German Diabetes Management Programs Improve Quality Of Care And Curb Costs

By Stephanie Stock, Anna Drabik, Guido Büscher, Christian Graf, Walter Ullrich, Andreas Gerber, Karl W. Lauterbach and Markus Lüngen
Health Affairs
December 2010

Abstract

This paper reports the results of a large-scale analysis of a nationwide disease management program in Germany for patients with diabetes mellitus. The German program differs markedly from “classic” disease management in the United States. Although it combines important hallmarks of vendor-based disease management and the Chronic Care Model, the German program is based in primary care practices and carried out by physicians, and it draws on their personal relationships with patients to promote adherence to treatment goals and self-management. After four years of follow-up, overall mortality for patients and drug and hospital costs were all significantly lower for patients who participated in the program compared to other insured patients with similar health profiles who were not in the program. These results suggest that the German disease management program is a successful strategy for improving chronic illness care.

From the Discussion

The quest to reorganize care for chronically ill beneficiaries has led to different approaches in the United States and Germany. While US Medicare invested in regional pilots that differ in their structure of care delivery and may use disease management vendors, German health plans decided on an approach with a heavy emphasis on quality assurance and the primary care physician as the program manager. The emphasis is on educating both the patient and the care provider. Characteristics of care considered desirable in a patient-centered medical home, such as coordination, integration, timeliness, efficiency, and effectiveness as well as the patient-centeredness of care, improved markedly.

http://content.healthaffairs.org/content/29/12/2197.abstract

The Germans have demonstrated what disease management should be all about. Using primary care medical homes as a base, the physicians and their in-house teams provided coordinated and integrated care for their diabetic patients with the result that physician-patient relationships were enhanced, costs were lower, major complications were fewer, and mortality was reduced in half compared to the control group.

The phenomenal success was no doubt in a large part due to placement of the disease management process precisely where it belongs – within the team at the patient’s own primary care medical home. This is a model based on patient service.

In contrast, the U.S. uses a business model, often with intrusive, fragmented interventions by outside vendors and private insurers. The U.S. model compounds our administrative excesses, fails to recover the additional costs of these outside, for-profit business entities, and yet has not demonstrated the dramatic benefit that this German approach has.

What is our problem here in the United States? Why do we keep insisting that “the market can do it better,” whatever that means? It is blatantly obvious that diseases are best managed by the patient’s own medical team – a team that is, gee, trained to manage diseases, and a team who knows the patient’s medical and cultural background. Yet we passively accept an expensive, intrusive, ineffectual insurance industry and their vendors because, somehow, we are mesmerized by the meme that the market can do it better, as if private practices weren’t the health care market that actually matters.

Of course, now the insurers claim that disease management should not be counted as an administrative service, but should be classified as a health care service so that it provides them with a more favorable medical loss ratio. Thus the insurers are claiming, in effect, that they are partially usurping the role of the health care team in providing health care services themselves, and they are even being paid for it with fees that they explicitly classify as health care expenses under the medical loss ratio.

Haven’t we had enough? Let’s throw them out and establish our own public national health program that will redirect our funds toward reinforcing our primary care infrastructure so that our physicians and their teams will be there to manage our diseases when we need them managed.

It was clear from the beginning of the health care “reform” charade that the insurance industry, the drug industry and other parts of the corporate medical industrial complex were working to assure that any legislation that passed would add to their financial bottom lines. They largely succeeded in this. The following examples illustrate how well some of these industries made out with the final result, the Patient Protection and Affordable Care Act of 2010 (PPACA), which passed in March:

• By way of the individual mandate, insurers will gain 32 million new enrollees,most requiring government subsidies to either patients or employers.

• The drug industry avoided importation of drugs from other countries and again fended off any role of the government to negotiate drug prices, as the Veterans Administration does so well in getting prices down to about 58 percent of usual costs.

• Existing specialty hospitals, physician-owned facilities that allow physicians to “triple dip” their incomes as providers, owners and investors, were grandfathered in.
But that was only the start of a continuing series of compromises by the Obama Administration that further weaken the bill and add fuel to the accelerating rate of health care inflation. When any of the corporate stakeholders raised objections to one or another part of the “reform” package, their objections were generally met with industry-friendly concessions.

The government had little room to negotiate. Having falsely assured the public from the beginning that they could keep their insurance if they liked it, the government had put itself into a corner where it has to cater to the insurance industry. Otherwise, the market would be “disrupted”, resulting in many people losing their coverage.

Waivers have become the instrument whereby to further coddle the insurance industry, rendering less effective any “teeth” that are in the bill. In the last few months, there have dozens of waivers granted, watering down a number of provisions of the PPACA. Here are some examples:

• When insurers complained that they may have to exit the market if forced to offer coverage of sick children on their parents’ policies, the government obliged by allowing brief open-enrollment periods whereby such coverage would be unavailable for much of the year; insurers were also granted permission to raise premiums for sick children until 2014, to the extent that state laws allow. (1)

• Insurers are still free to set their own premium rates, with little effective restraint by a government which can mostly just protest large increases; most rate-
setting “controls” are at the state level, where regulators tend to be industry-friendly. Thus premiums may be hiked up to 40 percent in the individual market.(2)

