Access To Care: Fact or Fiction?

Insurance is a huge piece of the overall health care puzzle. Make no mistake about that. As with any puzzle, there are many many other pieces that need to be put in place in order to complete it. eMax Health went undercover in the land of red tape and now share what they have found:

When interviewers posing as Medicaid patients called doctors’ offices that participate in the Florida Medicaid program, they were met in some cases by disconnected numbers, phone trees and time on hold before they could find out about scheduling an appointment.

How many of you, our readers, find that eerily familiar? With insurance (i.e. Medicaid) access to care is supposed to be assured. At least that is the common perception. Many low income families who rely on Medicaid would probably point out that it can often feel like access in name only.

Weekend and evening appointment times in some instances were scarce and some providers who said they were willing to take new patients proved to be less willing when they found out the new patient was part of the Medicaid program.

Hardly a surprise is you do some digging and see how low the actual reimbursement from Medicare to providers is. Do a little Googling, the results will probably shock you.

The study, which occurred in 2004, found that nearly 87 percent of the doctors in Florida’s Medicaid primary care case management program (MediPass) program told the interviewers that they would accept new patients, but only 68 percent said they were accepting new Medicaid patients.

While each of these problems might seem relatively small compared to the lack of insurance that keeps some patients away from regular care, Allyson Hall, Ph.D., and colleagues at the University of Florida argue that they can affect access to health care in significant ways.

“If an individual has a particularly difficult time getting in to see the usual physician, we could reconsider whether that physician is actually acting as a regular source of care for that patient,” the researchers write in the May 2008 issue of the Journal of Health Care for the Poor and Underserved.

The article goes on to examine aspects of the report in more depth, even bringing in some complementary data from a 2007 study done in Oregon. I predict that this is far from the last article we will see on this subject as election season progresses.

This issue is one that points out two major and related problems: the actuality of health care access and the reticence of providers who many times operate at a loss due to reimbursement rates from government plans. While profit may be vulgar to bring up, keeping a business (or medical practice) viable does require making more than you spend. For doctors this is a major sticking point. At the same time there is the plight of the low income American, lucky enough to have insurance but frequently stymied when attempting to use it.

Thank you for calling the United States. If you are experiencing a health care emergency please press "1"...

SOURCE: "Insured, Low-Income Patients Face Hurdles To Health Care Access" 05/08
photo courtesy of fuzzcaminski, used under its Creative Commons license

Kids Care, A Report Card

The subtitle of today's article du jour is, "Those that have the most access to insurance tend to have healthier children." This is hardly a shocking observation. What is shocking are the grades given to the various states of the U.S. by the Commonwealth Fund in their recent report U.S. Variations on Child Health System Performance: A State Scorecard. Steve Reinberg, HealthDay reporter for US News and World Report takes a look at the results:

According to the scorecard, if all states performed as well as the top few states:

• an additional 4.6 million children nationwide would have health insurance;
• 11.8 million more children would get their recommended yearly medical and dental check-ups;
• 10.9 million more children would have a "medical home" -- a regular source of care;
• 1.6 million fewer children would be at risk for developmental delays;
• and nearly 800,000 more children would be up-to-date on their vaccines.

Iowa, Vermont, Maine, Massachusetts, and New Hampshire are the top performing states, according to the report, while Arizona, Florida, Louisiana, Mississippi, New Jersey, Nevada and Texas are at the bottom.

As a Louisiana native, this is far from welcome, although unsurprising, news. With fifty states in the Union there are fifty different sets of standards being applied leading to a broad variance in results. Commonwealth Fund President Karen Davis stated in a Tuesday teleconference that more than a full third of American children receive care due to funding from the Federal Government and the states. SCHIP and Medicare were cited as crucial components in delivery of that care.

The scorecard took into account 13 indicators of children's health, including access, quality, costs, equity and the potential to lead a long and healthy life. While no state scored high on all categories, some regions surpassed others. For example, states in the Northeast and Upper Midwest often ranked higher in several areas, while the lowest rankings were in the South and Southwest, the report found.

