Continuing Education for Doctors: What Your State Requires

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Medicine is highly dynamic. By one report, there are 4,500 pages of new findings produced every day — that’s a huge amount of material. A conscientious practitioner is going to spend hours each day on homework. Some doctors do, some don’t.

What do states require? There are requirements for continuing education in most (but not all) states in the US. That’s simple recognition of the fact that what one learns in medical school will become obsolete over time.

The states vary from no requirement for continuing education to a requirement of an average of 50 hours per year.  Here are the tiers. (1)

  • No requirement:
    • Colorado
    • Indiana
    • Montana
    • New York
    • South Dakota
  • 15 hours per year (average):
    • Vermont
    • Wisconsin
  • 20 hours per year (average):
    • Arizona
    • Arkansas
    • Delaware
    • Florida
    • Georgia
    • Idaho
    • Iowa
    • Kentucky
    • Louisiana
    • Mississippi
    • Nevada
    • North Carolina
    • North Dakota
    • Oklahoma
    • Oregon
    • Rhode Island
    • South Carolina
    • Tennessee
    • Utah
    • Wyoming
  • 24 hours per year (average):
    • Texas
  • 25 hours per year (average):
    • Alabama
    • Alaska
    • California
    • Connecticut
    • District of Columbia
    • Maryland
    • Minnesota
    • Missouri
    • Nebraska
    • New Mexico
    • West Virginia
  • 30 hours per year (average):
    • Virginia
  • 33 hours per year (average):
    • Kansas
  • 50 hours per year (average):
    • Hawaii
    • Illinois
    • Maine
    • Massachusetts
    • Michigan
    • New Hampshire
    • New Jersey
    • Ohio
    • Pennsylvania
    • Washington

How much is enough? None is probably not good. Even 3 days per year seems light.

The problem is that doctors can’t be counted upon to sign up for training when it isn’t required. In one example, in 2015, to counter the current epidemic of painkiller abuse, the FDA required drug makers to offer opioid training classes for physicians. Unfortunately, only 38,000 of the roughly 320,000 physicians who prescribe these drugs signed up for the classes. (2)

What training has your doctor taken recently?


Sources:

  1. Medscape, “State CME Requirements,” last updated April 2016. http://www.medscape.org/public/staterequirements
  2. Bloomberg, “Undertrained Doctors, Overprescribed Drugs,” 4 May 2016. https://www.bloomberg.com/view/articles/2016-05-04/undertrained-doctors-overprescribed-drugs

Sources of a No Growth Economy

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ben_franklinYounger people are putting off marriage, children and buying  homes because they lack financial security — unstable jobs and too  much student loan debt.

That’s one of the interpretations of a new report from the Census Bureau on Millenials. (1)

In looking at generational change, the report compares 18 to 34-year-olds in 2016 versus 1975.  In looking at just the older portion of this group, 25 to 34-year-olds, there are striking differences:

  • 1975: 45% lived on their own, were working, had married and had a child.
  • 2016: 24% live on their own, are working, have married and have a child.

From the point of view of the economy, the difference is huge. Buying a home drives spending on furniture and appliances, as well as painters and a range of other services. Having children drives demand for larger cars and clothing. Doing neither reduces spending in all of these categories.

The average income for 25-34-year-olds in 1975 was $30,101. In 2016, it was $43,751. That sounds good until you factor in inflation.

  • A salary of $30,101 in 1975 dollars is worth $134,283 in 2016 dollars.
  • The percent of people with student loans has climbed from 17% in 1975 to 41% today.

More people have gone to college, but they’re paying more for education in order to earn functionally less than their parents.

The report also notes that among the growing percentage who live with their parents, there are issues with health or grandchildren that interfere with employment. There’s also an issue with a cohort of younger white males who lack a college degree and have very limited employment prospects.

As long as politicians ignore these trends, efforts to keep the economy going will run out of steam.  In this context, Andrew Cuomo, the government of New York, seems especially prescient in eliminating college cost as a burden for many New York residents.

 


Sources:

  1. Vespa, Jonathan, “The Changing Economics and Demographics of
    Young Adulthood: 1975–2016,”Current Population Reports,P20-579, U.S. Census Bureau,Washington, DC, 2017.

Politicians Take Care of Themselves

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This is either sad or funny.

24/7WallStreet ranked counties in the US on a combination of three measures:

  • Education (economic status of residents)
  • Poverty rate (how the local economy is doing)
  • Life expectancy (a measure of health and medical services)

The top 5 counties in the US (and 7 of the top 10) on these measures are suburbs of Washington, DC, where Congress lives.

