Wednesday, April 9, 2014

Health insurance is not health care

The title of this post is not original. I borrowed it from LA County Department of Health Services Director Mitchell Katz's JAMA Internal Medicine editorial about problems with ensuring access to health care for Medicaid recipients whose cheap public insurance usually doesn't even pay doctors enough to recoup costs of care, let alone earn a living. But somehow, during the impassioned political debates that preceded Obamacare, the botched rollout of Healthcare.gov, and the pointless debate about how many people got (or lost) health insurance from the Affordable Care Act, it's easy to omit this critical point, which Dr. Katz makes clearly: "Health insurance is a financial mechanism for paying for health care. It is not the care itself, or even a guarantee of that care."

Most of my colleagues would say that health insurance makes it easier for people, especially those with limited means, to access health care. I'm not sure I agree (especially for inexpensive primary care services), but it's easy to see why they feel that way. Health care spending makes up nearly 20 percent of economic spending in the U.S. On an individual level, what do you spend 20 percent of your income on? Housing? Transportation? Food? Unless you're exceptionally wealthy, it's hard to imagine finding another 20 percent to spend on health care, especially expensive care related to a catastrophe, such as a car accident or heart attack.

I believe that health insurance should be a mandatory financial mechanism for paying for unexpected, catastrophic health expenses, just as fire insurance will pay if my house burns down or flood insurance will pay if a hospital in a low-lying area is devastated by a hurricane. On the other hand, health insurance is a grossly inefficient mechanism for paying for expected care - that is, primary and preventive care.

Think about how insurance works when you visit a typical family physician. Depending on your plan, you may pay a fixed co-payment, or pay nothing. You receive medical services recommended by your doctor without knowing (or asking) how much any of it costs. What your doctor charges for these services has very little relevance to you and even less relevance to the insurance company, which will pay whatever price it has pre-negotiated for its members. This is the way health care financing has worked for so long that it's difficult to step back and realize how stupid it is.

Let's substitute food for health care and imagine there is such a thing as "food insurance." You enter the grocery store and pay a fixed co-payment, or pay nothing. You choose food items recommended by your grocer without knowing (or asking) how much any of it costs. What your grocer charges for the contents of your shopping cart has very little relevance to you and even less relevance to the food insurance company, which will pay whatever price it has pre-negotiated for its members. Does this sound like a good way to make food more affordable? When people are poor enough that they can't afford to buy food, governments don't provide them with food insurance, but food stamps (or supplemental nutritional assistance) so that they can purchase food directly. So it should be with health care.

A couple of years ago, I blogged about a friend who had the misfortune to need an appendectomy while he was uninsured. You might assume that after that experience my friend, whose name is Jose Padilla, would ridicule "consumer-driven health care" and be all for insurance paying for every single medical expense, no matter how minor. You would be wrong. Jose, who is now a candidate for Congress from the state of Nevada, told me recently that "insurance should be there for those situations where you don't have the time to negotiate and/or the cost would bankrupt you." In his opinion, the biggest problem with health care is that the prices are too high. The prices are too high because there is no price transparency (imagine how hard it would be to shop for groceries when you weren't told what the food cost until a bill arrived in the mail weeks or months later), and there is no price transparency because someone else other than the patient is paying most of the bills.

As Jose's health care platform observes, "the health care industry [is] one of the only U.S. industries where the addition of new technologies causes an increase in prices." Why? Because medical prices will increase as long as someone else - your employer, your government, Obamacare, whomever - is willing to pay them. Why else would ophthalmologist Salomon Melgen inject patients' eyes with a very expensive drug (Lucentis) instead of a much cheaper equivalent drug (Avastin)? Because he could bill Medicare Part B $11.8 million for those shots in 2012 instead of $500,000. In fact, 879 of the doctors who billed Medicare at least $1 million that year were ophthalmologists using Lucentis, according to the Washington Post. If you want to know how much money your doctor received from Medicare in 2012, click here. (I received $3,201.) Kudos to the Centers for Medicare and Medicaid Services for making this information public, and for reminding us of the disconnect between having health insurance and receiving health care.

Monday, April 7, 2014

Direct primary care called one of health care's "big ideas"

Graham Center Policy One-Pager in the April 1st issue of American Family Physician uses historical data to project the effect of the 2010 Primary Care Residency Expansion Program (PCRE). By its conclusion in 2015, the PCRE program will have funded an additional 900 residency trainees in family medicine, general internal medicine, and general pediatrics above the current cap on Medicare-supported residency positions. Based on historical trends, though, only 39 percent of internists in these particular programs will end up practicing primary care, compared to 51 percent of pediatricians and 92 percent of family physicians. As a result, only about two-thirds of these residents are likely to enter the primary care workforce. Of course, 600 new primary care physicians are better than none, but at an estimated $100,000 per year per resident, this well-intentioned federal program will also spend $90 million to train additional internal medicine and pediatric subspecialists that are already in plentiful supply.

