• The doctor is out: PCP availability beyond 2020

    This is a guest post by David Anderson, a research associate at the Duke-Robert J. Margolis, MD, Center for Health Policy. You can follow him on Twitter at @bjdickmayhew and read his other work at the Balloon Juice blog

    In 2020 and beyond, under the Senate’s BCRA, the working poor will have a very hard time finding primary care providers (PCP) who will schedule appointments with them. Providers, rightly, fear bad debt from high deductible plans. They will discriminate on the ability to pay upfront.

    In the NEJM, Karin Rhodes, Genevieve Kenney, and Ari Friedman looked at PCP appointment availability in the from the end of 2012 to Spring 2013. They found that appointments were usually quickly available if the person had insurance and unavailable if they were cash paying patients who could not afford the median price of services.**


    The overall rate of new patient appointments for the uninsured was 78.8% with full cash payment at the time of the appointment (Figure 2). The median cost of a new patient primary care visit was $120, but costs varied across the states, as indicated in the figure legend. Only 15.4% of uninsured callers received an appointment that required payment of $75 or less at the time of the visit, because few offices had low-cost appointments and only one-fifth of practices allowed flexible payment arrangements for uninsured patients.

    Why does this matter in the BCRA environment?

    The baseline plan will be a plan with a $7,500 deductible for a single person. For people with means, paying $120 for a PCP visit is unpleasant but not onerous. If I had to do that this afternoon, I would grumble as I pull out a credit card. I would pay that credit card off tomorrow after I got the transaction points. Not everyone can do that.

    Craig Garthwaite raises a good point this morning:

    Read the rest of this entry »

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  • The waivers in the Senate health bill are crazy

    From my latest at Vox, on the Better Care Reconciliation Act of 2017:

    The Senate bill retains [the ACA’s] waiver provision—but removes the guardrails that ensured state-based alternatives would offer strong coverage. Under the Senate bill, to get a waiver a state doesn’t have to demonstrate anything about coverage. Instead, it just has to show that the plan won’t “increase the Federal deficit.” Once a state makes that showing, the bill is explicit: the Secretary of Health and Human Services “shall” approve the plan.

    Not “may” approve the plan: “shall.” This is a crucial legal distinction. The Supreme Court has squarely held that this sort of mandatory language means what it says: if the condition is satisfied, the Secretary has no choice but to give his approval.

    That could lead to some bizarre consequences. What’s stopping a state from submitting a half-baked plan for a high-risk pool that will lead millions of people to lose coverage? Or, for that matter, from using Obamacare money to fund public schools or affordable housing? According to the Senate bill as written, the Secretary would have to approve plans like that so long as they don’t increase the federal deficit. …

    And once a waiver is granted, the Senate bill says that the federal government cannot terminate the waiver, no matter what. It is hard to overstate how unusual—even unique—this is. When the federal government offers money to states, it places conditions on how the states are to use that money—and reserves the right to cut the states off if they fail to adhere to those conditions. The cut-off threat is essential to prevent state abuse of federal funds.

    The Senate bill removes that threat. It says that a waiver “may not be cancelled” before the waiver’s expiration. If state officials blow the Obamacare money on cocaine and hookers, there’s apparently nothing the federal government can do about it. At the same time, the bill expands the duration of waivers from five years to eight years. The upshot, then, is that the next president won’t be able to renegotiate any waivers granted during the Trump administration, no matter how badly a given state might have abused its waiver.

    Believe it or not, that’s not even the craziest thing about the new waiver rule. Read the whole thing!



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  • Get Well Sooner? A Healthier Roommate Could Help

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

    Your speed of recovery in a hospital is related to many things. Among them is one you might not consider: the condition of your roommate.

    A recent study published in the American Journal of Health Economics found that hospital patients who are assigned healthier roommates require less care and are discharged more rapidly, with no negative effects on their health. For example, a patient who rooms with the healthiest roommate has a hospital stay that is about eight hours shorter, requiring 27 percent less medical attention, and costing about $840 less, compared with a patient with the sickest roommate. Female patients with healthier roommates are discharged in better condition and have a smaller chance of requiring re-hospitalization.

    The study examined a broad range of hospital patients, including those who had surgical procedures — like heart bypasses or joint replacement operations — as well as those admitted for medical conditions like pneumonia or cancer.

