Do Appointment Reminders Work?

If you’ve been to the doctor in the last few years, you’ve probably gotten one a phone call reminding you from your doctor’s office reminding you of your upcoming appointment. These calls usually come from 1 to 3 days prior to your scheduled appointment. Sometimes a member of the front office staff speaks to you in person. Other times you get an automated “robo-call.” And, while I’ve never experienced it, many providers are now contacting patients with reminders sent to their cellphones as text messages.

I’ve always found these reminders annoying, because I generally keep my appointments, but for the physicians, anything that helps to avoid missed appointments is a way to improve efficiency. After all, a physician’s day littered with missed appointments isn’t much different than a plane flying with empty seats. The phone call reminders are known to produce results, but if text messages are equally effective, they would be preferable, because they’re generally cheaper to send out than paying someone to make calls. But the big question is: Do these text message reminders work?

The answer, according to a meta-analysis appearing in the latest issue of Health Services Research, is a resounding yes. The study looked only at text message reminders, and synthesizing results from 18 separate studies, they found that text message reminders increased the likelihood of appointment attendance by nearly 50%. That’s a big effect. The only thing that’s concerning is who won’t be reached if providers migrate to text message reminders over telephone calls. Cellphone use is widespread, but there are pockets of people–the elderly, those in areas without cell coverage, etc.–that would stand to forget their appointments more often, because they don’t have a cellphone. Of course, if things get really bad, it will be the folks without cellphones who come out ahead.

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Supremes to Hear Case on Affordable Care Act

The legal challenges to the Affordable Care Act commenced just as soon as the bill became law in 2010. There have already been a number of lower courts that have ruled on the constitutionality of the law’s individual mandate, and I have written fairly extensively about these cases here, here, here, here, here, here, here, and here. Those links are in chronological order, and I’d suggest reading them if you need to get up to speed quickly on the issue.

More recently, the Court of Appeals for the D.C. Circuit ruled in favor of the individual mandate, and the decision is notable in that a conservative judge and Reagan appointee broke with the precedent of conservative judges ruling against the law. In fact, he was the second judge to do so. Jonathan Cohn has more of the details over at The New Republic as does Timothy Jost at the Health Affairs blog.

This decision was the prelude to the Supreme Court’s decision to hear the Affordable Care Act case early next year. In fact, they’re not only going to hear it, they’ve set aside a record amount of time for oral arguments–5 1/2 hours to be exact. The New York Times’ Adam Liptak has more.

Meanwhile, voters in Ohio passed a meaningless referendum rejecting the individual mandate. Why is it meaningless? Because if the Supreme Court finds the individual mandate unconstitutional, the Ohio amendment won’t be necessary, and if the Court upholds the mandate, federal law trumps state law, rendering the amendment useless. Which will it be? We’ll have our answer just in time for the election in 2012.

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Behind the Scenes in Washington

I have a lot of family and friends who like to complain that nothing ever gets done in Washington. While it’s true that the political process often winds up in gridlock (as the Founding Fathers’ system of checks and balances intended, by the way), that doesn’t mean that nothing happens. In fact, quite a lot happens, it just happens behind the scenes. There is extensive lobbying, most of which doesn’t make it into the paper or the evening news. If you’re not looking for the information, if you’re not part of the process, you’re not likely to know just how much activity there is at any one time.

For example, the so-called “Super Committee” is due to make its recommendations to Congress by November 23rd. The group has been tasked with identifying ways to reduce the deficit by at least $1.2 billion over the next decade. Cutting the budget means some groups stand to lose, and lobbyists who often work to make things happen, turn their attention to making sure that things (i.e., budget cuts) don’t happen to the groups they represent.

Not surprisingly, the Super Committee has heard from a number of national interest group organizations, and many of them represent the health care industry and concerns about cuts to Medicaid and/or Medicare. Kaiser Health News has compiled a list of some of the more prominent organizations and their goals for the outcome of the Super Committee’s process. It’s worth reading, and you can find it here.

