Theft? Madness is more like it

In the process of catching up on Google Reader post-convention, I came across this recent post from Robert Centor criticizing a recent NY Times Magazine article alleging that ‘America is stealing [sic] the world’s doctors.’ As Dr. Centor rightly points out, this is utter nonsense, on multiple levels. In this post, I want to address the aspect of the “foreign doctor/brain drain” question that applies to students like me; in the next I talk about physician and other “brain drain” more generally.

As a student at an LCME-accredited American medical school, I don’t fall into the “international medical graduate” (IMG) category in quite the same way as those in the article. And despite the fact that I’m “only” Canadian, I’m still foreign enough to have to figure out where my next visa will come from for residency, fellowship, and beyond. This post will not be an extended disquisition on the finer points of American immigration law and visa classifications (subjects with which I am far too familiar). You will, however, get a taste of how dysfunctional the American approach to foreign physicians is, especially at a time marked by widespread predictions of an impending doctor shortage.

Most public medical schools in the US and many private schools will not even consider non-citizen/non-permanent resident (foreign) applicants. Those of us who do get an offer somewhere find that we are not eligible for US government financial aid, and for a great deal of school-based aid as well. Despite this, we still benefit indirectly from taxpayer subsidies. Tuition makes up a minuscule fraction of medical school revenue; according to SUMS‘s tax returns, our tuition barely covers the costs of the medical education and educational technology support staff. Nothing more. The rest comes from patient care revenues and various grants, much of which in turn comes from the taxpayer.

After receiving a medical education at great personal financial cost (debt), yet one that’s also heavily subsidized by the US taxpayer, the expectation is that we go home. Or at least leave the country. Completing post-graduate training in the US requires finding residency programs that are willing to sponsor one of the two main types of visas that can be used for this purpose: the J-1 comes with a 95% iron-clad requirement to leave the US and work in one’s home country for two years upon completion of training before one can come back to this country; the H-1B comes with a 100% iron-clad time limit of six years (for reference, here is a list of residency length by field, not including sub-specialty fellowships). Even assuming one could find and be accepted into a program that will sponsor either visa, neither seems particularly conducive to “theft” of foreign physicians.

Unlike in medical school, foreigners in US residencies and fellowships often do benefit from direct US taxpayer subsidy, as Medicare pays for most residency positions, including salary and benefits. So what happens to foreigners who receive direct government subsidies to train in their specialty?

Again, the expectation is that we will go home (in the case of the J-1 visa), or at least leave the country (in the case of the H-1B). The United States is one of the few, perhaps the only, developed country that requires all long-term immigrants to be sponsored by an employer or a family member. There is no “points” system for independent applicants; no way for someone like me to prove that I’m smart, talented, possess in-demand skills, and probably ought to be allowed to stay indefinitely (not to mention the hundreds of thousands of dollars of subsidy I will have enjoyed by this point). More shockingly, there’s seemingly no desire on the part of the US government to hold on to the medical talent that it paid to develop.

What employer would sponsor a foreign physician? Moreover, what employer would sponsor any employee for permanent residence before at least a few years of full-time employment have passed? The H-1B comes with a six-year time limit; look at the length of various residencies at the link above. We’re short primary care physicians (3 years), yes, but we’ll be short general surgeons (5 years) and cardiologists (6 years) as well.

I, and those in my situation, are the lucky ones, comparatively. We don’t even have to jump through extra hoops for medical licensure and board certification the way “real” IMGs have to. It’s a wonder anyone manages this at all.

If the United States is “stealing” [sic] foreign physicians, it’s one of the most tragically/comically inept thieves I’ve heard of. Even in my “easy” case, after I will have spent 7+ years being educated at world-class American schools (11+ if you count college), the US is happy and indeed seemingly eager to see me go.

Some people would approach this conundrum entirely differently. They would argue that because foreigners in the American medical training process receive indirect and then direct government subsidies, the process should be closed to them in the first place. I understand the logic, but this strikes me as doubling-down on the foolishness of the current system. Getting into medical school and residency is frighteningly competitive. Being a foreigner only makes it harder. I make no claims as to myself, but one would therefore expect the marginal foreign applicant to be at least as good as the marginal American applicant… if not better. That some of them manage to stay in the US to practice medicine even in spite of the numerous hurdles along the way should suggest even more strongly that these are the people you want to hold on to.

Cavalcade of Risk #149: Single Best Answer

As I mentioned earlier, I’m starting to rev up the studying for the licensing exam. A lot of the studying takes the form of practice questions. They’re actually a lot of fun to do: they force you to think actively about the clinical scenario, keep you on your toes, and make it near-impossible for your eyes to glaze over as you semi-consciously read the same page for the 10th time in a row as your eyelids begin to feel heavy, droop, and you start to….

Yikes! Where was I? Right! The Cavalcade is back! Since I’m sure that most of you don’t believe me when I say that doing practice questions is actually fun, I’m going to use this opportunity to try to convince you. With the aid of sophisticated, peer-reviewed psychometric techniques (or not), I have converted each entry into a USMLE-style “single best answer” multiple choice question. Let’s see how you do!

 

Cavalcade of Risk: Step 1[49]

 

Instructions: For each of the following test items, select the one answer that best answers the question posed in the stem.

