Patient perception in the ED.....

THIS

Article was written by a good friend, and it has certainly caused a stir. From the abstract...

Physician assistants (PAs), nurse practitioners (NPs), and medical residents constitute an increasingly significant part of the American health care workforce, yet patient
assent to be seen by nonphysicians is only presumed and seldom sought. In order to assess the willingness of patients to receive medical care provided by nonphysicians,
we administered provider preference surveys to a random sample of patients attending three emergency departments (EDs). Concurrently, a surveywas sent to a random
selection of ED residents and PAs. All respondents were to assume the role of patient when presented with hypothetical clinical scenarios and standardized provider
definitions. Despite presumptions to the contrary, ED patients are generally unwilling to be seen by PAs, NPs, and residents. While seldom asked in practice, 79.5%
of patients fully expect to see a physician regardless of acuity or potential for cost savings by seeing another provider. Patients are more willing to see residents than
nonphysicians.

This brings up the subject of educating the public about various providers, and the various discussions of the principles of ethical assent to treatment.

But there are also some flaws in this study. When we look at the methodology, this was done at only 3 academic medical center ED's. This creates an automatic selection bias. While I understand the intention of the authors to examine patient willingness to be seen by residents, as well as PA's and NP's, it could easily be argued that patient expectations in academic tertiary centers are quite different from those in small, community or rural hospitals. Also, the study was conducted only at hospitals in Pittsburgh, or Dallas. There may be a geographic variation in patient attitudes that remains untested.

While this is an important study, and discussion ABOUT this study is imperative, we must also resist the urge to draw extreme extrapolations from a limited study.

Perhaps a validation study, done in a series of smaller community ED's with no residency presence may yield different results, maybe not?

Also, perhaps repeating this, using the HRSA data to break up the country into geographic regions, and examining one academic, one community, and one rural ED in each area would provide a rich data yield, and would be an outstanding validation attempt.

Just a few thoughts....

Football season is coming soon....

It is almost upon us.....YAY...

OF course I am a Browns fan, so perhaps I should be in mourning.

Jake Delhommw...REALLY????

Mandates.....

So, the election in Missouri came and went....

WOW....Proposition C passed by 71%. Sounded like a major defeat to the health reform legislation, and analysts like myself were scratching our heads thinking, WHAT? Mainly because polling was showing increased support for the legislation with about 50% of Americans supporting the bill (AP polling).

SO, I dug a little deeper, AHA, there it is.....turnout was 65% republican.....which means that (assuming all R's voted against it), that approximately 6% of independents and democrats don't like the mandate.

From this link.

As written on the ballot, voters had to decide whether to “Deny government the authority to penalize citizens for refusing to purchase private health insurance or infringe upon the right to offer or accept direct payment for lawful health care services” and “Modify laws regarding the liquidation of certain domestic insurance companies.”

Prop C did not ask Missourians if they’d like to repeal the entire federal health law (and, just an aside--how was a voter suppose to vote if, say, he or she supported the second statement but not the first?). That would require the ballot to also ask voters if they’re for or against parts of the law that the public approves, like prohibiting health insurers from excluding children with pre-existing conditions. Or banning the practice of insurance companies kicking people off their insurance plans when they get sick. But Missourians weren’t asked to judge these and other popular provisions of the health care act.

Absence

Sorry for all of those that read this, or should I say, USED to read this blog on a regular basis.

Summer came FAST and HARD. School was a bit overwhelming, trying to get two research projects off the ground, trying to get funding, and working. OH, and taking vacation. It left little time for anything else, and something had to give.

Anyway, I'm Baaaacccccckkkk.....

Robert Wood Johnson Fellowship

SO, when I was in DC, I was able to meet with, and talk with several of the Robert Wood Johnson Health Policy Fellows. It is a prestigious one year fellowship (residential) in DC for mid career providers to work ON the hill, and in the Senate and WH, writing the legislation, drafting proposals, leading meetings, and advising the POTUS and Congress.

It's an incredible position, and so far, NO PA has ever done it, it has always been MD's, and the occasional PhD, RN.

Well, to make a long story short, I also got to meet one of the directors who thinks I would be the "ideal" PA candidate with my interest in Health Policy, and my informal association with the Mayo Health Policy Center.

What an opportunity, but alas, I cannot. Family is more important. But I'd be lying if I said I haven't been thinking about it EVERY day since.

Annual AAMC Physician Workforce Research Meeting

So, last week, I was in DC for several things, including meeting with a lobbyist, and several good friends who work in various committees on the hill. I was also there for the AAMC Meeting. It was great.