    At first glance, there is an apparently obvious explanation for these findings: Patients are typically assigned to room with other patients of similar condition. In particular, healthier people are assigned to rooms farther from the nursing station. Therefore, healthier patients — those who require less care and are discharged more rapidly — also tend to room with relatively healthier patients. So there seems to be a noncausal connection between the recovery speed of patients and the health of their roommates.

    But the author of the study, Olga Yakusheva, a University of Michigan economist, controlled for the factors that nurses at the Connecticut hospital she studied use to assign patients to rooms, including diagnosis and specific room assignment. She found that even in a particular room at the hospital and even among patients with a specific diagnosis, those who ended up with healthier roommates fared better. (The study did not include patients who had single rooms.)

    What’s more, “placing a sick and a healthy patient in one room benefited the sicker patient without ill effects for the healthier roommate,” Ms. Yakusheva said.

    Had that particular hospital taken fuller advantage of this phenomenon in patient room assignments, it could have reduced total inpatient days by 900 per year, saving about $1 million, for the sample of patients the study examined.

    In recent years, most American hospitals have gone another way, though. They’ve added private rooms and renovated shared ones to accommodate only one person. The amount of hospital room space per patient has doubled since the late 1980s. Naturally, that increases costs.

    Many patients prefer the privacy of a single room. And some studies indicate that single rooms reduce the spread of flu and other infections, though the evidence is not conclusive. Despite the potential risks and preferences, having a hospital roommate, and a healthier one in particular, may be better than having no roommate.

    There are several hypotheses for how roommate assignments affect patients’ health. A healthier roommate — particularly one with a similar condition — may be better able to transfer important self-care knowledge or even lend a helping hand, as a few studies have documented. Or, patients with healthier roommates may feel better when they observe other patients doing well, relative to those who observe patients doing poorly. Some studies have found that patient interactions can reduce anxiety.

    Other possibilities are indirect. If your roommate is healthier, she may draw on fewer nursing resources (time and attention), leaving more for you. Or, you may be better able to rest because nurses and doctors are entering the room less frequently when your roommate needs less care. Additional analysis by Ms. Yakusheva doesn’t support these indirect explanations, however.

    The phenomenon is just one of many “peer effects” — the tendency for certain behaviors to spread through social interaction — that have been identified and studied by researchers. It’s probably no surprise that the nature of your social engagement with friends, family and colleagues influences your degree of cooperation and happiness, as studies have found. Research also suggests that it affects behaviors more closely tied to health. For example, obesity tends to spread in social networks. So does smoking behavior. Alcohol consumption follows similar patterns.

    Even if it’s plausible that healthier roommates improve hospital patients’ outcomes, we should acknowledge some limitations of the research in this area. There are very few studies of the subject beyond Ms. Yakusheva’s. Hers is a study of one hospital, with a sample that may not be representative of all hospital patients. Also, as with all observational studies (as opposed to randomized trials), there may be other important influences that could not be accounted for that affect the results.

    If there is a positive efect, of what use are the findings? If you’re hospitalized, could you increase your chances of being assigned to a room with a healthier roommate? The answer, according to Bradley Flansbaum, a hospitalist with the Geisinger Health System, is yes.

    “You could always ask the nurse in charge for a room change,” he said. “If asked why, and you say it’s for personal reasons, the nurse will probably accommodate.”

    But this might put too much onus on the patient, and there is no guarantee the new roommate will be any healthier. A better approach might be for hospital staff to systematically take the phenomenon into account when assigning patients to rooms.



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  • Healthcare Triage: Employer-Based Insurance Can Trap You at Work

    Here’s another possible consequence of repealing the Affordable Care Act: It would be harder for many people to retire early. That’s the topic of this week’s Healthcare Triage.

    This episode was adapted from a column Austin wrote for the Upshot. Links to sources and further reading can be found there.


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  • Healthcare Triage News: Losing Sleep Over Where Babies Sleep

    Last year, Claire Caine Miller and I teamed up to write about the then-new AAP guidelines on infant sleep. Those guidelines recommended that infants sleep in the same room as their parents until they were one year of age. We took issue with that. New research backs us up! This is Healthcare Triage News.

    If you want to read more:


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  • The Republican Senator Healthcare Uncertainty Principle

    I keep reading article after article about how Republican Senators are uncomfortable with the way that they are crafting their ACA repeal and replace bill. It’s too secretive. There’s no committee markup. It’s too fast. No one is listening. Many of them have no idea whatsoever is in the bill.

