Administrative burden on U.S. physicians

Posted by on Thursday, Oct 23, 2014

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.

Administrative Work Consumes One-Sixth of U.S. Physicians’ Working Hours and Lowers Their Career Satisfaction

By Steffie Woolhandler and David U. Himmelstein
International Journal of Health Services, Volume 44, Number 4 / 2014


Doctors often complain about the burden of administrative work, but few studies have quantified how much time clinicians devote to administrative tasks. We quantified the time U.S. physicians spent on administrative tasks, and its relationship to their career satisfaction, based on a nationally representative survey of 4,720 U.S. physicians working 20 or more hours per week in direct patient care. The average doctor spent 8.7 hours per week (16.6% of working hours) on administration. Psychiatrists spent the highest proportion of their time on administration (20.3%), followed by internists (17.3%) and family/general practitioners (17.3%). Pediatricians spent the least amount of time, 6.7 hours per week or 14.1 percent of professional time. Doctors in large practices, those in practices owned by a hospital, and those with financial incentives to reduce services spent more time on administration. More extensive use of electronic medical records was associated with a greater administrative burden. Doctors spending more time on administration had lower career satisfaction, even after controlling for income and other factors. Current trends in U.S. health policy—a shift to employment in large practices, the implementation of electronic medical records, and the increasing prevalence of financial risk sharing—are likely to increase doctors’ paperwork burdens and may decrease their career satisfaction.

From the Discussion

A few studies have examined the amount of time physicians spend on billing and insurance-related paperwork—a narrower definition of administrative work than we used. A 2000 California study estimated billing and insurance-related work consumed 4.9 percent of physician time. In a 2006 survey, physicians reported spending 3 hours per week interacting with private insurance plans, with primary care doctors and solo practitioners reporting slightly higher figures; 81.5 percent perceived that this work was increasing. A companion 2006 survey of office-based private practitioners in Ontario found they spent 2.2 hours per week interacting with insurers (vs. 3.4 hours in the United States when Medicare and Medicaid were included along with private insurers). Differences in the time spent on these tasks by non-physician office staff were even larger; 20.6 hours of nurse time per physician in the United States versus 2.5 hours in Canada; 53.1 hours per week of clerical time in the United States versus 15.9 hours in Canada; and 3.1 hours per week of senior administrators’ time in the United States versus 0.5 hours in Canada.

Much time and money are currently spent on medical billing and paperwork. A simpler system could realize substantial savings, freeing up more resources to expand and improve coverage.

International Journal of Health Services (click on the article for the abstract):

Full article:

PNHP Press Release:…

The health care system in the United States is unique for its profound administrative waste. This article by Steffie Woolhandler and David Himmelstein demonstrates the intensity of the administrative burden on physicians – a burden that is correlated with lower career satisfaction.

The good news is that we could reduce that burden and improve satisfaction by adopting a single payer system such as they have in Canada. But then the bad news is that we have left the political agenda in the hands of those who are adept at buying the votes in Congress – especially the insurance and pharmaceutical industries.

It doesn’t have to be this way. After all, we are a democracy, but we have to make the effort to have our voices heard.


Bureau of International Information Programs, U.S. Department of State

What Is Democracy?

The essence of democratic action is the active, freely chosen participation of its citizens in the public life of their community and nation. Without this broad, sustaining participation, democracy will begin to wither and become the preserve of a small, select number of groups and organizations.

At a minimum, citizens should educate themselves about the critical issues confronting their society–if only to vote intelligently for candidates running for high office.

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Important: Uwe Reinhardt on health care price transparency and economic theory

Posted by on Wednesday, Oct 22, 2014

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

Health Care Price Transparency and Economic Theory

By Uwe E. Reinhardt, PhD
JAMA, October 22/29, 2014

Citizens in most economically developed nations have health insurance coverage that results in only modest cost sharing at the time health care is used. Furthermore, physicians, hospitals, and other clinicians and entities that provide health care within most systems outside the United States are paid on common fee schedules uniformly applied to all clinicians, health care organizations, and insurers. That approach spares the insured the need to seek out lower-priced health care and obviates the need for transparency on the prices charged by individual clinicians and organizations that provide health care.

Not so in the United States, where every private health insurer negotiates prices with every health care practitioner and organization, where large public health insurance systems such as Medicaid and Medicare pay fees that do not cover the full cost of treating patients covered by these programs, and where uninsured, self-paying patients can often be asked to pay whatever can be extracted from their household budgets, sometimes with the help of debt collectors and the judiciary. Economists call the approach price discrimination, which means the identical service is sold to different buyers are different prices.

This approach to pricing health care has led in the United States to a system in which, at one end of the spectrum, hospitals and physicians are expected by society to treat low-income patients free of charge, on a charitable basis, or for modest fees that do not cover the cost of those treatments and then to finance that informal catastrophic health insurance system for the poor out of the other part of their enterprises that they can operate as profit-maximizing business firms. This is true even in some of the large segment of institutions referred to as not-for-profit. The harsh excesses that this quest for profits in health care can unleash—even among not-for-profit hospitals—have been well reported in various articles in the popular press.

Private employers in the United States have played a pivotal role in the evolution of this system. They hired as their agents in health care the private insurers who helped put that system into place, and they supported it. To gain better control over the growth of their health spending, employers have of recent resorted to a technique long recommended to them by the market devotees among health economists, namely, putting the patient’s “skin in the game,” as the jargon goes. It is done with health insurance policies imposing on the insured very high annual deductibles before insurance coverage even begins, followed by significant coinsurance, perhaps requiring patients to pay 10% to 20% of every medical bill, up to a maximum total annual out-of-pocket expenditure that can potentially exceed $10 000 for a family.

