Which emergency department visits are avoidable?

Posted by on Wednesday, Sep 6, 2017

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.

Avoidable emergency department visits: a starting point

By Renee Y. Hsia and Matthew Niedzwiecki
International Journal for Quality in Health Care, August 31, 2017

Abstract:

Objective
To better characterize and understand the nature of a very conservative definition of ‘avoidable’ emergency department (ED) visits in the United States to provide policymakers insight into what interventions can target non-urgent ED visits.

Design/setting
We performed a retrospective analysis of a very conservative definition of ‘avoidable’ ED visits using data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2011.

Participants
We examined a total of 115,081 records, representing 424 million ED visits made by patients aged 18–64 years who were seen in the ED and discharged home.

Main outcome measures
We defined ‘avoidable’ as ED visits that did not require any diagnostic or screening services, procedures or medications, and were discharged home.

Results
In total, 3.3% of all ED visits were ‘avoidable.’ The top five chief complaints included toothache, back pain, headache, other symptoms/problems related to psychosis and throat soreness. Alcohol abuse, dental disorders and depressive disorders were among the top three ICD-9 discharge diagnoses. Alcohol-related disorders and mood disorders accounted for 6.8% of avoidable visits, and dental disorders accounted for 3.9% of CCS-grouped discharge diagnoses.

Conclusions
A significant number of ‘avoidable’ ED visits were for mental health and dental conditions, which the ED is not fully equipped to treat. Our findings provide a better understanding of what policy initiatives could potentially reduce these ‘avoidable’ ED visits to address the gaps in our healthcare system, such as increased access to mental health and dental care.

From the Discussion
Our findings serve as a start to addressing gaps in the US healthcare system, rather than penalizing patients for lack of access, and may be a better step to decreasing ‘avoidable’ ED visits.

https://academic.oup.com…

This study is helpful in that the authors deliberately used a very conservative definition for which emergency department visits were avoidable. Under such a definition, 97% of visits were appropriate. The significance of this is that, instead of establishing often punitive policies to keep patients from supposedly abusing the emergency department, we should instead establish policies that would improve access for patients to more appropriate health care services and facilities.

A health care system designed to benefit the medical-industrial complex, including the private insurance industry, is going to use resources and incentives differently than a public system designed to benefit patients. Single payer supporters should have no difficulty in conceiving what those differences might be regarding urgent and emergency care.

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Anthem drops ACA coverage in only 17 Missouri counties

Posted by on Tuesday, Sep 5, 2017

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.

Anthem cuts back Obamacare coverage in Missouri to 68 counties

By Michael Erman
Reuters, September 1, 2017

U.S. health insurer Anthem Inc said on Friday that it will no longer offer Obamacare plans in 17 counties in Missouri but will remain in the bulk of the state, covering 68 counties that would not otherwise have Obamacare coverage for their residents.

https://www.reuters.com…

Boring. Boring. Boring. So Anthem eliminated coverage in 17 Missouri counties. That is so commonplace that it is a wonder that Reuters even reported it. But this is precisely the problem. We have accepted as routine the fact that Anthem and the other private insurers will take care of themselves first and use patients merely as a tool to achieve their own ends.

Contrast that with what an improved Medicare for all would be like. The public administrators would be making efforts to see that all regions are covered. It’s time that we put patients first rather than the rentier shareholders of the private insurers. Our Security and Exchange Commission protects the rentiers with the complicity of Health and Human Services – an agency that should be serving patients instead.

The voters can change that, but we keep hearing that the politics are too difficult. Really?

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Oregon expels half of Medicaid patients from their program

Posted by on Friday, Sep 1, 2017

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.

Oregon removes nearly 55,000 people from Medicaid after they failed eligibility checks

By Hillary Borrud
The Oregonian, September 1, 2017

Oregon has kicked nearly 55,000 people off its Medicaid program, after the state found they no longer qualified or failed to respond to an eligibility check.

The state made the announcement Thursday, after workers finally cleared a backlog of eligibility checks that built up due to technology troubles and a massive increase in Medicaid enrollment under the Affordable Care Act.

Historically, around 28 percent of Oregonians on Medicaid were found to no longer qualify at annual eligibility reviews. But when the state finished working through its backlog of 115,000 Medicaid enrollees, it took the free insurance away from nearly 48 percent of them.

The Oregonian/OregonLive has reported the state had to process hundreds of thousands of Medicaid applications by hand because an automated eligibility system failed along with the rest of the $300 million Cover Oregon project. More than 500 temporary workers were assigned to the project.

Medicaid is supposed to provide care for people with low incomes. To qualify in Oregon, single people can earn no more than $17,000 a year and a family of four no more than $33,000.

Historically, around 28 percent of Oregonians on Medicaid were found to no longer qualify at annual eligibility reviews. But when the state finished working through its backlog of 115,000 Medicaid enrollees, it took the free insurance away from nearly 48 percent of them.

http://www.oregonlive.com…

The Affordable Care Act supposedly was designed to expand health care coverage, including an expansion of the Medicaid program. Yet in Oregon almost half of Medicaid beneficiaries were kicked off the program. Isn’t that the opposite of one of the major goals of reform?

