PNHP

Cherry picking? Lemon dropping? How health insurers weed out sick people.

Cherry picking? Lemon dropping? How health insurers weed out sick people.

By Brenda Gazzar
Code Wack Podcast, July 26, 2021

Featuring Dr. Stephen Kemble, psychiatrist, board member of Physicians for a National Health Program and member of One Payer States, discussing tricks health insurers use to increase profits – at our expense – and a common “Trojan horse” found in state single- payer legislation.

Transcript

Welcome to Code WACK!, your podcast on America’s broken healthcare system and how Medicare for All could help. I’m your host, Brenda Gazzar.

How do managed care groups cherry pick and lemon drop their patients? What are the insurance industry’s Trojan horses when it comes to single-payer healthcare proposals? To find out, we spoke to Dr. Stephen Kemble, who practices at a hospital-based primary clinic in Honolulu. Kemble is also past president of the Hawaii Psychiatric Medical Association and the Hawaii Medical Association.

(5-second stinger)

Welcome to Code WACK!, Dr. Kemble!

Kemble: Thank you.

Q: So you recently collaborated on a paper called “Beware of Insurance Industry ‘Trojan horses’ in ‘Single-Payer’ proposals.” What does this mean in layman’s terms?

Kemble: The Trojan horses are ways of organizing health care that turn a supposedly single-payer proposal into a multipayer proposal and sabotage it from achieving any administrative savings, and where this came from, in the single-payer movement, is mainly in California because they have a very large presence of Kaiser and Kaiser is, they get capitated money.  You know they’re paid per member, either through premiums from an employer or by the state, if they’re serving the Medicaid or Medicare population. They’re given money per person, and then they have to deliver care within that amount of money so they are the ones taking insurance risk. They then have an incentive to cherry pick and lemon drop. In other words, to hang on to healthy people and get rid of sick people.

So they try to select a healthier than average patient population in order to make ends meet financially. But when you’re in Kaiser, it works pretty well, and it’s popular, so they didn’t want to eliminate Kaiser… Because Kaiser is an integrated system that’s capitated, their proposal is to say, Okay, we’ll pay Kaiser by capitation because that’s what they’re used to, but then you can’t pay their hospital with a global budget because you’ve already paid for it through their capitation budget. You can’t duplicate the payments so you can’t do hospital budgeting if you use capitation payments.

So you have these single payer bills that instead of budgeting hospitals they budget these multi-hospital, physician hospital organizations like Kaiser, with a separate budget. Now, you have multiple risk-bearing entities competing with each other, trying to avoid sick people and capture healthy people and claim that healthy people are sicker than they are to beat risk adjustment formulas…So you can’t do risk adjustment effectively. So you have all of these problems that are reintroduced into the system that add administrative costs and complexity and prevent you from achieving and saving single payer should achieve.

Q: Uh-uh. Got it. And this sounds like it has an impact on patients who might be denied care. Is that right?

Kemble: Yes, I mean one way a risk-bearing entity like an insurance company weeds out sick people by restricting their formulary and not offering the drugs needed for expensive conditions. So if you have those conditions you get hassled every time you fill your prescription so you quit that plan and go to whatever the public like traditional Medicare that has fewer restrictions or you switch to a different Medicaid Managed Care plan hoping that you’ll do better there but all of them are playing the same game because, you know, it’s musical chairs. Who wants to be stuck with the sick people? They keep trying to find a ways to make it difficult for them, and the result is obstruction and denial of care.

Q: Got it. So why should average people care about this?

Kemble: These things, they directly affect someone who’s got say Medicaid and a serious health condition that’s expensive but they drive up costs for everyone because the cost of these things is spread across the whole population. So all of this makes for a far more expensive healthcare system. Our multi-payer,  multiple gaps healthcare system costs twice as much as the average of other industrialized countries, and leaves a large percent of the population out, and it’s getting worse all the time and not better, and until we wake up and stop trying to have the system of competing insurance companies… financing healthcare, we’re not going to solve the problem.

You cannot solve it without taking on the whole insurance business model,  which is inappropriate to health care. You know if you have a risk like your house burning down which is presumably infrequent and unpredictable, then you might charge them more if they live in a forest than you would if they live in a city because you can see that’s higher risk, but you’re pretty much spreading it across a whole bunch of people because the risk is unpredictable. In health care, the risk is largely predictable. There’s too many people with preexisting conditions where you know it’s going to be expensive so the whole idea of using the insurance system falls apart because all you’re doing is trying to avoid sick people, which defeats the whole purpose of insurance.

