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“Do Medicare patients have longer waits to see doctors than those with commercial insurance?”

May 5, 2011 in Medicare, Physician Compensation, Supply of Medical Services, Wait Times | 1 comment

…and three other questions about physician care.

Do Medicare patients have shorter waiting times than those with commercial insurance?

  • In the 2010 survey, among those seeking an appointment, most beneficiaries (75 percent) and most privately insured individuals (72 percent) reported “never” having to wait longer than they wanted for an appointment for routine care.
  • Another 17 percent of Medicare beneficiaries and 21 percent of privately insured individuals reported that they “sometimes” had to wait longer than they wanted for a routine appointment.Finding a primary care physician was more difficult for privately insured individuals than for Medicare beneficiaries.  Seventy nine percent of Medicare beneficiaries reported that they had no problem finding a PCP compared to 69 percent of privately insured individuals.

Is Medicare the new Medicaid?

The answer is not yet; providers are still accepting Medicare patients at high rates, but the trend is towards fewer PCPs accepting Medicare.

  • “For 2008, among physicians with at least 10 percent of their practice revenue coming from Medicare, 90 percent accepted new Medicare patients. By specialty, 83 percent of primary care physicians and about 95 percent of physicians in all other specialties accepted new Medicare patients. The rate of primary care physicians accepting new Medicare patients fell from 88 percent in 2007.”
  • Medicare’s payment for physician fee-schedule services in 2009 averaged 80 percent of commercial rates for preferred provider organizations (PPOs)

Is concierge medicine the wave of the future?

Not yet.  In the fall of 2009, researchers found that there were 750 retainer-based or “concierge” physicians.  Thus number represents less than 1 percent of the total number of physicians practicing in the United States.  However, there is a trend towards more concierge medicine.  There was a 50% annual increase in the number of retainer-based practices from 2005 to 2009.

Where types of physician care is growing the fastest (and slowest)?

  • Volume per beneficiary grew 3.3 percent in 2009.
  • However, there was a decrease in 2009 of coronary artery bypass grafts (CABG), cardiovascular stress tests, colonoscopy, standard chest imaging, hip fracture repair, brain MRIs, and coronary angioplasty.
  • Increases in service volume per beneficiary were found in advanced, non-standard computed tomography (CT) scans, outpatient rehabiliation, and spine surgery.

What recent legislation will affect the provision of physician services in the coming years?

  • Since 1991, physicians and other health professionals who practice in designated health professional shortage areas (HPSAs) automatically receive a 10 percent bonus (relative to the fee schedule amount) on all Medicare services they provide.
  • Starting in 2010, CMS no longer recognizes the billing codes for consultation services
  • Starting in 2010, CMS started a four-year transition to practice expense relative values that incorporate data from the Physician Practice Information Survey.
  • Starting in 2011 and ending in 2016, primary care practitioners will receive a 10 percent increase in payments for selected Medicare services, as will general surgeons practicing in HPSAs
  • Under the Physician Quality Reporting System (PQRS), physicians and other health professionals may qualify for a 1 percent bonus on all Medicare services they provide in 2011 and a 0.5 percent bonus in 2012 through 2014.
  • Starting in 2015, those who do not satisfactorily report PQRS measures will be subject to a financial penalty starting at 1.5 percent of their Medicare services.
  • EHR incentive programs provides physicians with incentive payments for meaningful use of electronic health records (EHR).
  • Starting in 2015, eligible physicians who do not satisfy the EHR criteria will be subject to a financial penalty starting at 1 percent of their Medicare services.
  • Reimbursement changes from Health Reform (PPACA) can be found here.

Source:

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How San Francisco’s provides Health Care for the Uninsured

January 22, 2010 in Health Insurance, Public Policy, Supply of Medical Services, Wait Times | 3 comments

Most workers have employer-provided health insurance. The old have Medicare and the poor Medicaid. Children have SCHIP and veterans have the VA. But what about the people who fall through the cracks? What about individuals who work for small businesses who don’t offer insurance, entrepreneurs, or illegal immigrants? Where can they get health care? An article in San Francisco Magazine discusses how the Bay Area provides health care for the uninsured.