The reasons were entirely legitimate under our current system (which demonstrates, of course, what’s wrong with the system). Since Medicaid is a program for low-income individuals and families, those with incomes above the qualifying thresholds ($17,000 for individuals and $33,000 for a family of four) were removed. It is ironic that with a program that is designed to expand coverage, Oregon had to hire an additional 500 employees just to kick out those who were no longer qualified.

We have stated repeatedly that it is the highly flawed financing infrastructure that has created extensive administrative inefficiencies while frequently running counter the the stated goals of reform – in this example an increase in administrative activities merely for the purpose of taking coverage away from people.

The pressure is on to move forward in reform by tweaking ACA. Yet no number of tweaks will stabilize the Medicaid population. Not only does eligibility vary based on changing levels of income, other factors such as a change in employment, eligibility for Medicare, eligibility for ACA subsidies, veteran status and the like, perpetuate instability in health care coverage.

A single payer national health program – an improved Medicare for all – eliminates that instability. Coverage is for life. There is no necessity to hire a brigade of employees whose job it is is to see who should be expelled from their programs solely for reasons related to the defective design of the health care financing system rather than for any logical reason.

So the progressive commentators are telling us now that enacting and implementing a single payer system would be too disruptive. Maybe getting rid of those 500 employees who are taking health benefits away from people would be disruptive, but isn’t that precisely the kind of disruption that our highly dysfunctional system cries out for?

Correction of “Oregon expels half of Medicaid patients from their program”

The article used as the source included the following paragraph:

“Historically, around 28 percent of Oregonians on Medicaid were found to no longer qualify at annual eligibility reviews. But when the state finished working through its backlog of 115,000 Medicaid enrollees, it took the free insurance away from nearly 48 percent of them.”

It has been pointed out to me by Beth Capell and by Christopher Lowe that Oregon has over 900,000 enrollees in their Medicaid program (992,000 in May 2017, per KFF). Thus the 55,000 removed from coverage was not half of all enrollees but rather nearly half of the subset of a backlog of 115,000 enrollees.

Although it is a relief to know that only about 6% lost their coverage rather than 48%, unfortunately that does not change the absolute number that did – 55,000 people still lost their coverage.

The conclusion remains the same: “it is the highly flawed financing infrastructure that has created extensive administrative inefficiencies while frequently running counter to the the stated goals of reform – in this example an increase in administrative activities merely for the purpose of taking coverage away from people.”

Though single payer might be disruptive, “isn’t that precisely the kind of disruption that our highly dysfunctional system cries out for?”

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Iowa would slash retroactive Medicaid benefits

Posted by on Thursday, Aug 31, 2017

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.

Proposed Iowa Medicaid change would eliminate months of retroactive benefits

By Clark Kauffman
The Des Moines Register, August 30, 2017

Currently, Medicaid has a retroactive-eligibility provision that provides payment for health care services that were delivered in the three months leading up to a person being formally declared eligible for Medicaid.

It’s intended to ensure that health care providers accept patients even when those individuals have yet to apply for Medicaid. It often comes into play when people are hit with an unexpected health crisis and need immediate admission to a care facility. With retroactive payment, the facilities have some assurance that Medicaid will eventually pay for the care that pre-dates the decision on eligibility.

The Iowa Department of Human Services has asked the federal Centers for Medicare and Medicaid Services for permission to eliminate the three-month time-frame and have Medicaid pay only for the care that’s delivered from the first day of the month in which the patient applies for eligibility. The state says the move would save Iowa Medicaid, which serves more than 600,000 people and is funded by both the state and federal government, $36.7 million. The state’s share of the savings would be $9.7 million.

If approved, Iowa would become one of the first states in the nation to deny Medicaid beneficiaries three months of retroactive coverage. With more than 3,300 individuals enrolling in Iowa Medicaid each month, 40,000 Iowans would be affected by the change, which DHS hopes to implement in just four weeks, on Oct. 1.

The proposal is the result of actions taken by the Iowa Legislature during the 2017 session. Lawmakers approved a Human Services appropriations bill that specified several mandated cost-containment measures, one of which directed DHS to eliminate retroactive benefits for all Iowa Medicaid applicants. To do that, Iowa first needs the approval of CMS.

In its formal request to the federal agency, DHS says the change would “encourage individuals to obtain and maintain health insurance coverage, even when healthy.” It also says the change would make Medicaid more “closely aligned with the commercial market,” which doesn’t provide retroactive coverage to its customers.

http://www.desmoinesregister.com…

The need for retroactive qualification for Medicaid is obvious. Healthy individuals who otherwise would qualify for Medicaid on an income basis frequently do not want to bother signing up when they think they would have little use for the program. But unexpected, serious medical problems do occur, and retroactive qualification would cover care provided before enrollment could be completed.

It is not clear why the Iowa state government would want to deny that coverage when, in fact, it does fulfill the intent of the Medicaid program to cover health care for those individuals who otherwise cannot afford it. It seems to represent just plain meanness on the part of the legislators and state administrators who are pushing for denial of this important coverage. The savings to the Iowa government would be less than $10 million – a pittance relative to the importance of this program.

