It is difficult to navigate the health system. Insurance is a whole different ball game. People know they need it, but have no idea what programs they even qualify for.
I recently met Diane Lund-Muzikant, publisher, editor, organizer and all ’round charm for The Lund Report.
Every state should have such a publication focused on the local health system. And a fireplug to match Diane’s energy. She said I could write an editorial whenever I would like to highlight primary care issues.
Here is my first effort published September 22, 2015.
The greatest success of Obamacare, is the reduction in the number of uninsured. Most of this improvement has come in lower income groups, who disproportionately suffer the burden of illness and the most difficult social circumstances, including poor employment prospects. So it is unsurprising that Medicaid expansion accounts for over 2/3 of the newly insured, according to the Heritage Foundation. The political partisans use this as a weapon arguing that Obamacare resulted in little more than the expansion of the Medicaid entitlement. The other side feels that more has to be done to cover the remaining 10 million uninsured.
What about the social value of medical coverage to vulnerable populations, the economic benefits of health care to this group and a questioning of the cost relative to the benefits? Sometimes it is OK to spend tax money if there is value and accountability. If our nation is to spend public money on healthcare, it is incumbent on policy-makers to ensure the greatest value for the effort.
The greatest public value derived from modern medicine is derived from immunizations, maternal-child health and primary care. When the newly insured report that they do not have access, they mean primary care docs who understand their situation and listen to their concerns. Unfortunately, the healthcare system as it stands commoditizes primary care and works against the functions of primary care, especially continuity. Each time someone looks for new primary care provider, the system has failed.
Because healthcare in the US is purchased through employers, their entire family would change provider when jobs turn over. As health plans move to narrow networks, odds are increasing that their doctor will not be in the network offered by the next employer. This interferes with continuity of care over time and erodes outcomes.
The situation is worse for low income individuals and the Medicaid population. Some in this population suffer from mental health problems and are easily overwhelmed by the normal demands of life. They find it difficult to hold onto jobs for a long periods of time. Unstable insurance source from a Medicaid provider to a narrow network and back, repeatedly forcing them into new primary care relationships.
Long term relationships between doctors and their patients build trust. It is the trust built on years of knowing the person embedded within the context of family and community which improves outcomes and reduces costs. The lower the income level, the greater the vulnerability, the greater the risk of bouncing on and off Medicaid, with lapses and fluctuating access determined by deductibles and coinsurance.
Erika Bliss, the CEO of QLiance, a Direct Primary Care company in Seattle, suggested to me a few months ago an idea that could help bolster how primary care improves health system performance. Perhaps it is time to consider a primary care benefit that is portable from employer to employer and continuous with Medicaid. It is easy to carve primary care out of traditional insurance, where it should always represent the top dollar of healthcare spending. This is the idea behind the growing Direct Primary Care movement where high impact primary care is paid for on a monthly subscription basis. First, this helps maintain continuity between a doctor and their patient, a foundation stone of primary care. Second, it serves to create a sustainable business model for medical students to do what they idealistically entered medicine to accomplish and attract more smart people to primary care specialties. Third, primary care increases the efficiency of healthcare systems around the world, which seems to be the fundamental motivation behind the notion of value-based purchasing. If you want to buy value, invest in primary care not MRIs and pay as much as you reasonably can.
The Portland Business Journal recently sponsored a forum entitled Health Care of the Future, providing a glimpse into what Portland companies are doing to disrupt the healthcare system. Panelists discussed new models for healthcare, new technologies that extend the reach of physicians and financing methods. It was a hugely attended event, with a great buzz, fantastic networking opportunities and a lot of great information. But close to the end of the conference, a couple of comments were made by panelists that I found incredibly frustrating reflections of an old, broken, sick health care system that were oddly out of place.
First, Jared Short, the head of Cambia’s Insurance group (Regence BCBS) who recounted diagnostic failure in the primary care setting as one reason for high cost to the system. He brought up a personal experience with his son’s diagnosis of a chronic rheumatic condition that took over two years to diagnose, despite elaborate investigations. Of course we don’t know the clinical details, but that’s why it’s an unfair characterization of primary care.
