What Does It Cost Physician Practices To Interact With Health Insurance Plans?

By Lawrence P. Casalino, Sean Nicholson, David N. Gans, Terry Hammons, Dante Morra, Theodore Karrison, Wendy Levinson
Health Affairs
May 14, 2009

Physicians have long expressed dissatisfaction with the time they and their staffs spend interacting with health plans. However, little information exists about the extent of these interactions. We conducted a national survey on this subject of physicians and practice administrators. Physicians reported spending three hours weekly interacting with plans; nursing and clerical staff spent much larger amounts of time. When time is converted to dollars, we estimate that the national time cost to practices of interactions with plans is at least $23 billion to $31 billion each year.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.4.w533

And…

Peering Into The Black Box: Billing And Insurance Activities In A Medical Group

By Julie Ann Sakowski, Jeffrey M. Newman, James G. Kahn, Richard G. Kronick, Harold S. Luft
Health Affairs
May 14, 2009

Billing and insurance-related functions have been reported to consume 14 percent of medical group revenue, but little is known about the costs associated with performing specific activities. We conducted semistructured interviews, observed work flows, analyzed department budgets, and surveyed clinicians to evaluate these activities at a large multispecialty medical group. We identified 0.67 nonclinical full-time-equivalent (FTE) staff working on billing and insurance functions per FTE physician. In addition, clinicians spent more than thirty-five minutes per day performing these tasks. The cost to medical groups, including clinicians’ time, was at least $85,276 per FTE physician (10 percent of revenue).

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.4.w544

Much has been said about the large amount of premium dollars that are spent on the administrative excesses of the private insurance industry. These two important studies add additional evidence that the excesses of the private plans also increase the administrative burden placed on physicians and their co-workers.

The price paid for continuing to tolerate our dysfunctional, multi-payer system is tallied not only in manpower hours lost, but also in the monetary value of this wasteful burden placed on our health care professionals. Not quantified here is the price paid in loss of job satisfaction and the potential negative impact that could have on the enthusiasm for advocating for the best patient care possible within the resources made available.

Yesterday President Obama, boiling it down to basics, said, “But whatever plans emerge, both from the House and the Senate, I do believe that they’ve got to uphold three basic principles: first, that the rising cost of health care has to be brought down; second, that Americans have to be able to choose their own doctor and their own plan; and third, all Americans have to have quality, affordable health care.”

Americans have to be able to choose their own plan? Instead of having all essential care covered automatically by a single program, we have to choose a plan that limits coverage and limits choice of health care professionals? And for that we have to pay much more to cover the wasteful administrative costs of the insurers and the physicians? Why is that a basic principle?

The following statement by Dr. Quentin Young is in response to news reports on May 11 that the health care industry is promising the Obama administration that it will voluntarily reduce its rate of cost increases over the next 10 years.

The Obama administration is in peril of committing a colossal blunder. Powerful organizations, representing the major health industry groups, sent a letter to the president and subsequently met with him, pledging to reduce health cost inflation in the coming years.

The signers include America’s Health Insurance Plans, the Advanced Medical Technology Association, the American Hospital Association and the Pharmaceutical Research and Manufacturers of America.

Yes, health care costs are soaring and we urgently need reform. But these Johnny-come-lately rescuers are literally the cause of the crisis. Accepting their pledge of remedy is naïve and dangerous.

These corporate giants are legally bound to maximize return to their investors, which they do very well. They are the cause of the disarray in health care: double-digit inflation, 50 million uninsured and widespread medical bankruptcies.

How can any concerned administration rely on these culprits?

There is, of course, a different, proven remedy: single-payer national health insurance, an improved Medicare for all. Single payer slashes administrative costs, allowing us to provide universal, quality care for no more than we spend now. It also controls costs.

Can we hope President Obama will renew his earlier support for single payer and not accept the fool’s gold now proffered by the very malefactors who created the current crisis?

Quentin D. Young, M.D., M.A.C.P.
National Coordinator, Physicians for a National Health Program

“Financing Comprehensive Health Care Reform”

Committee on Finance
United States Senate
May 12, 2009

Testimony of Marcia Angell, M.D.

(file does not exist)

http://finance.senate.gov/sitepages/hearing051209.html

It didn’t happen.

