Tuesday, June 18, 2013

Punishing People by Denying Them Health Care

What if someone proposed a law to deny federally subsidized health insurance coverage to anyone who has violated a federal law?  And to make sure the punishment really hurts, to make it impossible for their children to get health insurance?  And to prohibit them from buying private health insurance at their own expense? And to impose such punishments even if they haven't actually been charged and convicted of a crime?

The result would be tens of millions of U.S. residents losing access to health insurance coverage--from college students who use marijuana to CEOs who don't report all of their income to the IRS to airline passengers who refuse to follow lighted signs and placards, each a violation of federal law.

If such a law were proposed, my guess is that most people would be outraged.

But denying access to healthcare for the millions of persons who are in the United States in violation of federal law (undocumented persons) is exactly what is being proposed by amendments being offered this week to a bipartisan Senate immigration reform bill. (To be accurate, being present in the United States in violation of federal immigration law is not, standing alone, a crime, although entering the U.S illegally can be a misdemeanor or a felony, depending on the circumstances.)

The Senate's bipartisan immigration reform bill would create a pathway for undocumented persons to transition to provisional legal residency status and then to permanent legal residency and later, if they meet all of the bill's many conditions, become citizens. How their immigration status would affect access to federal health care programs has become a flashpoint in the debate.

The bill as introduced would continue current federal laws that make undocumented persons ineligible for non-emergency Medicaid coverage, Medicare, or subsidized coverage under the ACA.  But once those previously undocumented persons achieve permanent legal residency status, they would, after a waiting period, be able to apply for federal health benefits, like any other permanent legal resident with a green card.  The bipartisan group of Senators that put together the bill generally agree with the principal that people in the U.S. who are not legal residents should not have access to federal health benefits, but after they gain permanent legal residency, they should be treated like anyone else who has the same legal status.

But several amendments up for debate this week would punish undocumented persons by, on the one hand, forcing them to buy health insurance they can't afford, and then on the other hand, making it harder and longer for them to qualify for federal health benefits even after they attained permanent legal residency status.  The American College of Physicians, in a letter sent on Monday to the entire U.S Senate, pointed out the deleterious impact such amendments would have on immigrants' access to health care and specifically, ACP made the following recommendations:


"ACP opposes legislation that would subject persons with registered provisional immigration status to the requirement that they purchase health insurance when they will have no ability to obtain subsidies to make such coverage affordable. According to the Institute of Medicine’s Insuring America’s Health report, inability to afford coverage is the primary reason people are uninsured. The College believes that to be successful, a requirement to purchase health insurance (i.e. an individual mandate) cannot exist on its own – it must be established along with comprehensive health insurance reforms that include subsidies to make coverage affordable for the uninsured, reforms to stabilize costs and ensure access, and an enforcement mechanism to guarantee compliance. The ACA established these reforms along with the requirement that individuals purchase health insurance. The College strongly believes that the individual mandate should only be established along with appropriate subsidies to help people purchase and afford quality coverage. Under the current reforms and proposed legislation, individuals with registered provisional immigration status would not be eligible for the ACA subsidies, including premium tax credits and lower co-payments. Therefore the College would oppose enforcing the individual mandate on individuals with registered provisional immigration status. Imposing this requirement would likely put undue financial strain on these individuals to purchase insurance that is beyond their financial means.

ACP supports allowing undocumented persons, as well as those with registered provisional immigration status, the ability to buy coverage through the ACA’s health exchanges at their own expense, without federal subsidies or an individual insurance requirement. As discussed above, the College would oppose requirements for individuals with registered provisional immigration status to purchase health insurance. However, the College supports allowing these individuals to purchase insurance through the ACA’s health exchanges using their own funds. The College opposes policies that prohibit persons, regardless of their residency status, from paying out-of-pocket for health insurance coverage through the health exchanges.

ACP supports treating all lawfully permanent residents the same when making determinations on qualifying for the ACA’s subsidies, access to exchanges, Medicaid coverage under the ACA, and other federal health benefit programs. Persons who have transitioned from registered provisional immigration status specifically should not be subjected to longer waiting periods or other benefit restrictions, other than those already imposed on lawfully permanent residents.

