Healthy Policy

ED's and the uninsured

The percentage of uninsured patients visiting emergency departments is apparently in sync with the general population:

Most emergency department patients have health insurance and regular primary care physicians, according to a study published on Wednesday by the American College of Emergency Physicians, the Los Angeles Times reports.  For the study, researchers from the Robert Wood Johnson Foundation and the University of California-San Francisco surveyed 32,669 households in the U.S. in 2001. According to the study, respondents without health insurance accounted for about 15% of ED visits. In addition, the study finds that about 84% of respondents who visited EDs four or more times annually had health insurance and that 81% had access to primary care through a physician or a clinic. About half of respondents who visited EDs four or more times annually were enrolled in public health insurance programs such as Medicaid or Medicare, and one-third had private coverage, the study finds. The study estimates that about 45 million U.S. adults made a total of 80 million visits to EDs between July 2000 and June 2001. Some experts said that the study indicates an expansion of health insurance alone would not significantly help EDs address problems with overcrowding, which they said results in large part because patients cannot obtain appointments with their physicians or must wait for hospital beds (Yi, Los Angeles Times, 3/29).

As 15% of the population is uninsured, this makes sense.  What's more interesting here is the realization that 45 million adults made 80 million visits -- which means that several patients (the majority being insured) are visiting the ED too often.  I've been a patient in the ER maybe twice in my life; several of these patients are going almost twice a year (and others certainly more). 

But I think most ED docs could tell you that an expansion of insurance alone would be insufficient to fix our emergency problems.

190 subpoenas for pharma

Bad news for pharma:

The Federal Trade Commission on Wednesday announced that it plans to subpoena 190 drug companies in an investigation of possible anti-competitive practices in the pharmaceutical industry, the AP/Los Angeles Times reports. The subpoenas, which require approval from the Office of Management and Budget, would be part of a probe into whether pharmaceutical companies are suppressing competition by releasing authorized generic versions of their own brand-name drugs to coincide with the introduction of products from generic drug makers. Under federal law, after a generic pharmaceutical company successfully challenges a patent held by a brand-name manufacturer, it has six months of exclusivity to sell the drug in the generic market by itself. However, a loophole allows brand-name manufacturers to authorize their own generic versions, which increasingly are entering the market at the beginning of the six-month exclusivity period. Generic drug manufacturers depend on that exclusivity period to recover their costs and make a profit, but with authorized generics entering the generic market sooner, profit margins are falling for generic manufacturers.

If definitely appears that this is an industry-wide practice, given that such a large number of firms are receiving subpoenas.

And now for everyone's favorite subject!

Booze!

A new study on drinking Red Bull with alcohol finds that.....you're still just as drunk!  You just don't feel like it!

Well, duh.  Obviously if we'd discovered a substance that makes you sober up to the point that your BAC slips back below 0.08, it'd be all over the place.

Since I am party to this trend, a few observations:

• I kinda like the taste of Red Bull, so every once and awhile I'll get one for that reason

• I'll get Red Bull/vodka when I go out if I'm really tired (and don't tell me I should just stay home in that case -- that's just silly sensical thinking)

• No one I know drinks RB/V and believes this makes their BAC go down and therefore enables them to drive home.  Really, people, you'd have to be pretty stupid to believe that. 

• Also, RB/V is a very expensive mixed drink (usually $3 more than standard vodka tonic)

Why do you need a study when you've got me, huh?

Hat tip to Medpundit

Teddy bears cause autism

This is a great graphic from Grand Rounds:

Health disparities, revisted

Matthew Holt has an interesting editorial from Brian Smedley on the recent health disparities study:

This view, however, squarely contradicts what the vast majority of research studies have found for decades – that some patients, most notably African Americans, Latinos, those who don't speak English well, and in some cases, women – receive a lower quality of health care than their counterparts, even when they have similar health insurance and are treated for the same health conditions in the same hospitals. This applies across the gamut of health care, ranging from basic services such as screening and immunization, to primary care, to more expensive, high-tech, specialty procedures.