From Boomer at Boomer&Echo: Which of the following behaviours of financial advisors correlates with the lowest risk of defrauding investors?
a) Claiming to have secret/exclusive insider tips that “your broker doesn’t want you to know.”
b) Counseling clients that investments with higher expected returns tend to be riskier.
c) Offering to move your money offshore to avoid taxation.
d) Pressuring you into making a hasty decision on an “exploding offer.”
e) Charging abnormally high membership fees.

From Ken Faulkenberry at the AAAMP Blog: If shares of the Notwithstanding Blog Internet Empire (NBIE) earned a 8% return in 2011 and exhibited a beta of +1.2 relative to a benchmark of shares in all medical blogs that collectively earned a 5% return, then:
a) The alpha for NBIE in 2011 was +2, making it a good investment.
b) The alpha for NBIE in 2011 was +3, making it a good investment.
c) The alpha for NBIE in 2011 was -3, making it a bad investment.
d) The alpha for NBIE in 2011 was -6.8, making it a bad investment.
e) The alpha for NBIE in 2011 cannot be calculated with this information.

From Van R. Mayhall III at the Insurance Regulatory Law Blog: Which of the following statements DOES NOT accurately characterize insurance company insolvency:
a) Most state-based insurance guaranty associations are more comparable to private member-based associations than true state agencies.
b) Insurance companies are subject to unique state-based insolvency protocols in lieu of entering the federal bankruptcy system.
c) Payouts from state insurance guaranty associations are subject to statutory caps.
d) Insurance guaranty associations are intended to provide “bailout” financing to prop up faltering insurers.
e) None of the above.

From Emily Holbrook at Risk Management Monitor: The shoe-shopping website Zappos.com recently earned positive press for:
a) Losing your examiner’s personal information, along with that of millions of other customers.
b) Locking out customers from your examiner’s home country for 4 days after a data breach.
c) Being named in a potentially-class action lawsuit seeking damages as a result of a data breach.
d) Having “some analysts” criticize the company’s response.
e) Having “some analysts” praise the company’s response.

From Jason Shafrin, the Healthcare Economist: Medicare’s new value-based purchasing initiative, which aims to reduce payment to “low-quality” doctors, currently uses treatment costs for which of the following chronic diseases as an element of its cost measure (as distinct from its quality measure):
a) Hypertension
b) Alzheimer’s disease
c) Diabetes
d) Lung cancer
e) Breast cancer

From Louise Norris at Colorado Health Insurance Insider: Colorado’s Medicaid program has recently undergone much change and provoked a great deal of controversy. What happened at the end of 2010 to put Colorado’s Medicaid program on better financial footing?
a) Successful negotiations to lower the fee schedule for physicians’ services.
b) A 55% increase in enrollment relative to 2007.
c) A one-time $13.7 million grant from CMS.
d) New dedicated revenue from a sales tax increase.
e) The introduction of Medicaid Managed Care programs.

From Dr. Jaan Sidorov, the Disease Management Care Blog: Which of the following is an accurate characterization of Dr. Sidorov’s assessment of Health Insurance Exchanges (HIEs) and recent Kaiser Health News commentary on the subject?
a) The left is doing their best to nurture this fledgling institution to maturity in anticipation of the PPACA’s full rollout.
b) It’s reasonable for consumers to spend more time shopping for consumer electronics than for health insurance.
c) Government-run HIEs will eventually match the ease-of-use and “cool” factor of iPhone apps and online purchasing aids.
d) Multiple insurance options on HIEs include variations in provider tiers, out-of-pocket costs, and exclusions.
e) Consumer expectations for HIEs will eventually be exceeded.

From Julie Ferguson at Workers Comp Insider: Doctors’ deaths differ from the deaths of other Americans in that:
a) Doctors often choose to forgo lifesaving chemo, radiation, and procedures.
b) Paradoxically, doctors often do not have access to the full range of lifesaving technologies as the rest of society.
c) Non-physicians tend to be more ready to accept death.
d) Doctors have a cultural bias against accepting death that isn’t shared by society at large.
e) Non-physicians who choose to fight their disease are often pressured by friends and family to be serene in the face of death.

Answer Key
Of course, since you read all the entries, you don’t need one! But just in case: B; A; D; E; C; C; D; A.

Examiner’s Notes

As always, it’s an honour and a pleasure to host the Cavalcade of Risk! If this is your first time at the Notwithstanding Blog, or if you’re coming back after a prolonged absence, I encourage you to take a moment and poke around some of other posts here. From health care policy to health professions training (i.e. medical school), I’ve got it covered.

The 150th(!) Cavalcade will be hosted on February 8th at My Wealth Builder.

Some Friendly, Unsolicited Advice for PNHP

Physicians for a National Health Plan (PNHP), as the name suggests, is the biggest and best-known group of American physicians who support replacing the current health care system with a national single-payer. I used to be a big booster of this idea, but it doesn’t take much poking around this website to figure out that my feelings towards American single-payer reform have cooled considerably (to say the least).

I’ve been fortunate to attend a number of events run by senior PNHP officers at SUMS and at other venues (e.g. the AMSA conference back in March). At one of the more recent events, I had the privilege of speaking at length to some of their representatives at length. As you might expect, the resulting discussion was direct but cordial.

Though I disagree with their proposed policies, I do respect PNHP as an organization. It is one of the biggest mobilizers of physicians and medical students who are in favour of radically changing how American health care operates. Their passion is palpable at even the most informal event. They do have a contribution to make to the health policy conversation. Unfortunately, while there is an intellectually-coherent case to be made for single-payer (a mistaken case, in my view, but respectable and honest), I have yet to hear it from anybody at PNHP (n=small).

