Medicaid managed care contracts with academic medical centers

Posted by on Monday, Oct 1, 2018

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.

Whipsawed: Low-Income Patients At UC Davis Losing Coverage Again

By Rob Waters
California Healthline, September 26, 2018

Whipsawed is not a medical condition, but it describes exactly how Lee Henderson feels about his on-again, off-again care at UC Davis Medical Center, a place he’s been visiting since he was a child.

For the second time in three years, Henderson is about to lose access to his primary care team at the Sacramento institution.

When Henderson had surgery there in 2015 to remove an adrenal gland that was severely elevating his blood pressure, he was covered by Health Net, the only Medi-Cal managed-care plan in Sacramento County whose members could go to UC Davis for primary care at the time.

But shortly after his surgery, Henderson learned that his insurer and the university were terminating their contract, forcing him and an estimated 3,700 other Health Net Medi-Cal members to leave UC Davis and find new primary care doctors.

Now, history is repeating itself. After briefly regaining access to UC Davis last year, when UnitedHealthcare entered the Sacramento Medi-Cal market and signed an agreement with the medical center, Henderson and 1,000 other patients are getting booted out again.

On July 25, those patients got a letter from UnitedHealth. “Dear member,” it began, “we’re writing to let you know that our Medi-Cal services in Sacramento County will be discontinued effective October 31, 2018.”

Medi-Cal, California’s version of the federal Medicaid program for low-income residents, serves 13.5 million people, about one-third of the state’s population. The vast majority of them — about 80 percent — are served by managed-care plans, in which the state pays insurers a fixed amount per enrollee to provide comprehensive care.

That contrasts with fee-for-service Medi-Cal, in which the state pays medical providers directly for services provided. Medi-Cal enrollees are generally required to sign up for managed care.

The exit of UnitedHealth from Sacramento County’s managed-care Medi-Cal program means that, once again, no Medi-Cal patients on managed-care plans in the county will be able to go to UC Davis for primary care.

At the core of the issue is money. UC Davis has complained for years about low Medi-Cal reimbursement rates. (UC Davis spokesman Charles) Casey said that in 2017 the health system absorbed more than $93 million in unreimbursed costs serving Medi-Cal patients.

(Senator Richard) Pan, who now chairs the Senate Health Committee, said the structure of Medi-Cal managed care in Sacramento, which gives enrollees the choice of multiple plans, was a lose-lose for UC Davis and UnitedHealth, because the sickest, most expensive patients wanted to be on a plan that gave them access to the medical center.

“You get all the sick people — asthma or cancer or sickle cell,” he said. “The Medi-Cal contract did not account for the fact that you have a sicker population.”

The sudden loss of access to the broad and highly skilled network of doctors at UC Davis is especially hard for patients with complex conditions, said Elaine Abelaye-Mateo, a community advocate with the Health Access Action Team of Sacramento Building Healthy Communities.

https://californiahealthline.org…

Although the concept of a single payer, improved Medicare for all has become quite popular, many in the policy community and legislative bodies would prefer to continue with our existing health care financing system as modified by the Affordable Care Act (ACA). Even if it were tweaked to further expand coverage, today’s report demonstrates just one of a great multitude of examples as to why the current system is unsatisfactory.

Under ACA, more low-income Californians were enrolled in Medi-Cal (California’s Medicaid program) – a total of about 13.5 million (more than the entire population of each of 46 other states!) and 80 percent of them have been shoved into Medicaid managed care plans on the theory that it would be cheaper (by administrative fiat – California ranks 47th of all states for Medicaid payment rates) and that care would be better managed (highly disputed and likely untrue).

So what are some of the policy considerations under Medi-Cal? Perhaps above all, Medi-Cal is a welfare program and thus is chronically underfunded, failing to meet the financing requirements for the essential health care services required by the enrollees.

Investor-owned, for-profit Medicaid managed care organizations are required to make a profit for their investors, so when underfunded with a fixed capitation rate, they can profit only by decreasing care provided. As masters of innovation, there are many ways the private insurers can do that, but basically their measures impair access to health care services.

An important component of the health care delivery system is the academic medical center (AMC). Patients with more complex and long-term problems will often select plans that include an AMC in their provider networks, especially if they are already patients of that center. Adverse selection is inevitable since the plans that include AMCs will attract sicker, more expensive patients. When a Medicaid managed care program is already operating at a loss, adverse selection will increase their losses and thus force a decision to withdraw from the market. This is exactly what Health Net and then UnitedHealth did with their contracts with UC Davis Medical Center. With no UC Davis Medi-Cal contract for primary care, Medi-Cal managed care patients were left without a choice of a plan that included UC Davis. Besides, Sen. Richard Pan says, “Why is a public, state-owned university that’s running a health system not contracting with the state health plan?”

