Tuesday, March 29, 2011

The Cold, Hard Facts About Tort Reform

Many physicians look for tort reform and would love to see it as part of any future health reform.  I admit that it would be nice to not have to worry about lawsuits when I'm working with patients.  However, I don't know that tort reform would save much money.

The CBO estimated comprehensive malpractice reform would save the government $54 billion over 10 yrs. However, the government pays $636 billion each year for healthcare costs.

One trillion is 1,000 billions; that means that $54 billion over 10 yrs / $6.36 trillion ($6,360 billion) over 10 yrs: I'm bad at math, but I get a 0.85% savings in healthcare costs from tort reform. Would that really make any drop in the bucket?

I think that if we were to have some ability to ensure that if we practice good medicine we would be protected in case of a bad outcome (such as some sort of safe harbor that if evidence-based guidelines are followed a physician would be protected from suit), this could impact practice patterns. So would reform that allowed physicians to actually spend the necessary time with patients to form long-term relationships, to discuss treatment options and truly engage in shared decision-making, and to allow for follow-up and adjustments to treatment plans when needed. This sort of reform--that put patient care above procedures, volume, etc--would likely make an even greater impact on patient care and (I think) have a bigger impact on practice patterns.

I learned in medical school that if a patient likes you, they are less likely to sue you. And if you actually sit and talk to a patient--and listen to them--they are more likely to like you.  And you're much likely to provide better care, and the care the patient needed.

Sunday, March 20, 2011

More information on the ¡Una Vida Sana! project

As a result of working with Spanish-speaking patients who lack access to preventive care and of meeting health professions students interested in working with Spanish-speaking communities, I helped establish ¡Una Vida Sana! The program allows for multi-disciplinary learning while providing necessary medical screenings.

This slide presentation goes over the project in more detail, and provides some background. As the program develops, we hope to have some additional information (and some research results) as a result.

Wednesday, March 16, 2011

International Medical Service

As part of my desire to work with marginalized communities, I have been involved in a number of international medical service projects. In 2010, I presented to the Virginia Academy of Family Physicians on the topic of how physicians can get involved in international medical work.

The slides of this presentation are below, and I am happy to provide further detail in the comments.

Tuesday, March 15, 2011

What we are celebrating, and what we are still fighting for

(Originally posted on the National Physicians Alliance blog March 15, 2011)


Next week marks the first anniversary of the passage of the Patient Protection and Accountable Care Act (PPACA).  This is a good time to remind ourselves what reforms were enacted in the PPACA.

The Robert Wood Johnson Foundation and the Urban Institute recently released a report (pdf) analyzing how the PPACA increases access to health insurance in the United States.  The study used the current (2011) baseline information regarding health insurance coverage, and then modeled the changes that would result if the PPACA was enacted all at once (instead of over the next few years).  This allows a more direct comparison of how the law's reforms affect health insurance coverage.  Some of the findings:
  • The percentage of uninsured non-elderly adults would drop by 10.3%, from 18.9% to 8.7%, meaning that more than 27.6 million more Americans would have health insurance under the PPACA.  This increase in insurance coverage would be most dramatic in states where people have less access to employer-sponsored insurance and are less likely to meet Medicaid eligibility requirements.  This indicates that the PPACA's reforms benefit patients who lack other opportunities to obtain health insurance.
  • Group health insurance exchanges would cover 8.9% of Americans.  The exchanges will have the greatest impact in states with limited access to employer-sponsored insurance and limited access to Medicaid.  Therefore, the health insurance exchanges provide an option for insurance coverage in areas where options would otherwise be limited.
  • Nationally, just over 30% of those covered in the insurance exchanges would have income >400% of the federal poverty level (FPL).  These individuals will not receive any government subsidies for their insurance, but would find the exchanges an attractive alternative to purchasing expensive individual insurance in the current marketplace.
  • The majority of cost-sharing and premium subsidies to help lower income individuals purchase insurance would help people under 200% of FPL.  63% of premium subsidies and 91% of cost-sharing subsidies would go to individuals under 200% FPL, meaning that these subsidies would increase health insurance access to those who are currently lacking it.
  • Medicaid expansion will enroll just under 5 million people currently eligible for coverage, but who are not receiving it, and 12.2 million people will be newly eligible for Medicaid coverage.  The majority of new enrollees will be non-parent adults.  These new enrollees will on average have lower health care costs than those adults already receiving Medicaid, many of whom have multiple co-moribd conditions.  New enrollees will make up approximately 20% of patients receiving Medicaid, but will only account for 15% of medical costs.
From this analysis, then, it is clear that the PPACA's reforms stand to meet one of the law's major goals: to reduce the number of uninsured Americans.  The fact that this law is needed is evident when you look deeper into the numbers: the majority of those who will receive coverage through group health insurance exchanges and through the Medicaid expansion are adults who would be unable to obtain health insurance through other means as a result of low incomes, lack of employer-sponsored insurance, and current Medicaid eligibility standards.  These are individuals the pre-PPACA insurance market left out.

