Dartmouth variations – looking back and looking forward

Posted by on Friday, Oct 16, 2009

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.

Looking Forward, Looking Back: Assessing Variations in Hospital Resource Use and Outcomes for Elderly Patients With Heart Failure

By Michael K. Ong, Carol M. Mangione, Patrick S. Romano, Qiong Zhou, Andrew D. Auerbach, Alein Chun, Bruce Davidson, Theodore G. Ganiats, Sheldon Greenfield, Michael A. Gropper, Shaista Malik, J. Thomas Rosenthal and José J. Escarce
Circulation – Journal of the American Heart Association
October 13, 2009

Background: Recent studies have found substantial variation in hospital resource use by expired Medicare beneficiaries with chronic illnesses. By analyzing only expired patients, these studies cannot identify differences across hospitals in health outcomes like mortality. This study examines the association between mortality and resource use at the hospital level, when all Medicare beneficiaries hospitalized for heart failure are examined.

Methods and Results: (Warning: This section is technical and you may want to skip it for now.) A total of 3999 individuals hospitalized with a principal diagnosis of heart failure at 6 California teaching hospitals between January 1, 2001, and June 30, 2005, were analyzed with multivariate risk-adjustment models for total hospital days, total hospital direct costs, and mortality within 180-days after initial admission (“Looking Forward”). A subset of 1639 individuals who died during the study period were analyzed with multivariate risk-adjustment models for total hospital days and total hospital direct costs within 180-days before death (“Looking Back”). “Looking Forward” risk-adjusted hospital means ranged from 17.0% to 26.0% for mortality, 7.8 to 14.9 days for total hospital days, and 0.66 to 1.30 times the mean value for indexed total direct costs. Spearman rank correlation coefficients were 0.68 between mortality and hospital days, and 0.93 between mortality and indexed total direct costs. “Looking Back” risk-adjusted hospital means ranged from 9.1 to 21.7 days for total hospital days and 0.91 to 1.79 times the mean value for indexed total direct costs. Variation in resource use site ranks between expired and all individuals were attributable to insignificant differences.

Conclusions: California teaching hospitals that used more resources caring for patients hospitalized for heart failure had lower mortality rates. Focusing only on expired individuals may overlook mortality variation as well as associations between greater resource use and lower mortality. Reporting values without identifying significant differences may result in incorrect assumption of true differences.


* Substantial variation has been documented among hospitals in the resources used to care for elderly Medicare beneficiaries with chronic illnesses during the last 6 months of life.

* By only including individuals who have died in the analyses, researchers cannot identify differences on health outcomes such as survival.


* This study found variation among California teaching hospitals in survival for patients hospitalized with heart failure. This variation would have been overlooked by a study that only examined heart failure patients who died.

* When analyzing all patients hospitalized for heart failure, California teaching hospitals that used more resources had lower mortality rates.

* When analyzing all patients hospitalized for heart failure, the variation in resource use among California teaching hospitals was 27% to 44% less than the variation observed when analyzing only heart failure patients who died.


As the nation attempts to identify ways of slowing the excessive growth in our health care costs, it is only natural that we would look at the great variability in health care spending that does not seem to correlate with health care outcomes. John Wennberg and his colleagues, in producing the Dartmouth Atlas, have confirmed that these variations are very real, though more recent refinements have demonstrated that the differences are not quite as great when corrected for other factors.

A prior study of California hospitals showed that these differences were not limited to those areas for which there seems to be an easier explanation (private hospitals with a liberal supply of high-tech services and professionals treating wealthier patients versus under-budgeted safety-net institutions treating low-income patients), but these Dartmouth differences were also noted between the various University of California teaching hospitals, which have similar funding, staffing and equipment.

This new study looked closer at the differences between the University of California teaching hospitals (including one private teaching hospital affiliated with UCLA). The authors showed that looking back for six months at patients who had died of heart failure did confirm the differences, although not as great since more variables were considered. Higher spending did not improve outcomes for the obvious reason that patients were selected for study on the basis of a common outcome – death.

The important contribution of this study is that they selected the same disorder as used in the death study – congestive heart failure – and looked forward for six months for the outcome of survival or death. This study showed that the teaching hospitals using more resources (spending more money) had a lower incidence of death.

Okay. Now, what care are we going to refuse to fund? Just looking at congestive heart failure alone, it is going to be very difficult to sort out the details to determine which interventions are of value and which are not. Now think of the task of sorting out these differences for all other serious disorders.

So how do we select out those services that should be eliminated from coverage? Legislators and bureaucrats certainly understand that they are not up to the task, so what do they recommend? They are suggesting that we lower spending by paying only for efficient care (i.e., by paying less money), by bundling payments and using accountable care organizations. Third party payers would distribute the funds while health care professionals would micromanage the use of those funds.

Think of the logistical nightmare of contracting with all the services and facilities that would be required in an accountable care organization. Even just informally gathering these services together to accept a bundled payment would entail similar logistical barriers. But then think of the internal conflicts that would occur when it comes time to decide how to divide up the spoils. The micromanagement within these entities would not be based on projected optimal outcomes, but they would be based on pecuniary interests.

If high-quality teaching institutions within the same university system are having difficulties fine tuning health care, how could we ever expect all facilities throughout the nation to adhere to the highest standards when they aren’t even understood?

