07/17/2019
Aaron CarrollAlthough various electronic health records (EHRs) have different features, nearly all seem to have alerts for potential problems with drug prescribing. It’s one thing that many believe that EHRs do very well. However, a recent study warns that when it comes to opioids and benzodiazepines, we shouldn’t always assume such alerts work as intended.
That’s the beginning of my latest piece over at the JAMA Forum. Go read it!
07/09/2019 Aaron CarrollResearch indicates that the malpractice system in the United States doesn’t do a lot to deter malpractice. There are several recent studies about malpractice that look at how many doctors have malpractice claims against them, and what happens to their careers after they have a problem.
This episode was adapted from a column I wrote for the Upshot. Links to sources can be found there.
04/25/2019 Aaron CarrollThe following originally appeared on The Upshot (copyright 2019, The New York Times Company).
Singapore’s health care system is sometimes held up as an example of excellence, and as a possible model for what could come next in the United States.
When we published the results of an Upshot tournament on which country had the world’s best health system, Singapore was eliminated in the first round, largely because most of the experts had a hard time believing much of what the nation seems to achieve.
It does achieve a lot. Americans have spent the last decade arguing loudly about whether and how to provide insurance to a relatively small percentage of people who don’t have it. Singapore is way past that. It’s perfecting how to deliver care to people, focusing on quality, efficiency and cost.
Americans may be able to learn a thing or two from Singaporeans, as I discovered in a recent visit to study the health system, although there are also reasons that comparisons between the nations aren’t apt.
Singapore is an island city-state of around 5.8 million. At 279 square miles, it’s smaller than Indianapolis, the city where I live, and is without rural or remote areas. Everyone lives close to doctors and hospitals.
Another big difference between Singapore and the United States lies in social determinants of health. Citizens there have much less poverty than one might see in other developed countries.
The tax system is progressive. The bottom 20 percent of Singaporeans in income pay less than 10 percent of all taxes and receive more than a quarter of all benefits. The richest 20 percent pay more than half of all taxes and receive only 12 percent of the benefits.
Everyone lives in comparable school systems, and the government heavily subsidizes housing. Rates of smoking, alcoholism and drug abuse are relatively low. So are rates of obesity.
All of this predisposes the country to better health and accompanying lower health spending. Achieving comparable goals in the United States would probably require large investments in social programs, and there doesn’t appear to be much of an appetite for that.
There’s also a big caveat to Singapore’s success. It has a significant and officially recognized guest worker program of noncitizens. About 1.4 million foreigners work in Singapore, most in low-skilled, low-paying jobs. Such jobs come with some protections, and are often better than what might be available in workers’ home countries, but these workers are also vulnerable to abuse.
Guest workers are not eligible for the same benefits (including access to the public health system beyond emergency services) that citizens or permanent residents are, and they aren’t counted in any metrics of success or health. Clearly this saves money and also clouds the ability to use data to evaluate outcomes.
The government’s health care philosophy is laid out clearly in five objectives.
In the United States, conservatives may be pleased that one objective stresses personal responsibility and cautions against reliance on either welfare or medical insurance. Another notes the importance of the private market and competition to improve services and increase efficiency.
Liberal-leaning Americans might be impressed that one objective is universal basic care and that another goal is cost containment by the government, especially when the market fails to keep costs low enough.
Singapore appreciates the relative strengths and limits of the public and private sectors in health. Often in the United States, we think that one or the other can do it all. That’s not necessarily the case.
Dr. Jeremy Lim, a partner in Oliver Wyman’s Asia health care consulting practice based in Singapore and the author of one of the seminal books on its health care system, said, “Singaporeans recognize that resources are finite and that not every medicine or device can be funded out of the public purse.”
He added that a high trust in the government “enables acceptance that the government has worked the sums and determined that some medicines and devices are not cost-effective and hence not available to citizens at subsidized prices.”
In the end, the government holds the cards. It decides where and when the private sector can operate. In the United States, the opposite often seems true. The private sector is the default system, and the public sector comes into play only when the private sector doesn’t want to.
In Singapore, the government strictly regulates what technology is available in the country and where. It makes decisions as to what drugs and devices are covered in public facilities. It sets the prices and determines what subsidies are available.
“There is careful scrutiny of the ‘latest and greatest’ technologies and a healthy skepticism of manufacturer claims,” Dr. Lim said. “It may be at the forefront of medical science in many areas, but the diffusion of the advancements to the entire population may take a while.”
Government control also applies to public health initiatives. Officials began to worry about diabetes, so they acted. School lunches have been improved. Regulations have been passed to make meals on government properties and at government events healthier.
