Sorry for our absence, but we are off somewhere studying for boards! We look forward to returning this fall. Wish us luck!
Sorry for our absence, but we are off somewhere studying for boards! We look forward to returning this fall. Wish us luck!
Mitch McConnell and the Senate Republicans introduced their revised Better Care Reconciliation Act (BCRA) yesterday. As of this morning, both Sen. Susan Collins and Rand Paul have opposed a motion to proceed on bringing the bill up for consideration to vote. This leaves the Affordable Care Act (ACA) repeal-and-replace in uncertainty, as 3 “No” votes would be enough to doom any chances of passing the Senate. Experts have said that they don’t expect the changes in this bill to alter the CBO’s previous estimate that 22 million could lose their health insurance coverage if passed. This may not matter, as Republicans have made it evident that they could try to push for a vote before the CBO concludes its analysis of the new bill.
Here are the main revisions from the previous bill, with some perspective from Vox:
Cuts to Medicaid remain unchanged, as does the shrinking of Medicaid expansion that more than 30 states have accepted and new patients have found satisfying. Both Republican opposition and citizen outcry thus far have been focused at these severe cuts to Medicaid, which covers half of the births in this country and 1 in 5 Americans, including 2 in 5 children and 2 in 3 nursing home residents. Shrinking the ACA’s program to expand Medicaid is also significant. The CBO has concluded in a separate analysis that these proposed cuts would shut off additional states from accepting Medicaid expansion, and would force some states that have accepted it to drop out, resulting in millions losing coverage.
Denying coverage based on pre-existing conditions has returned to Republican’s healthcare legislation. However, it has become more complicated (likely on purpose), so we’ll spend a little more time discussing it.
You may remember that the first rendition of BCRA left out what the House bill (AHCA) included concerning pre-existing conditions. But Sen. Ted Cruz has offered a new amendment included in the revised BCRA that returns a backdoor option for denying those with chronic health problems. As long as health insurers offer a comprehensive plan – that is, one with essential benefits that the ACA requires to be provided – they can also offer skimpier, deregulated plans. These deregulated plans give more control to insurers in raising costs so high that individuals with pre-existing conditions cannot afford to pay them. Thus, those with chronic health problems will be forced to buy the more expensive and comprehensive plans.
This has several avenues of predictable outcomes that all lead to an unstable marketplace. Ultimately two types of coverage will form: (1) cheap, barebones coverage for rich, healthy individuals, and (2) expensive (or unaffordable), comprehensive coverage for poor, sick individuals. This is explained by Vox author, Sarah Kliff:
Health policy experts know exactly how this would play out: Healthy people would pick the skimpier plan, while the comprehensive plan would essentially become a high-risk pool for sicker Americans.
Individual market enrollees would likely game the system too. A couple expecting a baby, for example, would be expected to upgrade to the [comprehensive] plan that covers maternity care for one year before returning to the cheaper plan they had before.
This tipping of the scales alone could be enough to make comprehensive plans too unaffordable for most individuals, forcing them out of coverage. Those looking to join a comprehensive plan will still be eligible to receive a tax credit in BCRA. However, out-of-pocket costs for deductibles and premiums would remain unbelievably unaffordable. For example, the CBO estimates that a 64-year old earning $11,500 would still need to pay $4,800 for a comprehensive health insurance plan.
Pre-tax money could be used to pay for premiums. Americans enrolled in health savings accounts (HSA), nearly 29% of workers, could now use this money to pay for premiums in addition to their co-pays and co-insurances. This is a great added benefit to those with HSAs, but falls short as a stand-alone option for those who struggle to afford health insurance premiums in the first place. And, as you may know if you have an HSA, this often doesn’t cover the entire cost of a premium.
Wealthy Americans would get less of a tax cut in the revised BCRA. The previous bill included more than $500 billion in tax cuts for high-income individuals and manufacturers. Republican writers decided to extend both a 0.9% investment tax and 3.8% Medicare payroll surtax from ACA that target wealthier individuals.
Keeping these two taxes in place would net the government an estimated $231 billion in revenue over the next decade, and eliminate some of the benefits high-income Americans would have received under the first draft.