Suppose we had a single payer Medicare for all instead. First, we would not have a separate health care welfare program for low-income people without much of a political voice; we would have a single, comprehensive program for everyone. We would not have private, investor-owned, for profit corporations managing the health care funds in a manner that, by necessity (ask SEC), places investors above patients; we would have a single, publicly-funded and publicly-administered program instead. We would not have stewards trying to create barriers to health care to improve the bottom line; instead our public  stewards would be assisting patients in gaining access to the care they need. We would not have patients arbitrarily excluded from academic medical centers; instead the centers would be providing specialized services to patients equitably, based on priority. We would not have a financing system that frequently results in adverse selection with all of its consequences; risk would be borne by the public payer rather than the providers or patients. We would not have sectors of health care that were deliberately underfinanced, with its consequences as well; the national global budget for health care would be adequate to meet the needs of the nation. We would not have narrow provider networks that deliberately limit access and fragment care for strictly business purposes; patients would have their choice of health care professionals and institutions.

The academic medical center should be available to the entire community with appropriate referral made through the primary care infrastructure and the universal, integrated referral system. Under a well designed, single payer, improved Medicare for all, AMCs would be available to all, as appropriate.

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TRUMPCARE by John Geyman, M.D.

Posted by on Friday, Sep 28, 2018

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.

TRUMPCARE: Lies, Broken Promises, How It Is Failing, and What Should Be Done

From the Preface

Chaos reigns throughout our increasingly fragmented and dysfunctional health care system. Corporate mergers and profits are the order of the day, with the business “ethic” to make more money trumping the traditional service ethic of care. Health care is becoming less and less affordable or accessible, while Americans continue to lose free choice of physician, other providers, and hospitals. Family budgets are already strained to the limits as many patients forgo necessary care, have worse outcomes if and when they finally get care, and often have to choose between food and medications.

Health care is a leading issue in the forthcoming 2018 midterm elections, and promises to be in the 2020 election cycle. This book undertakes four goals: (1) to describe what our increasingly dysfunctional health care system looks like after the ACA has been gutted by GOP sabotage; (2) to show how TrumpCare will fail patients, families, tax payers, and the nation; (3) to describe the increasing crisis in U.S. health care; and (4) to outline the only two future scenarios that could deal with this worsening situation, only one of which will work.

It is my hope that this book will help voters to better understand their options during the coming election cycles, as well as help candidates hoping to be elected to positions where that can make a difference.

https://www.amazon.com…

Our overpriced but underperforming health care system is being made worse under Trump policies. It is extremely urgent that we change direction. John Geyman explains what has gone wrong and what we can do about it so that absolutely everyone finally can have affordable, high quality health care.

By exercising their right to vote, people can change the national agenda. This book is designed to enable voters to make an informed choice in the current midterm election. More importantly, it will inform voters on sound policies that they can take to their respective parties to encourage incorporation into their party platforms for the next presidential election. A clear majority of Democrats and close to half of Republicans are already there. If both major parties were to include an improved Medicare for all in their platforms, then the next presidential election could actually provide a very real prospect of affordable health care for everyone.

Many have said that there are three scenarios for reform: Obamacare, TrumpCare, and single payer Medicare for all. Actually, as Geyman explains, there are only two since both Obamacare and TrumpCare are merely a perpetuation of our current, fragmented, dysfunctional method of financing health care with mere tweaks based on the ideology of the person holding office. Since Donald Trump is currently the president, the two nominal choices we have are TrumpCare and single payer Medicare for all. Geyman’s book explains why the latter is the only real choice if we want affordable, high quality care for everyone.

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AHIP’s CEO provides us with his vision for health care’s future

Posted by on Thursday, Sep 27, 2018

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.

AHIP CEO Matt Eyles on Value-Based Care and Evolving Healthcare IT

Change Healthcare, September 4, 2018

The rise of value-based care and the ongoing evolution of healthcare technology are just two of the many topics the new CEO of America’s Health Insurance Plans (AHIP) says are front and center on his upcoming agenda.

AHIP’s Matt Eyles takes a deep dive on those subjects and more while speaking with Rob Capobianco, the head of the Change Healthcare value-based-care analytics team, as part of the Change Healthcare Episode Intelligence podcast series.

***

Rob Capobianco: I think it only gets better from here. But with consumer side devices and machine learning and AI who knows what the future holds. But I think it will incrementally keep building. That’s what we’ve seen in healthcare over and over and over again is we just keep taking the ideas farther.