Q: I see. How else do these organizations cherry pick patients? How are they allowed to do that?

Kemble: Well, they market to healthy people. I don’t know about California but in Hawaii Kaiser ads are all about “thrive” and people jogging and they offer fitness clubs as bonuses. If you’ve got a chronic heart condition or dementia or renal failure, that’s not going to appeal to you but if you’re healthy, it will so they market to healthy people, they have restricted formularies that are stacked against people with expensive conditions. They have more prior authorizations for people with complex problems. That’s how they do it, and they’re very good at it. I mean there’s studies that have shown there are big differences in the risk pool for Medicare Advantage Plans compared to traditional Medicare. The Medicare Advantage Plans collect healthy people and push out sick people and there’s lots of evidence that that’s the case. That’s actually happening.

(5-second stinger)

Thank you Dr. Stephen Kemble.

Learn more about One Payer States at OnePayerStates.org and Physicians for a National Health Program at PNHP.org.

Find more Code WACK! episodes on ProgressiveVoices.com and on the PV App. You can also subscribe to Code WACK! wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for health care reform around the country.

https://heal-ca.org…

Happy Birthday, Medicare: You Showed That Public, Universal Health Insurance Is Superior

We must immediately end our moral crime of having the greatest health system in the world, but only for those who can afford it.

By F. Douglas Stephenson
Common Dreams,

Fifty-six years ago Congress enacted Medicare to provide health insurance for people ages 65 and older and the disabled regardless of income or medical history. Since 1965, Medicare has become living proof that public, universal health insurance is superior to private insurance in every way. Medicare is more efficient than private health insurance and is administered at a cost of 3% to 4%, as opposed to private, for-profit health insurance, which has administrative costs above 15%. In light of the burgeoning, severe losses of jobs/employment/health insurances caused by the ravages of the Covid-19 pandemic, it’s very Important to remember that Medicare is still providing stable coverage for everyone 65 and older. If the new and improved Medicare for All, as outlined below, were in place today, everyone’s health insurance, in spite of the Covid-19 pandemic, would continue uninterrupted because the Medicare for All insurance system is based on residence, not employment.

2021 is also a very special year in the history of single-payer health insurance and public health in the U.S. because Reps. Pramila Jayapal (D-Wash.) and Debbie Dingell (D-Mich.) introduced the modern Medicare for All Act of 2021 (H.R. 1976) in Congress. M4A 2021 is new legislation establishing a cutting edge single-payer national health program in the United States that addresses decades of health/mental health-related injustices that have been made even more painfully apparent by the Covid-19 pandemic.

Medicare for All Means Everybody In, Nobody Out!

H.R. 1976 upgrades Medicare with a 21st century modern and improved “Medicare for All” health insurance system that covers all age groups, cradle to grave. Newborns will leave the hospital with their new Medicare card, and drop it off years later at life’s end. Benefits of H.R. 1976 health insurance include the following new items and services if medically necessary or appropriate for the maintenance of health or for the diagnosis, treatment, or rehabilitation of a health condition:

  1. Hospital services, including inpatient and outpatient hospital care, including 24-hour-a-day emergency services and inpatient prescription drugs;
  2. Ambulatory patient services;
  3. Primary and preventive services, including chronic disease management;
  4. Prescription drugs and medical devices, including outpatient prescription drugs, medical devices, and biological products;
  5. Mental health and substance use treatment services, including inpatient care;
  6. Laboratory and diagnostic services;
  7. Comprehensive reproductive, maternity, and newborn care;
  8. Dentistry/oral health, audiology, and vision/ophthalmology services;
  9. Rehabilitative and habilitative services and devices;
  10. Emergency services and transportation;
  11. Early and periodic screening, diagnostic, and treatment services;
  12. Necessary transportation to receive health care services for persons with disabilities, older individuals with functional limitations, or low-income individuals (as determined by the secretary);
  13. Hospice care; and
  14. Services provided by a licensed marriage and family therapist or a licensed mental health counselor. (In addition to psychiatrists, licensed clinical psychologists, licensed clinical social workers, psychiatric nurses.)

Co-payments and deductibles paid at health professionals’ offices are ended because payment for health insurance is fully prepaid directly into Medicare, just like pre-payment into Social Security, and covered at first dollar amounts. This means the obsolete 80%/20% payment split between private health insurance companies and Medicare is eliminated, with Medicare for All 2021 covering 100%.

