Government and Politics

September 6, 2019 11:03AM

Looming Doctor Shortage Demands Innovative Solutions

The Association of American Medical Colleges projects a severe physician shortage by the year 2032, particularly in the primary care fields, as the population of patients as well as doctors continues to age, according to a report today by CNBC.com. AAMC projects the national primary care shortage will range from roughly 47,000 to 122,000.

The news report focused on Arizona, one of the fastest growing states in the union, which has a shortage of primary caregivers in every county. Arizona ranks 44thout of the 50 states in total active primary care providers (PCPs), at 77.9 per 100,000 population (the national average is 91.7 per 100,000) according to a recent report from the University of Arizona.

To deal with the problem efforts are underway in the state to expand residency training programs in order to produce more physicians. But that takes time and money. What is likely to have a more immediate beneficial effect is the state’s recent reform of its occupational licensing laws. Arizona this year became the first state to recognize occupational licenses in good standing granted by other states. This spares new migrants to the state who hold licenses in other states the hardship of repeating costly and time-consuming licensing procedures. As the CNBC report states:

Another way Arizona is hoping to help ease the shortage is by changing licensing laws. Republican Gov. Doug Ducey recently signed a Universal Licensing Recognition law that makes it easier for people licensed in other states to move to Arizona and gain similar accreditation. The measure is the first of its kind in the nation and impacts licensed occupations that range from barbers to physicians. Overall, 30% of occupations require a state-issued license.

This was indeed a good move on the part of the Arizona legislature and Governor and should be replicated in other states. But reforming scope of practice laws so that nurse practitioners, PAs, pharmacists, and other ancillary health care providers can provide services that are now the exclusive domain of people holding doctorate degrees will do even more to improve choice and access to patients in Arizona and across the country. One way to accomplish that would be to move to a system of private certification based upon proven proficiency and skill in a given area. In a recent paper from the Goldwater Institute, one of the co-authors, Murray Feldstein, MD, explains how this would work for health care practitioners:

A certified nurse practitioner, who has a bachelor’s in nursing, an RN license, and a master’s or doctorate in nursing, can do a vasectomy in Washington State. But in most states, that same individual must either fight a scope-of-practice battle in the legislature or go to medical school in order to perform a vasectomy. I am a board-certified urologist who has performed thousands of vasectomies. I am confident I could train an experienced, competent physician’s assistant or nurse practitioner to do the procedure within a few weeks and feel comfortable letting them do it independently.

It would also help for states to reform laws regarding the practice of telemedicine. Most states require telemedicine practitioners to obtain licenses in each state where they make their services available. Ironically, those states don’t prohibit their residents from traveling to the states where those practices are domiciled to receive treatment. Economist and Cato adjunct scholar Shirley Svorny investigated this issue in a Cato Policy Analysis, and suggested solutions. An easy reform would be to redefine the location of the patient-practitioner interaction from that of the patient to that of the practitioner, or for states to allow the practice of telemedicine by health care practitioners licensed by the state in which they are domiciled. 

The CNBC report featured comments by AAMC executive vice president Dr. Atul Grover, regarding the shortage. Dr. Grover called for more federal funding of training programs and for medical schools to expand their enrollments. It is unfortunate these other reform proposals were not mentioned. 

September 5, 2019 9:54AM

Michigan Bans Flavored E‑Cigarettes

By Jeffrey Miron and Erin Partin

Today, Michigan became the first state to announce an outright ban on the sale of flavored e-cigarettes. Governor Gretchen Whitmer (D) explained the decision by saying, “As governor, I’m going to do it unilaterally until I can get the legislature to adopt a statute and write it into law.”

This executive decision will impact nearly half a million Michiganders who use e-cigarettes. The ban prohibits the retail or online sale of flavored e-cigarettes or vaping liquid, including mint and menthol flavorings. Flavored e-cigarettes account for nearly three quarters of all e-cigarettes, so the impact will be widely felt.

The governor cites increasing youth use of flavored e-cigarettes and recent CDC reports of respiratory illnesses that may be associated with e-cigarette use in justifying the ban. However, this heavy-handed response goes far beyond what is necessary or acceptable.

Although youth use of e-cigarettes has increased in the past several years, the rate of cigarette use among young people has plummeted to near historic lows. Concerns that vaping may lead to respiratory illnesses are, as yet, unsupported by any robust research. The 215 cases of pulmonary disease under investigation by the CDC comprise less than one ten-thousandth of one percent of all e-cigarette users in the United States. Meanwhile, half a million people die each year from smoking cigarettes. Studies have shown that e-cigarette use is associated with a reduction in combustible tobacco consumption and an increase in smoking cessation efforts. A de facto ban on electronic cigarettes will drive consumers back to combustible tobacco products, ultimately leading to worse health outcomes.

