Capture Market Share, Raise Prices

Two principles in medical economics central to the Affordable Care Act (ACA) were dealt blows by recently published studies. The first principle is the belief that economies of scale will result in lower prices. The theory is that larger insurers will have lower prices because they are more administratively efficient. The second principle is that provider-owned health plans, usually hospitals, will reduce premiums. The theory is that  by controlling doctors over charging health plans in a fee-for-service model will lower prices.

The first study published in Technology Science found that the largest insurer in each of the states served by HealthCare.gov raised their prices in 2015 by an average of over 10 per cent compared to smaller competitors in the same market (1). Those steeper price hikes for monthly premiums did not seem warranted by the level of health claims which did not significantly differ as a percentage of premiums in 2014.

The second study published by HealthPocket compared the lowest monthly premiums for provider-owned to nonprovider-owned plans within twelve counties across the US (2). The counties analyzed were spread across the eastern, central, and western regions of the U.S. Premiums were based on a 40-year-old, non-smoker profile. Insurance offered by health-care providers such as hospitals, was on average 12% more expensive compared to  traditional insurers. The data were also analyzed by the type of plan under the ACA: bronze, silver and gold. There were too few platinum plans to perform an analysis. Table 1 shows the local results in the three western states analyzed.

Table 1. Monthly premiums for Provider and Non-Provider Health Plans Under the ACA (2).

Silver plans account for two-thirds of plan selections on the ACA marketplaces during the 2015 annual enrollment period (3). Only the premiums for the bronze and silver provider-owned health plans in Arizona cheaper. Both in New Mexico and Utah all the provider-owned health plans and the more frequently selected silver plan in Arizona were all more expensive.

The premises of economies of scale and elimination of the fee-for-service reimbursement are both central to the ACA. Both appear to be myths. The results of these studies illustrate the sobering reality that the best intentions in reforming American healthcare do not necessarily produce the intent imagined. Despite the theoretical promise of reducing expenses by eliminating waste, both studies show an increase in healthcare costs, opposite the direction that traditional economics predict. Both larger companies and provider-owned health plans have a profit motive with numerous conflicts which likely accounts for these increases in premiums. Rather than allowing mergers and focusing on controlling physician behavior as strategies in reducing costs, it is time to focus on the insurers. Their strategy appears to be "capture market share, raise prices" and therefore their profits. This later premise agrees more with the data. Most of us who work in healthcare know this, it is time for those in Washington to pay attention to what is going on rather than their prejudices and political beliefs. 

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References 

1. Wang E, Gee G. Larger Issuers, Larger Premium Increases: Health insurance issuer competition post-ACA. Technology Science. 2015081104. August 11, 2015. Available at: http://techscience.org/a/2015081104 (accessed 8/31/15).
2. Colemen K, Gleeson J. Cheapest healthcare provider-owned insurance plans still 12% more expensive than cheapest insurance plans not owned by providers. HealthPocket. August 20, 2015. Available at: https://www.healthpocket.com/healthcare-research/infostat/fee-for-service-and-provider-health-plans#.VeRqLPlVhBd (accessed 8/31/15).
3. Health Insurance Marketplaces 2015 Open Enrollment Period: March Enrollment Report. ASPE Issue Brief. (March 10, 2015).

*The views expressed are those of the author and do not necessarily represent those of the Southwest Journal of Pulmonary and Critical Care, the American Thoracic Society or the Arizona, New Mexico, Colorado or California Thoracic Societies.

Cite as: Robbins RA. Capture market share, raise prices. Southwest J Pulm Crit Care. 2015;11(2):88-9. doi: http://dx.doi.org/10.13175/swjpcc115-15 PDF

Guns and Sleep

Gun deaths are a problem in America. Irrespective of one’s position on gun control, the statistics do not lie. According to the Centers for Disease Control and Prevention (CDC), there were 11,208 deaths caused by firearms in 2013 (1). The recent high profile cases in Cincinnati, OH, Lafayette, LA and Memphis, TN further highlight the issue. Obviously, each case of death by a firearm had its own set of underlying factors that contributed to the final fatal outcome, but one wonders whether sleep deprivation can be implicated in some of them.

