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Opinion and Commentary from TMA

I Won’t Take the Nurse Practitioners’ Bait

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EHR_guide

The American Association of Nurse Practitioners (AANP) is obviously intent on picking a fight with physicians. No thanks. We’ll take the high road, fully aware of the dangers of their plans, and stick with what we know is best for our patients: the physician-led health care team. 

In a recent commentary published in USA Today, two of AANP’s allies repeated the trope that authorizing independent practice for nurse practitioners would somehow solve the shortage of physicians we all know America faces. In their misguided quest, the authors have twisted and misinterpreted the research they cite, and in the end hurt the very patients they say they want to help. 

Fleeger_MugI won’t rebut, point by point, the authors’ argument. I’ll leave it at this: My problem is not with NPs. They are an integral part of the health care team. We need them on the team to help with disease management and education. Indeed, it is hard to imagine our health care system without them. My problem is with independent practice and the false argument that this will somehow improve access to and decrease the cost of medical care for our patients. The data are clear: Regardless of whether or not they work in states that allow independent practice, the vast majority of NPs locate just where physicians do – in the big cities. Without appropriate supervision, they order more tests and consultations to compensate for a more limited diagnostic knowledge base.  

Meanwhile, members of the American Medical Association’s Scope of Practice Partnership shared an insightful slide presentation from a recent AANP meeting. I was drawn to one slide that lists AANP “Board Initiatives.” Parts of it are repeated in more detail in the AANP’s 2019 strategic plan. I call your attention to two bullet points on that slide: 

  • “Patients nationwide will have full and direct access to high-quality care and will choose NPs as their health care provider” (emphasis added); and
  • “NPs will have parity with physicians and other providers in reimbursement, payment, and government funding.” 

These kind of statements might be good for AANP membership, but they’re awful for our patients. A nurse is not a doctor. And a doctor is not a nurse or physical therapist or an audiologist or any other type of clinician on the team that has to work together on behalf of our patients. 

As I stated when I proudly took my oath to become your TMA president, “It is because we are professionals that we lead, supervise, educate, and monitor the other members of our health care team. They do not know what we know. They cannot do what we do.” 

Nonphysician practitioners work with physicians – but under our direction. That’s not a put-down. It makes little sense to create more fractionation in our already confusing health care “system.” That’s what we work for at the Texas Legislature, in the U.S. Congress, in the courts, and in regulatory agencies. That’s why we defeated more than 20 scope-of-practice expansion bills during the 2019 legislative session. Your association – and I – remain firm in this principle. (See our strong letter opposing President Trump’s plan to grant NPs payment parity in Medicare.) 

In 2013, with the full support of the nurse practitioners and physician assistants here, the Texas Legislature passed a groundbreaking law that replaced the old site-based restrictions for prescriptive delegation and supervision with a more flexible, collaborative model for physician-led, team-based care. 

Our legislators understand that our patients benefit when each member of the team brings his or her special talents, skills, and training to the bedside. They understand that the path to independence is through education, not legislation. We will not stand by and watch the AANP and their supporters try to pretend that our years of medical school training and residency do not make a difference. No one has the skills and education that physicians have that qualify us to lead the patient care team. And ultimately, we have the responsibility for our patients’ health. 

I won’t take the bait. I’ll just continue to stand up for Texas physicians and our patients. 


Expanding APRNs’ scope of practice will increase the cost of care   

• Research comparing APRNs to physicians found a 41-percent increase in hospitalizations and a 25-percent increase in specialty visits among patients treated in the same setting by APRNs.1  

• Collaborative care models, such as the patient-centered medical home, have demonstrated reductions in emergency department visits of up to 29 percent2, reductions in hospitalizations up to 40 percent3, and reduction in total medical costs by 9 percent.4  

Sources:  

1 Hemani A, Rastegar DA, Hill C, et al. “A comparison of resource utilization in nurse practitioners and physicians.” Effective Clinical Practice 1999 Nov-Dec; 2(6):258-265. 

2 Reid R, Fishman P, Yu O, et al. “A patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation.” American Journal of Managed Care, September 2009.  

3 BD Steiner et al, “Community Care of North Carolina: Improving care through community health networks.” The Annals of Family Medicine 2008;6: 361-367.  

4 Geisinger Health System, presentation at White House roundtable on Advanced Models of Primary Care, August 10, 2009. 

Making Prescribing Less Painful for Physicians

(Legislature, Public Health) Permanent link

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No one likes to be told what to do. 

We physicians, especially, are tired of government agencies and insurance companies and hospital administrators telling us how to take care of our patients. So I won’t be surprised if physicians around the state are feeling a little angst and anger over the coming March 1 requirement for physicians to check the Texas prescription monitoring program (PMP) before writing prescriptions for opioids, benzodiazepines, barbiturates, and carisoprodol. 

Fleeger_MugI don’t fault them one bit. This is just one more administrative burden placed on physicians. But I want all of you to understand just how much worse it would have been without the intervention of the Texas Medical Association. 

