Tuesday, February 28, 2012

Horace Mann describes "White Flight"... in 1842

From a text on the social underpinnings of education (picked up on whim), a selection from Horace Mann.
I have met many individuals, who, having failed to obtain any improvement in the means of education in their respective places of residence, have removed to towns whose schools were good, believing the sacrifice of a hundred, or even of several hundred dollars, to be nothing, in comparison with the value of the school privileges secured for their children by such removal.  Still more frequently, when other circumstances have rendered a change of domicile expedient, has this principle of selection governed in choosing a residence.
-  Fifth Annual Report to the Board of Education of Massachusetts, 1842
I don't think I can understand that without understanding more about public education in MA at that time.  How many towns had schools?  What percentage of the child population attended them, and what were their economic characteristics?  Were they a trendy municipal feature like highways in the fifties or streetcars today, or did they have deeper community roots?  It's an interesting quote either way.

Monday, February 27, 2012

Emergency Rooms

Last week Kaiser ran a Phil Galewitz story on for-profit hospitals that were screening emergency room patients.  Patients deemed to have non-emergency conditions were required to make a pre-payment, as much as $150 in HCA's case.

This week Kaiser noted a Wall Street Journal article on a Washington state Medicaid plan to stop reimbursing emergency rooms for providing non-emergency treatment.

Is there a meaningful difference between these policies?  For-profit corporation and state program alike, they both utilize financial incentives to prevent emergency rooms from being used for non-emergency care.  They demonstrate the point that rationing care isn't really optional, it is already happening.

What is optional is how much discretion and transparency we allow in the process of rationing.  The for-profits and Washington are opting for rote standards where care givers have no flexibility in distinguishing what care is necessary (and reimbursable) from what is not.  Contrast that with Oregon's CCO plan, which goes the opposite way in trying to find savings by empowering providers.  I don't know which approach will prove the better, but I know which one I'm rooting for.

Sunday, February 26, 2012

A question for Representative Conger

The CCO bill was finally passed, but the Exchange bill is still in a holding pattern.  The Lund Report caught a powerful statement by Representative Jason Conger (R-Bend), talking about the CCO bill (emphasis mine):
After listing many of those complaints about the legislation, Rep. Jason Conger (R-Bend) said “to do nothing is simply unacceptable,” adding that “it required leadership” to get the bill to the House floor for a vote.
“I don’t mean the twisted, pathetic concept of leadership that values political positioning and partisan gain over good policy,” he said. “I mean real leadership, to do the hard work that is required to address big issues that matter to Oregonians who are not in this building, to the rest of the state besides us. There is risk involved in passing this bill. But I believe that I know I was sent here to address those kinds of problems—like jobs, and yes, healthcare…despite the risk in the bill, I will be voting yes.”
 I'm impressed to see someone buck party for conscience in the way Conger did, especially because passage of the CCO bill was a near certainty once it came to a vote.  He could have just voted for it and held his peace, as 22 (of 30) other Republicans did.  Saying what he did took guts...  So why tolerate the stonewalling on the Exchange bill?  If Conger thinks people sent him to the legislature to work on the problem of health care, how is spiking the Exchange bill part of the solution?

Wednesday, February 22, 2012

Gender and Transit continued

I've been searching for any materials discussing gender issues and transit.  I haven't found anything Portland specific yet, but this post from a Seattle blogger pointed me to this study, part of a project called "Gendered Innvoations".

The GI study was mostly about how traditional metrics don't capture the full usage of transit by women because they are more likely than men to "chain" their trips, making multiple stops on the same excursion.  Because of the mismeasurement, transit agencies risked over emphasizing commuter service in ways harmful to women.  That's interesting, but not what I'm after.

The GI study also Included a chart showing women consistently utilizing public transit at higher rates than men, across ethnicity, I wonder how it looks when you break it down by income or age.  People who have no choice will use public transit, that isn't saying anything interesting.  What I'd like to know is, are there gender differences in how people who have a choice decide between driving and alternate transportation?