After nurses and physicians supporting single payer were removed from the audience, single payer was mentioned once only parenthetically.

During a discussion on the tax deductibility of employer-sponsored health plans, Sen. Max Baucus indicated that we should retain the tax preference, perhaps with modifications, since we should work with what we have and not make a radical change.

In response, considering that eliminating the tax preference would be a radical change especially impacting workers, Gerald Shea of AFL-CIO stated, “If we’re going to do a radical change, I think that single payer is really the way to go.”

Exclusive: Max Baucus’s Health Care Team

by Ezra Klein
The American Prospect Blog
May 6, 2009

I mentioned yesterday that Chuck Schumer’s public plan compromise wasn’t a freelance effort: Max Baucus had deputized him to work through the options on the public plan. But he’s not the only Finance Committee member that received some homework from Baucus. In fact, Baucus has given every Democrat on the committee a different piece of health reform to focus in on.

This is the list:

Jay Rockefeller: Medicaid Expansion, Premium Subsidies, Quality Improvements

Kent Conrad: Comparative Effectiveness, Chronic Care Management

Jeff Bingaman: Pay-for-Performance, Bundled Payments, IHS

John Kerry: Health Information Technology, Exchange, Small Business Tax Credit

Blanche Lincoln: Small-Group Rating Reforms, Small Business Tax Credit

Ron Wyden: Tax Exclusion, Non-Group Rating Reform

Chuck Schumer: Public Plan

Debbie Stabenow: Employer Pay-or-Play, Medicare Buy-in, HIT

Maria Cantwell: Long-Term Care Reform, Workforce Issues

Bill Nelson: Graduate Medical Education, Medicare Part D

Bob Menendez: Disparities, Individual Requirement

Tom Carper: Fraud and Abuse, Prevention and Wellness, Transparency

http://www.prospect.org/csnc/blogs/ezraklein_archive?month=05&year=2009&base_name=exclusive_max_baucuss_health_c

Sen. Max Baucus has set an agenda to send a comprehensive health care reform bill to President Obama within the next few months. The significance of the assignments given to each of the Democratic members of the Senate Finance Committee is that they provide considerable insight as to the policies that are likely to be included in the legislative package.

Many of these categories involve significant increases in costs, especially through additional and more complex administrative functions. Potential cost savings here are merely wishes not supported by any solid policy studies. The quest to slow the rate of health care cost increases has been one of the most important driving forces for reform, yet these measures will only add more to the cost burden.

Providing health care for everyone seems to be elusive, and these measures would hardly budge the numbers. Perhaps that is why they changed the goal of universal coverage to a goal of “aim for” universal coverage.

Much of the demand for reform stems from public dissatisfaction with the waste and abuses of the private insurance industry. In response, we were promised much greater regulatory oversight of the private insurers. But where is it? Is that what the “Exchange” is? If so, can you imagine John Kerry crafting legislation that would convert our private insurers into a system of social insurance? Do you think that his conservative approach based on a foundation of sloth might be the reason that he received this important assignment?

The senators have some busy work to do. It’s too bad that it’s not on health care reform.

By Margaret Flowers, M.D.

On May 5, eight health care advocates, including myself and two other physicians, stood up to Sen. Max Baucus (D-Mont.) and the Senate Finance Committee during a “public roundtable discussion” with a simple question: Will you allow an advocate for a single-payer national health plan to have a seat at the table?

The answer was a loud, “Get more police!” And we were arrested and hauled off to jail.

The fact that a national health insurance program is supported by the majority of the public, doctors and nurses apparently means nothing to Sen. Baucus. The fact that thousands of people in America are dying every year because they can’t get health care means nothing. The fact that over 1 million Americans go into bankruptcy every year due to medical debt – even though most of them had insurance when they got sick – means nothing.

And so, as the May 5 meeting approached, we prepared for another one of the highly scripted, well-protected events that are supposed to make up the “health care debate” using standard tools of advocacy. We organized call-in days and faxes to the members of the committee requesting the presence of one single-payer advocate at the table of 15. Despite thousands of calls and faxes, the only reply – received on the day before the event – was, “Sorry, but no more invitations will be issued.”