• The industry has strongly resisted the law’s requirements to set their medical loss ratios (MLRs) at 85 and 80 percent, respectively, for large employer and small employer/individual plans. That would force them to pay out at least 80 or 85 percent of their premium revenue on medical care. But what counts as “medical care”? The industry lobbied hard for a broad interpretation of that question, to include a number of non-medical expenses, even extending to commissions of insurance brokers. The latest rules, as recommended by the National Association of Insurance Commissioners and adopted by the Department of Health and Human Services (HHS), affect about 75 million people (11 million with individual policies, 24 million with small group coverage, and 40 million with large employer coverage). The insurance lobby won a number of concessions, including counting expenses of quality assurance as medical costs, allowance to deduct many of their taxes from their total premiums before calculating their MLR, and the ability to appeal for a lower MLR standard for up to three years in states where “there is a reasonable likelihood that market destabilization could harm consumers”. Four states have already sought such adjustments—Georgia, Iowa, Maine, and South Carolina. (3)

• Many insurance plans, including most large employers, are already exempt from the PPACA’s provisions. These plans have been “grandfathered in” without PPACA requirements, and have even been given other ways (eg. switching carriers) to keep that status.

• A recent ruling by HHS allows more than 100 employers and other insurers to retain very low annual limits of coverage (eg. only $2,000 a year, hardly qualifying as insurance). Employers such as McDonald’s Corp., after warning regulators that it might have to drop coverage for 30,000 hourly workers, handily won this concession for their “mini-med” policies. (4)

According to economists at the Centers for Medicare and Medicaid (CMS), health care spending will not be cut by the PPACA. By 2019 they expect that U. S. health spending will reach $4.6 trillion, accounting for almost 20 percent of GDP. By then spending on private health insurance will exceed $600 billion a year (32 percent of all health care spending). (5)

As health care inflation proceeds apace, employers are passing on more costs to their employees. Prices continue to soar throughout the system, even accelerating as hospitals and physician groups gain consolidated market clout. This leaves insurers and employers in a weaker negotiating position. Health insurance and care get less affordable every day for much of our population. And federal subsidies under PPACA are more than three years off in 2014, as is Medicaid expansion.

So the health care crisis continues unabated as proponents of PPACA and a defensive Administration posture how much it is helping us. The urgency and stakes for real reform just notch up with each passing month and year. Despite the losses of progressive policies in the recent midterm elections, there is one bright ray of hope in three states—Vermont, California and Hawaii—where the new leadership is supportive of real health insurance reform—single-payer universal coverage without exploitive profiteering by a dying insurance industry kept alive only by government subsidies of one kind or another.

References:
1. Pear, R. U. S. to let insurers raise fees for sick children. New York Times, October 13, 2010.
2. Ostrom, CM. Steep rate hikes on way for individual health insurance. Seattle Times, September 6, 2010.
3. Pear, R. New rules tell insurers: spend more on care. New York Times, November 23, 2010: A22.
4. Adamy, J, Johnson, A. Rules eased for some health plans. Wall Street Journal, November 23, 2010: B1.
5. Adamy, J. Health outlays still seen rising. Wall Street Journal, September 9, 2010: A7.

Adapted in part from Hijacked! The Road to Single Payer in the Aftermath of Stolen Health Care Reform, 2010, with permission of the publisher Common Courage Press.

Insurers sell products to fill the gap

By L. M. Sixel
The Houston Chronicle, Dec. 8, 2010

As employees face higher co-pays, deductibles and health care premiums, a relatively new insurance product has become increasingly popular.

It’s known as “gap” or “bridge” insurance, and it covers some of the out-of-pocket health care costs that are becoming more difficult for employees to shoulder, such as annual deductibles that are rising to $1,000, $2,500 or even $5,000.

Families that live paycheck to paycheck can’t absorb the increase in costs, said Brad Peak, vice president of products and marketing with the insurance carrier Assurant Employee Benefits in Kansas City, Mo.

The trend is moving toward the $2,500 deductible, Peak said. Assurant views that as the “sweet spot” that makes gap insurance attractive to employees on a budget.

Some employee benefits experts, however, question the value of gap insurance. It can be expensive for what it offers. Some limitations on coverage for pre-existing conditions can make it useless for someone with a chronic medical problem. And the rules may be prohibitively restrictive, such as limiting reimbursement to patients whose conditions require hospitalization.

(Brett Haugh, a partner with Employee Benefit Solutions in Houston) said the policies can be pricey, with about 50 cents of every dollar going toward the broker’s commission.

http://www.chron.com/disp/story.mpl/business/sixel/7330802.html

It was inevitable. First in the individual market and then in the employer-sponsored insurance market relief from skyrocketing insurance premiums was gained by switching to high-deductible plans. Although this slowed the acceleration of premium increases, actual health care access was impaired for many because of the often-inappropriate financial disincentives of the  deductibles and other cost sharing. This financial barrier opened the doors for the insurance industry to sell protection against the deductibles by offering an additional insurance product to fill the gap in the primary insurance product – an insurance policy to insure against the adverse effects of another insurance policy.

If it sounds familiar, it is. Medigap policies are purchased by the majority of individuals covered by the traditional fee-for-service Medicare program. Medigap plans are private insurance products that cover the gap for deductibles and other out-of-pocket expenses that Medicare beneficiaries would otherwise face when they have health care needs.

