Healthy Interests

Much of the increased need for primary health care services anticipated to follow full implementation of the ACA, especially in rural areas, will likely be filled by nurse practitioners and physician assistants. Yet, restrictive state licensing regulations in many states will hamper the ability of these mid-level practitioners to fill the void. Modern Healthcare’s 11th annual workforce report (subscription required) focuses on the scope of license issues facing these professionals just as their roles in providing health care could expand dramatically. The report suggest that turf wars between physicians and mid-level practitioners is at the root of some of the scope of license restrictions at issue.

This is an area where modern communication technology could really shine to provide both access to care and to ensure quality of care. As we move towards a more team-oriented approach to providing health care, either by choice or by sheer necessity, we need to be creative about remote supervision of mid-level practitioners by physicians where appropriate, and also be honest about when a physician’s expertise is really needed, and when a mid-level practitioner is perfectly able to do the job. The physicians shouldn’t really be worried, they will continue to be the team quarterbacks. But if the law is being used to protect the team’s home turf through outdated restrictions on scope of practice, a comprehensive review of the field is needed.

Just when I thought I had seen everything when it comes to deciding who gets health insurance and who does not, comes a report in Sunday’s New York Times about how Tennessee administers its Medicaid program for “medically needy” residents. These are people who have very high medical bills, but would normally not qualify for Medicaid because their income is too high. If their medical debt is high enough that their income falls below a certain threshold after the medical debt is taken into account, they may be eligible for Medicaid. Qualifying for Medicaid may mean the difference between having access to needed health care and being unable to get treatment for a high-cost illness. Keep in mind that to qualify for the program, in addition to having high medical bills such that they are impoverished after the bills are paid, people must be elderly, blind, disabled, or be the caretaker of a child who qualifies for Medicaid. These traditional Medicaid populations are considered by society to be “the neediest among us,” according to Justice Roberts’ opinion on the Affordable Care Act’s Medicaid expansion.

Apparently, Tennessee limits enrollment in this program to the first 2,500 eligible callers who get through on the phone to the Tennessee Department of Human Services starting at 6:00 p.m. on a particular day once every six months. So if you are one of “the neediest among us,” and happen to be able to continually hit “re-dial” on your phone at that time, or can use multiple phone lines to call, you might get lucky enough to get health insurance. According to the executive director of the Tennessee Justice Center, this system leaves “huge numbers of desperately ill people . . . out in the cold.” As lawmakers in many states (including Tennessee) debate about whether to expand Medicaid under the Affordable Care Act, they should consider whether or not the richest country in the world should require some of its most vulnerable residents to play the equivalent of a game of roulette in order to get access to health care.

In one of the first rigorous looks at the effects of employee wellness programs, researchers at the University of Arizona at Tucson and elsewhere concluded that the major effect of the programs on health care costs was to shift them from the inpatient setting to the outpatient settings. Costs for hospitalizations dropped, but costs for drugs and outpatient visits increased. The wellness program studied, at BJC Healthcare, a large St. Louis hospital system, targeted life-style influenced conditions: high blood pressure, diabetes, heart disease, chronic lung problems, serious respiratory infections, and stroke.

The ACA contains provisions designed to encourage the growth of employee wellness programs, including discounting up to 30% of the cost of employee coverage, and financial rewards for participating in healthy behaviors. If the thought was that participation in employee wellness programs would help lower direct health care costs, this study at least raises a serious question as to whether that is the case.

The study notes that it is possible that employers reap other benefits from wellness programs, such as reduced absenteeism and higher productivity. There is also the possibility that employees who participate in an employer-sponsored wellness program feel increased loyalty to their employer, and that is undoubtedly worth something. But it appears that we may have to look elsewhere to reap real savings in the direct costs of health care

Two recent stories in the New York Times highlight the fact that our health care system is so dysfunctional, that we don’t really have a clue as to how to fix it.  In a piece that has received a lot of media attention, a researcher discovered something that many of us already knew–that if you are trying to shop around for the best price for a health care service, you are out of luck.  Jaime Rosenthal, a student at Washington University in St. Louis, called more than 100 hospitals around the country, trying to get a price for a hip replacement for a 62-year-old (fictional) grandmother who would pay cash for the procedure.  Half of the hospitals would not provide any price estimate at all, while the other half quoted wildly divergent prices ranging from $11,100 to $125,798.  Some hospitals were willing to bargain, and lowered their prices for a self-pay patient when pressed.  For those who are proponents of “consumer-directed health care” (in which the consumer is given a certain amount of money to purchase health care, and is supposed to be able to shop around for the best price for the care), this points out the problems with assuming that anybody can be an”informed consumer” when it comes to health care services under our current system.  The inequity in bargaining power and the knowledge gap between the consumer and the provider is just too great.

