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.
Obamacare Limits Choices Under Some Plans
By John Tozzi
Bloomberg Businessweek, March 20, 2014
Ben Rosenthal was treated for prostate cancer four years ago and had gallbladder surgery the year before that. A former manager at a market-research firm in Los Angeles, Rosenthal, 57, paid for his own health insurance. Last fall, when his plan was discontinued because it didn’t meet standards set by the Affordable Care Act, Rosenthal bought the best insurance coverage he could find, a top-tier “platinum” policy from Blue Shield of California that costs $792 a month. He figured it would provide access to top hospitals. Then in February he learned the plan wouldn’t cover the hospitals where he was used to being treated.
Rosenthal is one of millions of Americans who have purchased insurance under the Affordable Care Act and are discovering that many of the new plans offer a narrow network of doctors and facilities. “If I had anything happen, I wouldn’t want to go to a hospital that I’m not familiar with and with doctors I don’t know,” he says.
Since the ACA created marketplaces for private health plans last fall, insurers expecting to lure customers with low premiums have fashioned smaller networks of medical providers. By cutting out expensive hospitals and negotiating favorable rates with doctors in exchange for sending more patients their way, insurers can keep premiums down. Blue Shield’s new network includes 43 hospitals in Los Angeles County, about 64 percent of what its standard coverage offers, spokeswoman Lindy Wagner says in an e-mail.
In addition to having fewer options, buyers are making decisions about which plans to buy based on incomplete or misleading information, says Karen Pollitz, senior fellow at the Kaiser Family Foundation, a health policy research group. “Consumers have a very limited ability to shop in advance and evaluate provider networks,” she says.
Plans on healthcare.gov and state marketplaces are required to include links to directories that show which providers accept the insurance. But the information is often missing, wrong, or difficult to navigate, says Oliver Kharraz, chief operating officer of ZocDoc, an online appointment booking company. ZocDoc tried to verify the accuracy of hundreds of directories by calling doctors listed as in-network providers. About half the listings were wrong, Kharraz says. The California exchange, one of 15 state marketplaces that operate independently of healthcare.gov, created a central directory on its website but took it down on Feb. 6 because of errors.
Pressures on insurers to keep premiums low—state regulators can reject plans that are priced too high—may mean patients will have to learn to live with restricted choices. “The industry’s had to find ways to cut costs,” says Hasday of Frenkel Benefits. The result, he says, is “much less transparent for the consumer.”
Reader comment: John Alexander
I had the exact same problem as Mr. Rosenthal only in Florida with Blue Cross Blue Shield. Got screwed, as I also picked the Platinum plan and found out my hospital and doctors were not covered. The best research I did before hand indicated I would be covered and found after the fact I was not. Got furious with BCBS and they agreed to correct a few cost items with my doctors. They are playing dollar games with our health and I am completely frustrated. I am not upset with Obama-Care, only with the sligh and sneaky Insurance companies. Cannot drop my insurance and/or change until November of this year. What a fiasco. A singly payer system would correct all of this smoke and mirror games played by the Insurance industry.
In Obamacare, go for bronze health plans. For most people, buying up to gold or platinum plans is a waste of money
By Scott Gottlieb
The American Enterprise Institute (AEI), January 24, 2014
We analyzed dozens of Obamacare plans, and found one striking result. The networks of providers, and in many cases the drug formularies, are the same whether you’re buying a particular insurer’s bronze plan, or purchasing the same insurance option in a gold or platinum offering. My American Enterprise Institute colleague Kelly Funderburk and I posted some of our data here.
The bottom line is this. When you’re choosing a particular insurance offering, you typically can’t trade up to a better benefit by buying the gold or platinum variety of that plan. It’s usually the exact same benefit regardless of the metal you choose.
So what varies between these different metal plans? Typically, just the co-pay structure and deductibles. As you pay higher premiums for a gold or platinum plan, your deductibles and co-pays will decline. The insurer will typically cover 60 percent of expected medical expenses in a bronze plan, 80 percent in a gold plan and 90 percent in a platinum plan. So, by buying the costlier plans, all you’re doing is fronting a higher premium to buy down your anticipated out of pocket costs. You’re not getting a better network of doctors or a better formulary of drugs.
Data to support this claim: http://www.scribd.com/doc/201871033/Comparison-of-Bronze-Versus-Platinum…
Hospital networks: Configurations on the exchanges and their impact on premiums
McKinsey & Company, December 14, 2013
Narrow and ultra-narrow hospital networks are more prevalent (70 percent of all networks), increasing the variety of network configurations available to consumers
Broader network offerings are fewer than in 2013, yet remain available in almost every rating area we analyzed. The prevalence of narrower networks varies across markets, with the average percent contraction of incumbents’ network breadth between 2013 individual market networks and 2014 individual exchange networks ranging from 11 to 60 percent.
Products with broad hospital networks reveal higher premiums, with a median premium increase of 26 percent between broad and narrower networks of the same carrier, product type (e.g., HMO, PPO), metal tier, and rating area. Also, the majority (84 percent) of lowest-price silver products utilizes narrow or ultra-narrow networks
Across silver tier networks in our 20 analyzed rating areas, 58 percent of the lowest-price products utilize ultra-narrow networks and another 26 percent utilize narrow networks. Network breadth appears to be positively correlated with premium levels in many cases, but the use of narrower networks is common at all price points.
Out-of-network coverage in New York? We left it up to the insurers
By Craig Gurian
Remapping Debate, October 30, 2013
New York’s health insurance exchange (called “NY State of Health”) offers individuals and families numerous insurance plan options at various “metal” levels. What it doesn’t offer in most parts of the state are plans that provide coverage for non-emergency out-of-network care. In a sample Manhattan zip code, for example, there are 62 plans available at all metal levels. Not one of those plans pays for out-of-network care.
Why then did New York State not require out-of-network coverage? “We left it up to the insurers,” said (Department of Health’s Randi) Imbriaco, and the insurers, she continued, arguing that “a closed network helps keeps costs low,” chose not to provide out-of-network coverage in most of New York State, including New York City (some plans in the western part of New York State do offer such coverage).
Dr. Andrew D. Coates is an internist based in upstate New York who is president of Physicians for a National Health Program (PNHP), an organization that advocates for a single-payer health insurance system. Coates, who was speaking during the interview for himself and not as a representative of PNHP, agreed with the idea that the lack of out-of-network options would enhance the ability of insurance companies to engage in cost cutting, regardless of whether patients were harmed, as, for example, in a push for doctors to see more and more patients each day.
He thought that doctors were increasingly being put in an “ethical bind” where their medical instincts might tell them in a particular instance to recommend an out-of-network physician — the “one oncologist that you can think of that should really evaluate what to do next” in the case of a rare cancer — even as they knew that following that recommendation would be financially ruinous for the patient.