This approach of shifting more of the cost of employment-based health insurance visibly and directly into the household budgets of employees amounts to rationing parts of US health care by price and ability to pay and delegates the bulk of the hoped-for belt-tightening to low-income families. Because the word rationing is anathema in the US debate on health policy, the strategy has been marketed instead under the felicitous label of consumer-directed health care, presumably designed to empower consumers in the health care market to take control of their own health care. However, this strategy, based mainly on economic theory, so far has put the cart before the horse.

In virtually all other areas of commerce, consumers know the price and much about the quality of what they intend to buy ahead of the purchase. This information makes comparison shopping relatively easy and is the sine qua non of properly functioning markets. By contrast, consumer-directed health care so far has led the newly minted consumers of US health care (formerly patients) blindfolded into the bewildering US health care marketplace, without accurate information on the prices likely to be charged by competing organizations or individuals that provide health care or on the quality of these services. Consequently, the much ballyhooed consumer-directed health care strategy so far has been more a cruel hoax than a smart and ethically defensible health policy.


Association Between Availability of Health Service Prices and Payments for These Services

By Christopher Whaley, BA; Jennifer Schneider Chafen, MD, MS; Sophie Pinkard, MBA; Gabriella Kellerman, MD; Dena Bravata, MD, MS; Robert Kocher, MD; Neeraj Sood, PhD
JAMA, October 22/29, 2014


Use of price transparency information was associated with lower total claims payments for common medical services. The magnitude of the difference was largest for advanced imaging services and smallest for clinician office visits.

In a JAMA editorial commenting on an article about price transparency and health care spending, Uwe Reinhardt first describes the ridiculous system we currently have, concluding, “the much ballyhooed consumer-directed health care strategy so far has been more a cruel hoax than a smart and ethically defensible health policy.”

He then discusses the article by Christopher Whaley and his colleagues in which they describe price savings resulting from health care price shopping: an average of a mere $1.18 for clinician office visits, $3.45 for laboratory tests, and a more impressive average savings of $124.74 for advanced imaging services.

Imaging aside, think about that one dollar saved by shopping office visit prices. Does that one dollar really pay for the labor involved in price shopping, much less the additional transportation costs and other inconveniences of going to a different doctor, not to mention the disruption in care provided by a primary care medical home? Not exactly a shopper’s paradise.

Even the more significant savings in advanced imaging can have drawbacks if it results in non-coordinated care outside of a system functioning as an integrated unit, whether or not it is technically a single integrated health care entity.

But what is really important here lies in Uwe Reinhardt’s comments. As he states, “other clinicians and entities that provide health care within most systems outside the United States are paid on common fee schedules uniformly applied to all clinicians, health care organizations, and insurers. That approach spares the insured the need to seek out lower-priced health care and obviates the need for transparency on the prices charged by individual clinicians and organizations that provide health care.”

Other nations pay the right amount to sustain he system, without the waste of overpaying some nor the threat of inequitable access caused by underpaying others. No matter how much price transparency we have in the United States, our highly dysfunctional, fragmented system of financing health care will never get pricing right.

Yes, we need a single payer national health program. Under such a system the pricing would be transparent to our public administrators, and who better could determine whether or not the price is right? We surely can’t.

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Pharmacy benefit managers moving to narrow networks?

Posted by on Tuesday, Oct 21, 2014

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.

CVS Smoke-Free Pharmacy Benefit Excludes Tobacco-Selling Rivals

By Bruce Japsen
Forbes, October 20, 2014

CVS Health (CVS) confirmed its Caremark pharmacy benefit management subsidiary would sell a smoke-free drugstore network to employers and health plans that would provide subscriber discounts for using “tobacco-free” pharmacies.

The move, which would benefit CVS Health pharmacies given the company’s decision to stop selling tobacco, could at the same time hurt rivals like Walgreens, Wal-Mart and others because a health plan subscriber that would use pharmacies outside the Caremark smoke-free network would pay higher co-payments and related cost-sharing.

CVS Health is able to exact some control on customer choices of prescription purchases through its Caremark pharmacy benefit management (PBM) subsidiary, which has contracts with CVS pharmacies as well as myriad other drugstore chains and independent pharmacies.

“Following our announcement that we would no longer be selling tobacco at CVS/pharmacy, a number of our pharmacy benefit management clients approached us about developing a tobacco-free pharmacy network,” Carolyn Castel, vice president of corporate communications at CVS Health said in an e-mailed statement to Forbes.

“As a result, CVS Health is in the process of identifying pharmacies that do not sell tobacco products to participate in such a new offering. We look forward to making this new pharmacy network available to our clients who choose this offering and providing their plan members with an option to select a tobacco-free environment for their prescription fulfillment needs.”

The Wall Street Journal’s Pharmalot blog reported CVS Health’s Caremark PBM would require a co-pay of “up to $15,” but CVS Health wouldn’t confirm any specifics on a cost-sharing structure.

It’s believed to be a first, according to health benefits analysts who see CVS Health’s move as a narrow network strategy, which is becoming more common from insurance companies and pharmacy benefit managers.

