Upside Down Health Care: Why It Matters

Posted by on Monday, Aug 15, 2011

Up to the middle of the last century, most Americans could count on good access to generalist primary care physicians with the training and commitment to evaluate and treat their medical problems, whatever they might be. Those days are long gone. The ratio of generalist physicians to specialists in this country reversed from about 80:20 percent in 1930 to 20:80 percent in 1970. Since then we have seen the generalist tradition being carried on by family physicians, general internists, general pediatricians, and osteopathic physicians, but their aggregate numbers today are no more than 30 percent. And that number is falling fast as more medical graduates seek out the higher pay and more attractive life styles of the non-primary care specialties.

These are some of the major ways by which Americans are hurt by the growing deficit of generalist physicians:

1. Can’t get a primary care physician.
It is getting harder and harder to find a generalist primary care physician still open to accepting new patients. In Massachusetts, for example, the passage of legislation in 2006 expanding insurance coverage for many people exposed a critical shortage of primary care physicians. (Fitzgerald, J. State medical group sees severe shortages in 10 specialties. Boston Herald, October 20, 2010) Patients on Medicare and Medicaid have particular problems finding a physician willing to take them on due to low reimbursement through those programs. Under the banner of fiscal austerity, many states are cutting Medicaid to the bone. In California, for example, where Medicaid (Medi-Cal) covers one in five Californians, Medi-Cal payment rates for physicians and other providers have been cut by 10 percent to just $11 a patient visit (Corcoran D. Doctors say Medi-Cal reimbursement is too low. San Francisco Chronicle, August 4, 2011) Even if one has a primary care physician today, the likelihood of a continued relationship in the future is becoming increasingly clouded due to physician retirements, mobility among physicians, and changes of providers in insurer networks that often force changes of physicians.

2. No access to breadth of primary care.
People without a primary care physician don’t get access to the breadth of primary care anywhere else in our “system”. Specialists are not trained or equipped to provide preventive services across the board, care for acute and chronic problems for patients of all ages, continuity of comprehensive care for all medical problems for years, with knowledge and understanding of their patients’ family and community setting. Emergency rooms and urgent care centers can focus only on the most acute problem at the time, with little follow-up, while so-called “retail clinics” for walk-in care are limited to non-emergency and low-acuity problems. As a result, many of the potential advantages of primary care are not available to a growing part of our population.

3. Higher costs and unaffordability of care.
Specialty care costs more than primary care—a lot more, for a number of reasons. For new medical problems, specialty physicians have to start “cold”, without context or knowledge of the patient, often ending up repeating tests and procedures that have been done previously, charging more than primary care physicians, and in the case of multiple medical problems, typically having to call upon other specialists for care. Since primary care physicians know their patients better, they order fewer tests than specialists, and help to protect their patients from inappropriate and unnecessary care. (Schoen, C, Osborn, R, Doty, M, Bishop, M, Peugh, J et al. Toward higher-performing health systems: adults’ health care experiences in seven countries. Health Affairs (Millwood) 26: w 717-34, 2007)

4. Foregone necessary medical care.
Foregone care is widespread and increasing. These markers document this growing trend:

• In the last year, one in three Americans skipped care, did not fill a prescription, or get other care because of cost. (Parashar, A. Compared to other countries, U.S. patients have more access to specialists, less to primary care. Kaiser Health News, November 18, 2010)
• One-third of uninsured adults have a chronic disease for which they
don’t get needed care. (Wilper, A, Woolhandler, S, Lasser, KE, McCormick, D, Bor, DH et al. A national study of chronic disease prevalence and access to care in uninsured U.S. adults. Ann Intern Med 1249 (3): 170-6, 2008)
• Two million cancer patients are now foregoing necessary care each year due to unaffordable costs. (Weaver, KE, Roland, JH, Bellizzi, KM, Ariz, NM. Foregoing medical care because of cost: Assessing disparities in healthcare access among cancer survivors living in the United States. Cancer online, June 14, 2010)
•. The number of annual patient visits to physicians has declined sharply since the onset of the Great Recession in 2008. (Johnson, A, Rockoff, JD, Mathews, AW. Americans cut back on visits to doctor. Wall Street Journal, July 29, 2010: A1)

