RAND COMPARE

Posted by on Wednesday, Jan 14, 2009

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

Comprehensive Assessment of Reform Efforts (COMPARE)

RAND Health

COMPARE is a transparent, evidence-based approach to providing information and tools to help policymakers, the media, and other interested parties understand, design, and evaluate health policies.

COMPARE has four objectives:

  • Synthesize what is known about the current health care system.
  • Describe policy options that have been proposed to address one or more existing challenges.
  • Analyze the effects of different health care policy options on multiple dimensions of health system performance.
  • Identify gaps in our knowledge about the effects of policy changes.

COMPARE was developed to help public and private decisionmakers systematically assess and compare the effects of different policies across multiple dimensions of health care system performance, encompassing cost, quality, and access. COMPARE gives users a comprehensive framework in which to examine both the intended and unintended effects of changes in health care policy and to examine trade-offs across policies, or across different dimensions of performance for any particular policy (e.g., the effect on spending compared to the effect on insurance coverage or on patient experience).

The Web site includes four main sections, U.S. Health Care Today, Policy Options, Analysis of Options, and Modeling Estimates.

http://www.rand.org/health/feature/compare/

Press release:
http://news.prnewswire.com/DisplayReleaseContent.aspx?ACCT=104&STORY=/www/story/01-13-2009/0004954039&EDATE=

And…

RAND COMPARE

Policy Options – Change Insurance Coverage

* Individual Mandate
* Employer Mandate
* Purchasing Pools
* Refundable Tax Credit
* Medicaid/SCHIP Eligibility
* Open Enrollment in FEHBPModeling Estimates – Policy Options

* Tax Credit
* Medicaid Expansion
* Individual Mandate
* Employer Mandate

Who funds COMPARE?

AARP
Abraxis BioScience, Patrick Soon-Shiong MD, Founder, Chairman, and CEO
Aetna Foundation
Alcoa
Amgen Foundation
Blue Cross Blue Shield of Massachusetts
California HealthCare Foundation
The Funari Family Foundation
General Motors Foundation
Johnson & Johnson
Karen Katen
Charles N. Martin Jr., The Martin Foundation
Pacific Business Group on Health
Pfizer
RAND Corporate Endowment
RAND Health Board, designated gifts from individual members
Robert Wood Johnson Foundation
John J. Rydzewski
Leonard D. Schaeffer
The Suzanne Nora Johnson and David G. Johnson Foundation
United Health Foundation
Wellpoint Foundation

http://www.randcompare.org/

To generate custom reports:
http://www.randcompare.org/analysis/reports/

RAND COMPARE provides both a valuable information resource on U.S. health care today, and an interactive tool that can be used to evaluate the impact of various policy options under different models of reform. It has now been released for public use.

Elizabeth McGlynn and Jeffrey Wasserman are codirectors of COMPARE. On a Webinar event January 13, the release of COMPARE was announced along with a discussion of how it works. When I noted that a single, public insurance model (single payer or Medicare for all) was not an option available on the COMPARE website, Dr. McGlynn assured me that it was a model that should be added.

In their press release they stated, "An individual mandate is the most cost-effective strategy for decreasing the number of uninsured." Innumerable other studies comparing models of reform have shown that a single payer model is the most cost-effective strategy and actually eliminates the uninsured. Models based on private insurance, such as the individual mandate, have been shown to be less effective, according to these other studies.

The sponsors surely support RAND’s function as "a nonprofit research organization providing objective analysis," and would want to see that objective data on the single payer model be made available immediately for comparison with the other options.

Since we are entering a period of intense activity in health care reform, it would be helpful to have the single payer model added as expeditiously as possible. If you agree, then please send a very brief message requesting that single payer be added ASAP. Email them at: COMPARE@rand.org

You may wish to share this message with others and ask them to make the same request.

UnitedHealth "praised for major leadership effort"

Posted by on Tuesday, Jan 13, 2009

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

Big Health Insurer Agrees to Update Its Fee Data

By Danny Hakim and Reed Abelson
The New York Times
January 13, 2009

In a settlement with one of the nation’s biggest insurers, New York’s attorney general, Andrew M. Cuomo, has ordered an overhaul of the databases the industry uses to determine how much of a medical bill is paid when a patient uses an out-of-network doctor.

A statement from Mr. Cuomo’s office said the industry had engaged in “a scheme to defraud consumers” by systematically underpaying the nation’s patients by hundreds of millions of dollars over the last decade.

The move, to be announced Tuesday, is part of a settlement with the insurance giant UnitedHealth Group, which operates the industry databases. It results from a yearlong investigation by Mr. Cuomo’s office that concluded the data had understated the true market rates of medical care by up to 28 percent.

The settlement will have a nationwide impact because UnitedHealth, the biggest health insurer in New York, operates the databases used by the entire industry, through its Ingenix business unit. The deal calls for creation of a new independent database, to be run by a university that is still to be selected.

Because insurers typically reimburse patients for only 70 to 80 percent of the “reasonable and customary” cost of medical services when they visit doctors outside the insurer’s designated network of physicians, the patient can get shortchanged if the insurer understates the prevailing local fees.

