Large employers moving en masse to high deductibles

Posted by on Wednesday, Jun 26, 2013

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 Cost Trend: Behind the Numbers 2014

PwC Health Research Institute, June 2013

Each year, HRI issues its projection for the following year’s medical cost trend based on activity in the market that serves employer-based insurance.

Consumer-driven health plans – insurance coverage with a high-deductible – are set to go mainstream in 2014. According to the 2013 PwC Touchstone Survey of major US companies, 44% of employers are considering offering high-deductible health plans as the only benefit option to their employees in 2014. Already, 17% of employers offer high-deductible plans as their only option in 2013, a 31% increase over 2012.

High-deductible health plans, which place greater responsibility on consumers, are designed to promote cost-conscious decisions. A recent study reported families that switched from a traditional health plan to a high-deductible plan spent an average of 21% less on healthcare in the first year.

The ACA, with its new insurance marketplaces, accelerates the move to consumer-driven plans. Many of the newly insured say they are willing to accept plan features such as higher deductibles in return for lower monthly premiums – as found in the new bronze and silver plans.

2013 – Average deductibles

$1,230 – In-network
$2,110 – Out-of-network…

The forces supporting consumer-driven health care (CDHC) have incessantly asserted emphatically that the answer to our health care spending problem is to place the consumer (i.e., patient) in charge of health care spending. Although some of us have been trying to explain the horrible consequences of this approach, the mainstream media disseminated the message of the CDHC advocates so effectively that it has now become a meme. The CDHC camp has won the policy battle.

How can we say this? CDHC has now become virtually synonymous with high-deductible health plans (HDHP). Whether or not the deductible passes through a health savings account or is paid directly really doesn’t make much difference since the designated cash account is simply a matter of tax policy rather than health policy. Let’s look at a very brief history of HDHPs to see if we can understand why we lost.

Large employer-sponsored group plans have been the mainstay of health coverage in the United States for decades. They have provided comprehensive coverage through high actuarial value plans which required only modest cost sharing by the patient. As health care costs increased, large employers depended more on controlling spending by creating networks of providers with contracted rates. In contrast, individuals, and to a certain extent smaller employers, were unable to afford the premiums for high actuarial value plans and so the insurers heavily marketed high-deductible plans that had much more competitive premiums; so that’s what people bought.

When the Affordable Care Act was written, it was recognized that high actuarial value plans would be unaffordable unless the government subsidies were much larger than members of Congress were willing to budget. Thus the decision was made to make the benchmark plan for the insurance exchanges a low actuarial value plan (silver), made possible only by using high deductibles.

Large employers have been looking for relief from the very high costs of their employee health benefit programs. It looks like they’ve found it, now that HDHPs are becoming the new standard set by our government for the plans in the exchanges. This report from PwC shows that 12 percent of employers used HDHPs as their only option in 2012, and that may increase to 44 percent next year! That is a phenomenal shift in such a short period, and is the basis for saying that the CDHC (HDHP) camp has won the policy battle.

Not only are patients assessed a significant financial penalty for seeking health care (an average $1,230 deductible), that penalty is almost doubled if the patient obtains care out of network ($2,110 deductible) – a greater likelihood as narrower networks become more prevalent.

HDHPs have become popular for one reason only, and that is not because they make patients better shoppers. It is only because the premium to purchase the health plans is more affordable (or for self-insured employers the amount paid out in benefits is less).

There are two important trade-offs for the lower premiums. One is that people will decline to obtain appropriate health care since they will have to pay full fees until the deductible is met. A properly designed financing system should make it easier for people to obtain the care they need, not more difficult. The other is that far too many people have little or no discretionary income, and high deductibles create a financial hardship for them. The health care financing system should reduce or eliminate financial hardship, not create it.

And the out-of-network penalties? A financing system should increase health care choices for patients, not reduce them.

This boat is not going to turn around. Within two or three years, HDHPs will be the standard for employer-sponsored coverage. More people will suffer. The media knew that this change had to come, but only because they didn’t listen to us. They simply dismissed single payer because of another meme – “it isn’t feasible.”

I’m not a violent person, but the next time I hear, “skin in the …,” watch out!

Swiss support single payer

Posted by on Tuesday, Jun 25, 2013

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.

Swiss voters back single-payer health insurance

Swiss Broadcasting Corporation, June 24, 2013

The proposal of creating a single fund for health insurance would be accepted by voters if the ballot for the initiative were held today, according to a poll commissioned by the pharmaceutical lobby group Interpharma.

About 65 per cent of the population would approve the proposal and 28 per cent would reject it, according to the first poll conducted on the issue. The result is still not very conclusive, as only about 31 per cent of people surveyed said they would actually participate in the vote.

In 2014 or 2015, the initiative for public health insurance will be put to a nationwide vote, which if accepted will see current providers of basic cover replaced by a single public fund. Under Swiss law, health insurance is compulsory, and residents currently may choose between offerings of about 60 companies which provide coverage.

The initiative – supported by the centre-left Social Democrats and by the Greens as well as by patient and consumer organisations – would leave only supplemental insurance in the hands of private companies.

The survey was conducted as part of the 2013 Health Monitor by GfS Bern research and polling institute.  The Health Monitor also showed that three out of four people in Switzerland view the health system in Switzerland positively, the highest share ever.…, April 19, 2013

According to the 2012 Health Monitor of the GfS Bern research and polling institute, 40 per cent of those questioned were in favour of a change, while 45 per cent preferred to stick with the current system.…

Whereas last year 40 percent of Swiss voters supported change in the health insurance system, the same poll this year shows that 65 percent support a single fund for health insurance – single payer. It is difficult to know if this support is malleable, and whether it would hold up under the political rhetoric of campaigns. A similar measure in 2007 was rejected by 70 percent of their voters.