Insurers and benefit managers can better control costs by limiting plan subscriber choices to a smaller group of medical-care providers. By limiting choices, insurers say they can better focus on quality of medical care that is delivered to plan customers.…

Last month CVS announced, with considerable fanfare, that it would discontinue sales of tobacco products at its drugstores – a move that would cost it $2 billion in annual sales. After a month-long publicity campaign touting its altruistic action in support of a healthier America, we learn of the not-so-noble purpose of their decision.

They are claiming that in response to this move, numerous pharmacy benefit manager (PBM) clients approached them to request that they develop “a tobacco-free pharmacy network.” Sure they did. One month ago, they announced the end of tobacco sales one, but making that announcement one month ahead of their intended schedule. By splitting the announcements, they a get a twofer: favorable publicity for ending tobacco sales, and then publicity for a new PBM program that would allow them to “focus on quality of medical care” by selling drugs in a tobacco-free environment (as if there were a difference in identical pills sold in their tobacco-free stores versus the stores of their competitors that still carried tobacco products).

They are clearly being dishonest when that say that this concept arose only as an afterthought when their PBM clients suggested that it would be a good idea to segregate tobacco-free chains in their PBM plans. Obviously this was a carefully thought out marketing plan. Tobacco-free was a ruse. Their obvious deception in their releases should make us question the integrity of their entire organization.

So what are they really doing? Two of the most important moves in health insurance products have been to shift more costs to the consumers (whom we call patients) and to establish narrow networks that are anti-competitive, benefiting the insurer financially. CVS now owns one of the nation’s largest PBMs: Caremark.

What they are doing is to establish a narrow network of tobacco-free pharmacies (primarily CVS) which will be dominated by CVS’s own Caremark PBM. If the customers (patients) obtain their prescriptions outside of their narrow network, they will be required to pay larger out-of-pocket costs. Wow! With their own PBM they are introducing the health insurer innovations of higher patient cost-sharing and narrow networks. We’re screwed again!

How would it be under single payer? We would have a national formulary that included all appropriate medications. Pharmaceuticals would be priced properly through bulk purchasing and other forms of administered pricing, and they would be paid for through equitable public financing. There would be no crooks controlling the gates that would otherwise impair access to the medications that we need.

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Covered California demonstrates the administrative complexity in renewing exchange plans

Posted by on Monday, Oct 20, 2014

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

California spends $13.4 million to fix Obamacare service woes

By Chad Terhune
Los Angeles Times, October 17, 2014

California’s health insurance exchange hired two outside firms for $13.4 million to address long wait times for consumers calling about their Obamacare coverage.

“We had call response times that were far too long,” said Peter Lee, the exchange’s executive director. “We were swamped.”

Lee said the exchange is nearly doubling its service-center staff to 1,300 to help more than 1 million Californians renew their health-law policies by Jan. 1. The first batch of renewal notices for 2015 went out this week.

Covered California said more than 200,000 people have signed up for Obamacare coverage since regular enrollment ended in April under the Affordable Care Act.

But in a sign of the churn in the individual insurance market, an additional 150,000 people dropped out of the exchange after getting health benefits at work or failing to pay their premium.

People who move, lose their employer coverage or have some other qualifying event in their life can enroll outside the normal sign-up period.

Overall, Covered California said it has 1.1 million people enrolled now, down from its previous tally of 1.2 million.

Part of that was because the exchange said 81% of enrollees paid their initial premium compared with its earlier estimate of 85%.…

When the Affordable Care Act (ACA) was being crafted, it was almost as if the designers thought that they were developing a relatively static system. They would simply cover the lowest-income individuals with Medicaid, make available subsidized private plans for moderately-low-income individuals, and then use individual and employer mandates, under threat of penalty, to force the rest of the uninsured into private plans. Although a limited amount of churning in and out of various plans and programs was expected, what they did not seem to understand was how unstable these categories actually are. The churning is massive.

California’s health insurance exchange – Covered California – provides an example of only one part of the churning – that within the exchanges. Just look at some of the numbers:

*  The 1.2 million enrolled in Covered California dropped to 1.1 million, though the instability is much more than the 100,000 difference

*  After open enrollment ended, 200,000 more enrolled in the several months following, allowable only because they had some qualifying event that changed their eligibility status

*  Only 81 percent of enrollees paid their initial premium, so the other 19 percent were dropped

*  150,000 dropped out of the exchange for reasons such as gaining health benefits at work, or failing to pay the premium for the exchange plans

*  1,300 Covered California staff members are required to help about 1 million Californians renew their coverage

Although this amount of churning did not seem to be expected by the designers of ACA, it was thought that at least those remaining in the exchanges would have stable coverage – a static situation for them. No, not really. Because of the variable bids of the private insurers, the benchmark plan – the second lowest cost silver plan – is changing for many exchange participants. Since most premiums are going up, not down, the change in the benchmark plans will change the portion  of the premium for which most of the exchange enrollees will be responsible. To keep their share of the premium lower, many will have to change plans. That means that they will have to shop not only the premiums but also shop the amount of the deductibles, and, as if that weren’t enough, they will have to shop the provider network lists which have been notorious for their inaccuracies, if you can even find a list. Even if the provider lists were accurate, they too are not a static as these lists continue to change as well, with providers moving onto and off of the lists.

If nothing changes, enrollees can accept automatic renewal. That means that nothing could have happened that would change eligibility – no change in employment, income, residence, family size, etc. Also it means that the insurer must be offering the same plan, and yet we know that plan designs change frequently. Nevertheless, everyone enrolled through the exchange plans should enquire as to their options for next year if for no other reason than that the benchmark plan will likely have changed, changing the amount of the premium they will have to pay. Some patients may be dismayed that shopping for premiums may cause them to lose their established health care providers.