More broadly, in Coates’ view, the greater empowerment of insurance companies was accelerating a turn towards “a corporate medical model that threatens to squeeze the humanity out of our interaction with our patients.”
According to the Bloomberg Businessweek report, Ben Rosenthal and reader John Alexander purchased the highest tier plans available – platinum plans – to ensure that they would have coverage for their current physicians and hospitals. No way. Insurers have pushed the perversity of narrow network plans all the way to the top.
Before Barack Obama was even nominated, the Democratic strategists had already decided that “Choice” would be a campaign slogan to market health care reform. Some of us protested that Celinda Lake and Herndon Alliance were pushing “choice of private health plans” when what the Democrats should have been advocating was “choice of physicians and hospitals.” It is clear which faction won this debate, as single payer supporters had the door slammed on them.
But look at the consequences. We were promised that we would have our choice of any plan we wanted with benefits as rich as desired, and with a selection of any health care providers we preferred. We could choose our doctors and our hospitals. But what happened?
So they did set up four levels of plans that we could choose from, plus a fifth catastrophic plan as an option for younger individuals. So we could buy a cheap bronze plan that would cover an average of 60 percent of our health care costs, 70 percent for silver, 80 percent for gold, all the way up to an expensive platinum plan that would cover 90 percent of costs. But there would be only negligible differences in the benefits since all plans had to cover the same ten categories of benefits, though some variation within each category is allowed as long as it had the same actuarial value.
But the shocker is the networks that the insurers established. As the AEI report indicates, for plans offered by the same insurer in the same market, the provider networks were just as limited for the high end platinum plans as they were for the cheapest bronze plans. If you want your medical bills paid, you do not have a choice of physicians and hospitals. You have to stay in network. Typically seventy percent of the providers are outside of the narrow network plans offered through the exchanges.
The Remapping Debate report reveals a further complication. Previously plans were available that provided reduced payments for care obtained out of network, with the patient paying a greater share of the costs. Now in areas such as New York City, none of these plans are available through the exchanges. You must stay in network or pay the full bill.
According to the McKinsey report, in some markets plans are available with broader networks, but these are less prevalent and declining in availability, and they are exorbitantly expensive. They will likely be subject to the death spiral since most markets do not have enough super wealthy individuals to maintain a vibrant market of broad network plans. The super wealthy then will simply pay their own bills.
So the Democrats traded off our choice of physicians and hospitals for a choice of deductibles and copayments, as the insurers took away the choices that we actually wanted. The narrow and ultra-narrow networks were a decision of the insurers, not us. We are getting what they want rather than what we want, simply because the Affordable care Act was designed to leave the insurers in charge.
As we’ve said before, all of this would go away if only we would enact a single payer national health program. As PNHP president Andy Coates says, physicians are placed in an “ethical bind” as they practice under “a corporate medical model that threatens to squeeze the humanity out of our interaction with our patients.”
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 Law Concerns for Cancer Centers
By Ricardo Alonso-Zaldivar
Associated Press, March 19, 2014
Cancer patients relieved that they can get insurance coverage because of the new health care law may be disappointed to learn that some the nation’s best cancer hospitals are off-limits.
An Associated Press survey found examples coast to coast. Seattle Cancer Care Alliance is excluded by five out of eight insurers in Washington state’s insurance exchange. MD Anderson Cancer Center says it’s in less than half of the plans in the Houston area. Memorial Sloan-Kettering is included by two of nine insurers in New York City and has out-of-network agreements with two more.
In all, only four of 19 nationally recognized comprehensive cancer centers that responded to AP’s survey (members of the National Comprehensive Cancer Network) said patients have access through all the insurance companies in their state exchange.
Not too long ago, insurance companies would have been vying to offer access to renowned cancer centers, said Dan Mendelson, CEO of the market research firm Avalere Health. Now the focus is on costs.
“This is a marked deterioration of access to the premier cancer centers for people who are signing up for these plans,” Mendelson said.
Those patients may not be able get the most advanced treatment, including clinical trials of new medications.
And there’s another problem: It’s not easy for consumers shopping online in the new insurance markets to tell whether top-level institutions are included in a plan. That takes additional digging by the people applying.
To keep premiums low, insurers have designed narrow networks of hospitals and doctors. The government-subsidized private plans on the exchanges typically offer less choice than Medicare or employer plans.
By not including a top cancer center an insurer can cut costs. It may also shield itself from risk, delivering an implicit message to cancer survivors or people with a strong family history of the disease that they should look elsewhere.
For now, the issue seems to be limited to the new insurance exchanges. But it could become a concern for Americans with job-based coverage too if employers turn to narrow networks.
In a statement, Anthem said its network was based on research involving thousands of consumers and businesses. “What we learned was that people are willing to make trade-offs in order to have access to affordable health care,” the company said. “Our provider networks reflect this.”
Members of the National Comprehensive Cancer Network (http://www.nccn.org/members/network.asp)
2015 Letter to Issuers in the Federally-facilitated Marketplaces
CMS, March 14, 2014
Section 3. Network Adequacy
Pursuant to 45 C.F.R. 156.230(a)(2), an issuer of a QHP that has a provider network must maintain a network that is sufficient in number and types of providers… to assure that all services will be accessible to enrollees without unreasonable delay. All issuers applying for QHP certification will need to attest that they meet this standard as part of the certification/recertification process.
CMS will assess provider networks using a “reasonable access” standard, and will identify networks that fail to provide access without unreasonable delay as required by 45 C.F.R. 156.230(a)(2).
If CMS determines that an issuer’s network is inadequate under the reasonable access review standard, CMS will notify the issuer of the identified problem area(s) and will consider the issuer’s response in assessing whether the issuer has met the regulatory requirement and prior to making the certification or recertification determination.
Kaiser Health Tracking Poll: February 2014
By Liz Hamel, Jamie Firth and Mollyann Brodie
KFF.org, February 26, 2014
The latest Kaiser Health Tracking Poll finds that, in general, the public leans towards more expensive plans with broader networks. About half (51 percent) say they would rather have a plan that costs more money but allows them to see a broader range of doctors and hospitals, while just under four in ten (37 percent) prefer a plan that is less expensive but allows them to visit a more limited range of providers. While older individuals and those with higher incomes exhibit a clearer preference for more expensive plans with broader networks, younger adults and those with lower incomes are more evenly divided in their preferences. But those who are either uninsured or currently purchase their own coverage – a group that is most likely to be in a position to take advantage of new coverage options under the ACA – are more likely to prefer less costly narrow network plans over more expensive plans with broader networks (54 percent versus 35 percent). Those who currently get their insurance through an employer (and are more protected from the cost of coverage) have the opposite preference: 55 percent prefer a more expensive plan with a broader network, while 34 percent would rather have a cheaper narrow network plan.