Contrary to the AAMC's usual position regarding workforce issues (train more physicians), they were very open to discussing teams of healthcare providers. Our AAPA has been working with the AAMC on some research into workforce issues, and they have been VERY impressed with our data. They have been very un-impressed with the NP workforce data mostly because it is so poor at this time.

One of the primary focuses of the talks, and agenda was a discussion of the recent legislation, and it's impact. Some of the absolute top researchers in the country were there, including several Robert Wood Johnson Fellows, as well as representatives of various medical schools. and several top think tanks such as the Robert Graham Center. Many of these folks, like the head of the Osteopathic Medical Association I've known, and talked at other meetings with, some were new to me.

The discussions surrounding Accountable Care Organizations, and the need for good primary care as it's foundation were good, and there were several research presentations dealing with PA's and primary care utilization, including community health clinics. Very positive outlook for the PA profession, and something that we should be very happy with.

One of my research focuses here, is going to be with experimentation in different care and team models, and how can we best design a team. My thoughts are ONE physician, and 4 PA/NP providers, and the preliminary numbers I've run show that this combination can see the equivalent of 4 physicians alone, or close (3.8 FTE by estimation).

Another thing that I learned on my trip, although not at the meeting per se, was that congress is becoming increasingly open to a cause that is very near and dear to my heart. Reducing the pay disparity gap in primary care. This will involve cuts to specialists, specifically interventionalists, and to a lesser degree surgeons, and an increase in pay to primary care. It makes sense, but Congress has been reluctant to involve itself in the marketplace in the past. However, this is one market that is in non pareto, and does not appear to be willing, or more specifically able to correct itself.

All in all, a great meeting, and the PA profession and community should be proud. I got more questions at the meeting, as well as many more after the meeting by email, than I have in a long time about PA training, education, and how can we increase the supply of PA's, and how to implement them into a team based model.

Plus I got have lunch with Len Nichols.....(BIG PLUS)

Kudos to you all, it is your work that has brought about these possibilities, I am but a mere ambassador and researcher.

Academic Medicine....

Most of you know that I live, work, and practice in Minnesota....which has one of the most liberal practice acts for PA's. I can prescribe Sched II-V, and basically do pretty much anything as long as it is allowed in my practice agreement, and is within my physicians practice standards. In EM, that covers a lot.

However, I also practice in an academic environment, which I enjoy for the most part, however, there are some detractions as well. I get to precept MS III's and IV's, and teach the residents occasionally, but too often, procedures will get passed to the residents. Not LP's of course, as I have done more of those than I ever care to think about, but chest tubes, intubations, and central lines often get re-assigned to the residents. I understand that they need to complete so many, as part of their training, but sometimes I like to do those things as well. At my other ER's I occasionally do them, and as I usually tell PA students, knowing WHEN, and WHY you want, or need to do these procedures is 1000 times more important than actually doing them.

I'm also heavily vested in research, particularly physician/medical workforce issues.

Occasionally, however, my faith is rewarded. Recently I got to do an elective cardioversion in the ED. Propofol sedation, Fentanyl, 100 joules biphasic, and BAM....NSR.

At another ER, I recently had to intubate someone as well. So, while the opportunities may be more limited than some of the EM PA's who work in non academic environments, I am for the most part, happy as a clam at mine.

Interstate Insurance competition.....

Another fancy reform gadget that is thrown around by both parties is the concept of “increased competition”, as if Adam Smith’s magical hand will wave over the marketplace and prices/premiums will magically lower. It is not true for a number of reasons, but a real discussion of free market economics in healthcare can wait for another day. Today, we will discuss insurance competition. There is much to discuss, although interstate competition has not been allowed, there is often substantial instate competition.

