Category: Health Care Access

Draining More Brains: Where Medicine is Heading

Watching the Affordable Care Act roll-out and reading about its gestation in Steven Brill’s book, America’s Poison Pill, makes one very aware that there is a serious brain drain under way in medicine.  Here’s what anyone can see:

Numbers of applicants to medical school, which once was 10 for every place, is now less than 1.  Physicians are telling their children not to go into medicine. There is now more than a 7 foot stack of regulations for the Affordable Care Act. As we all know, the slogan for this whole program has been “the healthcare system is broken.”  (If that is so true, why force feed new people into it?)

Some manifestations:  the adoption of the ICD-10 coding system, which defines conditions needing care in such detail that there is an unacknowledged administrative cost for compliance and a substantial legal and financial risk if there is mis-coding. Another is the forced adoption of Electronic Medical Records, with rules for “Meaningful Use.” This will produce electronic oversight of all medical care, in the guise of supporting “quality of care” and facilitating “Value-based Payments.”  Ultimately, the government regulators expect to have real time access to any person’s care and any physician’s performance.

Certificate of Need Laws Reduce Choice in Health Care

Imagine if you wanted to open a new hardware store and you needed a “Certificate of Need” issued by the state or local authority that your hardware store was needed. Needless to say, incumbent hardware stores would already be well armed with strong arguments that your hardware store was not needed. Crazy? Yes. Un-American? Yes. Unfortunately, these Certificates of Need exists in most U.S. states for hospitals or other facilities.

Scholars at the Mercatus Center have published a new ranking of states’ CON laws, finding that sates with Certificate of Need programs are associated with:

  • 131 fewer beds per 100,000 persons.
  • A reduction by between 1 and 2 hospitals providing MRI services per 500,000 persons.
  • A reduction of 37 percent in the number of hospitals offering CT scans.

Certificate

Washington, DC: Rich World’s Worst Capital for Infant Mortality

Save the Children has a new report ranking 25 of the world’s richest capital cities by childhood mortality. Washington, DC is the worst. Prague, Stockholm, Oslo, Tokyo, and Lisbon lead.

But I think the international ranking was just to get headlines. The real point of the report is to emphasize differences in infant mortality between rich neighborhoods and poor neighborhoods in these rich capitals:

  • In examining infant deaths in D.C., Save the Children found that in 2012 the infant mortality rate in DC’s poorest neighborhood (Ward 8) was more than 10 times higher than the rate in DC’s wealthiest community (Ward 3).

  • In 2012 the infant mortality rate in ward 8 was 14.9 deaths per 1,000 live births. In contrast in Ward 3, the city’s wealthiest ward, the rate was 1.2 deaths per 1,000 live births.

I suppose that many will use this report to call for increases in Medicaid spending, which has increased relentlessly over the years without eliminating this difference.

 

Is Patient Scheduling Software Valuable to Doctors?

I am a huge fan of entrepreneurs who want to make medical care more productive and consumer friendly. I wish all of them the best of success. Unfortunately, I am concerned that one of the trends attracting venture capital is chasing a shrinking market. That trend is patient-scheduling software in physicians’ offices.

I was at an angel investor pitch off in Arlington, Virginia, yesterday where one such firm was seeking investors. Two great incubator/accelerators, StartUp Health in New York and Rock Health in San Francisco (and, now, New York) have invested in Arsenal Health, inventor of Smart Scheduling.

Firms like this promise algorithms that use data to predict cancellations and no-shows. I suppose this is the flipside of ZocDoc, the remarkably successful business that doctors use to find new patients to fill appointments that have been cancelled.

These are all great ideas. I am just not sure they make sense in the future environment, where there will be surplus of patients and a shortage of doctors. A few years from now, when the U.S. has Canadian-style waiting lists to see specialists, why would a physician invest in technology to manage cancellations and no-shows?

Such technology would be very valuable where there is a surplus of doctors competing for a limited number of patients. But I don’t think anyone anticipates that for U.S. health care. I hope I am wrong.

Churn: Data Lacking on Critical Question

The media and most health policy wonks focus only on the number of insured versus uninsured people. They don’t really care if people are enrolled in Medicaid, Medicare, Obamacare plans, employer-based benefits, or whatever. As long as the percentage insured goes up, they are satisfied.

One of the problems this disguises is “churn” – people moving between different types of coverage, which leads to disrupted care. It is something that Obamacare surely makes worse, by introducing a new type of coverage for people within a certain range of income.

However, the people in charge of the new system are almost completely ignoring this problem, according to Modern Healthcare:

Experts say churn can be disruptive to people’s continuity of benefits and healthcare, particularly if they have medical conditions for which they are receiving treatment. In addition, it can be harder for people to access healthcare providers, particularly specialists, if they switch to Medicaid, which often pays lower rates.

