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.
State’s health insurance exchange gets $674-million federal grant
By Chad Terhune
Los Angeles Times, January 18, 2013
Federal officials awarded California’s new health insurance exchange a $674-million grant, providing money for a crucial marketing campaign aimed at millions of uninsured consumers.
The state-run insurance exchange, Covered California, is seeking to fundamentally reshape the health insurance market by negotiating with insurers for the best rates and helping consumers choose a plan.
In addition to “top down” advertising, Lee said, the exchange will be giving grants to religious groups and other community organizations for education at the grass-roots level.
The exchange also has the task of helping millions of Californians determine whether they qualify for an expansion of Medi-Cal, the state’s Medicaid program for the poor, or federally subsidized private coverage.
In addition to marketing, Covered California will use the federal grant money to help fund operations through January 2015, when the online marketplace will rely on fees assessed on health policies sold through the exchange.
Separately Thursday, the California Endowment said it would spend $225 million over the next four years to help implement the federal healthcare law in the state.
The administrative waste in our health care system far exceeds that of any other nation. During the political process of crafting the Affordable Care Act, we warned that this model would greatly add to this administrative waste. We are now beginning to see the extent of that expanded waste.
On just California’s insurance exchange alone, taxpayers are having to foot additional costs of two-thirds of a billion dollars just for administration and marketing of the exchange plans. In the future, these additional administrative costs will be downloaded to us through new fees assessed on the health policies sold through the exchange. Just think of all of the other administrative expenses for the multitude of other features of the Affordable Care Act, not just in California but throughout the nation. And not one cent of this additional administrative spending goes to health care. Sick!
Although taxpayers have already invested way too much in this wasteful program, we can still cut our losses and move on with an administratively efficient single payer system – an improved Medicare for all.
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.
Social Security Reform and Medicare Modernization Proposals
Business Roundtable, January 2013
Business Roundtable (BRT) is an association of chief executive officers of leading U.S. companies with more than $7.3 trillion in annual revenues and nearly 16 million employees. BRT member companies comprise nearly a third of the total value of the U.S. stock market.
“Medicare and Social Security were not designed to cope with America’s new demographic realities. CEOs are calling for gradual changes that will modernize these programs and preserve the safety net for future generations of retirees.”
– Gary W. Loveman, Ph.D., Chairman, CEO & President, Caesars Entertainment Corporation, and Chair of BRT’s Health and Retirement Committee
Essential Elements of a Medicare Modernization Proposal
• Protect Medicare for Those Approaching Retirement: Medicare’s age of eligibility should be moved to age 70. However, this will not affect those age 55 or older today.
• Expand Competitive Models of Care: By 2015, Medicare should offer seniors the opportunity to choose among competing and comprehensive private plans and traditional Medicare. The private plans would offer a benefit similar to the existing Medicare program with the flexibility to innovate, sell across state lines, and create greater value strategies. Plans would be required to accept all applicants and would risk adjust the premium to take into account age and health status. The traditional fee-for-service program would compete for enrollment with private plans on cost, quality and a more innovative benefit structure. We believe that competition in the provision of health care to America’s seniors will bring substantial benefits, as it has to most all other categories of personal expenditure. The recent experience of competition in the Medicare Part D program serves as a persuasive indication of the potential savings and improvement in care available through the provision of choice to well-informed seniors.
• Reduce Taxpayer Costs for Upper-Income Beneficiaries: Today, the Part B premium (physician services) and the Part D premium are means-tested and other types of means testing should be explored. By 2015, additional means testing for Medicare services should be considered.
• Protect the Safety Net for Low-Income Americans: Low-income beneficiaries should retain the existing financial support received today. Improvements should be made in care-coordination and a focus on wellness and chronic care management.
(Social Security recommendations available at this link.)
Doctoring Health Care, I
By Barbara Dreyfuss
The American Prospect, December 17, 2006
In early 2006, Glen Barton, the retired CEO of Caterpillar and former head of the Business Roundtable’s health-care task force, said the solution to the health-care crisis is a single-payer system, citing Medicare as a model.
Although the slick brochure from these wizards of industry at the Business Roundtable might make it look like these gentlemen are doing us a great favor by showing us how to save Medicare and Social Security from bankruptcy, their recommendations are, in fact, taking a supercilious approach to diminishing the effectiveness of America’s highly regarded social insurance programs.