According to Mr. Cuomo, the databases consistently understated the local “reasonable and customary” rates, which Ingenix collects from insurers. The report of the investigation’s findings described the industry calculations as “created in a well of conflicts” that produced information that was “unreliable, inadequate and wrong.”

In an interview Monday, Mr. Cuomo said: “For years this database was treated as credible and authoritative, and consumers were left to accept its rates without question. This is like pulling back the curtain on the wizard of Oz. We have now shown that for years consumers were consistently low-balled to the tune of hundreds of millions of dollars.”

The inability to decipher the insurer’s calculations can be overwhelming to patients with serious medical conditions.

Mary Jerome, a professor at Columbia who was found to have ovarian cancer in 2006, said she had been left with unreimbursed medical bills amounting to tens thousands of dollars. Her complaints to the attorney general’s office helped spur the investigation.

Ms. Jerome, who said she had been treated at Memorial Sloan Kettering, in large part because her primary care physician recommended the hospital, expected she would have to pay no more than her $3,000 deductible for going out of network. But she said she had soon been swamped with bills that left her $70,000 to $80,000 in debt.

Karen Ignagni, the president and chief executive of the industry trade group America’s Health Insurance Plans, praised UnitedHealth for its “major leadership effort” in reaching the agreement.

http://www.nytimes.com/2009/01/13/health/policy/13care.html?ref=business&pagewanted=all

The administrative waste of private insurers along with the excessive administrative burden they place on the health care delivery system alone is more than enough to warrant dismissing them as stewards of our health care dollars. A more fundamental moral reason to dismiss them is that they place service to patients in a secondary position to their efforts to achieve business success, frequently using dishonest deception to do so.

A prime example is this instance in which they have engaged in “a scheme to defraud” their own beneficiaries by deliberately falsifying the “reasonable and customary” cost of medical services. This is not simply an accounting trick to keep more money. This is thievery which has a negative impact on their own clients’ financial and physical health.

The experience of Professor Mary Jerome of Columbia demonstrates how nefarious this industry is. She had a $3000 deductible policy and used it at Memorial Sloan Kettering. You would think that this policy would allow her to obtain the care she needed without having to face financial hardship. But, no. She has been “swamped with bills that left her $70,000 to $80,000 in debt.”

Although New York’s attorney general has removed control of this data base from these crooks, they will continue to introduce more innovations that will enhance their bottom lines at the expense of patients and their health care professionals. The explosion in medical debt experienced by insured patients is proof that their innovations have the nefarious intent of defrauding their own beneficiaries.

And what does Karen Ignagni of AHIP have to say about this fraud? She praises UnitedHealth for its “major leadership effort.” Worse yet, what does it say about those controlling our national dialogue on reform when Karen Ignagni is included in almost every major forum, and single payer advocates such as the leadership of PNHP are deliberately excluded?

Do we really value these dishonest businessmen more than we value the health and financial security of our people?

Families USA report on COBRA

Posted by on Monday, Jan 12, 2009

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

Squeezed! Caught between Unemployment Benefits And Health Care Costs

Families USA
January 2009

By November 2008, more than 2.7 million people had joined the ranks of the unemployed since the recession began in 2007, and 10.3 million people were unemployed. Many of those people (and their families) lost their health coverage when they lost their jobs.

Some workers who had insurance through their former employers may be able to continue to purchase the same coverage — but they must pay the full cost out of their own pockets. This continuation coverage, called “COBRA” (from the Consolidated Omnibus Budget Reconciliation Act of 1986), could provide a vital health care lifeline for many families. Unfortunately, for most individuals and families, the cost of this coverage is prohibitively high, especially when compared to average unemployment benefits.

$1278 – Average monthly unemployment income

$388 – Average COBRA premium for an individual
30% – Premium as a share of unemployment income

$1069 – Average COBRA premium for a family
83% – Premium as a share of unemployment income

Conclusion

As our nation faces a severe recession, growing numbers of unemployed workers and their families are coping with the loss of health insurance. The short- and long-term physical and financial consequences of such a loss can be devastating. COBRA continuation coverage can be a crucial health lifeline for newly unemployed workers. But while many workers have the right to purchase such coverage, the cost is often prohibitively high. To make COBRA coverage truly affordable, a meaningful subsidy should be provided to recently unemployed workers. For those who do not have a COBRA coverage option, Congress should provide a temporary Medicaid benefit to recently unemployed, low-wage workers.

http://www.familiesusa.org/assets/pdfs/cobra-2009.pdf

Families USA has continued to be a source of highly credible studies demonstrating the severe deficiencies in health care financing in the United States. A prime example is this study of COBRA benefits. Although the intent of COBRA was to allow individuals and families to maintain their employer-sponsored coverage after losing their jobs, this study demonstrates that this is yet another failed policy as unemployed individuals are unable to pay for that coverage.