5. Decreased coordination and integration of care.
Coordinated and integration is a huge problem, especially for patients with multiple medical problems, the norm for older patients. The electronic medical record does not substitute for close communication between specialists for such patients. According to the Joint Commission on Accreditation of Healthcare Organizations, 80 percent of serious medical errors are associated with lack of communication or teamwork among specialists in hospitals. (Health blog. Joint Commission-Hospital Collaboration targets hand-offs. Wall Street Journal, October 21, 2010)

6. Decreased quality of care with worse outcomes.
Compared to those without primary care, patients with primary care receive earlier diagnosis and treatment of illness and better outcomes of care (Ferrante, JE, Gonzales, E, Pal, N, Roetzheim, RG. Effects of physician supply on early detection of breast cancer. J Am Board Fam Pract 13: 408-14, 2000), including lower mortality rates (Baicker, K, Chandra, A Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs (Millwood) 23: w 184-97, 2004)`

Unfortunately, the essential role of primary care in any health care system is not widely understood. In the next post we will consider some of the many misperceptions about it, and how they represent barriers to building a better health care system in this country.

Adapted in part from my recently released book Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans. Copernicus Healthcare, 2011, soon to be available as an Ebook on Amazon.

John Geyman, M.D.
Professor emeritus of Family Medicine, University of Washington
Past President, Physicians for a National Health Program

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Proposed rule for premium tax credits

Posted by on Monday, Aug 15, 2011

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Implementing Health Reform: Premium Tax Credits

By Timothy Jost
Health Affairs Blog, August 13, 2011

On August 12, the Departments of Health and Human Services and Treasury (Internal Revenue Service) issued three notices of proposed rulemaking (NPRM) as part of their continuing effort to implement the Affordable Care Act (ACA).

This post will describe the Treasury NPRM, the shortest of the NPRMs but also the one that deals with the most complex and unsettled issues.

The Basic Rules Regarding The Tax Credit

The consequences of underpayments and overpayments.

Although the tax credit is paid on a monthly basis, the actual amount of the credit will in fact be finally determined based on the household’s income as determined on the annual income tax return.  At that point “reconciliation” must occur.   If over the course of the year household income turns out to have been greater or less than projected, or if household composition or compliance with other eligibility requirements has changed, the final tax credit may turn out to be greater or less than the amount already paid. If the taxpayer turns out to have been eligible for more than had been paid, the taxpayer gets a refund.

If, however, the government has paid more than the taxpayer in fact turns out to be entitled to, the taxpayer must pay the money back. There are limits to this liability for taxpayers with household incomes up to 400 percent of the FPL (which have been amended twice since the ACA was adopted to increase liability), but the amount owed back can be substantial (up to $2500 for families at the upper ranges), and if final income exceeds 400 percent of poverty, even by one dollar, the entire premium tax credit must be paid back.

No help for those who owe money back because of overpayments.

A taxpayer must file a return to claim a tax credit, even though the taxpayer otherwise has no obligation to file a return.  As noted above, at the time the return is filed, the tax credit will be reconciled with actual reported household income and the taxpayer will have to pay the IRS if there was an overpayment in tax credits.  Overpayments in fact will be common, not only because income and household composition will change over the course of a year, but also because a person who loses or gains a well-paying job over the course of the year may end up with a high end-of-the year income even though, at the time the taxpayer applied, the credit was accurate for the taxpayer’s then-current income level. A taxpayer with income under 400 percent of poverty level could receive a credit through out the year based on anticipated income, but then receive an end-of-year bonus putting the taxpayer over the 400 percent limit and have to pay back the entire credit for the entire year.

Consumer advocates hoped that Treasury would use its statutory rule-making authority to meliorate these consequences, but Treasury does not believe it has the authority to do so and offers no mercy.

http://healthaffairs.org/blog/2011/08/13/implementing-health-reform-premium-tax-credits/

Department of the Treasury – Proposed regulations for the Health Insurance Premium Tax Credit:
http://www.ofr.gov/OFRUpload/OFRData/2011-20728_PI.pdf

Throughout the reform process Professor Timothy Jost has been very helpful in clarifying the impact of the Affordable Care Act, especially on health care consumers. As one example, here he shows how an individual who appropriately receives monthly premium tax credits for purchase of a plan through an insurance exchange could be required to pay back the entire credit for the entire year merely because of a year-end bonus that lifted income over the 400 percent poverty level. For most individuals, this could create a severe financial hardship.

