Staff burnout in federally qualified health centers

Posted by on Wednesday, Aug 9, 2017

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.

Federally Qualified Health Center Clinicians And Staff Increasingly Dissatisfied With Workplace Conditions

By Mark W. Friedberg, Rachel O. Reid, Justin W. Timbie, Claude Setodji, Aaron Kofner, Beverly Weidmer and Katherine Kahn (all from RAND)
Health Affairs, August 2017


Better working conditions for clinicians and staff could help primary care practices implement delivery system innovations and help sustain the US primary care workforce. Using longitudinal surveys, we assessed the experience of clinicians and staff in 296 clinical sites that participated in the Centers for Medicare and Medicaid Services (CMS) Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration. Participating FQHCs were expected to achieve, within three years, patient-centered medical home recognition at level 3—the highest level possible. During 2013–14, clinicians and staff in these FQHCs reported statistically significant declines in multiple measures of professional satisfaction, work environment, and practice culture. There were no significant improvements on any surveyed measure. These findings suggest that working conditions in FQHCs have deteriorated recently. Whether findings would be similar in other primary care practices is unknown. Although we did not identify the causes of these declines, possible stressors include the adoption of health information technology, practice transformation, and increased demand for services.

From the Discussion

Our findings are consistent with reports of increasing burnout and declining professional satisfaction among physicians across the United States, not just in safety-net clinics. However, they differ with the only assessment of longitudinal changes in provider experience during a medical home initiative published to our knowledge, in which transformation within a single Group Health Cooperative site was associated with improvements in provider burnout between 2006 and 2008. This discrepancy might be explained by differences in time frame, type of clinic (FQHC versus integrated system), and intervention design (the Group Health pilot was motivated by and designed to mitigate provider burnout). Moreover, some FQHCs have high staff turnover, and most serve patients with complex medical, behavioral, and social needs—which can make practice transformation more difficult. The finding that top-of-license scores did not improve suggests that many FQHCs in our sample may have transformed only to a modest extent. Applying for and receiving medical home recognition could have been a higher priority than transformation. In addition, when safety-net clinics have insufficient staffing levels, this can increase the risk of burnout associated with quality improvement efforts.


Clinicians and other staff members working in a national sample of federally qualified health center sites reported declines over time in multiple measures of professional satisfaction, work environment, and practice culture. Our analysis could not identify the factors contributing to these declines. However, as additional health system changes accumulate under the Medicare Access and CHIP Reauthorization Act of 2016 and new legislative and regulatory activity, policy makers should consider further study of how these forces could affect primary care working conditions—especially in FQHCs and other safety-net clinics.…

Imagine the satisfaction it must bring to health care professionals to practice in an environment wherein you know that you are providing health care access to less fortunate individuals who might otherwise go without care. Furthermore, these Federally Qualified Health Centers were engaged in improving the delivery system in a manner that should increase satisfaction through attaining the highest status level of patient centered medical homes. Yet measures of professional satisfaction, work environment, and practice culture all declined in this study, resulting in provider burnout. What went wrong?

One observation might give us a clue. A similar prior effort to transform a Group Health Cooperative site into a medical home resulted in a decline in provider burnout. The authors report that “the Group Health pilot was motivated by and designed to mitigate provider burnout.” In contrast the various innovations taking place today are designed by bureaucrats and policy wonks largely based on widespread application of health policy theory flavored by ideology. They don’t get it.

Could single payer improve the situation? It could if the stewards were always keeping in mind what is best for the patient, and that includes ensuring the contentment of the health care workforce. A single payer system should automatically establish the presumption that this is all about improving the health of the patients and the community at large. It is not about providing a favorable business environment for the stakeholders even though that means perpetuating health care injustices such as lack of insurance, impaired access, financial hardship, health care inequity, and poorer health outcomes.

So one of the more important gifts of converting to a single payer system would be an improvement in attitude. We really need it.

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Anthem issues policy threatening nonpayment for ’nonemergency’ ED visits

Posted by on Tuesday, Aug 8, 2017

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.

Anthem BlueCross BlueShield, May 11, 2017

Save the ER for emergencies — Or you’ll be responsible for the cost

Going to the emergency room or calling 9-1-1 is always the way to go when it’s an emergency. And we’ve got you covered for those situations.

But starting June 1, 2017, you’ll be responsible for ER costs when it’s NOT an emergency (this isn’t a change to your benefits plan).…


Physicians protest harmful Anthem emergency care coverage policy

By Andis Robeznieks
AMA Wire, August 7, 2017

A new policy by Anthem Blue Cross Blue Shield holds patients responsible for bills stemming from care delivered in emergency departments that is later deemed nonemergent.

The AMA has asked Anthem to immediately rescind the policy in states where it has been put into effect and halt implementation in all other states.