We knew that this couldn’t be correct. We had heard Sen. Baucus say on that very same day that “all options were on the table.” And so, the next day, we donned our suits and traveled to Washington. We had many knowledgeable single-payer advocates in our group. And as the meeting started, one of us, Mr. Russell Mokhiber, stood up to say that we were here and we were ready to take a seat. And he was promptly removed from the room.

In that moment, it all became so clear. We could write letters, phone staffers, and fax until the machines fell apart, but we would never get our seat at the table.

The senators understand that most people want a national health system and that an improved Medicare for All would include everybody and provide better health care at a lower cost. These facts mean nothing to most of them because they respond to only one standard tool of advocacy: money, and lots of it.

The people seated at the table represented the corporate interests: private health insurers and big business and those who support their agenda. The people whose voices were heard all represented organizations which pay huge sums of money to political campaigns. These interests profit greatly from the current health care industry and do not want changes that will hurt their large, personal pocketbooks.

And so, we have entered a new phase in the movement for health care as a human right: acts of civil disobedience. It is time to directly challenge corporate interests. History has shown that in order to gain human rights, we must be willing to speak out and risk arrest. We must engage in actions that expose corporate fraud and corruption. We must make our presence known.

And that is why the eight of us, knowledgeable health care advocates and providers, most of us parents, some of us grandparents, spoke out one-by-one at the Senate Finance Committee. And it is why we will continue to speak out and encourage others to do the same. Our voices must be strong enough to drown out the influence of corporate dollars.

Health care must become the civil rights movement of this decade. The opportunity is here. And we can create a single-payer national health care system.

Yes, we can.

Dr. Margaret Flowers is a pediatrician in Baltimore and co-chair of the Maryland chapter of Physicians for a National Health Program (PNHP). Her statement was co-signed by Mark Dudzic, Labor Campaign for Single Payer; Russell Mokhiber, Single Payer Action; Carol Paris, M.D., PNHP; Katie Robbins, Healthcare-NOW!; Pat Salomon, M.D., PNHP; Adam Schneider, B’more Housing for All; and Kevin Zeese, ProsperityAgenda.us.

Arrested for fighting for healthcare reform

The Ed Show
May 7, 2009

Ed Schultz interviews Dr. Margaret Flowers:
http://www.msnbc.msn.com/id/21134540/vp/30629823#30629823

Visit msnbc.com for Breaking News, World News, and News about the Economy

When you have 11 minutes, view this video. Then share it with others.

THE LANGUAGE OF HEALTHCARE 2009

By Dr. Frank I. Luntz

This document is based on polling results and Instant Response dial sessions conducted in April 2009. It captures not just what Americans want to see but exactly what they want to hear. The Words That Work boxes that follow are already being used by a few Congressional and Senatorial Republicans. From today forward, they should be used by everyone.

You simply MUST be vocally and passionately on the side of reform. The status quo is no longer acceptable. If the dynamic becomes “President Obama is on the side of reform and Republicans are against it,” then the battle is lost and every word in this document is useless. Republicans must be for the right kind of reform that protects the quality of healthcare for all Americans. And you must establish your support of reform early in your presentation.

THE 10 RULES FOR STOPPING THE “WASHINGTON TAKEOVER” OF HEALTHCARE

(1) Humanize your approach.

(2) Acknowledge the “crisis” or suffer the consequences.

(3) “Time” is the government healthcare killer.

(4) The arguments against the Democrats’ healthcare plan must center around “politicians,” “bureaucrats,” and “Washington” … not the free market, tax incentives, or competition.

(5) The healthcare denial horror stories from Canada & Co. do resonate, but you have to humanize them.

(6) Healthcare quality = “getting the treatment you need, when you need it.”

7) “One-size-does-NOT-fit-all.”

(8) WASTE, FRAUD, and ABUSE are your best targets for how to bring down costs.

(9) Americans will expect the government to look out for those who truly can’t afford healthcare.

(10) It’s not enough to just say what you’re against. You have to tell them what you’re for.

http://www.politico.com/static/PPM116_luntz.html

This is an important document. It is Frank Luntz’s recommendation to the Republican politicians on how to frame the debate over health care reform. If you have been listening to the Republicans speak on reform, you have already heard some of the rhetoric, and you will recognize it as you read this report.