Nevertheless, it should make us challenge those who keep telling us that we need a system just like the Swiss have – a mandate to purchase plans from a market in which about 60 insurers participate. Clearly, though they view their system positively, there is very strong support for a single public health insurance program.

CMS’s new website ( promotes the “Health Insurance Marketplace.” Sounds sort of like the Swiss system. If we’re going copy the Swiss, why don’t we skip their mistakes and go directly to single payer?

The good news on reference pricing isn’t all good

Posted by on Monday, Jun 24, 2013

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.

CalPERS Members Had Similar to Better Outcomes at Facilities Charging Less for Hip and Knee Replacements

Press Release, June 23, 2013

A pilot program for the California Public Employees’ Retirement System lowered the price of members’ hip and knee replacement surgeries by 19 percent in one year while also demonstrating similar to better outcomes at lower-cost hospitals.

The analysis, conducted by HealthCore, WellPoint’s outcomes research company, will be presented at the AcademyHealth Annual Research Meeting today in Baltimore. The study is based on findings for the referenced-based purchasing design program for CalPERS members developed by CalPERS and WellPoint’s affiliated health plan in California.

As part of the CalPERS intervention program, members of the California Public Employees’ Retirement System were given a list of designated facilities that charged less than $30,000 for in-patient costs associated with each knee and hip replacement surgery.

To qualify for the list, hospitals had to have already contracted with the network of WellPoint’s California affiliated health plan, which manages a robust credentialing process.

Members were able to either choose from 46 facilities on the list that would result in them paying little to no out-of-pocket costs beyond deductible or co-insurance or pay the difference if they used another facility that charged more than $30,000.

The result was that CalPERS health plan costs dropped significantly – by 19 percent from $35,408 to $28,695, per surgical-related admission.…


Hospitals cut some surgery prices after CalPERS caps reimbursements

By Chad Terhune
Los Angeles Times, June 13, 2013

When the California Public Employees’ Retirement System told its Anthem Blue Cross members it would pay only up to $30,000 for a knee or hip replacement surgery, some patients shopped around for a cheaper hospital.

What may be more surprising is that about 40 higher-priced hospitals in the state cut their surgery prices significantly to avoid losing patients. That response accounted for about 85% of the $5.5 million CalPERS saved over two years, researchers at UC Berkeley found, with the rest of the savings coming from patients opting for lower-cost hospitals.

It works essentially as a reverse deductible for employees and their families. Their employer will pay up to a certain amount for a surgery, colonoscopy or lab test and anything above that amount comes out of the patient’s pocket.…


Effects of a Reference-Based Purchasing Design Program on Healthcare Utilization and Outcomes of Knee and Hip Replacement Surgeries

Co-authors: Sze-jung Wu, HealthCore, Inc.; Michael Belman, Anthem Blue Cross; Andrea DeVries, HealthCore, Inc.
Presenter: Chia-hsuan Li, M.S., Senior Research Analyst, Health Plan Research, HealthCore, Inc.

AcademyHealth, 2013 Annual Research Meeting, June 23-25, 2013

Research Objective:

Controlling healthcare expenditure while ensuring the delivery of high-quality care is a priority for payers. Recognizing the wide discrepancies in cost for joint replacement procedures, a large employer group in California implemented a RBPD program (Reference-Based Purchasing Design program) beginning in 2011 for total knee replacement (TKR) and total hip replacement (THR) based on a threshold facility payment of $30,000. Members were given a list of designated facilities meeting the threshold and were told that they would be responsible for cost differences above the threshold if they chose non-designated facilities. This study is aimed at evaluating the impact of the RBPD program on utilization and patients’ health outcomes, relative to a comparison population.

Study Design:

A retrospective observational study was conducted using administrative claims. We compared TKR and THR rates at RBPD-designated facilities in the intervention group to a comparison group without the RBPD program at baseline year (2010) and intervention year (2011). The change in average cost per procedure was measured. We also compared postsurgery infection, complication, and hospital readmission rates between two cohorts. The difference in utilization and health outcomes between groups were examined by ANOVA and chi-square tests. Multinomial logistic models were fitted to examine the likelihood of unfavorable health outcomes between groups adjusted for age, gender, and comorbid conditions.

Population Studied:

Adults under age 65 diagnosed with osteoarthritis and receiving a unilateral TKR or THR. The intervention cohort consisted of members of the employer group where the RBPD program was implemented (N=799), whereas the comparison cohort contained individuals not covered by the employer health plan but living in the same geographic area (N= 5,279). Each patient was followed for 30 and 90 days following the surgery or until their health plan eligibility ended.

Principal Findings:

Use of RBPD-designated facilities rose 21% among the intervention group (from 45.7% in 2010 to 55.5% in 2011, p<.01) while decreasing 24% among the comparison group (46.5% & 35.4%, p<.01). Average allowed cost (sum of plan paid and patient out-of-pocket) decreased 20.6% for TKR (p<.01) and 13% for THR (p=.01) for the entire intervention group. Patients in the intervention group using RBPD-designated facilities experienced reductions in allowed cost, so did those using non-designated facilities. The reductions were greater for non-designated facilities users (p<.01 both procedures). Out-of-pocket cost remained unchanged (p>.5 both). RBPD-designated facilities were associated with lower adjusted likelihood of 30-day general infection and complication (OR: 0.47, 95% C.I.: 0.24 – 0.94 infection; 0.68, (0.47, 0.98) complication), and a statistical insignificant adjusted rate of 90-day hospital readmission (1, (0.58,1.77) ).