As another example, if the employee’s premium contribution for an employer sponsored plan is over 9.5 percent of income, then the employee is free to accept the tax credit and purchase a qualified plan through the insurance exchange. However, the employee’s contribution to the premium for the family does not count. Thus the employee, with an individual contribution under 9.5%, could have to pay much more than 9.5 percent of income to insure the entire family, and yet not be eligible for the option of accepting a tax subsidy for an exchange plan. Again, family coverage could create a significant financial hardship for the employee.

There is a profusion of complexities in the Affordable Care Act that adversely impact patient-consumers, many of which Professor Jost has described in this and other articles. Although, as an academic, he has limited his advocacy to supporting rules that benefit patients, we don’t have to limit our own advocacy so narrowly.

The Affordable Care Act is an abomination of inequitable and unjust administrative complexities and waste that can never achieve an equitable health system that serves everyone. Let’s continue to do our best to make sure that everyone understands this and understands that health care justice for all is achievable by the adoption of a single payer national health program.

In the meantime, the IRS does not believe that it has the authority to alter the provisions of the Affordable Care Act and thus offers no mercy. Mercy is left in the hands of us would-be reformers.

Professionalism, social justice, and the primacy of patient welfare

Posted by on Friday, Aug 12, 2011

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Medical Professionalism in the New Millennium: A Physician Charter

Annals of Internal Medicine
February 5, 2002

A project of the American Board of Internal Medicine Foundation, American College of Physicians–American Society of Internal Medicine Foundation, and European Federation of Internal Medicine

The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges center on increasing disparities among the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform health care systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients’ interests. To maintain the fidelity of medicine’s social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an action agenda for the profession of medicine that is universal in scope and purpose.

http://www.annals.org/content/136/3/243.full?ijkey=49cf14ffb35a6afdba3a14871f01fb39ad23066f&keytype2=tf_ipsecsha

And…

Government Policies in Violation of Human Rights as a Barrier to Professionalism

By Farrah J. Mateen, MD; Leonard S. Rubenstein, JD, LLM
JAMA, August 3, 2011

In recent decades, a set of reciprocal obligations between physicians and society have been identified as central to the concept of professionalism. In return for the high degree of autonomy society grants physicians, including licensure and self-regulation, the profession is expected to serve patients’ interests. At the heart of professionalism lie 3 fundamental principles: primacy of patient welfare, founded on altruism, trust, competence, and patient interest; patient autonomy, including educating and empowering patients to make appropriate medical decisions; and social justice, which considers available resources and the needs of all patients while taking care of an individual patient. However, deeply embedded institutional and organizational impediments often beyond the control of the physician (eg, inequitable access to care and reimbursement systems that create disincentives to proper care) can undermine physicians’ ability to adhere to these professional obligations in clinical practice.

http://jama.ama-assn.org/content/306/5/541.full

The Charter on Medical Professionalism was established almost a decade ago. It reaffirms physicians’ active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society. How are we doing?

Comparing USA and UK on efficiency and effectiveness

Posted by on Thursday, Aug 11, 2011

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

NHS among developed world’s most efficient health systems, says study

By Randeep Ramesh
guardian.co.uk, August 7, 2011

The NHS is one of the most cost-effective health systems in the developed world, according to a study published in the Journal of the Royal Society of Medicine.

The “surprising” findings show the NHS saving more lives for each pound spent as a proportion of national wealth than any other country apart from Ireland over 25 years. Among the 17 countries considered, the United States healthcare system was among the least efficient and effective.

Researchers said that this contradicted assertions by the health secretary, Andrew Lansley, that the NHS needed competition and choice to become more efficient.

“The government proposals to change the NHS are largely based on the idea that the NHS is less efficient and effective than other countries, especially the US,” said Professor Colin Pritchard, of Bournemouth University, who analysed a quarter of a century’s data from 1980.

“The results question why we need a big set of health reform proposals … The system works well. Look at the US and you can see where choice and competition gets you. Pretty dismal results.”

The study will be a blow for Lansley, who argues that patients should choose between competing hospital services and GPs.