So apparently, the cost of procedures currently depends solely on the amount of profit the provider thinks it needs to make.  Nevertheless, the New York Times today also reported a piece of good news regarding health care costs– growth in health care costs is sharply and persistently slower than the Congressional Budget Office had expected.  Growth continues to be at the lowest rate in decades for a fourth consecuitive year.  The article says that the consensus is that doctors and hospitals are changing how they deliver health care to eliminate waste, insurers are no longer paying per procedure, and market forces are driving down costs.

The juxtaposition of these two pieces of news tells me that prices for health care procedures have been so inflated for so many years that providers can charge prices that are likely to exceed 10 times the cost of their services, while at the same time we can experience a slowing in the growth of health care costs.  I am usually a skeptic about plowing money into “demonstration projects” and research, but I am  beginning to think that any money we put into research on the actual costs of health care services and theamount of profits being made on such services will be money well-spent.  After all, we can’t fix something we don’t understand

While most of the country continues to tie itself in knots agonizing over the Affordable Care Act, debating whether it is a good or bad thing, deciding whether it is truly a “government take-over” of health care, and keeping the courts and government bureaucrats busy responding to the endless questions about the law and its implementation, another small New England state may be acting as the laboratory for the next wave of health care reform (remember, Massachusetts was the model for the ACA). In 2011, Vermont passed a law authorizing the creation of a universal single-payer health insurance system, to be known as “Green Mountain Care” (the current name of the state’s public programs, such as Medicaid), According to the Associated Press, this small state next door to Canada wants something closer to the Canadian health-care system for its citizens, rather than the hodge-podge of coverage options that Americans seem to treasure. As a resident of another state that borders Canada, where I hear stories about Canadians coming to the United States to get medical treatment that they would not be able to receive as quickly in Canada, as well as Canadians residing in the United States returning to Canada to get medical treatments that they cannot get at all in the United States because they can’t get insurance or can’t afford to pay for them privately, I find Vermont’s decision to emulate a Canadian-style system interesting. The Vermont law lists as its purpose “to provide, as a public good, comprehensive, affordable, high-quality, publicly financed health care coverage for all Vermont residents in a seamless and equitable manner regardless of income, assets, health status, or availability of other health coverage.” Clearly, Vermont lawmakers decided that the possible inconveniences of waiting lists and delays were outweighed by the evils of being unable to get treatment at all. It’s a courageous decision, and it will be interesting to see how it unfolds.

The Vermont system can’t be implemented until 2017, because the state will require a waiver from the ACA, and those won’t be available until 2017. Nevertheless, the governor has been under pressure to explain how much the system will cost and how it will be financed, and last week, Governor Shumlin released a report that said that the state’s share of the cost of the new system will be $1.6 billion, out of a total cost of $3.5 billion. The difference will presumably be covered by federal contributions and assorted private payments. Although this sounds scary, the report notes that most individuals and employers would no longer be buying private health insurance, and that would result in a savings of $1.9 billion. The major criticism of the system is coing from people who say the cost is simply too high.

Will the Vermont experimentt be the forerunner of the next wave–a single-payer health system in the United States? Or is the cost really too high? We will have to stay tuned.

No blog addressing health law should let the 40th anniversary of Roe v. Wade go by without a mention. Whether you think the case was a tragedy, wrongly decided, poorly reasoned, a legal masterpiece, a vindication of women’s rights, or a major step forward in gender equality, etc., the debate about the case remains as fresh as if it was decided yesterday. It makes for an interesting contrast with what has happened with other constitutional cases that were ground-breaking, such as Brown v. Board of Education, for example. The principle that segregated education is inherently unequal and that this principle is inherent in the 14th Amendment, memorialized in Brown is rarely, if ever, questioned today. Yet the principle that the right to privacy is inherent in the Constitution (although without consensus on exactly where), and includes the right of a woman to have an abortion, continues to engender hot debate. Both decisions have been criticized as having relied on the wrong things, both involve the treatment of historically disfavored and disenfranchised populations, yet you don’t hear criticisms of Brown’s basic premise in polite society today. The correctness of Roe v. Wade, however, remains open to debate at all levels, in all forums. Why the difference in treatment of two ground-breaking decisions?

There could be many reasons for the different treatment of the two decisions by the general public (some more cynical than others), but one thing that the continuing debate about Roe v. Wade points out is that when proponents of change to our health care system say health care is different than other commodities we buy and sell on the market (even education), they appear to be correct on a number of levels.

Just last week, I gave a talk to a local seniors’ group about the Affordable Care Act and changes to Medicare and Medicaid. One member of the audience asked me what Arizona was doing about the Medicaid expansion (lots of folks here in frozen Spokane, Washington spend time in Arizona during the winter). I said, somewhat facetiously, that I didn’t know for sure, but I assume that if it is something that the federal government is offering the state, Arizona would say “no thank you.” After all, Arizona didn’t even join the Medicaid program until 1982, 17 years after the program was enacted. It was the last state to join the program. And Governor Brewer made her feelings about President Obama crystal clear in that famous photographed encounter on an airport tarmac in Mesa, Arizona, where they wagged fingers at each other.

