Medical Homelessness  

April 11, 2014

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With millions of people newly insured thanks to the Affordable Care Act, a lot of people will be seeking medical care for the first time in a while.  While many of these will be people with problems needing specialty care due to problems that have gone untreated, many others will be in search of primary and preventive care (most of which is not subject to cost sharing).  For several years there has been talk of a shortage of primary care physicians – seems that will only become more acute.

There has also been a lot of talk about increasing the supply of physicians selecting primary care specialties.  The pendulum swings back and forth.  But, as nicely summarized by Pauline Chen,  there has been no major, sustained trend toward more physicians going in to primary care, despite a variety of initiatives such as medical school expansions, dedicated primary care training tracks, loan repayment programs.  With many subspecialists enjoying shorter hours and much higher salaries – the recent release of data on Medicare payments to physicians was particularly eye-opening – simply creating more of the same doctors and asking them to pretty please go into primary care is simply not going to work.  We need to, as Steve Jobs said, “Think Different.”

1.  Expand the role of non-physician providers.  New York recently became the latest state to expand the ability of nurse practitioners to provide care independently by removing the requirement for a written practice agreement with a physician.  Nurse practitioners are already beginning to fill important holes in primary care in a number of underserved communities – including two inner-city clinics resulting from a partnership between Children’s Hospital of Wisconsin and Marquette University School of Nursing.  This model is very likely to be an important part of meeting the national primary care gap.  We need to commit to increasing the number of NPs, and to removing the unnecessary barriers to their ability to practice to the full extent of their training.

2.  Make primary care providers more productive.  Fields like education and medicine, being relatively reliant on the human element, typically have much smaller increases in productivity than industries like manufacturing that are amenable to automation.  That appears to be changing, with numerous actual or promised innovations such as remote sensors and other forms of telemedicine, better care management, and newer therapies that require, frankly, less skill.  By simply embracing innovations that promote efficiency – not to mention a shift in focus from medical care to maintaining wellness –  we should be able to get by with relatively fewer providers.

3.  Rethink how we train physicians.  The current model of medical education – four years of college, then four years of medical school with two full years of basic sciences, followed by a minimum of three years of residency – is neither long-standing nor the international norm.  In most European countries, university and medical training are combined over a period of six years, and tuition is often free or far lower than in the US.  In the 1970s and 80s, a number of medical schools in the US experimented with alternative pathways, including 6 year combined undergraduate and medical degrees, or 3 year medical school.

The 3 year alternative is attracting new attention.  One important motivator is to allow students to graduate with lower debt, thus decreasing the barrier to entry into lower-paying primary care fields.  At the Medical College of Wisconsin, a Community Based Medical Education Program is being implemented, with satellite campuses in rural parts of the state and a 3-year curriculum.  The idea is that by attracting students with an interest in primary care in a rural setting, allowing them to decrease their tuition burden by 20-25%, and providing residency training programs in those communities, it is much more likely that they will choose to practice primary care in those areas.

I certainly hope this works.  But I think we need to use the opportunity to re-examine what is required for medical education.  In designing the community-based program, there has been a lot of thought to how to provide the basic science education (e.g., remote learning, offering some classes on local campuses, etc.).   I think the real question is how much basic science do you need, especially for a clinical (as opposed to research) career.  The opportunity to do less microanatomy and biochemistry, with earlier clinical exposure, may be even more appealing to those with an interest in primary care.

This borders on heresy in the world of medical education.  Without thousands of hours of basic science instruction, doctors will simply be “technicians,” no different than nurse practitioners!  Hmmm…..


Drumroll, Please

April 4, 2014

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The March 31 deadline for open enrollment in plans offered on the healthcare exchanges has now passed.  The original goal was 7 million enrollees.  And the actual number was … 7.1 million.  Whew!

Some of these are folks that had previously had insurance, and were simply exchanging one plan for another.  But a recent study from the Urban Institute Health Policy Center shows that the number of uninsured adults in the US decreased by at least 5.4 million since enrollment began in October 2013.  This represents a drop of 2.7 percentage points, or a relative decrease of 15%.

I say at least because the data come with 2 caveats.  First, it does not reflect enrollments in the last couple of weeks of March, when activity surged.  Second, it does not show the effect of other provisions that have been shown to increase coverage, especially the provision allowing young adults to remain on their parents’ insurance until age 26 (that number is estimated to be about 3.1 million).

