More Prescriptions Go Unfilled, is Uncle Sam “Penny Wise?”

The New York Times reports that “One in seven Americans under age 65 went without prescribed medicines in 2007″ and that “that figure is up substantially since 2003, when one in 10 people under 65 went without a prescription drug because they couldn’t afford it, according to the Center for Studying Health System Change in Washington, D.C.”

The Times also reported that Laurie E. Felland, a senior health researcher at the center and lead author of the study, noted that because these numbers are from 2007, they may well be higher now due to the recession.

“The people who were least able to afford medicine were often those who needed it most, Ms. Felland said: uninsured, working-age adults suffering from at least one chronic medical condition. Almost two-thirds of them in the survey said they had gone without filling a prescription.”

The affect among those with chronic conditions is particularly disturbing in light of the data on the relative expense of treating chronic conditions, and the additional expense that neglect in treatment can cause. The Department of Health and Human Services (HHS) has reported that

Chronic Conditions Contribute to Higher Health Care Costs

Twenty-five percent of the U.S. community population were reported to have one or more of five major chronic conditions: ·

• Mood disorders
• Diabetes
• Heart disease
• Asthma
• Hypertension

Spending to treat these five conditions alone amounted to $62.3 billion in 1996. Moreover, people with chronic conditions tend to have other conditions and illnesses. , according to 1996 MEPS data. On an individual level, treatment for the average patient with asthma was $663 per year in 1996, but when the full cost of care for asthma and other coexistent illnesses is taken into account, the average cost was $2,779.

When the other illnesses are added in, total expenses for people with these five major chronic conditions rise to $270 billion, or 49 percent of total health care costs

Expenses for people with one chronic condition were twice as great as for those without any chronic conditions. Spending for those with five or more chronic conditions was about 14 times greater than spending for those without any chronic conditions. Persons with five or more conditions also have high hospital expenditures. In New York State during 2002, of the 1.3 million different persons admitted to the hospital, the 27 percent with five or more chronic conditions accounted for 47 percent of all inpatient costs. (emphasis added, footnotes omitted).
Perhaps as we consider the large number of persons with chronic conditions who are not taking prescribed medications, we should also consider a recent five-year retrospective study of almost 5 million California residents which found that “People who have spotty Medicaid coverage are more than three times likelier than those who maintain continuous coverage to be hospitalized for an illness that could have been managed outside the hospital with doctors’ visits and medication.”

Hospitalization is expensive.

Also, as we noted in a recent post, the Kaiser Foundation has shown that many seniors , who account for a great deal of the health expense in this country (but are not included in the the Center for Studying Health System Change report), also cease or diminish the use of their medications as a result of “the donut hole” in Medicare prescription drug coverage-a gap in coverage which leaves many seniors “on their own” for payments of thousands of dollars per year.

FDA Scientists Say FDA is “Fundamentally [More] Broken”

Just this last week we posted that a group of nine FDA scientists from the Center for Devices and Radiological Health– which is responsible for medical devices ranging from stents and breast implants to MRIs and other imaging machinery-authored a letter which asserted that “The FDA is “fundamentally broken” and requires reforms.”

We wrote:

With what A.P refers to as an “unusually blunt letter,” the group of federal scientists contacted “John Podesta, head of the transition team, as well as former Senate Majority Leader and HHS Secretary-designate Tom Daschle (D-S.D.); Baltimore Health Commissioner Joshua Sharfstein, who has led a team assembled by Obama to assess FDA; Senate Health, Education, Labor and Pensions Committee Chair Edward Kennedy (D-Mass.); and eight other lawmakers,” according to Kaiser.

In that post, we also called attention to the contention of the scientists that “Managers with incompatible, discordant and irrelevant scientific and clinical expertise in devices…have ignored serious safety and effectiveness concerns of FDA experts.”