This cavalier attitude is expressed in a comment by Caesars’ Gary Loveman, chairman of Business Roundtable’s Health and Retirement Committee that released this report. “Those of us who are in the BRT are paid to try to solve very difficult problems effectively. I would tell you that most of them are a lot harder than this, frankly” (Politico Pulse, Jan. 17).
What do they have in mind for Medicare? They would increase eligibility age to 70 – a disaster for future retirees. They would privatize the traditional Medicare program by throwing it into a market of private plans – a devious scheme to shift health care costs onto the backs of those with greater health care needs. They would also means-test benefits, losing the support of the wealthier individuals who have the strongest political voice, threatening to convert Medicare into a welfare program.
And Social Security? They would also increase Social Security retirement age to 70. And in a stroke of genius, they recommend that Americans simply save more for their retirement. Why didn’t we think of that before?
A word needs to be said about their recommendation to reduce future Social Security cost of living adjustments by converting to the chained-CPI. When individuals are forced into a frugal existence they learn to cut back and do without just so that they will have enough money for basic food and housing at the end of the month, if that. Under chained-CPI, the government assumes that this frugality represents the new, lower consumer price index for this sector, and so they adjust out the savings that the Social Security beneficiaries have accrued merely for the purpose of getting them all of the way through to the end of the month. Pretty cruel.
A decade ago, Glen Barton, Chairman and President of Caterpillar, led the BRT Health and Retirement Committee, currently headed by Gary Loveman. What a contrast. Glen Barton’s experience motivated him to become an advocate of “a single-payer system, citing Medicare as a model.” Lovemen? Well, you read it above. What a difference a decade made.
Class warfare? Ugly label, but…
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.
General Health Checks in Adults for Reducing Morbidity and Mortality From Disease
By Allan V. Prochazka, MD, MSc; Tanner Caverly, MD
JAMA Internal Medicine, January 14, 2013
The concept of general health checkups to identify disease at a stage at which early intervention could be effective has been promoted for nearly 100 years. Both patients and primary care physicians are interested in such examinations, which can include detailed history taking, physical examination, extensive laboratory testing, and imaging.
General health checks do not improve important outcomes and are unlikely to ever do so based on the pooled results of this meta-analysis spanning decades of experience. We should be clear about what a general health check is. A general health check is a visit dedicated solely to preventive counseling and screening tests. Other names, such as annual physical, preventive health examination, or periodic health evaluation, are often used. These terms exclude preventive care that occurs during visits for other reasons, such as during chronic care or acute care visits. In other words, we are talking about screening and counseling in addition to the prevention measures that occur during routine medical care.
General health checks are one of the most common reasons adults seek medical care, with an estimated 44 million seeing a physician for this reason each year from 2002 through 2004. During these health checks, an estimated $322 million is spent annually on laboratory tests that no guideline groups recommend. The costs of downstream testing and overtreatment are likely to be much larger. For example, the costs of mammography might be $4 billion a year assuming biennial screening. The cost of follow-up biopsies of normal breasts triggered by false-positive mammogram results alone is probably in the range of $14 to $70 billion annually. It is likely that follow-up testing from general health checks substantially contributes to the estimated $210 billion in annual spending on unnecessary medical services.
Is It Time To Re-Examine Workplace Wellness ‘Get Well Quick’ Schemes?
By Al Lewis and Vik Khanna
Health Affairs Blog, January 16, 2013
Virtually unheard of thirty years ago, workplace wellness is now embedded in large self-insured companies. These firms pay their workers an average of $460/year to participate in worksite wellness programs. Further, wellness is deeply enough engrained in the public policy consciousness to have earned a prominent place in the Affordable Care Act, which allows large employers to tie a significant percentage of health spending to employee health behavior and provides direct subsidies for small businesses to undertake these workplace wellness programs.
Yet the implausible, disproven, and often mathematically impossible claims of success underlying the “get well quick” programs promoted by the wellness industry raise many questions about the wisdom of these decisions and policies. In this post, we lay out the evidence demonstrating that the industry consistently mis-measures and overstates the direct healthcare cost savings. We suggest several strategies to prevent this and to re-allocate wellness dollars from “get well quick” schemes to the much more challenging, but ultimately more rewarding, task of truly creating a culture of wellness, a workplace that can attract and retain healthier, presumably more productive, people than competitors do. There is no guarantee that strategy would work and no easy way to implement it, but clearly the easy approach isn’t working.