ACP opposes legislation that would make it practically impossible for undocumented residents to ever achieve a status that would enable them to qualify for federal health benefit programs that are available to lawful permanent residents, once such undocumented persons achieve lawful permanent residency status. The College also opposes polices that would deny them the ability to achieve provisional or lawful permanent residency based on a determination that they would likely receive government benefits including health coverage under the ACA, Medicaid, CHIP, or other federal health programs."

The College's letter noted that immigrants contribute more to funding federal health programs than they take out in benefits. "A recent Health Affairs article found that immigrants, particularly noncitizens, heavily subsidize Medicare through several ways including self-employment taxes and payroll taxes. Researchers found that in 2009, immigrants contributed $13.8 billion more to the Hospital Insurance Trust Fund than it paid out on their behalf. In addition, immigrants, especially non-citizens, use less health care and spend less on health care than do the U.S.-born."

ACP concluded that, "in balancing the needs of our country, it is imperative that immigration reform legislation addresses access to health care for all immigrants. Access to health care for the immigrant population is important to the overall population of the U.S. ACP is strongly committed to advocating for increased access to quality health care for all, regardless of race, ethnicity, socio-economic status, or other factors."

Yet as important as this issue is for access to healthcare, it seems like much of organized medicine, unlike ACP, is sitting this one out.  Where is the AMA?  State and county medical societies?  Other specialties?  Where are the individual and collective voices of physicians in expressing to their Senators that the medical profession is united in opposition to laws that limit a patient's  access to health care in order to punish them for violations of immigration laws?

The Institute of Medicine has found that tens of thousands of U.S residents die because they lack health insurance.  Making it harder for immigrants to get coverage, then, is not just a slap on the wrist, but can be a form of capital punishment for what is, after all, usually just a misdemeanor offense under federal law. 

Today's question:  Do you think more physicians should speak out against proposals to punish undocumented persons by denying them access to health care?

Thursday, June 13, 2013

What baseball can teach physicians and nurses about working together

The seemingly irreconcilable conflict between the medical and nursing professions usually boils down to one question: who is in charge?  Physicians often use a football analogy: they are the quarterbacks of the team, calling the plays that others on the gridiron must follow, because of their greater training and skills.  Advanced Practice Nurses (APNs) respond: not so, we are also highly trained and qualified to call the plays and lead the team. 

Instead of looking to football on how to organize the relationship between the medical and nursing professions and others on the health care team, baseball may provide us with a better example. Consider this:  

Baseball is both a team and an individual sport.   In baseball, the final outcome depends on both the performance of the team as a whole but also, in any given situation, on the skills of the individual players: the control of the pitcher on the mound, the skill of the catcher in calling pitches and fielding balls in the dirt, the ability of the batter to wait for a pitch he can drive, the quickness of the infielder fielding a tricky one-hopper, or the outfielder positioning himself to make a running catch in the gap.  Each individual player’s contribution in each individual game situation determines what happens at that particular moment, but they can’t do it alone, it is the skill of the entire team working together that determines the outcome.  Does the pitcher make the right pitch to retire the batter, does the opposing team’s batter strike out or put the ball in play, if the batter puts it in play does the infielder field it cleanly and make a good throw, and if he does, will the pitcher get to first in time to take the infielder’s throw, beat the runner and get the out?

 So it is with healthcare.  The skill and performance of an individual clinician, in meeting the needs of an individual patient at any particular moment and in any particular clinical situation, may determine the immediate clinical outcome.  But if the attending clinician doesn’t work well with others on the team, doesn’t have others backing her up, doesn’t rely on others with different skills as needed, something is likely to go terribly wrong for the patient.

Baseball has both generalists and specialists.  Baseball’s “generalists” are the utility players who are versatile because they can field any position, they may not be the best hitters but they get plenty of playing time because every team needs them to fill in when someone gets hurt or as late inning defensive replacements.  Baseball’s specialists include the elite “five-tool” players who do everything well (except maybe pitch): they can field, run, hit for average, hit for power, throw and catch the ball as well as anyone. Players like the Washington National’s young Bryce Harper. 