This perverse behavior on the part of Iowa’s stewards reinforces some important principles:

* Above all, lifelong coverage for everyone should be automatic. Coverage should not be dependent on ever-changing personal circumstances.

* Coverage should not be based on ability to pay, but rather should always be automatic. Each individual’s contribution to the national health program should be based on ability to pay, but that is entirely separate from the principle that each person receives health care based on need for that care, regardless of what has been paid.

* Payment to the providers of health care should not depend on whether or not the patient has the resources or coverage to pay for that care, but rather it should be made automatic through public administration of the funds in a universal risk pool.

* The Iowa state administrators say that slashing retroactive coverage would align the state more closely with the commercial insurance market. Our outrageous costs in an underperforming system are due in a large part to reliance on the commercial market. Using the private insurers as a model is the opposite of what we should be doing.

* Perhaps the most important lesson is that we should reject the calls to turn over the health care financing of federal health programs to the states since too many of them are proving to us that their preferred policies are heartless. The federal government has a duty to ensure that every individual receives the health care that he or she needs. We cannot turn that responsibility over to state bureaucrats who have already proven to us that they do not care about the health and welfare of their people.

We all should care, and an improved Medicare for all would make it automatic so that we do not have to give another thought about administrative excesses designed to interfere with care, like the denial of retroactive authorization – a concept totally foreign to a financing system specifically designed to advance health care justice.

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Our next health care debate

Posted by on Wednesday, Aug 30, 2017

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.

By Andy Slavitt
JAMA Forum, August 30, 2017

This current debate isn’t over as long as the administration clings to talk of repealing the ACA. Still, the movement toward a single-payer system or another variant is beginning. There will be much written about the ideas that will shape our future. Whatever those ideas are, if we want them to succeed, we must begin now to create the ingredients for successful legislation finally worthy of our country.

https://newsatjama.jama.com…

***

Democrats Should Negotiate with the GOP on Health Care

By James C. Capretta
RealClear Health, August 30, 2017

While in office, President Obama often remarked that the ACA relies, at least in theory and to a degree, on the Republican principles of markets and private insurance. He was right, even if he failed to note that the ACA also includes levels of governmental control and federal spending that Republicans were never going to support. If Democrats are willing to abandon dreams of single-payer and stick with a framework that features competition and consumer choice, it should be possible to find common ground with Republicans while moving even closer to the enrollment of all Americans in a health insurance plan.

http://www.realclearhealth.com…

Andy Slavitt and James Capretta both support moving forward with health care reform, though one might be considered center-left and the other center-right. So where are we headed?

Republicans support less government and more markets and competition. In contrast, there has been a surge of Democrats voicing support for a government single payer program. But what is the actual record of Democrats?

Since the neoliberals assumed control of the Democratic Party, they have supported market solutions – first with the failed Clinton effort, and then with the Affordable Care Act and their marketplace insurance exchanges of private plans. Even well established government programs are shifting to the private sector with an expansion of private Medicare Advantage plans in the Medicare program, a massive transfer of Medicaid to private Medicaid managed care organizations, and even transferring care of VA patients into the private sector through the Veterans Choice Program.

In his full article (link above), Slavitt states, “Our goal should be to develop policies that we have real-world experience with, so we can avoid think-tank fantasies that either overstate the power of free markets or fail to see the unintended consequences of government intervention.” That’s very neoliberal of him.

Capretta states, “If Democrats are willing to abandon dreams of single-payer and stick with a framework that features competition and consumer choice, it should be possible to find common ground with Republicans while moving even closer to the enrollment of all Americans in a health insurance plan.” That’s very conservative of him.

The pro-market, pro-corporate views of the neoliberals place them in the same camp as the conservatives in regard to financing health care. Many Democratic politicians have given token tribute to single payer, even to the extent of signing on as co-sponsors of Conyers’ single payer bill – HR 676. But several of them qualify their support by describing single payer as being merely an “aspiration” but not a practical consideration at this time when we need to be supportive of the Affordable Care Act. More private Medicaid managed care. More private Medicare Advantage plans. More private VA care. More private plans in the ACA marketplaces. Introducing a public option that is public in name only since it would be designed along the model of private plans while being prohibited from competing “unfairly” and would be financed without government funds – crapola insurance.

There is a night and day difference between financing health care in the marketplace through private insurance and financing it through a government national health program. One is framed around businesses and the other is framed around patients. Today the conservatives and neoliberals are offering us only the business approach supervised by the medical-industrial complex.

Harold Pollack is a highly respected health policy expert from the University of Chicago who sometimes drives us at PNHP a little bit crazy with the legitimate concerns he expresses about the politics and logistics of single payer, even if none of it is insurmountable. But he said something interesting the other day: “Republicans’ failed repeal-and-replace effort has solidified the consensus around universal coverage and provided an exemplar process for radical policy change. A lot of Democrats are saying: ‘If they can try doing this with something so unpopular that would hurt tens of millions of people, why can’t we do something on that order that would be popular and help tens of millions of people?’”

