PNHP

VA experience suggests that most readmissions may not be preventable

VA experience suggests that most readmissions may not be preventable

VA Experience Shows Patient ‘Rebound’ Hard To Counter

By Jordan Rau
Kaiser Health News, September 12, 2011

The Veterans Health Administration, the largest integrated health care system in the country, has long employed many of the approaches Medicare is pushing on all hospitals to cut unnecessary readmissions. But new data show VA hospital patients are just as likely to end up back in a hospital bed as are patients at private hospitals.

Studies have found the VA does better than most hospitals in following appropriate guidelines for the best care to give patients.

The new statistics underscore how hard it may be for hospitals to stop patients from rebounding back through their doors, a major goal of Medicare as it seeks to curtail the nation’s ballooning health costs.

http://www.kaiserhealthnews.org/Stories/2011/September/12/VA-readmissions.aspx

Obviously, when a patient is discharged from a hospital, every effort should be made to avoid slip-ups that might result in an unnecessary readmission soon after discharge. Yet many patients have serious, unstable conditions that can require readmissions that are unavoidable.

Differentiating avoidable from unavoidable readmissions can be very difficult. This report on VA hospital readmissions reveals that it may be nearly impossible, or that the numbers may be negligible. The VA already has in place guidelines and systems that should prevent unnecessary readmissions, yet their readmission rates are the same as private hospitals.

This brings into question the current efforts by Medicare to save costs by penalizing hospitals for readmitting patients. This policy could be particularly harmful if it resulted in the refusal to readmit patients who really needed to be back in (e.g., manage them in the emergency room and then send them back home).

Although quality improvement should be a continuing effort, this is simply another example of the totally inadequate cost containment measures of the Affordable Care Act – measures that only pretend that we are going to control costs. We need a massive overhaul of the financing system if we ever expect to bring costs under control – yes, a single payer national health program.

A decade later

Following is the Quote of the Day from September 12, 2001.

Editorial
The New York Times, September 12, 2001

“But this is an age when even revenge is complicated, when it is hard to match the desire for retribution with the need for certainty. We suffer from an act of war without any enemy nation with which to do battle. The same media that brought us the pictures of a collapsing World Trade Center shows us the civilians who live in the same places that terrorists may dwell, whose lives are just as ordinary and just as precious as the ones that we have lost.”

https://pnhp.org/news/2001/september/nyt-editorial

And now…

Editorial
The New York Times, September 10, 2011

“A decade later, we’re still trying to understand, looking back and looking ahead. It is not enough simply to remember and grieve.”

http://www.nytimes.com/2011/09/11/opinion/sunday/loss-and-hope.html

A decade later

Following is the Quote of the Day from September 12, 2001.

Editorial
The New York Times, September 12, 2001

“But this is an age when even revenge is complicated, when it is hard to match the desire for retribution with the need for certainty. We suffer from an act of war without any enemy nation with which to do battle. The same media that brought us the pictures of a collapsing World Trade Center shows us the civilians who live in the same places that terrorists may dwell, whose lives are just as ordinary and just as precious as the ones that we have lost.”

https://pnhp.org/news/2001/september/nyt-editorial

And now…

Editorial
The New York Times, September 10, 2011

“A decade later, we’re still trying to understand, looking back and looking ahead. It is not enough simply to remember and grieve.”

http://www.nytimes.com/2011/09/11/opinion/sunday/loss-and-hope.html

Study: Costs Keep Med Students From Much-Needed Mental Health Care

By Fran Cronin
WBUR CommonHealth blog, Sept. 7, 2011

Medical students are a challenged lot — sleep-deprived, stressed and driven. With the constant cramming of facts into their overloaded heads, and the constant need to steel themselves against the daily rounds of disease and injury, many medical students are left mentally and emotionally drained. Like their patients, they need a doctor. But many don’t reach out for help.