All residents are guaranteed access to quality healthcare while achieving significant overall savings compared to our existing Medicare system by lowering administrative costs, controlling the prices of prescription drugs and fees for physicians and other health-/mental healthcare professionals and hospitals, reducing unnecessary treatments, and expanding preventive care.

Good healthcare is established as a basic human right, as in almost all other advanced countries. Nobody would have to forego needed treatments because they didn’t have insurance or they couldn’t afford high insurance premiums and co-pays. Nobody would have to fear a financial disaster because they faced a healthcare crisis in their family. Virtually all families would end up financially better off and most businesses would also experience cost savings compared to what they pay now to cover their employees. Health insurance is based on residence, not employment.

With M4A, citizens are guaranteed access to healthcare while achieving significant overall savings compared to our existing obsolete system. This is accomplished by lowering administrative and eliminating profiteering Big Insurance costs, controlling Big Pharma prices of prescription drugs, fees for physicians, and other healthcare professionals and hospitals, reducing unnecessary treatments and expanding preventative care.

Co-payments and deductibles paid at health professionals’ offices are ended because payment for health insurance is fully prepaid directly into Medicare, just like pre-payment into Social Security, and covered at first dollar amounts. This means the obsolete 80%/20% payment split between private health insurance companies and Medicare is eliminated, with Medicare for All 2021 covering 100%.

We finance our new and improved Medicare for All system by eliminating profiteering by the private health insurance industry and slashing the system-wide administrative waste they generate, with a single streamlined, nonprofit public payer health insurance system. Such savings, estimated in 2017 to be about $500 billion annually, would be redirected to patient care.

More than two dozen independent analyses of federal and state single-payer legislation by agencies such as the Congressional Budget Office, the General Accountability Office, the Lewin Group, and Mathematica Policy Research Group have found that the administrative savings and other efficiencies of a single-payer program would provide more than enough resources to provide first-dollar coverage to everyone in the country with no increase in overall U.S. health spending.

According to a 2016 study in the American Journal of Public Health, tax-funded expenditures already account for about two-thirds of U.S. health spending. That revenue would be retained and supplemented by modest progressive taxes based on ability to pay, taxes that would typically be fully offset by ending today’s very high premiums paid to the for-profit private insurance industry and out-of-pocket expenses for care. The vast majority of U.S. households—one study says 95%—would come out financially ahead. The system would reap savings by dealing with drug and medical supply companies for lower prices.

M4A is a solid investment in our country because it promotes a social service for universal access to affordable health insurance for everyone. The USA is a country where health insurance for medical and mental healthcare is a function of socio-economic status. Everyone knows that this inhumane system should have been corrected long ago, but the death and illness ravages of the pandemic crisis makes it impossible to any longer avoid reality. We must immediately end our moral crime of having the greatest health system in the world, but only for those who can afford it.

When Medicare was enacted 56 years ago, following a broad grassroots campaign, many believed the dream of a full national health insurance system was right around the corner. Five decades later, Medicare still has not been expanded. Most of the changes have been contractions with higher out-of-pocket costs for beneficiaries and repeated attempts at privatization by Big Pharma, the health insurance industry, and its champions in the White House and Congress.

It’s time to end inadequate and dangerous health insurance programs. Insist on real health insurance reform essential for individuals and families. American history is filled with examples of fundamental, democratic change brought about by successful mass action and public pressure against the counseling of the go slow, vested interest crowd. No more waiting! Ask your legislators to fully support Medicare For All. A majority of Americans support Medicare and want expansion of this program to provide health insurance for all. Write to your senators and representatives and let them know how you feel about expanding Medicare. The very best way to cope with the vast dangers of Covid-19 to everyone is to immediately implement improved Medicare for All 2021 with H.R.1976. By making health insurance available to all age groups, we can enjoy and celebrate Medicare’s 56th birthday with the assurance that this life-saving health insurance program will continue.

F. Douglas Stephenson , LCSW, is a retired psychotherapist and former instructor of social work in the University of Florida Department of Psychiatry. He is a member of Physicians for a National Health Program.

https://www.commondreams.org…

Over 100 people march in support of Medicare for All downtown

To view full video from the rally at Chicago’s Federal Plaza, click HERE (video queued to start with Dr. Pam Gronemeyer’s remarks at 33:40).

By Jenna Barnes
WGN-TV,

CHICAGO — More than 100 people marched from Maggie Daley Park to the Federal Plaza to draw attention to their fight for Medicare for All.