The RBPD program increased the use of designated facilities by 21% for the entire intervention group, achieving allowed cost reductions of 18% per procedure while out-of-pocket cost to members remained relatively flat. The quality was unaffected. Implications for Policy, Delivery or Practice: Traditional cost-sharing strategies have shown little effect on member’s choice in providers, most likely because members are insensitive to procedure costs and unaware of cost variation. RBPD addresses these barriers. This study suggests that a RBPD program can engage members to choose high-value services with lower cost but unaffected quality.

Funding Source(s): WellPoint, Inc.

AcademyHealth Podium Presentation Abstracts (page 33 for this report):…

Reference pricing controls spending by setting a price near the low end of market prices for a given health care service or bundled service, and then requiring the patient to pay any amount over the reference price. It is a reversal of charging the patient a deductible, in that the patient pays any excess at the top, rather than a set amount at the bottom. It is a form of defined contribution, and as such could expose the patient to potentially much higher costs above the reference price.

California Public Employees’ Retirement System (CalPERS) and WellPoint’s Anthem Blue Cross joined together in this pilot program on reference pricing. Prices for the services covered were reduced – 13% for total hip replacement and and 21 percent for total knee replacement – and out-of-pocket costs did not change for patients. It worked. Facilities reduced their prices to reference levels, and patients used facilities that adhered to reference prices, and therefore they were not penalized financially.

The primary trade off appeared to be that 21 percent of patients switched to facilities that were not their initial choices. This has a potential of disrupting established, integrated care patterns, though this was not evaluated in the study. An example might be of a reference price for diagnostic imaging that is available only in an institution not associated with your usual sources of care, leading you to either disrupt your care or suffer higher out-of-pocket spending.

There also can be a problem establishing a reference price. The insurer may set a price available only in distant urban regions – a price that is not available in your community. You could have a $50,000 procedure that might cost you $1,000 under a high-deductible PPO, but have a price of $30,000 under reference pricing, leaving you stuck with a bill of $20,000 if you find that a reference-based institution is not readily accessible. Reference pricing is not a perfect solution.

There is a much more fundamental problem with reference pricing that is not so obvious. In a September 2012 Health Affairs article on reference pricing (in centers of excellence), James Robinson and Kimberly MacPherson write, “Both reference pricing and centers-of-excellence contracting can be used by Medicare Advantage health plans because they have the ability to impose differential cost-sharing requirements and exclude providers altogether from their contractual networks. However, the new benefit designs will be applicable to traditional Medicare only if the program becomes willing and able to use consumer cost sharing to channel patients to particular providers based on quality and efficiency.”

From this comment, it is obvious that reference pricing is a creation of those who believe that the consumer (patient) should be in charge of making purchasing decisions based on price. It is the obsession of the policy community with this market concept of health care purchasing that has led to the highly dysfunctional, egregiously expensive, and poorly allocated health care system that we have today.

Think about it. The traditional Medicare program has been far more effective than the private insurers at getting health care priced appropriately, and yet they say that we should abandon that approach and “use consumer cost sharing to channel patients.” That is, we should shift risk to the patients – exposing them to financial penalties should they not make perfect decisions in their health care purchasing, even as the private insurers create yet more barriers to perfectly priced health care!

Forget reference pricing. Let’s let our public administrators obtain the best value for us through global budgeting of our hospitals and negotiated rates for professional services and products, as we would have with a single payer system. A “reference price” wouldn’t make any sense in such a logical system. There would be only one price, paid by our public administrator, based on legitimate costs and fair margins.

AcademyHealth’s ill-judged choice of the 2013 Article-Of-The-Year

Posted by on Friday, Jun 21, 2013

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.

From: Health Affairs <>
Date: Thu, Jun 20, 2013 at 4:37 PM
Subject: Health Affairs Wins AcademyHealth’s ‘Article-of-the-Year’ Award

AcademyHealth has chosen a Health Affairs article as its 2013 Article-Of-The-Year!

The ‘Alternative Quality Contract,’ Based On A Global Budget, Lowered Medical Spending And Improved Quality
By Zirui Song, Dana Gelb Safran, Bruce E. Landon, Mary Beth Landrum, Yulei He, Robert E. Mechanic, Matthew P. Day and Michael E. Chernew
Web First July 11, 2012; print August 2012


The ‘Alternative Quality Contract,’ Based On A Global Budget, Lowered Medical Spending And Improved Quality

By Zirui Song, Dana Gelb Safran, Bruce E. Landon, Mary Beth Landrum, Yulei He, Robert E. Mechanic, Matthew P. Day and Michael E. Chernew
Health Affairs, August 2012


Seven provider organizations in Massachusetts entered the Blue Cross Blue Shield Alternative Quality Contract in 2009, followed by four more organizations in 2010. This contract, based on a global budget and pay-for-performance for achieving certain quality benchmarks, places providers at risk for excessive spending and rewards them for quality, similar to the new Pioneer Accountable Care Organizations in Medicare. We analyzed changes in spending and quality associated with the Alternative Quality Contract and found that the rate of increase in spending slowed compared to control groups, more so in the second year than in the first. Overall, participation in the contract over two years led to savings of 2.8 percent (1.9 percent in year 1 and 3.3 percent in year 2) compared to spending in nonparticipating groups. Savings were accounted for by lower prices achieved through shifting procedures, imaging, and tests to facilities with lower fees, as well as reduced utilization among some groups. Quality of care also improved compared to control organizations, with chronic care management, adult preventive care, and pediatric care within the contracting groups improving more in year 2 than in year 1. These results suggest that global budgets with pay-for-performance can begin to slow underlying growth in medical spending while improving quality of care.