Although we can continue to study the differences and educate professionals on better practices, we can’t really look to the Dartmouth variations as a quick source of cost savings to finance our other health care needs.

But there is one quick measure that would provide a great start for achieving a higher-value health care system. Get rid of the private insurers and establish an improved Medicare system that would include all of us. That would save about $4 trillion in the next ten years that could be used on actual health care, without increasing our national budget deficit. With a single financin

Regence blames the patients

Posted by on Thursday, Oct 15, 2009

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.

Regence campaign: Consumers must make choices to reduce health care costs

By Paul Beebe
The Salt Lake Tribune
November 14, 2009

As the battle over health care reform rages in Congress, Regence BlueCross BlueShield is using a slick Internet site, social media and billboards to say that consumers bear much of the blame for high premiums.

The message isn’t that bald, but it’s there.

“It really is about motivating people about the real cost of health care and how the choices they make each day impact those costs. To motivate consumers to take action is really what it’s all about,” Regence spokeswoman Georganne Benjamin said Wednesday.

“Cost is a big factor in this debate, and we need to address the high rate of medical spending, or we will not have meaningful health care transformation. This campaign does play a role in that,” she said.

The heart of Regence’s campaign is an interactive Web site (What’s the Real Cost?). But if a visitor overlooks or doesn’t click on a link next to a navigation button, he won’t easily discern that the site was put up by (Regence BlueCross BlueShield).

Regence is also using traditional tactics.

It has erected billboards along Interstate 15 that display two messages: “Health care hums like a machine with no off button because we don’t question it” and “Should ‘Because it’s covered’ be guiding health care?”


What’s the Real Cost? (a game):

How many people do you know that request health care that they know they don’t need but they want to have “because it’s covered”? In over thirty years of my very busy family practice, I cannot recall one single patient with such a request. Yet the thrust of this Regence BlueCross BlueShield campaign is to blame the patient for requesting too much health care.

We know the primary sources of the very high costs for health care in the United States. First, the administrative excesses of our fragmented financing system waste hundreds of billions of dollars each year (about four trillion in the next ten years, reformers please note). Also our prices are much higher than in other nations. Although technological advances have increased costs, they do not account for our excess spending since the level of use is comparable to that of most other nations.

So what about the excess of unnecessary care? Health care decisions are predominantly supply-side, provider-driven decisions. In spite of the plethora of anecdotes of patients demanding too much care, very few health care decisions are demand-side, patient-driven decisions. Regence couldn’t be further off target with this campaign.

Regence BlueCross BlueShield is a not-for-profit insurer, theoretically a traditional Blues plan. But it, like the other not-for-profits, has adopted the market innovations of the other Blues such as WellPoint that have converted to for-profit for the primary purpose of making money, with patient service being only a secondary necessity.

Regence BlueCross BlueShield is part of the reason for our outrageous health care costs, both for the administrative waste from its own activities and the administrative burden placed on providers, plus its ineffectiveness in improving value by improving the allocation of our health care dollars. For Regence to place the blame with the patients for demanding too much care is the ultimate of chutzpah.

Guardian gets rid of the “dogs”

Posted by on Wednesday, Oct 14, 2009

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.

Insurer ends health program rather than pay out big

By William Ehart
The Washington Times
October 14, 2009

Ian Pearl has fought for his life every day of his 37 years. Confined to a wheelchair and hooked to a breathing tube, the muscular dystrophy victim refuses to give up.

But his insurance company already has.

Legally barred from discriminating against individuals who submit large claims, the New York-based insurer simply canceled lines of coverage altogether in entire states to avoid paying high-cost claims like Mr. Pearl’s.

In an e-mail, one Guardian Life Insurance Co. executive called high-cost patients such as Mr. Pearl “dogs” that the company could “get rid of.”

“The insurance companies are cheating in order to have obscene profits,” (Mr. Pearl’s father) said.

Guardian, a 150-year-old mutual company, reported profits of $437 million last year, a 50 percent increase over $292 million in 2007. It paid dividends of $723 million to policyholders and had $4.3 billion in capital reserves, according to its annual report. The company’s investment income totaled $1.5 billion that year, a small increase from the year earlier.


Although the individual private insurance market is infamous for discriminating against individuals with a potential for high health care costs, regulations largely prohibit group plans from singling out individuals for exclusion.

When private group plans prove to be unprofitable, they can often legally skirt the regulations by shutting down the entire plan or by withdrawing from unprofitable markets, often leaving the previously insured with very difficult or near-impossible choices. No matter how well regulated, the current proposed insurance exchanges cannot prevent an insurer that is failing in a market from shutting down. Even with guaranteed issue, other insurers would also shun unprofitable markets and unprofitable plans.

This problem is much more common than many realize. Look at the Medicare Advantage programs. This year many have declined to submit bids for renewal and will withdraw from unprofitable markets. Even this highly regulated option to Medicare can abandon patients, yet Medicare can’t. This is one more important reason why we should question the wisdom of Congress in insisting that reform be based on a market of private plans instead of an improved Medicare program for all of us.

Ian Pearl’s story has a couple of other important lessons for those supporting a public option as part of the reform package. Although private plans must always protect their business interests above the interests of the patients, a public option would have a mission requiring it to place patients first. The public option would be a victim of adverse selection since it would have to function as the safety net. Attempts to adjust risk would drive private insurers out of the exchange, leaving high-cost individuals with only very expensive options.

