Welcome to the Health Wonk Review! It’s an honor to host the HWR, and the posts in this edition are excellent, as always. We’ve got a wide range of topics today, but most of them are at least loosely associated with some aspect of health care reform, so here’s a brief visual summary for you.
Now that you know where we’re heading, here are the nitty gritty details. There’s something for everyone in this edition of the HWR, so keep reading!
Roy Poses, writing at Healthcare Renewal, explains how doctors are pushing back against corporate bosses who put profits above all else. His article describes two recent lawsuits filed by physician groups alleging that the hospital systems they worked for were sacrificing patient welfare in the name of profit. The details are sickening to read: One hospital group encouraged its docs to exaggerate the severity of patient conditions and needlessly admit patients from the ER to hospital beds in order to bill more for their treatment. Another hospital group that owns three hospitals and also partially owns an ambulance company was making patient transfers (using their own ambulance company despite slower response times) a top priority – to the extent that a doctor’s transfer rate was a factor in bonuses and performance reviews. An admin email stated that “the performance we are looking for are transfers.” Wow. Transfers just for the sake of racking up revenue – patient welfare had nothing to do with it, and was likely compromised when the slower ambulance company was used in cases where the transfer was actually warranted. These lawsuits are in their early stages and nothing has been settled in court yet, but they hint at very serious problems brewing in some for-profit (and even some non-profit) hospital systems.
Duncan Cross brings us an emotionally compelling article about Arijit Guha that is a must-read for anyone interested in the problem of under-insurance. Being under-insured might not be quite as bad as being uninsured, but while the uninsured know that they don’t have health insurance, people who are under-insured might not be aware of the specific short-comings of their coverage until they actually have a serious, ongoing medical condition. Arijit was a grad student at ASU, and he recently passed away from colon cancer. During his fight with cancer, he also had to battle his insurance carrier (Aetna) and raise money selling t-shirts in order to fund his treatment. He had a student health insurance policy, and those have long been notorious for having low coverage limits. Duncan has an insider view of some of the medical issues that Arijit had to face, and he, too, attended grad school for a while, 
working on campus at a job that afforded him faculty health insurance rather than student coverage. He notes that a major problem that wasn’t often addressed in articles about Guha is that the university was the organization responsible for choosing a health insurance plan for its students – Aetna just provided the coverage that the school requested.
Maggie Mahar‘s article at Health Beats will be appreciated by NPs and PAs. Her post A Doctor Confides: “My Primary Doc is a Nurse” is a great look at the increase in the number of PAs and NPs who are providing primary care, and the myriad issues that accompany this change. Maggie delves into topics like turf war and resistance on the part of MDs to accept NPs as quality primary care providers. She also addresses patient and provider satisfaction, patient safety, the cost of primary care, and the shortage of MDs who are choosing primary care versus the willingness of NPs to enter that arena. Her article is an excellent, well rounded look at the topic. For a personal anecdote, I’ll share my own two cents on this: For years, my primary care provider was a PA at a women’s clinic in Denver – I don’t think I ever saw any of the doctors at the practice at all. The PA handled all of my well-woman care needs perfectly. And now that we’re in Northern Colorado, I go to a practice run by nurse-midwives who provide excellent well-woman care. I would say it’s been at least a decade since I’ve seen an MD, and I’m 100% satisfied with the healthcare that I receive.
At Managed Care Matters, Joe Paduda aims his razor-sharp pen (keyboard?) at Gensco Labs and their nifty pain relief gels (sold at about $700 for 3 ounces) that they’re compounding and marketing to docs who take care of workers’ comp patients. The gels appear to have pretty simple ingredients like echinacea and arnica – the sort of stuff that you can get OTC for just a few dollars. Joe quotes a workers’ comp payer in FL who notes that in most cases, claims for these compounds are being denied. If it smells fishy, it probably is. And Joe does an excellent job – as usual – of calling out the conflicts of interest and general bad business practices going on with this racket.
From HealthAffairs, we have a piece by Peter Neumann and James Chambers of the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center. Medicare’s Reset on ‘Coverage With Evidence Development’ is a good look at how Medicare has used Coverage with Evidence Development (CED) over the past decade, essentially covering new technologies while gathering data from the patients being treated to determine whether the treatment is effective and evidence-based. The program has been a bit cumbersome however, and CMS is in the process of reworking the specifics (while keeping the general concept intact). The redesign is in the public comment phase, and Neumann and Chambers include in their article four very good questions regarding the new CED program design.
Hank Stern of InsureBlog brings us an excellent example of why it’s best to do your own research and always be skeptical (unless you’re reading the Health Wonk Review, of course). In Confusion Reigns Hank points out that even “experts” can get things wrong, and explains that he came across a comment posted on a forum by another insurance broker, lamenting 
that one of her clients in a same-sex partnership was being told by HR that she could no longer be covered as a domestic partner on her partner’s plan unless they got married, now that Maryland allowed same sex marriage. The details sounded a bit like over-hyped scare tactics that sometimes get fabricated and then spread around the internet when there’s a highly charged issue at hand (in this case, two highly charged issues: same sex marriage and health insurance). Huge kudos to Hank for going above and beyond to track down the official answers from the Maryland Insurance Administration. Turns out, nothing had changed regarding domestic partner eligibility for health insurance coverage. If everyone were to exercise the sort of due diligence that Hank did here, we’d have a lot fewer rumors flying around the internet, and we’d all be better informed.