Unfortunately, the conclusion of this study also represents yet another inadequate policy recommendation of Families USA. The obvious conclusion is that health insurance must be automatic, for life, and comprehensive enough to prevent financial hardship regardless of income or health status. Instead, Families USA would leave this flawed COBRA program in place, and merely tweak it so that a few of the 46 million uninsured could receive coverage. Temporary Medicaid? Come on!

It is no secret that PNHP and Families USA have had their differences. The leadership of PNHP has demonstrated that a single payer national health program would provide affordable health care for everyone throughout life. The leadership of Families USA has continued to insist that single payer is not feasible, and that reform must occur in incremental steps – increments such as subsidies for COBRA benefits.

We have been following for decades their preferred course of incremental reform, and all parameters are worse. We have an outrageously expensive system with increasing numbers of uninsured and underinsured, and ever greater financial hardship for those individuals and families with health care needs. Of nineteen industrialized nations, we have the worst rate of amenable mortality (premature deaths which are preventable). Incrementalism has been a cruel, miserable policy failure in the United States.

The leadership of Families USA understands this. Thus for the past decade they have supported “strange bedfellow” coalitions, bringing together organizations that traditionally have been at odds on the reform issues. Each of these efforts has been introduced with considerable fanfare, with the obligatory statements from each participating organization to the effect that finally we are coming together to fix our health care system.

What happens? Behind the scene the opponents of reform continue to sabotage the efforts. The opponents are using the reputation of Families USA to burnish their own tarnished images, while gaining additional years before they must face the inevitability of a bona fide national health program.

The opponents will never support a program that is contrary to their selfish interests or their right-wing ideology. NEVER!

For those who believe that we are close to bringing all interests together on reform, think about this. The leading reform proposal is based on private health plans which everyone knows are no longer affordable, and the Republicans will never approve an adequate “tax on the rich” that would be needed to pay for those plans. The supporters also have recommended the creation of a public insurance option which individuals could purchase (even though it wouldn’t be affordable either). Yet the opponents have blasted the proposal because it is an incremental step towards single payer. AHIP, USCOC and some of the Senate Republicans have made it clear that this is a non-starter.

Forget incrmentalism! Forget sleeping with the enemy!

Ronny, sorry, but what you’ve been doing just hasn’t worked. It’s time for you to get up out of that bed and join us in our crusade for the real thing – health care justice for all.

****

Note of Clarification: What is the fundamental disagreement? One side wants an affordable, high-quality health care system that really does include everyone. The other side is opposed, either because of anti-egalitarian ideology or simply because of selfish self-interest. That is where the battle must take place.

The debate over an incremental versus comprehensive strategy for reform has been an unfortunate digression that has splintered one side – the supporters of health care justice. PNHP, Families USA, UHCAN, Healthcare-NOW!, Health Care for All, the HCAN coalition, and all of the other individuals and organizations that share the common goal of health care for everyone must unify in support of truly comprehensive reform that does not compromise on the policies that will get us there. This goal must have precedence above all others and must represent the primary thrust of our efforts.

That does not mean that there is no place for incremental measures. The Children’s Health Insurance Program (SCHIP) is an incremental measure that must be renewed and expanded immediately, but only as an urgent, temporary measure until we can enact a comprehensive program for everyone, including children.

It is absolutely crucial that we all pull together now, pulling out all the stops, especially while we are in this political window. Once we have a comprehensive system, the incrementalists can have a field day tweaking the inevitable glitches in the system.

Commonwealth – analysis of health care bills

Posted by on Friday, Jan 9, 2009

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

An Analysis of Leading Congressional Health Care Bills, 2007-2008

(Part I, Insurance Coverage)

By Sara R. Collins, Ph.D, Jennifer L. Nicholson, and Sheila D. Rustgi
The Commonwealth Fund
January 2009

Overview

This report analyzes and compares leading bills of the 110th Congress aimed at expanding and improving health insurance coverage. Bills and proposals from members of Congress and President-elect Barack Obama include plans to fundamentally reform the health insurance system through mixed private–public approaches that build on our current system; a public insurance option available to the entire population; bills to change the tax treatment of employer benefits; federal–state partnership to provide grants to states to expand coverage; and bills that would expand coverage for children or disabled individuals, among others. Using analysis from the Lewin Group, the authors provide coverage and cost estimates for the proposed bills, which range from 48.9 million uninsured people gaining coverage to a net loss of coverage for 283,000 people; proposals could increase national health spending by as much as $64.1 billion or create savings of $58.1 billion.

Executive Summary:
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=777197

Full report (132 pages):
http://www.commonwealthfund.org/usr_doc/1223_Collins_analysis_cong_bills_2007-2008_part_I_ins_coverage.pdf?section=4039

For those who would like to have a better understanding of the various Congressional approaches to reform, this report is very helpful. The Lewin Group analysis brings reality to the claims being made by the proponents of each approach.

The proposals vary considerably in how effective they are (or are not) in expanding coverage to include everyone. Only one of the proposals evaluated, Representative Pete Stark’s AmeriCare Health Care Act, would be effective in covering everyone. The closest to this would be the Commonwealth (Obama/Baucus) and the Wyden proposals, but they would leave a few million without coverage.