What about private co-ops instead, owned by the beneficiaries? That would prevent insurers from “cheating in order to have obscene profits,” as Mr. Pearl Sr said. Oops. Look at the profit statement of Guardian. It is a mutual company, and the profits are returned to the policyholders as dividends. That is essentially what a co-op is! Yet that did not prevent Guardian from jerking the rug out from under Ian Pearl. Private plans with their own segregated risk pools will always use any means legal (and sometimes illegal) to protect their reserves from being spent on health care.

Creating a public option and then throwing it into the amoral, dysfunctional private insurance marketplace to have it compete on the same perverse terms as the private insurers is a very sick solution for our health care crisis.

Single payer anyone?

On Monday October 5th, Drs. Margaret Flowers and Paul Hochfeld led a delegation of 15 physicians and nurses to the White House gate. The occasion was a Rose Garden ceremony with over 100 physicians in white coats invited, a photo-op to showcase support among doctors for the President’s effort at health reform.

The single-payer delegation assembled together with the invited doctors at the inside gate. Several leading physicians recognized Dr. Walter Tsou, past-president of the American Public Health Association, and greeted him warmly. Many of the physicians also recognized and greeted Dr. Margaret Flowers, Congressional Fellow of Physicians for a National Health Program. Some took pictures of our banners.

Dr. Flowers patiently explained to a White House aide that many requests had been made to meet with the President, from Physicians for a National Health Program, from the Leadership Conference for Guaranteed Healthcare and from the Mad as Hell Doctors‘ roadshow as well as other single payer advocates. These entreaties have been ignored, she explained, in spite of the President’s September 9th, 2009 promise: “If you come to me with a serious set of proposals, I will be there to listen.”

Dr. Flowers pointed out that several of the Mad as Hell docs were in the delegation with us and that they had just completed a 26-city tour of the United States that concluded at the White House only days earlier. Supporters of the Mad as Hell Doctors along the way sent thousands of emails requesting a White House meeting only to find a solitary email in reply: stop sending these emails.

The White House staff member took PNHP business cards from Dr. Flowers and I for our contact information. He assured us that someone would be in touch with us very soon. (No one from the White House has contacted us or PNHP in the last week.) As the other doctors went in, PNHP members were told one by one that we were “not on the list.” Soon we were asked to leave the White House grounds.

Dr. Hochfeld remained at the inside gate, insisting upon a direct answer whether or not he might receive an impromptu invitation to attend the ceremony. Afterward Paul was not comfortable saying he had been invited to the photo-op. He preferred to say that he was “let in.”

Surely the White House staff, where the leader of the world’s last remaining superpower lives, knows precisely whom it does – and doesn’t – invite inside. It is no leap of imagination to think that after Dr. Hochfeld’s data was entered into the appropriate computer, someone inside must have said something like ‘good grief, let’s not give them an excuse for further protest.’

Dr. Hochfeld could not hear us cheering from a distance as he walked across the White House lawn, last of all. He reported that he was seated between two large men in suits, whom he presumed to be Secret Service agents.

At the conclusion of the ceremony we had the chance to interact again with some of the physicians in attendance. We were eager to hear from Dr. Hochfeld, who was soon inundated with interviews. He was later invited to share his impressions of the White House meeting on “Countdown with Keith Olberman.”

Our small delegation also took our banners amid a protest for peace, where dozens of activists were performing civil disobedience to demand an end to the wars in Afghanistan and Iraq and the closure of the United States’ prison in Guantanamo Bay, Cuba. We were welcomed with a spirited ovation and chants of “Healthcare, Not Warfare!”

Single-payer advocates should take note. Dr. Hochfeld was allowed to attend the ceremony, uninvited and at the last minute, because single payer cannot be ignored. Our persistence has proven effective. The goal of the mainstream discussion, orderly consensus for incremental change, with nary a ripple of discord, as remained elusive. Yet experience proves again and again that single payer swims just below the surface.

All year long it has become more and more clear – to more and more people – that single payer national health insurance is in fact the very least we need when it comes to health care reform that will work to improve our lives. As Dr. Flowers explains, “Anything less is unacceptable.”

This just-below-the-surface dynamic, combined with clear and persistent advocacy, that has taken single payer from “off the table” to “on the floor” this year. We now learn that the vote on HR 3200 – and with it, the Weiner amendment that would substitute single payer legislation for the text of the bill – may be imminent. Activists around the nation are pulling out all the stops.

So the single payer presence within the beltway continues, even now, to increase, not diminish. We also recognize that soon we will begin a new chapter in our efforts to educate and advocate for a single-payer national health program.

The other day Dr. Flowers received an email from a doctor who sought further dialogue following the President’s photo-op. Here is her reply. We can all learn from her perspective.

Don’t let the good be the enemy of the perfect

Thank you for inviting me to this conversation. I understand your concern to get some type of reform now. I hear your desperation. I have felt it myself. There is so much suffering that it is tempting to say – we must get something even if we know it is not the solution.

At some point we have to look at the facts that incremental change and compromise when it comes to health reform in this nation have not gotten us anywhere. While SCHIP is great, it has merely held the level of uninsured children at bay, not decreased it. Medicaid expansions have similarly not been able to keep up with the rising uninsured or been able to provide a financially sustainable and high quality solution. Why is this?

