Category Archives: health care reform

Kids with Benefits*

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The CDC issued a report last week on health insurance status in the United States.

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Given the stalled economy and the era-defining unemployment rate, you might not be surprised that there’s an overall increase in the number of uninsured Americans. After all, most of the coverage benefits of the 2010 health care reform act (PPACA) don’t go into effect until 2013.

Hey kids! Welcome to the mosh pit of health care.

But for one group, kids ages 19-26, there’s been a major increase in coverage. This is due to a provision in the law that allows kids to stay on their parents’ plans through age 26 [*clarification: until their 27th birthday], regardless of their career status (still in school? entered the workforce?) or their location (they aren’t required to be living at home or even in the same city!).

There were about a million more insured young folk in the first three months of this year compared to the same period a year earlier, according to the research. This exceeds the government’s own projections. Apparently, young people (O.K., their worried but smart parents) know a good deal when they see one.

I looked around for some criticism of this aspect of the health care reform law, but wasn’t able to find any. I wonder if that’s because it’s generally acknowledged that this age group is generally healthy (err, excepting some poor personal health choices on occasion) and seldom requires expensive items like hospitalizations, long term care, or costly medicines for chronic disease.

Health insurers must comply with this provision of the reform law, but they get to look magnanimous since it doesn’t cost them very much to provide the added coverage.

Proponents of national health insurance often speak of expanding Medicare (the government health insurance program for the elderly and disabled) to the vast middle of the population, those between the ages of 19-64. Well, starting at the easy end seems to be working. It’s what to do about that older end of the spectrum that gets challenging.

Anecdote alert: Young people, e.g. recent college grads, are starting to make their way in the world. I have a sister, herself a recent college graduate, who moved to a big city to pursue a job in business. By report of her and her peers, it seems companies are interested in hiring entry level kids in only in temporary positions–the better to avoid taking them on as full time employees with benefits. Some will eventually be hired, others may not work out. But in either case, these kids (assuming their parents still have health coverage) can safely remain on their parents’ policies.

Peace of mind for them and their folks.

____________________________

*clarification added in third paragraph regarding duration of coverage.

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Health Care Privacy Primer

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Health Care: Confidential?

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.                         - oath of Hippocrates, circa 400 B.C.

As part of our initiation into the profession, doctors recite the Hippocratic oath (or often a modernized version). I like to remind myself that the ancient Greeks valued confidentiality as much as we seem to today.

Since 1996, the law known as HIPAA has become paramount in enforcing this Hippocratic ideal here in the U.S. Originally intended to prevent the loss of health insurance due to change of employers, HIPAA has instead become a buzzword for protecting the public from its own medical records.

The law’s implementation demonstrates both sides of the government regulation debate: it came down as an unfunded regulatory mandate, forcing health care providers (especially hospitals) to invest heavily in creating infrastructure that neither delivers care nor brings in revenue in order to achieve compliance with the law. On the other hand, an entire industry and thousands of jobs have been created to administer, police, interpret, and adjudicate the new rules.

Hospitals have offices devoted to banging the drum in the name of protecting patients’ information from prying eyes. You have to wonder: Does any of this work?

One famous paper, citing the fact that no fewer than 75 different people have access to a hospital chart on average, called confidentiality a “decrepit concept.”

With the profusion of electronic medical records, the remnant notion of confidentiality is further challenged. Earlier this month it was discovered that a prestigious West Coast hospital experienced a breach in which more than 20,000 patients had their names and diagnoses publicly viewable on a website for almost one year. Because of incidents like this, the government now tracks these types of breaches in a publicly searchable database.

Take a look and you’ll find that over the last two years alone, more than 11 million people have had private health information exposed.

HIPAA can be fun!

With stakes including huge financial penalties, bad publicity, and the threats of termination (employment, not existence) and/or prison, you can see why hospitals take this stuff seriously. The downside is that it’s become onerous to obtain your own medical records.

Hoops to jump through. Copying costs (really? how about emailing it to me?). Waiting periods (you need this now? Fat chance.).

A friend of mine, recently hospitalized, came to a follow up appointment with her primary care doctor. She informed the medical assistant that she’d like copies of her records from the associated hospitalization. Instant shut down mode: “You’ll have to speak with the doctor about that.”