Yes, why can’t we? Not just the Democrats, but all of us. Like maybe single payer.

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Just over a year ago, the Democratic Platform Drafting Committee voted on whether or not to endorse single-payer Medicare for All, or national health insurance (NHI). It lost by a narrow vote of 7-6, with the no votes coming from delegates chosen by Hillary Clinton, a cautious centrist awash with campaign money from special interests in the for-profit health care industry. That position is in direct opposition to the will of the people, with about 60 percent support of single-payer, and of Democrats, with about 80 percent support.

So what’s happening today on this front as the Democratic Party tries to deal with its own split party on this issue? As centrist Democrats such as Chuck Schumer and Nancy Pelosi take a victory lap in defending (so far) the Republicans’ effort to repeal the Affordable Care Act (ACA), with or without replacement, they are trotting out their so-called Better Deal. While this has some good ideas, they are much too small for the moment and fail to take on the chains of Wall Street, the military-industrial complex, and the medical-industrial complex. The Better Deal does not come out in favor of single-payer Medicare for All, the only way we can ever achieve universal coverage to health care as a human right for all Americans.

While Democrats may take heart in seeing the demolition derby splitting Republicans asunder and opening up their own comeback in the coming 2018 midterms and the 2020 election cycle, they must acknowledge their own deep split if they are to win back the House and Senate next year and the White House in 2020. Their chances could not be better as the dysfunctional Trump administration and a Republican Congress take so many actions against the public interest. Progressive Democrats are sending a clear message that Medicare for All must be part of their Party’s platform. In the House, the Conyers bill for single-payer national health insurance (H. R. 676 has more co-sponsors than ever before (117), and Sen. Bernie Sanders plans to introduce a similar bill in the Senate when Congress re-convenes in September.

Instead, the so-called Better Deal that establishment Democrats are touting now has a few good ideas, but falls far short of what is needed, while risking further defeats in national elections by being too cautious. Even some supporters of health care reform, such as LeeAnn Hall, co-director of People’s Action and a member of the executive committee of Health Care for America Now (HCAN), are taking a too wimpy approach, by proposing such surrender in advance proposals as lowering the Medicare eligibility age, expanding Medicaid, and bringing back the public option. (Hall, L. People, not politicians, beat health care repeal. The Progressive Populist, September 1, 2017, p. 10).

Why should Democrats give up so much ground short of universal health care, which is so strongly supported by the public and by Democrats. Even if Democrats should win in their battle with Republicans with the inadequate “Better Way,” they will lose the real battle over universal health care. That would just extend for more years the power of corporate stakeholders in our for-profit health care system, continuing the profiteering of a failed private health insurance industry without real cost containment in sight. Much better would be to boldly adopt the recommendations of progressive Democrats to embrace Medicare for All, such as the People’s Platform, crafted by a coalition of grassroots organizations led by Our Revolution, which emerged from Sen. Bernie Sanders’ presidential campaign.

Why is the Democratic Party abandoning once again, as Hillary Clinton did in her 2016 election campaign, the will of the people on health care? The answer, of course, comes down to money. The Center for Responsive Politics tracks campaign contributions to both parties in the 115th Congress. In its latest report, here are some of the numbers of total amounts to leadership PACs and campaign committees:

In the Senate (including 2012-2016):
Sen. Mitch McConnell (R-KY) — $3,667,264
Sen. Orrin Hatch (R-UT) — $3,355,661
Sen. Charles Schumer (D-NY) — $2,715,088
In the House (including 2016):
Frank Pallone Jr. (D-NJ) — $1,333,126
Michael Burgess (R-TX) — $989,474
Steny H. Hoyer (D-MD) — $913,625
Nancy Pelosi (D-CA) — $471,060

After their disastrous losses in the 2016 elections, it is clear that the Democratic Party has not learned its lesson—to support the common good of those constituents they are supposedly representing. As Yogi Berra famously said, “It’s deja vu all over again.” That’s what is happening again as the DNC puts together its platform on health care. Dean Baker, co-director of the Center for Economic and Policy Research, identifies the enduring problem Democrats in winning over the public and elections:

Both of the Democrats’ leaders owe their position in large part to their ability to appeal to large donors. They are not going to completely change direction at this stage of their careers. That is why the Better Deal still doesn’t look like a very good deal.

—Dean Baker, A better deal than what? The Progressive
Populist, September 1, 2017, p. 11)

Ted Rall gives us this clear answer to the feckless Democratic Party platform on health care:

The answer, of course, is that the party leadership is owned by Wall Street, the Fortune 500 and big-moneyed special interests in general. Figures like Harris, Schumer and Clinton will never give the people what we want and need because their masters will never allow it. The question for us is: when do we stop giving them our votes—and start organizing outside the dead-end of the electoral duopoly?

—Ted Rall. The Democrats are a lost cause. The
Progressive Populist, September 1, 2017, p. 19.

John Geyman, M.D. is the author of Common Sense About Health Care Reform in America,
and  Crisis in U.S. Health Care: Corporate Power vs. The Common Good

visit: http://www.johngeymanmd.org/

Can we really celebrate the new numbers on health insurance coverage?

