Part II: The Senate’s “Better Care”

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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.

Image: Digg

Good Medicine Needs Good Business

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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

Episode 5: Single-Payer Healthcare and America’s Health Inequality Problem

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.

Episode 4: Sex n’ Drugs

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].

Wasted: Sensible Solutions for Unused Prescription Drugs

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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

Episode 3: Legalizing Midwives in Alabama and AHCA Moves to the Senate

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].

Jimmy Kimmel’s Reminder That Health Care Should Save Lives

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No parent should ever have to decide if they can afford to save their child’s life. It just shouldn’t happen. Not here.

Nearly 10 million people have heard this emotional plea from the tearful monologue on Monday night’s “Jimmy Kimmel Live.” Kimmel opened the show with an emotional retelling of the birth of his son, Billy, on April 21. After a nurse noticed that the newborn was turning purple, doctors detected a heart murmur and tests revealed that oxygen was insufficiently reaching the rest of his body. Kimmel described the chaotic and terrifying scene that followed as doctors and nurses filled in, surrounding Billy with a sort of frenzied focus. Eventually, Kimmel learned that his son was born with a heart disease and would require immediate surgery.

Billy was diagnosed with Tetralogy of Fallot, a four-part heart defect that includes a ventricular septal defect, or a hole between the ventricles that allows mixing of oxygenated and deoxygenated blood to be pumped throughout the body. After sharing that the emergency, three-hour surgery was a success, Kimmel taught us why we cannot look away from the health care battle. This story provides context to American’s fraught response to the Republican’s debate over scaling back Obamacare’s preexisting conditions clause. This clause requires insurers to offer coverage to everyone who can pay for it and protects sicker individuals from being subjected to astronomically high premiums, as Kimmel explains:

Before 2014, if you were born with congenital heart disease like my son was, there was a good chance you would never be able to get health insurance because you had a preexisting condition…you might not even live long enough to get denied because of a preexisting condition.

The most recent changes to President Trump’s health care bill include an amendment by Rep. Tom MacArthur that would allow states to get waivers that allow insurers to set prices based on how healthy a person is. That is, coverage for those with preexisting conditions would become largely unaffordable and force those individuals to seek new coverage in high-risk pools. The bill would set aside money to subsidize these pools, but experts agree that the subsidies aren’t nearly enough to cover those new costs.

What is the potential impact of this change? Nearly 52 million people, or one quarter of adults under the age of 65, have preexisting conditions whose coverage would be in jeopardy if their state was granted this waiver. Not to mention that radically interfering with balance in the marketplace would lead to expensive and less effective delivery of care. (For a simple, cartoon explanation of this phenomenon, refer to this Vox article.)

This is an important distinction to make from Trump’s recent (false) claims that adequate and fair coverage of preexisting conditions “has to be” and is indeed in the new health care bill. Though a tough sell would await the bill in the Senate, it appears as though the new bill will go for a vote in the House later today.

Here is what else the proposed health care bill would change. It would:

  • repeal the individual and employer mandate
  • remove subsidies for out-of-pocket expenses that are used to pay deductibles and make co-pays in 2020
  • roll back tax increases on high incomes, prescription drugs, medical devices and tanning salons
  • cut federal funding for Medicaid expansion in 2020
  • allow states to waive essential benefit rules that include maternity care, emergency visits and preventative services
  • allow insurers to charge older customers five times as much as younger ones
  • change premium subsidies from income- and location-based to a rudimentary age-based subsidy

As we mentioned in our podcast, advocacy’s willpower at town halls and in the inboxes of elected officials forced responsible action on the American Health Care Act. Moreover, it reminded Washington that its constituents realize what they stand to lose with irresponsible health policy. As the vote nears, Kimmel reminds us that we can all agree on one thing:

If your baby is going to die, it shouldn’t matter how much money you make. Whatever your party, whatever you believe, whoever you support, we need to make sure that the people who are supposed to represent us, the people who are meeting about this right now in Washington, understand that very clearly. Let’s stop with the nonsense. This isn’t football. There are no teams. We are the team. It’s the United States. Don’t let their partisan squabbles divide us on something every decent person wants. We need to take care of each other.

 

Image: Jimmy Kimmel

Episode 2: The March for Science and DO Day on Capitol Hill

This week on Diagnostocracy, Ti and Keifer welcome students Jennifer Fields and Jesse Aquino to review the March for Science and the inevitably partisan role of science in politics. Jennifer and Jesse then discuss their experience advocating health policy while at DO Day on Capitol Hill earlier this month.

