The GW Center on Health Insurance Reforms offers this explanation on the individual insurance cancellations – Policy Cancellations – Another Tempest in a Teapot?
Having an insurance company discontinue an insurance policy is not anything new. And actually, the term “policy cancellation” is a misnomer. Generally, an individual health insurance policy is sold via a 12-month contract between the insurer and the consumer. At the end of that contract period, the insurer has the option to discontinue or change that policy – nothing in federal law changes that. Current policyholders are not having their current policy cancelled – rather, the insurance company is exercising its option to discontinue the policy at the end of the contract year.
Ross Douthat writes in the NY Times – Obamacare’s Losers and Why They Matter
On the policy substance, meanwhile, despite his kind nod to our “reasonable” disagreement, I actually strongly agree with Cohn that it’s fair to ask some people to pay more for the health insurance they currently have in order to make health insurance more accessible to the currently-uninsured. As I’ve noted before, during the exciting debate about “bros” and health care reform early this year, every plausible conservative alternative to Obamacare does that in some form or another — and part of the reason that Republican politicians have been hesitant to embrace those alternatives, unfortunately, is an anxiety about precisely this reality and its potential political costs.
But not every form of “asking some people to pay more” is created equal. A cap on the tax break for employer-provided health insurance, for instance — which is central to most right-of-center health care proposals, and is taking effect in a more limited way in the form of Obamacare’s so-called “Cadillac tax” on expensive insurance plans — basically asks people who have been getting a very good deal from current health care policy (the well-off and upper middle class, and some union members with generous benefit packages) to live with a somewhat smaller subsidy and somewhat less generous employer coverage going forward. (For a more specific illustration of how this works, you can read Josh Barro explaining it using the example of Senator Ted Cruz and his wife.) This policy change isn’t cost free, and it would still violate President Obama’s unwise “if you like your plan, you can keep it” pledge. But it promises to level the health-insurance playing field somewhat while asking the most from those Americans who have benefited from its existing tilt.
But “rate shock” seems different, because premium increases in the individual market creates a set of Obamacare losers within a group of people who weren’t obviously winners to begin with. A couple like the Harrises of Fullerton, California, for instance, making $80,000 a year and buying on the individual market in a high cost-of-living state, were already disadvantaged relative to the millions Americans who get insurance through an employer and benefit from the employer tax break; now they’ll be paying an extra $1500 a year as well (albeit, yes, perhaps for more comprehensive coverage). Likewise some of the hypothetical Connecticut residents discussed in my column: If you’re 50 years old in my native state, make $50,000 a year, and buy on the individual market, you’re thrice a loser under the new system. You don’t benefit from the employer tax deduction, you don’t qualify for the new subsidies, and your insurance prices could be jumping by $200 a month.
So is this much ado about nothing? Is this a Fox News crisis? Or is this a fundamental problem for public acceptance of the law? The web site will get fixed. But what happens a year from now when business health plans must comply?
I want this to work, but the individual cancellation story (started by investigative reporting at the LA Times) does bother me. Is it fair to blame this problem on the insurance companies solely?
Affordable Care Act – the devil is in the details some think
NBC news, not exactly a raving right wing news source, published this investigative report – Obama administration knew millions could not keep their health insurance
Four sources deeply involved in the Affordable Care Act tell NBC News that 50 to 75 percent of the 14 million consumers who buy their insurance individually can expect to receive a “cancellation” letter or the equivalent over the next year because their existing policies don’t meet the standards mandated by the new health care law. One expert predicts that number could reach as high as 80 percent. And all say that many of those forced to buy pricier new policies will experience “sticker shock.”
None of this should come as a shock to the Obama administration. The law states that policies in effect as of March 23, 2010 will be “grandfathered,” meaning consumers can keep those policies even though they don’t meet requirements of the new health care law. But the Department of Health and Human Services then wrote regulations that narrowed that provision, by saying that if any part of a policy was significantly changed since that date — the deductible, co-pay, or benefits, for example — the policy would not be grandfathered.
Buried in Obamacare regulations from July 2010 is an estimate that because of normal turnover in the individual insurance market, “40 to 67 percent” of customers will not be able to keep their policy. And because many policies will have been changed since the key date, “the percentage of individual market policies losing grandfather status in a given year exceeds the 40 to 67 percent range.”
My friend is a victim of this problem. He, a lifelong Democrat and true liberal, is outraged.
This problem represents a classic problem of these huge bills. No one, and I do mean no one, understood the ACA prior to its passage. Republicans assumed that it was a bad bill, because they dislike the administration. Democrats assumed it was a good bill because thy like the administration. The goals of the bill are pure and desirable. But some provisions need rapid correction. This current issue is a very important one.
