As noted in my last essay, a major goal of the Patient Protection and Affordable Care Act (PPACA) is a dramatic reduction in the number of Americans without health insurance. The latest estimates I've seen indicate that the number of newly covered people will be 32 million (leaving another 15-20 million still uncovered), and about half of those (16 million) will be covered through expansion of Medicaid, the joint federal-state health insurance program for the poor.
This expansion of Medicaid to cover more Americans will happen chiefly through raising the income level of eligibility. In other words, one will not need to be quite as poor to qualify. This means that some of the working poor who currently earn too much to be eligible for Medicaid will qualify for this assistance.
This approach to covering more people raises many questions. Here are a few of them.
1. Where will the money come from? Most of it will be funded with federal tax dollars, but Medicaid is paid for jointly by the federal and state governments, and some state budgets will be under tremendous strain. Eligibility is currently variable from state to state. Poorer states (those with lower levels of per capita income) tend to have less money to spend on Medicaid, and so in those states you have to be poorer to qualify. Even though the federal government matches state expenditures more generously for these poorer states, you can't draw down federal matching dollars by spending money you don't have. (States, unlike the federal government, typically must balance their budgets.) Under PPACA, a bigger-than-usual share of the money for expansion will come from federal tax dollars, but the poorer states will still struggle.
How might the states struggling to fund their side of the Medicaid program deal with the challenge? Yes, you guessed it: by lowering payments to providers (especially hospitals and doctors). And that brings us to the next question.
2. Is Medicaid "real insurance?" The short answer is no. When you have health insurance procured through the private, commercial insurance market, what your insurance pays to providers is determined by a complex set of factors in that market. One of these factors is negotiation between insurers and providers. Another is competition among insurers. Every insurer wants as much business as possible, and they make their products attractive by doing their best to achieve a balance between cost (to employers and employees) and choice. So the buyers want a plan that will provide excellent coverage, with reasonable out-of-pocket expenditures for patients and wide choice of participating doctors and hospitals. At the same time, they want affordable premium costs. On the provider side, hospitals and doctors want fair payment for the services they render. They expect that if, through negotiation, they agree to accept somewhat lower payments, the insurer will make it more attractive for patients to choose these "participating providers," thus assuring them a greater volume of business.
When the "insurance" is Medicaid, all of these market factors disappear. Patients have no choices, unless they are offered Medicaid managed care, which introduces a few choices that for most patients are confusing and not terribly attractive. And providers are told what they will be paid for taking care of Medicaid patients. The rates are low (or very low) and non-negotiable. Some providers (notably hospitals) don't have a choice about whether to accept Medicaid patients, although if patients have Medicaid managed care, a patient who goes to the "wrong" hospital emergency department may have to be transferred to another hospital if inpatient care is needed. As for doctors, the choice is typically quite simple: accept Medicaid patients or not. More and more of them choose not.
So for many patients, Medicaid is not "real insurance," simply because in some markets it is really difficult to find a doctor who is accepting Medicaid patients. And that brings us to the third question.
3. Will these newly covered patients be able to find a primary care doctor? Again, the short answer is no. Remember, the number of newly insured patients is expected to be some 32 million. Half of those will have Medicaid. The current shortage of primary care doctors is estimated to be 40,000. Most uninsured patients don't have a primary care doctor. Most of those newly insured under PPACA will try to find one. The first challenge, in a health care system with a serious shortage of primary care doctors, will be finding one who is taking new patients. Now imagine that you are among the half of the newly insured patients with Medicaid. What do you think your chances will be of finding a primary care doctor who will be just as accepting of new Medicaid patients as new patients with "real insurance?"
4. What is the plan for providing primary care for all of these newly insured folks? There is no plan. At least there is no plan that appears likely to remedy the shortage of primary care doctors in the foreseeable future.
