Peggy Salvatore makes her Health Wonk Review hosting debut this week at the Healthcare Talent Transformation blog. She includes one of my posts, for which I am thankful, and the rest are pretty good, too. I always like HWR day, because it gives me a brief respite from having to come up with something to write about. Enjoy it! (I am.)
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There are a number of good articles on the topic of medical malpractice in the September issue of Health Affairs. Here is my very quick synopsis of four of them and how they fit together. Michelle Mello, Amitabh Chandra, Atul Guwande, and David Studdert make a valiant attempt at quantifying the national costs of the medical liability system. They put a price tag on malpractice claim and settlement payments, administrative expenses (i.e., lawyers), and defensive medicine costs. Defensive medicine contributed the bulk ($45.6 billion) of a total $55.6 billion. That’s a significant amount of money in absolute terms, but it actually represents just 2.4 percent of national health expenditures. Granted, the team based their calculations on assumptions, but they are transparent about what those assumptions were, and they present a range of estimates under differing assumptions. This estimate represents the middle of the road.
If we could cut that amount in half through tort reform, we’d be doing well, right? After all, reform can’t eliminate negligence or accidents. That’s exactly why William Thomas and colleagues report that tort reform would likely reduce national health care spending by a little less than 1 percent.
A better approach might be to implement some common sense policies, like surgical safety checklists, which, according to an article by Marcus Semel and colleagues would actually save hospitals a substantial amount of money. The authors estimate the implementation of a checklist system to cost $12,635 dollars, and to cost $11 each time it is used (mostly because of preventive antibiotic use). The cost of a major surgical complication averages $13,372 though, and happens in about 3% of the 4,000 or so non-cardiac inpatient operations an average hospital performs each year. Assuming that the checklist reduces major complications by 10% (by some accounts a very conservative estimate), using the checklist would save the average hospital almost $104,000 a year–and patients would benefit from it, too. What are we waiting for?
The biggest obstacle seems to be physicians’ fear of the unknown, coupled with a lack of control, which leads to gross overestimation of the probability of facing a malpractice suit. Doctors are more worried about being sued than the data suggests they ought to be. It seems likely that this drives the bulk of defensive medicine in practice, and short of granting physicians immunity, it’s unclear how tort reform may be able to alter this thinking.
I have to say, looking at these studies collectively, I think we need to focus our cost-saving efforts somewhere other than tort reform.
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This video from the Kaiser Family Foundation explains health reform in just 9 minutes. Did I mention that it’s animated? This is the kind of thing you not only need to watch, but should also circulate widely to everyone you know, because the only antidote to misinformation is information.
http://c.brightcove.com/services/viewer/federated_f9?isVid=1
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Before September ends, I need to turn my attention to some of the excellent studies in this month’s issue of Health Affairs. The focus here is on where Americans go for health care–especially as it concerns going to the emergency room. You’ll have to excuse the increasingly brief nature of my posts, they won’t always be so short, but I’m really trying to graduate in a timely fashion. Okay, I feel better now that that’s out there. On to the studies.
For starters, Stephen Pitt and colleagues find that fewer than half (42%) of patients’ acute care visits are to their primary care physician, while 28% are made to emergency rooms. The issue? Non-emergent care delivered in ERs is inefficient, and the last thing we need to be doing in this country is wasting more money on health care. So how do we get people to stay out of the ER when they don’t have an emergency? Well, for Medicaid patients, increasing co-payments for nonemergency use of ERs doesn’t work. Perhaps it would help if we made other alternatives more widely available? Apparently the answer here is yes and no. In rural counties with a community health center, ER visit rates were 33% lower than they were in counties without a community health center. At the same time, however, other research finds that people are still going to the ER when they could just as well be going to more efficient urgent care centers or retail clinics (the so-called “Doc in a Box”). This, I fear, is a sociological phenomenon, and effectively targeting policy to change it is likely to remain a challenge for quite some time.