Noting that

To say that these managers had “incompatible” and “discordant” scientific and clinical expertise in devices is one thing. One expects a certain degree of disagreement within the scientific community-and to some extent, one reasonably relies upon the crucible of such “discordant” viewpoints in scientific debate to provide tested answers to real problems. But the scientists who wrote this letter added one more word: “irrelevant.” And in this context, that leaves us uncomfortably with the knowledge that in the estimation of these nine scientists, the determining force in these particular scientific inquiries-the managers-lack relevant scientific expertise in the pertinent subject matter-medical devices.

Apparently, the “expertise” at issue in the approval of a breast cancer imaging device is alleged to go somewhat beyond the scientific.

The New York Times reports that it has obtained various FDA emails and internal documents which underlie the scientists’ complaint and are the present subject of both an FDA internal inquiry and a congressional investigation. The emails and documents are said to provide details of the investigations which had not previously been made public.

The New York Times reports that

An official at the Food and Drug Administration overruled front-line agency scientists and approved the sale of an imaging device for breast cancer after receiving a phone call from a Connecticut congressman, according to internal agency documents.

The congressman is Republican Chris Shay, who lost re-election in November. A component of the imaging device was produced by a Fujifilm Medical Systems, which “is based in Stamford, Conn., the heart of Mr. Shays’s former district,” according to the NY Times.

The article also states that

The legislator’s call and its effect on what is supposed to be a science-based approval process is only one of many of accusations in a trove of documents regarding disputes within the agency’s office of device evaluation.
Read more here.

Unemployment, Uninsured and Medicaid Rolls Up

The New York Times reports that
“The nation lost 524,000 jobs in December…. The unemployment rate, meanwhile, jumped to a 16-year-high of 7.2 percent, the Bureau of Labor Statistics reported on Friday.”

This is up from 6.7% in November, 2008; up from 4.7% in November 2007.

Last week, in a post about prognostications for health care in 2009 (”Ringing in a New Year in Health Care, For Whom the Bell Tolls?“), we quoted the following from Jane Sarosahn Kahn in The Health Care Blog:

Keep in mind the Kaiser Family Foundation’s metric on unemployment: an increase of 1% unemployment leads to 1.1 million uninsured, and 1 million more people added to Medicaid. This was the math that worked in 2007-8. The metric will probably change in 2009 as Governors struggle to balance budgets while providing medical services, education, and safe streets to citizens. The National Governors Association, and the individual state heads, have all warned that Governors will inevitably cut services in 2009 and into 2010 if tax receipts continue to decline.
In response, we stated:

According the U.S. Bureau of Labor Statistics, in November of 2007 the unemployment rate was 4.7%. For November of 2008 it was 6.7%. Regardless of the metric, the consequent health insurance math is less than reassuring.

Regardless of its lack of reassurance, perhaps the math should be done.

Using the Kaiser metric, understated as it may be for 2008-9, the half per cent increase in unemployment in December (7.2% from 6.7% in November) is equal to:

• 550,000 more people without health insurance
• 500,000 more people on Medicaid

This is in addition to a two per cent raise in unemployment from November 2007 (4.7%) to November 2008 (6.7%).
That 2% equals:

• 2,200,000 more people without health insurance
• 2,000,000 more people on Medicaid

Total from November 2007 (4.7% unemployment) to December 2008 (7.2% unemployment) equals:

• 2,750,000 more people without health insurance
• 2,500,000 more people on Medicaid

COBRA Costs Prohibitive for Many Unemployed

The Los Angeles Times has run a noteworthy AP article regarding the often prohibitive cost of COBRA coverage. COBRA is the program which enables unemployed Americans to continue their health insurance by purchasing it through their former employers. The national unemployment rate reached 7.2% in December. As noted here just yesterday, the Kaiser Foundation has devised a “metric on unemployment: an increase of 1% unemployment leads to 1.1 million uninsured, and 1 million more people added to Medicaid.” That metric, however, is thought by some to be somewhat understated for a current analysis as it does not take into account the various state cuts to Medicaid already enacted since the metric was designed– nor does it take into account those further cuts which are anticipated for the new year.

