This story was co-published with NPR. Choosing a Provider Preparing for an Emergency Getting Your Provider to Listen Paying Attention to Your Symptoms After the Delivery Grappling With the Emotional Fallout Four days after Marie McCausland delivered her first child in May, she knew something was very wrong. She had intense pain in her upper chest,… Continue Reading →
Using a powerful gene-editing technique, scientists have rid human embryos of a mutation that causes an inherited form of heart disease often deadly to healthy young athletes and adults in their prime. The experiment marks the first time that scientists have altered the human genome to ensure a disease-causing mutation would disappear not only from the… Continue Reading →
Go read this very smart piece. Nation writer Josh Holland on why:
There’s a common perception that because single-payer systems cost so much less than ours, passing such a scheme here would bring our spending in line with what the rest of the developed world shells out. But while there would be some savings on administrative costs, this gets the causal relationship wrong. Everyone else established their systems when they weren’t spending a lot on health care, and then kept prices down through aggressive cost-controls.
“Bringing costs down is a lot harder than starting low and keeping them from getting high,” says Baker. “We do waste money on [private] insurance, but we also pay basically twice as much for everything. We pay twice as much to doctors. Would single-payer get our doctors to accept half as much in wages? It could, but they won’t go there without a fight. This is a very powerful group. We have 900,000 doctors, all of whom are in the top 2 percent, and many are in the top 1 percent. We pay about twice as much for prescription drugs as other countries. Medical equipment, the whole list. You could get those costs down, but that’s not done magically by saying we’re switching to single payer. You’re going to have fights with all of these powerful interest groups.”
Baker is himself a single-payer advocate, and he’s worked with various groups that advocate for it, but, he says, “I don’t think you can get there overnight. I think you have to talk about doing it piecemeal, step-by-step.”
Hah! There’s research going back to the 1920s that found not only were people less likely to sue doctors who weren’t jerks, the actual outcome of treatment didn’t affect their decision to sue unless they felt like the doctor did not make them part of the decision process:
The Center’s researchers reviewed surgeons’ complaints from over 30,000 patients from 2015 to 2017 who had surgery at seven health centers. After categorizing the surgeons who had the highest number of complaints, they examined whether patients had complications within a month after operations.
The report found that patients of the surgeons with the most complaints were 14% more likely to have a problem after their surgery.
The Center’s authors think that this could be because surgeons who are discourteous to their patients also treat their operating room team members similarly, which results in a patient’s poor treatment.
Notably a 14 percent disparity in complications after surgery nationally would result in an extra $3 billion in costs to patients, insurers and hospitals.
Surgeons who receive the most patient complaints also get most of the medical malpractice suits.
Staggeringly, three percent of doctors nationally account for 50 percent of patient complaints, and they also account for 50 to 60 percent of the malpractice risk. This means that patients are discerning that something in their interaction with their physician did not agree with them.
Vanderbilt Medical Center works close to 150 hospitals nationwide, focusing on those who have a high number of patient complaints and medical malpractice cases. Performing peer interventions lowers the number of malpractice complaints. This also applies to other medical professionals – especially advanced practice nurses.
Hospital administrators are not surprised, as practicing medicine works better as a team. Receiving patient feedback is key: many hospitals survey patients to provide their ideas and thoughts regarding the care they received while hospitalized.
Another factor is doctors’ behavioral changes.
Attorney Gary Massey explained, “Getting feedback from patients shows the importance of their opinions. If a medical practitioner is not providing proper care, the medical institution should be aware of this.”
After failure of Republicans to reform health care, an outside observer might think that Congress is just dysfunctional, lurching from one extreme to another in search of something that works for health care reform.
The latest development has been the inability of Republicans to even agree on their own proposal and, worse yet, what should come next if it fails. Should they repeal the Affordable Care Act and worry about a replacement later or just try to “fix” the ACA now?
But the problem is much deeper than just a policy fix. As a former health insurance CEO and professor of health finance, it seems clear to me that Republicans are making five key implicit assumptions that are inherently problematic:
1. If it’s your own money, you’ll be more careful in how you’ll spend it.
This foundational belief rests on general experience in markets for most goods, and it has led to Republican support for Health Savings Accounts (HSAs), in which people set aside their own money to pay for their health care costs.
Landmark research showed that this approach could work – but under special conditions. The RAND Health Insurance Experiment is the basis for current HSAs. It demonstrated that people could save money – with no worsening of their health – if the cost sharing (deductibles and co-pays) was completely prefunded in individual HSAs. The only major exceptions were for kids and some chronic conditions.
But current proposals have extended this logic to populations, such as those with low incomes and few assets, where these findings are not applicable. Furthermore, HSAs generally are not fully funded to the levels used in the RAND research.
Yet, the Better Care Reconciliation Act, as the current Senate bill is officially called, adds a substantial boost to HSAs, and most state-level Medicaid proposals include a modestly funded health savings account. The problem with this Republican approach is that poor people don’t have any money to begin with and typically can’t afford to buy insurance or pay deductibles.