Sleep duration in adults over the past approximately 30 years has been declining in the United States (2). A variety of reasons can be cited as underlying causes such as greater use of artificial lighting, an expanding 24 hour non-stop society, promotion of a work ethic that values “burning the midnight oil”, and use of electronic devices before bedtime (especially those that emit blue wavelength light). In addition, both legal and illegal drugs have important impacts on sleep quality and quantity. For example, amphetamines can cause insomnia and by extension a reduction in sleep time (3), and perhaps more importantly, caffeine will have the same effect if used to excess (4). The most recent recommendation from the American Academy of Sleep Medicine is for adults to sleep at least 7 hours per night (5). However, recent CDC data indicate that 29.2% of adults sleep less than 6 hours per night and are thus chronically sleep deprived (2).

Symptoms of sleep deprivation include longer reaction times, lapses in attention or concentration, poor short term memory, errors of omission and sleepiness. However, sleep deprivation also leads to confusion, stress, irritability and impulsivity. Importantly, decision making and the ability to formulate reasonable moral judgments are impaired. All of these negative impacts of sleep deprivation can lead to high-risk behavior. Thus, can it be posited that in some cases, sleep deprivation, perhaps fueled by the legal or illegal use of stimulant compounds, leads to impaired judgment and increased impulsivity, poor decisions and fatal shootings?

Several years ago, I was asked to be a defense expert in a case where a jilted wife fatally shot her husband’s lover. After learning about her husband’s affair, the wife had become distraught and unable to sleep for ~2 days. She then sought out the victim and shot her. Her sleep deprivation was used as a mitigating factor to reduce the charge from 1^st to 2^nd degree homicide. Although not a shooting, more recently, a Florida man was acquitted of the murder by suffocation of his father because he was sleep deprived after consuming a large amount of Red Bull (80 mg caffeine per 8.46 fluid ounces). Cases such as these have led to speculation that sleep deprivation may be an effective defense where the fatal act could plausibly be explained by a change in mood or cognitive impairment.

The potential impact of sleep deprivation is likely not limited to citizens accused of fatal shooting, but law enforcement officers as well. Police officers frequently work overnight or rotating shifts, and many accept overtime duty as well. A recent survey of 4957 police officers found that >40% screened positive for at least one sleep disorder with 28.5% being excessively sleepy, suggesting an element of sleep deprivation (5). Most troubling was that those who were identified as having a sleep disorder had a 51% greater likelihood of making an error or safety violation and a 63% greater chance of exhibiting other adverse work-related outcomes including uncontrolled anger toward suspects. Could some of the recently publicized adverse interactions between police officers and citizens be partially explained by lack of sleep?

Although a possible causal link between gun violence and sleep deprivation is speculative, there is no doubt that insufficient sleep is becoming endemic in our society and has significant personal and public health consequences. There should be a concerted effort on the part of public health officials, public and private institutions and individuals to reverse this trend by publicizing the adverse impact of insufficient sleep, undertaking policy measures to promote adequate sleep and set themselves as examples of healthy sleepers.

Stuart F. Quan, MD

Gerald E. McGinnis Professor of Sleep Medicine

Harvard Medical School

Brigham and Women's Hospital

Boston, MA

References

1. Centers for Disease Control. Fast stats. Available at: http://www.cdc.gov/nchs/fastats/homicide.htm (accessed 8/6/15). 
2. Ford ES, Cunningham TJ, Croft JB. Trends in self-reported sleep duration among US adults from 1985 to 2012. Sleep. 2015;38(5):829-32. [CrossRef] [PubMed]
3. Coghill DR, Caballero B, Sorooshian S, Civil R. A systematic review of the safety of lisdexamfetamine dimesylate. CNS Drugs. 2014;28(6):497-511. [CrossRef] [PubMed]
4. Drake C, Roehrs T, Shambroom J, Roth T. Caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. J Clin Sleep Med. 2013 Nov 15;9(11):1195-200. [CrossRef] [PubMed]
5. Watson NF, Badr MS, Belenky G, et al. Joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society on the recommended amount of sleep for a healthy adult: methodology and discussion. J Clin Sleep Med. 2015;11(6):591-2. [CrossRef] [PubMed]
6. Rajaratnam SM, Barger LK, Lockley SW, Shea SA, Wang W, Landrigan CP, O'Brien CS, Qadri S, Sullivan JP, Cade BE, Epstein LJ, White DP, Czeisler CA. Harvard work hours, health and safety group. JAMA. 2011;306(23):2567-78. [CrossRef] [PubMed]