It is because the greatest impediment to health reform in this country is that the for profit (and not for profit in some cases, such as BCBS) health industries control the political process. No amount of incremental reform will change that. Regulation of the industry is expensive and has been ineffective. The industry can do an end-run around regulation so fast that it would make your head spin. With the proposed legislation, we will be throwing more money into an already overpriced and dysfunctional situation. We will delay enactment of better reform while we wait to see if this reform works, all the time knowing that it won’t. In the meantime, thousands of people will die unnecessarily, thousands of people will suffer, families will continue to go bankrupt and lose their homes, physicians will continue to leave practice.

Single payer was not supposed to be on the table this year, yet despite having little in the way of funding and no paid organizers (like HCAN has), we were able to move it forward and break through some of the media blackout through perseverance and dedication.

We must ask ourselves, how long are we willing to play the incremental game (knowing that while a few more get access to healthcare, many more continue to be left out)? When will we decide that we’ve reached the tipping point, and like other social justice movements, dig in and do the necessary work to enact change?

I am tired of hearing that we can’t have single payer or that it is not on the table. It will never be on the table and we will never get it until we do the work to put it there. We, as physicians (and the other health professionals), hold a unique position in society. For the most part we are seen as advocates for our patients and acting in the best interest of our patients (although sadly this vision is truer for nurses than for doctors). We are seen as “experts.” Thus, I believe that it is our professional responsibility to educate and advocate for effective reform. If we work together we can create real change. But it is harder than showing up for a photo shoot. It takes a lot of time and travel and writing and speaking and money and a willingness to put our bodies on the line.

Until more of us are willng to do this, we will have to continue to settle for crumbs. I am not willing to settle for crumbs. My part in this drama is to be a strong voice for single payer. And I won’t give in until we get there. The stories that I hear from patients and docs keep me going. Nobody should be left out. Everybody should have the same level of care. It is our responsibility to fight for this. Anything less is unacceptable.

My two cents, for what it’s worth.


What about primary care?

Posted by on Tuesday, Oct 13, 2009

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.

“Uncomplicated” Primary Care?

By Josh Freeman
Medicine and Social Justice
October 8, 2009

I have often written about the importance of primary care, the shortage of primary care physicians, and the fact that fewer medical students are choosing primary care careers, which will exacerbate the problem. A key part of this analysis is the large number of studies, by researchers from a variety of settings, that show that the presence of a higher proportion of primary care doctors decreases cost and increases quality.

However, not everybody agrees. In an earlier post, More Primary Care Doctors or Just More Doctors?, I discussed the position taken by Dr. Richard Cooper, former Executive Vice President and Dean of the Medical College of Wisconsin and currently Professor of Medicine and Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, who argues against this position.

Dr. Cooper and a group of equally distinguished colleagues restate this position; in particular that the value of primary care is overstated. In an excerpt from (their Physicians Foundation report) they note:

“Primary care has been a central focus of health care reform. In modeling the future workforce, the Project Team acknowledged the critical importance of primary care services and the role of generalist physicians in providing them. However, the Team rejected the claim by Starfield and others of lower mortality in regions with more family practitioners as a statistical anomaly, and it questioned the wisdom of deploying generalist physicians to take responsibility for the proposed medical homes. Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care.”

The American Academy of Family Physicians (AAFP) in its formal response to the Physicians Foundation report includes the following:

“This study is largely a recapitulation of the primary author’s paper in Health Affairs in January of this year. In that same issue, several researchers pointed out the fundamental flaws in this simplistic research showing that important basic adjustments showed this work to strongly support the prior studies it criticized. It continues to claim that population differences explain past findings for the value of primary care and variance in spending, when these were fully accounted for in these studies. This report does not repair those flaws. It labels several well-validated and valued studies as ‘anomalous’ and ‘simple frameworks’ without supporting evidence from other sources. We feel that such claims carry an obligation to point out specific errors of methodology or data, not just recapitulation of personal belief. The burden of proof is still overwhelmingly against the evidence upon which this reports rests. Its foundation is flimsy.”

Enough said about the lack of intellectual rigor, and essentially incorrectness about this piece. More important, I believe, the other assertion in the quote from Cooper’s paper, above, neatly packaged in the sentence “Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care”. What is this “uncomplicated primary care” of which you speak?

The myth is that primary care is about patients with colds and high blood pressure checks. The reality is that it is about people with multiple chronic diseases who need management of those conditions as well as coordination with whatever other specialists they are seeing; preventive services delivered; counseling and “asking for trouble” (“are you safe at home?”); discussion of whatever the other specialist may have recommended; and, of course, caring for acute complaints. This is hard, complex, time consuming and difficult.

(Joshua Freeman, MD is Professor and Chair of the Department of Family Medicine for the University of Kansas School of Medicine. He is author and editor of the Medicine and Social Justice blog.)



Health Bills In Congress Won’t Fix Doctor Shortage

By Phil Galewitz
Kaiser Health News
October 12, 2009

Even as Congress moves to expand health insurance coverage to millions of Americans, it’s doing little to ensure there will be enough primary care doctors to meet the expected surge in demand for treatment, experts say.