Not only is Stark’s AmeriCare proposal the most effective in expanding coverage, it is also the least expensive in terms of our total National Health Expenditures, actually reducing spending by about $58 billion.

The results are no surprise. Many studies, such as the California Health Care Options Project (a study of nine models of reform) have shown that those models that build on our current system of private and public plans are the most expensive models of reform, and fall short on goals of universality, comprehensiveness, and equity. In contrast, the single payer model and health service model actually accomplish those goals while being the least expensive models of reform (though most Americans would prefer government health insurance to a government-owned health care delivery system).

To be clear, Pete Stark’s AmeriCare is not a single payer model. AmeriCare, an improved and expanded Medicare-like program, would cover 85 percent of us. The existing Medicare program would be improved and cover another 10 percent of us. Qualified employer-sponsored plans would cover 1 percent (yes, only one percent). Dual Eligible and TRICARE would cover the balance. Of the proposals studied, AmeriCare is the closest to single payer, though many single payer advocates would have preferred that Representative John Conyers’ HR 676 single payer bill be included in the analyses.

Perhaps it’s better that it wasn’t since it could have led to a misinterpretation and inevitable misuse of the findings. HR 676 would require that investor-owned providers be converted to not-for-profit status, and that the investors be compensated by public funds at the appraised value of the converted facilities. As only one example, the hospital corporation HCA has a book value of $24 billion. That alone would wipe out close to half of the savings of the Stark proposal.

The importance of this analysis is that, regardless of the politics, it’s the policies that count. Senator Mike Enzi, senior Republican on Senator Kennedy’s Health, Education, Labor and Pensions Committee, says that reform should include the 80 percent of policies on which we agree, and exclude the 20 percent on which we don’t, which is code language for rejecting policies that are not in his plan. His approach, heavily dependent on private plans, is the most expensive of all and yet leaves 22 million people uninsured. He has said, “Forcing private plans to compete with a public program like Medicare, with its price controls and ability to shift costs to private payers, will inevitably doom true competition and could ultimately lead to a single-payer, government-run health care program.”

People are going broke, suffering and even dying, and we continue with academic exercises on ideology-tinged policy options? It’s time to move on beyond the politics of ideology, and finally get into gear with the politics of sound policy. With a health care bill of well over $2 trillion, we need reform that works!

CMS requirements for medical suppliers – a bureaucratic boondoggle?

Posted by on Thursday, Jan 8, 2009

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

Change in law costs medical supply firms

By Karen Shideler
The Wichita Eagle
January 8, 2009

Businesses that provide durable medical equipment, such as hospital beds and bottled oxygen, are being hit by more paperwork and new costs because of new federal requirements.

The Centers for Medicare and Medicaid Services are requiring most durable medical equipment suppliers to post a surety bond of $50,000 and to be accredited.

The federal requirements are, in part, the result of efforts to fight Medicare fraud and abuse. Medicare recently announced that it was revoking billing privileges of more than 1,100 medical equipment suppliers in south Florida and the Los Angeles area after an investigation found about $1 billion in improper payments.

In a news release, CMS acting administrator Kerry Weems said, “We know the majority of medical equipment suppliers and health care providers want to improve the health of Medicare beneficiaries, but we also know there are those who look for any opportunity to take advantage of beneficiaries and Medicare.”

“It’s more work and, let’s face it, it’s money out of our pocket,” said Leon Deaver, owner of Kimzey-Eilert Medical Supplies.

Bruce Schneider, owner and pharmacist at Hart Pharmacy & Home Medical Equipment, estimated the new requirements will cost him $20,000.

Brian Dechant, director of sales at Therapeutic Medical Supply, said the accreditation requirement doubles or triples the amount of paperwork required.

“If you’re running your operations like you should be, it’s not a real big thing,” Dechant said. He said his company was recently accredited for a three-year period. “It requires you to follow a certain set of standards… They review them, make sure everything’s kosher, then they actually look at our processes.”

Schneider said he has seen estimates that 28 percent of medical equipment suppliers nationwide could be out of business a year from now because of the new requirements.

But he and Dechant both said they expected the number in Wichita to hold steady. “We’re generally honest, good people,” Dechant said.

He, Schneider and Deaver all said the new requirements aren’t all bad.

For Schneider, they’ve resulted in some streamlining.

Deaver said they should help assure customers, too.

“We’re taking a very positive attitude, that it will help us do things better,” he said.

http://www.kansas.com/business/health-care/story/655455.html

A frequent complaint about government financing of health care is that government bureaucrats place an excessive administrative burden on the health care delivery system. This charge has already been refuted by studies demonstrating the much greater administrative excesses and waste of the private insurance industry when contrasted with a public program such as Medicare.

Nevertheless, when the government introduces a program to improve value in health care purchasing, such as this program to accredit medical equipment suppliers, howls of protest arise from the anti-government forces. This article on “more paperwork and new costs because of new federal requirements” provides these protesters with more support. Or does it?