This is a huge improvement in America’s shameful status among developed countries in providing healthcare coverage for its citizens.  The impact could have been even greater.  The drop in uninsured was less than half as big in the 24 states that opted not to expand Medicaid compared with those that did, leaving millions more uninsured.

BUT – I’m not giving 3 cheers yet.  The stated goals of the Affordable Care Act were to expand coverage (good start but more work to do), and to decrease costs (still more work to do).  In a previous blog I talked about how the ACA has likely already had a positive impact on healthcare spending.  However, now that there are millions more Americans with coverage, demand may start to increase, potentially reversing some of those gains.

Nevertheless, while the jury is still out, I think 8.5 million Americans with insurance coverage they didn’t used to have is something to celebrate.  I’m sure those people are celebrating.


Experience Matters

March 28, 2014

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In healthcare, experience matters.  And I don’t mean years of training or tenure – I mean patient experience.  For years we’ve resisted calling healthcare a “service industry,” and felt that “quality” was all that mattered.  If by quality we mean clinical effectiveness and outcomes, I’d argue it’s important but not enough.  Which is why the Institute of Medicine defines quality as having other domains beside effectiveness: safety, timeliness, efficiency, equity, and patient-centeredness.  This last dimension of quality includes incorporating  patients and families into the decision-making process and considering their preferences.  And patients are pretty clear that one of their preferences is to be treated with courtesy and respect.

There are now numerous sites where people can post ratings and comments about physicians, such as RateMDs.com.   The vast majority of comments are not about technical skill or knowledge, they are about listening, wait times, courtesy, bedside manner.  These things matter, especially as individuals are paying more of the very high cost of health care out of their own pockets, and demanding value for what they spend.  Not only consumers, but professional organizations such as the Robert Wood Johnson Foundation are leading efforts to make the health care experience more patient-friendly.

At Children’s Hospital of Wisconsin, we have long measured patient satisfaction and experience, but haven’t always been as focused on it as we should be.  This is changing, and with people at all levels of the organization starting to pay attention to experience, satisfaction is improving.  In some of our areas, like imaging, the emergency department, and the Surgicenter, our scores are now well above the national average for pediatric hospitals.  But we have a ways to go.  Eventually, we need to rethink many of our assumptions about how healthcare is different from other industries.  People used to think that cars, computers, and airline travel were different, too – too complex for the average person to evaluate on their own.  Yes, computers are complex; it takes as much education and training to build and program computers as it does to become a doctor.  But somehow even someone like me who has never taken a computer science class in his life can buy and use one without any specialized help.  Of course, when things don’t go right I seek expert assistance, but even there, I shop for that service the same way I do for everything else, judging them not on whether they can fix the problem (I expect that), but on how long it takes, whether they are nice or rude, how well they explain things, and how much it costs.

If you think experience doesn’t matter, watch this video comparing health care to the airline industry.  It’s funny and shameful at the same time.


Sold to the Highest Bidder

March 21, 2014

CHW LogoImagine if William Shatner were your doctor.  Crazy, no?  What about buying your health care from him?  After all, he has been the face of PriceLine.com, where you can bid on hotels, flights, cruises, etc.  Almost anything but healthcare.

Until now.  Along comes MediBid™, an online auction for medical care including physician services, hospital stays, durable equipment, etc.  Sounds like something from The Onion, but it’s real.  According to their Web site, “MediBid offers cash paying patients seeking care the ability to find the medical practitioner who best fits that patient’s set of criteria.  Criteria that can include price, location, time-to-treatment…. even professional credentials.  Unlike traditional network sources, your healthcare decisions are in your hands, not someone else’s.”

Prospective patients enter a request for a procedure such as MRI or knee replacement, and providers may then submit bids for that procedure.  MediBid charges fees for both requestors and bidders, but otherwise does not get involved in the transaction.  They do not handle any payments, and make it clear that they do not do any background checking or verification of a provider’s credentials.  So let the buyer beware.

It sounds radical, maybe even a little creepy.  And I’m not sure this is truly taking off; one article from October 2013 says that since its founding in 2010 MediBid has connected 1800 providers and patients.  But Star Trek communication devices and talking computers seemed far-fetched in the days when William Shatner played Captain Kirk.  Let’s not laugh this one off just yet.


