Health status in the United States and State Health Performance: The Commonwealth Fund report and potential solutions

The Commonwealth Fund has recently issued its 2018 Scorecard on State Health System Performance. This scorecard has data for each state (+ DC, so 51 spots), measuring performance against a variety of metrics evaluating access to health care, quality of care, efficiency in care delivery, health outcomes, and income-based health care disparities. Because the Scorecard has been issued 2013, Commonwealth can compare the current year’s rankings and performance to previous ones, seeing how states get better (or worse) on these individual measures as well as on overall performance.  

There is not much change. The Top 5 in performance remain Hawaii, Massachusetts, Minnesota, Vermont, and Utah, in the same order as last year. The Bottom 5 (47-51) are Arkansas, Florida, Louisiana, Oklahoma, and Mississippi, and are close to the same, the only change being Florida dropping 5 spots to join the group and displacing West Virginia, now at 46. Hawaii at the top and Mississippi at the bottom are not only unchanged, but remain far ahead or behind of their nearest competitor. The top regions are still the Northeast and Upper Midwest, with the West dragged up by Hawaii and Utah but otherwise an average to low average group.

Commonwealth also ranks the states on degree of improvement of their scores in each of 43 different indicators. More indicators improved than went down, which in itself is a good thing, but there are a lot of caveats. For one thing, it doesn’t measure amount of improvement, or how much less a state might have improved compared to others. For example, Oklahoma joins the list of the top 5 states with improvement on the most indicators (17, to rank it #4), and yet dropped two places in the overall ranking, from a dismal 48 to 50^th! This is not good. More important, however, were the areas in which indicators fell for many states and for the nation as a whole. This include rising death rates (a really big one!), including a 50% increase in deaths from suicide, alcohol, and drug use since 2005, rising obesity, and gaps in care with a rising disparity between and within states.

Many of the improvements are in areas that have been focal points of public health policy, like decreasing smoking. This is good, but this long-time-coming advance over the tobacco industry’s heavily funded effort to get people to continue to smoke, and young people to take it up, has still not been entirely won. More important, the lessons from the anti-tobacco campaign have not yet transferred to the other well-funded high-profit threats to health, notably sugar and guns, as well as alcohol and pharmaceuticals. Unfortunately, each of these struggles seems to need to rise up almost as if the others hadn’t been joined; activists can and do learn from the previous ones, but so do industries that manufacture unhealthful commodities. These industries replicate the strategies that tobacco used to delay change for so long. The main one, of course, is the liberal application of money to politicians. The same lobbyists who worked for tobacco work for sugar, and guns, and alcohol; the color of their money is still green, and politicians still enjoy receiving it.

While it is true that many politicians from both major parties have been recipients of such largesse, the retreat from reality-based policy that is the hallmark of both the Trump administration and the Republican Party in Congress has major impact on the causes of illness and will continue to do so into the future. One good example of the latter is the aggressive retreat from environmental regulation, personified by EPA administrator Scott Pruitt, rolling back auto-pollution emissions standards (a decision currently being challenged by a coalition of states led by California). Another is the firm resistance to common-sense regulation of guns, which result in over 30,000 US deaths a year, a tiny fraction of which are from foreign terrorists. Limitations on semi-automatic weapons and high-capacity magazines, waiting periods and background checks, absolutely would decrease the number of these deaths (the majority, by the way, are suicides), but are blocked by legislators feeding from the gun-industry funded NRA trough.

Not only politicians are recipients of graft; a recent New York Times exposé provides evidence of pharmaceutical companies using ostensible “speaker’s fees” to actual provide kickback payments to physicians who are big prescribers of their drugs. The article emphasizes payments to doctors who practice pain medicine and are in a position to prescribe large amounts of the opioids manufactured by these companies. Sadly, this is almost as unsurprising as the graft going to politicians to compromise our health. What we should be is outraged about it, and working to combat it. Certainly the politicians do not seem to be. In the conclusion to her “controversial” speech at the White House Correspondents’ Dinner Michelle Wolf noted that: “Flint still doesn’t have clean drinking water.” It is harsh, it is true, and it is almost as bad as the news that the government of Michigan will no longer be providing free bottled water, even though the tap water is still unsafe.