In addition to modest programs like PCRE, big ideas are needed to transform U.S. health care to a patient-centered system, grounded in primary care, that delivers the best possible health outcomes for all. Corey Fogleman, MD and Thomas Gates, MD propose several in a recent article in the Journal of Lancaster General Hospital, including:

1) Making medical school free, and providing residency training stipends only to graduates who choose primary care programs
2) Direct primary care: "eliminating the middle-man of third-party insurance"
3) Single payer systems providing universal insurance coverage on the state level

Of these three big ideas, direct primary care (discussed in a previous guest post on Common Sense Family Doctor) appears to face the fewest political and logistical obstacles and is rapidly becoming a reality in communities across the country. Drs. Fogleman and Gates observe:

Advocates of this approach point out that insurance is meant for large unexpected expenses, while expenses for primary care are relatively modest and predictable. It makes little sense to pay for these through an insurance model, any more than it would make sense to buy auto insurance to protect from the cost of an oil change or new tires. Instead, patients in direct primary care contract directly with a primary care provider for access to a broad range of office-based primary care services, in return for a monthly or annual retainer fee.

Unlike “concierge medicine,” the fee is modest (usually on the order of $500-$1000 per year), and can complement high-deductible or catastrophic insurance (which would cover large and unexpected expenses like hospitalization). An element of competition safeguards consumers: practices that don’t deliver quality and accessible primary care will quickly lose patients.


A collection of articles about direct primary care and membership-based practices is available on the Family Practice Management website. Clinicians and policymakers interested in learning more about direct primary care should also consider attending the second Direct Primary Care National Summit in June (registration code: MDUADPC).

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A slightly different version of this post first appeared on the AFP Community Blog.

Thursday, April 3, 2014

"Free" health screenings have hidden costs

Last week, I spoke to a class of undergraduates about the benefits, harms and politics of screening smokers for lung cancer using low-dose CT scans. Afterwards, a student asked how I felt about the Affordable Care Act's requirement that Medicare and private insurers cover U.S. Preventive Services Task Force "A" and "B" recommended screening tests and other preventive services without co-payments or deductibles, making them free at the point of care.

I admitted that I have mixed feelings. On one hand, some studies have found that even small out-of-pocket payments make patients less likely to receive recommended health screenings or counseling. On the other, it isn't clear why this particular set of services for healthy people (which include contraceptives classified as "pregnancy prevention") deserve to be valued more than medical interventions for people who actually suffer from chronic illnesses. The chance that a 50 year-old woman at average risk for breast cancer will have her life extended by a screening mammogram is around 1 in 1000; the chance that a 50 year-old woman with diabetes and high blood pressure will have her life extended by taking fitness classes and anti-hypertensive drugs is around 1 in 20. The healthy person receives a service for free; the ill person does not. And, as I wrote in a blog post shortly after the 2012 Presidential election, that mammogram isn't really free:

Thanks to the ACA / Congressional Democrats / President Obama, a typical political ad will say, women can now get free mammograms, Pap smears, cholesterol tests, and birth control pills! Isn't that great? This kind of ad is misleading because none of the preventive health services defined by the bill have suddenly become free. In fact, some cost hundreds or even thousands of dollars. Instead, the costs of these services have just been shifted - into higher insurance premiums, on to an employer, or to the federal government (and therefore the individual taxpayer or an international investor that holds some portion of the U.S.'s $16 trillion national debt).

A perceptive commentary in this week's JAMA by Drs. Joann Elmore and Barry Kramer offered more reasons to doubt the wisdom of mandating that marginally beneficial preventive services be provided for free:

With the goal of improving access to preventive services and medical screening, the ACA offers free screening mammography to women. However, women often pay for the consequences of screening, even if the screening examination is free. Women bear not only financial charges but also important human costs. Screening mammography can trigger recalls for more testing, biopsies, mastectomies, radiation, systemic therapy, days off work, and debt related to health care costs. These byproducts of screening can lead to adverse financial consequences and personal harm.

Two years ago, I bought a color printer for under $50 (practically free!) for my home office. It printed pages excruciatingly slowly, had a tendency to jam and leak toner, and sets of replacement cartridges came to $75 every other month. Several weeks ago it quit printing any documents that required black ink. After spending hours trying unsuccessfully to troubleshoot the problem, I paid five times as much for a new printer, and so far it's worked like a dream.

Do I provide mammograms and other USPSTF-recommended "free" screening tests to my patients? Of course I do. But I also caution them not to be deceived by the sticker prices for these services and exaggerated claims about their benefits, and to consider more than up-front costs in determining personal health values, as they would in making decisions about the value of any other service that costs money.

Saturday, March 29, 2014

Forecasting and adapting to the family medicine shortage

Projecting future physician workforce needs is a challenging calculation that must take multiple variables into account to avoid missing its mark. In the mid-1990s, the American Medical Association confidently predicted that the penetration of managed care would lead to a large "physician surplus" and convinced Congress to cap the number of graduate medical education (GME) positions subsidized by the Medicare program. Two decades later, there is a widespread consensus that the U.S. is actually experiencing a physician shortage that will worsen with population growth, the aging of the baby boomer generation, and an influx of newly insured from the Affordable Care Act.

