Expanding Insurance May Not Mean Long Lines and Trouble Seeing the Doctor

When health reform made it on the agenda in 2008-9, it took almost no time to hear the old familiar line that government-run health care will mean rationing, with crowded waiting rooms and the dreaded prospect of it taking months or years to get seen by the doctor or have an important surgery performed. It didn’t matter when Brits and Canadians chimed in to say “Actually, it’s not like that here at all.” Americans succumbed to the combination of logic and fear. The logic is apparent: If more people have the ability to go to the doctor, and there isn’t suddenly a corresponding increase in doctors, then either doctors are going to have to see more patients in less time (potentially reducing quality), or patients are going to have to wait to be seen (and we don’t like to wait). Given my parenthetical explanations in the preceding sentence, do I even need to elaborate on the fear aspect?

There’s just one important question: Is that really what will happen? This is where the good folks at Harvard who do health policy and health services research are so lucky. In Massachusetts, which basically implemented ObamaCare at the state level years before ObamaCare came into being, we have a nice policy laboratory to investigate this question. That’s precisely what Karen Joynt and colleagues did, as they report in a recent article in Health Services Research.

The very short version of what they did is this: Using Medicare data, they looked to see if people with chronic diseases like diabetes and hypertension had fewer outpatient visits to the doctor after the Massachusetts health reform was enacted, compared to the number of visits they had before the reform. They also looked at some quality metrics in the same way. That is, did the patients get the treatments we know they are supposed to get? And they also looked at health care costs. The cool thing about this is that they were able to use patients in other New England states that didn’t have health reform as controls. That means that their study design is really able to attribute any changes they see in Massachusetts above and beyond what they see elsewhere in New England to the health reform in Massachusetts.

The very short version of what they found is this: There was no decrease in health care visits or health care quality in Massachusetts because of health reform, but there was an increase in costs. Now, there are some limitations to what they did, but the authors acknowledge these nicely. The biggest issue is that Massachusetts had a low rate of uninsured persons to begin with, so their health care system was less flooded with newly insured than other places–like Kentucky–might be thanks to the ACA. The other big issue is that the study only examined the Medicare population age 65 and up, so we have no idea if the under-65 disabled Medicare population and everyone else may have experienced issues getting seen by a doctor. Still, despite these limitations, the study offers a ray of hope that our health care delivery system is responsive enough to adapt to an increase in demand without making us suffer lengthy waits to be seen for outpatient care, and that the ACA may well end up doing more good than harm.

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NFL Players Host Concussion Summit Week Before Super Bowl, Despite Ongoing Litigation

Real innovation is often driven by those who think outside the box; those who take the obvious and make it an actionable reality. The week leading up to Super Bowl XLVIII, a group of entrepreneurs created a unique and transformative meeting of the minds. At the Coalition for Concussion Summit (#C4CT), Brewer Sports International and Amarantus BioScience Holdings, Inc. joined forces at the United Nations’ (UN) New York headquarters to bring scientists, biotech companies and professional athletes together, with the goal of building awareness and advancing scientific and medical opportunities for traumatic brain injury (TBI), chronic traumatic encephalopathy (CTE) and concussions. Add in the weight of immediate policy implications of the National Football League facing litigation for not properly informing or protecting players and Northwestern University’s football team attempting to unionize in hopes of improving athlete’s rights, and a perfect storm is created to demand change. Collectively, the week of the Super Bowl developed into an ideal time, location and platform for changing standards of health care and promoting developments in mental medical care that are patient-centric.

NFL Litigation

In the months preceding the 2014 Super Bowl, the NFL and the NFL Players Association (NFLPA) found themselves in a heated battle over the allegations that the NFL withheld information from the players about the depth and breadth of research indicating that concussions, memory loss and memory deterioration are linked. The NFL has since agreed to a $765 million settlement, which was recently denied by Judge Anita Brody who claims that the in the suit, “not all retired NFL football players who ultimately receive a qualifying diagnosis, or their related claimants, will be paid.”