Pritchard points out that even Adam Smith, the Scottish economist and father of market-based ideology, thought the state was “probably better” at health and education.

http://www.guardian.co.uk/society/2011/aug/07/nhs-among-most-efficient-health-services#history-link-box

And…

Comparing the USA, UK and 17 Western countries’ efficiency and effectiveness in reducing mortality

By Colin Pritchard and Mark S Wallace
Journal of the Royal Society of Medicine Short Reports, July 1, 2011

Conclusions

In cost-effective terms, i.e. economic input versus clinical output, the USA healthcare system was one of the least cost-effective in reducing mortality rates whereas the UK was one of the most cost-effective over the period.

http://shortreports.rsmjournals.com/content/2/7/60.full

We continue to be faced with the painful truth that the United States has the highest health care costs while our mortality rates compare unfavorably to many other countries. The authors of this study suggest that the U.S. model of “choice and competition” may be a major source of our dismal results.

The British are using our model to show their would-be reformers that their single, integrated National Health Service is more efficient and effective than our model based on private, marketplace competition. When will we learn the same lesson?

Yesterday’s blog post by John Goodman and Thomas Saving of the National Center for Policy Analysis (NCPA) is the latest in an avalanche of unfounded assertions and distortions that have characterized the writings from this center for many years. The Dallas-based NCPA, established in 1983, describes itself as a “nonpartisan public policy research organization, with the goal to develop and promote private alternatives to government regulation and control, solving problems by relying on the strength of the competitive, entrepreneurial private sector” (its website). This latest post puts forward, without context and with cherry-picked references, carefully selected statements that might seem to some to support their case—that deregulated markets will solve all of our health care problems. It would take a very long paper, or a number of papers, to respond to the many unfounded claims in their latest post.

Here are just three of their unfounded claims, together with references from the health policy literature and recent publications that rebut their assertions:

• Re the alleged advantages of privatized Medicare, see my 2006 book (Geyman, JP. Shredding the Social Contract: The Privatization of Medicare. Monroe, ME. Common Courage Press, 2006), my extensive article in The International Journal of Health Services (Geyman, JP. Privatization of Medicare: Toward dis-entitlement and betrayal of a social contract. Intl J Health Services 34 (4): 573-94, 2004), a 2009 report by the Committee on Energy and Commerce (Committee on Energy and Commerce. New report highlights Medicare Advantage insurers’ higher administrative spending. Washington, D.C., December 9, 2009), a 2010 article in the Wall Street Journal on retrenchment of private Medicare plans (Johnson, A. Private Medicare plans are retrenching. Wall Street Journal, November 19, 2010: B1), and a recent article in The New England Journal of Medicine describing the failures of regulated competition among private insurance companies in the Netherlands and calling into question managed competition as a model for private Medicare plans in the this country. (Okma, KGH, Marmor, TR, Oberlander, J. Managed competition for Medicare? Sobering lessons from the Netherlands. N Engl J Med, June 15, 2011)

• Re the alleged advantages of private health insurance over single-payer national health insurance, see my 2008 book on the private health insurance industry (Geyman, JP. Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It. Monroe, ME. Common Courage Press, 2008), my extensive article in The International Journal of Health Services (Geyman, JP. Myths and memes about single-payer health insurance in the United States: A rebuttal to conservative claims. Intl J Health Services 35 (1): 63-90, 2005), and a 2009 report by the Congressional Research Service, The Market Structure of the Health Insurance Industry (Austin, DA, Hungerford, TL. The Market Structure of the Health Insurance Industry. Washington, D.C, Congressional Research Service, November 17, 2009).

• Re the claimed efficiencies of competition in health care, see a multi-year study by the Community Tracking Study showing the failures of markets to be more efficient or to enhance the quality of health care (Nichols, LM et al. Are market forces strong enough to deliver efficient health care systems? Confidence is waning. Health Affairs (Millwood) 23 (2): 8-21, 2004) and a recent article by Mark Weisbrot, co-director of the Washington, D.C-based Center for Economic and Policy Research (Weisbrot, M. Problems of U.S health care are rooted in the private sector, despite right-wing claims. McClatchy-Tribune Information Services, July 20, 2011).

Health policy is too important to leave to the biased, well-funded propaganda
machine of these “research” organizations that keep promulgating policies that have long since been discredited, either by their failing track record or legitimate research studies.