Posted by on Tuesday, Aug 29, 2017

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 Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January – March 2017

By Robin A. Cohen, Ph.D., Michael E. Martinez, M.P.H., M.H.S.A., and Emily P. Zammitti, M.P.H.
National Center for Health Statistics, August 2017

This report provides health insurance estimates from the first quarter of the 2017 National Health Interview Survey.

In the first 3 months of 2017, 28.1 million (8.8%) persons of all ages were uninsured at the time of interview — 0.5 million fewer persons than in 2016 (a nonsignificant difference) and 20.5 million fewer persons than in 2010.

In the first 3 months of 2017, among adults aged 18–64, 12.1% were uninsured at the time of interview, 18.9% had public coverage, and 70.5% had private health insurance coverage.

Among adults aged 18-64, 70.5% (138.8 million) were covered by private health insurance plans at the time of interview in the first 3 months of 2017. This includes 4.8% (9.4 million) covered by private health insurance plans obtained through the Health Insurance Marketplace or state-based exchanges.

The percentage of adults who were uninsured for at least part of the past year decreased, from 26.7% (51.0 million) in 2010 to 16.7% (33.0 million) in the first 3 months of 2017. There were no significant changes from 2016 through the first 3 months of 2017.

In the first 3 months of 2017, 42.3% of persons under age 65 with private health insurance were enrolled in an HDHP, including 16.9% who were enrolled in a CDHP (an HDHP with a health savings account [HSA]) and 25.3% who were enrolled in an HDHP without an HSA. The percentage of persons enrolled in an HDHP increased 17 percentage points, from 25.3% in 2010 to 42.3% in the first 3 months of 2017. More recently, the percentage of those enrolled in an HDHP increased, from 39.4% in 2016 to 42.3% in the first 3 months of 2017.

https://www.cdc.gov…

There are some important observations here on where we stand with insurance coverage in the United States.

* Coverage has stabilized with about 28 million people (8.8%) remaining uninsured. Under our current system of financing health care, those remaining uninsured will be very difficult to cover, even with tweaks to the Affordable Care Act.

* Among adults aged 18–64, 12.1% remain uninsured. That is a particularly difficult population to insure under our current system.

* There has been no significant further improvement in the numbers of individuals who remain uninsured for part of the year – 33 million (16.7%). Intermittent coverage is hazardous to both health and personal finances.

* The percent of individuals under 65 enrolled in a high deductible health plan (HDHP) continues to increase – now at 42.3%, an additional 2.9% increase in the last year alone, and 60% of individuals with an HDHP did not have a health savings account to back them up. This trend has continued to increase exposure to medical debt, already a major problem in the United States.

There will be those celebrating the success that these numbers represent when compared to 2010, but there should be no celebration when tens of millions remain exposed to physical suffering and personal debt – problems that could be ameliorated by simply enacting and implementing a single payer national health program.

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Health policy reform under compromised ethics

Posted by on Monday, Aug 28, 2017

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.

Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO

By John Hsu, Mary Price, Christine Vogeli, Richard Brand, Michael E. Chernew, Sreekanth K. Chaguturu, Eric Weil and Timothy G. Ferris
Health Affairs, May 2017

We examined the impact of patient participation in a Pioneer ACO and its care management program on rates of emergency department (ED) visits and hospitalizations and on Medicare spending.

From the Study Results

Overall participation in the ACO was associated with a reduction in Medicare spending of $14 per participant per month, a decline of 2 percent. This association was not significantly different from no change, but the magnitude of the decline was comparable to estimates in previous studies.

From the Limitations

The analyses also focused on Medicare spending but did not assess total spending, including program costs. To our knowledge, no other study of ACOs has included program costs in its analysis.

From the Discussion

There were modest overall ACO spending reductions, with magnitudes comparable to those of all ACOs as described in other published reports and generally consistent with the assessment of the Partners ACO by CMS.

http://content.healthaffairs.org…

***

On the Ethics of Accountable Care Research

By Kip Sullivan, J.D.
The Health Care Blog, August 25, 2017

The paper I am examining is the third that Hsu et al. have published in Health Affairs about Partners’ Pioneer ACO, the second largest of the 32 ACOs that entered Medicare’s Pioneer ACO program in 2012.

They found that Partners’ ACO cut Medicare’s costs by a statistically insignificant 2 percent. This outcome is consistent with CMS’s data on the performance of Medicare ACOs, as well as the extremely rare studies of total spending by private-sector ACOs. The only papers seeming to contradict this bad news are two “studies” of simulated ACOs . We may infer from the literature that if ACO start-up and operating costs, including the costs of disease management programs, are taken into account, ACOs are raising total health spending.

However, in this third paper, Hsu et al. did not convey to their readers the impression I have just conveyed: Despite their insignificant results, they claimed Partners’ ACO is cutting costs. “Our major overall finding is that participating in an ACO and a care management program lowered utilization and spending,” they concluded.

