Fraud and Telehealth

 I'm with Doggett on the problem of fraud possibly being enabled by telehealth.

I've been bothered by TV ads I see for various devices which support health--the claim is usually to the effect that the cane or walker or whatever is "free", because Uncle will pay for it.  

Our American Dentistry System

 I've commented before on the advantages of the Kaiser Permanente system, as opposed to the system of independent doctors, specialists, and testing labs found elsewhere.

Currently I'm gaining some (vicarious) experience with dentistry.  While Kaiser includes some dental coverage, it's not in-house but run through a separate organization.  It includes a directory of participating dentists, endodontists, and oral surgeons which are in-network. For a variety of reasons (not rational ones, but human ones), we're getting the work done outside the plan.

One difference between the medical side of our health system and the dental side is technology.  The various dentist/specialists have a lot more technology in their office. Where doctors had to send you out for blood tests, dentists have x-rays in their office, while the endodontists and surgeons have even more equipment. 

One similarity betwen the system is the referrals from dentist to endodontist and surgeons. It seems to an outsider there's likely an informal network in existence; whether the network is more than just mutual trust I don't know.  

From the patient's standpoint there's still the frustration of repetitive forms: health histories and legal documents. Within the Kaiser organization, that's avoided for medical issues.  

For any complex issue, there's a coordination issue.  That's likely true within Kaiser for medical issues, especially when you involve a hospital. 

Health System--Dentistry

 My wife and I use Kaiser for health care.  It works well, testing, drugs, specialties, all under one roof (at least metaphorically because there's one database and efficient handoff from one provider to the next).

Unfortunately Kaiser doesn't do dentistry, so when significant problems crop up we're thrown into a different world:

• each provider has her own set of questions to obtain personal data and health history, allergies, drugs, etc.
• each provider has a process to move information back and forth, sometimes still including the use of fax!!!! (This is the 21st century, people).
• each  provider has a separate website which may or may not have been updated and which have their own structure and feel.
• referrals from one to another are a bit kludgey.
• transparency is often lacking.

Otherwise the people are nice and capable. Just operating within a poor structure. 

The Last Mile in Health Care

 I follow Atul Gawande in the New Yorker and his books, particularly his advocacy for checklists (an indispensable tool for bureaucrats).  The new print issue of the New Yorker has an article by him concerning health in Costa Rica. 

Costa Rica has longer life spans than the US while spending much less on health care. Gawande credits the way in which they have done public health, a systematic way of having health care professional interact with everyone in their district. 

To my mind it's another example of the benefits of government focusing on the "last mile", the connection between government and the citizen.  FSA does it well for its clientele and programs but the US pattern is to have government work through states and localities. 

Collecting Statistics: Problems and Progress

GovExec had an article on the problems with data collection during the pandemic from the Covid Tracking Project.

Above and beyond any individual reporting practice, we believe that it was the lack of explanations from state governments and, most crucially, the CDC that led to misuse of data and wounded public trust. We tried our best to provide explanations where possible, and we saw transformation when we were able to get the message across to the public. Data users who were frustrated or even doubtful came to trust the numbers. Journalists reported more accurately. Hospitals could better anticipate surges.

If we could make just one change to the way state and federal COVID-19 data were reported, it would be to make an open acknowledgment of the limitations of public-health-data infrastructure whenever the data is presented. And if we could make one plea for what comes next, it’s that these systems receive the investment they deserve.

[Updated: Technology Review describes   a consortium to collect and standardize covid data into one database for research purposes. It sounds a bit klugey but that's the penalty for prioritizing privacy and silos over a rationalized centralized system. The question is whether we'll wake up and fund continuing efforts of this sort.}

We Do Better by Our Animals Than Humans?

This is a paragraph from a Washington Post article on an OK veterinary lab which got into Covid-19 testing:

The Oklahoma Animal Disease Diagnostic Laboratory’s scrappy, collaborative effort to shift gears amid a crisis was aided by basic biological similarities between humans and other species: Animals’ nasal passages are routinely swabbed for viruses, and nucleic acid is extracted from samples and amplified on state-of-the-art machines identical to those used in human testing for the novel coronavirus. But it also highlights the preparedness of many animal health labs, which — unlike public health labs — have been buttressed by federal grants to be bulwarks against outbreaks that could cripple livestock and poultry industries.

That last sentence struck me.

My Predictions?

I don't really have any, but I just saw a Politico post following up on various predictions made about Obamacare.  They mostly were wrong.  So with that in mind I'll venture this: at least 80 percent of the predictions ever offered about Covid-19 will turn out to be wrong.

Nicholas Kristof at the Times sketched the best and worst cases for the outcome. I'll venture the prediction that the outcome will be closer to the best than the worst.

The Marvels of Modern Medicine

I've some loss of hearing, so have been using hearing aids for about a year.  I don't wear them all the time, mostly when going out or watching movies. By themselves they are a marvel, small enough to fit inside the ear. The inside the ear bit is complicated--a tube, a little jobbie which fits into the tube but can be replaced when it gets clogged with earwax, and a rubber/plastic shield which fits over the jobbie which seems also to protect against earwas.