The American Academy of Family Physicians predicts that the shortage of family doctors will reach 40,000 in the next 10 years, as medical schools send about half the needed number of graduates into primary care medicine.

A proposal backed by Senate Majority Leader Harry Reid, D-Nev., and the teaching hospital lobby to add 15,000 Medicare-funded medical residency positions — a 15 percent increase that would favor more primary care training — was considered dead on arrival because of its $10 billion price tag over a decade.

Instead, the House and Senate overhaul bills would redistribute about 1,000 unfilled residency positions to teaching hospitals that commit to creating more primary care residencies.

Proposals to significantly increase Medicare payments for primary care doctors have gone nowhere in part because the money would come from payments to higher-paid specialists — who, not surprisingly, oppose a pay cut.

Dr. Darrell Kirch, CEO of the Association of American Medical Colleges, said the extra training slots emanating from the redistribution of unfilled residency position would amount to a “drop in the bucket.”


The report by Dr. Cooper and his colleagues, cited by Dr. Freeman, was “A Report to the President and the Congress.” Since it was released only one month ago, this report likely did not influence the current legislation, but it is important because it does represent the cavalier views of all too many within and outside of the health care arena.

One of the promises of reform was to reinforce our primary care infrastructure. Although there are a few measures in the bill such as a nominal primary care bonus and a medical home pilot project, failure to train more primary care physicians will require many patients to rely on expensive care in our emergency rooms and expensive care through often inappropriate, direct self-referral to specialists.

We were promised that everyone would be covered and costs would be controlled. Neither will happen. And now the promise of providing primary care access to everyone will fall far short. Jiggling 1000 existing medical residencies just won’t do it.

The Urgent Need for National Health Care Reform

Posted by on Tuesday, Oct 13, 2009

I have requested that this letter from the Harvard Medical School (Class of 1955) be posted on our blog. I wanted to call attention to this letter even though it doesn’t explicitly support single payer, because many of the signers are strong single payer advocates. The signers include significant leaders in medicine – chairmen of departments, deans, professors at major medical schools and prominent practicing physicians. I hope that they will turn their advocacy in the future towards promoting Medicare for All. —Oliver Fein, M.D.

Fifty-nine members of the Harvard Medical School Class of 1959 are convinced that reform of the American health care system is essential, must be substantial and carefully designed, and must include a public health insurance option.

We present our position in this statement, a result of intense discussions begun at our June reunion commemorating 50 years since graduation. We are a majority of our 112 living American classmates. Six declined to sign the statement because they disagree with it, 3 more because it is not detailed enough, and 44 expressed no opinion.

Each of the signers has 50 years of experience and leadership in clinical practice, medical education, administration, and/or research. Our collective careers cover a wide variety of primary care and specialty fields in a range of organizational settings, in both private practice and academia, across the United States.

We believe that our humane and enlightened country, committed to “life, liberty and the pursuit of happiness”, has the obligation to provide everyone with the opportunity to obtain affordable insurance and quality health care.

We support President Obama’s proposal that all citizens should be offered the option of a government-sponsored medical insurance plan, along with private options. In our opinion, health care reform will fail without the discipline of competition from a public option.

Excluding a public option would throw away a vital opportunity to test different ways to provide quality care for all. A public plan would help develop and evaluate new standards of practice, malpractice reform, and reimbursement of physicians, and would emphasize preventive care. To be affordable, it would have to avoid financial incentives for unnecessary services and contain measures that curb financial abuse and waste by some hospitals and, unfortunately, by some of our medical colleagues.

A public option would also identify and encourage use of demonstrated best practices shown to be effective at less cost, offer greater access, and provide higher quality of care. Administrative overhead, as now in Medicare, would be significantly lower without for-profit intermediaries. These innovations could help lift the competitive burden that health care places on American employers in the global marketplace, while also offering portability and continuity of coverage during job changes and illness.

Common sense demands a planned, full comparison of the relative benefits of public vs. private options. At the outset, there must be clear and uniform ground rules for measuring, reporting, and evaluating cost, access, and quality of care for all plans.

We urge Congress and the President to take this courageous step at a vital time in our nation’s history.

Names and relevant positions of signers are attached. This statement represents only their opinions, not necessarily those of other 1959 graduates of Harvard Medical School or of that institution.


Norman O. Aarestad, M.D., F.A.C.R.
Radiation oncology, retired
Denver, CO

Eugene M. Abroms, M.D.,
Formerly Prof of Psychiatry,
University of Wisconsin Medical School
Ardmore, PA

Robert S. Adelstein MD
Bethesda, MD

James E. Barrett, M.D.,
Research Professor Emeritus of Community and Family Medicine and Psychiatry,
Dartmouth Medical School
Hanover, NH

Harvey H. Barten, M.D.
Scarsdale, NY

Costan W. Berard, M.D.
Formerly Chairman, Department of Pathology and Laboratory Medicine,
St. Jude Children’s Research Hospital,
Past President, United States and Canadian Academy of Pathology,
St. Helena Island, SC

Robert S. Blacklow, M.D.
Formerly Dean, Northeast Ohio college of Medicine
Currently, Department of Global Health and Social Medicine,
Harvard Medical School
Lincoln, MA

Forst E. Brown, M.D.
Professor Emeritus of Surgery,
Dartmouth Medical School
White River Junction, VT

Charles E. Burden, M. D.
Bath, ME

Boyd R. Burkhardt, M.D,
Clinical Plastic Surgeon,
Tucson, AZ.