This is not a report on health policy. If you read it as if it were a policy paper, you will likely become angered over the liberties that Luntz takes with policy concepts. You will recognize a great many distortions and, worse, many instances in which his statements are not supported by the facts (i.e., “lies” in common parlance).

This is a report on political framing of the debate. It is designed to provide Republicans with political rhetoric that theoretically would shift support to the Republican positions for reform, and away from the Democratic positions. As you read it, you will see that there is a very strong emphasis on the latter, and very little on the former since the Republicans have almost nothing to offer in the way of substantial reform.

A note of caution: As you read the report, you will tend to fall into the trap of responding based on their framing of the issues. Do not do that. Always address the issues within our own framing structure. When you identify rhetoric that is blatantly untrue, you will tend to say, “That’s a lie.” Such ’tis so/’tis not debates are never productive and tend to favor the smooth talkers (predominantly Republicans). Instead, respond with highly credible facts that use the framing from our own arena.

Another word about lies. You will see that Frank Luntz does not have an issue with this. What counts is a strong message that appears to be credible, regardless of whether or not it is. On our side, we must never lie, nor even distort our message. We have established unblemished credibility with our message, and we must never do anything that might impair that credibility. That makes our task more difficult because we must be very careful that anything we say is supported by sound health policy science. But it also makes the Republicans vulnerable since they tend to concentrate on sound bites that are not based on sound policies. That risks exposing them as charlatans; we can do that with our carefully framed messages.

Some parts of the report actually provide good advice not only for the Republicans, but for the Democrats as well. In fact, you will identify some recommendations that have been lifted from our camp. We can continue to use these, and we should not attack them when they use the same rhetoric. Only when they twist it unfairly should we counter with our rhetoric describing the beneficial impacts of our policies.

Look at this example from the report: “What Americans are looking for in healthcare that your ’solution’ will provide is, in a word, more: ‘more access to more treatments and more doctors…with less interference from insurance companies and Washington politicians and special interests.’”

What Luntz left unsaid is that these are features that more closely describe the progressive position. Most of the Republican policies would make these worse. Again, you wouldn’t respond by saying, “That’s not true.” You would respond by providing accurate sound bites on how the single payer proposal provides improved access by eliminating financial barriers to care, and single payer would eliminate the private insurance industry so it could no longer interfere with your care.

Wait. Progressive? Single payer? Isn’t my comment supposed to be talking about the framing to be used the Democrats? Well, we have a problem here.

Look at another example from Luntz’s report: “We suggest ratcheting up the rhetoric against insurance companies to almost the same degree as you do against Washington bureaucracy. Call the Democratic plan a ‘bailout for the insurance industry’ — both because it is, and because it will build lasting credibility by going after the two things the American people hate most: Washington bureaucracy and insurer greed.”

Wow! Luntz is right! The Democratic plan IS a “bailout for the insurance industry.” In fact, the Democrats have lost all credibility on this one when they have AHIP’s Karen Ignagni front and center at every hearing, every forum, every summit, and her operatives providing input to the closed-door sessions, while they have excluded from the process those who most vigorously attack the insurance companies – the single payer advocates.

Read Luntz’s report. Be prepared to respond using our framing. Attack their credibility when they provide us with obvious openings.

What is sobering is that we have to use the truth to attack both the Republican and the Democratic politicians. And this was to have been our great opening to provide high quality care for everyone.

But don’t give up. The Democrats’ plan won’t work. They’ll still need us to fix our system when their failure becomes painfully obvious.

Schumer Offers Middle Ground on Health Care

By Robert Pear
The New York Times
May 5, 2009

In an effort to defuse the most explosive issue in the debate over comprehensive health care legislation, a top Senate Democrat has proposed that any new government-run insurance program comply with all the rules and standards that apply to private insurance.

The proposal was made Monday by Senator Charles E. Schumer of New York, the third-ranking member of the Senate Democratic leadership, in a bid to address fears that a public program would drive private insurers from the market.

Democrats in Congress hope to shift the debate from the question of whether to create a public health insurance plan to the question of how it would work.

“The public plan,” Mr. Schumer said Monday, “must be subject to the same regulations and requirements as all other plans” in the insurance market.

The chairman of the Senate Finance Committee, Max Baucus, Democrat of Montana, asked Mr. Schumer to seek a solution. In his response, Mr. Schumer set forth these principles:

* The public plan must be self-sustaining. It should pay claims with money raised from premiums and co-payments. It should not receive tax revenue or appropriations from the government.