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One-Stop Shopping

Wal-Mart used to be simply Wal-Mart. Then, it grew, and grew, and grew. Now Wal-Mart often appears as “Super Wal-Mart”–and it seems that you can get pretty much everything there. They have clothes, they have home furnishings, they have automotive supplies, pet supplies, music and electronics, fabric and crafts, books, magazines, groceries, shoes, tools, prescription drugs, optometrists, banks, and fast-food restaurants. Many even sell gasoline out in the parking lot. In fact, just about the only things you can’t get at Wal-Mart are legal advice and medical care, but corporate executives at Wal-Mart are hoping to change the latter.

Wal-Mart’s plan to begin providing primary care in a big way was first reported by Kaiser Health News. The move is ironic in that it comes at the same time that Wal-Mart announced it would further scale-back already atrocious employee health insurance benefits, but it might actually work for some basic needs.

Wal-Mart’s $4 price for many generic medications has been tremendously popular, and speaking from personal experience, undercuts the need for prescription drug coverage in many cases. It’s certainly possible that Wal-Mart can provide certain primary care services at low prices that increase access to those services and potentially steer people away from higher priced settings like emergency rooms and urgent care centers. However, there are concerns about quality and whether a retail-based primary care practice will be able to effectively manage the complex needs of people with chronic conditions. In effect, as the health care system continues to eye a movement towards the patient-centered medical home model, Wal-Mart may not be the best fit. The retail giant is a jack of all trades, but a master of none, unless cutting corners to drive prices down is a trade. They’ve cornered the market on that one, but is that how you want to care for your health?

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Mitt Romney For the Public Option?

When the Affordable Care Act was passed, it made it through without the so-called “public option” that progressives everywhere thought would save the U.S. health care system. Quite simply, the public option was to be a federal insurance plan that anyone could purchase, and it was considered a way to increase choice of plans for consumers while keeping insurers accountable by providing a competitive benchmark for cost and quality of coverage.

The problem was, the GOP decided that it hated the idea of competition. Not all competition, mind you, but any competition between the federal government and private industry. Never mind that this is precisely what they put in place themselves with the introduction of Medicare Advantage plans. When the other party’s in power, the playbook reads “Always say no” and thus, the rules changed. Now it appears that Mitt Romney, possible GOP nominee for the 2012 presidential election, favors competition again. In fact, it appears that he even favors the forbidden variety of government-private sector competition.

You see, last week, Romney outlined a plan to reform Medicare if he is elected. His plan gives seniors a voucher, the amount of which is based on their income, with lower income individuals receiving bigger payments, which they can then use to purchase health insurance coverage from either the government’s Medicare program or a private health insurer that offers a plan at least as good as Medicare. In theory, there would be competition, and prices would go down. That’s right, let our seniors shop for the best deal and let private insurers compete against the federal government for their business.

What’s likely to happen, though, is that private insurers either avoid the Medicare market altogether, or they cherry-pick the healthiest seniors to ensure they can turn a profit as we’ve seen happen with Medicare Advantage. In the former case, there will be no competition to drive down costs. In the latter case, the Medicare market will essentially be segregated into a healthier group with private coverage and a sicker group with traditional Medicare, which will have the effect of making insurers more money and sticking the federal government with the bill. The Romney plan attempts to get around this by requiring the private plans to accept everyone who seeks coverage, but how that plays out is debatable.

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Wonk Review For Your Review

Hank Stern at InsureBlog hosts the latest edition of the Health Wonk Review. I didn’t submit anything this go around, but a lot of other fine folks did. Check out the best of their work here.

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Mandate Realists

Last week, I wrote about what might happen if the Supreme Court struck down the individual mandate portion of the Affordable Care Act, leaving the rest of the law intact. It seems that others have been chiming in to, and if I interpreted the Lewin Group’s study in Health Affairs through a “glass half-full” lens, others aren’t convinced and certainly aren’t optimistic.