While that decision is pending, more lawsuits are beginning to surface from individual players. Last Tuesday, former Detroit Lions running back Jahvid Best sued the NFL and helmet maker Riddell, claiming that concussion problems contributed to ending his career early

However, according to Robert Griffith, a 13-year veteran of the league, it doesn’t take a career-ending hit to significantly impact long-term functioning. “Guys suffer the same symptoms even after a few years in the league, including, sleep deprivation, depression, mood swings, addictions and self worth problems.”

The same week of the Super Bowl, the Northwestern University football team also dropped a bomb on the sports world, despite efforts from the National Collegiate Athletic Association (NCAA) to curb player concussions. The team wants to change the way university’s view, treat and educate student athletes, claiming more players’ rights are needed. This comes in tandem with a more than two-year long effort by several college players to sue the NCAA for failing to protect student athletes from concussions. An irony, pointed out by Chris Nowinski, author and former professional wrestler with World Wrestling Entertainment (WWE), who noted that “We have pitch counts for shoulders, even in high school, but we don’t have hit counts.”

Health Policy at the Forefront

When the NFL, the United States’ most powerful sports league, is on the hot seat for neglecting players’ mental and physical health, it is only a matter of time before public outrage requires policy change. Not only does the NFL itself have the ability to change health policy for the better, but the trickle down impact could save many young athletes around the country the trauma that current and past players have suffered.

Ultimately, a new standard of care is possible in the near future. Because, as Jermichael Finley told me, “100% or 50%, it doesn’t matter how one steps on the field. It isn’t if you get hurt, it’s when you’ll get hurt.” Further, as one conference goer attested, “We are speaking on the floor of the United Nations about brain trauma. This has never before been possible.”

With that in mind, researchers and clinicians such as Andrew Maas, MD, PhD, Robert Stern, PhD, Kim Heidenreich, PhD and Jay Clugston, MD came together with patients and biotech companies to discuss the current state of trauma, neuroscience, degenerative diseases, sports medicine and public policy.

Meeting Of The Minds

Despite the exorbitant power of the NFL, surprisingly little has been done to advance the conversation between athletes and the scientists who work diligently to understand and protect our brains. Until now.

As the nation’s best football players ascended upon New York and New Jersey, Brewer Sports International and Amarantus BioScience Holdings, Inc. gathered a room full of athletes and scientists to educate one another and discuss the real world of traumatic brain injury, concussions and memory loss.

“As a former NFL player, I am passionate about making strides to improve the health and safety of my fellow professional athletes, both former and current,” said Jack Brewer, CEO of Brewer Sports International. “Instead of pointing fingers, we have put together a world class panel of researchers to discuss TBI-induced neurodegeneration and CTE with those directly affected by and equally passionate about the cause as we strive to enhance awareness and work to find viable treatments.”

Gerald Commissiong, President and CEO of Amarantus reinforced the originality of the idea saying that, “The true innovation in #C4CT lies in bringing all of the stakeholders on the concussion issue into one forum. Conferences that are medical in nature almost always overlook key groups such as patients, caregivers and advocates. By allowing patients to be part of the process, we are creating a paradigm shift that we hope will galvanise the broader community into action.”

Brain Function

Despite Super Bowl caliber athletes having athletic abilities that are superior to most, the brains and vulnerabilities of these athletes are comparable to all others. The impact of one hard hit or one concussion can disrupt brain function forever. A point that resonates with Mixed Martial Arts (MMA) fighters as well. Just yesterday, boxing rivals met on Capitol Hill with Senators to support efforts of the Cleveland Clinic in studying brain health. They were backed by more than 400 of their peers who wanted to maintain their profession, but ensure that the future is brighter for other athletes.

Even veteran players such as Clinton Portis assert that he does not have regrets about his career but that he, “will not let my sons play contact football until at least high school,” due to the limited research that exists on TBI and concussions.

Those downstream effects, many at the summit contend, are highly linked to neurodegeneration, memory loss and long-term functioning. However, this is exceptionally hard to prove given how hard apples-to-apples comparisons are of brain damage and functioning. This association is further limited by the ability to compare impact enumeration and force due to the small sample size that are athletes.