Matt Eyles: I think that notion of incrementalism is really important as well when you think about healthcare because there are efforts out there and I’m coming back to the policy world for a little bit that would try and sort of fundamentally disrupt and change what’s happening within the healthcare system, whether it’s moving more towards a government-driven solution or sort of taking government out of it even a little bit more than it’s in there today. And that kind of massive disruption requires a lot of transition. That, it’s really hard to do that. And so thinking about incremental improvements whether it’s coverage expansion, ways that we’re improving healthcare is delivered, measurement quality, those are all really important and ways that we can make real progress over a finite period of time and see what’s working and what’s not. Because as we know, it’s been said before but I’ll say it here healthcare is complicated. So when you have that many moving parts probably an incremental approach is a lot more effective than trying to do a wholesale dramatic change. Despite all the disruption that we’re seeing now and all of the change whether it be on the technology side or what we’re seeing with Amazon and JP Morgan, Berkshire Hathaway, that they want to disrupt things as well. But it’s really hard to do it in a massive way in a short period of time.

Rob Capobianco: Absolutely. Want to be cognizant of time. I’m sure you have way more meetings going out today and into the rest of the week. So for the audience here that doesn’t get the opportunity to speak to someone like you, just sort of any final words of wisdom for the audience? Things you want to leave them with?

Matt Eyles: I think it’s important to embrace the change that’s happening in the healthcare system. When I think whether it was my own personal journey professionally or the disruption that we’ve seen in different parts of the healthcare system if you’re able to embrace the change, sort of step back for a second and say okay, we’re going to figure this out. It might be hard. It might be really challenging. But we’re going to be better when we come out the other side because we will have learned something different. I think that’s a pretty important approach when you’re tackling big problems that are of the complexity that we see in healthcare. And don’t fight it because you’ll probably lose if you do. So you’re better off trying to figure out how can you work with the hand that you’ve been dealt, embrace the change, and try and make the system better.

https://www.changehealthcare.com…

Retraction:

Today’s Quote of the Day, “AHIP’s CEO provides us with his vision for health care’s future,” represented a non sequitur in that a discussion of the consequences of consolidation within the health care industry does not logically follow from the comments made by AHIP CEO Matt Eyles. Also the analogies resulted in an overstatement of the solidification and impenetrability that is taking place within the health care industry. Thus I am retracting the message (archived below).

Though I am retracting this particular Quote of the Day, I do want to reemphasize that delay in enacting and implementing an Improved Medicare for All is enabling the progression of structural changes that will create greater political and policy barriers to comprehensive reform. The need for reform is urgent.

Peace,
Don McCanne, M.D.

***

Original Comment:

As we witness the consolidation of the health insurance industry and the medical-industrial complex into an amalgam that lays down the future health care infrastructure for America, it is instructive to hear the words of Matt Eyles, the CEO and thus the spokesperson for America’s Health Insurance Plans (AHIP), as he provides us with his clear vision of where we are headed. Read his words.

Did I say a clear vision? Well, we’d better understand what is behind those somewhat obscure words since this seems destined to be the future of our health care system.

We are witnessing an acceleration of broad-based merger activity – horizontal, vertical, upside down, and inside out. Use a little imagination on where that will lead.

Our continual delay in implementing the reform that we need is further embedding the insurance industry and other components of the medical-industrial complex into our health care delivery system such that they are becoming a fused unit that will not be amenable to changes proposed in the PNHP model of single payer. The delays in moving toward an improved Medicare for All are allowing the creation of a health care machine that will leave the entire health care system in the control of the billionaires forever. We will not be able to eliminate the private insurers because the private insurers will be an integral part of the health care delivery system. This amalgam is already rapidly fusing.

How do you remove a private, for-profit insurer from the health care delivery system when it has already become the delivery system itself? How do you reduce the administrative waste when the health care machine is oiled with profound administrative excesses? How do you negotiate prices with a gigantic mega-amalgam that simply exists, dominating all of health care, while invulnerable to the actions of bureaucrats who have mastered passivity.

Think again how private insurers, hospitals, outpatient centers, medical groups, retail clinics, pharmaceutical firms, pharmacy benefit managers, retail pharmacies, information technology, innovative alternative payment models, accountable care organizations, Medicaid managed care organizations, privatized Medicare Advantage plans, and endless other entities are merging into a conglomeration that, as several have said, has made health care complicated. Then try tackling this conglomeration with single payer. That amalgam won’t separate out, and we’ll be stuck with it.

