With accelerating growth of medical technologies, specialization and sub-specialization since World War II, the U.S. now has 24 specialty boards and more than 135 certified subspecialties. As a result, a unified voice from the profession about how best to serve patients in a rational health care system has largely disappeared. At the same time, tensions and jurisdictional disputes have increased between generalists and specialists, as well as among specialists themselves. It is not surprising, then, that confusion, myths and misperceptions have developed over the role of primary care—the purview of generalists—both within the profession and the lay public.

We are indebted to the late Dr. Barbara Starfield of the Johns Hopkins School of Public Health for this basic definition of the four pillars of primary care: (1) first-contact care; (2) longitudinal continuity over time; (3) comprehensiveness, with capacity to provide care for the majority of health problems; and (4) coordination of care with other parts of the health care system. (Starfield, B. Is primary care essential? The Lancet 344 (8930): 1129-33, 1994) Dealing as they do with a broad spectrum of patients’ problems, generalist primary care physicians necessarily think and practice differently than specialists, who deal with a deeper level of knowledge and skills in a far narrower area.

These are some of the most common myths and misperceptions about the generalist primary care role in the U.S. today, together with brief responses to clarify them.

1. As a generalist, it’s impossible to know everything.
This is true—nobody can know everything. But the generalist’s knowledge is different from that of the specialist, both in kind, breadth and depth. This widespread sentiment reveals a fundamental misunderstanding about the nature of knowledge and information. It is based on the faulty assumption that all specialized knowledge must be vertical, in-depth knowledge about a narrow subject. Dr. Gayle Stephens, an early pioneer in the evolution of family medicine since the 1960s, reminds us that:

“None of the certifiable medical specialties were established on epistemological grounds. Most of them sprang up like Topsy and exist by virtue of political, economic, and technological factors that have little to do with a theory of knowledge. . . All of medicine is derivative, secondary, and applied.” (Stephens, GG. The Intellectual Basis of Family Practice. Tucson. Winter Publishing Company, Inc, 1982, p3)

2. Primary care deals with trivial content and problems.
Generalist physicians are attracted to the front-line nature of their work, dealing as they do with a wide spectrum of care spanning the entire life cycle (in the case of family medicine), medical emergencies, screening and prevention, diagnosis and management of acute and chronic illnesses, counseling and long-term care. They are prepared to definitively manage the majority of the problems brought to them, arrange for consultation with appropriate specialists when necessary, and then co-manage many patients with consulting specialists thereafter. A recent study comparing the relative complexity of patient encounters in three fields—general/family practice, cardiology and psychiatry—concluded that the practice of generalists is one-third more complex than that of cardiologists and five times more so than that of psychiatrists. (Katerndahl, D, Wood, R, Jaen. CR. Family medicine outpatient encounters are more complex than those of cardiology and psychiatry. J Amer Board Fam Med 24 (1): 6-15, 2011)

3. Anyone can do primary care.
Many specialists, with little experience, knowledge or understanding of primary care practice, denigrate it as “simple” and nowhere near as challenging or complex as their own specialty. Such a self-serving attitude often dates back to their own experiences in medical school, where they heard similar sentiments from some of their sub-specialist mentors with little of no experience in community practice.

In fact, generalist physicians today have three or more years of residency training after medical school, are willing and able to cope with the intellectual challenges and ambiguity of primary care practice, enjoy working closely with people, and have a mindset looking for patterns of illness beyond the shackles of arbitrary specialty boundaries.

4. Specialist care is better than generalist care.
Since our culture tends to worship technology and specialization, it follows that many Americans naturally assume that specialty care is of higher quality than that provided by generalists. A major review of the literature in 2007 attempted to answer this question, but yielded mixed results. Forty-nine studies compared the quality of care provided by generalists vs. specialists, but were limited by their focus on single discrete medical conditions, thereby advantaging specialists over generalists. We still don’t have a solid answer to this important question, since these studies failed to deal with multiple chronic conditions, little attention was paid to coordination and integration of care, case-mix adjustment was often inadequate, and characteristics of physicians’ practice settings (such as use of clinical practice guidelines and electronic medical records) were ignored. (Smetana, GW, Landon, BE, Bindman, AB, Burstin, H, Davis, RB et al. A comparison of outcomes from generalist vs. specialist care for a single discrete medical condition. Arch Intern Med 167 (1):10-20, 2007) At the macro level, however, a 2005 analysis of 100 ecological studies of the relative benefits of generalist vs. specialist care in various health care systems concluded that “primary care helps prevent illness and death . . .and . . . that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations.” (Starfield, B, Shi, L, Macinko, J. Contribution of primary care to health systems and health. Millbank Q 83: 457, 2005)