While we do not believe that employers need to adopt military-style standards, we do propose that it is illogical to expect sustainable reductions in medical care spending if corporate leaders treat their environments, personnel policies, practices, and procedures with the insouciance of people who believe that they can just wish something into existence.
HR departments need to reconfigure their benefits consulting relationships, since with few exceptions the latter have not provided critical thinking about wellness (and other “value-added” programs) on a par with that of insurers, who have universally shunned these programs for their fully insured members. (Most insurers will happily sell them to self-insured employers even so, because they clearly understand that “invalid” is not the same as “unprofitable,” especially when you do not bear risk for the outcomes and the customer’s consultants are demanding the service.)
In discussions of our exorbitant health care spending, we frequently hear that we need to change from a system that treats disease to a system that promotes prevention and wellness, as if prevention and wellness programs would displace disease and injury.
First, let’s be clear that the benefits of effective prevention programs are undeniable. But much of prevention is out in the community at large and not so much within the health care delivery system. Examples are public health services, community planning for safety and to promote physical activity, the promotion of healthy food choices, industry design of safer products such as automobiles, public policies to reduce hazards such as the ubiquitous accessibility of firearms, and innumerable other measures that are or should be promoted through both public and private efforts.
So what about routine preventive health checkups? The comprehensive meta-analysis published in the current JAMA Internal Medicine reveals that “general health checks do not improve important outcomes and are unlikely to ever do so,” but “it is likely that follow-up testing from general health checks substantially contributes to the estimated $210 billion in annual spending on unnecessary medical services.”
However, specific examples of preventive care that are a part of and integrated within the provision of care for acute and chronic disorders have been shown to be of some benefit and should not be abandoned until new evidence demonstrates that there are compelling reasons to do so. Nevertheless, we cannot look to the medical practice environment to find the health care paradise that will displace sick care with well care.
Which brings us to employer-sponsored wellness programs. Simply stated, they fall into the spectrum between naivete and outright fraud. As stated in the Health Affairs Blog article briefly excerpted above, “Even the iconic Safeway story of achieving a zero medical cost trend through wellness – the inspiration for the wellness provisions in the Affordable Care Act – turns out to be made up.”
If you wish to know the shocking truth on wellness programs (yes, shocking), you should read the entire article available at the link above. The fact that insurers promote these programs, but only for their non-risk bearing contracts with self-insured employers, certainly is revealing.
Pretending that we can control health care spending with checkups and wellness programs no longer cuts it. We need to tackle costs with proven methods that would ensure quality care for everyone. We should begin by enacting an improved Medicare for all.
Life Disruptions for Midlife and Older Adults With High Out-of-Pocket Health Expenditures
By David Grande, MD, MPA, Frances K. Barg, PhD, Sarah Johnson, BA and Carolyn C. Cannuscio, ScD
Annals of Family Medicine, January/February 2013
PURPOSE Out-of-pocket cost sharing for health care expenses is a growing burden. Prior research has emphasized the medical consequences of cost sharing. This study investigates the range of social, medical, financial, and sometimes legal disruptions from high out-of-pocket health expenses.
METHODS We conducted open-ended, semistructured interviews with 33 insured patients (two-thirds covered by Medicare). All had chronic illnesses and sought philanthropic financial assistance.
RESULTS We found that high levels of cost sharing precipitated considerable anxiety and substantial debt problems, as well as disruptions of medical care. Participants described various borrowing strategies (eg, credit cards), legal problems (eg, debt collections), and threats to their nonmedical household budgets (eg, food, housing). Participants described explicit and rank-ordered strategies for coping with new medical expenses. Participants understood their health benefits with exceptional detail but described considerable anxiety about changes to those benefits that could easily disrupt carefully managed household budgets. Benefit designs that resulted in large variations in financial liability from month to month (eg, large deductibles or coverage gaps) imposed considerable financial challenges.
CONCLUSIONS As health care cost sharing grows, policy makers will need to consider the consequences of high cost sharing for families facing strained household budgets. Although the generosity of health insurance is important, continuity of benefits and month-to-month stability of financial liability are also important and may be undervalued in policy discussions.