TMA began our work to simplify physicians’ administrative burden when prescribing opioids and other controlled substances early in the last decade. We claimed two important successes during the 2015 session of the Texas Legislature. Until that point, Texas doctors needed both a state controlled substances registration (CSR) permit and a federal Drug Enforcement Administration permit to write prescriptions for any controlled substance. Also, until that point, the state PMP was a law enforcement tool housed in the Texas Department of Public Safety. And, physicians who wanted to check a patient’s controlled substance history had to perform that task personally. 

Thanks to TMA's advocacy during the 2015 session, the CSR permit was eliminated, the PMP was moved to a new online system created by the Texas State Board of Pharmacy, and physicians were authorized to delegate checking the PMP to members of their staff. (That's a valuable time saver for our doctors that I encourage you to use.)

As the opioid abuse epidemic raged across the country, elected officials clamored for a crackdown on prescribing practices. In 2010, Colorado, Delaware, Louisiana, Nevada, and Oklahoma were the first states to require prescribers to search patients' drug histories before prescribing. By January 2017, when the Texas Legislature was ready to convene, 26 more states had imposed that mandate. (Currently, that number is up to 43 states.) 

Political pressure to do something was growing here in Texas. State lawmakers already had filed some extremely onerous pieces of legislation. It was obvious that Texas was about to join the list. It became TMA’s job to buy time for you and make sure the state was pushing a useful clinical tool for physicians, not another useless administrative burden. 

As we do so often, TMA and organized medicine went to work educating senators and representatives about the real-world impact of the bills they had filed. We pushed back hard against a proposed sweeping mandate for physicians to check the PMP before issuing prescriptions for any controlled substance. We persuaded lawmakers to limit the requirement to the four drug classes I mentioned above. And we won a two-year delay in the mandate so physicians, the Pharmacy Board, and other key players could prepare for this massive change. 

Finally, during the 2019 legislative session, we obtained two more big improvements for physicians. While at that point, most of the major electronic health record (EHR) vendors were working to integrate the PMP into their systems, they were not likely to be done with their work before the Sept. 1, 2019, deadline. We persuaded lawmakers to delay the mandate until March 1, 2020, to give physicians and EHR vendors time to properly integrate their systems with the PMP. Plus, the legislature appropriated an additional $5 million for the Pharmacy Board to upgrade the PMP to make it easier to integrate, as well as to cover the integration licensing fees for all state prescribers and pharmacists. 

To use a bad pun, this mandate is still a pain, but it hurts far less than it could have because TMA has been there for you. We also have a new PMP Resource Center on the TMA website that includes all the background on the mandate and a way to check if your EHR is connected to the PMP. We put together a webinar with 1.25 hours of CME (free to TMA members) to make using the PMP easier for you and the staff you delegate the task of checking the database, and more beneficial for you and your patients. We also are working on a public campaign to make sure your patients know the PMP mandate is coming and what it may mean the next time they visit their doctors. 

My hope is that because of all the work we’ve done, the PMP will actually be a valuable tool to help physicians prevent drug abuse, drug diversion, and doctor shopping, and that it will not delay, thwart, and complicate care for our patients.

The Math of Medicare for All

(Legislature, U.S. Congress) Permanent link

TMA_DC_Advocacy

This is an excerpt of a post originally published on Sarah Fontenot’s website. The opinions expressed are Ms. Fontenot’s. Texas Medicine Today is sharing them to further the conversation on the future of health care reform.

Support for Medicare for All has swept the nation – or at least Democratic primary voters.

In a September Kaiser poll of likely Democratic voters, 40% said they were in favor of replacing the Affordable Care Act (ACA) with Medicare for All. Of that segment 14% said they would only support a candidate who would bring Medicare for All to America (as opposed to other solutions, such as the Public Option).

With two of the current top Democratic candidates – Sens. Bernie Sanders (I-Vermont) and Elizabeth Warren (D-Massachusetts) – espousing Medicare for All, supporters and detractors alike are asking more in-depth questions about the proposal, particularly how much it will cost.

What do Senators Sanders and Warren mean by “Medicare for All”?

Medicare for All is a concept that has been around since the early 1900s, was an unrealized component of President Franklin Roosevelt’s New Deal, and was in the background of the Medicare law President Lyndon Johnson signed in 1965.

Senator Sanders picked up the banner in 1987 and has run on it ever since – most memorably in the 2016 presidential election.

In April, Senator Sanders updated his Medicare For All plan (the fifth time he has done so) in Senate Bill 1129. Among his 14 co-signers were four senators who were running for president at the time: Elizabeth Warren, Cory Booker, Kamala Harris, and Kirsten Gillibrand.

SB 1129 would create a single-payer health system in America, eradicating private health insurance and current government health care programs over four years.

The insurance described in the Sanders plan would be more comprehensive than any policy currently available on the market, more generous than Medicare as we know it now, and more generous than any government program in the world (including Canada, the United Kingdom, and Norway).

Almost every resident of the United States would be entitled to comprehensive health care through a new government program modeled on Medicare (not included: veterans, who would continue to receive health care through the U.S. Veterans Administration; and Native Americans, who would be served through Indian Health Service).

