Vol. 167 March 15, 2017 AHCA (RepubliCare) Revealed

March 15, 2017

WINNERS: Young, Wealthy, Healthy, “Blue States” (urban millennials)
LOSERS: Older, Poor, Sick, “Red States” (rural working poor)

The American Health Care Act (AHCA) was developed by Paul Ryan (R) who has been publicly promising a Republican health care act since 2009!  He apparently does not want his name attached to this one. Neither does Trump. So I choose to call it “RepubliCare”.

The Congressional Budget Office’s “quick and dirty” analysis of the American Health Care Act (actually two bills still in committee) estimates that 14 million people will lose their health insurance in 2018 if it “replaces” the Affordable Care Act (Obamacare). Of all the projections, this one is probably the most crucial, since it will be a factor in the mid-term elections.

The CBO is a non-partisan, independent body created by President Richard Nixon in his last act before resigning in 1974. The CBO aids Congress in developing their own budget proposals, in objectively costing out their proposed bills, and in analyzing budgets developed by the Executive branch. The Commonwealth Fund (a liberal think tank) has determined that all financial projections of ACA costs were inaccurate, but that the CBO was closest to the actual. This current CBO report was done in association with the Congressional Joint Committee on Taxation. It is “quick and dirty” because the sudden appearance of the two bills surprised them. The CBO states it had insufficient time to project the cost effects on states and other “macroeconomic” effects, as required by the House of Representative rules for any “major legislation”.  The published projections actually represent the mid-point between low and high estimates, neither of which have been made public.

RepubliCare is projected to trim $337 Billion off the federal deficit over 10 years. According to the CBO most of the increase in the uninsured and the cost savings (federal only) would result from repealing the individual mandate, lowering the federal subsidies for low-income non-group policies, decreasing the federal subsidy to Medicaid by going to “block grants” to states, and stopping any expansion of Medicaid coverage after 2020.

CBO had three weeks to analyze the ACA. They had 5 days with RepubliCare. CBO 2010 projections of the ACA costs were lower than actual because 1) more people opted for Medicaid coverage than expected, 2) actual Medicaid costs per enrollee were higher than expected,  3) the individual mandate (currently a $695 yearly penalty for not buying health insurance) proved too weak an incentive for young people to buy insurance, 4) health insurance exchanges (the private insurers market place) attracted only about half of the projected number of people, and 5) the general economy improved slower than estimated (“did not match the Ronald Reagan Recovery curve.”)

Rather than boring you with repeats of the number of “millions losing health insurance per year” under RepubliCare, here are some “fun facts” about it you can use to punctuate chats with your friends and colleagues:

  • It is 66 pages long. (That calculates out to about 8.25 pages per year for the writing pace of Paul Ryan (R).
  • 6 pages are devoted to changes in Medicaid eligibility rules, including the interesting item prohibiting any Lottery winner from being eligible for Medicaid.
  • replaces the individual mandate ($695 penalty tax) with tax credits worth about 1/12th of the average yearly insurance premium (for anyone, of course, who has a taxable income).
  • eliminates the 2.3% tax on medical devices. (The Advanced Medical Technology Association is the only Massachusetts medical organization that has expressed support of RepubliCare so far)
  • eliminates the 10% tax on tanning stores (Probably a blatant try for support from Trump and ex-senator John Boehner (R). Actually, pale Paul Ryan (R) could use a visit or two, though universities and colleges across the country are limiting student access to tanning stores because of the increased risk of melanoma).
  • removes coverage for substance abuse and mental health services by 2020.
  • eliminates tax surcharge on insurance executives “earning” more than $500,000 a year.
  • eliminates tax on big pharma-manufacturing companies
  • delays implementation of 40% tax on “Cadillac” health insurance policies for high income people until 2025.
  • prohibits Medicaid reimbursement to Planned Parenthood for any of their services. (a major source of revenue for the 97% of preventative and non-abortion treatment services PP provides)
  • retains prohibition against denying pre-existing conditions (but imposes a 30% surcharge for such for 1 year).
  • retains coverage of children under 26 on parents’ policy.
  • retains coverage for contraceptive and maternity benefits.
  • retains prohibition of any surcharges on women’s policies (“gender equivalence”)
  • allows elders to be charged 5 times the premium of younger people. (AARP is all over this one as age discrimination) ACA allowed a 3:1 premium ratio.
  • increases maximum contributions to Health Savings Account (HSA) from $3,400 to $6,500. ( Great , if you are making enough money to save.)

