“[In the 1970s] feminists argued that medical care needed to be demystified and women’s lives demedicalized.  They maintained that childbirth was not a disease and normal deliveries did not require hospitalization and the supervision of an obsterician.

The conflict over home birth proved to be one of the most bitter between the medical profession and the women’s movement.  While no state forbade home birth, the American College of Obstetricians and Gynecologists actively discouraged it as unconscionably risky.  Doctors who participated in home births by offering backup in emergencies were threatened with loss of hospital privileges and even their medical licenses.  Midwives in California were prosecuted for practicing medicine without a license.”

• The Social Transformation of American Medicine, Paul Starr.

A recent article, however, suggests that NPs may not be cost effective.  This is a curious result because NP salaries are much lower than primary care physicians (PCPs).  Consider the following difference between the hourly wage for  physician assistants compared to family and general physicians.

• Family and General Practitioner: $85.26/hour.
• Physician Assistant: $43.01/hour.

Drs. Liu and D’Aunno, however, argue that employing a nurse practitioner or physician assistance creates additional cost.  First, the physician often needs to supervise the nurse practitioner.  Physicians who spend time supervising NPs have less time to spend with patients.  Second, some share of patients will have more complex conditions that only the physician will treat.  These patients will have two office visits (first with the NP, then with the physician), but would only have needed one visit if they had seen the PCP initially.  Third, if the NP is underutiliized, then the practice will be paying the NP for little work.

This is not to say that NPs are not cost-efficient.  I believe that increasing the role of the NP can increase efficiency.  The Lui and D’Aunno article, however, does note some of the conditions that are necessary for practices to leverage NPs effectively.

Sources:

• Liu, N. and D’Aunno, T. (2012), The Productivity and Cost-Efficiency of Models for Involving Nurse Practitioners in Primary Care: A Perspective from Queueing Analysis. Health Services Research, 47: 594–613. doi: 10.1111/j.1475-6773.2011.01343.x
• Kreitzer, M. J., B. Kligler, and W. C. Meeker. 2009. “Health Professions Education andIntegrative Health Care.” Journal of Science and Healing 5 (4): 212–27.
• Laurant, M., M. Harmsen, H. Wollersheim, R. Grol, M. Faber, and B. Sibbald. 2009. “The Impact of Nonphysician Clinicians: Do They Improve the Quality and Cost-Effectiveness of Health Care Services?” Medical Care Research and Review 66(6): 36S–89S.

As physician wages have grown over time, however, the home visit has made less economic sense.  Consider the table below.  Primary care physician median wages are five times as high as the typical earners wages.  If it takes 30 minutes for the physician to drive and set up his equipment for a home visit, the incremental cost for the typical physician visit would be about $40 compared to only a time cost of about $8 if the patient visited the doctor. Having physician assistants or nurses make a home visit would be relatively more economical, but still is not economically efficient given the current labor market.

Nevertheless, home visits may be making a comeback.

A number of physicians in Great Britain’s National Health Service already make home visits. Further, Health Reform (specifically Section 3024 of the Affordable Care Act) mandated the creation of the Independence at Home (IAH) Demonstration. The IAH demonstration will begin in January 2012. Do home visits make economic sense?

According to the Medicare website, the IAH “…utilizes physician and nurse practitioner directed primary care teams to provide services to certain Medicare beneficiaries in their homes. Participating practices will be accountable for providing comprehensive, coordinated, continuous, and accessible care to high-need populations at home and coordinate health care across all treatment settings.”

The Demonstration sites will be required to:

• Have experience providing home-based primary care to applicable beneficiaries
• Make in-home visits
• Available 24 hours per day, 7 days a week
• Furnishes care to at least 200 applicable beneficiaries
• Uses electronic health information systems

Certainly the IAH increases the cost of physician visits. The IAH, however, could be economically efficient if it reduces the likelihood sick patients require hospital or nursing home care. Although in most cases it is more efficient for the patient to visit the physician, in some cases when the patient is very ill, the cost to patient to travel to the physician’s office should not be their hourly wage. If they are in serious pain, the would be willing to pay much more than the difference between their hourly wage and the physician’s hourly wage to have the physician visit them in their home.

If this is not an economical option, patient may simply forgo preventive care or regular check-ups. Failing to make these periodic visits to the physician could allow diseases to fester untreated and thus result in unnecessary hospitalizations.

Thus, the IAH demonstration will certainly improve convenience for patients, but will only be cost-effective if it can reduce the likelihood patient’s require hospitalization or long-term care.

Walmart announced it would stop offering health insurance benefits to new part-time employees, the retailer sent out a request for information seeking partners to help it “dramatically … lower the cost of healthcare … by becoming the largest provider of primary healthcare services in the nation.”

Why would Wal-mart want to provide health care services?  Here are some reasons:

• Many health care services are high margin.
• With some exceptions (e.g., Kaiser), most current health care service providers do not take advantage of economies of scale, particularly with respect to information technology (IT) services.
• Wal-mart could take advantage of their current IT infrastructure to readily create EHR.  In fact, Walmart has offered commercial EHR software & services to healthcare providers since 2009.
• This effort builds on the success of walk-in clinics at stores like CVS (MinuteClinic).  These efforts increase brand loyalty (people usually have a good opinion of the places they get health care) and increases store traffic.  Further, between 2007 and 2009 retail clinic use increased 10-fold.
• Wal-mart recently dropped health insurance for its employees.  This could be a public relations mechanism to provide some care to these employees.
• Wal-mart recently dropped health insurance for its employees.  These people will need low cost primary medical care since insurance won’t cover these services.
• It could create a service provider which is national in scope an already has an existing distribution network.  Wal-mart has 3,800 stores nationwide that it can use to house these clinical services.
• Wal-mart already delivers prescriptions drugs through its low cost generics program and Medicare Part D drug plan.

