Posted tagged ‘health care reform’

Obamacare: Is it working or not?

October 17, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

‘Tis a season, fraught and shrill. Volume has replaced thoughtful discourse. I realize many of us have long-ago made up our minds about the Affordable Care Act – and if you already know whether it’s good or it’s bad, this really isn’t the post for you. But if you’re one of the people in the eerie, quiet middle, curious for some context and facts, here’s one doc’s take on the status of what’s typically called “Obamacare.”

 

What are the problems?

There are two big ones, the way I see it. First, the whole program is not sustainable with the current model. When the ACA kicked in, the whole idea was to provide uninsured people with a way to purchase insurance plans, similar to the ones offered by employers. This looked like a big bumper crop of new customers for insurance companies, who initially lined up with all sorts of plans at affordable rates. The costs for consumers, at first, looked especially appealing, because government subsidies made premiums pretty cheap. At first.

But: insurance companies ended up taking a bath on those ACA insurance products. The people who signed up for them turned out to need more health care – to spend more money – than expected. The “young invincibles” who don’t need much health care spending aren’t signing up for these plans, despite having to pay a penalty. (The penalty is still cheaper than the premiums, and they can always sign up later if they develop a health problem. They’re young and invincible, but they’re not stupid.) Insurance companies have had to raise their rates, this year by an average of 10%, and in some areas as much as 55%. Many have exited this part of the insurance market entirely. It’s estimated that when enrollment starts in November, about 20% of people looking for individual plans in the ACA insurance exchanges will have only one plan from which to “choose.” And, of course, areas with fewer plans are seeing the highest rate increases.

Insurance companies would like to hold down rates, but so far their solutions have been both unsuccessful and unpalatable. Smaller “in-network” groups of physicians, hospitals, imaging centers, and labs do reduce costs. But inevitably that means clients – I mean, patients – have to wait longer for services, or travel farther, or navigate endless administrative roadblocks. Another idea to contain insco costs: increased deductibles and copays, which share more of the health care costs with patients.

Which brings us to the second Big Problem: many people are finding that their ACA-compliant plan is costing them, big time, to actually use. Just having health insurance doesn’t guarantee access to affordable health care if you’ve got huge deductibles and out-of-pocket expenses.

 

Have any parts of Obamacare worked?

Yes. The ACA has brought insurance to about 20 million Americans who lacked it, including about 9 million via expansion of state Medicaid programs to low-income families (that number could be much higher, if some states hadn’t refused to participate.) The uninsured rate has fallen from about 16% to 9%. Though deductibles can be high on some plans, people with insurance are at least protected against truly catastrophic costs from a serious hospitalization or chronic illness, like cancer or a heart attack.

Though premiums on the exchanges are rising, they’re actually about $600 a year below what was projected for 2016. And, overall, the rise in national health care costs has been reduced to record-lows, in part from ACA-required hospital cost-control and quality improvement mandates. Overall, federal government spending on health care in 2015 was $2.6 trillion less than it was expected to be – and that’s even with the 20 million more covered people in the system.

 

You’re full of sh*t. Obamacare is (the greatest thing ever)/(a complete disaster for everyone) <–ß you choose!

Yeah, well, see, I was hoping to weed out the partisans with that flowery introductory paragraph. People on either side of this issue seem to have a hard time seeing this from the other point of view. The very idea that “the other side” may have something worth saying and listening to doesn’t seem to jibe with the world of Facebook, Twitter, and the current election cycle. Democracy can be hard, but (I think) it’s the best system out there. Let’s give it a try!

 

OK, Hippie, we’ll try it your way. What do you suggest?

More young people need to sign up. This can be encouraged by increasing subsidies and/or increasing the penalty for non-insurance. Though forbidding insurance from excluding pre-existing conditions is a common-sense provision that needs to be retained, the rules can be tightened. People shouldn’t be allowed to take advantage of this by dropping insurance when they’re well and restarting it only when they get sick.