Healthy San Francisco (HSF) is the city’s two-year-old health-access plan that provides healthcare access most uninsured resident aged 18 to 64, regardless of employment, citizenship, or preexisting conditions. In a city of 800,000 people, about some 63,000 people (~8%) use HSF. Journalist Justine Sharrock notes that “Healthy San Francisco isn’t insurance—it’s a system of providers that uses the city’s superb healthcare infrastructure: neighborhood clinics, community hospitals, public health centers, and the state-of-the-art resources of UCSF. It doesn’t replace other government programs, like Medicare or Medi-Cal; it just ensures that people who don’t qualify for them don’t fall through the cracks. To enroll, all you do is show proof of residency and income: The cap is now $54,150, though officials hope to open HSF to all income levels by the end of 2010. Other than a requirement that new participants be uninsured for three months prior to joining the program, there isn’t even a waiting period.”

HSF is, hands down, one of the best healthcare bargains anywhere. For individuals earning less than $10,830 annually, the program is free. For everyone else, basic enrollment is $20 to $150 per month (versus $409 for the average California insurance premium), with rock-bottom copayments: $10 for primary care visits, $200 for hospital admissions, and $5 to $25 for medications.

The main advantage of HSF is that sick people can get affordable health care. The article describes a woman named Sharon Donnelly who has hydrocephalus (i.e., a condition in which fluid develops in her brain) and found it “nearly impossible” to purchase nongroup coverage. Because she could enroll in HSF, she quit her library assistant job and gave up her private coverage. She is extremely satisfied with the care. In fact, the Kaiser Family Foundation found that 94 percent of users expressed satisfaction with HSF. Further, the program is inexpensive for users. “For those earning less $10,830 annually, the program is free. For individuals earning less than $10,830 annually, the program is free. For everyone else, basic enrollment is $20 to $150 per month (versus $409 for the average California insurance premium), with rock-bottom copayments: $10 for primary care visits, $200 for hospital admissions, and $5 to $25 for medications. Additionally, having HSF may attract more young, innovative people to San Francisco. These entrepreneurial people can work in small internet start-ups without worrying about how to get by without health insurance.

The main disadvantage of the plan is that it raises taxes and does not replace a comprehensive insurance plan. Let us return to the case of Sharon Donnelly. The availability of HSF allowed her to quit her job and employer the accompanying employer group plan in order to look for better employment. However, San Francisco taxpayers must subsidize such an expensive patient. In fact, the high cost individuals without access to employer-provided plans are the ones most likely to take up HSF. Small businesses cost are higher in San Francisco, partly because of a pay-or-play mandate which compels businesses to offer health insurance to their employees. “Businesses with 20 or more employees must contribute $1.31 to $1.96 per worker per hour toward some form of healthcare: either private insurance, a flexible spending account that sets aside money for health¬care needs, or the city option, including HSF.” However, the pay-or-play employer contributions to HSF make up only 11% of the program’s cost. No wonder San Francisco’s sales tax is 9.75%.

Additionally, the program only covers you when you’re in the city. If you’re injured outside of San Francisco—even in another Bay Area city such as Oakland or Palo Alto—then you must pay for care out of pocket. The HSF website even warns: “Healthy San Francisco is not insurance. If you have insurance, do not drop it. Insurance is always a better choice.”

Further, treatment can be slow. As part of being in the HSF, the author had to pick up her medications at San Francisco General’s pharmacy which she claims has “confusing or non-existent procedures” and took an hour to get her prescription filled. Although the Ms. Sharrock finds “the sense of camaraderie with the other people in line oddly comforting,” most people more likely believe that this is a serious inconvenience, especially for those with more rigid work schedules.

