RAND Objects
RAND Corporation Vice President Arthur Kellermann objects to my Kaiser Health News commentary, “Is Medicare Real Insurance?” in a Letter to the Editor this morning. My general reaction: RAND is entitled to its own research, but not its own spin.
Goodman: “If you’re trying to get a primary care appointment, it appears your chances are better if you say you are uninsured.”
Kellermann: “The only scenario in which uninsured callers did better than Medicaid beneficiaries was when the caller said he or she was willing to pay the full visit fee in cash, up front. Goodman left this detail out.”
Response: Oops. Sorry. I thought that was understood. Okay, if you call for an appointment and announce that you don’t intend to pay, the appointment takes longer. Duh!
Goodman: “A very comprehensive RAND study found that the type of insurance people have — or whether they are insured at all — does not affect the quality of care they receive.”
Kellermann: “The RAND team found that patients received recommended care only 55 percent of the time. Interestingly, quality-of-care scores did not vary much whether the patient was covered by Medicaid, Medicare, private health insurance or was uninsured. Goodman interpreted this to mean that Medicaid doesn’t matter. By that logic, he could have reached the same conclusion about private health insurance.”
Response: Yes, that’s exactly what the study showed. Kellermann goes on to confuse this with a separate issue of whether the uninsured get less care because they are uninsured and refers to an Institute of Medicine (IOM) study on the health consequences of being uninsured.
Two points. First, serious scholars regard the IOM study as junk research. I won’t review the problems here. Interested readers should look at what Linda Gorman and June O’Neill have to say.
Second, (and I may have also been guilty of not making the point clearer) there are two different events: (a) whether a patient chooses to access the health care system and (b) what type of care the patient gets once there. The uninsured do not access the system as often. But once they get care, RAND research shows that the type of insurance they have doesn’t matter.
I agree with you. Kellermann is just offering spin.
I sometimes wonder why academics seem to have so little common sense. Does anybody really think an emergency room doc is going to treat patients differently, depending on their insurance? If you were a doctor and one patient offered to pay full price and another offered to pay Medicaid rates, which patient would you see first?
These issues are really no-brainers.
Ditto Nancy’s comments. I hope no one spent a lot of money affirming what should have been obvious.
Wouldn’t the patient’s insurance realistically have more influence in getting regular treatment from a GP than in an ER setting?
Nancy says:
April 13, 2011 at 10:53 am
“If you were a doctor and one patient offered to pay full price and another offered to pay Medicaid rates, which patient would you see first?”
Nancy, the obvious and professional answer is “Who needs treatment the most?”
Money should have no bearing on a basic triage decision made by doctors. If they do make that decision based on what they are paid they should be thrown out of the profession. That is part of the “cost” problem, putting profit before care.
Erik–you don’t know who needs treatment the most. People are calling a primary care physician to make an appointment.
I agree with Linda, this is an entirely different piece. It is surprising RAND would disagree with your premise, Dr. Goodman, it seems pretty easy to comprehend.
In the course of a study, researchers often come across surprising findings. Some of these are inconvenient to the conventional wisdom. On the other hand, some results are anticipated. It is even possible for different researchers to disgree on the meaning of a given finding. There is always room for different opinions even if the authors of the study do not agree with that meaning.
Yes, I am amazed that Dr. Kellerman thought it would be necessary to clarify that the uninsured who promised to pay the entire balance got appointments faster than those who could not.
It goes to show how crazy health-policy research is. Imagine conducting market research on any other sector of the economy by telephoning providers and asking if they’d give you their goods or services for free – and thinking that the negative result was a significant scholarly finding!
What Dr. Kellerman is confirming is that Medicaid does not solve the problem that it is supposed to solve: Increasing access to medical care in the low-income population.
Good response to RAND. I’m also supprised at Kellermann’s letter.
The more opinions the better. More room for discussion, and hopefully, better research in the future.
Ditto John Graham
Linda,
As a surviving cancer patient I know when I call my doctor for an appointment I will tell him why I am calling and the symptoms I have so he does not have to guess. I am sure most people do the same.