More flexibility will allow more competition, so people have a choice and premiums can be kept in check. Insurance companies should be allowed to offer products in any state, and regulations requiring certain kinds of coverage for all plans can be relaxed. People should be allowed to choose the kind of coverage they’re willing to pay for.

There are other good suggestions to improve the Affordable Care Act, but it will take a bipartisan congress of adults actually listening to each other to get it done. Their focus needs to be on making quality health care accessible, rather than protecting the profits of the insurance industry.

 

You’ve made some good points! Will you be our next Surgeon General?

I’ll consider it, but I certainly wouldn’t accept that nomination if <REDACTED> wins.

Balance is possible

Epipen price gouging: Sowing, reaping, and a senator’s daughter

August 25, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Parents, docs, and pundits are fuming. A life-saving, critical medication, used mostly in children, has become just about unaffordable for thousands of families. The Evil Drug Company Mylan has jacked up the price to over $500 over the last several years – this despite no increase in their costs. Congresspeeps, presidential candidates, and the ever-wise Facebook community all agree: Something must be done!

This isn’t the only example of weirdly-high prices for certain older drugs over the last few years. The system seems to be broken. To understand how best to fix it, it would be a good idea to go over just how the system was supposed to work.

After a drug is invented and tested, the company that developed it gets to sell it exclusively, under patent, for a set number of years. During that time the drug is only available as one “Brand Name”. The patent system is in place to reward the company for their innovation, allowing them to recoup their development costs, and make a profit. That encourages them to develop more new drugs, to make more money and to continue to bring new drugs into the marketplace. This part of the system certainly isn’t perfect – you can argue over just how many years drug companies should get exclusive rights to sell the drug they developed, and drug companies seem to be pouring more of their money into marketing and lobbying than into researching and developing new drugs. But the current problem really isn’t about new drugs or new patents.

What’s broken is the step that happens after the drug exclusivity patent expires. That’s when “generic” companies should be able to bring competing products to market. These are the same chemical, but packaged and sold by a different company. When multiple drug companies step in and produce generics, the market price of the drug falls precipitously. Many older drugs that now have multiple generic versions (including many antibiotics, statins, blood pressure, pain, and psychiatric meds) now have generics that are almost “free” – given away by grocery and pharmacy chains as loss-leaders. Yes, you can get a free supply of some antibiotics at Publix. That’s the marketplace at work. When it works, it works.

Except when it doesn’t. That price fall depends on generic companies being able to cheaply and easily bring the generic versions to market. Epinephrine, the medication in Epipen, has been around for decades, and it’s not under a patent. But regulatory issues have thwarted competitors from selling competing versions. One competitor, Auvi-Q, was recalled after a few dozen cases of wrong doses being dispensed by the device (to my knowledge no one was harmed by any of those errors.) In February, 2016 the FDA rejected Teva’s application for a generic epinephrine injector, and in June they delayed another company’s application, calling for expanded patient trials and more studies.

And it’s not just FDA regulations that gum up generic availability. Sometimes, drug manufacturers “pay off” generic makers to delay the introduction of generic medicines. These and other legal anti-competitive shenanigans create a marketplace that’s far from fair, preventing competition from driving down prices.

There is a very similar auto-injecting epinephrine device available, and it’s far cheaper: Adrenaclick. But the packaging and delivery system is different, so it’s not allowed to be freely generically substituted for an Epipen. If you want it, you have to have your prescriber specify that brand.

So: with no generic substitutions in sight, Mylan could freely increase their price. The same thing happens if there’s only one gas station in town, or only one health insurer in a local market. As we all learned from the board game, Monopolies are good for the monopoly, but bad for everyone else.

There’s more to the Epipen story. Mylan has been quietly jacking up the price for years, but no one really noticed until now. Until recently the list prices of medications were largely hidden from consumers. If you had health insurance, they paid the price, and you paid just a copay or whatever. Who cared what the “real” price was? Now that many of us have high deductible plans, those prices become important. Hiding the true cost of things from consumers, in the long run, doesn’t make for a fair or efficient marketplace.