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Medicare–insurance for seniors and the disabled–is an entirely federal program. Medicaid–the program for low-income persons–is jointly financed and operated by the federal and state governments. Health reform expands Medicaid and aims to make Medicare more efficient. It also arguably paves the way for Medicaid to become a purely federal program, which is something that most states would be pleased with, given the difficulties they have in balancing their annual budgets because of Medicaid costs. There are many other benefits to federalizing Medicaid, which are outlined in a policy paper authored by The Century Foundation’s Vice-President Greg Anrig. I’ve chosen to write about this topic today primarily because I want you to have the entire weekend to read the paper. Some of you might see shifting Medicaid away from the states to the feds as taking the country further down the road towards a single payer system. Others of you might see it as one of the most viable options for confronting some of the major problems in our health care system and our state economies. In my opinion, both of you would be right.
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Merrill Goozner wrote an opinion piece in The Fiscal Times recently explaining how “health reform could shift increases to consumers.” His piece basically speaks to employers deciding to forfeit the grandfathered status of their health plans by raising coinsurance rates in the face of rising premiums. I see a slight problem with the way he’s framed this. Because the Affordable Care Act requires insurers to pay out 85 cents worth of benefits for every premium dollar collected, insurers have a weak–albeit not absent–incentive to raise premiums. If an insurer charges $1,000 a year in premiums, they have to pay out $850. If they charge $2,000 a year in premiums, they have to pay out $1,700. They do, indeed, double their potential profit, but that’s quite different than if they were to charge $2,000, face no requirements to pay out more than the $850 and net a cool $1,150.
The point that Goozner makes, somewhat indirectly, is that employers can sidestep cost increases, or even get out of the game altogether. This is one of those things that people just don’t seem to get. **Ahem** YOUR EMPLOYER IS UNDER ABSOLUTELY NO OBLIGATION TO PROVIDE YOU WITH HEALTH INSURANCE, NOR TO PAY ANY PARTICULAR AMOUNT TOWARDS THE COST OF ANY COVERAGE THEY DO OPT TO OFFER YOU.
Sorry about that. The point is that if costs go up, or if they don’t, your employer may decide to shift the costs your way. Recessions help that sort of thing. Case in point, one of my family members was talking with me the other day about the increased amount they were going to have to pay for their health insurance. Let’s say their insurance cost $10,000 a year, but their employer paid 90% of the total. That left them paying $1,000. Well, now their employer is only going to be paying 80% of the total. That means, even if the insurance doesn’t get more expensive, they’re going to have to pay $2,000. That’s right. Their bill just doubled. So, if what you pay for health insurance goes up, don’t assume that it’s because of health reform. It could just be your employer deciding to shift a portion of their costs your way. I would say that they decided to shirk some of their responsibility, but per my statement in all caps above, it was never really their responsibility to begin with.
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Proponents of health reform have long claimed that one of the biggest problems with our health care system is an overemphasis on expensive specialists and an underemphasis on primary care physicians–who, much research shows, produce high quality care at a much lower cost. In essence, the argument is that we’re using (and paying for) rocket scientists to fly kites. If we bolster the primary care workforce, suddenly we’ll start saving buckets of cash and people will not only be just as healthy–but they might actually start becoming healthier, as greater emphasis is placed on things like prevention, continuity of care, and chronic disease management.
To be fair, not every study supports the “more primary care is better” philosophy, but that hasn’t much mattered. It has become a central tenet of reform for most. Tom Ricketts and I actually authored a paper that raises some methodological concerns, which call some of the typical findings into question. (Warning: If you’re not accustomed to reading academic papers, this may not be for you.) But the most recent kicker comes from the folks at the Dartmouth Atlas who are well known for their work revealing the wide geographic variation in Medicare spending. The group recently released a report that, simply put, says primary care isn’t the panacea many people claim it to be.
What in the world is one to make of this?! Nothing really. Primary care practices don’t exist in a vacuum. People’s environments, their lifestyle choices and health behaviors still play a large role in their health outcomes. Furthermore, patients rely on both generalists and specialists, not generalists alone. The Dartmouth report doesn’t mean that primary care is suddenly more expensive than previously thought, or that it doesn’t provide the high quality of care it was once believed to. Rather, it means that there is no “magic bullet” that will suddenly solve all that ails our country’s health care system. Let me be as clear as possible about this: Primary care is a good thing–it’s just not the only thing. Now back to your regularly scheduled programming……
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I went to the doctor recently and got a new prescription. The doctor was kind enough to give me some free samples, and a voucher that I could redeem to fill the prescription once at no cost. In the future, it will cost me $50 if I decide to refill it. If I didn’t have pharmaceutical benefits through my insurance coverage, the medication would set me back about $500 for a month’s supply. For those of you doing the math, yes, that’s $6,000 a year. Suffice it to say that I wouldn’t be filling the prescription. And that’s exactly what many Americans do.