Despite the positive benefits of the PPACA's reforms, it continues to be the target of much partisan opposition.  Much of this opposition claims that this bill amounts to a government take-over of health care.  However, as evident in this study most newly insured Americans will be insured through the group health insurance exchanges where private health insurance companies will sell their products.  Although federal subsidies will support people purchasing plans in these exchanges, the coverage will be provided by commercial companies.

The PPACA has already led to significant reforms in its first year, including eliminating lifetime caps and yearly limits on benefits, allowing adult children to stay on parents' insurance plans until age 26, eliminating rescissions, requiring no-cost preventive care, and regulating how much of your premium dollars must be spent on paying for benefits.  Once fully enacted, the PPACA will expand access to health insurance to more than 27 million uninsured Americans.

Meanwhile, according to a recent Robert Wood Johnson Foundation report (pdf) there are still approximately 18.5 million adults who will lack insurance coverage despite the PPACA's reforms.  Approximately 37% of these are individuals who will qualify for Medicaid but will not be enrolled, nearly 23% will have access to affordable health insurance options, and 24% will be undocumented immigrants.  Despite the important reforms embodied in the PPACA, we will need to continue to ensure that those who qualify for insurance are able to take advantage of them and we must review options to insure undocumented individuals have access to needed care.

These needed reforms are worth celebrating, and worth fighting for.

Saturday, March 5, 2011

The Individual Mandate is Necessary, and it is Constitutional

(originally posted on the National Physicians Alliance blog March 5, 2011)


Many of the reforms embodied in the Patient Protection and Accountable Care Act (PPACA) are widely popular, even among those who favor repealing the law (PDF; see the chart on the top of page 3).  The major reform of the PPACA that is unpopular is the individual mandate.  The requirement that everyone purchase health insurance or face a fine is consistently the least popular part of the law, despite the fact that many supporters of the bill feel that it is a necessary step to ensure the law’s health insurance reforms.

The individual mandate has also been the recent focus of the efforts to attack the PPACA in the courts.  The law’s opponents, including Virginia’s Attorney General, feel that the mandate to purchase health insurance is unconstitutional.  As of now, the courts have been divided on whether this is the case, and whether the mandate can be struck down in isolation or whether the PPACA as a whole would be invalidated if the individual mandate is found unconstitutional.  Recently, the New England Journal of Medicine published two articles I think are relevant.

The first article asks the question of whether Congress actually has the right to regulate economic inactivity.  The constitutional arguments both for and against the individual mandate focus on the Constitution’s Commerce Clause, in which Congress is given authority to regulate interstate commerce.  The argument made in support of the mandate is that everyone will have need for health care at some point, as a nation we have chosen to provide health care largely through private insurance, and the cost of this insurance is increased due to the care provided to uninsured patients.  Therefore: if everyone is paying more because many Americans lack health insurance coverage, then mandating health insurance is a segment of interstate commerce.  In essence, in this case, choosing not to purchase health insurance (inactivity) is in fact an active choice that ends up costing everyone.  Through their article, the authors believe that Judge Vinson’s recent ruling against the mandate is flawed and opposes Supreme Court precedent.

The second article analyzes the individual mandate in more detail, and considers alternatives if it were found unconstitutional when it finally reaches the Supreme Court.  The article concludes that although other options exist, it is not clear if they would be more politically viable than the mandate, and replacing the mandate with the listed alternatives would notably reduce the law’s benefits and would destabilize insurance pools that would be unable to turn away patients for pre-exisiting conditions and would be unable to limit lifetime benefits.

The PPACA includes many reforms that the American people support, and those reforms require that all Americans participate in the health insurance system.  The lack of participation, by choice or due to inability to pay, costs everyone.  The individual mandate, as unpopular as it is, is a key step to ensuring the law’s benefits and its inclusion in the PPACA is within Congress’s mandate to regulate commerce.