Defending the Mandate and its Tax/Penalty

From a contributor at the Daily Dish:

I do not understand why Democrats don't embrace the newly defined "tax", saying: you bet we raised taxes, but not on the hard-working, responsible middle class. This is a tax on those deadbeats who don't pay for their own insurance but still expect care when they show up at emergency rooms. It's a tax, all right, and I think we should agree to raise it even higher so they have more of an incentive to buy their own damned insurance and leave the rest of us alone. Let the Republicans protect the rights of deadbeats; Democrats are fighting for people who play by the rules.

This. This is exactly the right approach.

Matt, in the comments to the last post, asked a good question:

What is to stop people from paying a marginal penalty until they get a catastrophic disease, and then applying for insurance? This seems like rational behavior that will undercut the whole premise of "insurance". If I could buy car insurance with "pre-existing conditions" I'd never buy it until after I was in an accident.

Fair question. As I understand it there are two factors that make people willing to sign up for insurance when they are still healthy. The first is simply risk aversion. If you get hit by the proverbial bus or have any unexpected medical emergency, you can't sign up for insurance that day, or retroactively. So the possibility of a financially crippling medical emergency looms if you are healthy and uninsured. In fact, I believe you can't sign up until the next open enrollment period, which I think is every six months. You could be on the hook for quite a bit of medical expense (or denial of care) as a result.  This should be a powerful motivation. 


The second motivation is that in most cases, people want insurance. Sure, there are some objectors, but by and large, people perceive healthcare insurance to be a desirable thing to have. So the penalty is an incentive to buy something you already want to have. Would you rather pay $1000 and get nothing, or pay some higher number and have the thing that you actually wanted? Of course this doesn't work absent the subsidies that make the insurance affordable for working families and the medicaid expansion. 


The Massachusetts experience is that about 2% of people choose to pay the penalty, either because they are gaming the system, conscientious objectors, or in a particular financial hardship. If that number is replicated nationally, it's probably not enough to create a serious adverse selection death spiral.

OBAMACARE DEFEATS TRUMAN!

So this is great news and a great day. My quick reactions:

First of all, CNN & FOX. Once again proving that being first is a higher priority than being right. How embarrassing. At least their soon-to-be-fired producers will be able to get health care coverage.

Second, Roberts: I have to give him a little credit. I fully anticipated him to be a partisan hack and invalidate the law. Perhaps the burden of history weighed heavily on him, perhaps the delegitimization of the court influenced him, or perhaps the sheer radicalism of Scalia's dissent drove him to uphold the law. Regardless, he got it right. Make no mistake, though, he did what he could to advance his long-term agenda by slowly restricting the reach of the commerce clause.

While most of the focus centered on the the Heritage-Foundation-developed mandate (aka the greatest threat to liberty ever), it's important to note that the 4 conservatives wanted to invalidate the entire law, and there is far, far more than the mandate in Obamacare. 12 million Americans will get rebates from their insurers this year based on the ACA's insurance regulations. Rescissions of policies is now prohibited. In a couple of years, pre-existing conditions will be covered under the guaranteed issue provisions, and the moribund individual market will be resuscitated by the insurance exchanges. All of these huge reforms survived and will transform healthcare in a good way.

The mandate itself may work, or people may prefer to pay the "tax" penalty and go without insurance. We will see. If enough people opt out and insurers are experiencing serious adverse selection in a few years, perhaps the partisan rhetoric will have died down enough that Congress can tweak the incentives at bit. One can hope, anyway.

The Medicaid ruling was disappointing but not fatal. The gist is this: the ACA expanded eligibility for Medicaid all the way up to 133% of the poverty line. This is significant because in many states, the eligibility thresholds are very stingy, and in some if you're male and without dependents or a disability you are never Medicaid eligible no matter how little you make. So this is a very large expansion of coverage. It is still allowed under this ruling, but no longer can the Feds make it compulsory for the states.


So what does that mean? Not clear. Most states probably will implement the Medicaid expansion, which is for the moment fully funded by the feds. There are concerns that the feds may shift the costs back to the states in a few years, but that's not clear yet. I can see some GOP governors refusing to implement the expansion on these grounds (really just to be recalcitrant dicks; I'm looking at you Scott Walker), but there will be huge pressure on them from their medical community to accept what is essentially free money. If they do refuse, then it's going to leave a large portion of their lower classes without access to health insurance.


For the ER, I predict little will change. ER utilization has been going up nationwide for two decades, and that trend will not change, regardless of the fate of the ACA. When, in five years, ERs are busier and more overcrowded, I predict it will be held that this is a consequence of the "failure of Obamacare" and I'm going to call BS on that in advance unless it is shown that the rate of ER volume growth accelerated after 2014.  Which is possible, but I don't think is super likely. Many of the soon-to-be insured are already coming to the ERs as no-pay patients, and the only difference is that we will be reimbursed for those services that we are already providing.  Some of them may be diverted to PCPs' offices, though the limited capacity of the primary care network sadly ensures that will be a small number.  To the extent that ER volumes do increase, it's a failure on the part of the system to create enough primary care capacity, not the expansion of coverage.