5. Since medicine has become so specialized, generalists are no longer needed.
Actually, there has never been a greater need in this country for generalist physicians rebuilding the deteriorating primary care infrastructure. Current projections call for a shortage of 45,000 primary care physicians by 2020 (Krupa, C. Physician shortage projected to soar to more than 91,000 in a decade. American Medical News. Amednews.com, October 11, 2010). If the 2009 health care reform legislation ever gets fully implemented, some 32 million Americans will be newly covered by health insurance (including 16 million on expanded Medicaid) in 2014. But replacements of our dwindling supply of primary care physicians are nowhere in sight. Already, only 42 percent of patients’ annual visits to physicians for acute medical problems are made to their personal physicians; all the rest are made to emergency rooms (28 percent), to specialists (20 percent), or to hospital outpatient departments (7 percent), often with difficulty in arranging follow-up care. (Pitts, SR, Carrier, ER, Rich, EC, Kellerman, AL. Where Americans get acute care: Increasingly, it’s not at their doctor’s office. Health Affairs 29 (5): 1620-28, 2010) So we’re facing a growing crisis in having generalist primary care physicians available for patients to see that they know. More to be expected—continued growth in the numbers of patients without a primary care physician who are forced to seek care from strangers through emergency rooms, urgent care centers and other facilities without access to the full benefits of primary care.

Adapted in part from my latest book Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans. Copernicus Health Care, 2011.

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

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Employers continue to shift health care costs to employees

Posted by on Friday, Aug 19, 2011

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

Large Employers’ 2012 Health Plan Design Changes

National Business Group on Health
August 18, 2011

Medical Plan Costs

In 2012, 63% of employers will increase the employee percentage contribution to premium costs, and 39% will increase in-network deductibles.

Consumer-Directed Health Care

More employers will be offering a consumer-directed health plan (CDHP) in 2012 than in previous years, with 73% planning to offer at least one CDHP next year. In addition, 17% of employers have or will move to a full replacement CDHP design in 2012. The most common type of CDHP employers will offer next year is a high-deductible health plan (HDHP) with a health savings account (HSA) (75%).

The most common method employers use to load health accounts is by contributing a predetermined amount per participant, with 59% of employers with HSAs doing so, and 84% doing the same for health reimbursement accounts (HRA).

Pharmacy Benefits

To manage pharmacy benefits, most employers use prior authorization (76%). The next most popular techniques are:
• quantity limits (72%)
• step therapy (65%)
• three-tier design (59%)

Retiree Health

Fewer employers offer retiree benefits to current active employees, with 26% covering all current actives and 38% covering a portion of their actives. Very few employers offer retiree health benefits for new hires, with 12% offering coverage to pre-65 retirees and 7% offering post-65 supplemental coverage to new hires.

The top strategies being used to control retiree health care costs are capping company contributions (45%), increasing employee contributions (31%) and eliminating coverage for future retirees (28%).

http://capsules.kaiserhealthnews.org/wp-content/uploads/2011/08/2012-NBGH-Plan-Design-Survey-Report-Embargoed-Edition.pdf

And…

Survey: Employers shift rising health costs to their workers

By Sam Baker
The Hill, August 18, 2011

Businesses are shifting away from co-pays, wherein employees pay a fixed dollar amount for healthcare services and the plan picks up the rest. Instead, they’re charging workers a percentage of the total costs. That can help make consumers more aware of the total cost of the healthcare they use.

“We are clearly seeing a march toward a more aggressive consumerist system,” said Helen Darling, president of the National Business Group on Health.

Darling said Thursday that shifting from co-pays to coinsurance is “a more subtle way to increase what the consumer pays.” She predicted that eventually, only governments and unions will keep offering fixed co-pays.

http://thehill.com/blogs/healthwatch/health-insurance/177361-employers-shifting-healthcare-costs-to-workers

Employers are reducing the transparency of the massive shift of health care costs to their employees by using many different methods that individually do not look too onerous, but cumulatively have a major impact.

Some of the methods of shifting more health care costs to their employees include greater premium contributions, greater use of large deductibles and consumer-directed health plans, greater restrictions on pharmacy benefits, and a sharp reduction or elimination of retiree health benefits. One of the more subtle but important methods is reducing the use of co-payments (a fixed dollar amount for a service or product) and instead using coinsurance (a percentage of the amount charged). The percentages are usually much larger than the co-payments would be.