Under Senator Sanders’ plan, Medicare for All would include:

  • Care in any hospital;
  • Care outside of a hospital (free-standing facilities, labs, etc.);
  • All preventative health care and chronic disease management;
  • Comprehensive reproductive, maternity, and newborn care, including abortion;
  • Emergency health care services and treatments;
  • Primary and specialty health care;
  • Palliative and long-term care (including home-health);
  • Care for vision, hearing, and oral health problems;
  • Mental health and addiction services;
  • Prescription medication (the first $200 a year out of the patient’s pocket);
  • Medical equipment and supplies;
  • Diagnostic tests; and
  • Other services (this list is not all-inclusive) 

All this care would be available at no out-of-pocket cost to the patient, and there no longer would be insurance premiums, copays, or deductibles in America.

It is understandable why the concept of Medicare for All has proven so attractive to many Americans.

It is also apparent why the cost of the plan has remained one of the most consistent arguments against it. What level of investment by the federal government will be necessary to make Medicare for All possible?

What does Senator Sanders say about the cost of his plan?

He has historically been vague about the cost of Medicare for All. The last time he ran for president, the “false charms” of his plan were widely criticized (and that was before he added long-term care to the 2019 version of his proposal). 

Variables make projections of the cost of Medicare for All difficult: How many new patients will enter the system? How many health care services will be requested when insurance companies no longer act as gatekeepers? How low can payments to hospitals and physicians go before the health care community closes and creates access issues for patients? What will it cost to build an administrative agency large enough to manage the health care of the entire country? 

Even so, many economists have attached a specific price to Medicare for All. Senator Warren released her price tag recently. Senator Sanders remains more opaque, and inconsistent. 

For example, in an interview in July with the Washington Post, Senator Sanders quoted the price to the government at $30 trillion to $40 trillion over 10 years. 

However, during the September debate in Houston, Senator Sanders did not refute former Vice President Joe Biden’s assertion that Medicare for All would cost over $30 trillion. Instead he added, "Status quo, over 10 years, will be $50 trillion." 

In another interview in October, it appeared Senator Sanders was frustrated by the cost question: “We’re trying to pay for the damn thing” [through, in part, taxes on the top 1% in income in the country]. He later added, “You’re asking me to come up with an exact detailed plan of how every American – how much you’re going to pay more in taxes, how much I’m going to pay. I don’t think I have to do that right now.”

What does Senator Warren say Medicare for All will cost?

Senator Warren does not have a separate plan for Medicare for All, saying instead, "I'm with Bernie on Medicare for All," as she said in the Democratic candidate debate in June. But the two candidates differ on how to pay for the plan, and how much it will cost.

Senator Warren released her plan for funding Medicare for All in November. Her lack of an explanation on how she could deliver it without a tax increase on the middle class, as has been her promise, was a prominent moment in the last Democratic debate.

And here is her number: $26.6 trillion. (I know the headlines said “$20.5 trillion, but that was ignoring the $6.1 trillion she expects the states to chip in to support the program.)

As reported by the New York Times:

Ms. Warren would pay for the new federal spending, $20.5 trillion over 10 years, through a mix of sources, including:

  • Requiring employers to pay the government a similar amount to what they are currently spending on their employees’ health care, totaling $8.8 trillion over a decade.
  • Changing how investment gains are taxed for the top 1% of households, raising $2 trillion, and ramping up her signature wealth tax proposal to be steeper on billionaires, raising another $1 trillion.
  • Creating a tax on financial transactions like stock trades, bringing in $800 billion.
  • Beyond the $20.5 trillion total, she is also counting on states and local governments to contribute an additional $6.1 trillion to help pay for the system. 

Senator Warren explained more details on her plan in November, but for our purposes, here is the crucial line: “We don’t need to raise taxes on the middle class by one penny to finance Medicare for All.”

Senator Warren’s announcement immediately prompted criticism from Republicans as well as fellow Democrats. Saturday Night Live parodied her talking about her plan on the Cold Open the following night.

In the meantime, Senator Sanders retorted that his plan is “far more progressive” than Senator Warren’s. Recognizing his proposal includes raising taxes on the middle class, Senator Sanders predicts those taxes would balance with lower health care costs, while Senator Warren’s plan “might have a ‘very negative impact’ on job creation because of funds it could take from employers.”

(Vox.com has more details on the differences between the Sanders and Warren plans.)

What do economists say?

The Congressional Budget Office (CBO) provides Congress with financial estimates on proposed legislation, including Senator Sanders’ SB 1129. In May, the office released a detailed report on the primary features of establishing Medicare for All in America, explaining that the magnitude “is difficult to predict because the existing evidence is based on previous changes that were much smaller in scale.”

The CBO refrained from providing a specific, detailed cost estimate (as it would usually do), noting “that such a system would be so different from the country’s current situation that any hard estimates would be difficult, even with all the specifics laid out.”

However, economists outside of the government have been willing to derive specific numbers for the cost of Senator Sanders’ plan.

For my money (pun intended), the best guide to the Medicare for All cost estimates from economists (as opposed to politicians) is an interactive article in the New York Times.

I like this resource because it has dynamic, interactive visuals for each estimate, and compares figures from very conservative sources (such as the Mercatus Center) to very liberal ones (such as the Urban Institute).

