Wonk Review is up and running at the Health Business Blog hosted by David Williams. I made it in again, which is an honor considering the high quality of the posts surrounding mine. You should most certainly give it a look.

Oh, yeah, and get ready: I’m back hosting HWR myself on June 24th. Don’t have a theme yet. Suggestions welcome.

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Posted by on May 27, 2010 in Uncategorized


Where Your Information Comes From…

Let me start by acknowledging that this topic was brought to my attention by a post from Ezra Klein. Hopefully, since he’s in China right now, he won’t mind if I do a piece on his piece, which is itself a piece on a Kaiser piece. The topic is: How did people learn about health care reform? The results, gathered by the Kaiser Family Foundation’s Tracking Poll look like this:

What can we make from this? Well, the numbers in the left column aren’t especially interesting in and of themselves. They just say “Yes, I was exposed to information there.” That’s where the numbers in the right column come in. They say “This is the information I used to form my opinion on health reform.” So, with a little bit of math (dividing the figures in the second column by those in the first), we can compute a potency factor that explains how effective each information exposure is in influencing people. Here’s what that looks like:

So, congratulations FOX News and CNN for being the sources people seem to give the most authority to by nearly a 2:1 margin. And friends and family, maybe don’t try so hard to influence others, because it doesn’t look like your “friends” and family are really listening to what you have to say. I’m going to make an exception for myself, though, because at least blogs are tied with newspapers for second place.

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Posted by on May 27, 2010 in Uncategorized


Does Your Doctor Look Like You?

Racial and ethnic concordance between patients and physicians–that is having a doctor who looks like you or shares your ethnic heritage–has been repeatedly shown to improve patient satisfaction, adherence, and potential health outcomes. Conversely, discordant relationships often display biases on the part of both the patient and the physician that might contribute to different treatment decisions and some of the racial disparities in care all too prominent in the United States.

But what factors explain whether a patient is seen by a same-race or same-ethnicity physician? That’s just what Ana Traylor, Julie Schmittdiel, Connie Uratsu, Carol Mangione, and Usha Subramanian sought to find out in a study published in the June 2010 issue of Health Services Research. The authors examined a sample of diabetics enrolled in Kaiser Permanente’s Northern California region, did some standard logistic regressions (i.e., fancy statistics) and found some pretty common sense, yet important associations.

For starters, patients who were free to choose their physician (rather than having it assigned by the HMO) were more likely to have a same-race or same-ethnicity physician. This makes sense, given that one assumes patient-physician racial-ethnic concordance to be a preference of most patients. In addition, the availability of a same-race provider was a strong determinant of a concordant relationship. This makes sense, too, because, frankly, if there are fewer of “your kind” to choose from, then you’re less likely to get what you want. Conversely, if there are more of “your kind” then you stand a better chance of getting what you want–again, especially if you’re free to choose. There were also more practical factors. For instance, Hispanic and Asian patients with limited English proficiency were significantly more likely to have a same-race or same-ethnicity physician. After all, if you can’t talk to your doctor, why even bother going?

This study basically does three things. First, and foremost, it shows that patients seem to have a preference for physicians who share their same racial and/or ethnic background. If this were not so, it isn’t likely that patients who could choose their doctors would more often choose doctors who looked like them. Second, it shows that the racial and ethnic makeup of the physician workforce is an important factor in making sure that patients are able to get what they want. Given the disproportionately low number of African-American and Hispanic physicians vis-a-vis their proportion of the patient population, more work needs to be done to bolster minority presence in the workforce. Finally, it shows that there may be some practical–not just preferential–aspects, such as the ability to communicate effectively with their physician, that lead patients to seek concordant relationships.

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Posted by on May 26, 2010 in Uncategorized


A Day In the Life of a Primary Care Doc

Lawrence Casalino is a primary care physician. He’s also the Livingston Farrand Associate Professor of Public Health at Weill Cornell Medical College in New York City. This is a man who knows a lot about the field of primary care as both a practitioner and as an academic. While I like policy wonks, I think we need people like Dr. Casalino to be involved when we start talking about making health policy changes that will require physician buy-in to be successful. After all, who knows better how doctors think and will react to a proposed policy change than doctors themselves?