“John Lewis said if you see something is not right, not fair and not just, you have a moral obligation to do something about it,” registered nurse Martese Chism said.

The rally was part of rallies in more than 50 other cities across the United States in support for a single-payer health care system.

“Are we so star-spangled awesome that we can’t figure this out and everybody else can?” protester Tim Lively said.

Advocates for Medicare for All are calling for zero copays, zero deductibles, full dental and vision coverage and no out-of-network restrictions.

“If you get injured outside of your predetermined health care network, you have to pay for it all. Where’s the freedom in that?” Lively said.

A Gallup poll earlier this year found that one in five Americans are unable to afford the care they need. A Pew Research Study last year found that 63 percent of American adults said the government has a responsibility to provide health care coverage for all, something proponents said we’ve seen glimpses of during the COVID-19 pandemic.

“You show them your ID, you get your vaccine, you’re done. That’s the universal health care they always say can’t work here, but it did work here,” Cook County Green Party member Troy Hernandez said.

Critics of the proposal say the federal government can’t afford it, requiring a tax hike and eliminating all private insurance.

For protester Georgette Druck though, that doesn’t compare at all to what Americans are missing out on in health coverage.

“I think we can be number one. We used to be number one in everything in America, I don’t see how we can’t be number one in health care outcomes too,” Druck said.

https://wgntv.com…

Dr. Steve Auerbach rallies in NYC

PNHP New York Metro board member Dr. Steve Auerbach addressed a Medicare-for-All rally in New York City on July 24, 2021, alongside members of Students for a National Health Program (SNaHP). He reminded the crowd, “There is no policy debate anymore. There is no economic debate anymore. Single payer is the way to go.”

Video courtesy of Larry Melnicker.

Demonstrators in Louisville join nationwide ‘Medicare for All March’

By Michael Cadigan
Spectrum News, July 24, 2021

LOUISVILLE, Ky. — Dozens of people took to the streets of Louisville and marched demanding better access to Medicare. Louisville joined 55 other cities across the country in a march for Medicare for All.

Kay Tillow helped organize Saturday’s rally and said she felt very passionately about the cause.

“All of us know that we are one serious illness away from bankruptcy because we have a system where people pay too much and are not covered and people go without care because of deductibles and copays,” said Tillow, the chair for Kentuckians for Single Payer Healthcare.

Tillow joined others in calling health care a human right and demanding that Congress take action to pass a national single payer improved Medicare for All plan.

Bob Brown said he felt the need to attend the march because he recently turned 65 and understands the benefits a single payer pan can provide.

“The single payer plan has been wonderful. I have been lucky and have had insurance all my life through my occupations. This plan, as a retired man, is as good or better than any insurance I’ve ever had,” he said.

Dr. Garrett Adams, who has worked at the UofL School of Medicine, said there are many Kentuckians who are just a year or two away from hitting the key age of 65, who have limited finances and often put off seeking care until they qualify.

“People that are 63, or 63 and a half, or 64 can’t wait because they are working on hurt knees that they can’t do anything about. They can’t afford their medicine. They need advanced treatment for their congestive heart failure and they can’t wait for their 65th birthday so they can go on Medicare,” Dr. Adams said.

Tillow said the nationwide movement also calls for improvements to cover vision, hearing, dental, and long-term care. Demonstrators also want some barriers removed like copays, deductibles and forms they described as confusing. Tillow will continue to work organizing these events until lawmakers take action.

“It is going to take a few million people in action to persuade Congress that this is the right thing to do. But, we have to make it happen and we won’t stop until we have everyone covered under single payer,” said Tillow.

21 organizations participated in the Louisville Rally and March. They marched a half mile from the Romano L Mazzoli Federal Building to Jefferson Square Park to place flowers at the Breonna Taylor memorial.

https://spectrumnews1.com…

Dr. Garrett Adams and Kay Tillow on Spectrum News

PNHP part president Dr. Garrett Adams and PNHP board adviser Kay Tillow spoke with Spectrum News on July 24, 2021. They discussed the urgent need for single-payer reform as part of a segment covering a Louisville, Ky. march for Medicare for All; the Louisville action was part of a series of nationwide marches taking place that same day.

Dr. Pam Gronemeyer on Hard Lens Media

PNHP-IL Co-President (for Southern Illinois) Dr. Pamella Gronemeyer addressed a Medicare-for-All rally in Chicago on July 24, 2021. The rally was part of a series of nationwide marches taking place that same day, and was covered in Chicago by Hard Lens Media, WGN-TV, and others. Dr. Gronemeyer assured the crowd that physicians support, and that patients urgently need, single-payer reform.

