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Quiz of the Day: Define Overtreatment

Now that government is paying the health care bills we are hearing a lot about overtreatment. As always, where one stands on it depends upon how one defines it.

Here is what the National Cancer Institute says about mammograms and overtreatment:

Screening mammograms can find cancers and cases of ductal carcinoma in situ (DCIS, a noninvasive tumor in which abnormal cells that may become cancerous build up in the lining of breast ducts) that need to be treated. However, they can also find cancers and cases of DCIS that will never cause symptoms or threaten a woman’s life, leading to “overdiagnosis” of breast cancer. Treatment of these latter cancers and cases of DCIS is not needed and leads to “overtreatment.” Overtreatment exposes women unnecessarily to the adverse effects associated with cancer therapy

Why not leave the harmless DCIS tumors alone?

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Jun 06, 2014 | 15 comments | by

Yet More Reasons Why Doctors Do Not Participate in Medicaid

Claims about Medicaid’s effectiveness should be approached with caution simply because the population covered by Medicaid differs from that covered by private insurance in ways a variety of ways that are likely to affect overall health.

For example, Medicaid patients are more likely to be no-shows for medical appointments. No-shows are typically defined as either not showing up at all or calling to cancel on the same day. In one orthodontic practice, Medicaid patients accounted for almost 40 percent of missed appointments but only 27 percent of all appointments. Children most likely to miss dental visits were those with lots of cavities, poor behavior, multiple missed appointments, and no phone.

Broken appointments translate into a reimbursement rate of zero. Surveys of dentists suggest that they are even more important than low reimbursements in dentists’ refusal to participate in Medicaid.

The pattern does not change for more involved procedures like cochlear implants. At Children’s Hospital in Cleveland, Ohio, access to cochlear implants is the same whether patients are covered by Medicaid or by private insurance. But medical complications do vary with a patient’s insurance status. From 1996 to 2008, 133 children received unilateral cochlear implants. Complications in Medicaid-insured children were 5 times those in privately insured patients with 10 complications in 51 Medicaid-insured patients and 3 complications in 61 privately insured patients. Medicaid patients missed 35 percent of follow-up appointments. Privately insured patients missed 23 percent of follow-up appointments.

Given that behavioral differences exist for something as simple as keeping an appointment, challenges to getting high-quality care to Medicaid patients cannot be solved by just expanding Medicaid budgets.

Jun 05, 2014 | 11 comments | by

Tax Credits Cure Food Sales Tax Complexity. Why Not Use Them in ObamaCare Reform?

California’s tax treatment of food and ObamaCare’s tax treatment of health insurance have something in common. Both sets of regulation are so bad that people buying the same product can be taxed or subsidized differently in ways that are almost impossible to decipher.

As Joe Eskenazi of SF Weekly explains, California taxes the same bunch of carrots differently depending on whether the “buyer is a homeless shelter (no), a racetrack (yes), an ostrich farm (no), or a zoo (maybe).”

Sold in combination, a cup of coffee and a cup of gazpacho are a taxable meal. Sold separately, they are not. Cream-filled donuts are not taxable, but a croissant sandwich is. A cold sandwich with hot gravy poured on it is taxable even if it is cooled to room temperature. So is a previously hot, but currently cold, soup.

At first, the state held that movie popcorn was heated food. The movie theaters disagreed. They claimed that the lights over the popcorn were dehumidifier lamps, not heating lamps. They hired popcorn experts to measure the internal heat of the popcorn piles. Multiple hearings and many dollars later, the California Board of Equalization ruled that the heat in the popcorn was indeed a by-product of those dehumidifier lamps. Movie popcorn became a tax exempt food.

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May 27, 2014 | 14 comments | by

Yes Virginia (and California), Even Well Intended Regulation Increases Costs

Here’s a concrete example from the Coyote blog showing how seemingly innocuous state regulations can combine to discourage hiring.

Over time, California legislators have passed a variety of laws requiring employers to provide various types of paid and unpaid employee leave. The rules have to be given in an employee handbook. The business that compiled the list below had to hire an attorney to create it. It says that the list may be incomplete and that it is “published at the risk of having a California lawyer see it and say “aha! They have forgotten time off for the death of a beloved hamster. Let’s sue him.”

If asked, the author says his business would probably provide informal time off for most of the things listed. But because they are now legal requirements backed by the threat of expensive litigation if the company makes even the smallest mistake, he has to go to the irritation and expense of discovering the rules, tracking the leave, and keeping up with regulatory compliance.

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May 21, 2014 | 12 comments | by

Were 43% of Exchange Enrollees Insured in 2013?

health-insuranceAs predicted, people apparently are dropping pre-existing coverage to enroll in the exchanges. Express Scripts reports that 43 percent of the enrollees in the exchange plans that it contracts with were previously enrolled in a 2013 plan that also used Express Scripts. This means that at least 43 percent of exchange enrollees had previous coverage. The actual fraction of those with previous coverage may well be higher given that a one 2013 estimate concluded that Express Scripts controlled about 40 percent of the U.S. pharmacy benefit management market.

As this blog previously reported, Express Scripts also reported that exchange enrollees used 47 percent more specialty medications, drugs that account for more than a quarter of the nation’s spending on prescription drugs. The increased medication use is not surprising given that many states moved the people in their high risk pools into the exchanges.