With that in mind, I read with great interest a recent piece Dr. Casalino authored in Health Affairs, which looks at the way the typical primary care doc’s day is structured and asks “Is it the best arrangement?” One thing he talks about is using the phone and email to become more efficient. He writes:

“As the number of patients for whom a primary care physician feels responsible gets larger, the number of phone calls that could be made–for both minor acute and chronic care–continues to increase…But the more time we spent doing that, the less time we had to see patients in person–and the only thing for which we were paid was when I, the physician, saw patients in person. So we didn’t make as many calls as we knew would be optimal–a moral and professional compromise, but one that seemed necessary if we were to remain in practice.”

He even wonders what the typical primary care doc’s day would look like to extraterrestrial observer:

“The visitor would notice that physicians spend at least seven years training. Their time, therefore, should be valuable. Is this the best way for them to use it? As pieceworkers running from patient to patient as fast as they can? Always with a little clock in their heads, exquisitely conscious of the seconds ticking by while a patient tries to say something? As hamsters, running faster and faster just to stay in place? Doing things that less highly trained people could be doing?”

It’s obviously a set of rhetorical questions, to which Dr. Casalino’s answer is an emphatic “No!” But what do we do to change things? Well, for starters, he suggests that physicians begin to distinguish between necessary visits and those that could be handled with a phone call or an email. He offers six criteria for defining a necessary visit, for which I’ll refer you to the original article (a subscription may be required). This will help cut down on daily visits. By Dr. Casalino’s estimate, only 8 to 10 of a primary care doc’s 20 to 30 patients a day actually need to be seen in the office. In addition, he suggests that docs take on the task of better coordinating their staff, focusing on preventive care and chronic disease management, and establishing performance improvement processes.

Then the question becomes “How do we implement this change?” Dr. Casalino gives a fairly detailed answer, so I’ll just sum it up: We have to pay for it. Doctors aren’t going to take on new administrative tasks, send emails and make phone calls if they don’t get paid for it, no matter how much more efficient it might be in theory. So we need to find a way to pay docs for making phone calls and sending emails, but a way that can’t be easily abused and that doesn’t require a huge administrative burden. Capitation is one thought. Capitation with pay for performance is another. The other thing is that we need to start reimbursing for clinical services provided at the doctor’s office by someone other than the doctor. Of course, there are lots of institutional forces that fight against these types of changes. Still, I think Dr. Casalino makes a great point.

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Posted by on May 25, 2010 in Uncategorized


Out-of-Pocket Spending Continues To Rise

The purpose of health insurance is to pool risk so that individuals who fall ill and need health care services don’t end up facing an insurmountable amount of debt. Obviously, the current health insurance market works better for some than it does for others. Even two privately insured persons may face very different fiscal realities depending on the quality of their coverage. Health reform should begin to change that in the months and years ahead, but it’s still worth looking at where things are up to now (or more accurately, through 2006, the most recent year of data in the study I’m looking at today).

When people have health insurance, it usually doesn’t mean that they pay nothing for their health care. For starters, there’s the cost of their insurance premiums. These will vary based on the quality of the coverage, the number of family members enrolled, whether the individual has non-group or employer-based coverage, and how much of the costs their employer chooses to pay. Then, once care is sought, there are deductibles (amounts which the insured must pay before their benefit coverage begins), co-payments (fixed amounts the insured must pay for each visit to a provider), and co-insurance (usually a percentage of the total charges that the insured are required to pay themselves after the deductible has been met). So there are many areas in which the insured are still spending money on health care, and these are typically referred to as “out-of-pocket” (OOP) expenditures.

Using the 2006 Medical Expenditure Panel Survey (MEPS), Peter Cunningham took a look at both national and state trends in OOP between 2001 and 2006. The study appears in the May 2010 issue of Health Affairs (try the link, but a subscription may be required). Specifically, Cunningham measured financial burden, defined as the ratio of total OOP spending to total family income. In other words, how much of their money do families spend on health care? He goes on to define high-burden individuals as those whose financial burden exceeds 10 percent of family income.

In 2004, 14.4 percent of Americans were classified as high-burden, a figure which rose to 19.1 percent in 2006. It should be noted that this was prior to the economic recession we have recently experienced. The change depends significantly on the type of insurance coverage a person has. For instance, 19.3 percent of those with public insurance (e.g., Medicaid or Medicare) were high-burden in 2001, and the figure rose to just 19.6 percent in 2006. Similarly, the corresponding figures for the uninsured were 13.9 percent in 2001 and 15.3 percent in 2006. The low figures for the uninsured must not be misinterpreted, however. The reality is that the uninsured would face such enormous financial burdens if they were to seek care, that most of the time they actually choose not to do so, and their health tends to suffer for it.