  1. Falls Church (Independent City), VA ————————————- (DC metro)
  2. Arlington County, VA ———————————————————– (DC metro)
  3. Fairfax County, VA ————————————————————— (DC metro)
  4. Loudoun County, VA ————————————————————- (DC metro)
  5. Howard County, MD ————————————————————- (suburb of both DC and Baltimore; location of Columbia, MD)
  6. Douglas County, CO (part of Denver metro area)
  7. Los Alamos, NM (Federal nuclear research center)
  8. Fairfax (Independent City), VA ———————————————- (DC metro)
  9. Marin County, CA
  10. Alexandria (Independent City), VA —————————————- (DC metro)

Surprised?

Conversely, the worst counties in which to live are

  1. McDowell County, WV
  2. East Carroll Parish, LA
  3. Issaquena County, MS
  4. McCreary County, KY
  5. Clay County, KY
  6. Holmes County, MS
  7. Quitman County, MS
  8. Jefferson County, MS
  9. Calhoun County, GA
  10. Stewart County, GA

Given what I’ve posted recently on education and healthcare in the South, this list shouldn’t come as a surprise either.


Sources:

  1. http://247wallst.com/special-report/2017/01/13/the-worst-counties-to-live-in/
  2. http://247wallst.com/special-report/2017/01/24/the-best-counties-to-live-in/?utm_source=AOL&utm_medium=CPC&utm_content=the-best-counties-to-live-in&utm_campaign=AOL

ACA Repeal, Again

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According to Bloomberg, the White House wants Congress to vote on a revised bill next week.  There are some proposed amendments to the bill that failed in March in an effort to try to unify GOP House members to support the bill, but nothing has been finalized.

One item being considered is a proposal by Representative Tom MacArthur (R, NJ):

The amendment, reported earlier by Huffington Post, would allow insurers to charge higher premiums to people with pre-existing conditions in states that get a waiver. To obtain the waiver, states would have to provide sick people priced out of commercial insurance access to a so-called high-risk pool run by the federal government, or establish their own, and satisfy other conditions. (1)

A separate commentary on the same issue goes further:

According to a draft of the tentative deal obtained by POLITICO, the latest proposal would allow states to apply for “limited waivers” that would undermine Obamacare’s protections for pre-existing conditions. Under these waivers, states could opt out of Obamacare standards setting minimum benefits that health plans must offer and a requirement — called community rating — forbidding insurers from charging different prices to people based on health status. Both are provisions that the GOP’s ultraconservatives have pushed to eliminate as part of the repeal effort, contending that these coverage mandates drive up the cost of insurance.

What this means in practice is a two-tiered health system based on where people live. People in places like Mississippi and Kentucky that have relatively poor healthcare now, will have less access to healthcare and higher costs in the future. Conversely, states that offer better healthcare will maintain existing benefits. That’s a compromise that could pass, or could just make everyone unhappy.

Overall, this attempt keeps the negatives associated with the bill, and adds one more. Historically, risk pools haven’t worked. They’ve been budget-breakers when they’ve been tried for auto and health insurance in several states. If anything, more people will lose health coverage and costs will escalate as predicted by the CBO.


Sources:

  1. Billy House, Jennifer Jacobs, “White House, GOP leaders at odds over plans for Obamacare vote,” BenefitsPro, 20 April 2017. http://www.benefitspro.com/2017/04/20/white-house-gop-leaders-at-odds-over-plans-for-oba?kw=White%20House%2C%20GOP%20leaders%20at%20odds%20over%20plans%20for%20Obamacare%20vote&et=editorial&bu=BenefitsPRO&cn=20170420&src=EMC-Email_editorial&pt=News%20Alert
  2. Adam Cancryn and Josh Dawsey, “White House plans Obamacare showdown next week,” Politico, 20 April 2017. http://www.politico.com/story/2017/04/20/obamacare-repeal-republicans-new-deal-237397

 

Political Polarization

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If you think political dialog is becoming nastier, you’re right. A recent survey by Pew documents that differences between liberals and conservatives regarding the current president are more extreme than at any time in recent US history.

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Democrats  disapprove of Trump more than they disapproved of any other Republican president. Further, they disapprove of Trump more than Republicans ever disapproved of either Obama or Clinton, at the comparable point in their term in office. Conversely, the Republican base is still strongly behind Trump.