Liberals, Democrats, many Republicans, many governors, hospitals, physicians, the AARP, and even conservatives don’t like the bill.

“The AHCA does what it was intended to do; it lowers federal spending and reduces the number of people with health insurance.” (Michael Chernew, MD, Harvard University)

“ It would repeal far less of ObamaCare than the bill Republicans sent to President Obama one year ago. The House Republican leadership bill does not replace ObamaCare. It merely applies a new coat of paint to a building that Republicans themselves have already condemned.” Cato Institute 

Republicans in Congress are claiming that the CBO did not cover the “whole” plan. “What was not covered was what else we are going to do in terms of ‘regulation reforms’, state Medicaid rules, and future bills.”

I believe we are being asked to buy a hastily produced “pig in a poke”, an even bigger pig in a bigger poke than Obamacare.


Vol. 163 January 16, 2017 From Zero to $7,500: One Consequence of Obamacare Repeal.

January 16, 2017

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“As a doctor, I will take it and make it my mission
to heal the nation, reverse the course of Obamacare,
and repeal every last bit of it. ”
-Rand Paul

What exactly could happen if Obamacare was taken away? My daughter’s recent landing of a second part-time job offered an opportunity for me to understand the possible result in one case.

As a singer-songwriter, energy healer, and part-time retail clerk my daughter shares a common situation with many on Cape Cod; an annual income of less than $16,000, which is the current federal definition of poverty.  She is therefore eligible for Medicaid in Massachusetts. She pays no premium, has no deductible, and except for some named prescription medicines she has no co-pays. Preventative, pre-natal, and behavioral health services are covered. Her out-of-pocket cost per year is essentially zero. Some Obamacare repealers want to roll back the extension of Medicaid eligibility financed by federal subsidies. In many states that would strip this kind of  coverage from many of those newly covered under the ACA, but that is not a possibility in Massachusetts.

In my daughter’s case her new, second part-time job may push her annual income over $16,000. If so, she will no longer be eligible for Medicaid. As a part-time worker she is not be eligible for an employer-sponsored (and partially paid for) health plan. Her employer’s HR department told her she could buy a basic policy with a $2700 annual deductible for $226 a month through the school. “Co-pays varied and are difficult to predict.”  For her that is a new potential cost of $5400 out-of-pocket per year.

She got married last year and her spouse is in the same “low-income” bracket, so she inquired about a family policy (“for 2”). The answer: $400 a month at the same $2700 deductible amount for a $7,500 potential out-of-pocket cost. A $7,500 out-of-pocket cost “exposure” per year is a big nut for a family earning less than $22,000 a year.

Her other choice (besides going uninsured and paying a fine of $300-$2,085 in 2017 depending on income level) is buying an individual policy through an ACA Health Insurance Exchange. Under Obamacare any individual that is making less than 138% of the federal poverty level (about $22,000) can shop for a policy via a state or federal health insurance marketplace (also called health insurance exchange).  The exchanges can offer federally-financed subsidies of up to 60% of premium for eligible “working poor”. After lengthy website surfing, face-to-face help from the Health Connecter facilitator at a local hospital, and several phone calls with prolonged holding periods, she discovered that she could buy about the same basic policy of $2700 deductible for $226 a month through the health insurance exchange. BUT, despite providing all sorts of financial info they could not tell her…”yet” … what the premium would be and whether she was eligible for a premium subsidy. She was told that “things were in flux”, and that she could get a “call back in a week or two about that”. The enrollment deadline for signing up is January 31.