Individuals
The L.A. Times, based upon a recently released report by Families USA, reports that “Newly unemployed Americans would have to spend an average of about 30% of their jobless benefits to pay for health insurance through their former employer.”

That number, however, seems to have been somewhat skewed by the reporting of one state, as the article goes on to say that “In all those states except South Carolina workers would have to spend more than 40% of their unemployment insurance on COBRA premiums for individual coverage.”

Families
The LA Times also reports that if individuals “want coverage for their families, the report by Families USA says, it will take more than 80% of their unemployment check.”

Investors Business Daily reports that the Families USA study found:

“The average monthly Cobra premium for family coverage, $1,069, consumes 84% of the average monthly unemployment check, which is $1,287″
and that

In nine states — Alabama, Alaska, Arizona, Delaware, Florida, Louisiana, Mississippi, South Carolina, and West Virginia — average premiums for family coverage under Cobra equal or exceed total income from unemployment insurance….

Conclusions
The Health Law Prof Blog, which quoted from a similar article in the Washington Post, reported that Ron Pollack, executive director of Families USA, stated that “COBRA health coverage is great in theory and lousy in reality,”

and that

Pollack and House Speaker Nancy Pelosi (D-Calif.) said the new report highlights the need to include health insurance subsidies in the economic recovery package being crafted this month. “Without that,” Pelosi spokesman Brendan Daly said, “they [the unemployed] simply cannot afford to pay for temporary continuation of their health insurance.”

But Nina Owcharenko, a health policy analyst at the conservative Heritage Foundation, said it would be wiser to offer unemployed Americans a broad range of health insurance options, including high-deductible private policies or new state-based programs. Given how expensive COBRA is, she said, alternatives would “save the individual money and save taxpayer money.”

FDA Scientists Say that FDA is “Fundamentally Broken”

“The FDA is “fundamentally broken” and requires reforms, according to a letter sent to the transition team of President-elect Barack Obama by nine agency scientists, Dow Jones reports.” (Kaiser.org 1/8/08).

With what A.P refers to as an “unusually blunt letter,” the group of federal scientists contacted “John Podesta, head of the transition team, as well as former Senate Majority Leader and HHS Secretary-designate Tom Daschle (D-S.D.); Baltimore Health Commissioner Joshua Sharfstein, who has led a team assembled by Obama to assess FDA; Senate Health, Education, Labor and Pensions Committee Chair Edward Kennedy (D-Mass.); and eight other lawmakers,” according to Kaiser.

A.P reports that the letter was written on FDA Center for Devices and Radiological Health letterhead; “the center is responsible for medical devices ranging from stents and breast implants to MRIs and other imaging machinery.”

The letter reads in part as follows:

The purpose of this letter is to inform you that the scientific review process for medical devices at the FDA has been corrupted and distorted by current FDA managers, thereby placing the American people at risk. Managers with incompatible, discordant and irrelevant scientific and clinical expertise in devices…have ignored serious safety and effectiveness concerns of FDA experts. Managers have ordered, intimidated and coerced FDA experts to modify scientific evaluations, conclusions and recommendations in violation of the laws, rules and regulations, and to accept clinical and technical data that is not scientifically valid. (emphasis added)

To say that these managers had “incompatible” and “discordant” scientific and clinical expertise in devices is one thing. One expects a certain degree of disagreement within the scientific community-and to some extent, one reasonably relies upon the crucible of such “discordant” viewpoints in scientific debate to provide tested answers to real problems. But the scientists who wrote this letter added one more word: “irrelevant.” And in this context, that leaves us uncomfortably with the knowledge that in the estimation of these nine scientists, the determining force in these particular scientific inquiries-the managers-lack relevant scientific expertise in the pertinent subject matter-medical devices.

