Archive for March, 2012

Thoughts on “Why Aren’t State Exchanges Embracing Prudent Purchasing Strategies?”

March 19, 2012

Why Aren’t State Exchanges Embracing Prudent Purchasing Strategies?


The following are some of my thoughts on a March 19th, 2012,  Health Affairs Blog by:
by William Kramer


for the original blog.

My Thoughts:

It is easy to miss the real problems with the state exchange model. When this happens it is comforting to think that we might tweak a system a bit that was, in what will be the final analysis, guaranteed to fail from the start. Under the tweak approach we can fix a few isolated problems in much the same way that Copernicus fixed a few of the problems with the geocentric universe.

The problem, unfortunately, is that in insurance markets there actually is a single best, most efficient, and least problematic design. The optimal size for an insurer is the largest possible portfolio possible. In the case of health benefits this would entail eliminating hundreds of smaller, less efficient health benefit plans and insurance policies in favor of a single insurer covering all 309,000,000 Americans.

This single insurer, with a single set of benefits, a single set of forms, a single set of standards for evaluating the costs and outcomes of interventions, is the most mathematically efficient insurer possible.

By efficiency I refer, of course, to the proximity the insurer’s loss ratio to the population loss ratio for the population served. No smaller insurer will have loss ratios as close to the population loss ratio as the single largest insurer possible. In fact, simple applications of the Central Limit Theorem will allow us to specify how much further from the population loss ratio a smaller insurer’s loss ratios are likely to fall.

If a relatively large and reasonably efficient insurer, our Paradigm Insurer, has a loss ratio that wobbles around the population loss ratio of 0.7500 from year to year, in a manner that suggests that about 95% of years will produce loss ratios of 0.6500 to 0.8500, how far from 0.7500 would our national health insurer’s loss ratio be likely to fall over the same number of years if it is insuring 309,000,000 and offering identical benefits?

The answer is that the national health insurer’s loss ratio would lie between about 0. 7443 and 0.7557. This assumes that the standard error of the estimate of the population loss ratio for the Paradigm Insurer is 0.0500 and multiplies this by the square root of the ratio of the size of the national health insurer’s portfolio to that of the Paradigm insurer. In short, the standard error of the estimate of the population loss ratio for our national health insurer is about 0.0028, far lower than the Paradigm Insurer’s standard error.

Among the advantages of this largest possible insurer are that it would have a higher probability of achieving reasonable profits, it would have a far lower probability of incurring solvency threatening losses, it would provide higher benefits per premium dollar than any smaller insurer, and it would need far less surplus to assure its solvency. From a purely mathematical viewpoint there is no number of insurers greater than 1 that can compete with these operating characteristics.

No amount of political ranting and intentional misinformation can overcome the obvious advantage of a national health insurer yet this does not stop either the ranting or the intentional misinformation.

Even beyond the mathematical superiority of a single, optimally sized national health insurer, is the elimination of all the inefficiencies that accrue with hundreds of insurance companies, thousands of specific benefit benefit plan inclusions and exclusions, the resulting uncertainties about benefit eligibility, and the massive litigation over benefits, not to mention the waste and inefficiencies involved in insurance underwriting, rate making, reserving, and capitalizing all these inefficient insurers.

So, given that there actually is a mathematically, single most efficient insurer, we must focus on why we continue to look everywhere else but there for solutions to our problems, with all too predictable results.

In the final analysis the answer seems clear enough. Our current system of hundreds of health insurers and health benefits companies accomplishes something that the national health insurer will never be able to accomplish. We succeed in rationing care, limiting access to health care, delaying and denying potentially expensive health care services at arm’s length through our current system.

If we implement a national health insurer we will actually have to decide, and explain in detail, what benefits everyone will be eligible to receive. Politicians and benefit overseers will have to go on record and state that certain kinds of services will not be paid by the national health insurer. Perhaps we will not provide liver transplants to life long alcoholics. We may not provide tube feeding for near comatose patients in their 90s who have not communicated with anyone for years, but are lying in nursing homes because some entity is paying for their care.

This enormously successful ability to ration care, at arm’s length, with the notion of “Plausible Denial” about what we are doing, is the most obvious benefit our fragmented and fractured health care (finance) systems bestow at this point. Unfortunately, our fragmented and fractured health care (finance) systems provide this cover at far greater cost to individual patients, health care providers, payors, and the public at large, than would be the case with an optimally sized national health insurer.