Just “for the fun of it” and to satisfy my curiosity I masqueraded online as my daughter to experience the health insurance application process via the Mass Health Connector. Over three different days I persisted on the internet and on the telephone to try to get the answer to : ”What would it cost to buy a basic individual health insurance policy?”  After reviewing and clicking on 5 to 7 different logos with unfamiliar company names, after entering the same information on multiple screens, after holding for more than 20 minutes on three separate phone calls, after being passed on to three different “responders” on one phone call, and after twice being hung up on after saying that “I was currently on Medicaid, but was looking for insurance to start February 1 when I would become ineligible”, I GAVE UP THE QUEST WITHOUT AN ANSWER.

Different sites had different definitions of “basic” and most had three or more different levels of benefits (coverage). Descriptions of benefits were quite lengthy and often complex.  For instance, the Bronze (basic) Level of “Access Blue Saver II“ (from Blue Cross; the easiest comparison charts to read) offered a 9 page policy offering no preventative or prenatal care with a $3,350 deductible and $60 co-pay for office visit and $1000 co-pay for an ER visit. Silver, Gold, and Platinum “Access” policies had different benefits. I could not get any information about actual premiums without further phone calls to “licensed brokers.”

Why is this so convoluted and confusing in contrast to the simpler processes of Medicaid and Medicare? One answer is that individual insurance policies are a gamble. For instance, a life insurance policy is really a bet between you and the insurance company. If you lose (die), you win (receive all the premiums back). If you win (out live the term), you lose and the company wins (keeps all the premiums). Another answer is that 400,000 people more than 2015  are flocking to sign up through health insurance exchanges.(1)

Obamacare has not changed the basic premise of individual health insurance policies, and the insurance companies are trying to make their  “best bets”. The betting odds are not as clear as the 1:6 of Russian Roulette, though we know that lack of health insurance can be lethal. The betting odds are more like those of Black Jack. The dealer (health insurance company) is using multiple decks, other players (consumers) at the table can affect your odds, the best odds are not always intuitively obvious, and the dealer (health insurance company) can change the betting rules every year.

Medicaid and Medicare are insurance programs based on large populations and therefore need less of the gambling “tricks of the trade” of writing individual polices. Hence my support for a health insurance program based on a large population, sometimes called a single-payor system. If not “Medicare For All”, then how about state-based programs of “Medicaid For All.” (2)

References:
1. Boston Globe, pg.2, December 22, 2016, from the NY Times.
2. NEJM, 375;26, December 29, 2016, “Maintaining Insurance Access Under Trump – A Strategy”


Vol. 161 January 1, 2017 Recap of 2016 Hubslist Blogs

January 1, 2017

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“Don’t look back.
Something may be gaining on you.”
-#6 of Satchel Paige’s Guides to Good Living

Click on the date to view the entire blog.

January 1 –   “How bad is the heroin epidemic on a scale from 1 to 10?” Could physician compliance with the patient-reported pain scale have contributed to the over prescription of opioids?

February 1 –  From Z to A – Zika virus to autism with G and F for gluten-free diet in the middle.

February 15 – The “single blood drop” lab test that never panned out (my largest pile of misplaced enthusiasm and the poorest stock tip ever) and “Uber Doctor”.  The founder of Theranos was banned from engaging in any laboratory business for 2 years.

March 1 – “Smith” as the most likely name of your doctor went from #1 in 1930-39 to #4 in 1980-89, replaced by “Patel”, “Shah”, and “Lee”. The largest contingent (20%) of foreign-born U.S. physicians came from India during that period.

March 15 – Health apps (and now Alexa apparently) are not “secure” since they transmit data about your personal use back to company headquarters (at least, not to the NSA … we think)

April Fools Day – TrumpaCare Health Plan Revealed. It doesn’t read quite as tongue-in-cheek now as it did then.

April 15 – The bathroom bill and how diclofenac killed all the vultures in India and why that matters.

May 1 – Multiple private insurance companies pull out of Obamacare (ACA) which somehow continued to be attacked as a “socialistic, single-payor” scheme.