The AMA, the American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) also suggest that the new policy may violate the “prudent layperson standard” which has been codified into state and federal laws—including the Affordable Care Act (ACA). The standard defines an emergency medical condition as one that manifests itself “by acute symptoms of sufficient severity” that a prudent layperson could reasonably expect that the absence of immediate medical attention could place their health in serious jeopardy. Anthem’s retrospective review appears to be inconsistent with such a standard.…


AMA Letter:

From: James L. Madera, MD, EVP and CEO, AMA
To: Joseph R. Swedish, Chairman, President and CEO, Anthem, Inc.

On behalf of the American Medical Association (AMA) and its physician and student members, I write to state our concerns with Anthem’s policy in several states to deny coverage of many emergency services when the diagnosis is retrospectively determined not to have required emergency care. We ask that Anthem rescind this policy in states where it has taken effect, and halt implementation in all other states.

Physicians know that patients and caregivers should never second guess their instincts that emergency care is needed, nor should they be expected to self-diagnose to determine whether, for example, chest pain is a heart attack or indigestion. But with this policy, Anthem is asking that patients act as highly trained diagnosticians, skills our members spent many years of their lives acquiring. Moreover, Anthem’s policy requires that they diagnose their acute symptoms at a critical and emotional moment, when time could be of the essence. The impact of this policy is that very ill and vulnerable patients will not seek needed emergency medical care while, bluntly, their conditions worsen or they die.…

What a bizarre policy this is. Anthem assigns to the patient the responsibility for deciding if a medical situation is an emergency. Anthem then assumes for itself the responsibility of deciding only after the care has been given whether or not it was an emergency after all, even though the perspective of that judgment can be quite different after a problem is evaluated and managed. If Anthem unilaterally decides, only in retrospect, that the patient’s judgment that this was an emergency was in error, Anthem may refuse to fulfill its obligation to pay for the emergency department services.

Think of various reasons that a decision could be made retrospectively that the visit was not an emergency. Consider those patients who are commonly blamed for wasting health care dollars by abusing the emergency department. Now back up and consider the reasons that the patients thought, before the visits, that they should go to the emergency department. Your ankle was only sprained and not fractured so it could have waited until your physician or nurse practitioner was available on Monday. You are from out of town and you found that your insulin wasn’t packed in your luggage and so your blood sugar is suddenly out of control. You feel very ill and there is an epidemic of a potentially lethal virus but it turns out that you just had a nonlethal respiratory virus, written off as a common cold, even though you really felt sick. You have a seizure disorder and are whisked away to the emergency department while still in a postictal state – the third time this happened. Although it is likely that Anthem would agree to pay for these visits, the threat of nonpayment might keep these people away in situations that might have turned out to be more serious.

Yet you hear all the time about how people are abusing the emergency department. Okay, so you hear about someone who wants a sports physical exam form filled out, but that person doesn’t make it past the triage desk. In my experiences with emergency departments, direct and indirect, I’ve decided that abuses severe enough to penalize a patient financially are so rare that they are basically a fiction that reform opponents keep propagating. Low acuity and low severity might be considered an issue, but that is still relative and not absolute, and the patient should not be penalized for having to make an uninformed decision. People do not go to emergency departments just for social visits.

Based on a “prudent layperson standard” then anyone that clears the triage desk should be assumed to be there legitimately. Under their nonpayment for non-emergency policy, either Anthem would be refusing to pay for legitimate services, or Anthem is making a major PR faux pas by issuing an unnecessary directive that will only make people angry. Either way, this is a terrible policy to establish. But what else do we expect from the private, for-profit insurance industry that places its own net profits over the health care of the patients?

I’ve decided after the fact that getting rid of the private insurers is a true emergency. Let’s do it.

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Paul Krugman loses his way on the incremental path to reform

Posted by on Monday, Aug 7, 2017

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.

What’s Next for Progressives?

By Paul Krugman
The New York Times, August 7, 2017

For now, at least, the attempt to repeal the Affordable Care Act appears dead. Sabotage by a spiteful Trump administration is still a risk, but there is — gasp! — a bipartisan push to limit the damage, with Democrats who want to preserve recent gains allying with Republicans who fear that the public will blame them for declining coverage and rising premiums.

This represents a huge victory for progressives, who did a startlingly good job of marshaling facts, mobilizing public opinion, and pressuring politicians to stand their ground. But where do they go from here? If Democrats regain control of Congress and the White House, what will they do with the opportunity?

What would I do instead? I’d enhance the A.C.A., not replace it, although I would strongly support reintroducing some form of public option — a way for people to buy into public insurance — that could eventually lead to single-payer.

Meanwhile, progressives should move beyond health care and focus on other holes in the U.S. safety net.

So if it were up to me, I’d talk about improving the A.C.A., not ripping it up and starting over, while opening up a new progressive front on child care.

I have nothing against single-payer; it’s what I’d support if we were starting fresh. But we aren’t: Getting there from here would be very hard, and might not accomplish much more than a more modest, incremental approach. Even idealists need to set priorities, and Medicare-for-all shouldn’t be at the top of the list.


NYT Reader Comment:

By Don McCanne, M.D.
San Juan Capistrano, CA

Improving ACA?

None of the incremental proposals would cover everyone.

None of the incremental proposals would remove financial barriers to care.