There are about 1.7 million Californians who are eligible for coverage but who remain uninsured. This does not count the undocumented. For both logistical and administrative reasons, this will be a more difficult group to insure. Combine this with the fact that perhaps 1 million people already enrolled in Covered California will have to revisit their options means that the task will inevitably necessitate extensive administrative services.

And next year? This static system is not so static after all. And remember that here we are discussing only the administrative hassles of the exchanges. This does not count all of the hassles with Medicaid, employer-sponsored plans, private plans purchased outside of the exchanges, and the administrative nightmare of determining which of the uninsured must pay penalties, how much they must pay, and how the penalties are to be collected when they are linked to income tax refunds.

Suppose we had a single payer national health program. This annual renewal, with all of the administrative costs, hassle, and especially the grief, disappears. Why is nobody in power seriously considering an improved Medicare for all?

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Complexity of the 90 day grace period for paying exchange plan premiums

Posted by on Friday, Oct 17, 2014

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

The Ninety-Day Grace Period

Health Affairs, Health Policy Briefs, October 16, 2014

To help enrollees new to the system keep their insurance, the ACA provides a ninety-day grace period before an insurer can discontinue someone’s coverage for failure to pay a monthly premium. This applies only to those who have received an advance premium tax credit to purchase health insurance through the Marketplaces and have previously paid at least one month’s full premium in that benefit year.

The grace period allows for continuity of care for patients by preventing people from shifting or “churning” in and out of coverage when they fail to make a monthly premium payment.

In final regulations, CMS said issuers must pay all appropriate claims for medical services rendered to the enrollee during the first month of the grace period, and the insurer may put on hold claims for services rendered to the enrollee in the second and third months. Issuers must also notify HHS of such nonpayment and notify providers of the possibility for denied claims when an enrollee is in the second and third months of the grace period.

During these second and third months of the grace period, because the patient is still insured, he or she cannot be billed by the provider for any remainder that is owed for medical services that the enrollee received. But if an enrollee fails to pay his or her premiums and the entire grace period elapses, providers are allowed to seek payment for the medical services they gave to that patient and for which the insurance company did not reimburse claims.

Patient assistance programs: Some providers have expressed interest in providing premium and cost-sharing assistance for their patients enrolled in coverage through the Marketplaces. By helping their patients maintain coverage and avoid the grace period in the first place, providers hope to reduce the risk that medical claims for care they provide will go unpaid.

However, questions continue to swirl about the legality of such an approach. Although federal anti-kickback regulations might seem to prohibit this type of practice, HHS has stated that such regulations do not apply to the Marketplaces, their plans, and premium tax credits because they are not considered “federal health care programs.”

The ACA’s uniform grace period could prove to play an important role in keeping people enrolled in their plans. But big questions remain unanswered about the financial risks to which physician practices or hospitals could be exposed, as well as how much risk insurers face for claims in the grace period and how that might affect premium growth for all enrollees over time.

The Affordable Care Act provides a 90 day grace period during which health care coverage through exchange plans is continued before insurers can cancel the plans for non-payment of premiums. However, the insurers must pay claims for only the first 30 days, whereas providers are not allow to collect from the patient during the remaining 60 days. After 90 days of nonpayment of premiums, the patient can be retroactively billed, though collection can be difficult since most of these patients do not have enough funds to pay their premiums, much less their health care bills.If you read the full Health Policy Brief, you will see that the issues are even more complex. The 90 day rule is yet one more unnecessary administrative burden that ACA added to our already highly complex system of financing health care. Under a single payer system there would be no such thing as a 90 day grace period. Financing of the health care system would be as automatic as it is now with Medicare.

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Will malpractice reform prevent “defensive medicine”?

Posted by on Thursday, Oct 16, 2014

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

The Effect of Malpractice Reform on Emergency Department Care

By Daniel A. Waxman, M.D., Ph.D., Michael D. Greenberg, J.D., Ph.D., M. Susan Ridgely, J.D., Arthur L. Kellermann, M.D., M.P.H., and Paul Heaton, Ph.D.
The New England Journal of Medicine, October 16, 2014

Emergency department care has been a particular focus of a new generation of malpractice reform laws. Approximately a decade ago, the states of Texas (in 2003), Georgia (in 2005), and South Carolina (in 2005) changed their malpractice standard for emergency care to “willful and wanton negligence” (in Texas) and “gross negligence” (in Georgia and South Carolina). From a legal standpoint, these two standards are considered to be synonymous and are widely considered to be a very high bar for plaintiffs. Under typical interpretations of this standard, a plaintiff must show that a physician had “actual, subjective awareness” of “the likelihood of serious injury” but nevertheless proceeded with “conscious indifference.”

The Texas, Georgia, and South Carolina laws are intended to protect physicians who are practicing with incomplete information in high-intensity care settings. The enactment of these laws offers an unusual circumstantial experiment with which to evaluate a type of reform that is qualitatively different from what has been studied previously.

Study Design

We used a quasi-experimental analytic approach that was designed to evaluate the effect of legal reform on the treatment of Medicare patients in the emergency department; we attempted to isolate the effect of the law from temporal trends and from characteristics of patients and hospitals (i.e., to evaluate changes that could be attributable to the new policy).