We already know how lousy these products are. Medigap plans offer the worst value of commonly available insurance products. They impose a second wasteful administrative layer on top of the primary Medicare coverage. They typically have medical loss ratios of about 65 percent, meaning that they consume 35 percent of the Medigap premiums for their own intrinsic purposes. Yet seniors buy these plans because of fear of facing financial hardship just when health care needs are greatest.

In a bit of irony, the Patient Protection and Affordable Care Act requires that the Medigap plans be revised to “include nominal cost sharing requirements that encourage the use of appropriate Part B physician services.” Thus Congress, in its wisdom, wants Medicare beneficiaries to experience price sensitivity by establishing deductibles for the supplemental Medigap plans that pay the deductibles for the traditional Medicare program. What?

Now we have a market of similar private gap plans that cover private insurance plans, with all of the same inefficiencies and excesses as Medigap plans, except that they’ve added the market innovation of using half of the premiums just for the insurance brokers’ commissions (if you believe Brett Haugh, quoted in the Houston Chronicle article above).

This is so unnecessary. Deductibles have been proven to result in harm by causing patients to forgo appropriate care, yet they have very little impact in reducing our total national health expenditures. The administrative waste of gap plans can be avoided by simply eliminating the deductibles and other cost sharing. Then you wouldn’t need the gap plans at all.

In a recent response to a New York Times blog on how higher deductibles cause families to delay or forgo medical care I explained why the cost of eliminating deductibles is not that great. It is response # 23 at this link:
http://community.nytimes.com/comments/prescriptions.blogs.nytimes.com/2010/11/22/higher-deductibles-lower-spending/

Raising Premiums And Other Costs For Oregon Health Plan Enrollees Drove Many To Drop Out

By Bill J. Wright, Matthew J. Carlson, Heidi Allen, Alyssa L. Holmgren and D. Leif Rustvold
Health Affairs
December 2010

The Oregon Health Plan was created to be a sustainable program that could weather budgetary storms without having to cut enrollees from Medicaid. A 2003 redesign of the program increased premiums, raised cost sharing, and imposed rigid premium payment deadlines for members in the “Standard” version of the program but not for members of the “Plus” version. This paper adds two years of longitudinal data to a previous study on the impacts of these changes. It shows that the redesign was a key factor driving a 77 percent disenrollment rate in the Standard program, from a high of 104,000 enrollees in February 2003 to just 24,000 by the end of the study period, November 2005. Those who were in the Standard plan when the reduced benefits and higher member costs went into effect were also nearly twice as likely to have unmet health care needs compared to those in the Plus plan.

Impact In Oregon

The 2003 Medicaid redesign had profound effects on the Oregon Health Plan Standard population. In the months immediately after the redesign, many of those enrolled in the Standard plan left the program entirely. These people, as well as those who remained in the program, subsequently experienced greater unmet health care needs, reduced use of care, more medical debt, and greater household financial strain than members of the Plus plan, to whom the redesign did not apply.

Changes to the cost-sharing structure, which consisted of mandatory copays, increased monthly premiums for some members, and tightened administrative rules including a loss of coverage for nonpayment of premiums, affected Standard plan members in two main ways. First, the changes in premium rules led to heavy disenrollment initially, and those who left often experienced periods of uninsurance throughout the study time frame along with the other changes, such as higher rates of unmet need.

Second, even after gaps in coverage and other known differences between the populations were controlled for, members of the Standard plan experienced poorer outcomes than members of the Plus plan. This suggests that even for those who managed to stay enrolled in spite of higher premiums, increased cost sharing in the form of mandatory copays may have limited members’ access to and use of care, in addition to having a direct financial impact.

Implications For Other States

These findings contain lessons for other states, particularly as they implement Medicaid expansions under the Affordable Care Act. Some states already provide Medicaid coverage to nonelderly adults with incomes up to 133 percent of the federal poverty level, but the act is expected to result in more than seventeen million Americans’ becoming eligible for Medicaid by 2014.

Cost Sharing:

The first lesson is that although strict cost-sharing rules might be an appealing way to offset the costs associated with increased Medicaid enrollment, they create barriers for people to get and keep insurance.

Our data show that Medicaid members are sensitive to even small cost-sharing increases. Coupling those increases with stricter payment policies can create widespread coverage loss. In fact, previously published analyses of this study’s data suggest that the most vulnerable Standard plan members were the most likely to leave in response to changes in cost-sharing rules.

This fact is particularly important because recent analyses of census data suggest that nearly half of those who will become eligible for Medicaid under the new federal eligibility guidelines have incomes below 50 percent of the federal poverty level. In this newly eligible, very-low-income population, offering payment flexibility and exemptions might help ensure that the neediest benefit from coverage expansion.

Coverage Gaps:

Second, those who leave Medicaid in response to changes in cost-sharing rules are very likely to experience major coverage gaps. Over time, they have more difficulty meeting their health care needs, accumulate more medical debt, and experience greater financial strain than those who stay insured.

Unmet Need:

Third, even among those who remain enrolled, increased cost sharing in the form of copayments may result in greater unmet need for health care, along with increased household financial strain and medical debt. It may also greatly depress health care use. Although reducing unnecessary use is one of the goals of cost sharing, when reduced use is paired with an increase in unmet need, the question arises, does the reduction represent care that is needed or that would help prevent costly complications in the future?

http://content.healthaffairs.org/content/29/12/2311.abstract

Currently there is a fixation in the health policy community on designing plans that require a significant financial contribution from the beneficiary on the theory that high health care costs can be moderated by making patients more sensitive to those costs.