The Wall Street Journal Health Blog reports that earlier today, HHS Secretary-designate Tom Daschle appeared at “a friendly hearing before the Senate’s Health, Education, Labor and Pensions Committee.” Daschle, who was one of the recipients of the FDA scientists’ letter, did not mention it in his prepared speech. Daschle did, however, state the following:

Unfortunately, there is growing concern that the FDA may have lost the confidence of the public and Congress - much to our detriment. When Americans are nervous about eating spinach or tomatoes or cantaloupes, that’s not good for our health and it is terrible for our farmers. When nearly two-thirds of Americans do not trust the FDA’s ability to ensure the safety and effectiveness of pharmaceuticals, the result is Americans may hesitate to take important medications that protect their health. This is unacceptable.

California Foundations Advocate for Health Care Reform

The Los Angeles Times reports that “Nonprofits have dropped their usual detachment to crusade for healthcare reform in California, opening Sacramento offices staffed by former aides to lawmakers.” Apparently not satisfied with the results garnered through “years of financing studies and demonstration projects,” “California philanthropic foundations and think tanks are shedding their traditionally detached stances to crusade for healthcare reform in the state Capitol and in Congress.”

To lead this crusade, a number of foundations have hired high profile figures to advocate their ideas to policy makers, and, in some instances, foundations have promoted those ideas to the wider public as well. In defense of the practices, the LA Times reports that “Foundation leaders emphasize they have no interest in direct lobbying and that they promote ideas that are based in evidence, not ideology.”

Paul Brest, “president of the William and Flora Hewlett Foundation in Menlo Park and author of a book on philanthropic strategies” is quoted as saying: “What I’ve seen is foundations moving from thinking all we needed to do is support good research in the field and the rest will happen to realizing that unless we are going to support organizations to take the research and try to turn it into policy, then the research is going to sit in the bottom of a pile somewhere.”

Beware the IRS
The article also points out, however, that “Advocacy is risky for foundations, since most are categorized by the IRS as 501(c) nonprofits, which restricts them from direct lobbying or participation in partisan politics.” The experts of “The New America Foundation, a Washington, D.C.-based think tank underwritten by foundations,” are said to have “so much contact with lawmakers that the foundation requires them to keep track of their hours to ensure they do not exceed lobbying limits set on nonprofits.”

Despite the risks, the LA Times reports that “With billions of dollars at their disposal, the foundations are seeking to become bigger players.” Read full story here.

CMS Physician Quality Reporting Initiative, Experience

The American Association of Family Physicians (AAFP) has authored a somewhat disturbing article on the recent Center for Medicare and Medicaid Services (CMS) report “that examines participation data from its 2007 Physicians Quality Reporting Initiative, or PQRI, and also addresses physicians’ frustrations with the program.”

According to the CMS report, Physician Quality Reporting Initiative, 2007 Reporting Experience

The Centers for Medicare & Medicaid Services (CMS) is working to transform the Medicare program from a passive payer into an active purchaser of high-quality care by linking payment to the value of care provided. Initially, CMS developed a voluntary quality reporting program in 2005, the Physician Voluntary Reporting Program (PVRP), to encourage physicians to report information on the quality of care they were delivering. As authorized by Congress, the PQRI builds on the PVRP by linking payments to reporting quality information. The PQRI is an important first step toward establishing a value-based purchasing program for physicians.

The Tax Relief and Health Care Act of 2006 (TRHCA), enacted on December 20, 2006, required the Secretary to implement less than seven months later by the start of the first reporting period on July 1, 2007, a system for the reporting of data on quality measures. CMS termed this system “PQRI.” This implementation schedule required rapid finalization of the detailed specifications for 74 clinical quality measures (covering hundreds of procedure and diagnosis codes), the development of an expanded infrastructure to support the reporting system and extensive outreach to more than 700,000 professionals about the requirements they needed to follow to submit data on quality measures.
Physicians who successfully submitted the quality information were eligible for an incentive payment capped at 1.5% “of total allowed charges for covered Medicare Physician Fee Schedule services.”