John P. Geyman, M.D.
Professor emeritus of Family Medicine, University of Washington
www.copernicus-healthcare.org

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St. Louis Post-Dispatch editorial on single payer

Posted by on Wednesday, Aug 10, 2011

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Editorial: If U.S. is serious about debt, there’s a single-payer solution.

By the Editorial Board
St. Louis Post-Dispatch, August 10, 2011

If America truly is serious about dealing with its deficit problems, there’s a fairly simple solution. But you’re probably not going to like it: Enact a single-payer health care plan.

See, we told you weren’t going to like it.

But the fact is that everyone who has studied the deficit problem has agreed that it’s actually a health care problem.

That being the case — and nobody argues that it isn’t — there are two broad ways for the government to address its spiraling health care costs. One, shift more of those costs to recipients, by trimming benefits and/or extending eligibility ages and indexing eligibility to personal income. This is politically unpalatable, particularly to most Democrats, President Barack Obama being a conspicuous exception.

The second way for government to address its health costs is not to shift them, but to reduce them. This is what a single-payer health care system would do, largely by taking the for-profit players (insurance companies for the most part) out of the loop.

The advocacy group Physicians for a National Health Program estimates that “private insurance bureaucracy and paperwork consume one-third (31 percent) of every health care dollar. Streamlining payment through a single nonprofit payer would save more than $400 billion per year, enough to provide comprehensive, high-quality coverage for all Americans.”

Once everyone is covered, the government would have the clout to bring discipline into the wild west of health care spending.

Eventually, the United States will have a single-payer plan. But we’ll waste a lot of money and time getting there.

http://www.stltoday.com/news/opinion/editorial/article_97afa329-42f8-5f12-adb0-97fa305c3e4b.html

The Editorial Board of the St. Louis Post-Dispatch is right. Eventually we will have a single payer program, but only after wasting much more money and time.

Amidst all the crises confronting our country today—ranging from the deficit, rising unemployment and underemployment, mistrust of legislators and the government—there is another major crisis: the continued deterioration of primary care that threatens to break up the very foundation of U.S. health care. Underreported and widely misunderstood, the continued decline of primary care results in uncontrollable inflation of health care costs, decreased access to necessary care, increasing fragmentation and depersonalization of care, and unacceptable quality and outcomes of care. As health care costs spiral out of sight and consume an ever-increasing part of the country’s GDP, this trend, unless reversed, can destabilize and eventually bankrupt our health care system, and perhaps even our country.

This is the first in a series of four posts that will describe this crisis, how it has progressed over the last 50 years despite all attempts to deal with it, together with why it matters to all Americans and what can be done about it. These posts are drawn in part from my latest book Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans, just released by Copernicus-Healthcare and soon to appear as an ebook on Amazon.

Primary care is a term that many are unfamiliar with, often even including within the health professions. We’re talking here about generalist physicians and other health professionals working with them, in the ongoing care of unselected (not referred) patients of all ages for whatever problems they need to seek care. This is in the front lines of health care, for individuals and families, in their own community setting. General practitioners in earlier years represented this kind of physician. Since the 1960s, four other kinds of generalist physicians have evolved as various kinds of medical education programs have been developed—family practice (now family medicine), general internal medicine (for adults), general pediatrics (for children), and osteopathic physicians (with training that includes manipulative therapies).

Most advanced countries have at least 50 percent of their physicians as generalists at the foundation of their health care systems. While the U.S. had such a base until World War II, that number has declined over the last 60 years to less than 30 percent. And that number is dropping fast. Less than one in five U.S. medical graduates are now entering a primary care specialty, while most opt for better-paying, more attractive lifestyles of other specialties. (Pear, R. Doctor shortage proves obstacle to Obama goals. New York Times, April 27, 2010: A1) We now have a specialist-dominated system without anywhere near the number of generalists needed, as shown by Figure 1 in 2025. (Colwill, JM, Cultice, JM, Kruse, RI. Will generalist physician supply meet demands of an increasing and aging population? Health Affairs Web Exclusive, April 29, 2008, w 232-41)

In his recent article in The New Yorker, Dr. Atul Gawande, general and endocrine surgeon at Harvard Medical School, described the importance of the generalist in these compelling terms:

“Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.” (2) (Gawande, A. The cost conundrum: What a Texas town can teach us about healthcare. The New Yorker, June 9, 2009: 34-44.)