Events such as the Coalition for Concussions Summit are becoming imperative to change health policy. When organizations, individuals, researchers and policymakers cannot fight the battle alone, it takes a meeting of the minds to advance a message. Hopefully, assembling key stakeholders to address health care problems will become a norm to improve health and care in the US.

 

Mental Health Loses Funding As Government Continues Shutdown

In the months leading up to World Mental Health Day, DC has been shaken by a series of violent events that ended with innocent lives lost and our country’s mental health services called into question. During this same time period, Washington, DC has been consumed by a government shutdown, with lawmakers and policymakers trying to determine how to rein in our country’s financial burdens and overspending. Unfortunately, as federal and state governments look to cut budgets at every turn, mental and behavioral health services are often on the chopping block first. Financial cuts, compounded with US stigma often applied to mental health troubles and disparate access to services across the county, mean that those who need services most are often those left without proper care.

August though October brought DC into the spotlight for many reasons, the saddest of which is the violence that was covered by mass media as two shootings occurred. In one case, Aaron Alexis, a 34-year-old, perpetrated a mass shooting that left 12 people dead, in Washington’s Navy Yard. Previous to the shooting, it was reported that Mr. Alexis was treated at the VA for mental health issues including sleep disorders and paranoia, but had not lost clearance.

Miriam Carey, also 34, reportedly had an unhealthy obsession with the White House when she drove her car into the White House gates and led police on a chase around DC before being killed. Although she had no reported psychosis or supposed violent intent, it was noted in the months leading up to the incident she believed that the President had beenstalking her and might have suffered from postpartum depression. When killed by authorities on Pennsylvania Avenue, she had her 18-month-old child in the car.

Budget Cuts

Although societal stigma and knowledge of where to access behavioral and mental services are often barriers to care, budget cuts continue to make seeking care more difficult. Whether this be through decreases in available services, lack of providers due to poor reimbursements or less preventative actions in communities, the impact of mental health funding shortages is great. According to the National Alliance on Mental Illness, “increasingly, emergency rooms, homeless shelters and jails are struggling with the effects of people falling through the cracks due to lack of needed mental health services and supports.”

In the last five years, significant budget cuts have befallen mental health programs and services. From 2009 to 2011, states cut mental health budgets by a combined $4 billion- the largest single combined reduction to mental health spending since de-institutionalization in the 1970s. In Chicago alone, state budget cuts combined with reductions in county and city mental health services led to shutting six of the city’s 12 mental health clinics. These closures, along with other public and private center closures in Chicago, have eliminated vitally needed services, especially on the south and west sides where they are indispensable.

Threats of sequestration in 2013 had a significant impact on people’s ability to access mental health services and programs, including children’s mental health services, suicide prevention programs, homeless outreach programs, substance abuse treatment programs, housing and employment assistance, health research, and virtually every type of public mental health support. The Substance Abuse and Mental Health Services Administration(SAMHSA) claimed it alone would be cutting $168 million from its 2013 spending, including areduction of $83.1 million in grants for substance abuse treatment programs.

Consequences

Despite the need to balance budget and make all health care services more efficient, many argue that society has better long-term outcomes if more federal and state dollars are allocated to mental and behavioral health care. This includes preventative services as well as mental health testing and treatment.

Because individuals with untreated mental illness often find themselves in emergency rooms, homeless shelters and prisons, the societal cost of prevention and treatment may be exponentially less than funding those other outlets and catchment areas. This is especially true in the case of children, who face cycling in and out of the system throughout their lives if left untreated.

These costs can be exceptionally large over the lifetime given that the National Institute of Mental Health (NIMH) estimates that two-thirds of children with lifetime mental health problems never receive treatment. This takes substantial emotional and financial tolls on individuals and families, as well as the broader society. However, programs that address the mental health needs and provide services for youth show better outcomes in health and education that carry over the lifetime. For example, in the University of Chicago’s Crime Lab, therapy is being used to curb youth violence, especially amongst those with behavioral and mental health care needs.

