tag:theconversation.com,2011:/id/topics/health-care-costs-32546/articlesHealth care costs – The Conversation2023-02-13T13:24:26Ztag:theconversation.com,2011:article/1989522023-02-13T13:24:26Z2023-02-13T13:24:26ZCost of getting sick for older people of color is 25% higher than for white Americans – new research<figure><img src="https://images.theconversation.com/files/509317/original/file-20230209-20-w2n1zt.jpg?ixlib=rb-1.1.0&rect=62%2C107%2C5928%2C3628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Racial and ethnic inequality extends to what researches call 'disease cost burdens.'</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/image-of-daughter-holding-the-mothers-hand-and-royalty-free-image/1314187202">sukanya sitthikongsak/Moment via Getty Images</a></span></figcaption></figure><p>As you age, you’re <a href="https://www.ncoa.org/article/the-top-10-most-common-chronic-conditions-in-older-adults">more likely to get sick</a>. And health problems can affect your financial well-being too.</p>
<p>People with health problems spend heavily on health care – the cumulative cost of chronic diseases in the U.S. is <a href="https://www.americanactionforum.org/research/chronic-disease-in-the-united-states-a-worsening-health-and-economic-crisis/">nearly $4 trillion a year</a>. And illnesses make it less likely that you can work as many hours as you might have put in otherwise. Getting sick may even mean you have to stop working altogether. </p>
<p><a href="https://www.umb.edu/faculty_staff/bio/marc_cohen">We are</a> <a href="https://www.umb.edu/jane_tavares_phd">gerontology researchers</a> who study financial vulnerability in later life. We wanted to see if it was possible to estimate the economic tolls of chronic health problems and whether race and ethnicity makes a difference. </p>
<p>To do this, we took advantage of a relatively <a href="https://milkeninstitute.org/sites/default/files/reports-pdf/ChronicDiseases-HighRes-FINAL.pdf">new way to figure out the approximate</a> costs of treating illnesses and the missed income among people who are employed but have to reduce their hours or stop working. This missed income also represents lost productivity to the economy. Experts often lump these two costs into a single “<a href="https://www.cdc.gov/policy/polaris/economics/cost-illness/index.html">disease cost burden</a>” estimate.</p>
<p>This measurement is expressed in total dollars and makes it possible to better understand the costs associated with different groups of people when they get sick. When <a href="https://ncoa.org/article/the-inequities-in-the-cost-of-chronic-disease-why-it-matters-for-older-adults">we analyzed and cross-referenced</a> a nationally representative <a href="https://hrs.isr.umich.edu/about">panel study</a> of 11,820 U.S. adults age 60 and older using this new metric, the results were disturbing.</p>
<p>We found that Black people and Latinos over age 60 – who are typically less able to afford to get sick than their non-Hispanic white counterparts – face bigger financial consequences when they get chronic illnesses. </p>
<h2>$22,734 a year</h2>
<p>Most older Americans will have <a href="https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm">at least one of these common</a> <a href="https://www.cdc.gov/nchs/fastats/older-american-health.htm">and often fatal chronic conditions</a> sooner or later: diabetes, cancer, lung disease, heart disease, stroke and some kind of dementia, according to the Centers for Disease Control and Prevention.</p>
<p>Three other illnesses are also very common late in life: <a href="https://www.cdc.gov/aging/pdf/mental_health.pdf">hypertension, arthritis and depression</a>. </p>
<p>We used that new measurement, created by the <a href="https://milkeninstitute.org/sites/default/files/reports-pdf/ChronicDiseases-HighRes-FINAL.pdf">Milken Institute</a>, a think tank, to obtain estimates for the costs of lost wages for adults age 60 and over, and total treatment costs for specific illnesses. </p>
<p>We adjusted these combined costs to <a href="https://fred.stlouisfed.org/series/CPIMEDSL">reflect 2022 prices</a>. For people with multiple conditions, we summed up all of those costs.</p>
<p>We found that the average yearly disease cost burden associated with older people who are Black or Hispanic, including those who have to stop working or reduce their employment hours, is $22,734. That’s about $4,500, or 25%, higher than the $18,145 average cost of getting sick for their white counterparts.</p>
<p>Our data relayed findings regarding non-Hispanic white, non-Hispanic Black and Hispanic people. Our analysis also included similar results for other people of color but with smaller sample sizes.</p>
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<h2>Major disparities</h2>
<p>One big reason for this disparity is that older people of color are more likely to have losses in earned income when they get sick. For example, we found that 39% of people of color lost wages due to common chronic diseases, versus 17% of non-Hispanic white older adults – a rate more than twice as high. </p>
<p>Most people of color are particularly vulnerable due to three factors: </p>
<ol>
<li><p>They usually have <a href="https://www.federalreserve.gov/econres/notes/feds-notes/disparities-in-wealth-by-race-and-ethnicity-in-the-2019-survey-of-consumer-finances-20200928.html">less wealth than white people</a>.</p></li>
<li><p>The illnesses they tend to get <a href="https://hbr.org/2015/10/the-costs-of-racial-disparities-in-health-care">are costlier overall</a> as compared with non-Hispanic white people – even though health insurance covers the majority of costs for individuals in all groups.</p></li>
<li><p>They are also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690237/">more likely to have to leave the labor force</a> once they become ill.</p></li>
</ol>
<h2>Diminishing wealth</h2>
<p>We also divided the population of all older people into four equal groups based on how much money they lost in wages due to illness. Those who lost the least missed out on about $8,000 a year. Those who lost the most had to make do without more than $30,000 of earned income they would otherwise have taken home.</p>
<p>We then looked at the relationship between mean <a href="https://missioninvestors.org/news/investing-financial-innovations-narrow-racial-wealth-gap">household net wealth</a> – a broad measure of wealth that includes the value of any housing someone owns – and lost wages due to illness among these four groups.</p>
<p>We found that older Americans who lost the most in wages due to chronic illnesses tend to have the least wealth to spend on dealing with getting sick. We also found that Black people and Latinos who get chronic diseases and lose out on the most earned income have only 15% to 22% of the net wealth of older white people.</p>
<p>Taken together, this means that older people of color, who generally have fewer assets that can cushion the blow from their lost economic productivity, face the highest costs for the common chronic diseases that people 60 and up tend to get.</p><img src="https://counter.theconversation.com/content/198952/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marc Cohen receives funding from the National Council on Aging</span></em></p><p class="fine-print"><em><span>Jane Tavares receives funding from the National Council on Aging. </span></em></p>A study of medical costs and income losses found that those who can least afford to pay for health care and miss out on their paychecks rack up the biggest bills.Marc Cohen, Clinical Professor of Gerontology and Co-Director LeadingAge LTSS Center @UMass Boston, UMass BostonJane Tavares, Research Fellow, LeadingAge LTSS Center, UMass BostonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1919332022-11-14T13:26:01Z2022-11-14T13:26:01ZDoctors often aren’t trained on the preventive health care needs of gender-diverse people – as a result, many patients don’t get the care they need<figure><img src="https://images.theconversation.com/files/492839/original/file-20221101-14-z2rkvm.jpg?ixlib=rb-1.1.0&rect=43%2C58%2C4830%2C3593&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Gender-diverse adults have a harder time getting effective primary and preventive health care than their nontransgender counterparts.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/doctors-pockets-with-medical-instruments-royalty-free-image/91540120?phrase=stethoscope&adppopup=true">Peter Dazeley/The Image Bank via Getty Images</a></span></figcaption></figure><p>Preventive health care – such as cancer screening – is <a href="https://www.cdc.gov/cancer/dcpc/prevention/screening.htm">a critical tool</a> in the early detection of disease. Missed screening can result in a missed diagnosis, delayed treatment and <a href="https://doi.org/10.1093%2Fjnci%2Fdjab028">reduced chances of survival</a>. </p>
<p>But the medical system is poorly equipped to meet the needs of gender-diverse patients.</p>
<p>Around <a href="https://www.reuters.com/world/us/new-study-estimates-16-million-us-identify-transgender-2022-06-10/">1.64 million people in the U.S.</a> identify as transgender, nonbinary or gender diverse – people whose gender identity differs from the sex they were assigned at birth.</p>
<p>This adds up to 1.3 million or 0.5% of U.S. adults, all of whom are more likely to <a href="https://pubmed.ncbi.nlm.nih.gov/35308990/">encounter implicit, or unconscious, biases</a> when they seek medical care compared with their cisgender counterparts – those whose gender identity aligns with the sex they were assigned at birth. </p>
<p>I am a <a href="https://directory.hsc.wvu.edu/Profile/40295">primary care doctor in Appalachia</a>, as well as a <a href="https://doi.org/10.15766/mep_2374-8265.11111">medical educator</a> who studies <a href="https://doi.org/10.7189%2Fjogh.10.020387">how to improve the instruction</a> of future health care providers. I work hard every day to improve the health of the underserved. </p>
<p>Primary care doctors devote much of their lives to preventive medicine – the art of stopping disease before it starts. Cancer screening consumes much of my life. </p>
<p>So I’m concerned about the barriers to preventive care for patients who are transgender, including consistent access to <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/03/health-care-for-transgender-and-gender-diverse-individuals">adequate cancer screening</a>. </p>
<h2>The problems with the binary model</h2>
<p>Health care spaces and providers often focus on “men’s health” or “women’s health” specifically. Intake forms may have no option for declaring a gender identity separate from the <a href="https://theconversation.com/not-everyone-is-male-or-female-the-growing-controversy-over-sex-designation-172293?notice=Article+has+been+updated.">sex assigned at birth</a>. Health screening and insurance policies for diseases like cancer tend to remain geared to a flawed binary male-female model.</p>
<p>Gender-diverse patients often find themselves <a href="http://dx.doi.org/10.1136/fmch-2019-000130">teaching their primary care doctors</a> how to provide them with competent care, because many medical students <a href="https://doi.org/10.22454/FamMed.2021.509974">get little training</a> on providing gender-affirming care.</p>
<p>As a result, 1 out of 3 gender-diverse adults <a href="https://www.aafp.org/pubs/afp/issues/2018/1201/p645.html">do not seek preventive care</a>, according to a report by the <a href="https://transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf">National Center for Transgender Equality</a> – or they are not offered these services at all – when they see a health care provider. Even more alarming, 19% of transgender folks report that <a href="https://doi.org/10.21037%2Ftau-20-954">they’ve been refused care</a> altogether.</p>
<p>This may contribute to higher rates of <a href="https://transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf">tobacco use, obesity, alcohol use</a> and other cancer risk factors <a href="https://doi.org/10.1186/s12909-019-1727-3">in gender-diverse people</a>.</p>
<h2>Cancer care challenges</h2>
<p>Research to date shows that transgender adults over age 45 are screened for colon cancer <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347308/">at a lower rate</a> than cisgender patients. They are also more likely to be <a href="https://doi.org/10.1093/jnci/djab028">diagnosed at later stages</a> of lung cancer. This can be devastating, because <a href="https://www.cancer.org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/lung-cancer-screening-guidelines.html">finding lung cancer</a> before it spreads can literally mean the difference between life and death.</p>
<p>The University of California, San Francisco, one of the few places that has protocols for the care of transgender patients, recommends that transgender women who are older than 50 and have been <a href="https://transcare.ucsf.edu/guidelines/breast-cancer-women">taking a feminizing hormone</a> for five years begin getting <a href="https://transcare.ucsf.edu/guidelines/breast-cancer-women">screened for breast cancer</a>. However, according to a recent Canadian study, only <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347308/">about 1 in 3 transgender women</a> who are eligible for breast cancer screening receive mammograms, compared with 2 in 3 eligible cisgender women.</p>
<p>In a 2021 study, researchers found that transgender patients with <a href="https://doi.org/10.1093/jnci/djab028">non-Hodgkin lymphoma, prostate cancer or bladder cancer</a> had roughly twice the death rate of their cisgender counterparts. Since the researchers were able to firmly identify only 589 transgender individuals out of nearly 11.8 million records, they could not accurately compare rates for other types of cancer.</p>
<p>Since 2017, the American Society of Clinical Oncology has recommended including <a href="https://doi.org/10.1200/jco.2016.72.0441">data about patients’ sexual and gender minority</a> status in cancer registries and clinical trials. However, in 2022 the society found that <a href="https://ascopubs.org/doi/full/10.1200/OP.22.00084">only half of oncology care providers</a> are routinely collecting gender identity information. So it’s clear that there’s still a lot to learn about the barriers to inclusive cancer care.</p>
<p>Lack of training in both medical school and residencies – intensive training stints where new doctors hone their skills – perpetuates these disparities.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/Ee4fyqk997s?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">In a 2019 TEDx talk, educator Jo Codde discussed the importance of compassion, dignity and respect as a means to improving transgender health care.</span></figcaption>
</figure>
<h2>Bias in medical school</h2>
<p>Medical education is <a href="https://doi.org/10.1016/S0140-6736(20)30846-1">plagued by biases</a> that reflect society’s stereotypes and prejudices. Further, researchers have found that students can <a href="https://doi.org/10.1007/s11606-007-0160-1">unconsciously absorb</a> biases or stereotypes encountered in their medical education. </p>
<p>And just 26% of doctors directing family medicine clerkships – courses in which medical students start working and interacting with real patients – say they <a href="https://doi.org/10.22454/FamMed.2021.509974">feel comfortable teaching transgender health care</a>.</p>
<p>So the Association of American Medical Colleges has called for emphasizing at all levels of training the health of people who are lesbian, gay, bisexual, transgender, queer or questioning and other identities – <a href="https://www.aamc.org/news-insights/insights/keeping-our-promise-lgbtq-patients">known as LGBTQ+</a>. The association <a href="https://store.aamc.org/downloadable/download/sample/sample_id/129/">recommends that schools</a> take a “<a href="https://doi.org/10.1097/acm.0000000000003581">layered” approach</a> that integrates education on gender-affirming health care across their curricula. This can include incorporating LGTBQ+ health in early coursework, <a href="https://health.wvu.edu/news/story?headline=wv-steps-features-diverse-manikins-standardized-patients-for-students-to-gain-experience-working-wit">using practice patients in simulation</a>, and creating opportunities to care for patients with lived experience.</p>
<p>Many medical schools still fail to integrate gender-affirming care throughout the curriculum, though. Instead, <a href="https://doi.org/10.1007/s11930-018-0185-y">medical schools often append</a> it to the existing curriculum – offering dedicated lectures or small-group activities that address LGBTQ+ health. Medical schools overall are providing a median of only five hours of instruction <a href="https://doi.org/10.22454/FamMed.2021.509974">on gender-affirming health care practices</a>. </p>
<h2>Health insurance obstacles</h2>
<p>In 2015, the Centers for Medicare and Medicaid Services clarified that preventive care services are available under the Affordable Care Act, <a href="https://transcare.ucsf.edu/guidelines/insurance">regardless of gender identity</a>. </p>
<p>However, the main organizations guiding providers and insurance coverage regarding breast, cervical and prostate cancer screening <a href="https://doi.org/10.21037%2Ftau-20-954">continue to use</a> an approach based on the ingrained binary male-female model approach. </p>
<p>For example, the U.S. Preventive Services Task Force still gears its <a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervical-cancer-screening">recommendations for breast and cervical cancer screenings</a> toward cisgender women, with <a href="https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/jama-tf-approach-addressing-sex-gender-issues-bulletin.pdf">little guidance</a> on how to apply them to transgender patients.</p>
<p>This is driven in part by <a href="https://doi.org/10.21037%2Ftau-20-954">a lack of data</a> on how to best screen transgender patients for cancer. </p>
<p>Insurance coverage and companies also create hurdles. Gender-diverse patients are more likely to be <a href="https://doi.org/10.1093/jnci/djab028">uninsured or underinsured</a> – making it <a href="https://doi.org/10.1097/mlr.0000000000001693">much harder for them to access</a> preventive medical care. A gender identity mismatch in an <a href="https://doi.org/10.1093/jamia/ocab136">electronic medical record</a> can <a href="https://transcare.ucsf.edu/guidelines/insurance">trigger a denial</a> for a cancer screening. </p>
<h2>Momentum for change</h2>
<p>Fortunately, the medical field is recognizing that gender-diverse patients have unique health care needs.</p>
<p>Since 2017, the <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/03/health-care-for-transgender-and-gender-diverse-individuals">American College of Obstetricians and Gynecologists</a> has published recommendations
for health care providers on making their practices open and inclusive for all individuals. Training all staff and creating an open office space without a gendered approach is a key recommendation.</p>
<p>Now over <a href="https://transhealthproject.org/resources/medical-organization-statements/">20 medical organizations</a> give similar guidance, with hopes of increasing inclusion through the health care system.</p>
<p>Another encouraging sign is that some medical schools are integrating gender-affirming care into their coursework. The University of Louisville in Kentucky reports that it now offers <a href="https://louisville.edu/medicine/ume/ume-office/equality/curriculum">50 hours of LGBTQ+-specific topics</a>. And a faculty-student team at the Boston University School of Medicine has developed a tool to help medical schools assess and improve <a href="https://doi.org/10.1097/acm.0000000000004203">how they educate students</a> to provide sexual and gender-minority health care.</p>
<p>I’m hopeful that <a href="https://doi.org/10.4158/EP171758.OR">the next generation</a> of health care providers will be a <a href="https://www.mededportal.org/doi/10.15766/mep_2374-8265.10536">force for change</a> at their institutions; in my experience, <a href="https://www.npr.org/sections/health-shots/2019/01/20/683216767/medical-students-push-for-more-lgbt-health-training-to-address-disparities">incoming medical students</a> are more aware of health disparities than their older generations of educators.</p><img src="https://counter.theconversation.com/content/191933/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jenna Sizemore does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>From primary care to cancer screening and insurance coverage, gender-diverse people still face many hurdles to getting good medical care.Jenna Sizemore, Assistant Professor of Medicine, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1812392022-04-14T05:22:28Z2022-04-14T05:22:28ZThe Greens want Medicare to cover a trip to the dentist. It’s a grand vision but short on details<figure><img src="https://images.theconversation.com/files/457830/original/file-20220413-25-w4ga3t.jpg?ixlib=rb-1.1.0&rect=1%2C1%2C997%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/european-mid-pleased-dentist-woman-face-1941089188">Shutterstock</a></span></figcaption></figure><p>Universal and affordable access to dental care is the perennial health-care issue everyone cares about but no major political party seems willing to address in any substantive way. </p>
<p>Thank goodness the Greens consistently remind us of the pressing need to make dental care an essential part of health care. This election, they’ve been quick to push out <a href="https://greens.org.au/sites/default/files/2022-04/Greens-2022-Policy-Platform--Health--Dental.pdf">their policy</a> to integrate dental care into Medicare.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1513934052839018504"}"></div></p>
<p>They propose everyone with access to Medicare be eligible for what are described as the “clinically relevant services they require”. This includes general dental, orthodontics (such as braces) and restorative services (such as crowns). </p>
<p>To make sure there are enough dental professionals, the Greens propose university education and training for the dental workforce be fee-free.</p>
<p>Such an expansive scheme is very expensive. This has been costed at A$77.6 billion over the next decade, funded with new taxes on big corporations and billionaires.</p>
<p>The Greens (who might hold some sway in a new parliament but will never be in government with budget responsibilities) have the luxury of proposing a large-scale program with no information about its presumable gradual introduction.</p>
<p>The Greens have also proposed a funding mechanism that is very unlikely to fly, given both the Coalition and Labor view new taxes and tax reforms <a href="https://independentaustralia.net/politics/politics-display/bad-politics-and-the-death-of-tax-reform,15544">as political poison</a>. </p>
<p>The Greens’ publicly available <a href="https://greens.org.au/sites/default/files/2022-04/Greens-2022-Policy-Platform--Health--Dental.pdf">policy document</a> is just three pages long and very short on detail. A number of key questions go unacknowledged and unanswered.</p>
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Read more:
<a href="https://theconversation.com/voters-love-the-greens-message-more-than-ever-but-it-may-not-lead-to-a-surge-of-votes-for-them-180671">Voters love the Greens' message more than ever – but it may not lead to a surge of votes for them</a>
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<h2>How much will this cost?</h2>
<p>The policy has been costed by the independent <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Budget_Office">Parliamentary Budget Office</a>, so there must be more detail available about the program’s rollout and scope. </p>
<p>The policy document does not say if the proposed $77.6 billion investment includes, or is in addition to, current federal spending on dental care through the Medicare-funded dental services for eligible <a href="https://www.servicesaustralia.gov.au/child-dental-benefits-schedule">children</a>, public dentistry for some <a href="https://federalfinancialrelations.gov.au/agreements/national-partnership-public-dental-services-adults">adults</a>, and GP and hospital visits for dental needs. </p>
<p>This figure likely does not include the costs of free university education for dentists, which is part of the Greens’ <a href="https://greens.org.au/sites/default/files/2022-03/Greens-2022-Policy-Platform--Education--Free-Tafe-Uni.pdf">separate education policy</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/458072/original/file-20220414-26-u6vq6n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Dental students looking at dentures at university" src="https://images.theconversation.com/files/458072/original/file-20220414-26-u6vq6n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/458072/original/file-20220414-26-u6vq6n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/458072/original/file-20220414-26-u6vq6n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/458072/original/file-20220414-26-u6vq6n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/458072/original/file-20220414-26-u6vq6n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/458072/original/file-20220414-26-u6vq6n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/458072/original/file-20220414-26-u6vq6n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Does the proposed funding include educating the next generation of dentists? That would cost extra.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/dental-prosthesis-dentures-prosthetics-work-hands-458819089">Shutterstock</a></span>
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<p>This $77.6 billion investment over ten years is substantial. This equates to an average of $7.7 billion a year – <a href="https://budget.gov.au/2022-23/content/bp1/download/bp1_bs5.pdf">about the same</a> (see table 5.8.1) as the annual cost to the federal budget of the subsidy to encourage people to purchase private health insurance.</p>
<p>However, these costs should be balanced against the economic benefits a federal government investment in a universal dental-care program would deliver in terms of reduced health-care costs and increased productivity. </p>
<h2>What is covered?</h2>
<p>The proposal is said to be costed on the basis <a href="https://www.vice.com/en/article/qjb5g5/the-greens-want-to-use-a-billionaire-tax-to-make-dental-free-for-all">that 80%</a> of dental services will be “routine”. But especially in the early years of such a program, there will be a pent-up demand from people who have <a href="https://adavb.org/news-media/media-releases/public-dental-waiting-lists-balloon-as-the-impacts-of-covid-19-bite">waited years for care</a>. These people will need more extensive and expensive services. </p>
<p>Formal guidelines about what is “routine” or “essential” and a focus on prevention and early intervention will be critical to ensure targeted care and prevent cost blow-outs.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/two-million-aussies-delay-or-dont-go-to-the-dentist-heres-how-we-can-fix-that-113376">Two million Aussies delay or don't go to the dentist – here's how we can fix that</a>
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</em>
</p>
<hr>
<h2>The workforce</h2>
<p>Having the right dental workforce in the right places is essential for universal access to dental care.</p>
<p>Simply providing free university places for dental students will not address the current situation, <a href="https://pubmed.ncbi.nlm.nih.gov/30674395/">which sees</a> a surfeit of dentists in metropolitan areas and a scarcity in rural, remote and socially disadvantaged areas.</p>
<p>Many dental-care services can be delivered by <a href="https://grattan.edu.au/wp-content/uploads/2019/03/915-Filling-the-gap-A-universal-dental-scheme-for-Australia.pdf">dental hygienists and technicians</a> and any new scheme should encourage the most appropriate professional to deliver each service.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-brush-your-teeth-properly-according-to-a-dentist-177219">How to brush your teeth properly, according to a dentist</a>
</strong>
</em>
</p>
<hr>
<h2>What is missing?</h2>
<p>The policy does not specifically address providing oral health and dental care for people with special needs, including aged-care residents or people with a physical or mental disability.</p>
<p>The campaign materials talk about “free dental care” but provide no indication as to how this will be achieved. Under Medicare, neither the fees doctors and allied health professionals charge, nor bulk billing, <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp1617/Quick_Guides/Medicare#:%7E:text=Bulk%20billing%20is%20not%20mandatory,service%20free%20to%20the%20patient.">are mandated</a>. It would be very difficult to impose set fees and a requirement to bulk bill on dental professionals.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-shocking-state-of-oral-health-in-our-nursing-homes-and-how-family-members-can-help-77473">The shocking state of oral health in our nursing homes, and how family members can help</a>
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</em>
</p>
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<h2>First steps</h2>
<p>For too many years, I <a href="https://www.pc.gov.au/research/ongoing/report-on-government-services/2022">and</a> <a href="https://agedcare.royalcommission.gov.au/publications/final-report">others</a> <a href="https://grattan.edu.au/wp-content/uploads/2019/03/915-Filling-the-gap-A-universal-dental-scheme-for-Australia.pdf">have been writing</a> about the need to address <a href="https://johnmenadue.com/dental-care-must-be-on-the-election-agenda-its-time/">oral health and dental care</a>.</p>
<p>University of Sydney colleague Professor Heiko Spallek and I <a href="https://johnmenadue.com/dental-care-must-be-on-the-election-agenda-its-time/">recently proposed</a> that in the face of unwillingness of the major political parties to implement a universal dental-care program, there should be a more targeted approach to providing dental services.</p>
<p>For example, this could be a preventive program for children, oral hygiene programs for people in aged care, Medicare coverage of dental care for pregnant and post-partum women and for people with certain chronic medical conditions, such as cancer, diabetes or HIV/AIDS. Alternatively, a more limited approach could see the provision of designated essential services under a means-tested program.</p>
<p>I’ve <a href="https://theconversation.com/how-to-fill-the-gaps-in-australias-dental-health-system-35371">written before</a> about the need for teams of dental professionals and educators where they’re most needed, such as remote and under-served communities.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-fill-the-gaps-in-australias-dental-health-system-35371">How to fill the gaps in Australia's dental health system</a>
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</em>
</p>
<hr>
<h2>It’s important to start the debate</h2>
<p>Dental health has a huge impact <a href="https://johnmenadue.com/dental-care-must-be-on-the-election-agenda-its-time/">on people’s quality of life</a>. This includes health outcomes, self-esteem and employability. </p>
<p>But for too many Australians, the <a href="https://grattan.edu.au/wp-content/uploads/2019/03/915-Filling-the-gap-A-universal-dental-scheme-for-Australia.pdf">burgeoning out-of-pocket costs</a> of private dental care and <a href="https://www.aihw.gov.au/about-our-data/our-data-collections/public-dental-waiting-times">long waiting lists</a> for publicly-funded care are a major barrier.</p>
<p>It is time for politicians and the medical profession to see oral health and dental care as an essential health-care issue worthy of substantial investment. </p>
<p>The Greens’ proposal – despite its inadequacies – has a vision that should serve as a starting point for public debate.</p><img src="https://counter.theconversation.com/content/181239/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lesley Russell does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Such an expansive scheme is very expensive. It has been costed at A$77.6 billion over the next decade, funded with new taxes on big corporations and billionaires.Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1760822022-02-13T19:57:54Z2022-02-13T19:57:54ZWhy France is among the high-income countries where the most people died of Covid-19<p>As of February 8, 2022, the cumulative number of Covid-19-related deaths globally is close to 5.8 million. With more than 2,300 Covid-19 deaths per million people, the United States, Belgium, Italy and UK have recorded the highest number of fatalities, followed by Spain and France (with about <a href="https://covidtracker.fr/covidtracker-world/">2,000</a>). </p>
<p>At that time, France’s per-million total of Covid-19 deaths was 14% higher than the average for high-income countries (1,740) – but this was not always the case. The difference peaked at 113% on May 1, 2020 and gradually narrowed thereafter (80% in June, 2020; 50% in December, 2020). Once the first wave of the epidemic had passed, that would seem to indicate that France managed the health crisis better than other high-income countries, but without making up for its initial shortcomings.</p>
<p>France did indeed try hard, increasing its health budget by 8% in 2020 (compared to 2019) producing a <a href="https://solidarites-sante.gouv.fr/actualites/presse/communiques-de-presse/article/les-comptes-de-la-securite-sociale-en-2020-enregistrent-un-deficit-nettement">30 billion euro deficit</a> for the health sector (20 times higher than 2019).</p>
<p>France’s performance therefore looks debatable given the quality of the French health care system and the relatively high <a href="https://stats.oecd.org/Index.aspx?DataSetCode=SHA&lang=fr">share of GDP it dedicates to health care expenditure</a>. In 2019, this amounted to 11.1%, a similar rate to Sweden, Canada or Japan, but behind the US, Switzerland and Germany with 16.8%, 11.7% and 11.3% respectively.</p>
<p>So what happened to a country which, according to the World Health Organisation in 2000, provided the “best overall health care” in the world? There are three possible explanations: the health of the general population, health care system performance and specific responses to tackle the pandemic.</p>
<h2>A population more vulnerable to Covid-19?</h2>
<p>Age and comorbidities are the main determinants of Covid-19-related deaths. Could residents of France be on average more likely to develop severe or lethal forms after infection with Covid-19 than people infected in other OECD countries?</p>
<p>First, France ranks <a href="https://www.prb.org/resources/countries-with-the-oldest-populations-in-the-world/">9th worldwide</a> among countries with the largest proportion of +65 years old (20% of the population). Next, 38% of the French population aged 18 and over are living with <a href="https://www.oecd-ilibrary.org/docserver/908b2da3-en.pdf">at least one chronic condition</a> <em>versus</em> 35.2% in OECD countries.</p>
<p>Because smoking is associated with a higher vulnerability to infectious diseases, the high rate of <a href="https://www.oecd-ilibrary.org/fr/social-issues-migration-health/population-aged-15-and-over-smoking-daily-by-sex-2019-or-nearest-year_97d2be12-en">French daily smokers</a> (24% versus 16% in OECD countries) could also be a contributing factor. Finally, at 65 years old, the French may expect to live one healthy life year (HLY) less than the Germans, and five HLY less than the Swedes (<a href="https://www.oecd-ilibrary.org/fr/social-issues-migration-health/life-expectancy-and-healthy-life-years-at-age-65-by-sex-2019-or-nearest-year_e83a0e4b-en">OECD</a>).</p>
<h2>Universal, generous but… centralised public-hospital care system</h2>