From the Discussion

In year 1, total Blue Cross Blue Shield payouts to groups in the contract probably exceeded savings under the global budget. In year 2, savings achieved by the intervention group were generally larger than the surplus payments received. However, total payments to groups from Blue Cross Blue Shield of Massachusetts, including surplus sharing, quality bonuses, and infrastructure support, probably exceeded the savings achieved by most groups that year. This outcome reflects the design of the contract, which set targets based on actuarial projections to save money over its five-year duration, accounting for anticipated quality bonuses and other payments.

In addition, health care spending growth in Massachusetts slowed in this period as a result of general economic factors.

This model is informative for the broader movement toward accountable care organizations.

Published response:

Misleading Title And Abstract

By Kip Sullivan

In this article about the effect of the Alternative Quality Contract (AQC) administered by Blue Cross Blue Shield of Massachusetts (BCBS), the authors reported savings in what they variously referred to as “medical spending” and just “spending,” but they also reported that non-medical payments to providers (“surplus sharing, quality bonuses, and infrastructure support”) “probably” exceeded the savings in medical spending. They concluded: “Our findings do not imply that overall spending fell” (p. 1891).

In an earlier paper published in the New England Journal of Medicine, these authors offered the identical caveat.

Despite the authors’ warnings, Health Affairs’ editors permitted the phrase “lowered medical spending” to appear in the title of the paper, they permitted the unadorned word “spending” to appear numerous times in the abstract and text, and they failed to include in the title or the abstract the warning that “overall spending” (medical plus nonmedical costs) probably rose. This combination of errors was extremely misleading.

Health Affairs’ editors compounded these errors by permitting authors of two papers published in the next edition (the September edition) to make misleading statements about Song and colleagues’ article. Citing them, Markovich asserted that the AQC “slowed the…growth in medical spending” (p. 1974), and Sood and Higgins claimed the AQC has “demonstrated…a slowdown in the growth rate of health care spending” (p. 2043). Neither paper warned readers that medical spending is not synonymous with total spending, and that BCBS’s total spending may have gone up.

In a letter to the editor published in the November edition of Health Affairs, Rachel Nardin et al. criticized Song et al. for inserting “lowered medical spending” into the title when in fact total spending probably rose. In their reply, Song and Chernew agreed that “total payments are important” and that they probably rose. But rather than simply conceding that their title and abstract were misleading and that a few simple edits would have fixed the problem, Song and Chernew presented an illogical justification for confusing readers about the difference between medical and total spending. They argued that the need to know how providers respond to the AQC somehow justifies conflating medical with total spending. There is no justification for such an easily avoidable error.

Finally, I note that Song et al. made no effort to measure the cost to the providers of participating in the AQC, or if they did, they did not inform their readers of the outcome of this effort.

The three Health Affairs articles I have cited here are not isolated examples of scholars and editors downplaying or totally ignoring administrative or intervention costs and blurring the distinction between medical and total spending. This problem has plagued the health policy literature for four decades. It reached epidemic proportions in the 1990s.

There is an illogical but widespread assumption within the health policy community that if an intervention, such as the AQC, lowers medical spending, it must also have lowered total spending. But interventions designed to change provider behavior, be they HMOs, pay-for-performance schemes, electronic medical records, utilization review, or “medical homes,” are not free. They create new costs for both insurers and providers. Ignoring these costs, or obscuring them by celebrating reductions in medical spending and saying little or nothing about increases in total spending, should be no more acceptable than ignoring the side effects of drugs and procedures.…


Medical Spending And Global Budgets

By Rachel Nardin, David Himmelstein and Steffie Woolhandler
Health Affairs, November 2012

The title of the article by Zirui Song and colleagues (Aug 2012) claims that “The ‘Alternative Quality Contract,’ Based on a Global Budget, Lowered Medical Spending and Improved Quality.” But the Alternative Quality Contract (AQC) only lowered spending if you accept the authors’ idiosyncratic definition of the term medical spending.

In calculating medical spending, the authors exclude three categories of payments that Blue Cross Blue Shield of Massachusetts made to AQC providers: “surplus payments” to providers who kept fee-for-service billing below targets; bonuses for meeting quality goals; and special payments to support providers’ infrastructure to implement the AQC. The authors note, in passing, that these extra payments probably exceeded the “medical” savings. Unfortunately, they report no actual figures for the extra payments (although these figures were presumably available to the two coauthors who are executives at Blue Cross Blue Shield). In other words, Blue Cross Blue Shield’s total costs under the AQC went up by some undisclosed amount, not down.

Global budget payment strategies are currently being promoted as a way to lower total health care costs. The fact that the AQC failed to do this was probably overlooked by many readers and was clearly lost in media reports of these findings and hence in the policy debate.

The case for global budget payment strategies such as the AQC remains unproven.

The health policy community has hung its hat on accountable care organizations as being the be-all and end-all for reducing spending and improving quality in health care. Little does it matter that there is a dearth of objective evidence for this concept; they have continued to push it anyway in their support for the Affordable Care Act.

The ultimate gall of the policy community is shown in their selection of this article by Song et al, trumpeting the savings of this Massachusetts Blue Cross Blue Shield Alternative Quality Contract, when, buried in the article, we learn that the savings were burnt up by “surplus sharing, quality bonuses, and infrastructure support.”

Although the program costs, including additional administration, wiped out the medical savings, it is important to look at what the actual medical savings were. These savings were primarily due to “lower prices achieved through shifting procedures, imaging, and tests to facilities with lower fees.” There was virtually no accountable care magic here. They merely extracted better prices from some of the providers. At that, it was only 2.8 percent, a negligible amount when considering how much more effective publicly administered pricing is than pricing through private insurers. But, again, the all important bottom line is that this savings was lost through the non-medical costs of the program.

This AcademyHealth award should serve as a proxy for the compromised integrity that the policy community has shown in their efforts to push the highly flawed Affordable Care Act.