I still believe we need much of what the ACA provides, but it is time to admit the problems and fix them. This law effectively raised my friend’s “tax” by approximately 5k per year. And he has a higher deductible. He is not happy, and I understand completely.
The affordable care act, thus far – the good, the bad and the ugly
The good – the ACA represents an important attempt to markedly increase the percentage of citizens having health care. It ends the pre-existing condition problem that many of my patients face. It tries to expand Medicaid, and does in many states.
The bad – unfortunately there are winners and losers. On the practice green today, talking with a golfing buddy, I heard his story that markedly resembles this story from the LA Times – Some health insurance gets pricier as Obamacare rolls out
These middle-class consumers are staring at hefty increases on their insurance bills as the overhaul remakes the healthcare market. Their rates are rising in large part to help offset the higher costs of covering sicker, poorer people who have been shut out of the system for years.
Although recent criticism of the healthcare law has focused on website glitches and early enrollment snags, experts say sharp price increases for individual policies have the greatest potential to erode public support for President Obama’s signature legislation.
“This is when the actual sticker shock comes into play for people,” said Gerald Kominski, director of the UCLA Center for Health Policy Research. “There are winners and losers under the Affordable Care Act.”
Fullerton resident Jennifer Harris thought she had a great deal, paying $98 a month for an individual plan through Health Net Inc. She got a rude surprise this month when the company said it would cancel her policy at the end of this year. Her current plan does not conform with the new federal rules, which require more generous levels of coverage.
Now Harris, a self-employed lawyer, must shop for replacement insurance. The cheapest plan she has found will cost her $238 a month. She and her husband don’t qualify for federal premium subsidies because they earn too much money, about $80,000 a year combined.
“It doesn’t seem right to make the middle class pay so much more in order to give health insurance to everybody else,” said Harris, who is three months pregnant. “This increase is simply not affordable.”
My friend will have a monthly increase of around $400 and still have a higher deductible. At age 63 he only has to pay this for 2 years, yet he is clearly upset. I cannot answer his questions.
The ugly – the web site – no discussion needed.
I hope that this bill ends up improving health care. I worry about the many details in the law that we do not really understand. I worry about a bill that we do not yet completely understand. The goals are admirable. I hope the devil is not in the details.
The weight loss project 8 – becoming a runner
July 17th I wrote my first weight loss post. Over the past 14 weeks I have lost approximately 11 more pounds. Currently my weight loss is slow and steady. My diet remains one of portion control. Generally my food choices are lower fat, but I still eat full meals and healthy snacks. My goal for diet is to eat a bit less each meal.
Since that first post, I have increased my aerobic fitness dramatically. For a few weeks I only did treadmill running. During that time I worked on pushing myself for short periods. The great advantage of treadmill running comes for being able to dial in a speed, pushing ones comfort zone to improve fitness. During this time I was not really sure how much I had improved.
Last week I attended a meeting in Philadelphia. We finished early enough on Monday to go for a nice run. During that run I found that I could run as far as 1 mile without walking. Friday and Saturday I took long runs. Yesterdays was particularly satisfying – 4.55 miles in 45 minutes 48 sec – essentially at 10 min mile pace. My longest run segment was 1 mile, but I usually ran .45 miles and walked .05 miles. This run defines (for me) my fitness improvement. My 5k was a bit under 31 minutes. This represents a huge improvement. When I finished I was actually not exhausted. I am running, either the treadmill or outside, approximately 6 days each week.
My ability to do this astonishes me. I last was a runner during residency. Starting again at age 64 has been surprising and greatly satisfying.
Most readers trying to lose weight will not become runners. I become a runner almost by accident. Doing all the walking stimulated the idea of some jogging intervals. Obviously running burns many more calories per minute than walking. But running is more than losing weight. Through running my blood pressure went from borderline to very normal and my resting heart rate decreased.
The Nike Fuel Band has helped maintain my daily motivation. Each day I have a goal, and I set an ambitious goal (3000 fuel points daily). I rarely can meet this goal without at least a 30 minute run.
I am slowly approaching goal #4. At this point of the project (down greater than 20 pounds), I still have weight loss goals, but I am not in a big rush. Slow steady progress represents the right strategy to meeting each goal.
So the project continues. My wardrobe has changed – all new pants and shirts. I have rediscovered some clothes that I have not worn in 12 or more years.
What is the final goal? I do not yet know, but the biggest goal is to change my lifestyle to make maintenance highly likely.
