Jeffrey Beall is an academic librarian at the Auraria Library at University of Colorado Denver located in Denver, Colorado. He got tenure in 2012 and became an associate professor. For a number of …
In honor of bronchiolitis season, I am posting here a limerick I wrote summarizing the AAP’s 2015 guidelines for treatment of bronchiolitis:
When treating bronchiolitis,
Refraining from films would delight us!
Please also avoid
The neb and the ‘roid…
After all it is only a virus!
For other medical verse, please see my blog.
Source: Bronchiolitis guideline limerick
At 1:30 AM, January 12, 2017, the Senate passed a budget resolution to repeal the Affordable Care Act (ACA), with a party-line vote (51-48). A budget resolution needs only a simple majority to pass and thus represented the Republican Party’s quickest avenue to repeal the ACA. Congressional Republicans are pursuing a plan that would repeal parts of the law in early 2017 via budget reconciliation (see below for which parts), but may delay enacting a new system for up to three years (i.e. they plan to defund the ACA’s key coverage provisions, but delay a replacement).
On January 17, 2017, the nonpartisan Congressional Budget Office (CBO) released a report on how ACA repeal would affect health insurance coverage and premiums. The CBO assumed the repeal plan would be similar to that adopted by Congress in 2015 (sponsored by Congressman Tom Price, Donald Trump’s nominee for secretary of Health and Human Services, and vetoed by President Obama). The bill Congress passed did not contain policies intended to replace the ACA, presumably because a consensus did not exist on what form such an alternative should take. It is unlikely that supporters of ACA repeal will have agreed on an alternative before voting on repeal. Based on the 2015 legislation, the CBO report assumes that the forthcoming reconciliation legislation will do the following:
- the individual mandate penalties
- after a delay of two years, the premium tax credits and Medicaid expansions
- leave intact the ACA’s insurance reforms (cannot be amended through reconciliation under the Senate’s reconciliation rules)–including
- essential health benefit
- actuarial value requirements
- limitations on health status underwriting
- limitations on pre-existing condition exclusions
- rating requirements that allow premiums to vary only based on age, geographic locations, and tobacco use (and not on sex).
CBO Projections of Impact on Health Insurance Coverage:
If Congress does not repeal the ACA’s insurance reforms (listed above):
- 2017: No immediate dramatic effect because premium increases would already be established and enrollment set
- 2018: 18 million people would become uninsured, including 10 million fewer enrollees in the nongroup (or individual) insurance market, 5 million fewer with Medicaid coverage, and 3 million fewer with employment coverage.
- 2020: (following repeal of the Medicaid expansions and premium tax credits): 27 million will have become uninsured
- 2026: 32 million will have become uninsured (23 million fewer nongroup market enrollees, 19 million fewer covered by Medicaid, and 11 million more enrolled in employer coverage)
- These increases would be due to a combination of people dropping coverage because it was no longer mandated and to insurers abandoning the nongroup market and increasing premiums because of adverse selection concerns.
If Congress does repeal the ACA’s insurance reforms (listed above):
- 2026: 59 million would be uninsured; 21 percent of the population.
CBO Projections of Impact on Health Insurance Coverage:
- 2018: insurers would increase premiums by 20 to 25 percent
- 2018: insurers in some areas would leave the nongroup market in anticipation of further reductions in enrollment and higher average health care costs among enrollees who remained after the subsidies for insurance purchased through the marketplaces were eliminated. As a consequence, roughly 10 percent of the population would be living in an area that had no insurer participating in the nongroup market.
- 2020: nongroup market premiums would increase by 50 percent relative to current law projections and about half of the population would live in states with no insurer participation in the nongroup market
- 2026: nongroup market premiums would double and three-quarters of the population would live in states with no insurers in the nongroup market. Fewer than 2 million people would have nongroup market coverage.
The Urban Institute has released a similar Report on the Implications of Partial Repeal of the ACA through Reconciliatio, in December 2016, using the same 2015 bill as the model for the 2017 reconciliation bill repeal.
The key effects of the passage of the anticipated reconciliation bill are as follows, quoted verbatim from the report’s Abstract:
- The number of uninsured people would rise from 28.9 million to 58.7 million in 2019, an increase of 29.8 million people (103 percent). The share of non-elderly people without insurance would increase from 11 percent to 21 percent, a higher rate of uninsurance than before the ACA because of the disruption to the non-group insurance market.