In a research letter just published in the Journal of the American Medical Association, Drs. Rachel Nardin and J. Wesley Boyd — both from the Harvard-affiliated Cambridge Health Alliance (CHA) — help illuminate the vulnerability of U.S. medical students to untreated and debilitating depression and substance abuse. These at-risk students tend not to seek the mental health services they need, the researchers found, due to the overwhelming cost of appropriate mental health services.

Schools and parents may be mandated to provide health insurance, but the study found that many of the plans offered did not provide affordable or adequate coverage for mental health and substance abuse treatment.

Data culled for this first-time survey of health insurance offered to U.S. medical students was collected from June through December 2010. The findings from 115 of the total 129 public and private medical schools in the U.S. revealed wide variability in annual dollar and visit limitations across the non-uniform plans.

For example, mental health dollar limits ran from $1000 – $200,000 for outpatient services; $800 – $200,000 for outpatient substance abuse treatment; and $1000 – $200,000 for inpatient mental health and substance abuse treatment.

Nardin said the survey also revealed that “Private medical schools are more likely than public schools to offer worse-than-average cost-sharing for outpatient substance abuse treatment. The worst region in the country, she said, was the Northeast.

Boyd, a faculty psychiatrist and an outspoken advocate for physician health, served for six years as associate director of the Physician Health Services, Inc., a nonprofit subsidiary of the Massachusetts Medical Society that provides confidential consultation and support to at-risk medical students and doctors across the state.

“Over the past two decades,” he said, “I have seen medical schools try to humanize the student’s experience and observed hospitals ratcheting up easier practices along with their awareness of physician health.” But the reality remains that medicine is very intense and stressful for those who are vulnerable to depression, anxiety, and substance abuse.

Troubled students often resist seeking treatment at the onset of their symptoms, fearing high out-of-pocket costs and an accumulation of more school debt. “But with any psychiatric disorder or substance abuse,” said Boyd, “early intervention definitely correlates to better outcomes.”

“There is a lack of sympathy for this fear of debt,” he said. “Most people just assume doctors will make a lot of money. But mounting debt from long stints at expensive schools weighs very heavily upon the students and most will do anything they can to avoid increasing it.”

According to statistics from the graduating medical school class of 2008, Nardin said, the median debt for public school students was $145,00 and for private school students it was $180,000.

To provide context for the cost of outpatient substance abuse treatment, I spoke with Talbott Recovery Campus, in Atlanta, Georgia, well known by Boyd and others for its Impaired Professionals Program. Debbie Kingston of the intake department told me: “The 90-day residential treatment program costs $39,000 for out-of network plans. If in-network, most insurance plans only cover $2000-$8000 of the total cost.”

Kingston added that detox, even though required, was not included in this tab. Depending on the addiction, detox can take from two to ten days. These costs also do not include the need for on-going monitoring and mental health support once a patient completes their residential stay.

In an article posted recently on Commonhealth, Rachel Zimmerman reported on a study, also authored by Boyd, that points to a more general obstacle to mental health care. The study’s hypothesis, which was borne out, posited that availability of psychiatric services has greatly diminished “due to a combination of paltry reimbursement rates and budget cutbacks.” The study’s authors wrote: “Reimbursements for psychiatric services are far lower than for other types of care, so institutions frequently restrict access as stringently as possible.”

Of the 64 medical facilities listed by Blue Cross and Blue Shield in the greater Boston area and contacted for the study, only four could offer an appointment within two weeks. Others refused to offer an appointment due to requirements that all patients be enrolled with a primary care doctor affiliated with that particular psychiatric facility. Study researcher Andy Lindenmeyer, a fourth- year resident in the Harvard Longwood psychiatric program, said, “I think the point here is that having health insurance does not equal access to care.”

Stephanie Woolhandler, a professor of public health at City University of New York and a visiting professor of medicine at CHA, summed up  the state of mental health care in a recent email: “The reality is that access to mental health care is very poor in this country, even for people with private insurance. Because mental illness is stigmatized, the mentally ill are often unable or unwilling to fight their insurance company to get their care reimbursed. The result is a very uneven distribution of care, with abundant mental health resources available to those who can pay out of pocket, while those that must rely on their insurance find that mental health care is restricted or even unavailable.”