As an intern, I was responsible for the diagnosis of a case of lupus in a man who had been searching for a cause over ten years. I was not smarter than my colleagues or professors, but rather, the unique evolution of his disease made it impossible to diagnose earlier. Doctors knew that waiting and watching was the best possible strategy and in this patient’s specific case, there was sufficient trust that the patient was content to wait rather than pursue useless investigations. This is always necessary in a market where distortions are introduced by the fact that advanced investigations are essentially subsidized by payers. If patients understood what little value they added at time, they would decline. It is frightening that the head of one of the largest and most powerful payers in the Northwest has such a distorted view of the diagnostic process and value within the system.
If primary care is inadequate, then we should invest in supporting primary care and attracting the smartest minds. You do not get to underinvest in a key health system function for decades and then complain that it doesn’t do its job.
The other inexplicable comment is one I used to hear frequently in healthcare business circles in the past. Martie Ross, a principal in a consulting firm out east, made the point that insurers needed to find mechanisms of transferring risk to health providers with new value-based payment methodologies.
My point is that healthcare providers are not risk bearing entities and should generally be discouraged from doing so. It is not clear which features of ACOs predict their success, but some of the most successful ones have been where the risk was transferred to the ACO, but not necessarily to the providers. Providers should be in the business of taking care of people and doing the right thing, irrespective of the cost. As far as insurers go, their business is the management of risk, not the transfer of risk. To a lifelong family physician, insurance companies transferring risk seems like cheating.
Moreover, the only entities large enough to absorb this kind of risk are large integrated health systems which is the birthplace of perverse incentives for high volume, excessive and sometimes unnecessary care. Small practices arguably do better at quality where large systems are better at collecting data and generating revenue.
The disdain for primary care and the industry’s tone-deaf dehumanization of health to “risk transfer” are part of the reason our old system is broken and we are experiencing this generational opportunity for disruption. This is the health care of the past, not the Health Care of the Future.
More on Cannon and the USA Today article from 2007.
I have had trouble responding to Michael Cannon. I knew when I first read his response to my critique of his USA Today Op-Ed (that’s a mouthful to follow) that more should be said. He spent most of his time defending incorrect referencing in his Op-Ed, but there was something more. The more I read, the more I perceived a purposeful selection of data in support of an existing position. I am more familiar with the scientific method which requires the writer to follow the data, including contradictory evidence. Mr. Cannon comes from an ideological perspective to which I cannot relate. Perhaps no response is required for ideologues. After all, what is the purpose of the Cato Institute but to purvey a particular ideology?
I have a libertarian streak, but I am no libertarian. These ideas serve as a reminder that there are limits to what government can and should do. There are limitations to the financial resources of any society. I do not believe that there should be a single payer or that everyone is entitled to every possible medical intervention. But as I dig deeper, my understanding is growing of the ideology which shares these principles.
First let me direct some comments directly to Michael’s defense of the USA Today Op-Ed:
- To minimize the number of uninsured is to miss the point that there are vulnerable people in society who need some assistance. The government has a role in improving the quality of life of its citizens by supporting education, defense, law and order, health care and probably other areas as well. To believe the government has no role whatsoever is false, intellectually on the fringe and historically on the road to revolution.
- To suggest that all people covered by Medicaid would be better off with private insurance is as ignorant of the lives of the poor as Mariah Carey talking about poor starving kids and flies and death and stuff. Crowd-out as Michael Cannon describes is another name for cherry-picking. To force low-income individuals who are most likely to cost insurers more money is to keep private insurance more profitable for the insurers.
- Most medical care is not cost-effective, as measured by macro-level indicators. Since leaving Canada I have learned that no country ever became great by trying to be cost-effective, but rather by achieving its goals. Therein lies my objection to raising the issue of medical cost-effectiveness. The most important variable in cost-effectiveness is defining the goal, so as to know if you are being effective in achieving the goal. It would be cost-effective to focus efforts on coverage of the most vulnerable. It would be cost-effective to stop treating the elderly, the disabled and the mentally retarded. Sometimes we do things because we feel it is important as a reflection of the quality of our society. Economic reasons alone are not good enough to make decisions about health care policy, something I was taught by a health economist from Harvard.