That’s probably bad news for Trump. While there’s not much more he can do to alienate Democrats, he can lose independents who “lean Republican”, and that would affect the 2018 midterm elections. Percent approval among those who “lean Republican” may never change, but the number of people who “lean Republican” may shrink. Based on the history of other presidents, it probably will.

 

ACA Rule Changes

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If you were waiting for changes that would actually help consumers, don’t hold your breath.

Absent the actual repeal the administration sought, it announced rule changes late yesterday affecting consumer access to healthcare and the percent of costs health insurance will cover under marketplace plans. The point of the changes is to incent insurers to continue offering health insurance on the ACA marketplaces. The technical term for this is “market stabilization.”

A cynic might wonder why these changes come out on the even of holidays when most people will be distracted and might not notice.

The rule changes focus on what the insurance industry calls “adverse selection.” Insurers are concerned about people buying coverage only when they expect they will use it, and then dropping it immediately — which forces the insurer to take a loss on the policy.  The rule changes are designed to prevent that.

Here’s the basics:

  • Silver level plans will cover 66% of consumer medical costs, down from the original 70% requirement.
  • The new rules increase also increase subsidies to consumers buying these plans — provided the administration actually commits to making these payments.

At issue are cost-sharing payments that low-income people enrolled under the healthcare law receive to help cover out-of-pocket expenses. Trump has threatened to withhold the payments as a means to force Democrats to negotiate on healthcare legislation.(2)

[Actually, these subsidies can help people making up to $60,000 per year, which is more than “low income.” Half of US households earn less than that.]

  • As previously noted, the enrollment period is being shortened from three months to six weeks, starting November 1st.  Given the problem that CMS has had in handling the volume of people applying for coverage in the longer period in the past, it’s essential for consumers to apply as early as possible.
  • The administration is making it harder for consumers to qualify for special enrollment periods (SEPs). More people will be required to submit supporting documentation than in the past, which will extend the time required for enrollment. If approval is delayed by three months, the consumer will be required to pay for coverage for two of those months.
  • Consumers are being restricted in terms of their ability to change levels of coverage using a SEP.
  • Insurers can refuse to cover people who have failed to pay premiums for this insurance in the past. If you’ve had coverage and dropped it, you may have to wait a year or more before being able to get coverage again.
  • The determination of whether an insurer has an adequate network of doctors and hospitals in a state will be turned over to the state. Some states are much more rigorous than others.

The new rules don’t address some of the key issues challenging insurers:

  • Will the government continue to pay subsidies to help people afford insurance?
  • Will the government use financial penalties to force consumers to carry insurance?

Trump has said that he would eliminate the penalties and the subsidy, but his bill didn’t pass and no one knows about  his current thinking. A negative on the first question will drive insurers out of the market. A negative on the second will raise costs for everyone who needs insurance.

There’s speculation that the reduction in benefits for the silver policy might allow insurers to reduce the cost of these policies. However, any reduction will be subject to higher out-of-pocket costs for consumers who do incur expenses. The net impact isn’t clear.

Are these rule changes even needed? The Congressional Budget Office has stated that it expected the insurance markets to be stable in 2017 without these changes.  So, what is the point?


Sources:

  1. Virgil Dickson, “White House finalizes ACA rule to strengthen individual market,” Modern Healthcare, 13 April 2017. http://www.modernhealthcare.com/article/20170413/NEWS/170419936?utm_source=modernhealthcare&utm_medium=email&utm_content=20170413-NEWS-170419936&utm_campaign=am
  2. Associated Press, “Democrats seek to resolve health payments on spending bill,” 14 April 2017.
  3. Timothy Jost, “Examining The Final Market Stabilization Rule: What’s There, What’s Not, And How Might It Work?” Health Affairs Blog, 14 April 2017. http://healthaffairs.org/blog/2017/04/14/examining-the-final-market-stabilization-rule-whats-there-whats-not-and-how-might-it-work/

Just how smart are you with your money?

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The Future is coming, whether you like it or not. In fact, some parts are going to be very ben_franklinpositive, and some aren’t. You have to be prepared to deal with both. The sooner you start to prepare, the lower your costs will be!

We like to think about buying a house, buying a car, fancy weddings, babies and graduations. We don’t like to think about down payments, maternity costs or paying for college. However, as economist Milton Friedman famously wrote, “there’s no such thing as a free lunch.”

The statistics are simple.