So, the answer really is that the efficiencies the authors suggests could be achieved by combining state health insurance exchanges purchasing with better, more efficient benefit plan purchasers is exactly what our policy planners, researchers, and politicians are working so hard to avoid – a coherent, well documented, health benefit plan that would equally well serve everyone in the United States, where everyone would know what benefits were available, and in which those benefits would actually be provided.

Combing purchasing would eliminate the finely orchestrated system of inconsistent benefit entitlement determinations that have been finely tuned by insurers and insurance risk assuming health care providers, who are motivated by the increased profitability that denying and delaying services provides to them.

This finely tuned health care rationing system saves trillions of dollars each year compared to any imaginable system in which everyone would have the same exact access to health care services whether they were active duty military personnel, homeless veterans struggling with war zone injuries and PTSD, senior citizens, the poor, transients, college professors, or factory workers.

Apparently almost nobody in America really wants an efficient health care finance system or we would already have one since the mathematical basis for such a system is abundantly clear.


Governing Bodies and Spaces: A Critical Analysis of Mandatory Human Immunodeficiency Virus Testing in Correctional Facilities

March 17, 2012

I just read this article and since I was recently working in a prison correctional system I was intrigued to see if it would offer some new insights into the experiences of prisoners and my own reflections on the experience of correctional health care and correctional nursing.

The upside of such an article would be that it might draw correctional nurses into a new way of viewing the world they encounter and and become more politically aware of the environment. I am not sure this will happen, not because it would not be good, not because of what I see as some fundamental flaws in the article, but because correctional nurses are probably far less likely to entertain such thoughts than ANS’s readers, bloggers, and authors and even far less likely to read ANS than non-correctional nurses.

I would never suggest that my reflections are a fair representation of the reflections of anyone else. Since first reading Rosenhan’s “On being sane in insane places” I have been acutely aware that intentionally creating an opportunity to immerse oneself in an unusual role and environment, and intentionally reflecting on one’s own experiences, in such a setting, is far from normative behavior and that the insights, experiences, reality constructions, and descriptions of these environments by intentionally self-selecting and self-reflective individuals tend not to be anything like the insights, experiences, reality constructions, and descriptions of these environments by their customary participants.

So, some thoughts that I had during and since my participation in correctional health may be of interest, or not. I am however, almost certain that very few nurses working in correctional health will read them in this forum. Even more jarring, I find that my views are changing, cycling repeatedly as I adopt different perspectives for my self-reflections.

I was pretty sure, upon entering the system, that I would be dissatisfied with the quantity and quality of health care provided to inmates. I was right and I continue to be deeply troubled by that, though as I will suggest, there are some mediating issues.

I also assumed that I would find little, if any, “left of center,” or “liberal” political rhetoric in the environment. It was actually quite a bit worse than I imagined. Most of my training and orientation activities were with new correctional officers and/or correctional officers having mandatory annual training. These are not left leaning groups. It brought back a lot of memories of what it was like to be against the Vietnam war in 1964 when most of the country was still believing the party line that it was necessary and appropriate.

Before I get too carried away, I should focus on some of the surprises. I had previously worked in a maximum security prison as a mathematics teacher. Despite some exposure to some really bad, deeply damaged human beings, I still had a tendency to romanticize prisoners. It is not at all hard to do this as I think the article does to some degree. To be certain there are innocent people in prisons all across the world. This is a travesty because prisons are not good places for the thoroughly corrupt and amoral, and most certainly not for the innocent.

But innocent is a relative term. In my own area one doesn’t have to look very far to see that there are an awful lot of people who are not in prisons who ought to be there: Repeat offenders in crimes of assault, manslaughter, armed robbery, breaking and entering, sexual assaults, etc. I have become ever so much more acutely aware when I read local news stories that someone committed a crime who has been convicted of, or plead to, dozens of crimes in the past and has been repeatedly released only to commit new crimes.


I remember asking the Warden at my facility, after a neighbor who had been arrested for possession of firearms, drug dealing, possession of drug related equipment and materials, and a few other crimes came back home after a one night jail stay, “What does someone have to do to be incarcerated in this state?”

So it is perhaps important to recognize that very, very few people who are incarcerated in prisons today are completely innocent. They may, in fact, not be guilty of the crimes for which they were convicted, but there is a good chance that they were guilty of other crimes and that the notion that there are large numbers of innocent, political prisoners, in American prisons and jails is likely a fantasy. This was certainly not true in the first half of the 20th century, somewhat less true in the second half, and far less true in the second decade of the 21st century.