Baseball has other specialists:  elite and middling starting pitchers, middle relievers, set-up guys, closers, base stealers, pinch hitting specialists,  defensive replacement outfielders, lead-off hitters, and of course, the everyday position players (like shortstops, outfielders, catchers, third basemen) who have to master the intricacies of their own positions in a way that no one else can.

The specialists and generalists on baseball teams are not substitutable for each other:  Try asking a skilled shortstop to replace a skilled catcher, or vice versa, and you’ll be looking for trouble.  They are both skilled at their positions but they have different skills that aren’t substitutable or equivalent.   

So it is with healthcare.  Every healthcare team has specialists and generalists, each member of the them has his or her own role, each is skilled in what they do best and can’t substitute for someone with different skills, each knows they will be called upon when the patient’s situation requires their distinctive skills, and each knows that they can’t do it alone.  A neurosurgeon can’t substitute for an internist, or an internist for the neurosurgeon, or the advanced practice nurse for the internist, or the internist for the advanced practice nurse, all are needed to practice at the top of their skill level.

Baseball is situational and dynamic. In each particular game situation, you want the most skilled player available; your best power hitter when you need the three run blast, the guy with the highest on-base percentage when you need to get a rally started, the catcher who is most skilled at fielding balls in the dirt if you have a knuckleballer on the mound, your fastest runner to pinch run for a slow footed starting player, your lefty specialist brought in to get one player out, your best closer to end the game.  And when it is the equivalent of the game being on the line, you want your best five-tool player to be at bat or in the field, the one guy you know you can count on to get the job done.

So it is with healthcare. In each particular clinical situation, you want the most skilled clinician available, the trauma surgeon to treat trauma, the nurse educator to help the diabetic patient take control of her blood sugars, the neurosurgeon to operate on a life-threatening brain injury, the rheumatologist to take care of the lupus patient, the internist to diagnose and develop a treatment plan for the patients with the most challenging, presenting symptoms.   When it is the equivalent of the game being on the line, when it is a matter of life or death to someone, you want the physician who is the equivalent of the five-tool elite baseball player, the one with the highest skills needed to diagnose and treat that patient’s particular condition.   If it is a surgical procedure, you want the best surgeon with the specific training needed.  If it is a complex patient with multiple chronic conditions, you want an internal medicine specialist.  Calling Dr. Bryce Harper!

But you also want everyone else on the team to be performing at the top of their skills, because no one clinician can do it all.  Bryce Harper, for all his talent, can’t win games for the Nationals if others on the team don’t know their roles or aren’t performing as well they should (the Nat’s .500 underachieving record isn’t because Bryce isn’t doing his job well!).

In baseball, there is no one person in charge of everything.  The manager may ostensibly be in charge, but the manager doesn’t actually play the game, at least not since the days of player-managers like Pete Rose.  Managers rarely make decisions that determine the outcome of the game; instead, they count on their players to do what they have been trained to do. The best managers get the most out of the players by helping them think of themselves as being a team of equals (even though objectively, some are more talented than others).  Teams that are a collection of talented players with big egos but who don’t play well together won’t succeed over a long season.

Baseball also has its General Managers, the front office guys who hire the managers and who draft and trade for players within a budget set by the owners, but they don’t call the shots on what happens on the field.  Baseball has its coaches, the grounds crew, the equipment guys, the supporting cast who help make the team succeed, they are in charge of their own areas of responsibility, but they don’t run the team.

So it is in health care.  Health care teams rely on their administrators, their finance people, their information system specialists, their front office staff, to make them as effective as possible.  They rely on each clinician on the team to know what to do in any given clinical situation and to take charge of a particular aspect of care as the situation requires.  Not because they have been anointed as to be in charge of everything, but because they are the most qualified to handle a given situation within their own expertise and domain, and then another member of the team may take charge for other elements of care within their own expertise and domain.

In baseball, everyone is ultimately accountable for the results: underperforming players are traded, cut or sent down: underperforming managers and GMs are fired; even talented players who don’t get along with others are off-loaded.  And baseball’s outcomes are constantly measured: team outcomes like winning percentages, games behind or ahead in the standings, team batting average, and team pitching earned run averages. Individual players’ performances are measured by batting averages, on base percentages, home runs, RBIs, slugging percentage, and individual pitchers by ERA, strikeouts and walks per inning, saves and blown saves, and so many more sabermetrics.  (And you think physicians have it tough today with the rudimentary performance measures applied to them?)