Finally, the revised bill provides $45 billion to combat opioid abuse. But as Joshua Sharfstein, professor at the Johns Hopkins Bloomberg School of Public Health, says
The $45 billion they’ve added is a drop in the bucket compared to the amount of money that would be lost in the Medicaid cuts ($800 billion). It’s a tiny fraction of what Medicaid is already providing millions of people.
Think about it. Those addicted to and abusing pain-killing drugs need actual care through sustained coverage – which Medicaid provides – rather than an indiscriminate number of dollars. When you consider that funding for this opioid abuse program constitutes less than 6% of the total cuts imposed to Medicaid, it is sadly apparent that this is included mostly as political leverage. That is, ammunition for BCRA’s supporters to attack those who oppose the bill as a whole for any other legitimate reason.
Despite these poorly addressed flaws, a vote could happen this week. The voice of the people has made a difference at each step of the healthcare reform process. With just 12% approval and millions of lives at stake, BCRA will require sustained pressure on our elected officials. You can use the Trumpcare Toolkit to reach make your voice heard, and if you’re a member of the medical community searching for the right words, here is a great perspective to get you started.
Earlier this spring, the Centers for Medicare and Medicaid Services rolled out new parameters for the latest “doc fix” of the Affordable Care Act (ACA), called the Medicare Access and CHIP Reauthorization Act, or MACRA. MACRA is complex, but the main objective is to ease the transition to quality-based care standards required by ACA. Health Affairs summarizes:
MACRA creates a payment system for physicians that will accelerate Medicare’s transition from fee-for-service to payment based on performance metrics, patient experience, and patient outcomes.
Legislation like this creates a new business of medicine within which all physicians are undeniably tangled. The pressure to drive down costs while increasing quality of care requires an understanding that is beyond the scope of traditional medical school curriculum. Nearly half of U.S. medical schools offer a combined MBA program to their students. However, this adds significantly more work and costs to students who are already bleeding for time and money.
NEJM Catalyst discusses the need for medical schools to incorporate business school skills in an article re-released today. Its authors provide the concept of an interdisciplinary clinical rotation as a possible solution:
In our view, the best learning experiences would be project-based, combining components of didactic teaching sessions and hands-on experience. The goal of the four-week course would be for the student to identify and solve real problems facing the school’s hospitals and clinics. By the end, students would have developed the business skills needed to lead multi-disciplinary teams, serve as contributing team members, and apply data analytics to improve clinical practice.
Let’s take a look at each of these initiatives.
First, physicians are called on to be both team leaders and team contributors. Health care delivery from solo practice is disappearing in the United States. On the rise are larger hospital groups or small groups in an office setting with physicians leading mid-level providers. Thus, physicians must utilize team leadership strategies to survive. A group lives or dies by the physician leader’s ability to gain and keep patients, motivate and engage a team, understand its strengths and weaknesses, develop a culture of constructive feedback, and ultimately find financial success. These are just some of the skills that a business-orientated rotation could help teach medical students.
But a good leader isn’t the only important element of a team. Physicians should learn how to be a contributing team member:
Many business schools use simulated environments to teach team dynamics and help participants learn how to develop team culture, set clear expectations, and communicate effectively. These abilities require emotional intelligence and deep understanding of interpersonal dynamics — concepts and skills that are essential to maximizing quality, increasing patient safety, and improving clinical performance.
Transitioning from fee-for-service to value-based care in physician reimbursement also puts pressure on doctors to be better self-advocates. They can no longer expect a strong salary simply by providing a baseline of services or tests. Addressing salary and negotiating a contract with metrics, expectations, and incentives can take new doctors by surprise. Knowledge of business would help physicians transition better from medical training to the real world, where making money requires more than just clinical skill.
Finally, physicians must become experts in data, or operational analytics. Electronic medical records have allowed us to create warehouses of quality and performance data. It is now much easier to connect doctors to their performance in real-time. This is really the meat and potatoes of approaching value-based care. In order to improve quality and cut costs, physicians must first ask the right questions:
As reimbursements drop, physicians in the future will need to identify opportunities to improve performance by decreasing bottlenecks in their offices, reducing patient wait-times for the operating room, modeling alternative treatments to determine the most cost-effective option for a particular patient, and performing statistical analysis to identify trends in patient quality outcomes.