“For a patient under a physician’s care for a condition like cancer or renal failure, changing providers in the midst of chemotherapy or dialysis can be incredibly disruptive,” said Chris Stenrud, executive director of government relations at Kaiser Permanente.

A CMS spokesman said no data on churning between private plans and Medicaid were available for the nearly three dozen states using the federal marketplace. But a committee of health plans selling products on the federal exchange that has been tracking the trend has noted a small but steady exodus from exchange plans. The committee, however, could not determine whether the people exiting the exchange plans were transitioned to Medicaid or employer coverage or became uninsured.

The solution to churn is a refundable, universal tax credit that allows people to buy health insurance of their own choosing, and getting rid of the artificially fragmented market that Obamacare has made worse.

IS FDA Reporting Drug Shortages Adequately?

For a number of years, there have been critical shortages of certain generic drugs for injection. These are often important cancer drugs. In 2012, I wrote a report that concluded over regulation by the Food and Drug Administration (FDA) was the primary cause of the shortages.

The President and Congress acted, but their actions did not result in improvement for over a year.

Today, the FDA claims to have improved the situation. However, an article in Health Affairs points out that the number of drug shortages reported by the FDA and the number reported by the University of Utah Drug Information Service (UUDIS), the leading private source of this data is diverging dramatically:

Access to Health Care Unchanged After Obamacare’s First Year

The Centers for Disease Control and Prevention (CDC) has released early estimates of health insurance and access to health care for January through September 2014. The National Health Insurance Survey (NHIS) is (in my opinion) the most effective survey of health insurance, because it asks people three different but important questions: Are they uninsured at the time of the survey? Have they been uninsured for at least part of the year? Have they been uninsured for more than a year?

As shown in Figure 2, the proportion of long-term uninsured is about the same as it was circa 2000. The proportion of short-term uninsured has shrink a little in Obamacare’s first year.

F2

Senate Dems: Get Pregnant, Then Get Health Insurance

Women joggingWhile everyone else is wondering whether the Supreme Court will replace Obamacare in 37 states with the actual Affordable Care Act as written, some Democratic U.S. Senators are urging women to dive deeper into Obamacare’s perverse incentives by encouraging them to delay getting health insurance until after they become pregnant.

As reported by Lydia Wheeler in The Hill, Senator Patty Murray has round up 36 signatures on a letter addressed to U.S. Health & Human Services Secretary Sylvia Burwell urging her to pull yet another “special enrollment period” out of her bag of tricks.

In a statement, Christina Postolowski, health policy manager of Young Invincibles, said she’s thrilled to see a growing chorus of leaders calling on the administration to create a special open enrollment period to make maternity coverage available to pregnant women year-round.

According to Postolowski’s December 2014 report “Without Maternity Coverage” maternity care and delivery ranges from $10,000 to $20,000 without complications.

FDA Allows Direct-To-Consumer Genetic Tests

One year after a very public squabble with genetic-testing company 23andMe, the Food and Drug Administration has decided not only to allow 23andMe to directly market its genetic test to consumer as a diagnostic device, but to free other genetic-testing companies from pre-market review or prescription status:

“The FDA believes that in many circumstances it is not necessary for consumers to go through a licensed practitioner to have direct access to their personal genetic information. Today’s authorization and accompanying classification, along with FDA’s intent to exempt these devices from FDA premarket review, supports innovation and will ultimately benefit consumers,” said Alberto Gutierrez, Ph.D., director of the Office of in Vitro Diagnostics and Radiological Health in the FDA’s Center for Devices and Radiological Health. “These tests have the potential to provide people with information about possible mutations in their genes that could be passed on to their children.”

Obamacare Increases ED Use in Los Angeles County

Los Angeles County, Obamacare’s Ground Zero (so described because of the huge number of its residents enrolled in Obamacare’s health insurance exchange) is seeing an influx of patients into hospitals’ emergency departments:

Data hospitals report to the state show that as insurance coverage was extended to hundreds of thousands of residents, ER visits for ailments not serious enough to require an admission grew 3.9% in the county in the first half of 2014, compared with the same period the previous year. The growth is in line with annual increases of 3% to 5% in the three years prior to the federal healthcare overhaul. (Los Angeles Times)

This is no surprise to readers of NCPA’s Health Policy Blog. We have always appreciated the evidence that increases in government-funded health coverage lead to increased ED use.

What is interesting about the data from LA County is that ED use in public hospitals declined, while use in private hospitals increased. That might indicate something about the characteristics of the patients newly insured under Obamacare.