There are some very valid notions being floated regarding health reform, not the least of which are reducing payments to hospitals (which account for 50% of the country’s health care bill), increasing transparency of pricing and increasing consumer control of their own health care money and benefits. These proposals address many problems in health care today, but not the problems of those who need the greatest assistance. At the risk of sounding like a guild monopolist, physicians are better representatives of patients when they cannot speak for themselves than a policy wonk who’s never walked a day in clinic.
The first step in crafting health care policy is articulating a role for government. If you don’t believe there is any role for government in health care, then we have nothing more to talk about and we must agree to disagree. If the goal is a responsible approach to improving the well-being of the population through expanded health coverage while simultaneously improving accountability of the tax dollar, then there is a possibility of discussing the relative merits of various approaches.
Here is one Michael Cannon would prefer to forget. The problem with the ideologues is that they learn to reference their papers after they’ve written theM. So often, the articles do not say anything about what is being referenced. This is why I do not often use material from think tanks unless it is clear to me they do not have a political agenda and treat facts respectfully, with reason and an absence of rhetoric. From The Physician Executive in September in 2007. I will never delve this deeply into ideological clap-trap ever again!
Dear readers, I need your help.
As you may know, I am a proponent of a non-dogmatic approach to policy debate and would like to see some truly conservative approaches to health care reform. I despise the tools of rhetoric and the use of formal logical fallacies that characterize the current crop of so-called conservatives.
Yesterday (via InsureBlog), USA today published an op-ed by Michael Cannon of the Cato Institute, an organization which I usually find provocative and challenging, but not thoroughly manipulative nor responsible for shoddy scholarship. I reviewed the articles which Mr. Cannon offers as references and have trouble connecting the articles to the point being made. There are also some logical inconsistencies.
Here is a systematic breakdown of what I found:
1. US Census Bureau. Nothing wrong here, the Bureau’s number may very well bear re-examination since all surveys have strengths and weaknesses. There is no such thing as methodological perfection.
2. Agency for Health Research and Quality: “other recent surveys put the number between 19 million and 36 million” for the uninsured. The link takes us to a MEPS survey (Medicare Expenditure Panel Survey is a running survey of medical expenditures using a representative sample of the entire US population) which does not support Mr. Cannon’s statement. The study delves more deeply into the census bureau’s figures by looking at the duration of being uninsured. The census bureau counts people as uninsured if they have been uninsured for any time n the past 12 months. Since the public health concern is identifying a vulnerable population, this is an entirely valid definition. The MEPS survey states “In 2003, 25.4 percent of the population was uninsured at some point during the year, 18.8 percent was uninsured throughout the first half of the year, and 13.6 percent was uninsured for the entire year.” Even math errors on Mr. Cannon’s part does not explain why he is comparing the proportion of American uninsured for the first half, second half and at any time of the year.
3. The next link is used to support the phrase “As many as 20% of the “uninsured” are eligible for government health programs, so in effect they are insured.” This is the most egregious. It comes from data that many who are eligible for Medicaid do not sign up since 20% of those eligible are not signed up for SCHIP. The statement holds true only if all the uninsured are eligible for some kind of government program, which is inconsistent with a seprate implication, presented with no evidence, that so many of the uninsured are illegal. Moreover, it escapes me how someone who is eligible for a program is still covered if they chose not to sign up. How does this address the vulnerability associated with catastrophic health expenditures? Moreover, the study referred to is a sober and numbing methodological comparison of the MEPS and Census surveys, not one of the many studies which have demonstrated repeatedly that under-utilization appears to be the hallmark of programs like SCHIP.
4. Mr. Cannon uses a study by Bundorf and Pauly to support the statement that as many as 75% of the uninsured can afford insurance. The paper is a fascinating and illuminating look at the effect of different definitions of affordability on the population estimate. While 76% is the high end, 31% is the low end of the estimate. Their findings support a statement much different than Mr. Cannon’s, here I quote from Bundorf and Pauly’s conclusion: “Our results demonstrate that lack of “affordability” is an important barrier, but not the only or the major barrier to obtaining coverage for all, or even most, of the uninsured. […]Omitted variables related to health status are potentially of particular importance. If our measures of health status do not capture characteristics of individuals that result in unusually high premiums (potentially due to risk rating of premiums or denials of coverage in the individual market, for example), we may over estimate the affordability of health insurance for high risks. […]Deciding for whom health insurance is affordable is ultimately a normative decision on the part of policymakers and society. We believe that our definitions, however, offer researchers and policymakers a positive empirical framework with which to begin to evaluate this question by basing the definition of affordability on the behavior of other consumers with similar characteristics, rather than an arbitrarily chosen income threshold.” This is very wise, unlike Mr. Cannon’s inexplicable peripatetic diversion.