AHIP’s Matt Eyles says, “When I think whether it was my own personal journey professionally or the disruption that we’ve seen in different parts of the healthcare system if you’re able to embrace the change, sort of step back for a second and say okay, we’re going to figure this out. It might be hard. It might be really challenging. But we’re going to be better when we come out the other side because we will have learned something different. I think that’s a pretty important approach when you’re tackling big problems that are of the complexity that we see in healthcare. And don’t fight it because you’ll probably lose if you do. So you’re better off trying to figure out how can you work with the hand that you’ve been dealt, embrace the change, and try and make the system better.”

Just work with what we’ve been dealt and embrace the change? This is the future according to the private insurance guru? The longer we sit on our duffs spouting incantations about ineffectual policies such as ACOs or a public option, the more our amalgamated health system will solidify, making it impervious to the application of sound health policy science. It may already be too late, but we really won’t know that for sure unless we act…now. Otherwise how would single payer Medicare for all stewards know where to send the check?

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Ban Ki-moon says US health care system is ‘morally wrong’

Posted by on Wednesday, Sep 26, 2018

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.

Ex-UN chief Ban Ki-moon says US healthcare system is ‘morally wrong’

By Jessica Glenza
The Guardian, September 25, 2018

The former United Nations secretary general Ban Ki-moon has denounced the United States’ healthcare system as politically and morally wrong, and urged American leaders to enact publicly financed healthcare as a “human right”.

Ban made the comments in an exclusive interview with the Guardian in New York, as part of his work with The Elders, a group founded by Nelson Mandela to work on issues of global importance, including universal health coverage.

The US has the world’s most expensive health system, accounting for nearly one-fifth of American gross domestic product and costing more than $10,348 per American. The United Kingdom, by comparison, spends a little under 10% of GDP according to the latest available statistics, and healthcare is free at the point of delivery.

“It’s not easy to understand why such a country like the United States, the most resourceful and richest country in the world, does not introduce universal health coverage,” said Ban. “Nobody would understand why almost 30 million people are not covered by insurance.”

Failing to provide health coverage, he said, was “unethical” and “politically wrong, morally wrong”. He accused the “powerful” interests of pharmaceutical companies, hospitals and doctors that “inhibit the American government” of having prevented the US from moving towards universal healthcare.

https://www.theguardian.com…

Ban Ki-moon was Secretary-General of the United Nations from 2007 thru 2016. He knows something about the world. He says that the failure of the United States to provide health care coverage for everyone is “unethical” and “politically wrong, morally wrong.” He’s right, of course.

It doesn’t have to be this way. We have the greatest resources, but we are not allocating them efficiently nor equitably. We can correct that with one simple albeit massive change: Switch our health care financing to a well designed, single payer, improved Medicare for All. With such a financing system we can much more easily make the refinements needed to improve the functioning of our health care delivery system so it works well for everyone.

When our president opens his mouth before the United Nations General Assembly and they laugh at him, that should be a sure sign that we need more national soul-searching. Listening to and acting upon the words of Ban Ki-moon should be a great place to start.

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Reducing California’s single payer legislation to a public option

Posted by on Tuesday, Sep 25, 2018

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.

California Legislative Information

Assembly Bill No. 1810
Approved by Governor June 27, 2018. Filed with Secretary of State June 27, 2018.

PART 4. Council on Health Care Delivery Systems

1001. (a) Effective January 1, 2019, there is hereby established the Council on Health Care Delivery Systems as an independent body to develop a plan that includes options for advancing progress toward achieving a health care delivery system in California that provides coverage and access through a unified financing system for all Californians.

002. (a) On or before October 1, 2021, the council shall submit to the Legislature and Governor a plan with options that include a timeline of the benchmarks and steps necessary to implement health care delivery system changes, including steps necessary to achieve a unified financing system.

https://leginfo.legislature.ca.gov…

***

Assembly Bill No. 2472: An act to add Section 1002.5 to the Health and Safety Code, relating to health care coverage.

Approved by Governor September 22, 2018. Filed with Secretary of State September 22, 2018.

AB 2472, Wood. Health care coverage.

From the Legislative Counsel’s Digest

Existing state law establishes the Council on Health Care Delivery Systems as an independent body to develop a plan that includes options for advancing progress toward achieving a health care delivery system in California that provides coverage and access through a unified financing system for all Californians. Existing law requires the council, on or before October 1, 2021, to submit to the Legislature and the Governor a plan with options that include a timeline of the benchmarks and steps necessary to implement health care delivery system changes, including steps necessary to achieve a unified financing system. [AB 1810 (Committee on Budget), Chapter 34, Statutes of 2018]

THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

SEC. 2. Section 1002.5 is added to the Health and Safety Code, to read:

1002.5. (a) The council shall prepare an analysis and evaluation, known as a feasibility analysis, to determine the feasibility of a public health insurance plan option to increase competition and choice for health care consumers.

