Sunday, September 01, 2019

For further study

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I'm going to be a little Labor Day weekend lazy here and jot down a few questions I'd like to look into, rather than provide any actual information about them. If you have any answers, please comment!

1. Credential inflation.  My wife, a certified nurse-midwife, rolls her eyes at the increasing impossibility of getting credentialed in her field without a doctorate. She spoke recently to a young labor & delivery nurse who's planning to become a midwife and is facing four years of study and likely debt. Apparently you can't get certified as a midwife in NJ now without doing the doctorate (not a Ph.D.), and that's a nationwide trend. "We have to do it," was the word for a university program director, because all the other nursing specialty and other non-physician medical professions like OT are doing it.

Who's profiting? Is this essentially a tuition grab? Do hospitals and physician practices charge more for the services of nurses with doctorates? To what extent does the extra schooling improve practice? The ramped-up degree requirements mean more schooling and more debt for people seeking to advance in what's become one of the widest roads to the middle class in an economy where upward mobility has slowed to a crawl. Probably more salary pressure too. I'm reminded of the supervising nurse on a hospital floor where my father-in-law was being treated. She mentioned her doctorate and asked rhetorically, "where's my $200,000 a year?"

Update, 9/2: Of 37 accredited nurse-midwifery programs, by my bean-count, 10 offer a doctorate only, seven offer a doctorate or a masters, and 20 offer a masters only.

2. OOP elsewhere. It's been kicking around Twitter -- probably courtesy of Kaiser Health News's Shefali Luthra, who's reporting from Germany for a few months -- that Germany caps consumer out-of-pocket medical costs at 2% of income.  The sky-high OOP Americans stand for is unique. A tour through the Commonwealth Fund's International Profiles of Health Care Systems indicates that countries with universal health care systems that cap OOP generally cap it in the hundreds of dollars. Many systems have no cap but also have very low copays. On the other hand, the U.S. ranks near the bottom of OECD countries in the percentage of total medical costs (including premiums and OOP) paid by individuals (a bit over 10%, about half the OECD average). But total U.S. per capita costs are so much higher than those of other countries -- about double the OECD average -- that the U.S. average  ranks second to Switzerland. And while Switzerland is a major outlier with respect to average individual costs, the Swiss are exposed to  less risk than Americans: OOP is capped at a few hundred dollars above the deductible, which ranges from a couple of hundred dollars to near $2,000.

There's a lot of nuance in how much cost individuals shoulder in various wealthy country systems. Unique U.S. features in the peer group include a large uninsured population, narrow networks paired with predatory balance billing, high deductibles and high OOP maxes. Other countries spread often considerable individual expenditure with far less risk of financial impairment or ruin.

3. Managed care elsewhere.  U.S. healthcare coverage and social media are replete with horror stories from seriously ill people (or their family members) subject to onerous and often irrational prior authorization requirements -- not to say outright coverage denials -- impeding care. OTOH, healthcare economists and people with health insurance industry experience will tell you that ditching prior authorization entirely would constitute a "license to print money" (as David Anderson put it to me) for providers. I am curious how prior authorization, primary care gate-keeping, and national oversight of covered services play out in other countries. I suspect that the U.S. is uniquely infected by an ethos of profit maximization (or revenue maximization in nominally nonprofit hospitals) on both the payer and provider sides.

It's easier to pose questions than find answers...happy Labor Day!

1 comment:

  1. Very good questions....

    1. Maybe the FTC could get in there and fight credential inflation?

    Nurses often advocate for single payer, but without realizing that in some versions of single payer, their salaries would be cut across the board.

    2. Out of Pocket Limits

    This is a tool to hold down insurance premiums, for good or ill. In other countries, insurance 'premiums' are essentially taxes.

    3. In other countries, all providers agree to national fee schedules before the year begins. There is no opportunity for private equity to buy up ER physicians and probe for opportunities to price gouge.