I encourage you to access the resource yourself, but here are the bottom-line projections for the total costs of Medicare for All from that publication:

  • Gerald Friedman, a professor of economics at the University of Massachusetts, Amherst, whose estimates were frequently cited by the Sanders campaign in 2016: $2.76 trillion
  • Charles Blahous, a senior research strategist at the Mercatus Center at George Mason University, and a former trustee of Medicare and Social Security: $3.46 trillion
  • Analysts at the RAND Corporation, a global policy research group that has estimated the effects of several single-payer health care proposals: $3.24 trillion (plus $506 billion*)
  • Kenneth E. Thorpe, the chairman of the health policy department at Emory University, who helped Vermont estimate the costs of a single-payer proposal there in 2006: $3.20 trillion (plus $706 billion*)
  • Analysts at the Urban Institute, a Washington policy research group that frequently estimates the effects of health policy changes. $3.87 trillion (plus $514 billion*)

(*Some estimates of the Medicare for All price tag are not inclusive of all health care costs.)

What will voters say?

This is, of course, the most important question of all.

We will get the voters’ answer in November.

Sarah Fontenot is both a nurse and an attorney. Today, as a professional speaker, she travels the country, helping people understand how health care is changing and what it means for them as consumers.

Electronic Health Records: The Dream vs. the Reality

(Public Health) Permanent link

Accessing_Info

This story was originally published on Sarah Freymann Fontenot’s blog, Fontenotes.

Last week, I sat with my 95-year-old mom in the exam room with her primary care doctor. I watched Dr. T sit with a small digital tablet on her lap, knee to knee with my mom. 

Throughout the visit, Dr. T’s fingers skittled over the screen as she accessed lab reports, other doctors’ records, mom’s medication list, and any other necessary data. By the end of the visit, without ever leaving her chair, Dr. T had provided mom with a full review of the status of her health, with details about every other physician’s involvement in her care. In the process, she had ordered one medication, changed a dosage on another, ordered homecare and records from a physician mom saw before she moved to Texas. The pharmacy, lab, physician offices, and assisted living center where mom lives had all received orders, faxes, and release forms under Dr. T’s capable fingers on the little tablet.

This, I thought, was the epitome of all we hoped for in a “paperless” medical world in 2004, when I first started teaching about the possibilities and pitfalls of electronic health records (EHRs).

Two days later, an article from Kaiser Health News and Fortune hit my desk: “Death By 1,000 Clicks: Where Electronic Health Records Went Wrong.” It is an extensive, brutal, revealing account of all the ways EHRs are leading to increased costs, inefficiencies, and opportunities for fraud. Lack of interoperability causes critical orders and records to be dropped or missed; the article tells the tale of many people who have been injured or killed by these lapses. For more than 15 years, doctors have complained about the tedium of data entry that takes them away from patient care and is a considerable component of physician burnout.

In summary, the article is a damning report on the status of the drive toward integrating health information technology (HIT) into American medicine.

The contrast between my experience at mom’s side and the world depicted in the article is startling.

Which version is true? Is it possible both are?

Electronic Health Records: The Vision

There is no doubt the paper medical-record system that spanned ancient Greece to the 1990s (and still now) needs to be replaced. Unintelligible handwriting – long the most common joke about physicians – leads to patient injuries. Information in one setting (such as the doctor’s office) is unavailable in another (such as in the emergency department). Paper is inherently at risk of destruction – such as from a spilled cup of coffee, or on a regional level as seen during Hurricane Katrina when tens of thousands of patient records were swept away.

Paper records are cumbersome to write out longhand, and therefore can be incomplete. Documentation is critical for billing government programs or private insurance companies – so those same incomplete records mean many physicians (particularly primary care) leave money on the table because they do not have time to write everything they did on every patient every day.

People often have difficulty accessing a copy of their medical chart, and if their paper file is misfiled (a possibility with even the best record clerks), their information could be lost forever.

The “silo” nature of a paper medical office also makes monitoring physicians for quality of care, licensure violations, and fraudulent billing practices by both state and federal authorities more difficult.

Population-based research (can we cure the common cold?) is impossible in a paper world.

EHRs were going to change all of that.

The Slow Move Toward a Paperless Health Care System

The vision of a “Paperless Health Care System” began in 1972, but it wasn’t until the development of the internet in the 1990s that communication technology became relevant to health care.

Switching from a paper-based medical system has a long history of support from the White House. In 1991 President George H.W. Bush championed a model electronic record, and that same year the Institute of Medicine (IOM) suggested all physicians switch to a computer-based record by 2000. The U.S. Health and Human Services Department proposed the first national standards to protect patients' medical records under the Clinton Administration in 1999, in keeping with the HIPAA Privacy Act passed in 1996. President George W. Bush “pushed” computerized medical records in 2004; Barak Obama “proposed a massive effort to modernize health care by making all health records standardized and electronic” when he was still president-elect.

However, even with the push from Washington, adoption, especially by individual physicians, has been slow.

From the outset, money has been a significant barrier (an electronic record system cost $32,606 per physician 15 years ago). Third parties that may have been willing to help physicians purchase systems could not do so because of anti-kickback law.

Not only was the cost of a new system expensive, the necessary ongoing technical support added to the ballooning overhead for most physician offices. Training costs for all office employees, plus compliance with wave after wave of security concerns and privacy protection regulations, added exponentially to the initial investment.

As this transition was occurring, 30% of physicians were “boomers” who frequently lacked adeptness at a keyboard and felt stymied in their documentation and access to patient information.