Malpractice reform was not associated with a significant decrease in CT or MRI utilization in any of the three states. There was no significant reduction in per-visit emergency department charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction (95% confidence interval [CI], 0.9 to 6.2; P=0.01) in charges. There was no reduction in the rate of hospital admissions in any of the three states.


Malpractice reforms in Texas, Georgia, and South Carolina, which changed the liability standard for emergency care from ordinary negligence to gross negligence, provide unusually broad protection for emergency physicians. We did not find evidence that these reforms decreased practice intensity, as measured by the rate of the use of advanced imaging, by the rate of hospital admission, or in two of three cases, by average charges. Although there was a small reduction in charges in one of the three states (Georgia), our results in aggregate suggest that these strongly protective laws caused little (if any) change in practice intensity among physicians caring for Medicare patients in emergency departments.

In the context of the existing literature, our findings suggest that physicians are less motivated by legal risk than they believe themselves to be. Although a practice culture of abundant caution clearly exists, it seems likely that an aversion to legal risk exists in parallel with a more general risk aversion and with other behavioral, cultural, and economic motivations that might affect decision making. When legal risk decreases, the “path of least resistance” may still favor resource-intensive care. Our results suggest that malpractice reform may have less effect on costs than has been projected.

When the topic of controlling health care costs comes up, those opposed to single payer reform, and, for that matter, opposed to the Affordable Care Act, frequently cite the need for malpractice reform, often claiming that defensive medicine (ordering unnecessary tests and medical interventions merely to prevent lawsuits) is a major cause of excess health care spending. This article casts doubt that malpractice reform would reduce supposed defensive medicine.

The three states studied – Texas, Georgia and South Carolina – passed laws requiring a much more rigid standard of “gross negligence” for emergency department physicians to be found liable for malpractice. Data available from Texas demonstrates that their reforms did reduce malpractice claim filings by 60 percent, and reduced malpractice payments by 70 percent. Physicians were reassured that they were protected as long as they did not proceed with “conscious indifference” with care that had a “likelihood of serious injury.”

Now that there was no longer a need for CT and MRI scans and hospital admissions that  were done only to prevent lawsuits, the level of these presumed defensive medicine measures should have decreased. They did not.

This suggests that these measures were taken for reasons other than simply to prevent lawsuits. A low yield test or procedure is not necessarily a no yield intervention. These are done because there is a real chance, even if at low odds, that the intervention may benefit the patient.

This study leads us to conclude that the concept that there is excessive resource-intensive care provided strictly as defensive medicine should be abandoned and replaced with patient-centered outcomes research to better determine what is of value in health care (PCORI in ACA is such an attempt).

We should no longer allow ourselves to be distracted by false promises of health care savings through flawed concepts such as defensive medicine. We know what will greatly reduce wasteful spending, and that is a single payer national health program. We must not be distracted from trying to achieve that goal.

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States largely ignoring network inadequacies

Posted by on Wednesday, Oct 15, 2014

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.

Implementation of the Affordable Care Act: Cross-Cutting Issues: Six-State Case Study on Network Adequacy

By Sabrina Corlette, Kevin Lucia, and Sandy Ahn
Urban Institute, September 2014

During the transition to new health plans and new marketplaces under the Affordable Care Act (ACA), many insurers revamped their approach to network design, and many now offer narrower provider networks than they have in the past. In this study for the Robert Wood Johnson Foundation’s project to monitor ACA implementation, researchers assessed network changes and efforts at regulatory oversight in six states: Colorado, Maryland, New York, Oregon, Rhode Island, and Virginia. Researchers found that insurers made significant

changes to the provider networks of their individual market plans, both inside and outside the marketplaces, and that insurers took varying approaches to network design. Across all six states, insurers and state officials alike reported consumer and provider confusion about which plan networks included which providers, but most have received few consumer complaints about their ability to obtain in-network services. While three of the six states have taken action to improve provider directories, it appears unlikely that state legislatures, officials and regulators will dramatically change network adequacy standards, at least in the short-term.


Insurers have used—and are likely to continue to use— network design to curb costs and offer customers a more affordable premium. This was a clear trend in the individual market as insurers approached the 2014 plan year, and some of our informants believe it will soon extend to the group market as employers look for ways to reduce premiums. However, despite concerns among some regulators, consumer advocates, and providers that overly narrow networks could harm quality of care and place consumers at significant financial risk, most of our study states are not planning to significantly change their oversight of plan networks. Though consumers reported problems with inaccurate provider directories and a lack of consumer-friendly, comparable information about the scope of plan networks, only half of our study states report requiring insurers to improve the information made available to consumers. At the same time, state officials and insurers also reported that consumers were generally not complaining about difficulty obtaining needed care from providers. Consequently, most state legislatures, officials and regulators are unlikely to change network adequacy standards, at least in the short-term.…

Private insurers use narrow networks of physicians and hospitals so that they can negotiate more favorable provider rates which then supposedly allows them to keep their insurance premiums more competitive. The trade-off is that patients lose their choice of providers and increase the risk that they will suffer severe financial penalties because of unavoidable circumstances wherein care is obtained out of network, or worse, care is not received at all because of impaired access.

The use of narrow networks will cause harm to many patients. Yet, according to this report, for the present, “most state legislatures, officials and regulators are unlikely to change network adequacy standards.” Also, although provider directories are notoriously inaccurate, “only half of our study states report requiring insurers to improve the information made available to consumers.”

