Category: Policy and politics

Universal health insurance wouldn’t help that much anyway

published date
January 19th, 2007 by

A page one Wall Street Journal article (Health-Insurance Gap Surges as Political Issue), charts the ascent of the uninsured as a political issue. With one in six Americans lacking health insurance, it’s a juicy topic. Despite all the rhetoric, it’s unlikely we’ll see much happen at the federal level. The voices of change are too fractured and it’s unclear that there’s room for consensus.

The picture is different at the state level: Massachusetts has enacted legislation requiring residents to have health insurance. California and others are following suit.

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.

Employers complain now that the prevalence of uninsured patients drives up their premiums, but it could get worse if greater availability of insurance leads to the need for larger and larger subsidies.

Insurance mandates make sense in Massachusetts. The proportion of uninsured is relatively low, and a good number of the uninsured are healthy, young adults who could afford to pay. The cost of living is high; we need knowledge-based businesses that offer high pay and high benefits. I’m less sanguine about efforts in states like CA where the gap to close is much bigger and lower paying industries like agriculture are a substantial portion of the economy.

I’d like to see insurance for routine care done away with. Instead, allow a more efficient market to develop where people pay directly and doctors don’t spend so much trying to collect payment from third parties. Walmart, Walgreen, CVS and others are starting down this path. Physician practices could begin to do the same. If we hope to have affordable care, this is a more promising path than spreading insurance around to everyone.

Now available in your friendly neighborhood ER: Norovirus

published date
January 18th, 2007 by

I’ve been ranting recently about physicians recommending visits to the ER partly/mainly/largely to mitigate the risk of being sued instead of basing recommendations entirely on medical grounds. That costs patients and caregivers time (often a lot) and money, slows treatment for real emergencies, and makes health insurance more expensive by driving up costs to the system.

Does this phenomenon also represent a threat to public health? From yesterday’s Boston Globe (Intestinal germ leaves trail of misery)

More than 3,700 patients stricken with nausea, vomiting, and diarrhea have visited Boston’s emergency rooms during the past six weeks in a wave of gastrointestinal illness… “We have seen a large number of cases of what appears to be a sudden onset and intense, short-lived diarrhea, nausea, and some abdominal pain,” said Dr. Jonathan Olshaker , Boston Medical’s emergency department chief.

The cause?

[N]orovirus, an intestinal germ that travels easily from person to person.

The article says public health officials can’t quite figure out why it is spreading.

My first concern (attention commenters, get ready to pounce!) is why so many norovirus patients are in the ER in the first place. Sure some are at risk of dehydration. But how many are sent there by on call docs “just in case of lawsuit” for an illness that passes in 24 hours?

My second concern is the number of other ER patients and caregivers –some at the ER for no good reason as described before– who may be getting infected while they wait around for hours.

SARS spread in a similar fashion in Canada, after all.

The outbreak surfaced in February 2003, when a woman from the Toronto area contracted the virus on a trip to Hong Kong and returned home, dying soon after. Her son went to a hospital with an unidentified condition that was later diagnosed as SARS. While waiting for 16 hours in a crowded emergency room, the man transmitted the virus to two other patients, and it continued to spread, the commission’s report says.

Cavalcade of Risk #17

published date
January 17th, 2007 by

Welcome to the 17th Cavalcade of Risk, a roundup of the best blogging on the topic of risk.

Not (specifically) health care

Risky opinions

To get us started, Brian Kim explains how to counteract the tendency toward risk aversion as we age. Think of risk as a journey of exploration rather than a one-shot do or die deal.

Between Heaven and Earth, an advocate for Chinese human rights, savors the risks China is creating for itself in hosting the 2008 Olympics. China won’t dare restrict ticket sales based on political views, so we may see little old ladies from Falun Gong doing tai chi in the stands as a protest.

Long or Short Capital has a tongue in cheek cure for global warming: convert greenhouse gases into tasty foods. (I fear this might lead to secondary emissions during digestion.)

New York Personal Injury Law Blog wonders what the heck the Port Authority was thinking at the George Washington Bridge. They’d planned to post Geico billboards promoting safe driving. But intentionally distracting drivers seems anything but safe. (The plan’s been canceled now.)

Pick your peril. Bradley Wright speculates on the relative risk of hand gliding and paragliding. (Probably both are riskier than looking at Geico signs.)

Nice try: State Farm refused to pay a couple in Biloxi after Katrina destroyed their home, arguing the damage was caused by a storm surge (not covered) rather than a tornado that occurred during the storm (covered). A judge sided with the couple. The FRAUDfiles blog explains the case.

Securities lawsuits are falling, and not even the options backdating scandals are enough to reverse the trend, according to Specialty Insurance Blog.

Walmart has figured out how to shift the risk of customer traffic fluctuations onto its employees. However, that may open the company to additional workers comp exposure. Workers’ Comp Insider explains why.