May 15 – Medical fun facts about three presidents and Obama’s prediction in third grade about becoming President and “visiting all the places in Indonesia”.

June 1 – Placebos work better as therapy if they cost more. The Chinese reduced adult myopia by getting the kids to play outside more often while 40% of U.S. toddlers (under 2 yo.) already play with an electronic mobile device.

June 15 – Annual update on sun and bugs … actually anti-sun and anti-bugs.

July 15 – Medication Assisted Treatment (MAT) of opioid/heroin addiction works pretty well without making the patient lie down. So, more beds are NOT needed and are NOT the answer.

August 1 – Five reasons that playing video games improves learning in kids… IF the content is right.

September 1 – Various “redefinitions” of medical “truths” about teen age pregnancies, blood pressure medicines, and lead exposure.

September 15 –  How to be an appropriately skeptical reader of media reports of “medical advances” … aka “Beware of Percentages” in hyped reports of improved outcomes.

October 1 – “Light up or not.” Pros and cons of recreational marijuana referenda on 8 state ballots.

October 15 – Asking your doctor to make you a “DNT ” after “a certain age”. Nine medical tests that can be optional after 65 because their benefits are elusive and results may cause more problems than they are worth. Choose Wisely website.

November 1 – A really scary clown CAN kill you. The same physiological mechanism may have caused Debbie Reynolds’ sudden death while she was planning Carrie Fisher’s funeral.

November 15 – Real health CARE reform is the way to improve on the health care INSURANCE reform of Obamacare.

December 1 – Less old people are leaving their car keys in the refrigerator while Germany and Japan residents gain more weight in a year than we do.

December 15 –  Though the stakes are high (lack of health insurance causes 45,000 unnecessary deaths in the U.S.) it will probably take two years for Trump and the Republican Congress to turn back the accomplishments of Obamacare.
I am hoping that as an unintended consequence of their reframing of the ACA, the law will actually be improved.

HAPPY NEW YEAR from an eternal optimist.


Vol. 160 December 15, 2016 ACA or Not ACA, That Is The Question.

December 15, 2016

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As Trump continues to form his cabinet and Obama counts the days left while Hillary remains hidden in the woods, speculation about what will happen to the Affordable Care Act (ACA) is wide-ranging. Will it be repealed? CAN it be repealed? What will replace it? What if nothing replaces it?

It may help to remember that the vast majority of citizens who had health insurance before ACA were already heavily subsidized by government funds via Medicare, Medicaid, and tax subsidies for employer-sponsored insurance ($300 billion for the employer-sponsored policies alone). Studies have shown that 5% of the population accounts for 50% of health expenditures. The least costly half of our population accounts for 3% of the expenditures. (This is, of course, the essential element of risk spreading that makes insurance of anything “work”.)

ACA accomplishments since 2010

23 million citizens have gained health insurance coverage
-coverage that is not denied due to pre-existing conditions
-coverage of children up to 26 yo. on parents’ policy
-more than half of those (13.7 million) gained coverage under expanded Medicaid (by increasing the eligible income levels)
-all but 19 states took the federal subsidy to expand Medicaid coverage

Uninsured citizens dropped from 16% in 2010 to 9% in 2016
91% of U.S. citizens now have health insurance coverage (Spoiler Alert: in our big, or should I say “Hu-u-y-ge”, country that 9% translates into 29 million citizens still un- or underinsured.)

All this without additional net cost over the cost of medical services that was predicted in the U.S. without the ACA, i.e “no net increased cost due to the ACA.” (The largest single source of spending increase since 2013 was “retail pharmaceuticals”.)

Reduced “gender bias” by mandating maternal health benefits (coverage of contraception) as part of essential benefits package.

Mandated some mental health service coverage.

Mandated some coverage of substance abuse services.

What about repeal?

Unlikely, but possible. Outright repeal could immediately create another 23 million people without health insurance which would dump all that cost burden back on the states, the insurance companies, and the health care providers.