Most of the businesses surveyed are very large corporations (83 percent have over 10,000 employees). Their corporate executives and their passive shareholders have done very well in the last few decades, being beneficiaries of the upward transfer of wealth in our society. Their employees have not done so well and have experienced greater difficulties in managing their personal finances.

Rising health care costs are a problem for all of us. They are now so great that we need progressive methods of financing health care. Yet shifting costs from the wealthy corporate plutocracy to the employees is a regressive form of financing.

Supposedly employers are still contributing a large share of the premium, but only nominally. Most economists agree that employees pay the employer component of the premium though forgone wage increases, and wages have certainly been flat. Again, this is regressive financing.

In crafting the Affordable Care Act, efforts were made to protect employer-sponsored plans so that they would still be the largest source of health care coverage. Is this wise?

Not only is the financing regressive, it leaves in place the administratively wasteful private health plans that intrude on health care by taking away certain benefits and taking away choices of health care providers. It leaves in place the fragmented financing model of private plans that has been incapable of slowing the rate of growth in costs to a level closer to those of other industrialized nations. Furthermore, it leaves health policy decisions in the hands of corporate executives who are beholden above all to their investors, whereas the employees are mere pawns to be used to create wealth for the investors. Why else would they be using so many means to shift more health care costs to the employees?

Every time I write one of these commentaries, I think that the logic of an improved Medicare for All would make it an imperative. Maybe the problem is that logic would lead to health care justice, and that seems to be unthinkable in the United States.

John Goodman on IntegraNet as a private sector solution

Posted by on Thursday, Aug 18, 2011

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

Health Policy Schizophrenia

By John Goodman
National Center for Policy Analysis, August 17, 2011

An example of an IDN (Integrated Delivery Network) that is already doing what the Obama administration wants to try out with expensive pilot programs is IntegraNet of Houston, an organization with a network of about 1,200 doctors. Every Medicare patient has a medical home. The physicians follow evidence-based practices. Care is integrated and coordinated. Electronic records are being introduced. It appears that quality is higher and costs are lower than in conventional Medicare.

So what’s not to like? If the folks at CMS had any sense, they would camp out in Houston and try to find out how all this works. Instead, they have been spending their time and your tax dollars producing a 427-page book of rules on what Accountable Care Organizations (ACOs) have to look like….

In the meantime, there is no doubt in my mind that IntegraNet doesn’t satisfy all the government’s requirements by a long shot. For one thing, it pays its doctors fee-for-service. The Obama folks are convinced fee-for-service payment is the problem, not the solution. For another, IntegraNet intentionally pays doctors more than Medicare’s standard rates. Yet the administration’s Plan B for cost control is squeezing provider payments, not increasing them.

A third problem is that it is producing a medical loss ratio (MLR) of 70% or less for its insurance company clients. As previously reported that is 10 percentage points less than the minimum MLR the Obama administration thinks insurers should have. But that extra 10 percentage point profit (shared by the IDN and the insurer) is the whole reason IntegraNet is in business. No one is going to take risks and try new things if they can only get a regulated-utility rate of return.

(Understandably, John Goodman would prefer that excerpts from his articles not be read out of context. The entire article can be accessed at this link.)

http://healthblog.ncpa.org/health-policy-schizophrenia/

Selected responses:

Don McCanne says:
August 17, 2011 at 3:38 pm

With health care costs for a family now averaging over $18,000, not including insurer administrative costs (Milliman Medical Index), how can one justify adding another 43 percent to those costs (the administration and profit add-on for 70 percent MLR plans)?

The Affordable Care Act isn’t a whole lot better since it allows 18 to 25 percent add-on for qualified private plans.

We now have a new report from the IG of HHS that shows an important difference between private and public health care purchasing. When quality is controlled, government administered pricing is much lower than private sector pricing. Specifically, the government Medicaid program was able to obtain a 45 percent price reduction in brand-name drugs whereas the private Medicare Part D intermediaries were able to negotiate only a 19 percent reduction for those same drugs of identical quality.

Health care costs are now an issue for 80 percent of Americans. We can no longer afford to waste our funds catering to superfluous, intrusive, outrageously expensive, private sector insurance bureaucracies.

Since risk pooling remains an imperative, we do need some form of insurance, but without these wasteful private bureaucracies. It is no wonder that so many conservatives warn that we’ll end up with a single payer system. It seems inevitable.

Larry Wedekind says:
August 18, 2011 at 10:08 am

John, well said..thanks for the recognition of our efforts at IntegraNet.