(d) (1) The council shall submit the feasibility analysis to the Legislature and the Governor on or before October 1, 2021.

(e) This section does not authorize the council to apply for a waiver under Section 1332 of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any amendments to, or regulations or guidance issued under, those acts.

CONCURRENCE IN SENATE AMENDMENTS AB 2472 (Wood)
As Amended August 17, 2018

COMMENTS: According to the author, in California there are some counties that only have one health plan choice, including Monterey, San Benito, San Luis Obispo, Santa Barbara, Inyo, Mono, and in most of Kings County. Additionally, 22 other counties have two or fewer health plan choices. This limited plan choice has impacted not just the prices of health care in these areas but also the quality of health care that consumers receive. Although the federal Patient Protection and Affordable Care Act has greatly reduced the number of uninsured in California, premiums continue to rise for many consumers. Policymakers have an obligation to find ways to make healthcare more affordable and accessible to consumers. One proposed solution to the problem of limited health plan competition in the individual market is the establishment of a public option as an alternative to existing private plans. However, among other considerations, the structure, financing, and governance of a public option needs to be evaluated. This bill would require the Council to conduct an analysis and evaluation of a public health insurance plan option and determine if this public option is possible to implement in California.

A March 2018 issue brief published by the Insure the Uninsured Project (ITUP) entitled “Exploring Public Option in California,” highlights the issues and options related to public option. The issue brief defined public option as a publicly operated health plan choice that directly competes with private health plans in specified target markets. A public option does not include public programs such as Medicare, Medi-Cal, or the Children’s Health Insurance Program, but may be modeled after, or offered as an adjunct to, public programs. The issue brief highlights California-specific factors that will influence a public plan choice, including: an active purchaser exchange (Covered California); existing network of local public health plans; strong California standards and consumer protections; California communities with severe provider shortages and lack of competition; and, a state safety net linked to public health plans. In the issue brief, ITUP also developed three scenarios of how a public plan choice might be organized in California and notes that the scenarios acknowledge California’s extensive network of local health plans and the heavy concentration of managed care in the existing Medi-Cal program.

https://leginfo.legislature.ca.gov…

In June of this year, the California Legislature passed and Gov. Jerry Brown signed AB 1810 – a bill that, amongst other measures, would establish the Council on Health Care Delivery Systems with instructions to develop a plan that would provide coverage and access through a unified financing system for all Californians, whatever that means. This week, Gov. Brown signed AB2472 – a bill that instructs the Council on Health Care Delivery Systems to determine the feasibility of a public health insurance plan option to increase competition and choice for health care consumers, or, simply stated, a public option, and report back October 1, 2021 (deferring further consideration until after the next two year legislative session in California and after the next presidential election). So much for California’s single payer proposal.

Lest California’s single payer supporters go off in a funk, it should be realized that there is an opportunity here. What we really want is an improved Medicare that covers everyone throughout the entire nation. Californians should join in a coalition effort with other states to bring us, in the next presidential election, a Congress and an administration that would enact and implement such a national health program. We should encourage all political parties to participate, especially now that close to half of Republicans support the concept.

When do we start? Now! Don’t even consider waiting until after the midterm elections to begin the effort. There are many proponents of Medicare for all running now. We can start by electing them, thereby establishing an environment in Congress more conducive to serious deliberation of the clear superiority of a well designed, single payer, improved Medicare for All.

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People worry most about unexpected medical bills

Posted by on Monday, Sep 24, 2018

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.

Surprise medical bills could be a powerful campaign issue

By Drew Altman
Axios, September 24, 2018

As the chart shows, unexpected medical bills are the number one health cost problem people worry about, ahead of all the cost issues that get more attention, including deductibles, drug costs, and premiums. They’re even a bigger concern than other family expenses, such as paying the rent, mortgage, or utilities.

* Surprise medical bills also affect a lot of people. In a recent Kaiser Family Foundation tracking poll, four in ten adults (39 percent) say they had a surprise bill from a doctor, hospital or lab in the past year.

* 10 percent report that an unexpected bill was from an out-of-network provider.

* Almost 18 percent of inpatient admissions result in non-network claims for patients with large employer coverage.