Flint, of course, is a majority minority and overwhelmingly poor city. It has long been clear that its struggles with lead-poisoned water is not coincidental with the makeup of its population, and it not a coincidence that it is in Michigan. The Commonwealth Report illustrates a wide divide between those states that have better and those that have worse health status. Largely, the map is geographic with northern states better and southern states worse, but there is a tongue of northern states in the worse group, heading up from Kentucky and West Virginia into Indiana, Ohio, and on up to Michigan. What these states have in common with most of those in the south is control by Republicans who in most cases have not, in most cases, expanded Medicaid for their citizens. Expansion of Medicaid was a central part of the Affordable Care Act, but a Supreme Court left the decision on whether to do so optional for the states; those that have not done so have worse population health status. This is exacerbated by changes in federal policy that have increasingly made access to health care worse and more expensive in most states, with the impact felt most in states that have elected Republican government and that voted for President Trump.

In another blog post, First Look at Health Insurance Coverage in 2018 Finds ACA Gains Beginning to Reverse, the Commonwealth Fund notes that*:

·        About 4 million working-age people have lost insurance coverage since 2016

·        The uninsured rates among lower-income adults rose from 20.9 percent in 2016 to 25.7 percent in March 2018

·        The uninsured rate among working-age adults increased to 15.5 percent

·        The uninsured rate among adults in states that did not expand Medicaid rose to 21.9 percent

·        The uninsured rate increased among adults age 35 and older

·        The uninsured rate among adults who identify as Republicans is higher compared to 2016

·        The uninsured rate remains highest in southern states

·        Five percent of insured adults plan to drop insurance because of the individual mandate repeal

This is also not good news. Much of the problem is because employer health insurance costs (much of it passed on to workers) have been rising as Medicare and Medicaid control costs. A Washington Monthly article (excerpted by the great Don McCanne in his Quote of the Day) calls for price controls, noting that much of the cost (in lower wages) that workers bear for higher health insurance is not obvious to them, and they would thus have sticker shock from a Medicare for All program. Dr. McCanne notes that a current California bill, AB 3087, calls for price controls, and is supported by unions but opposed by industry and the California Medical Association so it has little chance of passage, suggesting that this solution is not more palatable to the powerful. He calls for well-thought out Medicare for All program, saying:

Now would it be that difficult to let people know about the hidden costs of health care that they are already paying? Do people really prefer being kept in the dark by an opaque financing system rather than being enlightened by the transparency of financing through an equitable tax system, especially if the amount being spent is somewhat less for all but the wealthiest of us?

I do not think so. It is time to do something to change a status quo that is unacceptable for the health of so many as well as unaffordable. It is time to do the right thing.

*Also summarized by Dr. McCanne

Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?

On February 2, 2011, I posted a piece titled Outing the RUC: Medicare reimbursement and Primary Care, describing the activities of this group, officially the “Specialty Society Relative Value Scale Update Committee” but known as the RUC, which is convened annually by the American Medical Association (AMA) to set the relative value of different kinds of work done by doctors. I included the accompanying graph, from the Robert Graham Policy Research Center of the American Academy of Family Physicians (AAFP). It shows the relative income of different specialists over time (FPs are the line at the bottom) and suggested that this might well impact specialty choice by students. I noted that the reason for the income disparities was the different weight given the work done by different specialists, and that the RUC was dominated by subspecialty societies. I pointed out that the real problem is that this encourages expensive procedures (by making them expensive) and that this skews the entire health care system.

I did not, however, call the RUC “The shadowy cartel that controls Medicare”. No, that is the title of a lengthy recent investigative piece in the Washington Monthly by Haley Sweetland Edwards that documents, in detail, the creation, formation, function, and results of the RUC’s activities that justifies this sobriquet. The problems documented are profound. Medicare has to pay for the work that doctors do, and it is pretty obvious that performing heart surgery should be paid more than freezing a wart. But how much more? And how does that relate to your doctor’s office visit or doing and interpreting a CT scan? And that doctor’s visit; is it for a cold or to manage 5 different chronic diseases? It’s complicated stuff. So the Center for Medicare and Medicaid Services (CMS) relies (90% of the time or more) on the recommendations of the AMA-convened RUC.

