Tag Archives: Health Policy

Consumer Choice in Health Insurance Markets Under the Affordable Care Act

If you’ve never had to shop for health insurance, consider yourself lucky. Between searching for affordable premiums, making sense of co-pays and coinsurance, and finding a plan with your favorite doctor, choosing a good health plan can be a daunting task. As a health policy student, I tried my hand last month at choosing a plan on the North Carolina exchange. Despite being well-versed in insurance concepts, I too struggled to figure out which plan would be best for me among the many options.

The Affordable Care Act (ACA) has been successful in its goals of increasing access to health insurance while preserving choice and competition in health insurance markets. It brought nearly 11 million people into the individual market who previously didn’t have insurance, and it offered them a variety of health insurance options to choose from. Despite achieving such historic milestones, however, it remains to be seen what the future might hold for the ACA. Until then, policymakers must continue working to make the process of buying insurance easier for the average American. Continue reading

Biggest Threat to Zika? Mosquito Love.

Photo Credit: James Gathany

Photo Credit: James Gathany

As of November 18th, the World Health Organization (W.H.O.) declared that Zika is no longer a global emergency. However, Dr. Peter Salama, executive director of the W.H.O.’s health emergency programs, stated that “we are not downgrading the importance of Zika. We are sending the message that Zika is here to stay, and the W.H.O response is here to stay.”

Though the W.H.O. has downgraded the threat of Zika, combating Zika remains a goal of the global health community. At the end of October 2016, $18 million was put towards a project to release millions of genetically modified Aedes aegypti mosquitoes. These mosquitoes were infected with a bacteria called Wolbachia to mate with Aedes aegypti mosquitos that transmit Zika, as well as Dengue and Chikungunya.

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Who is responsible for the health of this child?

Aixa Cano was described in a recent AP article as a shy, 5-year old girl from Chaco, a poor farming province in northern Argentina. What makes her different than most 5-year old girls is that Aixa was born with hairy moles all over her body. She fared better than her neighbor, Camila, a 2-year old girl born with multiple organ problems. Doctors, who cannot explain Aixa’s condition, say her birth defect may be linked to agrochemicals. The Argentine national government must hold itself responsible to protect the health of children born in rural areas.

Agrochemical use in Argentina has increased greatly according to the AP report, increasing from 9 million gallons in 1990 to 84 million gallons today. While it has led to a huge growth in agricultural production, rates of cancer and birth defects have increased dramatically in Argentina’s rural farming communities. In Aixa’s home province of Chaco, regional birth reports given by the AP show congenital birth defects soaring from 19.1 to 85.3 cases per 10,000 people in the decade after genetically modified seeds and their partner agrochemicals were approved in Argentina.

So if we were to assume an excessive use of agrochemicals leads to birth defects in children like Aixa, who is responsible for their misuse? Farmers and agrochemical companies, whether we like it or not, work to make money and not improve public health. If farmers don’t spray enough chemicals and their crop decreases, they lose money. Regarding the local government, while they should be out to protect public health, this mission can often be lost in the cause of economic development, which in rural communities often comes from agriculture. Thus, in my opinion the Argentine national government is at fault. The national government, while still influenced by the agriculture industry, is more able to resolve the problem than rural provincial governments because it is more isolated from agriculture’s impact considering the diversity of the national economy.

To remedy the problem, there are three things that I believe the Argentine national government can do better. First, it should change agrochemical regulation standards from being made at a provincial level to a national level. This will create clearer standards, and avoid undue influence by industry in poor provinces that depend highly on agriculture. Second, the national government should complete the work of the presidential commission formed in 2009 to study agrochemicals and health. They can do this by properly funding programs to fortify local government monitoring of agrochemical application, along with programs to educate farming communities on proper agrochemical use and application. Finally, the government should listen to its constituents and fund studies to investigate the potential health effects of agrochemical use.


The Elusive Cost of Care

My right knee started bothering me on a long run a month ago. After weeks of pain, fruitless physical therapy, and no clear diagnosis, I had an MRI scan of my knee. Thankfully, nothing major showed up – just a persistent case of tendonitis. As a competitive runner hoping to compete in the Olympic Trials, I asked my doctor several questions: When will I be able to run again? What kind of cross-training should I do in the meantime? How many times a day should I ice? What can I do to keep this tendonitis from recurring? Should I hold off on buying plane tickets to that big race in December?