Advanced countries around the world with higher-performing health care systems than the U.S. have all build their systems on a solid base of primary, generalist care, readily available to patients for common health care problems where they live. Secondary care includes more specialized care for less common problems, while tertiary care deals with rare or unusual medical problems in university medical centers or other large urban hospitals. In most of those countries, specialists serve as consultants for particular medical problems, while primary care physicians provide ongoing continuity of care for all of their patients’ problems.

This is how a 2008 report of the General Accounting Office sums up the primary care crisis in this country:

“Health professional workforce projections that are mostly silent on the future supply of and demand for primary care services are symptomatic of an ongoing decline in the nation’s financial support for primary care medicine. Ample research in recent years concludes that the nation’s over reliance on specialty services at the expense of primary care leads to a health care system that is less efficient. At the same time, research shows that preventive care, care coordination for the chronically ill, and continuity of care—all hallmarks of primary care medicine—can achieve better health outcomes and cost savings. Despite these findings, the nation’s current financing mechanisms result in an atomized and uncoordinated system of care that rewards expensive procedure-based services while undervaluing primary care services.” (GAO. Primary Care Professionals: Recent Supply Trends, Projections and Valuation of Services. Washington, D.C. GAO-08-4721. Government Accounting Office, February 2008, p 15)

In our next post, we will see how our upside-down system does not work, and how it is responsible in large part for most of our system problems, whether at the level of individual health care or population-based care.

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Obama asks Supreme Court to allow compromised care for Medicaid patients

Posted by on Tuesday, Aug 9, 2011

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Democrats Challenging Administration on Medicaid

By Robert Pear
The New York Times, August 8, 2011

In an unusual break with the White House, the Democratic leaders of Congress told the Supreme Court on Monday that President Obama was pursuing a misguided interpretation of federal Medicaid law that made it more difficult for low-income people to obtain health care.

Faced with severe budget problems, many states have reduced Medicaid payment rates for doctors, dentists, hospitals, pharmacies, nursing homes and other providers. In many parts of the country, payment rates are so low that Medicaid recipients have difficulty finding doctors to take them.

Federal law says Medicaid rates must be “sufficient to enlist enough providers” so that Medicaid beneficiaries have access to care to the same extent as the general population in an area.

The issue, of immense importance to poor people and states, comes to the Supreme Court in a set of cases consolidated under the name Douglas v. Independent Living Center of Southern California, No. 09-958. The court plans to hear oral arguments in October, with a decision expected by the spring. The original plaintiffs in the case, Medicaid beneficiaries and providers, say they were harmed by California’s decision to cut payment rates that were already among the lowest in the country.

The federal Medicaid law does not explicitly allow such suits. But the United States Court of Appeals for the Ninth Circuit, in San Francisco, said beneficiaries and providers could sue under the Constitution’s supremacy clause, which makes federal law “the supreme law of the land.”

The Justice Department, siding with California, told the court in May that no federal law allowed individuals to sue states to enforce this standard.

http://www.nytimes.com/2011/08/09/us/politics/09medicaid.html?_r=1&hp

President Obama’s Affordable Care Act relies heavily on the expansion of Medicaid to cover low-income individuals who are uninsured. Yet at the same time, his administration is appealing to the Supreme Court, under the supremacy clause, the federal government’s right to critically underfund the Medicaid program to the extent that patients will have significant impairment of their access to health care.

As we have stated many times in these messages, a severely underfunded welfare program for low-income individuals that clearly impairs access violates our sense of equity and health care justice. Apparently President Obama does not share this view. Otherwise, as a constitutional lawyer, why would he allow the Justice Department to take to the Supreme Court a case that would permit his administration to violate the law that says that Medicaid rates must be sufficient to enlist enough providers so that Medicaid beneficiaries have access to care to the same extent as the general population?

Where does this lead? Yesterday, in the context of reducing the deficit, he said that the country needs “modest adjustments to health care programs like Medicare.” More cuts.

Try doing that in nations with universal social insurance programs. It will never happen. But in our fragmented system, there is an opening for battles based on demographic divides. The tax-cutting, government-shrinking young rebels are taking up the cause of putting greedy geezers in their place.

Having been raised in the 40s and 50s – a time when there was great hope of an egalitarian America – I have to ask myself that trite but timely question, what kind of a country have we become?