Of course, I know I am overplaying the baseball and healthcare team analogy to make a point.  There are big differences between what really is just a game (although for die-hard fans like me, the outcome of a baseball game can seem like a life and death situation!), and health care, where the performance of the team really can mean life and death.  And surely, it is much harder to measure the performance of the clinicians on a healthcare team than baseball players.

But I think there are lessons from baseball that are applicable to health care.  The best baseball teams are the ones who get most things right: they have the right combination of specialists and generalists, they have players that perform well as individuals but also as teammates, they have players with great talent but also versatile utility players who can do a bit of everything, they are dynamic and situational, matching up and using the specific talents of each of their team members effectively based on the changing game situation at a given time, they let everyone play and contribute to the best of their ability, and they don’t need to be told by their manager who is in charge, because they know that they all are responsible and accountable for what happens on the field.

Shouldn’t this be true of health care teams as well?  There are no quarterbacks in baseball, and maybe it’s time to put aside the concept that there should be quarterbacks in health care.

Today’s question: Do you agree or disagree that we should put aside the concept that there should be quarterbacks in charge of the health care team?

Thursday, June 6, 2013

Can price transparency bridge the ideological divide over health care?

Most Republicans hate Obamacare for what they consider to be government over-reach, most Democrats support it because they believe only a strong policy of government intervention can extend coverage to the millions of uninsured—and there are no signs that their ideological battle will abate anytime soon.   But there may be one sweet spot that both parties could agree on: providing consumers (or patients, if you prefer) information on the prices charged by health care providers.

Free-market conservatives should welcome price transparency, because market competition can’t work without it.  If the best way to lower healthcare costs and improve quality is for consumers to shop around, then they need to know what each provider in their community will charge for a given medical procedure, and armed with this information, seek the best deal available..  But without price transparency, this is impossible.

Liberals should welcome price transparency, because having the government extend coverage to millions will be enormously expensive, unless the United States can also simultaneously use a combination of market competition and government purchasing power to drive down health care prices.  (Higher prices-- not excess utilization-- is the biggest reason that the U.S. spends more per person on healthcare than any other modern industrialized country).   Plus, liberals are naturally distrustful of for-profit health care.  But without price transparency, the government will be hampered in its ability to use its clout as the single biggest buyer of health care to get the best deal for taxpayers—and to empower consumers to shop around for the best price. 

But will physicians and hospitals welcome price transparency—or fight it?  You would think that most physicians would want to know what the local hospital, pharmacy and their physician colleagues are charging before they refer a patient to them.  (Maybe not for hospitals, which seem to mostly benefit from the lack of price transparency).   But what if shining the light on health care prices shows that a physician’s own prices are on the high side?  Or what if you are in a medical specialty that benefits from high pricing?  And, of course, a physician who is identified as having higher charges will likely respond that “my prices are higher” because my patients are sicker and more complicated” or “I am worth more because I am the best” or “prices aren’t the whole story—what about quality?”

A new must-read New York Times article, The $2.7 trillion Medical Bill: Colonoscopies Explain Why U.S. Leads the World in Health Expenditures, illustrates the practical and political challenges involved in introducing price transparency into U.S. health care.   Using colonoscopy as a case in point (although the article makes it clear that high prices and lack of price transparency in the U.S. is hardly limited to this one procedure), the article suggests that Americans pay far more for their healthcare than people in other countries do.  The article also shows how much variation there can be within the U.S. on the prices charged for medical procedures.  And it also shows how difficult it is to even understand what the actual price will be before you sign up for the procedure.

Variation in prices:  “Deirdre Yapalater’s recent colonoscopy at a surgical center near her home here on Long Island went smoothly: she was whisked from pre-op to an operating room where a gastroenterologist, assisted by an anesthesiologist and a nurse, performed the routine cancer screening procedure in less than an hour. The test, which found nothing worrisome, racked up what is likely her most expensive medical bill of the year: $6,385.That is fairly typical: in Keene, N.H., Matt Meyer’s colonoscopy was billed at $7,563.56. Maggie Christ of Chappaqua, N.Y., received $9,142.84 in bills for the procedure. In Durham, N.C., the charges for Curtiss Devereux came to $19,438, which included a polyp removal. While their insurers negotiated down the price, the final tab for each test was more than $3,500.”