Not quite 16% of eligible physicians participated; of those who did participate, “Of the more than 14 million quality data codes submitted, 51.6 percent were submitted correctly; 48.4 percent of submissions were invalid.”

AAFP offers this summary of the Submission Data

• According to the new CMS report, the agency paid eligible providers slightly more than $36 million in incentive payments for the 2007 PQRI reporting period. The average bonus paid to individual providers was $635. The average bonus paid to practice groups was $4,700.
  Of the more than 14 million quality data codes submitted, 51.6 percent were submitted correctly; 48.4 percent of submissions were invalid.
  CMS says that nearly 16 percent of all eligible providers and groups submitted at least one quality data code during the 2007 PQRI reporting period. Of those 109,359 providers or groups,
  92.5 percent submitted at least one quality data code that was valid;
  64 percent correctly reported quality data on 80 percent of eligible cases for at least one measure;
  52 percent earned an incentive payment by successfully reporting data on one to three applicable measures for 80 percent of applicable cases; and
  1 percent were subject to the PQRI incentive cap.

In the report’s executive summary, CMS says it is “committed to a successful PQRI program,” and promises to “reduce or eliminate” the issues identified in the report. As such, among other modifications, CMS warrants to revise the analytics, redesign the physician feedback report system– registration to which was “both cumbersome and time consuming,” and increase educational outreach. In addition, “CMS has established new reporting options making it easier for EPs to participate in PQRI for 2008.”

AAFP reports that “Earlier this month AAFP Board Chair Jim King, M.D., of Selmer, Tenn., blasted CMS for its bungling of the distribution of PQRI bonus payments and told CMS Acting Administrator Kerry Weems that if problems weren’t addressed, physicians might refuse to participate in the program.”

Read the full AAFP article here.

Ringing in a New Year in Health Care, For Whom the Bell Tolls?

Jane Sarasohn Kahn of The Health Care Blog has offered up some interesting, if not dismal, prognostications for 2009. Although issuing the caveat that “there are too many uncertainties that preclude us from doing a straight-line forecast for 2009, especially in health and health care,” she offers some insights based upon the present macroeconomic backdrop. They are worth noting, and a few may be found here below.

She asks us to take heed of the following:

Keep in mind the Kaiser Family Foundation’s metric on unemployment: an increase of 1% unemployment leads to 1.1 million uninsured, and 1 million more people added to Medicaid. This was the math that worked in 2007-8. The metric will probably change in 2009 as Governors struggle to balance budgets while providing medical services, education, and safe streets to citizens. The National Governors Association, and the individual state heads, have all warned that Governors will inevitably cut services in 2009 and into 2010 if tax receipts continue to decline.

According the U.S. Bureau of Labor Statistics, in November of 2007 the unemployment rate was 4.7%. For November of 2008 it was 6.7%. Regardless of the metric, the consequent health insurance math is less than reassuring.

As noted by Professor Frank Pasquale on this blog last week, the “Governors’ struggle” has already commenced. The Washington Post having reported that regarding Medicaid

“Already, 19 states — including Maryland and Virginia — and the District of Columbia have lowered payments to hospitals and nursing homes, eliminated coverage for some treatments, and forced some recipients out of the insurance program completely.”

As such, this line of forecast may be a bit “straighter” than others. The cuts and further prospective cuts in state funding are, as Frank Pasquale noted, “one more sad example of the procyclical nature of federalism here–states have less tax revenue during recessions, when need is greatest. No one should be surprised if more and more of the jobless uninsured, denied even basic dental care due to such cuts, fall into a “death spiral” of unemployment, disfiguring ailments, and a tendency to be underemployed due to such ailments.”