The most helpful part of the paper was a footnote describing safety improvements at stops and stations, referencing Schulz et al., 1996.  That reference is to this paper, Women and Transit Security: A New Look at an Old Issue.  It includes a history of efforts to safeguard women on public transit, beginning with attempts (that failed) to reserve the last car on New York Subway trains for women only, and other more successful ventures:
Those familiar with Progressive Era concerns about white slavery know that creation of such groups as the Traveller’s Aid Society were directly related to demands that women be present in train stations to protect young women, often runaways or working-class immigrants, from the clutches of those perceived as ready to lure them into lives of prostitution. Early policewomen, too, spent much of their time patrolling train stations, with the expressed aim of saving women from the perils believed awaiting them there. Thus concern about women and their safety in and around transit systems has a long history and plays an important role in women’s demands for public positions in both the social service and criminal justice fields.
The description of the Traveller's Aid Society strikes me as very relevant to Portland today, and the concept that women's entry into law enforcement and public transit are connected is interesting in a different way, but neither is what I'm after right now.  What I'm after is this reference included in the Schulz paper,
S. Rosenbloom and E. Burns, Do Environmental Measures and Travel Reduction Programs Hurt Working Women? (Tucson, AZ: Roy P. Drachman Institute for Land and Regional Development Studies, 1993)
 Sadly, that paper appears to be really, really hard to get.  But I found a review of it, which helps (emphasis mine):
Rosenbloom and Burns looked at surveys of workers conducted as part of employers' efforts to reduce solo driving by their employees in Phoenix and Tucson, Arizona in 1990 and 1991. They discovered that women, especially women with children, are more or as likely as men to be solo drivers and that women take longer to get to work despite their shorter commute distances.
The authors hypothesize that women with children and domestic duties use cars more because they find alternatives such as buses unsafe and impractical. The surveys did not ask respondents about "linked trips" (stopping at daycare on the way home from work), but the authors suggest that linked trips explain women's more time-consuming travel and their preference for solo driving. They offer the anecdote of the woman who worked across the street from her home but reported that it took her 15 minutes to get to work, because she had to first drive her children to daycare.
Rosenbloom and Bums assert that working mothers (about one third of women surveyed) will be hard hit by trip reduction programs aimed at reducing solo driving. "Many women will continue to drive," the authors suggest "accepting new expenses [financial penalties for solo driving], because driving still costs less than the additional child or eldercare needs created by longer commutes, or because they cannot obtain the needed care, or because they must use the time to conduct their domestic responsibilities, or because they cannot find or do not feel safe taking public transit Other women will change modes, but at some cost to the well-being of their families."
So they observe the same phenom noted in the GI paper about chaining trips, but connect it to what I think is a very logical preference for auto transport even without the safety issues.  The review concludes with this summation, again with my own emphasis:
While this report suffers from its authors' biases--they believe that the car is the best all around transport mode, that transit is unlikely to conquer the suburbs, and that "bicycling is largely a male mode," apparently not for women--their basic point needs to taken seriously by the environmental community. If working mothers' concerns are ignored, the road/auto lobby can claim that environmentalists care more about the earth than about women and children. Let's prove them wrong.
 Are we proving them wrong, Portland? 

Also, are there any more recent studies that follow up on this issue?

Tuesday, February 21, 2012

Gender and the City

Two recent posts in the O highlight the absence of gender in the Portland urbanization discourse.  A story on the increase in biking revealed the fact that men outnumbered women 2 to 1 among bicyclists.  And a letter to the op-ed page lamenting the absence of free parking included this passage:
By removing four blocks of free, albeit unsafe, parking, the number of available spaces within walking distance of my apartment has been cut in half. Think about the implications for safety and work schedule: For a woman who returns from work after dark, it does not appeal to abandon a car under the I-405 bridge.
That the cost of parking should be increased is an axiom among urbanists, but how often do you see an acknowledgement that walking, biking, or taking public transit as opposed to driving poses different trade-offs for different genders?  Do urbanists have anything more to say to women concerned with the safety implications of abandoning the car beyond, "Grin and bear it"?

OSPIRG and ineffective medicine

I was struck by an op-ed relating OSPIRG's efforts to open up the rate review process in Oregon.  OSPIRG working in concert with DCBS brought rate review before the public in a big way.  That is certainly a good thing.  But how good?  The trouble is, the individual and small group markets were already pretty well regulated:
Notice the horizontal axis crosses the vertical at 80%.  To be clear, the medical loss ratio is the portion of premium going to medical bills.  The portion above the medical loss ratio is production expense, admin and profit.  That insurance portion of premium is what OSPRIG is gunning for, they've said nary a word about the money on the medical side, where the vast bulk of the dollars go.

OSPIRG's efforts are further limited in that the review process they're promoting is limited to individual and small group markets.  In the latest Health Insurance in Oregon report those two groups total 36% of the private market.  Which is to say, among Oregonians who have private insurance for every one who might be helped by these efforts there are almost two who will not.