Repeal would require 60 votes in the Senate, and the Republicans are 8 short. There is speculation that some Democrats running for reelection in 2018 might join a repeal vote knowing that some of their Democratic colleagues that supported Obamacare lost reelection in 2016. The Gallup poll currently puts the public attitudes toward Obamacare at 50/50 “favorable/unfavorable”.

“Replacement” of selected provisions is more likely since it could be done as part of the “budget reconciliation process” which requires only a simple majority of 51 votes.

Replacement?

Coverage to age 26 on your parent’s policy and ban on denying coverage of pre-existing conditions are so popular that they are here to stay.
What parts might Republicans target to replace?
(An “ACA repeal bill” passed by the Senate in 2015 and vetoed by Obama gives us some clues).

Individual mandate – Even though this was proposed by Republican Mitt Romney and successfully passed the Supreme Court test as a tax, this penalty for not getting health insurance rankles the Republicans, and a sizable portion of the public. Proponents argue that it is essential to incentivize “healthy people” to buy insurance, a fundamental principle of spreading the risk over a large group.

Block grants to the states and/or vouchers for Medicare – Block grants would change this federal standard “entitlement” program into a state-controlled one with variable benefits and premiums. Vouchers, touted as making consumers more “powerful in the marketplace”, really shift the obligations (“unpaid bills”) to the states and health care providers

Reduce income level eligibility for Medicaid from the ACA level of 138% of federal poverty level (about $22,000 for a couple) back down to about $16,000 a year for a couple.

Middle-class subsidies via insurance marketplaces to be replaced by Health Savings Accounts (HSA), tax credits, across-state line insurance policies, and reestablishment of high-risk pools. All of these are advantages to people who have income, often sizable incomes.
-70% of HSAs are currently held by people with over $100,000 annual income.
-Many insurance companies already sell across state lines, but this provision would free companies from state mandated benefits and other state regulations.
-Reestablishment of high risk pools could provide higher premium policies for those with chronic diseases without unduly penalizing healthy individuals. This reflects a trend back toward indemnity or catastrophic insurance policies with few preventative benefits.

Rescind the new taxes to fund the ACA – details on how to pay for replacement provisions TBD.

Maternal health benefits– Trump suggests making contraception available over-the-counter without a prescription, thus avoiding the problem of exempting churches from this mandated benefit. Planned Parenthood would, of course, be defunded.

Medical liability reform – Though a cherished symbol of support of and a psychologically warm and fuzzy concept to physicians, all studies show that no significant cost reductions occur from tort reform because the actual cost of “defensive medicine” is very small compared to the total.

What about ACOs?

Remember them? Accountable Care Organizations are physician groups and hospitals organized together to reduce costs without degrading quality. The first ACOs, so-called “Pioneer” ACOs, could keep a share of any savings if they delivered care to a defined population at a cost below a “target cost” without missing any of the “quality targets.” If they overshot the “target cost”, they would owe money to the federal government at the end of the year.

This is the last year for the original 32 Pioneer ACOs, and only 16 remain in the program. Half have withdrawn from their contracts because of losing money, continuous wrangling over targets, and lack of flexibility in defining risks and benefits. The “Next Generation” ACOs are due to sign up in January 2017, and most will opt for sharing savings without taking financial risk for losses.

Bottom Line:

The vetoed 2015 Senate “ACA repeal bill” had a two-year transition period embedded in it, so even if a repeal bill is passed and Trump signs it the loss of health insurance will not be immediate. Many political experts, if we can still use that label for them after this election, suggest that even “replacement” of ACA provisions will be politically difficult and will take at least two years to pass. A new study by the Urban Institute shows that Paul Ryan’s proposed Republican replacement plan would result in more uninsured citizens than existed before ACA. 80% of those losing insurance would be part of a working family.

How high are the stakes? A 2009 study by Harvard Medical School and the Cambridge Health Alliance estimated that the lack of health insurance led to almost 45,000 unnecessary deaths. “Lack of health insurance can be fatal.”

So, for a variety of reasons, the next two years will be “vel-l-ly in-ter-esting” In the meantime if you have health insurance through a ACA-based insurance marketplace make sure you re-enroll by January 31 to continue coverage.