To Dr. Mittler (the author of another response not reproduced here),

The nature and benefit of competition is that private companies develop unique and better methodologies or products and in our free market they can become proprietary for awhile – this aspect of our society has produced many lasting benefits that would never have existed without the ability to patent or service mark unique ideas and products. I can tell you though that IntegraNet has not been able to keep our proprietary methodologies private very long due to the fact that physicians, Health Plan partners and our patients all experience our methods quickly and so they become public quickly. Its also very difficult to service mark our methods for the same reason.

Note also that insurance companies and IDN’s do not make any extra money in our Shared Risk/Savings Model unless the physicians make a lot of extra money. This is a unique feature of the Medicare Advantage Model that is easily forgotten. Why would you loath insurance company executives receiving more money for their wisdom in promoting the Shared Risk Model when physicians are paid the extra money first for their efforts?

Don McCanne says:
August 18, 2011 at 10:41 am

To Larry Wedekind,

Let’s see. The formula for success at IntegraNet is to use secret methods to reduce spending on actual health care (70% MLR) and keep more of the premiums so that “physicians make a lot of extra money”? With our outrageously expensive health care system, unique to the United States, can we really afford to perpetuate that kind of thinking, celebrating it as free market competition of private companies?

Value is what we should be striving for. In this model, the supposedly free market is being used to destroy value. When free markets fail in providing value for essential needs, it’s time for the government to step in. That might not appeal to those ideologically opposed, but one thing we can say: single payer systems do provide much better value in health care.

Larry Wedekind says:
August 18, 2011 at 11:16 am

To Don: I’m sorry, but you are very confused about the MA (Medicare Advantage) system. The fact that IntegraNet and other IDN’s consistently reduce the MLR to below 70% means that great value has accrued to the Medicare beneficiaries! To suggest otherwise is simply ignorant. Why? When a Health Plan experiences a 70% or less MLR because of the Care Coordination efforts of their IDN partner, this nearly always means that the beneficiaries are healthier and need the hospital less frequently. I submit to you that it is impossible to have a 70% or lower MLR without healthier patients.

This extra profit derived from the low MLR that is shared with the doctors in the IDN empowers the doctors to then spend even more time with their beneficiaries; this empowering the beneficiaries even more.

Remember that, due to the transfer of complete financial risk to the HMO and IDN, we have almost complete freedom to care for our beneficiaries under the MA Program the way we deem best. There is very little interference from CMS in our methods for caring for our beneficiaries under the MA Program.

The MA/IDN Risk Sharing model is actually the best example of free market competition within the healthcare market yet.

http://healthblog.ncpa.org/health-policy-schizophrenia/

As John Goodman said in this same article in an entirely different context, “It’s so bizarre that not even J.K. Rowling could make up a story like this.”

Government is runaway victor over private sector in obtaining lower drug prices

Posted by on Wednesday, Aug 17, 2011

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

Higher Rebates for Brand-Name Drugs Result in Lower Costs for Medicaid Compared to Medicare Part D

Office of the Inspector General
Department of Health and Human Services, August 2011

Prescription drug rebates reduce the program costs of both Medicare Part D and Medicaid. Medicaid rebates are defined by statute; additional rebates are required when prices for brand-name drugs increase faster than inflation. Unlike the Medicaid program, Part D sponsors (or contractors acting on their behalf) negotiate rebates with drug manufacturers without any statutory requirements on rebate amounts. In fact, the law establishing the Part D program expressly prohibits the Government from instituting a price structure for the reimbursement of covered Part D drugs.

In this review, we found that Part D sponsors and State Medicaid agencies paid pharmacies similar amounts for most brand-name drugs under review. However, statutorily defined Medicaid unit rebate amounts for brand-name drugs exceeded Part D unit rebate amounts by a substantial margin. As a result, Medicaid collected nearly two-thirds as much as Part D in rebates for the 100 brand-name drugs ($2.9 billion vs. $4.5 billion), despite having only about one-fourth of the expenditures ($6.4 billion vs. $24 billion).

Overall, rebates reduced Part D expenditures by 19 percent for the 100 brand-name drugs under review (from $24 billion to $19.5 billion) in 2009. Medicaid rebates accounted for a substantially higher percentage of total expenditures, reducing Medicaid spending for the 100 drugs under review by 45 percent (from $6.4 billion to $3.5 billion).

http://oig.hhs.gov/oei/reports/oei-03-10-00320.pdf

We are inundated with nonsense about how private health insurance competition in the marketplace brings us higher quality at lower costs when compared with government-administered programs. This study by the Inspector General of Health and Human Services provides an enlightening test of that theory by controlling for quality while measuring the differences in cost. Both Medicaid (government) and Medicare Part D (private) use the same brand-name drugs with identical quality, so cost becomes the sole variable.