UnitedHealth profits by not paying for care & the business case for single payer

UnitedHealth Group Earnings: What They Suggest about Patient Access to Care, American Hospital Association, July 15, 2021, by Rick Pollack, AHA President and CEO

Today UnitedHealth Group announced a jaw-dropping $6 billion in earnings in a single quarter. But not enough has been said about a big contributor to these profits: not paying for health care services. During the same quarter last year the company noted its $9.2 billion in profit was due in part to “broad-based deferral of care.” What that means in real-life: profit was earned off missed childhood vaccinations, reduced access to opioid misuse treatment and avoided emergency care for cardiac arrest. But even this isn’t the full story.

Throughout the course of the pandemic, United pursued a number of changes to its policies to further restrict patients’ coverage. United didn’t just profit from avoided care, it actively sought to scale back what care it would pay for at the same time.

  • Specialty Pharmacy Services: In many parts of the country, United has been rolling out coverage restrictions that no longer permit patients to access specialty pharmacy therapies in a hospital outpatient department even if that is where their doctors practice.
  • Surgeries: United will no longer cover a large number of surgical procedures performed in hospital outpatient departments.
  • Lab and Radiology Services: United has announced plans to restrict coverage for many lab and radiology services provided by hospitals and outpatient departments.
  • Primary Care and Specialty Services:  United, the nation’s largest employer of physicians, says it will begin restricting coverage for most physician evaluation and management services provided in hospital outpatient departments, including provider-based clinics.

United routinely rolls out these coverage restrictions throughout the year, meaning that enrollees purchase their health plans under one set of rules only to later learn that their providers and cost-sharing responsibilities have changed.

Our top private health insurer is rolling in cash. And it’s reducing coverage, Los Angeles Times, July 20, 2021, by David Lazarus, Business Correspondent

UnitedHealth Group, parent of UnitedHealthcare, the country’s largest private health insurer, earned $15.4 billion in profit last year. It took in more than $9 billion in profit during the first half of this year.

So what does a well-heeled insurer do amid such a windfall? It seeks to reduce people’s coverage, of course. …

The insurer won’t cover nonemergency treatment at non-network facilities outside a policyholder’s service area, which is defined as your state of residence and adjoining states.

This change mainly affects UnitedHealthcare members who want to travel to residential treatment facilities, rehabilitation clinics and other nonhospital healthcare providers.

Which is to say, if you’re a UnitedHealthcare member and you need rehab for any reason, you’d better stay in network and you’d better stick close to home. Otherwise, you’ll be footing the bill yourself. …

Coverage networks might save insurers a few bucks, but they’re not in the best interest of patients, who should be free to seek the best possible care from the best-qualified doctor or hospital.

Nor, for that matter, should people’s coverage be tethered to their jobs. Lose your job, lose your health insurance — what the hell kind of system is that?

We know from the experience of other developed countries that [insurance risk management] is done most effectively by creating a single risk pool comprising the entire population, and then having a single government program handle all claims consistently, fairly and transparently.

Studies have shown that the taxes paid into such a single-payer system — Medicare for all, say — would be less than the premiums, copays and deductibles that now constitute most out-of-pocket medical expenses for Americans.

Comment:

By Don McCanne, M.D.

UnitedHealth Group has demonstrated that it has mastered its ability to increase profits by not paying for health care services. They are serving their corporate shareholders at a cost to their customers, aka patients.

Contrast this private insurer function to what the role of a publicly financed and publicly administered insurer would be. Passive insurer shareholders and profits would play no role. The goal would be to pay for necessary health care services, not avoid them.

Even David Lazarus – the Business Correspondent for the LA Times – sees what UnitedHealth Group does and in response sings the praises of single payer.

Based on Rick Pollack’s comments, the American Hospital Association should be a valuable team member in our efforts to achieve health care justice for all.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

The Affordable Care Act (ACA) had limited effects in reducing uninsurance for Black, Hispanic and low-income Americans in many states: Harvard researchers

Large variation in state-to-state performance in covering uninsured minority and low-income populations tied to states’ decisions about ACA implementation

FOR IMMEDIATE RELEASE: July 21, 2021

Contact: Gregory Lines, M.D., M.P.H., glines@challiance.org
Danny McCormick, M.D., M.P.H., dmccormick@challiance.org
David Cecere, Senior Director of Corporate Communications, Cambridge Health Alliance, dcecere@challiance.org

Gains in health insurance coverage under the Affordable Care Act (ACA) were small for Black, Hispanic and low-income Americans in many states according to a new study from Harvard Medical School. The study, published today in the journal Health Equity found dramatic variation in states’ performance in expanding insurance coverage to these populations that have historically had low coverage rates.