Higher prices: “In many other developed countries, a basic colonoscopy costs just a few hundred dollars and certainly well under $1,000. That chasm in price helps explain why the United States is far and away the world leader in medical spending, even though numerous studies have concluded that Americans do not get better care.”

No price transparency:  “Consumers, the patients, do not see prices until after a service is provided, if they see them at all. And there is little quality data on hospitals and doctors to help determine good value, aside from surveys conducted by popular Web sites and magazines. Patients with insurance pay a tiny fraction of the bill, providing scant disincentive for spending. Even doctors often do not know the costs of the tests and procedures they prescribe. When Dr. Michael Collins, an internist in East Hartford, Conn., called the hospital that he is affiliated with to price lab tests and a colonoscopy, he could not get an answer. ‘It’s impossible for me to think about cost,’ he said. ‘If you go to the supermarket and there are no prices, how can you make intelligent decisions?’ Instead, payments are often determined in countless negotiations between a doctor, hospital or pharmacy, and an insurer, with the result often depending on their relative negotiating power. Insurers have limited incentive to bargain forcefully, since they can raise premiums to cover costs.”

Confusing prices:  The price of a colonoscopy depends not only on what the gastroenterologist charges for the procedure itself, but where the procedure is done (office or ambulatory surgical center) and whether an anesthesiologist is involved.  “Just as with real estate, location matters in medicine. Although many procedures can be performed in either a doctor’s office or a separate surgery center, prices generally skyrocket at the special centers, as do profits. That is because insurers will pay an additional “facility fee” to ambulatory surgery centers and hospitals that is intended to cover their higher costs. And anesthesia, more monitoring, a wristband and sometimes preoperative testing, along with their extra costs, are more likely to be added on . . .‘If you work as a ‘facility,’ you can charge a lot more for the same procedure, said Dr. Soeren Mattke, a senior scientist at the RAND Corporation. The bills to Ms. Yapalater’s insurer reflected these charges: $1,075 for the gastroenterologist, $2,400 for the anesthesia — and $2,910 for the facility fee.”

No price competition: “If the American health care system were a true market, the increased volume of colonoscopies — numbers rose 50 percent from 2003 to 2009 for those with commercial insurance — might have brought down the costs because of economies of scale and more competition. Instead, it became a new business opportunity.”

Patients insulated from price: “’Could that be right?’ said Ms. Yapalater, stunned by charges on the statement on her dining room table. Although her insurer covered the procedure and she paid nothing, her health care costs still bite: Her premium payments jumped 10 percent last year, and rising co-payments and deductibles are straining the finances of her middle-class family, with its mission-style house in the suburbs and two S.U.V.’s parked outside. “You keep thinking it’s free,” she said. ‘We call it free, but of course it’s not.”

Standards of care leading to higher prices: “Ms. Yapalater’s insurer paid $1,568 of the $2,400 anesthesiologist’s charge for her colonoscopy, but many medical experts question why anesthesiologists are involved at all. Colonoscopies do not require general anesthesia — a deep sleep that suppresses breathing and often requires a breathing tube. Instead, they require only ‘moderate sedation,’ generally with a Valium-like drug or a low dose of propofol, an intravenous medicine that takes effect quickly and wears off within minutes. In other countries, such sedative mixes are administered in offices and hospitals by a wide range of doctors and nurses for countless minor procedures, including colonoscopies. Nonetheless, between 2003 and 2009, the use of an anesthesiologist for colonoscopies in the United States doubled, according to a RAND Corporation study published last year. Payments to anesthesiologists for colonoscopies per patient quadrupled during that period, the researchers found, estimating that ending the practice for healthy patients could save $1.1 billion a year because ‘studies have shown no benefit’ for them, Dr. Mattke said.”