And: you might imagine, with all of this price-gouging talk, you’d hear calls for someone’s head on a platter, in front of congress. Not this time. Mylan’s CEO is Heather Bresch, daughter of Senator Joe Manchin (D-West Virginia.)

The situation with the Epipen will wash out soon. The manufacturer has announced new cost-savings programs, and will almost certainly be lowering the list price shortly. But the regulatory framework that led to this disaster is still there, and until that’s addressed we’re going to be seeing more examples of crazy-priced drugs (and other medical services) soon.

Price Gouging

You can’t always get what you want

April 13, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

“Customer service” is the new buzzword in health care. (Yes, I know it’s two words. Stay with me here.) Health care has become a service industry, like a restaurant or a company that comes to your home to replace a broken windshield. The shrimp is too salty, or the tech left footprints on your floor mat? You complain, and you send the shrimp back, and the tech apologizes and says “yes sir” and vacuums out your car. The customer, as we know, is always right.

Except in health care. Administrators and patients don’t want to hear this, but in health care the “customer” is not always right. And pretending that the customer is always right is costing us a whole lot of money and a whole lot of preventable sickness. We’re customer servicing ourselves into crappy health care, and docs and nurses seem to lack the power to prevent this from getting worse.

I’m part-owner of a few after-hours pediatric health clinics. Our sites are open when traditional pediatric practices are closed. Our patients – not customers– see genuine, board certified pediatricians for things like fever or sore throat or cough or ear pain. Common pediatric stuff. Rarely, we get complaints about or service or ugly remarks on Yelp, etc. Almost all of the negative reviews can be summarized like this: “I paid my money, and I didn’t get an antibiotic. I expect my antibiotic. I am the customer, and the customer is always right.” We don’t get comments about whether our doctors did a good and careful assessment, or whether they made a careful decision about recommendations. Nope, the customer is always right, and the customer wants an antibiotic. And if one isn’t given the customer is darn tootin going to complain about it.

We’ve had similar complaints on review sites about my own medical practice: “I brought in my child with a bad cold, and I didn’t even get an antibiotic! Zero stars for you!” I consider not giving antibiotics when they’re not needed – for a cold — a mark of a good practice. But someone skimming the reviews might just choose to go somewhere else. Perhaps a place that sees twice as many patients per hour, because explaining how to treat a cold correctly takes much longer than a quick antibiotic prescription.

It’s not just antibiotics, of course. In emergency departments all over the country, customer service and positive “reviews” are what drives physician salaries and hiring. You don’t make your patients happy, you’re going to take a pay cut or lose your job. But what if your patients – I’m sorry, customers – want something that isn’t good for them, like narcotics for chronic pain? We know narcotic addiction, driven by prescription products, is now the leading cause of accidental death in the US. But once patients become customers, they’re always right. And once doctors realize that negative reviews are going to cost them a job, what do you think is going to happen?

Of course, docs are being squeezed simultaneously in the other direction. The Feds don’t want us to “overprescribe” narcotics, either. They just want us to treat pain, quickly, and without our customers complaining. How exactly to do that is entirely up to us – we’re the doctors, of course, and no one would ever tell us what to prescribe – as long as we don’t use too much of the only drugs that work. Whatever “too much” is. That’s a secret. We’ll just monitor everything you do via your shiny new electronic medical record that you’re required to use. Which you hate. Please, don’t mind us.

