Different types of doctors
June 11, 2023
At DocSpot, our mission is to connect people with the right health care by helping them navigate publicly available information. We believe the first step of that mission is to help connect people with an appropriate medical provider, and we look forward to helping people navigate other aspects of their care as the opportunities arise. We are just at the start of that mission, so we hope you will come back often to see how things are developing.
An underlying philosophy of our work is that right care means different things to different people. We also recognize that doctors are multidimensional people. So, instead of trying to determine which doctors are "better" than others, we offer a variety of filter options that individuals can apply to more quickly discover providers that fit their needs.
June 11, 2023
Not only is the country's demographics changing, but KFF Health News reported on a trending change within the medical community. The concentration of allopathic doctors (with the MD credential) appear to be dropping in rural areas, while that of osteopathic doctors (with the DO credential) appear to be growing in rural areas. (The article specifically reported on Iowa, but it would not be surprising if this trend held true for other states as well.) What is particularly interesting is the growth in number of each type of physician: "From 1990 to 2022, [osteopathic physician] numbers more than quadrupled, from fewer than 25,000 to over 110,000, according to the Federation of State Medical Boards. In that same period, the number of MDs rose 91%, from about 490,000 to 934,000."
People talk about the projected physician shortage as America's population ages, so the growth in osteopathic medical schools (and therefore the number of graduates) could be one component of helping meet that challenge. It is also interesting that osteopathic physicians tend to be oriented around primary care, while allopathic doctors seem to increasingly specialize.
June 05, 2023
As another example of how automation can benefit a company, but create more hassle for its customers, KFF Health News published an article about how some insurers seem to be rejecting claims in bulk (one insurer denied 49% in 2021 and another denied 80% in 2020). The author collected some cases where the rationale for the rejections did not make sense (e.g. including rejecting a procedure that was not actually claimed).
Presumably, some patients will be too busy to contest the rejections and the insurers in question will benefit financially. Even if all of the wrongful rejections were ultimately resolved correctly, patients and providers still end up spending time (and maybe even money) to challenge the rejections. Assuming that these rejections were due to software that streamlines the process, automation in this case works asymmetrically in favor of the company (saving on some claims) while pushing additional administrative burden on others. If insurers were responsible for meaningfully compensating patients for lost time in challenging a rejection, they would probably be much more careful about their rejections.
The article ends with a discussion about the government being tasked with oversight and enforcement, but not actually doing so. Given the lack of penalties, it is perhaps not surprising that some insurers might test the boundaries to see how they can benefit.
May 28, 2023
California hospitals are asking for $1.5 billion of additional funding, even as the state projects a budget deficit forecast to be almost $32 billion. It appears that the trigger for the request was the recent closure of Madera Community Hospital. The dynamics seem to be such that the industry wants to make the closed hospital a poster child for what might happen to other hospitals if the state does not give more money, and hospitals probably feel that their request for additional funds is more likely to be heeded if they band together rather than having only select hospitals ask. KFF Health News reported on why the state probably should not simply accede to the request, even if it makes sense to bolster the finances of some hospitals -- namely that some of the financially better-off hospitals would benefit disproportionately.
Not surprisingly, a leader of the state hospital lobby said "The real underlying issue here is government underfunding." Given that reimbursements for serving Medi-Cal may be below the cost of the service, "government underfunding" is indeed likely an issue. However, the article points out that hospitals already receive bonus and incentive payments that can substantially change the profitability picture.
Interestingly, the article links to some financial reports of Madera Community Hospital, showing that the hospital actually made gross profit (profit before fixed expenses are subtracted) on serving Medi-Cal patients ($6.6 million from traditional plans and $8.4 million from managed care plans). While these reports provide some visibility into the hospital's finances, a big question is what is included in the $104 million of operating expenses (presumably fixed expenses such as building maintenance and administrator salaries). For example, a self-serving hospital administrator could advocate for more money from the state by showing a loss in order to increase his salary. Presumably, the leadership of Madera Community Hospital considered all possible options to trim expenses before deciding to close the hospital. However, who should scrutinize the financial reports for all state hospitals before deciding whether or not the state should give additional funding? It is not hard to imagine legislators deciding it easier and politically more expedient to simply grant the request for additional funding -- after all, which legislator wants to be known as the one who voted against maintaining hospitals?
May 20, 2023
Challenges with mental health care have been on the rise, and the Affordable Care Act mandated that insurers offer parity between mental health and physical health coverage. However, the efforts of insurers have been oriented around physical health for so much longer than for mental health, making parity in the short-term difficult. KFF Health News highlighted recent efforts by technology companies to offer apps as a partial substitute for mental health providers.
Understandably, insurers are eager for alternatives to offering mental health providers higher reimbursements. Unfortunately, the article points out that these solutions in their current form might not be effective, and might even do harm. Given the rapid pace of technological innovations, these apps might eventually offer convenient and cost-effective options for diagnosis and maybe even treatment. However, in the meantime, mental health continues to be a problem for many, and insurers might struggle to achieve parity between mental health coverage and physical health coverage.
May 14, 2023
KFF Health News published an illuminating article on how pharmacy benefit managers (PBMs) operate and complicate drug sales. The initial idea was probably for PBMs to specialize in the procurement of drugs to reduce drug costs for insurers and patients by purchasing drugs in large volumes. The article paints a very different picture of the role of PBMs. Over time, PBMs popularized the concept of large rebates while keeping list prices high (PBMs are frequently paid a percentage of prices, not of net payments). It appears that PBMs have gone far beyond large rebates, with the article offering:
"In other words, drug companies blame PBMs for high drug counter prices, PBMs blame insurers, and insurers blame the drug companies, all part of a health care system that hinges on an unspoken bargain: Make life comfortable for some — mostly the upper and middle classes — at the expense of lower-income and poorly insured people who get what they get."
Of particular concern is how the system has become complex enough that patient health is affected, with some patients believing that they are not able to find affordable options. The article reports on one provider who complains that the system is designed to obfuscate prices and how some of that provider's patients skip medications because of cost.
One of the major problems seems to be that the PBM industry was allowed to consolidate, with now only three PBMs controlling about 80% of prescription drug sales in the US. Earlier policy-makers might have expected that more powerful PBMs would have been able to bring more pressure to insurers and manufacturers, but perhaps missed other distortions that the powerful PBMs have brought.