None of the incremental proposals would return choice of your physicians and hospitals.

None of the incremental proposals would recover the profound administrative waste in our health care financing system.

Single payer?

Everyone is covered for life.

Obtaining care does not create financial hardship.

Patients can choose their health care professionals and institutions.

The efficiency gains would be enough to pay for the gains in coverage.

We need to quit pretending that patching our fragmented, dysfunctional system is almost as good as single payer. It doesn’t come close.…

Perhaps the greatest fraud in health policy today is being perpetrated by the politicians – Republicans who say health care will be more affordable and accessible by taking away coverage, and Democrats who say that incremental additions to the Affordable Care Act are almost as good as enacting single payer – an improved Medicare for all.

We will continue to spend over $3 trillion on health care. That is enough to pay for a system that would be superior to those of all other nations that spend on average half of what we do. Why should we accept less, far less, which is what we would be doing if we merely patched our system – the poorest performing financing system of all wealthy nations?

Once more. Incremental changes to ACA will not fix the fundamental flaws in our financing infrastructure that may leave people sick, broke, and even dead.

We cannot let Paul Krugman rest on his Nobel laureate status as he pontificates for “a more modest, incremental approach,” while acknowledging he would support single payer “if we were starting fresh.” Well, apparently a fresh start is precisely what we need.

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The bipartisan compromise: cheap, worthless plans

Posted by on Friday, Aug 4, 2017

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.

Bipartisan moves to steady insurance market face same old conflicts over regulation

By Harris Meyer
Modern Healthcare, August 3, 2017

Democrats and a growing number of Republicans are eager to steady the struggling individual market covering nearly 20 million Americans to prevent an exodus of insurers and healthy customers.

Senate HELP Committee chairman Lamar Alexander (R-Tenn.), who has scheduled committee hearings early next month on how to stabilize the market, wants to go further. He has proposed expanding state innovation waivers to allow states to waive ACA insurance requirements such as minimum essential health benefits. A bipartisan group of 40 House lawmakers, calling themselves the Bipartisan Problem Solvers Caucus, has offered a similar proposal.

The GOP goal is to allow insurers to lure more healthy people into the market by offering lower-priced plans. “Any solution… should also include greater flexibility for states in approving health insurance policies,” Alexander said.

Alexander also wants to let everyone buy very high-deductible catastrophic plans, erasing the ACA’s age cap of 30. That could conceivably win support from some Senate Democrats who offered a bill in 2014 to let insurers sell cheaper “copper” plans, with a lower actuarial value than bronze plans. It raises big concerns, however, among insurance leaders and experts who say consumers can’t afford the deductibles and cost sharing under current plans.

Alexander also might try to revive a bill he introduced with his Tennessee GOP Senate colleague Bob Corker earlier this year to help consumers in counties where no exchange plans are being offered. The bill would let them use ACA premium tax credits buy plans sold outside the exchanges, including plans that do not comply with ACA coverage rules.

The Bipartisan Problem Solvers Caucus seeks changes in Section 1332 (which lets HHS grant states waivers to establish their own, customized coverage systems) to make it easier for states to win approval for setting up their own systems and to give them more leeway. House lawmakers also want to make it easier for states to enter into compacts that allow insurers to sell health plans across state lines in participating states.

ACA supporters and insurers say they’re potentially open to making 1332 waivers easier to get and more attractive to states, but only within limits. “My sense is there’s a willingness to expand state flexibility on 1332 waivers, it’s got a lot of potential,” said (Tom Daschle, the former Democratic Senate Majority Leader who’s now a healthcare lobbyist at Baker Donelson), who issued joint recommendations on that issue with former Republican House Speaker Newt Gingrich in late 2015.

Despite the looming policy clashes, some observers see a narrow window for a compromise deal on a market stabilization bill, especially since some Democrats in the past have signaled openness to letting insurers sell cheaper, skinnier plans.…

One of the great faults of the Affordable Care Act is that it was designed to make plans cheaper (lower premiums) by reducing the actuarial value of the plans (the percent of health care costs that the plans would cover) by requiring higher out-of-pocket costs, especially high deductibles. Although federal subsidies have softened the burden, cost sharing has made health care much less affordable, especially for middle-income Americans. Now Congress wants to make this problem even worse.

In the name of bipartisanship, Congress would supposedly save the individual health insurance market by making plans more affordable. They would do this by allowing an even lower actuarial value – higher deductibles – thus shifting more of the costs to individuals who actually need health care. They would also allow a reduction in the benefits covered, perhaps eliminating obstetrical care, mental health services, drug dependency programs, and preventive health services. Increasing out-of-pocket costs and stripping out benefits from the plans is the exact opposite of what most Americans want.

Of course, this would not salvage the individual market. If the premiums were low enough, healthier individuals might buy these cheap plans. Given a choice, many of the healthy would not buy the more expensive, more comprehensive plans. It is the individuals with significant health problems that would buy the higher actuarial value plans. Concentrating high cost individuals in these plans would cause the premiums to skyrocket, making them unaffordable for most, and the market would collapse in a “death spiral.” In the meantime, those buying the cheap plans who then develop significant medical problems would find that they are insolvent or bankrupt because of the unaffordable cost sharing. So the market for cheap plans wouldn’t work ether.