From inception, adoption of an electronic record system has been voluntary (and remains so today). Multiple federal initiatives added incentives (and increasingly penalties) for doctors that said “no.” But many, with a conviction mirroring that of the late Charlton Heston, continued to hold their pens in their “cold (ok, alive) hands.”

The first real boost to physician adoption of EHRs came with the HITECH Act (part of the Recovery and Reinvestment Act of 2009), which offered the first financial incentives to physicians and hospitals investing in EHRs. By 2017, 86% of office-based physicians were electronic, and 96% of nonfederal acute care hospitals were on board as well. (It is worth noting that some physicians, admittedly a small minority, are reverting to their old paper records.)

However, as depicted so well in “Death By 1,000 Clicks,” the achievement of near 100% participation in electronic health care records did not alleviate the problems with the technology. In many cases the issues have become more entrenched. The top five the article discussed in detail are:

  1. Continuing patient harm;
  2. Ease of fraudulent billing;
  3. Gaps in interoperability and access;
  4. Doctor burnout; and
  5. Secrecy due to policies that “keep software failures out of public view.”

David Blumenthal, President Obama’s national coordinator for health information technology and an “architect of the EHR Initiative,” reflects the disappointment – the gap from the vision to EHRs in 2019 – in this quote: "EHRs have not fulfilled their potential. I think few would argue they have.”

Why Does Dr. T’s EHR Work for Her?

Looking back on mom’s visit to Dr. T, how can I reconcile that technology-driven excellence in delivering care with all the above?

I believe there are five reasons why Dr. T’s EHR experience avoids so many of the problems with EHRs encountered nationally:

 

  1. Length of use: Dr. T has been on an EHR for more than 15 years. She is “an early adopter.” The standard rule of thumb on EHR adoption is it will take a physician (and the staff in a medical office) two years to fully acclimate to this new model of recordkeeping and communication. Partly Dr. T’s skill can be attributed to her years of experience.
  2. Proper IT support/upkeep: Dr. T works in an office with multiple physicians, who collectively invest in readily available IT support. Many physicians can’t sustain the cost of on-site HIT support, notably the 15% that remain in solo practice.
  3. Mobility (tablet) and eye contact: Another major complaint about EHRs from physicians is they detract from the closeness of the traditional physician/patient relationship; lack of eye contact is the No. 1 patient complaint about EHRs. The small tablet Dr. T referenced from her lap allowed her to sit knee to knee with my mom and establish the connection necessary to leave them both satisfied. However, tablet models of EHRs only became available in the past decade (the University of Chicago was the first hospital to work with tablets on a large scale in November 2010).
  4. Recent technology: As is true with all technology, EHRs modify and advance significantly – and rapidly. In 2012, many EHRs were on their second, even third, iteration. Dr. T represents a physician who has continued to update her technology as advances came on the market. However, the cost of new HIT software will keep many physicians holding onto older technology as long as possible.
  5. Interoperability (at least within her system): As explained in detail in the "Death By 1,000 Clicks," arguably the biggest disappointment about EHRs in 2019 is the continuing lack of interoperability. Globally, that is also true in our hometown where Dr. T practices. Many hospital systems (large) and individual hospitals/medical communities (small) have conquered interoperability within their system. In a rural community where all providers are interwoven, local connections mimic what was imagined on a grand scale. Sitting in her office, Dr. T was connected to all the doctors and labs she was referencing in mom’s care (save the one doctor in Rhode Island from before mom’s move). The vision of EHRs can’t be realized without true interoperability across all barriers local, state, and federal. But in the interim, Dr. T can work happily on a local level.

 

How Do We Address the Problems with Our EHRs?

We are approaching 30 years from the birth of a vision for a national electronic medical recordkeeping system, and we are almost 20 years beyond IOM’s 2000 due date for complete adoption.

Nonetheless, and as extensively detailed in ”Death By 1,000 Clicks,” the problems with EHRs are enormous. But even those authors do not suggest the answer is to return to paper. The problems encountered in the old system are untenable in our technology-driven world.

The only way forward is to continue to improve the electronic record system we have, but to do so with a vigor we have not expended to date. We need a significant increase in federal funding and to draw the best minds in technology to build a fully integrated system. We need significant input from physicians and nurses to create EHRs that are intuitive, efficient, and reliable.

Most of all, we need to make technology companies responsible for true interoperability across the nation – with consequences if they fail.

Unfortunately, we also need more time.

Sarah Fontenot is both a nurse and an attorney. Today, as a professional speaker, she travels the country, helping people understand how health care is changing and what it means for them as consumers. Visit her website.

Texas Neighborhoods Worlds Apart in Life Expectancy

(Public Health) Permanent link

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Sometimes, statistics make you wonder – especially when they don’t add up. 

The Houston-based Episcopal Health Foundation last week issued a report comparing the life expectancy at birth of someone born in each of Texas’ 4,709 census tracts. The data came from the U.S. Small-Area Life Expectancy Estimates Project, which is run by the National Center for Health Statistics. 

