Wednesday, October 29, 2014
Monday, October 27, 2014
Is the Affordable Care Act Working?
After a year fully in place, the Affordable Care Act has largely succeeded in delivering on President Obama’s main promises, an analysis by a team of reporters and data researchers shows. But it has also fallen short in some ways and given rise to a powerful conservative backlash.
A Perfect Fit for Some, but Not Others
By Jason Millman October 23
With an estimated 25 million new people becoming insured over the next few years, a coalition of family physicians has a message for the country: Don't forget about us.
The timing is right for the group, which on Thursday announced a five-year, $20 million campaign aimed at promoting the importance of primary care. The flood of newly insured patients presents a big opportunity for primary care doctors, when you consider this: just one-third of uninsured adults said they have a regular doctor, about half the rate of the insured population, according to a 2013 Kaiser Family Foundation survey.
"Many of our colleagues have been taking care of these folks for years," said Glen Stream, a family physician who's chairman of the campaign, called "Health is Primary."
"It's now that we can give them better care. We have some catching up to do in the health of these folks who are newly insured," he said.
Managing health — and not just providing care when an illness arises — is something that the uninsured struggle with much more than the privately insured. The uninsured are less likely to get preventive care, like cancer screenings, and they are less likely to do follow-up visits after the diagnosis of a chronic condition. So the doctors see there's an educational need here, and an opportunity to reduce costs in the health-care system. That goes for all patients, though, and not just the newly insured, the doctors groups say.
Their campaign also comes at a time when there are increasingly more convenient ways to get some services usually provided in the doctor's office. Take the rise of retail clinics, for example. Though some of these clinics employ doctors or they have partnerships with local health-care systems, doctors are also skeptical about the level of care they provide. The American Academy of Family Physicians says it sees a role for these clinics, but the group warns that the settings could make it harder to coordinate care for the highest-need patients, like those with chronic conditions.
Ultimately, the groups behind the new campaign say primary care has to adapt to these changes in the health-care system, which is also moving more online.
"We want to be part of a voice that helps patients and doctors both evaluate apps — to identify those that are beneficial in providing that connection between the patient and the doctor," Stream said. "At the end of the day, if it doesn't improve health, even if it only costs 99 cents, you didn't get your money's worth."
Meanwhile, a new report issued Wednesday shows the public's trust in the medical profession has been plummeting.The big takeaway from the study: People think doctors are just watching out for themselves.
Those providing health-care services are also facing tougher demands to better coordinate care, keep patients healthier and keep down costs. This new campaign is trying to make the pitch to those who pay for care, as well as policymakers, that primary care will lead the way.
Giving the Doctor a Second Chance
“What can I help you with today?” It’s the question I open every visit with, but it heralds a moment of suspense. The reply is what doctors enter into the chart under “Chief Complaint,” but it’s really a moment of suspense because you never know how a visit will unfold.
I recently posed this question to a patient, a healthy middle-aged woman whom I’d seen once before, a year earlier, for a routine checkup, as I ushered her into my office. I smiled as we sat down, prepared for a straightforward visit.
She stared stonily at the wall in front of her as my question hung, too long, in the air. “I almost didn’t come back today,” she said. “I was ready to choose another doctor, but I decided to give you a second chance.”
There was a reflexive start in my chest from her unexpectedly harsh reply, but I held my composure. What could this be about?
I quickly scanned the chart from our last visit to see if there had been anything we’d disagreed about or any unresolved issues. But no, it had been a routine checkup. Nothing beyond standard health screening issues and some run-of-the-mill acid reflux.
“Someone had said you were a good doctor,” she said derisively, still addressing the wall, “but I was not impressed. My previous doctor, even though he was just a resident in training, was much better than you.”
That certainly stung, especially since I still had no idea what had transpired between us, but I endeavored to stay quiet and let her finish speaking.
“But he graduated, and now I’m stuck with you.” She folded her arms across her chest, pursed her lips, and then was silent.
I kept my voice as low key as possible. “I’m so sorry if there was something that upset you. I’m trying to recall — —”
“You don’t remember?” she snapped. “It figures!”
Now I was scraping desperately around in my mind. What had I done? Making a patient livid isn’t something you typically forget, but I couldn’t come up with anything for this patient.
“I apologize,” I said, as genuinely as I could, “but I honestly don’t recall what happened. Could you tell me?”
She looked at me for the first time, her eyes taut and icy. “You didn’t do a physical exam! All you did was talk to me, and then you handed me a prescription. My old doctor always did a physical exam, but you didn’t even bother.”