 

These are the conclusions of literally hundreds of studies published in peer-reviewed journals over the last two decades.  And while a few studies, such as the Asch study, find that disparities are diminishing or that all groups receive equal (albeit poor) treatment, their findings must be considered relative to the massive volume of evidence to the contrary. Even the U.S. Department of Health and Human Services' National Healthcare Disparities Report, released in January and which represents the most comprehensive survey of its kind, finds that, despite some areas of improvement, racial and ethnic healthcare disparities persist, and are worsening in some areas.   For example, the NHDR found that Latino patients with diabetes are receiving poorer quality care today than they were even a few years ago. 

Smedely doesn't discuss where the research disparity comes from, but clearly there's something to think about here.  Asch's study may very well be abberration, but the bottom line is that quality of care is poor, and everything else tells us it's even worse for the actual poor.   Also, remember again that Asch's study only looked at what happens after patients get to the hopsital -- it says nothing about those who can't afford care. 

psst...I have a life!

HPites,

Your fearless leader is heading to DC later today for job interviews and will be there the rest of the week.  She will attempt to continue providing the usual content, but will mostly likely fall short of doing so, so keep this in mind when you swing by and she's conspicuously absent. 

Thanks

La Grand Rounds

Seriously, it's that time again?  Apparently.

Grand Rounds is up at the NHS Blog Doctor

When care harms

This post about two cancer patients' last months of life, one through the medical system, one with no medical care, is worth a read.

Pecking at nothing

Apparently Medicaid is now requiring all nursing homes to return "left over" medications:

CMS has ordered state Medicaid programs to require nursing homes to return unused medications to pharmacies and to ensure Medicaid is repaid for unused treatments when nursing home patients die, are discharged or have their prescriptions changed, according to a March 22 letter, the Atlanta Journal-Constitution reports. In the letter, Dennis Smith, director of the Center for Medicaid and State Operations at CMS, also wrote that state Medicaid programs should limit the amount of medications provided to nursing homes at one time to "help to curtail prescription drug waste."

It's not that anything is particularly wrong with with this program, but honestly, this is how we're going to cut back on waste in health care?  By ordering nursing homes to return medications? 

How much money will this actually save anyways?  Particularly once you factor in the administrative costs of such a program. 

It's just such a backward way of controlling costs.  Random comparison: my home state of Kansas recently legalized concealed weapons.   Some advocates claim that concealed weapons actually make people safer because "criminals" will be less likely to draw guns or use force because the person they're trying to rob/kill might have a concealed weapon.   Well, I guess on some weird planet that logic makes sense.  But not compared to simply much tighter gun control laws to get guns out of people's hands, period. 

Reinhardt responds to Salgo

Everybody's favorite health care economist, Uwe Reinhardt, sent in a letter to the editor responding to Peter Salgo's New York Times Op-Ed "The Doctor Will See You for Exactly Seven Minutes".  Reinhardt takes issue with the blame game:

Dr. Salgo also says that "publicly traded H.M.O.'s, for example, began restricting doctors to an average seven-minute 'encounter' with each customer." I defy him, or any doctor, to produce a memorandum from an H.M.O. to that effect.

During the 1990's, H.M.O.'s did extract discounts from doctors. To keep their income at previous levels, doctors voluntarily shortened visits. The H.M.O.'s were not to blame.

Finally, the average length of hospital stays started declining in the mid-1980's, after Medicare began paying hospitals a flat fee for each admission. Hospitals found it profitable to voluntarily reduce the length of stays.

Another letter echoes part of these sentiments -- that it's not up to patients to enact change, but that doctors need to take more responsibility for the deterioration of the doctor-patient relationship, because they didn't do enough to stop changes in the first place.

UPDATE:  Roy Poses of Health Care Renewal offered some thoughtful comments:

With all due respect, Prof. Reinhardt is quibbling.
Clearly managed care (and Medicare) have periodically either cut reimbursement for office visits, or have failed to raise reimbursement to keep up with inflation. Also, they have imposed ever greater bureaucratic burdens on office practitioners that increase their overhead...See this article that shows that primary care physicians' charges (reflective of patient volume) have increased much faster than their compensation, which has failed to keep up with inflation:
http://www.ama-assn.org/amednews/site/free/bil10920.htm
For Reinhard to call physicians' responses to managed care and government practices "volunary" is sophistry.  Furthermore, I wonder if perhaps Prof Reinhardt's thinking is being influenced by his conflicts of interest?