Street Medicine Series: Homelessness as a Medical Condition

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I went into medicine with the full intent of serving the less fortunate. However, I didn’t discover street/homeless medicine until after college, and I quickly fell in love with it. During the last four years, I discovered that most people — especially my peers — don’t know that street medicine is a field. So here I am, armed with a laptop and the effervescent desire to share my passion and educate (or rather, I now have an outlet to rant forever and ever without seeing the glazed look in your eyes).

I’m starting a Street Medicine series on Diagnostocracy in which each article will cover a different aspect of medical care for the homeless, since there is so much to talk about. Through the series, I want to not only open your eyes to a special field of medicine but to also to reverse the stigma that weighs so heavily and unjustly on homeless individuals. Diagnostocracy is about promoting change, whether it be medical, social, intellectual, or spiritual. Ideally, I’ll tap at least the surface on all of those with this series.


Homelessness in Paradise

All right, let’s jump to it.

When we think of Hawaii, we think of paradisiacal beaches against a soft sunset glow, some guy setting your alcoholic drinks on fire at a tiki hut bar, or an intimate honeymoon getaway. (I’ve never been to Hawaii, but this is what the ads tell me.) What’s cast in shadow behind all of this is the fact that Hawaii has the highest rate of homelessness in the country.

One of Hawaii’s representatives, Senator Josh Green, is also a physician, and he recognizes that homelessness isn’t just a social problem; it’s a medical one, too. In January 2017, he co-introduced legislation titled “Declaring Homelessness to be a Medical Condition in the State for Purposes of Medicaid Eligibility and Recognizing that Housing Instability is a Major Health Factor that Negatively Affects Homeless Individuals’ Health and Well-Being.” I’m going to call it by its other name, SCR4, for short.

SCR4 has a couple of lines that encapsulate the aforementioned concept that homelessness is the intersection between an extremely simplified medical vs. social Venn diagram:

“…according to the National Alliance to End Homelessness, ‘[h]omelessness both causes and results from serious health care issues, including addiction, psychological disorders, HIV/AIDS, and a host of order [sic] ailments that require long-term, consistent care’”

“… because housing instability detracts from regular medical attention, homeless individuals’ conditions often get worse, which allows these medical conditions to become more dangerous and costly”

Supporters of the SCR4 measure see homelessness as an illness and housing as a treatment, and it’s easy to see why. Homeless individuals are more susceptible to substance abuse and medical co-morbidities, such as HIV and cardiovascular disease. A study found that the mortality rate in homeless individuals is three to six times higher than that of their housed counterparts.

As future healthcare professionals, there are some things we should think about.

  • Since homelessness is tied to a decrement in health, should we be able to use public insurance, like Medicaid, to fund housing?
  • What are the shortcomings of starting social intervention before medical treatment and vice-versa?
  • How do we approach this issue if housing is just correlated with, not a cause of, a decline in health?
  • With whom can we collaborate outside of medicine to derive a solution?
  • What kinds of biases or other limitations do we have that may be holding us back from tackling this problem effectively and efficiently?

I talked to a homeless patient who tried to stay overweight to appear bigger and therefore intimidating to others on the streets as a defensive measure. What can we do about this battle between health and safety?

How You Can Help

I’d like to ask you to distribute water bottles, food, hand sanitizer, bug spray, hats, and/or sunscreen as you see homeless individuals during your drives or walks. The weather is warming up, so let’s think of ways we can help alleviate the discomfort of our fellow human beings.


I like to keep my articles short and to the point, but sometimes, it’s difficult with a topic that I love talking about. With that being said, please contact me via email, through the Diagnostocracy contact page, or catch me at school if you’d like to know more about homelessness as a medical condition. I have much more to add, some of which I hope to eventually incorporate in this new Street Medicine series, so please stay tuned!

Image: Al Jazeera

Episode 1: The American Health Care Act and Court Battles Over Lethal Injection in Arkansas

Welcome to Diagnostocracy’s first podcast episode! Today Ti and Keifer introduce you to the pod. Then their fellow classmate, Leigh Graziano, joins them as they discuss the American Health Care Act (AHCA) and the court battles happening in Arkansas over lethal injection.