How much do the insurers really save by using narrow networks? The savings is not the difference between the prices specified by the providers and the amount contracted with the narrow network providers. Insurers already receive sharp discounts from the providers in their broad networks. So the savings is only the very modest additional amount squeezed out of those who contract for the more exclusive narrower networks. That savings is surely not worth the impaired access, loss of choice, and potential financial hardship brought by narrow networks.

With a single payer system, fair payments apply to all physicians and hospitals, therefore there is no need to establish separate networks. The one network is the entire health care delivery system (except for those who choose integrated delivery systems such as Kaiser Permanente). Government administered pricing is far more patient friendly than market-based manipulations, and isn’t the patient what it is all about?

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Status of higher payment for primary care under Medicaid

Posted by on Tuesday, Oct 14, 2014

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.

Medicaid in an Era of Health & Delivery System Reform: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2014 and 2015

By Vernon K. Smith, Kathleen Gifford, Eileen Ellis, Robin Rudowitz and Laura Snyder
Kaiser Family Foundation, October 14, 2014

Primary Care Payments

The ACA included a provision to increase Medicaid payment rates for primary care services to Medicare rates from January 1, 2013 through December 31, 2014. The federal government funded 100 percent of the difference between Medicaid rates that were in effect as of July 1, 2009 and the full Medicare rates for these two years. States were asked about their plans to extend this provision beyond December 31, 2014 (at regular FMAP rates). For states that have Medicaid rates for physician services that were already at or close to 100 percent of Medicare rates, this issue was not significant.


  • Twenty-two states indicated that they would not be continuing the primary care rate increase.
  • Fifteen states (Alaska, Alabama, Colorado, Connecticut, Delaware, Hawaii, Iowa, Maryland, Maine, Michigan, Mississippi, Nebraska, Nevada, New Mexico, and South Carolina) indicated that they will continue the higher rates at least partially if not fully. For example one state will provide a proportionate increase for all primary care physicians (half of the ACA rate increase); others plan to continue temporarily or target it to certain types of primary care.
  • Fourteen states indicated they had not yet made a decision on this policy and were still evaluating whether the enhanced rates had any impact on provider participation. Given the delayed implementation of the rate enhancement and the difficulty of attributing changes in provider enrollment and access to the enhanced payments, the impact of the increased rates is difficult to determine.…


Primary Care Services under Managed Care Delivery Systems

Qs &As on the Increased Medicaid Payment for Primary Care CMS 2370-F – MANAGED CARE

The requirements under 42 CFR 438.804 specify that the states submit two methodologies to the Centers for Medicare & Medicaid Services (CMS) for review and approval to implement this rule. How does approval of these methodologies impact the approval process for managed care contracts and rate packages for 2013?

Implementing regulations at 42 CFR 438.804 require states to submit to CMS a methodology for calculating the July 1, 2009, baseline rate for eligible primary care services and a methodology for calculating the rate differential eligible for 100 percent of Federal Financial Participation (FFP) by March 31, 2013. Further, 42 CFR 438.6 (c)(5)(vi) establishes Managed Care Organization (MCO), Prepaid Inpatient Health Plan (PHIP) or Prepaid Ambulatory Health Plan (PAHP) contract requirements to comply with this provision. It is CMS’s expectation that as soon as practicable after the State submits the required methodologies in 42 CFR 438.804 and receives CMS approval, the State will:

  1. submit revised actuarial certification documents reflecting the Medicare rate for eligible primary care services in their MCO, PIHP or PAHP capitation rates; and
  2. submit amendment(s) to this contract to ensure compliance with 42 CFR 438.6 (c)(5)(vi).

After CMS approval of the revised contract and rates, the MCO, PIHP or PAHP must direct the full amount of the enhanced payment to the eligible provider to reflect the enhanced payment effective January 1, 2013. Federal financial participation (FFP) is available at a rate of 100 percent for the portion of capitation rates attributable to these enhanced payments; however, receipt of the enhanced FFP is contingent upon the state’s successful completion of this process.…


The final rule specified that states will need to recoup the enhanced payments made to non- eligible providers identified through the annual statistically valid sample. Must health plans follow the same procedure for non-eligible providers?

States must require health plans to recoup erroneous payments found through the sampled pools of providers, and in a number of states, this sample will include both FFS and managed care providers.

Are MCOs permitted to include amounts sufficient to account for the payment differential on expected utilization while still holding the sub-capitated primary care physicians at risk for some level of increase in utilization due to the higher rates? Or must MCOs remove the risk to primary care physicians for utilization to ensure that these physicians receive the increased amount for actual experience?

The purpose of section 1202 of the Affordable Care Act and the final rule is to ensure access to and utilization of beneficial primary care services. Towards that goal, eligible primary care physicians must receive the full benefit of the enhanced payment at the Medicare rate for eligible services rendered. If a Medicaid managed care health plan retains sub-capitation arrangements, the health plan would be obligated to provide additional payments to providers to ensure that every unit of primary care services provided is reimbursed at the Medicare rate.…

As the Affordable Care Act (ACA) was being crafted, it was recognized that the expansion of coverage under Medicaid could result in greater access problems because of the low Medicaid payment rates and the lack of willing providers. In order to improve access, at least to primary care, it was decided to increase Medicaid primary care payment rates to the same level as Medicare for the years 2013 and 2014. As with so many of the ACA provisions, this seemingly simple solution has proven to be more complex.