Actually, um, no. HIPAA was never intended to prevent transmission of records to patients themselves, nor was it intended to block sharing of medical data among care providers. But too often that’s the message health professionals take away from their annual compliance, safety, and HIPAA lectures.

For the intrepid, I challenge you to figure out: What’s been the overall cost of HIPAA implementation? More importantly, has the law accomplished what it was drafted for? After all, it took the passage of Obama’s health care reform bill (PPACA) to ensure that people won’t lose health insurance despite changes in job status. Is HIPAA simply a smorgasbord of unintended consequences?

On the flipside of protecting private health information, what about the public’s right to know about the doctors that they go to? In an unrelated news story, the government yanked the public’s query access to something known as the National Practitioner Data Bank, a 1986 invention that keeps track of misconduct (either intentional or unintentional) by doctors. The Data Bank is used by all states and hospitals with regard to medical licensure and credentialing. Seems like the public has a compelling interest at stake here.

As in the real world, the medical world is locked in eternal an eternal struggle between privacy and transparency.

Soon the day will come when medical documentation shall be composed in plain language rather than jargon, and patients will not only have a right to that documentation, but will receive it at the “point of purhcase.” Eventually this will be a compelling market proposition; in the present, health care remains too local. People are willing to put up with whatever they can get nearby.

Comparison shopping has always been tough in medicine, where pricing is entirely convoluted and people don’t typically have “skin in the game.”

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Ruckus over the RUC

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An interesting legal case brewing in the medical world that’s worth sharing…

A legal challenge to specialty dominance.

A group of six physician plaintiffs from Georgia are suing the government (the Secretary of Health and Human Services) in a federal district court claiming damages from the fact that Medicare, the massive program that covers the elderly and disabled, fails to execute due diligence by rubber-stamping a reimbursement structure that overvalues procedural medicine over cognitive services.

Huh?

Some background is in order.

It’s no secret that specialists (e.g. radiologists, cardiologists, dermatologists, urologists, etc.) make higher incomes than primary care doctors (family doctors, internists, and pediatricians). Obvious reasons include more training, differentiated skill, and an ability to handle specific technical and/or surgical procedures that generalists aren’t able or authorized to provide.

But the non-obvious reason is a poorly publicized and shadowy body known as the Relative Value Scale Update Committee, or RUC. The RUC is a committee convened by the American Medical Association (AMA) and about two dozen medical specialty societies.

The RUC promulgates an annual report to CMS, the government’s Medicare and Medicaid arm. The update advises CMS on the ‘relative value’ of an extraordinarily lengthy list of medical services, including both procedures (things ‘done’ to patients) and cognitive services (those done for patients with a doctor’s hands, stethoscope, and brain).

The RUC has twenty-nine members, twenty-three of whom come from medical specialty societies. The list is publicly available.

Critics of the RUC point out that it’s a little like the Senate, in that smaller specialties gain outsized importance since representation is not proportional. This has in effect, so the argument goes, perpetuated the overvaluation of procedural skill over cognitive service. The downstream effect of this is twofold: a disparity in doctor incomes between generalists and specialists, but more importantly, ever-increasing cost of delivering health care as the premium on procedures incentivizes them.

Early commenters seem to suggest that the case will have meritorious legal standing. It certainly will be interesting to see what happens as the case wends its way through the judicial system.

There’s an excellent synopsis of the suit and the issues surrounding it on the Health Affiairs blog by Brian Klepper and David Kibbe, which I recommend to anyone with further interest. Here’s a key paragraph that may inspire you to click over:

The policy community should keep a close eye on this case, because its target is the beating heart of the American health care cost crisis. Aside from the primary care community, the plaintiffs are unlikely to have many organized supporters within a health care industry that has benefited so handsomely from the current payment regime. But the employer community as well as anyone who cares about the larger economic issues facing America should see the opportunity to largely correct a tremendous wrong in our system.

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County [Updated]

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Those of you that like to see behind the veil of medical care in the U.S. will enjoy the new book by Dr. David Ansell: County: Life, Death, and Politics at Chicago’s Public Hospital.

Ansell began internship at Cook County Hospital in 1978. He stayed there seventeen years.

Along the way, he got involved in politics, fighting the good fight for the poor and disenfranchised of Chicago. He co-authored the landmark 1986 New England Journal of Medicine article understatedly titled “Transfers to a Public Hospital,” that led to the passage of EMTALA that same year.