Providing care is expensive. Despite being the number one spender of health care in the world, millions of Americans struggle to get the care that they need. But when physicians are called on for solutions, they should be adequately prepared to answer. Luckily, the AMA and other groups provide resources on the business side of medicine.
Medical school teaches future physicians how to make the right decisions for their patients, but this isn’t enough. Combining clinical and financial decision-making into a student’s curriculum could be a first step in the right direction.
Four weeks would be similar in length to the majority of other rotations, and an adequate amount of time to identify and examine a real-world problem. Students working in groups could conclude how best to increase the rates of screening for cancer or how they might streamline the hospital discharge process. This program would not be a complete business and leadership education. Like other fourth-year elective rotations, it would develop the foundation for lifelong learning in this area.
Better financial decisions for health care are made when physicians are at the table, so let’s give them the confidence and ability to pull up a chair.
Image: Physician’s Weekly
Companies like “23andMe” have allowed us to have a little fun with personalized genomics. Spit in a cup and let our knowledge of genetic diseases and traits predict that which you may or may not know about yourself, they propose. A genetics professor in college once told my class that the ability to read out our personal genetic code is as useful as one of us trying to build and fly a Boeing 747 from blueprints; that is, blueprints aren’t everything.
Similarly, simple maps of our brains might be of no more value to us than a personality test or a pretty desktop background. But new technology is advancing the ways in which we can study, predict, and potentially therapeutically intervene in mental illness.
A recent study in Neuron used brain scans of nearly 50 prison inmates to explain how disturbances in certain brain circuits may translate into criminal behavior. Josh Buckholtz, senior author of the study and Associate Professor at Harvard, used mobile MRI scanners on the brains of inmates participating in a verbal delayed gratification test. The test asked whether the participant preferred to take less money now or more money later, if given the choice. Those who scored high for psychopathy showed greater activity in the ventral striatum, an area of the brain associated with evaluating subjective rewards. Buckholtz says,
So the more psychopathic a person is, the greater the magnitude of that response. That suggests the way they are calculating the value rewards is dysregulated, they may over-represent the value of an immediate reward [taking less money now rather than taking more money later].
As they mapped the connections between the ventral striatum to other regions known to be involved in decision-making, they found a possible explanation:
We found that connections between the striatum and the ventral medial prefrontal cortex were much weaker in people with psychopathy.
This portion of the prefrontal cortex is thought to provide one with the ability to envision future consequences for actions. We rely on the prefrontal cortex to evaluate our decision-making process and predict what may happen to us in when we act out a particular decision. Think of it as a computer program that maps out every possible move in a chess game, and every result associated with those moves. As you might imagine, a deficiency in this relay, resulting in a preference for immediate reward, could prompt one to make a bad decision (i.e. participate in criminal behavior).
Finally, this weakened striatum-to-cortex regulation was so pronounced that the group was able to accurately predict frequent convictions of crimes in the inmates studied.
An old way of thinking has left us with an incomplete understanding of how to approach mental health. The media does a poor job explaining mental health as a source of violent crime, and our justice system has not learned how to punish criminals who have obvious mental illnesses. So it is easy to see why we get trapped into blaming the wrong mechanisms.
However, a new wave of neuroscience research is challenging the long-standing idea that emotion drives behavior. Buckholtz’s study suggests that we turn instead to the choices that criminals make as a result of an imbalance in risk and reward, perpetuated by dysregulated brain circuitry. Once we identify deviations in neuronal signaling, we can start to predict behavior and attribute emotion:
If we can put this back into the domain of rigorous scientific analysis, we can see that psychopaths aren’t inhuman, they’re exactly what you would expect from humans who have this particular kind of brain wiring dysfunction.
These new technologies are not redrawing old blueprints. They are telling us that the blueprint has been there all along—we were just busy building the wrong plane.