Prohibition does not work. Since the early 2000s, e-cigarettes have provided smokers with alternatives to combustible tobacco and facilitated cessation efforts. Banning products that have a proven track record of harm reduction, due to unsubstantiated fears, is not the way forward. Governor Whitmer’s ban is certain to face legal challenges. One can only hope that reason will prevail.

September 3, 2019 10:14AM

VHA Doc’s 3,000 Errors, DHS Docs’ ‘Dual Loyalties’

It has been a rough news day for government-run health care. But not nearly so rough as government-run health care has been to its victims.

First, The Washington Post reports on the matter of Robert Morris Levy, a former pathologist at the Veterans Health Admininstration hospital in Fayetteville, Arkansas who repeatedly showed up for work intoxicated and who "VA officials say...made 3,000 errors or misdiagnoses dating to 2005." Levy showed up for work one day with a blood alcohol level of 0.4 percent, five times Arkansas' legal limit. He misdiagnosed patients who actually had cancer and whose cancers spread untreated for years, leading to their deaths. "Federal prosecutors charged Levy, 53, last week with three counts of involuntary manslaughter in the deaths of three veterans. VA officials now acknowledge that he botched diagnoses of at least 15 patients who later died and 15 others whose health was seriously harmed."

Veteran Kelly Copelin, whose neck and throat cancer went misdiagnosed by a VHA hospital for 13 months. Photo credit: Bonnie Jo Mount/Washington Post

Veteran Kelly Copelin, whose neck and throat cancer went misdiagnosed by a VA hospital for 13 months. Photo credit: Bonnie Jo Mount/Washington Post.

Levy continued to practice at the VHA for 15 years in part because, according to prosecutors, he easily defeated the agency's quality controls for pathologists. While his actual error rate was "nearly 10 percent, more than 10 times the normal frequency of mistakes by pathologists," Levy was able to make his error rate appear to be 0.7 percent or at times zero. So not only did the agency not fire him for showing up to work intoxicated (neither did Arkansas' medical licensing authorities, for that matter), the VHA paid him multiple bonuses atop his $225,000 salary while his lower-income patients endured unnecessary suffering and "horrible" deaths. Your tax dollars at work.

It would have been fairly simple for the VHA to adopt quality-control measures that Levy could not have defeated and that therefore would have identified his errors earlier and saved lives. But the VHA faces insufficient incentives to adopt such measures. It does not operate in a competitive market and neither the agency nor its employees face the same sort of liability for malpractice that private actors do. In a competitive market, these sorts of horrible consequences would damage a company's reputation and cause patients to flee. But the VHA is a near-monopoly government provider with a captive clientele who typically have no other options.  As for liability, Cato adjunct scholar Shirley Svorny writes

The 1946 Federal Tort Claims Act (FTCA) shields government-employed physicians from medical malpractice claims. This includes medical professionals who work for the Department of Veterans Affairs, the Indian Health Service, the Department of Defense, and other federal agencies. The FTCA makes the federal government responsible for defending federal employees when malpractice claims arise, and makes taxpayers liable for harm due to negligence...

Shifting liability for malpractice from physicians to taxpayers shields government physicians from underwriting and oversight by private insurers. Federal agencies, such as the Department of Defense and the Indian Health Service, do often create risk-management programs. Yet government agencies have less of an incentive to reduce the risk of negligent injuries than private malpractice insurers do, because the money at risk in a malpractice suit is a common resource (federal revenues), rather than a privately owned one. Because private malpractice insurers have more at stake in a malpractice suit than government agencies do, the government’s risk-management efforts are likely to be less rigorous. Indeed, federal investigators have found that in some cases, such as community and migrant health centers, the government is ill-equipped to provide risk management. In most cases, consumers would be better off were government agencies not to shield their physicians from malpractice immunity.

As an indication of whether the remaining incentives are enough to prioritize quality and patient safety, the Post reports:

Inspector General Michael Missal’s office in recent years has identified multiple VA physicians who continued to practice even after they were found to have compromised patient care. A report this year by the Government Accountability Office found weak systems for ensuring that problems are quickly addressed when a physician’s quality of care to veterans is compromised.

Veterans thus get hit by a double-whammy. The VHA has insufficient incentive to change -- that is, to save lives -- because killing veterans really doesn't affect the bottom line of the agency or of individual physicians. A single-payer, Medicare-for-All system would subject all Americans to the same double-whammy.

