Ultimately, the solution to the drug problem might be the solution to the problem of life, which is how to navigate our time here with minimal suffering. Unfortunately, the policy that offers that solution will be not a drug policy but an existential one, and it remains as elusive as ever.
Graeme Wood in The New Republic.
Do you watch Jeopardy? Have you ever played the game 20 questions? Or Trival Pursuit? Either way, if you like questions, this is the perfect Health Wonk Review for you.
Views on the Affordable Care Act (a.k.a. Obamacare, a.k.a. Health Reform) are mixed. Despite the fact that many people support individual provisions, overall, the measure is unpopular. Why would that be the case?
A revealing Health Affairs interview with Cythnia Morgan, may reveal the answer. Morgan is a fifty-eight-year-old former hotel manager, has been out of work and uninsured for the past three years. Her income is low, but not low enough to quality for Medicaid. She is exactly the type of person the health insurance exchange is supposed to help. So why wouldn’t like someone like her support the Exchanges?
After being told of how the ACA’s health insurance exchanges would work, she stated:
Oh, God, that would be great—if there’s going to be a plan that’s affordable. But come on now, it’s really hard to believe.
A Democrat would read this and claim that Mrs. Morgan is ignorant of the provisions and yes, in fact, this is exactly what the ACA will do. Republicans will say that Mrs. Morgan is 100 percent correct. Although the provisions do promise affordable care, she is correct to be skeptical that government can deliver on this promise when private industry could not.
When asked, most people support the individual provisions of the ACA. This is not surprising since expanding entitlements are generally popular. The biggest backlash against the ACA is not the individual provisions, but a skepticism that government can deliver on their promises without making the health insurance market worse than it already is. With tightening provider networks and higher deductibles, the question is whether the insurance products that will be made available in the Exchanges are products that consumers really want to buy. That remains to be seen.
Recently in the news, a psuedo-randomized trial of Oregon’s Medicaid expansion found that people with Medicaid used more healthcare services. They use more doctor visits, more medications and even a few more ER visits and hospitalizations (though these last two were not statistically significant). Some policymakers believed that insurance will decrease ER visits and hosptializations due to increased access to primary care.
Although this is not the case in Oregon, in Wisconsin (my home state) Tom Deleire and co-authors (2013) found:
In the twelve months following enrollment in public insurance, outpatient visits for the study population increased 29 percent, and emergency department visits increased 46 percent. Inpatient hospitalizations declined 59 percent, and preventable hospitalizations fell 48 percent.
How did Deliere’s team determine this was the case? The used a natural experiment introduced by a Medicaid expansion in Wisconsin.
In 2009 Wisconsin introduced a new public health insurance program—the BadgerCare Plus Core Plan—for adults without dependent children who have incomes up to 200 percent of poverty and who do not have access to other forms of health insurance. In January 2009 the state automatically enrolled 12,941 childless adult residents from Milwaukee County. The rollout of the program included extensive outreach by the state and county to providers, advocacy groups, community-based organizations, and eligible people.
Because enrollment was automatic for this subset of individuals, the insurance choice was in effect an exogenous variable.
Although inpatient hospitalizations decreased, ER visits rose. The authors conclude that access to primary care and outpatient mental health services may mitigate any increase in ED use and its associated inefficiencies.
Patients generally prefer physicians to nurse practitioners (NP) or physicians assistants (PA) assuming a visit to either costs the same. However, what happens when one takes into account waiting times? A paper by Dill et al. (2013) reveals the following:
Respondents were given a choice between seeing a physician assistant or nurse practitioner today or a physician tomorrow for a worsening cough. Nearly 60 percent preferred the physician assistant or nurse practitioner today, with only 25 percent preferring to wait a day to see a physician.
As patients interact more frequently with NPs and PAs, their popularity is only likely to grow.
Those with recent exposure to a physician assistant or nurse practitioner were more likely to want to see one again than to wait a day for the physician. Those who had never seen one showed a slight preference for waiting for the physician visit, 43.0 percent, compared to 39.5 percent who preferred a physician assistant or nurse practitioner.
Medicare beneficiaries, paticularly those with Medigap, are least likely to have seen a PA or NP. Unsurprisingly, Medicaid beneificiaries are most likely to visit an NP or PA.
Only about 50% to 60% of individuals eligible for Medicaid actually take-up the coverage. Why is this case? Many people claim that individuals only take up Medicaid insurance when they get sick. Others claim that state outreach efforts have been subpar. Youjin Hahn, however, offers another explanation rates: Medicaid insurance is just not that valuable.