The Congressional Budget Office (CBO) and Joint Committee on Taxation (JCT) released their completed report on the Senate’s highly anticipated “Better Care Reconciliation Act” (BCRA) earlier today. In general, the major provisions of this bill are:
The CBO concluded that 15 million individuals would lose their health insurance next year under BCRA, and ultimately 22 million would be forced out of coverage by 2026. This is similar to the respective 14 million and 23 million figures from the CBO report on the House’s version, AHCA.
Though the report estimates that premiums would increase by up to 20 percent (relative to Obamacare) in the first couple of years, they would eventually become cheaper in 2020. However, this would largely be a result of a decrease in services covered by health insurance companies under BCRA.
Bluntly, yet still shocking, the CBO states that this bill would save costs by shunning both elderly and low-income individuals from even purchasing a coverage plan “despite being eligible for premium tax credits.” Overall, the cuts in BCRA could result in a death spiral of drastically increased premiums as younger, healthier individuals drop from a pool composed greatly of older, sicker individuals that require more health services.
Finally, the money breaks down as such:
Senate GOP just dropped the highly anticipated “Better Care Reconciliation Act” (read our latest Health on the Hill post about it here). Keifer and Ti break it down [1:19] before talking with Martha Streng, PhD candidate in neuroscience at the University of Minnesota [27:46]. She discusses the threats of significant cuts to research funding under a Trump Administration and what effects it could have on the already shaky climate in academia, and sheds light on the dawn of a new era in neuroscience tech research.
Trump’s new budget proposal includes steep cuts to basic science research, and does not show any understanding of the relationship between basic and translational sciences. Martha argues that these cuts would be detrimental not only to advancing research on the treatment of disorders like schizophrenia, but to our comprehension of even the normal brain.
This week, Keifer introduces a study in Health Affairs that shows the United States sinking behind the rest of the world in health equality, and how Americans perceive health as a function of wealth [1:55]. Keifer and Ti then discuss single-payer healthcare with Dr. Robert Zarr [6:38]. What are some misconceptions? How would “Medicare For All” look in America? Public and medical opinion about single-payer are evolving in the current political environment. What can you do and where can you go to learn more about it?
Dr. Zarr is a practicing pediatrician in Washington D.C. He is immediate past president of Physicians for a National Healthcare Program (PNHP) and past president of the D.C. Chapter of the American Academy of Pediatrics. He is the founder and director of Park Rx America for which he’s been profiled in NPR and the Washington Post. He received his medical degree from Baylor College of Medicine and completed his pediatric residency at Texas Children’s Hospital in Houston. He also holds a Master of Public Health degree from the University of Texas School of Public Health.
Keifer and Ti are joined by classmate Misha Vadodaria to discuss the Fair Drug Pricing Act that was re-introduced in Congress this week. Ti takes the group to “Dinner @ the White House” [29:18] before playing “Fake News and Friends,” a quiz game about ridiculous news headlines. Finally, the group explores the data and rationale behind the wage gap between men and women in medicine [38:20].
Most of us keep all of our medicine in a designated location in the house. Be it the medicine cabinet in the bathroom, the kitchen shelf just above the coffee maker, or the gallon-sized plastic bag we tend to see patients bring during their office visits, most of us have prescription drugs and over-the-counter medications stockpiled somewhere.
But when was the last time you took a moment to organize that medicine cabinet, figure out which medicines you are no longer taking, and review expiration dates?
There are safe ways to dispose of expired and unused medications. (No, I am not talking about flushing them down the toilet.)
The U.S. Drug Enforcement Administration (DEA) hosts a semi-annual National Prescription Drug Take Back Day, where you can take your expired and unused drugs to a designated collection site in your community to be disposed of appropriately. Typically, collection sites are at local police stations, fire stations, pharmacies, clinics, or hospitals. Collection sites are community-specific and can be found on the DEA website.
The most recent National Prescription Drug Take Back Day wrapped up on Saturday, April 29, and program organizers are waiting to see just how many drugs were collected. This time last year, the DEA set an all-time collection record.
On May 6, 2016, Americans turned in more unused prescription drugs than on any of the previous 10 events since it began in 2010, demonstrating their understanding of the value of this service. The DEA and over 4,200 of its state, local, and tribal law enforcement partners collected 893,498 pounds of unwanted medicines—about 447 tons—at almost 5,400 sites spread through all 50 states, beating its previous high of 390 tons in the spring of 2014 by 57 tons, or more than 114,000 pounds.