The Express Scripts analysis was based on a national sample of more than 650,000 pharmacy claims from approximately 423,000 people enrolled in a public health insurance exchange from January 1, 2014 to February 24, 2014.

May 20, 2014 | 30 comments | by

Wellness Fails Again

UntitledPepsiCo is the latest large employer to report that its wellness program has a negative return on investment, returning $0.48 for every dollar invested.

A voluntary program to help people manage actual diseases returned $3.78 per dollar invested.

The authors note that the results likely overstate the return on investment because they did not include the cost of program staff or the cost of employee time.

Beginning this year, ObamaCare requires that the government spend $200 million on wellness grants for small businesses that did not have a program in place when the law passed in 2010.

May 19, 2014 | 21 comments | by

Patient “Activation” in the Spin Cycle — Professors, Scams, and Conflicts of Interest

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(Fowles, et al. Journal of Patient Education and Counseling, 2009)

If you “strongly agree” with most of the questions above, you are a “highly activated,” patient. According to an article in the Wall Street Journal, health researchers have determined that the Patient Activation Measure (PAM) can identify “highly activated” patients, and that “highly activated patients” have better outcomes. (A New Vital Sign to Gauge: The Patient’s “Activation” Level, p. D1).

Judith Hibbard, identified as lead developer of the PAM assessment and a senior researcher at the University of Oregon’s Health Policy Research Group, assured the article’s author that the PAM is more than just a non-stick cooking spray: “Everyone assumes this is sort of a soft science, but we can measure patient activation just as rigorously and scientifically as other things in health care,” she reportedly said.

If that’s the case, health care is in bad shape.

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May 15, 2014 | 8 comments | by

Administrative Costs for Disability Plans: Do-It-Yourself vs Specialization

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The table provides some general estimates on the costs and benefits of do-it-yourself health coverage. It was developed by Milliman, for employers considering self-funding a short-term disability plan of 10,000 lives. It is interesting because it sheds some light on what Milliman believes specialized insurers do well.

Companies that specialize in insurance have lower claims administration and eligibility determination expenses. The accompanying report emphasizes that the advantage from self-funding depends heavily on the cost of developing expertise in claims management. Self-insured employers must be adept at medical bill reviews, reviews of medical treatment plans, rehabilitation programs, workplace modification, claims management, and fraud prevention. Non-specialists will have higher claims costs, and the cost of developing this expertise, and the infrastructure needed to support it, “could be prohibitive” for many employers.

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May 09, 2014 | 7 comments | by

Does Failure To Expand Medicaid Kill People?

Who’s killing whom?

Writing in The New York Times the other day, Paul Krugman had this to say:

And while supposed ObamaCare horror stories keep on turning out to be false, it’s already quite easy to find examples of people who died because their states refused to expand Medicaid. According to one recent study, the death toll from Medicaid rejection is likely to run between 7,000 and 17,000 Americans each year.

Really? 17,000 deaths per year? This outrageous claim flies in the face of years of careful study by real economists — who have concluded that there is almost no relationship between health insurance and mortality in the general population. As we previously reported:

In independent empirical papers, Richard Kronick and David Card and his colleagues find little evidence that health insurance coverage significantly reduces mortality. Former Director of the Congressional Budget Office June O’Neill and her husband Dave also conclude that lack of insurance has little or no impact on mortality. See the discussion at this blog here, here and here.

So where does Krugman’s claim come from? Not from economists, it turns out, but from a Health Affairs blog post  by Sam Dickman, David Himmelstein, Danny McCormick and Steffie Woolhandler. And notably, they do not do what serious scholarly papers do — acknowledge the work of other scholars who have addressed this same topic.

Their numbers rely on surveys known to overestimate the uninsured and on results from papers with methodological problems that are both serious and widely known. Their claim that failing to expand Medicaid in conformance with ObamaCare dictates will kill somewhere between 7,115 and 17,104 people a year confuses ideological posturing with scholarship.

Knock, knock, knockin’ on heaven’s door

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Apr 21, 2014 | 27 comments | by

Colorado Health Exchange Premiums Roughly Equal to Those of High Risk Pool

iStock_000004795595LargeIn 2013, Rebecca Ryan of Fort Collins, Colorado, paid $375 a month to be insured by CoverColorado, the state’s plan for people who are uninsurable. When the state ended that plan on December 31, 2013, 14,000 people became uninsured and had to find ObamaCare plans.

Ms. Ryan went to the state exchange. The least expensive available option was a Kaiser-Permanente HMO that cost about $360 a month. Ms. Ryan says that it had a roughly similar deductible of $5,000 per person and total out-of-pocket costs of $6,350. Unlike Kaiser, however, CoverColorado allowed members to see any provider in the state.

The Kaiser plan did not include Ms. Ryan’s longtime physician. The only exchange plan that did that was a new, untested, Co-op plan that cost $526 a month. When asked, the exchange representative agreed that “they are going to penalize me because I want to keep my doctor.”

Keep in mind that CoverColorado charged individual premiums that were 137 percent of the “industry average,” calculated as weighted average of Colorado’s five largest individual health insurance carriers’ premiums, adjusted for benefit differences.

Ms. Ryan’s experience in the exchange suggests that ObamaCare may have raised Colorado’s average individual premiums by 37 percent.

Apr 03, 2014 | 24 comments | by
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