 Everyone benefits from higher prices (except the consumer?): “ Hospitals, drug companies, device makers, physicians and other providers can benefit by charging inflated prices, favoring the most costly treatment options and curbing competition that could give patients more, and cheaper, choices. And almost every interaction can be an opportunity to send multiple, often opaque bills with long lists of charges: $100 for the ice pack applied for 10 minutes after a physical therapy session, or $30,000 for the artificial joint implanted in surgery.”

Now, before I get a lot of angry comments from ACP members who are gastroenterologists, let me say that I have quoted extensively from the NY Times article because it chose to focus on colonoscopy—but the same combination of variation in prices, higher prices,  lack of price transparency,  confusing prices,  no price competition, patients being insulated from prices, standards of care leading to higher prices, and the fact that a lot of people benefit from higher prices, except maybe the consumer, applies to almost all health care services in the U.S.  And there may be  reasons that patients benefit from the pricing structure for a colonoscopy—and I would love to hear from gastroenterologists about them.   There may be good clinical reasons to have anesthesia administered by an anesthesiologist.  There may be benefit to the patient in having it done in an ASC. There is always another side to the story.

Still, it is hard to see how the U.S. will get a handle on health care costs unless it finds a way to make it easy for people to know in advance what they will be charged, to introduce real competition—price, quality, total cost of care—into the system, to allow the federal government to use its purchasing power to get the best price, quality and cost of care provided to persons in government-funded insurance programs, and to give patients some skin in the game on paying some of the cost if they can afford it.

Two former advisors to President Obama, who helped create Obamacare, call for such a “transparency initiative,” in a commentary  published in ACP’s Annals of Internal Medicine:

“For meaningful progress on transparency to occur, there must be a change in attitude throughout the system. All payers should be required to make their claims data publically available, with privacy protections, to enable quality measurement. Of importance, to protect privacy, the federal government should substantially increase the penalties for inappropriate patient re-identification. Personalized pricing information should be made available for comparison before patients enter a care process. Both total price and patient price should be transparent to providers in shared-savings payment models to enable cost management. Only patient price should be available to providers in fee-for-service networks to mitigate the risk for price increases. Fortunately, there is much that stakeholders can do. The federal government can relax restrictions on access to Medicare data. Other states should follow the lead of California and Massachusetts and require providers to disclose prices to patients before elective care. Health plans and employers should also support such transparency tools as Castlight.”

ACP itself, in a letter sent last week to the Senate Finance Committee, called on Congress to “Direct HHS to explore ways to provide physicians with accurate data on the quality and total cost of care provided by other clinicians and hospitals within their geographic communities to enable them to make informed referral decisions.”   The College also called for Congress to “Eliminate provider-based billing delivered in an outpatient, hospital-system owned practices when the care being provided is not dependent on the hospital facility and its associated technologies. However, elimination of provider-based billing in such circumstances should only be carried out in conjunction with other new and innovative approaches, building on payment and delivery system reform efforts, in order to ensure adequate support of safety-net facilities.”

And recently, Medicare has taken preliminary steps to make comparative pricing data more available, earlier this month for hospital inpatient charges and then this week, for  hospital outpatient department charges  for common procedures.  And, a federal judge recently overturned a 33-year old ban on patients having access to physicians’ claims data.  The NBC News report notes that  “The American Medical Association had fought lifting the ban, arguing that disclosure of the information would violate physicians' right to privacy. Doctors had successfully made the same argument in 1979, when a judge ruled the release of such information would violate the 1974 Privacy Act.”

So here is my challenge to readers of this blog, especially physicians: if you are a liberal who wants to get the best value for the health care that the government is buying under Medicare, Medicaid, the VA, TriCare, and Obamacare, or a conservative who believes that market competition is the best way to drive down health care costs, will you unite behind efforts to shine a light of health care prices?  Even if shining that light raises difficult questions about what you, your colleagues and your hospitals are charging for your services, your ownership of diagnostic and treatment centers, your standards of care, and your referral patterns?   Or will the medical profession try to keep all of this out of the public eye, even if it means,  “Whether directly from their wallets or through insurance policies, Americans pay more for almost every interaction with the medical system.”

Today’s question: Will you support making data readily available to the public, and to physicians, on the price, quality and total cost of care of the services that you, your hospital, and your colleagues provide, before care is delivered (whenever possible)?  If not, why not?