It is only natural that honest businessmen who are trying to provide quality products and services would be annoyed with new government requirements. But they understand that the taxpayers should not be expected to pay a billion dollars to crooks that permeate their own industry. They also admit that these new requirements “aren’t all bad,” that they have motivated “some streamlining,” and that they will help “assure customers” of the integrity of this industry that has been given a black eye by the the nefarious element amongst them.

How would the private insurance industry have handled this? Would they have used their very large pool of administrative funds to require accreditation and surety bonds of the suppliers? No. They use their administrative funds to write and market innovative plans that don’t even cover these supplies and services. When they do provide this coverage with premium plans, they burn up more administrative dollars to be sure that they sell these more comprehensive plans only to those healthy individuals who would be less likely to need these benefits. An obvious irony is that these administrative costs for the private insurers are much greater than would be a program of accreditation and surety bonds.

Never fear. As with other Medicare administrative efficiencies, the private insurers will get a free ride by using the Medicare lists of accredited suppliers. Once again, the taxpayer foots the bill, while the private insurers take their spoils to the bank.

UnitedHealth's Evercare

Posted by on Wednesday, Jan 7, 2009

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

Is Texas looking out for you? Health-care outsourcing is rolling on, but many patients suffer from silent treatment

By Gregg Jones
The Dallas Morning News
January 4, 2009

(UnitedHealth’s) Evercare of Texas was supposed to coordinate medical and long-term care for more than 80,000 elderly, blind or disabled North Texans. “We help make it easier to get the care you deserve,” the company promises on its Web site.

For many Texans, it hasn’t worked out that way.

“They ought to call them ‘Nevercare,’ ” said (Mary) Hunt, among the hundreds of people who have complained about denied or delayed medical care.

Evercare’s health management program is just one of a growing list of outsourcing efforts embraced by Gov. Rick Perry and the Texas Legislature as a way to save money while still delivering state-funded care. But rather than providing a surrogate safety net, private contractors have failed needy Texans and taxpayers.

Texas is near the bottom among the 50 states in per-capita spending on health and human services, but it is a leader in outsourcing these functions to private contractors. Since taking office in 2000, Perry has pushed some of the nation’s most ambitious outsourcing endeavors, going well beyond his predecessor, George W. Bush.

“We have a leadership that believes the private sector does things better,” said Celia Hagert, senior policy analyst and privatization expert at the Center for Public Policy Priorities, a nonpartisan research group in Austin.

“Whether it’s ideology or philosophy — simply believing that people shouldn’t be on these programs in the first place — these things have combined to create a very stingy social safety net system in Texas.”

Since 2000, the Texas Department of Insurance has fined UnitedHealth or one of its units seven times totaling more than $10 million for violations involving claims payouts, reporting requirements and other problems.

Texas doctors have long complained about UnitedHealth and its handling of claims under employer-provided insurance plans.

“They’re dishonest, and they’re sneaky,” said Dr. William Walton, a family doctor in North Dallas. “If you’re not really on top of it, you’ll lose lots of money working with United Healthcare.”

The fines haven’t changed UnitedHealth’s way of doing business, he said, adding, “That’s just a cost of business in their eyes.”

http://www.dallasnews.com/sharedcontent/dws/news/texassouthwest/stories/DN-son1mainbar_04pro.ART.State.Edition2.4a74df6.html

So, another ho-hum report on the bad behavior of a private insurer. And more fines that for these insurers are only a nominal and routine part of doing business.

Is this really the way we should be financing care in the United States? Set up rules for the private insurers and then rap their knuckles when they misbehave?

And the next step in reform? Not only more rules and more knuckle rapping for the private insurers, but now new rules and new knuckle rapping for the tens of millions of uninsured individuals who cannot afford to purchase private health insurance.

Does our new political leadership share the fantasies of Bush and Perry that the private insurance sector does things better? Hopefully not, but it’s looking more and more like they do. Establishing a single payer health financing infrastructure would automatically eliminate these perversities. Why has that been taken off the table?

Headlines on slowing in health care spending miss the real story

Posted by on Tuesday, Jan 6, 2009

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

National Health Spending In 2007: Slower Drug Spending Contributes To Lowest Rate Of Overall Growth Since 1998

By Micah Hartman, Anne Martin, Patricia McDonnell, Aaron Catlin the National Health Expenditure Accounts Team – Centers for Medicare and Medicaid Services (CMS) Office of the Actuary
Health Affairs
January/February 2009

In 2007, U.S. health care spending growth slowed to its lowest rate since 1998, increasing 6.1 percent to $2.2 trillion, or $7,421 per person. The health care portion of gross domestic product reached 16.2 percent, up from 16.0 percent in 2006. Slower growth in 2007 was largely attributed to retail prescription drug spending and government administration. With the exception of prescription drugs, most other health care services grew at about the same rate as or faster than in 2006. Spending growth from private sources accelerated in 2007 as public spending slowed; however, public spending growth has continued to outpace private sources since 2002.

http://content.healthaffairs.org/cgi/content/abstract/28/1/246

This annual CMS report on health care spending is being celebrated in headlines throughout the nation as demonstrating a slowing in the growth of health care spending. Such headlines are missing the terrible news in this report.