Combining the market distribution with a lowball MLR pick of 80% and you get this:
Not as ineffective as Republicans when it comes to health care reform, but it sure does leave room for improvement.

Saturday, February 18, 2012

Real Tort Reform

I don't have time now to do a full write-up of what I think tort reform should look like and why, and to my surprise I discovered I don't need to.  I guess I'm not the first person to think that a workers comp style process is applicable to Medical Malpractice.  Closer to home, I found that Jack Roberts had written about this very concept back in 2009 in the O (emphasis mine):
Other proposals are more specific to medical malpractice, such as specialized health care courts and safe-harbor practices to protect doctors from liability even if something goes wrong. But maybe it's time to consider a more radical reform, such as a system of no-fault insurance for medical malpractice similar to the workers' compensation system.

Since the adoption of workers' comp laws early in the last century, workers injured on the job are covered without regard to whether the injury was caused by the negligence of the employer, a co-worker, the worker himself or simply bad luck. Injured workers have their medical bills and other out-of-pocket costs covered as well as receiving compensation for loss of income and certain general damages in accordance with an established schedule. In return, they give up the right to bring an individual lawsuit against their employer and with it the hope of winning a lottery-size award or settlement.

Applied to medical malpractice, such a system would compensate any patient whose surgery or other treatment (or lack of treatment) resulted in an adverse result, whether or not the doctor, hospital or nurse was at fault. It could redirect resources currently spent finding fault to compensating patients who have been harmed. And it would recognize that even where medical providers have performed their jobs badly, large jury verdicts are not paid by the wrongdoers but shared by everyone through the insurance system.
 To get a sense of how much more efficient workers comp is at delivering benefits than med mal, let's look at Oregon state wide experience:
ALAE are expenses that can be directly attributed to a specific claim.  So the cost of a court filing for instance is particular to a claim while the cost of a claims department generally is not.  In practice, for these lines ALAE is mainly defense counsel.

What these figures show is that from 2003 to 2010 only half of the med mal premium dollars went to indemnity payments to claimants.  The rest was chewed up by defense costs, overhead and profit.  In contrast only 13% of the Workers Comp premiums were diverted in this way.  The difference is even more striking when you realize med mal claims are much more likely to have a plaintiff's attorney involved than workers comp, and they are paid from indemnity proceeds.  So not even half of the med mal premium money actually reaches patients suffering harm.

A lot of ink has been spilled on the extension of a tort cap, but I think all of the above shows that we need to ask a deeper question.  Does the way we've structured Medical Malpractice liability make sense?  As our experience with Workers Compensation shows, alternate structures exist that have far less costly processes for adjudication.

Thursday, February 16, 2012

What Opt-In Does

Nick Christensen does a write-up on how Metro councilors view Opt-In, a registration-required online survey tool.  I think this gets at what this service really does, and what it replaces:
Metro spent $76,000 on Opt In in 2011, generating  more than 20,000 responses – about $4.50 per completed survey.
By comparison, said a staff report for Tuesday's work session, Metro spent about $400 per open house attendee during the 2010 roll-out of then-Metro chief operating officer Michael Jordan's growth and policy recommendations; those numbers soar to $2,800 per completed survey at each of those open houses. The agency also spent $35 per attendee at the dozens of stakeholder meetings Jordan attended.
Opt-in is a new way of connecting with citizens, in a way that allows two way communication- both Metro and citizens learn from the interaction.  And look at the number of people reached, a recent survey had 4,000 respondents.  How many public meetings or open houses have you seen that attracted 4,000 people?  How about a meeting where 4,000 people got to get up individually and express their view?

Some councilors expressed concern that their hands would be tied by the surveys.  How could they justify a vote that went against "majority opinion?"   Even aside from concerns about the opt-in demographics, councilors have a pretty solid excuse:  Voters elected them, not a survey.

The people who should be nervous are the interest groups who make up most of the participants at conventional public meetings.  They are the people most motivated to attend, and most likely through pooling and coordination to have a representative available to attend a meeting at 9am on a weekday.  Most individuals don't have the time or interest for that.  That dynamic gives interest groups a dominant role in reflecting "the public", quite independent of how much popular support their positions actually have.  As Metro President Tom Hughes said,
"Public hearings are an avenue for getting public input, but they're imperfect at best," Hughes said. "They're usually repetitive, not very helpful and usually the people who show up are the people who are absolutely directly involved – you don't get a sense of what the public wants."
Opt-in offers a potential check on interest groups, it creates an opportunity for a truer test of the popular will.  Whether it fulfills that potential depends on participation.  If the only people who sign up are the same people who would otherwise be represented by interest groups, nothing changes.  So if you're a Metro resident not already signed up, please consider it.  Especially if you disagree with me.