  • The average life expectancy (LE) in the US is 78.8 years (1) — shorter for the poor and Southerners; longer for women and the affluent.
  • The healthy life expectancy (HLE) in the US is 68.1 years. By comparison, the HLE for Bosnia is 68.8 years and for Canada it’s 72.3 years. (3) HLE in the US varies by state and is shorter for Southerners. (2)
  • The difference between LE and HLE is the amount of time you can expect to have to deal with some kind of physical impairment. In the US, that amounts to a decade of trouble on average.

A new study confirms what people with elder parents already knew: older people need help with daily living. Even if they are fairly independent, both finances and medications can get out of control. They may not have or want to be dependent on family members to manage either.

Over 10 years, 10.3% of those aged 65 to 69 needed help managing medications and 23.1% needed help managing finances. These rates rose with age, to 38.2% and 69%, respectively, in those over age 85. Women had a higher risk than men, especially with advancing age. Additional factors linked with an increased risk for both outcomes included a history of stroke, low cognitive functioning, and difficulty with activities of daily living. (4/5)

There are resources, but they aren’t free.

  • The average cost of in-home healthcare in the US is $3,600 per month, as I mentioned in a prior blog. The average cost of a nursing home is $9,200 per month. Medicare can pick up the first 100 days. One of the Trump proposals for Medicaid reform involves eliminating Medicaid as a way to deal with these expenses.
  • There is a  category of professional, “daily money managers.” These aren’t financial planners, but they deal with records management, budgeting, checking the validity of expenditures, and bill payment. Costs for these services vary but can start at around $450 per month. (6) Not only do they keep things together for their clients, they are an important line of defense against scammers preying on seniors.

So, how are your parents going to deal with this? How are you going to deal with this when it’s your turn?

These problems are  best addressed when you do what most people don’t — act early on them.

  • Set aside dedicated savings for retirement.
  • Purchase permanent life insurance with a rider that allows you to take up to 50% of the face value of the policy for disability and long term care expenses. (7)

Both of these actions are best done earlier in life rather than later

  • Starting savings early allows the most time for compounding of interest.
  • Starting life insurance early minimizes cost. Insurance premiums are directly related to the length of time the carrier expects to have your money before they have to pay out. The earlier you buy, the less it will cost and the more you can afford. For example —
    • In NJ, for a woman age 24 non-smoker, a new $200,000 whole life policy might cost $113.68 per month.
    • In NJ, for a woman age 44 non-smoker, the same policy would cost $365.08 per month.
    • In NJ, for a woman age 59 non-smoker, a new $100,000 policy would cost $395.08. From the carrier used to quote these examples, a $200,000 whole life policy would not be available for someone that age.

With age, the price goes up and what you can buy goes down.

Procrastination costs you money. Don’t put this off.

If you practice a healthy life style, you can try to minimize the gap between LE and HLE, but you can’t count on eliminating it. There are just too many factors outside of your control (e.g., ice, drunk drivers, pollution, etc.).

 


Sources:

  1. Centers for Disease Control and Prevention, “FastStats,” 17 March 2017. https://www.cdc.gov/nchs/fastats/life-expectancy.htm
  2. Centers for Disease Control and Prevention, “State-Specific Healthy Life Expectancy at Age 65 Years — United States, 2007–2009,” 19 July 2013. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6228a1.htm#fig1
  3. World Health Organization, “Healthy Life Expectancy at Birth — 2000 to 2015,” http://gamapserver.who.int/gho/interactive_charts/mbd/hale_1/atlas.html
  4. Nienke Bleijenberg, Alexander K. Smith, Sei J. Lee, Irena Stijacic Cenzer, John W. Boscardin, Kenneth E. Covinsky. Difficulty Managing Medications and Finances in Older Adults: A 10-year Cohort Study. Journal of the American Geriatrics Society, 2017; DOI: 10.1111/jgs.14819
  5. Wiley. “Many older adults will need help with managing their medicines and money.” ScienceDaily. ScienceDaily, 7 April 2017. <www.sciencedaily.com/releases/2017/04/170407113035.htm.
  6. For those in the NJ area, I have a friend, Nancy Sobin, who offers these services. Please see her at http://paperwork-services.com/. She belongs to the American Association of Daily Money Managers, http://www.aadmm.com/.
  7. There are some companies that offer these riders for term insurance, which is much less expensive than permanent. The problem is that term insurance typically terminates by age 65, and home or nursing home care expenses typically start after that age. There’s no point having a rider that’s not going to be in force when you need it.