Shifts in health care delivery raise questions
Christopher Weaver at Kaiser Health News has done two stories recently on new care models driven by insurers eager to save money. Both stories lay out issues that AHCJ members can examine in their own communities, particularly regarding the influence insurers will have over health care delivery and how it differs – or does not differ – from the HMOs of the 1990s.
What questions do you have about health reform and how to cover it?
Joanne Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
The first story, in May, (Health Insurers Opening Their Own Clinics To Trim Costs) was about insurers (specifically Medicare Advantage plans) opening clinics to treat some of their patients that need a lot of health care, and tend to get it in costly (to the insurer) as well as unpleasant (to the patient) places like emergency departments. Giving high-needs patients easy access to care in a clinic – which one could think of broadly as a type of “medical home” – can give them continuity of care, avoid health crises, and cost less money in a closed system where the insurer can shape the payment incentives and share in savings.
The second, more recent, story (Managed Care Enters the Exam Room as Insurers Buy Doctor Groups) reported on a trend that isn’t getting too much attention. Big insurers are buying up physician medical groups, or launching physician management companies. Weaver wrote that it’s “part of a strategy to curb rising health costs that could cut into profits and to weather new challenges to their business arising from the federal health law.”
As Weaver and other reporters have noted, more doctors are giving up solo and small practices in favor of large groups, multi-specialty groups, or staff positions at hospitals. (This Washington Post piece looked at the related trend of hospitals hiring primary care physicians.) Many health policy experts believe the trend toward larger groups and more integrated practices will help reduce fragmentation and duplication, saving money and improving quality.
But what happens when the insurers control the purse strings? Weaver wrote:
“The doctors, at the end of the day, control the patients and currently [in the regular fee for service system, not this insurer-owned model] they’re financially incentivized to do more tests, more procedures,” said Chris Rigg, a Wall Street analyst for Susquehanna Financial Group. “But, if they’re employed by a managed care company, they’re financially incentivized” to do less.
That thought unnerves consumer advocate Anthony Wright of Health Access in Sacramento, Calif., who worries profit pressure could affect care decisions. But Wright also said there may be upsides to more tightly managed care: “No patient wants to get more procedures than they actually need.”
So that’s the dilemma. Will these insurer-owned and operated systems be curbing costs by getting rid of the unnecessary, wasteful and sometimes harmful care, or will they skimp on care? If they formally become Accountable Care Organizations under Medicare, they will have to be accountable for not only the cost but the quality, in defined and measurable ways. But if they are just slapping an “accountability” label on themselves, it’s less clear who they are accountable to, and what they are accountable for. It’s not a given that it will be a reprise of the HMOs.
The business environment – purchasers of insurance wanting quality and value – is different than the 1990s. State-based exchanges starting in 2014 may be able to inject more accountability into the system. Medicare and Medicaid as well as state governments are doing more on quality measurements, value-based purchasing etc. But it’s not clear exactly how all that will play out in the insurer-driven model and whether consumers will resist in ways reminiscent of the managed care backlash 10 or 15 years ago.
“There’s a gigantic Murphy’s law emerging here,” Weaver quoted a health care consultant as saying. “The very people who were the demons in all of this, that the public can’t stand” – managed-care firms – “are the big winners.”
How will aging doctors affect your community?
Filed under: Health journalism, Hot Health Headline
AHCJ member Ryan Sabalow, a reporter at the Redding (Calif.) Record Searchlight, recently looked at the age of doctors in his county, finding that “nearly two thirds of Shasta County’s doctors are older than 50, and there aren’t nearly enough young doctors lining up to replace their retiring peers.”
Sabalow freely admits he’s not the first to cover the topic and acknowledges the work of Ventura County Star reporters over the summer. In a Reporting on Health blog post, Sabalow suggests that reporters contact the state medical board and request the an age range of physicians in their county.
The Association of American Medical Colleges forecast that the “passage of health care reform will increase the need for doctors and exacerbate a physician shortage driven by the rapid expansion of the number of Americans over age 65.” For a look at how many physicians are practicing in each state, as well as how many are in school, see the organization’s state-by-state statistics.
Some resources on workforce issues for AHCJ members:
- AHCJ article: How will retiring boomers affect the national health agenda?
- AHCJ article: Caring for aging population will require health care transformation
- Tip sheet: Addressing current and future health workforce hurdles
- Tip sheet: Assessing health reform: Is there a looming doctor shortage?
- Report: VA facilities face shortage of nurse anesthetists
- Report: Preparing for aging boomers
- Report: AAMC’s 2009 workforce report
- Award entry: ‘State struggles with primary care workforce incentives,’ KHI News Service
- Presentation: The Health Workforce Dream Team: Who Will Provide the Care?
M.D. journalist suggests guidelines for dual roles
Filed under: Conflicts of interest, Health journalism
Tom Linden, M.D., looks at the role of physician reporters in covering disasters, particularly in light of the Haiti earthquake which saw a number of high-profile physician reporters cover the story and render care.