Note, above, that in the full name of the RUC the term “specialty society” is included; the members of the RUC are appointed by medical specialty societies, but are then told to then be completely objective and not look out for the interests of those societies, the specialists, or themselves! “Put your RUC hat on,” Edwards describes the chair of the committee telling its members, But even if you believe that this is possible, the outcome of RUC decisions would demonstrate that it is not in fact the case (“…in talking to a half-dozen current and former RUC members, including both generalists and specialists, the image of the committee that emerges is less a gathering of angels, cloaked by some Rawlsian Veil of Ignorance, and more akin to a health care-themed Game of Thrones.”) While the RUC only makes recommendations for Medicare, because all other payers base their payment rates upon Medicare, it is essentially controlling the cost of the entire health care system.

Medicare spending is like a pie, a fixed amount of dollars divided up based upon RUC recommendations. The original basis for this division, the Resource Based Relative Value Scale (RBRVS), developed by William Hsiao, may not have been equitable for primary care, but the modifications since then have been a disaster. When the first Bush administration gave the task of making these decisions to the AMA, “…the most powerful interest group in the industry,” Hsaio says “…that was the point where I knew the system had been co-opted….It had become a political process, not a scientific process.”

Edwards goes on, in great detail, to show the ways that the AMA maintains power – and makes lots of money – by controlling the RUC and the charge codes that are associated with it. And also describes, in detail, how it has a negative impact on primary care (“These manipulated prices are also a major reason why specialists are in oversupply in many parts of the country, while a worsening shortage of primary care providers threatens the whole health care delivery system. It’s precisely because the RUC has overvalued certain procedures and undervalued others that radiologists now make twice what primary care docs do in a year—that’s an average of $1.5 million more in a lifetime”) and why (“While the primary care docs make up roughly 40 percent of physicians nationwide, they have only 14 percent of the votes on the RUC.”). I would argue with the math, though; over a 30-year career every $100,000 of additional annual income results in an additional $3 million in lifetime income, and many sub-specialists earn several times $100,000 more than primary care doctors.

The idea of having independent, non-governmental, groups advise on policy is not necessarily a bad one. An excellent example of this is the US Preventive Services Task Force (USPSTF), which makes recommendations, based on the scientific evidence, about which preventive tests are effective and which are not. In Guidelines, bias, and your health, June 30, 2013, I cite an article by 2 USPSTF members who are concerned that by tying payment for services to positive recommendations by USPSTF, the Affordable Care Act (ACA, “Obamacare”) could politicize their work. The RUC has no such compunctions. While USPSTF is intentionally composed mostly of primary care physicians and examines only the scientific evidence, the RUC is dominated by specialists, who are appointed by specialty societies, who have a great financial stake in its decisions. And if the cartoons attached depict the doctors as poker players, the AMA is the “house”, which not only takes a cut of all decisions, but owns them and sells them back to anyone who wants to use them.

Edwards’ article is full of quotes from important – especially those who were formerly important in public life, both Republican (e.g., Gail Wilensky and Thomas Scully, heads of CMS during the GHW Bush and GW Bush administrations respectively) and Democratic (e.g., Bruce Vladeck, who headed CMS under Clinton), who are extremely critical of the entire process behind the RUC, see it as corrupt, and see it as a major contributor to a US health system that spends incredible amounts of money in a wrong-headed, upside-down way to reach mediocre health outcomes. Unfortunately, none of them changed it when they had government power (if they even tried to).

I would like to add two notes:

1. All specialists are not paid the same. Some (e.g, psychiatrists, some subspecialty pediatricians, some neurologists) are earn much the same as primary care doctors. Some (e.g., radiologists, orthopedic surgeons, neurosurgeons, anesthesiologists) earn several times more. Much of this is built into the RBRVS, which vastly overvalues procedures compared to cognitive care, and exacerbated by the RUC.
2. The last time I wrote about the RUC, I received a response from the AMA (AMA response to "Outing the RUC", February 5, 2011). It said "The entire premise of this column is false.” If you wish, you can read my reply in that blog piece. Nice to know they read it.

In summary, the flaw is not just the RUC, but the entire nonsensical non-system of medical care we have in the US. Medical care should be paid for by a single payer, and rates determined by an independent body without a financial stake in the outcome. Health care should be a lot more than simply medical care. And the health of our people will be most impacted by investment in the core functions of society: housing, food, education and jobs.