Yes, many people are unhappy with the high premiums that they are paying and want something done about it, but, no, they do not want their plans replaced with skimpy, almost worthless coverage that potentially leaves them exposed to insurmountable debt.

What do Americans want? They want to have the health care that they need, when they need it, without having to negotiate significant financial barriers to that care. In other words, they want a single payer national health program. Numerous polls have shown that they are beginning to grasp that concept.

Congress is going home for the summer recess. Republicans will face angry voters who feel that they have been betrayed by the failure of the Republicans to deliver on their false promises for a better health care system. The Democrats will mount their white horses to spread the message that they are ready to work with the Republicans to make health insurance more affordable. Neither camp will be honest with the voters and let them know what the low actuarial plans they have in mind really are, and how little health care the plans will actually cover.

What is our task? Members of Congress returning to their home districts must hear from us, their constituents – in the loudest, most unequivocal terms possible – how we reject the fraud of cheap health insurance, and that we demand the proven model of single payer national health insurance – an improved Medicare for all.

Get out your bullhorns!

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The rhetoric of payer-provider relationships, but where’s the patient?

Posted by on Thursday, Aug 3, 2017

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 reform driving payer-provider partnerships

By Les Masterson
Healthcare Dive, August 2, 2017

Payers and providers have for decades stayed in their silos, leading to a more fractured and adversarial healthcare system. That relationship, however, is starting to soften for many in the industry. Payer-provider partnerships put the two groups on the same team in hopes of reducing costs and improving care and outcomes through sharing data and better communication.

A major driver of these partnerships is the move away from fee-for-service payments and toward valued-based payments and population health management.

The payer-provider partnerships popping up across healthcare vary in type, size, location and model. There are 50/50 joint ventures with co-branding, and less intensive partnerships like accountable care organizations (ACO), patient-centered medical homes (PCMH), pay for performance and bundled payments.

The first step in these partnerships is building trust between payers and providers.

Another key is communication. (Chuck Lehn, president of Banner Health Network) acknowledged that communicating across systems and platforms between two organizations and healthcare providers requires time, attention and resources.

Caring for the whole patient works best when payers and providers share data, so there is improved care management, better interventions and better analytics around population health.

The two sides can go much deeper into care for patients by going beyond claims. In partnerships, payers shouldn’t have to wait for claims to see how their members are doing and doctors shouldn’t have to hope that their patients tell them when they have received care elsewhere.

In addition to regular back and forth, payers and providers need regular meetings, whether monthly or quarterly, that focus on strategic issues about the partnership, said (James Leatherwood, marketing communications manager at Availity).

One barrier that still needs resolution in partnerships is moving providers away from phone communication.

Leatherwood said a more efficient way is a queue system. In this system, a provider could check the status of all claims and get alerts when they need to provide more information. The system would allow providers to look in one queue, update the claims information and then move on with their day. Payers would have their own queue and would get alerts when providers have questions. This would reduce phone calls and create immediacy.

Leatherwood said the healthcare system is stuck in a “chart chase” between providers and payers, and moving to an automated queue system would be a gamechanger.

“I think in the near-term what we’re going to see is larger healthcare providers are going to be more strategic, working directly with payers. The health plans are going to be more interested not just in working with the staff level, but executive levels,” said Leatherwood.

The third part of a successful partnership is aligning incentives that focus on keeping people healthy and creating a positive healthcare experience, said (Thomas Robinson, partner at Oliver Wyman).

Partnerships must provide patients the right incentives, integration, investment, insight and innovation to work with the plan to deliver improvements across cost, quality, outcomes and experience, said Robinson.

“The point of these partnerships is to create something new, rather than just building the same old offerings with a narrow network. Successful partnerships will take the opportunity to innovate around the product and experience now that the incentives, insight, investment and integration are all for it,” said Robinson.

Aetna and Banner Health agreed on the partnership in October 2016 and have been laying out the groundwork before its launch this month in Maricopa and Pinal counties in Arizona. The two companies hope to expand the program statewide ultimately.

To prepare for the partnership, Tom Grote, who became CEO of Banner/Aetna joint venture in May, told Healthcare Dive that Banner Health and Aetna have developed joint operating committees, including marketing/sales and population health, that include members from both organizations.

The partnership looks to improve consumer experience by fully integrating providers, Aetna and administrative services, while eliminating redundancies in care and administrative problems. Aetna and Banner Health expect streamlining care and services will lead to savings for patients and employers.

(Brigitte Nettesheim, president of transformative markets for Aetna) said the partnerships are about “each side playing to its strengths, aligning incentives and driving scale.”

(Tom Leyden, director II of the Value Partnerships Program at BCBSM) said providers want to be active participants in system transformation.

“This requires ongoing support from the payer and demonstrated evidence of practice transformation and clinic results from the provider community,” said Leyden. “Administration of these programs is an integral aspect of measuring performance.”