These authors, along with the Health Affairs editors who approved the misleading title, and the committee members who selected this article for the award are no doubt good people, but they did not have the courage to stand up and say, “This conclusion is (expletive deleted)!”

We know what they should have said: “Although we have shown that the promise of the accountable care organization is not fulfilled, nevertheless we do know how to control spending while improving quality and that is through the enactment of a single payer national health program.” But, no, they didn’t have the courage.

Redesigning Medicare cost sharing

Posted by on Thursday, Jun 20, 2013

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.

Restructuring Medicare

Health Affairs, Health Policy Briefs, June 20, 2013

To reduce federal spending, advance entitlement reform, and simplify benefits, policy makers have proposed redesigning Medicare cost sharing.

What’s The Issue?

Some policy makers have recommended redesigning the program to protect beneficiaries from high out-of-pocket spending, better align incentives to reduce overuse of services, and potentially lower costs for the federal government. Opponents of such reform efforts fear that, in trying to reduce federal spending, reforms will shift costs onto beneficiaries and could make them less likely to seek needed care.

What’s The Debate?

Supporters of redesign believe that cost sharing under a redesigned Medicare program will be more predictable and simpler for beneficiaries to understand and better align incentives to reduce any overuse of services. Others fear that, if designed to reduce federal spending, restructuring the benefit design would likely shift costs onto many Medicare beneficiaries. Critics note that Medicare beneficiaries already spend three times as much of their income on health care as do people under age 65. Critics believe most beneficiaries cannot afford to pay more for their health care and are particularly concerned about proposals that include even higher deductibles or out-of-pocket caps.

Reforms of supplemental coverage, particularly efforts to limit first-dollar coverage, are also controversial. Opponents particularly question the wisdom of Medigap reforms that would likely reduce beneficiaries’ use of both necessary as well as unnecessary services.

The National Association of Insurance Commissioners (NAIC) recently recommended that the Department of Health and Human Services not add cost sharing to Medigap plans. NAIC noted that supplemental plans have little ability to change what care Medicare beneficiaries seek as well as how effective it is: The Medicare program determines what services are covered or not covered, and physicians guide individual beneficiaries on what particular care they need. NAIC expects that beneficiaries are unlikely to disagree with physicians about whether specific care is necessary, regardless of financial incentives.

What’s Next?

Medicare redesign remains a topic of interest on Capitol Hill. The House Ways and Means and Energy and Commerce Health Subcommittees held hearings on this subject on February 26 and April 11, respectively. Ways and Means Subcommittee Chair Kevin Brady (R-TX) indicated that he expected to hold more hearings on the future of Medicare and hoped to forge a bipartisan approach to reforming the program.

The topic of “entitlement reform” doesn’t go away. Regarding Medicare, virtually all proposals under current consideration include mechanisms of shifting more costs onto the beneficiaries. As this policy brief states, “Medicare beneficiaries already spend three times as much of their income on health care as do people under age 65.” We cannot place this additional burden on those who need health care the most.

The National Association of Insurance Commissioners agrees that cost sharing should not be added to Medigap plans, for the reasons mentioned above. Why should only those with Medigap plans be protected? The Medigap benefits need to be folded into the traditional Medicare program so that all can benefit by having financial barriers to care removed.

Sadly, the political momentum is moving in the opposite direction – “saving” Medicare by making it less affordable and therefore less accessible for those who need it. Do we simply sit back and watch it happen? If so, “Improved Medicare for All” will continue to wither as a health care justice goal for the nation.

In-network providers are often not available

Posted by on Wednesday, Jun 19, 2013

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.

Out-of-Network Physicians: How Prevalent Are Involuntary Use and Cost Transparency?

By Kelly A. Kyanko M.D., M.H.S., Leslie A. Curry Ph.D., M.P.H., Susan H. Busch Ph.D.
HSR, June 2013


To determine the proportion of privately insured adults using an out-of-network physician, the prevalence of involuntary out-of-network use, and whether patients experienced problems with cost transparency using out-of-network physicians.

Data Sources

Nationally representative internet panel survey conducted in February 2011.

Study Design

Screener questions identified a sample of 7,812 individuals in private health insurance plans with provider networks who utilized health services within the prior 12 months. Participants reported details of their inpatient and outpatient contacts with out-of-network physicians. An inpatient out-of-network contact was defined as involuntary if: (1) it was due to a medical emergency; (2) the physician’s out-of-network status was unknown at the time of the contact; or (3) an attempt was made to find an in-network physician in the hospital but none was available. Outpatient contacts were only defined as involuntary if the physician’s out-of-network status was unknown at the time of the contact.

Principal Findings

Eight percent of respondents used an out-of-network physician. Approximately 40 percent of individuals using out-of-network physicians experienced involuntary out-of-network care. Among out-of-network physician contacts, 58 percent of inpatient contacts and 15 percent of outpatient contacts were involuntary. The majority of inpatient involuntary contacts were due to medical emergencies (68 percent). In an additional 31 percent, the physician’s out-of-network status was unknown at the time of the contact. Half (52 percent) of individuals using out-of-network services experienced at least one contact with an out-of-network physician where cost was not transparent at the time of care.


The frequency of involuntary out-of-network care is not inconsequential. Policy interventions can increase receipt of cost information prior to using out-of-network physician services, but they may be less helpful when patients have constrained physician choice due to emergent problems or limited in-hospital physician networks.

An important role of private health insurers is to control prices through provider contracting. The current trend is to narrow their networks of providers even more. This allows them to further squeeze payments to the providers, in exchange for reducing the numbers of their competitors. If that will slow the increase in insurance premiums, then shouldn’t patients be supportive? No, and here’s why.