<p>Another explanation for the higher French mortality figures may come from the health care system itself. Dating to 1945, the French health care system is based on a so-called <a href="https://en.wikipedia.org/wiki/Bismarck_Model">Bismarckian approach</a> (an insurance model related to salary), combined with goals of universality similar to the <a href="https://en.wikipedia.org/wiki/Beveridge_Model">Beveridge model</a> of Britain’s NHS developed over the past 20 years. It is highly regulated in terms of the price, quantity and quality of care.</p>
<p>Statutory health insurance (SHI) is compulsory and uniform for all French residents. In 2000, SHI was extended to all legal residents through universal health insurance. Benefits covered under SHI and health care expenditure are defined at the national level. Moreover, complementary health insurance (CHI) supplements SHI for 96% of the French population. After all reimbursements, the average <a href="https://data.oecd.org/healthres/health-spending.htm">out-of-pocket payment</a> in France is one of the lowest among OECD Countries (9% of current health care expenditure, behind South Africa with 7.7%). However, clear social disparities exist, especially in terms of access to specialists, medication, dental and optical care.</p>
<p>As far as primary care is concerned, the French healthcare delivery policy is not based on primary health care or public health. In this respect, the proportion of health expenditure devoted to ambulatory care is low compared to OECD countries (about 22% of health expenditure, and on average six physician visits, mainly to GPs). In addition, the number of doctors per head of the population is lower in France than the OECD average, with respectively 3.2 and 3.6 practising doctors per 1,000 people.</p>
<p>Since the mid-2000s, France has pursued a policy of reinforcing primary care. It implemented a patient enrolment system (the attending physician has acted as gatekeeper since 2004) and referral and diversified payment methods (physicians and specialists are mainly paid via a fee-for-service system). France has promoted and developed cooperation and multi-professional practice, in particular in health centres and clinics, and more recently, territorial coordination.</p>
<p>Finally, the French health care system is a centralised public-hospital care system built around the management of chronic diseases. Even if ambulatory care is increasing, hospital expenditure still accounts for almost half of all health care expenditure.</p>
<p>The initial health system response to the flood of positive Covid cases was therefore focused on the public hospital, leaving out private actors (such as clinics and self-employed physicians).</p>
<p>The number of hospital beds and flexibility of use are key factors in addressing any unexpected additional demand for intensive care. In 2019, the number of adult intensive care beds per 100,000 people in France was very slightly higher than the average for OECD countries (<a href="https://www.oecd-ilibrary.org/fr/social-issues-migration-health/adult-intensive-care-beds-2019-or-nearest-year-and-2020_b0083b5c-en">16.4</a> <em>vs</em> 14.1) but far behind Germany (28.2) or the USA (21.6). As a result, the French public hospital system became extremely congested.</p>
<h2>Underinvestment in health prevention and medical research</h2>
<p>The health crisis has laid bare weaknesses in the French health care system which have increased pressure on hospitals.</p>
<p>First, the French model is characterised by an underinvestment overall public health and long-term health strategy. In 2015, institutional spending on prevention represented 1.8% of current health spending, compared to 2.8% in <a href="https://www.oecd.org/health/health-at-a-glance/">OECD countries</a>.</p>
<p>However, in 2007 France developed a very ambitious protection system against pandemics by building an agency called Eprus. Initially, substantial stocks of FFP2 and surgical masks, respirators and oxygen cylinders, equipment for analysis laboratory and accessories were available. For financial reasons and political choice, however, its budget was drastically reduced from 281 million euros in 2007 – before the H1N1 crisis – to 25.8 million euros in 2015, meaning that by early 2020 strategic stocks of masks and equipment were very low.</p>
<p>Then the pandemic exposed the limits of a centralised decision-maker and high level of bureaucracy in relationships between the Health Ministry, the regional health agencies and health professionals, which do not allow a fast and differentiated response according to different heterogeneous territories or populations needs. Measures adopted to limit epidemics may be more effective when defined at a smaller, more localised level, as in Germany (<em>Länder</em>).</p>
<p>Another reason stems from the lack of coordination between primary care and hospitals, public and private stakeholders and health care (handled at regional level) and nursing homes services (depending on a smaller administrative entity, the <em>département</em>). In 2020, care-home deaths amounted to <a href="https://ltccovid.org/international-reports-on-covid-19-and-long-term-care/">43%</a> of all Covid-19 deaths, most of them occurring at the beginning of the crisis.</p>
<p>In addition, the low level of investment in innovation and medical research has hampered the French system’s ability to cope with the pandemic. For instance, in 2020 the share of adults treated by a doctor via a remote service since the start of the pandemic is the weakest in France among OECD Countries (23% vs 45%).</p>
<p>Finally, the failures of the Pasteur Institute and Sanofi to develop their own vaccine have made France totally dependent on the international market.</p>
<h2>Rolling back the epidemic in a climate of suspicion</h2>
<p>Starting on March 17, 2020, and continuing for eight weeks, France imposed a strict national lockdown similar to the one in Italy to counter the initial wave of the epidemic.</p>
<p>That year, the “test track isolate” strategy advocated by the government was only partially effective. First, even though screening tests were delivered free of charge (by October 15, 2021), there was a severe shortage due to difficulties in supplying machines and detection kits and to the rigidity of the French system.</p>
<p>Mass screening programmes were conducted in several countries due to the many asymptomatic forms of the virus. On May 31, 2020, when in France there were <a href="https://ourworldindata.org/explorers/coronavirus-data-explorer?zoomToSelection=true&time=2020-03-01..latest&facet=none&uniformYAxis=0&pickerSort=desc&pickerMetric=new_cases_per_million&Metric=Tests&Interval=Cumulative&Relative+to+Population=true&Color+by+test+positivity=false&country=FRA%7EDEU%7EGBR%7EUSA">10 cumulative Covid-19 tests per 1,000 people</a>, there were already 25 in the UK, 51 in Germany and 58 in the United States.</p>
<p>There were also delays in implementing patient follow-up through tracking. Isolation, which is highly dependent on population density and the role of individual freedom in the existing political system, was not implemented either. These shortcomings in the identification, follow-up and referral of Covid-19 patients heavily affected <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8007943/">the hospital system</a>.</p>
<p>The lack of available masks and communication mistakes, combined with declining trust in governments and defiant behaviour that spread during the first weeks of the pandemic, especially when it came to complying with sanitary rules and, in the medium term, vaccination adherence.</p>
<p>To conclude, the quality of France’s healthcare system and the exceptional involvement, innovation and cooperation of health workers were able to offset a significant part of the high French death rate recorded at the beginning of the health crisis, which stemmed mainly from the country’s public health deficit and the centralisation and lack of flexibility of the French health system.</p><img src="https://counter.theconversation.com/content/176082/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas Barnay ne travaille pas, ne conseille pas, ne possède pas de parts, ne reçoit pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'a déclaré aucune autre affiliation que son organisme de recherche.</span></em></p>France’s per-capita death toll from Covid-19 is higher than the average for high-income countries. A lack of prevention and the initial rigidity of the French system are largely to responsible.Thomas Barnay, Full Professor in Economics, ERUDITE, UPEC (on leave) / Visiting Professor, Health Care Policy Department, Harvard Medical School and French Harkness Fellow in Health Care Policy and Practice (The Commonwealth Fund) (2021-2022), Université Paris-Est Créteil Val de Marne (UPEC)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1612782021-06-30T19:55:21Z2021-06-30T19:55:21ZPeople are using their super to pay for IVF, with their fertility clinic’s blessing. That’s a conflict of interest<figure><img src="https://images.theconversation.com/files/407848/original/file-20210623-19-lr0da7.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/two-female-lgbt-lesbian-couple-best-1987833428">from www.shutterstock.com</a></span></figcaption></figure><p>People can access their superannuation early <a href="https://www.smh.com.au/politics/federal/australians-tap-super-for-500m-outlay-on-ivf-weight-loss-surgery-and-dentistry-20210207-p57086.html">to pay for</a> expensive fertility treatments such as IVF.</p>
<p>They can claim “mental disturbance” if they want part of their funds released early on compassionate grounds.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1358500810137628672"}"></div></p>
<p>However, in our recent paper in the <a href="https://www.unswlawjournal.unsw.edu.au/article/emptying-the-nest-egg-to-fill-the-nursery-early-release-of-superannuation-to-fund-assisted-reproductive-technology/">UNSW Law Journal</a>, we question whether the rules are tight enough to protect future retirement incomes. We also consider whether involvement of fertility clinics and other companies in the process is a conflict of interest.</p>
<p>Here’s how it all works and what needs to change.</p>
<h2>Here’s what happens</h2>
<p>People can apply to the Australian Tax Office to <a href="http://classic.austlii.edu.au/au/legis/cth/consol_reg/sir1994582/s6.19a.html">legally access</a> their super funds early on compassionate grounds for a range of medical procedures, including IVF. Last year, <a href="https://www.smh.com.au/politics/federal/australians-tap-super-for-500m-outlay-on-ivf-weight-loss-surgery-and-dentistry-20210207-p57086.html">tax figures show</a> almost 34,000 people did this, accessing a total of more than A$513 million. That figure has grown considerably since 2015, where 14,000 people accessed $184 million.</p>
<p>If that medical procedure is dentistry or surgery, people need to show the procedure is needed to alleviate pain or to treat a life-threatening injury or illness.</p>
<p>But to access IVF or other fertility treatments, these criteria don’t apply. So the only avenue is for people to claim they are experiencing “acute, or chronic, mental disturbance” that can only be alleviated by the fertility treatment. </p>
<p>People must also submit <a href="https://www.ato.gov.au/Individuals/Super/In-detail/Withdrawing-and-using-your-super/Early-access-on-compassionate-grounds/?page=5#Evidence_required_for_your_application">two medical practitioner reports</a> certifying the treatment is necessary.</p>
<p>The Australian Tax Office did not provide a breakdown of how many people accessed super funds for IVF this way when we requested detailed figures. However, we understand accessing super for IVF is one of the <a href="https://www.releasemysuper.com.au">main medical</a> <a href="https://www.smh.com.au/politics/federal/australians-tap-super-for-500m-outlay-on-ivf-weight-loss-surgery-and-dentistry-20210207-p57086.html">reasons</a>.</p>
<p>We do not advocate a blanket ban on the process. For many people, having a baby is more important than the amount of money they retire with. But to protect individuals and couples seeking fertility treatment, we need to reform the rules surrounding early release of super for IVF.</p>
<p>This is needed so people are aware of the implications of accessing their super early, have enough money to retire on, and that this option is only available after a rigorous assessment process independent of private fertility clinics.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/considering-using-ivf-to-have-a-baby-heres-what-you-need-to-know-108910">Considering using IVF to have a baby? Here's what you need to know</a>
</strong>
</em>
</p>
<hr>
<h2>What does ‘mental disturbance’ mean?</h2>
<p>Superannuation legislation <a href="http://classic.austlii.edu.au/au/legis/cth/consol_reg/sir1994582/s6.19a.html">does not define</a> the term “mental disturbance”. It’s not a term <a href="https://www.ranzcp.org/news-policy/policy-and-advocacy/position-statements/diagnostic-manuals">used to diagnose</a> mental illness. So it can be interpreted in many ways. </p>
<p>This might mean someone may have an “acute, or chronic, mental disturbance”, such as a diagnosis of severe depression. Or they may not have a diagnosed mental health condition, but nevertheless may be extremely distressed about wanting a baby and not being able to afford IVF.</p>
<p>A 2018 parliamentary paper <a href="https://treasury.gov.au/consultation/c2018-t341625">suggested</a> the term “diagnosed mental illness or behavioural disorder” instead; we agree. These words are consistent with the language psychiatrists and psychologists use and understand; are more specific and clearer; and people would have to meet clearly defined criteria before being diagnosed.</p>
<h2>Who are these medical practitioners?</h2>
<p>The legislation is vague about the qualifications a certifying medical practitioner needs to have, a topic considered <a href="https://jade.io/article/349673">in a case</a> that went to the Federal Court.</p>
<p>So theoretically, it might be possible for a fertility doctor from an IVF clinic to be one of the certifying doctors, which may be a conflict of interest. </p>
<p>If that fertility doctor doesn’t also have psychiatric expertise, this also means the doctor doesn’t have the expertise to certify someone has a “mental disturbance”.</p>
<p>This situation might lead people to think the doctor might not be impartial or objective, whether or not that’s the case. This is because the fertility clinic ultimately profits from the release of any super funds.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/407851/original/file-20210623-15-1osbqjf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A couple on sofa holding hands sitting next to psychologist or therapist" src="https://images.theconversation.com/files/407851/original/file-20210623-15-1osbqjf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/407851/original/file-20210623-15-1osbqjf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/407851/original/file-20210623-15-1osbqjf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/407851/original/file-20210623-15-1osbqjf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/407851/original/file-20210623-15-1osbqjf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/407851/original/file-20210623-15-1osbqjf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/407851/original/file-20210623-15-1osbqjf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A doctor with mental health expertise needs to get involved, not just a fertility doctor.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/patient-couple-consulting-doctor-psychologist-on-1457837060">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>To prevent any perceived or actual conflict of interest, we strongly recommend one of the certifying medical practitioners have clinical expertise in mental health, such as psychiatry, who would then evaluate the person wishing to access their super for IVF.</p>
<p>We recommend this person be independent of the fertility clinic, to be further removed from any actual or perceived conflict of interest.</p>
<p>An appropriately trained mental health practitioner would also ensure the person gets mental health care (in addition to medical advice) before IVF is prescribed and administered. </p>
<h2>Other companies get involved</h2>
<p>Specialist companies <a href="https://www.releasemysuper.com.au">help people</a> <a href="https://mysupercare.com.au/our-services/">access their super early</a> for services, including IVF. Some <a href="https://fertilityfirst.com.au/supercare/">advertise their services</a> on fertility clinic websites.</p>
<p>Some of these third-party intermediaries <a href="https://www.ato.gov.au/Individuals/Super/In-detail/Withdrawing-and-using-your-super/Early-access-on-compassionate-grounds/?page=6">charge a fee</a> to help people prepare and submit their applications to the Australian Tax Office. In some cases, fertility clinics <a href="http://fertilityfirst.com.au/supercare">refer people</a> to them.</p>
<p>And <a href="https://treasury.gov.au/consultation/c2018-t341625">a 2018 parliamentary paper</a> noted a greater awareness of third-party intermediaries may have contributed to an increase in applications for early release of super on medical grounds.</p>
<p>The practice also <a href="https://www.afr.com/wealth/superannuation/calls-for-tougher-consumer-protections-for-early-release-super-20181128-h18h3j">raises ethical concerns</a> about companies that have built their business model on taking a cut of people’s super at a time where they may be vulnerable or their mental health fragile.</p>
<p>This has led some consumer groups and financial planners <a href="https://www.afr.com/wealth/superannuation/calls-for-tougher-consumer-protections-for-early-release-super-20181128-h18h3j">to call for</a> more stringent controls on third-party intermediaries and their involvement in early access to super on medical grounds, especially when medical practitioners are likely to financially benefit.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-business-of-ivf-how-human-eggs-went-from-simple-cells-to-a-valuable-commodity-119168">The business of IVF: how human eggs went from simple cells to a valuable commodity</a>
</strong>
</em>
</p>
<hr>
<h2>Independent financial counselling</h2>
<p>We recommend people be required to undertake affordable financial counselling before starting IVF or other fertility treatment, whether or not they’re accessing their super early to pay for it. This should be impartial and independent of any fertility clinic to avoid any potential or perceived conflict of interest.</p>
<p>This should allow people to make informed financial decisions based on their assets and liabilities, and the most effective and equitable funding avenues for treatment. This may or may not involve early access to super. If people do go ahead, they need to understand the short- and long-term costs of doing so. </p>
<p>This is especially important for women, who generally have <a href="https://www.smh.com.au/money/planning-and-budgeting/what-government-can-do-to-reduce-super-gender-gap-20210430-p57nqd.html">lower super balances</a> than men due to lower life-long earnings, gendered pay gaps and career breaks. And it’s women who are <a href="https://www.aph.gov.au/parliamentary_business/committees/senate/economics/economic_security_for_women_in_retirement/report">more likely</a> to access their super early <a href="https://www.mamamia.com.au/superannuation-to-pay-for-ivf/">for IVF</a> or other reasons.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/standard-ivf-is-fine-for-most-people-so-why-are-so-many-offered-an-expensive-sperm-injection-they-dont-need-158227">Standard IVF is fine for most people. So why are so many offered an expensive sperm injection they don't need?</a>
</strong>
</em>
</p>
<hr>
<h2>Where to now?</h2>
<p>For some people, accessing their super early for fertility treatments is their only chance to start or extend their family. So they need better protection to make sure their interests are not compromised by any financial motivations of fertility treatment providers — whether perceived or actual. </p>
<p>We also need to reduce the need for people to rely on their super to pay for IVF in the first place. That’s why we also <a href="https://www.unswlawjournal.unsw.edu.au/article/emptying-the-nest-egg-to-fill-the-nursery-early-release-of-superannuation-to-fund-assisted-reproductive-technology/">recommend</a> greater availability of public funding for fertility technologies, such as IVF.</p>
<p>This would mean people would still be able to access IVF, regardless of whether they are in genuine distress, have a mental health diagnosis, or just want to start or extend their family.</p>
<p>Changes such as these might go some way in providing better security in retirement, greater faith in the fertility industry and fairer provision of treatment.</p>
<hr>
<p><em>Lily Porceddu, a lawyer in private practice in Victoria, co-authored this article.</em></p><img src="https://counter.theconversation.com/content/161278/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Neera Bhatia does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For some people, accessing their super early for fertility treatments is their only chance to start or extend their family. And they need better protection.Neera Bhatia, Associate Professor in Law, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1543282021-03-02T13:22:25Z2021-03-02T13:22:25ZCOVID-19 costs could push hospitals to rethink billions of dollars in wasted supplies<figure><img src="https://images.theconversation.com/files/385934/original/file-20210223-16-14962ps.jpg?ixlib=rb-1.1.0&rect=10%2C10%2C6679%2C4456&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The pandemic's supply crunch led to more reuse and decontamination techniques that can save money and reduce waste.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/nurse-reaches-for-supplies-in-clinic-supply-room-royalty-free-image/1245241080">SDI Productions via Getty Images</a></span></figcaption></figure><p>The United States <a href="https://data.oecd.org/healthres/health-spending.htm">spends more on health care</a> than any other nation. What many people don’t realize is that a large portion of this spending goes to waste.</p>
<p>Every year, an estimated US$760 billion to $935 billion is wasted through overtreatment, poor coordination and other failures, amounting to about <a href="https://www.doi.org/10.1001/jama.2019.13978">a quarter of total U.S. health care spending</a>, research has shown. Medical supplies and equipment are part of that. One study estimated that <a href="http://doi.org/10.3171/2016.2.JNS152442">nearly $1,000 in unused supplies</a> are wasted on average during each neurosurgery procedure.</p>
<p>With hospitals <a href="https://www.aha.org/guidesreports/2020-05-05-hospitals-and-health-systems-face-unprecedented-financial-pressures-due">under financial pressure</a> from COVID-19 and medical waste <a href="https://www.waste360.com/medical-waste/hidden-risks-medical-waste-and-covid-19-pandemic">volumes even higher</a>, the pandemic could finally trigger a much-needed reset in how health care organizations and hospitals think about supply-related waste. That includes how they reuse supplies, how they plan for surgeries and what they look for in prepackaged surgical supplies.</p>
<h2>Decontaminating and reusing supplies safely</h2>
<p>It’s important to recognize that not all single-use equipment and supplies are safer. Cleaning, sterilizing and reusing equipment can be safe and cost less in the long run. For example, the U.S. Food and Drug Administration points out that surgical instruments such as clamps and forceps <a href="https://www.fda.gov/medical-devices/reprocessing-reusable-medical-devices/what-are-reusable-medical-devices">can be reprocessed and reused</a>, but they are often thrown away after a single use.</p>
<p><a href="http://doi.org/10.1001/jamainternmed.2020.4221">New sterilization methods</a> can help. For example, N-95 masks that were sterilized and sanitized with ethylene oxide and vaporized hydrogen peroxide were able to retain their more than 95% filtration efficiency. The approvals hospitals received from the Centers for Disease Control and Prevention to <a href="https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html">decontaminate</a> some disposable items could become long-term safe methods to reduce waste.</p>
<figure class="align-center ">
<img alt="Supplies on tables in an operating room during surgery" src="https://images.theconversation.com/files/385930/original/file-20210223-18-unrksz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/385930/original/file-20210223-18-unrksz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=374&fit=crop&dpr=1 600w, https://images.theconversation.com/files/385930/original/file-20210223-18-unrksz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=374&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/385930/original/file-20210223-18-unrksz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=374&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/385930/original/file-20210223-18-unrksz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=470&fit=crop&dpr=1 754w, https://images.theconversation.com/files/385930/original/file-20210223-18-unrksz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=470&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/385930/original/file-20210223-18-unrksz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=470&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Operating rooms are a large source of hospital supply waste.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/surgeons-performing-open-heart-surgery-royalty-free-image/467546155?adppopup=true">Thierry Dosogne via Getty Images</a></span>
</figcaption>
</figure>
<p>Being able to <a href="https://doi.org/10.1016/j.ajic.2020.10.013">reuse personal protective equipment</a> could not only reduce waste in landfills, lower the environmental footprint of supply production and delivery, and save money, but it could also strengthen health care organizations’ ability to be prepared for supply chain breakdowns in future pandemics.</p>
<h2>Ways to cut waste in the operating room</h2>
<p>Operating rooms are a source of large amounts of hospital supply waste. They account for over <a href="http://doi.org/10.1007/s10729-015-9318-2">50% of hospital revenues and 25% of their expenses</a>.</p>
<p>Supplies and materials in operating rooms average nearly <a href="http://doi.org/10.1097/ACO.0b013e32832798ef/">half of operating room spending</a> and account for <a href="http://doi.org/10.1016/j.jhsa.2017.11.007">70% of the 4 billion pounds of health care waste</a> produced in the United States annually. </p>
<p>A big part of that waste happens when there is a mismatch between the supplies requested and those actually needed during surgery. Surgeons submit a physician preference card that lists all the supplies they believe they will need in the operating room. In one study, my colleagues and I found that <a href="https://doi.org/10.1002/joom.1070">more frequent updates</a> to those preference cards before surgery can reduce unplanned costs.</p>
<p>We estimated that the unplanned costs in operating rooms averaged about $1,800 per surgery, adding up to tens of millions of dollars. These costs include both supplies that are opened but go unused and additional supplies brought in during surgery that make it harder to manage supply use efficiently. We found that as the frequency of updating physician preference cards increased, waste and costs initially went up but then came down as surgeons were able to narrow down the supplies actually needed. This learning can translate into an annual cost reduction of millions of dollars. </p>
<p>Just understanding how supplies are being wasted can help. When surgeons in a San Francisco hospital were given information about their supply use and an incentive to reduce it, they <a href="http://doi.org/10.1001/jamasurg.2016.4674">cut their supply waste by 6.5%</a>.</p>
<p>Rethinking packaging, including working with suppliers to reformulate surgical packs, could also reduce waste. Supplies used in the operating room often come in surgical packs, which include items typically needed during a procedure, but not all are used.</p>
<h2>Ramping up recycling</h2>
<p>Hospitals can also increase their recycling. A survey conducted across four Mayo Clinic locations across the United States in 2018 found that single-use plastics made up <a href="https://doi.org/10.1016/j.amjsurg.2018.06.020">at least 20% of medical waste</a> generated in the hospitals. Among the more than 500 hospital staff members surveyed, 57% didn’t know which items used in operating theaters could be recycled; 39% said they either sometimes or never recycled; and 48% said the greatest barrier to recycling was “lack of knowledge.”</p>
<p>In fact, <a href="http://doi.org/10.1016/B978-0-08-102528-4.00008-0">only 15%</a> of health care wastes are hazardous. The remaining 85% include packaging materials that can be recycled and gloves. Gloves worn to inspect a noninfectious patient are not hazardous and can be reused.</p>
<p>The pandemic-triggered awareness of supply waste in health care could provide an impetus for a fresh look at health care supply chain management. The result can benefit patients, hospitals and the environment, as well.</p>
<p>[<em><a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=experts">Expertise in your inbox. Sign up for The Conversation’s newsletter and get expert takes on today’s news, every day.</a></em>]</p><img src="https://counter.theconversation.com/content/154328/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anand Nair does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Hospitals have a lot of room to reduce, reuse and recycle supplies – as many were forced to discover during the pandemic.Anand Nair, Eli Broad Endowed Professor, Department of Supply Chain Management, Michigan State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1482472020-11-25T13:38:33Z2020-11-25T13:38:33ZHomeless patients with COVID-19 often go back to life on the streets after hospital care, but there’s a better way<figure><img src="https://images.theconversation.com/files/371144/original/file-20201124-19-1sidbf5.jpg?ixlib=rb-1.1.0&rect=15%2C0%2C5023%2C3553&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Union Square in Manhattan, where many of New York City's homeless live. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/person-sleeps-on-the-ground-in-union-square-as-the-city-news-photo/1277493033?adppopup=true">Noam Galai via Getty Images</a></span></figcaption></figure><p>In 2019, about 567,715 homeless people were living in the United States. While this number had been steadily decreasing since 2007, in the <a href="https://www.statista.com/statistics/555795/estimated-number-of-homeless-people-in-the-us/">past two years it has started to increase</a>. For New York City, even before COVID-19, 2020 was already turning out to be a record year for homelessness. But as the lockdown commenced in mid-March, the <a href="https://www.coalitionforthehomeless.org/wp-content/uploads/2020/07/NYCHomeless-ShelterPopulationWorksheet1983-Present.pdf">60,923 homeless people</a> staying at the city’s shelter system found themselves disproportionately affected by the pandemic.</p>
<p>That’s not all of the city’s homeless, of course; the 60,000-plus doesn’t include homeless people hidden within patient rolls and emergency department waiting rooms. In 2019, <a href="https://healthandhousingconsortium.org/hospital-homeless-count/">the city’s annual count</a> of hospital homeless shows more than 300 on any given night who are patients or using the hospital as temporary shelter.</p>
<p><a href="https://sph.cuny.edu/people/j-robin-moon/">As a health care practitioner, educator and researcher</a> in the field of public health and social epidemiology who works in the city, I’m fully aware of the challenges faced and the tragedies already seen. As of May 31, the New York Department of Homeless Services <a href="https://www.coalitionforthehomeless.org/wp-content/uploads/2020/06/COVID19HomelessnessReportJune2020.pdf">had reported</a> 926 confirmed COVID-19 cases across 179 shelter locations and 86 confirmed COVID-19 deaths. In April alone, DHS reported 58 homeless deaths from COVID-19, 1.6 times higher than the overall city rate. While there is no reliable analogous data for other cities, what happens in New York can be a lesson for others.</p>
<figure class="align-center ">
<img alt="A protest supporting the homeless men given temporary living quarters at a New York City hotel in the Upper West Side." src="https://images.theconversation.com/files/371146/original/file-20201124-23-1n4h18o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/371146/original/file-20201124-23-1n4h18o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/371146/original/file-20201124-23-1n4h18o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/371146/original/file-20201124-23-1n4h18o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/371146/original/file-20201124-23-1n4h18o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/371146/original/file-20201124-23-1n4h18o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/371146/original/file-20201124-23-1n4h18o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A protest supporting the homeless men given temporary living quarters at New York City’s Lucerne Hotel in the Upper West Side.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/new-york-city-public-advocate-jumaane-williams-speaks-at-a-news-photo/1271572562?adppopup=true">Steven Ferdman via Getty Images</a></span>
</figcaption>
</figure>
<h2>Homeless shelters are vulnerable</h2>
<p>The susceptibility of the homeless population to COVID-19 is not unique to New York City. Homeless shelters nearly everywhere are particularly vulnerable to disease transmission. Shelters are typically unequipped, heavily trafficked and generally unable to provide safe care, particularly to those recuperating from surgery, wounds or illnesses. </p>
<p>Add to that the inability to isolate, quarantine or physically distance the homeless from one another during COVID-19. New York City responded by <a href="https://www.ny1.com/nyc/all-boroughs/homelessness/2020/06/25/close-to-20-percent-of-nyc-hotels-are-housing-the-homeless">using almost</a> 20% of its hotels as temporary shelter facilities, with one to two clients per room. That helped, but it was hardly a perfect situation. </p>
<p>So the question is: Where do homeless patients go to convalesce when discharged from acute medical care, especially in the post-COVID-19 era?</p>
<p>Homeless patients discharged from hospitals or clinics who then go to drop-in centers, shelters or the street sometimes do not fully recover from their illnesses. Some inevitably wind up back in the hospital. The result is a detrimental and costly cycle for both patients and the health care system.</p>
<p>And the situation continues to deteriorate: <a href="https://gothamist.com/news/report-nyc-homeless-deaths-increased-dramatically">Between July 2018 and June 2019</a>, 404 of the city’s homeless died – 40% higher than the previous year and the largest year-over-year increase in a decade. There is no data since the outbreak began, but early evidence suggests that the number of deaths is higher between June 2019 and June 2020. </p>
<figure class="align-center ">
<img alt="A New York City hotel on Wall Street converted to a homeless shelter." src="https://images.theconversation.com/files/365877/original/file-20201027-16-vzzcvd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/365877/original/file-20201027-16-vzzcvd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/365877/original/file-20201027-16-vzzcvd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/365877/original/file-20201027-16-vzzcvd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/365877/original/file-20201027-16-vzzcvd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/365877/original/file-20201027-16-vzzcvd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/365877/original/file-20201027-16-vzzcvd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A former Radisson Hotel in New York City converted to a homeless shelter.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/view-of-a-former-radisson-hotel-at-wall-street-that-were-news-photo/1228817935?adppopup=true">John Nacion/SOPA Images/LightRocket via Getty Images</a></span>
</figcaption>
</figure>
<h2>Medical respite: A possible solution</h2>
<p><a href="https://nhchc.org/clinical-practice/medical-respite-care/">Medical respite</a> is short-term residential care for homeless people too ill or frail to recover on the streets, but not sick enough to be in a hospital. It provides a safe environment to recover and still access post-treatment care management and other social services. Medical respite care can be offered in freestanding facilities, homeless shelters, nursing homes and transitional housing.</p>
<p>Medical respite has worked in municipalities across the U.S.; health outcomes for patients have improved, and hospitals and insurance providers, particularly Medicaid, have saved money. But <a href="https://nhchc.org/clinical-practice/medical-respite-care/medical-respite-directory/">these programs</a> are few and far between. In 2016 there were 78 programs operating across 28 states. Most programs are small, with 45% having fewer than 20 beds. </p>
<p>The care models vary, but essentially they provide beds in a space designed for convalescence, follow-up appointment support, medication management, medically appropriate meals and access to social services such as housing navigation and benefits assistance. Some programs provide on-site clinical care. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/9624194/">Research shows</a> that homeless patients in New York City stay in the hospital 36% longer and cost an average of US$2,414 more per stay than those with stable housing. By discharging patients to respite programs, hospitals reduced emergency visits post-discharge by 45%, and readmissions by 35%. The New York Legal Assistance Group, conducting a cost-benefit analysis, showed savings of nearly $3,000 per respite stay (the provider saved $1,575, the payers saved $1,254) through reduced hospital readmissions and length of stay. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/23728025/">Studies outside of New York</a> also show improved health outcomes in a variety of ways. One noted that 78% of patients were discharged from respite “in improved health.” Patients showed 15% to 19% increases in connection with primary care after discharge to medical respite. Moreover, at least 10% and up to 55% of medical respite patients who discharged eventually went to permanent or improved housing situations.</p>
<h2>Next steps</h2>
<p>While there are agreed-upon national standards for medical respite, program models can adapt to meet the needs of a specific community. Already, dozens of respite models exist across the country, in both major cities and small towns. One complication, however, is the sheer breadth of the medical respite approach. Because it intersects housing, homelessness and health care, medical respite does not fit neatly within a single system and would require collaboration and agreement among multiple city and state agencies.</p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>Still, a growing number of communities are looking to medical respite to fill the gap. <a href="https://www.chicago.gov/content/dam/city/depts/cdph/policy_planning/Board_of_Health/Chicago%20Homelessness%20and%20Health%20Response%20Group%20for%20Equity%2005.20.2020.pdf">Chicago is partnering</a> with providers to deliver health care to the homeless. This includes providing them with temporary residential facilities and clinics to help blunt the impact of COVID-19. </p>
<p>There is a dire need to help the homeless with both housing and health care. Medical respite is a potential solution. It has successfully provided recuperative housing and medical care during a pandemic. Why shouldn’t it become a permanent part of our service system?</p>
<p><em>Andrew Lin, Supportive Housing Program Developer at BronxWorks, a non-profit group that offers homeless and housing support services in the Bronx, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/148247/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>J. Robin Moon does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>What happens to unhoused people who get COVID-19?J. Robin Moon, Adjunct Associate Professor, City University of New YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1460062020-10-16T11:02:33Z2020-10-16T11:02:33ZHispanics live longer than most Americans, but will the US obesity epidemic change things?<figure><img src="https://images.theconversation.com/files/363729/original/file-20201015-17-18kvuez.jpg?ixlib=rb-1.1.0&rect=5%2C21%2C3589%2C2274&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Juan Duran-Gutierrez kisses his newborn daughter Andrea for the first time in his home after bringing her home from the hospital on Aug. 5.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/juan-duran-gutierrez-kissed-his-newborn-baby-girl-andrea-news-photo/1279220691">Elizabeth Flores/Star Tribune via Getty Images</a></span></figcaption></figure><p>Anti-immigrant sentiments have fueled recent national and state-level health policy efforts. In 2019, Donald Trump signed a <a href="https://www.whitehouse.gov/presidential-actions/presidential-proclamation-suspension-entry-immigrants-will-financially-burden-united-states-healthcare-system/">presidential proclamation</a> that would deny visas to immigrants who could not provide proof of insurance. He argued that they would financially burden the health care system. More recently, Missouri’s August election ballot proposed Medicaid expansion, and <a href="https://www.kansascity.com/news/politics-government/election/article244613202.html">opponents warned</a> that it would overwhelm Missouri hospitals with undocumented immigrants, even though they are ineligible for Medicaid benefits. </p>
<p>We study <a href="https://scholar.google.com/citations?user=Fk9a3NEAAAAJ&hl=en">immigrant health</a> and <a href="https://scholar.google.com/citations?user=N_hRBeEAAAAJ&hl=en">population health</a>. Our work suggests that viewing immigrants as a drain on the U.S. health care system is largely unfounded. For decades, research has shown that immigrants tend to be healthier than U.S.-born whites. Immigrants outlive U.S.-born whites, and, among Hispanics, both immigrants and the U.S.-born have longer life expectancies than whites. </p>
<p><a href="http://dx.doi.org/10.15195/v7.a16">Our latest study</a> suggests that Hispanic immigrants will continue to enjoy longer lives than U.S.-born whites in the near future; but the life expectancy of U.S.-born Hispanics may fall to levels on par with U.S.-born whites. Why? Like many Americans, U.S.-born Hispanics increasingly face a high risk of obesity and obesity-related health complications such as diabetes and heart disease. </p>
<p>To us, the juxtaposition of expected trends in life expectancy between Hispanic immigrants and U.S.-born Hispanics suggests that immigrants are not a drain on the U.S. health care system. Instead, the U.S. is a country with many issues that undermine the health of Hispanics and society more generally. </p>
<figure class="align-center ">
<img alt="Two landscaping workers." src="https://images.theconversation.com/files/363739/original/file-20201015-21-6r1wnj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/363739/original/file-20201015-21-6r1wnj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=405&fit=crop&dpr=1 600w, https://images.theconversation.com/files/363739/original/file-20201015-21-6r1wnj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=405&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/363739/original/file-20201015-21-6r1wnj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=405&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/363739/original/file-20201015-21-6r1wnj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=509&fit=crop&dpr=1 754w, https://images.theconversation.com/files/363739/original/file-20201015-21-6r1wnj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=509&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/363739/original/file-20201015-21-6r1wnj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=509&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Landscape workers from Guatemala at a job in San Rafael, California.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/illegal-immigrants-misael-amrocio-and-jose-augustine-both-news-photo/74262174?adppopup=true">Justin Sullivan/Getty Images</a></span>
</figcaption>
</figure>
<h2>A perplexing paradox</h2>
<p>Hispanic immigrants to the U.S. live three to four years longer than U.S.-born whites, and U.S.-born Hispanics live two years longer than <a href="https://doi.org/10.1016/j.ssmph.2019.100374">U.S.-born whites.</a> Hispanics’ life expectancy advantage is a long-standing phenomenon that has perplexed researchers. Education and income are strong predictors of life expectancy, and on average Hispanics lag behind whites on both indicators of socioeconomic status. This has led researchers to label Hispanics’ life expectancy advantage as an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477704/pdf/pubhealthrep00183-0027.pdf">“epidemiological paradox.”</a> </p>
<p>What is behind it? One primary driver is Hispanics’ <a href="https://doi.org/10.1016/j.socscimed.2012.12.028">historically low smoking rates</a>. Smoking has long been the leading cause of preventable U.S. deaths. <a href="https://www.lung.org/quit-smoking/smoking-facts/impact-of-tobacco-use/tobacco-use-racial-and-ethnic">Whites smoke more than Hispanics</a>, and when Hispanics do smoke, they smoke less frequently and persistently than whites. </p>
<p>Immigrants’ life circumstances also contribute to their longevity. Moving to a new country <a href="https://doi.org/10.1007/s10903-012-9646-y">requires the physical ability to work</a>. This is especially important for Hispanic immigrants, as they tend to have jobs that require taxing physical labor.</p>
<figure class="align-center ">
<img alt="Signs for fast food restaurants along a Los Angeles street." src="https://images.theconversation.com/files/363738/original/file-20201015-15-12cdwn6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/363738/original/file-20201015-15-12cdwn6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/363738/original/file-20201015-15-12cdwn6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/363738/original/file-20201015-15-12cdwn6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/363738/original/file-20201015-15-12cdwn6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/363738/original/file-20201015-15-12cdwn6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/363738/original/file-20201015-15-12cdwn6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Signs for fast-food restaurants line the streets in the Figueroa Corridor of Los Angeles. South LA has the highest concentration of fast-food restaurants in the city.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/signs-for-taco-bell-grinder-mcdonalds-panda-express-fast-news-photo/82055766?adppopup=true">David McNew/Getty Images</a></span>
</figcaption>
</figure>
<h2>Could obesity and smoking change this?</h2>
<p>In recent decades, obesity has emerged as a serious health problem. It now joins smoking as one of the <a href="https://theconversation.com/obesity-second-to-smoking-as-the-most-preventable-cause-of-us-deaths-needs-new-approaches-129317">two leading causes of preventable U.S. deaths</a>. Among the U.S. population as a whole, the increasing prevalence of obesity has not led to an expected life expectancy decline because it has been offset by <a href="https://doi.org/10.1007/s13524-013-0246-9">substantial declines in smoking</a>. </p>
<p>Researchers have been concerned that <a href="https://doi.org/10.1177/0164027515620242">smoking and obesity trends may not offset each other among Hispanics </a>– especially those who are U.S.-born. This possibility has fueled speculation that Hispanics’ paradoxical life expectancy advantage might erode as new generations age.</p>
<p>We wanted to know if this speculation is warranted. We calculated how much smoking and obesity changed among Hispanics and whites born in the six different decades between 1920 and 1989. We then estimated how much life expectancy could change as a result of estimated smoking and obesity trends. </p>
<p>We found that the <a href="http://dx.doi.org/10.15195/v7.a16">proportion of smokers</a> among U.S.-born whites, U.S.-born Hispanics and Hispanic immigrants declined across decades. Yet smoking declined fastest among Hispanic immigrants. During this same period, the obesity prevalence increased for all groups, but U.S.-born Hispanics had the steepest rise. </p>
<p>What do these trends mean for the future of the epidemiological paradox? Our study results suggest that Hispanic immigrants will likely retain their life expectancy advantage over whites. In contrast, U.S.-born Hispanics will likely lose their life expectancy advantage, because their declines in smoking do not offset their increasing obesity prevalence. </p>
<p>In addition, <a href="http://dx.doi.org/10.15195/v7.a16">obesity has a stronger influence</a> on U.S.-born Hispanics’ risk of death relative to whites. This could possibly be because Hispanics are less likely than whites to manage diabetes and other obesity-related health problems. Hispanics also use health care services less frequently than whites, despite stereotypes to the contrary. </p>
<h2>Putting it all together</h2>
<p>Should we be alarmed about the erosion of the epidemiological paradox? After all, Hispanic immigrants are expected to retain their life expectancy advantage, and U.S.-born Hispanics face declines in life expectancy, but not to the point of living shorter lives than whites. </p>
<p>As researchers, our answer to this question is a resounding “yes.” Federal agendas for building a healthier nation call for <a href="https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities">eliminating racial and ethnic disparities in health</a>. Plans to achieve this goal aim to improve health among groups with worse outcomes. </p>
<p>Therefore, the converging life expectancies of U.S.-born Hispanics and whites that result from declines among Hispanics are not an outcome to celebrate. </p>
<p>Hispanic immigrants’ persistent life expectancy advantage should also be a wake-up call for all Americans. Life expectancy is a leading indicator of a nation’s health. Immigrants may be stereotyped as drains on the health care system, but the reality is that their health behaviors and longevity set a standard which we believe U.S.-born Americans should strive to attain. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>Signs point in the opposite direction. Average U.S. life expectancy has actually declined, a phenomenon due in large part to <a href="https://doi.org/10.1001/jama.2019.16932">deaths from drugs, excessive alcohol use and suicide</a>. This decline occurred even before the COVID-19 pandemic, <a href="https://www.npr.org/sections/health-shots/2020/10/13/923253681/americans-are-dying-in-the-pandemic-at-rates-far-higher-than-in-other-countries">which is hitting the U.S. especially hard and much worse than other high income nations</a>. </p>
<p>To us, projected declines in life expectancy among U.S.-born Hispanics due to obesity; increasing U.S. deaths from drugs, alcohol and suicide; and the toll of the COVID-19 pandemic suggest that immigrants are not threatening the U.S. health care system. Instead, the U.S. faces a wide array of population health problems that jeopardize how long Americans will live.</p><img src="https://counter.theconversation.com/content/146006/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michelle L. Frisco has received funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Robert Wood Johnson Foundation. </span></em></p><p class="fine-print"><em><span>Jennifer Van Hook has received funding from the Eunice Kennedy Shriver National Institute of Health and Human Development, the National Science Foundation, and the Russell Sage Foundation. She is a nonresident fellow at the Migration Policy Institute and on the faculty at the Pennsylvania State University. </span></em></p>Hispanics born in the US have worse health outcomes than Hispanics in the US who were born in countries from which they emigrated.Michelle L. Frisco, Associate Professor of Sociology and Demography, Penn StateJennifer Van Hook, Roy C. Buck Professor of Sociology and Demography, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1374792020-05-04T12:11:02Z2020-05-04T12:11:02ZCoronavirus medical costs could soar into hundreds of billions as more Americans become infected<figure><img src="https://images.theconversation.com/files/332028/original/file-20200501-42935-h3ssw6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2148%2C1427&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">As larger percentages of the U.S. population become infected, a study shows how direct medical expenses for treating COVID-19 will rise. Those costs will come back to everyone. </span> <span class="attribution"><a class="source" href="http://gettyimages.com">Scott Eisen/Getty Images</a></span></figcaption></figure><p>As states push to reopen businesses, arguing their economies are losing too much money under current coronavirus precautions, they can’t ignore the other side of the economic equation – the one involving human lives and potentially hundreds of billions of dollars in medical costs.</p>
<p><a href="https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html">More than 20,000 new COVID-19 cases</a> are still being reported in the U.S. every day, and the coronavirus that causes the disease is still spreading. </p>
<p>If the U.S. reopens its economy prematurely and COVID-19 cases surge again, medical expenses will surge, too. Someone has to pay those costs. If you own a business, pay for <a href="https://hbex.coveredca.com/data-research/library/COVID-19-NationalCost-Impacts03-21-20.pdf">health insurance</a> or pay taxes, that someone is you. </p>
<p>To get a better sense of what the nation’s COVID-19-related health care costs could be as more and more of the population is infected, our <a href="https://sph.cuny.edu/people/bruce-y-lee/">Public Health Informatics, Computational, and Operations Research</a> team at the <a href="https://sph.cuny.edu/">City University of New York (CUNY) Graduate School of Public Health and Health Policy</a> developed a computer simulation of the entire United States.</p>
<p>It allows us to quantify what could happen depending on how the pandemic progresses and the resulting direct medical costs and health care resource needs. The <a href="https://doi.org/10.1377/hlthaff.2020.00426">results were published</a> in the journal Health Affairs.</p>
<h2>Building a Sim nation for COVID-19</h2>
<p>Our team develops computer simulation models to help decision-makers better understand and address different infectious diseases, including <a href="https://doi.org/10.1377/hlthaff.2011.0992">MRSA</a>, <a href="https://doi.org/10.1377/hlthaff.2010.0778">the flu</a>, <a href="https://doi.org/10.1371/journal.pntd.0005531">Zika</a> and <a href="https://doi.org/10.1179/2047773214Y.0000000169">Ebola</a>. During the 2009 H1N1 influenza pandemic, <a href="https://www.forbes.com/sites/brucelee/2017/02/19/bill-gates-warns-of-epidemic-that-will-kill-over-30-million-people/#1de02a4c282f">the team was embedded in the U.S. Department of Health and Human Services</a> to help with the national response. </p>
<p>These models try to recreate all of the people, processes, resources and systems involved in a given health or public issue, such as a pandemic, to serve as virtual worlds to test different possible scenarios, policies and interventions and calculate the expected costs. </p>
<p>For this latest coronavirus model, we created virtual representations of the entire U.S. population. </p>
<p>Each virtual person had probabilities of becoming infected with the new coronavirus, SARS-CoV-2. Like a real person, the virtual person had chances of developing mild or severe symptoms, or having no symptoms at all during the course of the infection. No symptoms naturally meant no health costs. </p>
<h2>How medical costs pile up</h2>
<p>If the person developed symptoms, what happened next depended on how severe the symptoms became and what the person ended up doing.</p>
<p>For example, treating a child with only a mild illness requiring no more than a telephone call to a doctor would typically cost around US$32 (in most cases ranging from $19 to $56). The cost for an adult in the same situation would be about $17 (in most cases ranging from $16 to $67). Our model incorporated the variations in costs that occur, so that two people could have the exact same paths, yet still have different costs. </p>
<p>Not surprisingly, costs increased substantially if the person had more severe symptoms that required hospitalization. </p>
<p>The costs of a hospital bed, health care personnel, medications and potentially the use of medical equipment such as ventilators quickly add up, pushing up the median cost for a person hospitalized to $14,366. (We use the median cost rather than the average because a few very costly cases can push up the average significantly.)</p>
<p>Most COVID-19 patients don’t require hospitalization, so the median cost for any person with symptoms turned out to be $3,045 during the course of the person’s infection. But this is still over four times the typical cost <a href="https://doi.org/10.1016/j.vaccine.2007.03.046">of a symptomatic influenza case</a> and around 5.5 times that <a href="https://doi.org/10.1086/425006">of a symptomatic pertussis case</a>. Consider this further evidence that COVID-19 is <a href="https://www.forbes.com/sites/brucelee/2020/03/21/how-does-the-covid-19-coronavirus-kill-what-happens-when-you-get-infected/#1bf479e06146">definitely not “just like the flu.”</a></p>
<p><iframe id="Aly5x" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/Aly5x/7/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Health care costs for the coronavirus don’t end when the patient leaves the hospital. Patients with severe illness may require follow-up visits to the doctor, imaging such as X-rays and CT scans, lab tests, medications or even additional hospitalizations. Those with significant lung damage, for example, may be more susceptible to subsequent infections. </p>
<p>The resulting health care costs over the year after the initial infection raise this median cost per patient by 30% to $3,994.</p>
<p>This shows that you can’t ignore what happens after the initial infection. That would be like walking out of a three-hour movie after just the second hour. </p>
<p>For some patients, the suffering and medical costs don’t end once the virus is no longer present. For example, those who experience <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/what-coronavirus-does-to-the-lungs">lung damage</a> may continue to have breathing problems. Those who managed to survive sepsis and organ failure can have a variety of <a href="https://abcnews.go.com/Health/coronavirus-long-term-effects/story?id=69811566">persistent symptoms</a>. Given these persistent problems, for some, COVID-19 may become <a href="http://dx.doi.org/10.1136/thx.2004.030205">more like a chronic condition</a>.</p>
<h2>Herd immunity and the high cost of viral spread</h2>
<p>Our findings also shed light on what can happen when more and more of the population becomes infected. </p>
<p>We found that if 20% of the U.S. population gets COVID-19, it would mean about 11.2 million people would be hospitalized, and the sickest among them would spend a combined 13 million days on ventilators. </p>
<p>This would cost about $163.4 billion in direct medical expenses, and that’s before accounting for the costs incurred after the infection is over. It also does not include many other health-related costs, such as physician fees that can vary from doctor to doctor, the costs of public health measures such as widespread testing and the costs of protecting health care workers and other patients.</p>
<p>If half the population becomes infected before a vaccine is ready, the numbers jump to 27.9 million hospitalizations and 32.6 million ventilator days. The median cost: $408.8 billion, rising to $536.7 billion with a year of follow-up medical costs taken into account. </p>
<p>That’s getting close to what’s known as herd immunity, the point where enough people are immune that the disease no longer finds hosts to spread it. With the coronavirus, herd immunity is believed to be reach when <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30985-5/fulltext">at least 60%</a> of the population has either been infected naturally or vaccinated.</p>
<p>If 80% of the population gets infected, the numbers rise to 44.6 million hospitalizations, 52.2 million ventilator days and $654 billion in direct medical expenses. With a year of follow-up medical expenses included, that median cost rises to $1.25 trillion.</p>
<p>All of this shows what could happen if the country allows more people to become infected by prematurely relaxing social distancing or trying “herd immunity strategies” that just allow people to get infected. The costs also go well <a href="https://calmatters.org/commentary/what-a-cost-analysis-shows-of-going-back-to-work-during-the-coronavirus-pandemic-vs-californias-stay-at-home-policy/">beyond health care expenses</a> when lives are at stake.</p>
<p>Good decision-making during this pandemic requires good science and data. Ultimately, not considering the potential associated medical costs can be like ignoring a large part of the field in a football game. And that could be a losing proposition.</p><img src="https://counter.theconversation.com/content/137479/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bruce Y. Lee received funding for the described work from the City University of New York (CUNY) School of Public Health, the Agency for Health care Research and Quality (AHRQ), the United States Agency for International Development (USAID), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), and the National Institute of General Medical Sciences (NIGMS). </span></em></p>Reopening state economies too soon risks a second wave of the pandemic, and a surge in medical costs. Anyone who pays insurance premiums and taxes will be picking up the tab.Bruce Y. Lee, Professor of Health Policy and Management, City University of New YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1361072020-04-16T12:19:47Z2020-04-16T12:19:47ZWhy Boris Johnson won’t have to pay any hospital bills<figure><img src="https://images.theconversation.com/files/327801/original/file-20200414-117598-1pgr1cv.jpg?ixlib=rb-1.1.0&rect=10%2C10%2C3583%2C1961&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">U.K. Prime Minister Boris Johnson thanks National Health Service workers for saving his life.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Virus-Outbreak-Britain/7dd0771846704aff91c9164430bd988a/1/0">Twitter Boris Johnson/Downing Street via AP</a></span></figcaption></figure><p>While British Prime Minister Boris Johnson recovers from a life-threatening bout of COVID-19 that hospitalized him for a week, <a href="https://www.bbc.com/news/uk-politics-52262012">including three nights in an intensive care unit</a>, he won’t have to <a href="https://www.cnn.com/2020/04/11/health/nurse-last-words-coronavirus-patient-trnd/index.html">worry about medical bills</a>. </p>
<p>He will be able to resume leading his country through the greatest crisis it has faced since World War II without that worry for one simple reason, and it’s not that he’s a high-ranking, powerful government official. It’s that he <a href="https://www.nhs.uk/using-the-nhs/nhs-services/visiting-or-moving-to-england/how-to-access-nhs-services-in-england/">lives in the U.K.</a></p>
<h2>A publicly funded single-payer system</h2>
<p>The U.K.’s <a href="https://www.nhs.uk/">National Health Service</a>, which provides <a href="https://www.nhs.uk/service-search">all types of health care</a> – including pharmacies and primary doctors, dental and mental health care, sexual health services, ambulances and hospitals – does not charge for most services. There are <a href="https://www.nhs.uk/using-the-nhs/help-with-health-costs/when-you-need-to-pay-towards-nhs-care/">modest fees for dental and vision care</a>, as well as prescriptions. But in general, nobody collects patients’ insurance information or credit card details – because they don’t need to. </p>
<p>Nobody even has to <a href="https://www.healthcare.gov/appeal-insurance-company-decision/appeals/">argue with an accountant at an insurance company</a> about whether a payment should be approved. More expensive treatments and medications are rationed to some degree, but not based on a patient’s ability to pay for the treatment or an expensive insurance plan that will cover it. Instead, the <a href="https://www.nice.org.uk/">National Institute for Clinical Health Excellence</a> makes <a href="https://www.vox.com/2020/1/28/21074386/health-care-rationing-britain-nhs-nice-medicare-for-all">cost-effectiveness recommendations</a> about treatments based on how many years of good health will result from a particular approach. </p>
<p>Around 11% of Britons have some form of <a href="https://www.kingsfund.org.uk/sites/default/files/media/commission-appendix-uk-private-health-market.pdf">private health insurance</a> to provide additional coverage outside the National Health Service. But the vast majority of British people don’t deal with insurance companies at all. </p>
<p>Instead, the NHS is largely <a href="https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/how-nhs-funded">funded by income taxes</a>. It also gets some additional revenue from workers, who pay <a href="https://www.gov.uk/national-insurance">compulsory national insurance contributions</a>, nominal charges for prescriptions, dental and eye care – and some extra fees like access to hospital parking lots. </p>
<p>The NHS covers all those designated as “<a href="https://www.gov.uk/guidance/nhs-entitlements-migrant-health-guide">ordinarily resident</a>” in the U.K. – which doesn’t include tourists and undocumented immigrants, though they can still get emergency services and <a href="https://www.nhs.uk/using-the-nhs/nhs-services/visiting-or-moving-to-england/how-to-access-nhs-services-in-england/">treatments for communicable diseases</a> like tuberculosis or HIV and the coronavirus, in some cases for free.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/327803/original/file-20200414-117583-kbz8e3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/327803/original/file-20200414-117583-kbz8e3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/327803/original/file-20200414-117583-kbz8e3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/327803/original/file-20200414-117583-kbz8e3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/327803/original/file-20200414-117583-kbz8e3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/327803/original/file-20200414-117583-kbz8e3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/327803/original/file-20200414-117583-kbz8e3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/327803/original/file-20200414-117583-kbz8e3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Residents of a London neighborhood cheer and clap to thank National Health Service workers for their efforts to fight the coronavirus outbreak.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/tenants-of-lissenden-gardens-join-in-the-weekly-applause-to-news-photo/1217878026">Leon Neal/Getty Images</a></span>
</figcaption>
</figure>
<h2>A popular program</h2>
<p>The service itself is <a href="https://www.nuffieldtrust.org.uk/files/2018-06/the-nhs-at-70-how-good-is-the-nhs.pdf">very popular, accessible and efficient</a>: The Brexit movement Johnson led claimed that the country could <a href="https://www.bbc.com/news/uk-politics-eu-referendum-36040060">invest in the National Health Service</a> the millions of pounds it otherwise would send to the European Union. </p>
<p>While some people are <a href="https://www.kingsfund.org.uk/press/press-releases/british-public-satisfaction-nhs-lowest-decade">frustrated with how the NHS is run</a>, that may be due to <a href="https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/nhs-budget">consistent underfunding</a> over the past decade. Since 2010, the Conservative Party, which Johnson now leads, has attempted to reduce overall government spending in the U.K.</p>
<p><a href="https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/nhs-budget">Funding for health services</a> rose by an average of just 1.4% a year between 2009 and 2019, reaching £140 billion in 2019-2020. This means that funding decreased in real terms: Inflation averaged <a href="https://www.bankofengland.co.uk/monetary-policy/inflation/inflation-calculator">3.1%</a> between 2009 and 2018. </p>
<p>It’s not yet clear what effect Johnson’s hospital stay may have on his desire to <a href="https://www.nytimes.com/2019/12/13/world/europe/uk-election-brexit.html">uphold his earlier commitments</a> to boost NHS funding. But the public nature of his illness and recovery provides Americans with a close look at an alternative model of paying for health care.</p>
<h2>A clear social mission</h2>
<p>Created in 1948, the National Health Service built on a <a href="https://www.prospectmagazine.co.uk/politics/labour-party-history-keir-starmer">pre-existing patchwork system</a> of social services.</p>
<p>At the time, some local authorities like the London County Council <a href="https://www.historic-uk.com/HistoryUK/HistoryofBritain/Birth-of-the-NHS/">offered public access to health care</a>, but many others did not. <a href="https://theconversation.com/what-was-healthcare-like-before-the-nhs-99055">By the mid-1930s</a>, around half of workers – but not their families, who relied on charitable free clinics – could get government-run health insurance plans that provided physician services; employer-run or cooperative funds frequently met the cost of hospital treatment. </p>
<p>In 1942, <a href="https://www.newstatesman.com/politics/2014/12/welfare-wrapped-patriotic-flag-importance-toynbee-hall">Sir William Beveridge</a>, a pioneering activist for the Liberal Party, the forerunner of the U.K.’s present-day Liberal Democrats, laid out a plan for a different future. He released a report, “<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2560775/">Social Services and Allied Insurance</a>,” that identified five “evils” hindering the proper development of British society: <a href="http://pombo.free.fr/beveridge42.pdf">“want,” “disease,” “ignorance,” “squalor” and “idleness.”</a> </p>
<p>Beveridge urged the nation to fight those evils by developing a “<a href="http://broughttolife.sciencemuseum.org.uk/broughttolife/techniques/nhs">cradle to grave</a>” welfare state that provided health care, promised full employment and granted benefits to those in need. </p>
<p>The Labour government elected in July 1945, and headed by Prime Minister Clement Attlee, expanded on Beveridge’s ideas. Labour argued that a universal welfare state, particularly a National Health Service, could provide “<a href="https://www.newstatesman.com/politics/2015/03/aneurin-bevan-stormy-petrel-labour-left">for the most far-reaching extension of social citizenship</a>” in British history, forging a new sense of national community through equal access to publicly funded social services.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/RNcX_t_AuVA?wmode=transparent&start=50" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">British Prime Minister Clement Attlee lays out his principles in a 1951 speech.</span></figcaption>
</figure>
<h2>A cure for society’s ills</h2>
<p>Attlee’s government had <a href="https://www.penguin.co.uk/books/192/192782/the-rise-and-fall-of-the-british-nation/9780141975979.html">three main goals</a>:</p>
<ol>
<li>Ensuring full employment for everyone who wanted to work</li>
<li>Developing a mixed economy that balanced nationalized industries like coal, steel and rail with export-driven private enterprise</li>
<li>Building a more equal society by providing universal health care, improving education, offering workers compensation, creating a comprehensive social safety net and creating a system of child benefits that were paid directly to mothers.</li>
</ol>
<p>At the center of this <a href="https://www.nhs.uk/using-the-nhs/nhs-services/">reimagined, fairer nation</a> was the National Health Service. On July 5, 1948, this new system of <a href="https://www.theguardian.com/society/2016/jan/18/nye-bevan-history-of-nhs-national-health-service">government-run health boards</a> took control of most of the country’s 3,000 or so hospitals.</p>
<p>From the start, the NHS was intended for everyone. Attlee’s Health Minister Aneurin “Nye” Bevan wanted to “<a href="https://www.theguardian.com/society/2016/jan/18/nye-bevan-history-of-nhs-national-health-service">universalize the best</a>” health care in Britain, making it free and available to all on the basis of need rather than wealth.</p>
<p>Speaking in 1951, toward the end of his tenure as prime minister, Labour leader Attlee <a href="http://www.britishpoliticalspeech.org/speech-archive.htm?speech=161">declared his pride</a> in the “<a href="https://www.nationalarchives.gov.uk/education/resources/attlees-britain/">new Jerusalem</a>,” a society of equality and prosperity, that his government had built in the U.K.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/327790/original/file-20200414-117583-1qkoce8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/327790/original/file-20200414-117583-1qkoce8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/327790/original/file-20200414-117583-1qkoce8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=419&fit=crop&dpr=1 600w, https://images.theconversation.com/files/327790/original/file-20200414-117583-1qkoce8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=419&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/327790/original/file-20200414-117583-1qkoce8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=419&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/327790/original/file-20200414-117583-1qkoce8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=527&fit=crop&dpr=1 754w, https://images.theconversation.com/files/327790/original/file-20200414-117583-1qkoce8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=527&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/327790/original/file-20200414-117583-1qkoce8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=527&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Anenurin Bevan, Labour health minister, standing at left, visits a British hospital on the first day of the National Health Service, July 5, 1948.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/liverpoolhls/14465908720">University of Liverpool Faculty of Health and Life Sciences/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Few changes, with service for all</h2>
<p>The private sector is more involved in health care now than it was then, largely in eye and dental care, and with <a href="https://www.kingsfund.org.uk/publications/articles/big-election-questions-nhs-privatised">private companies</a> doing cleaning and food distribution in hospitals. But core NHS services like doctor’s visits and hospital treatment remain free. </p>
<p>Even the pro-market Thatcher governments dared not privatize health care. Nigel Lawson, a keen supporter of economic liberalization, who was chancellor of the Exchequer between 1983 and 1989, <a href="https://www.theguardian.com/commentisfree/2018/feb/26/welfare-system-beveridge-75-years">complained</a> that the NHS was “the closest thing the English people have to a religion.”</p>
<p>That religion, and Bevan’s dream, remains strong today. When Boris Johnson fell ill with the coronavirus, he did not enter an exclusive private health care facility. Instead, he was admitted to <a href="https://www.guysandstthomas.nhs.uk/Home.aspx">St. Thomas’</a>, a major teaching hospital located in the center of London.</p>
<p>The appeal of the NHS is its universality. Everyone, rich or poor, receives the same treatment. Although polling is sparse, a survey conducted by <a href="https://yougov.co.uk/topics/politics/articles-reports/2017/05/19/nationalisation-vs-privatisation-public-view">YouGov in 2017</a> found that 84% of people thought that the NHS should remain publicly funded. Another YouGov poll in <a href="https://yougov.co.uk/topics/politics/articles-reports/2018/07/04/brits-still-love-nhs-they-are-nervous-about-its-fu">2018</a> found that just 4% of people supported a system similar to that found in the United States, where private insurance and wealth largely determines who can access medical care.</p>
<p>Johnson may once have been skeptical about people who get sick – a former colleague describes him as viewing illness as “<a href="https://www.theguardian.com/focus/2020/apr/11/boris-johnsons-darkest-hour-one-week-that-shook-the-nation">a form of moral weakness</a>” – but he now has the chance to learn Attlee’s lesson: Illness can strike anyone, and everyone deserves top-notch medical care.</p>
<p>[<em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=youresmart">You can read us daily by subscribing to our newsletter</a>.]</p><img src="https://counter.theconversation.com/content/136107/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Luke Reader was a press officer in the U.K. civil service between 2000 and 2002. While a press officer, he dealt with matters relating to health care. He also has a family member who recently completed medical school and will soon begin work for the NHS.</span></em></p>In the UK, nobody collects patients’ insurance information or credit card details. There’s simply no charge for services, including doctor visits, ambulances and hospitalizations.Luke Reader, Teaching Fellow, History Department, Case Western Reserve UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1274272019-11-27T13:49:25Z2019-11-27T13:49:25ZWhat the Trump administration gets right about hospital price transparency<figure><img src="https://images.theconversation.com/files/303345/original/file-20191124-74599-13gv8jw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">President Donald Trump pictured with HHS Secretary Alex Azar on June 24, 2019, after signing initial legislation to require hospitals to reveal their prices. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Health-Care/0b2107915eaa4c4ab21239df98c95830/1/0">Caroline Kaster/AP Photo</a></span></figcaption></figure><p>New federal regulations finalized Nov. 15 require hospitals to <a href="https://www.hhs.gov/about/news/2019/11/15/trump-administration-announces-historic-price-transparency-and-lower-healthcare-costs-for-all-americans.html">make public all the prices </a> they negotiate with insurers and health plans, starting in 2021. The aim is to untangle the hospital marketplace with a wave of consumer-friendly information that will promote competition that leads to lower costs. </p>
<p>Hospitals are not happy, but advocates of well-informed, patient-centered health care should be cheering. </p>
<p>I am a <a href="https://scholar.google.com/citations?user=PvgfCuUAAAAJ&hl=en">professor of health policy</a> at the Price School and Schaeffer Center at USC and have published several papers and worked with startups that aim to improve price transparency and consumer decision-making. I’m among those cheering.</p>
<h2>Real numbers, real comparisons</h2>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1196097392027881473"}"></div></p>
<p>Hospitals already post online their <a href="https://revcycleintelligence.com/features/the-role-of-the-hospital-chargemaster-in-revenue-cycle-management">so-called standard or “chargemaster” rates </a>for the thousands of codes used in their billing systems. Almost nobody actually pays these rates; they are <a href="https://fas.org/sgp/crs/secrecy/RL34101.pdf">intentionally inflated prices</a> that give hospitals an edge in negotiating with insurers. </p>
<p>Under the new regulations, hospitals, which account for about <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf">one-third of all health care costs</a>, also have to divulge the actual rates paid by health plans and insurers for those same codes.</p>
<p>To help consumers make apples-to-apples comparisons, hospitals will be required to go beyond the individual codes and post their negotiated rates for a list of 300 so-called “shoppable” services that consumers might examine before selecting a provider. This requires hospitals to link services that usually accompany each other, such as laboratory and pathology charges along with surgery.</p>
<p>As for insurers, there is still a two-month public comment period before new regulations become final. As drafted now, the new law would force insurers to disclose negotiated rates, as well as rates paid for out-of-network treatments. They would also have to give cost information to consumers in advance. </p>
<p>This is one of the moments when regulations free a marketplace rather than restraining it. I believe health care desperately needs the cleansing effects of transparency, which can help reduce spending without hurting quality or access to care. It can also help reestablish faith from consumers, who believe that they are getting ripped off by unknowable forces in an industry that has outsized effect on their lives and finances. </p>
<h2>A win for consumers, but fear from providers</h2>
<p>The new regulations from the Centers for Medicare and Medicaid Services will by no means be a cure-all. But they take several important steps toward rebuilding trust in the health care system. </p>
<p>To those who are ready to give up on market forces in health care, the regulations may be seen as too little, too late. They argue that consumers in <a href="https://www.healthcare.gov/glossary/high-deductible-health-plan/">high-deductible health plans</a>, who presumably have the greatest incentive to find lower cost services, <a href="https://doi.org/10.1001/jamainternmed.2015.7554">rarely shop around</a>. That is true, but that is largely because consumers don’t have the information they need. These regulations will help consumers do what they already <a href="https://doi.org/10.1377/hlthaff.2016.1471">want to do</a>. </p>
<p>In fact, the advent of high-deductible plans under the guise of giving consumers “skin in the game” has been something of a cruel trick. They have been hit with <a href="https://www.ajmc.com/journals/issue/2018/2018-vol24-n4/financial-burden-of-healthcare-utilization-in-consumer-directed-health-plans">higher out-of-pocket costs</a> but haven’t been told how <a href="https://doi.org/10.1377/hlthaff.2016.1471">they can reduce them</a>.</p>
<p>Hospitals and insurers see danger in the regulations. The industry business model is built around confidential rate negotiations. Hospitals fear that revealing their lowest prices will mean having to give those prices to all payers. </p>
<p><a href="https://fas.org/sgp/crs/secrecy/RL34101.pdf">Insurers fear</a> they will lose the ability to win deeper cuts than their competitors. Hospital groups are <a href="https://www.healthcaredive.com/news/hospitals-pledge-to-fight-trump-admin-price-transparency-plan-in-court/567474/">planning to go to court </a>to block the regulations, arguing that prices stemming from closed-door negotiations are trade secrets, and that CMS lacks the authority to mandate their disclosure.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/303630/original/file-20191126-84240-13qwqca.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/303630/original/file-20191126-84240-13qwqca.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=413&fit=crop&dpr=1 600w, https://images.theconversation.com/files/303630/original/file-20191126-84240-13qwqca.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=413&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/303630/original/file-20191126-84240-13qwqca.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=413&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/303630/original/file-20191126-84240-13qwqca.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=519&fit=crop&dpr=1 754w, https://images.theconversation.com/files/303630/original/file-20191126-84240-13qwqca.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=519&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/303630/original/file-20191126-84240-13qwqca.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=519&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hospital patients will be able to shop for some procedures, comparing prices, under a new law that goes into effect in 2021.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-nurse-talking-patient-hospital-73518340?src=7153f6a9-21c0-4f00-a365-1708d7bbfd44-1-56&studio=1">Alexander Raths/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>No doubt transparency will be disruptive, but I believe it is a risk worth taking. Making prices more transparent saves money. The regulations will spur greater price competition and reduced prices will benefit all consumers, not just those who will shop around. </p>
<p>We saw this when hospitals began reporting quality measures. Quality jumped despite consumers not using the information directly in making <a href="https://doi.org/10.1257/aer.103.7.2875">decisions</a>. No hospital wants to be known as the lowest quality or highest priced facility. And public reporting of prices will be invaluable to researchers and policymakers on the lookout for unfair business practices. </p>
<p>Transparency is crucial to society beyond its effect on prices. Consumers and voters know something is seriously wrong with health care prices; they just don’t know what they can do about them. In the absence of real, actionable information about prices, patients will continue to conclude that they are pawns in a system built to obfuscate who is profiting from their health care dollars. As long as that condition persists, health care will drive cynicism at large. </p>
<p>Without transparency, providers and insurers lack proof that they are putting patients first, and that is a dangerous position indeed. </p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/127427/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Neeraj Sood receives funding from National Institute for Health, Patient Centered Outcomes Research Institute, Agency for Health Care Research & Quality and Health Care Services Corporation. He is a strategic advisor for Payssurance a start-up aiming to improve consumer decision-making in health care. He has been a consultant for several organizations in the health care industry.</span></em></p>Would you buy a pair of shoes without knowing the price? Consumers have bought medical care from hospitals for years without knowing the costs, but new regulations will change that.Neeraj Sood, Professor of Public Policy, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1244622019-10-04T18:10:10Z2019-10-04T18:10:10ZHow the US could afford ‘Medicare for all’<figure><img src="https://images.theconversation.com/files/295086/original/file-20191001-173375-kx5th2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Several Democrats running for president in 2020 support some version of Medicare for all. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Health-Overhaul/282fcbe52d4c41798af387619f949ee1/118/0">AP Photo/Andrew Harnik</a></span></figcaption></figure><p>Health care is <a href="https://www.realclearpolitics.com/real_clear_opinion_research/new_poll_shows_health_care_is_voters_top_concern.html">Americans’ number-one priority</a>, based on recent polls, so it’s no wonder it’s been a <a href="https://www.npr.org/2019/09/13/760364830/democratic-debate-exposes-deep-divides-among-candidates-over-health-care">hot topic</a> in the Democratic primary.</p>
<p>Every candidate is <a href="https://www.washingtonpost.com/graphics/politics/policy-2020/medicare-for-all/">offering a plan</a>, ranging from Joe Biden’s Affordable Care Act upgrade to Bernie Sanders’ “Medicare for all” that would abolish private health insurance. Even the president is joining the bandwagon and <a href="https://www.npr.org/sections/health-shots/2019/10/03/766816709/targeting-medicare-for-all-proposals-trump-lays-out-his-vision-for-medicare">unveiled his own Medicare plan</a>. </p>
<p>On the high end, a full-scale single-payer heath care system would come at a steep price: <a href="https://www.hopbrook-institute.org/single-post/2019/03/29/Working-Paper-No-2-Yes-We-Can-Have-Improved-Medicare-for-All">I estimate about US$40 trillion</a> over 10 years. </p>
<p>There is, however, a simpler and less costly path toward single-payer, and it may have a better chance of success: simply strike the words “who are age 65 or over” from the <a href="https://www.ssa.gov/OP_Home/ssact/title18/1811.htm">1965 amendments to the Social Security Act</a> that created Medicare, which would mean virtually everyone would be covered by the existing Medicare program.</p>
<p>I have been researching health care for over four decades. While this idea wouldn’t be single-payer – in which the government covers all health care costs – and private insurers would continue to operate alongside Medicare, I believe it would be a substantial improvement over the current system. And it might even be <a href="http://www.sacbee.com/opinion/op-ed/soapbox/article165105902.html">politically possible</a>.</p>
<h2>Medicare and what it was meant to be</h2>
<p>Striking the words “over 65” from the Medicare statutes was an idea <a href="https://theconversation.com/when-pat-and-bob-nearly-saved-health-care-reform-a-lesson-in-senatorial-bedside-manner-81649">championed by the late Sen. Daniel Patrick Moynihan</a>. </p>
<p>Moynihan, who held several roles in the Kennedy and Johnson administrations, was an <a href="http://www.hup.harvard.edu/catalog.php?isbn=9780674574410">original architect of the War on Poverty</a> and a central figure in the evolution of health care policy in the latter half of the 20th century. </p>
<p><a href="https://global.oup.com/academic/product/healthy-wealthy-and-fair-9780195170665?cc=us&lang=en&">Many original Medicare advocates intended</a> it to be the basis for universal health insurance. A key reason it serves so well as the foundation is that it includes a funding mechanism – the 2.9% Medicare payroll tax paid by you and your employer, alongside modest monthly premiums.</p>
<p>In addition, its limited scope, skimpy benefits and cost-sharing keep costs low. Medicare covers only a <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Age-and-Gender.html">little more than half</a> of participants’ health care spending, forcing many elderly Americans to buy private insurance and pay significant out-of-pocket expenses. A little over 11 million poorer participants <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4193634/">also rely on Medicaid</a>, especially for long-term care.</p>
<p>For example, <a href="https://www.medicare.gov/coverage/inpatient-hospital-care">Medicare covers hospitalization</a> only after a person has paid the $1,364 deductible, and there’s a copay of $341 per day after 60 days and double that beyond 90. It also covers only 80% of the cost of doctor visits and the use of medical equipment – though only after a <a href="https://www.cms.gov/newsroom/fact-sheets/2019-medicare-parts-b-premiums-and-deductibles">$185 deductible</a> and the monthly $136 premium. </p>
<p>Still, it provides meaningful protection against the <a href="https://www.cnbc.com/id/100840148">potentially crippling cost</a> of accident or illness. </p>
<h2>Giving Medicare to everyone</h2>
<p>In its pure form, a single-payer program would make the government everyone’s insurer, largely replacing private insurance.</p>
<p><a href="http://www.businessinsider.com/us-single-payer-debate-comparisons-to-canada-uk-germany-2017-6">This is the way</a> health insurance is provided in the United Kingdom and Canada. Sanders’ plan would follow this framework, even extending it to cover long-term care.</p>
<p>A simple expansion of Medicare would be more like a hybrid system in which the government program exists alongside private insurers, with residents free to use any combination of the two. </p>
<p>One of the reasons single-payer health care has failed in the United States is that even though it might eventually lower costs, it would require substantial new taxes up front. Sanders’ plan, as I noted earlier, <a href="https://www.hopbrook-institute.org/single-post/2019/03/29/Working-Paper-No-2-Yes-We-Can-Have-Improved-Medicare-for-All">would cost around $4 trillion a year</a>. But because of its lower benefit levels and built-in revenue stream, a simple Medicare expansion would cost substantially less, maybe only half that. </p>
<p>In 2018, the last year with complete data, <a href="https://www.kff.org/medicare/state-indicator/total-medicare-beneficiaries/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">nearly 60 million Americans</a> received Medicare benefits – including most elderly Americans and 9 million who were disabled. <a href="https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html">Total spending was over $700 billion</a> that year, or an average of $11,800 per recipient. </p>
<p>A simple expansion would add the nondisabled population under age 65 to Medicare: <a href="https://www.kff.org/other/state-indicator/total-population/?dataView=1&currentTimeframe=0&selectedDistributions=uninsured&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">28 million without insurance</a>, 66 million <a href="http://www.kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/?currentTimeframe=18&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">covered by Medicaid or the Children’s Health Insurance Plan</a> and 176 million with private insurance. For the <a href="http://www.dollarsandsense.org/Funding-Medicare-for-All-explanation-170918.pdf">purposes of my calculations</a>, which I last conducted earlier this year, I assume everyone eligible for Medicare would take advantage of the program. </p>
<p>Because the vast majority of the new enrollees would be younger and healthier than current Medicare participants, the cost per person would be much less, or about $5,527 for the <a href="http://www.thesoutherninstitute.org/docs/publications/Policy%20Resources/KaiserReport.pdf">once uninsured</a> and $3,593 for everyone else. With a <a href="http://www.dollarsandsense.org/Funding-Medicare-for-All-explanation-170918.pdf">few other calculations</a>, the total annual price tag of an expansion would tally around $836 billion.</p>
<h2>Substantial savings</h2>
<p>Something that often gets lost in the debate over the cost of single-payer is that its implementation would lead to a host of savings that make the bill to taxpayers a lot less than the sticker price. </p>
<p><a href="https://www.hopbrook-institute.org/single-post/2019/03/29/Working-Paper-No-2-Yes-We-Can-Have-Improved-Medicare-for-All">I estimate</a> that a full single-payer system would likely save about 20% of current spending, or nearly $700 billion in 2019. A simple Medicare expansion – the kind I’m suggesting here – wouldn’t save quite as much, but it’d still be significant.</p>
<p>So where would the savings come from? </p>
<p>To begin with, <a href="http://www.commonwealthfund.org/interactives/2017/july/mirror-mirror/?omnicid=EALERT1243408&mid=gfriedma@econs.umass.edu">studies show</a> that medical billing is more expensive in the U.S. than in many countries. </p>
<p>The U.S. health care system <a href="https://www.ncbi.nlm.nih.gov/pubmed/22419800">spends twice as much</a> as Canada, for example, because <a href="http://annals.org/aim/article/2605414/single-payer-reform-only-way-fulfill-president-s-pledge-more">more “payers”</a> means more complexity. Savings from a simple Medicare expansion could reduce this waste by about $89 billion a year.</p>
<p>Another source of savings is on insurance administration. Private insurers <a href="http://cepr.net/blogs/cepr-blog/overhead-costs-for-private-health-insurance-keep-rising-even-as-costs-fall-for-other-types-of-insurance">spend more than 20%</a> of total expenditures on overhead, compared with <a href="http://healthaffairs.org/blog/2011/09/20/medicare-is-more-efficient-than-private-insurance/">around 2%</a> for traditional Medicare. Savings from moving everyone to Medicare would approach around $200 billion because of economies of scale, lower managerial salaries and more meager marketing expenses.</p>
<p>A third way a simple Medicare expansion would yield savings is by <a href="https://www.forbes.com/sites/theapothecary/2011/08/22/hospital-monopolies-the-biggest-driver-of-health-costs-that-nobody-talks-about/#47bf25132ce8">reducing the ability of hospital networks with market power</a> to <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Inpatient2015.html">overcharge</a> private insurers. By using its market power to negotiate lower prices, Medicare pays prices barely half as high <strong>and</strong> <a href="http://medpac.gov/docs/default-source/reports/mar17_entirereport224610adfa9c665e80adff00009edf9c.pdf?sfvrsn=0">is able to pay 22% less</a> for the same services as do private health insurers. If we all paid Medicare prices, we would save nearly $400 billion on hospital overcharging.</p>
<p>Making conservative estimates, and assuming that the expanded Medicare would only cover services it already does, these three areas then would save $220 billion, bringing the cost down to $618 billion. </p>
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<h2>One small step</h2>
<p>While $618 billion still seems like a hefty price tag, taxes wouldn’t have to be raised much to pay for it. </p>
<p>For starters, most everyone would pay the <a href="https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-costs.html">premiums already charged</a> by Medicare. This would generate an additional $210 billion in revenue.</p>
<p>In addition, a Medicare expansion would reduce the need for two current insurance subsidies: one for <a href="https://www.treasury.gov/resource-center/tax-policy/Documents/Tax-Expenditures-FY2016.pdf">employer-provided insurance plans</a> and another that the <a href="https://www.cbo.gov/sites/default/files/recurringdata/51298-2015-03-aca.pdf">ACA provides insurers</a>. This would save about $161 billion. </p>
<p>This leaves about $246 billion that would still need to be raised through additional taxes. This could be done with an increase in the <a href="https://www.thebalance.com/fica-taxes-social-security-and-medicare-taxes-39825">Medicare tax</a> that gets deducted from your paycheck. The tax, which is split evenly between employee and employer, would need to rise to 5.9% from 2.9% today. This would amount to just under $15 a week for the typical employee. </p>
<p>Campaigns for universal health insurance coverage have failed in the United States <a href="http://www.nejm.org/doi/full/10.1056/NEJMhpr1411701">when they run up against</a> the cost of providing coverage. Medicare, <a href="https://hub.jhu.edu/2015/07/23/medicare-at-50/">America’s greatest success</a> in advancing health care, succeeded precisely because it was limited and had its own dedicated funding streams. </p>
<p>We might learn from this example. Rather than jump all the way to a comprehensive single-payer system like the one Sanders favors, we could take a step along the way at a fraction of the cost by simply expanding Medicare to everyone who wants it.</p>
<p><em>This is an updated version of an <a href="https://theconversation.com/medicare-for-all-could-be-cheaper-than-you-think-81883">article originally published</a> on Sept. 19, 2017.</em></p><img src="https://counter.theconversation.com/content/124462/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gerald Friedman is affiliated with Business for Medicare for All and Healthcare-Now.</span></em></p>There’s a very simple way to give Medicare to all: delete six words from the legislation that created the program in 1965.Gerald Friedman, Professor of Economics, UMass AmherstLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1188952019-07-24T11:09:04Z2019-07-24T11:09:04ZUS health care: An industry too big to fail<p>As I spoke recently with colleagues at a conference in Florence, Italy about health care innovation, a fundamental truth resurfaced in my mind: the U.S. health care industry is just that. An industry, an economic force, Big Business, first and foremost. It is a vehicle for returns on investment first and the success of our society second.</p>
<p>This is critical to consider as <a href="https://www.nbcnews.com/politics/2020-election/democrats-duel-over-health-care-new-campaign-dust-n1030171">presidential candidates</a> unveil their health care plans. The candidates and the electorate seem to forget that health care in our country is a huge business.</p>
<p>Health care accounts for almost <a href="https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html">20% of GDP</a> and is a, if not the, job engine for the U.S. economy. The sector added <a href="https://www.bls.gov/careeroutlook/2017/data-on-display/projections-industry-sectors.htm?view_fullmuch">2.8 million jobs</a> between 2006 and 2016, higher than all other sectors, and the Bureau of Labor Statistics projects another <a href="https://www.bls.gov/ooh/healthcare/home.htm">18% growth in health sector jobs</a> between now and 2026. Big Business indeed.</p>
<p>This basic truth <a href="http://www.oecdbetterlifeindex.org/">separates us from every other nation</a> whose life expectancy, maternal and infant mortality or incidence of diabetes we’d like to replicate or, better still, outperform.</p>
<p>As politicians and the public they serve grapple with issues such as prescription drug prices, “surprise” medical bills and other health-related issues, I believe it critical that we better understand some of the less visible drivers of these costs so that any proposed solutions have a fighting chance to deflect the health cost curve downward. </p>
<p>As both associate chief medical officer for clinical integration and director of the center for health policy at the University of Virginia, I find that the tension between a profit-driven health care system and high costs occupies me every day.</p>
<h2>The power of the market</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/284368/original/file-20190716-173329-13qq2t3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/284368/original/file-20190716-173329-13qq2t3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/284368/original/file-20190716-173329-13qq2t3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/284368/original/file-20190716-173329-13qq2t3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/284368/original/file-20190716-173329-13qq2t3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/284368/original/file-20190716-173329-13qq2t3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/284368/original/file-20190716-173329-13qq2t3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Prescription drug prices, like everything else in society, is market-driven.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-searching-web-internet-recruitment-health-336058883?src=LZ6aDSUkCWt60CcEZPSJ9A-1-53&studio=1">angellodeco/shutterstock.com</a></span>
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</figure>
<p>Housing prices are <a href="https://brainmates.com.au/brainrants/what-does-a-market-driven-product-really-mean/">market-driven</a>. Car prices are market-driven. Food prices are market-driven. </p>
<p>And so are health care services. That includes physician fees, prescription drug prices and non-prescription drug prices. So is the case for hospital administrator salaries and medical devices.</p>
<p>All of these goods or services are profit-seeking, and all are motivated to maximize profits and minimize the cost of doing business. All must adhere to sound business principles, or they will fail. None of them disclose their <a href="https://www.accountingtools.com/articles/2017/5/4/cost-driver">cost drivers</a>, or those things that increase prices. In other words, there are costs that are hidden to consumers that manifest in the final unit prices.</p>
<p>To my knowledge, no one has suggested that <a href="https://www.rolls-roycemotorcars.com/en-US/home.html">Rolls-Royce Motor Cars</a> should price its cars similarly to <a href="https://www.ford.com">Ford Motor Company</a>. The invisible hand of “the market” tells Rolls Royce and Ford what their vehicles are worth. </p>
<h2>Prescription drugs pricing has different rules</h2>
<p>Ford can (they won’t) tell you precisely how much each vehicle costs to produce, including all the component parts that they acquire from other firms. But this is not true of prescription drugs. How much a novel therapeutic costs to develop and bring to market is a proverbial black box. Companies don’t share those numbers. Researchers at the Tufts Center for the Study of Drug Development have estimated the costs to be as high as US$2.87 billion, but that <a href="https://www.managedcaremag.com/news/20170914/costs-bring-drug-market-remain-dispute">number has been hotly debated.</a></p>
<p>What we can reliably say is that it’s very expensive, and a drug company must produce new drugs to stay in business. The millions of research and development(R&D) dollars invested by Big Pharma has two aims. The first is to bring the “next big thing” to market. The second is to secure the almighty patent for it. </p>
<p>U.S. drug patents typically last <a href="https://www.drugpatentwatch.com/blog/how-long-do-drug-patents-last/">20 years</a>, but according to the legal services website <a href="https://www.upcounsel.com/how-long-does-a-drug-patent-last">Upcounsel.com</a>: “Due to the rigorous amount of testing that goes into a drug patent, many larger pharmaceutical companies file several patents on the same drug, aiming to extend the 20-year period and block generic competitors from producing the same drug.” As a result, drug firms have 30, 40-plus years to protect their investment from any competition and market forces to lower prices are not in play.</p>
<p>Here’s the hidden cost punchline: concurrently, several other drugs in their R&D pipelines fail along the way, resulting in significant <a href="https://www.pharmaceutical-technology.com/features/featurecounting-the-cost-of-failure-in-drug-development-5813046/">product-specific losses </a>. How is a poor firm to stay afloat? Simple, really. Build those costs and losses into the price of the successes. Next thing you know, insulin is nearly <a href="https://www.statnews.com/2019/02/19/no-generic-insulin-who-is-to-blame/">US$1,500 for a 20-milliliter vial</a>, when that same vial 15 years ago was about $157. </p>
<p>It’s actually a bit more complicated than that, but my point is that business principles drive drug prices because drug companies are businesses. Societal welfare is not the underlying use. This is most true in the U.S., where the public doesn’t purchase most of the pharmaceuticals – private individuals do, albeit through a third party, an insurer. The group purchasing power of 300 million Americans becomes the commercial power of markets. Prices go up.</p>
<h2>The cost of doing business, er, treating</h2>
<p>I hope that most people would agree that physicians provide a societal good. Whether it’s in the setting of a trusted health confidant, or the doctor whose hands are surgically stopping the bleeding from your spleen after that jerk cut you off on the highway, we physicians pride ourselves on being there for our patients, no matter what, insured or not. </p>
<p>Allow me to state two fundamental facts that often seem to elude patient and policymaker alike. They are inextricably linked, foundational to our national dialogue on health care costs and oft-ignored: physicians are among the highest earners in America, and we make our money from patients. Not from investment portfolios, or patents. Patients. </p>
<p>Like Ford or pharmaceutical giant Eli Lilly, physician practices also need to achieve a profit margin to remain in business. Similarly, there are hidden-to-consumer costs as well; in this case, education and training. Medical school is <a href="https://www.thebalance.com/average-cost-of-medical-school-4588236">the most expensive professional degree</a> money can buy in the U.S. The American Association of Medical Colleges reports that median indebtedness for U.S. medical schools was <a href="https://news.aamc.org/medical-education/article/7-ways-reduce-medical-school-debt/">$200,000.00 in 2018</a>, for the 75% of us who financed our educations rather than paying cash.<br>
Our “R&D” – that is, four years each of college and medical school, three to 11 years of post doctoral training costs – gets incorporated into our fees. They have to. Just like Ford Motors. Business 101: the cost of doing business must be factored into the price of the good or service. </p>
<p>For policymakers to meaningfully impact the rising costs of U.S. health care, from drugs to bills to and everything in between, they must decide if this is to remain an industry or truly become a social good. If we continue to treat and regulate health care as an industry, we should continue to expect <a href="https://theconversation.com/why-thousands-are-getting-hit-with-unexpected-medical-bills-117955">surprise bills</a> and expensive drugs. </p>
<p>It’s not personal, it’s just…business. The question before the U.S. is: business-as-usual, or shall we get busy charting a new way of achieving a healthy society? Personally and professionally, I prefer the latter.</p><img src="https://counter.theconversation.com/content/118895/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Williams does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Presidential candidates have been proposing plans to expand health coverage, lower prescription drug costs and make hospital bills more transparent. But few get to the real problem. Here’s why.Michael Williams, Associate Chief Medical Officer for Clinical Integration; Associate Professor of Surgery and Director of the UVA Center for Health Policy, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1151032019-06-24T21:34:27Z2019-06-24T21:34:27ZHealth care price transparency: Fool’s gold, or real money in your pocket?<p>The news is full of stories about monumental <a href="https://www.nytimes.com/2019/06/24/upshot/health-care-price-transparency-trump.html">surprise hospital bills</a>, <a href="https://www.healthcarefinancenews.com/news/high-drug-prices-whos-really-blame">sky-high drug prices</a> and <a href="https://www.thebalance.com/medical-bankruptcy-statistics-4154729">patients going bankrupt</a>. The government’s approach to addressing this, via an executive order that <a href="https://www.washingtonpost.com/health/trump-to-sign-executive-order-to-compel-disclosure-of-health-care-prices/2019/06/24/98ab87f6-9684-11e9-8d0a-5edd7e2025b1_story.html?utm_term=.65c8e11adce9">President Trump signed June 24, 2019</a>, is to make hospitals <a href="https://www.washingtonpost.com/health/trump-to-sign-executive-order-to-compel-disclosure-of-health-care-prices/2019/06/24/98ab87f6-9684-11e9-8d0a-5edd7e2025b1_story.html?utm_term=.770f4c18dd54">disclose prices</a>, including negotiated rates with insurers, so that patients supposedly can comparison shop. But this is fool’s gold – information that doesn’t address the real question about why these prices are so high in the first place.</p>
<p>I know from my time as an <a href="https://weatherhead.case.edu/faculty/j-b-silvers">academic researcher, hospital board member, adviser to Congress and health insurance CEO</a> that the problems in health care are far deeper than just knowledge about hospital charges that few will ever pay. </p>
<p>While it is easy to blame greedy pharmaceutical manufacturers, health insurers and hospital executives, the problem comes from the very nature of our confused system. Who actually benefits from these high prices and why do they persist? Is it just greed, or something endemic in the system?</p>
<h2>Should the EOB be DOA?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/281017/original/file-20190624-97794-1v0j01d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/281017/original/file-20190624-97794-1v0j01d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=449&fit=crop&dpr=1 600w, https://images.theconversation.com/files/281017/original/file-20190624-97794-1v0j01d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=449&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/281017/original/file-20190624-97794-1v0j01d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=449&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/281017/original/file-20190624-97794-1v0j01d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=564&fit=crop&dpr=1 754w, https://images.theconversation.com/files/281017/original/file-20190624-97794-1v0j01d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=564&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/281017/original/file-20190624-97794-1v0j01d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=564&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The EOB is not a bill, the insurance companies want you to know.</span>
<span class="attribution"><span class="source">Lynne Anderson</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Many in the health care system, including <a href="https://www.healthaffairs.org/do/10.1377/hblog20190416.853636/full/">hospitals, doctors and insurers</a>, are complicit in this confusing mess, although all can justify their individual actions. </p>
<p>The confusion begins for the patient when he or she receives an explanation of benefit (EOB). This typically says it is “Not a Bill,” although it really looks like one. What it actually shows is incredibly high provider prices and an equally implausible discount. The bottom line lists the actual payment and the amount the patient owes. Patients are supposed to be grateful for the discounts after they recover from the sticker shock of the listed price. </p>
<p>When a service is provided out-of-network, or is not covered at all, or the person doesn’t have insurance, the patient is supposed to pay this full amount. Such <a href="https://khn.org/news/are-surprises-ahead-for-legislation-to-curb-surprise-medical-bills/">“surprise bills”</a> typically come to those least prepared to pay and, as a result, providers typically recover very little. So no one wins, except the collection agency and the lawyers. </p>
<p>I believe the standard EOB is the beginning of unnecessary complexity that leads to higher prices and an impossibly flawed market where shopping can never really work properly. </p>
<p>This ridiculous situation actually starts with insurance companies selling policies to ill-informed <a href="https://www.siia.org/i4a/pages/index.cfm?pageID=4546">employers</a> who don’t understand health care but effectively are the purchasers. Employers hire brokers and consultants to collect proposals from insurers; by some estimates, as many as <a href="https://www.siia.org/i4a/pages/index.cfm?pageID=4546">50 million people</a> in the U.S. are covered by such plans. </p>
<p>These proposals frequently focus on the size of the discount from providers’ list prices as an indicator of how much the employer can save. The overall total cost or coverage is more important, but harder to estimate, since it depends on actual care delivered to employees. The unrecognized incentive for providers and insurers is to increase prices in order to increase the size of the discount.</p>
<p>I have actually seen cases where the insurer requests higher list prices from a provider to pump up the discount they can report to employers. This is crazy.</p>
<h2>Stop the madness</h2>
<p>One solution to this mess would be to require uniform prices by all providers to all purchasers. Maryland has a form of this <a href="https://www.advisory.com/daily-briefing/2018/05/16/maryland-all-payer-model">“all-payer” system</a> where everyone pays the same under rate regulation or negotiation. France, Germany, Japan and the Netherlands also use this <a href="https://www.commonwealthfund.org/publications/2019/apr/considering-single-payer-proposals-lessons-from-abroad">form of control</a>.</p>
<p>Benchmark pricing against what Medicare pays would do something similar, with everyone paying a fixed percent of these nationally regulated rates. This would blunt the ability of hospitals to <a href="https://www.rand.org/pubs/research_reports/RR3033.html">arbitrarily jack up list charges</a> and negotiate contract prices with insurers based on relative market power.</p>
<p>Unfortunately for consumers, such rate setting may be a political “bridge too far.” While some progressives might like regulation, conservatives likely will not because it challenges their faith in the superiority of free-market negotiations around prices. </p>
<p>And it might dampen innovation and even competition, depending on how realistic and flexible the regulators are in responding to new technology, alternative procedures, quality differentials and consumer demands – the decisions where markets are supposed work well. </p>
<h2>Can price competition work?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/281029/original/file-20190624-97751-1dy6xg5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/281029/original/file-20190624-97751-1dy6xg5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/281029/original/file-20190624-97751-1dy6xg5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/281029/original/file-20190624-97751-1dy6xg5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/281029/original/file-20190624-97751-1dy6xg5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/281029/original/file-20190624-97751-1dy6xg5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/281029/original/file-20190624-97751-1dy6xg5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It’s hard to shop around for some procedures, such as complex surgeries.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/surgeons-perform-complex-operation-save-persons-1217273515?src=OyEv6ijT7W-TvKfDqaMm5g-2-2&studio=1">Yulai Studio/shutterstock.com</a></span>
</figcaption>
</figure>
<p>The overarching question is whether patients and employers can ever do comparison shopping effectively. Clearly for many things, there can be no head-to-head choice. Trauma, highly complex surgery and other care cannot be predicted ahead of time or standardized to fit a consumer market model. </p>
<p>However, some things can be compared. Insurers now routinely let consumers know if a test or image could be <a href="https://www.anthem.com/blog/your-health-care/?cnslocale=en_US_mo&page=7">done for less</a> elsewhere. Perhaps comparing just a few services as an overall cost indicator is the best we can do. </p>
<p>But it may also be possible to determine overall relative bargains for a typical package of care to guide choices. My Cleveland hospital, MetroHealth System, manages Medicaid patients for a total cost which is <a href="https://doi.org/10.1377/hlthaff.2014.1380">29% less</a> than when they wander around without a medical home. This is a meaningful difference.</p>
<p>A first step towards comparison shopping might be eliminating the EOB as we know it. Rather than showing meaningless list prices, it would be more revealing if hospitals and insurers had to disclose their actual payment terms. </p>
<p>An alternative benchmark might be to provide health care consumers with a range of contract rates or the Medicare rate for a service. Then the difference between what you and others actually pay could be useful in comparing providers and insurers.</p>
<p>Those who long for a total overhaul of our system through “Medicare for All” or its variants, such as many <a href="https://www.washingtonpost.com/graphics/politics/policy-2020/medicare-for-all/?utm_term=.020e658dd6ed">Democrats vying for the nomination,</a> will still have to deal with the question of how to contract and pay for all these moving parts. The temptation will be toward simple solutions involving prices, discounts and rate regulation – still, I believe, effectively a pursuit of fool’s gold.</p><img src="https://counter.theconversation.com/content/115103/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>J.B. Silvers does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>President Trump has been backing transparency in hospital pricing so that consumers can compare prices. But will that help when the real deals are done in secret?J.B. Silvers, Professor of Health Finance, Weatherhead School of Management & School of Medicine, Case Western Reserve UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1162362019-05-07T11:22:17Z2019-05-07T11:22:17ZRobotic health care is coming to a hospital near you<figure><img src="https://images.theconversation.com/files/272815/original/file-20190506-103071-7ksb68.jpg?ixlib=rb-1.1.0&rect=952%2C26%2C5038%2C2559&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Are you ready for this?</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/smart-medical-technology-conceptadvanced-robotic-surgery-1226695306">MONOPOLY919/Shutterstock.com</a></span></figcaption></figure><p><a href="https://ssrn.com/abstract=2739462">Medical robots</a> are <a href="https://interestingengineering.com/15-medical-robots-that-are-changing-the-world">helping doctors and other professionals</a> save time, lower costs and <a href="https://mayoclinichealthsystem.org/hometown-health/featured-topic/robotic-surgery-shortens-recovery-time-for-patients">shorten patient recovery</a> times, but patients may not be ready. Our research into human perceptions of automated health care finds that people are wary of getting their health care from an automated system, but that they can adjust to the idea – especially if it saves them money.</p>
<p>Hospitals and medical practices are already using a fair amount of automation. For instance, in one San Francisco hospital and other places, delivery robots – <a href="https://www.cnet.com/news/robots-give-a-helping-hand-in-san-franciscos-newest-hospital/">about the size of a mini-fridge</a> – zip through the hallways delivering pills, bringing lunch to patients and ferrying specimens and medical equipment to different labs. Some hospitals are set up for delivery robots to open remote-control doors and even use elevators to get around the building.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/REEzJfGRaZE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Robots can navigate a complex hospital environment.</span></figcaption>
</figure>
<p>Robots can also assist with more complex tasks, like surgery. Their participation can range from simply helping <a href="https://www.roboticsbusinessreview.com/health-medical/ai-assisted-surgery-improves-patient-outcomes/">stabilize a surgeon’s tools</a> all the way to <a href="https://www.healthline.com/health-news/are-you-ok-with-a-robot-dentist#1">autonomously performing the entire procedure</a>. Perhaps the most famous robotic surgery system lets a surgeon operate full-size, ergonomically friendly equipment as a remote control to direct extremely tiny instruments what to do inside a patient’s body, often <a href="https://www.robotics.org/content-detail.cfm/Industrial-Robotics-Industry-Insights/Robots-and-Healthcare-Saving-Lives-Together/content_id/5819">through extremely small incisions</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/-XRFe0nupM8?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A da Vinci Surgical System robot demonstrates how it can help a user do very sensitive tasks, like peeling a grape.</span></figcaption>
</figure>
<p>Robots are also beginning to serve as caregivers, especially for older people. The <a href="https://www.nih.gov/news-events/news-releases/worlds-older-population-grows-dramatically">world’s population is aging</a>, increasing demand for assistance with daily chores and medical tasks, as well as checking on patients’ well-being and safety. Many of those jobs are tiring, often thankless and relatively low-paying for people, but <a href="https://nurse.org/articles/nurse-robots-friend-or-foe/">robots can help</a> with tasks as diverse as cleaning, <a href="https://www.digitaltrends.com/cool-tech/riken-robear/">getting out of bed</a> and other daily needs.</p>
<p>Medical service robots can even provide companionship, to reduce the isolation felt by many older people. In one study, a robotic companion was more successful than a regular plush toy at <a href="https://www.reuters.com/article/us-health-dementia-paro-robot/families-of-dementia-patients-see-positive-effect-of-social-robot-seal-idUSKBN1E837G">helping dementia patients communicate</a> with their families.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/VC_Qe-2g4Ts?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A robotic assistant welcomes patients to a medical practice and discusses general health issues.</span></figcaption>
</figure>
<h2>How do people feel?</h2>
<p>Robots can do a lot, but people don’t necessarily accept them in those new roles. A lot depends on <a href="https://doi.org/10.1108/JOSM-04-2018-0119">how easy the robot is to interact with</a> and the <a href="https://commons.erau.edu/edt/435/">patient’s own views</a> about new technology and the emotions they’re feeling, such as fear about an upcoming medical procedure.</p>
<p>A human-like robot can be more acceptable – but only if it’s not too similar to a real person, because the differences can seem <a href="https://www.theguardian.com/commentisfree/2015/nov/13/robots-human-uncanny-valley">creepy and unsettling</a>. That can discourage people from trusting and interacting with the robot.</p>
<p>Another factor is the invasiveness of the surgery. Our research investigating <a href="https://www.healthline.com/health-news/are-you-ok-with-a-robot-dentist#1">patients’ willingness to undergo robotic dentistry</a> found that the complexity of the procedure matters. Two-thirds of our respondents said they would not want a robot to handle an invasive procedure like a root canal; 32% said they would decline robotic cleaning and whitening.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/272812/original/file-20190506-103053-1hij89u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/272812/original/file-20190506-103053-1hij89u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272812/original/file-20190506-103053-1hij89u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272812/original/file-20190506-103053-1hij89u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272812/original/file-20190506-103053-1hij89u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272812/original/file-20190506-103053-1hij89u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272812/original/file-20190506-103053-1hij89u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272812/original/file-20190506-103053-1hij89u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">How would you feel if a robot were cleaning your teeth?</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/closeup-female-dentist-examining-mid-adult-144113650">stockfour/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>However, <a href="https://www.docseducation.com/blog/would-your-patients-agree-be-treated-robot-50-normal-fees">price is a factor</a>. When patients were told a robotic procedure would cost just half as much as one done by a person, <a href="https://news.erau.edu/headlines/high-level-event-features-embry-riddle-studies-of-robotic-dentistry-medical-errors-more">83% said they would accept</a> a robotic cleaning and whitening.</p>
<p>Participants in the study said they were concerned that the robots might <a href="https://doi.org/10.1007/s00464-015-4368-6">malfunction and cause them physical harm</a>, or might even complete the <a href="https://psnet.ahrq.gov/primers/primer/18/wrong-site-wrong-procedure-and-wrong-patient-surgery">wrong operation</a>. These concerns are not unfounded: The Food and Drug Administration, which oversees health care in the U.S., is investigating reports of <a href="http://doi.org/10.1371/journal.pone.0151470">robotic surgery failures and malfunctions</a>. One study found that <a href="https://dx.doi.org/10.1515%2Fmed-2016-0055">about 3% of surgeries</a> between 2005 and 2014 had some sort of problem; of those problems, <a href="https://dx.doi.org/10.1515%2Fmed-2016-0055">21% were related to various robotic failures</a>.</p>
<p>There are <a href="https://dx.doi.org/10.1007%2Fs11934-017-0710-y">not yet industry or professional standards</a> for training operators of robotic surgery equipment. At the moment, many doctors get online instruction and an in-person session lasting between one day <a href="https://sors.memberclicks.net/index.php?option=com_jevents&task=icalrepeat.detail&evid=5&Itemid=115&year=2019&month=05&day=13&title=basic-robotic-surgical-course&uid=d3cb8feec88180843d1bdf1379323e68">and a week</a>. There are plenty of options for <a href="https://dx.doi.org/10.1007%2Fs11934-017-0710-y">expanding training options</a>, including using virtual reality simulations, lab training and experience in the operating room under supervision and instruction from more experienced surgeons.</p>
<h2>Are robots in your hospital?</h2>
<p>Humans are not obsolete yet – robots can’t yet process <a href="https://doi.org/10.1108/JOSM-04-2018-0119">complex emotional and social tasks</a>, though they can perform a variety of complex functions and <a href="https://www.dailymail.co.uk/sciencetech/article-5543905/Charles-mind-reading-robot-mimic-human-emotions.html">even mimic some emotions</a>. Most patients still want an actual human doctor in the room, particularly if they <a href="https://www.cbsnews.com/news/kaiser-permanente-medical-center-california-man-learns-he-is-dying-from-doctor-on-robot-video-2019-03-09/">might be receiving negative news</a>.</p>
<p>However, if you live in, or seek care in, a major city like San Francisco, Chicago or New York, you <a href="https://www.modernhealthcare.com/article/20130525/MAGAZINE/305259957/robots-get-to-work">may encounter medical robots</a> in hospitals. If you find yourself with the option of robotic surgery, there’s no need to get anxious or upset. Have an open discussion with your doctor and consider any differences in price, as robotic health care may be much cheaper. Most importantly, make sure you are receiving the highest quality health care possible and make sure you understand all the risks – robotic and otherwise.</p><img src="https://counter.theconversation.com/content/116236/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>How willing are people to accept medical care from a robot or an automated system? It depends on the procedure – and the price.Mattie Milner, Ph.D. Candidate in Human Factors, Embry-Riddle Aeronautical UniversityStephen Rice, Professor of Human Factors, Embry-Riddle Aeronautical UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1131492019-03-22T10:44:20Z2019-03-22T10:44:20ZElectronic health records cannot replace a doctor who knows you<figure><img src="https://images.theconversation.com/files/263398/original/file-20190312-86717-1m9y8ee.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Electronic medical records can be costly and time-consuming.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-tablet-doctor-hands-on-light-418261519">Africa Studio/Shutterstock.com</a></span></figcaption></figure><p>The introduction of <a href="https://healthit.ahrq.gov/key-topics/electronic-medical-record-systems">electronic health records</a> (EHRs) was accompanied by a great deal of fanfare. Such systems, which replace old paper-based charts in doctor’s offices and hospitals, were designed to make patient data more accurate, safer and more accessible. It was also claimed that they would make it easier for doctors and other health professionals to monitor medical care and ensure that guidelines were followed. The federal government was so keen on EHRs that it provided financial incentives to doctors and hospitals to adopt them, totaling <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5089148/">US$25 billion</a> by 2016. </p>
<p>More recently, we and many other doctors have realized that EHRs are no panacea, or cure-all. They are expensive; one study showed for a five-doctor group, the cost is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5089148">$162,000</a> to install and $85,000 per year to maintain. These systems force doctors to follow generic <a href="https://www.physicianspractice.com/ehr/pros-and-cons-using-templates-ehr">templates</a> that may not reflect the needs of a particular patient. </p>
<p>In addition, health professionals often find themselves spending more time and energy tending to the EHR than to their patient. One study at <a href="https://www.ncbi.nlm.nih.gov/pubmed/27595430">Dartmouth</a> showed that physicians spend two hours on the EHR for every hour they spend with patients. Too often, the EHR seems better adapted to <a href="https://www.pbs.org/newshour/health/doctors-think-electronic-health-records-hurting-relationships-patients">coding and billing</a>, or collecting revenue, than excellence in patient care.</p>
<h2>A patient’s story</h2>
<p>Yet there is a far deeper and more pervasive problem with EHRs that was brought home to us recently by a patient we know. Mary is a frail woman in her 60s who was first diagnosed with a form of lymphoma about 20 years ago. She had been doing well until she developed abdominal pain, which was traced to diverticulitis. Surgery fixed the problem with her colon, but her recovery was quite difficult. Eventually, she was well enough to be sent home, but she was quite discouraged.</p>
<p>At home, she developed a urinary tract infection and returned to the hospital. There she told the doctors treating her that she did not want any further treatment, and instead wanted to be referred to hospice. Plans were made to do so. Fortunately, her husband reached out to her long-time oncologist, who came and saw her. He persuaded her to accept a transfer to his hospital service, where she received a feeding tube, was placed on antidepressants, and about a week later, turned the corner.</p>
<p>That was eight years ago. Today Mary is leading a healthy, happy life. But had her oncologist not seen her, she would have been transferred to the hospice service and likely died. The teams of doctors responsible for her care all had access to the same information through the EHR, but none of them actually knew the patient. They were making decisions that made sense from the point of view of data, but not from the perspective of a good doctor relying on a long-standing patient-doctor relationship.</p>
<h2>The patient-doctor relationship</h2>
<p>Many <a href="https://med.stanford.edu/content/dam/sm/ehr/documents/EHR-Poll-Presentation.pdf">experienced doctors</a> can point to such stories. Too often, sophisticated new technology – in this case, the EHR – interposes itself between the patient and the doctor, drawing the doctor’s attention away from the patient and sometimes making the data in the medical record – physical examination findings, laboratory values, radiology scan results – seem more reliable and even more real than patients themselves.</p>
<p>Over time, it becomes progressively more tempting for doctors and other health professionals to suppose that because they have thoroughly reviewed the EHR, they have a thorough grasp of the patient’s medical situation. Yet there is a profound difference between looking at the data and actually laying eyes on the patient; between reading physical exam findings reported by a colleague and performing your own; and between reading the patient’s story and actually hearing it yourself.</p>
<p>This difference was dramatized in a patient presentation by one of our third-year medical students. He reported that his patient was “status post BKA,” meaning that the patient had undergone a below-the-knee amputation. “Really?” said the faculty doctor, “Let’s go see the patient.” When the team walked in the room, the patient was seated on the side of the bed, two feet and 10 toes resting on the floor. Obviously, the patient had not had his leg amputated.</p>
<p>What happened? Several years ago, the patient had been admitted in DKA, or diabetic ketoacidosis. The voice recognition dictation system had mistranscribed DKA as BKA, and that bit of the patient’s history had been copied and pasted from one admission note to the next over several hospitalizations. Why wasn’t it detected and corrected? The EHR has become so central in health care that the information it contains is all too easily regarded as the ultimate source of truth about each patient.</p>
<h2>Putting patients before systems</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/263403/original/file-20190312-86710-4d22oi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/263403/original/file-20190312-86710-4d22oi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/263403/original/file-20190312-86710-4d22oi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/263403/original/file-20190312-86710-4d22oi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/263403/original/file-20190312-86710-4d22oi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/263403/original/file-20190312-86710-4d22oi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/263403/original/file-20190312-86710-4d22oi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A patient about to enter a CT scanner.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/asian-lady-on-ct-scan-bed-673161826">krit26/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>As this case also illustrates, patient data in an EHR should never be regarded as an adequate substitute for a doctor’s firsthand knowledge. The EHR has a role to play, but it is merely a tool, like a stethoscope or CT scanner, that must be wielded by a human being. When the EHR begins to be regarded as the most complete, reliable and illuminating source of medical knowledge, we think that doctors will have become the tools of their tools.</p>
<p>This sense of having been transformed from a professional into a tool by the EHR is one of the <a href="https://catalyst.nejm.org/videos/physicians-facing-crisis-emr-burnout/">principal reasons</a> that many doctors and other health professionals feel discouraged about their work. Such people went into medicine to take good care of patients, but too often they find themselves devoting most of their attention to a computer screen and keyboard. Their work makes them feel like data entry specialists, not patient-focused professionals.</p>
<h2>Repairing the damage</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/263404/original/file-20190312-86693-162kmep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/263404/original/file-20190312-86693-162kmep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/263404/original/file-20190312-86693-162kmep.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/263404/original/file-20190312-86693-162kmep.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/263404/original/file-20190312-86693-162kmep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/263404/original/file-20190312-86693-162kmep.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/263404/original/file-20190312-86693-162kmep.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The doctor-patient relationship is always the most important.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/indian-doctor-talking-female-patient-doctors-110078714">Stuart Jenner/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>If over-reliance on the EHR is the diagnosis, what is the appropriate therapy? First, doctors need to insist that all such systems be designed and deployed for the principal purpose of enhancing their ability to care well for patients. Allowing coding and billing, compliance or risk management to supersede the interests of optimal patient care represents a violation of every health professional’s oath. The systems should serve patients and doctors, not the other way around.</p>
<p>Second, patients need to take an active interest in their own care. Ensuring the best medical care is not primarily a technical challenge. It is a human challenge, which requires patients and doctors to be able to form deep and long-standing relationships. In most cases, the better your doctor knows you, the more likely she or he will be to ensure that you receive the best care. Changes in insurance contracts and the like should not supplant medical excellence.</p>
<p>Third, it is important to remember what medicine really is. It is not a means of sustaining hospitals, drug and device manufacturers, software developers, insurers or government health agencies. Medicine is an art dedicated to the care of patients, whose interests should always come first. In the right hands, an EHR can help patients get better care, but too often EHRs become ends in themselves, displacing patients as the center of medical attention. Patients and doctors will thrive only if we keep patients front and center.</p><img src="https://counter.theconversation.com/content/113149/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Electronic medical records were supposed to improve health care. Are they doing that? Two doctors describe the problems.Richard Gunderman, Chancellor's Professor of Medicine, Liberal Arts, and Philanthropy, Indiana UniversityJames W Lynch, Professor of Medicine, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1116802019-02-13T11:47:45Z2019-02-13T11:47:45ZConfusing and high bills for cancer patients add to anxiety and suffering<figure><img src="https://images.theconversation.com/files/258586/original/file-20190212-174894-1t4wykc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Having cancer is bad enough, and dealing with the costs and confusion of billing systems makes things harder.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-patient-lying-hospital-bed-626815895?src=GItKPrntz3VolOt88zSy8A-1-0">KieferPix/Shutterstock.com</a></span></figcaption></figure><p>Weeks after my father passed away from cancer in 2010, my newly widowed mother received a bill for US$11,000. </p>
<p>Insurance retroactively denied a submitted claim for one of his last chemotherapy treatments, claiming it was “experimental.” All of the prior identical chemotherapy treatments he had received had been covered, and the doctors had received pre-authorization for the treatment. </p>
<p>Was it suddenly experimental because it was not prolonging life anymore? Was it a clerical error, with one insurance claim submitted differently than the others? </p>
<p>As my mother and family grieved, we had this bill looming in the backs of our minds. We took turns calling the insurance company and the hospital billing office, checking websites, and deciphering billing codes on various pieces of paper.</p>
<p>Advances in cancer treatments have improved patient outcomes overall, but many of these interventions have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647336/">increased costs of care</a>. Even when care is “covered,” the definition of “coverage” can include <a href="https://www.fightcancer.org/sites/default/files/Costs%20of%20Cancer%20-%20Final%20Web.pdf">high deductibles, copayments, coinsurance, and surprise out-of-pocket bills</a> for patients. As one participant in a <a href="https://doi.org/10.1177/1077558718820232">recently published qualitative study</a> of cancer survivors told us, “You just have to call both parties and figure out, what are you chargin’ me for? Plus … you’re getting billed for months ago.” </p>
<p>By the time patients receive these delayed bills, they may be unable to recall the particular visit in question, which makes it exhausting for them to manage their finances and diagnosis. The problem is so significant that the National Cancer Institute has a term for this: <a href="https://www.cancer.gov/about-cancer/managing-care/track-care-costs/financial-toxicity-hp-pdq">financial toxicity.</a></p>