Those who prefer narrow network plans may be less likely to prefer them if it means they can’t see their usual providers. When those who prefer a less costly narrow network plan are presented with the possibility that they would not be able to visit the doctors and hospitals they normally use, the share who continue to prefer this option drops from 37 percent to 23 percent among the public overall, and from 54 percent to 35 percent among the uninsured and those who buy their own insurance.
On the other hand, when those who initially prefer a more expensive plan with a broader network are told that they could save up to 25 percent on their health care costs, the share continuing to prefer the more expensive option drops from 51 percent to 37 percent among the public overall, and from 35 percent to 22 percent among those the uninsured and those with non-group coverage.
For decades we have been hearing heartrending stories of children and adults under 65 who develop cancer but were uninsured. For those of us striving for a comprehensive health care program for everyone, there could not be a greater motivating force than the desire to eliminate forever the twin tragedies of impaired access to care and personal financial ruin for these unfortunate cancer victims.
The Affordable Care Act brought us expanded access to private insurance plans with incentives for the insurers to provide plan innovations to help slow spending on health care. Although plans already were using limited networks to leverage lower prices from the providers, the degree to which they would further narrow networks was not expected, except perhaps by the cynics amongst us.
But the insurers have no shame. Cancer management is expensive. What better place to restrict access could there be than to remove most members of the National Comprehensive Cancer Network from many of their insurance networks. Only four of nineteen of these centers are included in all exchange plan networks within their respective states.
CMS tells us that they will use a “reasonable access” standard when the plans are recertified for the federal exchanges next year. This is a relative rather than an absolute standard. They have no intention of opening up insurer networks to all comers. That would defeat the insurance innovation of controlling costs by blocking access to out-of-network providers, especially the expensive ones such as the members of the National Comprehensive Cancer Network.
The latest Kaiser tracking poll is of concern since it shows that lower-income and uninsured people will select the plans with more restricted networks simply because the premiums are lower. No centers-of-excellence cancer care for them.
Although insurers are prohibited from denying coverage, just think of the advantage they would have in avoiding adverse selection by being able to tell those patients who have cancer that they really don’t want to buy the plans they offer since the nation’s noted cancer institutions are not covered. They can do the cancer victim a favor by sending her to a competitor. Then they can retreat into their headquarters to devise yet more insurance innovations that work this well.
A single payer national health program would not have networks. Patients could go anywhere. With an improved primary care infrastructure, they would receive assistance in obtaining the best care for their medical condition. For those with cancer, there would be no private insurers profiting off of discount cancer care, though the single payer system would take care to see that the services are priced right for the benefit of us taxpayers who would be financing our health care system.
This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
Medical Home: An Evolving Model of Primary Care
By Melinda K. Abrams
Commonwealth Fund Blog, February 25, 2014
Today, the Journal of the American Medical Association (JAMA) released a study, cofunded by The Commonwealth Fund, evaluating a three-year medical home pilot in Pennsylvania. The study, led by RAND’s Mark Friedberg and colleagues, found the program was not associated with significant improvements in quality of care or cost reductions. ….
While some may be ready to hand medical homes a failing grade, the study’s findings underscore what we already knew about this team-based model of primary care: we need to continue to improve how care is delivered, how providers are paid, and how the model is implemented in different settings.
Since the Pennsylvania initiative was launched in 2008, we have learned more about how best to implement an effective patient-centered medical home. For example, it’s become clear that the payment model needs to reward cost savings as well as quality improvement. ….
In addition, evidence suggests that sites targeting patients with complex medical conditions are more likely to see an impact on outcomes and utilization than those serving patients with more routine needs. ….
But this study also raises questions about whether recognition criteria used by NCQA and other accrediting organizations need to better reflect meaningful practice transformation….
The February 25 edition of JAMA published a study of “patient-centered medical homes” (PCMH) by Mark Friedberg et al. The authors reported that PCMHs had no effect on costs and almost no effect on quality (PCMHs outperformed the control clinics on only one of 11 quality measures). In fact, it appears that PCMHs raised costs when the costs associated with setting up PCMHs and rewarding PCMH doctors is taken into account.
The PCMH may not survive much longer if research continues to show that it cannot cut costs. The loss of the “medical home” metaphor will be inconsequential, but if the termination of the PCMH experiment sets back the campaign to strengthen the primary care sector, that will be a significant loss. To avoid that outcome, PCMH proponents should cease hyping the PCMH as a cost containment device applicable to entire “populations” and instead focus on specific services for specific patients.
Cutting costs has always been one of the primary goals of PCMH advocates. For private insurers, it is not merely a goal – it is a precondition. Unless it is ordered to do otherwise by state legislatures or Congress, the American insurance industry will not, over the long haul, subsidize clinics to provide “home” services if those services do not reduce the industry’s net costs – their subsidies to PCMHs plus their expenditures on claims. Nor will clinics certified as PCMHs provide, over the long term, the services PCMHs are expected to provide if insurers refuse to compensate them for those services. And if insurers and PCMHs refuse to pay for those services, it is extremely unlikely patients can be persuaded to pay for them.
The “medical home” label was originally coined to refer to clinics which held all the records of children with special needs. But in 2007 the concept was greatly expanded by the American Academy of Family Physicians and three other primary care specialty groups and promoted as a means to bring more resources into the entire primary care sector while simultaneously cutting costshttp://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiati…. As Robert Berenson et al. put it in a 2008 paper, “[T]he medical home can be viewed as an alternative way to recognize and support primary care activities, particularly those that are not considered to be part of evaluation and management service codes….”http://content.healthaffairs.org/content/27/5/1219.abstract As Ed Wagner and other PCMH advocates put it in a 2012 paper for the Commonwealth Fund, “Among the experts, stakeholders, and patients consulted for this report, there was broad agreement that … sustaining the PCMH model and making the case for increased primary care payments hinge on success in reducing health care costs.”http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report…
Promoting the “medical home” as a cost-containment tool rather than simply calling for more resources for primary care may turn out to have been a mistake. It is becoming increasingly apparent that the cost-cutting prowess of the “home” was vastly exaggerated by its proponents. It should have been described only as an approach or model that might cut costs if applied to specific categories of chronically ill patients. Thanks to research like the paper by Friedberg et al., that realization seems to be dawning on PCMH advocates. The comment on the Commonwealth Fund blog quoted above is one example. An editorial accompanying the JAMA paper, aptly entitled “One size does not fit all,” is another. Even the ever-optimistic Patient-Centered Primary Care Collaborative (which last year added Liz Fowler to its board http://www.pcpcc.org/2013/07/23/liz-fowler-jill-hummel-hal-lawrence-and-…) said of the JAMA paper, “There was no targeting and/or analysis of chronically ill patients.” http://www.pcpcc.org/2014/02/26/pcpcc-leadership-responds-jama-article-m…
The “medical home” movement would be well advised to stop exaggerating the cost-containment powers of the PCMH and instead call for experimentation and research on specific services for specific types of chronically ill patients. Let me offer one example suggested by the Friedberg paper. The PCMH model studied by Friedberg et al. focused on diabetes care – six of the 11 quality measures measured some aspect of diabetes treatment. The one measure at which the PCMH clinics excelled turned out to be a diabetes measure (kidney exams). How did the PCMH clinics achieve this laudable outcome? We don’t know, but it is reasonable to infer that the high percentage of diabetes measures in the quality measurement set caused the clinics to “teach to the test” – to concentrate resources on diabetes patients, possibly at the expense of patients without diabetes. Did they use some or all of the diabetes disease management techniques that have been shown to improve the health of diabetics and pre-diabetics? We don’t know.