- Of the 29.8 million newly uninsured, 22.5 million people become uninsured as a result of eliminating the premium tax credits, the Medicaid expansion, and the individual mandate. The additional 7.3 million people become uninsured because of the near collapse of the non-group insurance market.
- Eighty-two percent of the people becoming uninsured would be in working families, 38 percent would be aged 18 to 34, and 56 percent would be non-Hispanic whites. Eighty percent of adults becoming uninsured would not have college degrees.
- There would be 12.9 million fewer people with Medicaid or CHIP coverage in 2019.
- Approximately 9.3 million people who would have received tax credits for private non-group health coverage in 2019 would no longer receive assistance.
- Federal government spending on health care for the non-elderly would be reduced by $109 billion in 2019 and by $1.3 trillion from 2019 to 2028 because the Medicaid expansion, premium tax credits, and cost-sharing assistance would be eliminated.
- State spending on Medicaid and CHIP would fall by $76 billion between 2019 and 2028. Also, because of the larger number of uninsured, financial pressures on state and local governments and health care providers (hospitals, physicians, pharmaceutical manufacturers, etc.) would increase dramatically. This financial pressure would result from the newly uninsured seeking an additional $1.1 trillion in uncompensated care between 2019 and 2028.
- The 2016 reconciliation bill did not increase funding for uncompensated care beyond current levels. Unless different action is taken, the approach will place very large increases in demand for uncompensated care on state and local governments and providers. The increase in services sought by the uninsured is unlikely to be fully financed, leading to even greater financial burdens on the uninsured and higher levels of unmet need for health care services.
- If Congress partially repeals the ACA with a reconciliation bill like that vetoed in January 2016 and eliminates the individual and employer mandates immediately, in the midst of an already established plan year, a significant market disruption would occur. Some people would stop paying premiums, and insurers would suffer substantial financial losses (about $3 billion); the number of uninsured would increase right away (by 4.3 million people); at least some insurers would leave the non-group market midyear harming consumers financially.
- Many, if not most, insurers are unlikely to participate in Marketplaces in 2018—even with tax credits and cost-sharing reductions still in place—if the individual mandate is not enforced starting in 2017. A precipitous drop in insurer participation is even more likely if the cost-sharing assistance is discontinued (as related to the House v. Burwell case) or if some additional financial support to the insurers to offset their increased risk is not provided.
The Urban Institute’s report concludes:
This scenario does not just move the country back to the situation before the ACA. It moves the country to a situation with higher uninsurance rates than was the case before the ACA’s reforms. To replace the ACA after reconciliation with new policies designed to increase insurance coverage, the federal government would have to raise new taxes, substantially cut spending, or increase the deficit.
With the Republicans on the verge of dismantling the Affordable Care Act and Medicaid, much of their focus has been on how much healthcare insurance “costs”. I thought it would be timely to revisit a 2015 analysis in the American Journal of Public Health, “Considering Whether Medicaid is Worth the Cost: Revisiting the Oregon Health Study.” (full text) The investigators performed a cost-effectiveness analysis using data from the Oregon Health Study (OHS), the experiment that began in 2008 when the state randomly selected uninsured participants to apply for Medicaid coverage creating a randomized controlled trial of a social policy. They concluded that Medicaid is in fact a cost-effective program.
The authors’ cost-effectiveness analysis found that the observed benefit of providing Medicaid was $62,000 per quality-adjusted life-year (QALY) gained. As a reference point, placing smoke detectors in homes provides a benefit of $210,000 per QALY.
The study reminds us that health benefits are best understood broadly and over the long term, rather than through a narrow focus on one year’s “cost” in the cost-effectiveness balance.
A study published online today in Annals of Emergency Medicine (“Association Between the Opening of Retail Clinics and Low-Acuity Emergency Department Visits”) demonstrated that, contrary to expectations, retail clinics had little effect on rates of low-acuity visits to nearby emergency departments (EDs). This contradicts the popular theory that retail clinics would reduce ED visits. A 2015 report “Building a Culture of Health: The Value Proposition of Retail Clinics“, found that consumer use of retail clinics was rising, with consumers citing convenient hours/location and perceived lower cost as the main reasons for choosing retail clinics for care. Another study projected that 13% to 27% of US ED visits could be treated in retail clinic settings, with an estimated cost savings of $4.4 billion.