I harbour no illusions about my ability to persuade hard-core single-payer believers in a short blog post. I do, however, have some friendly and hopefully helpful advice on how to talk to the uninitiated and the un-converted more productively:

1) Don’t try to twist the data to support your case. It shows. At best, data on Medicare-vs.-private administrative costs are equivocal, cross-country infant mortality comparisons are spurious, life expectancy at birth captures a lot of mortality that is out of the hands of the healthcare system, and so on. The empirical case for single-payer superiority is thin gruel.

2) When someone asks whether you’d trust a Republican President and Congress to implement single-payer well, don’t duck the question. It’s a more important one than you seem to acknowledge. If you want to centralize control in government, be prepared to talk about how you will deal with your ideological opponents who tend to win elections every now and then.

3) Your moral argument is a lot stronger than your empirical argument. Why not make it explicit? Americans don’t tend towards collectivism, but neither are most people data-oriented policy wonks. Instead of making a weak case based on weak data, you should be prepared to talk about the moral strengths of single-payer relative to the alternatives. Where are the mentions of equity, obligation, and collectivism? (I ask this seriously, not passive-aggressively)

4) Be fluent in the language business, politics, and economics. When your executives are being matched point-for-point by medical students who majored in biochemistry and similar fields, you know you have a problem. If you’re going to call for the dismantling of private insurance, have some idea of how the sector actually operates. If you want to give control of the health system to government, be able to discuss the nuances of Washington power structures. Be able to respond to phrases like “deadweight loss,” “price-vs.-income problems,” and “underwriting” with more than a blank stare.

5) Anecdotes are rarely dispositive of policy questions. When someone points this out about anecdotes involving people you know, don’t get offended; this rarely advances discussion. When you introduce your friend’s problems to the debate, it’s not your opponent who’s trying to use them to score “cheap points.”

6) Milton Friedman is said to have told an up-and-coming Walter Williams, after the latter appeared on TV to discuss school choice, that “[Williams] was right about everything but [had] made one mistake […], when you talk about liberty, you have to smile.” You may not be talking about liberty as Friedman understood the term, but his advice is every bit as applicable.

 

The Other “Medicare”

I’m surprised that it’s taken me so long to devote even a cursory post to health care in Canada (or as it’s referred to back home, “medicare”). After all, as my disclaimers page says, “if the blog title didn’t give it away, I’m Canadian.” However, a recent series of posts at Medscape’s medical student blog “The Differential” [free registration required] inspired me to take on the subject.

I want to make clear at the outset that this post is intended to be descriptive. My thoughts on Canadian medicare and its implications for proponents of single-payer in the US can wait for another time.

Before delving into the Medscape commentary itself, we should begin with some general background on health care in Canada.^[1]

***

[1] – Much of this background was assembled while preparing a presentation that for the first  health economics course I took in university. I have done my best to bring things up to date. Depending on the minutiae of when laws are introduced vs. passed (and which of the two you refer to), some of the earlier dates in the History section may be 1-2 years off from what you read in some other sources.

History

Canadians feel strongly about their medicare. Most of them love it, or at least love the idea of it. If you’re a politician wanting to discuss the system in terms of anything other than providing more funding for the system, you’re likely to be toast in short order. And don’t even think about promoting “two-tier” health care! Governments at the federal and provincial level have risen and fallen based on the health care issue; it’s a major component of provincial government spending, and many Canadians view medicare as a component of national identity.

Government involvement in Canadian health care began in earnest in 1944, when the government in the province of Saskatchewan introduced a system to provide free health care to the elderly and retirees. This was followed shortly in 1947 by a public hospital insurance plan featuring a $5/person/year premium. In 1959 the socialist government of Tommy Douglas (considered one of the “fathers of medicare“) announced the first universal public health insurance program in Canada. Needless to say, Saskatchewanian (Saskatchewanite? Saskatchewanish?) physicians were wildly opposed, even going on strike for a few weeks in 1962.

A decade later, the ideals that drove the new program in Saskatchewan came to fruition on the national stage, as medicare was introduced in the remaining Canadian provinces beginning in 1967. This was not done in one fell swoop. The constitution in Canada has established health care as the domain of the provinces. The federal government rolled out medicare across the country not by fiat, but by offering matching funds (now block grants) to provincial health plans that met certain legislative criteria; this has given the federal government an important role in both financing and “regulating” provincial health care plans, though in recent years the federal share of health financing has fallen as low as 15-20%, with the rest paid by the provinces. In this sense, the structure of Canadian health care financing more closely resembles that of US Medicaid than of US Medicare. It should also be noted that both the earlier and current iterations of provincial health plans covered mostly to exclusively hospital and physician services: no home care, drugs, devices, etc.

Federal Legal Framework

By the mid-1970s, the last Canadian province had signed on to medicare and the program was not due for another major shake-up until 1984, the year the Canada Health Act was passed. The CHA is still the current governing framework for public health care in Canada. It re-affirmed the five basic criteria and two conditions for federal funding, but unlike the previous federal legislation, the CHA more clearly authorized the federal government to withhold transfer payments as a penalty for provincial transgressions.

The CHA imposes 5 basic eligibility criteria for provincial plans to receive federal support.