From the Results:
Four issues figured prominently. First, the structure of health insurance—especially gaps in coverage, such as the Medicare Part D “doughnut hole” — powerfully affected financial well-being. Second, financial stress and debt from medical expenditures had a strong influence on day-to-day personal, financial, and medical decision making. Third, participants turned to family and other sources to help manage the costs of their illnesses, which resulted in financial, emotional, and social challenges for all family members. Fourth, participants managed high out-of-pocket health care costs using a range of strategies that were potentially disruptive to their medical care.
We have plenty of studies which demonstrate that out-of-pocket cost sharing for health care can expose patients to significant financial burdens and impair their access to care. This study provides a valuable addition to our knowledge base because it demonstrates just how disruptive these expanding innovations in cost sharing can be.
This study does not quantify the problem, nor was it intended to. Rather it provides us with a qualitative assessment of those who do face insurance-induced financial barriers to care, including, significantly, cost sharing in the Medicare program (part of the reason we want an improved Medicare).
Read the last paragraph in the excerpts above, under “From the Results.” These insurance innovations that supposedly are designed to make patients better shoppers of health care are causing severe financial stresses, unwise but unavoidable choices in forging health care, while fostering “financial, emotional, and social challenges for all family members.”
How well will the Affordable Care Act address these problems? First, the design of the essential health benefits required of the plans, although fairly broad, allows important benefits to be excluded as long as there is token representation of each general category of benefits. Also most exchange plans will penalize patients for obtaining care outside of their networks – again impairing affordability and access to important services that may be available only outside of the networks.
Probably the most significant disruptive element in the exchange plans is that most people will be enrolled in plans with either 60 or 70 percent actuarial value. Most of the plans will achieve these low actuarial values by requiring high deductibles and perhaps co-payments or coinsurance – some of the very tools that result in the disruptions described in today’s article. Although the Affordable Care Act does provide subsidies for both premiums and out-of-pocket expenses, for many individuals these subsidies will not be adequate to prevent the disruptions described.
Many nations with far lower total health care costs than ours are able to provide comprehensive health care for everyone – with first dollar coverage! They do not need to use disruptive out-of-pocket cost sharing to keep their level of spending sustainable. It is no secret how they do it. So why do our policy makers seem to want to keep it a secret here in the Unites States?
Health Care and Profits, a Poor Mix
By Eduardo Porter
The New York Times, January 8, 2013
Our reliance on private enterprise to provide the most essential services stems, in part, from a more narrow understanding of our collective responsibility to provide social goods. Private American health care has stood out for decades among industrial nations, where public universal coverage has long been considered a right of citizenship. But our faith in private solutions also draws on an ingrained belief that big government serves too many disparate objectives and must cater to too many conflicting interests to deliver services fairly and effectively.
Our trust appears undeserved, however. Our track record suggests that handing over responsibility for social goals to private enterprise is providing us with social goods of lower quality, distributed more inequitably and at a higher cost than if government delivered or paid for them directly.
From the high administrative costs incurred by health insurers to screen out sick patients to the array of expensive treatments prescribed by doctors who earn more money for every treatment they provide, our private health care industry provides perhaps the clearest illustration of how the profit motive can send incentives astray.
By many objective measures, the mostly private American system delivers worse value for money than every other in the developed world. We spend nearly 18 percent of the nation’s economic output on health care and still manage to leave tens of millions of Americans without adequate access to care.
Today, again, entitlements are at the center of the national debate. Our elected officials are consumed by slashing a budget deficit that is expected to balloon over coming decades. With both Democrats and Republicans unwilling to raise taxes on the middle class, the discussion is quickly boiling down to how deeply entitlements must be cut.
We may want to broaden the debate. The relevant question is how best we can serve our social needs at the lowest possible cost. One answer is that we have a lot of room to do better. Improving the delivery of social services like health care and pensions may be possible without increasing the burden on American families, simply by removing the profit motive from the equation.
Eduardo Porter’s NYT article on the poor mix of health care and profits resonated with PNHP members, and appropriately so. It reminds us that our mission is not only to provide an efficient health care financing system that would cover everyone equitably, but also to ensure that health care be provided as “a public service rather than bought and sold as a commodity” (from PNHP Mission Statement). Including passive investors in health care has moved the bottom line up as the top priority while relegating patient service to a footnote.