Monday, February 13, 2012

Oregon Republicans disappoint

Right after I write about why Democrats should compromise on the CCO bill, Republicans prove me wrong.
A coalition of 30 Republicans and 1 Democrat in the state House of Representatives blocked approval of Oregon's health insurance exchange this morning, prompting concern that bills are being taken hostage to leverage other votes in the month-long 2012 Legislature...

[A Republican house leader] said questions had arisen in a recent caucus meeting of House Republicans over what commitments existed over federal funding of the program, as well as the potential for a change to the legal status of federal health care reforms, currently under consideration by the U.S Supreme Court.
In contrast to tort reform and the CCO bill, this looks like a straight forward attempt to spike the Health Insurance Exchange.  That would put Oregon in league with the other red states that are standing around waiting for a federal exchange to be dropped on them.  Thing is, only in the most sheltered, isolated, reality deprived imagination could today's Oregon be conceived of as a red state.  Efforts like this ensure it never will be.

Sunday, February 12, 2012

CCO Bill and Tort Cap

The Oregon Legislature is trying to figure out whether or not to include a tort cap in the CCO bill.  The stakes are high, as legislators are expecting up to $2.5 billion in federal aid if the CCO bill passes.  I don't know the politics well enough to guess what would happen if a CCO bill doesn't pass in this session.  Maybe the federal money will still be there next year, maybe not.  But since the state already banked savings resulting from CCO's in the current biennium budget, it doesn't really matter.  The bill needs to pass.

For that reason I think Democrats need to hold their noses and pass the bill with the tort cap included.  While it is true that Republicans are engaging in hostage taking and you risk encouraging such behavior by giving in, there are some mitigating factors.
  • One of the central purposes of CCO's is to save money by reducing unnecessary or ineffective care.  The tort cap may be politically undesirable and only marginally effective, but however slightly it still promotes the goals of the CCO.  Tacking this on isn't as irresponsible as would be say, a demand for PERS reform or tax cuts.
  • Passing the CCO bill with a tort cap does not forestall pursuing more effective tort reform in the next session.  Passage of a more comprehensive reform which affected all providers state wide would render the CCO compromise moot.  And make no mistake, there is ample reason to pursue tort reform quite apart from CCO's.
 Given the money at stake and the relatively small compromise needed, legislators would be grossly negligent if they fail to pass this bill.  Jawbone and posture all you want.  Call out the fine 15 for committing to the proposition that $20M in annual savings is worth more than $2.5B, a trade that takes 125 years to pay off.  But at the end of the day, we need this bill.  Get it done.

Wednesday, February 8, 2012

Honesty in Medicine

Incidental Economist is another great blog I wholeheartedly recommend.  Aaron Carroll calls attention to a study of physician attitudes towards honesty.  The punchline, emphasis mine:
They[sic] survey also asked specifically about things subjects had actually done in the last year. That’s where it gets even more depressing. More than 10% of docs had told an adult patient or guardian something that wasn’t true. Almost 20% had – in the last year – not fully disclosed a mistake because they were afraid of being sued. And more than a quarter of physicians had revealed, either intentionally or unintentionally, personal health information of one of their patients to an unauthorized person.
Bear in mind those are physicians voluntarily self-identifying their behavior, in the wild it's probably even more common.  I've said it before, but doctors really are not angels.