* The public plan should pay doctors and hospitals more than what Medicare pays. Medicare rates, set by law and regulation, are often lower than what private insurers pay.

* The government should not compel doctors and hospitals to participate in a public plan just because they participate in Medicare.

* To prevent the government from serving as both “player and umpire,” the officials who manage a public plan should be different from those who regulate the insurance market.

In addition, Mr. Schumer said, the public plan should be required to establish a reserve fund, just as private insurers must maintain reserves for the payment of anticipated claims. And he said the public plan should be required to provide the same minimum benefits as private insurers.

Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group, said, “We are very, very grateful that members of Congress have been thoughtfully looking at our concerns.” But she said she still saw no need for a public plan “if you have much more aggressive regulation of insurance,” which the industry has agreed to support.

http://www.nytimes.com/2009/05/05/health/policy/05health.html?ref=politics

The success of the effort to reform health care seemed to be threatened by the disagreement over whether or not a public insurance option should be offered to compete with private health plans. All Republicans have expressed opposition to the public option, indicating that it would be a deal breaker if included. The Progressive Caucus in the House, which actually wants single payer, has taken a position that leaving the public option out of the reform legislation would be a deal breaker.

To prevent gridlock, Sen. Charles Schumer offers the simple solution of “public option light” so that it would not be a deal breaker for either side. The progressives would have a government-sponsored plan in the mix of private plans, and the Republicans would have government-sponsored plan that is indistinguishable from private plans, creating a level playing field. Thus each side could move forward with reform without having to implement their deal-breaking rhetoric.

This is not simply Sen. Schumer’s personal effort defuse this bomb. His public option compromise was prepared at the request of Sen. Max Baucus who has been working closely with Sen. Charles Grassley to craft truly bipartisan reform legislation. In fact, at yesterday’s Senate Finance Committee hearing on expanding health care coverage, in addition to the fifteen scheduled witnesses, Sen. Baucus called on committee member Schumer to present the public option compromise.

Look at the history of what has happened here. The progressives were told by the moderates that the votes for single payer were not there. So negotiations began from a position that single payer was off the table. The progressive community then decided to concede that the Republicans and the insurance industry could have their market of private plans, and that the compromise position that all could accept would be the addition of a public insurance option.

In the compromise process, the Republicans and the insurance industry finally made their move. That was, “drop dead.” The Progressive Caucus responded with, “we’ve already come more than half way, so now you drop dead.” So now we have the Schumer compromise of public option light, which now has been blessed as the current, official Democratic position, even though it moves even closer to the Republican position.

What have the Republicans conceded so far? Nothing. What is the insurance industry’s position on a competing public plan that looks just like their private plans? Karen Ignagni of AHIP says that she still sees “no need for a public plan.” No concession.

The Democrats have already conceded on an effective public plan option. They have conceded that universal coverage is not possible so we should merely “aim for universal.” They have admitted that they have not figured out a way to pay for plans with adequate benefits for working families. They have abandoned support of policies that would improve value while controlling costs.

The Democrats have already given away all major policies for reform, and the Republicans haven’t had to budge the least. Why should they when the Democrats are rushing in their direction?

It is ironic that yesterday, at the Senate Finance hearing, one by one, eight individuals, including physicians from PNHP, stood up and offered to present policies that would work.

One of them stated, “… single payer national health care; we want a seat at the table.”

Sen. Baucus responded, “We want police,” and he got them. Each was arrested in turn.

That allowed enough time for Sen. Baucus to add Sen. Schumer as an additional pseudo-witness so that they could kill the last, but all-too-feeble effort at real reform – the public option.

Hearing on “Expanding Health Care Coverage”

Senate Committee on Finance
May 5, 2009

The opening of the hearing was disrupted by a passionate protest from the audience…

Person from audience: (at end of the protest)… We need health care now! Put single payer on the table now!