Growth In Medicare Spending Per Beneficiary Continues To Hit Historic Lows
By Richard Kronick and Rosa Po
U.S. Department of Health and Human Services, January 7, 2013
Medicare spending per beneficiary grew just 0.4% per capita in fiscal year 2012, continuing a pattern of very low growth in 2010 and 2011. Together with historically low projections of per capita growth from both the Congressional Budget Office and the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary, these statistics show that the Affordable Care Act has helped to set Medicare on a more sustainable path to keep its commitment to seniors and persons with disabilities today and well into the future. The success in reducing the rate of spending growth has been achieved without any reduction in benefits for beneficiaries. To the contrary, Medicare beneficiaries have gained access to additional benefits, such as increased coverage of preventive services and lower cost-sharing for prescription drugs.
At a time when politicians are ready to attack Medicare spending, this report on the projected slow growth in Medicare spending per beneficiary might seem to be useful in helping to keep the wolves away. But there are some very serious concerns behind these projections.
There has been some debate about whether the slowing is due to the recession and slow recovery, or if it is due to the implementation of some of the features of the Affordable Care Act, or if it simply due to changes in practice patterns related to evolving efforts of health care professionals to improve the practice of medicine. It is likely that all play some role.
Beyond dispute, however, is the fact that Medicare has been very effective in slowing the growth in spending though various forms of administered pricing, such as DRGs. The S&P Healthcare Economic Indices have shown that Medicare has been far more effective than the private commercial insurers in slowing the rate of growth in health care spending.
As this and other reports have shown, spending controls have not been at the cost of a reduction in benefits to Medicare beneficiaries; in fact benefits have expanded, though only modestly. Spending controls have been limited to slower payment growth for health care professionals and institutions. Although the Affordable Care Act has introduced measures to allegedly improve quality while controlling spending, the current efforts at implementation indicate that the emphasis is on spending restraint, with only token attention to quality measures – measures which are of dubious effectiveness anyway.
Thus there are two major fronts of attack over which we should be acutely concerned:
1) The government, under the banner of the Affordable Care Act, will continue to selectively ratchet down growth in Medicare spending while largely leaving the private sector plans alone. The expanding differential between lower public payment through the Medicare and Medicaid programs and higher private payments through the private insurance plans will cause more health care providers to abandon the public programs, with a consequent threat of impaired access for the beneficiaries of the public programs. As long as private insurers are there to provide a relief valve, there is a very real risk that the public programs will be underfunded. If private plans were eliminated, as a single payer the government would be obligated to ensure the solvency of the health care delivery system.
2) The current political push for austerity measures has made these public programs vulnerable to the “we-have-a-spending-problem-not-revenue-problem” cranks that populate our nation’s capitol. There is a genuine fear that some of the critical thinkers negotiating with the cranks will plea pragmatism as they trade away important features of our social programs.
We need the opposite approach. We need to reinforce Medicare and then expand it to cover everyone. Complacency with the current politically-expedient implementation of Affordable Care Act will lead us further down the path of no return, that is unless we’re ready for a revolution.
U.S. Health in International Perspective: Shorter Lives, Poorer Health
Institute of Medicine, January 2013
The United States is among the wealthiest nations in the world, but it is far from the healthiest. Although Americans’ life expectancy and health have improved over the past century, these gains have lagged behind those of other high-income countries. This health disadvantage prevails even though the United states spends far more per person on health care than any other nation.
To gain a better understanding of this problem, the National Institutes of Health (NIH) asked the National Research Council and the Institute of Medicine to convene a panel of experts to investigate potential reasons for the U.S. health disadvantage and to assess larger implications. The panel’s findings are detailed in its report, U.S. Health in International Perspective: Shorter Lives, Poorer Health.
The panel was struck by the gravity of its findings. For many years, Americans have been dying at younger ages than people in almost all other high-income countries. This disadvantage has been getting worse for three decades, especially among women.
When compared with the average of peer countries, Americans as a group fare worse in at least nine health areas:
* infant mortality and low birth weight
* injuries and homicides
* adolescent pregnancy and sexually transmitted infections
* HIV and AIDS
* drug-related deaths
* obesity and diabetes
* heart disease
* chronic lung disease
Many of these conditions have a particularly profound effect on young people, reducing the odds that Americans will live to age 50. And for those who reach age 50, these conditions contribute to poorer health and greater illness later in life.