Getting to the Healthiest Kids – Update

March 14, 2014

CHW LogoThe link between socioeconomic status and child health has long been appreciated at least intuitively, but the details of that link are becoming clearer.  Two recent studies in the journal Pediatrics provide specific details about aspects of poverty that adversely affect the health of children.  Such knowledge, in turn, can inform policies aimed at making kids healthier.

1.  A study from Cornell University examined the relationship between income inequality and child abuse.  Looking across all 3142 US counties, there was a linear relationship whereby the counties with the highest levels of income inequality had the highest rates of child maltreatment.  The effect was independent of other factors such as absolute levels of poverty and education.  This confirms other studies that have shown that not only income but income inequality affects the health and well-being of individuals.

2.  Researchers at American University reported that, among households at below 300% of the federal poverty level, food prices are associated with rates of overweight children. Specifically, higher local prices of fresh fruits and vegetables correlate with higher weight and body mass index (BMI); conversely, lower prices for soft drinks correlate with higher weight and BMI.  The authors exploited the fact that the database they used tracked children over time.  Not only was the relationship between fresh food price and weight true when looking across children who live in different areas, but it also held when they examined children who had moved over time; such children’s weight trajectory was different depending on food cost differences between old and new areas of residence.  Again, this bolsters our previous understanding about how lack of access to fresh foods can adversely affect child health.  Fortunately, the 2014 farm bill contains some provisions that may mitigate this, including increased support for organic farming, ability to use food stamps at farmer’s markets, and programs getting schools to grow their own food.


Decisions, Decisions

March 10, 2014

CHW LogoI consider myself somewhat  risk averse.  For example, my brother-in-law is an entrepreneur who is borrowing and putting a good bit of his savings to start a new craft brewery; as much fun as that sounds, I don’t have the stomach for that kind of gamble, and I suspect the majority of people don’t (that’s why most of us are not entrepreneurs).  On the other hand, lots of people buy lottery tickets, which also seems like a pretty risky gamble.  So what’s the difference?

The answer may lie in prospect theory, as explained in a recent JAMA article.  Building on work by behavioral economists Daniel Kahneman and Amos Tversky (and laid out in more detail in Kahneman’s book Thinking, Fast and Slow), prospect theory is a framework for understanding choice.  There are several basic tenets.  First is that people tend to simplify complex choices by focusing on key differences, while ignoring similarities.  For example, when deciding on a vacation destination, if choice A will cost $2000 and require 8 hours of travel, while choice B costs $5000 but only 7 hours of travel, the difference in travel time will likely not even be considered in the decision, which then becomes simpler.  Second, choices are made with regard to a reference point, not on the absolute value.  Two candidates for a position will see a salary offer of $50,000 very differently if one is currently making $40,000 and the other is making $60,000.  This may seem obvious.  In health care, treatment outcomes are going to be weighed against that reference point, which may be a patient’s current state of health, or a remembered past state of health.  Difference in reference points explain some of the difference in risk tolerance between individuals.  A corollary to the concept of the reference point, one that is backed by a good deal of experimental evidence, is that people tend to prioritize preventing a loss over achieving an equal gain.  This is called the endowment effect – we feel the loss of something we already have more than the regret at not getting something we only hoped for.   In one interesting experiment, people were offered the chance to buy a mug a coffee mug, or given the mug and then given the chance to sell it.  People were willing to pay on average about half as much to acquire mug they didn’t have, compared with what they would accept to part with the one they had gotten for free.  It appears that a bird in the hand is quite literally worth two in the bush.

The third element of prospect theory is that, after simplifying and framing the choice, people consider the desirability and probability of each outcome and estimate the expected value of each choice.  However, there are many cognitive inconsistencies and biases that creep in.  For example, we tend to place more weight on proportional than absolute differences.  A difference between winning  $1 and $3 is not treated the same as the difference between $98 and $100, even though each results in someone being able to buy one additional cup of coffee the next day.   Conversely, very small probabilities are difficult to deal with intuitively.  We tend to either ignore them completely (as in, my chance of winning the lottery went up 10-fold, from 1 in 10,000,000 to 1,000,000 – it’s still nearly impossible so I’m still not buying a ticket) or blow them out of proportion (as in, Did you see that the size of the pot is at a record $700 million – how could you not buy a ticket!)  Prospect theory only helps us understand decision-making.  It doesn’t actually make it rational.