5. To support the statement that “many economists can find no evidence that it [expanding coverage] is a cost-effective way to improve health” Mr. Cannon uses a non-peer reviewed piece of secondary literature that is actually an interesting review of the literature with respect to causality between insurance and health. The reviewers observe that if the causal chain fails, it may be either health insurance or health care that may not improve the health of the population. That is an established fact, which is not at issue because we are talking about extending health coverage to vulnerable sub-populations. The poor represent the majority of the uninsured unless you believe the prior misinformation. Perhaps the argument against covering the uninsured is being used as an argument against either government run or universal health insurance.
6. A rapid sequence of references asserting that expanding health coverage will not
a. Improve quality: New England Journal article shows that income is more important than race. The study does not address access to which coverage is most relevant.
b. Reduce disparities: Paper argues that reducing poverty is more important to health than improving health care access.
c. Affect life expectancy: A New York Times article about education being related to longevity.
d. Reduce cheating: A Health Affairs analysis of how health care costs for the uninsured are currently distributed. No mention of how not having a program deters cheating on the aforementioned non-existent program, i.e. Mr. Cannon’s argument is nearly circular.
7. The Kaiser Family Foundation says that the average family of four spends $11,000 a year. Individuals are pegged at $4,000. What the average cost per employee is, I just don’t know. Using one number without the other is not an honest presentation of the problem and I may be a little dense here… what was the point? Health care is expensive? We know that.
8. Several correct citations regarding the number of people covered by employer-sponsored insurance, rise in health insurance premiums, a White House press release, Rudy Guliani’s campaign website and a CBO letter.
Please review what you can (not everyone has full text access to Bundorf & Pauly) and let me know if I have mis-read any of Mr. Cannon’s references. Please note the title of the editorial refers to making Americans care about health care. This is a very promising position. I hunger to hear the argument, but am I just dense, or did he completely skirt around the cost, except a passing mention of average family insurance expenditures? I think there are extremely cogent arguments to be made.
Not a big fan of big pharma. Not a big fan of big insurance. Come to think of it, I’m not a big fan of anything big: government, hospitals, or anything else for that matter. This bias is evident in this post from The Physician Executive.
Peter Pitts appears to be a very intelligent person. As a former head of the FDA, he knew how to find the money and took off to run the Center for Medicine in the Public Interest, generally recognized as a front for Big Pharma. I like reading his posts, for the same reason I like reading the Cato; I am always looking for good arguments on the side of any position.
So I came across this interesting article suggesting that we need to stop insurance companies from switching people to generics all the time. This was published the same day that Wal-Mart added terbinafine, once $300 a month, to it’s $4 generic list.
As a clinician, my frustration is that insurance companies, or more specifically the pharmacy benefit managers, forcing patients to change meds. They insist that a certain medication in a given class is not covered and the patient must change to a different drug in the same class. It’s like don’t take amoxicillin, you have to take penicillin. Alternatively, the physician can somehow demonstrate or certify an adverse reaction or lack of effect before they authorize going back to the original drug. I already know drug A doesn’t work, from experience on the previous insurance. The insurance requires that we try Drug A again, before they reimburse for Drug B, which the patient has been taking for a long time.
I understand the complications of dealing with expanded formularies and the inefficiencies of having to stock so many similar drugs. I also understand the value of the discounts available when you order in bulk.
I just don’t think it’s a good idea to swap chemical entities because I have a healthy respect for the risks of consuming anything on a regular and ongoing basis. Once you have a functional and safe regimen, it is unwise to change.
Here’s the bone I’m going to throw to Big Pharma; sometimes a softer argument makes a greater effect than one so strident, the bias encourages the reader to discard it without a thought.