[EMTALA is the law that was enacted to prevent "patient dumping," the practice of transferring patients from one emergency room to another (such as Cook County) because of a patient's lack of insurance.]

Dr. Ansell was responsible for another success: he helped establish a breast cancer screening program for women at Cook County. Prior to his work, it was believed by many that only specialized breast surgeons could implement such a screening program. Ansell fought medically and politically to achieve better access for poor and uninsured women, in addition to showing that disease screening could adequately be handled by frontline health personnel and not just specialists.

Part of what made the book so interesting for me was the recent history of Chicago and the stories of Ansell’s colleagues at County–many of whom I’ve been lucky to meet and learn from over the years:

There’s Quentin Young, social activist and physician who doctored to MLK and Jesse Jackson, among others. There’s husband and wife team Gordy Schiff and Mardge Cohen, who have inspired generations of Chicago medical students to put their progressive values out front when thinking about their profession. There’s also Renslow Sherer, a pioneer in developing AIDS treatment both at home and abroad, and someone I’ve been blessed to call a colleague for the last few years.

County is an excellent exploration of one doctor’s professional development over a lengthy career. Ansell, in an NPR radio interview, was asked about the poor conditions at the hospital. He likened it to working in the developing world. He and his colleagues were “Doctors within Borders,” as contrasted with the esteemed NGO that works globally in humanitarian disasters.

One thing Ansell didn’t touch on: He now is Chief Medical Officer at Rush, a major academic teaching hospital in Chicago. He made the leap from anti-establishment to major power player in the Chicago health stratosphere. I would have appreciated learning more of his mindset as he made this transition to leadership. I wonder, too, about reconciling values from his longhair days of picketing and demanding change to the more cloistered world of institutional change in the executive suite.

Maybe I’ll ask those questions diplomatically when I interview him.

[UPDATE: Abigail Zuger reviewed County in the NY Times. Link here.]

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Thinking about Moms on Father’s Day

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Archival poster.

Last week an anesthesiologist in Los Angeles named Karen Sibert stirred up a hornets’ nest of controversy in an op-ed piece that was published in the NY Times.

The piece, titled “Don’t Quit This Day Job,” addressed the hackneyed issue of physician shortage in the United States.

Citing federal subsidies for graduate medical education (i.e. residency training), Dr. Sibert suggested that in order to stem the tide of part-timers (mostly women) contributing to the physician shortage, “…we can only depend on doctors’ own commitment to the profession.”

All well and good; yet depending on the magnanimity of those in a profession to save it from itself is never a successful strategy without a robust marketplace of ideas and innovation.

Dr. Sibert’s solution to the problem, however, was anything but hackneyed:

Students who aspire to go to medical school should think about the consequences if they decide to work part time or leave clinical medicine. It’s fair to ask them — women especially — to consider the conflicting demands that medicine and parenthood make before they accept (and deny to others) sought-after positions in medical school and residency. They must understand that medical education is a privilege, not an entitlement, and it confers a real moral obligation to serve.

Really?

We should ask women about their child-rearing plans before letting them go to medical school or take on a residency? Does that seem like a sensible way forward?

Dr. Sibert, citing her own full time commitment to the profession, declares:

You can’t have it all. I never took cupcakes to my children’s homerooms or drove carpool, but I read a lot of bedtime stories and made it to soccer games and school plays. I’ve ridden roller coasters with my son, danced at my oldest daughter’s wedding and rocked my first grandson to sleep. Along the way, I’ve worked full days and many nights, and brought a lot of very sick patients through long, difficult operations.

I’m glad for Dr. Sibert, but she comes across as self-righteous in the personal revelation in support of her larger claim. I certainly respect her right to have worked full time, but I’d never begrudge another professional the opportunity to work part time to help raise a family.

As you may imagine, there were some outraged letters sent in, including this one:

To the Editor:

While Dr. Karen S. Sibert’s point about the shortage of doctors entering primary care fields is valid, her proposal to address it by querying women on their future child-rearing plans smacks of patriarchy and sexism. Even if every medical school seat today were filled by a male student, at current rates of matriculation into primary care fields it would do little to mitigate the problem.

I chose to work as a part-time doctor early in my career to be supportive to my full-time physician wife. Being asked about my parenting intentions at any point in the process would have been chilling.

JOHN HENNING SCHUMANN
Chicago, June 13, 2011

I’d love to hear your thoughts.

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