Percent who are very or somewhat worried about being able to afford…

67% – Unexpected medical bills

53% – Health insurance deductible

46% – Gasoline or transport costs

45% – Prescription drugs

43% – Monthly utilities

42% – Monthly health insurance premium

41% – Rent or mortgage

37% – Food

The bottom line: Unlike consumers, experts do not generally put surprise bills at the top of their list of the problems in the health system. But people talk about their unexpected bills a lot, and with a sense of outrage.

https://www.axios.com…

Discussion draft of “Protecting Patients from Surprise Medical Bills Act”:
https://www.scribd.com…

According to this survey, unexpected medical bills such as the surprise bills from out-of-network providers are the number one health cost problem that people worry about. Even if insured, an individual may be exposed to large medical bills that were not expected.

Currently under discussion is proposed federal legislation that would limit the patients’ exposure to these unexpected bills but would shift at least some of the extra charges to the insurer. Not only would those costs be transferred to the insured through higher premiums, but we should also ask if it is fair to pay physicians who agree to becoming a network provider less than is paid to those physicians who refuse to cooperate. Although opinions on that would certainly vary, we can say that such a payment scheme is, at least, inequitable.

The fundamental problem is more than the fact that insurers deliberately limit the breadth of their provider networks; it is that private insurers include a multitude of design features to enhance their business model for the benefit of their investors.

Under a well designed, single payer, improved Medicare for all there would be no surprise medical bills, nor would there be any of the other injustices that a market model would inflict upon their enrollees. Plus everyone would be included and it would be affordable for all. We spend a lot of time talking about the injustices of our fragmented, dysfunctional system such as these surprise bills, but it is the last point – affordable care for everyone – that should be the driving force behind health care reform.

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For profit hospitals have higher readmission rates

Posted by on Friday, Sep 21, 2018

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.

Proprietary management and higher readmission rates: A correlation

By Manish Mittal, Chih-Hsiung E. Wang, Abigail H. Goben, Andrew D. Boyd
PLOS ONE, Abstract, September 18, 2018

Introduction

Reducing preventable readmissions among Medicare beneficiaries is an effective way to not only reduce the exorbitantly rising cost in healthcare but also as a measure to improve the quality of patient care. Many of the previous efforts in reducing readmission rate of patients have not been very successful because of ill-defined quality measures, improper data collection methods and lack of effective strategies based on data driven solutions.

Methods

In this study, we analyzed the readmission data of patients for six major diseases including acute myocardial infarction (AMI), heart failure (HF), coronary artery bypass graft (CABG), pneumonia (PN), chronic obstructive pulmonary disease (COPD), and total hip arthroplasty and/or total knee arthroplasty (THA/TKA) from the Center for Medicare and Medicaid Readmissions Reduction Program (HRRP) program for the period 2012–2015 in context with the ownership structure of the hospitals.

Results

Our analysis demonstrates that the readmission rates of patients were statistically higher in proprietary (for profit) hospitals compared to the government and non-profit hospitals which was independent of their geographical distribution across all six major diseases.

Conclusion

This finding we believe has strong implications for policy makers to mitigate any potential risks in the quality of patient care arising from unintended revenue pressure in healthcare institutions.

From the Discussion

The policy makers need to carefully evaluate and design healthcare policies that mitigate potential risks associated with unintended revenue pressure in harming patients.

https://journals.plos.org…

Is the primary mission of the health care organization to serve the needs of patients, or is it to make a buck? It makes a difference. This study shows that readmission rates were higher in proprietary (for profit) hospitals than in non-profit hospitals.

This fundamental difference in hospitals that must cater to passive investors is one reason why the single payer, improved Medicare for all model as supported by Physicians for a National Health Program would covert for profit entities to non-profit. Unfortunately, this important policy recommendation is being left out of many of today’s discussions on health care reform.

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With growing support among the public and with many Democratic candidates taking strong positions for single-payer Medicare for All, a battle is being engaged again between supporters and opponents in the Democratic Party. Support for universal coverage through Medicare for All, or national health insurance (NHI), should become a litmus test for Democrats and their platform for 2020, but already we are seeing vacillation among centrists in the party establishment reminiscent of the surrender in advance strategy that prevailed in the run-up to the 2008 elections.

This article briefly reviews that history, summarizes what is happening now, and shows how the Democrats are likely to once again lack enough unity and political courage to advocate for this issue in the public interest.

Barack Obama, after his inauguration as President in 2009, missed his opportunity to enact lasting health care reform despite his 2003 speech to the Illinois AFL-CIO: “I happen to be a proponent of a single payer universal health care program reform health care. . .  (applause). . . I see no reason why the United States of America, the wealthiest country in the history of the world, spending 14 percent of its Gross National Product on health care, cannot provide basic health insurance to everybody.” (Obama, Speech to the Illinois AFL-CIO, June 30, 2003.) That failure started with how the Democrats framed the issue—they rejected the words “universal health care”, substituting “guaranteed affordable choice” and “competition”, thereby playing right into the GOP’s playbook.