Vol. 158 November 15, 2016 REAL Health Care Reform

November 15, 2016

Trump 2Mr. Trump (now that he is President-elect we need to show “Donald” some respect) has recently said that he may keep the Affordable Care Act (Obamacare) ban against denying coverage for preexisting conditions as well the extension of parental policies to  26 -year-old children because “everyone seems to like those provisions”. As President-elect Trump begins to soften his bombastic, total opposition to Obamacare (and replace portions of “the Wall” with a fence) the 1.2 trillion dollar question becomes, “what is he going to do next?”

Since passage of the ACA 20 million Americans have gained health insurance coverage. 63% of that gain was produced by expansion of Medicaid in the half of our states that choose that federally subsidized route under ACA. The other 40% of increased coverage came from the federally subsidized premiums on policies purchased through health insurance exchanges. Not every state established health insurance exchanges, and  those states that did establish exchanges were twice as effective in getting people to enroll in health insurance.

The “individual mandate”  that was resisted so fiercely by Republicans as “another government tax” was originally composed by Governor Mitt Romney and  became law in Massachusetts years before the ACA passed. The  ACA 2014 “individual mandate” was  a $95 fine if you did not obtain coverage, and it proved to be fairly ineffective. In 2016 that fine goes up to $695 (or 2.5% of your taxable income), so it may prove more of an incentive this year. (1)

What about the rest of the ACA? We shall see, but just tinkering with the ACA (“repeal/replace” or “fix”) raises the concern that we may waste a lot of time and energy getting entangled in the trees while losing sight of the forest.

Can we get REAL about health care reform, or do we just continue arguing about health care insurance? It just so happens that a physician colleague of mine wrote a succinct, clear, eminently quotable Op Ed column about that question in our local paper yesterday! (2)  I  am going to shamelessly plagiarise* it.

“We have given providers incentive to ration care and collect data while ignoring non-provider stakeholders responsible for major system expenditures.”
.             Like: big pharma that advertises directly to consumers for great profit
.                       medical device companies with excellent, high-paid, effective lobbyists
.                       health insurance companies with more lawyers, consultants, lobbyists, and way more overhead than Medicare.

“We seem determined to jump through ever more hoops to limit provider options while the rest of the industry revels in the lack of any kind of market control.”

“Resources that used to represent [provider] profit or ability to retain staffing are now spent on fighting insurance claims and bolstering hospital advertising budgets.”

New payment-bundling schemes with buzz words like “pay for value”, “pay for performance”, and “population basis” will “transfer unprecedented financial risk to providers.”

“Constraints placed on health care providers cannot adequately repair our system.”
What actions can repair our system according to Dr. Urbach?
.              “expanding the public option should not be politically toxic” when  50% of Americans are already covered by government
insurance;
.               reforming malpractice tort law to save big dollars by reducing the costs of “defensive medicine”;
.               having thoughtful discussions about appropriate use of resources at end of life;
.               allowing Medicare to negotiate drug and device costs;
.               devoting adequate medical resources to the mentally ill rather than putting them in jail.

“We must stop pretending that exerting ever more financial pressure on our doctors, nurses, and hospitals (while ignoring bigger fish) will get the job done.”

Now, Dr. Urbach is not a disgruntled primary care physician who is whining about poor reimbursement and non-appreciation of his skills and talents. He is an experienced, well-respected cardiologist, a specialty near the top of the payment and prestige pyramids, who shared these reflections on the occasion of his son’s graduation from medical school. He prays that his son and his peers “will not only make themselves into great clinicians, but that they will also do what my generation of providers largely failed to do – make themselves into a courageous political force that can effectively force comprehensive reform of the heath care system by demanding sacrifice from all stakeholders, not only the caregivers.”

And I say, Amen.

References:
1. New England Journal of Medicine, 375;17,  October 27, 2016, p.1605
2. Cape Cod Times, November 14, 2016. “Let’s get real about health care reform”; David Urbach, MD
* “When you copy one person’s words, it is plagiarism. When you copy many persons’ words, it is research.”