Hsu et al. employed two tactics that lulled readers into thinking their data supported their claim that Partners’ ACO “lowered spending.” The first was to treat the statistically insignificant reduction in Medicare spending as if it were statistically significant. The second was to ignore the overhead costs incurred by CMS and Partners’ ACO, a problem that occurs so frequently I have proposed giving it a name – the “free-lunch syndrome.”

Hsu et al. reported that Partners’ ACO cut Medicare spending on beneficiaries attributed to the ACO by CMS during 2012 and 2013 by a statistically insignificant 2 percent. As the authors put it, “this association was not significantly different from no change” (p. 880). Yet the authors treated this 2 percent difference as if it were significant. Throughout the paper they claimed Partners’ ACO had lowered “Medicare spending.” They did so in the title (“Bending the spending curve….”), the abstract (“ACO participation had a modest effect on spending”), and in the text (see the quote above, as well as, “There were modest overall ACO spending reductions….” and, “This study provides some evidence of how one large … ACO appears to have achieved its stated savings….”).

Even if the 2-percent savings had been statistically significant, the authors should have subtracted from the claimed savings the cost of the interventions that led to the savings. These costs fall into two categories: Those CMS incurred to run the Pioneer program and those Partners’ ACO incurred attempting to achieve savings. Not reporting these offsetting costs made it easier for Hsu et al. to mislead readers into accepting their statement that Partners’ ACO “bent the cost curve.”

Hsu and his co-authors in fact warned readers that they intended to ignore all “program costs” incurred by the ACO, CMS or any other entity, that is, all costs that didn’t require reimbursement by Medicare under Parts A, B or D. They didn’t say why. The only explanation they offered was, “To our knowledge, no other study of ACOs has included program costs in its analysis.” This is true. The vast majority of American health policy researchers think it’s totally appropriate to ignore program costs when analyzing the impact of ACOs. Moreover, they think that if their limited analysis shows the ACO cut Medicare’s gross spending it’s ok to state repeatedly the ACO “bent the cost curve” or “lowered spending.”

The data in Hsu et al.’ paper is useful even if it is incomplete. It contributes to a growing body of evidence indicating that ACOs cannot cut total spending, in part because ACOs cannot focus. They are measured on their ability to cut the cost of an entire population by unspecified means rather than on their ability to cut the cost of a clearly defined slice of their sickest “attributees” by clearly defined methods.

My criticism of Hsu et al. is their misuse of their data. They implied statistically insignificant results were significant, and by stating over and over that Partners’ ACO cut “spending” they misled readers into thinking they had measured total costs when they hadn’t.

Footnote 8:

I encourage readers to peruse RTI’s evaluation of the CMP (care management program) to get a clearer view of the complexity and expense of Partners’ CMP program. To give you just a taste of the resources Partners is investing now for the 4,000 CMP enrollees examined by Hsu et al., consider these excerpts from RTI’s report describing elements of the program for the 2,000 CMP enrollees during 2006-2009:

*  “Eleven nurse case managers [each of whom worked with about 200 patients] who received guidance from the program leadership and support from the project manager, an administrative assistant, and a community resources specialist” (p. 7);

*  “a social worker to assess the mental health needs of CMP participants” (p. 6);

*  “a mental health team director, clinical social worker, two psychiatric social workers, and a forensic clinical specialist (M.D./J.D.), who follows highly complex patients with issues such as legal issues, guardianship and substance abuse” (p. 10);

*  “a pharmacist to review the appropriateness of medication regimens” (p. 6);

*  “home delivery of medications five days per week” (p. 7);

*  “a nurse who specialized in end-of-life-care issues” (p. 7);

*  “a patient financial counselor who provided support for all insurance related issues” (p. 7);

*  “The clinical team leader provided oversight and supervision of case managers” (p. 8);

*  “The medical director provided oversight and day to day management of MGH’s CMP….” (p. 8);

*  “MGH developed a series of clinical dashboards using data from the MGH electronic medical record …, claims data, and its enrollment tracking database” (p. 8);

*  “MGH provided [200] physicians with a $150 financial incentive per patient per year to help cover the cost of physician time for [CMP-related] activities” (p. 8);

*  “a designated case manager position to work specifically on post discharge assessments to enhance transitional care monitoring” (p. 9);“ and

*  “a data analytics team to develop and strengthen program’s reporting capabilities” (p. 10).

http://thehealthcareblog.com…

Everywhere you turn these days you see articles stating that we need to shift from paying for volume of health care and pay for value instead. They contend that new payment models, such as accountable care organizations, are doing precisely that. Yet evidence for increased value – lower costs and higher quality – is lacking.

The Hsu et al. article from Health Affairs (above) has been cited extensively for demonstrating that this approach is resulting in savings. Yet in the article the authors state, regarding the reduction in Medicare spending, “This association was not significantly different from no change.” Kip Sullivan’s critique details the problems with the conclusions and is well worth reading if you want to better understand health policy chicanery, or at least unrealized health policy wishes camouflaged as health policy science.

This is more than an annoyance. In the past month a multitude of articles have called for rejecting the lure of single payer and instead moving ahead with improving the Affordable Care Act. Many of these articles contend that new payment models are bringing us the cost efficiencies that we need, and so we do not need to resort to the disruptive changes of transitioning to single payer. “There are many ways we can get to a universal system,” they keep telling us.