The Wall Street Journal reports that Wal-mart is actively seeking partners for its health care expansion.  I would assume that Wal-mart with staff the clinics with low-cost nurse practitioners (NPs) and physician assistants (PAs).

Although some health reformers have aimed to bolster the role of primary care providers, Wal-mart’s actions may help NPs and PAs who provide primary care while putting competitive pressures on MDs who provide primary care.

Source:

• Ashwood, J.S. et al. “Trends in Retail Clinic Use Among the Commercially Insured” American Journal of Managed Care Vol. 17, No. 11 November 2011 e443-e448

These integrated models, however, may not serve one population very well: truckers.  Because truckers are on the road all the time, they frequently will need care outside of their area.  In fact, they may often need moderate amounts of treatment initially and then well seek more intensive treatment with their primary care doctor upon returning home.

The Healthy Trucking Association of America (HTAA) and the Convenient Care Association (CCA) have announced one solution to this problem: provide health insurance which relies on a geographically widespread network of retail clinics.  Although the CCA clinics may not be perfect, they do have two advantages: i) they are cheap, ii) they are located nationwide.

According to a recent press release:

“Located in retail stores like major pharmacies and large supermarkets, CCA clinics are much more accessible and affordable for drivers than traditional doctors’ offices or emergency rooms,” says Tine Hansen-Turton, executive director of the CCA. “Retail-based convenient care clinics provide a perfect venue for employees, and their families, to receive accessible, affordable, high-quality services.”

Are these cut-rate plans?  Possibly.  I don’t know about the generosity of these plans in terms of cost sharing or benefit structure.  The plans, however, are interested in adopting recent initiatives shown to improve patients care.

“…other trucking organizations who have expressed great interest in the clinics’ ability not only to identify and manage chronic disease risk but to support Compliance Safety Accountability Act 2010 federal guidelines through electronic medical records, standardized medical protocols, and technology solutions to reach drivers while traveling on the road,” says Stewart Levy, R.Ph., President of Health Promotion Solutions.

Medical homes and ACOs may help most people, but tailoring health care needs to the individual patient is vital.  The HTAA-CCA partnership seems to provide a good fit for the trucker population.

What was surprising about the video was the following observation: 33.7% of Massachusetts births in 2007 were caesarean sections.

Why are there many caesareans?  Dr. Gene Declerq claims the reason is the cascade of intervention.  Dr. Declerq defines this term using the following scenario: “…they come in and they’re relative low risk, but to be cautious, they put a fetal monitor on them…because things do not appear to be going as quickly as they would like, they induce them or stimulate the labor.  And then because the contractions–as a result of the induction–become very strong, they have to do an epidural to try to relieve the pain from those now stronger  than natural contractions…that may slow labor a little further and then they have to keep adding intervention upon intervention to the point where at the end, somebody says ‘we’re going to do a Caesarean.  Thank god we’re able to do the Caesarean’ whereas if they hadn’t start that series of interventions in the first place, we may have never gotten to that point.”

An economist would simply claim that physicians do Caesareans because they are revenue enhancers.

Why aren’t midwives more popular?  Couldn’t midwives be the first option and only if there are problems would the patient be transferred to the hospital?  One reason is that obstetricians want to protect their turf.  Having midwives perform more births will not only take a large chunk of the birth market share, it may also drive down price.

Economists may to often run to the conclusion that financial incentives are the sole driving factor motivating human behavior.  In this case, however, one cannot help but arrive at the conclusion that hospitals and physicians have made giving birth a high-cost, high utilization process to increase their revenue.

The national Caesarean rate, 31.8 percent, has been rising steadily for the last 11 years and is fed by repeat patients. Critics say that doctors are performing too many Caesareans, needlessly exposing women and infants to surgical risks and running up several billion dollars a year in excess bills, precisely the kind of overuse that a health care overhaul is supposed to address.

In fact, the rate of vaginal birth after Caesarean (VBAC) is now below 10%.  Some doctors claim that VBACs risk tearing the mother’s scar tissue on her uterus, but others–including the profiled women on a Navajo reservation–successfully undergo multiple VBACs.  Why are the rates VBAC rates so low?

• Fears of malpractice
• Physicians make more money Caesarean rather than a vaginal birth
• Caesarean’s use fewer physician hours than vaginal births
• Fewer expected number of pregnancies
• Patient demand

Why are Caesarean rates so much lower on the Navajo reservation?  On the reservation, physicians are federally insured against malpractice, are paid a salary, and the use of midwives is much more common.  Additionally, Navajo “couples often want more than two children, but repeated Caesareans increase the risk of each pregnancy, so doctors and patients are motivated to avoid the surgery.”

To see further evidence of how different physician compensation methods can alter surgery rates, see my own study in Health Economics.

How does it work? The treatment’s placebo effect explains the study’s findings. Researchers found that acupuncture was effective whether or not the skin was punctured.

“Dentist Lance Knight said the practice aimed at “making dental healthcare more accessible and convenient to better meet patients’ needs.”

The private surgery will go head to head with the NHS, charging £16 for a check up, which is slightly less than NHS fees.”

• Hat tip: Carpe Diem

“Roughly 90% of the patients came for one of 10 relatively simple treatments… ‘Most of the conditions cared for in retail clinics likely do not require the level of training of a physician.’”

Insurance companies are starting to support these retail health clinics.  Insurance paid for 67% of visits.

• Original Article: Mehrota et al. (2008) “Retail Clinics, Primary Care Physicians, And Emergency Departments: A Comparison Of Patients’ Visits,” Health Affairs27(5): 1272-1282.