1. Public administration: each province’s health plan must be administered by a publicly-accountable, non-profit entity. In practice, this is usually a government agency or arm’s-length government-owned insurer.
2. Comprehensiveness: all “medically necessary” services must be covered, though provinces get surprisingly wide latitude in defining what is medically necessary.
3. Universality: all residents of a province must have access to public insurance on the same terms and conditions. In other words, all insured must be equal, and all are equally insured. The Act defines “insured persons” in such a way that treatment sought under worker’s compensation or auto insurance regimes escapes some of the dictates of the Act. In addition, provinces are allowed to impose minimum residency length requirements (e.g. 6 months in Ontario) before residents are eligible for coverage; in some provinces, this even applies to Canadians moving from other provinces.
4. Portability: provincial plans must reimburse insured persons for medical services used during temporary absences from the province, at least at the rate specified in the provincial plan’s fee schedule.
5. Accessibility: access to coverage must be uniform and barrier-free. There can be no discrimination or disparate treatment based on age, income, health, etc. On the provider side, provinces are required to have a clear and transparent fee schedule, with providers being “reasonably” compensated.

In addition, the CHA imposes two more specific conditions on funding that cut more closely towards health care delivery, as opposed to the five conditions that govern financing.

1. Balance-billing (or “extra-billing” as it’s sometimes called in Canada) is banned. Physicians and hospitals are not allowed to charge provincially-insured persons for provincially-covered services in addition to the province’s payment for the service. This is similar to US Medicare’s ban on balance-billing.
2. Provinces are not allowed to impose “user charges” for insured services. This became an issue recently as the government of Quebec toyed with the idea of introducing modest co-pays for some services for some insured. Not allowed.

The result is a “system” that’s not just one system. Each province (and possibly each territory?) has its own provincial health insurance plan that is run subject to the constraints of the Canada Health Act. The federal government administers health plans for members of the armed forces, the RCMP, and First Nations living on reservations. Worker’s compensation and auto liability insurance also play small roles.

The provincial plans are the major players, and are what most people in Canada and the US think of when they discuss the “Canadian health care system.” Though the criteria laid down by the CHA result in the appearance of national uniformity (and to be fair, a good deal of actual uniformity) in how health care is financed, administered, and delivered in Canada, there is a good deal of meaningful variation between provinces.

The Private Sector

One important dimension of variation is the role of the private sector in delivering and insuring services that are covered by provincial plans.  As of 2005 (I haven’t looked more recently, but am unaware of major changes since them):

• Four provinces (QC, AB, BC, PEI) allowed physicians and other covered providers to set their own fees for providing covered services without billing the province. However, these provinces did not allow any reimbursement of patients or providers for covered services not billed to the province. In addition, these provinces banned private insurance coverage of any service covered under the provincial plan, even if delivered in the private setting.

  In 2005, a physician and his patient sued the Quebec government, arguing that the ban on private insurance coverage of privately-delivered publicly-covered medical services violated the Canadian Charter of Rights and Freedoms and the Quebec Charter of Rights and Freedoms, especially given long waiting times for treatment in the public system. The case made its way to the Supreme Court of Canada, which ruled that the prohibition violated the Quebec Charter of Rights and Freedoms. Given that the decision was grounded in QC provincial law, it had only limited direct impact in the other three provinces.

• Three provinces (ON, NS, MB) forced providers going outside the public payment system to charge at the public fee schedule. They also banned private insurance coverage of privately-delivered care that was also covered by the provincial plan, though two of these provinces (ON, MB) reimburse patients for out-of-pocket expenses paid to private providers.
• Three provinces (SK, NB, Nfld) allowed unfettered private delivery and private insurance for services covered by the provincial health plans. Newfoundland would reimburse patients for out-of-pocket expenditures to private providers up to the provincial fee schedule, whereas SK and NB provided no reimbursement for private expenditures.

   

• Private diagnostic clinics were beginning to emerge in three provinces (QC, ON, AB) in response to a pervasive lack of timely access to diagnostic imaging services. Though these clinics operated outside the public system, Ontario and Alberta actually contracted with some of them to provide services to public patients. For those with the means, however, payment could secure an earlier appointment for imaging, shortening the amount of time waiting for a diagnosis, and where applicable allowing earlier entry into a queue for treatment.

A National Single-Payer?

One of the features of health care in Canada that is often overlooked by proponents of single-payer in the United States is that Canada as a whole does not have a “single payer,” which means it’s hard to make sweeping generalizations about details. Covered services, the quality and quantity of care provided, and physician/provider payment vary across provinces. Not earth-shatteringly so, but enough to introduce a small modicum of inter-provincial competition for physicians, and “competition” in services and benefits mediated through political pressure (e.g. “Patients in BC can get this drug, why won’t you pay for it here in Nova Scotia!”). Given the perennial importance of medicare as a political issue, the importance of popular pressure to increase funding and expand services should not be trivialized.

It’s also worth pointing out that about 30% of Canadian health care spending is individuals’ out-of-pocket payments for things like drugs, home health, hospital amenities, and other non-covered services. This is 2-3 times the fraction of health care spending in the US that comes directly out of individuals’ pockets in exchange for services received.