Ms. Sarosahn Kahn also makes a very important point about medical infrastructure:

“Hospitals’ credit woes will continue to constrain providers’ operations. Reports from all of the major credit rating agencies, including Standard & Poors, Fitch, Best and Moody’s, have all negatively opined about the state of hospital finance for 2009. Fitch and Moody’s downgraded the nonprofit hospital sector to negative. The American Hospital Association’s survey in November 2008 found that 1 in 2 hospitals was considering or actually postponing capital expenditures. This would include renovations, increasing capacity, and other capital programs. The cost of borrowing money has made it nigh impossible to find hospital financing for improvements.”

This too would seem to qualify for “straight line” prognostication. Hospitals are closing, layoffs have ensued, and as we and A.P. noted earlier this week, industry consultants predict “More closings and mergers are on the way.”

The A.P further noted that

Hospitals, which employ 5 million people, are reporting that donations and investment returns are down, patient visits are flat and profitable diagnostic procedures and elective surgeries are declining as people with inadequate insurance delay care. But those patients are turning up later at ERs, seriously ill…
Ms. Kahn also points out that among the ill, prescriptions are not being filled.

Manhattan Research found that 40 million Americans didn’t fill prescriptions due to cost constraints by the fourth quarter of 2008. This number could increase in 2009, leading to worsening health outcomes. In particular, scripts for mental health conditions weren’t filled as frequently as Rx’s for other types of conditions.

All in all, the equation itself would seem to not require Daniel; if left unchecked, only the particulars of the miserable sum remain unknown.

There are a few bright spots in this analysis, however, Ms. Kahn points out that

“Clinical effectiveness is becoming part of the larger analysis for spending scarce resources. There’s no better time than a recession to bring this concept into play on a mass scale.
She’s right, when times are tough, people have a tendency to want specifics when they get the bill– and to know that what they paid for worked.”

And there is this larger point,

“Policymakers and influentials have come to understand that health is integrated into the larger macroeconomy. It is a welcome sign that those who will be at the helm of the new economy on Team Obama recognize the intimate relationship between health and the American economy. Peter Orszag, just out of the Congressional Budget Office and soon to lead the Office of Management and Budget, has spoken publicly about health care costs and the GDP over the past eighteen months. His sober and smart observations give me comfort insofar as he will be playing a key role in reshaping the broken U.S. Economy.”

As we ring in the New Year and begin to contemplate the inter-relatedness of the macro-economy and commence what may well be the “fall into a ‘death spiral’ of unemployment, disfiguring ailments, and a tendency to be underemployed due to such ailments,” it might be worth a moment to consider the often sudden and unexpected nature of both job loss and catastrophic illness– and John Donne.

The bell which John Donne refers to in his most famous quote is “the passing bell,” tolled by the Church for those who are dying. As Donne lay very ill in his bed and heard this bell being tolled, he wondered if he were, in fact, sicker than he thought. And that perhaps that bell was being rung for him personally. He came to realize, however, that whether that was the case or not was largely irrelevant because

“No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend’s or of thine own were. Any man’s death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee.“

Model Wanted

The NY Times reports that according to Dr. Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and an associate professor at the Harvard School of Public Health, “there’s a drastic decline in the number of geriatricians - and just 300 new ones are being trained each year - yet the number of people over 65 will double in the next 20 years. Those who work in geriatric care are among the worst paid in the health care system.”

That last statement, as shown in a recent post regarding physician compensation, is backed up by numbers. According to the American Group Medical Association (AMGA) the median compensation for a geriatrician is $179,344. The median compensation for a podiatrist is $180,080. These AMGA numbers have been approved by the Center for Medicare and Medicaid Services (CMS) for use in CMS related calculations.

Dr. Gawande “and others see a pressing need for new approaches to keep aging patients as healthy as possible and living independently as long as possible.” The Times reports that “Dr. Chad Boult, a geriatrician at Johns Hopkins School of Public Health in Baltimore, says the goal should be care that is well coordinated, and patients and families who are involved in and educated about the care plan.”