Savelly B. Chirman, M.D.
Internal Medicine, retired
Santa Barbara, CA

Norman A. Clemens, M.D.
Clinical Professor of Psychiatry,
Case Western Reserve University School of Medicine,
Cleveland, Ohio

Richard E. Conway, M.D.
Orthopedic Surgery
Rockport, MA

Richard W Darrell, M.D, ScD
Clinical Professor Emeritus of Ophthalmology,
Columbia University
Fort Myers, FL

Donald E. Dillon, M.D.
Hematology/Oncology, retired
Ocean View, DE

Hall Downes, M.D.
Professor Emeritus of Physiology and Pharmacology,
Oregon Health Sciences University
Portland, OR

Karl Engelman, M.D.
Professor Emeritus of Medicine,
University of Pennsylvania
Hilton Head, SC

Charles J. Epstein, M.D., D.Sc.(h.c.)
Professor Emeritus of Pediatrics, , and
Former Director of the Program in Human Genetics,
University of California School of Medicine, San Francisco
Tiburon, CA

Lois Barth Epstein, M..D., D.Sc.(h.c.)
Professor of Pediatrics, Emerita, and
Former Director of the Tumor Immunology and Interferon Laboratory,
Cancer Research Institute,
University of California School of Medicine, San Francisco
Tiburon, CA

Gerald C. Finkel M.D.
Clinical Professor of Pathology,
Univ. of Washington
Seattle, WA

Frederick B. Glaser, M.D., F.R.C.P. (Canada)
Professor Emeritus of Psychiatry,
Brody School of Medicine, East Carolina University
Greenville, NC

Warren M. Gold, M.D.
Professor of Medicine,
University of California, San Francisco
San Francisco, CA

Robert A. Goldstone, M.D.
Orthopedic Surgery
Glen Rock, NJ

Anne M. Haywood, M.D.
Associate Professor of Pediatrics and of Microbiology & Immunology,
University of Rochester
Rochester, NY

Arthur L. Herbst, M.D
Joseph B Delee Distinguished Service Professor Emeritus,
University of Chicago
Chicago, IL

Kenneth Herrmann, M.D.
Research Virologist,
Centers for Disease Control & Prevention, retired
Atlanta, GA

David Korn, M. D.
Vice Provost for Research,
Harvard University
Professor of Pathology,
Harvard Medical School
Boston, MA

Anton O. Kris, M.D.
Clinical Professor of Psychiatry,
Harvard Medical School
Cambridge, MA

Nelson R. Lampert, M.D.
Clinical Professor of Surgery, retired
University of California, San Francisco
Ross, CA

Lucian L .Leape, M.D.
Adjunct Professor of Health Policy,
Harvard School of Public Health
Cambridge, MA

Cavin P. Leeman, M.D.
Clinical Professor Emeritus of Psychiatry,
SUNY Downstate Medical Center
New York, NY

Herbert Lessow, M.D.
New York, NY

John T. Maltsberger, M.D.
Associate Clinical Professor of Psychiatry,
Harvard Medical School
Boston, MA

Ira Marks, M.D., F.A.A.P.
Pediatrics, retired
Old Chatham, NY

Kilmer McCully, M.D.
Chief, Pathology and Laboratory Medicine,
VA Boston Healthcare System
Winchester, MA

John F. Merrifield, M.D.
Psychiatry, retired
Lexington, MA

Eli C. Messinger, M.D.,
Formerly Clinical Associate Professor of Psychiatry,
New York Medical College
New York, NY

Roger V. Moseley, M.D.
Formerly Asst. Clinical Professor of Surgery,
College of Medicine and Dentistry (NJ)
Princeton, NJ

J. David Poutasse, M.D.
Radiology, retired
Pittsfield, MA

James W. Prichard, M.D.
Professor Emeritus of Neurology,
Yale Medical School,
West Tisbury, MA

Judith L. Rapoport, M.D.
Washington, DC

Stanley I. Rapoport, M.D.
Washington, DC.

George D. Raymond, M.D.
Gastroenterology, retired
West Palm Beach, FL

William Reed, M.D.
Internal Medicine, retired
Albuquerque, NM

Richard S. Rivlin, M.D.
Formerly Professor of Medicine, and
Director, Career Development Program,
Nutrition and Cancer Prevention,
Weill-Cornell Medical College
Scarsdale, NY

John J. Roach, M.D.
Seattle, WA

Norman Robbins, M.D., Ph.D.
Professor Emeritus of Neurosciences,
Case Western Reserve University School of Medicine
Shaker Heights, OH

Irwin H. Rosenberg, M.D.
University Professor and Dean Emeritus,
Tufts University and Friedman School of Nutrition Science and Policy
Boston, MA

David Rush, M.D.
Professor Emeritus of Nutrition, Community Health and Pediatrics,
Tufts University
Cambridge, MA

Kevin G. Ryan, M.D.
Radiologist, retired
Port Ludlow, WA

Richard G. Sanderson, M.D.
Cardiothoracic Surgery, retired
Tucson, AZ

Paul E. Sapir, M.D.
Clinical Assistant Professor of Psychiatry & Human Behavior,
Warren Alpert Medical School, Brown University
Providence, RI