“We need our medical schools to push themselves to provide students with more affordable care,” said Boyd. “What’s best for the health of our students will result in better physicians and the future well-being of their patients.”

A note of disclosure: Both Drs. Boyd and Nardin, authors of the survey letter published in JAMA, are active members of the group Physicians for a National Health Program, an organization of physicians who advocate for single-payer national health insurance.

http://commonhealth.wbur.org/2011/09/med-students-psych-care/

New health care jobs we don't need

Health Care Reform and the Health Care Workforce — The Massachusetts Experience

By Douglas O. Staiger, Ph.D., David I. Auerbach, Ph.D., and Peter I. Buerhaus, Ph.D., R.N.
The New England Journal of Medicine, September 7, 2011

In 2006, Massachusetts enacted legislation to provide universal health insurance coverage that later served as a model for the national health care reform legislation passed in 2010.

Since implementing these provisions, Massachusetts has achieved near-universal insurance coverage but has also seen continuing growth in health insurance premiums, a net increase in state spending on health care, and growing political pressures to control cost growth. Polls of the public and of physicians indicate that the state’s health care reforms are generally viewed favorably, though physicians are concerned about access to primary care and administrative burdens.

The Massachusetts reform experience has been watched closely for indications of what might occur throughout the country as national health care reform is implemented under the Accountable Care Act (ACA). One aspect of the Massachusetts experience that has remained unexplored is the impact on the health care workforce, particularly the question of whether greater numbers of health care professionals or support personnel were needed to ensure the success of the reform in increasing access to care.

Since Massachusetts enacted the Health Care Reform Plan in early 2006, total health care employment per capita in the state has grown more rapidly than that in the rest of the country.

Most of the divergence in employment growth between Massachusetts and the rest of the country occurred in 2006 and 2007, when the Massachusetts reforms were being phased in. Had health care employment in Massachusetts grown at the same rate as in the rest of the country, approximately 18,000 fewer people would have been employed in health care by 2010.

Most of the difference in health care employment growth occurred in administrative occupations. From 2005–2006 to 2008–2009, employment per capita in administrative occupations grew by 18.4% in Massachusetts, as compared with 8.0% in the rest of the country. These administrative occupations include management, business and financial operations, and office and administrative support (including medical records and health information technicians). In contrast, employment levels in nonadministrative positions in Massachusetts increased by 9.3% after health care reform, an increase similar to that of 8.6% in the rest of the United States.

The Massachusetts experience provides lessons for national health care reform. First, reform may accelerate the trend toward health care’s being the dominant employment sector in the economy. More important, our analysis supports physicians’ concerns about the administrative burden of health care reforms, an issue that will have to be addressed as the ACA is implemented. Finally, rather than requiring greater numbers of physicians and nurses, reform may require larger numbers of people supporting the work of such health care professionals.

http://healthpolicyandreform.nejm.org/?p=15255

Comment: 

By Don McCanne, MD

With today’s high unemployment rates, some have celebrated the fact that employment in the health care sector has continued to grow. This study confirms that health care employment in fact has grown within the state of Massachusetts, which has served as a model for our national reform through the Affordable Care Act. Should we be celebrating these newly generated jobs?

When the Massachusetts plan was proposed the policy experts at Physicians for a National Program warned that the additional administrative excesses would add to the already very heavy administrative burden that uniquely characterizes the U.S. health care system. PNHP issued the same warning when the Affordable Care Act was under development.

And what are these new jobs in Massachusetts? According to this report, “Most of the difference in health care employment growth occurred in administrative occupations.” More administration!

Although there is much interest in finding new employment opportunities for residents of the United States, there is also a compelling interest in controlling runaway health care costs. With a single payer system, one of the most important efficiency targets is to reduce this profound administrative waste. Instead, our legislators brought us changes that dramatically increase this waste!