Using state-level survey data from over 500,000 working age Black, Hispanic and low-income adults, the researchers compared insurance coverage rates in each US state prior to and after implementation of the ACA in 2014. The study also examined the size of the remaining uninsured Black, Hispanic and low-income populations in each state following the ACA.

The study found that while the best performing states were able to reduce rates of uninsurance among black, Hispanic and low-income adults by approximately 60%, the worst performing states reduced uninsurance by less than 10%, a six-fold difference. In addition, states’ performance in reducing uninsurance in these populations was strongly correlated with states’ choices about how to implement the ACA. States that did not invest in public education about the ACA, provide assistance to residents to sign up for ACA or participate in the ACA’s optional Medicaid expansion were much more likely to perform poorly.

While previous studies demonstrate that the ACA substantially increased coverage and reduced racial and ethnic disparities in coverage in the United States, the authors say the study data sheds new light on the extreme variation in state level performance in expanding coverage to populations most in need. “Our study shows just how little progress was made for people of color and low-income Americans in some states under the ACA,” said one of the study’s lead authors, Dr. Gregory Lines, an internal medicine physician at Cambridge Health Alliance and instructor in medicine at Harvard Medical School. “And, it is clear that this poor performance stems from political leaders’ decision to undermine full implementation of the ACA. More comprehensive health care reforms that do not rely as heavily on the whims of individual states are clearly needed–it is a matter of racial and economic equity.”

The study also found that, 2 years after ACA implementation, in six states one quarter of Black adults remained without insurance coverage; and in 20 states, one quarter of low-income adults continued to lack coverage. In addition, in 13 states, over 40% of Hispanic adults lacked coverage following ACA implementation. In several states, the results were most dramatic. For example, after the ACA, 28.7% of Black Americans remained uninsured in North Dakota as did 61.8% of Hispanics in North Carolina and 45.3% of low-income adults in Texas.

The study authors believe that the high rates of uninsurance in many states after the ACA are having negative health consequences currently. “The poor performance of many states under the ACA essentially locked in the high levels of uninsurance that those states entered the COVID-19 pandemic with,” said the study’s senior author, Dr. Danny McCormick, an associate professor of medicine at Harvard Medical School and a primary care physician at the Cambridge Health Alliance. “COVID-19 took a large toll on people of color and the poor, and these populations are larger in poor performing states. This has likely translated into greater difficulty accessing COVID-19 care and worse health outcomes for these populations at highest risk.”

“States’ performance in reducing uninsurance among Black, Hispanic and Low-income Americans following implementation of the Affordable Care Act,” Gregory Lines, M.D., M.P.H.; Kira Mengistu, M.D.; Megan Rose Carr LaPorte, M.D., M.P.H.; Deborah Lee, M.D.; Lynn Anderson, M.D.; Daniel Novinson, M.D., M.P.H.; Erica Dwyer, M.D., Ph.D.; Sonja Grigg, M.D.; Hugo Torres, M.D., M.P.H.; Gaurab Basu, M.D., M.P.H.; and Danny McCormick, M.D., M.P.H. Health Equity. Published online first, July 21, 2021, 3PM ET.

Minorities Less Likely to Receive Specialist Care

By Linda Carroll
Medscape, July 21, 2021

(Reuters Health) – People of color are less likely than white patients to receive care from surgical specialists, medical specialists and pulmonary specialists, a new U.S. study suggests.

Analysis of nationally-representative data on more than 130,000 U.S. adults found that adjusted rate ratios (ARR) of visits to 29 different types of specialist were often lower among Black, Hispanic, Asian/Pacific and Native American patients compared to white individuals, according to the report published in JAMA Internal Medicine.

“If you take a step back, we already know that people of color in the U.S. have a lower life expectancy than white individuals,” said the study’s lead author, Dr. Christopher Cai, a resident physician at Brigham and Women’s Hospital and the Harvard Medical School in Boston.

One factor may be that, despite a greater need among people of color in some areas for specialty care, doctors are granting more appointments to white individuals, Dr. Cai said. “The primary cause appears to be inequities in insurance,” he added. “The bottom line is that we need to remove barriers to accessing health care.”