Some 12.3 percent of those with private employer-based coverage were high-burden in 2001, with 18.4 percent of the group considered high-burden as of 2006. Without question, however, the private non-group market takes the biggest hit, with 35.9 percent considered high-burden in 2001, rising to 47.8 percent in 2006. Just for fun, I thought I’d plot these four groups’ high-burden percentage over time and fit a predictive line over them. Granted, these regression lines are based on the three-year trend from 2004-2006 continuing at a steady rate, making them a rough guess, but one that’s probably not far off. What you’ll see is that by 2016, upwards of 60 percent of families with private non-group coverage might expect to spend more than 10 percent of their income on health care, as would more than 30 percent of families with private employer-based coverage (that’s most of us, by the way). The deep recession, however, might increase the slope of these lines considerably. Hopefully, the implementation of health reform will do its part to flatten them back again. I’ll revisit this blog post in 5 years and let you know how well my crystal ball worked.

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Posted by on May 24, 2010 in Uncategorized


An Argument Against The Soda Tax

Back before health reform became law, one of the biggest problems Congress had to solve was how to pay for it. They came up with lots of ideas, some of which are now law, some of which were discarded entirely, and others which didn’t make it into the law, but are still garnering a lot of interest and support from a variety of stakeholders. One of the ideas in this last category is a proposal to levy a tax on the manufacturers of soft drinks like Coca-Cola and Pepsi.

The thinking is fairly straightforward: Overconsumption of sugary soft drinks plays a major role in the obesity epidemic. So, a tax on the product has the potential to raise significant revenue while combating one of our society’s most plaguing health problems. If you want to get a better look at the data behind this argument, you should check out David Leonhardt’s piece in the New York Times. The “public good” argument–and let’s face it, I live in a School of Public Health–is a convincing one.

As for the soft drink industry, it is fighting hard against such a tax for the obvious reason that it stands to cut into corporate profits. This won’t be because the companies have to pay a tax–they’ll pass those costs on to consumers–but because the consumers will end up purchasing less of the companies’ products. From the perspective of shareholders–and I should go on record as saying that I (as a proud Georgian) own a bit of Coca-Cola stock–reduced profits are a bad thing.

So, given my own personal competing interests in this issue, you might be asking where I stand. In that case, I suggest you revisit this post’s title. I think the soda tax is a bad thing and here’s why:

Unlike traditional sin taxes on products like alcohol and cigarettes, a soda tax would apply to a product for which there is no surgeon general’s warning nor legal restrictions regarding its purchase. In effect, a soda tax would affect an overwhelming number of people. This is one of the reasons why groceries are taxed at a much lower rate than other goods. Of course, one might then argue that soft drinks are not like other groceries in that they are not essential for life. Food and water are really all we need if you get down to it, and the reduced grocery tax should apply only to those items.

I can think of a great number of things one buys at a grocery store that ought also to be taxed if we start taxing soft drinks. These would include coffee, tea, certain types of “juice”, potato chips, frozen pizzas, donuts, cookies, and so forth. We do not require any of these things to live, consuming too much of any of them will lead to obesity or other health problems, and thus, they should be subject to additional taxation. In fact, the only things that would perhaps be rightfully excluded from such a tax would be those very essential items–here I am thinking of things that one can buy with food stamps or as part of the WIC program–like eggs, milk, cheese, and bread. You know, all the things southerners buy in droves when severe weather threatens.

Then, too, there’s the issue of what happens to diet soft drinks. Presumably they do not contribute to the obesity epidemic because they are very close to calorie-free. Would they be taxed? If not, I might warm to a soft drink tax just a little more–and hold out hope that they invent a calorie-free Cheeto. Until then, I remain opposed to taxing anything that becomes harmful only through a gross lack of personal responsibility. Having said that, I apologize to my liberal friends, and ask my conservative friends to pick their jaws carefully up off the floor. Have a great weekend!