When patients obtain their care outside of provider networks, they are inflicted with severe financial penalties, sometimes receiving no coverage at all, plus losing the controlled rates that the insurers have negotiated. This study shows that using out-of-network providers is frequently unavoidable. The problem is particularly severe with in-hospital care, adding to the already burdensome expenditures for high-deductibles and coinsurance.

This is a direct result of placing private insurers in the role of financial intermediaries for our health care. They profit by selling us an inordinate amount of administrative services that we don’t want and shouldn’t need, while penalizing us for obtaining care that we need when we are unable to access providers within their narrow networks.

The model is all wrong. We need to dump the intrusive and wasteful private insurers who are forcing on us services that we don’t want but have to pay for – like taking away our choice under threat of financial penalty. We need to replace them with our own public program that is designed to ensure that we get the care we need, without penalizing us for doing so.

ACOs and liability for institutional malfeasance

Posted by on Tuesday, Jun 18, 2013

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 Looming Threat of Liability for Accountable Care Organizations and What to Do About It

By H. Benjamin Harvey, MD, JD; I. Glenn Cohen, JD
JAMA, June 17, 2013

Hundreds of health systems across the country have already adopted the ACO model (accountable care organization) and in so doing have taken on a new role of cost containment. What may be less clear to them is that they are taking on new liability risks.

Unlike MCOs (managed care organizations), ACOs will generally not have the benefit of ERISA, which does not cover them; nor are they slated to get comparable federal liability protections. As a result, ACO cost-containment efforts may be scrutinized by the court when poor patient outcomes result in malpractice litigation. For example, if a poor outcome occurs in a patient with congestive heart failure (CHF), a plaintiff could challenge an ACO’s more stringent CHF hospital admissions criteria, asserting a prioritization of cost savings over patient care. In the absence of a federal law that could offer protection, this medical liability claim would be judged by state-based standards, which do not consider federal cost containment goals when determining whether a medical decision was appropriate. Based on MCO liability case law, state courts may hold ACOs liable in this situation.

Under “agency theory” in tort law, a plaintiff in a malpractice suit is permitted to hold a health system liable for the negligent actions of its employee, ie, the treating clinician. A patient may also sue a health system directly, claiming that policies or actions of the health system are negligent. Thus, whether ACOs or not, health systems are exposed to institutional liability related to medical malpractice. How big of a divergence is ACO liability from the existing forms of institutional liability common to health systems? The key difference is the introduction of a new dimension of medical malpractice liability that goes hand in hand with the cost containment charge: the claim that the ACO’s actions or policies prioritized cost savings over patient safety, contributing to the plaintiff’s harm.

Allegations of institutional malfeasance related to cost-saving efforts could increase liability costs and create a chilling effect on ACOs. Moreover, these suits need not progress to trial to threaten ACOs. The assertion of institutional malfeasance alone adds strength to a lawsuit and introduces the potential for punitive damages. This could increase jury awards and settlement amounts. In addition, the broader nature of the claims will enable more robust discovery beyond the care received by the patient. Discovery could now reach into the corporate boardroom as a plaintiff attempts to show that institutional policies regarding resource utilization or physician compensation stifled appropriate treatment. For the ACO, this increased complexity means greater defense costs and increased pressure to settle. Beyond cost increases from more garden-variety medical malpractice cases, ACOs also could be exposed to new theories of liability. It is possible to envision a class action suit seeking injunctive relief or damages against institutional policies felt to be potentially harmful to patients, such as physician incentives payments.

The primary purpose of accountable care organizations is to reduce health care spending. By participating in these schemes – accepting financial rewards for reducing care – physicians are exposing themselves not only to malpractice claims for negligence through failure to provide adequate health care services, but they are also exposing themselves to punitive damages for participating in institutional malfeasance related to cost-saving efforts. Surely during the trials the plaintiffs’ attorneys will let slip out the “G” word – GREED!

Greed: The secret word a la Groucho Marx (15 seconds):

Single payer saves money by reducing waste and improving resource allocation. It does not do it by paying physicians incentives for reducing health care. Most physicians surely would want to avoid even the least semblance of greed.

Replace volume with quality?

Posted by on Monday, Jun 17, 2013

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.

Should Physician Pay Be Tied to Performance? No: The System Is Too Easy to Game—and Too Hard to Set Up

By Steffie Woolhandler
The Wall Street Journal, June 16, 2013

Paying doctors for better care—not just more of it—seems like a no-brainer. Yet rigorous studies of pay-for-performance bonuses have found no health benefits and some unintended harms.

An exhaustive analysis of pay-for-performance research by the Cochrane Collaborative, an international group that reviews medical evidence, unearthed “no evidence that financial incentives can improve patient outcomes.”

Consider these cases. In Britain’s massive pay-for-performance program, family doctors earned almost perfect scores (and big bonuses) for hypertension treatment, but population surveys found no decrease in blood pressure or its main complication, strokes. Meanwhile, aspects of quality that didn’t bring bonuses deteriorated.

The largest U.S. pay-for-performance experiment—Medicare’s Premier Demonstration—also flopped. The 200 hospitals that offered bonuses scored slightly worse on patient death rates than other hospitals.

Proponents argue that programs like these were flawed in one way or another, and that the next trial—or the one after—will certainly do better. They also claim successes with other programs. But none of these claims rest on rigorous science, and all those that have subsequently been subjected to rigorous tests have failed.

No Easy Measurement

Why do these programs consistently fall short? Measurement is distorted once you pay doctors based on the data they themselves create. High scores may reflect real excellence, but can just as easily reflect cherry-picking or gaming the measurement system.