We do need more jobs, but not more administrative jobs in a profoundly expensive health care system that is now almost sinking under the costly added burden of administrative excesses. There are far more important potential employment opportunities throughout society that would benefit all of us if Congress were to enact the type of jobs program that we need.

Instead of adding to our profound administrative waste, let’s use our health care dollars for, of all things, health care!

New health care jobs we don’t need

Health Care Reform and the Health Care Workforce — The Massachusetts Experience

By Douglas O. Staiger, Ph.D., David I. Auerbach, Ph.D., and Peter I. Buerhaus, Ph.D., R.N.
The New England Journal of Medicine, September 7, 2011

In 2006, Massachusetts enacted legislation to provide universal health insurance coverage that later served as a model for the national health care reform legislation passed in 2010.

Since implementing these provisions, Massachusetts has achieved near-universal insurance coverage but has also seen continuing growth in health insurance premiums, a net increase in state spending on health care, and growing political pressures to control cost growth. Polls of the public and of physicians indicate that the state’s health care reforms are generally viewed favorably, though physicians are concerned about access to primary care and administrative burdens.

The Massachusetts reform experience has been watched closely for indications of what might occur throughout the country as national health care reform is implemented under the Accountable Care Act (ACA). One aspect of the Massachusetts experience that has remained unexplored is the impact on the health care workforce, particularly the question of whether greater numbers of health care professionals or support personnel were needed to ensure the success of the reform in increasing access to care.

Since Massachusetts enacted the Health Care Reform Plan in early 2006, total health care employment per capita in the state has grown more rapidly than that in the rest of the country.

Most of the divergence in employment growth between Massachusetts and the rest of the country occurred in 2006 and 2007, when the Massachusetts reforms were being phased in. Had health care employment in Massachusetts grown at the same rate as in the rest of the country, approximately 18,000 fewer people would have been employed in health care by 2010.

Most of the difference in health care employment growth occurred in administrative occupations. From 2005–2006 to 2008–2009, employment per capita in administrative occupations grew by 18.4% in Massachusetts, as compared with 8.0% in the rest of the country. These administrative occupations include management, business and financial operations, and office and administrative support (including medical records and health information technicians). In contrast, employment levels in nonadministrative positions in Massachusetts increased by 9.3% after health care reform, an increase similar to that of 8.6% in the rest of the United States.

The Massachusetts experience provides lessons for national health care reform. First, reform may accelerate the trend toward health care’s being the dominant employment sector in the economy. More important, our analysis supports physicians’ concerns about the administrative burden of health care reforms, an issue that will have to be addressed as the ACA is implemented. Finally, rather than requiring greater numbers of physicians and nurses, reform may require larger numbers of people supporting the work of such health care professionals.

http://healthpolicyandreform.nejm.org/?p=15255

With today’s high unemployment rates, some have celebrated the fact that employment in the health care sector has continued to grow. This study confirms that health care employment in fact has grown within the state of Massachusetts, which has served as a model for our national reform through the Affordable Care Act. Should we be celebrating these newly generated jobs?

When the Massachusetts plan was proposed the policy experts at Physicians for a National Program warned that the additional administrative excesses would add to the already very heavy administrative burden that uniquely characterizes the U.S. health care system. PNHP issued the same warning when the Affordable Care Act was under development.

And what are these new jobs in Massachusetts? According to this report, “Most of the difference in health care employment growth occurred in administrative occupations.” More administration!

Although there is much interest in finding new employment opportunities for residents of the United States, there is also a compelling interest in controlling runaway health care costs. With a single payer system, one of the most important efficiency targets is to reduce this profound administrative waste. Instead, our legislators brought us changes that dramatically increase this waste!