  • Most health care spending growth did not slow. The overall rate was lower partially due to decreases in drug costs, especially because many block-buster drugs came off of patent, and generic prescribing increased disproportionately. The increase in Medicare spending for 2006 was 18.5 percent, primarily because of the costs of the Part D drug benefit and the higher costs of the Medicare Advantage plans. Increases in Medicare spending for 2007 were still fairly high at 7.2 percent, but the decline from an extremely high percentage increase to a high percentage increase may be a decline in the rate of increase, but is still a very large increase. Next year’s report on the rate increases for 2008 likely will not reflect these downward distortions.
  • Even with the downward adjustments, the overall rate of increase was still 6.1 percent, well in excess of the rate of inflation. A smaller increase over the rate of inflation cannot be interpreted as good news when the problem of increased costs is growing progressively worse.
  • A very small but extremely important number in this report is that the percent increase in health care as a portion of our gross domestic product (GDP) was 0.2 percent, an increase from 16.0 percent to 16.2 percent. How can you celebrate a decline in the rate of increase in costs when those costs continue to encroach on our other spending?

Health care spending is in a crisis mode, and it only gets worse. Congress and the administration must act, but what do they intend to do? They are going to enact laws and regulations requiring us to give money to the private insurance industry to act as stewards of our health care dollars.

Yes, the insurers will be told to do a good job (through regulation), and when they fail (which they will), what will be their response? The same as now: Doctors and patients and hospitals and drug firms and tech firms keep running up the costs, and we can’t do anything about it.

Well, they’re right; they can’t. But the people can, by convincing Congress to enact our own single payer national health program – a program through which we can demand greater value in our health care purchasing.

Another middleman, with a Donald Trump wig!

Posted by on Monday, Jan 5, 2009

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

Dallas’ American CareSource sees stock jump 120% in 2008

By Jason Roberson
The Dallas Morning News
January 2, 2009

American CareSource is the nation’s first publicly traded ancillary care network company. The company basically serves as a middleman, connecting payors, such as insurers, with the providers of such services as lab work and diagnostic imaging.

Ancillary services now represent 30 percent of health care expenditures, valued at $574 billion annually, according to U.S. Center for Medicare and Medicaid Services.

While most insurers can handle the 70 percent of health care dollars that go to hospitals and physicians, the largest insurers form networks with ancillary services. That’s where American CareSource comes in.

American CareSource targets smaller insurers, unions and employers that aren’t able on their own to purchase ancillary services in bulk.

(American CareSource) bills itself as a cost-saver to both payors and ancillary providers. It acts as the providers’ advocate by collecting hard-to-get payments from insurance claims; it serves as the insurers’ advocate by offering lower costs than they could get on their own.

“In some ways, we want to be the Wal-Mart or Target of health care,” said David Boone, CEO of American CareSource.

He maintains a small-company management style. Whenever a new client is secured, an old ship’s bell is rung in celebration. When the company hit $1 million in profit, Boone, as promised, strutted in the middle of the office and proceeded to do a “money dance,” wearing a Donald Trump wig, a comical green jacket and hat of dollar bills.

http://www.dallasnews.com/sharedcontent/dws/bus/stories/010309dnbuscaresource.38426b8.html

As long as we insist that health care continue to be financed through our dysfunctional, fragmented multi-payer system, we will continue to see more innovative middlemen organizations capturing and siphoning away dollars that should be directed to health care instead.

Now we have a for-profit, publicly-traded entity that adds an additional, expensive administrative layer between the health plans and the providers of ancillary services. American CareSource provides no health care products or services – only more administrative waste.

I don’t know about you, but I’ve grown weary listening to those who say that single payer advocates have failed to demonstrate that a single payer system would bring us more than only nominal, one-time savings in administrative costs. Go to the PNHP website (www.pnhp.org) and type in “administrative waste” in the search window at the top of the opening page, but be prepared to spend a lot of time.

Massive, middlemen administrative waste permeates our entire health care system. It is not limited to the excesses of the private insurance industry, though that industry is a major contributor, both directly in its own costs, and indirectly by the burden placed on the health care delivery system. There are a great many other innovative administrative organizations involved, often subsidiaries of the insurers.

These same individuals who discredit the potential for recovering administrative waste also fail to mention the other benefits of single payer such as true universality, equity, efficiency, improved value in health care purchasing, and humane methods of cost containment.

But I have to hand it to David Boone, CEO of American CareSource. What could be more appropriate for this entrepreneurial middleman organization than celebrating success with a ship’s bell, a Donald Trump wig, and a hat stuffed with dollar bills? How fitting!

This should inspire the insurance industry’s AHIP. When Congress passes health care reform based on private health plans, AHIP can pass out the Donald Trump wigs with the hats stuffed with money. But the bell? Shipping in that bell from Philadelphia won’t do since it has a crack in it. That’s okay. Piping in the opening bell of the NYSE would much more befit the occasion anyway.