In the United States, the American Academy of Pediatrics and the American Heart Association recently called on policymakers to impose taxes and advertising limits on the soda industry. But that’s merely guidance; there’s no power behind it.
In Singapore, campaigns have encouraged drinking water, and healthier food choice labels have been mandated. The country, with control over its food importation, even got beverage manufacturers to agree to reduce sugar content in drinks to a maximum of 12 percent by 2020.
Should beverage companies fail to comply, officials might not just tax the drinks — they could ban them.
Singapore gets a lot of attention because of the way it pays for its health care system. What’s less noticed is its delivery system.
Primary care, which is mostly at low cost, is provided mostly by the private sector. About 80 percent of Singaporeans get such care from about 1,700 general practitioners. The rest use a system of 18 polyclinics run by the government.
As care becomes more complicated — and therefore more expensive — more people turn to the polyclinics. About 45 percent of those who have chronic conditions use polyclinics, for example.
The polyclinics are a marvel of efficiency. They have been designed to process as many patients as quickly as possible. The government encourages citizens to use their online app to schedule appointments, see wait times and pay their bills.
Even so, a major complaint is the wait time. Doctors carry a heavy workload, seeing upward of 60 patients a day. There’s also a lack of continuity. Patients at polyclinics don’t get to choose their physicians. They see whoever is working that day.
Care is cheap, however. A visit for a citizen costs 8 Singapore dollars for the clinic fees, a little under $6 U.S. Seeing a private physician can cost three times as much (still cheap in American terms).
For hospitalizations, the public vs. private share is flipped. Only about 20 percent of people choose a private hospital for care. The other 80 percent choose to use public hospitals, which are — again — heavily subsidized. People can choose levels of service there (from A to C, as described in an earlier Upshot article), and most choose a “B” level.
About half of all care provided in private hospitals is to noncitizens of Singapore. Even for citizens who choose private hospitals, as care gets more expensive, they move to the public system when they can.
So Singapore isn’t really a more “private” system. It’s just privately funded. In effect, it’s the opposite of what we have in the United States. We have a largely publicly financed private delivery system. Singapore has a largely privately financed public delivery system.
There’s also more granular control of the delivery system. In 1997, there were about 60,000 ambulance calls, but about half of those were not for actual emergencies. What did Singapore do? It declared that while ambulance services for emergencies would remain free, those who called for nonemergencies would be charged the equivalent of $185.
Of course, this might cause the public to be afraid to call for real emergencies. But the policy was introduced with intensive public education and messaging. And Singaporeans have identifier numbers that are consistent across health centers and types of care.
“The electronic health records are all connected, and data are shared between them,” said Dr. Marcus Ong, the emergency medical services director. “When patients are attended to for an emergency, records can be quickly accessed, and many nonemergencies can be then cleared with accurate information.
“By 2010, there were more than 120,000 calls for emergency services, and very few were for nonemergencies.”
Singapore made big early health leaps, relatively inexpensively, in infant mortality and increased life expectancy. It did so in part through “better vaccinations, better sanitation, good public schools, public campaigns against tobacco” and good prenatal care, said Dr. Wong Tien Hua, the immediate past president of the Singapore Medical Association.
But in recent years, as in the United States, costs have started to rise much more quickly with greater use of modern technological medicine. The population is also aging rapidly. It’s unlikely that the country’s spending on health care will approach that of the United States (18 percent of G.D.P.), but the days of spending significantly less than the global average of 10 percent are probably numbered.
Medical officials are also worried that the problems of the rest of the world are catching up to them. They’re worried that diabetes is on the rise. They’re worried that fee-for-service payments are unsustainable. They’re worried hospitals are learning how to game the system to make more money.
But they’re also aware of the possible endgame. One told me, “Nobody wants to go down the United States route.”
Perhaps most important, the health care system in Singapore seems more geared toward raising up all its citizens than on achieving excellence in a few high-profile areas.
Without major commitments to spending, we in the United States aren’t likely to see major changes to social determinants of health or housing. We also aren’t going to shrink the size of our system or get everyone to move to big cities.
It turns out that Singapore’s system really is quite remarkable. It also turns out that it’s most likely not reproducible. That may be our loss.
04/09/2019 Aaron CarrollStudy after study affirms that doctors treat their patients differently, depending on the patient’s race. Minority patients get different diagnoses, different treatments, and are often subject to being stereotyped by their physicians.
This episode was adapted from a column I wrote for the Upshot. Links to sources can be found there.
07/17/2018 Aaron CarrollThe ACA expanded Medicaid coverage to a lot of people, and it was implemented differently in lots of states. So, what happened? Lots of studies are coming out about expanded access, and how that access has changed outcomes.