Leyden said the payer strives to make the programs as manageable as possible because physicians need to perform many administrative tasks on an ongoing basis. BCBSM regularly solicits feedback from providers during quarterly meetings and phone calls, emails, webinars and in-person meetings on what’s working, what’s not and what needs to be changed.

“If we keep the customer — the end user — in mind and build partnerships with that as our North Star, we believe we will have a more successful, efficient and collaborative health system,” said Grote.…

Wow! These are the people who are in charge. They control the medical industrial complex. Based on this rhetoric they no longer have to be concerned about medical loss ratio minimums of 80 or 85 percent since their administrative functions have fused into health care delivery. That way they can best serve the “the customer — the end user.”

We need to throw these jerks out and establish a single payer national health program so that we can best serve, yes, the patient!

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Tom Price is taking care of physicians rather than patients

Posted by on Wednesday, Aug 2, 2017

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.

With Tom Price in charge, doctors are winning again in Washington

By Erin Mershon
STAT, August 1, 2017

As the Senate was barrelling toward one of its votes to repeal the Affordable Care Act earlier this summer, Tom Price was corralling a small group of doctors into a tiny, dimly lit conference room in a nondescript building in downtown Dallas.

It was, on its surface, another of the health secretary’s many meetings with “victims” of Obamacare — this time with some of the conservative physicians who felt the law was hurting their patients and their own bottom lines. An official readout from Price’s staff trumpeted the eight participating physicians as “witnesses” to Obamacare’s failings.

But that wasn’t Price’s only message to the doctors, according to two participants in the meeting. The health secretary also signaled he would protect the doctors from a raft of regulations that were put in motion by the Obama administration. And although Price, a former orthopedic surgeon, didn’t address specific regulations, he made clear he was listening to the physicians’ complaints about issues like Medicare payment rules and burdensome electronic health record requirements.

Quietly, away from the spotlight cast on his effort to dismantle Obamacare, Price has been rolling back regulations that have been criticized by his former physician colleagues. And, unlike with the ACA, he has been able to do so without the blessing of Congress.

He’s given an American Medical Association committee (RUC) even more power over how much the federal government pays for different medical services. He has pitched retroactively reversing certain Medicare rules to ensure some physicians no longer face penalties they would otherwise have had to pay. He has proposed using almost $1 billion in savings that would be achieved through cuts to certain hospital payments to boost spending on physicians.

And over and over again, he has delayed Obama-era regulations that would have penalized doctors who aren’t ready or able to move away from Medicare’s longstanding “fee-for-service” approach.

As the congressman for Georgia’s 6th District, Price made no secret of his strong relationship with doctors and their specialty societies. He fought for industry wish-list items like malpractice reform and a legislative change to let doctors charge Medicare patients higher prices.

Doctors rewarded him in turn. Health care providers and groups like the AMA and the American Academy of Orthopaedic Surgeons together donated nearly $500,000 to Price’s 2016 campaign and leadership committees, according to the Center for Responsive Politics’s OpenSecrets website.

In one of his first acts as secretary, Price took aim at a bipartisan 2015 law overhauling the way Medicare pays doctors. The law — referred to by its acronym, MACRA — gives bonuses to doctors who do an especially good job at certain activities like using electronic health records, coordinating care, or improving patient safety. Those who don’t get hit with penalties, which ramp up over time.

Price voted for the law in Congress, as did many of his Republican colleagues. The AMA and other physician groups supported it, largely because the package also eliminated a different payment program (SGR) that they had been fighting for nearly two decades.

“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” Seema Verma, the administrator of the Centers for Medicare and Medicaid, said in a statement unveiling the proposal. “That’s why we’re taking a hard look at reducing burdens.”

The agency wants “to be responsive to the concerns of the clinician community,” it wrote in the proposal.

The regulatory changes backed by Price are about more than avoiding penalties. He has promised that his administration, unlike the previous one, will accept the recommendations of an AMA committee (RUC) that lets physicians themselves decide how much Medicare should pay them for individual services.

The controversial and secretive committee lets doctors fight out among themselves whether to pay a certain specialty less or more, as procedures become less time-intensive or less expensive (or more so), despite what critics say is an obvious conflict of interest. The AMA and many specialty societies have defended the panel, saying doctors know best which services are most complicated.

CMS is proposing the values for individual services that generally reflect the expert recommendations from the [committee] without as many refinements as CMS has proposed in recent years,” the new administration said openly in a press release.

It’s a major concession to doctors and especially specialists, who perform more of the procedures that some primary care doctors have suggested are overvalued.

“The idea they would tell staff to just leave the [panel] alone is a concession to physicians, and in particular, physicians like orthopedists,” said Dr. Bob Berenson, an internist and a fellow at the Urban Institute, who has been critical of the committee. “The specialties that do procedures do very well with these misvalued codes, like orthopedists.”