447 tons is roughly equal to the weight of five NASA Space Shuttles. With growing awareness of the opioid epidemic in our country, it is certainly possible that the record may have been broken again this year.
As future physicians, it will be important for us to spread the word and continue to facilitate awareness of community disposal programs like this to our patients. According to the DEA, the majority of prescription drug abusers report in surveys that they get their drugs from friends and family. By cleaning out medicine cabinets and disposing of medications appropriately, we can reduce accidents, thefts, and the misuse and abuse of these medicines—including the opioid painkillers that accounted for over 33,000 deaths in 2015.
Proper disposal of expired medications is crucial, but what if there were other, more efficient, more cost-effective options for the medications that are not expired and go unused? What if unused prescription drugs could be recycled and redistributed?
A recent ProPublica investigation found that nursing homes waste millions of dollars in prescription drugs every year. Marshall Allen, the author of the investigation, recently gave an interview on NPR. Medications are discontinued for many reasons, including when a patient passes away or gets discharged, “and so in most nursing homes around the country, they just throw those drugs away,” said Allen.
With the rising costs of healthcare and the unprecedented costs of prescription drugs these days, it is a little disturbing to hear that millions of dollars of perfectly good prescription drugs are literally being flushed down the toilet. As Allen reports, Medicare and other commercial insurance payers have already paid for the prescriptions, so why not recycle them?
That is exactly what a program in Iowa is doing. SafeNetRx retrieves unused prescription drugs and redistributes them to uninsured or underinsured patients for free. This program estimates that they receive close to $5 million worth of drugs in a year that they redistribute to communities in need.
“The National Academy of Medicine estimated in 2012 that the U.S. squanders more than a quarter of what it spends on health care – about $765 billion a year.”
Can you imagine what impact we could have on healthcare costs across the nation if we recycled and redistributed prescription drugs that would otherwise be thrown in the trash, incinerated, or flushed down the toilet?
When patients are non-compliant in taking their medication because they are unable to afford their prescription, they frequently wind up in the emergency room—putting greater financial strain on hospitals, taxpayers, and communities across the country.
From a health policy perspective, efforts have been made to pave the way for the donation and redistribution of drugs.
The National Conference of State Legislatures said 39 states had passed laws that allowed the donation of drugs. But almost half of these states with laws lack programs to get the drugs safely from one appropriate user to another, and many of those that do have programs are focused on cancer drugs, the analysis showed.
The logistics of such a program appear to be the biggest barrier to getting formalized prescription drug recycling off the ground, and this highlights a classic issue in writing health policy.
“It’s like people have created legislation and it’s a feel-good thing, but nobody’s come back to see why it’s not working,” says Mark Coggins of Diversicare, a chain of nursing homes in 10 states.
Though legislation to address these issues sometimes becomes law, too often it fails to provide adequate investment for carrying out the idea. In Iowa, SafeNetRx is state-funded for about $600,000 a year, and is considered a best-practice, common sense solution for recovering and redistributing prescription drugs to those most in need.
Many patients that benefit from the SafeNetRx program are saving hundreds, if not thousands, of dollars on prescription drugs (not to mention savings for the insurance companies), including low-income and fixed-income senior citizens with multiple chronic conditions.
The next time you clean out your medicine cabinet, or advise your patients to do so, consider where those medications could go. They could be thrown away, or they could go back in the hands of patients that need them the most. With little effort, you can be part of a life-saving solution that also saves millions of healthcare dollars.
If you’re interested in learning more and helping to solve this problem, I encourage you to explore what your state is doing to recover, recycle, and redistribute prescription drugs.
Image: Wise Rx Card
This week, classmate and fellow Kathryn Petersen joins Keifer and Ti on the podcast to talk about new legislation that would allow certified professional midwives to practice in Alabama [1:22]. After playing Diagnostocracy’s new game, “Who Said It?” [19:46], the group breaks down the passing of the newly revised AHCA, its future in the Senate, and what you can do about the fundamental, political divide in the health care debate [23:10].