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Posted by on May 21, 2010 in Uncategorized


Medical Malpractice Premiums

Conservatives seem to think that reforming the medical malpractice system will fix everything that ails the health care system. The logic goes something like this: Doctor X has to pay a bunch of money for his malpractice premiums, so he’s motivated to recoup that money–and moreover, he’s very concerned about what will happen to those premiums should he happen to be subjected to a lawsuit, so he practices “defensive medicine” to make sure that all his bases are covered. (As an aside, no one ever seems to talk about the potential for defensive medicine to produce harm through over-treatment.) Most health policy experts, however, don’t see much potential to lower health care costs through tort reform. What you’re most likely seeing is the GOP–who gets tremendous financial support from the physician lobby–taking a stance that will help that group at the expense of the Democrats who get tremendous financial support from the trial lawyers’ lobby.

I’m not going to go into the various peer reviewed literature on the weak malpractice-health care costs link, because I’ve already done that. Instead, I wanted to share a resource with those of you who might be inclined to look at it, and overwhelm the rest of you with one of the busiest charts you’re likely to encounter. The resource is historical data on medical malpractice insurance premiums for all states for the years 2000 through 2008 and is furnished by the Medical Liability Monitor Survey. You can take a look to see just how much rates vary by geographic location (a lot), physician specialty (a lot more), and time (mixed results).

But, because many of you won’t explore the site, I created a chart that shows the highest and lowest malpractice premiums reported for internists, general surgeons, and OBGYNs in the state of North Carolina. You’ll see a few things: First, there’s often (but not always) quite a range between the lowest and highest premiums within a specialty. It kind of makes you wonder if the actuaries just pick numbers out of a hat. Second, there is a clear difference in premiums according to specialty. This difference makes sense for the most part, with internists facing much lower premiums than general surgeons, and OBGYNs paying more than either group. The more likely you are to encounter an adverse outcome in your field, the more you can expect to pay. Awards are often higher when the birth of a child is involved, because juries take into account the resultant damages, and a newborn has more to lose over their remaining lifetime than a 50-year old. Finally, you’ll note that premiums haven’t just climbed onward and upward. I think this is interesting. It’s probably the result of new insurers entering and exiting certain markets, and may well be affected by certain insurers paying out large claims in a given year, but what it doesn’t do is show the same steady rise as health care expenditures. That doesn’t mean defensive medicine plays no role in rising health care costs, but it is a bit curious. Anyway, enough of my rambling…’s the eye-popping chart, which you may need to click to see entirely. (Advil recommended immediately after viewing).

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Posted by on May 20, 2010 in Uncategorized


Lacking Insurance in the ICU

Dr. Sarah Lyon and colleagues of the University of Pennsylvania published a study Monday comparing the experiences of insured versus uninsured patients in intensive care units across the state of Pennsylvania. What they found is just more evidence that lacking health insurance can mean worse health outcomes. Obviously the mechanism by which being uninsured leads to poorer health would have to do with differences in health care utilization between the insured and the uninsured, but how much of that difference is driven by the patients and how much is driven by the providers isn’t entirely clear.

The study was based on nearly 167,000 non-elderly patients admitted to an ICU in Pennsylvania from 2005 to 2006. Dr. Lyon’s group found that uninsured ICU patients were 21 percent more likely to die within 30-days post-admission than their insured counterparts. Of course, it’s possible that the uninsured arrive at the ICU in worse condition than the insured–the result of persistent financial barriers to care–or that the uninsured differ from the insured in other important ways. The study isn’t able to control for every conceivable factor.

What’s more concerning, though, is that health care providers may go about treating uninsured patients differently than they treat insured patients. You might hope that such things wouldn’t happen, but we have ample evidence that physicians who deny having any racial prejudices do demonstrate different courses of treatment based on the patient’s race. So, it’s plausible that physicians might pursue different treatments for the two groups. This would also help to explain why the disparity in mortality was observed within the same hospital. In other words, it isn’t because the uninsured get sent to the worst hospitals while the insured get sent to the best hospitals. On the contrary, the difference seems to be taking place either before the patient gets to the hospital or after they’re admitted. The authors carefully couch their discussion to avoid placing blame on providers by using the standard academic conclusion “more research is needed.” But, if I had to guess, I think it’s probably a combination of both patient and provider factors. Uninsured patients probably have more comorbid conditions than insured patients, and providers probably treat insured patients more aggressively because they and the hospital know that they will be paid for those services. I suppose everything really does have a price.

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Posted by on May 19, 2010 in Uncategorized

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