One statistic that suggests disparities in health insurance may play a big role is the fact that one of the few areas in which people of color get similar access to specialists is nephrology.

“The unique thing about kidney disease,” Dr. Cai said, “is that Medicare offers coverage for end-stage disease. An approach like Medicare for All would go a long way to reducing these disparities.”

To take a closer look at the use of specialty services by race and ethnicity, the researchers turned to data from 2015 to 2018 Medical Expenditure Panel Survey (MEPS), which collects demographic (including self-reported race/ethnicity) and health care utilization data from a nationally representative sample of the noninstitutionalized, civilian U.S. population. Focusing on adults 18 years or older, Dr. Cai and his colleagues tabulated office and outpatient department visits to each physician specialty by each racial/ethnic minority group compared with the white population and adjusted for age.

The researchers included 132,423 individuals in their analysis. They found that Black individuals had low visit rates compared with white individuals to most specialties (23 of 29 versus 17 of 29 specialties). Among specialties with many visits, the Black versus white disparities were especially marked in dermatology (ARR 0.27), otolaryngology (ARR 0.38), plastic surgery (ARR 0.41), general surgery (ARR 0.55), orthopedics (ARR 0.59), urology (ARR 0.62), and pulmonology (ARR 0.63).

Black individuals had higher visit rates to nephrologists (ARR 2.78) and hematologists (ARR 1.65) and similar visit rates to internists, geriatricians, and oncologists.

The visit ratios for Hispanic and Asian/Pacific Islander individuals compared with white individuals were lower than 1.0 for 26 of 29 (89.7%) and 26 of 27 specialties (96.3%), respectively, and significantly lower for 20 of 29 (69.0%) and 21 of 27 specialties (74.1%). Similar patterns were seen for American Indian and Alaska Native individuals, although the 95% confidence intervals were wide.

The disparity among Hispanic versus white individuals was marked for dermatology (ARR 0.39), otolaryngology (ARR 0.47), and pulmonology (ARR 0.55). For Asian/Pacific Islander versus white individuals, ratios were markedly low for hematology (ARR 0.18), pulmonology (ARR 0.26), and otolaryngology (ARR 0.39).

“This study gives us a very detailed view into racial and ethnic disparities in the use of specialty care, which is an incredibly important metric of health care access given the rising proportion of U.S. adults with chronic conditions and multiple comorbidities,” said Jamie Daw, an assistant professor of health policy and management at the Columbia University Mailman School of Public Health in New York City. “The findings are even more troubling given that people of color have higher rates of chronic conditions such as diabetes, stroke, and heart disease, which require specialist care. Yet, the authors find that communities of color are using these services less than white patients.”

Daw believes the big problem is inequities in health care.

“The U.S. health insurance system is likely a significant driver of these disparities. A disproportionate share of people of color are enrolled in Medicaid or uninsured,” Daw said in an email. “Because Medicaid pays lower prices than private insurance, fewer doctors take Medicaid patients, especially specialists. It would have been interesting for the authors to look at whether these disparities persisted within Medicaid or private insurance, or if the disparities were reduced after age 65, when Medicare eligibility begins,” he noted.

“Health inequities in the U.S. are fundamentally driven by an unequal and unjust allocation of power and resources in the health care system and society at large,” Daw said. “Addressing these disparities will require acknowledging that both interpersonal and structural racism drive differences like those found in this study, and developing policies that can fundamentally shift the distribution of resources and social attention to meet the needs of people of color.”

“This important research shows that non-white individuals are less likely to see specialists, particularly ones who focus on procedures. Structural factors, including structural racism, may play a role in this disparity,” said Dr. Carol Horowitz, a professor of population health and of medicine, and director of the Institute for Health Equity Research at the Icahn School of Medicine at Mount Sinai in New York City.

“I think it also points out limits of focusing on health care as sole driver of health disparities,” Dr. Horowitz added. “For example, life expectancy is significantly greater in Asian populations in large part because of reduced deaths from heart disease and cancer. Yet, Asian populations were much less likely to see the oncology, cardiology, internal medicine and family doctors who primarily prevent and treat these diseases. Black populations who were just as likely to see these doctors have higher heart disease and cancer death rates. This means we must also look beyond differences in who sees doctors that do procedures, and focus on the non-health drivers of health disparities that stem from generations of structural racism, including poverty, lower quality education, pollution and stress.”

https://www.medscape.com…

From the Wards: Looking Out at Insurance Barriers to Ongoing Care

Comment:

By Isabel Ostrer, M.D.