HHS, moreover, may just be getting started in its work to improve Medicare for physicians. Attached to nearly everything the agency has released this year has been a very straightforward request to doctors, hospitals, and other health care stakeholders: Tell us what regulations you want us to nix.…

HHS Secretary Tom Price, an orthopedist and former Congressman from Georgia, has long supported measures that benefit physicians, often to the detriment of patients. His positions on MACRA and RUC exemplify this.

As a member of Congress, Price supported the Medicare Access and CHIP Reauthorization Act (MACRA) with its Merit-based Incentive Payment System (MIPS) and the Alternative Payment Model (APM). He did so in order to relieve physicians from having to comply with the Sustainable Growth Rate (SGR) which otherwise would have caused a reduction in physician payment rates. But, as we warned repeatedly, MACRA and its predecessors would create a major burden for physicians.

It is reassuring to see that Price and CMS administrator Seema Verma now recognize this burden and want to provide regulatory relief. The problem is that their concerns are directed towards physicians rather than patients. They support other policies that would reduce coverage and expose patients to greater health care costs. Even Verma’s physician husband refuses to accept Medicaid patients.

Price strongly supports the American Medical Association’s Specialty Society Relative Value Scale Update Committee (RUC). It provides advice to CMS on physician payment rates. It has long been criticized because of its bias toward procedures resulting in specialist rates that are much higher than rates for primary care. As an orthopedist, Tom Price fared very well under RUC. Again, Price is advocating for physicians when it is the patients that should be his primary concern.

What can we do? Let’s intensify our advocacy for a system that puts patients first – a single payer improved Medicare for all. We need to reach a threshold of support at which our nation’s leaders have no choice but to enact and implement a system that works best for all of us. Physicians and other health care professionals would do just fine under such a system.

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Medicare Value-Based Payment Program penalizes more dedicated physicians

Posted by on Tuesday, Aug 1, 2017

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.

Association of Practice-Level Social and Medical Risk With Performance in the Medicare Physician Value-Based Payment Modifier Program

By Lena M. Chen, MD, MS; Arnold M. Epstein, MD, MA5; E. John Orav, PhD; et al
JAMA, August 1, 2017

From the Introduction

Ambulatory pay-for-performance programs provide incentives for physician practices to improve the care they deliver. The Medicare Physician Value-Based Payment Modifier (PVBM) Program, which launched in 2015, will be the largest mandatory pay-for-performance program for physicians when fully phased in. Under this program, physician practices receive penalties or bonuses (from −1% to 10% of Medicare payments in 2015) based on the quality and costs of care. The PVBM Program serves as a precursor to the Medicare Quality Payment Program, which will launch in 2019, apply to clinicians and practices, and measure performance across a broader array of metrics. Clinicians eligible in the PVBM Program include physicians, nurse practitioners, and physician assistants.

Despite the growth of ambulatory pay-for-performance programs, there is concern about unintended consequences, including disproportionately penalizing practices that care for complex patients. Prior studies have shown that patients with high levels of medical risk as well as patients with social risk factors, such as those dually enrolled in Medicare and Medicaid, have worse quality outcomes. Thus, it is possible that physician practices that care for these high-risk populations will fare poorly in pay-for-performance programs.

Key Points

Question: Was there an association between the social or medical risk of patients treated at physician practices and performance during the first year of the Medicare Physician Value-Based Payment Modifier Program?

Findings: Practices that served more socially high-risk patients had lower quality and lower costs, and practices that served more medically high-risk patients had lower quality and higher costs. These patterns were associated with fewer bonuses and more penalties for high-risk practices.

Meaning: As value-based payment programs continue to increase in size and scope, practices that disproportionately serve high-risk patients may be at particular risk of receiving financial penalties.…

Rather than being smart and actually improving our health care system by enacting a single payer program, the bureaucrats and policy community have fixated on magical solutions that supposedly would improve quality and reduce costs by paying for value instead of volume. One of these programs is the Medicare Physician Value-Based Payment Modifier Program (PVBM).

Under PVBM, “Practices that served more socially high-risk patients had lower quality and lower costs, and practices that served more medically high-risk patients had lower quality and higher costs. These patterns were associated with fewer bonuses and more penalties for high-risk practices.”

We are penalizing physicians who take care of more socially high-risk patients and more medically high-risk patients!

Value instead of volume? Our greatest problem with volume is that we are not giving enough care to people who are uninsured or under-insured. And value? Experience in Canada has shown that bringing in patients who need care tends to displace some of the care that is of little value.

So let’s get smart. Let’s enact and implement a single payer national health program. That would bring us much more value than these rinky-dink programs such as PVBM.

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Single payer vs. universal public coverage through managed competition

Posted by on Monday, Jul 31, 2017

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.

Universal Health Coverage? Why?

By Walter McClure, Alain Enthoven, and Tim McDonald
Health Affairs Blog, July 25, 2017

The Congressional health care debate has become a war between two seemingly irreconcilable extremes, coverage versus budget control. Health care is a right, thunders Bernie Sanders (I-VT). There’s no free lunch, roars back Rand Paul (R-KY). We think both sides miss the boat. Forcing health care into this simplistic left-right straitjacket misleads the nation. It is time to recast the issue properly.