If instead of testing the impossibly amorphous, one-size-fits-all “home” concept, the PCMH clinics had tested their ability to improve the health of diabetics with specific treatments and interventions, we might now be reading a paper with useful information about what treatments work for diabetics and whether those treatments cost more to deliver than they saved in future medical costs. Instead we are left to scratch our heads about why the latest over-hyped managed care fad with the saccharine name isn’t working.
The AAFP and other proponents of the “medical home” should never have burdened the concept with the expectation of cost containment. If they were serious about cost containment, they should have endorsed single-payer legislation. If they were serious about strengthening the primary care sector, they should have called for more money for primary care, period.
Warning: Opting Out Of Your Insurance Plan’s Provider Network Is Risky
By Michelle Andrews
Kaiser Health News, March 18, 2014
Many plans sold on the health insurance marketplaces offer a tradeoff: lower premiums in exchange for limited networks of providers. But consumers who opt for a narrow network plan with the idea that they’ll go out of network when necessary may be taking a big financial risk.
The health law generally places limits on how much consumers can be required to pay out of pocket for medical care (not including premiums). In 2014, the limit for an individual plan is $6,350 and for a family plan, $12,700. But those limits apply only to care provided by doctors and hospitals in a plan’s provider network. There may be a separate out-of-pocket maximum for services provided out of network in marketplace plans, or no cap at all.
Similarly, the health law requires that preventive care such as vaccines, cancer screenings and annual checkups be covered at no cost to consumers in most health plans. If someone uses an out-of-network provider, however, they can be charged.
Going out of network opens the door to higher costs in other ways as well. Plans may require patients to pay a higher copayment or coinsurance for an out-of-network provider. In addition, since the doctors, hospitals and other providers are not under contract with the insurance company, in many states those providers may bill patients for any charges not covered by the insurance, a practice known as “balance billing.” The contracts signed by providers who join plan networks generally contain provisions that prohibit them from balance billing enrollees.
Plans sold on the marketplace are divided into four levels based on the amount of consumer cost sharing required. On average, a bronze plan pays for 60 percent of covered medical services, a silver plan pays for 70 percent, a gold plan, 80 percent, and a platinum plan, 90 percent. But those percentages don’t take any out-of-network care into account.
A McKinsey & Co. analysis of 120 silver-level exchange plans found that 70 percent were narrow network plans, in which at least 30 percent of the area’s largest hospitals are not in the plan, or ultra narrow network plans, in which that number grows to at least 70 percent.
Narrow networks can be a particular problem in HMO-style plans that don’t cover any out-of-network care except for emergency services. According to the analysis by Breakaway Policy Strategies, roughly a third of mid-level silver plans are of this type, typically leaving consumers on the hook for the entire bill if they get care from an out-of-network provider.
The health law does provide protection for consumers when they receive emergency care from a hospital that’s not in their provider’s network. In such instances, health plans can’t charge consumers higher coinsurance or copayments.
However, patients placed on observation status or admitted to the out-of-network hospital from the emergency department are no longer shielded from higher out-of-pocket costs.
“Once the patient is stabilized, the patient will be responsible for whatever the insurer doesn’t pay for that observation or admittance,” says Jeffrey Bettinger, an emergency physician who is chairman of the reimbursement committee of the American College of Emergency Physicians.
Whichever type of plan they choose, the onus is on consumers to dig into the details and make sure they understand what they’re signing up for. There’s a tremendous amount of variability in exchange plans, even among silver level plans, says Richard Smith, executive vice president at Breakaway Policy Strategies.
“I don’t see a lot of standardization,” he says. “Consumers need to be really cognizant. There are design features of these plans that consumers need to be aware of.”
Most people who have been paying any attention at all are quite aware that health plans inside and outside of the exchanges limit coverage to physicians and hospitals within their contracted networks. Although some plans may also offer limited coverage outside of the networks, it is less clear as to the extent and adequacy of that coverage. This article helps to clarify that issue by showing how muddled the coverage is.
Some of the traps include care provided outside of HMOs, care provided after an emergency patient is stabilized, free preventive services that may not be free outside of the network, services provided within network that are not benefits of the specific plan selected, and so forth. What is particularly treacherous is that, not only do you usually have to pay in full for these services, but your payments may not apply to your maximum out-of-pocket expenses, which can be unlimited out-of-network. The ACA promise that out-of-pocket expenses will be capped for the year ($6,350 for an individual and $12,700 for a family) comes from the same book of promises that gave us “you can keep your plan if you like it.” It is possible to end up with expenses over six figures. That is quite a whack for the person who was trying to do the right thing by buying a qualified insurance plan.
The precise out-of-network coverage depends on the specifications of the plan selected, and there are very few standards with which the plans must comply. So how do you select the right plan?
When people purchase their plans, they usually look first at the premium. Then they look at the deductibles and then the copayments or coinsurance. Usually, when assisted by a plan navigator or equivalent, they will also look at the tax credits for the premiums and the subsidies for cost sharing. Since many benefit from these they often select a silver plan because that is the only tier that includes cost-sharing subsidies.
The next step is to check the list of providers to see if your physician(s) or hospital(s) are on the list. This is where it becomes more tricky since those lists are often difficult to access, and they can be quite unreliable. Even physicians can be confused since they may be included on an insurer’s plan outside of the exchanges, but excluded from the exchange plans, and yet they may not be aware of the exclusion.
Finally, just try to find out the precise rules for coverage of care obtained outside of the network. Since there are very few standards, it is important to know this. The various insurers may approach such charges quite differently. You could end up with only modest additional expenses, but it is not too difficult imagining a six-figure bill when you are admitted to an out-of-network hospital. The insurer may cover the charges in the emergency room, but once the stabilized patient is admitted, she may well be on her own for all additional charges.
