Category Archives: Uncategorized

Study shows more young adults have health insurance after Massachusetts health reform

Uncategorized

The Massachusetts health reform law (often called “chapter 58”) made several special provisions for young people (defined as those between 19 and 26), because they represented a disproportionate share of the uninsured population, and were less likely to have access to insurance through work (as most of the jobs available to people in that age group don’t come with insurance). The Urban Institute recently reported a study of the impact of chapter 58 on insurance rates among young people which showed that these special provisions have worked as intended. The uninsurance rate in this group fell 60% (from 21% to 8%, in round numbers).

Achieving this goal, though, required some compromises. Young adults were largely brought into the insurance fold via “Young Adult Plans”, insurance plans with important exclusions and relatively high deductibles. In addition, many have annual maximum coverage amounts (usually around $50,000). Most young people will be fine with these restrictions, as most people in this population are healthy. These plans are similar to the “college plans” which were available before reform; unfortunately, these plans were cited in a 2009 article in the Boston Globe for having higher administrative costs, and that slightly less than 1% of covered students exceeded the $50,000 cap on benefits (951 people)(Link to complete study result). A more recent investigation by the New York attorney general reported in the Chronicle of Higher Education showed that these issues are neither limited to Massachusetts nor have they stopped due to the investigations in Massachusetts.

Regardless of the potential downsides to Young Adult Plans, they do bring important benefits. Access to primary care, in particular, is an enormous benefit (all Massachusetts plans require at least three routine primary care visits be covered). And in the spirit of beginning as we mean to go on, getting people insured in their youth may form a habit of receiving regular preventive care which can translate into benefits in later life, as well as benefits now through the screening and teaching which are big components of the primary care visit. There hasn’t yet been an analysis of the downsides, and while the statistics suggest there are few people who outrun the limitations of a young adult plan, for those who do the impact, financially and personally, can be devastating.

Palliative care helps you live longer and better at the end of life

Uncategorized

Many of you will remember the “death panel” controversy during the health care reform debates last year. For those who don’t, a proposal to create a better payment mechanism for discussions between physicians and patients about end-of-life choices was derided by opponents of reform as funding for “death panels” which would make sure that elderly people chose the option of “dying early” to save on health care costs. Now it appears that early palliative care not only helps you be more comfortable and more in control of your health during serious illness, it can help you live longer as well.

A recently completed study from the Massachusetts General Hospital, researchers studying end of life care in a group of lung cancer patients found that the group assigned to early palliative care had higher quality of life and less depression than patients who received “standard care” (without early palliative care). Alone, this wouldn’t be a surprise; the surprise came when they found that the patients who received early palliative care lived longer, as well.

The policy implications of this finding are profound and seem to run counter to common sense. People have the idea that they can either fight disease as aggressively as possible, to live as long as possible or opt for care whose very name – palliative – seems to say that you’ve given up, and you’re just going to paper over the disease. The research from MGH is telling us that this is a false choice. Early palliative care-care which pays attention to relieving the symptoms of the disease-as well as fighting the disease through the usual means, you can live longer and feel better.

Far from demanding that we “die early”, advocates for palliative care want us to live as long as possible, but to help us keep our dignity and our humanity while we fight, and to make us ready for whatever our next step may be. Death is still inevitable; it doesn’t have to be miserable as well. We have it in our power to ease the transition, as well as delay it, and there doesn’t have to be a choice between the two. Promoting better and earlier use of palliative care is good healthcare policy choice, as well as a good use of our healthcare dollar.

On psychiatry

Uncategorized

Some of you have heard my psychiatry rant. In short, it goes like this: Psychiatrists are not doctors, in the “physician” sense. They don’t do any of the things I recognize as “being a doctor”; they don’t examine patients or their pathologic equivalents (xrays, tissue slides, lab values-doctors do that stuff in some specialities and are still “physicians” in my book). Yes, they went to medical school, they learned all the stuff I learned, and then proceeded to enter a field where most of that knowledge is largely unnecessary.

It’s not that mental illness isn’t disease-it is, in the truest sense of the word; patients with mental illness are some of the most tormented people I’ve seen. But the discipline which cares for them is “mental health” (an umbrella term which most people use to include psychologists, social workers, various subsets of counseling and “life coaching”, etc.), not “psychiatry”. And it’s an entirely different mindset.