Studies have shown that in states with high numbers of uninsured children, those children are less likely to get recommended health care, vaccines, dental care and regular checkups. These children are also at greater risk for developmental delays and infant mortality, Davis said.

But even in the highest-ranking states, quality of care falls short of goals, the report noted. In Massachusetts, the top-ranked state in quality, 75 percent of the children were seen by a doctor and a dentist in the past year, compared with only 46 percent of children in Idaho.

The conclusions reached by Davis, as related by Mr. Reinberg, are that states that do a better job of insuring their children, particularly those of low income, are among the most highly ranked overall for quality of care in the report.

For those who do not have the time or desire to dig into the actual report itself, Mr. Reinberg does a fine job of communicating the high points. The rest of his article covers comparisons of the highest and lowest ranking states, the concept of the "medical home," and more. Once again we find that the actual statistics of the current crisis in care are disheartening, but defining a problem is the first step towards rectifying it.

Continued studies such as these will help us to refine our focus on what areas need to change and how to properly go about it. We can create a system of universal care in this country. To paraphrase a line from an old television show, "We can rebuild it, make it better than it was. Better. Stronger. Faster."

SOURCE: "AStates' Scorecard Finds Big Differences in Kids' Health Care" 05/28/08
photo courtesy of M@rg, used under its Creative Commons license

The S.E.C. Gets Involved

The Securities and Exchange Commission has gotten involved in the ongoing health care debate, and is bringing shareholders along with them. Robert Pear at The New York Times reports:

The Securities and Exchange Commission, shifting its position, has told companies they must allow shareholders to vote on a proposal for universal health insurance coverage.

Shareholders, including religious groups and labor unions, have offered the proposal in an effort to draw the nation’s largest corporations deeper into a debate over the future of health care, fast emerging as one of the most important issue in domestic policy.

The S.E.C. has told Boeing, General Motors, United Technologies, Wendy’s International and Xcel Energy over the last several months that they may not omit the health care proposal from their proxy materials.

This move has been cause for surprise at many corporations, especially since the SEC allowed the exclusion of these materials in the past. Reactions have been varied. Opponents include Boeing and Reynolds American while others such as General Electric have adopted universal coverage as a principle. Many more are, or have been, negotiating with their shareholders in an attempt to find a workable middle ground. IBM and Wal-Mart are included in that number.

"We are working for a national policy that provides universal access to health care, and we do hold more than 30,000 shares of General Electric stock," said Barbara Kraemer, a Roman Catholic nun who is national president of the School Sisters of St. Francis. "As we pursued the proposal with G. E., the company requested a dialogue in lieu of the shareholder resolution, so we withdrew it. The dialogue was productive, resulting in G. E.’s public endorsement of the Institute of Medicine principles."

Labor unions and religious groups said they intended to broaden the proxy campaign by bringing in more pension plans next year. If the dialogue between companies and shareholders were to continue, as expected, it could help bridge the divide that has frustrated earlier efforts to cover the uninsured.

It seems that the conflicted nature of views on health care reform continues to hold sway when looked at from this angle. Mr. Pear offers several examples that show the array of self-interests at work in this strata of the health care crisis. From the fears of Reynolds American that funding for change would come out of their tobacco based business in the form of cigarette taxes, to the strange proxy battle that United Health (insurer of over 70 million people) engaged in recently, he covers the whole array.

It will be worth watching to see what comes out of the SEC in relation to this topic over the next several months. Whichever way they jump, it will have far reaching ramifications, especially after January 20 when a new President enters the Oval Office.

SOURCE: "S.E.C. Backs Health Care Balloting" 05/27/08
photo courtesy of takomabibelot, used according to its Creative Commons license

Unmanaged- Economics of Health Care

There is a book excerpt on the Forbes site for John Hammergrin and Phil Harkins' new book, Skin in the Game. I bring this up because Mr. Hammergrin brings up a lot of the same points that our own Mr. Halvorson addresses in Health Care Reform Now! and two of them share many common conclusions. Here are a few small teasers drawn from the excerpt for your perusal:

What's becoming better understood is that our health care crisis is fundamentally a business problem. The system is overstrained and is breaking down due to outdated information technology (IT); poor application of the basic principles of market economics; overall inefficiency in terms of work flow, care delivery and the spreading of best practices; a lack of transparency around quality and cost; and blocked access to making informed consumer choices.