Student Debt, Resident Hours, and Primary Care

Posted by on Friday, Jan 2, 2009

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

Student Debt, Resident Hours, and Primary Care Redux

By Josh Freeman
Medicine and Social Justice (A Blog)
January 2, 2009

The December 18, 2008 issue of the New England Journal of Medicine includes Perspectives on 3 topics that have been previously addressed on this blog: Medical student debt (Dec 14), resident duty-hours (Dec 3, 9), and the future of primary care (Dec 11).

The piece on “Medical Student Debt — Is there a Limit?” by Robert Steinbrook presents data on the extraordinary rise in tuition, and debt, among medical students, most surprisingly in the public medical schools. “For the current academic year, tuition, fees, and health insurance at private medical schools range from $15,278 (for Texas residents) or $28,378 (for non-residents) at Baylor University to $51,969 at Tufts University in Massachusetts and $52,236 at Temple University (for nonresidents of Pennsylvania — state residents are charged at $43,232.” While tuition rates at private medical schools are generally higher than at public, the non-resident tuition at public schools is about the same as that of the privates, and the rate of rise (percent change) in the last 10 years at public schools has far exceeded that at private schools (100% vs 50% increase). Indebtedness ranged from an average (high is different) of $80,000 to $163,000 at public schools, and $70,000 to $182,000 at private schools. Some schools give significant tuition scholarships, but others are more challenged: Stanford’s endowment allows it to give a far larger number of scholarships relative to loans than does, say Drexel. More important, the article points out that the high debt burden may discourage lower-income students from applying to medical school, and to enter specialties with higher income potentials. “It is not surprising that a recent analysis showed a ‘strong direct correlation’ between higher mean salary in a specialty, such as orthopedic surgery or radiology, and the percentage of residency positions filled by US graduates.” The piece says that there is no easy solution, and probably there is not. But most countries have very low medical school tuitions, but require national service of their graduates.

“Revisiting Duty Hour Limits — IOM Recommendations for patient safety and resident education” by John Iglehart, discusses that topic in a balanced way. It points out the acknowledgment in the IOM report that “Although some might propose further reductions in total duty hours, the report notes, ‘evidence suggests it is an indirect and inefficient approach given the moderate correlation that exists between resident duty hours and sleep time.'” Igelhart also notes that “the 2003 limits on duty hours have resulted in an increase in handoffs of patient care between physicians — transitions associated with increased risks to patient safety.” I have discussed this at length, but I did note that this article includes a table with a recommendation I had missed — that internal and external moonlight be counted against the 80-hour per week limits. I have no difficulty with that conceptually, as it makes perfect sense — what is the point of limiting work hours in the residency if residents can moonlight for extra money in an unrestricted fashion? — but I wonder about the legal ability of program directors to restrict the moonlighting activities of their residents in their off hours.

“The Future of Primary Care — the Community Responds” involves a followup to a series of opinion pieces and a roundtable discussion with Drs. Thomas Bodenheimer, Barbara Starfield, Katharine Treadway, Allan Goroll, and Thomas H. Lee that appeared in the November 13, 2008 issue. The comments, and responses from the roundtable participants, are salient and generally useful. Several writers noted the role of physician assistants, and one (Paul Lombardo) states that “Patients, and the U.S. health care system as a whole, would be better served if the content of and level of primary care education were better matched to the needs of patients. The physician assistant (PA) model of medical education, with its emphasis on physician-physician assistant teams, needs to be expanded.”

These are all thorny, and not unrelated, issues. What is the relationship between resident work hours and physician’s assistants? Well, someone has to do the work. Since residents, even with the 80-hour restriction, work twice as many hours as do physician’s assistants, for about half the salary, and have a greater scope of practice, it would be incredibly expensive for hospitals to replace resident labor with that of physician’s assistants, not to mention physicians. As hospitals complain about the “cost” of resident education, this needs to be kept in mind; they are much better at accounting the cost than the benefit. Even if a hospital closes its residencies because it assesses the costs are greater than the benefit, this usually includes the fact that the residents care for many medically indigent patients, and you can be sure that the hospitals are planning to no longer care for them at all, not to pay someone else to do it. This, of course, again decreases access for the most needy.

I have repeatedly said that the nucleus of a solution is a comprehensive national health program, which includes a single-payer and a system that is tasked with ensuring the health and access to quality health care of all Americans. With such a system, addressing issues such as resident work hours, medical student debt, and the composition of the physician (and NP and physician assistant) workforce could be feasible; without it, they all remain insoluble because they all depend upon each other.

(Joshua Freeman, M.D. is Professor and Chair of the Department of Family Medicine at the University of Kansas School of Medicine, though the comments in this blog are his own. He does understand his topic: http://www2.kumc.edu/fammed/Chairman.htm)

http://medicinesocialjustice.blogspot.com/2009/01/student-debt-resident-hours-and-primary.html

Josh Freeman’s comments were selected to start off this year of reform (hopefully) because they set the theme that reform should not be simply about tweaking private and public insurance options; reform needs to be about fundamental restructuring of our health care financing and delivery systems.