Many studies have now confirmed that these plan designs impair access to health care because of affordability issues, and result in impaired health outcomes. Although this is certainly true for those with moderate incomes, this new study confirms once again that it is particularly disastrous for low-income individuals.

As a result of the Patient Protection and Affordable Care Act (PPACA), in 2014 an estimated 17 million individuals will be added to state Medicaid programs. Because of tight budgets, states are already seeking federal waivers that would relax the PPACA requirements.

It is likely that most states will soon seek waivers for their Medicaid programs to allow flexibility in innovation. The innovations will not be for the purpose of assisting patients in getting the care that they need, but rather they will be for the purpose of reducing the Medicaid component of the state budgets.

PPACA has already enshrined high cost-sharing by establishing low-actuarial value plans (high deductibles, etc.) as the standard within the state insurance exchanges. The temptation for states to expand this concept to Medicaid will be great.

The Oregon Health Plan may have provided an important lesson for other states, but that won’t prevent them from doing the same. After all, making price-sensitive shoppers out of people who have no money is effective in reducing health care spending, even if it does result in further financial hardship, physical suffering, and even death, and dead patients are the least expensive of all.

McAllen And El Paso Revisited: Medicare Variations Not Always Reflected In The Under-Sixty-Five Population

By Luisa Franzini, Osama I. Mikhail and Jonathan S. Skinner
Health Affairs
December 2010

Medicare spending for the elderly is much higher in McAllen, Texas, than in El Paso, Texas, as reported in a 2009 New Yorker article by Atul Gawande. To investigate whether this disparity was present in the non-Medicare populations of those two cities, we obtained medical use and expense data for patients privately insured by Blue Cross and Blue Shield of Texas.

Variations In Medicare Use And Spending

Total price-adjusted Medicare spending was 86 percent higher in McAllen than in El Paso, and was 75 percent above the national average in 2007.

In 2007, Medicare enrollees in McAllen were far more likely to be admitted to the hospital and to die in the hospital than they were in El Paso. They were also much more likely to be seen near the end of their lives by more than ten physicians — a good measure for fragmentation, in that the involvement of a large number of physicians typically signals a lack of coordination of care provided to patients. Finally, there were sharp differences in the extent of cardiac surgical procedures; again, rates were higher in McAllen.

Variations For The Insured Population Under Age Sixty-Five

Surprisingly, and in contrast to the Medicare data, for the population insured by Blue Cross Blue Shield of Texas, total spending per member per year in McAllen was 7 percent lower than in El Paso. Although spending for professional and inpatient services were similar in the two regions, spending for outpatient services in McAllen was 31 percent less.

Use of medical services was also similar or somewhat lower in McAllen compared to El Paso. Inpatient admissions in McAllen were 84 percent of admissions in El Paso; professional and outpatient services in McAllen were 94 percent and 72 percent, respectively, of those in El Paso.

(Variations by age for those under sixty-five)

For those age fifty and younger, use rates were generally similar or lower in McAllen than in El Paso — particularly for the population ages 25–50, for whom use of inpatient, outpatient, and professional services in McAllen were 66 percent, 80 percent, and 86 percent, respectively, of those in El Paso. Patterns were similar for spending measures.

It was in the population age 50 and older – largely people ages 50–64 — that strong differences between El Paso and McAllen in the use of inpatient medical services and spending emerged. Indeed, inpatient admissions for the Blue Cross and Blue Shield of Texas population age 50 and older were 89 percent higher in McAllen. Per patient inpatient spending for this same age group was 117 percent higher in McAllen — roughly the same difference as the overall difference in the use of Medicare services and spending. In part, the higher inpatient use of medical services and costs for this group are offset by lower outpatient medical services use and spending, leaving overall spending in McAllen for this age group 23 percent above those in El Paso. That is still well below the 86 percent Medicare differential between the two cities.

Conclusions

We have demonstrated that the sharp differences in the use of Medicare services between El Paso and McAllen, Texas, were not generally found in the population of Blue Cross and Blue Shield enrollees under age sixty-five in Hidalgo County (McAllen) and El Paso County. We considered several explanations for these patterns, including differences in prices, health, incomes, and other factors. Ultimately, we hypothesize that some part of the puzzle may be explained by private insurance companies and Medicare exhibiting very different interactions with local health care providers.

Thus, our study is consistent with Gawande’s finding of a “culture of money “— increasing the use of profitable Medicare services when there is diagnostic and procedural discretion and clinical latitude — but that such a culture may also be constrained by private insurance plans with their more stringent reviews of the use of medical services.

Because our study was limited to just two regions, we do not know to what extent providers may compensate for lower pricing from Medicare by negotiating higher prices, or cost shifting, to private insurance. Nor do we entirely understand why hospitalization rates for the privately insured residents of McAllen who are older than age fifty are so much higher — and outpatient rates so much lower — than in El Paso.

Further research is needed, such as the variations study mandated by the Affordable Care Act that is now being carried out under the auspices of the Institute of Medicine. But our preliminary results are consistent with the idea that health care providers can respond quite differently to incentives embedded in large federal programs such as Medicare compared to those present in private insurance programs.

http://content.healthaffairs.org/cgi/content/abstract/29/12/2302

And…

Study: Private insurance plans better at controlling costs

By Jason Millman
The Hill
December 7, 2010

Private insurance plans might be better at controlling healthcare costs than Medicare, according to a Health Affairs study released Tuesday morning.

http://thehill.com/blogs/healthwatch/medicare/132329-study-private-insurance-plans-better-at-controlling-costs

And…

The Cost Conundrum

Posted by Atul Gawande
The New Yorker
December 6, 2010

A new study introduces a fascinating — and hopeful — wrinkle to the McAllen, Texas, cost conundrum.