Don't get me wrong: I 'm not assigning blame for any of these built-in flaws. They are a result of the way our health care system has developed into a set of parallel cottage industries that until recently have never had a real chance of being integrated into a seamless, efficient industry. Doctors, hospitals, insurers, suppliers and the government have all run their shops separately and distinctly from each other, so that literally one part of the system cannot talk to another in any trustworthy, efficient, error-free way.

He then goes on to address another huge factor -- the opaque, disjointed, and incredibly irritating nature of dealing with health care as a patient. Anyone who has had so much as a simple blood test can relate to that one. Take your average doctors visit as an example. First, Mr. Hammergrin touches on the universal experiences that go along with you as you navigate the experience: long waits (no matter how far in advance you schedule), brief and unsatisfactory time with your physician, and the additional time and confusion that result if a prescription needs to be filled afterwards.

Mr. Hammergrin states that the average doctor actually only has 12 minutes to spend with you once you are finally in the same room. I would say, from my own experience, that sounds about right. Then comes the clever bit:

The economics of the entire interaction are a complete mystery to you. Your doctor's visit will cost you a co-pay fee up front, if you have insurance, but you won't know what the examination really cost until you get the bill months later. If you have insurance, you probably don't bother to check that statement, but if you do, the numbers and codes are almost impossible to unravel, and you would get little comfort knowing how much confusion is rampant behind the scenes in those back offices. The doctor charges one thing, the insurance company pays something else, and chances are, it takes three exchanges back and forth before the final claim is settled, and you are lucky if you do not receive calls or notices drawing you into the dispute.

Small wonder. There are 1.5 trillion claims each year, and a full 30% of those claims have errors, while 15% get lost. Twenty-five percent of claims are still paper-based, and it costs $20 to $25 to manually process them.

Wow. In what other industry is this sort of margin acceptable? It is simply stunning to think that in a field as important as health the level of accuracy and efficiency is so dismal.

Consider how strange this would be if it were applied to any other economic transaction. Imagine you go to Macy's to buy a tie or blouse. You want to pay for the item, but the price isn't marked. You ask the salesperson, who says, "Sorry, we have to mail you the bill." You insist you want to pay right now, and the salesperson's manager says, "We just can't do it that way. The price is different for different people, and we don't know what your credit card company or bank will allow us to charge you." Four to eight weeks later you get the bill, but you have no idea if you've been charged the right price.

Perversely incentivized, disorganized and top heavy with complexity, the American health care system is truly in crisis. That is something that there is wide consensus on. Despite the precedents set in the past there is an urgent need to reboot the entire system and bring it into the 21st Century. While advances have continually improved the ability to care for various medical conditions (Jenner and Jarvik come immediately to mind), the ability to deliver that care to those who need it has been mired in bureaucracy and confusion.

It is time for a change! Check out the rest of Hammergrin's excerpt here.

SOURCE: "Unmanaged Care" 05/23/08
photo courtesy of bdunnette used under its Creative Commons license

Transparency: The Government Angle

One of the big issues with American health care is the lack of ability to compare prices and care quality between care providers. As many people step forward in favor of market driven solutions -- a very good idea in many respects -- this sort of information is crucial to making informed decisions about said market. As a matter of fact many of the posts in our archives here on the blog are concerned with efforts to create this sort of transparency. Now the federal government, in the form of the U.S. Department of Health and Human Services, is embracing that stance.

Cherie Black over at the SeattlePI takes a look:

The U.S. Department of Health and Human Services is running ads in both Seattle daily newspapers Wednesday showing consumers how to compare services and quality of care in area hospitals by using a new Web site.