I failed to ask one important question, though: How much money will I have to pay for treatment? This failure is especially frustrating and surprising since my year-long Master’s Project focuses on clinical conversations about healthcare costs. I spend hours each week reading, writing, thinking, and talking about how doctors and patients can more effectively discuss out-of-pocket costs. If anybody should have the knowledge and resources to discuss medical costs, I should.

Yet here I was, a patient so focused on my running career that I completely forgot to ask how much my knee injury would cost. That MRI had a price tag worth more than just time, but my doctor and I did not discuss my ability or willingness to pay for it. Later, I felt stupid for agreeing to an expensive test without first knowing the toll it would take on my bank account.

I justified my experience somewhat by knowing the high value I placed on the information an MRI could offer. Even if I had known the exact stomach-churning price of my MRI, I probably still would have gotten the test. Others in my position may not have placed as high a premium on that information, however, and would have chosen a few more weeks of watchful waiting over high-priced MRI test results. The absence of cost information makes it nearly impossible for most patients to decide whether such tests are worth it for them.

Once I returned for my follow-up visit, I investigated the cost of my MRI in earnest. I spoke with half a dozen Duke Sports Medicine employees to try and learn how much I would pay for this test. None of these people could give me an answer. I have the same insurance as most Duke students – Blue Cross Blue Shield Student Blue – so I pay 20% coinsurance for most treatments, tests, and procedures. This means that, to learn the amount I pay for an MRI, I must first know the total cost of the MRI (then I pay 20% of what’s left after I pay the co-pay). No one at the clinic could tell me the total cost – not even the patient financial counselor. I had no possible way of knowing my out-of-pocket cost.

Patients have experiences like mine all the time. Most patients, however, do not study health policy and are even less well equipped to find, discuss, and consider healthcare costs. This is a huge problem. Duke Professor Peter Ubel argues that healthcare providers should make patients aware of the “financial toxicity” of treatment options, just as they discuss other potentially toxic side effects. Rule Number One of functional, competitive markets is that consumers – patients, in this case – should have access to the information necessary to make rational economic decisions. To the extent that healthcare is a market in this country and patients pay for their care with “skin in the game,” their ability to make good decisions is severely limited by the absence of treatment cost information.

Both healthcare providers and patients have a responsibility to consider patients’ out of pocket costs when making treatment decisions. Policy can enable these discussions by making cost information more accessible. Price transparency laws, cost calculators, and clinical communication aids are just a few of the alternatives that policymakers and healthcare administrators are currently exploring.

But policy alone cannot drive this major change in clinical culture. Insurance companies and other stakeholders must also shift to more patient-centered perspectives to foster good communication and create truly competitive healthcare markets. This means designing user-friendly insurance policies with less fine print, making all out-of-pocket costs available for patients and their doctors to discuss when deciding on treatments, and creating a healthcare culture that encourages and rewards effective communication around cost issues.

Until these changes occur, the onus will remain on patients to include cost queries in their litany of questions for medical providers. But even then, clinicians may not have the resources to provide answers.

GM foods: To label or not to label

In my law class, titled Risk Regulation: the U.S., Europe and Beyond, we will be discussing this week the topic of food safety. Thus, it was quite ironic this morning that I opened the local newspaper to an article about Washington state voters planning to vote on genetically modified (GM) food labeling on November 5th . If passed, the measure would be a first in the United States for GM food labeling.

Similar to initiatives related to a soda tax, the food industry is strongly against the measure, with agribusiness giant Monsanto and others funding a $17 million campaign against GM food labeling in Washington state according to the article. They contend that there is no scientific reason to add thousands of new labels to foods, and that 70 to 80 percent of the products on the market already contain genetically modified ingredients. Currently, most GM crops are used either for industrial purposes, such as cotton, or for livestock feed and production of sugars and oils coming from soy and corn. Pro-consumer groups are for the labeling measure, contending a consumer’s right-to-know, with a concern for potential health effects.

Should Washington state, or the federal government for that matter, enforce GM food labeling? I am all in favor of providing more information to the consumer to help him or her make the correct decision, especially concerning health, but what kind of information would a GM food label provide a consumer? Are GM foods less healthy or environmentally friendly than non-GM foods? That question is still in debate. On the one side, GM crops do provide benefits such as increased protection against pests and disease, while on the other we are still trying to understand potential health and environmental effects from the introduction of genetic traits from other organisms into a food crop.