Furthermore, even those with more money aren’t very good at using their HSA money to shop for care, due to opaque prices for services and lack of information about treatment requirements.
2. Many or most poor people (Medicaid recipients) can work and should contribute to pay for insurance.
While the Medicaid expansion enrollees are working already (by definition, they have income above the poverty line), their job prospects and history are marginal. The 30,000 Medicaid recipients in the health insurance plan that I ran as CEO, for example, had about nine months of Medicaid eligibility before they got a job and lost coverage.
But the myth persists that Medicaid is loaded with moochers who simply do not choose to work and won’t pay for coverage anyway.
The fact is that very few fall in this category. Work requirements and required premiums may be simply a way to reduce Medicaid rolls using a faulty assumption.
3. Government restrictions are holding back insurers from competition that would drive costs lower.
Both the Senate and House alternatives cut restrictions and taxes on insurers. Most important of these are the broadening of the range of premiums allowed and the elimination or weakening of required essential health benefits, such as preventive care and maternity coverage. Undoubtedly, these changes will allow premiums to drop – but primarily for the healthy population that needs insurance less while others pay more.
Cross-state competition among insurers is a big Republican talking point. The rules of Congress exclude consideration for this particular legislation, however.
What’s more, it is wishful thinking that, with less regulation, there would be a flood of out-of-state insurers entering new markets and driving health care costs down. Insurers are able to compete on premiums by obtaining favorable contracts with providers. New entrants simply won’t get rates comparable to those already in a market.
In any event, the fact is that it is recent government-induced uncertainty that is driving insurers out of the market and forcing huge increases in premiums filed for 2018 offerings.
It is more than ironic that Senate Majority Leader Mitch McConnell suggested that they may need to “shore up the individual market” when the Congress has been the main reason for the instability.
4. Physicians should be the only ones making care decisions (with the consent of their patients) since they know best.
Health and Human Services Secretary Tom Price, an orthopedic surgeon, was a vocal advocate of this view – before he accepted the Cabinet job.
Recently, however, from my observations, he seems to have discovered that payment incentives and organizational innovation actually do improve quality, satisfaction and cost.
Perhaps acknowledging this, the Senate plan sought to extend these payment incentives and other ACA innovations through a new “Medicaid Flexibility Program” under its block grant options to the states.
Unfortunately, however, the total amount of funds available to state Medicaid programs would have been cut dramatically. On the principle, however, the Republicans seem to have conceded that health care is a team sport requiring action regarding incentives, organization and knowledge, much like the Democrats, albeit with less funding.
5. Government should help people – but not too much.
The original flat premium subsidies proposed by the House are both inadequate and regressive – hurting those with lower incomes. They would have covered almost all of the premium for young people but perhaps half for older enrollees. Also, they would go to everyone regardless of income, unlike Obamacare subsidies, which were based on a defined percent of the purchaser’s income.
The Senate partially corrects this bad arithmetic – and economics – by allowing subsidies to vary somewhat by income. Unfortunately, the base level is far lower than under the ACA. Subsidies are cut substantially for the poor while giving the wealthy tax relief.
So the bottom line is that the implosion of the Obamacare exchanges that Republicans have predicted may become a self-fulfilling prophecy under continued threats to sabotage it by administrative action or inaction.
Unfortunately, even with the demise of the Senate bill, it is likely that the grand experiment of Obamacare – advancing the social objective of a fully insured population using a competitive but regulated marketplace – will fade away as insurers run away from unpredictable markets.
We may come full circle. We could end up with a dysfunctional individual market and a much smaller Medicaid population with many more uninsured people. Once again, Republicans and Democrats continue to debate specifics – rather than deal with differences in beliefs – in an evidence-free brawl.
This story was co-published with NPR’s Shots blog. The box of prescription drugs had been forgotten in a back closet of a retail pharmacy for so long that some of the pills predated the 1969 moon landing. Most were 30 to 40 years past their expiration dates — possibly toxic, probably worthless. But to Lee Cantrell,… Continue Reading →
ProPublica Share on Facebook Share on Twitter Comment Donate Lost Mothers An estimated 700 to 900 women in the U.S. died from pregnancy-related causes in 2016. We have identified 120 of them so far. by Nina Martin, ProPublica, Emma Cillekens and Alessandra Freitas, special to ProPublica July 17, 2017 The U.S. has the highest rate of… Continue Reading →
Ever since the first dental school was founded in the United States in 1840, dentistry and medicine have been taught as – and viewed as – two separate professions. That artificial division is bad for the public’s health. It’s time to bring the mouth back into the body. In 1840, dentistry focused on extracting decayed teeth… Continue Reading →
— Mike Lee (@SenMikeLee) July 18, 2017
Not just the motion to proceed, but the healthcare bill itself. At least in this current version, it’s dead.
Mind you, these senators won’t back it because it’s not “conservative” enough. Stay tuned for developments.
Trump voters on Trumpcare: