Which would you prefer; overtreatment or undertreatment? That’s the fundamental question behind a recent Harvard study.

Peter Ubel, writing in Forbes, tells us that American physicians dole out lots of unnecessary medical care to their patients. He says they prescribe unnecessary antibiotics for people with viral infections, order expensive CT scans and MRIs for patients with “transitory back pain”, and obtain screening EKGs for people with no signs or symptoms of heart disease.

Several allegations have been made against doctors to explain this:

• More tests and treatment are ordered for private (wealthier) patients than for those on Medicaid and those without insurance.
• Physicians order unnecessary tests and treatment to bolster their incomes.
• Physicians order fewer tests and treatment for people who cannot pay.

 

A Harvard study recently tested these hypotheses. Michael Barnett and his colleagues researched how often patients received “unnecessary services.” They compared patients with private insurance to those with Medicaid and also those without any insurance.

Study Results

The results may surprise you. They certainly surprised Peter Ubel. Here is a summary:

• Almost 20% of private insurance patients receive “unnecessary services.”
• Almost 20% of Medicaid patients receive “unnecessary services.”
• Almost 20% of the uninsured receive “unnecessary services.”

In other words, doctors treat people the same regardless of their type of insurance – or lack of insurance! Would we want it any other way?

Ubel believes this is disturbing because he says, “In short, there’s way too much wasteful care, regardless of what kind of insurance people have or don’t have.”

The study did note some variations in the type of “unnecessary services” received by insurance coverage. Private insured and Medicaid patients received “unnecessary antibiotics” for respiratory infections about half the time while this happened to three-quarters of the uninsured. Narcotics were prescribed for back and neck pain more often for the uninsured (almost 50%) but only 33% for Medicaid and 25% for private insurance.

Ubel, who is an academic physician at Duke University, guesses at explanations for these findings:

• When ordering tests like EKGs, physicians operate “out of habit.”
• Patients are “powerless” and don’t push back when doctors order “unnecessary services.”
• Contingency antibiotics – they order these more often for patients they don’t know (and can’t rely on to return) than well-established patients
• Narcotic insanity – he has no idea how to explain these findings
• There is no evidence of physician greed in these findings.

 

Ubel says he would be eager to hear the thoughts of clinicians who care for these populations to hear their explanations. Here are mine:

• “Unnecessary services” is very subjective and good doctors can easily disagree on what is unnecessary.
• Most “unnecessary services” are ordered out of an abundance of caution to avoid unnecessary complications. Would you rather have undertreatment?
• Our litigious culture demands doctors protect themselves from malpractice claims by an abundance of caution. No one is suited for overtreatment or too many tests.
• While overtreatment may increase costs and have deleterious effects on the nation as a whole, it rarely adversely affects individual patients. Unnecessary antibiotics do lead to antibiotic-resistant organisms.
• The uninsured usually represent a more transient, sicker population that warrants overtreatment when follow-up is unreliable.
• Patients are not powerless. If they can’t afford treatment or tests they usually don’t get them.
• Medicaid patients and the uninsured generally demand narcotics more often than the privately insured population. Both populations are frequented by those who abuse narcotics or sell them or both. (see Medicaid and the Opioid Crisis,  Medicaid and the Killer Drugs)

 

Hospital Waste

Wasteful healthcare spending is more of a problem when considering the difference between private physicians and those who are employed by hospitals. There is an alarming trend toward hospitals acquiring private physician practices because they can charge more for the same services. These physicians are often subjected to quotas that incentivize their treatment decisions.

Therefore, it is no surprise to me that Mr. Ubel also references another study in the Journal of the American Medical Association Internal Medicine that drew the following conclusions:

“Visits to US hospital-based practices are associated with greater use of low-value computed tomography and magnetic resonance imaging, radiographs, and specialty referrals than visits to community-based practices, and visits to hospital-owned community-based practices had more specialty referrals than visits to physician-owned community-based practices. These findings raise concerns about the provision of low-value care (unnecessary) at hospital-associated primary care practices.

 

What’s the best healthcare system for low-income children? The recent GOP tax reform bill extended the Children’s Health Insurance Program (CHIP) for another six years. Is this a good thing?

John C. Goodman, healthcare economist, writing in Forbes, thinks it is not.