Unions, Public Employees, and Hospitals

Contrary to what I’m told is common belief in the US, most Canadian physicians are not government employees. Though some provinces hire doctors for what I surmise are analogues to Community Health Centers, the vast majority of physicians are independent contractors paid on a fee-for-service basis according to the provincial fee schedule. In Ontario, some family physicians practicing in so-called “Family Health Teams” are capitated, and some emergency physicians are paid by the hour. An interesting wrinkle is that some provinces have hard caps on how much a physician can earn in any year; obviously this creates disincentives to working so hard / so much that the cap would be reached in a year. (It’s not just hypothetical: I have a few physician friends in Canada who have made great strides in their golf game as a result of this cap).

Hospitals, on the other hand, are closer to highly-regulated public utilities. In Ontario, most hospitals are non-government or arms-length, non-profit entities. Most of their money comes from a “global budget” (i.e. “this is your budget for the year”), though there have been experiments with US Medicare-like prospective payment systems for certain conditions. Patients also pay per-diem fees for non-covered amenities (e.g. private inpatient rooms, phone and TV service as inpatients). Provinces (or regional health authorities, or whichever provincially-created entity is in charge in a given province) have at least some control over hospitals’ capital spending. In Ontario, regional health authorities determine what sorts of specialty services and facilities are available at which hospitals within their purview. Hospitals are allowed to engage in public fundraising for capital campaigns; I’m not sure how this interacts with provincial controls on capital spending.

Physician licensing and governance is a point of special interest to me. There is the usual plethora of physician groups, specialty societies, etc., similar to what is found in the US. However, given the effective monopsony power of provincial governments in the market for physicians’ services, provincial medical associations have emerged whose main function is to represent physicians in fee schedule negotiations with government. Canadian physicians seem to have more input into provincial fee schedules than American physicians do into Medicare fee schedules. Whereas American physicians set the relative weights of various services in the Medicare fee schedule (and only indirectly lobbying for changes in the monetary conversion factor), Canadian physician organizations typically negotiate for dollars directly with government.

The Ontario Medical Association is one of these organizations. Unlike groups such as the American Medical Association, their orientation (and their website!) is very physician-centric. In addition to negotiating the terms of the provincial fee schedule, the OMA also sets maximum rates that physicians can charge for certain non-covered services (phone consultations, insurance forms, etc.).

Physician licensure and discipline is also done at arm’s-length from government. Unlike in the US, where medical licenses and disciplinary action are typically the domain of state government medical board, most (if not all) Canadian provinces have allowed the medical profession to remain somewhat self-regulating. For instance, the College of Physicians and Surgeons of Ontario is the licensing and disciplinary body for physicians in Ontario. Its governing body is composed of 16 physicians elected by their peers, 3 physicians selected from Ontario’s 6 medical school faculties, and 13-15 members appointed by government. Also of note is the fact that many provinces, including Ontario, condition licensure on the Canadian equivalent of specialty board certification. The opposite conditionality holds in the US.

By the Numbers

It would be foolish to try to replicate this series of three posts at the Healthcare Economist, where Jason Shafrin does a wonderful job of collecting the major summary statistics for infant mortality, life expectancy, access to care measures, and physicians per capita.

Next Time

In an upcoming post, I’ll discuss common American medical student perceptions of Canadian health care (as exemplified by the post at The Differential mentioned at the outset, and with some telling anecdotes from March’s AMSA conference), along with the always-hot topic of waitlists for treatment.

AAFP Doubles Down on Government Trough, SGR

Few physicians are fans of the Sustainable Growth Rate: the formula by which Medicare is (supposed) to make adjustments to physician payment each year. Primary care physicians would be especially hard hit by the massive payment cuts that the formula calls for. So far, these cuts have been staved off for months at a time over the course of the last few years, resulting in a cycle of impending doom followed by temporary relief as the can is kicked yet further down the road.

The Wall Street Journal’s Health Blog had this to say on physician organizations’ proposals to Congress for longer-term solutions to the SGR mess:

 American Medical Association: Repeal the SGR, then “implement a five-year period of stable Medicare physician payments that keep pace with the growth in medical practice costs.” During that period, pilot “a new generation of payment models” (medical homes, for example), then transition to those that improve quality, care coordination and costs. The AMA also wants Medicare to permit balance billing — physicians charging Medicare beneficiaries for an amount above and beyond what the government program covers.

American Academy of Family Physicians: After SGR repeal, there would be a five-year transition to the patient-centered medical home. Primary-care physicians would receive a higher reimbursement rate than other specialties, and primary-care incentives included in the health-care overhaul law would be increased and extended.

American College of Surgeons: After SGR repeal, set a “realistic budget baseline” for future payment increases, ” which should “fairly reflect the costs of providing quality health care and are sufficient to preserve the patient-physician relationship and ensure patients have continued access to the physician of their choice.” During a five-year transition to different payment models,  reimbursement growth would vary by service.

To my surprise, it’s the AMA that’s on to a nugget of something good: allow balance billing. Not a perfect solution, but it could be a major step towards something sustainable in the long run.

Somewhat less surprising is the willingness of the AAFP to double-down on the model that’s already failed them for so many years. It’s unfortunate. If primary care is going to be attractive to people like my classmates and me, the pay will have to be better, and the job will have to be better. Living an even more bureaucratic work experience and making a living that continues to be at Congress’s mercy aren’t on any medical student’s wish list.