However, this theory did not align with the new study’s findings. During the study period (2007-2012), the number of retail clinics grew from 130 to nearly 1,400 in the 23 states studied. During the same period, the rate of retail clinic penetration – in other words, the proportion of each ED’s catchment area that overlaps with a 10-minute drive radius of a retail clinic – more than doubled (8.1 to 16.4).
In the 2,053 emergency departments in these states, more retail clinics did not correlate with fewer low-acuity ED visits; however, increased retail clinic density did correlate with a slight reduction in the subset of low-acuity visits, albeit only among the privately insured. As an example, for an ED with 40,000 annual visits and 50% private insurance, there would be approximately 8 fewer visits per year for each 10% increase in retail clinic density.
The accompanying editorial offers three theories as to why retail clinics increase health care use:
- They meet unmet demands for care. The demand for episodic acute care often exceeds the supply of physicians or facilities in many communities, and retail clinics attempt to meet this need.
- Motivations for seeking care differ in EDs and retail clinics. A patient who might otherwise not seek care for a cough would stop by the neighborhood retail clinic but would not invest the time and travel to schedule an appointment with their medical home or risk a long ED wait.
- Groups of people who are more likely to use EDs for low-acuity conditions–particularly patients withMedicaid and ED super-users–do so because they have little access to other types of care, including retail clinics. Retail clinics follow the money–they locate in affluent areas in which few Medicaid patients live. Also, Medicaid plans often do not cover retail clinic use. ED superusers commonly have Medicaid insurance and infrequently live in affluent neighborhoods, and often have complex medical/mental health conditions that cannot be cared for in retail clinics.
As an ED physician, my primary concern is that these clinics introduce added fragmentation into an already fragmented health care system. I treat many patients who have sought care for an illness from 1-2 different retail clinics in the past week, without seeing their regular doctor, and then end up in my ED with no record (other than the patient’s recollection) of what happened at those clinics and why. I do my best to reconstruct the story–the antibiotics given for the sore throat on Monday at one retail clinic where they did not check a strep test, followed by a visit to a second retail clinic on Wednesday for the ongoing sore throat where they sold them different antibiotics from the co-located pharmacy and where they did check a strep test and some type of blood test that were both negative–and make a coherent decision based on guessing why each retail clinic did what it did and how the patient is today.
A second concern is illustrated by my patient anecdote. Retail clinics tend to compete with primary care providers for patient business, and, in so doing, they prescribe more antibiotics to meet patients’ expectations.
If patients continue to vote with their feet, using convenient retail clinics in lieu of their primary care providers, my hope is that we find a way to better integrate them into the healthcare system so that we are all working collaboratively to best serve the patient.
In September, the Pediatric Policy Council (PPC)—a nonpartisan collaboration of the Academic Pediatric Association, the American Pediatric Society, the Association of Medical School Pediatric Department Chairs, and the Society for Pediatric Research dedicated to promoting public policies to advance child health and well-being—developed four general questions related to child health to be sent to the campaigns of the two major party candidates for President of the United States, Donald J. Trump and Hillary Clinton, with the goal of better understanding where both candidates stand for children.
In early October, the campaigns of both presidential candidates submitted their responses, which are as follows.
An Upshot column “The High Costs of Not Offering Paid Sick Leave” argues that employees and their co-workers may be better off with an incentive to take time off when sick. About 45 percent of the American work force does not have paid sick leave; that’s about 50 million workers. Families with less ability to afford unpaid time off are more likely to lack paid sick leave. According to a study in Health Affairs, 65 percent of families with incomes below $35,000 had no paid sick leave, while the same was true of only 25 percent of families with annual incomes above $100,000. Those without sick leave were farm ore likely to go to work sick (“presenteeism”), as well as to forgo seeking medical care for themselves or for an ill family member. Although expanding health insurance helps people pay for health care, it does nothing to help them afford to take time off to get it.
Another study in Health Services Research by a Cornell economist supports the theory that paid sick leave could reduce the spread of contagion. This study found that each week, up to 3 million U.S. employees go to work sick. Females, low-income earners, and those aged 25 to 34 years have a significantly elevated risk of presenteeism behavior.