Think of how administratively complex the private insurers have already made our system. Then think of the administrative excesses that arise just from handling the muddled out-of-network care. The insurers are forcing upon us even more of their primary product – administrative services – while evading the very purpose of health care coverage by not paying for medical services that the patient needs.
If we had a single payer national health program with first dollar coverage (like many other nations with much lower health care costs) then this out-of-network nonsense would go away. What is really perplexing is why haven’t our people demanded this before now? Don’t facts matter?
In fairness, when we, as experts, think of how much effort we have to put in just to understand these issues, it is no wonder the the insurers and the rest of the medical-industrial complex have been so successful in bamboozling the public at large. We can use the political process to overcome this, but it would require a massive effort. After a couple of decades of working on this, I don’t see it happening. Prove me wrong.
Hearing: “Access and Cost: What the U.S. Health Care System Can Learn from Other Countries”
Testimony of Sally C. Pipes, President and CEO, Pacific Research Institute
U.S. Senate Committee on Health, Education, Labor and Pensions, Subcommittee on Primary Health and Aging, March 11, 2014
Those Canadians who can afford to do so have simply opted out of their healthcare system. An enormous number jump the queue for care in their native land and travel to the United States to receive medical attention. In 2012, over 42,000 Canadians crossed the border to get treated.
Frasier Institute Reports:
Leaving Canada for Medical Care 2010
Estimated number of patients receiving treatment outside Canada, 2010: 44,794
Leaving Canada for Medical Care 2011
Estimated number of patients receiving treatment outside Canada, 2011: 46,159
Leaving Canada for Medical Care 2012
Estimated number of patients receiving treatment outside Canada, 2012: 42,173
Waiting Your Turn: Wait Times for Health Care in Canada 2011
Average Percentage of Patients Receiving Treatment Outside of Canada, 2011: 1.0%
(See Page 58, Table 11)
Waiting Your Turn: Wait Times for Health Care in Canada 2012
Average Percentage of Patients Receiving Treatment Outside of Canada, 2012: 0.9%
(See Page 62, Table 11)
Waiting Your Turn: Wait Times for Health Care in Canada 2013
Average Percentage of Patients Receiving Treatment Outside of Canada, 2013: 0.9%
(See Page 64, Table 11)
Phantoms In The Snow: Canadians’ Use Of Health Care Services In The United States
By Steven J. Katz, Karen Cardiff, Marina Pascali, Morris L. Barer and Robert G. Evans
Health Affairs, May 2002
To examine the extent to which Canadian residents seek medical care across the border, we collected data about Canadians’ use of services from ambulatory care facilities and hospitals located in Michigan, New York State, and Washington State during 1994–1998. We also collected information from several Canadian sources, including the 1996 National Population Health Survey, the provincial Ministries of Health, and the Canadian Life and Health Insurance Association. Results from these sources do not support the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home.
Phantoms in the snow.
Despite the evidence presented in our study, the Canadian border-crossing claims will probably persist. The tension between payers and providers is real, inevitable, and permanent, and claims that serve the interests of either party will continue to be independent of the evidentiary base. Debates over health policy furnish a number of examples of these “zombies”—ideas that, on logic or evidence, are intellectually dead—that can never be laid to rest because they are useful to some powerful interests. The phantom hordes of Canadian medical refugees are likely to remain among them.
Each year the Fraser Institute of Canada issues a report claiming that over 40,000 patients leave Canada for medical care. Yet a highly credible study done over a decade ago revealed that many of these supposed patients were merely “phantoms in the snow” and that this is another “zombie idea” that, on logic or evidence, is “intellectually dead” but “can never be laid to rest because (the concept is) useful to some powerful interests.” So it is important to understand the source of the Fraser numbers.
Warning: The following is wonkish
As part of their annual survey of specialists to determine waiting times in Canada, the Fraser Institute asks the following question (the last question of their survey):
12. Approximately what percentage of your patients received non-emergency medical treatment in the past 12 months:
In another province? ______ % Outside of Canada? ______ %
Then, within each of twelve specialties in each of the ten provinces, they average the percent of patients who reportedly obtain care outside of Canada, as estimated by the practitioners of those specialities. If you look at Table 11 in any of the “Waiting Your Turn” reports listed above (choose 2013 as the latest example), you will see that this creates a grid of 120 percentages. Averages are obtained for each province (bottom line) and for each specialty (column on the right). These are then averaged to get the final percentage for all of Canada – 0.9% for 2013.
Stop here and think about that. Each practitioner was asked to estimate a percentage of his or her patients who left Canada for care (not specifically for care in the United States as Canada has a very large immigrant population – about one-fifth were born outside of Canada). If they had been asked for specific numbers, each may have been able to make a fairly reasonable guesstimate. But they were asked for a percentage. If there were not very many then the lowest full integer might come to mind – one percent (“Oh, it can’t be more than one percent”). In fact, 37% of the 120 sections of the grid reported zero percentages of patients leaving the country for care – probably a more realistic assessment since those specialists likely couldn’t remember any patients who left. Nevertheless, the majority estimated percentages well below one percent, i.e., there weren’t very many.
But look at Table 11 for 2013. There is quite a wide variation in the 120 results listed. For 2013 that ranged from 0.0% (the most common response) to 5.0%. The responses of 1.0% and higher were the outliers. With the outliers, it is difficult to imagine why a given specialty in a given province would have such a high number of patients leaving the country for health care. When we hear about delays in care in Canada, the most common one is orthopedics – joint replacement, etc. Yet in all of Canada, orthopedics is listed at 0.7%, below the 0.9% average for all specialties combined. It is suspicious that some physicians, intentionally or unintentionally, may be making high estimates which would skew the numbers upwards.
Let’s look at Table 11 for 2011 and 2012 as well as 2013. Urology in British Columbia was 1.3% in 2011, 2.0% in 2012, and 3.8% in 2013. Plastic surgery in British Columbia was 7.8%, 1.3%, and 0.4% in those same years. Cardiovascular survey in New Brunswick was 0.0%, 3.0%, and 0.5%. Internal Medicine in Manitoba was 3.4%, 0.5%, and 0.3%. Radiation oncology in New Brunswick was 0.5%, 7.0%, and zero. Obviously there is a large scatter in the high outliers that changes from year to year. Further, the entire population of specialists surveyed in 2013 totaled only 2,160 physicians scattered amongst 120 categories in the grid. It is quite obvious that only a few individual outliers, who either guessed high or wanted to make a political point, were able to skew the percentages upward. Eliminating the outliers likely would reduce the net percentage in half and maybe more.
For the next step, the Fraser Institute “(combined) these percentages with the number of procedures performed in each province and in each medical specialty (to give) an estimate of the number of Canadians who actually received treatment outside the country.” The results are in Table 1 of each of the three reports, “Leaving Canada for Medical Care.” If their percentages were correct (which they likely are not) and the tally of the procedures were correct (uncertain) then this calculation might give a very rough approximation of the number of procedures performed outside of Canada for each of the 120 categories of the grid. But talk about soft numbers.