The United States does enjoy a few health advantages when compared with peer countries, including lower cancer death rates and greater control of blood pressure and cholesterol levels. Americans who reach age 75 can expect to live longer than people in the peer countries. With these exceptions, however, other high-income countries outrank the United States on most measures.
Why are Americans so unhealthy?
The panel’s inquiry found multiple likely explanations for the U.S. health disadvantage:
* Health systems. Unlike its peer countries, the United States has a relatively large uninsured population and more limited access to primary care. Americans are more likely to find their health care inaccessible or unaffordable and to report lapses in the quality and safety of care outside of hospitals.
* Health behaviors. Although Americans are currently less likely to smoke and may drink alcohol less heavily than people in peer countries, they consume the most calories per person, have higher rates of drug abuse, are less likely to use seat belts, are involved in more traffic accidents that involve alcohol, and are more likely to use firearms in acts of violence.
* Social and economic conditions. Although the income of Americans is higher on average than in other countries, the United States also has higher levels of poverty (especially child poverty) and income inequality and lower rates of social mobility. Other countries are outpacing the United States in the education of young people, which also affects health. And Americans benefit less from safety net programs that can buffer the negative health effects of poverty and other social disadvantages.
* Physical environments. U.S. communities and the built environment are more likely than those in peer countries to be designed around automobiles, and this may discourage physical activity and contribute to obesity.
The tragedy is not that the United States is losing a contest with other countries, but that Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary. Superior health outcomes in other nations show that Americans can also enjoy better health.
“U.S. Health in International Perspective: Shorter Lives, Poorer Health” – Full 405 page report can be downloaded for free at this link:
The United States is sick, literally and figuratively. We have the most expensive health care system, yet the worst health outcomes of the wealthier nations. The failures are not only with our health system but with much broader sociopolitical institutions.
In response to these glaring deficiencies, this NRC/IOM report places an emphasis on further research to better define the problem and identify interventions that would help. Research is fine, but we do not need to wait any longer when so many of the deficiencies our already in our face.
The brief paragraph above on health systems confirms the pressing need for an effective universal insurance system, along with an expansion of our primary care infrastructure. Enacting the PNHP single payer model would finally set us in the right direction toward a high-performance health care system.
The social and economic conditions, physical environments, and health behaviors demonstrate a crying need for much more effective sociopolitical public policies. Not only do we need a reinforcement of our public health system, we also need greater public action in education, community planning, and especially responsible government policies to correct the gut-wrenching social and economic injustices that permeate our society.
From the opponents of reform we continue to hear that we have the greatest health care system in the world and that we have the very best health outcomes. Download this highly credible report so that you will have it readily available to expose these liars for what they are. Also use it to educate politicians on the broad spectrum of urgent public policies that we so desperately need.
And while we’re at it, we need to fire the politicians who are promulgating these cruel lies.
Retention of Rural Family Physicians After 20–25 Years: Outcomes of a Comprehensive Medical School Rural Program
By Howard K. Rabinowitz, MD, James J. Diamond, PhD, Fred W. Markham, MD and Abbie J. Santana, MSPH
Journal of the American Board of Family Medicine, January-February 2013 vol. 26 no. 124-27
“The shortage of primary care physicians in rural areas, especially family physicians, has been a serious problem for decades, with major implications in access to health care for a substantial proportion of the US population….Retention is a key component of the rural physician supply, in part because it has a multifold impact on the rural workforce; for example, one physician practicing in the same rural area during a 35-year career has a similar impact as 5 physicians who practice for an average duration of 7 years…”.
The authors describe the impact of the Physician Shortage Area Program (PSAP), a special program at the Jefferson Medical College of Pennsylvania that “…recruits and selects medical school applicants that have grown up or lived in a rural area or small town for a substantial portion of their life after college and who were committed to practicing family medicine in a similar area” and provides them with other experiences during medical school. “Of the 37 PSAP graduates [from 1978-86] who originally entered rural family medicine, 26 (70.3%) were still practicing family medicine in the same rural area in 2011 (including 5 in adjacent counties). Comparable data for non-PSAP graduates showed that 24 of 52 (46.2%; P = .02) were in the same rural area (including 5 in adjacent counties).”