So, even being far more reflective and generally of a persuasion that prisons are filled with political prisoners than virtually all of my co-workers, I have to say that innocence is likely to be a very rare commodity in prisons.

This then goes to the heart of some of the issues addressed in the article. Yes, prisoners are segregated in prisons for a variety of reasons and their activities are closely monitored, though I would argue that they are not monitored anywhere near as closely as they ought to be. If they were more tightly monitored there would be far fewer prison assaults, thefts, and rapes. Security in prisons, as in the world, tends to come at the expense of freedom to do as we please. In prisons this is necessary because we are dealing with a population that is already starkly different than the non-prison population.

I was alternately surprised and appalled at the caring and uncaring attitudes of doctors and nurses, the skills and lack of skills, the commitment to patient’s well being and the lack of such commitment. In the setting I was in 60-70% of the nurses were agency/temp nurses. Many did not come back after their first 1 – 2 shifts either because, like me, they realized they could not accept the level of care being provided, or risk their licenses in a dysfunctional setting. But many were simply unwilling to work so hard.

Far too many nurses came in, sat down, and their attitudes toward their roles/patients brought to mind Bob Dylan’s lines from “Just Like Tom Thumb’s Blues”:

“Because the cops don’t need you
And man they expect the same. “

Far too many nurses felt that merely arriving, sitting in the nursing station, and feigning only the slightest interest in patients, was more than anyone ought to have expected from them.

As it turns out, upon looking into the matter, I realized that there were an overwhelming disproportionate number of registered nurses with “9”s as the first digits of their license numbers within 5 miles of the facility. There were four people in my nursing school graduating class who I knew had prior criminal records, all of whom had the tell tale “9”s in their licenses while all the rest of my classmates that I looked at did not. So I knew what I was looking for when I did a geographic analysis of nurses in the area around the highest concentration of prisons in the state.

So one of the most important lessons I took away from the situation was that the nurses with whom I worked in the correctional health system, were not really reflective of the nurses I went to school with, nor with the nurses in the community. This is of particular importance when we consider the manner in which test results were reportedly conveyed to patients in the article. To say I am not surprised that the communication was callous, understates the reservations I have about the quality of care in correctional health systems. The problems prisoners face in accessing care in prison facilities ought to be of farm greater concern than the incidental harms presented by mandatory HIV testing.

But again, I think it is important to contextualize some of this. While the nurses’ behavior was poor, it didn’t take long to realize that the behavior of prisoners was part, though certainly not all, of the problem. Prisoners are confined to prisons, for the most part, because they routinely violated community norms of behavior, intruded on the rights of others, lied, cheated, and manipulated people during their careers as citizen criminals. These behaviors continue inside prisons and many of the issues related to supervision and control occur because prisoners have 24 hours a day, 7 days a week, to sit around thinking about how to screw with the system and how to make trouble for, and manipulate correctional staff.

It doesn’t take long to realize that the relationships between prisoners and correctional nurses are nowhere near as healthful and sincere as the relationships between nurses and patients outside of prisons, though I would be the first to argue that the relationships between nurses and patients in the community are more and more likely to be deceitful and fraudulent because of the way we finance health care in the US.


It is, at best, a challenge to be a nurse in a correctional environment because nursing is always, and quite frankly ought to be, subordinate to security in correctional health settings. I personally struggled with one of the most difficult standards of interaction: referring to “patients” as “inmates,” finally all but abandoning the word “inmate” in any of my discussions about health issues. Some patients and staff resented that, some appreciated it, and most seemed to take no note at all.

That said, I remain both appalled and deeply concerned about the quality and quantity of health services, available to prisoners, the manner in which those services are provided, and the nature of the relationships between nurses and patients in correctional settings. But, I also think the issue of HIV testing is a bit more complex than that portrayed in the article.

In normal nurse-patient, and citizen-citizen interactions, there is at least a thin veneer of sociability and reciprocity. People in ordinary, non correctional settings still engage in risky behavior on many levels. But one is highly unlikely to encounter a sociopath in the community because the sociopaths are disproportionately represented in prison populations (Well, except for Wall Street investment firms). But in correctional facilities the number of sociopaths is very high (See below).

Even when prisoners do not qualify as true sociopaths, their behaviors are very likely to mimic those of true sociopaths. So, a case can be made for isolation, supervision, identification, and control of prisoners who are HIV+/AIDS, have Hepatititis, or other communicable diseases because in prison settings these people are far more likely, than in civilian populations, to knowingly and intentionally infect others.