Vol. 151 July 15, 2016 Heroin Users Don’t Need To Lie Down To Kick The Habit.

July 15, 2016

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“It is how you act, not what you take, that defines you as an addict.”

 

 

Much is being said and written about our current “opioid use/abuse epidemic”, “heroin addiction epidemic”, “opioid dependency problem”, “opioid crisis”, or other politically-correct term that catches your fancy. Speculation, and some good data, is abundant about causes, prevention, treatments, and consequences. Today’s blog will restrict itself just to treatment, Medication Assisted Treatment, or MAT. Outpatient MAT using Suboxone (1) has proved to be effective  treatment for the disease of opioid dependency. Opioid addiction is a disease that we can treat, just like we can treat diabetes with insulin.

Many popular press articles and consultant’s reports are calling for “more opioid treatment beds”, BUT you don’t need a bed to detox from heroin dependency. In fact, most heroin dependent patients don’t even need to “detox”, in the traditional sense of abstaining from a substance for days, going through withdrawal symptoms for days, and coming out “clean” at the other end.

This cry to “increase beds” as the answer to opioid dependency sounds to me a bit like the cry to increase hospital beds in the 70’s and 80’s. In hindsight that urge looks misguided at best as we marvel today at replacing heart valves without surgery with 2 days in the hospital rather than 2 weeks, delivering high potency intravenous medications from the ICU formulary to patients in their homes, and the sprouting up of numerous networks of hospital-run ambulatory diagnostic, treatment, surgical, and urgi-centers. It is getting to the point where they barely let us lie down for some procedures before we are out the door.

Most substance abuse detox centers are based on the alcohol detox model with a bed in a protected residence, help with alcohol withdrawal symptoms by IV or IM or oral medications, IV hydration if necessary, and behavioral support. That model is NOT relevant to heroin dependency treatment, and, as we now know, it does not work very well.

Heroin or opioid detox centers could be described as “revolving doors” as revealed in numerous studies and as depicted in a recent HBO film. Studies have shown that people with substance addiction undergo an average of 3-4 detox stays over a median of 9 years before staying free of substance abuse for 12 months. Each stay may be as long as 3 weeks and cost about $550 a day. Heroin detox stays may, in fact, increase the chance of a fatal overdose for a patient since their tolerance of heroin decreases, and their “usual dose” before detox, if they relapse and take it, may be too much for them. “Recent abstinence is a major risk factor for fatal opioid overdose.” (2)

Today a heroin or opioid user seeking treatment for his disease can walk into a health care provider’s office and receive his first dose of Suboxone in as little as 12-24 hours after his last dose of heroin. That is how fast heroin “washes out” of the body. (Unlike alcohol withdrawal symptoms, like the DTs, which may not start until 2-3 days after the last drink.) Most heroin users starting on Suboxone experience only mild withdrawal symptoms like jitteriness or changes in bowel movements which can be treated with numerous oral medications “on the hoof”. They do not have to lie down. Their behavioral support system, required by all high quality MAT programs, can be initiated and nurtured “on the hoof.”  After the first week or 10 days the Suboxone prescriptions (filled at the local pharmacy and covered by most insurance plans) are issued on a monthly basis while the outpatient mental health visits and behavioral support groups continue. A patient on Suboxone can be treated both medically and behaviorally for a year for about the same total charge as a 3-week detox center stay.

“Treatment of drug use does not require lying down.
Stand up for yourself!”

Our current thinking about the urgent need for more opioid treatment beds may be part of an outdated, knee-jerk response by legislators and policy makers to “do something” about the opioid crisis. Policy changes and public funds might be better focussed on effective, ambulatory Medication Assisted Treatment (MAT) rather than “more beds”.

References:
1. Suboxone is taken daily in tablet or sub-lingual form and contains two drugs: Buprenorphine relieves pain like opioids but does not produce euphoria plus Naloxone which causes immediate withdrawal symptoms if taken intravenously or intramuscularly.
2. New England Jour of Medicine 373;22, November 26, pg. 2015, 2095-7;  an excellent brief history of a century of Federal drug control.