As Linden points out in the Electronic News journal, the networks promoted their reporters’ medical efforts and showed them providing care. He brings up a number of relevant questions about the duties of a physician reporter, whether network s or stations should promote them providing care, privacy of patients and more.
Beyond asking questions and discussing the implications of such coverage and promotion, Linden proposes a set of guidelines “to help clarify boundaries between medical and journalistic practices.”
In short, he says it’s bad journalism and inappropriate for physician reporters to report on themselves providing care.
When physician journalists become the story, medical reporting loses its way.
Linden, a professor of medical journalism in the School of Journalism and Mass Communication at the University of North Carolina at Chapel Hill and director of the medical and science journalism program, is no stranger to the subject, as he has worked as a medical journalist for CNBC and local news stations.
Related
- Press release about Linden’s piece
- Debate over M.D. reporters in Haiti continues
- Doctor or journalist? Roles become blurred in Haiti
Lundberg’s list of why health care costs are rising
While people on the streets, experts and legislators debate the causes of rising health care costs, George Lundberg, M.D., editor-at-large of MedPage Today, does no such hand wringing.
He declares that a survey of the topic that was posted by his publication missed the point and did not provide the correct answers.
Lundberg, who edited the Journal of the American Medical Association for 17 years and is a member of the Institute of Medicine, lists what he sees as the “Primary Drivers of Rising Healthcare Costs.”
Texas data shows origin of foreign-trained doctors
Filed under: Health data, Hot Health Headline, Public records
Emily Ramshaw and Matt Stiles of The Texas Tribune looked into where that state’s doctors were trained and who received fast-tracked medical licenses in exchange for treating government-subsidized patients.
They found that “Of the roughly 1,500 doctors who have received fast-tracked licenses in the last three years for agreeing to treat Medicaid and Medicare patients, about 40 percent were trained at international medical schools, while just a quarter were trained at Texas medical schools.”
The site then used the data, obtained from the Texas Medical Board, and Google Gadgets to create an interactive map showing where Texas doctors were educated.
Related
- Tip sheet: Foreign-born doctors exploited by U.S. physicians
- Indentured doctors, Las Vegas Sun
Data Mine reports on access to practitioner data
The Center for Public Integrity’s Data Mine focuses on the National Practitioner Databank and the lack of public access to information in the database, which contains information about loss of privileges for medical professionals, malpractice payments and license revocations.
The public can access and use statistical information from the database but it cannot find out information about specific professionals. The American Medical Association, opposes making information in the database public because it “is riddled with duplicate entries [and] inaccurate data,” according to the Data Mine’s report.
A report last year from Public Citizen revealed that hospitals take advantage of loopholes to avoid reporting disciplined physicians to the database.
AHCJ Resources
- Access to list of disciplined health workers in limbo
- A road map for covering your local hospital’s quality
- How well does your state oversee nurses?
- State oversight of health professionals
- Records show ‘dangerous doctors’ rarely face discipline
- Health reporting resources for reporters covering state and local government
- Investigating health care: Essential public records
Drug firms turn to private doctors for promotion
Filed under: Conflicts of interest, Hot Health Headline
Pharmaceutical companies are turning to doctors in private practice to promote their products as universities have developed conflict-of-interest policies that limit their doctors’ activities, according to the latest report from John Fauber of the Milwaukee Journal Sentinel.
Fauber, who has been covering conflicts of interest in medical research for more than a year, reports that “So much money is at stake that in January one academic doctor resigned his job at Harvard rather than give up his speaking income.”
Medical schools can restrict doctors who work for them from advocating particular drugs and can require that they inform patients of their ties to drug companies, but private physicians have no such obligations.
In previous articles, Fauber has reported on University of Wisconsin doctors who were making six-figure sums from drug and medical firms by serving as consultants or doing promotional speeches.
Critics say the talks can be biased and contribute to spiraling health care costs by promoting the use of expensive brand-name drugs over generics. The practice, according to critics, also leads to more non-approved and potentially harmful use of those drugs, so-called off-label prescribing.
Defaulted doctors: Hundreds fail to pay on loans
More than 300 health care providers who received Health Education Assistance Loans made no payments during 2008, despite having earned income that year, according to a new report from the Office of the Inspector General of the Department of Health and Human Services.
These 312 HEAL defaulters earned $13.4 million and owed $47.5 million on their loans in FY 2008. Ninety-eight of these defaulters (31 percent) earned $50,000 or more. These 98 defaulters were responsible for nearly $15 million of the $47.5 million owed.
The program, known by the acronym HEAL, provided federal insurance for educational loans made by private lenders to more than 156,000 graduate health professions students between 1978 and 1998. Loans were available to students in schools of medicine, osteopathy, dentistry, veterinary medicine, optometry, podiatry, public health, pharmacy, chiropractic, health administration or clinical psychology.
The names of borrowers who are in default on their loans are published online in a searchable database quarterly. Information available includes the borrower’s name, discipline, state, amount due, school and date of graduation or separation.