One Boston-area hospital we observed improved its quality score 40% just by getting doctors to change the words they wrote in patients’ charts. Medicare gives hospitals more credit for saving patients with “acute respiratory decompensation” than those with “COPD exacerbations,” although these terms are synonyms. That kind of practice is neither illegal nor unusual.

Beyond that, it’s devilishly difficult to quantify doctors’ performance in the first place. Hospital death rates seem, at first glance, an ideal measure of medical quality. Yet, four widely used algorithms yield completely different mortality rankings; a hospital rated outstanding in one often looks downright dangerous in another.

Even if—as some proponents argue—we find performance measures that work for one group of doctors, it’s unlikely that they’ll work for all providers in all patient populations. Moreover, many providers interact in providing care, and influence each other and patients’ outcomes in complex ways. It’s hard to imagine that incentives could optimize this as a system.

Ignoring Psychology

There’s also psychology at work. Rewarding performance ignores the complexity of human drive, particularly the role of intrinsic motivation—the desire to perform an activity for its own inherent rewards. Offering your dinner-party host a $10 reward for cooking a wonderful meal isn’t likely to motivate future invitations.

Studies have found that financial incentives often crowd out intrinsic motivation. For instance, college students will spontaneously play with interesting puzzles, but once they’re paid to solve them, they lose interest in playing for nothing. When day-care centers in Israel imposed fines on parents for picking up children late, tardiness increased. Promptness transformed from a moral duty to a market transaction.

Pay for performance undermines the mindset required for good doctoring—the drive to do good work even when no one is looking. Moreover, it forces doctors to shift their attention from patients to computer screens—documenting trivial details useless for patient care but essential for compliance.

None can doubt medicine’s grave quality problems. As a remedy, pay for performance suggests manipulating greed. This can certainly change medicine, but not necessarily in the ways that we would plan, much less hope for.

(Dr. Woolhandler is a physician and professor at the City University of New York School of Public Health. David U. Himmelstein, also a physician and professor at the School of Public Health, and Dan Ariely, the James B. Duke professor of behavioral economics at Duke University’s Fuqua School of Business, contributed to this article.)…

We keep hearing over and over that we are going to have to quit paying physicians based on the volume of their services and pay on the quality of those services instead. There are two problems with this.

The first problem is that there is a certain volume of health care that needs to be delivered. If the physician is told that quality counts but volume doesn’t, then wouldn’t that physician be motivated to cut back on work done? Does anyone seriously suggest that sloth is fine – payment would be the same regardless of the volume of work? Of course not. Whether fee-for-service or salaried, the physician is going to have to produce.

The second problem is that the abstract concept that physician pay should be tied to quality does not translate into a practical model of measuring and rewarding quality. Physicians already attempt to provide the best quality they can under the given clinical circumstances. Typical measures selected are only a infinitesimal sampling of the entire work product of the physician. Today’s article explains the deficiencies of trying to come to any conclusion about quality based on this process.

The counter opinion to the article above was written by François de Brantes, executive director of the Health Care Incentives Improvement Institute, and is available at the same link above. Some of his comments are instructive: “show poor outcomes in some pay-for-performance trials,” “design flaws,” “doctors were rewarded for results that were actually poor,” “it has worked, if not always as well as it should,” and, “problems can be fixed by not letting providers set benchmarks.” If physicians, with their conflicts of interest, don’t define quality, then who does? The MBAs? Is that really better?

We definitely must address medicine’s many quality problems, ideally through beneficent public policies, but manipulating greed through pay for performance schemes is not the way to get there.

Would Syria benefit from a single payer system?

Posted by on Friday, Jun 14, 2013

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.

Syria: An overview of MSF programmes in and around the country


The conflict in Syria is extremely intense. Frontlines continue to shift. The medical system is reduced to tatters. An estimated 6.8 million people are in urgent need of humanitarian assistance inside Syria and in the neighbouring countries. And people in enclaves are cut off from assistance.

Despite the very real challenges of operating in the country, MSF is now running five hospitals inside Syria and is increasing mobile clinic activities around some of these hospitals. Simultaneously, MSF is actively seeking to open new projects where it is safe to do so.

MSF is using only private donations for its work in Syria in order to remain entirely independent of all political positioning around the crisis.

MSF is also working in the neighbouring countries: Iraq, Jordan, Lebanon and Turkey where some 1.5 million Syrians have fled. These countries have been overwhelmed by the influx of refugees and the humanitarian response has so far been unable to meet their needs.


U.S. Is Said to Plan to Send Weapons to Syrian Rebels

By Mark Mazzetti, Michael R. Gordon and Mark Landler
The New York Times, June 13, 2013

The Obama administration, concluding that the troops of President Bashar al-Assad of Syria have used chemical weapons against rebel forces in his country’s civil war, has decided to begin supplying the rebels for the first time with small arms and ammunition, according to American officials.

Supplying weapons to the rebels has been a long-sought goal of advocates of a more aggressive American response to the Syrian civil war.

But even with the decision to supply lethal aid, the Obama administration remains deeply divided about whether to take more forceful action to try to quell the fighting, which has killed more than 90,000 people over more than two years.…

New York Times Reader Comment:

Don McCanne
San Juan Capistrano, CA

They have a tragic conflagration over there and we’re helping by pouring more gasoline on it?

Is “Peace on Earth” only for Christmas cards?…

Syria needs their Mahatma Gandhi – someone who will be an inspiration for non-violence and civil rights.

And single payer for Syria? We can’t even get single payer in the United States. Perhaps we need our own Mahatma Gandhi.

Why does Kaiser have the highest premiums in the California exchange?

Posted by on Thursday, Jun 13, 2013

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.

Kaiser’s Obamacare rates surprise analysts

By Chad Terhune
Los Angeles Times, June 12, 2013

In California’s new state-run health insurance market, Kaiser Permanente will cost you.