Public Investment

Universal health coverage is better viewed as neither owed to us by government nor a govern­ment give-away; both labels misinform. A more insightful analogy is universal public edu­cation. Does government owe people a public education? Is universal public educa­tion a handout to “takers” who ought to go out and buy it on their own?

When universal public education was first proposed, many of the privileged might have said, what do you want to educate “those” people for, you are just throwing away our tax dollars; if people wish education for their children, let them go out and buy it … ignoring that many could not afford it. Fortunately, we did not listen. We wisely invested in public education for all, and the productivity of our workforce boomed.

In the same way, universal health coverage is a wise public investment. Done right, it will return far more to our national prosperity than it costs in tax dollars.

Perverse Incentives

The crucial caveat is “done right.” Neither Medicare, nor Obamacare, nor the unsound private health insurance market have yet done that kind of broad public investment right. All three lack serious incentives on providers to focus on the long-term, reducing cost while raising quality and keeping people healthy; indeed, the incentives are to raise cost no matter the quality. In particular, all three totally lack either means or incentives for patients to iden­tify and choose providers who are better for less over those who are more costly.

The left’s faith in “single-payer” has proven ill-founded; we have had a public single-payer program for 50 years, Medicare, that absolutely controls the over-65 market. Yet despite the best efforts of the agency its costs still balloon out of control. The right’s faith in the private health care and insurance markets has proven equally ill-founded because both are severely unsound and, as Adam Smith taught us, unsound markets do not self-correct. As a consequence, in the same five decades the private market has done no better than Medicare on cost control. Five decades of efforts by both approaches using bureaucratic controls, micro­manage­ment, and token bonuses to make providers efficient have failed to contain run-away cost.

Looking Beyond The Symptoms

If the object is to broaden and improve the productivity of our workforce, then trying to contain cost by butchering eligibility, benefits, or quality of care and coverage is false economy of the worst order.

The correct approach to true cost containment is to drastically improve the quality and productivity of our bloated medical care system.

It’s not that we don’t know how to practice this kind of medicine, ample research studies show we do. It’s that the present system punishes providers with less revenue if they seriously try, and the most efficient are hurt most of all. It rewards those who run up costs regardless of quality. And because most medical care is a judgment call, there is no way that bureau­crats can second-guess doctors into serious cost contain­ment. But, patients, if properly informed and incented and thereby enabled to freely choose providers for value, would hold them to account by their choices far better than any regulators, public or private, ever could.

In other words, the runaway cost and compromised quality of our present health care system are symptoms of a deeper diagnosis: powerful perverse incentives. Policy keeps missing the diagnosis and treating the symptoms

Moving Beyond ‘Single-Payer Versus Private Market’

We need patients choosing among provider groups and delivery systems, not individual services. Patients generally don’t know what services they need, that’s why one goes to medical school; so a market of individual services makes no sense. Choosing a provider group, on the other hand is something we can expect of informed patients. And once provider groups learn that patients are choosing them based on the value they provide, those groups will begin choosing to deliver the services and referrals that get the best results at least cost, and may, desirably, begin to consolidate into more efficient integrated delivery systems. In short, if we turn the present perverse incentives around—by giving patients (1) objective ratings showing which provider groups are better for less, and (2) rewards consumers to choose them over costly providers (both objectives feasible in practice)—we can, slowly but surely, turn our health care system around into the high-quality, efficient system we seek for our children, our workforce, and our elderly.



By Richard N. Gottfried (Chairman of the New York Assembly Committee on Health):

Any set of payment methodologies or delivery system reforms can be done in a way that does good or ill. If we have insurance company payers, they will use their power to serve their interests well, not ours. With a public payer, there is a much better chance that the payer will work for change that is in the public interest. And if the wealthy and powerful are in the same boat as the rest of us, they will make sure they’re in a good boat, and the rest of us will benefit. Yes, a universal coverage system should be “done right.” A single-payer system is how we have the best chance at a system that serves the public, not insurance company stockholders. And a single-payer system enables us to remove financial barriers to care and pay for it fairly, based on ability to pay.

By Don McCanne, M.D.

It’s great that the authors remind us about some of the serious policy defects in our health care system, but there are a few issues here that warrant special comment.

Kenneth Arrow told us why markets do not work well in health care. The efforts to provide patient-consumers with price and quality information have not been very effective, whereas inducing price sensitivity through cost sharing, especially large deductibles, provides an example of an approach that the authors warn us against – “trying to contain cost by butchering eligibility, benefits, or quality of care and coverage.” Unleashing health care shoppers is not the path to value.

The authors have long supported competition between truly integrated health care delivery systems – “managed competition.” But assume each system provides comprehensive services. Oversimplifying, yet making a point by using a graphic construct, imagine four competing integrated systems located on four corners of a central intersection in a large city, each with a full complement of services, including specialized services such as cardiac surgery units or neuroscience centers. That duplication of services obviously is wasteful, not to mention that it would still be difficult to shop which integrated system to join for all future care. Since clustering them is not logical, should we spread them out so they serve the four quadrants of the city? Then health care shoppers are more likely to choose based on geographical considerations since bypassing your own center to go to one of the others would impair access because of transportation challenges, not to mention that having coverage under one system would prevent access to noted specialized services in the other centers. And satellite clinics? Do the four systems provide four competing clinics in each suburb or rural community?