AMSA Follies: By Reader Demand

I was originally going to abandon any effort to post the remainder of my coverage of the American Medical Students Association’s 2011 annual convention when it become clear that it would be so delayed that it could hardly be considered topical. A small number of readers have encouraged me to post the highlight anyways, using the arguments: better late than never; the events left to be blogged were the most interesting; and finally, I may as well “complete the chronicle.”

Below the cut, for those interested in how health policy was presented at the AMSA convention, are highlights from two events: a debate between Michael Cannon (Cato Institute) and Robert Zarr (American Academy of Pediatrics, Physicians for a National Health Plan); and a later event featuring Walter Tsou (immediate past president, PNHP).

Cavalcade of Risk #123: Exam Season

 

After the initial enthusiasm of the start of medical school fades away, as excitement for the distant future is replaced with the quotidian routine of classes, lab, and review sessions, the realization finally settles in: we’re, um, expected to know all of this?

Most students at medical schools across the country respond to this challenge in the same way, living their lives by a simple, two-word credo that serves to guide their acquisition of knowledge. While I can’t say I show the same fervent devotion to it that many others do, it’s indisputably a part of medical school culture, and is certainly a useful mindset to have when it comes time to study for exams. It is in celebration of that spirit that I present to you today:

Cavalcade of Risk #123:  High-Yield Edition

The Basics

Risks and probabilities are important aspects of clinical medicine. How well are medical schools teaching future doctors to process statistics and other research information from the clinical literature? What does it mean for the quality of future physicians? Jin Packard, a New York Medical College student blogging at Low-Yield Med, draws from his own experiences to argue that the level of training is “nothing shy of a disgrace.” I went one step further and called it a straight-up failure.

Darwin of Darwin’s Money brings us back to the basics, with a clear, concise explanation of how to compare sums of money across time (i.e. “present value” and “future value”). A dollar today is worth more than a dollar in 10 years. Darwin explains the “how” and “why.” Understanding this sort of calculation, and the sorts of assumptions embedded in it, is integral to understanding so much of finance, insurance, and economics. This is a great post to use to learn it, or for a quick refresher.

Health Insurance

Jeff Rose, blogging at Good Financial Cents, features a guest post summarizing the major changes to health-related Flexible Spending Accounts that took effect at the beginning of the New Year. The highlights are the need to get prescriptions for OTC drugs, restrictions on what kinds of stores can accept FSA debit cards, and higher penalties for breaking the rules. All in all, it’s become much more difficult to use FSA money to pay for over-the-counter medications and other health expenses.

Closing out an “ACO ‘orgy week’ of postings” (his words, not mine!) at the Disease Management Care Blog, Dr. Jaan Sidorov takes a look at a recent Medicare demo of these new-fangled, orgiastic Accountable Care Organizations. While, as he says, “ACOs are arguably the only good long term answer to controlling costs, reportedly by making doctors and hospitals play nice with each other and participate in downstream savings,” he wonders why “they, compared to managed care insurers, any less likely to withhold costly care.”

Louise, blogging at Colorado Health Insurance Insider, discusses the proposal by a Colorado legislator to remove the cap on tax-deductible contributions to Health Savings Accounts in the name of sensible health reform. She argues that while this would be a boon to higher-income families who could thus contribute more money to HSAs (and thus shelter more income from taxes), it would do nothing to expand access to health care for those at lower ends of the income scale.

There are consumer protections, and then there are consumer protections. I point out an unusual pair of health policy stories from the past week: on one hand, PPACA supporters warning Republicans not to mess with the new law’s “consumer protections”; on the other hand, healthcare lawyers pointing out that for the law’s vaunted ACOs to have a decent chance of success, many existing “consumer protections” in healthcare may have to be gutted. I ask what the juxtaposition of these two implies about the moral necessity of the healthcare regulatory apparatus as a whole.

Other Insurance

Ryan at CashMoneyLife provides a quick, easy-to-digest rundown on life and viatical settlements, with attention paid to the risks and benefits for both buyers and sellers of life insurance policies in these transaction. These settlements allow life insurance policyholders to “cash out” some fraction of the policy’s face value, and investors to (maybe) make a profit when the policy pays off. Ultimately, while acknowledging that they are not evil and have their roles to play in the insurance marketplace, he concludes that these certainly “aren’t right for the majority of people out there.”

Free Money Finance touts the merits of umbrella insurance policies: they’re relatively inexpensive for the coverage that you get; and that coverage can come in really handy when one lawsuit could be all it takes to exhaust the coverage that your home and auto policies provide. As he points out, “even if your assets are low, your future earnings are probably not,” and both are fair game in a lawsuit.

Hank Stern of InsureBlog fame dissects some finance/insurance “wisdom” posted at an AOL personal finance website. He wasn’t too impressed with their list of “Seven Insurance Policies That Aren’t Worth The Money,” finding that there wasn’t much “profound wisdom to be had.” It’s worth remembering the need to keep your wits about you when reading financial advice on the Internet… or anywhere else, for that matter.

The Digerati Life makes the case that consumers should generally avoid buying the type of insurance that they’re most often offered: extended warranty programs. They’re often costly, and may duplicate coverage provided by your credit card. The proposed alternative is to save the money that would have been spent on these warranties as a personal “warranty fund” of sorts.

Non-insurance risk management

While prognostications about financial markets are dime-a-dozen, some of them still make for interesting reads. This interview with a Canadian asset manager, conducted by Arjun Rudra and posted at InvestingThesis, is one of them. The discussion touches upon prospects for gold, the likelihood that QE2 will succeed, interest rates, emerging markets, and the Canadian dollar (with a bearish outlook on most of these).