Health Business Blog’s David Williams takes a good look at online doctor reviews and finds them a bit lacking – although they’ll probably improve as time goes by. David’s post was inspired by an article about a doctor who sued a patient over a critical blog post, which he found to be a bit more sensational than what’s really going on when it comes to the average online doctor review. David looked at Yelp, Angie’s List, MHQP (Mass. specific) and HealthGrades, and gives a detailed rundown of what the sites provided when he searched for specific doctors that he and his loved ones use. He also lists a few improvements that could be made to the online review process – hopefully those will be coming soon.
From Anthony Wright at Health Access Blog, we have Roger Ebert on Obamacare, Anthony includes several excerpts from articles that Ebert wrote about healthcare reform, and they’re well worth reading. Ebert wrote from the unique vantage point of having good quality health insurance (which he eventually maxed out in the course of his cancer treatments), a highly public position, and a serious medical condition. It’s tough to find any real flaws in his logic. RIP Mr. Ebert – We’ll see you at the movies.
Peggy Salvatore, writing at Healthcare Talent Transformation, compares the aviation industry and the healthcare industry, and wonders if we might be heading down the path towards over-regulation in healthcare. She notes that the aviation industry has an excellent safety record and that healthcare has done well by emulating aviation’s checklist philosophy in order to improve patient outcomes. But she also describes a retired pilot friend’s observations that FAA regulations have gone from being 30 pages in 1964 to “hundreds, if not thousands, of pages and nobody can possibly know everything that is in there.” Peggy worries – and I would say that she’s definitely not alone in this concern – that healthcare might be getting to a point where the burden caused by regulations starts to interfere with the outcome improvements that the regulations were ostensibly intended to create.
Health Blawg’s David Harlow interviews Tim Waidmann, Senior Fellow at the Urban Institute’s Health Policy Center about the current state of Medicaid and the burden of healthcare expenses (particularly for low-income households) relative to income from one state to another. There’s an audio file of the interview, as well as a transcript, so you can listen or read. 
They discuss general aspects of the Medicaid expansion aspect of the ACA (keep in mind that Medicaid expansion was the one part of the ACA that SCOTUS altered last summer, giving states the right to choose whether or not they wanted to expand their Medicaid programs and get the additional federal dollars that go along with that option), and also covered state-specific issues for some of the states that have the highest healthcare cost burden on low-income (but not currently Medicaid-eligible) families. This interview is an interesting look at the way things are now, and will be a good benchmark to compare how things look a decade down the road, once each state has had time to expand Medicaid, implement some other form of low-income premium assistance for private health insurance, or make no changes at all.
At Workers’ Comp Insider, Julie Ferguson asks “why isn’t there a workers’ comp app for that?” She then goes on to describe numerous workers’ comp and workplace saftey related apps, but she notes that most of them aren’t getting a lot of use thus far. The tide is certain to change in that regard as time goes by – everything is going online and going mobile, so it’s likely that a few years from now, apps (or whatever takes the place of apps that we can’t even conceptualize yet) for workplace safety, workers’ comp claims, OSHA standards, etc. will be a regular part of any basic workplace safety protocol.
Jason Shafrin, aka The Healthcare Economist, takes a look at whether Medicare or private health insurance has more regional variation in healthcare spending. His article notes that the private sector tends to control utilization, while the public sector (Medicare) tends to control prices. So it’s unclear at first glance which should have greater regional variation in spending. The study Jason describes found that regional variation in utilization was much higher with Medicare, but even so, regional variation in spending is still greater in the private sector, which seems to highlight the importance of Medicare’s price controls.
UPDATE: We’re adding another entry to this edition, a little after the fact. One of our favorite bloggers, Casey Quinlan, left a comment noting that although the HWR included lots of great topics, there was nothing dealing with price transparency in healthcare. We often hear talk of patients being “consumers,” but purchasing healthcare is definitely not comparable to buying much of anything else on which we spend our money. We’ve addressed this issue several times over the years, including a three-part series on Jay’s experience with a self-pay dermatology treatment (you can read the whole story or I can sum it up for you: As a patient, obtaining and comparing healthcare costs prior to receiving care is a daunting task and sometimes downright impossible. Although there has been some progress in this area in the six years since we wrote that series, there is still a long way to go). We asked Casey if she’d like to include an article on healthcare cost transparency for this edition of the HWR, and she offered up this outstanding compilation of healthcare cost resources. Her post includes a ton of great links, and you’ll also find the #howmuchisthat hashtag on Symplur (be warned that you might end up spending the next hour of your day over there – it’s overflowing with excellent information and data). Thanks for adding your voice, Casey!
That does it for this edition of the HWR. We hope you found some good reading material and learned something along the way. Don’t miss the next Health Wonk Review, which will be hosted by Hank Stern at InsureBlog on April 26th.
