Catching up from NYC on a trip. Can't reply to it all. Will limit myself to:
Sure, what works in Canada won't work here, but of course no one has remortely proposed transplanting their system. All national system are different. We can study what works and adopt it for our use. This is how all quality improvement should work: review the published data and adapt it at home.
And number two question: Bill, you want to tell me what documented HARM there is for checkups? I'm interested in specifics. I'm not a big believer in regular checkups "because" but there are some services like blood pressure and cholesterol screening that we need periodically, not to mention subpopulations at STD risk, and populations that need cancer screening. It's a complex issue and I think an NP with a good screening tool could identify those who need an internist or family practice well, especially if that were their primary job. That would save huge physician costs, just to start, and if the screening were evidence based rather than on physician whim.... well, I'm shocked insurance companies haven't made it happen. I guess those AMA lobbyists probably had their say.
Lastly, Bill, all of those ambulance chasers who wrote you
1) barely make a reasonable wage
2) only have your best interests at heart
3) only take clear cut cases deserving prosecution
4) vocally support any and all measures which would make their jobs unnecessary such as enhanced safety processes and mediation.
IJ wrote:
all of those ambulance chasers who wrote you
1) barely make a reasonable wage
2) only have your best interests at heart
3) only take clear cut cases deserving prosecution
4) vocally support any and all measures which would make their jobs unnecessary such as enhanced safety processes and mediation.
That's the funniest thing I've seen written today, Ian. Thanks, I needed that.
Here's my poster boy of ambulance chasers. This guy made a living litigating OBs for things that absolutely, positively wasn't their fault (CP babies)
And the poor lad barely made a living doing that. Dude had to raise his family in a shack!
Good thing we know this guy is an otherwise upstanding lad.
Or... well at least we know part of him is still upstanding.
New Eng J Med Volume 362:320-328 January 28, 2010 Number 4
Increased Ambulatory Care Copayments and Hospitalizations among the Elderly
Amal N. Trivedi, M.D., M.P.H., Husein Moloo, M.P.H., and Vincent Mor, Ph.D.
ABSTRACT
Background When copayments for ambulatory care are increased, elderly patients may forgo important outpatient care, leading to increased use of hospital care.
Methods We compared longitudinal changes in the use of outpatient and inpatient care between enrollees in Medicare plans that increased copayments for ambulatory care and enrollees in matched control plans — similar plans that made no changes in these copayments. The study population included 899,060 beneficiaries enrolled in 36 Medicare plans during the period from 2001 through 2006.
Results In plans that increased copayments for ambulatory care, mean copayments nearly doubled for both primary care ($7.38 to $14.38) and specialty care ($12.66 to $22.05). In control plans, mean copayments for primary care and specialty care remained unchanged at $8.33 and $11.38, respectively. In the year after the rise in copayments, plans that increased cost sharing had 19.8 fewer annual outpatient visits per 100 enrollees (95% confidence interval [CI], 16.6 to 23.1), 2.2 additional annual hospital admissions per 100 enrollees (95% CI, 1.8 to 2.6), 13.4 more annual inpatient days per 100 enrollees (95% CI, 10.2 to 16.6), and an increase of 0.7 percentage points in the proportion of enrollees who were hospitalized (95% CI, 0.51 to 0.95), as compared with concurrent trends in control plans. These estimates were consistent among a cohort of continuously enrolled beneficiaries. The effects of increases in copayments for ambulatory care were magnified among enrollees living in areas of lower income and education and among enrollees who had hypertension, diabetes, or a history of myocardial infarction.
Conclusions Raising cost sharing for ambulatory care among elderly patients may have adverse health consequences and may increase total spending on health care.
"Few studies have assessed the consequences of increased outpatient copayments on subsequent utilization of inpatient care. In the RAND Health Insurance Experiment, persons who had to pay an annual deductible for outpatient care made fewer outpatient visits and also had fewer inpatient admissions than did persons who received free care, suggesting that increased cost sharing for outpatient care does not promote greater use of hospital care.2 However, the RAND experiment excluded elderly patients and ended in 1982. Therefore, these findings may not be generalizable to contemporary elderly populations. For example, the rates of use of inpatient care in our study were approximately twice as great as the rates reported for the cohort in the RAND experiment. (...)
"According to the findings of the RAND Health Insurance Experiment and other studies of nonelderly insured populations, cost sharing has generally been thought to reduce total health care spending without harming health for the average person.2,27,28,29,30,31,32 Our results, however, suggest that increasing copayments for ambulatory care among elderly Medicare beneficiaries may be a particularly ill-advised cost-containment strategy. Assuming an average reimbursement of $60 for an outpatient visit,33 seven annual outpatient visits per enrollee, and an average copayment increase of $8.50 per visit, a Medicare plan would receive an additional $5,950 in patient copayments and avert $1,200 in spending on outpatient visits for every 100 enrollees, for a total of $7,150 in savings for the health plan. However, assuming an average cost of $11,065 for hospitalization of a person 65 to 84 years of age in 2006,34 our estimates suggest that expenditures for inpatient care will increase by $24,000 for every 100 health plan enrollees in the year after copayments for ambulatory care are increased. Even if we used the upper bound of the 95% confidence interval for the estimate of outpatient visits, used the lower bound of the 95% confidence interval for the estimate of inpatient admissions, and doubled the average reimbursement for an outpatient visit, additional expenditures for hospital care would still exceed any savings from the copayment increase by a factor of nearly two."
Just worth pointing out that while people having a stake in the game reduces utilization, it doesn't always result in the best decisions on their part. We know from other work that people don't value preventive care and if copays go up for that, they are undertreated. We need to find ways to incentivize not just cost reductions but reductions selectively in optional or ineffective services, not cost effective and beneficial services, especially when there are downstream consequences like these.
IJ wrote:
"According to the findings of the RAND Health Insurance Experiment and other studies of nonelderly insured populations, cost sharing has generally been thought to reduce total health care spending without harming health for the average person.2,27,28,29,30,31,32 Our results, however, suggest that increasing copayments for ambulatory care among elderly Medicare beneficiaries may be a particularly ill-advised cost-containment strategy.
That's from the article you cited, Ian.
I take exception to the generalization of the RAND HIE as stated above. Yes, cost sharing works pretty well. But it's been demonstrated in the RAND studies that there are cases where individuals will be "cheap" when they shouldn't be - particularly when it comes to routine care of chronic conditions.
That stated, the results aren't surprising.
The solution? Be more aggressive about treating said chronic conditions. An excellent Electronic Health Record system and a proper understanding of HIPAA can lead to a paradigm where the health care practitioner reaches out to those who need maintenance care. Such activities have been demonstrated to lower hospital days (per 1000 members).
IJ wrote:
And regarding the doctors reaching out, well, there needs to be a national system. They need to be incented too (if you want it to happen).
You're going to have to work with me on that one, Ian. While I agree that incentives are screwed up and we can do better, the "national system" thing doesn't make me feel so warm and fuzzy. Health-care is such a localized phenomenon.
I personally believe most MDs want to do the right thing, but process and poorly-aligned incentives get in their way.
And most patients know what they need. Some however over-use the health-care system. Financial disincentives work well with them, and that in turn helps with "over-use" quality issues. Others who need care the most need a stick of TNT under their butts to make them get that care. Consider the number of people who smoke and/or eat cr@p they know they shouldn't. I rest my case.
The "art" of managing patients with chronic conditions is the "science" of behavioral modification. For some it's easy. For others it takes that come-to-Jesus moment to get them to do the right thing. There are days when it seems like a black art. And for that, I'm thankful for people who do it well.