For many low-income uninsured Americans, a number of important medications are out of reach because they are simply unaffordable. These are medications that treat chronic diseases like hypertension, high cholesterol, and other common illnesses. They are effective medications that can make a huge difference in a person’s quality of life–including whether or not they die an avoidable death. In a show of good faith, most pharmaceutical manufacturers provide access to no-cost or reduced-cost brand name medications (the ones they manufacture, of course) to this “gap” population. The trouble is, few people know about these programs, which offer tremendous assistance, but require people to jump through a number of application hoops to qualify for the cheap or, in some cases, free meds.
Dr. Heather Whitley has an article out in the latest issue of The Journal of Rural Health, which attempts to quantify the value of these prescription assistance programs (PAPs) at a clinic in Alabama. Head south from Tuscaloosa, and you’ll find yourself in Hale County–one of the 50 poorest counties in America with an average annual income of $14,927 per person. In Hale County, is a town called Moundville, and it is here that the Moundville Medical Clinic operates with a single physician, a nurse practitioner and a couple of nurses. This is one of those places that most Americans don’t know–or at least really don’t like to acknowledge–exists in the United States. If ever anyone needed help obtaining prescription medication, the patients of the Moundville Medical Clinic would be first in line.
The clinic has a pharmacist who works two days a week to help patients navigate the PAP application process. Costs are offset by charging patients $5 per completed and mailed application. In most cases, that is a small price to pay. Dr. Whitley looked at the data collected by the clinic to assess the value of the program–that is, how much free or reduced-cost medicine were patients getting?–and found that across a two-year period (2007 and 2008), the PAP program at the Moundville Medical Clinic brought in more than $138,000 in free medications. That’s a lot, yes, but what is even more striking is when you consider that that was only for a total of 31 patients. In other words, each patient received about $4,500 in free medication on average during the study period. That’s a pretty remarkable benefit in return for filling out some complicated paperwork, and it suggests that–until real health reform and cost-control is achieved–clinics that see a number of PAP-eligible patients should strongly consider investing in such programs, even if it means having someone volunteer their time one day a week. The benefits far outweigh the costs, but there are administrative hurdles that must be cleared before the benefits can be accessed.
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This article from Slate is very, very interesting. It makes me stop and think: Does a similar psychological filtering process explain why conservatives will rarely read my blog and even more rarely be convinced by my arguments if they do? And, to be fair, somewhere a more conservative blogger will ask the same question of liberals? In fact, this all suggests that even if my blog strives to strike a “fair and balanced” position–showcasing the work of those on both left and right (which I have done, albeit not always well)–the reader will assign more weight to the ideas that reinforce their own ideas, and ignore the ones that run counter to their own. So, that interesting article might also serve to teach me that changing anyone’s mind about anything health care related is largely a Sisyphean endeavor. Perhaps I should move to Boulder.
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It struck me recently that while I have often pointed you to a particularly good post I’ve come across, I have neglected to establish much of a “blogroll” — the list of links to blogs I think are worth checking out regularly. One of the ways I can improve the blog is by collecting these references for you in one place. So, beginning today, I’ll be doing that, but I also need your help. If you write a health care blog, read a health care blog, or just know of a health care blog that you think is worthy of telling others about, send me an email or leave a comment and let me know about it. I’ll take a look at it and decide whether to include it in the list or not.
Today, I’m introducing you to Pulse–Voices From the Heart of Medicine and Christopher Johnson, MD. Pulse is full of narratives and poetry about the practice of medicine. It’s not a place to learn about policy, but it is a place to get inside the mind of the clinician. One of the recent entries, “Broken”, by Jordan Grumet paints a vivid picture of the process physicians go through in confronting so much human misery–and hopefully finding their way back to peace. Dr. Johnson is a pediatric intensive care physician with much to say on a variety of subjects in health care, including a recent piece on the value of electronic medical records and why some physicians are more willing to use them than others.
Give those pieces a read, check those blogs periodically, and send me your suggestions for others….
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Brad Wright, PhD
Shirie Leng, MD
Nicole F. Roberts
Wright on Health 