Taxpayers ripped off by for-profit hospices

Posted by on Monday, Aug 8, 2011

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Medicare costs for hospice up 70%

By Kelly Kennedy
USA Today, August 7, 2011

Medicare costs for hospice care have increased more than in any other health care sector as for-profit companies continue to gain a larger share of the end-of-life medical market, government records show.

A recent report by the inspector general for Health and Human Services, which oversees Medicare, found for-profit hospices were paid 29% more per beneficiary than non-profit hospices.

At the same time, some of the nation’s largest for-profit hospice companies are paying multimillion-dollar settlements for fraud claims and facing multiple investigations from state and federal law enforcement agencies.

Critics say costs have also increased because for-profit organizations have cherry-picked patients who live the longest and require the least amount of care — such as those with dementia or Alzheimer’s, rather than those with cancer.

“Certain hospices seem to be seeking out beneficiaries with particular characteristics, and these beneficiaries are often found in nursing facilities,” said Jodi Nudelman, a regional inspector general for HHS in a webcast about the report.

In a growing number of cases, hospices are collecting the same daily rate for visiting patients in nursing facilities as other hospice programs that also provide patients’ room, board and medical care not related to their terminal illness.

http://yourlife.usatoday.com/health/medical/story/2011/08/Medicare-costs-for-hospice-up-70/49854600/1

Report of the Inspector General of HHS:
http://oig.hhs.gov/oei/reports/oei-02-10-00070.pdf

PNHP has long advocated removing for-profit corporations, with their passive investors, from the health care equation. This report on hospices from the HHS Inspector General provides more compelling support for this view.

For-profit hospices that provide care to Medicare patients have been ripping off taxpayers by cherry-picking less expensive patients, collecting much larger fees by providing services prematurely, and, worst of all, collecting full fees for merely providing what is not much more than house-call-type services in nursing homes rather than providing the full range of services expected in hospice care. Their multi-million dollar fraud settlements don’t seem to deter them.

It is imperative that we remove passive investors and their corporate executive goons from health care.

Medi-Cal’s lesson for reform

Posted by on Friday, Aug 5, 2011

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Doctors say Medi-Cal reimbursement is too low

By Dustin Corcoran
San Francisco Chronicle, August 4, 2010

Medi-Cal covers essential health care services for the poorest and most vulnerable Californians, including seniors, pregnant women, children and people with disabilities. Despite the lifesaving care and preventive treatment that so many Medi-Cal patients have received, the state is planning drastic cutbacks to Medi-Cal that will irreparably harm patients and cost taxpayers more in expensive hospitalizations and emergency care.

The Legislature passed, and Gov. Jerry Brown signed, AB97, which includes a 10 percent reduction in Medi-Cal payment rates to physicians, hospitals, nursing homes and other providers, patient co-payments ($50 per emergency room visit, $5 per physician visit, $100 per day in the hospital), and a limit of seven physician office visits per year. If these cuts are allowed to take place, Medi-Cal would pay doctors just $11 per patient visit, just a fraction of what it would cost to take your dog to the veterinarian.

Cuts in reimbursement rates force physicians to reduce the number of Medi-Cal patients they can see, and now more than half of all Medi-Cal patients say they can’t find a doctor.

Currently, Medi-Cal is the source of health care for 1 in 5 Californians (about 7 million). With the implementation of health care reform right around the corner, 3 million more uninsured will soon be added to the state’s Medi-Cal program. But how can we adequately provide more care to more people with fewer resources? California already ranks last in Medicaid payment rates per enrollee.

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2011/08/04/ED4T1KIL9C.DTL

California has a Democratic governor and a Democratic legislature, yet look at what they just did. Although California already ranks last in Medicaid payment rates, they are reducing payments another 10 percent. Much worse, they are imposing unaffordable co-payments on these low-income patients, and are not allowing them more than an arbitrary seven office visits a year. Punishment of patients and their health care professionals is not the reform that we needed.

Whether or not California is successful in obtaining federal approval to impose these cuts, this action confirms that we cannot allow our government to condemn low-income patients to a bottom-tier welfare program, yet this is precisely what the Affordable Care Act calls for.

Let’s fix Medicare and expand it so that we can bring in everyone under an umbrella that isn’t riddled with leaks.

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