I visited McAllen, some readers may recall, to speak with doctors and hospital leaders about why its costs for Medicare patients have, for going on a decade, run almost double that for Medicare patients up the border in El Paso—almost sixteen thousand dollars per person versus eight thousand three hundred dollars in 2007. The populations had similar levels of poverty and poor health. By many quality measures, the hospitals were, if anything, better in El Paso. Yet the Medicare data showed McAllen doctors ordering markedly more tests, more surgery, more specialist visits, more home health services, more hospital admissions, more everything.

Yet can we really extrapolate from the costs of older Medicare patients to all younger ones? After the article was published, Texas Blue Cross Blue Shield gave unusual access to the complete cost files of their members under the age of sixty-five to researchers at the University of Texas School of Public Health and Dartmouth. This week, in the journal Health Affairs, the researchers published their findings. They discovered a shift with age. For members fifty or older, McAllen was indeed significantly more expensive than El Paso. But for those under fifty, McAllen was downright ordinary — even less costly than El Paso. They had escaped high-cost care.

It’s true that employees younger than fifty with Blue Cross coverage are a somewhat distinctive group. They are healthier than average and account for only a small percentage of local health costs. Nationally, people older than fifty account for about seventy per cent of total spending; among people under fifty, the poor and disabled account for much of the rest. The overall cost problem remains. But there is an important revelation here: not all the health care in a high-cost community has to be out of whack. The questions we then must ask are why the pattern is different for some groups of people, and whether such differences suggest ways to change the pattern for everyone.

There are two main explanations for the discrepancy: McAllen doctors could simply offer a lower-cost care for the kinds of conditions people under fifty have (pregnancies and traumatic injuries tend to be the big-ticket items); or Blue Cross could be particularly effective at restricting overspending. It’s hard to know which is the answer. Looking at the evidence available, we can’t be sure. But I am rooting for the idea that Blue Cross is making a difference.

http://www.newyorker.com/online/blogs/newsdesk/2010/12/the-cost-conundrum.html

According to this new study published in Health Affairs, the widely-publicized differences in Medicare use and spending between McAllen and El Paso did not occur in those individuals covered by Blue Cross and Blue Shield of Texas (BCBST), at least not quite. Today the media are reporting this study as demonstrating that private insurance plans are better at controlling costs than is Medicare. A closer look at the findings should make us question this conclusion.

Atul Gawande’s original report certainly confirmed that both health care use and spending in Medicare were much higher in McAllen than in El Paso, which he attributed to a culture of doctors in McAllen who treated patients as profit centers by increasing the intensity of services.

Is it true that BCBST was able to control the excesses of the McAllen physicians through managed care and other incentives? Or is there a more plausible explanation?

The population studied was insured by BCBST, which meant that, especially for the portion under 50, they were primarily healthy employees and their young, healthy families, certainly much healthier than the Medicare population. These individuals do not need much health care, and what they do use is quite straightforward. Preventive services, maternity care, fractures, acute illnesses and the such all have simple diagnostic and management algorithms. There really isn’t much leeway for adding superfluous services, so it is no surprise that use and spending would be about the same in both McAllen and El Paso.

What about the people over 50 on BCBST? These people are beginning to develop chronic disorders that do require more health care. During a continuum of care, there are more options for physicians to increase the frequency and intensity of services. For patients over 65 on Medicare, McAllen physicians do provide greater intensity of care, but does BCBST’s private insurer management techniques successfully control these excesses for patents under 65?

For BCBST patients aged 50 to 64, inpatient admissions in McAllen were 89 percent higher than in El Paso. Per patient inpatient spending was 117 percent higher in McAllen. Although outpatient use and spending were lower, overall spending was still 23 percent higher in McAllen for this age group. Besides, where are the real bucks? In the hospital or in outpatient care?

Gawande is “rooting for the idea that Blue Cross is making a difference.” Is an 89 percent increase in hospitalization rates really an endorsement of the management services that the private insurers keep selling us?

And the media? You would think that they would read the study before reporting on it (only 8 pages) instead of merely lifting a few points from the Health Affairs press release this morning. The title: “New Health Affairs Study Suggests That Private Insurers Control Health Care Spending Better Than Medicare.” Maybe the Health Affairs editors also should read their own articles before issuing press releases on them.

Innovative Plan To Keep Yosemite Clinic Open

By Diana Marcum
California Healthline
December 6, 2010

The medical clinic in Yosemite National Park… will become the first medical clinic in a national park to be operated by the U.S. Public Health Service Commissioned Corps.

It’s an unusual solution to a problem that threatened to leave the storied tourist draw without a clinic.

Tenet — the Dallas-based investor-owned hospital company that’s owned the clinic since 1995 — has been losing money on the facility every year.

“There’s lots of patients, but not a lot of revenue,” said Yosemite spokesperson Scott Gediman, adding, “The bottom line was we were looking for a way to keep a clinic open when it couldn’t make money.”