They then add a “residual” number of procedures for which people are waiting. “To estimate this residual number, the number of non-emergency operations not contained in the survey that are done in each province annually must be used” – using CIHI and other data which they “pro-rated.” This “residual” for 2012 was 18,265 of the 42,173 total estimated to have exited Canada for health care. It’s a convenient number to boost the figures, even if they are “operations not contained in the survey.”
Talk about phantoms in the snow. This data is almost useless for estimating the number of Canadians who leave Canada for health care, much less whether or not they received it in the United States.
More importantly, the premise of those who use these unreliable numbers of patients exiting Canada for care is that single payer financing results in excessive queues which then triggers this exit. That should not necessarily follow since queues can be tamed if the stewards of the system are attentive to system capacity and queue management. Many nations with comprehensive systems do not have problems with queues.
In contrast, in the United States, the financial barriers to care (that do not exist in Canada) are so great that tens of millions who need care do not even gain a place in the queue – rationing based on ability to pay. Only a fool would recommend our callous system over Canada’s egalitarian single payer system.
For those who read this far, it might be worth your time to look at one more item. The “Waiting Your Turn” reports are the same reports that are used each year to claim that Canadians have intolerable delays in accessing their health care. For the 2013 Waiting Your Turn report, look at Chart 6 on page 10. Except for plastic surgery, orthopedics and internal medicine (not primary care), the actual median time between an appointment with a specialist and treatment is quite close to the median time that the specialists deemed to be a reasonable wait. And where there are problems, they are working on it.
More reliable data on wait times in Canada is available through the Canadian Institute for Health Information:
By Samuel Metz, M.D.
In a recent commentary at the JAMA Forum titled “The Innovation vs Consumer Protection Tug-of-War in Health Policy” , health economist Austin Frakt reflects on the possible sacrifice of innovation created by a single payer, universal health care plan.
“Greater regulation constrains choices, but may, in some ways, improve the options available and the choices people make,” he writes. “Market innovation encourages more options, including both helpful and harmful ones, and also allows more scope for people to make poor choices. A balance must be struck, and the left-right/protection-innovation tug-of-war that we see in health policy today reflects a debate about where to strike it.”
Dr. Frakt wonders whether consumers (his term) would be harmed or helped by a single payer plan that eliminates insurance plan innovation.
What consumers ultimately want from health care innovation is access, lower costs, and better health. When confronted with the unpredictability of human physiology and the complexity of our insurance options, consumers (we physicians call them patients) become intensely uncomfortable making choices that could lead to bankruptcy or an avoidable death of a family member if the wrong choice is made.
Professor Frakt is correct: when confronted by insurance packages with a bewildering variety of benefits, premiums, co-pays, deductibles, and networks, patients usually choose badly. Overwhelmed by the responsibility to guess which future diseases might afflict their families, patients default to plans that appear to promote their short-term financial interest, but which later prove to be against their long-term financial (and medical) interests [2-4].
Single-payer systems eliminate insurance innovation. All patients must accept one plan (single payer) with one risk pool (human beings), one set of benefits (all treatable conditions receive treatment), and one network (all physicians).
In return for sacrificing insurance innovation, patients participate in a health care system with guaranteed access, lower costs, and the best health care outcomes. This is not conjecture: for every population in which it is used, single-payer systems provide better care to more people for less money than American private insurance .
Professor Frakt summarizes this well when he observes that innovation includes both helpful and harmful choices. By eliminating insurance innovation, single payer removes the most terrifying choice most patients (and consumers) will ever confront. It would be a rare patient indeed who yearns for the good old days of insurance innovation.
1. Frakt, A. JAMA Forum: “The Innovation vs Consumer Protection Tug-of-War in Health Policy.” New@JAMA, March 12, 2014.
2. Abaluck J, Gruber J. “Choice Inconsistencies among the Elderly: Evidence from Plan Choice in the Medicare Part D Program.” American Economic Review, 2011;101(4): 1180-1210.
3. Zhou C, Zhang Y. “The Vast Majority Of Medicare Part D Beneficiaries Still Don’t Choose The Cheapest Plans That Meet Their Medication Needs.” Health Affairs 2012;31(10): 2259-2265.
4. “The Health Insurance Experiment. A Classic RAND Study Speaks to the Current Health Care Reform Debate.” Rand Research Highlights. 2006. http://www.rand.org/content/dam/rand/pubs/research_briefs/2006/RAND_RB9174.pdf. accessed February 25, 2014.
5. Davis K, Schoen C, Schoenbaum SC, Doty MM, Holmgren AL, Kriss JL, Shea KK. “Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care,” The Commonwealth Fund, May 2007. http://www.commonwealthfund.org/Publications/Fund-Reports/2007/May/Mirror–Mirror-on-the-Wall–An-International-Update-on-the-Comparative-Performance-of-American-Healt.aspx. Accessed March 12, 2014.
Dr. Samuel Metz is a Portland anesthesiologist and a member of Physicians for a National Health Program and Mad As Hell Doctors, both advocates for single-payer health care, and of Health Care for All Oregon, an umbrella organization advocating for publicly funded universal care for all Oregonians.
YouTube, March 12, 2014
On March 11, 2014, several authorities on single payer health care systems of other nations testified before a committee of the United States Senate, chaired by Sen. Bernie Sanders. The hearing was not only the topic of a recent Quote of the Day (March 12), it also has been covered extensively in the media and on the Internet throughout the United States and Canada.