Reference as: Quan SF. Guns and sleep. Southwest J Pulm Crit Care. 2015;11(2):68-9. doi: http://dx.doi.org/10.13175/swjpcc107-15 PDF

Is It Time for a National Tort Reform?

With the Supreme Court upholding the nationwide implementation of the ACA, the topic of tort reform adoption on a national scale has been in the limelight again.

Since the 1970s, the issue of national tort reform has had several reincarnations in the country’s different legislative bodies (1). The duration of the debates and discussions are largely dependent on the interest and influence of the two major stakeholders - the insurance companies and the physicians.

Currently, 38 states have implemented various versions of tort reform, mostly centered on the caps on noneconomic damages (2).

Groups advocating for national tort reform argue that having no limits on medical malpractice financial awards, has fueled the practice of ‘defensive medicine’. This leads to costly but ineffective medical interventions and higher insurance premiums. Both consequences are cited as major contributors to the country’s spiraling healthcare expenditure (1,2). Proponents also contend that the absence of tort reform negatively affects the size and composition of the physician workforce (3). Statistics show that states with damage caps have 12% more physicians per capita than those without (4).

On the other hand, those against national tort reform claim that caps on medical malpractice lawsuits would lead to more medical errors and negligent physician practices. They also cited the lack of supporting evidence of tort reform’s favorable effect on the reduction of healthcare spending (1).

Most studies on tort reform are related to healthcare spending and based on state-level enforcement. The data show that healthcare costs are only modestly affected by increases in malpractice premiums and litigation costs (3,5). The CBO estimated that if a national tort reform package was enacted, healthcare spending would be reduced by 0.5% (5). Baiker and Chandra (3), showed that state implementation of tort reform did not lead to physician shortages except for a minor reduction in some rural areas. The CBO (2009) reported that state tort reforms did not result in adverse patient health outcomes (2,5).

It is evident from these findings that there needs to be a comprehensive tort reform that does not solely focus on the cost and risk of malpractice litigation. Tort reform should be approached from a different perspective where the emphasis is on interventions that improve physicians’ efficiency, promote patient safety and reduce costs. Once studies consistently show the benefits of a multidimensional tort reform package adhering to nationally-accepted standards, then its nationwide implementation may be closer to becoming a reality.

Cielo Marie Maca, MD

Pulmonary, Critical Care and Sleep Medicine

Covering VA Medical Centers in VHA 23, VHA 16, VHA 18

References

1. Scott B. Who benefits from tort reform?. Medical Economics. Aug. 9, 2013. Available at: http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/alice-g-gosfield/who-benefits-tort-reform?page=full (Accessed July 9, 2015).
2. Congressional Budget Office. A CBO Paper: The effects of Tort reform: Evidence from the States. June 2004. Available at: http://www.cbo.gov/sites/default/files/report_2.pdf (Accessed July 9, 2015).
3. Baicker K, Chandra A. The effect of malpractice liability on the delivery of health care. Forum for Health Economics & Policy (Abstract) 2005;8(1). http://www.degruyter.com/view/j/fhep.2005.8.1/fhep.2005.8.1.1010/fhep.2005.8.1.1010.xml?format=INT DOI: 10.2202/1558-9544.1010 (Accessed July 10, 2015).
4. New Physician. Which States Have Tort Reform? http://www.newphysician.com/articles/tort_reform_list.html (accessed July 10, 2015).
5. Congressional Budget Office. Letter of the CBO to US Senator Orrin G. Hatch. Oct. 9, 2009. https://www.cbo.gov/sites/default/files/10-09-tort_reform.pdf (Accessed July 10, 2015).