Not restricting such inmates from working in food preparation areas would be an actionable tort if such inmates were allowed to work in these areas and used that opportunity to harm other patients. In fact, one might imagine a series of articles on the failure of prison officials to protect general prison populations from harm if they allowed prisoners who are HIV+/AIDS, have Hepatitis, or other communicable diseases access to food preparation areas.

As I suggested above, prisons are dangerous places. I think a strong case might be made that in general the most sensitive, caring, compassionate, and altruistic prisoners are less so than the least sensitive, caring, compassionate, and altruistic correctional health system nurses. It is all too easy to compartmentalize on either side of the rights of prisoners and the duties of nurses. It is far too easy to romanticize prisoners and denigrate correctional nurses.


Prison budgets are inadequate and becoming more so. Prisons house a very large number of socially maladapt people as prisoners and staff. But, we ought not forget that we have prisons, with all the problems and contradictions this entails in modern day democracies, because there are some people who, if left to their own consciences, will intentionally and repeatedly harm others.

In the 2002 article: Fazel, Seena; Danesh, John (2002). “Serious mental disorder in 23 000 prisoners: A systematic review of 62 surveys”. The Lancet 359 (9306): 545. doi:10.1016/S0140-6736(02)07740-1; the authors suggested that 47% of male prisoners and 21% of female prisoners had antisocial personality disorder. I’d go a step further and suggest that adopting the attributes of people with antisocial personality disorder may be a necessary and appropriate adaptive response to incarceration, elevating the number of quasi-sociopaths one is likely to encounter significantly when one is inside a correctional facility.

In the final analysis I come back to something that disturbed me at the very beginning of the article, when the authors stated:


“We begin this discussion by rejecting the idea that testing prisoners without their consent is somehow justified or somewhat necessary. We also reject the notion that more aggressive forms of testing are warranted in correctional facilities and the common perception that early detection is inherently beneficial for prisoners.”

I think the premature rejection of these ideas weakens the authors’ arguments.

There are, I would suggest, compelling reasons for differentially identifying, isolating, and restricting the behaviors of some prisoners whose biological capability to cause lethal harm to others, exceeds those of prisoners without such biological capabilities, because the populations of prisons are dramatically different than the populations outside prisons. Failing to address the most significant reasons why it might be appropriate to engage these prisoners in different ways than other prisoners fails to be compelling chiefly because it ignores the most profound considerations involved, and hence fails to refute the case that might be made by people who see the issue differently.

I think one could analyse the failure to identify and segregate, given the capability to identify and segregate, in much the same way the authors approach their work. Would it not be incumbent upon prison officials who could identify and segregate some prisoners who represent a significantly higher than average risk of harm to others, to do so? Indeed, would not their failure to act, to protect staff and other prisoners, be a classic case of negligence?

In the end, the best way to preserve one’s own individual liberties is by not self-selecting conduct highly likely to lead to incarceration. The more one avoids such conduct the less likely one is to suffer the consequences of incarceration.


It is important to note that I assume that incarceration is highly likely to be life threatening because of the obvious inadequacy of care in penal settings. Prisoners are far more likely to be affected by callous denial and delay of diagnoses than by premature diagnoses. In my limited experience I would be inclined to think that even so short a prison stay as 5 years is highly likely to result in premature death from treatable but undiagnosed and/or untreated conditions, and that these harms are more significant and affect more prisoners than the harms resulting from mandatory HIV testing.

In fact, one might argue quite the opposite, that mandatory testing carries with it the possibility of legal action; by, or on behalf of, prisoners, to demand treatment from prison systems notoriously disinclined to diagnose and treat HIV+/AIDS patients.


We know what we know about the incidence and prevalence of highly communicable diseases in prison populations because of mandatory testing protocols, without which we would know so much less than we do, and this knowledge can potentially lead to better care, rather than harm to the prisoners affected, which would be inconceivable without such protocols.


I suspect I spent a lot more time, during entry and exit,  between the two main gates, doing Sly Stallone’s assessment, as John Rambo, in First Blood, of how to escape from the facility I worked in than most of my colleagues. It helps me in thinking of how the prisoners themselves view their situation, and how they interact with each other and the staff. It leads me to conclude, at least at the moment, that prisoners appropriately spend most of their time trying to figure out how to attain and maintain an advantage in a very dysfunctional environment, and that many of the ways they would do that would involve inflicting knowing and intentional harm onto others.


This alone may be sufficient to justify the disparate treatment accorded to those with communicable illnesses.