Circumcision has been shown to dramatically reduce the risk of males contracting HIV from heterosexual sex. The government of Swaziland has begun a mass circumcision campaign in the hopes of reducing HIV incidence. Jason Shafrin, the Healthcare Economist, discusses why such an effort might actually increase HIV incidence: moral hazard.

At some point afterI grow up and become a doctor, I will be sued. When that happens, I want a defence like the one described (with illustrations) by David Williams at the Health Business Blog. A patient died shortly after an operation to replace a stenosed bicusoid aortic valve. The plaintiff argued that the operation was performed improperly, and that the replacement valve chosen was of an incorrect size. The defence argued the opposite, supported by the visual aids that David has posted, and obtained a verdict in their favour.

Julie Ferguson of Workers Comp Insider sends along a wreck of a video (literally) accompanied by advice for truck operators looking to avoid mismatches between the height of their vehicle and the clearance of that rapidly-approaching underpass. Along with the usual advice to plan your route and heed signage about clearance, it’s also recommended to check in advance with local/state departments of transportation for information about low underpasses… a source of information that many people (myself included) might not think of.

Content, NOS

It was a pleasure and an honour to host this edition of the Cavalcade of Risk! Now that you’re done with the best risk-related blog posts of the past fortnight, I’d like to invite you to poke around the rest of The Notwithstanding Blog, home to tales from medical school, health policy analysis, critiques of the academic medical zeitgeist, and the occasional bonus Canadiana. I think you’ll like what you see!

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The next edition of Cavalcade of Risk will be hosted by Dr. Sidorov on February 9th.

What one hand giveth, the same hand taketh away

Here are two health policy developments from the past week… near-poetic juxtaposition:

Via John Goodman, a link to Cato’s Michael Cannon writing at Kaiser Health News to take on the White House’s contention that the PPACA’s new insurance regulations collectively represent “consumer protections” that Republicans should be wary of tampering with. Cannon argues that this is a mis-branding, and that while these protections are superficially appealing, they will have (and have had) deleterious effects below the surface.

Via Jason Shafrin, an article by the American Health Lawyers Association outlining the existing legal barriers to the establishment of one of the PPACA’s much-hyped cost-control/delivery-improvement mechanisms: the Accountable Car Organization (ACO). The list of existing regulations that may need to be waived is extensive, including elements of the Stark Law, prohibitions on balance billing Medicare beneficiaries, and various anti-kickback provisions… the sorts of things that one might characterize as consumer protections.

Truly delicious, isn’t it?

This raises the question: if these longstanding consumer protections intended to prevent physician conflict-of-interest and Medicare beneficiary exploitation need to be brushed aside (for some entities, anyhow) to allow the Next Big Thing in health policy to go forward, what does that say about their worth and utility more generally?

Why should we be any less wary of tampering with these “consumer protections” than the ones allegedly found in the PPACA?

If you support “consumer protection” generally, especially those added in the PPACA, I’m curious: if the latter set of regulations do end up getting waived for nascent ACOs, as I expect they will in at least some cases, will those ACOs’ patients be worse off for the lack of protection?

From plain film to 3D: radiologists as superstars?

Like other enthusiasts of health policy, I spent plenty of time reading and thinking about the Wall Street Journal’s recent reporting on the RUC — the panel that decides how Medicare pays for physicians’ services.  The existence of this system was news to many of my classmates, one of whom zeroed in on the hourly wage figures.  By MedPAC’s calculation, radiologists would make approximately $193/hr if all of their work was paid at Medicare rates, compared to $101 for primary care physicians and $161 for surgeons.

Why, asked my classmate, should radiologists be paid so much relative to surgeons, given that the training length for diagnostic radiology and surgery is similar, and radiologists arguably play a smaller role in the care of an individual patient, face less malpractice risk (I might quibble with this, but I let it stand), and are able to work “better” hours, doing work that’s less physically demanding?

Now, the WSJ article helps to explain exactly how this situation has come about.  The “market” for physicians’ services is one in which nominal and relative prices are set from above.  They’ve been set in such a way that the “ROAD to happiness” starts with Radiology.  (The “ROAD,” for those unfamiliar with the term, consists of Radiology, Ophthalmology, Anesthesiology, and Dermatology)

This lends itself to an interesting thought experiment.  Would diagnostic radiologists fare this well under a market system?  I think they would, and here’s why:  I think that radiologists are medicine’s superstars, at least in an economic sense.

The reason that major-league athletes and Hollywood A-list celebrities command such high pay is not strictly because we as a society think they are individually more important than, say, an individual teacher or firefighter (or physician).  It’s because these athletes and actors are in an industry where the consumer will pay a premium for the “best” (as opposed to minor league teams, indie movies, etc.), and in which many, many consumers can be reached at low marginal cost (cf. television, the internet).  The athlete/actor doesn’t have to add a lot of value to a given person, but instead is compensated handsomely because he is able to add some amount of value to a lot of people who are willing to pay for it.  Average class size in a public school may be 30, but most sports stadiums can fit tens of thousands, to say nothing of TV and radio audiences.

This strikes me as at least superficially similar to some aspects of diagnostic radiology.  The use of medical imaging has exploded in the past 20 years, but it would be bold to claim that none of that increase has to do with the value that it adds to clinical decision-making and patient care (at least when used appropriately).  And we as a society have decided that we want the best:  that is to say, we want our scans read by radiologists.