If you read the health policy literature extensively and carefully you will find that many noted policy experts who have been working on these financing concepts from the beginning have been disappointed with the results. The models are not reducing costs significantly and the improvements in quality are negligible. Nevertheless, the attitude amongst them seems to be that we should continue with these studies, perhaps trying various modifications of the models to see if maybe something will eventually come of it.

But the lay media have not picked up on this. The reporting fad of the day is that we can get to a universal system that is affordable without having to resort to Medicare for all.

From the experience of other nations we already know that single payer would save us hundreds of billions of dollars by reducing administrative waste while using other single payer tools to achieve greater value and equity in our health care system.

In his full article, available at the link above, Kip Sullivan asks a series of questions regarding the ethics of this particular health policy assessment. When the policy community, supported by the lay press, advocates for health care reform that has not held up to scrutiny while rejecting a proven model that does work – single payer – they are indeed compromising ethics, even if some don’t quite understand that.

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California Speaker Anthony Rendon calls for hearings on universal health care

Posted by on Friday, Aug 25, 2017

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.

By Speaker Anthony Rendon
California State Assembly, August 24, 2017

Assembly Speaker Anthony Rendon (D-Lakewood) today announced that Dr. Joaquin Arambula (D-Fresno) and Dr. Jim Wood (D-Healdsburg), the chairs of the Assembly Select Committee on Health Care Delivery Systems and Universal Coverage, will hold ongoing hearings beginning in the legislative interim so the committee can develop plans for achieving universal health care in California.

“The fight to protect the Affordable Care Act helped galvanize the principle that health care is a basic right,” Rendon said. “There are several different approaches being proposed, including Medicare for all, single payer, hybrid systems and ACA expansion. I have called for these hearings to determine what approach best gets us there – what gets us to ‘yes’ when it comes to health care for all.”

Speaker Rendon stressed that the hearings would not simply go back over information covered in the past, but will provide a new opportunity to determine the best and quickest path forward toward universal health care. Overcoming potential federal and constitutional obstacles, ensuring delivery of care, and examining funding mechanisms will all be part of the committee’s purview.

“It’s not a question of debating whether we move toward health care for all – it’s a matter of choosing how best and how soon,” Rendon said. “The committee’s work will help fill the void of due diligence that should have been done on SB 562 or any universal health care bill that so profoundly affects so many Californians.”

“It is my direction that these hearings be focused and thorough, and produce real results,” Rendon said. “In addition to the oaths they took as legislators, Dr. Wood and Dr. Arambula have also taken oaths to protect and defend patients’ health, so I know they will take a vigorous approach to this challenge, and the committee will begin the heavy lifting needed to advance serious proposals for health care for all.”

https://speaker.asmdc.org…

***

Close to Home: The path to universal health care

By Jim Wood, Chairman of the Assembly Health Committee
The Press Democrat, August 25, 2017

Readers of The Press Democrat have seen opinion pieces on Senate Bill 562, the “Healthy California Act.” That bill, often called single-payer or Medicare for all, is being held in the state Assembly, and I have been criticized for not doing more to overturn that decision.

Let me be clear, I have always supported health care for all. I am a health care provider, chairman of the Assembly Health Committee and strongly believe that health care is a right.

Medicare for all has been a term used to describe the bill, and it is a concept I can actually support, but that’s not what SB 562 is. Medicare recipients have the option to purchase a supplemental policy that provides prescription coverage and may reduce or eliminate co-pays and shared cost. What would seniors think of folding their well-liked program into a state program?

As a legislator, I am doing whatever I can to protect the progress we have made with the Affordable Care Act. In addition, Assembly Speaker Anthony Rendon announced this week that I will join Assemblyman Joaquin Arambula, who is a physician, to co-chair the Assembly Select Committee on Health Care Delivery Systems and Universal Coverage, which will hold hearings beginning in the legislative interim so the committee can develop plans for achieving universal health care in California. My priority will be to ensure that whatever system is proposed is sustainable.

It is my responsibility to endure whatever criticism is sent my way and to persevere, for as long as it takes to ensure that the end result is a sustainable and comprehensive health care system and not something that might sound good, but end up being an empty promise.

http://www.pressdemocrat.com…

California Assembly Speaker Anthony Rendon received quite a push-back when he decided to withhold SB 562 – the “Healthy California Act,” a single payer bill for California. Under threat of recall, he has now established a special committee during the legislative interim that will “develop plans for achieving universal health care in California.”

Of concern is the fact that the committee is not being charged with the task of expanding SB 562 into a comprehensive, single payer package, as was the original legislative intent. Rather the committee is being instructed to look at “several different approaches being proposed, including Medicare for all, single payer, hybrid systems and ACA expansion.”

The California legislature already authorized a comprehensive study of various models of health care financing – The California Health Care Options Project. According to the study, single payer is vastly superior to other models, except for a government health service. The results were used to craft other single payer bills, including the two Kuehl bills that were passed by the California legislature only to be vetoed by Gov. Schwarzenegger.