Before and during this transition most states were moving many or all of their Medicaid patients into managed care programs. So the government had to issue guidelines on how to move enhanced Medicaid primary care payments into managed care organizations receiving capitation payments, and to be sure that these enhanced payments were directed to the eligible primary care providers (more administrative excesses). Although we are near the end of the two year period in which primary care payments are enhanced, news reports suggest that confusion and delays have not been entirely resolved.

Although these enhanced payments were considered to be crucial in ensuring adequate participation of primary care providers, twenty-two states have indicated that they would not be continuing the primary care rate increases. Fifteen states have decided to continue, though many at lower rates and perhaps only temporarily. Fourteen states are undecided. “Given the delayed implementation of the rate enhancement and the difficulty of attributing changes in provider enrollment and access to the enhanced payments, the impact of the increased rates is difficult to determine.”

Medicaid is a welfare program, and, as such, will continue to be chronically underfunded. Medicaid patients frequently have difficulties accessing primary care services, and the continued underfunding will perpetuate that problem. Access to specialized services is even more limited because of the very low participation rates of specialists.

Single payer would eliminate these injustices since we would all have the same high-quality program – an improved Medicare for all.

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Private health plans no longer assure adequate protection

Posted by on Monday, Oct 13, 2014

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.

Privately Insured in America: Opinions on Health Care Costs and Coverage

The Associated Press-NORC Center for Public Affairs Research, October 2014

A significant minority of those with private health insurance, including those covered by high-deductible health plans (HDHPs), are greatly impacted by the out-of-pocket cost of health care—they are concerned with the uncertainty of major expenses, skip necessary medical treatment, and experience real financial burden when obtaining health care. All told, about 1 in 8 privately insured Americans—or more than 16 million people—face major financial hardships like going without food or using up all of their savings as a result of medical bills.

When asked about nine specific behaviors to reduce personal health care expenses, about half of privately insured adults age 18-64 experienced at least one of them.

  • As a result of health care costs, significant minorities of privately insured individuals don’t go to the doctor when they are sick (19 percent), go without preventive and recommended care (18 percent), use up all or most of their savings (18 percent), and go without basic needs (13 percent).
  • A quarter of privately insured adults age 18-64 lack confidence in their ability to pay for a major unexpected medical expense.
  • The privately insured who report having a HDHP are more likely than those who do not to decrease their contributions to savings (41 percent vs. 26 percent) and retirement plans (28 percent vs. 15 percent) as a result of health care costs.
  • Nearly 1 in 4 adults age 18-64 covered by a HDHP reports that paying for health care expenses caused them to use up their savings.
  • Thirty-five percent of those surveyed indicate that when enrolling in a health insurance plan, their current plan was the only option available.
  • With out-of-pocket costs emerging as a major source of uncertainty among the privately insured, more privately insured Americans choose a health care plan with a relatively high monthly premium but lower out-of-pocket costs (52 percent) over a plan with relatively low premiums and higher out-of-pocket costs (40 percent), when presented with the tradeoff.
  • But, there isn’t overwhelming support for plans with select networks5 designed to keep out-of-pocket costs low. Twenty percent say they are extremely or very willing to participate in this type of plan, 38 percent are somewhat willing, and 40 percent are not too or not at all willing.

Of those who indicate they have used health care services since enrolling in their current health insurance plan, 39 percent say the out-of-pocket costs being higher than expected has been a major (14 percent) or a minor (24 percent) problem.

As the health care marketplace is evolving with the advent of new exchanges, those who purchase their health insurance plans directly or through exchanges are more likely to express difficulty finding health care providers covered under their plans.

Those who have changed health insurance plans and say they have HDHPs are especially likely to cite increased costs without a corresponding increase in quality.

This new survey conducted by the Associated Press-NORC Center for Public Affairs Research confirms, once again, that private health insurance in the United States often is not providing adequate financial protection for those with health care needs. More than 16 million people who have private insurance “face major financial hardships like going without food or using up all of their savings as a result of medical bills.” The one-half of Americans who use hardly any health care at all likely do not realize that they are one major illness away from similar financial hardship.

When something is not working, we should fix it. The inadequacies of private plans cannot be repaired without intolerable increases in health insurance premiums. Yet a well designed single payer national health program could remove the financial barriers to care – for everyone – without any increase in our current national health expenditures. Without action, 30 million will remain without any insurance at all, and many of the rest of us could remain vulnerable to high out-of-pocket medical costs in spite of our private insurance coverage.

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“Reference pricing” is yet another intrusive diversion from real reform

Posted by on Friday, Oct 10, 2014

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.

Reference Pricing: A Small Piece of the Health Care Price and Quality Puzzle

By Chapin White, Megan Eguchi
National Institute for Health Care Reform, NIHCR Research Brief No. 18, October 2014

As purchasers seek strategies to reduce high health care provider prices, interest in reference pricing—or capping payment for a particular medical service—has grown significantly. However, potential savings to health plans and purchasers from reference pricing for medical services are modest, according to a new analysis by researchers at the former Center for Studying Health System Change (HSC) using 2011 private insurance claims data for about 528,000 active and retired nonelderly autoworkers and their dependents. In 2011, the California Public Employees’ Retirement System (CalPERS) adopted reference pricing for inpatient knee and hip replacements. Using quality and price information, CalPERS set an upper limit of $30,000—the reference price—for hospital facility services for a knee or hip replacement. CalPERS designated certain in-network hospitals as meeting the reference price, and patients using designated hospitals are responsible only for the health plan’s usual cost-sharing amounts. However, if patients use a non-designated hospital, they are responsible for both usual cost sharing and any amount beyond the $30,000 reference price. While reference pricing for inpatient services has some potential to steer patients to hospitals with better quality metrics, only limited savings—a few tenths of a percent of total spending—are possible from applying a similarly narrow reference pricing to other privately insured populations. The potential savings from reference pricing are modest for two reasons: Shoppable services only account for about a third of total spending, and reference pricing only directly affects prices at the high end of the price distribution. When considering reference pricing, employers and health plans need to weigh potential savings against increased plan complexity and financial risk to enrollees, along with the analytical and financial resources needed to create and manage the program.