One more example: I have here, mailed to my home, a flyer from my health insurance company. (I guess I shouldn’t tell you which one, but they’re huge, and you can rearrange the letters in their name to spell “Aetna.”) They offer a service, Teladoc, which costs “$40 or less”. Available “anytime, anywhere”, you get 24/7/365 access to “U.S. board-certified doctors” to treat things like “sinus problems, bronchitis, allergies” and “ear infection” over the phone! The doc can diagnose and prescribe medication for “many of your medical issues.” All without, you may have noticed, even pretending to do a physical exam. Or maybe they have a really long stethoscope that they can shove through the little tiny holes in their phones, or a 7 mile long swab to do a strep test. These clowns are going to know whether or not you need antibiotics without an exam, without touching you, without seeing you or without even being in the same room as you. That’s not medicine. It’s dark magic.

But you know what? They program will probably be successful. Because we know that many people don’t want a physician’s judgement – they just want antibiotics and prescriptions. So, with a wink and a nod, “Teledoc” gives us exactly what we’ve come to expect. The customer is always right. $40 out of pocket, and you can bet “Aetna”, or whoever they are, is saving some serious money by paying Teledoc next to nothing instead of paying a real doc to do a real evaluation. Everyone wins. Except you.

As philosopher Mick Jagger famously said, “You can’t always get what you want.” And at least in health care, you shouldn’t. Unfortunately, even if you try, it’s becoming harder to get what you genuinely need.

Mick

Spend more, save more! (Lawsuits, that is)

November 16, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

A November, 2015 study shows that doctors who spend more money are less likely to get sued.

Researchers from Harvard, Stanford, and UCLA looked at data from admissions to Florida hospitals from 2000-2009, examining the rates of lawsuits filed against physicians versus the amount of money spent on the admission. Sure enough, in six of the seven specialties evaluated, there was a clear trend showing that at each step-up in spending, there was as step-down in the rate of lawsuits filed. For instance, in internal medicine the lowest fifth of spenders (~$20,000 for admission) had a 1.5% risk of a lawsuit; the highest fifth (~$40,000) had a risk of .3%. Double your spending, decrease your risk of a lawsuit by five times. Not a bad deal, really, for the doctors.

But was it a good deal for the patients? These investigators didn’t look at outcomes, but overall we know higher spending does not equal better care or healthier outcomes. More spending may seem to increase “patient satisfaction scores”, but high patient satisfaction negatively affects overall health. More tests often lead to the overdiagnosis of conditions that didn’t need to be treated, causing more worry and spending even more money.

So why do some docs spend more than others? This study reinforces the evidence for so-called defensive medicine: tests and procedures done only to ward off lawyers, the way garlic keeps away vampires. But garlic is cheap and harmless, and vampires are, well, imaginary. In the real world, docs are doing unnecessary tests and procedures, harming patients and flying through money, to stay out of the courtroom. Do I blame them? No. Is there a better way? I hope so.

Phoenix-Wright-Objection

The paperwork. It burns.

July 10, 2014

 

The Pediatric Insider

© 2014 Roy Benaroch, MD

I love seeing patients, and I love being a doctor—at least when I get a chance to be a doctor, in the short gaps left during the day when I’m done with telephone calls and “paperwork.”  Here’s a few gems from my inbox this week.

From UnitedHealthcare came a letter reminding me that their “members” will incur additional costs if they use an out-of-network lab. This, I knew. We actually have a specific process in our office to steer patients toward their “in-network” labs, so they can save a few bucks. The new development came in this paragraph:

uhc letter cropped

“If the member elects to receive services from a non-network lab, you must complete the Member Advance Notice Form, obtain the member’s signature on the form and retain it for your records.”

Wait—the member (I prefer to call them patients, but I’m old-fashioned) is the one who decided to go to a non-favored lab. So now it’s my job to obtain this form, get it signed, and keep it? I’m supposed to be UnitedHealthcare’s goon enforcer? Maybe I ought to get a truncheon and dimly lit room, you know, to convince them of the error of their ways. Those members, trying to make their own decisions. Fools!