One of the cynics (realists?) is Mark Hall, who I know and admire. He has a well-written article critiquing the Health Affairs piece, where else but the Health Affairs blog. In his post, he does an excellent job of explaining why Lewin’s research is an outlier and why we should put more stock in the doomsday predictions of Jonathan Gruber and friends. He also puts forward a sort of Pascal’s Wager in support of the mandate: We don’t know how bad things will be without a mandate, but we do know that things won’t be bad with the mandate, so better to make the safe bet. I actually agree with all of this, with one exception: It ignores the case of the status quo, which I think is worse than all the other elements of health reform minus the individual mandate, which is itself worse than all of the elements of health reform including the individual mandate.

I’m all for the individual mandate, I’m just not ready to throw in the towel if that single piece of the law takes a hit. For more on how there’s “no ‘silver lining’ in repealing [the] insurance mandate” check out this excellent piece from Naomi Freundlich at Health Beat.

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The Buck Doesn’t Stop Here

America’s Health Insurance Plans commissioned consulting firm Oliver Wyman to make some predictions about what will happen to health insurance once the Affordable Care Act is implemented. According to the report, premiums are going to increase, because health insurers are going to build into premiums the costs of new taxes that are being levied against them by the ACA. Meghan McCarthy has the story here. T

his isn’t really news in the sense that it was most certainly anticipated, but it does raise an important question: Will the people stand for it? We’ve seen the popular backlash that occurred with managed care in the 1990s, and we’re watching similar opposition unfold with the Occupy Movement and the displeasure being voiced over large banks charging fees for debit card use. There’s no reason that people shouldn’t vote with their feet if their insurer threatens to pass the tax on to the consumer. An insurer that opted not to do so would win favor among the people.

Unfortunately, most of our coverage is obtained through the group market. Collective action could stop the practice, but a handful of dissenters would likely find themselves faced with a choice: Pay the increased premium or lose your coverage. Hopefully the provision of the ACA requiring that 80 to 85 percent of premiums collected are spent to cover medical claims will keep this sort of behavior in check, but if this teaches us one thing it’s this: Insurance companies exist for the sole purpose of making as much money as possible. The question is: What do they do to earn it?

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U.S. Health Care Costs In Perspective

It was Stalin who said “A single death is a tragedy, a million deaths is a statistic.” We might not like to be reminded that he was right, that we could possibly think that way, but I’m afraid we do. It’s why the news can’t provide us enough coverage of the mysterious disappearance of a single child, but no one decries their failure to mention the thousands of children that day every day from a host of preventable diseases, poverty, and inhumane acts.

It’s also why we can grow outraged at anything that might affect our own health care or insurance coverage, but can more or less ignore just how much of a mess our health care system is in financially. A dollar out of my own pocket is a tragedy, a million dollars is a federal government rounding error. Perspective seems to be the missing ingredient. We can identify with that single death, that single dollar out of our pocket, that person we know, but most of us can’t imagine a million deaths, don’t know a million people, and don’t have a million dollars. Physics aside, if I ask you how long it would take you to walk to the moon, it’s a math problem you might solve, but it’s not an experience you could understand.

But if we stop comparing apples and oranges and start comparing similar things to each other, we find that we suddenly gain tremendous clarity. Let me show you how it works. If I tell you that the United States spent $2.6 trillion dollars on health care in 2010, you probably think something like “That sounds like a lot” or “That is a big number” or “I wish I had that much money.” (As a side note, according to the law of mo’ money mo’ problems, no you don’t.) I could try to make the number more understandable by telling you how many of something you could buy with the money. The problem is, that thing also has to be pretty expensive, otherwise the resulting number is still extremely large. Case in point: that amount of money would buy you 10 million homes at $260,000 each.