These are really good results, demonstrating that the PSAP at Jefferson is effective in training students who not only enter rural practice but remain in it over time. And, they indicate, “PSAP outcomes are similar to those of the 5 other RPs with published outcomes.”
The Redistribution Of Graduate Medical Education Positions In 2005 Failed To Boost Primary Care Or Rural Training
By Candice Chen, Imam Xierali, Katie Piwnica-Worms, and Robert Phillips
Health Affairs, January 2013, 32(1):102-110
ABSTRACT Graduate medical education (GME), the system to train graduates of medical schools in their chosen specialties, costs the government nearly $13 billion annually, yet there is little accountability in the system for addressing critical physician shortages in specific specialties and geographic areas. Medicare provides the bulk of GME funds, and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 redistributed nearly 3,000 residency positions among the nation’s hospitals, largely in an effort to train more residents in primary care and in rural areas. However, when we analyzed the outcomes of this recent effort, we found that out of 304 hospitals receiving additional positions, only 12 were rural, and they received fewer than 3 percent of all positions redistributed. Although primary care training had net positive growth after redistribution, the relative growth of nonprimary care training was twice as large and diverted would-be primary care physicians to subspecialty training. Thus, the two legislative and regulatory priorities for the redistribution were not met. Future legislation should reevaluate the formulas that determine GME payments and potentially delink them from the hospital prospective payment system. Furthermore, better health care workforce data and analysis are needed to link GME payments to health care workforce needs…
Note: Today’s message on the shortage of rural family physicians was prepared by Joshua Freeman, MD, Professor and Chair of the Department of Family Medicine at the University of Kansas Medical Center. He also writes a highly commendable weekly blog on Medicine and Social Justice, accessible at: http://www.medicinesocialjustice.blogspot.com/
What is wrong with this picture? Taken together, these studies show us that despite the fact that we know what strategies work to increase the number of rural family physicians, they are not being truly embraced by policymakers at either the medical student or resident level. The PSAP and similar programs are effective, but are far too small. Twenty percent of Americans live in rural areas, but over the 9 year period studied in which 37 PSAP graduates entered rural practice, Jefferson Medical College, which has an enrollment of over 250 students a year, thus graduated over 2200 students. This is at a school with one of the nation’s most successful programs; at many schools it is much worse. At the graduate training (residency) level, only 3% of redistributed positions went to rural training, despite that being a primary intent of the policy.
The problem is that there are powerful forces whose interests conflict with these goals. Medical schools and their faculties are often more interested in replicating themselves by recruiting students with high grades who will enter medical subspecialties or research than they are in recruiting students who will meet the most urgent healthcare needs of our nation. The same motivation affects graduate medical education, where most training positions are not in primary care, and the vast majority are in urban centers. In addition, hospitals, which are the main sponsors of residency training, tend to be more focused on their own interests than the community’s. They therefore prefer residents and fellows in specialties that can make them more money or lower their costs rather than those training to be rural primary care providers.
At the medical student level, programs like PSAP need to be dramatically increased, even if taking more students committed to rural practice decreases the number admitted who have more “traditional” strengths. At the residency level, loopholes must be closed so that new residency positions intended to create more rural primary care doctors are not instead used for other, more popular or more financially desirable, specialties. To the extent that medical schools and hospitals can “game” the system, they will, so policymakers must recognize these tendencies and explicitly block them.
Idaho governor: Eliminate personal property tax
By The Associated Press
The Examiner, January 7, 2013
(Idaho Gov. C.L. “Butch”) Otter is… not immediately endorsing the expansion of Idaho’s Medicaid coverage to include more than 100,000 additional low-income residents whose bills would largely be paid for with funding from Washington.
Instead, Otter now plans to spend the next year studying how Idaho’s federal-state funded health care system for the poor can be revamped to make it less focused on paying fees for services and more on requiring Medicaid beneficiaries to take more responsibility for their health.
Wow! What a great idea! Instead of paying for essential health care services for Medicaid patients, let’s make those people “take more responsibility for their health.” We could expand the same concept to everyone, including Gov. Otter, and then our health care spending problem would be solved.
Please excuse the abject frivolity of this comment, but what I really want to know is, what has happened to compassion in America?