Reference as: Maca CM. Is it time for a national tort reform? Southwest J Pulm Crit Care. 2015;11(1):45-6. doi: http://dx.doi.org/10.13175/swjpcc092-15 PDF

Time for the VA to Clean Up Its Act

One year after a Veterans Affairs (VA) scandal was ignited here in Phoenix, the number of veterans on wait lists is 50 percent higher than at the same time last year, according to VA data (1). The VA is also facing a nearly $3 billion budget shortfall. VA Secretary Bob McDonald has asked for “flexibility” to reallocate billions of dollars in clinical funds to cover the shortfall.

Since the scandal broke last year, VA providers have increased their workloads, adding 2.7 million more appointments than the previous year. However, the VA has played "games" with patient eligibility for years. When money was plentiful VA administrators would open the doors to patients since the following years' budgets were based on the number of patients seen. However, when money was tight, the doors would be slammed shut leaving many patients in the lurch scrambling to obtain health care elsewhere. Now it appears that patients might be returning to the VA.

“Something has to give,” the department’s deputy secretary, Sloan D. Gibson, said in an interview. “We can’t leave this as the status quo. We are not meeting the needs of veterans, and veterans are signaling that to us by coming in for additional care, and we can’t deliver it as timely as we want to.” Now the VA is asking Congress' permission to use clinical funds to pay for the budgetary shortfall.

The VA has threatened furloughs and hiring freezes to reduce spending. This seems to be quite sensible. However, in the past, the VA has cut clinical positions which undoubtedly contributed to longer wait times. For example, when I was chief of pulmonary at the Phoenix VA, one of my physicians retired, giving 6 month notice. However, we were not allowed to replace the physician because of a "hiring freeze". This apparently only applied to clinicians since a new associate director was hired.

As we predicted over a year ago, the VA would continue to be troubled due to lack of reform and oversight (2).  The present VA secretary, Robert McDonald, is still relatively new on the job and inexperienced in both healthcare and government service. His inaction suggests that he may be confused, or worse, listening to long-entrenched central office bureaucrats. Below are some suggestions which could result in substantial savings and would have little impact on patient care.

Furlough the staffs of the Veterans Integrated Service Networks (VISNs), the 21 VA regional offices which are scheduled to be downsized. The VISNs provide no healthcare and the savings in salaries from the nearly 5000 employees would be substantial (2). Similarly, VA central office which grew from 800 employees to 11,000 in less than 15 years could probably do with a few less administrators (3).

Local VA bureaucracies reflect the growth of central office and VISN bureaucracies. It is unclear what many of the hospital associate and assistant directors do other than sit in meetings. Most hospitals could do without them for a while. Similarly, compliance officers and patient "advocates" really serve no purpose. Despite multiple patient complaints about wait times, the lack of action that led to the VA scandal demonstrates that they are not effective. There are also some physicians and nurses who do not see patients. For example, most VA Chiefs of Staff do not see patients. Nursing administration is bloated with "clip board" nurses who do little than attend meetings and create an ever increasing, and seemingly never ending, stream of paperwork for nurses who are already overworked. Surely, we could do without some of these people. 

It seems unlikely that VA officials will implement any meaningful cost savings. Instead they will try to preserve the status quo by petitioning Congress to allow them to shift clinical funds depriving veterans of healthcare. That includes using funds from a new program that was a priority for congressional Republicans called the “Choice Card”. This program allows certain veterans to obtain taxpayer-funded care from private doctors. VA administrators have blamed the budget shortfall on this program along with a new treatment for hepatitis C (1). The VA has been accused of dragging its feet on the Choice program and once again appears to be trying to sabotage the program and keep the funds. Gibson said in the interview that in future years more money will also be needed. He said he intended to tell lawmakers, “Veterans are going to respond with increased demand, so get your checkbooks out.”

