Of course emergency department visits are increasing

Health reform and ED use. Not everyone missed the mark

Health reform and ED use. Not everyone missed the mark

The lead paragraph in yesterday’s Wall Street Journal article (Emergency-Room Visits Keep Climbing) is typical:

Emergency-room visits continued to climb in the second year of the Affordable Care Act, contradicting the law’s supporters who had predicted a decline in traffic as more people gained access to doctors and other health-care providers.

Some ACA supporters did make that claim. Meanwhile it’s long been evident to many other supporters –including me– that those with insurance tend to use the emergency room and other medical services more than the uninsured.

Interestingly, I’ve never seen an article like this citing opponents of the law who called this issue out ahead of time. That’s because at the time many conservatives were busy blaming the uninsured for clogging up the emergency department! These folks probably bought into the fallacy tying the uninsured to emergency room use more than supporters of health reform did. Remember, before the ACA, the idea of a universal mandate for coverage was espoused by conservatives, not liberals.

The emergency department utilization issue is pretty simple, actually. If you have insurance you’re less worried that going to the emergency room is going to wipe you out financially.

The ACA was passed in 2010. Here’s a few posts I wrote about the emergency department and insurance in the years leading up to it:

2006: Is the MA health care reform law built on shaky assumptions?

The uninsured may seek a greater proportion of their care in the ER (or maybe not) but they tend to avoid the medical system in general. Meanwhile, insured people are at least as likely as the uninsured to use the ER in a given year.

That doesn’t mean the health care reform bill is a bad idea. It just means that absent other reforms –namely increasing throughput in physicians’ offices through the use of smarter scheduling and webVisits– it will lead to higher costs and lower service levels.

2007: Universal insurance wouldn’t help that much anyway:

But just for a minute, assume we did achieve universal insurance coverage. There would still be plenty of problems; costs might be even higher. A common argument is that costs would go down as uninsured patients head to less costly primary care physicians rather than emergency rooms for routine treatment. That would be great if true, but there’s evidence that insured patients use the emergency room more than uninsured patients. That could be because the uninsured tend to avoid treatment unless they’re in dire straits. Once the same patient has insurance he or she may want to test it out.

2008: Welfare queens for modern times: ER freeloaders

The perception that the uninsured are clogging up emergency rooms is a dangerous one, not only because of the bias it represents against the less fortunate, but also because it drives incorrect policy assumptions. One of the arguments for universal health insurance in Massachusetts and California was that it would [at least partly] pay for itself by shifting patients from the ER to primary care.

Actually what happens is the insured use all modes of treatment more. Providing people with health insurance means they’ll consume more of everything, as we’re seeing in Massachusetts.

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

Huffington Post reports on Health Business Blog’s first decade

I was flattered that the Huffington Post decided to publish a story (“Think how your are adding value”: David Williams interview) to commemorate the first 10 years of the Health Business Blog. Author Svetlana Dotsenko does a nice job of drawing out some of the highlights including my interviews with candidates for Governor of Massachusetts, analysis of drug distribution policies, and interviews with entrepreneurs.

By healthcare business consultant David E. Williams, president of Health Business Group.

Big Vertex bonuses seem defensible to me

Is that for me?

Is that for me?

The Boston Globe devoted its top story this morning to criticizing Vertex Pharmaceuticals for paying $54 million in retention bonuses to top executives (Cystic fibrosis drug could bring millions to executives. Critics decry plan to compensate executives if costly new drug is profitable.) The Globe story argues that the bonuses are undeserved, unnecessary, and harmful to patients.

Thankfully, the story includes enough facts so that a perceptive reader can draw their own conclusions. Here’s my take:

  • The bonuses are performance based. They will only be paid if the company reaches profitability, which has taken 25 years to achieve. Profitability is key for the long-term success of Vertex and it’s reasonable for executives of this company to have that as an explicit, public goal
  • The new drug that could take Vertex to profitability is likely to offer major benefits to cystic fibrosis patients, enabling them to live longer and enjoy a better quality of life. We’re not talking about a toenail fungus or “me-too” treatment here
  • Vertex management is delivering returns to shareholders: more than a $15 billion increase in value in the past year. The bonuses are small compared to that
  • There is a rationale for retention bonuses, because these executives are attractive to others hoping to emulate Vertex’s success

Of course there are other important issues here: drug pricing, the increasing gap between the richest and everyone else, cost of drug development, government involvement in healthcare, etc. But attacking this particular bonus plan strikes me as a distraction and not worthy of the attention the Globe is providing.