    Correct me if I’m wrong, but they have 52 votes in the Senate. If just three of them would actually say this is a problem at the same time in the same place then it might mean that they could actually change this process. If just three of them said they wouldn’t vote for a bill created this way, then they’d have to do it in the more usual fashion.

    Instead, there are a lot of opportunities for many more of them to voice their concerns individually, thus giving the appearance that there’s nothing they can do. They’re powerless alone.

    Why someone in the media can’t point that out to them and ask them about it is beyond me. Why can’t we get three of them together and ask them?


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  • I feel like I’m losing my mind. What are Republican Senators trying to do?

    You’ve probably already read a million thought pieces on how the Republican Senate AHCA bill is being written totally in secret, no one knows what’s in it, etc. So I’m not going to bother with that. But this exchange, in a revealing post over at Vox  where reporters asked Republican Senators to explain their bill, has me losing my mind:

    Tara Golshan, Vox: Generally, what are the big problems this bill is trying to solve?

    John McCain: Almost all of them. They’re trying to get to 51 votes.

    Tara Golshan: Policy-wise. What are the problems in the American health care system this is trying to solve — and is the bill doing that right now?

    John McCain: Well, it’s whether you have full repeal, whether you have partial repeal, whether you have the basis of it. It’s spread all over.

    Tara Golshan: But based on the specifics of the bill you have heard so far, is it solving the problems in the health care system?

    John McCain: What I hear is that we have not reached consensus. That’s what everybody knows.

    Tara Golshan: Right, but outside of getting the votes. From what you hear of the actual legislation being written is it solving the problems you see —

    John McCain: It’s not being written. Because there’s no consensus.

    Tara Golshan: But generally speaking, what are the big problems it is trying to solve?

    John McCain: You name it. Everything from the Repeal caucus, which as you know they have made their views very clear — Rand Paul, etc. And then there are the others on the other side of the spectrum that just want to make minor changes to the present system. There’s not consensus.

    Five times Tara Golshan (who deserves some sort of an award) asks Senator McCain what the bill is trying to do, what problems it’s trying to solve. FIVE TIMES. And, five times, Senator McCain can only discuss the difficulties of getting to 50 votes. Fifty Republican votes, mind you.

    There’s literally no discussion of cost, of quality, of access. No mention of premiums or deductibles or even taxes. No concerns about anything even remotely related to healthcare at all.

    I can’t tell if he didn’t want to answer, or if actual healthcare literally didn’t cross his mind. Some days I despair.


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  • Are we taking the drug overdose epidemic seriously?

    I recently argued that:

    The drug overdose epidemic is a public health catastrophe in the same class as AIDS.

    Arguably, it’s worse. Annual deaths by drug overdose are substantially higher than the worst year of the AIDS epidemic. The current very rapid increase in deaths by drug overdose shows no signs of slowing. Drug overdose is now the leading cause of death for Americans under 50. AIDS never achieved that.

    If you measure the magnitude of an epidemic by the sum of the years of life lost by the victims, drug overdoses compete with cancer, not just AIDS. Many more Americans die of cancer (about 600,000) than drug overdose (an expected 60,000 in 2017). But more than half of cancer deaths occur in people 75 years or older (UK data). The average drug overdose victim dies in his or her early 40s and loses many more years of life.

    Are we responding to the drug overdose epidemic in a way that is commensurate to these facts?

    I don’t think the NIH is. The 2017 NIH Budget request slides presented by Director Francis Collins discussed:

    • The National Cancer Moonshot.
    • The Precision Medicine Initiative.
    • The Brain Initiative.
    • AIDS research.
    • Alzheimer’s research.

    These are all great things to do with federal dollars. But it’s remarkable that Collins did not mention drug or alcohol abuse or the current epidemic.

    Why aren’t we focused on this epidemic? It’s the same problem that plagued the early years of AIDS. The victims were stigmatized and those not in their families or neighbourhoods didn’t take their deaths seriously.

    Turning the tide on AIDS required that we rethink our values, not just our virology. Now it’s time to rethink how we feel about the people suffering from drug and alcohol problems.


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  • Cystic Fibrosis, Life Expectancy, and the Greatest Health Care System in the World

    Cystic fibrosis is an inherited disorder that affects the lungs, pancreas, intestines and other organs. A genetic mutation leads to secretory glands that don’t work well; lungs can get clogged with thick mucus; the pancreas can become plugged up; and the gut can fail to absorb enough nutrients.