Ezekiel Emanuel (Rahm’s brother), has found a way to put it all into relative perspective that makes alarming sense. According to Zeke, “The United States spends on health care alone what the 65 million people of France spend on everything: education, defense, the environment, scientific research, vacations, food, housing, cars, clothes, and health care.” That’s pretty simple. Our health care spending can be succinctly described as France. Just for fun, our health care spending is also “slightly less than half of what China spends on everything.” California likes to bill itself as the “eighth largest economy in the world,” but they really shouldn’t brag: After all, America’s “health care spending is the fifth largest economy in the world.”

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What If The Supreme Court Strikes Down the Individual Mandate?

Any ruling by the Supreme Court on the constitutionality of the Affordable Care Act’s controversial individual mandate isn’t likely for at least another several months, but it’s worth thinking about what might happen after the case is decided. The first scenario is easy: If the Court upholds the mandate, the ACA goes forward as planned to the continued objections of many conservative Americans and politicians. The second scenario is less clear: If the Court finds the mandate unconstitutional, do they find it severable from the rest of the law? If not, they’ll strike the whole ACA down. This seems like the least likely outcome. If, on the other hand, they do invoke severability, the ball is back in the White House’s court. The decision at that point would be whether or not health reform can be successful without the individual mandate.

The concern here is the death spiral first described by Nobel Prize-winning economist Joseph Stiglitz. In essence, if we don’t require everyone to buy insurance, then insurance will be disproportionately purchased by the sick, making it more expensive and leading many to discontinue coverage in a continuous cycle that drives the price higher and higher until no one can afford insurance any more and the system collapses. By contrast, getting everyone into the pool is seen as the only way to keep costs down and maintain the insurance system. So the question is: What happens if the Supreme Court strikes down the individual mandate? Does the Obama adminsitration wash its hands of health reform, proclaiming that it can’t be done without the individual mandate because costs will rise too rapidly and the insurance system will collapse, or does it forge onward and see what happens?

Option one is the safe bet if you believe that a bad status quo is better than a potentially worse change, but it’s absolutely terrible politics. It would be admitting defeat on one of the defining aspects of the Obama presidency. Moreover, it would have tremendous negative implications for the future of health reform initiatives generally. Option two looks good politically for all of the opposite reasons, but it could destroy the health insurance market and hurt Americans in the process. That’s bad leadership. While such action might lead to the type of catastrophic collapse necessary to precipitate true change, it would be incredibly painful.

New evidence suggests, however, that the pain might not be as great as many–myself included–fear. John Sheils and Randall Haught of the Lewin Group ran a simulation model to see what might happen to coverage and costs if reform went forward as planned with the exception of the individual mandate. Remember, the concern is that fewer people would be covered and health insurance premiums would increase. What they found is that, yes, compared to estimates under health reform with an individual mandate, health reform without the individual mandate would mean fewer people would be covered and insurance premiums would increase, but things would still be better than if we did nothing at all.

How much better? Well, without reform, they estimate that 51.6 million Americans would be uninsured. With reform, that number drops to 20.7 million. With reform, but without the mandate, their estimate stands at 28.5 million. Not too shabby. As for premiums, the authors estimate that eliminating the individual mandate will mean a 12.6% increase. Not a welcome increase, but not necessarily the kiss of the death spiral.
That said, other estimates by the Congressional Budget Office and MIT health economist Jonathan Gruber have not been as optimistic. The CBO expects that axing the individual mandate will mean 16 million fewer insured persons and a premium increase between 15 and 20%. Gruber puts the figures at 24 million fewer insured and premium increases on the order of 27%. Because of the sheer volume of people involved and the uncertainty of their decision making processes, it’s really hard to know who’s calculations are the most reasonable.

What you can count on is this: If the Court finds the individual mandate unconstitutional, the White House will have more actuaries and health economists crunching numbers than you can imagine. These latest results from Lewin suggest that even if the Court says no to the individual mandate, it shouldn’t necessarily mean the Obama adminsitration should give up on health reform.

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