Single payer is frequently conceived of as simply an administrative system of collecting funds for health care through an equitable system that is designed to include everyone. Well, it is that, and that would be a great improvement over the dysfunctional, fragmented, inequitable, and inadequate system that we have.

But there is the other side to single payer: spending. Imagine having two and a half trillion dollars under the control of our own single, public purchaser of health care – a monopsony. Scary? Well, yes, but not when you compare it to the horrendously frightening system that we now have – a system which the policy makers in Washington unbelievably wish to expand.

Our current system bankrupts and even kills people. With our own public single payer system the funds would be used to save lives, preserve health, and prevent financial hardship in the face of medical need. Professor Freeman is right on target when he says, “the nucleus of a solution is a comprehensive national health program, which includes a single-payer and a system that is tasked with ensuring the health and access to quality health care of all Americans.” Otherwise our problems “all remain insoluble because they all depend upon each other.”

If we expect someday to have an efficient, high-performance health care system for all of us, repairing and expanding our primary care infrastructure is not an option; it’s an absolute necessity.

Health economists: Their facts, but our values

Posted by on Wednesday, Dec 31, 2008

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 Economists’ Views of Health Policy

By Michael A. Morrisey and John Cawley
Journal of Health Politics, Policy and Law
August 2008

This article reports the views of a national survey of U.S. health economists on a series of questions ranging from mergers among health care providers to the profits of pharmaceutical manufacturers to fundamental health care reform. We find a high degree of agreement on issues of fact but considerable disagreement on issues that depend on values.

Issues of Fundamental Disagreement

Arguably the most divisive statement in our entire survey was, “The United States should adopt a Canadian-style system of universal and compulsory health insurance.” Of U.S. health economists, 47 percent agreed that the United States should adopt such a system. What makes the responses to this question so divided is the fact that the entire range of answers is used; 22 percent strongly agreed, 25 percent agreed, 21 percent disagreed, and 22 percent strongly disagreed. The nearly uniform spread of answers is unique; for all other issues reported, answers tend to be concentrated around the middle (agree or disagree) with few responses in the extreme tails (strongly agree, strongly disagree). Moreover, only 10 percent responded that they didn’t know, which is among the smallest response in that category to any question.

http://jhppl.dukejournals.org/cgi/content/abstract/33/4/707

Almost all of us want 2009 to be the Year of Health Care Reform. Almost all of us agree on the facts. We agree not only on what the deficiencies are in our health care financing and delivery systems, but we also largely agree on what the impact would be of various public policies that might be enacted during the reform process.

But the debate isn’t about facts; it’s about values! Just think about the strongly held values on the two sides of the debate over whether or not “the United States should adopt a Canadian-style system of universal and compulsory health insurance.”

Many of us can speak to one side of that debate. We want a health care system that can provide high-quality care for everyone at a cost that we can afford, both individually and collectively. An improved Canadian-style single payer system would do that. Those strongly opposed to single payer have not provided us with any model that would come close to all of those goals.

If the other side doesn’t share our specific goals, then what values do they support? Perhaps it’s unfair to try to describe their values since there is such an intense disagreement, but we can parrot some of their published statements on their values.

Many support the concept of individual responsibility. Each individual should be responsible for acquiring the means to obtain whatever products or services they desire, including health care. For those who are truly incapable, minimal basic services can be provided by private charity or by public safety-net welfare programs. For average-income individuals who can no longer afford health care, it is their responsibility to make choices – either a choice to advance themselves so they can afford care, or a choice to reduce other spending such as on rent, transportation, education or other less essential products or services, or simply to do without health care.

Many oppose wealth transfer, especially in the form of progressive taxes. They believe that those who have achieved great wealth should be allowed to keep it, and those who haven’t should simply make do. Wealth should not be confiscated by the government simply because tens of millions of individuals are not capable of paying for health care that they might need. In their view it is morally just that society be stratified, richly rewarding the producers.

Many passionately support the concept of freedom, meaning “free exercise of the natural right of sole dominion over their own lives, liberty and property,” relegating government to a minimal, custodial role. They specifically reject the United Nations Universal Declaration of Human Rights, which states, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.”

They value greatly the entrepreneurial spirit of the private marketplace that brings us wealth-creating insurance company middlemen, and an abundance of expensive technologies that shift the profit/benefit ratios ever upward. To them, private business success has a priority over public social policies.

Freedom, entrepreneurialism, and individual responsibility are values that are not the exclusive domain of the opponents of single payer, for we all share them. The disagreement is in how we value public policies that make these concepts work for all of us. We need freedom – freedom to chose our health care professionals – a freedom that the insurers have taken away from us. We need entrepreneurialism to provide us with better technology – but technology that meets the test of value. We need to exercise our individual responsibility to take care of ourselves – but along with our responsibility to support public policies that will enhance the health of all of us.

Princeton health economist Uwe Reinhardt has said that we can do this. The facts are easy. You tell us your values and then we can design a health care system that matches them. The question is, whose values will Congress and the Obama administration honor?

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