<h2>A scary disease, an opaque system</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/258588/original/file-20190212-174887-y2pkhp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/258588/original/file-20190212-174887-y2pkhp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=250&fit=crop&dpr=1 600w, https://images.theconversation.com/files/258588/original/file-20190212-174887-y2pkhp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=250&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/258588/original/file-20190212-174887-y2pkhp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=250&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/258588/original/file-20190212-174887-y2pkhp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=314&fit=crop&dpr=1 754w, https://images.theconversation.com/files/258588/original/file-20190212-174887-y2pkhp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=314&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/258588/original/file-20190212-174887-y2pkhp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=314&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Cancer is one of the scariest and most expensive diagnoses a patient can receive.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-depressed-cancer-patient-standing-front-554782237?src=4O7lcsk0EicSd1HxhZ3Pow-1-4">Sasa Prudkov/Shutterstock.com</a></span>
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<p>In the U.S., cancer is <a href="https://meps.ahrq.gov/data_files/publications/st470/stat470.shtml">one of the most expensive diseases to treat</a>; only heart disease costs more. This cost burden is often passed on to patients. </p>
<p>And to make matters worse, lack of transparency about cost and coverage can be confusing. Seemingly arbitrary changes in insurance decisions can contribute to patients’ <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4523887/">financial toxicity</a>, or the hardship, psychological stress and behavioral adjustments associated with costs of care. For example, some patients have unexpected <a href="https://www.npr.org/sections/health-shots/2016/08/30/491839847/when-a-screening-test-for-colon-cancer-leads-to-a-pricey-follow-up">bills</a> after they receive a diagnosis or abnormal result on a screening test.</p>
<p>In these cases, care that was previously categorized as preventive (and free from out-of-pocket costs) can become a diagnostic or surveillance test, with associated fees. Other patients are surprised when they receive a bill for physician time as well as a <a href="https://publicintegrity.org/health/hospital-facility-fees-boosting-medical-bills-and-not-just-for-hospital-care/">hospital facility fee</a>. It is difficult for patients to keep track of all of these changes and adjust cost expectations.</p>
<p>The impact of high care costs is substantial. People with high out-of-pocket costs are <a href="https://www.businesswire.com/news/home/20180214006069/en/New-CarePayment-Research-Shows-Americans-Can%E2%80%99t-Afford">less likely to receive necessary care</a>, which can compromise cancer treatment and may affect overall or cancer-specific mortality. In a recent study, almost a third of adults said they <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2714507?resultClick=3">delayed or avoided care due to costs</a>.</p>
<p>A patient participant in a <a href="https://doi.org/10.1177/1077558718820232">study we conducted</a> talked about the time she spent navigating the billing process, commenting, “The billing was extremely daunting. I kept a three-ring binder that was three inches thick … tried to match things up. It was a mess.” That time and effort could be spent healing or engaging in valued activities, she relayed to us.</p>
<h2>Hidden costs of care</h2>
<p>In addition to direct costs of care, there are indirect costs of care, such as fees for transportation, parking, housing when needed, and the time spent managing the financial aspects of care on top of treatment.</p>
<p>My father had to pay between $18 and $30 per day just to park at the hospital in New York City where he received his treatments, depending on how long he stayed. This parking fee was on top of tolls ($15) and the time spent traveling to and from the hospital. For him, this meant anywhere from 45 minutes to two hours, depending on traffic and road conditions. Transportation and parking costs are typically not covered by insurance, though some hospitals, health centers and nonprofit organizations <a href="https://www.cancer.org/treatment/finding-and-paying-for-treatment/understanding-health-insurance/if-you-have-trouble-paying-a-bill/programs-and-resources-to-help-with-cancer-related-expenses.html">offer assistance with these</a> indirect care costs.</p>
<p>Many other patients have to take time off <a href="https://theconversation.com/we-need-more-support-systems-for-people-who-want-to-work-during-and-after-cancer-treatment-65540">work</a> while they are undergoing cancer treatment or follow-up care. Cancer patients who are unemployed may even have <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00577-8/fulltext">lower survival rates</a>. One patient in <a href="https://journals.sagepub.com/doi/full/10.1177/1077558718820232">our study</a> commented, “It takes me two-and-a-half hours to get here. I was coming every month, then every two months. Now I’m every three months. Eventually, I go to six months, but I have to take off work every time to come.” Another patient stated, “My vacation and sick time ran out … I had to go on disability.”</p>
<h2>Policy suggestions</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/258590/original/file-20190212-174857-1scs4pw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/258590/original/file-20190212-174857-1scs4pw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/258590/original/file-20190212-174857-1scs4pw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/258590/original/file-20190212-174857-1scs4pw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/258590/original/file-20190212-174857-1scs4pw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/258590/original/file-20190212-174857-1scs4pw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/258590/original/file-20190212-174857-1scs4pw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A cancer patient and her doctor discuss her treatment. Talking with doctors about costs may make a difference.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-telling-patient-woman-results-her-645685942?src=NH0EqD2pGC_rxPebluxvpg-1-0">Rido/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Although addressing out-of-pocket care costs for patients requires multiple systemic changes, there are strategies that can help.</p>
<p>First, patients and their clinicians can discuss the costs of care and create <a href="https://journals.sagepub.com/doi/10.1177/0272989X15626384">cost-saving strategies</a>. Patient-clinician cost discussions can reduce overall costs to <a href="https://europepmc.org/abstract/med/26618364">patients</a>, but many clinicians are hesitant to talk about costs with <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2015.1280">patients</a>.</p>
<p>If there is more than one treatment option available with equal effectiveness data, patients can ask, “<a href="https://theconversation.com/why-treating-breast-cancer-with-less-may-be-more-78514">is there a difference in price between options”</a>? Developers of <a href="https://www.bmj.com/content/347/bmj.f4147">patient-centered decision aids</a> can also add the relative costs of treatments so that patients can weigh cost along with other aspects of treatment to support their choice.</p>
<p>Health care institutions may be underutilizing social workers, financial navigators and other care center resources. Social workers, financial navigators and other care center resources staff with adequate training that promotes patients’ access to care and assistance can help manage their out-of-pocket expenses. This process can yield positive outcomes for both patients and <a href="http://ajmc.s3.amazonaws.com/_media/_pdf/AJMC_03_2018_PAN_SpecialIssue_Yezefski%20final.pdf">health care institutions</a>.</p>
<h2>Less may be more</h2>
<p>Sometimes, treatments are not needed and may add burden to patients. For example, a <a href="https://theconversation.com/why-treating-breast-cancer-with-less-may-be-more-78514">shorter duration of radiation for early stage breast cancer</a> works just as well as longer durations; chemotherapy might not benefit some patients at <a href="https://wa.kaiserpermanente.org/kbase/topic.jhtml?docId=tv8464">earlier stages of cancer</a> or some <a href="https://www.gotoper.com/publications/ajho/2015/2015mar/adjuvant-chemotherapy-in-older-adults-with-colon-cancer">older adults</a>; and some scans <a href="http://www.choosingwisely.org/patient-resources/tests-and-treatments-for-women-with-breast-cancer/">may be excessive</a>. </p>
<p>Until we change norms and engage patients, clinicians and systems to weigh the pros and cons of care that is considered unnecessary or even harmful, many patients and clinicians might fear less aggressive treatment. There’s also the Choosing Wisely <a href="http://www.choosingwisely.org/">campaign</a> which is designed to help by summarizing evidence in plain language and recommending commonly overused interventions.</p>
<p>Finding sustainable solutions to reducing cancer-related financial toxicity requires a collaborative effort between doctors, patients, policymakers, health insurance companies and health care institutions. Easing the cognitive burden associated with the financial stress that comes with cancer care can lead to better outcomes for cancer patients’ health and quality of life.</p>
<p><em>Research coordinator Nerissa George, MPH, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/111680/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mary Politi receives funding from the Agency for Healthcare Research and Quality (AHRQ), the American Cancer Society (ACS)
the Barnes Jewish Hospital Foundation (BJHF), Merck & Co, the National Institute of Health (NIH), the Patient Centered Outcomes Research Institute (PCORI), and the Society of Family Planning (SFP). </span></em></p>A cancer diagnosis is one of the scariest of all. The pain and fear are worsened by a confusing landscape of bills, opaque billing systems and changing insurance rules, rates and reimbursements.Mary C Politi, Associate Professor of Surgery, Division of Public Health Sciences, Washington University in St. LouisLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1018772019-01-18T11:40:42Z2019-01-18T11:40:42Z3 ways Trump could disrupt health care for the better<figure><img src="https://images.theconversation.com/files/254384/original/file-20190117-32810-11jf9xv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More data may be key to disrupting health care. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/smart-health-care-internet-things-hospital-744180298?src=jvteHRmRzSY9lsl4RBzJ-g-1-4">Zapp2Photo/Shutterstock.com</a></span></figcaption></figure><p>Since his winning presidential campaign, Donald Trump <a href="https://www.cbc.ca/radio/thecurrent/the-current-for-november-10-2016-1.3843974/trump-as-ultimate-political-disruptor-breaking-all-the-rules-to-victory-1.3844016">has been</a> <a href="https://thehill.com/opinion/white-house/411535-donald-trump-the-great-disruptor">repeatedly</a> billed as a disrupter. From trade and <a href="https://www.cnn.com/2018/09/16/world/world-order-under-president-trump/index.html">foreign policy</a> to <a href="https://www.politico.com/story/2018/12/22/trumps-crackdown-hits-legal-immigrants-1039810">immigration</a>, Trump has consistently tried to shake up the status quo. </p>
<p>As <a href="https://scholar.google.com/citations?user=EWB2mpsAAAAJ&hl=en&oi=ao">experts</a> in health care management and policy, we believe the president should now focus his talent for disruption in our sector. </p>
<p>And unlike the issue of <a href="https://www.pbs.org/newshour/politics/trump-says-theres-a-crisis-at-the-border-heres-what-the-data-says">immigration</a>, there is <a href="https://news.gallup.com/poll/223403/americans-hold-dim-view-healthcare-system.aspx?g_source=link_newsv9&g_campaign=item_226607&g_medium=copy">widespread</a> <a href="https://www.kff.org/health-reform/press-release/bipartisan-majorities-support-trump-administrations-push-to-get-drug-prices-in-advertisements-even-after-hearing-counter-arguments/">bipartisan appreciation</a> of the crisis in health care, with <a href="https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-start">bloated costs</a> and an industry that <a href="https://doi.org/10.1377/hlthaff.26.6.1534">fiercely resists change</a>. </p>
<h2>Why health care needs disrupting</h2>
<p>While the growth of health care costs has been relatively muted in recent years, they are still cripplingly high and pose a threat to the entire economy. </p>
<p>Health care <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/ForecastSummary.pdf">now accounts for</a> about 18 percent of the economy – up from <a href="https://www.healthaffairs.org/do/10.1377/hblog20110919.013778/full/">about 13 percent two decades ago</a> – and is expected to make up about a fifth of the U.S. gross domestic product by 2026. The United States spends more on health care than <a href="https://www.doi.org/10.1377/hlthaff.22.3.89">any other country</a>. </p>
<p>Yet Americans have little to show for it. U.S. life expectancy at birth, for example, <a href="https://www.kff.org/slideshow/life-expectancy-in-the-u-s-and-how-it-compares-to-other-countries-slideshow">is lower</a> than 11 other high-income countries including Japan, Germany and the U.K. At the same time, infant mortality <a href="https://www.healthsystemtracker.org/chart-collection/infant-mortality-u-s-compare-countries/#item-infant-mortality-higher-u-s-comparable-countries">is the highest</a>. </p>
<p>In addition, despite the mitigating impact of the Affordable Care Act, <a href="https://www.healthaffairs.org/do/10.1377/hblog20180913.896261/full/">28.3 million remained uninsured in 2018</a>.</p>
<p>Furthermore, rising health care costs <a href="https://www.marketwatch.com/press-release/new-report-shows-the-harmful-effect-rising-health-care-costs-have-on-wage-stagnation-2018-09-04">crowd out other consumer spending</a>, which has the potential to erode Americans’ standard of living. </p>
<p>Here are three ways Republicans and Democrats can come together to disrupt the health sector to reduce costs and improve efficiency. </p>
<h2>1. Let nurses and pharmacists do more</h2>
<p>One of the key drivers of rising health care spending is the <a href="https://www.doi.org/10.1377/hlthaff.22.3.89">high cost of labor</a>. </p>
<p>And one reason for that is state laws and regulations control what <a href="https://jamanetwork.com/journals/jama/article-abstract/198677">medical professionals can and cannot do</a> in a way that requires <a href="https://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT&_ga=2.187967080.1163415374.1547405100-1371956472.1547405100">high-paid physicians</a> to perform certain duties or make medical decisions that nurses, pharmacists and others <a href="https://doi.org/10.1377/hlthaff.2014.1367">with more modest salaries</a> could easily do. While the intent may be to ensure quality, the end result of this ring fencing in our view is that it protects certain groups – including nurses and others – from competition. It also ties the hands of health care managers seeking to improve efficiency. </p>
<p>For example, <a href="https://www.forbes.com/sites/adammillsap/2018/06/19/its-time-to-expand-scope-of-practice-laws/#6e2fbc762c64">state scope of practice rules</a> generally restrict prescribing medications to physicians – even though others such as nurse practitioners and pharmacists are fully qualified to do this in most cases. Similarly, ophthalmologists rather than optometrists are primarily allowed to prescribe eye medication, while dental hygienists require the supervision of a dentist. </p>
<p>And as for the impact on quality, a 2013 study showed that the <a href="https://doi.org/10.1016/j.nurpra.2013.07.004">quality, safety and effectiveness of care is similar</a> between less costly nurse practitioners and more costly physicians. </p>
<p>To <a href="https://www.gfrlaw.com/what-we-do/insights/time-reform-corporate-practice-medicine-doctrine">change this</a>, Trump could direct federal regulators to craft guidelines that greatly expand the scope of what nurses, pharmacists, hygienists and the like can do, and then have Medicare and Medicaid make payments to health plans, hospitals and states contingent on compliance with those guidelines. </p>
<p>Increasing competition and letting less well-paid health care professionals handle more of these duties and decisions <a href="https://doi.org/10.1377/hlthaff.2014.1367">should help contain</a> and <a href="https://www.medpagetoday.com/practicemanagement/reimbursement/74505">possibly even lower costs</a>. </p>
<h2>2. End the monopoly on drugs</h2>
<p>Another major culprit behind out-of-control health care inflation is <a href="https://www.communitycatalyst.org/resources/publications/document/2018/CC-PrescripDrugPrices-Report-FINAL.pdf">high prescription drug prices</a>, especially for patented medicines. Most prescriptions are for generic products that are commonly inexpensive, but new drugs often command eye-popping prices.</p>
<p>Studies show <a href="https://www.communitycatalyst.org/resources/publications/document/2018/CC-PrescripDrugPrices-Report-FINAL.pdf">Americans pay at least three times</a> more for drugs than residents of other high-income countries. And a quarter of Americans who take a prescription drug say they skip doses or take fewer pills than they should because of the high cost. </p>
<p>Pharmaceutical firms can charge such high prices for new drugs because patents give them monopoly power for years. Moreover, insurers have been willing to pay. </p>
<p>The Trump administration <a href="https://www.nytimes.com/2018/10/25/us/politics/medicare-prescription-drug-costs-trump.html">has already made an important if narrow move</a> to remedy this by <a href="https://www.healthaffairs.org/do/10.1377/hblog20181026.360332/full/">directing that Medicare Part B</a> use international <a href="http://www.pharmexec.com/international-reference-pricing-us-style">reference prices</a> in some cases when reimbursing pharmaceutical companies. That is, the program would pay the average price of a drug in a basket of countries, which is <a href="https://www.medpagetoday.com/publichealthpolicy/healthpolicy/77258">usually lower</a> than prices in the U.S. A recent government study of the impact estimated the program <a href="https://aspe.hhs.gov/system/files/pdf/259996/ComparisonUSInternationalPricesTopSpendingPartBDrugs.pdf">would have saved more than $8 billion</a> had reference pricing been used in 2016. </p>
<p>But it could do more, particularly as there is <a href="https://www.kff.org/health-reform/press-release/bipartisan-majorities-support-trump-administrations-push-to-get-drug-prices-in-advertisements-even-after-hearing-counter-arguments/">significant bipartisan interest</a> in the issue. </p>
<p>An even bolder approach would involve reforming the patent system underpinning biomedical research. Currently the patent system <a href="https://journals.sagepub.com/doi/abs/10.1177/2168479016648730">provides incentives for biomedical research</a>, with the potential to reap enormous profits. A more efficient way to finance groundbreaking research in our view would be to put a tax on the sale of prescription drugs and use the proceeds to fund research on new ones. </p>
<p>Pharmaceutical and other biomedical companies would compete for those grants – making the decision over what types of drugs to develop a social decision rather than a private one – and any drug they develop with the money would be patent-free. Nobel Prize-winning economist Joseph Stiglitz, for one, <a href="https://opinionator.blogs.nytimes.com/2013/07/14/how-intellectual-property-reinforces-inequality">has argued in favor</a> of an approach similar to this. </p>
<p>In our view, this would drastically reduce prices.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/254414/original/file-20190117-32837-loouc1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/254414/original/file-20190117-32837-loouc1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/254414/original/file-20190117-32837-loouc1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/254414/original/file-20190117-32837-loouc1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/254414/original/file-20190117-32837-loouc1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/254414/original/file-20190117-32837-loouc1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/254414/original/file-20190117-32837-loouc1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Giving consumers of health care more control over their data could curb costs.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/row-multiethnic-people-sitting-side-by-123325801?src=N1RnRbllnp08aqgn84mH9w-1-89">Tyler Olson/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>3. Put consumers in the driver’s seat</h2>
<p>A third problem that leads to high health care spending is the lack of consumer control. </p>
<p>Normally, when someone wants to buy something – be it groceries or a car – a consumer looks around in stores or online and compares prices to make an informed choice about what works best given her needs and budget. </p>
<p>Health care does not conform to this model. Information is asymmetric —- which means one side knows more than the other —- and consumers tend to defer to their providers. Moreover, insurance renders consumers insensitive to prices with little incentive to shop. Cost containment breaks down if shoppers <a href="https://www.researchgate.net/publication/275023198_Price-Transparency_and_Cost_Accounting_Challenges_for_Health_Care_Organizations_in_the_Consumer-Driven_Era">cannot obtain prices</a>.</p>
<p>Trump could empower consumers by aggressively pushing for greater standardization and use of technology in health care. This could include giving consumers more control of their health records in the cloud and requiring insurers and providers to give them more information about prices and the quality of competing options. And as with occupational control, the administration could condition Medicare and Medicaid payments on following its standards. </p>
<p>Knowledge that all providers have ready access to all your medical information will likely encourage switching to lower cost providers. And just as giving consumers more control <a href="https://hbr.org/2002/07/lets-put-consumers-in-charge-of-health-care">led to significant innovations, competition and savings</a> in retirement plans, the same thing would happen in health care.</p><img src="https://counter.theconversation.com/content/101877/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>I have received funding over the years from the following agencies:
Human Services Research Council in South Africa,
National Library of Medicine,
Centers for Disease Control,
US Department of Education,
Ortho Biotech,
Via Medical,
Agency for Healthcare Policy and Research,
Iowa Hospital Association,
Greater Quad Cities Hospital Council,
Iowa Family Planning Council
Peter Hilsenrath is affiliated with Center for Health Policy and Research, College of Medicine, University of California at Davis. </span></em></p><p class="fine-print"><em><span>I have been PI on grants from the National Cancer Institute and from The Iowa Mental Health Consortium. I’ve worked on projects that were funded primarily by the Healthcare Information Management System Society (including one jointly funded with Siemens) and a project funded by the Iowa Department of Human Services.</span></em></p>The president should use his penchant for shaking up the status quo to tackle the genuine crisis in health care.Peter Hilsenrath, Joseph M. Long Chair in Healthcare Management & Professor of Economics, University of the PacificDavid Wyant, Assistant Professor of Management, The Jack C. Massey Graduate School of Business, Belmont UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1014472018-08-14T10:33:13Z2018-08-14T10:33:13ZShort-term health plans: A junk solution to a real problem<figure><img src="https://images.theconversation.com/files/231761/original/file-20180813-2909-1nup4l7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sen. Lindsey Graham, R.-S.C., left, and Senate Majority Leader Mitch McConnell pictured Sept. 26, 2017 before the vote on Graham's bill to gut Obamacare. Like others before it, the bill failed.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Health-Overhaul/bb2a77849e58432dbe62004f92634852/87/0">Andrew Harnik/AP</a></span></figcaption></figure><p>After <a href="https://theconversation.com/how-the-tax-bill-opens-wide-a-big-back-door-to-overhaul-health-care-88624">failing to overturn most of the Affordable Care Act in a very public fight</a>, President Donald Trump has been steadily working behind the scenes to further <a href="https://theconversation.com/trump-isnt-letting-obamacare-die-hes-trying-to-kill-it-81373">destabilize former President Barack Obama’s signature achievement</a>. A major component in this effort has been an activity called <a href="https://academic.oup.com/jpart/advance-article-abstract/doi/10.1093/jopart/muy033/5056341?redirectedFrom=fulltext">rule-making</a>, the administrative implementation of statutes by federal agencies like the Department of Health and Human Services.</p>
<p>Most recently, citing excessive consumer costs, the Trump administration issued <a href="https://www.cambridge.org/core/journals/american-political-science-review/article/influence-and-the-administrative-process-lobbying-the-us-presidents-office-of-management-and-budget/638F34BC73235AB4833C852B24C431AF">regulations</a> to vastly expand the availability of short-term, <a href="https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-16568.pdf">limited duration insurance plans</a>. </p>
<p>While the <a href="https://theconversation.com/born-in-the-usa-having-a-baby-is-costly-and-confusing-even-for-a-health-policy-expert-99719">cost of health care</a> is one of the overwhelming problems in the American health care system, short-term health plans do nothing to alter the underlying causes. Indeed, these plans may cause great harm to individual consumers while simultaneously threatening the viability of many states’ insurance markets. Having studied the U.S. health care market for years, here is why I think states can and should take quick action to protect consumers. </p>
<h2>Comparing crab apples and oranges</h2>
<p>Short-term, limited duration insurance plans, by definition, provide insurance coverage for a short, limited period. <a href="https://www.gpo.gov/fdsys/pkg/CRPT-104hrpt736/pdf/CRPT-104hrpt736.pdf">Since being regulated by the Health Insurance Portability Act of 1996 (HIPAA)</a>, this has meant for less than one year. Sold at least since the 1970s, they were offered as an alternative to major medical insurance intended for individuals with temporary and transitional insurance needs such as recent college graduates or those in between jobs.</p>
<p>However, after passage of the Affordable Care Act <a href="https://www.federalregister.gov/documents/2016/06/10/2016-13583/expatriate-health-plans-expatriate-health-plan-issuers-and-qualified-expatriates-excepted-benefits">further concerns emerged</a> over the misuse and mismarketing of these kinds of plans. As a result, the <a href="https://www.federalregister.gov/documents/2016/10/31/2016-26162/excepted-benefits-lifetime-and-annual-limits-and-short-term-limited-duration-insurance">Obama administration restricted</a> their duration to three months.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/231766/original/file-20180813-2906-wmk4lt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/231766/original/file-20180813-2906-wmk4lt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/231766/original/file-20180813-2906-wmk4lt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/231766/original/file-20180813-2906-wmk4lt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/231766/original/file-20180813-2906-wmk4lt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/231766/original/file-20180813-2906-wmk4lt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/231766/original/file-20180813-2906-wmk4lt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Serious illnesses like cancer often are not covered by short-term health insurance policies.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-white-robe-smiling-looking-out-671185213?src=i2TPJNGkMM51IyPSm0ICCg-1-0">Photographee.eu/Shutterstock.com</a></span>
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<p>In addition to being shorter in duration, these policies’ benefits tend to also be much skimpier than for those plans sold on the Affordable Care Act’s marketplaces. For example, plans often do not cover crucial services such as prescription drugs, maternity care, or major emergencies like cancer. Equally problematic, even those benefits covered come with <a href="https://www.kff.org/health-reform/issue-brief/understanding-short-term-limited-duration-health-insurance/view/footnotes/#footnote-255134-12">high deductibles, strict limitations, and annual and lifetime coverage limits</a>. </p>
<p>It is important to note that short-term health plans are also not subject to any of the <a href="https://www.sciencedirect.com/science/article/pii/S0168851014002607">consumer protections established by the Affordable Care Act</a>. This means, for example, that insurers can set premiums, or even refuse to sell to an individual, based on a person’s medical history. Moreover, consumers must update their health status every time they seek to purchase coverage.</p>
<p>Crucially, short-term health plans have shown to be particularly discriminatory against women. For one, women are <a href="https://theconversation.com/how-bills-to-replace-obamacare-would-especially-harm-women-79819">charged higher premiums</a>. Moreover, they are likely to be disproportionately affected by medical underwriting for <a href="https://theconversation.com/how-pre-existing-conditions-became-front-and-center-in-health-care-vote-77138">pre-existing conditions</a> like domestic and sexual abuse and pre- and postnatal treatment. </p>
<p>Because plans are so limited in benefits, and because insurers are able to deny coverage to sicker individuals, short-term health plans come with much lower premiums than standard insurance plans with their more expansive benefits and vastly superior consumer protections. Indeed on average, <a href="https://www.healthedeals.com/articles/is-temporary-health-insurance-right-for-you">premiums amount to only one-fourth</a> of ACA-compliant plans. </p>
<h2>Too good to be true</h2>
<p>While short-term insurance plans are more affordable in terms of premiums, they come with a slew of problems for consumers.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/231771/original/file-20180813-2891-xo5cix.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/231771/original/file-20180813-2891-xo5cix.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=432&fit=crop&dpr=1 600w, https://images.theconversation.com/files/231771/original/file-20180813-2891-xo5cix.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=432&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/231771/original/file-20180813-2891-xo5cix.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=432&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/231771/original/file-20180813-2891-xo5cix.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=543&fit=crop&dpr=1 754w, https://images.theconversation.com/files/231771/original/file-20180813-2891-xo5cix.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=543&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/231771/original/file-20180813-2891-xo5cix.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=543&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The U.S. health care system is confusing to the young and old.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-couple-going-over-their-medical-143842354?src=8x9jly8lSWEqeIhTOr90Ew-1-1">Lisa F. Young/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>For one, consumers have a tremendously hard time understanding the <a href="https://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-082313-115826">American health care system and health insurance</a>. Predatory insurance companies have been known to take advantage of this shortcoming by camouflaging covered benefits, something the <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/puar.12065">Affordable Care Act sought to ameliorate</a>. Mis- and underinformed consumers often find themselves <a href="https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2017/rwjf441920">surprised when they actually try to use their insurance</a>.</p>
<p>Even for those who are aware of the limitations, problems may arise. Unable to predict major medical emergencies, consumers may be confronted with tens of thousands of dollars of medical bills if they <a href="https://www.kff.org/health-reform/issue-brief/understanding-short-term-limited-duration-health-insurance/">fall sick or face injury</a>.</p>
<p>Moreover, insurers are also able to rescind policies after major medical expenses have been incurred if consumers failed to fully disclose any underlying health conditions. This even applies to health conditions that consumers had not been aware of prior to getting sick.</p>
<p>While some may argue that this is the fault of the those who purchase short-term insurance, it causes problems for all of us. </p>
<p>For one, these individuals may refuse to seek care. This could result in severe consequence for their and their family’s well-being and ability to earn a living. </p>
<p>At the same time, medical providers will <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1541-0072.2012.00446.x">shift the costs</a> of the resulting bad debts to <a href="https://www.kff.org/report-section/uncompensated-care-for-the-uninsured-in-2013-a-detailed-examination-cost-shifting-and-remaining-uncompensated-care-costs-8596/">other individuals with insurance or the general taxpayer</a>.</p>
<h2>Bad for the individual, worse for all of us</h2>
<p>Short-term insurance plans are perhaps even more problematic for the health of the overall insurance market than they are for individual consumers.</p>
<p>With a very short implementation time frame, insurance regulators in the states only have <a href="https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-16568.pdf">until October</a> to prepare for the potentially significant disruptions to their markets. This leaves little time for analysis and regulatory preparation.</p>
<p>Yet long-term consequences are even more concerning. <a href="https://www.degruyter.com/view/j/for.2013.11.issue-3/for-2013-0056/for-2013-0056.xml">Healthier and younger consumers are naturally drawn to the low premiums</a> offered by these plans. At the same time, older and sicker individuals will value the comprehensive benefits and protections offered by the Affordable Care Act. The result is the <a href="https://www.degruyter.com/view/j/for.2013.11.issue-3/for-2013-0056/for-2013-0056.xml">continuing segregation of insurance markets and risk pools into a cheaper, healthier one and a sicker, more expensive one</a>. As premiums rise in the latter, its healthiest individuals will begin to drop their coverage, leading to ever more premium increases and larger coverage losses. If left unchecked, eventually the entire insurance market may collapse in this process.</p>
