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Clinical General Healthcare Cost Healthcare Costs Healthcare Disparities Innovation Patient-Centered Care Primary Care Quality Improvement

Let Me Be Brief: Medicaid Expansion

A series of briefs by the Texas Medical Association’s Medical Student Section

By: Ammie Rupani and Alwyn Mathew

In 2019, 18% of Texans had no form of health insurance.1 650,000 Texans have lost their health insurance due to unemployment during the pandemic. The rate of uninsured Texans is staggering and has only been worsened by the pandemic. During this critical time, we must talk about Medicaid Expansion and the potential solutions for millions of people with no health insurance. As a medical student, I have seen patients defer life-saving medications such as insulin in order to afford rent or groceries. Consequently, these choices have brought such people to the Emergency Room in diabetic ketoacidosis, which could have been easily avoided with regular insulin treatments. Stories like this are far too common in Texas, and it is important to recognize such outcomes are easily preventable with improved access to health insurance coverage. How can we as students learn to treat people, when the system we are bound to  practice in is perpetuating their very diseases?

Retrieved from Texas Comptroller

Medicaid is a health insurance program managed through the Federal Centers for Medicare and Medicaid Services (CMS). Medicaid is currently jointly funded by the Federal and State governments with the Federal government matching each dollar the State spends. Texas Medicaid is primarily a fee-for-service model that has poor reimbursement rates and high administrative burden that discourages physicians from accepting Medicaid in their practice. Currently, Texas Medicaid coverage is only offered to children, pregnant women, seniors, and people with severe disabilities, who also fall below a certain income threshold. For example, a single mother making minimum wage at her  full-time job is not eligible for Medicaid because she earns too much. However, she does not qualify for Federal subsidies covering some of the insurance cost because she does not earn enough. The Patient Protection and Affordable Care Act of 2010 would help address this woman’s dilemma since Medicaid Expansion would cover all individuals with incomes up to 138 percent of the Federal Poverty Level, amounting to $16,643 for individuals and $33,948 for a family of four. Medicaid Expansion would provide a health insurance option to an estimated 2.2 million uninsured low-wage Texas adults.2

Although the original arguments against Medicaid Expansion in Texas focused on States’ rights and limiting Federal dependence on funding, the primary opposition to this program was the Federal mandate. In 2012, the US Supreme Court ruled that the Federal government could not mandate the Expansion of Medicaid in any State, leading to Texas and several States opting out of the program. Realizing the benefits and improvement in health outcomes, several States have since adopted the Expansion program offered through CMS, including Arkansas (2014) and Louisiana (2016). Currently, Texas spends nearly $40 billion (State and Federal funds) for the Medicaid program, with a 60-40% distribution between the Federal and State Government respectively.3 Expansion would be fiscally sound for Texas as it will reduce the strain on our State budget and draw in more Federal resources. Looking past the dollar amount, it is crucial that medical students and other healthcare professionals recognize the benefits of improved access and early medical intervention that can be achieved through Medicaid Expansion.3


TMA’s Legislative Recommendations4
  • Develop a meaningful, statewide health care coverage initiative using federal dollars to:
    • Extend meaningful coverage to low-income uninsured working-age adults, and
    • Establish a state-administered reinsurance program to reduce premiums for people enrolled in marketplace
  • Provide 12-months’ comprehensive coverage for women who lose Medicaid 60 days
  • Establish 12-months’ continuous coverage for children enrolled in Medicaid, the same benefit given to children enrolled in the Children’s Health Insurance Program.

  1. Accounts TCof P. Uninsured Texans. Retrieved from- https://comptroller.texas.gov/economy/fiscal-notes/2020/oct/uninsured.php
  2. How Many Uninsured Adults Could Be Reached If All States Expanded Medicaid? – Tables. KFF. https://kff.org/report-section/how-many-uninsured-adults-could-be-reached-if-all-states-expanded-medic aid-tables/. Published June 25, 2020.
  3. Federal and State share of Medicaid Spending, 2019, Kaiser Family Foundation- retrieved from – https://kff.org/medicaid/state-indicator/federalstate-share-of-spending/?dataView=1&currentTimeframe=0 &sortModel=%7B%22colId%22:%22State%22,%22sort%22:%22desc%22%7D
  4. Provide Meaningful Health Care Coverage for Uninsured Texans. Texmed. https://texmed.org/Template.aspx?id=55300.
  5. Status of state medicaid expansion decisions: Interactive Map, 2021. Retrieved from- https://kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
Categories
Clinical General Healthcare Costs Opinion Patient-Centered Care Reflection

Excellent, good, or fair? How accurately can patient satisfaction surveys measure quality of care?

Last week I had my semiannual dentist appointment. Right after I stepped out the door, I received an email: Dental Office – Patient Satisfaction Survey. Hi, thank you for visiting the dental office. Please take a minute to complete the survey…. Was it a déjà vu? Didn’t I just fill this out recently? Oh wait no. That was for the hygienist? Or was it for that new periodontist? Maybe it was my other specialists?