“Drive 15 minutes through the biggest counties in Texas and you can go from a neighborhood where people usually live more than 85 years to another where the average person dies before he or she is 65,” Elena Marks, president and CEO of the Episcopal Health Foundation, said in announcing the report. “These numbers should spark important conversations across the state on how we can all take action to address the non-medical, root causes of these dramatic differences in health.” 

Given the growing recognition of the importance of social determinants of health, I thought I’d dive into the report to find some good examples to share with you. I didn’t realize how deep that dive would become. 

After finding, creating, downloading, unzipping, and sorting dozens of Census Bureau files, I’m still scratching my head. Maybe, in general, the levels of poverty, educational attainment, and minority population are good indicators for life expectancy in Texas neighborhoods. But at the extremes? Not so much. 

I started here in Austin, with Travis County, since a map of the neighborhoods here makes some intuitive sense to me. To my surprise, among the county’s 217 census tracts, the one where residents can expect to live the longest is right next to the one with the lowest life expectancy. They’re both south and west of Austin, in and around the community of Oak Hill. 

Astoundingly, there’s a 20.3-year difference in expected length of life between these two areas. The life expectency for children born in census tract 19.15 is just 68.6 years. Just to the west, in census tract 19.08, it’s 88.9 years. Wow! 

I know South Austin pretty well. I’ve lived the past 30 years or so within 5 to 10 miles of both of these neighborhoods. I would have guessed that 19.15 is a little bit worse off than 19.08, but not by much, and these two areas are far from the best or worst – socioeconomically – in Travis County. Right? 

Answering that question required me to spend some time with the U.S. Census Bureau’s American FactFinder project and the searchable data it provides from the 2017 American Community Survey. Once you figure out how to ask for what you want, FactFinder is really quite amazing. 

Here’s what I found about those two Travis County census tracts:

  • In 19.08, where folks can expect to live 88.9 years, the median household income is $110,833, 86% of the population is white, 89.4% have health insurance, and 60.1% have a high school diploma or some college education.
  • In 19.15, where babies can expect to live to be just 68.6 years old, the median household income is $64,599, 81% of the population is white, 78.3% have health insurance, and 63.6% have a high school diploma or some college. 

So, OK, the 19.08 population is generally in better shape than the people in 19.15 – except for education levels. But 26 of Travis County’s census tracts have higher median household income than in 19.08, and 99 tracts have lower income than in 19.15. Those trends hold for the other key variables: one tract is in the top decile or quartile, and the other is in the bottom group. But both are far from the extreme ends. 

So how do these two areas compare to the other 4,707 census tracts in Texas? When it came to life expectancy, they were in the top and bottom 1%, but they were again quite ordinary when I looked at the social determinants of health that supposedly drive length of life. 

More travels through the Census Bureau rabbit holes led me to these rather confounding findings:

  • The neighborhood where babies can expect to live the longest – 89.7 years – is right on the border with Mexico, in Hidalgo County, in the middle of the city of Weslaco.
  • We know that the Rio Grande Valley in general, and Hidalgo County in particular, are some of the poorest places in the country. By those standards, Weslaco is maybe a bit better off. The median annual household income in the neighborhood with the longest life expectancy is $37,257; for the county as a whole, it’s about $400 less. But for all of Texas, median household income in 2017 was more than double that: $70,136.
  • If you sort all of the state’s census tracts by life expectancy from highest to lowest, Hidalgo County again stands out – at the high end. Five of the 25 Texas tracts where babies born live the longest are in impoverished Hidalgo County. Only Harris County, home to Houston, has as many, and that’s likely a statistical anomaly driven by Harris County’s immense size and diversity.
  • At the other end, the lowest life expectancy in Texas falls to babies born in census tract 102, which is smack-dab in the middle of Wichita Falls. That’s a rather poor neighborhood (median household income is $19,406), but certainly not the poorest in the state. In fact, household income is lower in 51 other census tracts.
  • By the way, the poorest census tract in the entire state? It’s nearly across the street from where I’m sitting now and encompasses The University of Texas at Austin campus. The Census Bureau says median household income there is just $8,975 a year. And the life expectancy for a baby born in the shadow of the UT Tower? Not listed. 

If you’ve made it this far with me, I owe you some concluding remarks. 

First, the Census Bureau has amazingly detailed amounts of data and statistics about Americans, broken down into some of the tiniest slices, and it’s really pretty easy to navigate. 

Second, statistical analysis of population groups may be well suited to looking at data about groups of groups – e.g., how do income or educational level compare with life expectency for each 10% slice of the state’s census tracts? Looking at the individual neighborhoods at the extreme ends of this list leads you to … well, to not much at all other than a handful of large Census Bureau spreadsheets. 

Finally, if you’re going to put a statistical report through a does-this-make-sense test, start with some examples that mesh with your personal experience and intuitive knowledge. (If life expectancy in Travis County had shown up as lowest in parts of East Austin and highest in Northwest Hills – which is what I would have expected – I probably would have stopped right there. And maybe you wish I had.)

Retiring the R-Word: The Right Thing to Do

(Public Health) Permanent link

 Words_Matter

Quiz time. Which of the following words or phrases are now officially in the American Medical Association’s “not-preferred” category? (Apologies ahead of time if this Type-K question elicits stormy med school flashbacks among physicians of a certain age.) 