Well, I join with the Arizona legislature in my surprise at Governor Jan Brewer’s announcement yesterday that she will push for Arizona to expand Medicaid to childless adults making less than 138% of the federal poverty level. According to the Associated Press, even Republican leaders in Arizona’s legislature were surprised by Governor Brewer’s announcement, joining surprised journalists who were provided an advance copy of Brewer’s speech without the section on the Medicaid expansion.

This speaks to what a good deal the Medicaid expansion is for the states, but it remains to be seen whether or not the Arizona legislature will agree with Governor Brewer. Governor Brewer did say that she would propose that any expansion of Medicaid would include a “circuit-breaker” that would roll back enrollment if federal reimbursement rates decrease from the current low of 90%. It remains to be seen if once a state expands its Medicaid program, it can disenroll from a portion of the program and continue to receive federal funding for the remainder of the program. Until the recent SCOTUS ACA decision, the answer would clearly have been no, but now it is unclear. The SCOTUS decided that the states could decline to expand their programs and must continue to receive federal funding for the pre-existing program, but that does not necessarily mean that the state can expand its Medicaid program for some period of time, and then disenroll from a portion of the program if the federal government changes the matching percentage. Another example of how the SCOTUS decision created at least as many questions as it answered for Medicaid and other cooperative federal-state spending programs.

2013 promises to be a very active year for health-care-related cases at the SCOTUS. Today, the SCOTUS is hearing oral argument in Delia v. E.M.A., in which the state of North Carolina defends its statute creating a lien on any tort recovery equal to the lesser of (a) the total funds advanced by the state Medicaid program for the medical expenses of a Medicaid recipient or (b) one-third of the total recovery. The question to be decided is whether the North Carolina statute is preempted by the Medicaid Act’s anti-lien provision, 42 U.S.C. §§ 1396a(a)(25), 1396k(a)? Apparently, the Fourth Circuit and the Supreme Court of North Carolina disagree about this, with the Fourth Circuit holding the statute preempted, and the North Carolina Supreme Court holding it is not preempted. The case highlights many of the problems with insurer or government attempts to recover payments made for medical care out of tort recoveries, especially the ability of the tortfeasor and the plaintiff in such a case to characterize settlements so that the payments are not allocated as reimbursement for medical expenses already incurred. In this case, there is a particularly sympathetic plaintiff, a child who sustained birth injuries and received a multi-million-dollar settlement against the physicians who attended the birth. Interestingly, despite the push to cut costs in public spending programs, the United States is at odds with the state in this case, siding with the child. Sounds like North Carolina will be going it alone on this one. Should be an interesting oral argument.

In the December 3 issue of Modern Healthcare, a reporter interviewed a number of the members of the new Congress who are also physicians.  They were all asked what they thought were the most important health care priorities remaining after the Affordable Care Act.  Many of the answers were shocking to me in that they were completely focused on preserving physician incomes, totally ignoring issues that were more broadly applicable to the American public or improving health care in this country.  The vast majority of the physician-legislators cited things like allowing physicians to balance-bill patients, decreasing antitrust oversight of physicians, enacting tort reform so that doctors can’t be sued easily, and fixing the Medicare sustainable growth rate so that there are no cuts to physician reimbursement every year.  With a few exceptions,they failed to cite issues that might actually improve the quality and availability of health care in this country, like increasing the number of slots in medical schools to address the upcoming shortage of doctors, studying treatments to determine what really works and what is costly but does not work, or reducing medical errors and improving hospital safety. 

Although I’m not sure why I should be surprised at this unyieldingly self-serving focus in Congress, it really made me fear for the future of American health care.  If the people who have the best professional backgrounds, credibility,  and the positions to effect real change in our health care system are more interested in protecting the incomes of their cronies, what will really happen?   How very sad for us, and what a sad statement about the ethics that are taught in medical school or are acquired through political activity.  Bah Humbug!

The National Institutes of Health spends around $30 billion per year on biomedical research around the world.  But in an article posted by Reuters last week, according to some experts, the money is not going to the scientists who have the greatest impact on research and advancement of science, but to scientists who are engaged in conventional, incremental scientific research, not the true innovators.  According to the article, only 40 percent of the 700 primary authors of the biomedical papers published since 2001 that had been cited at least 1,000 times were not serving on NIH panels.  Clearly this indicates that the NIH likes its own, rather than original thinkers who might be less well-connected to the establishment.

This means that much of the innovative and creative biomedical research being done today is privately funded.  Sometimes, the private funding comes from a reputable, responsible institution, like the Howard Hughes Medical Institute, but sometimes it doesn’t.  If creative and innovative research is not being funded by the public, then the public will have trouble getting the benefit of the breakthroughs and controlling the risks  inherent in novel biomedical research.

Although NIH recently established new grants for “pioneering” research, clearly more needs to be done to persuade the NIH to take greater research risks.  NIH should not be falling into the trap that so many private businesses fall into when doing their hiring–wanting to hire somebody who is just like the boss.