Not all sore throats are self-limited – the role of antibiotics
Over the past month I have linked to 2 articles that give rationale to my long term belief that some sore throat patients need empiric antibiotics. The argument against empiric antibiotics revolves around the belief that most sore throats represent self-limited disease and do not respond to antibiotics. Unnecessary antibiotic use may hasten our antibiotic resistant problem and cause side effects.
Globally this does not make sense! A Start to Saving Lives: Treating Sore Throats.
The authors of a recent paper in the journal Global Heart estimate that a quarter of all sore throats are caused by strep A bacteria and that such infections lead to as many as 500,000 deaths a year, almost all of them in poor countries.
Strep tests available in these countries usually take too much time, requiring days to observe the growth of bacteria. The heart-valve damage is also hard to diagnose; a stethoscope catches only 10 percent of the cases that echocardiograms do.
One penicillin shot within nine days of infection usually prevents any heart damage. Cuba, Costa Rica and Martinique have sharply reduced rheumatic fever by public education about sore throat, screening for strep by symptoms, and treating quickly.
Infectious disease experts in the US and Europe will argue that this strategy does not make sense here – only there! Very few bacteria remain sensitive to penicillin in 2013. Group A strep, despite 60-70 years of penicillin exposure, remains sensitive to penicillin. How could penicillin use increase antibiotic resistance – almost every other bacteria already has penicillin resistance.
This strategy will also decrease suppurative complications – peritonsillar abscess in pre-adolescents and both peritonsillar abscess and Lemierre syndrome in adolescents.
Meanwhile French otolaryngologists are protesting against pharmacies providing rapid strep tests and treating only positive test patients. Screening of angina in pharmacies: The ENT sounding the alarm. The term angina here refers to pain, and not chest pain. This article is written in French, but the translate button allowed me to read the article clearly.
These ENTs note increasing numbers of peritonsillar abscess. They argue that sore patients deserve more than a rapid test. They argue for a history and physical done by a physician who looks for complications and explains red flags to the patient.
Long time readers know that I lament the term “just a sore throat”. While most sore throats are self-limited, we still should respect the possibilities for either suppurative or non-suppurative complications. I argue regularly that our sore throat treatment nihilism can lead to unnecessary morbidity and mortality.
Using clinical features we can exclude 40-50% of patients from empiric antibiotics. The key here is that sore throats are best treated with very narrow spectrum antibiotics – penicillin or amoxicillin or a narrow spectrum cephalosporin. We should teach all physicians, NPs and PAs the sore throat warning signs – persistent fever (more that 2 days), drenching night sweat, rigors, or unilateral neck swelling. All such patients should see an experienced physician who should consider suppurative complications.
The puzzling edema solved
The answers, both on this blog and on twitter, showed great thought processes. Here is how I discussed it with my team, and the data we used.
The patient had peripheral edema, but had a good oxygen saturation and no dyspnea. We had a previous echocardiogram that showed very mild pulmonary hypertension, so we did not believe that this was the reason for worsening edema.
Next I asked for an albumin level, and it was 2.9 down from 3.9 two weeks earlier. Why would the albumin be so low?
Low albumin must be:
1. Decreased protein intake
2. Decreased albumin production (i.e., cirrhosis)
3. Increased losses – either urine (nephrotic syndrome) or stool (protein losing enteropathy)
The urinalysis showed no urinary protein. The patient had no evidence of cirrhosis. So I asked the team about the patient’s food intake.
I went “old school” and asked for patient weights. The patient had lost 5 kg over the 2 weeks.
At the bedside the patient looked and acted depressed. She said that she did not like the nursing home food and was not eating well.
To confirm we checked a pre-albumin and it was significantly low.
An echocardiogram showed that the LVEF had improved to normal!
A CXR showed no pulmonary edema.
Lower leg doppler studies showed no thrombosis.
This rather straightforward problem shows students and residents how careful thinking can help direct us to the correct diagnosis. Diagnosis requires clear organized thinking. I hope this story is helpful to residents, students and medical educators.
Worsening edema – a diagnostic puzzle
70-something woman admitted to our service with worsening lower extremity edema. She is “billed” as worsening CHF. We know the following things about this woman:
COPD – but not on home oxygen
Systolic dysfunction – last left ventricular ejection fraction 25%
Type II Diabetes Mellitus for approximately 4 years
history of hypertension
Medications include
Insulin
carvdelilol
amlodipine
furosemide 40 mg daily
She has spent 2 weeks in a nursing home. Does not complain about dyspnea, only about lower leg edema.