Recently I picked up a copy of “Unhinged”, a critique of psychiatry by Daniel Carlat, a psychiatrist in Newburyport. It’s an excellent read, I recommend it highly. But here, in a nutshell, is the issue with “psychiatry”, as per Dr. Carlat:

“It is called “medical school” for a reason. Its purpose is to teach students how to combine patient interviews, physical exams, and laboratory tools to diagnose biomedical diseases, and then to combine advice, medications and technical procedures to cure them [ed note: I would add “or control them”, but that’s a quibble] The basis for it all is an understanding of pathophysiology. But in psychiatry, we do not know the pathophysiology of mental illnesses, and therefore we do not use physical exams or laboratory data to diagnose” [emphasis mine]

He goes on to say trenchant things about why psychiatrists should not go to medical school, arguing persuasively that it’s bad for psychiatry and mental health in general (psychiatrists often try very hard to be kings of the mental health hill, because they’re doctors, you see), bad for medical school, and bad for patients. He argues for a new model of mental health professional, with a wholly revamped training program, combining the best of the various disciplines which now constitute mental health (psychology, social work, etc.)

I think it’s an intriguing idea. And like I said, an excellent book.

(And to hopefully forestall some ranting: yes, there is a neuroscience of mental illness. It isn’t ready for prime time. When I can measure your serotonin or norepinephrine, and use that to diagnose your illness or gauge your treatment response, then we’ll have another conversation. When I can do a depression scan, or a schizophrenia scan, or a bipolar scan, with some idea of exactly what I’m measuring and use that knowledge to guide treatment, reconsideration may be in order. But psychiatry *isn’t there yet*. Mental health has made *immense strides* since Freud invented the idea, and kudos to all the people working in that field both treating patients and working to advance the understanding of their disease. That work needs to keep happening. And medicine and mental health need to work together to care for *our* patients. But psychiatry has become an empty shell of a once proud profession IMO, as understanding of non-mental illness (or perhaps “less mental” illness) has advanced faster than the understanding of mental illness. What that says to me is that mental illness is a hard, complex problem, not that it’s less prestigious or not a problem)

What, exactly, counts as “health”?

Uncategorized

The health reform law (now mostly called the Patient Protection and Affordable Care Act, or just the Affordable Care Act (ACA) requires many insurers to maintain a “medical loss ratio” of at least 85%. The medical loss ratio is the percentage of premiums which the insurer must pay out as health care. So if the premium for health insurance is $100 per month, the insurer must, on average, spend $85/month on payments for health care used by everyone insured by the company.

Naturally, health insurers are interested in maximizing the kinds of things they get to call “spending on health care”. For instance, is utilization review “spending on health care”? Generally, I would argue it is not; it is generally of little benefit to the individual person insured, but of significant benefit to the insurance company. (Utilization review is the process an insurance company uses to assess whether you still need to be in the hospital, or if you really need that MRI, or if you could manage with a less costly medication). Is there a benefit to these programs? Well, yes and no; the individual doesn’t benefit that much. The group of beneficiaries as a whole benefits some, since every dollar saved by UR is a dollar which can potentially be spent on other health care. But UR is much hated by patients and doctors, not because it is done (it’s done some useful things for length of stays, which were arguably way too long when UR started in the 80’s), but because it’s so haphazard. Everyone has their own rules, the rules are often arbitrary, or arbitrarily enforced, and the appeals process is arduous and uncertain.

The National Association of Insurance Commissioners (the group of state insurance commissioners; this is a government organization, like the association of governors, etc,) has recently come out with a guidance document which has a relatively narrow definition of “health care spending”. And unsurprisingly, the insurance companies, led by Karen Ignani (the remarkably effective president of America’s Health Insurance Plans, or AHIP), are incensed that their favorite spending categories, (investments and fraud prevention) are not counted as “health expenditures”. Naturally, they couch this in language calculated to frighten patients into calling their congresscritters: “the current proposal could have the unintended consequence of turning-back-the-clock on efforts to improve patient safety, enhance the quality of care, and fight fraud” according to Ms. Ignani.

Uh-huh. Investments did so much to improve patient safety. And fighting fraud is a cost of doing business, not a direct cost of health care. Now Ms. Ignani is a smart woman; she knows the buttons to push. But I wish they insurance companies would, just once, recognize that the exemption from anti-trust law they enjoy is at least in part a statement of the public’s faith that they will act in the public’s interest. You know, from time to time. So far their record is spotty to a kind reading. (To a fair reading it’s exploitative, in my opinion, but I’ll stick with spotty for now).

Confidence is low

Uncategorized

A story in today’s Modern Healthcare (a magazine I just discovered through the good offices of Emily Friedman, who was one of my favorite teachers at BUSPH) (Also, registration required) reports that a significant minority of nurses have little confidence in the institutions where they work, and a remarkable 72% majority feel that the institution where they work understaffs for the work done.