It's worth noting that the ACA does contain a 10% boost to primary care providers' reimbursements. So that may help improve access to primary care, and there are also significant expansions of Community Health Centers.


Cost control is where ACA is weakest, and more will need to be done to bend the curve of health care inflation. Sure, the IPAB may have some effect, if it is ever implemented. Medicare is already putting into place other reforms such as value based purchasing and others. But this is certainly the point where the ACA is only a start. Wether Congress can get it together well enough to add onto it in a productive fashion is to be seen. 


The saddest element of this whole kerfuffle is that liberals and policy wonks are celebrating the survival, by the thinnest of margins, of reforms which in the best-case scenarios will leave the US with the worst access to health care and health insurance in the OECD, with the highest cost per capita in the developed world, and with the worst outcomes in the industrialized countries. The passage and survival of the ACA are big wins, but they still leave the US with the worst health care in the world, and one party is hell-bent on dragging us backwards. So I will celebrate the win and spike the football and all that fun stuff, but tomorrow morning we've got to get up and keep working to reform our system further. Because what we have is not good enough.

Let us give thanks

I began my shift with a small prayer:

Let us give thanks for Alcohol, Anxiety, and Gravity, without which we would be out of business...

Adds my partner, who happened to overhear me:

"Don't forget methamphetamines and impulsive decision-making."

Obamacare and EMTALA

From today's LA Times:

ACA Strikedown would complicate who pays for ER care for the uninsured:

"Whether people know it or not, whether people appreciate it or not, access to emergency care became a right in this country in 1986," said Dr. Wesley Fields, an emergency room physician in Orange County. "But the law that did that never addressed the big question of whose responsibility it was to deal with the cost." 

That unresolved question — who pays? — helped shape President Obama's 2010 healthcare law and its requirement that Americans get health insurance. For years, it even convinced many Republicans, including former Massachusetts Gov. Mitt Romney, to champion an insurance mandate. But today, the insurance mandate is the central target of GOP opposition to the law. 

Within days, the Supreme Court will rule on whether the new law is constitutional. If the law is upheld, millions of newly insured patients will have many of their hospital bills covered by insurance. But if the law, or just the insurance mandate, is struck down, those bills will be passed on to taxpayers, hospitals and privately insured patients, as they have been for the last quarter century.

As they have for the last quarter century.


The whole thing is well worth the read, and nothing that I haven't been saying for years. The coda, however, is striking for its understated demonstration of the cognitive dissonance displayed by the opponents of the mandate:

In the past, the cost shifting was cited by many conservatives as a reason why the federal government should require Americans to have health insurance. 

"If a man is struck down by a heart attack in the street, Americans will care for him whether or not he has insurance," the Heritage Foundation's Stuart Butler said in 1989. "We will not deny him services — even if that means more prudent citizens end up paying the tab." 

Butler, like many Republicans, has since renounced the insurance mandate.

They don't care about healthcare. They just care about scoring political points.  And now we wait to see if that neutral arbiter, the Roberts Court, the umpire whose only job is to call balls and strikes, will rewrite 75 years of constitutional law to deny his political opponents a victory, thereby shifting the cost of care for the uninsured back onto healthcare providers.

Go Live

Whew. Mind = blown.


Our entire hospital booted up a new Electronic Medical Record (EMR), from top to bottom, we are now an Epic facility. Today was my first shift in the ER after go-live, which was Saturday. Holy smokes, what a project it was to get it up and running. This system now runs everything in the hospital, from the ER to the OR to the wards, to the business and billing function, stocking, housekeeping, nursing, RT/PT/OT, social work — EVERYTHING. And we went live with a "big bang," all at once.

The good news? It went, if not perfectly, very well, and certainly better than expected. There were no major issues, which was a huge relief since the programming team was frantically building critical elements until the day before go-live. It's really disconcerting to sit with tutors three days before the event, ask how to order labs, and be told, "well, this is how you'll do it, but you can't do it now since that module is still in development." But to their credit, they got it done and it works.

The bad news? Not too much, other than the fact that the system is massive and really, really complex. This makes the learning curve super steep, and the impact on operations during the first week has been substantial. We have lots of support, with tutors and specialists standing by our elbows guiding us through each workflow, but every simple little thing takes forever as you're learning it.

How complex is this system? Just my interface, and I am but one provider of many classes, has by my count at least 15 different screens I interact with, and each screen has dozens of widgets and elements I need to operate. Worse, the behavior of each widget isn't always consistent from one context to the next. There are multiple ways to get some common tasks done, which is nice, but it's so easy to get lost in all the menus, windows and panes. It's pretty overwhelming, and mistakes can be frustrating to undo.

And I'm an eager adopter, a computer savvy guy. For me to be completely on overload, I pity some of the less nerdy folks working in our hospital.

I don't want you to think I'm down on this system. I loved our old EMR, Picis, because it was super elegant and simple and easy to get stuff done. This is much more intricate, which is a big challenge to learn but — I think — will be more powerful once I get it mastered. I can see myself being much more efficient than I was before within a couple of months. I hope.