Then this showed up: a subtle thing, but it rubbed me the wrong way.

form nurse clip

 

A fax, addressed to my “Form Nurse.” I don’t have a “form nurse”! Nurses are there to care for the sick, to teach, to help deliver medical care. They’re part of my essential team. They are not just there to complete forms. If you’ve worked hard and gotten your nursing degree and license, and then someone wants you to be a “form nurse”—no patients, no icky touching people, just filling out forms, day after day—any nurse I know would just poke their own eyeballs out with a fork.

Of course, I’d rather them aim their forks at the UnitedHealthcare goons.

Punctual patients perfect performance? Perhaps

June 23, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Here’s a clever study, just published in BMJ Open. Physicians affiliated with Johns Hopkins School of Medicine looked at the consequences of a new, hard-nosed policy for patients arriving late to a pain management clinic.

Under the new rules, any patient arriving late was told that they had to reschedule. The authors then tracked the level of “unpunctuality” (their word) of the patients over twelve months, along with other measures of how the clinic and patients were staying on time.

At the beginning of the study, at baseline, 90% of patients in this clinic arrived on time; after implementation, the clinic was able to improve that to 95%. The average time patients came to their appointment changed from 20 minutes early to 25 minutes early. I’m not thinking that either of those changes is huge, but this clinic started with a population that was used to coming in early for appointments. Maybe the effect would be larger in a more-typical setting.

Also, the authors found that under the new policy they were able to see all patients within their four hour allotted clinic time about 50% of the time, versus about 40% before the study. I suppose closing the clinic on time more often would be helpful for doctors and staff.

But was it helpful for patients? Not so much. The average wait time over the study period actually increased by one minute, mostly because patients started coming in even earlier for their appointments.

So: the new policy or refusing to see late patients did change behavior, by getting patients to show up 5 minutes earlier for their appointments. It helped the clinic run a little more efficiently, at least as measured by closing on time more often, though that effect was modest. The patients just ended up waiting a little longer.

There’s got to be a better way.

The dark side of patient satisfaction scores

May 27, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

We’re living in a world or ratings. Books get rated on Amazon*, dry cleaners get rated on Yelp. Doctors are getting rated, too—not only on web sites, but also in ways that end up dictating how much money we can make, or whether we can keep our ability to work in a hospital. Is this a good way to improve medical care or medical outcomes? Is it even fair?

We already know that ratings don’t reflect good medical care. In fact, patients who rate their doctors the best have shorter lifespans. They get more tests, more scans, more antibiotics—which may make them happier, but also makes them sicker.

You do not want a doctor who does what he thinks is going to make you post a positive review. You want a doctor who listens carefully and helps you make the best medical decision. Even if that means you don’t get an antibiotic.

 

But there may be an even worse, more odious problem being caused by the reliance on “ratings” to determine income. As Daniela Drake has written, quite bluntly, in The Daily Beast, minority doctors are likely to suffer the most under Affordable Care Act provisions that tie payments to patient satisfaction scores. The bottom line: patients are far more likely to rate a doctor positively if they are of the same race. Black doctors, if you look at the statistics quoted in that essay, are going to get royally screwed. They may be doing great medicine and helping their patients, but if they don’t get the ratings, their income will drop. Not only that—but it becomes less likely that they’ll be hired by hospitals, because they need to get those high satisfaction scores too.

Paying doctors more for doing good medicine makes sense, but only if you’ve got a good way to measure doctor performance. Measurements ought to reflect whether good medical decisions are being made, and whether docs are helping their patients by following good medical practice. Some elements of being a good doctor are going to be hard to measure, like listening skills and empathy and caring. But it’s clear that patient satisfaction, as it’s measured now, isn’t measuring good doctoring. Let’s abandon “patient satisfaction scores”, at least until we figure out a way to do it right.

 

*One of my books on Amazon has a one-star rating… because only one person has rated it, and that person was LOOKING FOR SOMETHING ELSE AND SAYS SHE DIDN’T EVEN READ THE BOOK. Am I bitter? Of course not. Would I appreciate your zipping over there and flaming her review? Yes, yes I would.