5. Where will these patients go? Remember, these are folks who currently have no insurance. Many of them are afraid of huge medical bills they cannot pay, and so they do not seek medical care when they think they probably should, hoping things will somehow get better on their own. When that doesn't happen, they wind up in the emergency department, much worse off than if they had sought care earlier, and have to be hospitalized. Under PPACA, they will have coverage, eliminating their fear of bills they can't pay. But without access to primary care, they will go to the only place they know that will always take care of them, 24/7/365. The upside: they will be less likely to wait until they are critically ill. The downside for those of us in the emergency care system: our capacity is limited, too, and we will be overwhelmed.
Elected officials and policymakers, are you listening? I think we know that answer.
Friday, August 26, 2011
Tuesday, August 23, 2011
Marketing the ER
At many of the nation's hospitals, business is brisk in the emergency department. For large portions of the day (and round the clock in some institutions), all of the treatment rooms are full, patients too sick to stay in the waiting area until there is a room for them are lying on gurneys in the hallways, and there are more in the waiting room.
And yet, as they drive to work, doctors and nurses who care for all of those patients see billboards advertising the services they provide.
You know the one-word question that crosses their minds: "Seriously?"
So why are ED services being marketed? Marketing is all about generating business. If you are advertising your emergency department, there are basically two ways to get more business. The first is to get patients to seek medical care who otherwise wouldn't. If you've read earlier essays in this blog, you know what I think about that. There is a small group of patients for whom that is an appropriate, ethically responsible thing to do: patients with symptoms of something serious, like a stroke, who might not realize their symptoms are cause for concern or that they should seek care promptly rather than waiting around to see if the symptoms will go away. But otherwise, we should not be trying to increase total demand for ED services.
The second way is to take "market share" away from someone else. If that someone else is the ED at a competing hospital, and your place has excess capacity, go right ahead. Tell people you have better doctors, better nurses, shorter waits, a friendlier atmosphere. Tell them whatever you want, as long as it's true, or at least not demonstrably false. But if you're already at or above capacity, don't do it.
If the someone else from whom you are taking "business" away is the patient's primary care doctor, because the patient doesn't need an appointment, and you never close, and you see everybody today whether the problem is urgent or not, that could be OK. "Really?" I hear you asking. Well, yes, IF the local primary care doctors are busier than one-armed paper hangers and your ED has excess capacity, which means seeing more patients doesn't overburden the available resources and helps cover overhead. But that's not the case in most communities, and part of the effect of ED marketing is, indeed, to take patient visits away from the office of the doctor who knows them. This is unwise and not responsible stewardship of health care resources.
Not long ago I saw a bit of marketing fluff (yes, that is advisedly pejorative) from a highly respected tertiary care, academic medical center in my city (not the one where I work) in which one of the emergency physicians was quoted as saying his staff cared for patients with everything from colds to heart attacks. You know what I thought. Colds? Please! You have now officially given permission to people to seek care in the ED for a cold, instead of going to a drugstore.
(Remember those commercials? "Sudafed - Aisle 5." I like Sudafed - the original, that you can still get by asking the druggist, not the new "PE" version that's allowed on the shelf because you can't use it to make crystal meth. And no, I don't own stock in the company that makes it.)
This kind of marketing has many unfortunate effects. One of them - the one that bothers me the most - is that it tends to support the theory that, in health care, supply generates demand. That theory has gotten us into a lot of trouble. It was propounded by Joseph Califano, Secretary of Health, Education & Welfare during the Carter administration. As a result of Califano's influence, funding for medical education was cut in order to restrain growth in the supply of physicians (and thereby restrain growth in demand for their services). Our current shortage of physicians is due in large measure to that mistake.
If we don't want policymakers thinking lots of people use the ED for non-emergencies, which is what they think now, the least we should do is make sure our marketing targets people who have emergencies. I liked one billboard used by a hospital where I worked years ago. It showed a guy falling off a ladder. If he got hurt badly enough to need medical attention, the billboard suggested, our place was his best choice. I believed that, and I wanted him to come to our place even if we were busy.
And yet, as they drive to work, doctors and nurses who care for all of those patients see billboards advertising the services they provide.
You know the one-word question that crosses their minds: "Seriously?"