These insights into how we, and our patients, make decisions may help us in practice.  There are several studies showing that parents and physicians differ in the values they assign to various short- and long-term outcomes, presumably because of different reference points.  Parents and patients also make different choices when the decision is framed in terms of a gain or a loss, for example, chance of survival versus chance of dying.  This all suggests a need to see the world through someone else’s eyes if we want to help them come to the best decision for them.  We need to understand the filters – theirs and ours.

It also helps us potentially make better business decisions.  Prospect theory suggests that in the face of a small chance for a large gain, we tend to reject choices with a much greater degree of certainty for something that is less lucrative.  For  example, if offered $2 in cash or a $2 lottery ticket, most people would take the ticket.  We don’t see either choice as a loss, and from our reference point the high likelihood of the small gain may not be worth forgoing the small chance to hit it big.  But a forgone gain IS a loss (I gave up a free cup of coffee).  This argues for a rigorous process for providing an objective calculation of the actual expected value of  each of the possibilities in a business decision.  As another example, “cutting one’s losses” may be the best strategy for avoiding further losses.  But we know that, because of the endowment effect, we tend to overvalue what we already have, which makes it emotionally difficult to let go even when that would make the most sense.

In  the meantime, while starting a brewery may not be in my risk comfort zone, the Old Bust Head beer is pretty tasty – trying one is no gamble at all.  (Alas, it’s only available in Virginia for now….)


Obama’s Fault Again?

March 3, 2014

CHW LogoDaniel Patrick Moynihan, former NY senator and UN ambassador, once said, “Everyone is entitled to his own opinion, but not to his own facts.”  This came to mind immediately when I saw the results of a recent Kaiser Family Foundation poll on health reform.  The poll, which has been tracking public opinion about the Affordable Care Act (a.k.a. Obamacare) for the past four years, found that support remained anemic at 47% overall favorable.  As Moynihan said, everyone is entitled to his or her opinion.  (Disclaimer: I was not originally a big fan of the ACA – I didn’t think it went far enough – but have come to think it’s better than nothing.)  But two other statistics caught my eye.  Half of all respondents believe that health care costs are now rising faster than usual since Obamacare was passed, and 48% think that Obamacare is the primary reason.  That’s playing with the facts.

The reality is that healthcare costs have actually risen more slowly since 2009, a trend that has continued for four years.  Moreover, we need to distinguish the different ways this is often expressed.  First is overall healthcare spending.  That has risen, an average of 3.7% annually since 2009, compared with an average of 6.1% for the four previous years.  More importantly, for the first time in decades, health care spending grew slower than overall GDP in 2012.  As a result, the proportion of all US spending that goes to health care decreased from 17.3% of GDP to 17.2%.  Not exactly time to spike the football (the next highest country is still only around 11%).  But it’s clearly the opposite of an increase.

Of course, overall spending is a factor of a number of things – population, price, and utilization.  Some of the overall increase is a result of more people, so when we look at total spending per capita, the story is even more dramatic: a 1.9% annual increase since the ACA, compared with a prior average of 3.9% per year.  And arguably, price is the thing that people are most concerned about – how much is the same service going to cost me?  Medical price inflation was only 1.7% in 2012; after decades where health care price increases outpaced general inflation, it is now essentially the same.  And when parsing how much each of the factors contributes to the overall increase in healthcare spending, price increases now account for 50% of the increase, in contrast to the 80% proportion in earlier years.

There is a good deal of debate about why health care spending increases have slowed.  Among the factors postulated include: the generally bad economy (though the decreases have persisted despite 3 years of solid albeit suboptimal economic growth); the shift to high-deductible health plans (i.e., more consumerism), a trend driven in part by the so-called “Cadillac health plan tax” in the ACA; and some provisions of Obamacare such as accountable care organizations, Medicare payment changes, and penalties for hospital readmissions.  The consensus seems to be that the ACA itself has probably played a minor but real role.

So let’s have a debate about why spending has slowed down.  Feel free to opine about whether Obamacare is good policy, whether it will do what it set out to do, whether the roll out could have been handled better, or even whether you like the name.  Those are all fair game, and I myself have mixed feelings about all of these.  But regardless of the degree to which you credit Obamacare for the decrease in spending growth, you cannot blame it for the faster spending increase, which didn’t actually happen.  That’s just making stuff up.


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