We do need more jobs, but not more administrative jobs in a profoundly expensive health care system that is now almost sinking under the costly added burden of administrative excesses. There are far more important potential employment opportunities throughout society that would benefit all of us if Congress were to enact the type of jobs program that we need.

Instead of adding to our profound administrative waste, let’s use our health care dollars for, of all things, health care!

Blue Cross outsourcing shows need for single payer

By Rick Ford
Letters, The Palm Beach Post, Sept. 7, 2011

The excellent reporting by The Post’s Stacey Singer (“Blue Cross shifts business/cuts rates”) revealed that Blue Cross/Blue Shield of Florida has outsourced the management of its mental health network to an out-of-state company, which will ration the delivery of mental health care by hiring fewer doctors and therapists and paying these providers less.

This is probably only the first of many sub-specialties of medicine such as dermatology, ophthalmology, general surgery and podiatry in which health care and doctors will be rationed by Blue Cross via middleman corporations in order to assure profitability. There is no evidence that decreasing the number of doctors and therapists available or paying the remainder of Blue Cross health care doctors less will improve the quality of care. Despite this, Florida patients and businesses can be assured that their insurance premiums and out- of-pocket expenses to Blue Cross will not be reduced.

The future of health care does not involve hiring more for-profit middle-men corporations to ration quality health care at the expense of patients and small businesses.

Single-payer national health insurance based on Medicare would prevent this abuse of Florida’s patients and small businesses by multi-level for-profit health insurance companies by providing publicly financed, privately delivered health care for all Floridians at lower cost.

Editor’s note: Rick Ford is the president of Floridians for Health Care, which favors a single-payer system of health care insurance. He resides in Palm Beach Gardens, Fla.

http://www.palmbeachpost.com/opinion/letters/letters-paul-right-about-putting-an-end-to-1823863.html?printArticle=y

Uninsured figures due Tuesday; Single payer gets new wind

Sept. 8, 2011

Dear PNHP colleagues,

While the state of the U.S. economy understandably continues to dominate the news, the festering health care crisis is not far below the surface. And the compelling merits of single-payer health reform are bubbling up again in public discourse – including in newspaper editorials and in Congress.

What follows is a heads-up on an opportunity for adding your voice to this national discussion, a few highlights of recent media coverage of single payer, and news of two PNHP leaders’ upcoming appearances on Capitol Hill.

Register now for PNHP’s Annual Meeting in D.C.

We cordially invite you to attend PNHP’s Annual Meeting on Oct. 29 in Washington, D.C., to help us strategize about the next steps forward for the single-payer movement. Register today! You’re also invited to attend our popular Leadership Training Institute the day before. If you’d like to help sponsor a health-professional student’s attendance at the meeting, please donate to the Nicholas Skala Health Activist Scholarship Fund. If you’re a student, you can apply for a scholarship by filling out this form.

1. Next Tuesday, the U.S. Census Bureau will announce its findings on the number of uninsured persons in the United States in 2010. That figure – which is part of the bureau’s annual report on income, poverty and health insurance coverage – was 50.7 million in 2009, reflecting a record one-year increase of 4.3 million people.

Because of continuing job losses, companies dropping employee health insurance benefits, families going without coverage due to high costs, and the paring back of state Medicaid rolls, it’s likely the 2010 figure will be even higher.

Such predictions are always risky, of course. But one thing is certain: the problem of tens of millions of people who lack coverage will not go away anytime soon, even with the full implementation of the Affordable Care Act (assuming it survives legal challenge).

Nor will the pervasive problem of inadequate or shoddy coverage, what Dr. Don McCanne, senior health policy fellow at PNHP, calls the “new norm” of “unaffordable underinsurance,” go away until our nation adopts a single-payer system.

We urge you to be alert for the Census Bureau announcement and, when the new numbers are released, to write an opinion piece or a letter to the editor citing the those figures and making the case for single-payer national health insurance, an improved Medicare for all.

In addition, on Tuesday or Wednesday we’ll be releasing a PNHP statement on the Census Bureau report and providing a state-by-state breakout of the uninsured numbers – a state-specific figure that can serve as a news peg for your local media.