So why are ED services being marketed? Marketing is all about generating business. If you are advertising your emergency department, there are basically two ways to get more business. The first is to get patients to seek medical care who otherwise wouldn't. If you've read earlier essays in this blog, you know what I think about that. There is a small group of patients for whom that is an appropriate, ethically responsible thing to do: patients with symptoms of something serious, like a stroke, who might not realize their symptoms are cause for concern or that they should seek care promptly rather than waiting around to see if the symptoms will go away. But otherwise, we should not be trying to increase total demand for ED services.
The second way is to take "market share" away from someone else. If that someone else is the ED at a competing hospital, and your place has excess capacity, go right ahead. Tell people you have better doctors, better nurses, shorter waits, a friendlier atmosphere. Tell them whatever you want, as long as it's true, or at least not demonstrably false. But if you're already at or above capacity, don't do it.
If the someone else from whom you are taking "business" away is the patient's primary care doctor, because the patient doesn't need an appointment, and you never close, and you see everybody today whether the problem is urgent or not, that could be OK. "Really?" I hear you asking. Well, yes, IF the local primary care doctors are busier than one-armed paper hangers and your ED has excess capacity, which means seeing more patients doesn't overburden the available resources and helps cover overhead. But that's not the case in most communities, and part of the effect of ED marketing is, indeed, to take patient visits away from the office of the doctor who knows them. This is unwise and not responsible stewardship of health care resources.
Not long ago I saw a bit of marketing fluff (yes, that is advisedly pejorative) from a highly respected tertiary care, academic medical center in my city (not the one where I work) in which one of the emergency physicians was quoted as saying his staff cared for patients with everything from colds to heart attacks. You know what I thought. Colds? Please! You have now officially given permission to people to seek care in the ED for a cold, instead of going to a drugstore.
(Remember those commercials? "Sudafed - Aisle 5." I like Sudafed - the original, that you can still get by asking the druggist, not the new "PE" version that's allowed on the shelf because you can't use it to make crystal meth. And no, I don't own stock in the company that makes it.)
This kind of marketing has many unfortunate effects. One of them - the one that bothers me the most - is that it tends to support the theory that, in health care, supply generates demand. That theory has gotten us into a lot of trouble. It was propounded by Joseph Califano, Secretary of Health, Education & Welfare during the Carter administration. As a result of Califano's influence, funding for medical education was cut in order to restrain growth in the supply of physicians (and thereby restrain growth in demand for their services). Our current shortage of physicians is due in large measure to that mistake.
If we don't want policymakers thinking lots of people use the ED for non-emergencies, which is what they think now, the least we should do is make sure our marketing targets people who have emergencies. I liked one billboard used by a hospital where I worked years ago. It showed a guy falling off a ladder. If he got hurt badly enough to need medical attention, the billboard suggested, our place was his best choice. I believed that, and I wanted him to come to our place even if we were busy.
Friday, August 19, 2011
Thou Art Commanded: Buy Health Insurance
People don't like being told what to do by government. The states don't like being told what to do by the federal government. When this happens, there are always questions raised about whether government is exceeding its constitutional authority.
Over the last couple of centuries the power of Congress has dramatically expanded, and the Supreme Court has very infrequently ruled that Congress was overstepping its bounds. Article I, Section 8 of the Constitution enumerates the powers of Congress, and the last paragraph affords Congress fairly sweeping authority to exercise those powers through the enactment of laws which "shall be necessary and proper" to that exercise. So once the Court can find a basis for Congressional action in some enumerated power, the "necessary and proper" clause, as it was dubbed by Justice Brandeis, provides broad latitude.
But the "necessary and proper" clause doesn't give Congress the power to do whatever it wants. So much of what Congress does falls into the realm of regulating interstate commerce. Pretty much any economic activity that crosses state lines then falls under congressional power. But some are under the misapprehension that the beginning of Section 8, which empowers Congress to provide for the "general Welfare" (they capitalized a lot of common nouns back then), lets Congress do whatever it wants for the good of the country (which is, of course, in the eye of the beholder).