  1. Retarded
  2. Junkie
  3. Aid in Dying
  4. Schizophrenics 
  1. A only
  2. both A and C
  3. both B and D
  4. A, B, and C
  5. All of the Above 

The correct answer, obvious to those of you who know the difference between “person-first language” and “person-centered language” is No. 4. The AMA House of Delegates last month adopted policy that would put the first three phrases on the verboten list for physicians. When it comes to “schizophrenics” – as opposed to “people with schizophrenia” – the answer is, it depends. Typical Type K question, eh? 

Kudos to the delegates for recognizing that words, especially in the mouths and pens of powerful people like physicians, really do matter. 

Good words, the right words, spoken and written, inspire, inform, enlighten, uplift. The wrong words confuse, hurt, intimidate, discourage. 

Take “mentally retarded.” Clinically, it may be an accurate but overly broad term to describe a person with an intellectual disability. That’s yesterday. The R-word is toast. Parents should no longer have to hear a doctor say, “Your child is mentally retarded.” 

Some argue that opposition to that phrase is just part of parental delusion over the intellectual shortcomings of their son or daughter. That may be some of it. But when a word becomes a generic putdown and a nasty schoolyard taunt, it’s time to retire it from a physician’s lexicon. 

I’m proud of the Texas Medical Association’s Medical Student Section, who got the TMA House of Delegates to recommend that physicians use the term “intellectual disability” instead of “mental retardation” in clinical settings. Then they worked with the Texas Delegation to the AMA to win approval on a national scale. 

Briefly, on some of the other word-choice decisions the AMA house made:

  • Stigmatizing terminology such as “abuse” and “junkie” in the language of addiction, the delegates agreed, interferes with good patient care and puts extra potholes in the road to recovery. U.S. Surgeon General Jerome Adams, MD, speaking at the AMA meeting, said Americans should be “wrapping our arms around” people with substance use problems, not demeaning them.
  • Supporters of “aid in dying” lost out as part of a decision, finally, that upholds AMA’s ethical guidelines against physician-assisted suicide. “Despite its negative connotations, the term ‘physician assisted suicide’ describes the practice with the greatest precision,” the AMA Council on Ethical and Judicial Affairs wrote. “Most importantly, it clearly distinguishes the practice from euthanasia. The terms ‘aid in dying” or ‘death with dignity’ could be used to describe either euthanasia or palliative/hospice care at the end of life, and this degree of ambiguity is unacceptable for providing ethical guidance.”
  • The delegates also put the kibosh on such titles as “nurse anesthesiologist” and “podiatric physician.” That’s an important tool in our fight against scope-of-practice creep. And, of course, a physician is not a provider. 

Finally, there’s the question of labeling people by their disease or disability. I’m hoping “the gall bladder in room 418” is something you no longer hear in a hospital ward. The concept of person-first language has been around since the early ’80s. By saying, “Mrs. Smith is a person with diabetes” rather than “… is a diabetic,” you acknowledge that there’s more to her than that particular diagnosis. She’s also a carpenter and a mom and a soccer coach, and maybe even schizophrenic. Person-first language, which the AMA uses and is part of TMA’s official style guide, also does away with phrases like “cancer victim” and “wheelchair bound.” 

The problem is, some groups of people with disabilities – like the deaf – and some individuals, don’t like person-first language when it refers to them. They identify with their condition and want that word to come first. And so, we’ve come to person-centered language, which “focuses on each person’s individual preferences rather than using generalizing terms for a group when referring to a disease state or disability.” That’s the approach the AMA house adopted in June. 

So back to the quiz. “The schizophrenics” might be a phrase you avoid. Or not.

Photo: Taro Taylor

Beyond the Slogan “Medicare for All”

(Legislature, Public Health, U.S. Congress) Permanent link

US capitol
 This is an excerpt of a post originally published on Sarah Fontenot’s website. The opinions expressed are Ms. Fontenot’s. Texas Medicine Today is sharing them to further the conversation on the future of health care reform.

Medicare For All has become a rallying cry for many (if not most) Democrats, but it was independent Sen. Bernie Sanders of Vermont who started the movement in the 2016 presidential election.

Senator Sanders introduced his Medicare for All Bill in September 2017 with 13 Senate co-sponsors, including five who have announced their candidacy for president in 2020.

The public is embracing the concept as well. Polling is mixed, but as high as 70 percent of Americans now support Medicare for All, including 85 percent of Democrats and 52 percent of Republicans, according to a recent Reuters survey.

However, as popular as the concept is, the details are lost in the simple slogan of “Medicare for All.”

To further confuse the issue, the specifics of any Medicare for All plan may differ between advocates, with “Single-Payer,” “Public Option,” and “Universal Health Care” all added into the mix to further confuse what any politician or pundit believes.

“Voters have become casualties as candidates toss around these catchphrases – sometimes vaguely and inaccurately,” Kaiser Health News wrote in November.

Health care was the top issue in the midterm elections, and is expected to be a dominant issue in 2020 as well. The potential of an overhaul of our health care delivery system is far too complicated (and weighty) to capture in a jingle.

I will take four options all affiliated with Medicare for All and provide a bit of detail on each.