Our government-run Medicaid program has been able to negotiate a 45 percent discount on these brand-name drugs, whereas the private Medicare Part D sponsors or contractors have been able to extract only a 19 percent discount on these same drugs. Clearly, when quality is controlled, the private sector brings us much higher prices than does the government.

Under a single payer national health program – an improved Medicare for All – these highly wasteful middlemen would be eliminated and the government would use its monopsonistic buying power to get the prices right. Payment would be based on actual costs, including legitimate research, plus fair profits.

Having to change the rhetorical framing of the dialog from “markets and competition” to “social solidarity” is a small price to pay for achieving the efficient use of our health care dollars. Thinking about that, being able to dump the ideology behind the intrusive, wasteful middlemen is not a price that we would be paying, but a superb benefit that we would be gaining.

John Nichols on replacing the mandate with Medicare for All

Posted by on Tuesday, Aug 16, 2011

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

Can We Have Health Reform Without an Individual Mandate? Yes, It’s Called ‘Medicare for All’

By John Nichols
The Nation, August 13, 2011

The individual mandate was always a bad idea. Instead of recognizing that healthcare is a right, the members of Congress and the Obama administration who cobbled together the healthcare reform plan created a mandate that maintains the abuses and the expenses of for-profit insurance companies — and actually rewards those insurance companies with a guarantee of federal money.

Those who think that the for-profit (or even not-for-profit) insurance industry has to control any healthcare reform initiative have every right to be upset with the 11th Circuit’s ruling — which almost certainly will send the case of the Obama healthcare plan to the US Supreme Court.

But those of us who have no desire to perpetuate the insurance industry can and should recognize that the proper — and entirely constitutional — reform is an expansion of Medicare to cover all Americans.

While Medicare is exceptionally popular, polling shows that the individual mandate is not — according to recent surveys, roughly 60 percent of Americans oppose it.

It also passes constitutional muster.

As former Labor Secretary Robert Reich notes: “[No] federal judge has struck down Social Security or Medicare as being an unconstitutional requirement that Americans buy something. Social Security and Medicare aren’t broccoli or asparagus. They’re as American as hot dogs and apple pie.”

“So if the individual mandate to buy private health insurance gets struck down by the Supreme Court or killed off by Congress,” says Reich, “I’d recommend President Obama immediately propose what he should have proposed in the beginning — universal health care based on Medicare for all, financed by payroll taxes.”

The insurance companies would, of course, scream.

But let them complain.

Americans don’t need mandates. They need healthcare.

And they have every right to ask, as activists with Physicians for a National Health Program have, that Medicare be expanded to cover all Americans — affordably, efficiently, capably and constitutionally.

http://www.thenation.com/blog/162765/can-we-have-health-reform-without-individual-mandate-yes-its-called-medicare-all

Americans overwhelmingly support Medicare, yet an unequivocal majority oppose a government requirement to purchase private health insurance. Why should we have to wait until we’re 65 to have Medicare, while in the interim being required to buy something we don’t want? Let the Supreme Court rule that the individual mandate is unconstitutional, and then maybe we can convince a newly elected Congress to pass the reform that we really need.

We are pleased that Washington correspondent John Nichols of The Nation has joined with Physicians for a National Health Program and the growing chorus of other enlightened voices who call for a vastly superior model of reform that actually would pass constitutional muster – an improved Medicare, expanded to include everyone.

Upside Down Health Care: Why It Matters

Posted by on Monday, Aug 15, 2011

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

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

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

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

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

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

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

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

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

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

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

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

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Proposed rule for premium tax credits

Posted by on Monday, Aug 15, 2011

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

Implementing Health Reform: Premium Tax Credits

By Timothy Jost
Health Affairs Blog, August 13, 2011

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

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

The Basic Rules Regarding The Tax Credit

The consequences of underpayments and overpayments.

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

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

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

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

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

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

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

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

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

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

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

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

Professionalism, social justice, and the primacy of patient welfare

Posted by on Friday, Aug 12, 2011

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

Medical Professionalism in the New Millennium: A Physician Charter

Annals of Internal Medicine
February 5, 2002

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

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

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

And…

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

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

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

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

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

Comparing USA and UK on efficiency and effectiveness

Posted by on Thursday, Aug 11, 2011

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

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

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

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

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

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

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

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

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

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

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

And…

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

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

Conclusions

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

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

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

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

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

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

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

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

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

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

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

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