This episode was adapted from a column I wrote for The Upshot. Links to references can be found there.
06/15/2018 Aaron CarrollThe Trump administration has released Medicaid report cards, which allow citizens and health care journalists to look at the results of Medicaid, state by state. The good news: our beloved Indiana is doing OK! The bad news, there’s a lot of missing data in this reporting process, so it’s hard to really know what these report cards mean.
06/16/2017 Aaron CarrollYou’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.
06/15/2017 Aaron CarrollCystic 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.
10/31/2016 Aaron CarrollHospitals and many insurance carriers care about patient satisfaction. It especially matters to hospitals because insurance payments can be influenced by how patients rate the care they receive, as well as by the health of the patient, which hospitals usually report.
Many people in the health care profession are put off by this. They argue that patient satisfaction scores aren’t necessarily aligned with outcomes. Moreover, they say that trying to improve satisfaction is a waste of time.
It’s possible, however, that patient satisfaction is being rewarded already, and that the efforts we are making to highlight it aren’t helping as much as we think. That’s the topic of this week’s Healthcare Triage.
This episode was adapted from a column I wrote for the Upshot. Links to sources and further reading can be found there.
09/28/2016 Aaron CarrollThe following originally appeared on The Upshot (copyright 2016, The New York Times Company)
Three years into Obamacare and it seems as if much of the news is bad: private insurers exiting the exchanges, networks being narrowed, premiums rising and competition dwindling out of existence.
But it’s important to remember that many, if not most, of the newly covered Americans became insured through an expansion of Medicaid. Here, too, you hear a lot of bad news: that Medicaid offers poor quality and little choice of providers, that it is expensive for the states to administer and that its growing cost will eventually bankrupt states. As of today, 19 states have still refused to participate in the expansion.
Such declarations consider only one side of the equation, though. In most ways, Medicaid offers an excellent return on investment.
A rigorous analysis of the health benefits of being insured shows that Medicaid works on a number of levels. Critics of the program will point to studies that show that having Medicaid is associated with poor outcomes, even worse than those for the uninsured. Such studies are often flawed, however, in that those on Medicaid are often poorer and sicker than those who are uninsured.
Some good randomized trials do exist. The Oregon Health Insurance Experiment is one of the most recent and best known. Many news articles have been written on the short-term findings of that study, which have been interpreted in many ways, both good and bad. But even that study couldn’t answer many of the long-term, holistic questions about its effects on health.
To see the longer-term benefits across a wider population, we need to turn to other types of studies. They exist as well, usually taking advantage of changes in policy. Medicaid coverage of children and births expanded rapidly from the late 1970s through the early 1990s. When expectant mothers got early prenatal coverage, babies were less likely to be obese when they grew up. They had fewer hospitalizations, especially preventable hospitalizations, for any number of chronic disorders.
Another study from last fall went further. By exploiting new Medicaid eligibility policies, researchers were able to closely compare people with and without benefits. They found that African-Americans who had more years of Medicaid eligibility as children had fewer hospitalizations and emergency department room visits as adults. More years of coverage achieved better results, even with respect to mortality.
Benefits from Medicaid extend beyond health. A 2016 National Bureau of Economic Research working paper examined the effect of the Medicaid expansion on financial outcomes of beneficiaries. Using credit report data, researchers showed that the expansion was associated with a reduction of collection balances of as much as $1,000 for those receiving Medicaid.
The financial benefits extend to society. A study from early 2015 looked at how expanding coverage to children in the 1980s and 1990s affected long-term finances. The analysis showed that children whose eligibility increased were more likely to go to college, earn higher wages and pay more taxes by the time they were 28 years old.
In fact, after accounting for other factors, the researchers estimated that the government would recoup 56 cents on each dollar spent on childhood Medicaid by the time beneficiaries reached age 60. Other studies confirm that Medicaid in childhood makes children more likely to finish high school and college.
At a national level, the expansion of Medicaid continues to yield benefits. Its coverage was increased, and its quality raised. Some states that have expanded Medicaid are even expecting net savings for the next few years. In states where Medicaid was expanded, hospitals had fewer uninsured visits.
Focusing on only the positives can be as misleading as focusing on only the negatives. Policy decisions, including those involving health, need to be considered in terms of trade-offs. It is true that providing Medicaid can cost the federal government, and even states, a lot of money, which can’t then be spent on other worthy pursuits. It is true that Medicaid reimburses physicians and hospitals less generously, and that it often leaves beneficiaries with fewer choices than private insurance might.
But when we look at the balance sheet for Medicaid — health benefits, financial security, societal improvements through education — it’s not hard to argue that money allocated to Medicaid is well spent.