Anyhow I've used the aids often enough that I've had to replace the shield and the jobbie a couple times.  But two weeks ago a confluence of errors,including failing to test that the shield was securely attached, meant that the shield came off and was stuck way inside my ear.  Uncomfortable.

Anyhow after some days in denial, I went to the doctors.  My internist wasn't able to reach it, so I got a referral to an EMT specialist.  He had this machine connected to a TV screen so when he inserted his implement into my ear both he and eye could see the shield inside the ear canal. No sooner had I realized what I was seeing than he'd grabbed the shield with the implement and removed it.  Total elapsed time < 1 minute.

I don't know how economists account for such improvements in productivity.

Rising Insurance Rates: Car Not Health

Via Marginal Revolution a Wired post discusses the increasing costs of car insurance. It's up 30 percent in a decade.  It's interesting--who knew Houston lost 1 million cars?  But one thing it doesn't cover is whether there's any parallel between auto insurance and health insurance.

Great Advances in Medicine

Saw the doctor today at Kaiser.  (It'd been a couple years so I was overdue.)  Many changes since my last visit

• checking in by entering data at a kiosk, rather than a reception clerk at the waiting area.
• changing the format of the printout summarizing the visit.
• eliminating the weigh-in station--they upgraded the examining table/recliner with one which can register your weight.  It also raises and lowers, so your feet can be on the floor instead of dangling in the air.

I'm sort of mocking the healthcare industry here, but it's worth noting that there's a record decrease in the death rate from cancer.

Healthcare and Education Costs

Both healthcare costs and costs of higher education have soared over the past 20 years, as shown in this tweet.

One explanation often offered for the costs of healthcare is that providers (doctors, hospitals, etc.) are highly paid.  It makes sense to me--the comparisons of doctors salaries here and abroad which I've seen show our doctors to be much more highly paid.  If that explanation is right, then is it also the case that our education providers, professors and colleges, get more money than educators overseas?  That seems counter-intuitive somehow, but that may just be my erroneous impressions.

[update: saw a reference to the fact that average college debt for doctors is $200,000, so it's possible that the high cost of college plays some role in creating the high cost of health care??]

Soaking the Rich--What's Triviial, What's Possible

I had an early response to Megan McArdle this morning--without doing a lot of work to reconstruct: she wrote that soaking billionaires as Sen. Warren now proposes as part of her financing of Medicare for All would contribute a "trivial" amount; I responded her definition of "trivial" must be different than mine.  Apparently (because I still don't understand Twitter fully) that became part of a bigger discussion.  Coming back to the exchange this afternoon, the points seem to be that billionaires may have between $2 and $3 trillion in wealth, and taxing them as Warren proposes would produce around 4 percent of the total cost. 

Meanwhile Kevin Drum has done a preliminary analysis of the proposal here.  It's a convenient summary but very preliminary.  Anyhow, over 10 years he shows total costs as $52 trillion, the contribution of a 6 percent tax on billionaires as $1 trillion.  That means a contribution of 2 percent of total, which would, I agree, qualify as "trivial".  (IMO 4 percent is a tad above "trivial".)

I should make it clear I'm as ambivalent about soaking the rich as I am about many things.  I've seen the reservations of many on the right, particularly about the difficulties in collection (bureaucratic efficiency is always a big consideration with me.)  But disregarding those issues, here's how I think of it today:

• I'm told I can withdraw 4 percent of my savings (TSP, IRA) each year and likely maintain my capital.  Anything over 4 percent is likely to cause to me to exhaust my savings.
• Based on that, it seems reasonable to hit billionaires with a 4 percent yearly tax--their fortunes wouldn't diminish, on average, and any especially productive or lucky entrepreneurs could increase them.
• Going over 4 percent is killing the goose--you can be decreasing inequality, which is good IMO, but you need to plan to get an alternative revenue source (or finding savings) for the long run.

My opinions are subject to change, particularly as Drum updates his analysis.

Dentists and the Healthcare System

Went to the dentist today.  Not my favorite way to spend the afternoon.  Growing up I think I saw a dentist once or twice--it wasn't a thing for my family.  Consequently I've some irregular teeth, which is appropriate since I'm an irregular person.  A couple appointments ago my dentist asked about braces.  I barely restrained my laughter--not at my age.

Anyway I had a couple fillings while in the Army, then mostly avoided dentists again until my first wisdom tooth decayed and needed to be extracted.  I eventually hooked up with my wife's dentist--he was a monosyllabic single practitioner who did all his own work, perfectly fitted my preferences.  But then he retired and I had to find a new one, which I eventually did in Reston.

For the first time I started looking to my healthcare insurance to pay part of the dental costs.  It's strange because Kaiser, my health insurance company with which I'm very satisfied, doesn't do dentistry as it does other health issues, by employing its own dentists.  Instead they contract with a dental insurance company.