To that end, Dr. Boult is participating in the testing of a “team approach” which is somewhat reminiscent of the subject of a recent post, Alaska’s Southcentral Foundation’s “medical home” approach. Southcentral’s “comprehensive” health care strategy has shown some promising results. The Times reports that

Dr. Boult is involved in testing a team approach, in which nurses trained in geriatrics are helping physicians in the Baltimore-Washington area provide coordinated care for 50 or 60 of their highest-risk older patients. The nurses go to patients’ homes, develop comprehensive care plans, help the patients in self-monitoring, help them overcome obstacles to self-care and connect patients and their families to community agencies.

According to geriatrics experts, social workers trained in the problems of the elderly can also participate by performing home assessments, for example, to prevent falls and costly, disabling fractures. They can help overcome barriers to good nutrition, and they can help make the community connections for assistance with the activities of daily living, like shopping.
Dr. Boult said that “The Baltimore team project has already demonstrated an improvement in the quality of care that ailing elderly patients receive, and by keeping patients out of the hospital, he expects it will save money for insurers like Medicare.

The NYTimes also reports, however, that the current fee for services compensation scheme has not yet been structured so as to provide monetary incentives for such prophylactic care. The Times states: “While current insurance systems pay many thousands of dollars for hospital-based care, they cover only a fraction of the far less expensive care delivered by doctors and nurses that can keep patients out of the hospital,” and that experts say “a new model of care is needed.”
Read full article here.

Physician Compensation II

Yesterday’s post displayed recent Bureau of Labor Statistic figures concerning physician compensation, and offered a link to recent median physician compensation data approved for use by Centers for Medicare and Medicaid Services (CMS) for calculations regarding direct graduate medical education under 42 CFR 413.78(f). The producer of this data, AMGA, also offers an interactive physician compensation survey which shows “average” and “starting” compensation for various specialties. A click on the arrow underneath “average” will sort from lowest to highest.

Here below is a list of a few of the CMS approved median physician compensation figures for a number of different specialties. The numbers are taken from the 2008 report.

The median compensation for a practitioner:

• Pediatric & Adolescent, Internal 161,444
• Pediatric & Adolescent, Infect. Disease 174,154
• Family Medicine, w/out Obstetrics 176,280
• Family Med., w/out Obst., Branch* 190,182
• Geriatrics 179,344
• Podiatry: 180,080
• Transplant Surgery, Kidney 368,750
• Dermatology, Branch* 301,111
• Dermatology, Mohs 423,848
• Not neural, Non-Interventionist, Radiology 420,858
• Mammography 540,028
• Orthopedic Surgery, Spine 611,670

*Branch is defined by AMGA as: These specialties have the same basic definition as the main specialty. These physicians located in small satellite or branch offices at least five miles from the main campus. The branch office practices primarily as its own separate entity, and often has different compensation and/or performance expectations than its main campus colleagues, there would be no teaching responsibilities at these locations.

With these numbers, over the course of ten career years, if calculated at a constant rate without regard to future increases in compensation, the median paid “Family Doctor, Branch” will have earned $1,900,182. During those same static ten years, a “Mammographer” will have earned $5,400,280. If the Family Doctor were to consult with the Mammographer at the end of those ten years, she would be doing so with someone who had made $3,500,098 more than she–nearly 3 times as much. If that same Family Doctor were to then consult with someone from the lowest paid of the three categories of Radiologist, Not neural, Non-Interventionist, she would be doing so with someone who had made $4,208,580 during that time-which would be $2,308,398 more than she–or more than twice as much.

Perhaps by way of consolation for the PCP, the Geriatrics specialist and the Pediatric Infectious Disease specialist would have fared worse, and even the Kidney transplant specialist who consults with the radiologist would be speaking with someone who had made a half of a million dollars more than he did.