To help you in your efforts, we can offer a new, up-to-date PNHP fact sheet on the health care crisis and the case for an improved Medicare for all, along with some tips on how to write an op-ed or letter.

Please also consider calling your representative or senators in support of single-payer legislation like Rep. John Conyers’ H.R. 676 or Sen. Bernie Sanders’ S. 915, citing the latest figures.

2. A recent letter to The New York Times on single payer from Dr. Samuel Metz of Portland, Ore., provoked an extraordinary response.

Dr. Metz wrote in part: “Health care reform could provide better care at less cost by replacing individual mandates with a single-payer national health care plan financed by taxes. Congress’s power to mandate purchase of private products sold at a profit is disputable, but Congress’s power to tax is not.”

The Times decided to showcase the letter and made a special appeal for reader responses. The result, according to a reliable source, was about 500 letters in support of Dr. Metz’s letter, and only 2 that were opposed – one of which was anonymous! The Times ended up printing 8 “for,” 1 “against.”

3. In recent weeks, at least five newspapers – the St. Louis Post-Dispatch, the Cleveland Plain Dealer, the Kansas City Star, the Charleston (W.Va.) Gazette and the Cape Cod Times – have published editorials describing the merits (and undisputed constitutionality) of a single-payer plan, with several citing PNHP’s research. Columnists like John Nichols of The Nation and economist Robert Reich have also upped their writing about an-improved-Medicare-for-all approach.

4. As yet another sign of the growing interest in single payer, two PNHP leaders have been invited to speak on Capitol Hill next week. On Tuesday, I am scheduled to testify before a subcommittee of the Senate Health, Education, Labor and Pensions Committee on “poverty and health care access,” and on Wednesday, PNHP co-founder Dr. Steffie Woolhandler has been invited to meet with several members of Congress and to deliver a congressional staff briefing on “Single Payer 101 and Cost Control.”

5. Finally, we’d like to draw your attention to a new study in the Journal of the American Medical Association, JAMA, showing that medical schools offer subpar private health insurance coverage to their students for mental health and substance abuse treatment, thereby imperiling doctors-in-training and their future patients.

The authors, including PNHP board member Dr. Rachel Nardin and PNHP member Dr. J. Wesley Boyd, told reporters that their findings are yet another reason for adopting a single-payer system. The study was covered by Medscape, WBUR’s CommonHealth blog, The Chronicle of Higher Education and Inside Higher Ed.

Cordially,

Garrett Adams, M.D., M.P.H.
President

Downward mobility for the middle class

Downward Mobility from the Middle Class: Waking up from the American Dream

By Gregory Acs
The Pew Charitable Trusts, Economic Mobility Project, September 2011

The idea that children will grow up to be better off than their parents is a central component of the American Dream, and sustains American optimism. However, “Downward Mobility from the Middle Class: Waking up from the American Dream” finds that a middle-class upbringing does not guarantee the same status over the course of a lifetime. A third of Americans raised in the middle class — defined here as those between the 30th and 70th percentiles of the income distribution — fall out of the middle as adults.

http://www.pewtrusts.org/uploadedFiles/wwwpewtrustsorg/Reports/Economic_Mobility/Pew_PollProject_Final_SP.pdf

Comment: 

By Don McCanne, MD

Extensive studies have shown that over the past few decades income has dramatically shifted upwards to the wealthiest individuals. This study adds to that data base by showing the impact on the middle class. A third of Americans raised in the middle class have fallen out of the middle (and this was before the economic downturn).

Because health care costs are now so high the middle class can no longer afford to fund an insurance pool that would be adequate to cover their collective health care needs. If the middle class is to receive adequate health care then it is imperative for the wealthy to contribute a greater amount through a progressive financing system (i.e., taxes).