What’s more, it’s entirely plausible that a diagnostic radiologist can add her full armamentarium of value to more cases per day than a physician in many other specialties.  That it may take less time to read a scan doesn’t lessen the value added by having the scan read.  The worth of the information to the patient is independent of the time it takes to derive it (within limits).

So, would radiologists still be on the ROAD in a market-based system of payment?  The case in favour looks pretty good.  Of course, the challenge facing American radiologists in my lifetime may not be justifying their value in patient care so much as justifying their value over and above their American-boarded Indian-based counterparts.  Communications technology has helped make superstars of American radiologists… will it make them overpriced and obsolete as well?

This is why we can’t have nice things anymore

For someone like me — young, healthy (knock on wood), and with no need for frequent contact with the health care system — a primary care physician is a nice thing to have.  I can go to my family physician for medical school checkups, vaccines, minor acute illnesses… but honestly, if I were to wind up “medically homeless” it wouldn’t be the end of the world.

For someone older or in poorer health, maybe with a chronic medical condition or two, a primary care physician is much more than “a nice thing to have.”  Chronic condition management, specialty consult management, generally looking after all the patient’s medical problems… that can wind up being the difference between well-managed illness on the one hand and an expensive trip to the emergency room on the other.

As I’m sure you’ve heard, there’s a growing consensus that the US does not have enough primary care physicians.  Why not?  There are a lot of potential answers to that question floating around out there, some of which are probably correct at least in part.  Opinion tends to coalesce around the following explanations:

• Primary care physicians tend to earn less than other physicians
• Primary care physicians’ lifestyles are not as enviable as those of some other physicians
• Primary care practice is perceived as being relatively more exposed to the hassles and red tape of third-party payers
• Medical students aren’t sufficiently exposed to primary care/good primary care role models and/or medical students encounter too much disrespect for primary care from faculty in other specialties.
• There aren’t enough primary care residency positions relative to specialty residency/fellowship positions.

I can believe all of these to varying degrees, though I’d hazard that the first two (to me, the third is a subset of the second) on the list are the main causes right now.  The last one doesn’t strike me as all that persuasive.  Residency slots have to be filled by international medical graduates, or simply stay unfilled, because not enough US medical students want to go into those fields.  Increasing the number of training positions in primary care won’t solve anything without an increase in medical student willingness to fill these slots.  The problem is clearly medical student demand, not training position supply.

Many of the proposals to “fix” primary care have rightly focused on the most plausible causes for the shortage.  Some professional organizations would hope to narrow the pay disparity by either cutting specialist pay, tweaking the Medicare pay formula to better compensate “Evaluation and Management” service codes, or simply by going back to Congress and begging for more money (sense a theme here?).  Others believe the solution lies in expanding retainer practice, which would have the added bonus of improving pay and lifestyle/regulatory hassle issues.  There are some who think that the “Patient-Centred Medical Home” and “Accountable Care Organization” will save primary care (or not).

Others would take more roundabout routes to creating more PCPs.  Instead of (or perhaps, in fairness, in addition to) changing the nature of the job to make it more desirable, they would take steps to essentially hoodwink medical students into choosing primary care as a field.  Some people think that Nurse Practitioners and Physician Assistants can and will step in to fill the void left by medical students (while “can” may be questionably questionable, the “will” is an even more uncertain proposition).

Yet others have jumped the shark entirely.  Via John Goodman some time ago, and KevinMD more recently is a summary of an AMA expert report on the real reason more students aren’t going into primary care:  it seems that we’re too nerdy, insufficiently altruistic, and (*gasp!*) bad at advocacy and community organizing.  Too much problem-solving acumen, not enough passion for social justice!

Because clearly, primary care has nothing to do with problem solving.

The links above point out the many, many flaws in this line of reasoning.  There are two big ones that come to my mind, however.

The first is the issue of “social justice.”  It’s a nice phrase, and an amorphous concept.  I’m in favour of social justice, and for certain methods of achieving it.  Ask a typical left-liberal what they think of my conception of social justice and my preferred means of advancing it, and you’ll likely provoke a good deal of rage, sputtering, and denunciation.  It’s one of those terms that’s thrown around a lot without being defined.  That said, it’s really only one segment of the political spectrum that has a high affinity for that phrase… when you see the AMA using it, you can be pretty sure what it is they’re referring to.  According to them, medical school admissions should be based on a political orthodoxy because, well… apparently it will produce more primary care physicians.

This isn’t even the biggest problem with the proposal.  Remember how I mentioned earlier that one of the reasons students aren’t going into primary care fields is because of pervasive disrespect for them in the medical academy?  The lack of role models and exposure?  The constant denigration by medical and surgical specialists?  The idea that someone is “only” a primary care physician?

How does the implication that primary care work doesn’t require problem-solving skills do anything other than contribute to these sorts of perceptions?  The very idea amounts to a proclamation that primary care is “lesser” medicine!  “Primary care physicians aren’t real doctors… I mean… the important skillset for them is community organizing for social justice!”

While this report may have its heart in the right place, I’m sure that medical students will be smart enough to read between the lines and see that it’s merely confirming the prejudice that they’re seeing in all other areas of their training.

This is the medical academy’s solution to save primary care.  And that… that is why we can’t have nice things.