It was the responses of Dr. Danielle Martin of Canada to the questions from Committee Ranking Member Sen. Richard Burr, that caused this story to go viral. For those who missed it, the 7 minute segment that includes the exchange between Dr. Martin and Sen. Burr can be viewed at this YouTube link: http://www.youtube.com/watch?v=iYOf6hXGx6M
You can read more about this exchange by Googling “Danielle Martin.” Some of the other coverage:
National Post: “Toronto doctor smacks down U.S. Senate question on Canadian waitlist deaths”: http://news.nationalpost.com/2014/03/12/toronto-doctor-smacks-down-u-s-senate-question-on-canadian-waitlist-deaths/
Los Angeles Times: “Watch an expert teach a smug U.S. senator about Canadian healthcare”:http://www.latimes.com/business/hiltzik/la-fi-mh-watch-a-canadian-20140312,0,2995139.story
Huffington Post: “Watch This Doctor Totally School An Anti-Obamacare Senator On Health Care”: http://www.huffingtonpost.com/2014/03/13/danielle-martin-richard-burr_n_4958164.html
Huffington Post Canada: “Canadian Doctor Gives U.S. Senator A Clinic On Public Health Care”: http://www.huffingtonpost.ca/2014/03/13/canadian-doctor-us-senator-health-care_n_4956468.html
CBC.ca (audio): “Canadian doctor schools U.S. Senator on public health care”:http://www.cbc.ca/asithappens/features/2014/03/12/canadian-doctor-schools-us-senator-on-public-health-care/
MSNBC: The Rachel Maddow Show (3/14/14, Ari Melber, guest host):http://www.msnbc.com/rachel-maddow-show
The Maddow Blog: “Martin 1, Burr 0″: http://www.msnbc.com/rachel-maddow-show/martin-1-burr-0#break
Salon: “Canadian doctor makes anti-Obamacare senator look like a buffoon”:http://www.salon.com/2014/03/13/canadian_doctor_makes_anti_obamacare_senator_look_like_a_buffoon/
Toronto Star: “Toronto doctor smacks down U.S. senators’ myths about Canadian health care”:http://www.thestar.com/life/health_wellness/2014/03/13/toronto_doctor_smacks_down_us_senators_myths_about_canadian_health_care.html
Canada.com: “Watch: Canadian doctor schools American senator on health care”:http://o.canada.com/health/danielle-martin-richard-burr-health-care-410599/
Huffington Post Canada: “Republicans Ruin Health Care By Ignoring Jesus (And Canada)”:http://www.huffingtonpost.ca/michael-bolen/canada-america-health-care-christian-nation_b_4957509.html
Well, you get the point.
For those interested in viewing the entire hearing (1 hour, 45 minutes), or wish to download witness statements: http://www.help.senate.gov/hearings/hearing/?id=8acab996-5056-a032-522e-e39ca45fcfbe
Medicaid And Marketplace Eligibility Changes Will Occur Often In All States; Policy Options Can Ease Impact
By Benjamin D. Sommers, John A. Graves, Katherine Swartz and Sara Rosenbaum
Health Affairs, April 2014 (online March 12, 2014)
Beginning January 1, 2014, the Affordable Care Act (ACA) established two pathways to health insurance for nonelderly US citizens and legal residents. The first was an expansion of Medicaid coverage for people with annual incomes of up to 138 percent of the federal poverty level in states that elected to expand their programs. The second pathway was subsidizing private coverage purchased via health insurance Marketplaces for people with incomes of 138–400 percent of poverty who do not have an offer of affordable coverage through an employer. The pathways are designed to work in tandem, but a major challenge is how to promote continuity of coverage and health care for people when their incomes and life circumstances cause them to transition between Medicaid and subsidized private coverage.
In states that opt out of the ACA’s Medicaid expansion, changes in income or family circumstance will lead many people to lose coverage entirely unless they qualify for coverage under one of the traditional categories of Medicaid eligibility: pregnancy, disability, or being the impoverished parent of a minor child. A less stark problem that presents a different set of challenges will occur in states that do expand Medicaid: the potential for moving between Medicaid and Marketplace coverage.
Both of these types of “churning”—loss of coverage and frequent transitions in the source of coverage—can cause difficulties. The total loss of coverage raises the most serious problems in terms of access to care, but frequent transitions across coverage pathways also raise important issues for beneficiaries, health plans, providers, and policy makers. From one year to the next or during any given year, many individuals and families will experience changes in eligibility either for Medicaid or for Marketplace coverage. These eligibility changes could lead to both gaps in coverage and disruptions in the continuity of care, because people might have to find new providers or change their existing health treatments if their new insurance plan uses a different provider network or covers different services than their old plan did.
Previous research has estimated that approximately half of low-income adults might experience a change in income or family circumstances leading them to transition from Medicaid to Marketplace coverage (or vice versa) each year.
From the Discussion
We estimated that approximately half (plus or minus 5 percentage points) of adults likely to be eligible for Medicaid or subsidized Marketplace coverage will experience an eligibility change within twelve months.
It is important to recognize that the eligibility changes we have analyzed are the result of an effort to expand pathways to affordable coverage for all Americans. Churning has often been used to describe the negative outcome of moving into and out of insurance coverage and becoming uninsured. In contrast, we are discussing changes that are a by-product of a system that allows for transitions among insurance pathways. These transitions increase the risks of disrupting care continuity and of having short gaps in coverage. But they represent a different (and less problematic) form of churning than that between having Medicaid or Marketplace coverage and being uninsured.
However, when low-income adults in states that opt not to expand their Medicaid programs experience a loss of income that drops them below 100 percent of poverty, most will not be eligible for subsidized coverage in the Marketplace or for Medicaid. Most nonexpansion states restrict Medicaid eligibility for adults to pregnant women, certain low-income adults with disabilities, and parents of minor children with incomes of no more than 35 percent of poverty on average. In other words, most adults who lose Marketplace subsidies in nonexpanding states will become uninsured, as has traditionally happened to adults who lose Medicaid eligibility.
A number of policies have recently been proposed to mitigate the effects of churning between Medicaid and Marketplace coverage, and state policy makers should consider them in the light of our findings.
One option is for states to adopt twelve-month continuous eligibility periods in Medicaid as a means of overcoming the churning effects of periodic income fluctuations
A second, more incremental option offered in CMS’s 2012 regulations allows states to assess people’s ongoing eligibility for Medicaid using projected annual income instead of current monthly income.
A third option for states is to use Medicaid funds to purchase coverage in qualified health plans in the Marketplace for people with incomes below 138 percent of poverty.
A fourth approach is the Basic Health Program, an option under the ACA that enables states to combine their Medicaid expansions with Marketplace subsidies into a single program for individuals and families with incomes of up to 200 percent of poverty.
A fifth option relates to how and when income changes are verified.
Finally, a state option that combines enrollment and marketing strategies is to encourage certified Medicaid managed care plans to enter state Marketplaces.
The Affordable Care Act (ACA) compounded and locked into place our highly fragmented, multi-payer method of financing health care. It is a system that makes churning inevitable – moving in and out of various plans or having no coverage at all, simply because program eligibility varies depending on each individual’s circumstances which often are in an intermittent state of flux.
As if there was not already enough instability with employer-sponsored and individual market plans, this study shows that under the two major expansions of ACA, “approximately half of adults likely to be eligible for Medicaid or subsidized Marketplace coverage will experience an eligibility change within twelve months.” Half in just the first year alone. What after that?
Eligibility change is highly disruptive to care. It changes the amounts that the individual or family will have to pay for premiums, cost sharing, and non-covered services. It changes the provider networks that vary under different plans. It can disrupt treatment programs. It can result in gaps in coverage or no coverage at all. As is typical with Medicaid, it can even change the willingness of physicians to accept the individual or family as patients.
And that line about keeping the coverage you have if you want it? Within one year, half will have a change in their eligibility. And the recommendations of the authors will only tweak the instability, but the fundamental problem will not be corrected. It is the ACA model that is irreparably flawed.