The healthcare giant has the highest rates in Southern California and some other areas of the state, surpassing rivals such as Anthem Blue Cross and other smaller competitors. The relatively high premiums from such a strong supporter of the federal healthcare law surprised industry analysts, and it has sparked considerable debate about the company’s motives.

Some experts say Kaiser intentionally bid high to avoid drawing too many customers next year who are sick or who have been uninsured for years and may be costlier to treat. Others suspect Kaiser was worried that lower premiums would bring an influx of newly insured patients that could overwhelm its in-house roster of doctors and hospitals.

“Kaiser is not as low cost as many people think,” said Glenn Melnick, a USC health policy professor. “They appear to be protecting themselves because the people signing up in the first year are likely to be the sickest ones.”

Overall, Kaiser is the state’s biggest health insurer with a 40% share of the market.

(Marian) Mulkey of the California HealthCare Foundation said Kaiser has regretted being the low-cost option at times in the past and being overrun by too many members at one time. Other insurers may have more flexibility to add doctors and hospitals to their network as enrollment builds.

Kaiser, on the other hand, could face the costly decision to contract with outside hospitals to absorb some of its overflow.

“We are focused on sustainable prices for the long haul,” (Bill Wehrle, Kaiser’s vice president of health insurance exchanges) said. “If you make a large mistake in this environment, it can be hard to recover.”,0,793…

Kaiser Permanente was the prototype health maintenance organization (HMO) that sparked the managed care revolution, seeking lower costs supposedly without compromising quality. So why should a low cost leader come in with the highest premiums for Covered California – California’s new exchange that is being established under the Affordable Care Act (ACA)?

The strategies and negotiations were secret, so we don’t really know. But there are a couple of possible explanations. Initial enrollment may include more people with health problems who need insurance, whereas healthier individuals may opt out since initial non-participation penalties are very small, and they can always join later. By Kaiser setting premiums higher, this initial influx of less healthy but more expensive patients would be diverted to competing plans because of the attraction of their lower premiums.

Another possible reason is that the current Kaiser patient population is relatively stable at about 40 percent of the California insurance market. When patients change their PPO or HMO plans that use provider networks, they do not have as much disruption as they do when they move into or out of Kaiser Permanente. Such a move always entails a complete change of their physicians and hospitals. Since Kaiser realizes that they have not only dominant market share but also a stable group of satisfied patients who do not want any disruption in their care, they know that they can charge a little bit more for their plans since patients are willing to pay the modest differences to avoid such disruptions.

There is another reason that is perhaps the most important of all. Kaiser Permanente is a truly integrated health care delivery system with its own hospitals, clinics, health care professionals and other components of the health care delivery system. They can provide virtually all services to every one of their plan members. Carefully planning and executing system capacity is absolutely essential in the Kaiser model.

Large, abrupt changes in enrollment can be catastrophic from a business perspective. If they lose too many patients all at once they are sitting there with expensive excess capacity that is not generating revenues. On the other hand, if they have a sudden large influx of patients, especially patients who would require greater amounts of health care, they would strain their capacity, with overloads in their primary care clinics, with patients destined for admission waiting in the hallways because the hospital’s beds are full, and with intolerably excessive queues for patients waiting for high-tech and specialized services. Obviously, they would have very unhappy patients.

Instead of making large, abrupt changes in their system capacity to match large fluctuations in patient enrollment, Kaiser controls their patient enrollment, keeping patients out if there are too many, or increasing aggressive marketing if there are too few. Under our fragmented, dysfunctional system of financing health care, it is only natural that Kaiser would adjust its patient enrollment to fit its business model rather than adjust its business model to better accommodate patients.

This issue of capacity is important. The United States needs to improve central planning since we have amongst the worse maldistribution of capacity. We have too many regions with excess capacity, which causes wasteful over-utilization, and other regions with deficient capacity, which impairs access to needed care. As a major player, allowing Kaiser to have autonomy in its planning takes good care of Kaiser but at a cost of fragmenting the systemic planning that we need.

Most proposed single payer models include integrated health systems such as Kaiser Permanente. Presumably Kaiser, like other players in the system, would negotiate global budgets, fees and capitation rates, and negotiate separate budgets for capital improvements.

But what about patient choice? The new accountable care organizations (ACOs) would still ensure patient choice, especially since, under the ACA rules, patients may not even know that they have been assigned to a particular ACO. Should Kaiser, which, in essence, is a transparent mega-ACO, be allowed to lock their patients into their own system when other ACOs cannot?

Suppose their patients had the freedom to come and go as they please. Would  the patient choices be that be much different from choosing another primary care entity that has well established referral patterns for high-tech and specialized services, and established practice relationships with other hospitals? Isn’t the goal of expanded information technology to provide a similar level of interconnectedness between all providers that Kaiser has within its own system?

Instead of being a closed system, shouldn’t Kaiser just be another choice for patients within the health care delivery system? Under a single payer system, that choice would not be based on price since single payer eliminates the need to shop prices. Rather choice would be based on perceived quality. Wouldn’t it be better if the various elements of the health care delivery system were knocking themselves out to be sure that they have very contented, healthier patients?

(Changing the Kaiser Permanente model is controversial. Today’s comment should not be considered a specific recommendation, but should be used to get people thinking about what type of structural reforms would best serve the interests of patients – all patients, not just Kaiser’s).

About this blog

Physicians for a National Health Program's blog serves to facilitate communication among physicians and the public. The views presented on this blog are those of the individual authors and do not necessarily represent the views of PNHP.

News from activists

PNHP Chapters and Activists are invited to post news of their recent speaking engagements, events, Congressional visits and other activities on PNHP’s blog in the “News from Activists” section.