The previous literature on the determinants of Medicaid take-up has largely focused on the cost of enrolling in public programs. This current study departs from the previous literature by focusing on how the value of Medicaid affects take-up. In particular, I examine the relationship between take-up and patient access to care, using the Medicaid-to-Medicare fee index as a proxy for access to care provided by Medicaid. Historically, Medicaid reimbursement levels for physicians are low. As a result, physicians are not incentivized to treat Medicaid patients, and this creates access-to-care problems for this group. In fact, 20 percent of pediatricians in the United States do not see Medicaid patients at all, and 40 percent limit the number of Medicaid patients in their practice. All else being equal, increasing the Medicaid payment to physicians would lead to a higher participation rate among physicians
Hahn uses information collected by the Urban Institute to calculate the ratio of Medicaid to Medicare payment rates. Medicaid take-up rates are measured using the March Current Population Survey (CPS). The sample is limited to children whose households fall below the poverty line.
Hahn finds the following results:
…an increase in the Medicaid-to-Medicare fee index by 10 percentage points (about a half of standard deviation of the fee index) is associated with a decrease in the uninsured rate by 1.24 percentage points within the low-income population. As about 41 percent of the 9 million uninsured children are in poverty (and thus eligible for Medicaid), the finding indicates that a 10 percentage point increase in fee payments would lead to a reduction of about 45,800 low-income uninsured children.
The answer is yes, but maybe not as much as you may thought.
A paper by Ryan and Bao use data from a randomized controlled trial (RCT) called IMPACT (Improving Mood-Promoting Access to Collaborative Treatment) to determine if errors in physician quality profiling are due mostly to random variation or missing data. For this report, the authors outcome of interest is remission of depression symptoms at 6 months after the start of treatment.
The IMPACT data include both a clinical registry used by care managers in the trial to document exposure to the intervention and to track patient outcomes (“registry data”) as well as longitudinal research interviews, which independently assessed patient outcomes at regular intervals (“research data”). The authors use both the registry and research data to to generate parameters for the simulation.
The authors describe their simulation model as follows:
To initiate the Monte Carlo simulation, we assigned each provider a true quality score and a rate of missingness, each drawn randomly from distributions shown in Table 1. On the basis of data from the IMPACT trial, we assumed a correlation between missingness and true quality that was common to all providers. Then, 200 patient-level random draws, first determining whether an observation was missing or nonmissing and then determining patient remission (conditional on missing status), were taken for each provider. We then aggregated information from these draws, calculating provider-level “observed” quality scores under one of the two conditions: (1) using remission outcomes only from patients with nonmissing data, so that profiling error was a combination of error from missing data and from random sampling; and (2) using remission outcomes from patients with both missing and nonmissing data, so that all profiling error was due to random sampling.
The authors reached a number of findings:
There is an important caveat to these findings, however. The reason the missing data error is so small is due to the observation that in IMPACT data, missing data were not strongly related to the remission outcome in the IMPACT data. If patients with observations missing from the data were much more (or less) likely to experience remission, then the missing data error would have made up a much larger share of the overall profiling error.
In the health insurance exchange, premiums will rise significantly. At least according to Robert Laszewski of Health Care Policy and Marketplace Review:
One of the reasons health insurance in the exchange will cost a lot more in most states is because the new health law outlaws many of the existing plans now being offered and requires only those much richer plans to be sold.
Are people going to get more coverage for their money? Yes. Do they want more coverage if the premium costs for those plans is a lot higher? Likely yes if taxpayers are paying for most of it. If not, clearly they didn’t want to pay for it before. Come January, lots of California consumers in the small group and individual market are going to get a letter from their existing insurer telling them their current plan is no longer available and the cost of the new required plans will be a lot more.
Note that rate increases are not as high as were expected. However, plans in the exchange may only cover a limited network of providers.
…one of the largest insurers in California, Blue Shield, announced that their average rate increase would be 13% under the new law. That sure looks better than the predicted 30% increase for California exchange plans.
But wait, that Blue Shield exchange plan in LA, for example, does not include UCLA Medical Center or Cedars Sinai. In fact, Shield’s exchange network includes a total of only 24,000 physicians compared to 66,000 doctors in their full PPO network––only 36% of their usual network docs will be available.
Jeff Rose hosts this week’s small, but powerful, roundup of risk-related posts. From fast-food to k-rations, you’ll run little risk of being disappointed. The Healthcare Economist bats leadoff.