Monday, February 6, 2012

Hospitals and Data mining

More reporting from Phil Galewitz.  Back in December he described how hospitals were using former drug reps to target physicians to get referrals for "profitable, well-insured patients".  The suggestion that doctors could and would prompt patients to get particular procedures at a particular facility at the whim of a sales rep is pretty grotesque, even to someone who has read a lot about health care finance.  But at least there is a possibility of responsibility, doctors after all do take an oath to do no harm.  What happens when hospitals cut them out and go straight to the patients?  And not just ad buys on TV, but specific procedures marketed directly to individuals:
[Provena St. Joseph Medical Center] is one of a growing number of hospitals using their patients' health and financial records to help pitch their most lucrative services, such as cancer, heart and orthopedic care. As part of these direct mail campaigns, they are also buying detailed information about local residents compiled by consumer marketing firms — everything from age, income and marital status to shopping habits and whether they have children or pets at home.
While hospitals may profit from offering cholesterol tests and mammograms, the big payoff is in what those screenings may lead to – additional tests and procedures, including surgery.
"It's all about downstream revenue," says Patrick Kane, senior vice president of marketing at Cape Cod Healthcare in Massachusetts who used such approaches at Wellmont Health System in Kingsport, Tenn. "The old adage in business is that it’s easier to sell an existing customer new services, rather than find a new customer."
One of the biggest pluses for hospital executives is that they can track a campaign's financial success by comparing the amount of services used by targeted consumers against those in a control group with the same demographic and economic characteristics, but who are not sent mailings.
When the Henry Ford Health System promoted mammograms last year in mailings to 30,000 women aged 40 or older, more than 5,700 responded -- 304 more than in the control group. The mailings generated $268,000 more in profit than the control group -- a return of more than four to one on the cost of the campaign, says Denise Beaudoin, vice president of customer engagement.
"Some doctors used to be leery about the effectiveness of these marketing campaigns, but not when we can show them data like this," she says.
It's nice to know that while we don't know much about whether one treatment works better than another, we have randomized controlled trials on the effectiveness of their marketing.  Great job folks!

Saturday, February 4, 2012

Passages I like

From Cringely:
My kids go to the best public school in Sonoma County. I know that because I chose my house based on that research. But when Cole finishes his math problems in a quarter the time it takes anyone else in the class, his teacher has him insert a wait state by putting his head down on his desk.  Conversely, when some other kid never quite gets the problem set finished, ever, well he/she never gets a rest and never masters the material, either.

The current system is unfair to both kids.

The only solution I can see is one teacher per student. And the only way something close to that is going to happen is through technology.  And it’s coming.
 A followup passage that I don't like but agree with:
My conclusion, then, is that schools serve a limited social and cultural function but our kids mainly learn despite them. My own experience is that I learned a lot about learning from half a dozen teachers in my life, so those relationships are both rare and essential. But are they reliable enough to even justify modern schools?  I don’t know. What I do know is that if I want to improve the educational environment for my children in the next year or two, I’ll probably have to come up with my own solutions.

Republicans and Medicare Cuts

I don't mind saying, John McDonough's blog is worth following.

The claim that Democrats voted to cut Medicare through the ACA has gotten a lot of play.  Here in Oregon it came up a lot in the Bonamici-Cornilles race, with Cornilles claiming Bonamici wanted to restrict choices for seniors.  Via McDonough, here is an aspect that didn't get a lot of press (emphasis mine):
In the new Republican-controlled House of Representative in 2011, House Budget Chair Paul Ryan (R-WI) advanced a controversial federal budget plan which included a major restructuring of the Medicare program to change the program from largely fee-for-service to premium support/vouchers. This proposal drew widespread praise and condemnation, and mountains of attention.
Less noticed was the part of the Ryan budget plan which repealed most of the ACA, with one huge and unnoticed exception -- the $449 billion in Medicare reductions, documented in the CBO report on the Ryan plan. The Ryan plan was put before the entire House, and nearly every Republican member voted for it; the plan was also put before the Senate and endorsed by all Republican members minus four (one of those four was MA Senator Scott Brown).
So the one part of the ACA that congressional Republicans are on record as supporting are those same Medicare cuts that Republican candidates use to bash Democrats.  And Rob Cornilles was as culpable as Bonamici (neither served in Congress for the ACA or its repeal vote) of everything he accused her of.  Gee, I wonder how Politifact missed that.

Thursday, February 2, 2012

Health Insurance is not Auto Insurance

John McDonough reviews Mitt Romney's concept of cost control: co-insurance and high deductibles (emphasis mine)
...Mitt Romney's approach to controlling private sector health spending growth is to continue and to accelerate the shift to insurance policies that expose patients to higher and higher levels of cost sharing. This reflects a view, popular among conservative health economists, that health insurance should, as much as possible, resemble auto insurance, where you only get help for catastrophic events.
 There is a big problem with equating health insurance and auto insurance.  With auto insurance underlying costs tend to correlate with income.  Someone working minimum wage probably drives a beater with no collision and minimal liability limits.  That policy costs much less than the one for a one-percenter driving a porsche with $1M limits.  Cost, and thus premiums correlate with income.

In contrast with health insurance there is no correlation, poorer people do not need less expensive care than richer people.  There is no equivalent to a "beater" surgeon, cutting people open in a dirty basement.  At least not today...