Not so, sayeth the Supreme Court. If you read that first paragraph, it looks that way. But the Supreme Court has said that phrase in the first clause of Article I, Section 8 means only that Congress can use its taxing authority to provide for the general welfare, not that it can do anything at all to accomplish that goal.
(My own view on this is ambivalent. On the one hand, I think limiting congressional authority is generally a good idea. On the other hand, there is a comma in that first clause that must be ignored for the view expounded by Justice Joseph Story to make sense linguistically. Recognizing, however, that commas were sprinkled generously in 18th-century writing, I'll go with Justice Story's interpretation.)
So look at the enumerated powers in Section 8 and try to find one that allows Congress to force a person to buy health insurance. Keep looking. No luck? The 11th Circuit Court of Appeals couldn't find it either. And so it disagreed with the 6th Circuit, which has upheld the "individual mandate" of the Patient Protection and Affordable Care Act (PPACA, also known as Obamacare). Remember what is likely to happen when two appeals courts within the federal judiciary issue contradictory rulings: the issue will wind up in the Supreme Court.
I hesitate to predict how the Supreme Court will settle this question, but I think the 11th Circuit is on firmer ground. Sometimes constitutional law defies practicality. By this interpretation Congress cannot tell me I must buy health insurance, but Congress can confiscate some of my earnings for the purpose of providing me with health insurance.
Why is this so important? Because for the financing of our health care system to work well, everyone must participate in the insurance risk pool. We can do that if we all buy health insurance (or at least all of us who aren't already covered by public health insurance, meaning Medicaid and Medicare). Or we can do that by paying taxes to provide public health insurance for everyone. The 11th Circuit's ruling would seem to push us in the latter direction. Many Americans don't want to go in either direction, even as they acknowledge that having 50 million of us uninsured is a bad thing.
The other major reason is the matter of "pre-existing conditions." Most of us agree that an insurance company should not be allowed to refuse to sell you health insurance because of a pre-existing condition or to exclude that condition from coverage. If we require everyone to purchase health insurance, we can tell the insurance companies they cannot exclude pre-existing conditions. Otherwise, many people will wait until they have something serious wrong with them to buy health insurance. It's like buying car insurance after you get into a crash and expecting it to be covered.
So what is the right answer? The goal is universal coverage, and the surest way to get there is to expand public insurance programs to cover everyone. Many Americans oppose that at the same time they agree we should have universal coverage. It's time to make some hard choices.
(Oh, if you're still wondering about the "states' rights" basis for opposing Obamacare, you'll have to wait for another blog entry. One constitutional issue at a time.)
Over the last couple of centuries the power of Congress has dramatically expanded, and the Supreme Court has very infrequently ruled that Congress was overstepping its bounds. Article I, Section 8 of the Constitution enumerates the powers of Congress, and the last paragraph affords Congress fairly sweeping authority to exercise those powers through the enactment of laws which "shall be necessary and proper" to that exercise. So once the Court can find a basis for Congressional action in some enumerated power, the "necessary and proper" clause, as it was dubbed by Justice Brandeis, provides broad latitude.
But the "necessary and proper" clause doesn't give Congress the power to do whatever it wants. So much of what Congress does falls into the realm of regulating interstate commerce. Pretty much any economic activity that crosses state lines then falls under congressional power. But some are under the misapprehension that the beginning of Section 8, which empowers Congress to provide for the "general Welfare" (they capitalized a lot of common nouns back then), lets Congress do whatever it wants for the good of the country (which is, of course, in the eye of the beholder).
Not so, sayeth the Supreme Court. If you read that first paragraph, it looks that way. But the Supreme Court has said that phrase in the first clause of Article I, Section 8 means only that Congress can use its taxing authority to provide for the general welfare, not that it can do anything at all to accomplish that goal.
(My own view on this is ambivalent. On the one hand, I think limiting congressional authority is generally a good idea. On the other hand, there is a comma in that first clause that must be ignored for the view expounded by Justice Joseph Story to make sense linguistically. Recognizing, however, that commas were sprinkled generously in 18th-century writing, I'll go with Justice Story's interpretation.)