Peter B. Schneider, M.D.
Professor of Medicine and Radiology (Nuclear Medicine),
University of Massachusetts Medical School
Worcester, MA

Richard Lee Schoenbrun, M.D., Ph.D.
Psychiatry, San Francisco Community Mental Health Center
Belvedere, CA

Gordon M. Shepherd, M.D., D.Phil.
Professor of Neurobiology,
Yale University School of Medicine
Hamden, CT

John J. Soltys, M.D.
Professor of Psychiatry, retired
Univ. Of North Carolina Medical School
Chapel Hill, NC

Bruce W. Steinhauer, M.D.
Professor, Internal Medicine,
College of Medicine of the University of Tennessee
Memphis, TN

John Urquhart, MD, FRCPE, FAAAS, FRSE
Emeritus Extra-ordinary Professor of Pharmaco-epidemiology,
Maastricht University (Netherlands)
Adjunct Professor of Bioengineering and Therapeutic Sciences,
Center for Drug Development Science,
University of California San Francisco Medical Center
Chief Scientist, AARDEX Group
Palo Alto, CA

Elliot S. Vesell, M.D., Sc.D.
Founding Chairman of Pharmacology,
Evan Pugh Professor of Pharmacology,
Pennsylvania State University College of Medicine
Hershey, PA

Rodberg – Is There Any Way Out for Obama?

Posted by on Friday, Oct 9, 2009

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.

Is There Any Way Out for Obama?

By Leonard Rodberg

Progressives worry that, if Obama’s health reform plan (hereafter called the “Plan”) fails to pass, a latter-day right-wing Gingrich movement will take over the Congress in 2010 and the White House in 2012. What I have not heard, but what I am increasingly coming to believe, is that, if the Plan passes in any of its current forms, things will go just as badly for him! Why is that?

The general reason is that the Plan is a DOG. It is a terrible, complex plan that will accomplish almost nothing. Relatively few people will benefit from it, while everyone who has to use health care will continue to experience the mess that is, and will continue to be, the American health care system. And, because of the new requirements built into the Plan, health care finance will become even more complex and confusing.

More specifically:

1. The large majority of people, who receive their insurance from their employer, will see no benefit whatsoever from the Plan. Most will, in fact, find their premiums rising as new requirements imposed by the Plan (e.g., the elimination of lifetime limits) raise the cost of insurance. And, of course, to their undoubted surprise, most of them will not have access to the public option, even if there is one.

2. Most provisions of the Plan will not become effective until 2013. This gives four years for Republicans to criticize the Plan, including (1) its use of cuts in Medicare reimbursements and Medicare Advantage premiums as principal sources of funding, (2) its lack of any real or believable mechanism for containing costs, and (3) its bureaucratic complexity.

3. The taxes on high-cost insurance plans, the other principal source of funding, will cause those who now have good insurance (called, pejoratively, “Cadillac” plans) to find these plans heavily taxed and their employers given a strong incentive to cut back on their benefits. Instead of reducing underinsurance, this part of the Plan will increase it! (And the rest of the plan does little about underinsurance at all.)

4. During the four years of waiting for the Plan to take effect, costs will continue to rise. By the time the Plan takes effect, costs are likely to be at least 25% greater than now. Even more people will find insurance and health care unaffordable. People will ask “What was health reform about?” The disillusionment will be great.

5. The complexity of the plan, including (1) federal rules regarding what kinds of employer-based insurance plans are “qualified,” (2) new income tax forms that will be needed to implement the individual mandate, and (3) the process of determining income eligibility for everyone, will all lend themselves to criticism and even ridicule.

Is there a way out? Not, in my view, as long as Obama sticks with this worthless and unworkable Plan. Only if we were to adopt a much simpler plan that would benefit everyone — a Medicare for All plan — would he be seen as actually addressing the problem and really offering a workable solution. Short of that, he, and all of us, are in real trouble.

(Leonard Rodberg, Ph.D. is Professor and Chair, Urban Studies Department, Queens College/CUNY.)

“If we don’t pass this…”

You hear that phrase in almost every speech made in support of the “Plan” – the reform proposal of President Obama and the Democrats in Congress. It has the implicit threat that if the Plan is not passed, we will be condemned to continue to live with the deteriorating health care mess that we now have. If we do pass the Plan, we will be condemned to live with the deteriorating health care mess that we will have – the mess that Professor Rodberg so adeptly describes.

With all of the rhetoric about choice, why should we be limited to these two options? Neither one is acceptable!

We cannot leave things the way they are. Yet we cannot allow this awful legislation to pass. We may have to have a lockdown of Congress until they get it right, but, if that’s what it takes, let’s do it!

What is the right penalty to enforce an individual mandate?

Posted by on Thursday, Oct 8, 2009

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.

Give people breathing room

By Sen. Charles E. Schumer
USA Today
October 8, 2009

Sen. Olympia Snowe of Maine and I decided to give some breathing room to families faced with the uneasy choice of buying insurance they can’t afford or paying a stiff penalty that they also can’t afford. Our proposal, which passed the Senate Finance Committee 22-1, exempts Americans from the requirement to buy insurance if the cost of the available plans exceeds 8% of their income. We also reduced the amount of the penalty and phased it in over time, to make sure the reformed system works before we punish people for not participating.