Most national parks don’t have their own clinics because they are near cities. But no clinic in Yosemite would mean rangers, tourists and workers in the country’s most visited park would be more than an hour’s drive away from medical care.

In October, as the clinic’s fate remained precarious, local climbers hung a sign reading “Save Our Clinic ” high up on El Capitan, the iconic 3,000-foot vertical rock formation at the north end of Yosemite Valley.

Housed in a stone and timber lodge in the heart of Yosemite Village, the clinic, which opened in 1929, is a family practice and outdoor adventure emergency department rolled into one. The clinic has served about 7,000 patients annually.

“We see everything here,” Sean Pence, the clinic manager, said. He added, “We get colds and flus, abrasions, heart attacks. We’re orthopedic central — lots of ankles and wrist injuries from falls. We see snowboarders with head injuries, climbers with frostbite.”

The two agencies — Public Health Service and the National Park Service — will man the clinic together. The health service is providing doctors and nurses, and the park service is providing building maintenance and support staff.

http://www.californiahealthline.org/features/2010/innovative-plan-to-keep-yosemite-clinic-open.aspx

Yosemite visitors know how isolated Yosemite Valley is. With a large permanent park staff and the highest volume of tourists of all national parks, Yosemite’s 24-hour clinic has been a godsend for those with urgent or sometimes life-threatening needs. So what were they to do when the clinic’s operator, investor-owned Tenet, decided to leave because the clinic wasn’t profitable?

Where do we usually turn when there is a crying need that the private sector fails to fulfill? Did I hear… The Government?

Yes. Talk about an ideal solution. Our own Public Health Service providing health care in our own national park. Socialized medicine at its finest. This is an essential service being provided to those who need it – not based on the ability to milk a profit, but based simply on meeting the health care needs of a community, albeit an unusual community including many foreign visitors.

Think of how fortunate the park employees and visitors will be. They will have available, 24 hours a day, medical services of which we can be envious. Think about that. Wouldn’t it be nice if we had in our own communities 24-hour clinics staffed with our own public employees who were there with a mission to serve, rather than a mission to enhance profits?

Maybe we’ve been too wimpy in pushing merely for a single payer insurance program. We’re already pay more per capita through the tax system than do nations with socialized medicine. Maybe we should be advocating for a better deal by improving and expanding the National Health Service so that we could all have access to it. Not just Medicare for all, but National Health Service for all.

The opponents of health care reform have moved the goal posts so far to the right that even a Blue Cross/Blue Shield-like public option has been excluded. Suppose we move our goal posts far to the left to a program of socialized medicine – an improved National Health Service for all. If the opponents of reform really believed that was a genuine threat, maybe they would meet us center field with a private health care delivery system financed by a single payer Medicare for all.

Can we expect that coming from a government that is too timid to stand up to the billionaires who have benefited from the massive transfer from the workers to the wealthy? A government that would dig our deficit hole deeper by not allowing a temporary, decade-long, partial tax holiday for billionaires to expire as scheduled? Don’t think so. Obama promised health care for all, but instead he is delivering much more wealth for the wealthiest, and we’re paying.

The European Parliament voted overwhelmingly on November 24 to approve draft legislation that encourages direct-to-consumer “high quality information” from pharmaceutical companies to patients.

The measure reaffirmed the European ban on television and radio drug advertisements, and recommended that nations extend the ban to print media. Nevertheless the vote was greeted as a victory by the pharmaceutical companies. The European Federation of Pharmaceutical Industries and Associations called it a “constructive approach.” The Director General of that trade group called the vote “clearly a step in the right direction.”

In response, our friends at the International Association of Health Policy and the Federation of Associations for the Defense of Public Health issued this statement:

The advertising to users of medicines puts at risk the health and sustainability of health care systems

December 2, 2010

The European Parliament has just approved the possibility that the pharmaceutical industry to report directly to patients about medication on prescription.

This measure, which supposedly done to improve the information of the citizens, is really a major setback to the right of reliable information and quality.

There is much evidence that the information the industry provides to professionals contains numerous biases that magnify the effects of pharmaceuticals and minimizes or hides the health risks.

It turns out to be difficult therefore to think that the own industry that makes the products and it has direct interests to promote his sale could favour a ” objective and impartial ” information, and it is expected that this information is addressed to encourage inappropriate consumption of drugs and shoot up pharmaceutical cost (as has been demonstrated in countries like USA where there is direct advertising of medicines to “consumers”), which is particularly irresponsible and dangerous in a time of economic crisis and can lead to damage patients health.

The legislation leaves it to the EU member states the final regulation of this information, and obviously this way can establish control mechanisms to reduce the worst effects of this rule. Anyway, the experience of USA and Canada leaves room for little doubt about the negative health effects and costs of this measure.

Therefore we understand that the Council of the EU where their member states are present must veto this initiative that represents a step backwards on the current situation, an attack to public health and puts at risk the health of citizens and the sustainability of the European Union health systems.

International Association of Health Policy
Federation of Associations for the Defence of Public Health

Government Payment for Health Care — Causes and Consequences

By Victor R. Fuchs, Ph.D.
The New England Journal of Medicine
December 1, 2010

The most obvious, easily quantifiable difference between the United States and countries that have national health insurance is that those countries spend much less on health care, whether measured per capita or as a share of the gross domestic product. Not only is the United States the highest spender, but the gap between it and the other countries is unnaturally large.