Additionally staining on the mental health care system is that during times of recession and budget cuts the caseload for mental health actually increases. It has been estimated that during this most recent recession, the caseload of community mental health services alone has increased almost 50 percent. This increase has most notably been seen in the Native American community, where suicide prevention is an essential part of the cultural health care demands.

Everyone Benefits

The NIMH contends that one in 17 people suffer from a “seriously debilitating mental illness,” we as a society are accountable for ensuring that those in need have resources for care. Not only does access to quality mental and behavioral health care ensure that individuals are being properly treated, but that America as a whole saves money and resources caring for those in need in other, more expensive settings. It may further prevent violent acts like those in DC from happing.

On this World Mental Health day think about the ways in which access to and support of mental and behavioral health care can be improved in your community.

 

How Much Weight Should Anecdotes Really Have In Health Policy?

There’s something compelling about the personal narrative that vast mountains of quantitative data cannot rival. Anecdotes are, quite simply, powerful. They tap into our shared humanity, making something seem somehow more real by putting a face on it. This is why, if you follow politics for very long, you will find numerous cases of policymakers championing issues that have touched their own lives in some way. For example, Senator X doesn’t care about issue Y, until they discover that their son or daughter is affected by it. Then, almost overnight, they seem to care more about issue Y than almost anything else. Such a shift is completely understandable, but often out of proportion to the true scale of the issue in society.

In health policy, the personal narrative can also be very powerful. In fact, the journal Health Affairs routinely runs a “Narrative Matters” section that puts a face on the health care issues of the day. It is absolutely critical that health policymakers, health services researchers, and others, not lose sight of the fact that their work and the subsequent decisions it informs, are based on real people. However, it is equally critical for objectivity to be maintained, and narrative can threaten our work in this regard.

As an example, Tom Perkins recently wrote in the Wall Street Journal about his ongoing battle with prostate cancer in his eighties. His article takes issue with recommendations from the U.S. Preventative Health Service that call for moving away from prostate cancer screening (the PSA blood test). It’s hard to argue with his case, specifically, because he had an aggressive form of prostate cancer that was caught early and is being treated with at least moderate effectiveness. Had he not been screened, the cancer would most likely have killed him. You can see why he would consider the U.S. Preventative Health Service to be a “death panel” (his words, not mine).

The problem is that Tom Perkins is an anomaly. The overwhelming majority of prostate cancer is not aggressive. This is why you may have heard the saying “Most men die with prostate cancer, not of prostate cancer.” One of the greatest things about health services research is the opportunity it affords to step back from the trees and take stock of what is happening to the forest. What we discover then leads us to confront more philosophical questions. For example, are we okay with paying for 100 people to be screened for something that will only help 1 of them? If you were making this decision the way you make decisions about most everything else you buy, you’d want to know some things. For instance, how much does the screening test cost? If the test isn’t done, what else could the money be used for? How accurate are the results of the test? How much will the 1 person be helped? Do I know the 1 person? Am I the 1 person?

These questions represent the continuum from purely objective research to very subjective personal anecdote. They all deserve to be answered, and each answer informs our decision-making in a different way. Unfortunately, when people espouse one extreme or the other, which is admittedly much easier to do than holding the two in tension, something very important gets lost.

 

Rationalizing Rationing

When will we ever be free of the dreaded “R” word in health care? Will we ever accept that we can’t have our cake and eat it too? I’ve written about rationing many times before. Today, I want to share with you the words of Dr. Don Berwick, outgoing director of the Centers for Medicare and Medicaid Services. In a speech at the Institute for Healthcare Improvement National Forum on December 7, 2011, Dr. Berwick had this to say:

“Inscribed on the wall of the great hall at the entrance to the Hubert Humphrey Building, the HHS Headquarters in Washington where my office was, is a quotation from Senator Humphrey at the building’s dedication ceremony on November 4, 1977. It says: ‘The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the handicapped.’

I believe that. Indeed, I think that Senator Humphrey described the moral test, not just of government, but of a nation. This is a time of great strain in America; uncertainty abounds. With uncertainty comes fear, and with fear comes withdrawal. We can climb into our bunkers, each separately, and bar the door. But, remember, millions of Americans don’t have a bunker to climb into–they have no place to hide. For many of them, indeed, the crisis of economic security that we all dread now is no crisis at all–it is their status quo. The Great Recession is just their normal life….