The ads, which are running in more than 50 other newspapers across the country, promote Hospital Compare (hospitalcompare.hhs.gov), a Web site that scores 26 quality and patient satisfaction measures at nearly 4,000 hospitals nationwide.

This should be an interesting website launch to follow. The media blitz should get them a lot of traffic, and I am sure that soon there will be a lot of commentary floating around the net.

Using metrics like price of procedure, volume (how many of a single procedure are performed), percentage of patients who received anitbiotics an hour before surgery, and how many patients received help when they asked for it the site seems to cover a lot of ground. It is exactly this sort of information which can help create the informed market needed for a free market solution to gain traction.

More transparency in health care is a good thing, said Dr. Ed Walker, medical director at the University of Washington Medical Center, and this site shows how physicians are having more open conversations about errors and prevention.

"I bought my last car by going to Consumer Reports and looking at the comparisons," Walker said. "We have a populous who expects us to be like Consumer Reports, and while that may be a bit ahead of our time, we still have a good balance."

Indeed. This is the 21st Century, people are accustomed to being able to look up anything by simply spending a moment at their keyboard. Instant gratification is something that Americans have always had a penchant for. Google and the Internet have brought that attitude to the world of information and people are becoming highly dissatisfied with the delays endemic to almost any interaction with our health care system. In that respect this is a good thing.

But Walker cautioned consumers to realize that no one measure defines a hospital, and some measures can be imprecise. For example, some measures, such as whether patient received antibiotics before a surgery, are easily defined -- there's a surgery checklist to consult or an empty bottle from the pharmacy as evidence. How long a patient had to wait to see a nurse after he or she was called is more subjective.

"How soon a nurse responded is influenced by a lot of things, including how many patients they have at one time," Walker said. "They weigh the needs of the patients simultaneously -- but we should aspire. These are our patients telling us how we're doing, and we should listen to that."

All in all, I expect this to be a major move forward. Only time will show how well they are able to implement and manage this service, but more transparency and more available information are always good things!

SOURCE: "New Web site compares hospital care: Services, costs and patient satisfaction are all measured" 05/21/08
photo courtesy of edans, used under its Creative Commons license

Reform and Technology

It is no secret that much of the discussion about health care solutions hinges on technology. Efficiency improving, cost reducing tech such as electronic medical records are rightfully brought up in any serious debate on the subject.

With that in mind, today I'm going to point you towards a recent piece in ZDNet's healthcare section by Dana Blankenhorn which discusses the application of Moore's Law to medical reform and technology:

Moore’s Law, the idea that technology gets faster-and-faster faster-and-faster, is not applied often enough to health care. Regulation frustrates it, constantly. We want to audit every data transfer, or place expensive hurdles before any improved device.

Moore’s Law is the force behind the biggest trend in health care, personalized health care. Instead of guessing about what you should do based on test results when you get sick, doctors prescribe lifestyle changes beforehand, based on genetic knowledge.

It’s Moore’s Law which enables Google Health to let you have your personal health records, free. And it’s Moore’s Law which enables Microsoft to store and move all a hospital’s records through its Amalga system.

It’s Moore’s Law which enabled the human genome to be decoded early this decade, and is now enabling the start of decoding how genetics codes for proteins.

It is a significant conundrum, and not an unfamiliar one. Complete deregulation of any big business usually has unwanted consequences, but the speed at which the tech advances is orders of magnitude more rapid than attempts at regulation or legislation. Yet it is this rapid advancement creates better options at lower costs.

As our nation struggles to find a workable solution to the current health care crisis, technological advancements consistently present options that can increase systems thinking and efficiency, improve quality of care while driving down the cost of said care, and enable a more preventative approach.

A workable middle ground needs to be created between regulation and scientific advances. As a nation we desperately need it!

SOURCE: "Moore's Law and Health Care" 05/20/08
photo courtesy of Jurvetson, used under its Creative Commons license

Credit Cards, Health Care, and McCain's Vision

Robert Gordon of Slate offers a prescription of comparison as a cure for rhetoric. While examining the health care proposals of Senator McCain, he examines a similar situation in recent history: the treatment of the credit industry in the late 1970s.