    It has no cure. Over the last few decades, though, we have developed medications, diets and treatments for depredations of the disease. Care has improved so much that people with cystic fibrosis are living on average into their 40s in the United States. In Canada, however, they are living into their 50s. That’s the topic of this week’s Healthcare Triage.

    This episode was adapted from a column I wrote for the Upshot. Links to reading and further references can be found there.


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  • There’s No Magical Savings in Showing Prices to Doctors

    The following originally appeared on The Upshot (copyright 2017, The New York Times Company).

    Physicians are often unaware of the cost of a test, drug or scan that they order for their patients. If they were better informed, would they make different choices?

    Evidence shows that while this idea might make sense in theory, it doesn’t seem to bear out in practice.

    recent study published in JAMA Internal Medicine involved almost 100,000 patients, more than 140,000 hospital admissions and a random distribution of laboratory tests. During the electronic ordering process, half the tests were presented to doctors alongside fees. While the cost to the patient might vary, these Medicare-allowable fees were what was reimbursed to the hospital for the test or tests being considered. The other half of the tests were presented without such data.

    The researchers suspected that in the group seeing the prices, there would be a decrease in the number of tests ordered each day per patient, and that spending on these tests would go down. This didn’t happen. Over the course of a year, there were no meaningful or consistent changes in ordering by the doctors; revealing the prices didn’t change what they did much at all.

    This isn’t the first time a study like this found that showing prices to doctors doesn’t make a difference. Earlier this year, a study published in Pediatricsreported on a similar randomized controlled trial on physicians caring for children. In this case, doctors were randomized to one of three groups. The first group saw the median price of a test when they ordered it. The second saw both the price (often lower) when obtained within the current health care system and outside it. The third group saw no price at all.

    Pediatric-focused clinicians showed no effect from price displays. Adult-focused clinicians actually ordered more tests when they saw the prices.

    similarly designed study of more than 1,200 clinicians in an accountable care organization published earlier this year also found no effects from telling physicians prices.

    Some older studies have found that physicians might alter their behavior on individual tests, but in only five of the 27 they examined. Another found a small, but statistically significant, difference. Unfortunately, this study suffered from asymmetric randomization. Even before the intervention began, the tests chosen for the price-showing group were ordered more than three times as much as those chosen for the control group. More expensive tests appeared in the control group for some reason as well.

    Of course, any one study has the potential to be an outlier or subject to limitations that might warrant skepticism. These can be minimized by looking at the body of evidence in systematic reviews.

    One was published in 2015, and argued that in the majority of studies, giving physicians price information changes their ordering and prescribing behavior to lower the cost of care. A closer look, though, reveals that most of the studies in this analysis were more than a decade old. Many took place in other countries. And all were published before these latest, and largest, studies I discussed above. Another systematic review that looked at interventions focusing only on drug ordering found similar results, with similar caveats.

    I should be clear: We have good reason to want to believe that interventions focusing on giving physicians information about the prices of the things they order should make a difference. In 2007, a systematic review demonstrated that doctors were ignorant of the costs of prescription drugs. They underestimated the prices of expensive drugs, overestimated the prices of inexpensive ones, and did not understand the extent of the difference in price between those considered cheap and those considered pricey. Another, published in 2015, explored 79 studies, 14 of which were randomized controlled trials, that suggested that physicians could be educated to deliver “high-value, cost-conscious care.”

    But that education probably needs to be holistic. Flashing one point of data at a doctor does not get the job done; knowledge transmission needs to be accompanied by what this review called “reflective practice and a supportive environment.” Simply focusing on cost information may not be enough. The reasons that physicians order tests are more than financial, and efforts to influence their behavior most likely need to be more than informational.

    Additionally, it may be that issues of price transparency need to involve more than one component of the health care system. While focusing solely on physicians, or on patients, might not work well, trying to work on both simultaneously might. It’s also possible that intervening solely on one procedure, test or drug at a time may not be as powerful as trying to influence spending on care over all.

    Finally, trying to make physicians focus strictly on cost may be off base as well. Some care, even more expensive care, is worth it. What we really should attend to is value — the quality and impact relative to the cost. It is certainly harder to determine value than price, but that metric might make more of a difference to physicians, and to their patients.


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