As someone who is not a nurse, but works with a lot of them very regularly, I agree with this assessment on both counts. While it is not unusual for employees to feel they are overworked, nurses are asked to provide direct care to increasing numbers of increasingly ill patients, which requires not only making people comfortable and handing out their meds, but making accurate snap judgements on how they’re doing, whether they’re getting better or worse, how to intervene if things aren’t going well, and generally expected to be the patient’s first line of defense against the system (which we all know patient’s need defending against, ref. IOM report on medical error). Institutions don’t want there to be many nurses (because a good nurse is expensive), and so try to remove a lot of the “direct care” from nursing hands, leaving them with the more technical aspects of care. This ignores a huge part of what a nurse does, though; nurses spend a lot of time with patients in the course of changing the sheets, bathing and toileting, assisting with ambulation, and all of the “direct care” which can be done by others but ought to be done by nurses. Because it’s that time with the patient where the nurse learns the patient’s baseline, and can then judge departures from that baseline, and either intervene themselves, or call other providers to intervene if the problem is outside their scope of practice.

It’s like this: when I was learning physical diagnosis (how to examine people), one of my instructors pointed out the value of seeing as many “normal” things as possible. That way, when I saw something subtly abnormal, I would recognize it as abnormal and investigate, even if I didn’t know what exactly the abnormality was. Realizing that something “doesn’t look right” is a highly valued skill in medicine. Nurses are in a position to look at a patient and recognize, because they’ve spent a lot of time with the patient, that they “don’t look right”. They may not know exactly what is wrong (although usually they do, especially at the higher experience levels), but they know it’s something. The earlier that recognition takes place, the earlier something can be done, and a problem, error or complication avoided.

This is the problem which led the California Nurses Association to demand, and get, mandatory staffing levels in California hospitals. Hospitals moaned loudly, because nurse staffing has traditionally been a management prerogative, but since nursing management (like physician management) has been co-opted by general management (whose priority is profit, even in non-profit institutions), that prerogative has been abused in the service of improving the bottom line. Rather than pay for proper nursing, management would rather buy a new magnet (MRI machine), or outfit a catheterization lab for which they don’t have enough volume, in the hopes of increasing that volume, or do some other thing which increases their “business competitiveness” while decreasing their ability to perform the core function of a hospital, which is to care for the patient. CNA had little confidence that management would protect the core mission when confronted with the desire of physicians and managers (and, let us be honest, patients) for the latest and greatest technology. And my confidence is just as low.

Told you so…

Uncategorized

So there’s a story in today’s Boston Globe, which reports that slightly more than half of overweight adults are healthy, as measured by their cholesterol levels and blood pressure (and a few other things, basically measuring ‘metabolic health’). And not a few (about one quarter) of people of ‘normal’ weight were unhealthy by those measures.

Well, that’ll set the fox in the henhouse, won’t it?

Let’s have a look at the original, shall we? It does say about what is reported (have a look), but is interesting for what else it says:

“The independent correlates of 0 or 1 cardiometabolic abnormalities among overweight and obese individuals were younger age, non-Hispanic black race/ethnicity, higher physical activity levels, and smaller waist circumference.”

So, young white people who exercise and have smaller waists than hips are healthier than you might expect based on their body mass index. What does this tell us? Mostly, it tells us that BMI is a blunt instrument with respect to measuring cardiovascular health. If you’re paying attention at all, this is not news, although it is nice to have it confirmed by a data set as large as NHANES (National Health and Nutrition Examination Survey-it’s a Really Big, Really Good data set). Basically, obesity is not as big a problem as fat distribution. To quote the paper: “There is not yet a standardized definition of body size phenotype”. Perhaps we should work on that, because where the fat is, and whether you are ‘physically active’, may mean more in terms of health than BMI alone. So, now wither obesity prevention? Because it’s going to be hard to base any kind of health intervention on BMI, which is what we’ve been doing for a while now.

This matters for a couple of reasons. If you’re going to design an intervention with respect to obesity (and believe, me, a lot of money is going to be spent on this in the upcoming few years), you need to point the money at the right problem. And BMI is looking like the wrong problem. So what is the right problem? We’re getting a grip on it, but we need a ‘standardized definition of body size phenotype’. We also need to get a grip on activity. How do activity and ‘body size phenotype’, whatever we decide that is, interact? Which is more important, or are they interacting terms?

And this matters right now. I interviewed today for a position at a local health care think tank, which has a sizable initiative on obesity intervention. What is the future of that initiative, in light of these findings? It’s not dead, but it might need significant reworking in light of this paper. The nice part is, if I get the job (it’s an internship, but hey, still a job as far as I’m concerned), I might get to do some of the rework.

Ain’t science grand?