<p>This could be particularly problematic in states with relatively small insurance markets like Wyoming or West Virginia where <a href="https://www.huffingtonpost.com/entry/iowa-teenager-obamacare-scapegoat_us_59f4715de4b077d8dfc9dd70">even one truly sick individual can drive up premiums tremendously</a>.</p>
<h2>States have options</h2>
<p>The expansion of short-term health plans is one action by the Trump administration that states can counteract relatively simply. Currently, <a href="https://www.sciencedirect.com/science/article/pii/S0168851014002607">states serve as the primary regulator of their insurance markets</a>. As such, they have the power to make decisions about what insurance products can be sold within their boundaries. </p>
<p>Action can be taken by insurance regulators and legislature to create relatively simple solutions. While the vast majority of states have failed to create consumer and market protections, a small number of states have done just that.</p>
<p>New York, for example, <a href="https://www.commonwealthfund.org/publications/fund-reports/2018/mar/state-regulation-coverage-options-outside-affordable-care-act">has banned the sale of these plans</a>. </p>
<p>Others, like Maryland, have <a href="https://www.commonwealthfund.org/publications/fund-reports/2018/mar/state-regulation-coverage-options-outside-affordable-care-act">strictly limited their sale and renewability</a>.</p>
<h2>Treating the symptoms, not the cause</h2>
<p>Many Americans struggle to access insurance and services despite the Affordable Care Act. <a href="https://read.dukeupress.edu/jhppl/article-abstract/40/2/281/13726">While the Affordable Care Act has unquestionably improved access</a> to insurance for Americans, <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1541-0072.2012.00446.x">cost control and affordability are truly its Achilles heels</a>. Indeed, some Americans <a href="https://www.factcheck.org/2014/04/millions-lost-insurance/">lost their limited benefits, lower cost plans</a> when the Affordable Care Act did not recognize them as viable coverage.</p>
<p>The Trump administration has rightfully highlighted to high costs of the American health care system. However, offering consumers the opportunity to purchase bare-bones insurance at lower costs does nothing to solve America’s health care cost problems. </p>
<p>If access to insurance is truly a concern for the Trump administration, I believe it should seek to convince the remaining hold-outs <a href="https://read.dukeupress.edu/jhppl/article-abstract/40/2/281/13726">to expand their Medicaid programs</a>. Also, I think discontinuing its <a href="https://theconversation.com/trump-isnt-letting-obamacare-die-hes-trying-to-kill-it-81373">actions to destabilize insurance markets</a> would also go a long way to reducing premiums.</p>
<p>Yet when it comes to altering the underlying cost calculus, there are <a href="https://theconversation.com/us-health-care-system-a-patchwork-that-no-one-likes-85252">no simple solutions</a>. <a href="https://theconversation.com/us-health-care-system-a-patchwork-that-no-one-likes-85252">Administrative costs are too high</a>. <a href="https://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-082313-115826">Medical quality is too low</a>. <a href="https://theconversation.com/us-health-care-system-a-patchwork-that-no-one-likes-85252">Resources constantly get wasted</a>. Consumers could do more to be healthier.</p>
<p>Ultimately, I see it coming down to one crucial problem: Providers, pharmaceutical companies, device makers and insurers are making too much money. And it is these vested interests that make structural reform of the U.S. health care system a truly herculean endeavor.</p>
<p>But unless Americans and policymakers of both parties are willing to address this root cause, any reform effort amounts to nothing more than rearranging the deck chairs on the Titanic.</p><img src="https://counter.theconversation.com/content/101447/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Trump administration’s latest effort to undermine the Affordable Care Act is the expansion of short-term insurance plans. But these shorter plans are also short on real benefits.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/997192018-07-16T10:40:23Z2018-07-16T10:40:23ZBorn in the USA: Having a baby is costly and confusing, even for a health policy expert<figure><img src="https://images.theconversation.com/files/227510/original/file-20180712-27021-thzcs1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Lukas Haeder, the author's son, on his birthday. </span> <span class="attribution"><span class="source">Simon Haeder/Author</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>It is hard to believe that it has been just over since five months since our second son, Lukas, was born on Feb. 3. His mother, Hollyanne, is doing well, which is something to be thankful for, given the <a href="https://www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-world">excessive maternal mortality rates in the U.S.</a> Lukas is also healthy and growing, albeit sleeping little at night. What is unbelievable is the fact that I am still receiving bills for his birth. </p>
<p>Of course, I “knew” what was going to happen when we found out that my wife was pregnant. I <a href="http://simonfhaeder.wixsite.com/home">study health policy for a living</a>, and I have <a href="https://scholar.google.com/citations?user=QY68LSIAAAAJ&hl=en">written extensively about the American health care system</a>. Yet for all the reading and writing, experiencing health care in America personally is a rather shocking experience. Keep in mind, our birthing experience was without any complications and we have health insurance.</p>
<p>I cannot imagine how overwhelming the experience must be for someone with fewer resources and less of an understanding about health care in America. </p>
<h2>Being pregnant and giving birth: Not what it used to be</h2>
<p>From the first doctor’s appointment, we were introduced to what to expect: lots of paperwork and lots of bills. There are of course all the monthly, then biweekly, and then weekly doctor’s visits with the corresponding bills. </p>
<p>In West Virginia, due to the <a href="https://theconversation.com/how-killing-the-aca-could-lead-to-more-opioid-deaths-in-west-virginia-and-other-trump-states-79991">opioid epidemic</a>, most doctors will also insist on a drug screen.</p>
<p>As it turned out, my wife’s doctor ordered copious amounts of blood work and ultrasounds – “outpatient diagnostic services,” totaling thousands of dollars. It is hard to question any of these when all you want is a healthy baby - and your doctor is the only one who knows which tests are necessary. </p>
<p>Like most parents, we also wanted to know whether our baby was going to be healthy. Here is the total amount of the bill for genetic testing sent to our insurance company: US$26,755.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/227513/original/file-20180712-27042-2kd61k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/227513/original/file-20180712-27042-2kd61k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=372&fit=crop&dpr=1 600w, https://images.theconversation.com/files/227513/original/file-20180712-27042-2kd61k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=372&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/227513/original/file-20180712-27042-2kd61k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=372&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/227513/original/file-20180712-27042-2kd61k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=467&fit=crop&dpr=1 754w, https://images.theconversation.com/files/227513/original/file-20180712-27042-2kd61k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=467&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/227513/original/file-20180712-27042-2kd61k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=467&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A stay in the maternity ward is pricey, even if the child birth itself is quick, as is was with the birth of Lukas Haeder.</span>
<span class="attribution"><a class="source" href="https://www.healthcare.gov/glossary/flexible-spending-account-fsa/">Inked Pixels/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Giving birth to our first son, Nico, had been quite an arduous experience for my wife. She labored for more than 30 hours. Determined not to spend hours in the hospital, my wife practically gave birth this time in the front seat of our car. Ultimately, I was able to throw my wife onto a bed in the maternity ward, and Lukas popped right out. </p>
<p>I joked to my wife: “At least they cannot charge us for delivery.” At the very least, I should file a claim with our insurance company.</p>
<p>I am still not quite sure how wrong I was, because every time I ask for a detailed bill, new items appear while others miraculously disappear. </p>
<h2>About $65 an hour, for lodging</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/227514/original/file-20180712-27024-p22c15.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/227514/original/file-20180712-27024-p22c15.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=423&fit=crop&dpr=1 600w, https://images.theconversation.com/files/227514/original/file-20180712-27024-p22c15.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=423&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/227514/original/file-20180712-27024-p22c15.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=423&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/227514/original/file-20180712-27024-p22c15.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=531&fit=crop&dpr=1 754w, https://images.theconversation.com/files/227514/original/file-20180712-27024-p22c15.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=531&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/227514/original/file-20180712-27024-p22c15.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=531&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Various bills for the birth and care of Lukas and Hollyanne Haeder.</span>
<span class="attribution"><span class="source">Simon Haeder</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>The delivery room, which we used for all of one minute, cost about $7,000. Room and board for my wife for 48 hours cost just over $3,100. Two Tylenols for my wife: $25. Laboratory work: $1,200. </p>
<p>That does not account for Lukas. Room and board for him was just over $1,500. Various laboratory work charges added another $1,400 or so. The hearing test cost $260.</p>
<p>I tried to keep track of all the medical personnel coming and going, but after a while it all became a blur. The doctor, who was not present at birth, charged $4,200 for delivery and care. Pediatricians stopped by a few times to check on Lukas for $150 per look. </p>
<p>We were not able to take advantage of a tax-favored <a href="https://www.healthcare.gov/glossary/flexible-spending-account-fsa/">flexible spending account</a> for most of these expenses, because “being pregnant” does not count as a “life event.” While “giving birth” does count, the added contributions cannot be applied to previous costs associated with the birth.</p>
<h2>Bringing the baby home</h2>
<p>As demanding as giving birth is, in many ways, the real challenges of raising children start when one leaves the hospital.</p>
<p><a href="http://www.pewresearch.org/fact-tank/2017/03/23/access-to-paid-family-leave-varies-widely-across-employers-industries/">Like many American women</a>, my wife, a teacher, did not have access to paid maternity leave. Hence, we had to make do with one income for a few months. Of course, this could not have been a more inconvenient time to lose a paycheck, because literally every day we received medical bills. Many of the bills misspelled someone’s name or got another fact wrong, which led to countless phone calls with providers and our insurer. </p>
<p>Diapers and other baby items, naturally, are also not cheap.</p>
<p>Once my semester ended in early May, my wife went back to work as I watched Lukas. This brought new challenges with it. </p>
<p>For one, as a professor, I am also not getting paid over the summer.</p>
<p>Moreover, while the <a href="https://read.dukeupress.edu/jhppl/article-abstract/40/2/281/13726">Affordable Care Act provides added benefits and protections</a> for breastfeeding, there are limitations. For one, not all breast pumps are covered, and <a href="https://khn.org/news/insurer-slashes-breast-pump-payments-stoking-fears-fewer-moms-will-breastfeed/">insurance companies are getting stingier</a>. This is of course ironic given that there is <a href="https://theconversation.com/au/topics/breastfeeding-953">a whole other effort going on to encourage mothers to breastfeed more</a> because it has been found so beneficial for mother and child. </p>
<p>Finding an appropriate place and time to pump breast milk at work, even with a decent pump and <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">governmental protections</a>, comes with a slew of challenges. Currently my wife is using every free minute she can find and locks her classroom. Finding the time and space when doing continuing education or field trips is, of course, a whole other story.</p>
<p>Going forward, we are rather lucky. </p>
<p>Thanks to the Affordable Care Act, <a href="https://www.sciencedirect.com/science/article/pii/S0168851014002607">well-child visits and preventive care like immunizations will be included in our insurance</a>. Of course, should something serious happen, like a hospitalization, we will be on the hook again for potentially thousands of dollars. </p>
<p>My employer allows me to work from home during the fall semester so I can take care of Lukas at the same time. Of course, while I do not have to teach a class on campus, expectations about research and service will not diminish. </p>
<p>Yet soon, we will have to put Lukas into day care. We have been on several waiting lists since the moment we found out my wife was pregnant. Last time, I had to drive my son Nico 45 minutes one way to a <a href="http://wvpublic.org/post/parents-struggle-find-affordable-childcare-w-va">day care we were comfortable with in Pennsylvania</a>. Even if we are lucky to find a nice day care close by, fees will exceed in-state tuition at <a href="https://politicalscience.wvu.edu/faculty-staff/haeder">West Virginia University, my employer</a>. </p>
<h2>Putting our experience in perspective</h2>
<p>Our experience is, of course, not unique. </p>
<p>America’s poorest members of society are somewhat shielded from medical costs. Medicaid <a href="https://theconversation.com/not-just-for-the-poor-the-crucial-role-of-medicaid-in-americas-health-care-system-78582">generally does not require out-of-pocket contributions</a>. For those on the <a href="https://theconversation.com/time-to-stop-using-9-million-children-as-a-bargaining-chip-90293">Children’s Health Insurance Program</a> and those with <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/puar.12065">cost-sharing subsidies</a> on the Affordable Care Act insurance marketplaces, out-of-pocket contributions are limited. In both cases, the high costs of giving birth <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1541-0072.2012.00446.x">are passed on</a> to public sources and those of us with private insurance. </p>
<p>The <a href="https://www.nytimes.com/2015/12/18/upshot/rich-children-and-poor-ones-are-raised-very-differently.html">real struggles of the poor begin</a> as they seek to raise their children with limited resources and diminishing governmental support.</p>
<p>Yet the middle class more and more often finds itself squeezed between a rock and a hard place when it comes to health care. <a href="http://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2014.1406">Premiums, deductibles and co-payments continue to increase while services and choices grow narrower</a> every year. </p>
<p>With Republican efforts to undo much or all of the Affordable Care Act, <a href="https://www.sciencedirect.com/science/article/pii/S0168851014002607">even those of us with employer-sponsored insurance may lose many protections</a>.</p>
<p>Many of us are simultaneously struggling to pay back our student loans, which already forces many to <a href="https://wtop.com/local/2018/07/student-loan-debt-wealth-divide-are-harming-millennials-homeownership-dreams/">delay marriage, have kids, or buy a house</a>.</p>
<p>For us, and many others, this also meant cutting back on virtually everything, including family vacations and replacing appliances. It also meant taking up every opportunity to add income for both of us by taking side jobs. </p>
<p>Any potential future pay raises are likely to be swallowed up by premium increases and co-payments as health care cost continue to <a href="https://www.bloomberg.com/news/articles/2017-07-27/with-or-without-obamacare-health-care-costs-are-battering-the-middle-class">grow unabated</a>.</p>
<h2>Too rich for government programs, yet too poor to avoid financial hardship</h2>
<p>Given these struggles, it is perhaps not surprising that the <a href="https://www.nytimes.com/2013/12/21/business/new-health-law-frustrates-many-in-middle-class.html">frustrations of the middle class</a> breed resentment toward publicly supported programs. Support for work requirements and more punitive and stigmatizing approaches to social programs are perhaps the understandable result. </p>
<p>Our current approaches to encourage and support parenthood are willfully inadequate. Health care, parental leave, day care, parental support, education. As a country, I think that we should strive to do better to support our families.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/227516/original/file-20180712-27027-n3xin3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/227516/original/file-20180712-27027-n3xin3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/227516/original/file-20180712-27027-n3xin3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/227516/original/file-20180712-27027-n3xin3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/227516/original/file-20180712-27027-n3xin3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/227516/original/file-20180712-27027-n3xin3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/227516/original/file-20180712-27027-n3xin3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Lukas Haeder at 5 months old.</span>
<span class="attribution"><span class="source">Simon Haeder</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure><img src="https://counter.theconversation.com/content/99719/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A routine childbirth proves expensive and complicated. Insurance company adjustments, inconsistent billing and mystery costs flummoxed even a health policy expert and his wife, a teacher.Simon F. Haeder, Assistant Professor of Political Science, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/990432018-07-09T15:27:10Z2018-07-09T15:27:10ZCorruption in the Nigerian health sector has many faces. How to fix it<figure><img src="https://images.theconversation.com/files/225312/original/file-20180628-117436-1as1nq8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Corruption in the health sector in Nigeria takes many forms. </span> <span class="attribution"><span class="source">RTI International/Ruth McDowall</span></span></figcaption></figure><p>Countries plagued by corruption can attest to the fact that, once it becomes entrenched, it can be found in all sectors of an economy. But in low and middle income countries the health sector is particularly vulnerable, according to <a href="https://www.transparency.org/news/feature/corruption_perceptions_index_2017">Transparency International</a>. This is because competence and integrity are undermined by poor working conditions and weak systems. </p>
<p>This rings true for Nigeria. The challenge is that there’s no clarity on what constitutes corruption in the country’s health sector or the different ways in which it manifests. </p>
<p>In many instances, practices that should be considered corrupt – like offering bribes and diverting patients to their private practises – are accepted as normal. And it’s difficult for researchers and policymakers to agree on what corruption is – and how to tackle it – given that measures designed to stop it from happening don’t distinguish between illicit practices, corruption and poor governance. </p>
<p>This scenario is commonplace in low and middle income countries like Nigeria. The impact is clearly visible in <a href="https://www.premiumtimesng.com/news/top-news/229062-nigeria-ranked-152-188-countries-human-development-index.html">critical development indices</a> such as life expectancy and education. </p>
<p>We were part of an anti-corruption consortium led by the <a href="https://ace.soas.ac.uk/">School of Oriental and African Studies</a> that looked at corruption in the health sector in Nigeria. As part of <a href="https://ace.soas.ac.uk/health-providers-nigeria/">our study</a> we set out to find the five corrupt practices that most affected the delivery of health care services. We identified them as: absenteeism, procurement-related corruption, under-the-counter payments, health financing-related corruption and employment-related corruption. </p>
<p>The list of corrupt practices all affect the standard of care that patients received.</p>
<p>Based on these findings, we believe that it’s perfectly feasible for government to put policies in place to tackle all five practices. All it requires is the political will to put the necessary policy and regulatory frameworks in place.</p>
<h2>How we did it</h2>
<p>There were three parts to our study. First we did a systematic review to identify a list of types of corruption that had been identified previously in the health sector. </p>
<p>We then compared this list with one from frontline health workers in the public sector who had a wealth of experience between them. These included doctors, nurses, pharmacists, medical laboratory scientists, radiographers and midwives based at tertiary, secondary and primary health facilities in Abuja and Enugu states. Most were frequently exposed to corruption and were very aware of how it had become embedded in the health system. </p>
<p>After identifying the most prevalent practices we asked this cohort of people to identify the practices that would be most feasible to address given Nigeria’s current political context as well as its regulatory frameworks. </p>
<p>In the third part of the study we engaged senior health care managers and policy makers to ask them to discuss the list of corrupt practices we’d identified. They also provided very useful suggestions on how each one could be tackled.</p>
<h2>Our findings</h2>
<p>The front line workers, senior managers and policymakers were able to identify what was driving the corrupt practices. They also offered ideas on how to address them. </p>
<p>Some of the practices were more difficult to tackle than others. For instance, procurement-related corruption was found more complicated to address because it usually involves a number of actors including sale representatives, doctors, auditors and pharmacists. </p>
<p>Employment related corruption, such as employing unqualified people, was also considered difficult to manage as the government directly employs workers at public facilities.</p>
<p>Absenteeism topped the list as the most prevalent type of corruption as well as one that was the most feasible to address. It was mostly driven by health care workers’ wanting to make more money by running their own practises and there being no rules around it. </p>
<p>The problem could be addressed by getting managers to monitor clocking-in and out processes, applying rewards and sanctions, salary increases and allowances as well as providing health workers with accessible transportation services. Allowing more flexibility in workers’ contracts would also reduce the practise. </p>
<p>Patients were more prone to make under-the-table-payments in secondary and primary healthcare centres to get served quicker and to get unauthorised medicines. Patients were clearly uninformed about the dangers of using unauthorised medicines. The practices appeared to be driven by inadequate staffing and workers’ need for money. </p>
<p>The practise could be reduced by informing patients and health workers about the dangers of using unauthorised medicine. In addition, regular audits, and decentralised distribution, would have also have a dramatic impact. </p>
<p>We found a range of corrupt practices when it came to payments. These included patients being over billed, unnecessary and unprofessional check-ups being carried out, irregular payments to the National Health Insurance Scheme as well as health providers and health workers issuing fake receipts. </p>
<p>These practises could be curtailed by making the price of health services public, instituting electronic payment mechanisms and introducing suggestion boxes.</p>
<h2>What’s next</h2>
<p>In many countries, health systems unknowingly create incentives for health workers to engage in corrupt practices. This leads to inappropriate and ineffective care for patients and translates into high costs and poor outcomes for those in need of care.</p>
<p>The proposed solutions could help address these practices. But they can’t be implemented through a top-down approach because health workers are likely to resist them. Instead, health workers, managers and the facilities needed to agree on what action needs to be taken that there’s buy in.</p>
<p>The interventions will still need to be fine-tuned. But ultimately they could all be implemented in the Nigerian health sector to eliminate corruption among frontline health workers.</p><img src="https://counter.theconversation.com/content/99043/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The Anti-Corruption Evidence Consortium received funding from the DFID to do the research. </span></em></p><p class="fine-print"><em><span>Aloysius Odii, Chinyere Mbachu, Dina Balabanova, Eleanor Hutchinson, Hyacinth Ichoku, Pamela Adaobi Ogbozor, Prince Agwu -, and Uche Shalom Obi do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Corruption in Nigeria’s health sector can be eliminated by the implementation of a few simple strategies.Obinna Onwujekwe, Professor of Health Economics and Policy and Pharmaco-economics/pharmaco-epidemiology in the Departments of Health Administration & Management and Pharmacology and Therapeutics, College of Medicine, University of NigeriaAloysius Odii, Ph.D. candidate in Demography and population studies, University of NigeriaChinyere Mbachu, Lecturer in the Department of Community Medicine, University of NigeriaEleanor Hutchinson, Assistant Professor in Anthropology and Health Systems , London School of Hygiene & Tropical MedicineHyacinth Ichoku, Professor in the Department of Economics, University of NigeriaPamela Adaobi Ogbozor, Research associate at Health Policy Research Group, University of NigeriaPrince Agwu -, Researcher in the Department of Social Work, University of NigeriaUche Shalom Obi, Research associate at Health Policy Research Group, University of Nigeria, University of NigeriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/987472018-06-22T10:29:04Z2018-06-22T10:29:04ZThe Bezos-Buffett-Dimon health care venture: Eliminate the middlemen<figure><img src="https://images.theconversation.com/files/224327/original/file-20180621-137714-x93z7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Warren Buffett of Berkshire Hathaway, Jeff Bezos of Amazon and Jamie Dimon of JPMorgan Chase created a health venture in January.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Amazon-Berkshire-JPM-Health-Care/04a54687af0c468eb355c434bb880f9c/1/0">AP File Photos. </a></span></figcaption></figure><p>The new health care venture formed by <a href="https://www.bloomberg.com/news/articles/2018-06-20/the-article-that-made-the-buffett-dimon-bezos-health-pick-famous">Amazon, Berkshire Hathaway and JPMorgan Chase announced</a> June 20 that Harvard professor and well-known author Atul Gawande would be the company’s CEO. The idea for the new company is to innovate by cutting costs from the health care system, starting with the more than 1 million employees of the three companies behind the venture.</p>
<p>Previous efforts to contain health care spending – from managed care to high deductible health plans to alternative payment models – shared the goal of eliminating unnecessary and overly expensive services. But these practices are very hard to change, since they’re based on physicians’ clinical judgment and patient preferences. </p>
<p>The new joint venture may find it is easier to start with a different question entirely: Can we reduce spending by 15 to 20 percent just by cutting out unnecessary middlemen? </p>
<p>As business school professors, we know that cutting the unnecessary transactions costs generated by unneeded middlemen is the classic first step. We expect it will quickly be seen as the low-hanging fruit for this new organization.</p>
<h2>Tackling inefficient health care arrangements</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/224329/original/file-20180621-137746-1ugn5bi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/224329/original/file-20180621-137746-1ugn5bi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/224329/original/file-20180621-137746-1ugn5bi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/224329/original/file-20180621-137746-1ugn5bi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/224329/original/file-20180621-137746-1ugn5bi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/224329/original/file-20180621-137746-1ugn5bi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/224329/original/file-20180621-137746-1ugn5bi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Amazon has built a worldwide empire by selling goods online.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/honolulu-january-12-2017-amazon-logo-655556107?src=YGTRWw6TR3Cdt5e8MC7ifQ-1-4">Eric Broder Van Dyke/Shutterstock</a></span>
</figcaption>
</figure>
<p>In its main business, Amazon <a href="https://supplychaingamechanger.com/cutting-out-the-middle-man-presenting-shipping-with-amazon/">cuts out everyone</a> except the original supplier of what they sell – and the post office. That’s how they have cut prices of other consumer products.</p>
<p>There’s ample room to replicate that success in health care, because the system in the U.S. has long been plagued by excessive <a href="https://www.investopedia.com/terms/t/transactioncosts.asp">transaction costs</a> – the expenses incurred when buying or selling goods and services. These include irrational pricing, as evidenced by the price of services <a href="http://guides.wsj.com/health/health-costs/how-to-research-health-care-prices/">varying wildly</a> for hospitals, insurers and patients. This, along with unnecessarily complicated <a href="https://www.bloomberg.com/view/articles/2018-03-26/medical-billing-bogs-down-u-s-health-care-system">billing systems</a>, creates the need for extensive bureaucracies to manage all the varied relationships. </p>
<p>Businesses like Amazon try to fix this sort of mess and make shopping for services more convenient and transparent. Imagine an easy-to-use platform where patients can readily assess the price and quality of competing providers and quickly schedule appointments or perhaps even initiate an online consultation. We bet Dr. Gawande is imagining it.</p>
<p>There are also several less visible sources of unnecessary transactions costs that are vulnerable to disruption. Two of these center on <a href="https://www.thebalancesmb.com/largest-pharmacy-benefit-managers-2663840">pharmacy benefit management companies</a> (PBMs) and insurance brokers and consultants.</p>
<p>Lately, the <a href="http://fortune.com/2018/05/21/drug-prices-pharmacy-benefit-managers/">big pharmaceutical firms have pointed at PBMs</a> to deflect the blame for their sky-high drug prices. <a href="https://www.bloomberg.com/news/articles/2018-05-07/drug-plans-drop-as-trump-official-targets-pbms-ahead-of-speech">President Donald Trump</a> seems to share this view. However, PBMs are just middlemen whose only purpose is to lubricate the relationship between insurers, <a href="https://www.drugwatch.com/manufacturers/">Big Pharma</a> and pharmacy chains. They let pharmacies know what your plan covers and what you owe – a valuable service worth a nominal payment. </p>
<p>But PBMs also work the system by <a href="https://khn.org/news/tracking-who-makes-money-on-a-brand-name-drug/">collecting rebates</a> of up to <a href="http://healthpolicy.usc.edu/documents/USC%20Schaeffer_Flow%20of%20Money_2017.pdf">25 percent</a> from drug manufacturers as an agent for insurers. They then pass some, but not all, of them on to the insurance companies and their customers. We believe these <a href="http://money.cnn.com/2018/05/07/news/economy/drug-prices-rebates/index.html">rebates</a> should be understood for what they really are: bribes that Big Pharma pays in an attempt to bias insurers to favor their higher-priced products over others. </p>
<p>Health insurers, such as the plan one of us ran as CEO, receive these higher rebates based on volume – but only for drugs with a competitive alternative where there is a choice of what to cover. The growth of <a href="http://money.cnn.com/2018/05/07/news/economy/drug-prices-rebates/index.html">drug rebates</a> clearly indicates these bribes work independent of clinical appropriateness and input from doctors.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/224328/original/file-20180621-137720-1hvovq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/224328/original/file-20180621-137720-1hvovq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/224328/original/file-20180621-137720-1hvovq7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/224328/original/file-20180621-137720-1hvovq7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/224328/original/file-20180621-137720-1hvovq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/224328/original/file-20180621-137720-1hvovq7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/224328/original/file-20180621-137720-1hvovq7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Customers sometimes have coupons they present at checkout at their pharmacies, which shields them from the high costs of drugs.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pharmacist-client-pharmacy-418238929?src=AWBjKA__ghM9kPMOUMDCLQ-1-42">Pikselstock/Shutterstock</a></span>
</figcaption>
</figure>
<p>Furthermore, Big Pharma’s use of <a href="https://www.healthline.com/health-news/big-pharma-insurance-giants-battle-over-drug-coupons">coupons</a> and donations to reduce what patients pay permits huge increases in drug prices, which more than offsets these rebates. The patient is insulated from higher prices at the pharmacy but still ultimately pays more. The cost of these coupons and donations shifts to the insurer, and the insurer then gets it back in premium hikes. This whole mess rests on rebates as an unproductive transaction cost that has little real reason to exist at all. </p>
<p>Insurers are not blameless. They also try to buy business, creating unnecessary transaction costs in the process. For instance, employers typically hire <a href="https://selectebs.com/5-reasons-to-consider-hiring-an-insurance-broker/">brokers</a> and consultants to advise them on coverage for their employees. Given the complexity of insurance plans, seeking such help is usually a rational decision. But the hidden fact is that these middlemen, in addition to fees from their clients, are taking side payments from insurers <a href="http://securities.stanford.edu/filings-documents/1032/MMC04_01/20061013_r01c_048144.pdf">up to 16 percent of the premium</a> – clearly designed to bias their recommendations to employers. These payments are another case of unproductive transactions costs that can be eliminated by bargaining directly with insurers and drug companies.</p>
<h2>More targets for the joint venture</h2>
<p>Efforts to remove the middlemen won’t stop with PBMs and brokers.