The Democrats’ failure to enact universal health care reform, despite controlling the White House and both chambers of Congress, was foretold by these events during 2008-2009:

  • Senator Max Baucus (D-MT), an opponent of NHI and chairman of the key Senate Finance Committee, barred eight single-payer activists from an open hearing of the committee, having them handcuffed and sent off to jail for “disorderly conduct.”
  • Centrist Democrats put forward an incremental idea—the public option— but Obama withdrew support for it when confronted by opposition from the private health insurance industry.
  • As a member of the Baucus Eight, Dr. Margaret Flowers summed up the political dynamics of the time in this way:

    In order to disarm the corporate interests, the health industries that had opposed previous reforms were included on the inside. In order to disarm the Right, bipartisanship was at the forefront. In order to disarm the supporters of a single payer plan, who are the majority, a campaign was developed around a promised ‘compromise’, the public option, and given tens of millions of dollars for organizing and advertising. The public option succeeded in splitting the single payer movement and confusing and distracting it with endless discussion about what type of public option would be effective.

Although health care is a leading issue during the approaching 2018 midterms and the 2020 election cycle, we now see increasing division among Democrats over NHI as well as the expected opposition from the private sector within the medical-industrial complex, together with large amounts of campaign money intended to defeat single-payer Medicare for All. Here are some of the markers of this effort:

  • Senate Minority Leader Chuck Schumer, who said in 2017 that “single payer will happen . . .  in 10 or 20 years,” took in more than $2.7 million in campaign contributions from the health sector in 2017, according to the Center for Responsive Politics.
  • A new group disingenuously named “The Partnership for America’s Health Care Future,” led by private insurers and Big PhRMA, is leading the latest fight against single-payer Medicare for All over the next two years, and of course, will be very well funded.
  • The five members of Congress who comprise the top leadership of the Democratic Congressional Campaign Committee (DCCC) have already received almost $3 million in contributions from the health care industry in their careers, with more than $780,000 in the current election cycle; the DCCC is opposed to single-payer Medicare for All.
  • Third Way, the New Democrats’ most prominent think tank, opposes single-payer by warning that “it is not as popular as advocates suggest” and that “Republicans are salivating to use single-payer as a cudgel.” (Winning on Health Care. .)
  • The Center for American Progress (CAP), another prominent liberal think tank, promotes its vaguely worded “Medicare Extra for All” proposal, which would “build on Medicare” but leave the multi-payer private health insurance industry in place, a major problem of today’s system; we can expect this proposal to confuse the public, sound good to the uninformed, and please their campaign donors.
  • Other centrists want to bring back the public option, which was killed in 2009, and which, like the other timid incremental proposals, would fail to provide universal coverage, contain costs, or improve access or quality of health care.
  • After their short August recess, Senate Democrats have decided to run in 2018 on the merits of the ACA, especially favoring its banning of insurers’ coverage based on pre-existing conditions, without apparent concern for the failures of the ACA to contain costs and prices of health care and the fact that more than 30 million Americans remain without health insurance. Senate Democrats stay focused on health care even during short August recess.

Although a July 2018 Health Tracking Poll by the Kaiser Family Foundation found that more than three of four respondents say that single-payer should be considered or is very important or the single most important factor in the upcoming election, powerful corporate forces are already mobilizing against it as they derailed real reform in 2008-2009.

As Yogi Berra classicly said, this is “deja vu all over again.” That applies here within a split Democratic party, which is frittering away its potential power through needless internal divisiveness. There is a plan for real reform—single-payer Medicare for All. Democrats have the opportunity to confront the profiteering medical-industrial complex and ensure that all Americans gain access to all necessary health care in the most efficient, affordable, and fair way. Do they have the spine and political will to seize this opportunity?

Adapted in part from my soon to be released book, Trumpcare: Lies, Broken Promises, How it is Failing, And What Should Be Done

visit: http://www.johngeymanmd.org

Opening the Pandora’s Box of commercial insurance data

Posted by on Thursday, Sep 20, 2018

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 Care Spending Under Employer-Sponsored Insurance: A 10-Year Retrospective

By Amanda Frost, Eric Barrette, Kevin Kennedy, and Niall Brennan
Health Affairs, September 19, 2018