So besides rating my favorite restaurants and shops on Yelp and Google, now my clinics and insurance companies also want to know how I would rate my doctors– how splendid!

To my surprise, when I clicked the link, the questions were trickier than I expected. According to the email title, it seemed like the survey was about my dentist, but 75% of the questions were about the clinic itself: Waiting time in reception area, appointment phone call answering friendliness, waiting room neatness, office decoration….(Wait…my dentist is responsible for decoration? Great, let’s talk about changing the interior lighting and repainting the wall at the next appointment). As I was filling out the questionnaires, my head started to spin with my own questions: It was a normal checkup appointment, will “fair” be good enough? But I remembered I had given the hygienist an “excellent,” and honestly I couldn’t tell which one was better…oh boy! How are they going to use my answers? Who will be reading my survey responses? Who will be affected by my answers?

To me, it’s difficult to judge the doctors’ performance fairly. I can measure a finance manager by his portfolio performance, a designer by how many designs have been ordered, and a lawyer by how many lawsuits she has won. But judging a doctor is more like judging a piece of artwork: there’s a lot of subjectivity. How do I know Dr. ABC is better than Dr. XYZ? By my test result? Or by the number of medications they prescribe? Like with my dental visit, I couldn’t really tell the difference between that cleaning from the previous ones. Interestingly, some physician groups use patient satisfaction surveys to allocate bonuses [1]. That would make the weight of responsibility seem heavier; I would hate to find out that my dentist lost his Christmas bonus because of my thoughtless answers.

Needless to say, it’s difficult for management to evaluate every department and employee in a large organization. I truly hope that upper management does not blindly rely on this “big data” to determine a doctor’s career path. I would very much like my doctor to focus on my health, instead of for him or her to be driven by monetary incentives and to act as a salesperson. If the survey data is used for allocating the budget, perhaps the survey needs to be transparent about how the clinic is going to use the result: “This survey is for quality training purposes only” or “this survey is for determining the best doctor of the month and who gets the nearest parking spot.” I suspect that knowing the purpose of the survey helps the respondent think twice before jotting down comments or complaints. It might motivate patients to actually finish the survey (I would very much like to meet the saintly soul who is able to finish 30 ambiguous questions without losing their temper). Also, I would like to suggest that since we are giving patients such power, perhaps we can give some power to the physicians too and allow them to rate their patients (like how Airbnb and Uber lets hosts/drivers grade their guests/riders).

Surveys and ratings can be important sources of information. If I need to find a new doctor or specialist, the first thing I do is go on Yelp and sort the list by how many stars they have. Some industries routinely rely on survey systems to improve their customers’ experiences [2].

I understand that the idea behind patient satisfaction surveys is to encourage more communication. But at the end of the day, I believe that the doctor and the patient should have a strong mutual trust that enables them to communicate and give feedback freely and respectfully, without needing to rely on 30 ambiguous survey questions.

 

Reference:

  1. White, B. (1999, January 01). Measuring Patient Satisfaction: How to Do It and Why to Bother. Retrieved April 17, 2018, from https://www.aafp.org/fpm/1999/0100/p40.html
  2. Columbus, L. (2018, April 22). “The State of Digital Business Transformation, 2018.” Retrieved April 25, 2018, from https://www.forbes.com/sites/louiscolumbus/2018/04/22/the-state-of-digital-business-transformation-2018/#761f84535883


Edited by Shaun Webb

Photo credit: Steve Harris

Special thanks to Blog Associate Editor, Janie Cao, for some last-minute content revisions

To learn more about the author, please visit her website here

Categories
General Healthcare Cost Humour Lifestyle Opinion Pharmacology Psychiatry Psychology Public Health Reflection

Well, Well, Well: Products and services compete for shelf space in trendy wellness market, but are they worth your money?

When a friend recently asked me to join them for a class at Inscape, a New York-based meditation studio that New York Magazine described as the “SoulCycle of meditation”, I was skeptical. On the one hand, I usually meditate at home for free, so paying almost $30 for a meditation class seemed a bit silly. On the other hand, my meditation practice had dropped off considerably since the beginning of the year. Maybe an expensive luxury meditation class was just what I needed to get me back into my regular practice. Stepping off bustling 21st Street into the clean modern space, I heard the sounds of, well…nothing. It was incredibly quiet. Before getting to the actual meditation studios, I had to pass through Inscape’s retail space. The minimalistic shelves hold a variety of supplements, tinctures, and powders that include unique ingredients like Reishi medicinal mushrooms and cannabidiol extract. Many contain adaptogens, herbal compounds that purport to increase one’s resistance to stress, though their efficacy has never been quantitatively proven.[1] These products’ promises run the gamut from shiny hair and stress relief to aura cleansing. I may be a super-skeptic, but even I am not immune to the lures of top-notch marketing. With great consideration, I purchased one of the many magical powders for sale labeled as ‘edible intelligence.’