Cynicism diverts energy from the great moral test. It toys with deception, and deception destroys….If you really want to talk about ‘death panels,’ let’s think about what happens if we cut back programs of needed, life-saving care for Medicaid beneficiaries and other poor people in America. What happens in a nation willing to say to a senior citizen of marginal income, ‘I am sorry you cannot afford your medicines, but you are on your own?’ What happens if we choose to defund our nation’s investments in preventive medicine and community health, condemning a generation to avoidable risks and unseen toxins? Maybe a real death panel is a group of people who tell health care insurers that it is OK to take insurance away from people because they are sick or are at risk for becoming sick….

And, while we are at it, what about ‘rationing?’ The distorted and demagogic use of that term is another travesty in our public debate….The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry ‘foul’ about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people–elders, the poor, the disabled–who are least able to bear them. When the 17 million American children who live in poverty cannot get the immunizations and blood tests they need, that is rationing. When disabled Americans lack the help to keep them out of institutions and in their homes and living independently, that is rationing. When tens of thousands of Medicaid beneficiaries are thrown out of coverage, and when millions of seniors are threatened with the withdrawal of preventive care or cannot afford their medications, and when every single one of us lives under the Sword of Damocles that, if we get sick, we lose health insurance, that is rationing. And it is beneath us as a great nation to allow that to happen.”

Why don’t you ponder that over the next few days, and have a Merry Christmas!

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Wasting Money At the End of Life?

Peter Bach is a physician with a recent op-ed appearing in the New York Times. Dr. Bach’s piece about whether or not end-of-life health care spending is wasteful is compelling. I recommend you read his essay, but I want to hit some of the high points.

The first is that we may be making an error based on hindsight. Precisely because hindsight is 20/20, we can fall into the trap of evaluating health care decisions after the outcome is known, which is not how health care decisions are actually made. So, as Dr. Bach stresses, a tremendous amount of health care spending may be deemed warranted if it saves the life of the patient, but the same spending would be labeled wasteful if the patient dies. This is an excellent point.

Other points Dr. Bach makes relate to supposed sources of bias. For example, sick people need more health care (which costs more money) and are also more likely to die. Ergo, the link between health care spending and death is likely to be positive, but the reality is that health status is the common denominator. He also laments the fact that data on end-of-life spending is much more readily available than data on other types of health care spending. That’s also a pretty accurate assertion.

It’s in his concluding remarks that Dr. Bach gets to the real matter at hand: We don’t know who is going to benefit and who isn’t. In his essay, he describes how he saved someone’s life. As it turns out, the condition that person had is fatal in about 1 of every 8 cases. In other words, paying to intervene for that condition seems like a good bet. If, on the other hand, only 1 out of 8 people with the condition survived, it might be a tougher sell. Of course, what that scenario underscores is that the overall costs and benefits are important to understand, but so are the individual risks and benefits. For example, if you have the condition, you are probably hoping that you are the 1 person who will survive after receiving the intervention, not counting on your being 1 of the other 7.

Research that can help us understand not only which procedures are generally more effective than others, but also who the 1 person who loses or benefits (given the two scenarios above) will be, are the next frontier in improving the health care system–cutting costs without harming quality. Of course, this type of research will bring accusations of “death panels” back out of the woodwork. I just hope few people will actually take such things seriously, so that the necessary work can proceed. Without it, I’m not sure that there’s much hope.

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The Rationing Primer

If you wade through the various arguments made in opposition to governmental involvement in health care, you will soon find that it all boils down to one thing: rationing. People may speak of things like “socialized medicine” or “death panels” and make appeals to the free market as they bemoan the loss of personal freedom that they see as inherent in any health care system with almost any level of governmental involvement. What they are really saying is that they are worried that the government will make decisions for them and that they may not agree with the decisions that are made on their behalf. They are chiefly worried about rationing, which they define as the government refusing to pay for a health care good or service that the person anticipates they might benefit from some day. In fact, they often seem to think that the government will literally prohibit them from seeking the care they anticipate needing at some point in the future.