My jaw actually dropped when she said that. I’d forgotten the physical exam? How could I have done that?
As an internist, I’m well aware of the limits of the modern physical exam. For most medical ailments, nearly all the crucial diagnostic information is gathered in the history, in the conversation between doctor and patient. The physical exam serves mainly to confirm the diagnosis, though once in a while something unexpected does turn up. And, as I’ve written here, it remains an important part of my interactions with patients, a refuge from the encroachment of technology that can help foster intimacy and often uncover a patient’s true concerns.
So now I really did feel like an idiot, both negligent and a hypocrite. Looking back at my notes, I honestly couldn’t tell if I had been running late that day, or was distracted, or simply had a momentary lapse. But the simple truth was that I’d neglected part of the medical visit and the patient was appropriately calling me on it.
“I am truly sorry,” I said to her after composing myself. “I honestly have no idea why I didn’t do a physical exam that day. I really don’t.” I placed my hands down on the desk between us. “I can only offer you an apology, both for my shortcoming that day and also for the bad feeling that it left you with.”
She gave a small nod of acknowledgment, and the muscles of her face softened somewhat.
Our gazes simultaneously traveled to the exam table and then back to each other, questioning. “It’s up to you,” I said. “I would completely understand if you would feel more comfortable with a new doctor.”
She shrugged. “Like I said, I’m willing to give you a second chance.”
It was an awkward physical exam, no doubt for both of us. I felt like I was being given a test but appreciated the opportunity to face up to a mistake and work through it.
Though “objective” measures of “quality” abound in medicine these days, getting meaningful feedback is actually quite rare. Getting it directly from a patient, rather than on a spreadsheet from an institution, is rarer still. And even though it’s never pleasant to be reminded of your shortcomings, I actually felt quite lucky that this patient had the grit to come back and tell me directly. She could just as easily have moved on to another doctor, and I never would have known.
It makes me wonder how many other times I may have disappointed a patient but been completely unaware. I’m sure the number is larger than I’d care to acknowledge, and probably rising as time pressures and documentation requirements mount.
I thanked my patient for giving me a second chance and we parted cordially. I’ll find out next year if I passed.
Yes on Proposition 45 going to the airwaves
By MARC LIFSHER
th just over a week until election day, backers of Proposition 45, the health insurance rate regulation initiative, are finally putting ads on television.
Though their opponents have used a $55-million campaign war chest to flood the airwaves, Consumer Watchdog, the Santa Monica activist group that put the measure on the ballot, only has $1 million to spend on limited TV and radio spots.
The TV ads, set to air beginning Monday in the Los Angeles market, show marching, animated banknotes and warn voters that "health insurance companies have unleashed armies of money to mislead you about Proposition 45."
The initiative is needed, the ad says, to keep insurers from being free to raise rates as much as they please.
The radio ads, which are airing in Los Angeles and the San Francisco Bay Area, pose the question: "When did health insurance companies ever spend $55 million against a ballot measure to protect you?"
The anti-Proposition 45 campaign, which has increased its lead in recent polls, called the Consumer Watchdog message misleading.
A radical cancer therapy: Don't treat
By NORA ZAMICHOW
We learned about my husband's inoperable brain tumor from a nurse who doled out the news as though providing his cholesterol count. Mark stood frozen. I clutched at him and wailed.
“Are you OK?” the nurse asked.
Was she insane? Which part of this could remotely be described as OK?
Mark worried about how we would tell the kids, three adult children from his first marriage and our 11-year-old daughter.
“We will tell them,” he said thoughtfully, “that we hit a rough patch.” Only Mark could refer to a widespread brain tumor as a “rough patch.”
My husband was a hardcore journalist, relentless in pursuit of a good story, no matter whose sacred cow he skewered. He was also a really smart guy, winning a scholarship to Harvard University from a San Bernardino public school. He began studying chess at age 15 and eventually became a ranked master. After leaving newspapers, he ran his own public relations firm. His greatest fear, he later told me, was that something might happen to his brain.
After diagnosis, we hit the ground running, signing on with a top doctor at UCLA. Quality of life, we told him, was our most important priority. But when he offered hope that Mark might be able to gain another five years of life, we leapt at the chance.
Still reeling from the diagnosis, we readily agreed to the arduous treatment course the specialist suggested: six weeks of chemotherapy and radiation conducted concurrently. This would be followed by five days of chemo every month. At 58, Mark was relatively young and strong, and a doctor told us that 50% of the UCLA patients with his kind of tumor were alive after five years.