The health insurance market has been traditionally regulated in a federalist model with each state being responsible for various regulations, including coverage limits, financial solvency of both the individual, as well as the insurance company, and to help protect against fraudulent behavior, ensuring that members/enrollees are provided the benefits as promised. State regulations have also imposed rating, and rate banding legislature to prevent health insurers from charging too much for certain “high risk” patients (Kofman, Pollitz, 2006). Additionally, there is variance between states as pertains to a “guarantee of issue”, as many states have different qualifications, this could potentially destabilize the market by causing an asymmetry, as sicker patients would not likely qualify for out of state insurance, while healthier patients could opt for cheaper out of state plans. Kofman and Pollitz also describe how the detection, and prosecution of fraudulent activity would be quite difficult, and might even raise some state constitutionality issues when trying to enforce different state laws. This creates a murky situation at best, and potentially exposes many patients to fraud, and potential predatory pricing tactics, as well as many companies to unfavorable market conditions. As mentioned above, another potential problem that arise with sales of health insurance across state lines, is the risk of creating an adverse risk pooling. Health insurance, like any other insurance commodity, relies on pooling of risk, meaning that costs need to be spread across both sick and healthy people in order to maintain a stable economic foundation. By allowing the sale of insurance across state lines, out of state insurers will get to “cherry pick” individuals, and because there is no guarantee of issue for an out of state transaction, healthier individuals may be offered lower rates than they can obtain locally, while sicker individuals will be denied coverage. This will result in the in-state insurers covering an increasing percentage of sick individuals resulting in an adverse risk selection bias. This will undoubtedly cause prices to rise in-state, and overall health insurance premiums will increase as a result. This is especially important when we realize that only 5% of our population accounts for 49% of healthcare spending (Stanton M, 2006). By denying insurance companies that ability to pool risk, and to spread healthcare costs throughout a specific population, they will have no choice but to increase premiums for those who are sick, or have chronic medical conditions. When we examine the interstate sales of health insurance, it appears on the surface to be a good idea, however, real time examination of current markets may reveal otherwise. An important concept in financial exchanges is leverage, and companies and institutions will attempt to use whatever leverage is available to negotiate better financial terms. In healthcare, this frequently occurs between health insurers and healthcare providers/institutions. When one party gains leverage on the other it is used to either raise, or lower prices depending on the entity involved. When we look at certain markets, as BNET reported, for example Milwaukee, where there is no dominant insurance company, leverage is given to the healthcare providers and hospitals, and many physicians will not accept less than 200% of Medicare rates, in contrast to a nearby city like Chicago, where typical payments for private payers are only 112% of Medicare rates (Terry K, 2009). Which raises an interesting dilemna.

Providers in the example provided via BNET, are actually driving costs higher, due to decreased market share in the insurance industry. I got all excited, and actually though of doing this as a full on study, using the Herfindahl index and getting to play around with some fancy math, but the NBER beat me to it...unfortunately, they found that an increased concentration in the marketplace, could only account for an increase of 2% in premiums over an 8 year time span, with health insurance premiums rising an average of 10% or more per year over that same time period.

PAPER HERE
We examine whether and to what extent consolidation in the U.S. health insurance industry is leading to higher employer-sponsored insurance premiums. We make use of a proprietary, panel dataset of employer-sponsored healthplans enrolling over 10 million Americans annually between 1998 and 2006 to explore the relationship between premium growth and changes in market concentration. We exploit the differential impact of a large national merger of two insurance firms across local markets to estimate the causal effect of concentration on market-level premiums. We estimate real premiums increased by 2 percentage points (in a typical market) due to the rise in concentration during our study period. We also find evidence that consolidation facilitates the exercise of monopsonistic power vis a vis physicians, whose absolute employment and relative earnings decline in its wake.

Let's talk tort reform....

Lot’s has been said about the holy grail of tort reform by those in the medical field. The problem is, most of it isn’t true. Physicians and providers are very good at assigning the blame for rising costs on every one else. We are good at describing the “evil” insurance companies, and “greedy” pharmaceutical companies (partly true here), and those “bastard” lawyers. However, this blame game ignores the fact that while all of those players are culpable to a degree, it is the provider that also shares a significant amount of blame for cost increases.

Tort reform is currently the shiny object over in the corner of the room. That’s not to say that it can’t help, but the latest CBO estimates are a savings of 54 billion over ten years, or roughly 5.4 billion per year. In a 2.4 trillion dollar healthcare system, that doesn’t amount to much. Latest estimates are 0.5% savings. I would posit, that perhaps it might be closer to 1% once defensive practices are slowed. However, I don’t think the CBO is too far off here.

Let’s look at Texas, in 2003, they introduced the most aggressive tort reform legislation to date in the US. It is true that this reform, after 2003 lowered malpractice premiums, and increased physician supply to the state. However, Texas, since 2004 has seen a growth in testing expenditures that has outpaced the national average by more than 50% (Arkush, Gosselar, Hines, Lincoln, 2009). Additionally, the same report found that Medicare spending per patient had doubled between 2003 and 2007, in contrast to the decline in Medicare spending that was noted prior to the laws enactment. They also found that Texas has the highest rate of uninsured patients in the country, both prior to the law, and accelerating after the law was passed. The additional physician presence has only increased because of an increasing population as well, and there was only an increase of 0.4 physicians per capita after the law was passed. In addition, ACEP gave Texas an “F” on access to emergency care in 2009. Lastly, the National Board of Economic Research (NBER) commissioned a comprehensive study, which concluded that a targeted reform may have some impact, but that overall, it would be neglible (Lakdawalla, Seabury, 2009). Additionally, they found that for every 10 percent reduction in medical malpractice costs related to liability, there is a 0.2% increase in patient mortality. The NBER article is particularly poignant, and I have posted the summary here, as the article is 60 pages long, and the economic math is quite intensive.