Although medical schools have expanded to meet the anticipated demand for doctors, the AMA and others are still pushing for the GME cap to be lifted so that new medical graduates will have enough places to train. But how has the specialty of family medicine fared, and what else can be done to extend capacity of the existing primary care workforce? These questions were the subjects of two recent Georgetown University Health Policy seminars.

Image courtesy of the American Academy of Family Physicians

Modest gains in the numbers of U.S. and foreign medical graduates matching into family medicine residency programs over the past five years will fall well short of supplying an additional 52,000 primary care physicians by 2025, a shortage projected by the Robert Graham Center. A recent issue of Health Affairs examined potential strategies to extend primary care capacity in the absence of an (increasingly unlikely) surge in generalist trainees. For example, telehealth technologies could lighten the load on family physicians by promoting patient self-management of chronic conditions; improving medication adherence; and facilitating real-time specialist consultations. A more radical and controversial proposal aims to provide EMT-style training to a new profession of "primary care technicians" who could provide basic primary care services under the supervision of a physician, freeing physicians to "focus on patients with more complex conditions."

As our discussion pointed out, though, these proposals have serious disadvantages. By reducing face-to-face interactions, telehealth could easily make family medicine less rewarding. Family physicians who end up seeing only patients with multiple complicated chronic conditions could burn out faster, leaving even fewer in the workforce. As a broad cognitive rather than a narrow, procedure-focused specialty, family medicine is less likely to be suited to care by technicians than, say, anesthesiology or gastroenterology. Finally, given the persistent and growing income gap between family physicians and subspecialists, the real solution to the primary care shortage may still be staring us in the face.

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This post first appeared on The Health Policy Exchange.

Thursday, March 27, 2014

The best recent posts you may have missed

Every other month or so, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from December, January, and February:

1) Movings and dislocations in life and medicine (2/9/14)

Will newly formed alliances of clinicians and hospitals succeed in organizing themselves to provide accountable care that improves population health outcomes? In other words, is this seemingly inexorable movement toward a brave new health system forward progress, or a temporary dislocation?

2) What can Rwanda teach the U.S. about primary care? (12/2/13)

It's sometimes easier for a patient with musculoskeletal low back pain to get an appointment with a spine surgeon or for a patient with panic attacks see a cardiologist than it is to find a family physician. You can get a same-day MRI for any number of problems that probably don't require any imaging at all. ... To improve population health in the U.S., we need to flip the pyramid so that primary care services are the base for all other health care structures.

3) Will Choosing Wisely change the way family physicians practice? (2/3/14)

The ultimate success or failure of the campaign will depend on how well physician societies can convince their members to curtail commonly accepted but nonbeneficial services, such as the annual physical examination in healthy adults.

4) Of impersonal statements and meaningless use (2/26/14)

Perhaps these electronic exercises collectively known as meaningful use will someday improve care and outcomes. Until then, I know it's only a matter of time before I read a personal essay from an earnest medical school applicant who once aspired to be a professional coder but decided he could have his nonsensical documentation requirements and treat patients, too.

5) Two types of "scut work" (12/16/13)

I am not nostalgic about trying repeatedly to place an 18-gauge IV in a patient with no palpable veins at four in the morning, or replacing a delirious patient's nasogastric tube for the fifth time in as many hours because he kept pulling it out. But at least that kind of scut, unlike the tedious tasks involved in electronic documentation, was work that was meaningful to patients.

If you have a personal favorite that isn't on this list, please let me know. Thanks for reading!

Monday, March 24, 2014

Antibiotic overuse: truth and consequences

The cover article of American Family Physician's March 15th issue, "Common Questions About Clostridium Difficile Infection," reviews truths about a disease that is a direct consequence of medicine's good intentions: antibiotic use, both appropriate and inappropriate. A recent Vital Signs report from the Centers for Disease Control and Prevention (CDC) addressed the magnitude of the latter by demonstrating that broad-spectrum antibiotics are up to three times as likely to be used in some hospitals compared to others. Additional analyses concluded that 37 percent of prescriptions for intravenous vancomycin and antibiotics for urinary tract infections were not supported by diagnostic testing or documentation of symptoms.

The CDC estimated that reducing the use of broad-spectrum antibiotics by 30 percent could eliminate more than 1 in 4 Clostridium difficile infections. CDC Director Thomas Frieden, MD, MPH outlines seven steps for hospitals to improve accountability and monitoring of antibiotic prescribing in the video below.



Increasingly, Clostridium difficile infections are occurring in outpatient as well as inpatient settings. A study published in Pediatrics revealed that 71% of laboratory-confirmed Clostridium difficile infections identified by a U.S. population-based surveillance system from 2010 to 2011 were community-acquired, with the highest incidence among children 3 years of age or younger.

According to the review article by Dr. Bradford Winslow and colleagues, many Clostridium difficile infections can be prevented by minimizing the frequency and duration of antibiotic prescriptions; practicing hand hygiene and adhering to contact precautions; and prescribing probiotics to patients who are taking antibiotics for infections.

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This post first appeared on the AFP Community Blog.