So look at the enumerated powers in Section 8 and try to find one that allows Congress to force a person to buy health insurance. Keep looking. No luck? The 11th Circuit Court of Appeals couldn't find it either. And so it disagreed with the 6th Circuit, which has upheld the "individual mandate" of the Patient Protection and Affordable Care Act (PPACA, also known as Obamacare). Remember what is likely to happen when two appeals courts within the federal judiciary issue contradictory rulings: the issue will wind up in the Supreme Court.
I hesitate to predict how the Supreme Court will settle this question, but I think the 11th Circuit is on firmer ground. Sometimes constitutional law defies practicality. By this interpretation Congress cannot tell me I must buy health insurance, but Congress can confiscate some of my earnings for the purpose of providing me with health insurance.
Why is this so important? Because for the financing of our health care system to work well, everyone must participate in the insurance risk pool. We can do that if we all buy health insurance (or at least all of us who aren't already covered by public health insurance, meaning Medicaid and Medicare). Or we can do that by paying taxes to provide public health insurance for everyone. The 11th Circuit's ruling would seem to push us in the latter direction. Many Americans don't want to go in either direction, even as they acknowledge that having 50 million of us uninsured is a bad thing.
The other major reason is the matter of "pre-existing conditions." Most of us agree that an insurance company should not be allowed to refuse to sell you health insurance because of a pre-existing condition or to exclude that condition from coverage. If we require everyone to purchase health insurance, we can tell the insurance companies they cannot exclude pre-existing conditions. Otherwise, many people will wait until they have something serious wrong with them to buy health insurance. It's like buying car insurance after you get into a crash and expecting it to be covered.
So what is the right answer? The goal is universal coverage, and the surest way to get there is to expand public insurance programs to cover everyone. Many Americans oppose that at the same time they agree we should have universal coverage. It's time to make some hard choices.
(Oh, if you're still wondering about the "states' rights" basis for opposing Obamacare, you'll have to wait for another blog entry. One constitutional issue at a time.)
Sunday, August 7, 2011
The Things We Know That Just Ain't So
Last week the American Psychological Association adopted a resolution calling for "full marriage equality for same-sex couples."
This is the same organization that, until 1975, classified homosexuality as a mental disorder (as did the American Psychiatric Association until 1973).
I freely admit that I have never been a fan of diagnostic criteria in mental health. After all, the same mental health professionals who once said homosexuality was a mental disorder now have diagnostic criteria for such "illnesses" as "oppositional-defiant conduct disorder." A child who consistently behaves badly is mentally ill? Seriously? I guess it was too much to hope that organizations that de-medicalized a phenomenon of human behavior in the 1970s would know better than to medicalize other phenomena of human behavior in more recent decades. Perhaps we have this diagnosis so parents will accept the notion that professional counseling is a better option than regular opening of a can of whoop-ass. A randomized clinical trial of that would be interesting.
It is sometimes tempting to join the camp of those who are skeptical of the value of the mental health professions altogether. But there is no question in my mind that people with schizophrenia and major depression have benefited greatly from scientific advances. So I differ with my father, who once remarked (probably mainly to steer me away from it) that psychiatry was a terrible waste of a good medical education.
Some days, though, I wonder, especially when it seems at least half the patients I see during a shift in the emergency department have been diagnosed with bipolar disorder.
But let us not come down too hard on the specialty of psychiatry. Recently a colleague called to my attention a condition called "status lymphaticus," which was the subject of a fascinating article in the journal Medical History. This condition was invented to explain otherwise mysterious cases of sudden death in previously healthy people, especially children. For many decades in the 19th and early 20th centuries, doctors published articles in medical journals on this disease. Sadly, this invention amounted to more than mere foolishness, because it led to the belief that the thymus gland in young children was sometimes too large and should be surgically removed.
The frequent performance of such useless surgery, with the inevitable complications that might accompany any surgery, was bad enough. But after therapeutic use of x-rays came along, the practice became widespread of irradiating the thymus gland in children. This was especially common for those who were going to have surgery and whose thymus looked "large" on chest x-ray. We now know that there is a wide range of normal in the size of this gland in young children, but in those days it was thought a large gland put the child at risk for sudden death when general anesthesia was administered. (In fact, of course, it was the anesthesia itself that was the problem.)