As a first-year internal medicine resident, I entered the hospital eager to both treat patients’ acute illnesses and empower them to stay healthy outside the hospital. But only weeks into residency, it’s already abundantly clear that very little of a patient’s health and well-being is tied to their hospital stay. Sure, we gather comprehensive histories, run tests, think critically about a patient’s medical problems, and dole out diagnoses and drugs to treat a patient’s immediate clinical crisis. But the best critical thinking and immediate pharmacologic management can only go so far if ongoing care is suboptimal. And I’m learning how insurance can dictate medical options.

Mr. Y came into the hospital after experiencing crushing chest pain for many hours. By the time he arrived, his heart attack had likely been in full swing for half a day. He had his blocked heart vessel opened with a stent, but in the interim he lost blood flow to a significant portion of his heart muscle, killing some cells. He ended up developing an abnormal heart rhythm, atrial flutter, where the top chambers of the heart don’t pump blood effectively. He needs a specific medicine to prevent him from developing blood clots that can lead to a stroke. Between two nearly identical (from a medical perspective) options, I prescribed the one that could be taken once a day, instead of twice a day. More convenient, I thought, and moved on. I have no idea how much the medicines I prescribe cost patients. Luckily, I got a message from the clinical pharmacist asking if I would consider the other option because it would cost my patient $17/month, instead of $200/month. A 92% reduction. For many of the patients I see, a seemingly inconsequential medical decision I make can quite literally mean financial ruin. This compromise to convenience seems reasonable enough, but what if the pharmacist hadn’t called?

Ms. M, another patient I cared for in the hospital, has end-stage heart failure. She came into the hospital in cardiogenic shock – her heart was so weak it couldn’t pump enough blood to the rest of her body. She ultimately recovered well enough to go home. Like Mr. Y, she needs to be on life-saving medicines to keep her heart failure symptoms in check, or else she will be hospitalized again and again. I wanted to set her up for success so messaged the case manager on my hospital team – an incredible patient advocate – to ask if we could enroll her in a home health program where she would get help managing her medicines – to keep her alive and out of the hospital. His reply read, “Sure, I can try, but she has really poor insurance, so it might be tough to arrange home health.”

As a doctor in training, I’m soaking up all the medical knowledge I can so that I can give my patients the best medical care possible and the greatest chance of staying healthy outside of the hospital. I’ve quickly realized this is hard work in a system that is short-sighted. Acute interventions in healthcare, especially inpatient, are very well-reimbursed. But the longer, harder work of “health” — making sure patients can access medications and manage their chronic conditions — often falls by the wayside.

Medicare for All would offer patients a better chance at success, by assuring high quality insurance for everyone. An insurance system that focuses on patient well-being over profit is one that meaningfully negotiates drug prices to ensure that life-saving medications are affordable for patients. It is also a system that treats care at home as a necessary service that isn’t limited by whether you’re privileged enough to have “good” insurance.

http://healthjusticemonitor.org…

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ACRA, ICHRA and CEOs

By George Bohmfalk, M.D.
Aspen (Colo.) Daily News, Letters, July 21, 2021

Editor:

Your Monday story on ACRA’s presentation of a new health care alternative (“ACRA early to highlight health care alternative during May meeting,” July 19) was a challenge to comprehend, as is the proposed new alternative itself. As best I can determine from further reading, an ICHRA (Individual Coverage Health Reimbursement Arrangement) is nothing more than yet another attempt to reduce the amount that employers are obligated to pay for their employees’ health care. This is another step in “cost-shifting” this expense onto employees. I appreciate that Mr. Laird saved some money for the Third Street Center, but inevitably this cost his employees in either dollars or adequacy of coverage. There is no free lunch.

But there is a much better one that can cost everyone less — Medicare for All. Rather than sifting through the complexities of byzantine plans like ICHRAs, and dumping responsibility on employees, why not have a single plan — one size that indeed fits all needs — and pay less for it? Employers, employees, self-employed, and unemployed would all have guaranteed, comprehensive health care coverage, equitably paid for by progressive taxes, with no restrictive provider networks, deductibles or other out-of-pocket costs. Employers could focus on their businesses rather than health care insurance.

Ask the next foreign visitor you encounter whether they would trade their current health care coverage for an ICHRA. Be prepared for them to laugh at the idiocy of what we do here, or cry in sympathy for you.

https://www.aspendailynews.com…