Second, the Post reports on a Journal of the American Medical Association article that alleges the Department of Homeland Security places unethical employment conditions on physicians who treat migrants in the agency's detention facilities. The authors of the JAMA article write:

[P]hysicians and other health professionals are often put into situations in which they cannot fulfil their obligations to their patients because of competing obligations imposed on them by detaining authorities; this is often referred to as the problem of dual loyalty. Given the reports of inhumane, overcrowded, and unsanitary conditions, including insufficient water and toilets, lack of clean clothing and bedding, high exposure to psychological stress, and poor medical care in many of the DHS processing and detention facilities, how can and should needed medical care for detainees be structured, especially given the dual loyalty challenges that emerge if physicians are employed by the agency in charge of detaining migrants?

First and foremost, health care professionals should insist on and adhere to clinical independence to ensure they are able to provide the highest standards of care that are in the best interests of the patient. This independence also demands that physicians and other health care professionals are not subject to retribution for reporting, both in medical charts and openly and transparently to authorities, including legislative oversight bodies, about their evaluations of conditions of detention that impede their patients’ health and the availability of quality medical care. Currently, all DHS employees, consultants, and subcontractors are required to sign nondisclosure agreements that are quite strict and clearly state that if violated, the person “…could be subject to administrative, disciplinary, civil or criminal action…” Such nondisclosure agreements could conflict with physicians’ primary duties to the health of their patients.

In addition, the Post reports, the U.S. Customs and Border Patrol refuses to provide flu shots to detained migrants, even though influenza has been a problem in its facilities and "at least three children died of the disease, according to autopsy reports." 

Yet this "dual loyalty" problem is just another manifestation of the same problem we see at the VHA. Each agency has interests that are different from and often conflict with those of their wards. The VHA and the doctors it employs value their patients but they also value stable budgets and job security. DHS, CBP, and their employees value national security but also stable budgets and job security. The main differences are: VHA employees care about their wards, while DHS and CBP employees are openly hostile to theirs; the VHA has a figuratively captive clientele, while DHS and CBP's clientele are literal captives; and yet, even so, the VHA probably does more to harm the health of its clientele. Such is the power of the principal-agent problem that it can overwhelm the agents' intentions to act in the interest of the principals.

The principal-agent problem appears in private-sector health care, too, where the interests of the insurer often conflict with those of the patient. (So does the interest of the physician, for that matter, and not only because of the insurer.) The solution to the principal-agent problem is to let principals (consumers) choose among different agents (health care providers). The resulting competition rewards health care providers who devise the best ways to align their interests with those of consumers. The reason the principal-agent problem is manageable in the markets for haircuts and auto repair is not that those services are less complicated than health care. It is because those markets are markets. In health care, government has defeated the market mechanisms -- principally, consumer choice and competition -- that would otherwise keep the principal-agent problem in check. 

There may be some scenarios where consumer choice and competition among health care providers may not work -- for example, when the patient is someone the government is holding captive. Better health care then becomes one more reason why the government should hold fewer people captive.

September 3, 2019 9:43AM

New Roads for Marijuana Research

By Jeffrey Miron and Erin Partin

News that the DEA is moving forward to improve access to marijuana for research purposes should be cause for celebration. But, if history is any guide, marijuana advocates should remain cautious. It has been three years since the process of increasing the number of entities registered under the Controlled Substances Act to “facilitate research involving marijuana and its chemical constituents” began. Prior to the 2016 announcement, the DEA had a monopoly on growing marijuana for research purposes. That no progress has been made in the past three years is outrageous, yet not unexpected from the prohibitionist bureaucracy of the DEA.

Israel, the Netherlands, and Canada are leading the way in marijuana research. Studies show that marijuana is an effective treatment for pain, epilepsy, Alzheimer’s, glaucoma, and other medical conditions. By refusing to expand researcher access to marijuana, the DEA is taking an indefensible stand against medical progress.

This might be a turning point in the fight for marijuana research, or it may be just another empty promise. One way or another, time will tell.

August 26, 2019 3:09PM

Hemp Bill Leaves Texas Prosecutors in the Smoke

By Jeffrey Miron and Erin Partin

News that Texas effectively decriminalized marijuana through poorly written hemp-farming legislation has upset state lawmakers and confused law enforcement officials and prosecutors.