<a href="http://www.politifact.com/truth-o-meter/statements/2017/sep/20/bernie-s/comparing-administrative-costs-private-insurance-a/">Insurers</a>, the biggest middlemen, are certainly vulnerable with their high administrative costs ranging from 12 percent to 18 percent. And this new joint venture might also ask why they would pay wildly variable prices for similar health care services when they can dictate <a href="https://hbr.org/2017/06/why-ge-boeing-lowes-and-walmart-are-directly-buying-health-care-for-employees">package prices</a> for a given episode of care and channel employees to higher-quality providers willing to bargain. Employers like these three can even <a href="http://www.modernhealthcare.com/article/20151205/MAGAZINE/312059980">hire their own clinicians</a> and save another layer of overhead. And if they can do it for their own employees, they can share these efficiencies with others.</p>
<p><a href="https://www.washingtonpost.com/news/wonk/wp/2013/09/04/the-coase-theorem-is-widely-cited-in-economics-ronald-coase-hated-it/?noredirect=on&utm_term=.16f0551d1f7c">Ron Coase</a>, who won the Nobel Prize in economics in 1991, demonstrated that industries are organized ultimately to minimize transactions costs. This is obvious in the history of other sectors where fragmented producers gradually transformed into integrated organizations, and then into assemblers as labor and transportation costs changed. In a similar way, the internet has allowed radical restructuring of many businesses as transaction costs have fallen. </p>
<p>So far, the health care system has largely avoided such transformations. The Amazon, Berkshire Hathaway and JPMorgan Chase venture suggests their time is coming.</p><img src="https://counter.theconversation.com/content/98747/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>J.B. Silvers is affiliated with Case Western Reserve University and MetroHealth System. </span></em></p><p class="fine-print"><em><span>Mark Votruba does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Noted physician and author Atul Gawande was named CEO of a new health care venture aimed at cutting costs and improving care. But the most important man to keep an eye on in this effort isn’t Gawande. It’s the middleman.J.B. Silvers, Professor of Health Finance, Weatherhead School of Management & School of Medicine, Case Western Reserve UniversityMark Votruba, Associate Professor of Economics and Medicine, Case Western Reserve UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/941592018-05-02T10:41:57Z2018-05-02T10:41:57ZIn Brazil, patients risk everything for the ‘right to beauty’<figure><img src="https://images.theconversation.com/files/216868/original/file-20180430-135817-1pza6i0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A plastic surgery-themed magazine is displayed in a Brazil storefront.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/keishaf/5094464539/">hollywoodsmile310</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>In the U.S., if you want a face lift or a tummy tuck, it’s generally assumed that you’ll be paying out of pocket. Insurance will tend to cover plastic surgery <a href="https://www.zwivel.com/blog/insurance-coverage-plastic-surgery/">only when the surgery is deemed</a> “medically necessary” and not merely aesthetic. </p>
<p>In Brazil, however, patients are thought of as having the “right to beauty.” In public hospitals, plastic surgeries are free or low-cost, and <a href="http://www.osul.com.br/cirurgia-plastica-reparadora-cresce-mais-que-a-cirurgia-estetica-no-brasil/">the government subsidizes nearly half a million surgeries every year</a>.</p>
<p>As a medical anthropologist, I’ve spent years studying Brazilian plastic surgery. While many patients are incredibly thankful for the opportunity to become beautiful, the “right to beauty” has a darker side to it.</p>
<p>Everyone I interviewed in Brazil admitted that plastic surgeries were risky affairs. In the public hospitals where these plastic surgeries are free or much cheaper than in private clinics, I heard many patients declare that they were “cobaias” (guinea pigs) for the medical residents who would operate on them.</p>
<p>Yet these patients, most of whom were women, also told me that living without beauty in Brazil was to take an even bigger risk. Beauty is perceived as being so central for the job market, so crucial for finding a spouse and so essential for any chances at upward mobility that many can’t say no to these surgeries.</p>
<p>The very long queues for plastic surgery in public hospitals – with wait times of several months or even years – seem to confirm this immense longing for beauty. It’s made Brazil the second-largest consumer of plastic surgery in the world, with <a href="http://g1.globo.com/bemestar/noticia/2016/08/cai-numero-de-plasticas-no-brasil-mas-pais-ainda-e-2-no-ranking-diz-estudo.html">1.2 million surgeries carried out every year</a>. </p>
<h2>Brazil’s ‘pope of plastic surgery’</h2>
<p>Today, Brazil considers health to be a basic human right <a href="https://www.carnegiecouncil.org/publications/articles_papers_reports/0236">and provides free health care</a> to all its citizens – a hard-won victory of social activists after Brazil’s dictatorship fell and a new democratic constitution was written into law in 1988. However, public hospitals remain severely underfunded, and most middle-class and upper-class Brazilians prefer to use private medical services. </p>
<p>In effect, Brazil has a two-tiered system. There is a private health care system that is cutting-edge and luxurious and a public one that is strapped for cash but provides essential services to the working class.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/216871/original/file-20180430-135840-13ez7kh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/216871/original/file-20180430-135840-13ez7kh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/216871/original/file-20180430-135840-13ez7kh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/216871/original/file-20180430-135840-13ez7kh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/216871/original/file-20180430-135840-13ez7kh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=576&fit=crop&dpr=1 754w, https://images.theconversation.com/files/216871/original/file-20180430-135840-13ez7kh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=576&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/216871/original/file-20180430-135840-13ez7kh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=576&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A billboard advertises a private plastic surgery clinic in Barra da Tijuca, a wealthy neighborhood in Rio de Janeiro.</span>
<span class="attribution"><a class="source" href="http://pictures.reuters.com/C.aspx?VP3=SearchResult&ITEMID=PBEAHULRNBZ&RW=1317&RH=708">Gregg Newton/Reuters</a></span>
</figcaption>
</figure>
<p>Plastic surgery is considered an essential service largely due to the efforts of a surgeon named Ivo Pitanguy. In the late 1950s, Pitanguy – <a href="http://www.cmjornal.pt/mais-cm/obituario/detalhe/morreu_brasileiro_ivo_pitanguy_papa_da_cirurgia_estetica">now known as the “pope of plastic surgery”</a> – convinced President Juscelino Kubitschek that the “right to beauty” was as basic as any other health need. Pitanguy <a href="http://www.ciplastica.com/ojs/index.php/rccp/article/view/28">made the case</a> that ugliness caused so much psychological suffering in Brazil that the medical class could not turn its back on this humanitarian issue. </p>
<p>In 1960, <a href="http://www.iip.org.br/instituto.html">he opened the first institute that offered plastic surgery to the poor</a>, one that doubled as a medical school to train new surgeons. It was so successful that it became the educational model followed by most other plastic surgery residencies around the country. In return for free or low-cost surgeries, working-class patients would help surgeons learn and practice their trade.</p>
<p>Brazil was the perfect testing ground for this idea. In the early 1920s, Brazilian eugenic scientists suggested that <a href="https://www.tandfonline.com/doi/pdf/10.1080/13569325.2015.1091296">beauty was a measure of the nation’s racial progress</a>. Beauty started to assume more cultural clout, and plastic surgeons inherited these ideals, seeing their trade as “fixing” the errors of too much racial mixture in Brazil, particularly among the lower classes.</p>
<h2>Beauty’s hidden costs</h2>
<p>In my recently published book, “<a href="https://www.ucpress.edu/book.php?isbn=9780520293885">The Biopolitics of Beauty</a>,” I question the idea that humanitarianism is the driving force of plastic surgery in Brazilian public hospitals. </p>
<p>Burn victims and individuals with congenital deformities were once the main beneficiaries of plastic surgery in these hospitals. But at many of the clinics where I carried out my research, nearly 95 percent of all those surgeries have become purely aesthetic. I documented hundreds of instances where surgeons and residents purposely blurred the boundaries between reconstructive and aesthetic procedures to get them approved by the government. </p>
<p>Since most of the surgeries in public hospitals are carried out by medical residents who are still training to be plastic surgeons, they have a vested interest in learning aesthetic procedures – skills that they’ll be able to later market as they open private practices. But they have very little interest in learning the reconstructive procedures that actually improve a bodily function or reduce physical pain.</p>
<p>Additionally, most of Brazil’s surgical innovations are first tested by plastic surgeons in public hospitals, exposing those patients to more risks than wealthier patients. Working-class patients are understood as subjects for inquiry, and I spoke to the small but significant number who were very unhappy with the results of their surgery. </p>
<p>Take one woman I interviewed named Renata. The medical resident who operated on her left her with deformed breasts and uneven nipples. She also developed severe infections that took months to heal and left significant scars. She considered suing the doctor, but discovered she would need a costly expert medical evaluation. She also knew that the Brazilian legal system would likely grant her very little in terms of damages. In the end, she settled for another free surgery, one that she hoped would provide a better result and leave her less unhappy.</p>
<p>This was a typical story among low-income patients that were harmed by plastic surgeons. Their lack of financial resources made it nearly impossible for them to find any justice if anything went wrong, so they assumed all of the risk.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/217100/original/file-20180501-135810-xm2zk5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/217100/original/file-20180501-135810-xm2zk5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=801&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217100/original/file-20180501-135810-xm2zk5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=801&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217100/original/file-20180501-135810-xm2zk5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=801&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217100/original/file-20180501-135810-xm2zk5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1007&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217100/original/file-20180501-135810-xm2zk5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1007&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217100/original/file-20180501-135810-xm2zk5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1007&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Extensive necrosis in a patient after an application of PMMA.</span>
<span class="attribution"><span class="source">Anderson Castelo Branco de Castro</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Plastic surgeons, on the other hand, are eager to try new techniques if they seem promising, no matter how risky they might be. A technique known as “bioplastia,” for example, consists of injecting a liquid compound called <a href="https://en.wikipedia.org/wiki/Poly(methyl_methacrylate)">PMMA</a> into the body in order to permanently reshape a patient’s features. The compound, which is similar to acrylic glass, doesn’t cause problems in most patients. But in a small minority <a href="http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-72992007000600019&lng=en&nrm=iso&tlng=en">it causes very severe complications</a>, including necrosis of facial tissue. Yet many doctors I interviewed strongly defended the technique, claiming it was a phenomenal tool that allowed them to transform the human body. Risk, they argued, was inherent in any surgical procedure.</p>
<p>Around the world, Brazilian plastic surgeons are known as the best in their field, and they gain global recognition for their daring new techniques. During an international plastic surgery conference in Brazil, an American surgeon I interviewed told me, “Brazilian surgeons are pioneers… You know why? Because [in Brazil] they don’t have the institutional or legal barriers to generate new techniques. They can be creative as they want to be.”</p>
<p>In other words, there are few regulations in place that could protect low-income patients from malpractice.</p>
<p>In a country where appearance is seen as central to one’s very citizenship, patients agree to becoming experimental subjects in exchange for beauty. But it’s often a choice made under duress, and the consequences can be dire.</p><img src="https://counter.theconversation.com/content/94159/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alvaro Jarrin received funding from the Wenner-Gren Foundation and the American Council of Learned Societies to carry out his research on beauty in Brazil.</span></em></p>Who’s really benefiting from a health care system that provides free or low-cost plastic surgeries for the poor?Carmen Alvaro Jarrin, Assistant Professor of Anthropology, College of the Holy CrossLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/938262018-03-28T10:41:19Z2018-03-28T10:41:19ZHospitals hit back on drug pricing, but will they knock out the problem?<figure><img src="https://images.theconversation.com/files/212013/original/file-20180326-159078-1xvspoh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Heather Bresch, CEO of Mylan, holds two EpiPens as she testified before Congress Sept. 21, 2016 about rising costs of the drug.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/EpiPen-Mylan-Overcharges/51ae0fa265de46ce916afdda81f62404/13/0">AP Photo/Pablo Martinez Monsivais</a></span></figcaption></figure><p>Drug manufacturing and pricing vaulted into the news several years ago when a privately held company <a href="https://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html">raised the price of a drug</a> used for infections from US$13.50 to $750 for one pill.</p>
<p>After an outcry from hospitals, the company later relented, dropping its price by a small margin. Still, this single dramatic increase shed light on the once obscure arena of older generic drugs that continue to be in short supply and whose <a href="https://www.theatlantic.com/health/archive/2015/09/daraprim-turing-pharmaceuticals-martin-shkreli/406546/">prices occasionally skyrocket</a>.</p>
<p>Frustrated with these shortages and alarmed by the potential for price gouging, a coalition of hospitals has recently struck back. Four not-for-profit, religiously affiliated hospital systems and the U.S. Veterans’ Administration announced their intent to form a company that <a href="https://www.nytimes.com/2018/01/18/health/drug-prices-hospitals.html">would manufacture generic drugs</a>, thereby helping to mitigate or eliminate shortages and prevent future massive price spikes for rarely used generic drugs. </p>
<p>I’m an economist who has studied the health care industry, including the U.S. generic industry, and I see a few regulatory and business hurdles to this approach.</p>
<h2>Worthy goal, but challenges aplenty</h2>
<p>The formation of a generic drug company by not-for-profit hospital chains to address continuing drug shortages and mitigate periodic price spikes of old, rarely utilized generic drugs is understandable and reflects a worthy goal. It is important to realize, however, that there are reasons the markets for these old drugs are small. <a href="http://www.nber.org/papers/w23640">Most are unprofitable</a>, and drug availability may not be guaranteed even if they are produced and marketed by not-for-profit organizations. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/rKRza3aiQ5Q?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Prof. Ernst Berndt explains three challenges facing the consortiun.</span></figcaption>
</figure>
<p>Three substantial challenges face the new generic company, each involving coordination clashes within the buying consortium. First, what specific generic drugs should the new generic company manufacture and market? A press release accompanying the announced collaboration suggested the consortium would market about <a href="https://www.sltrib.com/news/health/2018/01/19/utahs-intermountain-healthcare-fights-skyrocketing-drug-prices-shortages-by-forming-its-own-company-project-rx/">20 generic drugs</a>. </p>
<p>But which generic drugs? Those drugs with the greatest price increases? Those whose shortages most threaten public health? Those critical drugs currently available, but whose possible price increases or supply disruption pose the potentially greatest threat to the public health? Those associated with the lowest production costs or least complex manufacturing? Given diverse preferences among its membership, the coalition may find it very difficult to reach a consensus on which generic drugs to manufacture. </p>
<p>Second, once a decision has been reached on which generic drugs to manufacture and market, the consortium must obtain <a href="https://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/ApprovalApplications/AbbreviatedNewDrugApplicationANDAGenerics/default.htm">regulatory approval</a> from the FDA via the Abbreviated New Drug Approval process, either by reaching an agreement with an existing manufacturer with that approval, or by filing completely anew.</p>
<p>If the former, the consortium would need to utilize the identical manufacturing processes, facility sites and equipment as specified in its Drug Master File accompanying its original application for new drug approval. That would have to happen even if those manufacturing processes were now antiquated and inefficient given technological progress in biochemical manufacturing.</p>
<p>If instead the consortium decided to upgrade the manufacturing processes, then it would need to work with the FDA to satisfy regulatory <a href="https://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ucm075207.htm">bioequivalence</a> requirements with the new equipment, a process that involves capital expenditures and can take several years. Bioequivalence means that there is no important difference in the rate and extent of absorption of the active pharmaceutical ingredient. In this latter case, it may instead be preferable to file a completely new application. </p>
<p>Even in that case, though, the consortium would need to decide whether it would self-manufacture the generic product or outsource it to a willing and FDA-acceptable contract manufacturing organization. Agreements and contracts would be required for each generic product, although it is possible that a single contract manufacturer could be identified who could manufacture several of the desired generic drugs. The process by which necessary FDA regulatory approval would be obtained would therefore involve drug-specific approvals and numerous contractual negotiations, consume a considerable amount of time and potentially require substantial capital investments. </p>
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<img alt="" src="https://images.theconversation.com/files/212015/original/file-20180326-159066-73q6b5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/212015/original/file-20180326-159066-73q6b5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/212015/original/file-20180326-159066-73q6b5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/212015/original/file-20180326-159066-73q6b5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/212015/original/file-20180326-159066-73q6b5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/212015/original/file-20180326-159066-73q6b5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/212015/original/file-20180326-159066-73q6b5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">With thousands of drugs on the market, it would be hard to know which drugs the consortium would try to manufacture.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/colorful-medication-pills-above-324566462?src=SY1p0ssuaQGCyZXI9PNBiQ-1-3">Pavel Kubarkov/Shutterstock.com</a></span>
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Third, once decisions were made on which generic drugs to market and how they would be manufactured to ensure they satisfy FDA regulatory requirements, the consortium must determine how to store, distribute and price the medicines. If, given the prices charged by the consortium, the demand for the generic drugs exceeds available supply, how will the unsatisfied demand be rationed – by price increases, an algorithm based on members’ previous purchases from the consortium or by profit versus not-for-profit considerations? How to unload product if supply exceeds demand, generating unused inventories of old generic drugs?</p>
<p>It is possible, of course, that the newly announced generic consortium will be able to overcome coordination challenges and mitigate the market imperfections – and it is important that private, public and philanthropic organizations provide the consortium with various forms of support – but the challenges are indeed daunting. The ultimate success of this generic drug consortium initiative would be a wonderful development – but I wouldn’t count on it.</p><img src="https://counter.theconversation.com/content/93826/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ernst Berndt does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The rising costs of generic drugs have led to outcries. In a search for solutions, four hospital systems are proposing to make drugs on their own. Could their idea work?Ernst Berndt, Professor of Management, MIT Sloan School of ManagementLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/813072017-09-13T02:33:48Z2017-09-13T02:33:48ZWant to fix America’s health care? First, focus on food<figure><img src="https://images.theconversation.com/files/180401/original/file-20170731-22175-67v3q2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Poor diet hurts our health and our wallets.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/closeup-home-made-tasty-burger-on-440673169?src=5ZiZh-oDCb7zYkmg0ZoiOQ-1-26">Lukas Goja/Shutterstock.com</a></span></figcaption></figure><p>The national debate on health care is moving into a new, hopefully bipartisan phase. </p>
<p>The fundamental underlying challenge is <a href="http://www.politico.com/magazine/story/2017/05/24/the-health-care-debate-is-about-money-215189">cost</a> – the massive and ever-rising price of care which drives nearly all disputes, from access to benefit levels to Medicaid expansion. </p>
<p>So far, policymakers have tried to reduce costs by tinkering with how care is delivered. But focusing on care delivery to save money is like trying to reduce the costs of house fires by focusing on firefighters and fire stations. </p>
<p>A more natural question should be: What drives poor health in the U.S., and what can be done about it?</p>
<p>We know the answer. Food is <a href="http://doi.org/10.1001/jama.2013.13805">the number one cause</a> of poor health in America. As a cardiologist and public health scientist, I have studied nutrition science and policy for 20 years. Poor diet is not just about individual choice, but about the systems that make eating poorly the default for most Americans.</p>
<p>If we want to cut down on disease and achieve meaningful health care reform, we should make it a top nonpartisan priority to address our nation’s nutrition crisis.</p>
<h1>Food and health</h1>
<p>Our dietary habits are the leading driver of death and disability, causing an estimated <a href="http://doi.org/10.1001/jama.2013.13805">700,000 deaths each year</a>. Heart disease, stroke, obesity, Type 2 diabetes, cancers, immune function, brain health – all are influenced by <a href="https://doi.org/10.1161/CIRCULATIONAHA.115.018585">what we eat</a>. </p>
<p>For example, our recent research estimated that poor diet causes <a href="https://doi.org/10.1001/jama.2017.0947">nearly half</a> of all U.S. deaths due to heart disease, stroke and diabetes. There are almost 1,000 deaths from these causes alone, every day. </p>
<p>By combining national data on demographics, eating habits and disease rates with empirical evidence on how specific foods are linked to health, we found that most of problems are caused by too few healthy foods like fruits and vegetables and too much salt, processed meats, red meats and sugary drinks. </p>
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<p>To put this in perspective, about twice as many Americans are estimated to die each year <a href="https://doi.org/10.1001/jama.2017.0947">from eating hot dogs and other processed meats (~58,000 deaths/year)</a> than <a href="http://www.iihs.org/iihs/topics/t/general-statistics/fatalityfacts/state-by-state-overview">from car accidents (~35,000 deaths/year)</a>. </p>
<p>Poor eating also contributes to U.S. disparities. People with lower incomes and who are otherwise disadvantaged often have the <a href="https://doi.org/10.1001/jama.2016.7491">worst diets</a>. This causes a vicious cycle of poor health, lost productivity, increased health costs and poverty.</p>
<h1>What a poor diet costs</h1>
<p>It’s hard to fathom how much our country actually spends on health care: currently <a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf">US$3.2 trillion per year</a>, or nearly 1 in 5 dollars in the entire U.S. economy. That’s almost $1,000 each month for every man, woman and child in the country, exceeding most people’s budgets for food, gas, housing or other common necessities. </p>
<p>Diet-related conditions account for <a href="https://doi.org/10.1161/CIR.0000000000000350">vast health expenditures</a>. Each year, cardiovascular diseases alone result in about $200 billion in direct health care spending and another $125 billion in lost productivity and other indirect costs. </p>
<p>At the same time, health care costs cripple the productivity and profits of American businesses. From small to large companies, crushing health care expenditures are a <a href="https://www.forbes.com/sites/castlight/2014/12/29/how-rising-healthcare-costs-make-american-businesses-less-competitive/">major obstacle to growth and success</a>. Warren Buffet recently called rising medical costs the “<a href="https://www.nytimes.com/2017/05/08/business/dealbook/09dealbook-sorkin-warren-buffett.html">tapeworm of American economic competitiveness</a>.” Our food system is feeding the tapeworm.</p>
<p>Yet, remarkably, nutrition is virtually ignored by our health care system and in the health care debates – both now and a decade ago when Obamacare was passed. Traveling around the country, I find that dietary habits are not included in the electronic medical record, and doctors receive <a href="http://dx.doi.org/10.1155/2015/357627">scant training</a> on healthy eating and other lifestyle priorities. Reimbursement standards and quality metrics rarely cover nutrition. </p>
<p>Meanwhile, total federal spending for nutrition research across all agencies is only about <a href="https://www.ers.usda.gov/amber-waves/2015/june/federal-support-for-nutrition-research-trends-upward-as-usda-share-declines">$1.5 billion per year</a>. Compare that with more than $60 billion spent per year for industry research on drugs, biotechnology and medical devices. </p>
<p>With the top cause of poor health largely ignored, is it any mystery that obesity, diabetes and related conditions are at epidemic levels, while health care costs and premiums skyrocket?</p>
<h1>Moving forward</h1>
<p><a href="https://doi.org/10.1161/CIRCULATIONAHA.115.018585">Advances</a> in nutrition science highlight the most important dietary targets, including foods that should be encouraged or avoided. Policy science provides a road map for successfully addressing our country’s nutrition crisis. </p>
<p><a href="https://doi.org/10.1371/journal.pmed.1002311">For example</a>, according to our calculations, a national program to subsidize the cost of fruits and vegetables by 10 percent could save 150,000 lives over 15 years, while a national 10 percent soda tax could save 30,000 lives. </p>
<p>Similarly, a government-led initiative to <a href="https://doi.org/10.1056/NEJMoa0907355">reduce salt</a> in packaged foods by about three grams per day could prevent tens of thousands of cardiovascular deaths each year, while saving between $10 to $24 billion in health care costs annually. </p>
<p>Companies across the country have been rethinking their approach to employee health, providing a range of financial and other benefits for healthier lifestyles. <a href="https://www.jhrewardslife.com/rewards-article-introducing-the-john-hancock-vitality-healthyfood-program.html">Life insurance</a> has also realized the return on the investment, rewarding clients for healthier living with fitness tracking devices, lower premiums and healthy food benefits which pay back up to $600 each year for nutritious grocery purchases. Every dollar spent on <a href="https://www.acoem.org/uploadedFiles/Knowledge_Centers/Health_and_Productivity/Healthy_Workforce_Now/Investingin_ReducesEmployerCosts.pdf">wellness programs</a> generates about $3.27 in lower medical costs and $2.73 in less absenteeism. </p>
<p>Similar <a href="http://www.nutrisavings.com/">technology-based incentive platforms</a> could be offered to Americans on Medicare, Medicaid and SNAP (formerly known as Food Stamps) – together reaching one in three adults nationally. In 2012, Ohio Senator Rob Portman proposed a Medicare <a href="https://www.portman.senate.gov/public/index.cfm/wellness-rewards">“Better Health Rewards”</a> program to reward seniors for not smoking and for achieving lower weight, blood pressure, glucose and cholesterol. This program should be reintroduced, with updated technology platforms and financial incentives for healthier eating and physical activity.</p>
<p>Several other key strategies should be added, together forming a core for modern healthcare reform. Incorporating such sensible initiatives for better eating will actually improve well-being while lowering costs, allowing expanded coverage for all. </p>
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<p>By any measure, fixing our nation’s nutrition crisis should be a nonpartisan priority. Policy leaders should learn from past successes such as tobacco reduction and <a href="http://circ.ahajournals.org/content/circulationaha/133/2/187/F10.large.jpg">car safety</a>. Through modest steps, we can achieve real reform that makes healthier eating the new normal, improves health and actually reduces costs.</p><img src="https://counter.theconversation.com/content/81307/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dariush Mozaffarian reports honoraria or consulting from Astra Zeneca, Acasti Pharma, GOED, DSM, Haas Avocado Board, Nutrition Impact, Pollock Communications, and Boston Heart Diagnostics; scientific advisory board, Omada Health and Elysium Health; chapter royalties from UpToDate; and research funding from the National Institutes of Health and the Gates Foundation.</span></em></p>Poor diet kills hundreds of thousands per year. If we want to achieve meaningful health care reform, we need to address our nation’s nutrition crisis.Dariush Mozaffarian, Professor of Nutrition, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.