But perhaps it is not consolation enough; the AMA has reported that the nation faces a shortage of 35,000 to 40,000 Primary Care Physicians.

The Congressional Budget Office Puts Numbers on It

Articles in both the NY Times and Kaiser.org explain the recently published CBO findings regarding the financial impact of various health reform proposals and parts thereof. The CBO issued two reports: “Key Issues in Analyzing Major Health Insurance Proposals,” and “Budget Options, Volume 1: Health Care.” Both CBO reports may be accessed through the hyperlinks above which include the reports, charts, and a CBO explanatory blog. The reports may also be accessed through the “Resources” section of this blog.

According to the CBO blog, “The first document, Key Issues in Analyzing Major Health Insurance Proposals, focuses on large-scale proposals, provides extensive background information, and explains CBO’s analysis of numerous issues that could arise should the Congress seek to enact major changes in the health insurance system.”

“The second document, Budget Options, Volume 1: Health Care, is much more specific and focused on discrete changes. It presents 115 discrete options, encompassing a broad array of issues related to the financing and delivery of health care. (Volume 2 of Budget Options, which will address policy options in other areas of the federal budget, will be issued in 2009.) The health care volume includes some options that would reduce spending and others that would increase it, as well as changes that would reduce or raise revenues.”

Poll Shows Americns Not in Favor of Mandatory Health Insurance, But Do Want a Return on Taxpayer Funded Medical Innovation

Marketwatch reports that a recent poll conducted by Consumer Watchdog shows that”Less than 15% of U.S. voters support, and 53% oppose, a proposal pushed by health insurers requiring every American to provide proof of private health insurance or face tax penalties or other fines.” A mandatory individual health insurance requirement is one of the provisions included in the recently unveiled AHIP health care reform proposal. Earlier in the week, in The American Spectator, Jeff Emanuel likened AHIP’s Proposal to an automobile manufacturer bailout which required every American to buy a car. See Health Reform Watch post here.

Marketwatch reports that the poll also found that “by just under a two-to-one margin voters favor requiring a return on taxpayer-funded research that leads to new medical treatments or prescription drugs.”

Marketwatch noted that “The issue is particularly important as President-elect Obama is proposing doubling research funding from the National Institutes of Health. He is also expected to end the Bush Administration’s ban on federal fund of most embryonic stem cell research.” Read full article here.

Cato Institute: Medical Licensing is Ineffective and Inefficient, and Patients Would be Better Served by Relying on Brand Recognition

The National Center for Policy Analysis quotes from a recent Cato Institute report written by California State University economics professor and Cato Institute fellow, Shirley Svorny, to reach the headline conclusion that “Medical Licensing Impedes Quality, Affordability of Care.”

“Additionally, says Devon Herrick, a senior fellow with the National Center for Policy Analysis, restrictive medical licensure and numerous other needless regulations have kept physician care a cottage industry,” the article states. The article states that Ms. Svorny said “she approached the issue as an economist” and that “Patients are being misled by the license. If there were no licensing, they’d say, who is this guy? And we’d go to national recognition.”

In the Cato Institute Report, “Medical Licensing, an Obstacle to Affordable, Quality Care,” Ms. Svorny argues that “licensure not only fails to protect consumers from incompetent physicians, but, by raising barriers to entry, makes health care more expensive and less accessible.” Devon Herrick continues: “The accounting industry is an example of how medical licensure should work. For instance, a Certified Public Accountant is not exclusively licensed to practice; anyone can hang out a shingle advertising bookkeeping to the public. Yet accounting professionals seeking to prove their skills can obtain that certification to illustrate professional competence, and consumers are free to decide the level of accounting skills they are willing to pay for.”

Ms. Svorny further argues in her report that “Consumers would benefit were states to eliminate professional licensing in medicine and leave education, credentialing, and scope-of-practice decisions entirely to the private sector and the courts.”

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