VA administrators appear more concerned with keeping money inside their dysfunctional agency than caring for vets. Based on past history, Congress will probably let the VA shift the money and none of the recommendations above will happen. If furloughs occur, they will be lower level employees and result in little financial saving. Of course, administrative bonuses will be hefty this year because in their eyes, the administrators have successfully averted a financial crisis. Unless there are some fundamental changes made at the VA, the trend of the last 20 years of bloating the bureaucracy at the expense of healthcare will continue.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Oppel, RA Jr. Wait lists grow as many more veterans seek care and funding falls far short. New York Times, June 20, 2015. Available at: http://www.nytimes.com/2015/06/21/us/wait-lists-grow-as-many-more-veterans-seek-care-and-funding-falls-far-short.html (accessed 6/24/15).
2. Robbins RA. VA administrators breathe a sigh of relief. Southwest J Pulm Crit Care. 2014;8(6):336-9. [CrossRef]
3. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med 2014;371:295-7. [CrossRef] [PubMed] 

Reference as: Robbins RA. Time for the VA to clean up its act. Southwest J Pulm Crit Care. 2015;10(6):350-1. doi: http://dx.doi.org/10.13175/swjpcc088-15 PDF

Eliminating Mistakes In Managing Coccidioidomycosis

Tim Kuberski MD, FIDSA

Maricopa Medical Center

Department of Internal Medicine,

Infectious Diseases

2501 East Roosevelt Street

Phoenix, Arizona 85008

This editorial is in response to the article "Common Mistakes in Managing Pulmonary Coccidioidomycosis" by Drs. Galgiani, Knox, Rundbaken and Siever (1).  These authors are eminently qualified to discuss the management of pulmonary coccidioidomycosis. However, these “mistakes” have been made for many years and, truth be known, the authors probably made some of those mistakes when faced with their first patient with a serious Coccidioides infection. What obviously is missing from these experts are solutions to keep the mistakes from happening. I would like to fill in the deficit by offering remedies for important issues raised by the article, and more.

Who am I to offer solutions? I am board-certified in Infectious Diseases (therefore, qualified). I went into private practice in Phoenix 35 years ago solely doing Infectious Disease consultations. As a consequence I am pretty sure I have seen more patients with coccidioidomycosis (I can spell it 4 c’s, 4 i’s and 4 o’s; abbreviated by me as “coccy” which avoids the often used contraction of “cocci” which applies to a completely different pathogen) than anyone in the world. I am not smarter, but there are 5 million people in Phoenix and they all get coccy - this qualifies me as experienced. In addition, I was Clinician of the Year for the Infectious Diseases Society of America (IDSA) in 2007 (validation as a clinician and not a kook). My perspectives have evolved as a problem-solving clinician in the coccidioidomycosis trenches. Early on I quickly came to the conclusion that the IDSA guidelines for the treatment of coccidioidomycosis were of value only to lawyers and administrators, more about that later. Let’s get started on solutions.

Number 1.  To get a license to practice medicine (all specialties) in Arizona you have to demonstrate proficiency in coccidioidomycosis. Before coming to Phoenix I spent some time defending my country in Hawaii and I had to get a medical license to practice medicine in Hawaii. At that time, Hawaii licensure required “proficiency” in leprosy. You were given a booklet on leprosy and then you were given the choice of watching a movie on leprosy or actually seeing patients with leprosy, I chose the latter. Then you had to pass a written test on the diagnosis of leprosy. It must have helped because that test is no longer required and there are no Hansen’s Disease patients on Molokai. Implementing a similar proficiency test for coccy licensure in Arizona might require legislation which should not be too difficult since most of the legislators have either had Valley Fever or heard about it. It would be one of the few things of educational value about getting a medical license to practice medicine in Arizona.