An overzealous financial institution sent Emergent Chaos’s author two letters confirming a change of address. Somehow the institution changed the address to ALL CAPS and triggered who knows how many pages of correspondence.

Tips and tricks

InsuranceHelpHub suggests ways to cut your car insurance. (You might as well save somewhere –it won’t be on your health insurance.)

Getting Green warns against debt consolidation and elimination companies. Through the immature magic of context-specific advertising, several Google ads for just such services are displayed alongside the post!

Want to save a million dollars? Better start now, says Bryan Fleming. Financial page notes that 44 percent of households are at risk for inadequate retirement assets, based on the National Retirement Risk Index, so get cracking.

Think you’ve covered your risk by buying insurance? Think again. The Digerati Life has tips on how to collect your claims, starting with sucking up to the company’s reps.

Health care

Massachusetts eHealth Collaborative Blog adds balance to a Business Week story on medical identity theft. Not only was one of the “new” frauds tested and rejected by Tony Soprano years ago, but the BW authors neglect to mention the ways e-health records can reduce the risks faced in a paper-based world.

Managed Care Matters describes the risks inherent in so-called consumer-directed health plans. Risk #1: the physician is the consumer!

Physicians commenting on my post admit directing patients to the ER in order to reduce their own risk of being sued. It’s rational for patients to second-guess their docs in such circumstances. Would you hire a lawyer or accountant who always provided the most conservative advice with the most expensive consequences?

Medicaid is supposed to be a safety net for the poor. If so, why are so many poor people uninsured? Check out InsureBlog to learn more.

Granting temporary privileges to physicians can lead to permanent problems for hospitals, according to MSSPNexus Blog.

Anthem Blue Cross Blue Shield is making a smart move to obviate the need for universal health care coverage in Colorado, says Colorado Health Insurance Insider. Meanwhile Roth & Company thinks the Gubernator has lost his mind by proposing a tax to support universal health insurance. (Anthem, can you help?)

Catastrophic injury and traumatic brain injury are on the rise due to the wars in Iraq and Afghanistan, making it harder for the VA to fulfill its mission, reports the Sentinel Effect. (If the military keeps expanding we may end up with a single payer system as everyone becomes VA eligible.)

NitroMed obtained approval to market BiDil specifically for African American patients. Should the government be allowed to decide which races benefit from which drugs asks Healthcare Economist.

Want to reduce your chance of illness? Lose weight, Health Blog says.

Concluding thoughts

A saying I read twenty years ago in the New York Times comes to mind whenever I think of risk:

There are old mushroom hunters and there are bold mushroom hunters, but there are no old, bold mushroom hunters.

On the other hand, hosting the Cavalcade is low risk. Cav of Risk founder Hank Stern of InsureBlog supported me every step of the way, even hunting for posts to round out those that were submitted. If he asks you to host, just say yes!

The problem with medical tourism

published date
January 15th, 2007 by

I’m an advocate for sending patients overseas for medical treatment when it’s justified by quality and cost considerations. However, I really object to the term medical tourism. To me, tourism connotes an entertaining, fun-filled vacation trip made with discretionary dollars. I suppose spa treatments and some cosmetic procedures could fit the definition, but tourism seems like just the wrong term for a trip to another country for a hernia repair or kidney transplant.

It’s really more like a business trip than tourism, though I don’t think medical business would be the right term either.

Promoters will make some progress marketing a trip that combines fun with medical care, but I think positioning the services more seriously would be a much better idea.

The upside of dermatology delays

published date
January 15th, 2007 by

I posted last week on the delays Boston-area patients face in obtaining an appointment with a dermatologist. A superficial analysis suggests waits may be shorter in England.

A couple new points came up over the weekend:

The Globe published a response by Dr. Kathryn Bowers, President of the MA Academy of Dermatology. Her assessment wasn’t especially encouraging.

Most dermatologists train their office staff to identify patients with an urgent problem and attempt to fit them into the schedule as soon as possible. With doctors fully booked and, frequently, overbooked, this is often not feasible.

That’s a pretty sad admission. She also laments the “brain drain” of dermatologists who train in MA but then move elsewhere because of the difficult practice environment. I’m sympathetic to the challenges of practicing in MA, however the original article reported that Boston had the highest concentration of dermatologists of any city surveyed and the longest wait for an appointment. There must be other factors at work.
Meanwhile, a friend who is a dermatology resident in Boston confirmed the long waiting lists for an appointment at his institution, then told me:

It’s just as well that there’s a long wait. Someone who comes in with a rash is likely to be biopsied and end up with a scar. If they wait until an appointment is available the rash will probably have cleared up.

I told him that tolerating long waiting times was an awfully blunt approach to reducing unnecessary biopsies!