Option No. 1: Senator Sanders’ plan

The most common interpretation of Medicare for All is the option espoused by Senator Sanders. Although he did not invent the idea of a single-payer health care system, he made the concept a trend.*

Senator Sanders’ plan dispenses with private insurance and creates a government-run health coverage plan (like Medicare) for everyone. There would be no copays or deductibles, and everyone would have access to inpatient and outpatient care for needs as diverse as substance-abuse treatment and long-term care. Prescription drugs, diagnostic tests, and vision care will be obtainable to all.

Unlike a socialist health care system (for example the United Kingdom), in this plan doctors, hospitals and other health care providers will remain independent – the government will pay for care but not provide it.

Paying for this version of Medicare For All is controversial and has incited debate. It will at least be paid for partially by multiple new taxes in the bill, such as a tax on households earning more than $28,800 (escalating for those with annual earnings over $250,000), as well as taxes on capital gains and dividends, and a new “Responsible Estate Tax” on Americans inheriting more than $3.5 million. The tax on employers under Senator Sanders’ bill is 6.2 percent of their employees’ incomes.

As helpful as those revenues may be, the biggest argument against Senator Sanders’ plan is the predicted cost. Senator Sanders estimates a $1.38 trillion per year expenditure; other calculations range from $2.4 trillion to $2.8 trillion – and a report last July by the Mercatus Center at George Mason University placed the cost at a staggering $3.26 trillion annually.

Cost is a significant barrier, but there are other reasons not everyone is endorsing Senator Sanders’ plan. A federal government takeover of health care raises questions about federalism, and there are a lot of people that like the insurance they currently have – such as people with generous employment benefits. The eradication of the health insurance industry would hit small-town insurance brokers on “Main Street, Everywhere” and devastate insurance centers like Hartford, Conn. Finally, this plan would destroy much of the structure created by the Affordable Care Act (ACA), when support for the law is at an all-time high.

*Although I am focusing on the Bernie Sanders’ Bill, in March an even more ambitious plan for Medicare For All – HR 676 – was introduced by 124 progressive Democratic representatives in the House. The bill makes health insurance illegal as well as any for-profit health institution.

Option No. 2: The Public Option

Other lawmakers who endorse Medicare for All want the return of the Public Option. (Some of these people are arguing for both plans simultaneously.)

I wrote about the Public Option in detail in Fontenotes No. 25. This version of “Medicare for All” would not extend government-backed health care coverage to everyone but would make a Medicare-like product available for purchase on the ACA (also called “Exchanges”). Presumably, this would help to control costs within the pool of available policies and could help bring insurance costs down across the industry.

This idea – individuals choosing to buy in to Medicare – was born (and died) in California in 2001. Presidential candidate John Edwards revived the idea in 2008; candidates Barack Obama and Hilary Clinton adopted similar proposals in their campaigns that year.

As President Obama and Congress moved forward writing the ACA, the Public Option remained part of the design, but increasingly it became controversial as private insurance companies argued they could not compete in the market with a government-backed alternative. Democrats ultimately killed the public option, with Sen. Joe Lieberman (D-Conn.) delivering the final blow. (Why? Hint: Where is the Insurance Capital of America?).

Hillary Clinton raised the public option from the ashes as part of her 2016 Presidential Platform.

Now, as we face the presidential election cycle of 2020 the public option has resurfaced again, but under the rubric Medicare for All.

The persistence of this idea was predicted in 2010; that tenacity may point to its value.

The Public Option does not require destroying the private insurance industry, people can keep the insurance they like, and the structure of our providers (profit and not-for-profit) remain the same – there is no immediate government takeover of health care.

The only downfall may be the threat the Public Option poses to the private insurance industry, but that would seem to prove the point. Could the Public Option ultimately lead to a single-payer government-run health care system? Yes, but over time and only if the insurance industry fails to adapt.

Option No. 3: Expanding Medicare eligibility

There are some in Washington with a much smaller expansion of Medicare in mind – simply lowering the age of eligibility to 50 (or 55). Private insurance companies charge more to cover those who fall in the 50 to 64 age range (known as the “age tax”).

Arguments for allowing people as young as 50 into Medicare include the prevention of health conditions that could cost the government more in the long run if untreated until 65, and the business opportunity for private insurance companies offering Medicare Advantage plans to this segment of the population.

The reason to not expand Medicare is, of course, the cost to American taxpayers.

Option No. 4: Leave it to the states

And as another wrinkle, some Democrats want Medicare for All to be a choice each state makes – state-run single-payer plans.

How do any of these options compare with what voters envision?

It is possible that none of the options I described match the expectation of Americans marching under the Medicare for All banner.

Based on promises from politicians, talking heads, and 30-second sound-bites, the vision of many Americans appears to be a health care system even more glorious than any under consideration in Washington. The prospect of obtaining all the care they need, from any provider, without permission from an insurance company, and at no cost is a clarion call for voters.

Democratic politicians, particularly those with their eyes on the presidency, continue to stoke those dreams without addressing the realities: the costs, payoffs, and pitfalls of their plans. One progressive leader described the “pleasant ambiguity” of Medicare for All, which creates “a broad umbrella where any candidate can embrace some version of it.”

American voters deserve better. We need to demand facts, numbers, and clarity as we head into this heated political season. The first question we should ask is “What do you mean by Medicare for All?”