We never thought about that other 50%, and when we discussed treatment options, no one proposed the most basic: Do nothing.
But amid the flurry of medical meetings, a friend introduced Mark to a doctor who had also been diagnosed with a brain tumor, though one considered less aggressive. Mark spoke with him. Oddly enough, this fellow had passed up certain treatments. Why, we wondered, would he do that?
Why? Because doctors don't die like the rest of us.
Our View: LePage’s low-income health plan not affordable
High co-pays and out-of-pocket costs put care out of reach even with subsidized premiums.
The Affordable Care Act has a new fan: Gov. LePage.
In explaining why he rejected $350 million a year from the federal government to insure 70,000 low-income workers, the governor has repeatedly said that they would be better off as a result, because they will be able to buy subsidized private insurance on the ACA marketplace, known as the exchange.
The governor’s sudden enthusiasm for the exchange is odd, because he pushed the state into a lawsuit that sought to ...
Choosing a Health Plan Is Hard, Even for a Health Economist
A confession: I am a health economist, and I cannot rationally select a health plan.
I buy health insurance through the Federal Employees Health Benefits Program, or F.E.H.B.P., which is very similar to the Affordable Care Act’s exchanges. Like the exchanges, the federal employee program runs an online marketplace with a choice of plans, which vary by region.
Most workers don’t have a lot of choice among plans offered by their employer. But the federal employee program offers me about 20 plans to choose from, and a similar number to almost all other federal employees. This puts me in a position akin to a consumer selecting among many plansin an Affordable Care Act exchange or a Medicare beneficiary selecting among many Medicare Advantage plans.
I have a lot of sympathy for consumers in these markets. Comparing health plans is hard, even for a health economist like me. (And it’s arguably harder on the Affordable Care Act exchanges, where consumers may also need to report income and apply for subsidies. Federal employees just need to choose a plan.) Each year when I shop for coverage through my employer, I feel like I’m buying myself at least as much grief as I am insurance.
In one sense, buying health insurance is not different from buying any other product, like a laptop computer or a refrigerator. There are two things to consider: how much you pay (the price) and what you get (the quality). Quality can mean a lot of things for a health plan, and your criteria may differ from mine. For me, the most important aspect is which doctors and hospitals are in its network and, hence, most generously covered. (Some plans cover out-of-network providers less generously; some not at all.)
A health plan’s price is more amenable to quantitative analysis, but still hard to assess.
Each laptop has a sticker price, as does each refrigerator. Health insurance has not one but many price-like characteristics. The premium is the most salient price, perhaps. But there are lots of others like co-payments (fixed dollar amounts you pay each time you visit a doctor, get a lab test or pick up a prescription), co-insurance (a percentage of the cost you pay for each visit, test or prescription), and deductibles (how much you pay before your plan pays a single dollar). Complicating matters, deductibles do not apply to every service, and co-payments and co-insurance can vary by service — a different amount for a hospital stay vs. a primary care visit vs. a visit to a specialist, for a brand-name drug vs. a generic, and so forth.
Reality check: There's no easy way to put a lid on healthcare costs
Editorial Board - LA Times
Critics of the 2010 Affordable Care Act complain that it doesn't do much to control the healthcare costs that are becoming unsustainable for families and businesses. In fact, the law does many small things; the latest is the grant program announced last week to teach Medicare and Medicaid doctors new ways to offer higher-quality, better-coordinated, more cost-effective care. The four-year goal is to turn $840 million in grants into $5 billion in savings — a number that sounds big until it's compared with the nearly $4 trillion in annual healthcare spending in the United States. The modesty of the effort reflects the reality that there's just no easy way to put a lid on healthcare costs.
The Congressional Budget Office projects that major federal health programs could cost 85% more in 10 years than they do today. That's because multiple forces are driving up healthcare expenditures, including new technologies and medications, the prevalence of chronic disease, and payment systems that give doctors and hospitals incentives to perform ever-more procedures.
Those forces can't be counteracted by simply slapping a limit on how much people spend on healthcare or how much doctors and hospitals charge. Such approaches would ration care, directly or indirectly. Instead, any effort to slow the growth in spending has to shift the incentives in the system so that doctors and patients alike are motivated to reduce the demand for care.
US For-Profit Health Care Industry is Always Innovating New Ways to Steal Your Money
by Jon Walker