Monthly Archives: September 2010

Uninsurance rate up as poor economy rolls back insurance levels

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Writing for the Commonwealth Fund, a well respected health policy foundation, Karen Davis (one of the two important Karen’s in health policy, the other being Karen Ignani, the leader of America’s Health Insurance Plans or AHIP) noted that the number of uninsured people in the US continues to rise. This is a fairly clear result of the ongoing recession, as more people lose employer sponsored insurance, and more employers don’t offer employer sponsored insurance. Last year 7 million people lost the insurance they had through their employer. Seven million people added to the rolls of taxpayer funded health care, or left without any health care at all. Oh, sure, they can go to the Emergency Department, as former President George W. Bush famously remarked. But if they do, they’ll get a bill, and probably a bigger bill than their insurance company would have received for the same service. and definitely a bigger bill than they would have gotten for going to their own doctor-emergency departments charge a premium for being open 24/7/365, because it makes their overhead much higher.

“But wait”, you ask. “Wasn’t this part of the problem health care reform was supposed to solve?” Well, yes, it was. But the important provisions of that law, with a few exceptions, don’t take effect until 2014. Some of the provisions do take effect sooner-importantly, the provision which requires insurers to cover “minor children” up to age 26 takes effect today (September 23, 2010), as well as the elimination of lifetime coverage limits. But the major parts-the health insurance exchanges, the premium subsidies for middle-income families with children, the expanded Medicaid eligibility, and COBRA assistance for the unemployed-are still three years away. That may be too long for some folks who don’t have insurance now, but still need health care.

Here in Massachusetts we have an advantage-we’ve set those things up already, and when time comes to implement them, all we’ll really need to do is make sure they meet the Federal standards. Since Congress used the Massachusetts law as something of a template for the Affordable Care Act, most likely our exchanges will exceed the requirements quite a bit. We ought to be proud of that.

Doctors who care for poorer patients get poorer performance ratings

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Doctors and health policy analysts at the Massachusetts General Hospital in Boston recently examined performance measures for physicians – this is the data from the surveys you fill out occasionally when your insurance company asks you to rate your doctor. They found that doctors who take care of poorer patients (as measured by annual income) generally receive poorer performance ratings. This is a somewhat counterintuitive finding; most physicians perceive that patients with higher incomes (and generally higher corresponding educations) are more difficult to please.

This has serious implications for the future of performance measurement. Because insurers and Medicare want to link these performance measures to physician payment, anything that affect them is going to be closely analyzed by doctors, who naturally want to maximize their pay. If taking care of poorer (but insured) patients decreases doctors pay, doctors will be less likely to take care of this class of patient. On the other hand, adjusting the formula by which performance is measured to correct this specific imbalance will be politically difficult; physicians who have few of these types of patients will feel they are being penalized for their patient mix or choice of practice location.

Unanswered in all of this is the question of why these physicians get poorer ratings. All of the physicians in the study are in the same practice group; there is no mechanism by which patients can tell which doctors take care of poorer patients (so wealthier patients are not able to tell by looking at the patients around them whether their doctor is taking care of “rich” or “poor” patients, for instance). Do patients of higher socioeconomic status simply have an easier time communicating with doctors, and hence are more satisfied with their care than less-well-off people? Inquiring minds want to know (and are probably working on it even now).

This kind of data helps to craft better performance ratings, and may also help explain some aspects of health disparities. While some aspects of your health are solely under your control, knowing why people act a certain way towards health care providers can help you control those aspects better.