Finally, the creation of HSF will induce Tiebout sorting. If you am someone who earns $40,000 per year working for a small business in the city who does not offer insurance, living in San Francisco is a great way to get health insurance. However, if you make $200,000 working in the city with an employer-sponsored plan, you may choose to move to a nearby San Mateo county and commute to work. If this occurs, San Francisco will lose out on tax revenue from many of the high wage workers.

Overall, it is clear that individuals who participate in the HSF plan receive significant benefits. Because HSF is not self financing, those who do not participate in the plan will have to subsidize these costs. The effect of migration into/out of San Francisco is ambiguous: having HSF will attract workers but the higher taxes needed to pay for HSF will drive some people away as well. HSF is similar to the current health care reform proposals in that it will expand coverage, but does little to control costs or significantly change the healthcare system.

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How is the financial crisis affecting the UK’s National Health Service

December 22, 2009 in International Health Care Systems, Wait Times | No comments

In the 1990s, the UK’s National Health Service may have imitated most American’s idea of what is wrong with a single payer system.  However, when Tony Blair became Prime Minister in 1997 government spending on the NHS increased.  Over the past decade spending on the health service has risen by over 6% a year in real terms.  In addition, the NHS set ambitious performance targets and introduced reforms to foster more local independence.  In 2000, the government also declared a “war on waiting” and wait times in the subsequent decade did drop dramatically.  Other improvement include:

  • Hospitals have been able to purchase expensive new equipment like scanners. By 2007 the NHS had 8.2 MRI units per million people, below the average of 11 for the OECD, but above the figure in Canada.
  • The number of hospital consultants has gone increased 56% between 1998 and 2008.  The rise in nurse employment is 26% over this period.
  • Life expectancy continues to rise, with particularly rapid gains for men. Mortality rates from cardiovascular diseases, the leading cause of death in rich countries, have tumbled.
  • Extra cash, together with targets and performance management, have had a large impact on health care quality.

However, not all the reforms have had positive effects:

  • When Labor came to power, it abolished “the internal market in the health service introduced by the Conservatives in the 1990s, in which around half of GPs had become fund-holders with their own budgets for drugs and elective care, giving them an incentive to curb demand and a tool to bargain with powerful hospitals. With this lever gone, the government at first had to rely on instructions from the centre backed by performance ranking.”
  • “Since Mr Brown became prime minister in 2007…[t]he drive to ginger up the NHS by putting more hospital work out to the private sector has faltered.”
  • Even single payer systems can be disjointed. The Economist argues that electronic records need to be adopted so that GPs can better coordinate the care of their chronically ill patients when they enter into a hospital.
  • Productivity has declined 0.4% over the last decade.

With the government coffers more bare after the financial crisis, what does the UK plan to do with its National Health Service?  The Economist reports that–because of the financial crisis–the recent increases in NHS spending will likely stop, but the NHS will experience few cuts (unlike most other government services).

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Socioeconomic Status and Wait Times in Europe

December 17, 2009 in Health Care Around the World, Wait Times | 7 comments

One of the most contentious parts of the healthcare debate in the U.S. is whether or not to move towards a more European style of health care.  Those in favor cite the equality of the system, the lower cost, and lower administrative cost.  Those against rail against the lack of provider choice and the long wait times for many specialist services (see graphic).

But do all people in Europe experience the same waiting period for medical care?  A paper by Sicilliani and Verzulli (2009) find that individuals with higher socioeconomic status have shorter wait times in Europe.

“…individuals with high education experience a reduction in waiting times of 68% in Spain, 67% in Italy and 34% in France (compared with individuals with low education). Individuals with intermediate education report a waiting-time reduction of 74% in Greece (compared with individuals with low education). There is also evidence of a negative and significant association between education and waiting times for non-emergency surgery in Denmark, the Netherlands and Sweden.”