So the bottomline is there's three parties involved, four when you count my teeth.  Ordinarly I think of myself as an informed consumer, but not now, not with these players.  Instead when my dentist speaks, I salute and say "yes, ma'am", take my medicine and pay whatever bill is presented.  (A slight exaggeration--I just vetoed a separate appointment for a small filling in favor of combining it with my next 3-month (3-month!!) appointment.  But it turns out the three parties have their own problems in keeping their paperwork straight.  My dentist tried to explain the confusion to me (she didn't have a receptionist--hard to get help these days) but failed--I just paid the bill.

My bottom line: as with my sister years ago, I'm amazed by the administrative dysfunction of our healthcare system.

How Far Ahead Are Democrats Thinking?

There's lots of comments about the impact of Kavanaugh on the Supreme Court.  There's also Democratic proposals for what they want to do if and when they are elected in 2020.  I wonder though about  this issue:

Given the decision on Obamacare (this name seems to be fading in favor of ACA--not sure why the change) by SCOTUS, what sort of constitutional basis can the Dems use for future health care legislation?  Can they fix ACA in 2021 by reviving the provisions Trump is killing?  Would such revivals find support in SCOTUS?  There would still be the 5 Justices who supported its legality but on divided opinions.  Would the Dems need to redo ACA to base it more firmly on the authority to tax?  Would they want to?

And how about the next bridge further--legislation to provide Medicare for All?

I Don't Understand Insurance: Obamacare and Crop Insurance

From a Politico story on the improving profit picture for insurers in Obamacare markets:

Insurers in the Obamacare marketplaces spent 75 percent of premiums on medical claims in this year's first quarter, an indication the market is stabilizing and insurers are regaining profitability, according to a Kaiser Family Foundation study released this week. By comparison, in the prior two years, insurers spent more than 85 percent of premiums on medical costs during the same period, which translated into huge losses.

Insurers lose money when they spend 85 percent on medical costs? That means to me their administrative costs are 15 percent.  I'm no expert on crop insurance, but I think USDA doesn't support 15 percent in administrative costs.

Did a quick google search and found this CBO analysis of a proposal:

"This option would reduce the federal government’s subsidy to 40 percent of the crop insurance premiums, on average. In addition, it would limit the federal reimbursement to crop insurance companies for administrative expenses to 9.25 percent of estimated premiums (or to an average of $915 million each year from 2015 through 2023) and limit the rate of return on investment for those companies to 12 percent each year.b [emphasis added]

 My personal opinion is that 9.25 percent is still too high, at least that FSA could administer an insurance program at less cost, given a reasonable time and resources to gain expertise.

Drum's TrumpamaCare Compromise

I hope my fellow liberals are not so stuck in opposition that they wouldn't be open to a compromise on healthcare similar to that outlined by Kevin Drum.  I fear though that we are, though my fears are somewhat assuaged by the idea that Trump will never go for it. But maybe I underestimate him?

Cataract Followup

I blogged the other day complimenting Kaiser on its cataract surgery setup.  Very good, but...

My mother-in-law had cataract surgeries about 10 years ago, in the office of her ophthalmologist, with the staff just a nurse, the receptionist, and the doctor.  Her results were good.  I'd assume Kaiser does a better job by devoting more people and better routines (i.e., checklists, etc., everything Atul Gawande would approve of). But "better" is at the margins, an incremental improvement.  Now when it's my eyes, I want every little increment I can get, but as a society we might be better off if one of the Kaiser staff was employed as a home-visiting nurse.  Might be, but there's no way in our society to get there from here.

Women's Health in Nineteenth Century

The Jstor blog has a piece on de facto first ladies.  What's telling is that the list ends in 1915, with Woodrow Wilson's daughter (his wife died and there was a (short) time before he remarried).  There are 13 daughters, daughters-in-law, and nieces listed for the 19th century, but only one for a bachelor (Buchanan).  (The list does omit Anna Roosevelt, who often acted for FDR because her mother was out doing good works.)  That factoid shows two things:

• life was hard for 19th century women
• life, particularly because of public health improvements, was better for 20th century women.

Habits and Back Pain

Interesting piece here on what our health dollars are spent on.

" The three most expensive diseases in 2013: diabetes ($101 billion), the most common form of heart disease ($88 billion) and back and neck pain ($88 billion)."

"only about 4 percent of spending on low back and neck pain was on pharmaceuticals. Generally, more spending is done on elderly people, but about 70 percent of the spending on low back and neck pain was on working-age adults"

Several years ago I was having low back pain.  Finally mentioned it to my doctor who gave me an exercise routine which takes 15 minutes a day.  No more back pain.  I wonder how much of the pain people suffer could be avoided with similar routines: 10 percent maybe? That's a bunch of money.

It requires access to doctors, establishing habits, and perseverance. 

Medicare Scams: Braces

I'm old.  I'm on Medicare. I see ads on Accuweather for knee and back braces covered by Medicare.  I get phone calls offering free braces. 

When I google "Medicare scam braces" I get a long list of hits.  Apparently some scams can work by getting access to your Medicare number, then billing Medicare for stuff, which may or may not be delivered, but never is prescribed by a doctor.