What won’t work is an underfunded welfare program for the poor (Medicaid) and exchanges of low actuarial value under-insurance plans for the middle class, yet this is what the Affordable Care Act is bringing us.

What will work is a single comprehensive risk pool that is equitably funded and includes everyone. If the wealthy were allowed to have a higher standard for themselves with a lower, mediocre standard for everyone else then their support for the health plans serving the “commoners” would diminish. By having a single high standard for everyone, the wealthy would use their influence to see that the health care system met their standards, thereby pulling up the standards for everyone else.

Of course, that is precisely the goal of an improved Medicare for all.

Downward mobility for the middle class

Downward Mobility from the Middle Class: Waking up from the American Dream

By Gregory Acs
The Pew Charitable Trusts, Economic Mobility Project, September 2011

The idea that children will grow up to be better off than their parents is a central component of the American Dream, and sustains American optimism. However, “Downward Mobility from the Middle Class: Waking up from the American Dream” finds that a middle-class upbringing does not guarantee the same status over the course of a lifetime. A third of Americans raised in the middle class — defined here as those between the 30th and 70th percentiles of the income distribution — fall out of the middle as adults.

http://www.pewtrusts.org/uploadedFiles/wwwpewtrustsorg/Reports/Economic_Mobility/Pew_PollProject_Final_SP.pdf

Extensive studies have shown that over the past few decades income has dramatically shifted upwards to the wealthiest individuals. This study adds to that data base by showing the impact on the middle class. A third of Americans raised in the middle class have fallen out of the middle (and this was before the economic downturn).

Because health care costs are now so high the middle class can no longer afford to fund an insurance pool that would be adequate to cover their collective health care needs. If the middle class is to receive adequate health care then it is imperative for the wealthy to contribute a greater amount through a progressive financing system (i.e., taxes).

What won’t work is an underfunded welfare program for the poor (Medicaid) and exchanges of low actuarial value under-insurance plans for the middle class, yet this is what the Affordable Care Act is bringing us.

What will work is a single comprehensive risk pool that is equitably funded and includes everyone. If the wealthy were allowed to have a higher standard for themselves with a lower, mediocre standard for everyone else then their support for the health plans serving the “commoners” would diminish. By having a single high standard for everyone, the wealthy would use their influence to see that the health care system met their standards, thereby pulling up the standards for everyone else.

Of course, that is precisely the goal of an improved Medicare for all.

Med Students' Own Mental Health Care

By Elizabeth Murphy
Inside Higher Ed, Sept. 7, 2011

A study published Tuesday paints a grim picture of America’s increasingly stressed medical students, in what researchers say they hope will be a “wake-up call” to the nation’s medical schools and health care policy makers.

The study, led by researchers at the Cambridge Health Alliance, a hospital system near Boston, includes data from 115 of the nation’s medical schools, looking specifically at what type of health insurance they offer to students with mental health and substance abuse problems.

“This is one small example of how the system is failing at-risk people,” said Rachel Nardin, chief of the neurology division at Cambridge Health Alliance and a co-author of the study, which was part of a special issue of the Journal of the American Medical Association on medical education. “The study is partly a wake-up call to look at the health insurance [the schools] offer. They are struggling in the face of a health care system that has unsustainable costs.”

Studies have shown medical students have higher rates of depression than their peers and are equally at risk for substance abuse issues, said Nardin, also an associate professor of neurology at Harvard.

The researchers looked at medical students’ annual maximum visit limits, co-pay amounts, dollar limits and co-insurance, which is the percentage of total costs paid by the patient. The study found that fewer than 22 percent of the medical schools provided mental health and substance abuse coverage without a cost-sharing requirement. What’s more, six of the 115 offered no coverage for in-patient mental health visits, substance abuse treatment or either.

“This is worrisome because of evidence that cost-sharing discourages students from seeking both [mental health treatment and substance abuse treatment],” the study says.

Researchers culled student insurance data from college websites and surveys. The study did not look at how many students use outside insurance or university-wide counseling services separate from the specific colleges. Those limitations were among several problems cited by medical school officials about the JAMA study.