Image courtesy of iosphere at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

The new primary care docs: retrained specialists

Sign me up!

Sign me up!

As the US healthcare system becomes more cost conscious, demand for primary care physicians is outstripping supply. Various solutions are being tried, such as increasing number and elevating the role of nurse practitioners and physician assistants and increasing immigration.

Dr. Leonard Glass, a retired surgeon in Southern California, had a different idea: Why not retrain retired or semi-retired specialists as primary care physicians? In this podcast interview, Dr. Glass discusses Physician Retraining & Reentry, his vehicle to make it happen.

These are the questions and time stamps:

  • (0:13) What problem are you addressing? Why does this organization exist?
  • (1:50) How is PRR different from others who are addressing the PCP shortage?
  • (3:52) How did you come up with the idea?
  • (6:23) What is the program like and how long does it take?
  • (10:22) What kind of candidate is a good fit for the program?
  • (12:02) What’s involved in the program and how much does it cost?
  • (14:09) What happens after a doctor finishes the program?
  • (17:04) Do you have a favorite story of a PRR graduate?

By healthcare business consultant David E. Williams, president of Health Business Group.


Do it yourself death panel

How are you feelin' today, mom?

How you feelin’ today, mom?

Federal law allows states to recover Medicaid costs from heirs. This little known provision is getting more attention as part of the debate over Medicaid expansion. The Wall Street Journal (New Wrinkle for Health Law) wrote a balanced article about it, highlighting consumer fears about having to sell assets while also sharing the government perspective that “estate recovery helps shore up the program for others who need it.”

The online comments and letter to the editor generally support the view that recipients’ estates should have to pay back the government. The letter (First, Estates Should Repay the Taxpayersis characteristic of the righteous indignation provided by the commenters.

Where is it written that a person is entitled at death to leave assets to children, particularly after someone else, in this case the taxpayers who fund Medicaid, has paid the health-care bills? Where is it written that children are entitled to inherit assets from a parent who has unpaid bills for services received during his or her lifetime?

Maybe if the issue were framed differently the commenters would rethink. Two points in particular:

  • If we seek to reclaim Medicaid payments we need to reclaim Medicare payments as well. Although recipients pay into the system, Medicare is far from self-sustaining. More than 40 percent of Medicare spending is financed from general revenues.
  • If the government starts going after estates for medical expenses more broadly, dying patients will worry that heirs will ration care to preserve their own inheritances. And with so much at stake, it’s not a paranoid thought

So here’s my question for the commenters and letter writers: Are you willing to expand this logic to Medicare and provide your own heirs with an incentive to form a death panel for you?

Image courtesy of artur84 at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.


Meaningless Use: Pediatric portal example

I love my family’s pediatrician. He’s an old school guy who keeps up with the literature, is a great diagnostician, has an informative and comforting manner, and uses the hospital system’s medical records and phone calls to track the progress of his sicker patients as they deal with specialists. He’s available for a call-in hour every morning.

The practice’s patient portal from eClinicalWorks is another matter. The “PHR-View” has tabs for Allergies, Vitals and Immunizations. The information appears to be complete, which is nice, but where is the standard form that I need for school, camp, etc? It’s nowhere to be found and I have confirmed with the practice that it isn’t available. The practice doesn’t like to use the secure message system, which anyway doesn’t allow attachments.

Bottom line? I obtain the forms the same way I did close to 20 years ago: Call the practice and ask them to fax the form. They are always happy to do it, but it seems a little silly. Surely we can expect more from patient and family portals in 2015.

By healthcare business consultant David E. Williams, president of Health Business Group.