National Health Spending In 2011: Overall Growth Remains Low, But Some Payers And Services Show Signs Of Acceleration
By Micah Hartman, Anne B. Martin, Joseph Benson, Aaron Catlin, the National Health Expenditure Accounts Team
Health Affairs, January 2013
In 2011 US health care spending grew 3.9 percent to reach $2.7 trillion, marking the third consecutive year of relatively slow growth. Growth in national health spending closely tracked growth in nominal gross domestic product (GDP) in 2010 and 2011, and health spending as a share of GDP remained stable from 2009 through 2011, at 17.9 percent. Even as growth in spending at the national level has remained stable, personal health care spending growth accelerated in 2011 (from 3.7 percent to 4.1 percent), in part because of faster growth in spending for prescription drugs and physician and clinical services. There were also divergent trends in spending growth in 2011 depending on the payment source: Medicaid spending growth slowed, while growth in Medicare, private health insurance, and out-of-pocket spending accelerated. Overall, there was relatively slow growth in incomes, jobs, and GDP in 2011, which raises questions about whether US health care spending will rebound over the next few years as it typically has after past economic downturns.
Faster growth in 2011 reflects higher cost sharing for group health insurance plans and increased enrollment in consumer-directed health plans that have higher deductibles, copayments, or both. Additionally, increases in the number of uninsured people over the past few years had resulted in more direct out-of-pocket spending than might otherwise have been the case.
Slower growth in Medicaid spending reflected states’ efforts to control expenditure growth as the enhanced federal matching rates expired and state revenues continued to increase at a slow rate. With fewer federal matching dollars and continued pressure on their budgets, some states implemented cost-control measures that included provider reimbursement reductions, eligibility restrictions, benefit reductions, and increased cost sharing.
Medicare spending for physicians’ services also accelerated in 2011, increasing 7.6 percent compared to 3.2 percent growth in 2010, even as the increase in physicians’ fees was lower in 2011. Faster fee-for-service spending growth for physician services, therefore, is attributable to a rebound in the volume and intensity of services after unusually slow growth in 2009 and 2010.
In 2011 national health spending increased 3.9 percent—the same rate of growth experienced in 2009 and 2010. The recent recession had an immediate and noticeable effect on the health sector because of high unemployment, loss of private health insurance coverage, and a reduction in the resources available to pay for health care. All of these factors contributed to historically low growth in aggregate health spending during 2009–11.
In 2011, however, there were some signs of change, evident in faster growth in nonprice factors such as the use and intensity of health care goods and services. Additionally, insurance coverage expanded in 2011 for dependents under age twenty-six, and overall private health insurance coverage did not decline as had been experienced in the prior three years.
Nonetheless, economic, income, and job growth in 2011 was modest and less than might normally be expected during an economic recovery. This fact raises questions about whether the near future will hold the type of rebound in health care spending typically seen a few years after a downturn. Data for the years 2012 and 2013 will provide important indications of the state of the US health system as the major insurance expansions associated with the Affordable Care Act grow nearer on the horizon.
National Health Expenditures (NHE), 2011
$2,700.7 – NHE, billions
17.9 – NHE as percent of GDP
$8,680 – NHE per capita
In 2011, health care costs grew at the same rate as the growth in the gross domestic product (GDP). Thus the recent severe recession and slow recovery, plus the initial phase of implementation of the Affordable Care Act, have not had a major impact on the growth of health care spending.
At a time when Medicare spending is under close scrutiny, especially for potential opportunities to reduce the federal deficit, the fact that the volume and intensity of services have increased disproportionately warrants scrutiny. Physician behavior may drive reforms that could have other consequences, favorable, or more likely unfavorable.
Shifts in Medicaid spending should raise red flags. More of the costs are being shifted to states at a time that they are facing budget crises. States are responding with measures such as provider reimbursement reductions, eligibility restrictions, benefit reductions, and increased cost sharing. These changes can result in greater impairment of access just at a time when massive enrollment increases are anticipated. This can have very serious consequences for a welfare program that is already critically underfunded.
Out-of-pocket spending is increasing, especially due to an increase in enrollment in consumer-directed health plans with high deductibles – a market strategy to reduce health care spending by erecting financial barriers to care.
Although reducing the increase in health expenditures down to the rate of increase in the GDP sounds like good news, the trends behind the numbers should have us all deeply concerned.
Need I say, a single payer…
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