The majority of medical schools are making a “valiant effort” to provide mental health coverage for their students that is affordable and cognizant of the societal stigma attached to such disorders, said Sam Parrish, associate dean of student affairs at Drexel University’s College of Medicine.

Parrish pointed to a 2009 survey conducted by the Association of American Medical Colleges, which indicated that 59 percent of schools reported that mental health services for students were available with no out-of-pocket costs associated. The survey did not separate out substance abuse care. Parrish, a member of the AAMC survey’s committee, said his college provides a psychologist and psychiatrist for its medical students at no cost. Communication between those professionals and their patients are kept confidential by several “firewalls” put in place by the college, he said.

This, however, does not fully address the issue of confidentiality, Nardin said. Some medical students fear that by seeking help for mental health or substance abuse issues, they will jeopardize future opportunities as doctors, especially if that help is from someone right in the college, she said.

Elizabeth Wiley, a fourth-year medical student at George Washington University, said access to services that entail seeing faculty members can be difficult for some medical students. At George Washington, the psychiatry faculty who oversee students in class are also oftentimes the doctors that treat students.

“The only option is to be seen by someone that will likely play a role in evaluating you,” Wiley, also a student member of the American Medical Student Association, said. “It creates a deterrent in seeking care.”

“My goal is not to demonize these schools that are struggling,” Nardin said. “Health care costs are just staggering for all types of institutions these days. Although it was bad, it’s not necessarily worse than private coverage in general. This is a particularly poignant example of this because we can see the consequence of this for these patients.”

At-risk medical students are an example of a larger systemic problem with a health care system that relies on a patchwork of private plans, Nardin said.

The real solution, Nardin believes, will not come from the schools themselves. It’s lawmakers on the national level who have to put in place more regulation to protect students, medical or otherwise.

Aaron Smith, co-founder and executive director of the health care advocacy group Young Invincibles, said the reality is that college health care plans vary widely.

Smith said it is a “weird contrast to have these medical students who are so passionate about helping others” be left in the lurch when it comes to mental health and substance abuse care from their schools.

“I think all schools, not just medical schools, should see this as an opportunity to provide decent health care for their students and improve it when it is not up to par,” he said.

But students can hopefully look forward to new proposed regulations for student health care, Smith said. Proposed federal regulations through the Department of Health and Human Services call for less cost-sharing, restrictions on benefits caps and free preventive care, among other policies. If approved, these regulations would tentatively take effect next academic year, Smith said.

Even so, Parrish said the mental health professionals at his school have been consistently busy for the 11 years he has held his position. If time is any marker, this is a problem that is unlikely to go away.

http://www.insidehighered.com/news/2011/09/07/study_finds_mental_health_care_coverage_for_medical_students_lacking

Single-payer works

Letter to the Editor
Helena (Mont.) Independent Record, September 5, 2011

The IR’s editorial of Aug. 28 suggests that the “state needs insurance competition, … giving Montanans … choice and competition for their health insurance dollars.”
I disagree. The notion that competition and choice between health plans will improve care or lower costs is a fantasy; it hasn’t worked for decades. Competing plans do little else than drive up administrative costs currently costing the public nearly one-third of every dollar spent on health care. Of the $6.2 billion Montana spent on health care in 2008, $1.922 billion went to administration, $1,980 per Montanan.

Health care reform could provide better care at less cost by replacing competing insurance companies with a single-payer health plan. An improved Medicare for All would reduce administrative costs leaving the state with enough funds to provide universal care. Vermont recently passed legislation to move in that direction and Montana would be wise to study this option.

Robert W. Putsch, MD, Canyon Creek
Member, Physicians for a National Health Program

Read more: http://helenair.com/news/opinion/readers_alley/single-payer-works/article_9f5cd6c8-d782-11e0-88e7-001cc4c03286.html#ixzz1XH8wmRyr