The difficult question is why the special interests have more influence over health policy in the United States than they do elsewhere. The answer probably lies in part in the structure of the U.S. political system, including the role of primary elections, long and expensive election campaigns, the separation of powers, the numerous congressional committees and subcommittees with overlapping authority, and the need for supermajorities in the Senate in order to pass meaningful legislation. But the quirks of the political system can’t be the whole answer. If the U.S. public wanted a different outcome, over time they could move policy in that direction.

A second large difference between health care in the United States and in countries with national health insurance is the more important role of redistribution in the latter countries. Such redistribution is evident in the greater equality of access to care and in the sharing of costs through taxes on income or payroll, value-added tax or sales tax, or other forms of taxation that are either proportional or progressive with respect to income. Of course, all insurance is redistributive after the fact. The large amount of care utilized by a small proportion of policy holders is paid from the premiums of others who use little care. The important distinction is that under a national health insurance system, the redistribution occurs before the event, since it is clear that some individuals will pay much less tax than the value of their insurance and some will pay much more.

Since redistribution plays a greater role in the health care systems of other countries than it does in the United States, there is an implication that a more egalitarian ethos holds sway in Europe, Canada, Australia, and New Zealand. From de Tocqueville to the present, many observers have commented on the stronger role of individualism in the United States than elsewhere, but there is no consensus regarding its explanation. Possible contributors to the phenomenon include the heterogeneity of the population, the revolutionary origins of the country with its dedication to “life, liberty, and the pursuit of happiness,” and the absence of many centuries of a common language, history, and culture. In speculating about the possible rise of despotism in a democracy, de Tocqueville painted a grim picture of individualism taken to the extreme. He wrote, “Each . . . living apart, was a stranger to all the rest — his children and private friends constitute to him the whole of mankind; as for the rest of his fellow citizens, he is close to them, but he sees them not; he exists but in himself and for himself alone.”

The lower spending and the greater redistribution in countries that have national health insurance are not independent phenomena. If spending in these countries were at U.S. levels, the taxation required to accomplish their redistribution goals would probably wreck the economy. Given the social or political desire to redistribute health care resources, constraints on spending become a necessity. These constraints take various forms, such as controls over the number and specialty mix of physicians, limits on facilities and acquisition of expensive technologies, hard bargaining over prices charged by drug companies and other suppliers, and restraints on physicians’ fees and incomes, among others.

Because the governments in these countries pay for most medical care — usually 70 to 90% of total expenditures — they are in a good position to apply these cost-restraining measures. They have what economists call “monopsony power.” The U.S. government, although it pays for almost 50% of health care, makes very little use of its power to restrain costs. Thus, in one sense, Americans wind up in the worst of all worlds, with government bearing a big part of the burden of paying for health care, with the concomitant large burden of taxes, but exercising very little control over the cost of care. As an indication of how absurd the situation is in the United States, government currently spends more per capita for health care than eight European countries spend from all sources on health care.

http://healthpolicyandreform.nejm.org/?p=13263

And…

What’s Ahead for Health Insurance in the United States?

By Victor R. Fuchs, Ph.D.
The New England Journal of Medicine
June 6, 2002

The announcement that most of the nation’s biggest insurers — Aetna, CIGNA, Humana, the United Health Group, and Wellpoint Health Network — will be introducing a new kind of health plan during the next year or two signals the beginning of a new era in health insurance in the United States. These plans feature a complicated menu of premiums, copayments, and deductibles. One of their major effects will be to shift the burden of health care costs from employees who use little care to those who use more. Thus, the new plans will be another nail in the coffin of health insurance as a form of social insurance.

The Reemergence of Social Insurance

The case for the fairness of the social-insurance model will be strengthened as people realize that most health problems have, at least in part, a genetic basis. The case for the model’s efficiency will benefit from recognition that employment-based insurance has high administrative costs but provides no advantages to society as a whole. The desire to exert more direct control over increasing expenditures will provide an additional reason to introduce some form of national health insurance.

The timing of such a change, however, will depend largely on factors external to health care. Major changes in health policy are political acts undertaken for political purposes. The political nature of such changes was apparent when Bismarck introduced national health insurance to the new German state in the 19th century. It was apparent when England adopted national health insurance after World War II; and it will be apparent in the United States as well. National health insurance will probably come to the United States after a major change in the political climate — the kind of change that often accompanies a war, a depression, or large-scale civil unrest. Until then, the chief effect of the new plans will be to make young and healthy workers better off at the expense of their older, sicker colleagues.

http://www.nejm.org/doi/full/10.1056/NEJM200206063462314

In his 2002 NEJM article, Victor Fuchs explained the inevitability of national health insurance in the United States, but cautioned that will likely only come to our nation “after a major change in the political climate – the kind of change that often accompanies a war, a depression, or large-scale civil unrest.” In his current NEJM article, he provides plausible reasons as to why there has been such resistance to the inevitability of national health insurance – intense enough perhaps to require political upheaval, if we expect action. We have been trying war and deep recession. Does that mean our only hope left is “large-scale civil unrest”?

Rate Review: Spotlight on State Efforts to Make Health Insurance More Affordable

Kaiser Family Foundation
December 2010

The Patient Protection and Affordable Care Act (ACA) requires the Department of Health and Human Services (HHS) to work in collaboration with state insurance departments to conduct an annual review of “unreasonable increases in premiums” for “nongrandfathered” health plans. Plans that propose an unreasonable rate will be required to provide a justification for the increase to HHS, and post the justification on their websites.