Number 2. Develop a reference laboratory solely for Coccidioides testing.  Even if you do everything right in managing coccy, one of the major impediments to the management of coccy is a lack of a rapid and accurate test for the disease. A not un-common scenario (i.e., “mistake”) is a primary care physician, recently moved to Arizona and trained elsewhere sees a patient on a Friday evening as an outpatient. The patient has a mild community-acquired pneumonia and has an occasional wheeze on examination. The patient gets oral doxycycline and a short course of steroids and told to schedule a follow up appointment in a week. A coccy serology is too frequently not ordered, but if it is done, the results will come back in a minimum of 4 days later and often still does not get back to the physician in a timely way. Follow up does not happen as the steroids made the patient feel better - for a while. The next time the physician finds out about the patient, the coccy has disseminated or a letter is received from a lawyer. The point is that serology for coccy is inaccurate too often and the turn-around time too long. Some of the smaller hospitals do not do coccy serology testing on a daily basis and/or on the weekend. That means patients with a fulminant pneumonia in the ICU do not get a serologic diagnosis until precious time has passed. The solution is a reference laboratory that does only coccy-related tests rapidly and accurately. In my experience, non-clinicians like laboratory directors and pathologists decided the fate of coccy serology. Over the years I have had meetings with every hospital in Phoenix (more than 10) about the status of their coccy testing generally without sustained success. These tests need to be taken out of the hands of hospitals and commercial laboratories. The vast majority of my complicated coccy patients have had their serology tests done by Dr. Demo Pappagianis at his coccy laboratory at the University of California at Davis. These patients were followed by serologies done at that laboratory for over 20 years with amazing consistency and accuracy, illustrating that it can be done. A good businessman with good technicians under the right circumstance should monopolize coccy testing to the benefit of the Arizona community.

Number 3. Arizona needs a coccidioidomycosis registry. Perhaps now that there is a medical school in Phoenix, an effort can be made to collect better clinical and epidemiologic data on cases to enable clinical trials on the treatment of coccy. I mentioned the IDSA guidelines for the treatment of coccidioidomycosis previously. Those guidelines are on the basis of expert opinion and not much validated science – there are no double-blind controlled studies on the treatment of any type of infection due to coccy. If you are a physician dealing with a patient with disseminated coccy and have no experience with the disease – those guidelines are of no substantial help. The IDSA guidelines should be abandoned and substituted with a good review on the treatment of coccy written by Dr. Galgiani and if you are still lost, call the Valley Fever Centers of Excellence for advice. Huge amounts of time and money are squandered on these guidelines.  A coccy registry – similar to a tumor registry, would provide the opportunity to do good clinical studies in Phoenix because of its population base.

Since coccy is a reportable disease in Arizona there should be an effort to establish more detailed information on patients hospitalized in Arizona. Most major hospitals have infection control nurses who are accustomed to data collection. I propose they fill out more detailed information on patients hospitalized with complicated coccy. The infection control nurses should be incentivized by compensating the infection control department for each report. There is much more information that could be collected (i.e., socio-economic impact) on the various forms of coccy. You get the picture. Since Arizona has the most reported cases of coccy in the Country we should be the leader in coccy and related issues.

Another interesting observation is that there are many more deaths in Arizona due to coccy than Ebola. Considering the amount of money given to Arizona devoted to Ebola, we need to develop a registry for Ebola and coccy, since we will never see a case of Ebola. In addition, when a coccy patient is entered into the registry a serum specimen should be collected and maintained at the reference laboratory for seroepidemiologic and other studies for emerging new tests and research.

Conclusions

The usual excuses for not implementing these suggestions are there is no money and/or time. However implementing these three recommendations would do more for coccy in Arizona and help resolve the “mistakes” made by its physicians than anything that has happened in the past 35 years. Money will always be an issue, but implementing mandatory proficiency in coccy should not be too difficult by absorbing it into the licensure process. A central coccy laboratory should be self-sufficient if run as a business. A coccy registry would need “orphan disease” status to get start up funds and should be maintained ideally by the new medical school in Phoenix and/or the Valley Fever Centers of Excellence. It will require experts like the authors, the Arizona legislature, Maricopa Medical Society and the new medical school to join forces to make Arizona a leader in all things coccy – except “mistakes”.

Reference

1. Galgiani JN, Knox K, Rundbaken C, Siever J. Common mistakes in managing pulmonary coccidioidomycosis. Southwest J Pulm Crit Care. 2015;10(5):538-49. [CrossRef] 

Reference as: Kuberski T. Eliminating mistakes in managing coccidioidomycosis. Southwest J Pulm Crit Care. 2015;10:250-2. doi: http://dx.doi.org/10.13175/swjpcc062-15 PDF