If you are a student of medical history, as I am, you may know that thymic irradiation was accompanied by tragic consequences, as it exposed to x-rays the nearby thyroid gland. The thyroid is quite sensitive to radiation, and the result was an astonishing number of cases of thyroid cancer.
One of my favorite quotations (from which the title of this entry is taken) has been attributed to Mark Twain and Will Rogers, among others: "It ain't what we don't know that gets us in trouble; it's the things we know that just ain't so."
I suspect there are a lot of things in 21st-century medicine we know that will one day prove to be wrong. I would like to think that as medicine has become more scientific, and more and more doctors skeptically demand that knowledge meet the highest standards of what we call evidence-based medicine, the number of "things we know that just ain't so" will steadily decline.
By the way, the journal Medical History is online and free, and I highly recommend it. It helps to remind us of where we have been - and to give us greater insight into how far we still have to go.
This is the same organization that, until 1975, classified homosexuality as a mental disorder (as did the American Psychiatric Association until 1973).
I freely admit that I have never been a fan of diagnostic criteria in mental health. After all, the same mental health professionals who once said homosexuality was a mental disorder now have diagnostic criteria for such "illnesses" as "oppositional-defiant conduct disorder." A child who consistently behaves badly is mentally ill? Seriously? I guess it was too much to hope that organizations that de-medicalized a phenomenon of human behavior in the 1970s would know better than to medicalize other phenomena of human behavior in more recent decades. Perhaps we have this diagnosis so parents will accept the notion that professional counseling is a better option than regular opening of a can of whoop-ass. A randomized clinical trial of that would be interesting.
It is sometimes tempting to join the camp of those who are skeptical of the value of the mental health professions altogether. But there is no question in my mind that people with schizophrenia and major depression have benefited greatly from scientific advances. So I differ with my father, who once remarked (probably mainly to steer me away from it) that psychiatry was a terrible waste of a good medical education.
Some days, though, I wonder, especially when it seems at least half the patients I see during a shift in the emergency department have been diagnosed with bipolar disorder.
But let us not come down too hard on the specialty of psychiatry. Recently a colleague called to my attention a condition called "status lymphaticus," which was the subject of a fascinating article in the journal Medical History. This condition was invented to explain otherwise mysterious cases of sudden death in previously healthy people, especially children. For many decades in the 19th and early 20th centuries, doctors published articles in medical journals on this disease. Sadly, this invention amounted to more than mere foolishness, because it led to the belief that the thymus gland in young children was sometimes too large and should be surgically removed.
The frequent performance of such useless surgery, with the inevitable complications that might accompany any surgery, was bad enough. But after therapeutic use of x-rays came along, the practice became widespread of irradiating the thymus gland in children. This was especially common for those who were going to have surgery and whose thymus looked "large" on chest x-ray. We now know that there is a wide range of normal in the size of this gland in young children, but in those days it was thought a large gland put the child at risk for sudden death when general anesthesia was administered. (In fact, of course, it was the anesthesia itself that was the problem.)
If you are a student of medical history, as I am, you may know that thymic irradiation was accompanied by tragic consequences, as it exposed to x-rays the nearby thyroid gland. The thyroid is quite sensitive to radiation, and the result was an astonishing number of cases of thyroid cancer.
One of my favorite quotations (from which the title of this entry is taken) has been attributed to Mark Twain and Will Rogers, among others: "It ain't what we don't know that gets us in trouble; it's the things we know that just ain't so."
I suspect there are a lot of things in 21st-century medicine we know that will one day prove to be wrong. I would like to think that as medicine has become more scientific, and more and more doctors skeptically demand that knowledge meet the highest standards of what we call evidence-based medicine, the number of "things we know that just ain't so" will steadily decline.
By the way, the journal Medical History is online and free, and I highly recommend it. It helps to remind us of where we have been - and to give us greater insight into how far we still have to go.
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