Yet the ACA does not alter states’ existing regulatory authority over health insurance rates. Such state authority varies dramatically, ranging from states with no authority at all to those that have robust authority to review and approve or disapprove rates before they are implemented.

Key findings include the following:

A state’s statutory authority often tells little about how rate review is actually conducted in the state.

In many cases, statutory authority to disapprove rates does not extend to all market participants.

Most states we interviewed use a subjective standard to guide the review and approval of rates.

Most of the states we interviewed have made little or no effort to make rate filings transparent.

Many states lack the capacity and resources to conduct an adequate review.

http://www.kff.org/healthreform/upload/8122.pdf

Proponents of the Patient Protection and Affordable Care Act (ACA) have claimed that states will be given broad powers to control private health insurance premiums, making health plans affordable again. Can we really anticipate relief from the outrageous prices of private health plans?

Under ACA, the federal role in premium regulation is limited to reviewing unreasonable rate increases and requiring plans to post on their websites a justification for their increases. The law does not alter the states’ existing regulatory authority over health insurance rates.

So how well are the states doing? Not very well. You need only look at the numerous media reports of outrageous premium increases that have provoked the state regulators to demand explanations for these unconscionable incidences of rate gouging (is it really gouging?). The followup stories reveal that the regulators have been successful in convincing insurers to roll back their increases to mere multiples of the rate of inflation. Year after year. The current level of premiums is proof that the state regulators have been ineffective in making decent health plans affordable.

This report from the Kaiser Family Foundation confirms that state regulation is spotty at best, but we know that even in states with greater regulatory power, premiums have continued to rise inexorably. The only successes in slowing premium increases have been in those instances in which the regulators permit plans to strip benefits and shift costs to patients. Of course, that has resulted in making health care unaffordable, impairing access and sometimes resulting in personal bankruptcy.

If a plan is going to provide adequate coverage for health services, those costs will have to be paid by the insurer, and there is no way that state insurance regulators can demand a rollback to rates that would deplete the insurers’ reserves and drive them into bankruptcy.

It’s nice that the Department of Health and Human Services has been granted the authority to require the insurers to post explanations for why their premiums are so high (it’s the costs of health care, stupid), but it is disingenuous to say that this would have any real impact in slowing premium increases for adequate insurance plans.

An unfortunate, unique feature of health care financing in the United States is the profound administrative waste that has been a major contributor to placing us first amongst all nations in what we spend on health care. The premium game that state insurance regulators are playing is only one more example of that waste.

Single payer supporters already know what we should do to reduce this egregious waste. Eliminate the insurance middlemen and replace them with our own public monopsony (single buyer) – an improved Medicare for everyone. Then we can use more effective and more equitable single payer tools to slow future cost increases.

Final Report of National Commission on Fiscal Responsibility and Reform

C-SPAN
December 1, 2010

From a discussion of the final recommendations, to be voted on by December 3:

Sen Dick Durbin (D-IL): We are hastening the day when the only option left will be a public option.

Rep. Paul Ryan (R-WI): I think Sen. Durbin probably said it right. We are hastening the day when the only option is the public option. I think you’re right (directed to Sen. Durbin), and I think that this advances that possibility and likelihood.

Rep. Jeb Hensarling (R-TX): I would agree with Sen. Durbin… you are hastening more people into the public option.

Rep. Jan Schakowsky (D-IL): To say that we’re going to reduce our deficit and our debt by asking Medicare beneficiaries to pay more for their health care, I think is absolutely unconscionable.   …already 30 percent of their income going to health care costs, I think is absolutely the wrong way to go when we do have other options. I put on the table, not as an if-all-else fails, a public option to reduce health care costs.

http://www.c-span.org/Watch/Media/2010/12/01/HP/R/41336/Debt+Commission+recommends+Dramatic+Budget+Cuts+Votes+Friday.aspx

PNHP has issued a response to the commission recommendations:
“Deficit panel’s Rx is wrong medicine: doctors’ group”
http://www.pnhp.org/news/2010/december/deficit-panels-rx-is-wrong-medicine-doctors-group

The commission members understand that health care is the greatest contributor to our federal budget deficit. Most of them recognize that the health spending recommendations in their final report are inadequate to control continuing cost escalation.

Some would reduce government spending by shifting more costs to Medicare beneficiaries, even though they understand that current out-of-pocket costs are already excessively burdensome. To others, that would be unconscionable.

There seemed to be an understanding by both Democratic and Republican commission members that the failure to control Medicare spending will hasten the day when the public option will be the only option.

Why a public option? Apparently there is bipartisan agreement that a government insurance program would be more effective in slowing future health care spending. They understand that government systems have worked well in other nations.

Where they are confused is that they seem to think that all you need is the option of choosing a government plan, and that is enough to enable all of the single payer efficiencies. Of course, this is where they’re wrong. A government plan offered within our market of private plans is incapable of instituting most of the changes that make single payer systems work. As simply another player in our fragmented, dysfunctional system, it would be a very feeble force for efficiency.

So what does this really mean? It says that both Republicans and Democrats know that we are going to have to have direct government involvement if we ever hope to control health care spending, but they still need to learn that there is a tremendous difference between a powerful single payer monopsony and a wimpy public option.