I will grant them that if such things were true, they would be terrifying. Thankfully, they aren’t true at all. What’s perhaps more alarming is how some people’s definition of rationing has grown so limited. Compare people’s concerns with the present reality: They are worried that government will make decisions on their behalf, which they may not agree with. Why then are they not equally as worried about all of the decisions already being made on their behalf by the employee benefits managers at the places where they work or by the claims specialists at their insurance companies? It seems to me that both situations violate the principal that individuals should be free to make their own decisions. People are also worried that the government will “ration” by preventing them from getting the care they need. The reality is that the government has no such authority and that money talks.

Here we are introduced to the true meaning of rationing, where prices dictate the exchange of goods and services. Today, anyone with enough financial resources can make an appointment with any doctor they choose, get any services they need, and so on. They don’t need insurance. They can, in effect, self-insure, and no health reform will change that. If the “Big Brother Plan” doesn’t cover something they need, they can simply pay out-of-pocket and get whatever care they want.

The flip-side of this is that those without the financial resources to do so cannot be assured of getting the care they need. Today, there are people who go without. Why? Because we ration care based on the ability to pay for it, and not everyone is able to do so. Health reform is designed to help these people gain access to basic medical care. Many of us, it seems, are unwilling to believe that this is rationing. Others surely understand the current system, and simply fear that in a world where rationing is inevitable, giving to those who have not will necessitate taking from those who have. To some extent they are right. However, the impact of that transition can be lessened by capitalizing on the reduction of systemic inefficiencies. Moreover, none of us can be certain that we will not fall catastrophically ill in the future, and if such a fate should befall us, I imagine that we will hope desperately for a system to come to our aid, rather than resign ourselves to suffer as victims of a system motivated by unabashed self-interest.

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Health Care Rationing: The Basics

Another one of the political hot potatoes is “rationing.” Put simply, rationing is the distribution of resources. More specifically, rationing is the distribution of limited or scarce resources. Most goods and services are inherently limited. That is to say that there is not an unlimited supply of much of anything in the world. For example, there is not an endless supply of cheeseburgers. If there were, then everyone would be able to have as many cheeseburgers as they wished. Obviously, given a sufficient demand for cheeseburgers, we would run out of cattle at some point. Cheeseburgers are, therefore, a limited resource.

Health care is no different. It is not possible for everyone to get all of the health care they might desire whenever they happen to want it. So, we must — and, indeed, already do — ration health care. Consequently, when I hear someone say that the government wants to ration health care, I have no choice but to laugh. Rationing is a current reality.

What is really being confronted is not whether or not we will ration health care (since we already do), but more precisely how we intend to ration health care in this country. Generally, opponents of government involvement in health care believe that we should continue to ration on the basis of free market principles (i.e., ability to pay).

Now, I certainly believe that those who have managed to become financially successful should retain their freedom to choose more expensive health care services as they see fit. What I am uncomfortable with is our all-or-nothing system of market rationing. We have a very inequitable system wherein many individuals are effectively excluded from the system. Sure, they can and do get some care occasionally, but nowhere near what those of us with insurance experience.

Somehow, people have gotten the notion that government is going to put a cap on what type of health care benefits people will have access to in this country. There appears to be an overwhelming sense that limits will be put in place that limit choice. As Ezra Klein points out, however, we are talking about a floor and not a ceiling.

What this means is that government wants to set a guaranteed minimum standard that ensures that all Americans have access to certain essential health care services. In no way is the plan going to restrict how much care you can receive. Just as in other countries the world over, there will always be an option to “top up” — to purchase supplemental coverage. The well off will continue to have access to the best health care.

We already have a “safety net” system that helps provide coverage to those in need, but nets have holes. What we need is a safety blanket — an absolute guarantee of basic coverage for everyone. The market doesn’t have any interest in operating at this margin, because it doesn’t represent a profitable opportunity for insurers. It is all a matter of how well we intend to treat the least well-off in our society.

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