For those who are interested, we have the ASAP module with the Notewriter function, but my off-the-cuff reaction is that Notewriter is utter crap and I don't think I'll ever use it. I've constructed a H&P skeleton with a lot of datapoints auto-populated from the chart and I am using Dragon dictation. The current release of Dragon seems much more accurate than older ones I have used, and there were Dragon experts there giving us lots of tips & tricks to really take advantage of the shortcuts available.

For example, I can order meds & labs verbally, and even common lab panels, using the mic. I can also drop in a standard age/gender/complaint specific physical exam with three words. (IMPORTANT: proofread/edit the output to make sure it's appropriate for the actual patient!) Also, I've made a slew of medical decision making notes with links that pull in personal/clinical data from the chart for common situations.

So it's a powerful tool, and I may wonder how I ever got by without it in a year or two. But for now, my head is spinning and I've gotta go lie down.

[EDIT: The de-identified screenshot was provided by the nice folks at Epic.]

Medicaid and the power of a relationship

Arthur Kellerman on the Washington State Medicaid ER ban, in the NEJM.

Key graf:

The genesis for the idea of denying payment for nonemergency ED visits is frequently traced to the research of John Billings, a professor of health policy at New York University. In the early 2000s, he developed an algorithm that used discharge diagnoses to identify ED visits that are “ambulatory care sensitive.” In his view, ambulatory care–sensitive visits fall into one of two groups: those that are “primary care treatable,” meaning that the problem could safely be managed in a doctor's office, and those that are “primary care preventable,” meaning that the visit might have been averted if care had been provided sooner. An uncomplicated lower urinary tract infection would be considered “primary care treatable.” An asthma flare-up would be categorized as “primary care preventable.”
Unfortunately, policymakers have generally misinterpreted Billings's findings. The fact that many ED visits could be managed in primary care settings does not mean that such care is available. In fact, Billings himself asserted that high rates of ED use for ambulatory care–sensitive conditions are a strong indicator of poor access to care — not poor judgment on the part of patients.

I couldn't have said it better myself. Which, I suppose is why I'm writing here and he's writing in NEJM. One other nugget I wanted to expand on — Kellerman writes:

Perhaps the Authority's actions will encourage Medicaid beneficiaries to forgo nonemergency ED visits and instead forge enduring relationships with primary care providers.

This is an important point that goes beyond access to care — note the words "enduring relationships." That's a pretty huge element of primary care. I've been with my PCP for a dozen years. (Oddly he was medicine chief resident in my university when I was a 3rd year med student, in a university 2500 miles away. Life is weird.) The family practitioner who delivered me was still my doctor when I got accepted to medical school. These relationships are enduring and that's a big part of why they are so valuable. They are also a big part of why med students go into primary care.

Now our community has decent access to primary care. It's not great, but I am sure it's better than some places. We have a large and reasonably well-funded network of Community Health Centers (many of which were funded by Obama's ARRA and ACA, but that's another topic). They're overburdened; the demand exceeds their capacity, but they do good work with limited resources. Unfortunately, the doctors there are not well paid, many are doing public service to get loan forgiveness, and they tend to come and go pretty frequently. They have decent access for acute care, again, they do their best, but most urgent visits get shunted to an urgent care area staffed by mid-level providers, not the regular medical staff.

Commonly enough, I see CHC patients in the ER with, as Dr Kellerman calls them, "ambulatory care sensitive conditions." Cutting the BS, these are trivial things to go to an ER for. Cough/URI. UTI. Flu. Medicine refills. A rash. Back pain. We all know the non-emergency crap that fills our ERs, and despite ACEP's dishonest PR claims, it's a hell of a lot more than 7% of ER cases.

So why do these patients come to the ER instead of accessing their established primacy care doctor? They do have them, so what's the issue? Well, I make it a point to ask them, politely and non-judgmentally. Part of it is my curiosity, and part is to encourage them to actually go there in the future. The answers I get generally fall into about three distinct categories:

• Anxiety
• Access
• Absence of Relationship

Anxiety is straightforward enough: "My baby (18 months old) had a fever and a cough and I'm an 18 year old single mother and I was worried." Fair enough. Access is also a common issue: "I called the clinic but they didn't have any openings." Again, I can't argue with that. But I have been surprised at how often the reason patients give for bypassing their PCP and coming to the ER is that they don't feel like they have a relationship with an actual person: "Every time I go there I see someone different."

This is actually huge, and commonly overlooked. I go to see my doctor because I like him and trust him, and he knows me. If I had to go to a clinic where I'd never see the same person twice, well, the added value of that over an ER is nil, and on top of that you have to call and get and appointment and wait for the appointment, while the ER is just "drop in convenience." From the perspective of the patient, especially a medicaid, "cost-insensitive" patient, I can see why they come to the ER.

I don't know what the solution is. I don't see more money coming into the care-for-the-indigent tier of our two-tier health care system, and as more patients come onto medicaid in coming years, I can only assume the access barriers and the depersonalization of the CHC system will worsen before it gets better.

We'll be here to see them in the ER. Hopefully the state won't punish us by refusing to pay.