Vol. 147 May 1, 2016 Why UnitedHealth Group Is The Poster Child For What’s Wrong With Our Health Care

May 1, 2016

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UnitedHealth Group, the nation’s largest health insurer, said Tuesday
that in 2017 it will exit most of the 34 states where
it offers plans on the Affordable Care Act insurance exchanges.

                                                          –Washington Post, April 16, 2016

 

The creation of state health insurance exchanges were incentivized by the Affordable Care Act (ACA) in order to encourage the offering of health insurance policies at competitive prices to individuals not covered by employer plans. Individuals that earned just enough to be ineligible for Medicaid coverage (aka “the working poor”)  could apply for federal subsidies to help pay for exchange health insurance policies. Health insurance companies anticipated that many uninsured people would become premium-paying people resulting in a significant revenue increase to the health insurance companies.  Like any insurance scheme, all the companies had to do was to set “competitive rates” (based on their actuarial estimates) that would bring in more revenue than the expense of what they would pay out for claims.

UnitedHealth Group (UHG) is withdrawing from 34 state health insurance exchanges because the company lost $650-720 million on their exchange policies (aka “marketplace polices”);i.e. claims for medical care received exceeded the premium revenue. Speculations about the reasons for this include:  the companies priced their policy premiums too low in response to the competitive nature of the exchanges (“They screwed up”);  the people who took out these policies were inherently “high-users” of medical services; or the higher than estimated use of medical care represented a backlog of unmet need for medical care.

The fact that the ACA has decreased the uninsured and underinsured in America by 36 million is uncontested.  About 12 million or 33%  of these people gained access to medical services from policies available from the health insurance exchanges.  Close to 87% of those were eligible for and received partial subsidies for the cost of premiums. Most of the rest of the increased access came from expanded state Medicaid insurance subsidized by the federal government under ACA. But 11 million individuals remain uninsured,

“…Depicting the Affordable Health Care Act as a “slippery slope” to single payer is bizarre, given that it relies on private insurance.” (1) Health insurance policies have tremendous influence on medical care delivery by determining who is eligible for what medical service and where. Differential rates, deductibles, and co-pays can favor one type of delivery site (hospital bed, ER, ambulatory center,  provider’s office, home care, or nursing home) and even the type of provider (MD, NP, or PA). Specific coverage for selected medical services (named and unnamed when you buy the policy) can be denied. Coverage of prescribed drugs and even procedures can be unilaterally changed annually by the insurance company simply by mailing to policy owners a fine-print booklet that lists what will be available and at what price for the coming year. In a more positive vein, one study showed that in states that expanded their Medicaid programs under ACA the number of newly diagnosed cases of diabetes increased by 23% as opposed to less than 1% in states not choosing to expand Medicaid. Early diagnosis can be life-saving and cost-effective in a chronic disease with effective treatments like diabetes .

The effect of UHG’s withdrawal will have little real effect on the insurance offered by the exchanges. Premiums for policies from the remaining companies may only increase by 1% or $4 a month. But the UHG withdrawal brilliantly spotlights the profit motive as the basic driver of our health insurance system. Private health insurance has a place in any medical care system, and does exist in most, if not all, of the state-based universal health insurance programs in other developed countries, but only in the U.S. do the profit-motivated health insurance companies have such profound influence on to whom and how medical services are delivered.

Despite what some members of my Monday night pool group may say of me,  I think capitalism is great. It has produced multiple “wonder drugs”, nurtured the widespread distribution of fantastic medical technologies, and can provide the best medical care in the world… for many… but not all.   I also think that is silly to think that profit-motived health insurance will ever be able to provide universal access to medical care, a universal access that could enhance the continued physical and economic good health of our country.

References:
1. The Virtues and Vices of Single Payer Health Care, NEJM 374;15, April 14, 2016; 1401; J. Oberlander, Ph.D.

 

 

 


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