At this point, I believe that it is too early for a GM food label. While the label would notify a consumer of a food’s genetically modified status, there still has not been enough research done to inform the consumer on the benefits and costs of genetically modified foods to society. Much of Europe has taken a high and unfounded level of caution against genetically modified foods, stemming from the unrelated mad cow disease incident that happened in Great Britain in the 1990s. Regulation without proper evidence can lead to a lack of innovation, which in turn could prevent the invention of food products that are more healthy or environmentally friendly.

What do I think is the proper way forward on GM food labeling? Considering the demand for GM food labeling, with 26 states so far this year introducing GM food labeling bills, let us allow GM food labeling much in the way of cage free raised eggs. In this situation, the consumer who wants GM free food products will be able to choose them without drawing unusual and unfounded alarm to GM food products by the general consumer who, before the label, was unconcerned. All of the interest in GM food labeling needs to be taken into account by state and federal governments and should come with increased funding to study the potential health and environmental effects of GM foods, not by creating unfounded concern by the public through a GM food label.

Will Health Providers Survive Health Reform?

 

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by Mark Dakkak

When I first told my primary care physician that I was leaving my hometown to start medical school, he sat me down in his office. He pointed to his copy of Sir Samuel Luke Fildes’ painting The Doctor, and confided in me “medicine isn’t always the noble profession you may think it is.” He warned that to spend quality time with patients involved “far too much work and far too little compensation”.

 

My ignorant bliss didn’t last long. I just finished The Darkest Year of Medical School, during which the ‘high-minded traits’ that my classmates and I entered school with began to erode.  The first year working in the hospital revealed that much of what we “learned about doctor-patient communication, bedside manner, and empathy turns out to be mere lip service when it comes to the actualities of patient care.” Dr. Ofri explains that the rigorous biomedical education that is standard to American medical schools “coarsens the very qualities that inspired students to enter medicine in the first place.” Our experiences in the hospital chisel away at the concepts we have of ourselves as future physicians. Unfortunately, we can be left with “shadows” of ourselves, as David Bornstein recently described, because “as the price of admission, medicine implicitly asks its members to leave aspects of themselves behind.”

 

There is already great pressure on medical students and physicians to reconnect with our values to address physician burnout and patient safety, but the stakes are rapidly rising. Open enrollment in the federal and state healthcare markets began last Tuesday. Depending on state decisions, Medicaid expansion together with other provisions in the Affordable Care Act could cut the number of uninsured in half, adding millions of newly insured patients to a stretched network of safety-net providers. Media campaigns opposing Obamacare are simultaneously threatening the trust that is fundamental to the doctor-patient relationship. If our healthcare workforce wasn’t already imploding, the increasing external pressure might just be the straw to break the camel’s back.

 

Now is the time to strengthen the future of the healthcare workforce. This means creating a learning environment that reinforces the core values that bring medical students into this field. David Bornstein argues that doing so can protect students “against the assaults of the medical curriculum and even the health care system itself.”

 

Wonderful programs are emerging. The Healer’s Art, a medical school elective described as a possible ‘fix’, brings veteran physicians and students side-by-side to connect with core values as a community. Similarly, last spring a narrative show called Voices of Medicine featured five Duke physicians, fellows and medical students. In the midst of my busy internal medicine rotation, hearing providers at all levels share their experiences recharged my commitment to the field. It meant the world to see supervisors struggling to hold on tight to their values.

 

But while extracurricular activities can be incredibly meaningful, more needs to be done in the workplace. First, students should be assigned to good mentors – not every MD deserves a chisel. A surgery fellow I was assigned to work with for three weeks did me a great favor by telling me to join the other team on the floor. I later learned my new supervisor was known around the health system for his teaching. Second, rotation schedules should include regular interaction with clinical mentors. By my 12th month of clerkships, I couldn’t wait to finish; I continued to live in a daze, being whisked between radiology sub-rotations every 2 days. Meanwhile, my friend who participated in the longitudinal clerkships of Duke’s Primary Care Leadership Track was emotional about his last weeks with supervisors he had developed close relationships with over the year. Lastly, standards of professionalism must be established with a confidential system in place to report mistreatment. Last month, I attended an ‘etiquette dinner’ event geared towards business and policy graduate students and was startled by the complete lack of norms in the medical profession. Even after a year, I can’t describe the ‘appropriate’ way to interact with team members.

 

Medicine’s struggle continues to gain publicity while external pressure builds to unprecedented levels. How will physicians welcome millions of new patients under their care? To survive the implementation of reform, the healthcare workforce must build its strength from the inside out. The medical education system needs to train doctors who grow into the values they bring with them rather than erode those values away. Maybe then, medicine will be the noble profession you may think it is.