From the Implications

The CalPERS reference pricing experience tells two different but equally true stories—a dramatic percentage decline in prices and spending on knee and hip replacements and an extremely small percentage decline in total spending. To significantly impact spending among the privately insured, reference pricing would have to be applied quite broadly. And, even using a very inclusive list of shoppable services, the potential savings are relatively modest.

Both conventional network-based plans—preferred provider organizations and health maintenance organizations—and reference pricing suffer some of the same limitations. Both types of plans rely on patient cost-sharing differentials to steer patients to certain providers, but the higher cost sharing cannot reasonably be applied in emergencies when patients can’t choose their provider. Also, both types of plans are vulnerable to the demands of dominant “must-have” providers, either to be in network or to be both in network and designated.

Compared to a limited-network plan, reference pricing faces at least three additional logistical hurdles. First, the health plan must have reliable price data for specific providers for specific services so that it can set the reference price and designate providers. Even very large plans will lack the historical data to accurately measure the prices they typically pay to smaller hospitals. Second, the plan would ideally have provider-specific quality metrics on hand that can be used to assure patients that they are not being steered to low-quality providers. Although hospital quality metrics and rankings abound, the methodologies behind those rankings are still under development. Third, reference pricing requires new customer-service tools to support shopping by patients and to deal with inevitable member complaints. Implementation would require commitment of significant resources by the plan, potentially offsetting some or all of the savings from reductions in payments to high-price providers.

The main disadvantage of reference pricing is that it adds a new layer of complexity for plan administrators and enrollees. Rather than facilities simply either being in or out of the network, there are now three types of facilities: in-network designated, in-network non-designated and out of network. Even more confusingly, a single facility might be designated for one type of service—for example, an inpatient hospital providing a knee replacement—but not designated for another—that same hospital providing a colonoscopy in an outpatient department. Additional complexity raises significant concerns, given that the basic elements of conventional benefit design are already beyond the grasp of many consumers.

One question is whether a reference pricing program can steer patients to lower-price, adequate-quality providers. The answer, based on the CalPERS experience, appears to be yes. But, that may not be the right question. A better question may be why private health plans would ever pay negotiated prices over $30,000 for inpatient knee and hip replacements. The CalPERS reference pricing program seemingly took a hard line against hospitals charging unreasonably high prices—$30,000 or more—for knee and hip replacements. But, is $30,000 really a reasonable price for an inpatient knee or hip replacement? To put that amount in perspective, the Medicare program on average paid $14,324 for inpatient knee and hip replacements in 2011.

Our policy wonks continue to look for methods of controlling health care costs that will protect the role of private insurers, and, above all, prevent us from drawing the inevitable conclusion that we desperately need a single payer national health program. Reference pricing is one more supposed cost-saving tool that has garnered much interest. What is it and will it work?

Reference pricing is a process in which a maximum price is set for a given medical service. The patient then either goes to a designated provider who has agreed to accept that amount, along with contracted patient cost sharing, as payment in full, or, if the patient chooses a provider with higher prices, the patient must pay the full difference.

California Public Employees’ Retirement System (CalPERS) experimented with reference pricing by establishing $30,000 as a reference price for the hospital services for a knee or hip replacement. The experiment was considered to be a success based on the fact that 15 to 30 percent of patients who would have gone to a non-designated hospital switched and went to a designated hospital instead. But how do you define success?

The package fee that the private market was able to negotiate was $30,000. Medicare on average paid $14,324 for the same services. Is it a success when private insurers are paying double the fees set by a public insurer?

Some might consider it to be a success when the patient did not have to pay the difference between the reference price and the price that would have been charged in a non-designated hospital, though what is the patient giving up?

Consider how a decision is usually made to have a joint replacement. The patient typically goes to his or her primary care professional where initial evaluation indicates that a joint replacement may be indicated. A referral is made to a specialist qualified to do joint replacements. If the decision is made to go ahead with the procedure, arrangements are made with the hospital the specialist is associated with. But then the insurer intervenes and threatens the patient with severe financial penalties (all costs above the reference price) unless the patient agrees to give up the specialist and hospital that is part of the team of her primary care professional, either as a formal integrated health system or as an informal team of community professionals working together. To escape the financial penalty, the patient pays the penalty of disruption in care.

So what did this successful experiment that everyone wants to emulate actually accomplish? Care of 15 to 30 percent of patients was disrupted in exchange for establishing a cap on payment that was twice what Medicare pays, and yet netting only “an extremely small percentage decline in total spending.”

Another important consideration discussed in this report is that reference pricing significantly increases administrative complexity – just what we need in a system that is unique in the world for all of its profound administrative waste. But very telling is the comment in this report that some of this administrative increase will be in the form of new customer-service tools “to deal with inevitable member complaints.”

Great – a disruptive program that doesn’t work very well but ticks everyone off! We’ll say it again – single payer.

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