HERE

The impact of liability for medical malpractice on the cost of medical care has been one
of the highest profile issues in debates over the U.S. health care system for many years.
Malpractice payments have grown enormously over the past 15 years, but this has likely had a
modest impact on the cost of health care in the US. It may have other significant effects, such as
decreasing the supply of physicians or changing the nature of treatment. Our findings, however,
suggest that limiting malpractice liability is no panacea for rising health care costs.
Moreover, while the mortality benefits of malpractice may be quite modest, these seem
more likely than not to justify its direct and indirect health care costs. Therefore, we conclude
that — for values of statistical life traditionally employed by US regulators —reducing
malpractice costs is not likely to be a worthwhile policy goal in itself. As emphasized by Currie
and MacLeod (2008), however, specific policies must be evaluated on a case-by-case basis, as
they can have unexpected effects on physicians’ expected liability and incentives. In addition,
there may be policies that reduce malpractice costs but have other social benefits; we do not rule
those out, but note that the case for their adoption rests on their auxiliary effects.
At a minimum, our analysis reveals the tenuousness of the case for tort reform, but it is
important to note its limitations. First, we account only for impacts of tort reform on medical costs and mortality, excluding its impacts (if any) on morbidity, physician utility, and patient
satisfaction. These quantities are extremely difficult to measure objectively. In addition, we do
not account for the adjustment costs (e.g., on the utilization of the health care system) that would
be induced by any large-scale reform project. The size and even direction of these excluded
effects is not clear. Finally, even if we ignore these limitations and accept the estimates at face
value, the probabilistic nature of our analysis means we cannot rule with (even approximate)
certainty for or against tort reform over conventionally accepted values of life.
Putting our results together with earlier work suggests that malpractice may have
substantial impacts on the care and costs of specific patient subgroups — like heart attack
patients — but much more modest impacts on the average patient, and on health care spending as
a whole. Future research should endeavor to determine whether tort reform can be targeted
toward these subgroups in a cost-effective manner.
Another important avenue for future work is to evaluate whether malpractice has effects
on more fine-grained outcomes in the health care system, such as morbidity, disability, or the
nature of care delivery. Medical costs and mortality are likely to be the first-order costs and
benefits of changes to the malpractice system, but the auxiliary effects may be quite significant.
If, for example, malpractice risk has had limited impacts on costs but appreciable positive
impacts on average outcomes other than mortality, the malpractice “crisis” may be anything but.
If, on the other hand, it has negative impacts on outcomes, the major costs of malpractice may be
in health rather than in dollars.

Real Effects of the legislation.

I got this email from a friend who also works in the health policy arena. I thought is particularly poignant, and obtained his permission to post it here. It is sometimes easy to get lost in the data and statistics, and forget, that there are REAL people out there, and this will have REAL effects.

I turned on the television tonight and saw a newsflash that the last vote had been taken on health care reform. For some reason it hit me – the sheer magnitude of the events of the last week, the last few months, and the last few years.

It made me think of my dad. Born in 1952, he has lived his life with a form of muscular dystrophy that has deteriorated the muscles in his legs. He has lived his life as a hard working farmer, as the sole owner/operator of an auto body shop, and as the best role model I’ve ever known. Considering his medical condition and his line of work, he has always had to purchase his own insurance – and has never been able to afford it.

No insurance plan would ever cover my dad’s condition and he has never received the kind of therapy that he truly needs.

He has now applied for disability as he is no longer able to work, an incredibly difficult decision for a proud, hardworking man. He is only months away from spending the rest of his life in a wheel chair, and this would have been preventable if he only had access to medical care.

The work that we have done, and the work that we will continue to do, is important as it truly impacts people’s lives.

With the new health care reform legislation, my dad now qualifies for the immediate high risk insurance pool until he is eligible for Medicaid, and is approaching Medicare eligibility. But, more importantly, millions of individuals like my dad will now be able to afford insurance and seek high quality health care from the finest medical institutions in our great country, and never reach the point where they are on disability and have to give up their livelihood.

My sister, born in 1981, has the same muscular dystrophy as my dad, and is currently uninsured. She will now be able to afford insurance through the exchange and receive the type of therapy early in her life that my dad was never able to afford.

My family owes each of you a debt of gratitude, individuals and families across this country owe each of you a debt of gratitude, and I am proud of what this team has accomplished.

I am going to celebrate. You should celebrate. And we should celebrate this historic accomplishment together.

I honestly believe that every day of our lives is a momentous day, and considering how many individuals like my dad and sister who will truly benefit from this health care reform, this is especially true of our collective days over the last few years.

Thank you for all you’ve done and all you continue to do. And thank you for the continued dedication we will all carry with us as we enter a new era of health care reform.

Josh