CHIP covers roughly 9 million children. It is a government-run healthcare system administered by the states. State governments choose the benefits and dictate the prices paid to the providers. The money parents receive cannot be used to purchase private health insurance or enroll their children in an employer-sponsored plan.

This is single-payer healthcare for kids. If you follow this blog regularly, you know how I feel about single-payer healthcare systems, like Canada. If you’re not a regular reader, please see my archives under “single-payer.”

Goodman says there are two ways to insure children in low and moderate income families:

• Offer a tax break to parents – who provide insurance for the children but leave them free to choose the type of insurance: employer plan, public program (Medicaid) or private insurance from the marketplace
• Offer a public plan – directly funded by the government

 

CHIP is widely supported by the public, especially Democrats, because they believe it is the answer for universal coverage. But it was actually created by the Republican-controlled Congress of 1997 under the Clinton presidency. This bipartisan plan called CHIP was created mainly for low and moderate income families who earned too much for Medicaid eligibility.

Goodman says the problem is there was no requirement made for parents to insure their children in order to claim the tax credit. Parents may be financially better off but the children are not necessarily insured nor does this money make the economy larger.

The tax credit has been extended in the new tax reform bill from $1000 to $2000, with $1400 refundable (not based on taxes paid). But this is still not contingent upon the children receiving health insurance. Moreover, there has been no reform of CHIP. CHIP funds still cannot be used for private insurance, and Health Savings Accounts (HSAs) have not been expanded.

All of the limitations of single-payer healthcare still apply to the children, as well. Costs are controlled by delays in treatment and the government controls all treatment decisions. If it doesn’t work well for adults, why do we think it will work any better for children?

 

There is an opioid crisis in America. That much is clear. Now we are learning what is contributing to this crisis.

Recent evidence is pointing the finger at the expansion of Medicaid. Senator Ron Johnson (R – WI) released a report this month from the Senate Homeland Security and Governmental Affairs Committee that connects the dots between Medicaid and the opioid epidemic. That’s the conclusion of the report as reported by The Wall Street Journal editorial board.

Contributing to this problem are several factors:

• Too many opioid prescriptions – especially in the Medicaid population
• Drug marketing – by pharmaceutical companies
• Profits from the resale of opioids – on the black market

 

According to the Centers for Disease Control and Prevention (CDC), the opioid epidemic kills on average 115 Americans per day. About 40% of overdose deaths in the U.S. involve a prescription opioid.

Medicaid offers cheap access to astronomical quantities of pills that can be resold on the black market. For as little as a $1 co-pay, Medicaid beneficiaries can get up to 240 oxycodone pills that can be resold for $4,000, according to the report. Since 2010 more than 1,000 people across the country have been charged or convicted of improper use of Medicaid to obtain prescription opioids.

Where there is the potential for big profits, there is certain to be criminal behavior. The report gives case examples including a Connecticut drug dealer who “preyed on” Medicaid beneficiaries who were “down on their luck” according to a detective interviewed by the committee. The drug ring leader would pay Medicaid beneficiaries, say, $50 to get a prescription filled. Pharmacists tended to trust the Medicaid system and filled the scripts. Then the perpetrator would sell the opioids on the street for up to $3,000 for a single bottle. The perpetrator of this crime pleaded guilty to multiple charges in 2015.

This is just one small slice of the pie. The Johnson report discusses everything from a drug ring in the Bronx to a Maryland pharmacist charged with $90,000 in Medicaid fraud to a $1 billion fraud from a cabal of healthcare providers in Miami. A fictionalized story recently written by Michael Connelly, called Two Kinds of Truth, describes such drug activity in California by Mexican and Russian cartels based on real drug criminals who prey on Medicaid and Medicare patients.

The connection to Medicaid expansion is real. More than 80% of nearly 300 cases were filed in Medicaid expansion states. These include New York, Michigan, Louisiana, New Jersey and Ohio as the worst offenders. The report says,
“The number of criminal cases increased 55 percent in the first four years after Medicaid expansion, from 2014 -2017, compared to the four-year period before expansion.”

Clearly there is a problem here that is especially unique to the Medicaid population. It is apparent that criminals, including corrupt physicians and pharmacists, contribute to this problem by preying on those who are most vulnerable. Expanding the population of those covered by Medicaid has only expanded the opioid problem. We must find a better way to meet the healthcare needs of these low-income Americans without contributing to the opioid crisis.