|WHAT WE’RE READING
Stuff we read this week that made us think.
Rethinking scope of practice could generate huge savings
The number of advanced practice providers (APPs) is growing in nearly every market we visit, but limits on their duties vary widely. Scope of practice is determined at the state level, and only 24 states allow full-scope practice for nurse practitioners (NPs). New research from Brookings’ Hamilton Project caught our eye, quantifying the value of removing anti-competitive barriers to APP practice. The authors cite a broad range of potential cost reductions, including 12 to 14 percent lower cost of care delivered by APPs for Medicaid patients, a 12 percent reduction in ED use for ambulatory-sensitive conditions, and lower rates of complications and C-sections in nurse midwife-led deliveries. In sum, they estimate that broadening scope of practice could save Medicare, Medicaid and the larger healthcare system billions of dollars annually.
Quality could also be improved by increasing scope of practice. A range of research (this systematic review is a good overview) demonstrates that the quality of care provided by APPs practicing at top of license is as good or better than care delivered by doctors. You have to search hard to find studies that show the opposite—we looked. Incentives in the billing system, however, favor keeping APPs underneath doctors. Medicare pays APPs who practice independently 85 percent of the physician rate. When practicing under direct supervision of a physician, APPs bill at the physician rate—these “incident-to billing” rules provide an incentive for doctors to keep scope of practice in check. (One study estimated that care for Medicare patients provided by NPs practicing independently was 29 percent lower than care provide by primary care doctors; only a portion of that difference can be explained by incident-to billing.)
The authors push for changes in policy at the federal level to eliminate incident-to billing, but recognize that scope of practice will, and should, remain regulated by states. Eliminating anti-competitive practice rules at the state level will increase access, reduce costs, and (at minimum) maintain quality of care; the effects will be magnified for the most at-risk patients, as APPs are more likely to practice in rural areas or treat vulnerable populations. State legislatures concerned about rising healthcare budgets would be wise to move toward increasing practice scope rather than succumbing to pressure from professional guilds to maintain the status quo.
We are not ready for the next global pandemic
Gates Foundation simulations show that a severe flu pandemic could kill 33 million people in 250 days. And it’s just a matter of time, as researchers estimate that there are over 800K animal and avian viruses potentially capable of leaping to humans. A new article in The Atlantic examines the science, politics, and economics that drive our ability to manage the next flu, Ebola or other global health pandemic crisis. (Warning: don’t read this article right before going to bed, thinking about it may keep you up a while.)
Some of the factors increasing our risk of pandemic are well-known: a globalized economy and rapid, high-volume transportation means that infection can spread from a formerly-remote area to any corner of the globe in days. Low margins have made pharmaceutical companies slow to develop vaccines. But other elements of our healthcare economy also elevate risk. We operate with a “just-in-time” supply chain that leaves little room for rapidly-increasing supply or dealing with a disruptive event. Who knew before last year that most of the IV-fluid bags in this country are manufactured in Puerto Rico? Critical care assets are particularly hard to mobilize en masse: a Johns Hopkins biosecurity expert estimates his system would need “seven times as many critical-care beds and four times as many ventilators as we have on hand” to handle a 1918-style flu.
What is the answer? Contain potential pandemics close to their source. Nigeria created an expert-driven response system credited for preventing the mass spread of Ebola in that country four years ago. This was funded by investments from the US and other countries, which have been helping 49 developing countries increase their epidemic preparedness. (President Trump’s 2019 budget would cut this funding by 67 percent.) Healthcare leaders must not only increase their systems’ readiness to handle a pandemic event, but lobby to maintain funding and resources for management on the other side of the globe, to keep these events in check, as far from home as possible.
Casting a skeptical eye on Lasik surgery
A disturbing piece in the New York Times this week raised questions about the safety and long-term outcomes of Lasik eye surgery, and caught our (glasses- and contacts-wearing) eyes. The article shares the stories of many Lasik patients who’ve been plagued by months or even years of painful after-effects from having the popular vision-correction surgery. These can include dryness, double or blurred vision, eye pain, and other vision problems, which according to the article are often downplayed by Lasik providers—eye surgeons who frequently have a financial stake in encouraging patients to have the procedure. Last year alone, more than 700K Lasik surgeries were performed in the US, and 9.5M Americans have had the procedure since it was first approved by the Food and Drug Administration in the 1990s. Now, there is a growing concern that Lasik might not be as safe as first assumed, and some researchers are calling for the FDA to re-examine the procedure.
Lasik is typically not covered by insurance because it is considered a cosmetic, elective surgery. Most consumers pay the full price of the surgery out of pocket, to the tune of around $4,000 per eye. And the Lasik market is typical of other consumer markets—with the same marketing, advertising, and pricing strategies common in other parts of the economy. As the broader healthcare industry begins to move toward consumerism—with greater patient cost-sharing driving a need to develop retail pricing and consumer engagement approaches—Lasik provides a useful case study of healthcare consumerism taken to the extreme. We often complain about the additional cost added by “middlemen” in our industry and bemoan the administrative complexity of our third-party payer system. But it’s interesting to think about how the Lasik business would have developed had the surgery been included in our traditional insurance framework. Would there have been more scrutiny of the safety and efficacy of Lasik surgery had insurance company budgets, and not just consumer wallets, been at stake? What might be the implications of moving toward a direct-to-consumer model in other parts of healthcare? Important questions raised by the stories in this piece.