Abstract

Using a national sample of health care claims data from the Health Care Cost Institute, we found that total spending per capita (not including premiums) on health services for enrollees in employer-sponsored insurance plans increased by 44 percent from 2007 through 2016 (average annual growth of 4.1 percent). Spending increased across all major categories of health services, although the increases were not uniform across years or categories. Growth rates for total per capita spending generally slowed after 2009 but increased between 2014 and 2016. Spending on outpatient services grew more quickly (average annual growth of 5.7 percent) compared to spending on the other types of services. However, the overall distribution of spending across categories remained largely unchanged. In the context of the dramatic economic and policy events that have taken place since 2007—including the Great Recession, the Affordable Care Act, and numerous medical innovations—this assessment of ten-year spending trends provides insights into how the largest insured population in the US contributes to health care spending growth.

https://www.healthaffairs.org…

Previously much of our access to data on health care spending has been through government programs – Medicare and Medicaid. Data on commercial insurance spending, especially employer-sponsored plans, were hidden in a cloud of secrecy as proprietary information. Now a group of major insurers has made that information available though the Health Care Cost Institute. Having this information is helpful because it can reveal underlying health care spending trends in the very large sector of commercial insurance (covering 54 percent of Americans) that was not disturbed by the Affordable Care Act (ACA).

In the decade that included the Great Recession and the enactment and implementation of ACA, there was an initial slowing in the rate of health care spending increases. The ACA enthusiasts were quite willing to take credit for that slowing, though there was not much evidence that the specific polices contained in ACA could be credited for it. It seemed much more likely that the slowing in health care spending growth was merely a manifestation of the global slowing of the economy during the recession.

In the latter part of the decade studied, health care spending growth increased again. Although ACA is still in force, this increase further suggests that the previous slowing was due to the recession and not due to any magical policies contained in ACA. In fact, many other studies have demonstrated disappointing results in the ACA measures that were supposedly designed to contain spending.

The significance of this is that it is wrong to continue to support ACA based on the concept that we merely need to give it more time to work, maybe while adding a public option – an option that would not change in any fundamental way the huge, highly dysfunctional, fragmented infrastructure of our health care financing system. It is wrong to reject a proven model that would be effective in reducing the rate of spending increases to sustainable levels – a single payer national health program.

Now that we have opened the Pandora’s Box of private commercial insurance data, we have confirmed that private insurance is not capable of containing the excessive growth in health care spending. So let’s move forward with establishing our own public program that would work – a single payer improved Medicare for all.

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What do Americans want done about our high prescription drug prices?

Posted by on Wednesday, Sep 19, 2018

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.

High Prices, Broken Promises

NORC at the University of Chicago, September 13, 2018

Three-quarters of Americans consider the cost of prescription drugs in the United States to be “unreasonable,” and despite promises from the President and members of Congress to rein in prices, few approve of either’s handling of the issue, according to a new national poll from the West Health Institute, a nonpartisan, nonprofit healthcare research organization, and conducted by NORC at the University of Chicago.

The survey found the high cost of healthcare is a top public policy issue for Americans. When presented with a list of six issues, 78 percent said addressing healthcare costs was their highest priority, similar to the number who say the same about jobs and the economy (76 percent), and ranking higher than national security (71 percent), the environment (63 percent), immigration (51 percent), or trade (38 percent).

High prescription drug prices are a particular worry for most Americans. Sixty-five percent said they are extremely or very concerned about the issue. Another 88 percent said lowering medication costs should be a top priority for candidates running for Congress.

From the Survey:

To reduce the cost of prescription drugs, should…?

82% – Medicare be allowed to directly negotiate with drug companies to get lower prices on prescription drugs

82% – More lower-cost generic prescription drugs be allowed to compete with the equivalent high-cost brand name prescription drugs

80% – Drug companies be required to release information to the public on how they set their prices

65% – Americans be allowed to buy prescription drugs from Canada

52% – Prescription drug advertisements be eliminated

31% – Drug companies be required to set the price for a drug based on how well it works

Press release:

http://www.norc.org…

Full issue brief and results:
http://www.norc.org…

Topline:
http://www.norc.org…

Not only do Americans object to the high prices of prescription drugs, they also feel that the President and members of Congress have failed us in not doing more about it.

When offered a list of various options on what we can do, to no surprise at the top was that Medicare should be allowed to negotiate for lower drug prices (along with more generic drug competition and more transparency in the setting of drug prices). Again, Americans support a major government role in drug pricing.

With the current popularity of Medicare for All it would have been interesting to see how strong the support would have been for including drugs as a benefit of an improved Medicare that covered everyone, but they didn’t ask that. Regardless, if we already had in place a comprehensive, single payer, improved Medicare for all that included a drug benefit, there is no question that it would be extremely popular.

We hear the opponents of reform talk about how bad the systems in Canada and Great Britain are, yet we hear from their people that they would never consider transforming their systems into one like ours. Since the majority of our politicians continue to fail us, it seems that we should replace them with leaders who can hear our message.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

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