CBO Understates Major Impact Of Weakened Individual Mandate

BlueCross BlueShield Association
October 7, 2009

It is difficult to understand why the Congressional Budget Office (CBO) estimate did not show a greater impact from the significant weakening of the mandate in the amended bill. Amendments approved during the Senate Finance Committee mark-up eviscerated the individual mandate — completely eliminating it in 2013, significantly lowering penalties to the point that it will only represent about 15 percent of the cost of a premium by 2017. Further, many individuals would be exempt from the penalties altogether. This is likely to result in millions of people foregoing coverage.


The current reform proposal before Congress would encourage more uninsured individuals to purchase health care coverage by assessing a financial penalty on those who fail to do so, thus enforcing an individual mandate to purchase insurance.

As Senator Schumer states, if that penalty is too high, those who can’t afford the insurance premium wouldn’t be able to afford the penalty either. Thus the Senate Finance Committee passed an amendment that offers these individuals and families “breathing room” by granting them the right to remain uninsured by paying a more modest penalty than previously proposed. That penalty might still be a hardship for many, but worse would be the hardship of having no health insurance al all.

BlueCross BlueShield Association points out that these lower penalties would likely result in millions of people foregoing coverage. That would risk adverse selection in which individuals who need health care would buy the plans, and the healthy would opt out as long as their health care needs were minimal. That would drive up premiums, making the plans even less affordable. Worse (strictly from the private insurers’ perspective) is that would knock out a significant portion of the market that they are attempting to capture.

So what is the proper balance to achieve optimal benefit from the penalty under the individual mandate? Students of George Lakoff will recognize that we have here a problem with framing. Members of Congress have decided that their preferred solution to the problems of coverage and affordability is that everyone not eligible for public programs must purchase private health plans. This framing eliminates more effective solutions and excessively limits the policy options. Seeking the proper balance for the mandate penalty leads to a dead end since there is no proper balance. The flaw is not in the penalty. The flaw is in the mandate to purchase unaffordable private plans.

We can help Congress with framing that will lead to the reform that we need, but will they ever be willing to listen?

IBM CEO Palmisano on single payer

Posted by on Wednesday, Oct 7, 2009

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.

IBM CEO Sees Big Opportunity In Health-Care Technology

By Peter Loftus
The Wall Street Journal
October 6, 2009

The chief executive of International Business Machines Corp. (IBM) sees a huge business opportunity in making the U.S. health-care system more efficient.

(Sam) Palmisano sees IBM providing everything from electronic-health records technology to ultra-tiny personal devices that read DNA and cost less than $1,000. He likened those technologies to health-care equivalents of universal bar-codes in the retail industry, which made that industry more efficient.

But Palmisano acknowledged that single-payer, government health systems outside the U.S. make it easier to use technology for health-information sharing, because health information is more centralized.

“The advantage of a government payer or centralized system is they can begin to create incentives for change much more so than you can in a fragmented model,” he said.

He said the federal government could save itself $900 billion over 10 years in health-care spending by simply managing it better.


So IBM CEO Sam Palmisano says that single payer, government health systems have an advantage over fragmented systems (like ours in the U.S.) since they can create incentives for change. That seems counter to those who claim (falsely) that government systems suppress innovation.

He also states that the federal government could manage health care spending better (as Medicare and the VA have done).

Wow! Welcome aboard!

Bad advice from the OECD

Posted by on Tuesday, Oct 6, 2009

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.

The Organization for Economic Cooperation and Development and Health Care Reform in the United States

By Don R. McCanne
International Journal of Health Services
Volume 39, Number 4 / 2009


Among OECD nations, the United States is an outlier in having the highest per capita health care costs in a system that unnecessarily exposes many individuals to financial hardship, physical suffering, and even death. President Obama and Congress are currently involved in a process to reform the flawed health care system. The OECD has contributed to that process by releasing a paper, “Health Care Reform in the United States,” which describes some of the problems that must be addressed, but then provides proposed solutions that omit consideration of a more equitable and efficient universal public insurance program. The same omission is taking place in Washington, DC. By reinforcing proposals that support the private insurance industry, the source of much of the waste and inequities in health care, the authors of the OECD paper have failed in their responsibility to inform on policies rather than politics.


The OECD has a mission of bringing together governments “committed to democracy and the market economy.” Their release of a paper supporting a private insurance model of reform for the United States seemed to be a fulfillment of this mission. But even their paper added nothing that would refute what we already know from our efforts at reform: the private insurance model is an expensive, wasteful, inequitable, and a fairly ineffective model of ensuring affordable, high quality care for everyone.

It’s not too late to change. Many undoubtedly contend that most of the political capital has been spent and that we cannot go back, but political capital is not a finite commodity. Political capital can be wasted, as it has been on the current reform process. Pursuing policies that cater to the private insurance industry at the cost of health care justice very rapidly depletes political capital. But new political capital can be generated simply by pursuing popular policies that would lead to success in achieving our goals.

The OECD is not going to help us infuse more political capital into the process, but we can do it ourselves. Communicate. Educate. Grassroots. Coalitions. Just think of how much political capital we could generate as long as our goal is affordable, high quality health care for everyone. The supply would be endless.

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