The site says it lists borrowers who:
- had one or more default claims paid by the Department of Health and Human Services (DHHS);
- been excluded from the Medicare program as a result of his or her HEAL default; and
- not had the Medicare exclusion stayed, or lifted, by the Office of Inspector General as a result of entering a settlement agreement.
The site says it was last updated in November 2009, so reporters will need to verify any information found on the site. But it could be a starting place for stories about local health care providers.
Doctors turn to ‘speed dating’ to find patients
American Medical News‘ Victoria Stagg Elliott outlines a Texas program called “Doc Swap,” which is a sort of speed dating for medical professionals and patients. A doctor and potential patient have five minutes to find out if they’re a good fit for each other before the rotation bell rings and they start the five-minute discussion over again with another partner. 
For Texas Health, it’s a “low-cost way to drive patients to affiliated physicians.” For physicians, even representatives say it’s “good marketing,” as they can net three or four new patients for just an hour’s worth of unpaid effort.
Elliot writes that it appears to be the first such event in the country, though less formal doctor-patient meet-and-greets are common. Physicians say it’s a good way to filter out patients who wouldn’t be a good fit for their practice and expertise, and to help direct patients to the right specialist from the start.
Firing patients
“Doc Swap” and its take on the doctor-patient relationship fit with a recent column on doctors “firing” their patients. Beck says it’s a common topic of discussion among doctors, and lays out the basic criteria for showing a patient the door.
The list of reasons is relatively short, according to medical associations: Patients who are chronically abusive, disruptive or drug-seeking may be asked to leave a practice. So might those who habitually miss appointments or refuse to pay reasonable bills. Failing to heed medical advice isn’t necessarily grounds for a split, but some doctors suggest that patients who won’t quit smoking, use illicit drugs or have potentially harmful habits (daily enemas, say) might be more comfortable in another practice.
The comments on a related blog post provide a few more physician perspectives.
Debate over M.D. reporters in Haiti continues
Discussion and debate continues about the ethics of reporters also serving as doctors in Haiti. [Earlier post]
The Washington Post’s Paul Farhi spoke to some network officials - including Paul Friedman, executive vice president of CBS News, who “says that competitive issues have factored in boosting [Dr. Jennifer] Ashton’s role since [CNN's Dr. Sanjay] Gupta became a star.”
In Baltimore, The Sun’s Kelly Brewington posted the question of whether doctors can also be reporters to readers in that paper’s “Picture of Health” blog.. Curtis Brainerd, on the Columbia Journalism Review’s Web site, wrote about the concerns being raised over the dual roles doctor/reporters are serving in.
Last week, the Society of Professional Journalists released a statement cautioning journalists to not become part of the story. When some people, including new media professor and blogger Jeff Jarvis, interpreted that to mean reporter/doctors should not treat patients, the discussion became more heated. Blogger Tyler Dukes took on Jarvis’ denigration of SPJ’s statement, saying that Jarvis “chose to argue his points with hyperbole and distortion.”
The Canadian Broadcasting Corporation discussed the issue on the Jan. 21 edition of its “As it Happens” show. [Listen]
On Jan. 27, National Public Radio’s media correspondent David Folkenflik appeared on New Hampshire Public Radio’s Word of Mouth and talked about how much of a role should a reporter perform in the midst of a story.
Folkenflik, who has spoken to ABC’s Dr. Richard Besser and NBC’s Dr. Nancy Snyderman, says, “The real question is ‘Is it required for them to tell those stories through their own experiences? Are they somehow diverting attention from those who might need it most by focusing their camera and their aid on these, these people and are they in some ways subtley changing the nature of outcomes there?”
Folkenflik says, “Nobody’s saying these people shouldn’t help” but that “The question is ‘Is there any need to keep the camera rolling while they do it?’ I think that’s fundamentally the issue.”
NPR’s On the Media delved into the topic on Jan. 22, with Neal Shapiro, president of WNET Public Television in New York and former president of NBC News; AHCJ member Gary Schwitzer, of the University of Minnesota and publisher of Health News Review; Bob Steele, a journalism ethicist at DePaul University and member of the Poynter Institute’s faculty; and Dr. Bob Arnot, former chief medical correspondent for NBC News.
Arnot, who has intervened medically while on assignment - without the cameras rolling - pinpointed some of the concerns of performing medical procedures on camera:
DR. BOB ARNOT: Look, the real risk is here that your producer calls up and says, hey we just saw the other network’s doctor deliver a baby, could you do an amputation. There’s a real risk that doctors could be pushed into things they shouldn’t be doing because of the pressure of the suits or the producers, to just get better ratings.
BOB GARFIELD: Things they shouldn’t do, he says, such as treating somebody in the street who can just as easily and more safely be attended to at a clinic or hospital, and such as exploiting the pain of an earthquake victim, not to mention the emotions of the audience, for three minutes of drama, genuine or otherwise.
DR. BOB ARNOT: Absolutely, I mean, look-it. If this happened on the streets of New York, do you think you could do that with the current HIPAA regulations? So, sure, you’re potentially exploiting the patient, and you are becoming more of a showman than you are a medical doctor out there.
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