The Upshot column presents the benefits of paid sick leave for one illness, flu, although morbidity and mortality from other contagious conditions would also be reduced:
Paid sick leave slows the spread of disease. Cities and states that require employers to offer paid sick leave — Washington, D.C.; Seattle; New York City; and Philadelphia, as well as Connecticut, California, Massachusetts and Oregon — have fewer cases of seasonal flu than other comparable cities and states. Flu rates would fall 5 percent if paid sick leave were universal. According to one estimate, an additional seven million people contracted the H1N1 flu virus in 2009 because employees came to work while infected. The illnesses led to 1,500 additional deaths.
Beyond reducing flu deaths, paid sick leave is associated with
- reduced rates of occupational injuries
- reduced rates of heart attacks
- enhanced productivity
- reduced rates of employee turnover
- increased rates of breastfeeding and preventive health care for children of workers
Though a few cities and states mentioned above mandate employers provide paid sick leave, the Family and Medical Leave Act requires only unpaid sick leave be provided by employers with more than 50 workers. A new Obama administration rule is extending paid sick leave to ~300,000 private-sector employees working on government contracts starting on Jan. 1. Policy makers should consider the potential public health implications of their decisions when contemplating guaranteed sick leave benefits.
Amidst news of the increasing premiums and decreasing choice of plans in some healthcare markets, the New York Times‘ Upshot column brings us this visual display of the impressive and varied impact of Obamacare on insurance coverage rates from 2013-2016. States that decided to expand their Medicaid programs saw much larger declines in their uninsured rates compared with those that didn’t. The proposed mechanisms for this effect were that Medicaid expansion
- provided a new coverage option for childless adults below or near the poverty line
- helped spur many people who were already eligible for the program to sign up
- boosted enrollment in Obamacare’s marketplace plans.
The column analyzed the difference in insurance coverage expansion between states that did and did not take the Medicaid expansion:
Neither of the two drugs used most frequently to prevent migraines in children–amitriptyline and topiramate–is more effective than a placebo, according to results of the Childhood and Adolescent Migraine Prevention (CHAMP) trial published this week in The New England Journal of Medicine. The investigators found no significant differences in reduction in headache frequency or headache-related disability in childhood and adolescent migraine with amitriptyline, topiramate, or placebo over a period of 24 weeks.
The active drugs were associated with higher rates of adverse events. One child on topiramate attempted suicide. Three taking amitriptyline had mood changes; one told his mother he wanted to hurt himself, while another wrote suicide notes at school and was hospitalized.
Migraine headaches are common in children. Up to 11 percent of 7- to 11-year-olds and 23 percent of 15-year-olds have migraines.
A recent study in Annals of Internal Medicine found that physicians in four office-based specialties spent the majority of their time on documentation and paperwork:
- Overall, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on documentation (paper and electronic).
- While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on documentation.
- Physicians reported 1 to 2 hours of after-hours work each night, devoted mostly to electronic health record tasks.
A Forbes commentary noted there was a steady increase in the proportion of physician time taken up by paperwork. Reasons for this trend include
- The multitude of diverse stakeholders requiring increasing amounts of documentation in the paperwork, including administration, lawyers and insurance companies. For example, for a patient with a broken arm, insurance companies require that we ask about at least ten organ systems (a “review of systems“) and document our findings completely. So at least part of that clinical face time is spent asking the patient with the broken arm about things like pain with urination and visual change.
- The stakeholders, and not the physicians, design the forms, and so they are not designed in a way that fits a medical way of thinking about a patient encounter and are often redundant. For example, when I transfer a patient from one hospital to another, I fill out a form for the lawyers (the EMTALA form, explaining the medical necessity of the transfer) and a form for the insurers explaining the medical necessity of the transfer. These contain a lot of the same information.
- Hospitals and clinics do not seem to be investing in clerical and administrative support for doctors, sometimes because of regulations requiring a physician complete the forms. For example, 90% of the information on the two transfer rationale forms I mentioned above both could be completed by clerical personnel, or could be copied by a non-MD from one form onto the other.
The Forbes piece notes that the trend pushing ever increasing paperwork burdens onto physicians is a recipe for low career satisfaction and burnout.