However, the authors don’t attempt to explain why individuals with higher socioeconomic status have shorter wait times.  Here are some explanations I came up with:

  • Private health insurance spillovers.  Let us assume that the government allocates healthcare resources on a per person basis.  Also assume that wealthier individuals are more likely to buy private health insurance.  If this is the case, wealthy/educated individuals living in “better” neighborhoods will experience shorter waits at the government run health centers because many of their neighbors will be using privately supplied medical services.
  • Buying votes.  The government may allocate more healthcare dollars to neighborhoods with wealthier individuals.  Politicians may do this to court the votes (and donation dollars) of the wealthier voters.
  • Tiebout sorting.  Let us assume that healthcare quality is randomly distributed geographically.  Property values will increase in areas with better public health facilities.  The people who can afford homes/rents in these high-quality healthcare neighborhoods will naturally be those who can afford it (i.e., those with higher socioeconomic status.)
  • Personal connection.  Physicians have high socioeconomic status and are more likely to be friends with patients who have high socioeconomic status.  Thus, they may be doing favors for their friends by getting them in earlier.  This likely happens, but does not explain the large disparities Sicilliani and Verzulli find.
  • Rich people complain.  If more educated individuals are more likely to complain about long wait times, physicians may have an incentive to schedule them first.
  • Bribes.

Any others?

Source:  Sicilliani L and Verzulli R (2009) “Waiting times and socioeconomic status among elderly Europeans: evidence from SHARE,” Health Economics, v18(11):1295-1306.

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50 days to see a doctor in Boston…Is Massachusetts’ universal coverage laws the cause?

June 9, 2009 in Health Insurance, Supply of Medical Services, Wait Times | 8 comments

From the USA Today, here are the wait times to see a doctor in the following cities:

  • Boston: 49.6
  • Philadelphia: 27
  • Los Angeles: 24.2
  • Houston: 23.4
  • Washington, D.C.: 22.6
  • San Diego 20.2
  • Minneapolis: 19.8
  • Dallas: 19.2
  • New York: 19.2
  • Denver: 15.4 days
  • Miami: 15.4 days

The first thing that jumps out from these numbers is that Boston has by far the longest wait to see a doctor.  Is this caused by the universal health coverage enacted in Massachusetts?  The answer is maybe.  Physician supply adjusts slowly (i.e., it takes a long time to finish med school).  On the other hand, Massachusetts decision to increase insurance coverage lead to a spike in the demand for medical services.  Thus, universal health care may have caused the run up in wait times, but this phenomenon may be short lived.  Physicians may migrate to Massachusetts as insurance coverage becomes more available.  

Do wait times reflect quality of care?  If Boston residents have very short waits to see nurse practitioners or physicians assistants, this could be a cost-effective substitute for services provided by physicians in the primary care setting.  Further, longer wait times for specialists could be a good thing.  While longer wait times would certainly hurt some patients–likely the most seriously ill patients–it would discourage other patients from waiting to see a specialist.  This patients could, instead, forego treatment if had a low marginal benefit to begin with or they could rely on their primary care provider.  

Let’s dig deeper into the numbers (see original report):

  • Wait times for Boston cardiologists decreased from 37 days in 2004 to 21 days in 2009.  
  • Wait times for Boston orthopedic surgery increased from 24 days in 2004 to 40 days in 2009.  
  • Wait times for a Boston ObGyn increased from 45 to 70 days between 2004 and 2009 in Boston.
  • Wait times for a Boston Family Practice physician was 63 days in 2009. 

We see that after the Massachusetts health reform was enacted, there was no uniform effect on specialist wait times, but there was a large increase in wait times for primary care providers.  This could be explained by a number of phenomenon:

  • Those who gained health insurance after the Massachusetts health reform were a healthier population and used their new insurance coverage to increase the number of primary care visits, but not specialist visits.
  • After the Massachusetts health reform, the increase in demand was homogenous across primary and specialty care.  However, physician supply adjusted.  Specialist may have been more attracted to practicing in Massachusetts, but primary care doctors were not.  Specialists may have moved to Massachusetts in larger numbers, particularly if New England health plans reimburse specialists at a much higher rate.  
  • This could be a statistical anomaly.  Sample sizes in were less than 20 for five specialities in Boston.

Whatever the case, further study is needed to understand how health insurance expansions affect waiting times in both the short- and long-run.

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