Let's start with his recap of the way that credit-card business migrated to the states that had the least regulation:

Until the late 1970s, South Dakota and Delaware didn't have an outsized share of the credit-card business. Banks had to obey the interest caps of the states where borrowers lived. So, for example, loans to New York residents were always subject to New York's limits on interest rates. At 12 percent back then, and with high inflation, these laws sharply limited profits on credit cards.

Then in 1978, the Supreme Court said banks should follow the rate cap in their home states. This meant that as long as a credit-card company relocated to a state with a higher interest-rate limit, the company could lend to borrowers anywhere under that higher limit. Following the court's ruling, Citibank chairman Walter Wriston offered Gov. Bill Janklow a deal: If South Dakota lifted its rate cap altogether and formally invited Citibank to the state (as federal law required), the banking giant would move its credit-card operations to South Dakota—along with 400 good jobs.

The bill was introduced and passed in the space of a day. Soon after, Delaware lifted its cap, too. Voilà, South Dakota and Delaware became the hosts of most credit-card companies.

An excellent illustration of the fact that one needs to looks not only at the proposed actions to be taken, but also at the ramifications of those actions. This brings us to the Senator's statements about "allowing families to purchase insurance across state lines." Seemingly sound upon first glance, the actual repercussions bear scrutiny.

McCain argues that different states' regulations "prevent the best companies, with the best plans and lowest prices, from making their product available to any American who wants it." Although he hasn't given details, his supporters say that he favors an approach, endorsed by President Bush and championed by McCain's Arizona colleague John Shadegg, that would allow insurers to choose the state laws under which they are regulated. (I e-mailed the campaign about the specifics of McCain's approach and didn't hear back.) An insurance company that chose to be regulated under Arizona law could sell policies in New York without following New York rules. Arizona, like most states, lets companies charge what they want to people who are sick—or simply deny them coverage altogether. Under Shadegg's bill, insurers wouldn't even need to pick up and move their operations; it would be enough to file some paperwork with a state insurance commissioner and pay that state's relevant taxes.

Now the classic Libertarian argument about credit-cards would probably be that no one forced anyone to get a credit card in the first place. However, that argument is incomplete. It fails to take into account the usurious practices that tend to flourish in an environment where consumer protections and regulation are minimized to this extent.

With the individual market for health care, the libertarian argument fails on its own terms: Sick people can't get coverage they can afford. It's as though the rafts are reserved for people who already have life preservers. Americans with pre-existing conditions—cancer, asthma, diabetes, and the like—would need to pay even more than they do today. Through no fault of their own, more of them would end up without insurance. Meanwhile, insurers would improve their own profits by offering targeted policies to people with the fewest health expenses. As with the history of credit cards, it's Robin Hood in reverse. Apart from the obvious injustice, this approach could add to spiraling health costs. The sickest 10 percent of Americans are already responsible for 70 percent of the nation's health expenses. When more such Americans go uninsured, skip checkups, and land in the emergency room, they end up costing taxpayers more.

It is hardly shocking that once again we come full circle to one of the points in George C. Halvorson's book Health Care Reform Now!. Chronic conditions are the lion's share of health care expenses in the U.S. The looming financial specter of the emergency room casts a very long shadow across the health care crisis. Despite President Bush's famous remarks last July (“The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you just go to an emergency room.”) this approach does nothing but drive overall costs upward while overextending the ER's to the point of massively increasing wait times and decreasing quality of care. Besides, when was the last time you know of someone going to the emergency room for chemotherapy?

There are many measures that can be taken to help pull our nation out of its downward spiral, but they all require careful thought and practical implementation. Both regulation and deregulation and powerful things and both have far reaching effects that will ripple across America. We need to be decisive yet act with care, especially those of us who are getting older.

Check out the original article and see what you think.

SOURCE: "Reverse Robin Hood Why is John McCain wrong on health care? Think credit cards." 05/19/08
photo courtesy of SoggyDan, used under its Creative Commons license