Since wellness has become trendy, a considerable space in the retail market has opened for associated products dedicated to helping people live their best lives. As Amy Larocca pointed out in her June 2017 article The Wellness Epidemic, “[In the wellness world] a loaf of bread may be considered toxic, but a willingness to plunge into the largely unregulated world of vitamins and supplements is a given.” Even a recent episode of Modern Family poked fun at the wellness trend when Haley Dunphy applied for an ultra-competitive job with fictional wellness guru Nicole Rosemary Page. During her interview at Page’s Nerp company headquarters, Page laments, “People say that Nerp is nothing more than a con-job, a cash grab vanity project from a kooky actress. I want to turn Nerp into the next Disney-Facebook-Tesla-Botox. It’s a world changer.” Though Page is a fictional character, I can’t help but wonder whether the character was inspired by the very real Amanda Chantal Bacon, the founder of Moon Juice, which bills itself as an adaptogenic beauty and wellness brand. Bacon’s Moon Dusts retail for $38 a jar and come in varieties such as Spirit, Beauty, and Dream.

The bottom line is that a sense of well-being needn’t come at the price of thirty-plus dollars an ounce. In fairness to those who choose to spend lavishly, I believe that plunking down a chunk of cash might create an intention to use and derive value from a product, thus positively influencing one’s perception of how well the product works. Rest assured, however, that living with intention and gratitude can be just as easily accomplished without spending any money at all. Carving out time in the day to create a small ritual for yourself can be as simple as spending a few minutes in the morning listening to jazz as you drink your first cup of coffee or allowing yourself to become immersed in a good book before drifting off to sleep. These simple acts allow us to bestow kindness upon ourselves that is especially important in our stressful and busy lives as medical students. My suspicion is that by performing such rituals with intention, we derive much of the same benefit whether our mug is filled with the trendy mushroom coffee or just plain old Folgers.

I’m always thinking about ways I can improve my own well-being, but as graduation approaches I also find myself thinking about how these practices might help my patients as well. One of my fundamental goals as a future psychiatrist will be to help my patients see the value in themselves and in their own lives. I predict that for many of my patients, achieving this goal will depend perhaps on medications but also on the deployment of simple wellness tactics such as I described. I’m not going to lie…I’m still intrigued by many of the wellness products that can be found in places like Inscape, Whole Foods, and the Vitamin Shoppe, especially when I think about the potential benefits they might have for my future patients. I figure that if these products do even half of what they promise to, some of them might even be worth the money. So what happened when I added a sachet of intelligence powder to my usual morning smoothies? Pretty much nothing. At one point, I got excited when I began to feel my fingers getting tingly. Then I realized I had been leaning on my ulnar nerve. Not so brainy after all.

[1] Reflection Paper on the Adaptogenic Concept, Committee on Herbal Medicine Products of the European Medicines Agency, May 2008.

 

Photo credit: Open Grid Scheduler / Grid Engine

Categories
Clinical General Healthcare Costs Law Opinion Patient-Centered Care Primary Care Public Health Reflection

Discontinuity in Care

My resident tries fairly hard to take care of his patients. When he is with them, I catch him paying attention to all sorts of details that he could have easily let slip past. So it made it all the more difficult when I saw him enraged. When he opened up his list of clinic appointments one morning, on the list was a patient he did not want to see. It was not just that she was a new patient to him. It was not just that her problem list went on like a run-on sentence. It was that both were true, and my resident was still expected to see her in only 15 minutes.

While chart reviewing, he learned that the only consistency in this patient’s medical care at our clinic had been a history of inconsistent providers—and based on their notes, none of them had the complete story. “Why am I even seeing her?!” my resident asked rhetorically, as he frantically searched for answers he knew he did not have the time to find. I wondered, too. This visit seemed to benefit no one except the Billing Department, and even that would depend on whether the Medicare reimbursements actually made it through.

That patient’s experience was hardly unique, though. While rotating through various specialties as a medical student, I have met several patients who were passed from one provider to another. Maybe the provider had to switch services. Maybe they left the institution for better opportunities elsewhere. The reasons were myriad. Stories like those suggest that continuity of care may still only be a priority in primary care literature.

I think one reason for this reality is a lack of incentives to keep doctors and patients together. In any field, including medicine, we see money driving people’s attention and vice versa. Since our country has historically kept primary care on the back burner, there is little evidence to believe that practical incentives for continuity of care will spontaneously appear in the near future.

So, for the primary care fans out there, it might be worth it to start speaking up.

 

Photo credit: Norbert von der Groeben/Stanford School of Medicine, posted by National Center for Advancing Translational Sciences