Unless we change our model of financing, instability and disruption will be the norm, not only because of shifting eligibility but also because plans obtained through employment or in the market are undergoing dramatic changes – even if less transparent – that will impact all of us with greater cost sharing, narrower networks, and other changes that none of us want. Do Americans really accept this mess as our preferred option for health care financing?
Change to a single payer national health program and this all goes away.
The Great Debate – Single Payer or Private Insurance
By Katie Britton
WAMC, March 13, 2014
Students for a National Health Program at Albany Medical College presented The Great Debate at WAMC’s The Linda on the evening of February 21st. Moderated by Dr. Kimberly Kilby, the debate featured Dr. Paul Song of the Physicians for a National Health Program (PNHP) from California and Dr. Mitchell Heller of the Benjamin Rush Society from New York City as they argued for and against single payer vs. private insurance.
For an audio of the debate (55 minutes): http://wamc.org/post/great-debate-single-payer-or-private-insurance
Resolved: The United States should switch to a single payer health care system
Speaking in favor is Paul Song, MD, representing Physicians for a National Health Program – an organization of physicians and others who advocate for “a universal, comprehensive single-payer national health program.”
Speaking in opposition is Mitchell Heller, MD, representing the Benjamin Rush Society – an organization of physicians and others “who believe that the profession of medicine calls its practitioners to serve their patients, rather than the government.”
“We as a society are defined by how we take care of the least amongst us.” – Dr. Song
“It’s hard to understand how command and control models like single payer still gain intellectual traction at all.” – Dr. Heller
Although you should listen to the debate before hearing the results, many of you do not have the extra 55 minutes. So here is the vote:
Before the debate:
66% – For
5% – Against
29% – Undecided
After the debate:
80% – For
2% – Against
18% – Undecided
Subcommittee Hearing – Access and Cost: What the US Health Care System Can Learn from Other Countries
Committee on Health, Education, Labor and Pensions (HELP) , Subcommittee on Primary Health and Aging
United States Senate, March 11, 2014
Tsung-Mei Cheng, LL.B., M.A.
Health Policy Research Analyst
Woodrow Wilson School of Public and International Affairs, Princeton University
Today’s hearing is focused on “international single payer health system models that provide universal coverage of health care.” I will tailor my remarks according to the three sub-themes the Committee wishes to explore, namely:
* Primary care access in single payer systems
* Health care costs in single payer systems, and
* Cross-country comparisons of health outcomes
Before proceeding with the Committee’s agenda in more detail, however, I would like to provide the Committee with a summary of my main points:
1. If equity and social solidarity in access to health care and financing health care were fundamental goals of a health care system, the single payer system provides an ideal platform for achieving these goals.
2. Single-payer systems typically are financed by general- or payroll taxes in a way that tailors the individual’s or family’s contribution to health-care financing to their ability to pay, rather than to their health status, which until this year has long been the practice in the individual health insurance market in the U.S.
3. These systems protect individual households from financial ruin due to medical bills.
4. Single-payer health systems typically afford patients free choice of health-care provider, albeit at the expense of not having a freedom of choice among different health insurers. Remarkably, in the U.S. households have some freedom of choice of health insurers – to the extent their employer offers them choice – but most Americans are confined to networks of providers for their insurance policy. In other words, Americans appear to have traded freedom of choice among providers for the sake of choice among insurers.
5. In single-payer systems “money follows the patient.” Therefore providers of health care must and do compete for patients on the basis of quality and patient satisfaction, but not price.
6. In a single payer health insurance system, health insurance is fully portable from job to job and into unemployment status and retirement. The “job-lock” phenomenon prevalent in the US is unknown in those systems, contributing to labor-market efficiency.
7. Because all funds to providers of health care in a single-payer system flow from one payer, it is relatively easy to control total health spending in such systems. Indeed, total national health spending as a percent of GDP in countries with single-payer systems is lower than it tends to be in non-single-payer health systems. This does not mean providers are left without a voice. Provider inputs are part of the formal negotiations over health-care budgets.
8. For the most part, single-payer systems achieve their cost control by virtue of the monopsonistic market power they enjoy vis a vis providers of health care. It is a countervailing power that the highly fragmented U.S. health-insurance system lacks vis a vis providers.
9. As part of their effort to control total health spending, however, and to avoid the waste of excess capacity that easily develops in health care, some single-payer systems (the UK and Canada) put constraints on the physical capacity of their health system (number of inpatients beds, MRI scanners, etc). That approach can lead to rationing by the queue. The alternative to rationing by such administrative devices, of course, is rationing by price and ability to pay, an approach used by design or by default in the United States. Rationing by price or by non-price mechanism are just alternative forms of rationing.
10. A single-payer system is an ideal platform for a uniform electronic health information system of the sort, for example, used by our Veterans Administration health system (a single-payer system in its own right). There is a common nomenclature which enables 100% electronic billing and claims processing, thus yielding significant savings in administrative costs.
11. Because they conveniently capture information on all health-care transactions, single-payer systems provide a data base that can be used for quality measurement, monitoring and improvement, and also for more basic research on what drives health spending and what clinical treatments works and does not work in health care. It enables evidence based medicine and the tracking of efficacy and safety of new drugs and devices once they are introduced after approval by government based on results of clinical trials.
Statement of Tsung-Mei Cheng (28 pages):http://www.help.senate.gov/imo/media/doc/Cheng.pdf
Video of the hearing and links to statements of all participants:http://www.help.senate.gov//hearings/hearing/?id=8acab996-5056-a032-522e…
Sen. Bernie Sanders chaired a Senate committee hearing on what the health care system in the United States can learn from other countries. Tsung-Mei Cheng provided an excellent overview of single payer and of the sharp contrasts between the United States and other nations. Her 28 page statement is well worth downloading to use as an information resource in educating others about single payer.
Other informative presentations included those of Victor Rodwin on France, Ching-Chuan Yeh on Taiwan, Danielle Martin on Canada, and Jakob Kjellberg on Denmark. Even the presentations from the other side by Sally Pipes and David Hogberg were helpful in that they showed how silly (sadly) their views were when contrasted with a group of experts who understand well how systems based on solidarity work. If you can find the time, viewing the entire video (1 hour & 46 minutes) and reading the statements would be well worth the effort (link above).
If you don’t have the time, at least view this 4 minute YouTube video of clips from the hearing: https://www.youtube.com/watch?v=9WdqtPLRc1A
Physicians for a National Health Program's blog serves to facilitate communication among physicians and the public. The views presented on this blog are those of the individual authors and do not necessarily represent the views of PNHP.
PNHP Chapters and Activists are invited to post news of their recent speaking engagements, events, Congressional visits and other activities on PNHP’s blog in the “News from Activists” section.