Examination slows the patient is afebrile, pulse 68, BP 130/90, respirations 18
lungs are clear except bibasilar rales
heart without murmurs, regular rate and rhythm
extremities – increased painful lower extremity edema (the intern had seen the patient 2 weeks previously)
The question for you – provide a differential diagnosis and order diagnostic tests – I will give the test results and then you should explain what happened to this woman
On being a good doctor – working around prescription costs!
This article should frustrate everyone – The Soaring Cost of a Simple Breath
Everyday that I make rounds, we have discussions about prescription drug costs with the students and residents. We are all learning to become adept at finding low cost alternatives to high drug costs.
This particular article describes a most troubling problem – the ridiculous cost of asthma inhalers. I do mean the adjective ridiculous. This pricing is obscene. It leads to patients not being able to afford to treat their disease.
In the adult inpatient service we mostly see COPD patients. I almost never prescribe inhalers. Inhalers work well, but for price reasons we use nebulizer machines instead. Nebulizer machines are much less expensive than a single inhaler, and then we can prescribe generic asthma medication solutions to use with the nebulizer. They are inexpensive through Walmart, Walgreens and other pharmacies. Often we can get patients a free nebulizer in our hospital, and then the costs become reasonable.
For hypertension, we have become adept at using generic drugs. We try the same for diabetes, left sided heart failure and even lipid medications.
We have a responsibility to our patients to weigh the costs of their medications. We should learn the unreasonable costs of prescription meds and work around those costs.
The pharmaceutical manufactures will lower their prices if they see that high prices lead to fewer profits. We physicians must lead the charge to think of the patient’s finances first!
Ward rounds – does style matter?
Over the past few weeks I have had several discussions about the style of ward attending rounds. Medical educators who I respect greatly have argued strongly that they have the best way to do rounds. The more variations that they report, the more I am convinced that we have many ways to skin that cat.
When we started our ward attending round research over 10 years ago, we wanted to discover something about the style of rounds. We discovered a great deal, but nothing about the style of rounds. We learned the characteristics and domains of successful rounds.
Quoting from our recent letter to the editor of JAMA:
We learned that successful attending rounds required a multidimensional skill set comprised of 5 distinct domains: learning atmosphere, clinical teaching, teaching style, communicating expectations, and team management. As Wachter and Verghese explained, current work hour restrictions and hospital expectations create a demand for team management skills, one of our domains. This domain includes timeliness, efficiency, and accommodating absences required for administrative demands.
While team management is an important domain, it did not outweigh clinical teaching, learning atmosphere, teaching style, or communicating expectations. Trainees valued teaching. They rated “sharing of attending’s thought processes” as the top attribute for successful rounds. They also valued bedside teaching and role modeling. These less precise attributes of clinical wisdom trumped the teaching of evidence-based literature. Students and residents felt they could read books and medical literature, but they wanted and needed attending physicians to demonstrate clinical reasoning, patient communication, physical examination skills, and professional physician behavior.
There are many successful styles of attending rounds. We should not debate the proper structure of rounds. We should understand that our personalities influence how we like to run rounds. Learners care less about structure than they do about sharing ones thought processes, having some bedside teaching and role-modeling.
I encourage all ward attending physicians to develop their own structure and style for making rounds. Structure and style are less important than content. Our job is to use rounds to insure superb care for our patients and give our learners the opportunity to gain expertise. We should understand that our learners need us to provide role-modeling, not just through words, but also through observation. How we interact with patients matters. That we make certain that patients understand what is happening in the seemingly hostile atmosphere of a hospital matters. That we share our thought processes matters. And these activities trump style and structure.
Teaching tough
This article from the WSJ last Saturday has struck many readers as important – Why Tough Teachers Get Good Results. The main theme of the article is that tough teaching works.
Prof. Seery’s findings build on research by University of Nebraska psychologist Richard Dienstbier, who pioneered the concept of “toughness”—the idea that dealing with even routine stresses makes you stronger. How would you define routine stresses? “Mundane things, like having a hardass kind of teacher,” Prof. Seery says.
How does this relate to medical education? Of course, this is my interpretation of tough, and other readers may have different interpretations.
I interpret tough as demanding. As I consider the best attending physicians, I recall that they all make expectations clear. They challenge students and residents to become better. They expect careful history taking, accurate physical examinations, and excellent notes. They expect careful review of old records. They expect the learners to investigate problems through reading and study.
They do not just expect, they demand. They hold the learners to high standards.
Learners respond to high expectations.
Tough does not necessarily imply mean. Attending physicians who set high expectations induce better performance. Our learners want to become the best possible physicians that they can become. They respond well to high expectations.
Reading the article should stimulate your thoughts. I would love to read your personal recollections of tough teachers and how they impacted your career.