The legislation in question, H.B. 1325, amended the state agricultural code to permit production, sale, and possession of hemp and CBD products containing a THC concentration of 0.3 percent or less. What lawmakers missed was the inability of state crime labs to determine THC concentration. Shortly after the act was signed by the governor, the Texas District and County Attorneys Association advised their members it might be necessary to wait until the state acquires equipment to perform the appropriate tests before pursuing legal action against marijuana defendants. In addition, the Texas Department of Public Safety informed police that, “effective immediately, personnel will cite and release for any misdemeanor amount of marijuana.”

In 2017, Texas made 62,057 arrests related to marijuana possession, accounting for 44 percent of all drug-related arrests and 8 percent of total arrests. Since 2010, even as total arrests have declined (from 1.1 million in 2010 to 0.8 million in 2017) the share of arrests attributable to marijuana violations grew from 6.8 percent to 8.2 percent.

But if the directives issued by the TDCAA and TDPS become the new standard, Texas could see a huge decline in arrests and prosecutions. This will generate budgetary savings and facilitate re-allocation of law enforcement and judicial resources to more pressing issues.

Texas may, of course, repeal HB 1325; or worse, spend taxpayer money on the necessary testing equipment. That would be a shame. Even though this de facto decriminalization was an accident, it was a good one.

August 16, 2019 10:15AM

On Oren Cass and Industrial Policy

A lot of “national conservatives” and those sympathetic to their economic goals have been pushing for the federal government to adopt an explicit “industrial policy.” Chief among them has been Oren Cass, a thoughtful scholar at the Manhattan Institute, whose writings on the dignity of work I’ve written briefly about before.

Though a lot of his arguments echo those heard historically or in other countries, his specific case is worth addressing directly, as it seems to be resonating in conservative circles. So today I’ve published an extensive critique of his recent speech at the National Conservatism conference as a Cato commentary.

In short, I’m disappointed by the lack of empirical grounding to his arguments. And I think he makes a fundamental mistake in assuming that, even if an industrial policy was feasible and could be faithfully executed, it would generate both “stable employment” for low-skilled workers and high productivity growth.

I conclude:

Oren Cass asserts that markets cannot generally allocate resources efficiently by industry. Yet he provides no meaningful metrics to show this is the case, nor shows why his policies would deliver better outcomes. His two main claims about the benefits of a manufacturing sector — “stable employment” and “strong productivity growth” — are directly contradictory. A plethora of evidence suggests as countries’ get richer due to automation and technological improvements, they demand relatively more services, and so the industrial sector declines in employment terms.

It would hurt, not improve, general economic performance to try to create stable employment in manufacturing industries given these trends, and would be particularly foolish given the likely rising demand for high-end manufacturing and services (healthcare, education, insurance, finance, etc.) as the global middle-class develops.

You can read the whole piece here.

August 16, 2019 9:54AM

It’s Not The Number of Pills – It’s The Number of Deaths That Matter

letter to the editor in the August 14 New England Journal of Medicine by researchers at the University of Michigan proudly reported on the results of their effort, called the Michigan Surgical Quality Collaborative (MSQC), to reduce the volume of opioids prescribed for postoperative pain. The Collaborative developed a set of guidelines for its participating prescribers.

As a result, they found that from January 2017 through May 2018, the mean number of pills prescribed for postoperative pain decreased from 26 (+/-2) pills pre-guideline to 18 (+/– 3) pills post-guideline. Patient pill consumption also decreased from an average of 12 pills (+/-1) pre-guideline to 9 pills (+/-2) post-guideline. During that period there was no discernible difference in the pain scores reported by these patients pre-and post-guideline.

It seems all of health care is now fixated on getting the number of prescription pain pills down. Yet there is no correlation between prescription volume and nonmedical use or use disorder/addiction. And as prescription volume has dramatically come down since 2010, the overdose rate has dramatically increased. Furthermore, in 2017 at least 75% of opioid-related overdoses were from heroin or fentanyl, while 40% of overdoses involving prescription opioids had multiple other drugs onboard, including heroin, fentanyl, alcohol, and tranquilizers.

So, as academic physicians continue to virtue signal and show the media and regulators how well they are complying with the "new opiophobia" by reducing opioid prescribing, the overdose rate continues to climb.

To be fair, an oversupply of prescription pain pills to patients can lead to more pills getting diverted into the black market for nonmedical users. But as a doctor who cares about reducing deaths, I would prefer that nonmedical users take diverted prescription opioids as opposed to heroin or fentanyl or counterfeit prescription pills made from fentanyl

The focus should be on the number of deaths, not the number of pills. For that to happen, policy must to shift to harm reduction.