Sen. John Kerry: Is there anyone in the audience who didn’t come to…

(Laughter)

Sen Max Baucus: Let me say this. I think I speak for everybody on the committee and everybody in the Congress… deeply, deeply respect the views of all members of the audience and of all Americans who feel deeply about health care reform, especially those who are worried about single pay system, public option, who really do fervently believe that is the proper result. That is a view that many people have. It’s a view which I respect. There are other approaches to health care reform which also I respect. The whole point of this hearing and other hearings is to try to determine the best route, the best option, in determining how to best reform our country’s health care system. So for those of you who remain in the audience who may be inclined to stand up and, out of order, to state your views, I encourage you to not do so, because I want you to know that I personally care deeply about your views. I deeply respect your views. I hear what you say. I talk to a lot of people in my home state of Montana who have the exact same views. I represent 900,000 of the world’s best bosses, Montanans, and many of them have the very same view. But we aren’t going to get the best result here… the more we can have an orderly discussion of how we should best reform the health care system. So I want to say to everyone, especially those of you who might be inclined to stand up, that I urge you not to so we can proceed with the hearing holding your views also deeply in mind as we proceed. Thank you.

http://finance.senate.gov/sitepages/hearing050509.html (includes the list of witnesses and their testimonies)

Apparently the single payer views must have been held very deeply, hidden in the minds of the Senators and the witnesses, since at no time during the hearing was single payer discussed as an option for reform.

It is one thing to respect the views of those who support a model of reform that actually would provide all necessary health care for everyone and make it affordable for each and every individual, but it is quite something else to restrict the discussion to options that cannot ever achieve those goals.

This hearing represents the the framework of reform that is being crafted behind closed doors. The tragedy is that any bill that results from this process will delay further the reform that we desperately need. In the meantime, tens of millions or more will face unnecessary physical suffering and financial hardship, and many will die.

The epitaph: BUT MY VIEWS WERE RESPECTED

Where Did All the Doctors Go?

The New York Times
May 3, 2009
Letters

To the Editor:

Re “Shortage of Doctors Proves Obstacle to Obama Goals” (front page, April 27), about a lack of primary care providers :

As those of us responsible for delivering health care know, the battle between specialists and primary care doctors has been going on for years, and one side has been winning.

The marketplace has rewarded specialists financially, and like any other special interests, they are amply financed for this conflict. Still, I don’t fault them. They have studied and worked hard, and are responding to market incentives, like good red-blooded Americans.

What we really need is a European-style single-payer system, with primary care doctors who emerge from their training with European-style debt loads: zero.

Georganne Chapin
Tarrytown, N.Y.

The writer is president and chief executive of the Hudson Health Plan, a not-for-profit managed care organization.

http://www.nytimes.com/2009/05/04/opinion/l04doctors.html

And…

Subject: Graduate Medical Education: Trends in Training and Student Debt

GAO (Government Accountability Office)
May 4, 2009

In summary, we found that medical students prefer surgical and procedural specialties, and physician subspecialization is increasing. Relative to the number of available residency positions, more medical students have preferred surgical and procedural specialties over primary care specialties since 1999, according to national data.

Some factors may also lead students to pursue certain specialties while avoiding others. For example, the desire for a controllable lifestyle — a predictable schedule and fewer on-call hours — and high salary may lead students to pursue procedural specialties such as anesthesiology, and avoid other specialties such as primary care.

Medical school tuition and fees have increased significantly since 1998. Medical students can borrow up to $40,500 per year through the federal Stafford loan program with additional funding available through other federal loan programs; these loan programs can cover the full cost of medical school. The median amount of educational debt for indebted medical students graduating in 2008 was $155,000 — a 53 percent increase since 1998, controlling for inflation. Once out of medical school, residents earn stipends — on average about $3,729 a month for a 1st year resident. With $155,000 in debt, a resident’s monthly loan payment could reach over $1,700 (about 48 percent of pretax income). However, residents have repayment options that can reduce their monthly debt payment until they complete postgraduate training.

http://www.gao.gov/new.items/d09438r.pdf

This statement from a highly respected executive of a not-for-profit managed care organization, and this new GAO report, both further confirm what we already knew. Medical students are graduating with excessive debt, and this is likely contributing to the decline in the numbers choosing the primary care specialties.

Without increasing total health care spending, a few policies could be adopted which would realign incentives to improve our primary care infrastructure, while relieving students of the necessity of accumulating debt. That would be much easier to accomplish through a single payer monopsony than through a dysfunctional, fragmented, multi-payer, health care financing system.