ACA expansion or hybrid systems would perpetuate the profound administrative excesses that characterize the U.S. system. They would also fall short on universality, equity, access, and affordability. We do not need more study of those deficient models.

Jim Wood, the chairman of the Assembly Health Committee and co-chair of the Assembly Select Committee on Health Care Delivery Systems and Universal Coverage, calls himself a health care provider, though he is a dentist – a member of a health care sector not noted for its single payer advocacy. He states that he has directed his attention to protecting ACA.

Chairman Wood also states that it is his “responsibility to endure whatever criticism is sent my way and to persevere, for as long as it takes to ensure that the end result is a sustainable and comprehensive health care system and not something that might sound good, but end up being an empty promise.” It sounds like he is bracing himself to endure the criticism he will receive when he opposes the “empty promise” of single payer. Let’s hope that is not what he means.

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What about Sen. Brian Schatz’s proposal for a Medicaid buy-in?

Posted by on Thursday, Aug 24, 2017

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.

We asked 7 experts about Sen. Brian Schatz’s big new Medicaid buy-in plan

By Jeff Stein and Dylan Scott
Vox, August 23, 2017

In a recent interview, Sen. Brian Schatz (D-HI) laid out his plan to allow every American to buy into Medicaid if their state allows it. It could be a significant expansion of the program, at the least as a public option for Obamacare’s marketplace. At the most, it could set up a road that leads to Medicaid as the vehicle for single-payer health care.

But it also raises a bunch of questions, about both the plan’s ideological goals and its policy mechanics.

We asked seven health policy experts, in the middle and on the left and right, what they thought.

Adam Gaffney, Harvard University:

Though the Affordable Care Act has so far withstood the Trumpcare battering ram, 28 million remain uninsured in the United States, an entirely unacceptable state of affairs. Might a Medicaid-based “public option,” as proposed by Sen. Brian Schatz (D-HI), be the answer?

Unfortunately, the bill would not rectify our nation’s serious health care woes. While it could potentially expand coverage, its impact would probably be modest, or even marginal: After all, in 2013 the Congressional Budget Office scored a somewhat similar public option and found that it would have no significant impact on the number of the uninsured. Moreover, Schatz’s bill would be optional for states and so would likely be declined by many, further limiting its impact. It is also probable that even with subsidies, some will find the premiums and deductibles of this plan unaffordable, as they have under the ACA.

Just as importantly, the bill would not solve the issues faced by Americans with insurance: narrow networks of doctors and hospitals, unaffordable drug prices, paltry access to dental and long-term care, and rising out-of-pocket costs (e.g., copayments and deductibles) that are squeezing household finances and creating an epidemic of “underinsurance” in America. And finally, it would not create the greater administrative efficiencies of a single-payer system, which by one estimate would be greater than $500 billion a year.

The only answer to those myriad issues is a universal single-payer “Medicare-for-all” system, which would ensure equitable access to comprehensive health for everyone in the nation. Medicare-for-all should thus remain the Democrats’ central health care goal in the coming months and years.

Robert Frank, Cornell University:

Anything you can do in this direction is a step forward.

Larry Levitt, Kaiser Family Foundation:

I read this as basically a public option delivered through Medicaid.

Loren Adler, Brookings Institution:

To me, the fundamental question here is whether you intend to create a level playing field or not.

Matt Bruenig, People’s Policy Project:

Up to this point, the liberal establishment, including Barack Obama and [the] Center for American Progress, has only endorsed what I would call the Loser Public Option.

David Anderson, Duke University:

I need to see the details.

Avik Roy, Foundation for Research on Equal Opportunity:

It’s completely unworkable.

https://www.vox.com…

Sen. Brian Schatz (D-HI) is currently drafting legislation that would allow Americans to buy into the Medicaid program, supposedly providing them with a “public option” and perhaps a path toward a single payer system in the United States. Vox has published the responses of seven “experts.”

Comments varied from those who approve based on the fact that any incremental improvement should be supported, to those opposed primarily based on conservative ideology. Those responses are recorded above with cryptic excerpts.

The response of Adam Gaffney is reproduced in its entirety since it is exceptional in that it clarifies how far off topic the current debate on reform has become. We should be discussing reform that corrects the serious defects in our overpriced and underperforming health care system. Instead the conversation has turned to disturbingly inadequate proposals such as the public option or buying into a public program.

It is not that even minimally beneficial measures should be opposed, rather we should not be burning up our resources for advocacy on these lesser measures when a single payer national health program – an improved Medicare for all – is an absolute imperative that requires urgent action. The crime is that it has required urgent action for decades while we have diddled around with deficient measures that have unnecessarily perpetuated financial hardship, physical suffering and even death.

Suppose we pass a public option or a buy-in. Those in support will celebrate success and then walk away. But what about the promise that this would lead to single payer? “Are you kidding? I support single payer, but that’s not feasible. I’m tired of you Bernie people trying to tell us liberals what to do. Get lost!”

Well, we’re more than just the Bernie people. We are a majority of the nation. We did get lost when they gave us ACA, and that didn’t lead to single payer. We can’t make that mistake again.

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