It would be far better to have our entire healthcare system integrated. That can best be done though central planning and separate budgeting of capital improvements. That would greatly diminish the waste that we now have because of duplication in competing systems, while ensuring that access to appropriate facilities and services would be more optimal.

In contrasting free market solutions with a publicly financed and administered single payer system, the authors suggest that these are two extremes of political ideology, creating a “simplistic left-right straitjacket.” But when you look at the important issues in health care such as universality, access, affordability, efficiency, equity, and choice of health care providers, it is the public system and not the private market that is designed to ensure that those goals are met. Think of the freedom in the traditional Medicare program and contrast that with the private insurance system (narrow networks, high premiums, high deductibles, instability of coverage, administrative waste, inequity, etc.), and the straitjacket seems to be in the market.

A well designed single payer system – an improved Medicare for all – would provide a framework in which to incentivize quality and value. Integrated systems such as Kaiser Permanente would still provide services within a single payer financing system, but displacing our entire health care delivery system with a cluster of Kaiser Permanente-type entities is not a practical or efficient solution.

(There are also excellent comments by Sarah K. Weinberg and Johnathon Ross available at the link below.)…

The authors support public universal health coverage while rejecting single payer on the left and private insurance markets on the right as “two seemingly irreconcilable extremes, coverage versus budget control,” yet they advocate for competing integrated delivery systems – Alain Enthoven’s dream of “managed competition.”

Dismissing the “simplistic left-right straitjacket” as if it represented two equally ill-advised extremes is in itself a simplistic approach to health policy. The recent Republican effort to get private health insurance right is only the latest example of the deficiency inherent in the fragmented private insurance and public program model of financing health care. We have had over half of a century of experience to prove that it doesn’t work.

In contrast, a well designed single payer model not only resolves most issues with the financing of health care, but it also improves the distribution and efficiency in utilization of resources (see

The authors’ suggestion that the entire health care delivery system be integrated into individual competing delivery systems, like Kaiser Permanente, does not substitute for many of the design features and goals of a single payer system. Plus the concept introduces new logistical challenges such as inefficient duplication of facilities and services, and failure to cover regions that do not support the business plans of the integrated systems.

Patient choice of integrated delivery systems can certainly be included in a single payer system, but such integrated systems alone cannot duplicate all of the important functions of a single payer system that would ensure true universality, access, affordability, efficiency, equity, and choice of health care providers.

Health care professionals and institutions could still compete on perceived quality and service, but we should use central planning to avoid inefficient, wasteful duplication of facilities and services under the theory that we should be promoting price competition in the marketplace. Public administered pricing based on legitimate costs and fair margins is more effective and more efficient.

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The obvious Obamacare replacement, but when?

Posted by on Friday, Jul 28, 2017

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

The obvious Obamacare replacement has been here all along

By John Garamendi
The Sacramento Bee, July 27, 2017

The ongoing uncertainty in Congress surrounding health care legislation, and the intentional sabotage of the Affordable Care Act, is destabilizing the insurance marketplace, driving up costs, discouraging new enrollments, and making Americans worried about the future of their health care.

In the short term, Congress should shore up the Affordable Care Act with bipartisan, commonsense improvements, such as a reinsurance program to stabilize the market for high-risk policyholders, legislation to make cost-sharing reductions permanent, and government permission to negotiate for lower prescription drug prices. But in the longer term, the time is right to think about ways to make access to health care truly universal and cover those who are still left behind. By far the simplest solution is Medicare For All.

Opponents may point to the difficulties California has had in trying to implement its own state-based universal health care system. A stand-alone plan in California would somehow have to incorporate existing federal health insurance programs – an impossible task given the political realities of the Trump Administration.

But a federal Medicare for All program would face no such obstacles: It would simply use the existing Medicare infrastructure and expand it to cover everyone.

Seniors know the peace of mind that comes from having the guarantee of health insurance. Imagine if all Americans could say the same.

John Garamendi represents the 3rd congressional district in California.…

As soon as John McCain joined Susan Collins and Lisa Murkowski and cast the vote that defeated the Republican effort to repeal and replace Obamacare, Senate minority leader Chuck Schumer repeated McCain’s earlier plea to return to regular order and reform health care on a bipartisan basis through the usual committee process. That inevitably leads to incremental change, if any change at all, which would have only a negligible impact compared to the need that exists.

Americans previously understood the deficiencies of the Affordable Care Act, and now they have been shown that reducing a government role in oversight of the private insurance industry would never fulfill the promise by the politicians of better care at a lower cost. Americans are ready for a national health program, and that is reflected in the response of the 115 members of Congress who are cosponsoring John Conyers’ HR 676, the Expanded & Improved Medicare for All Act.

Congressman John Garamendi of California represents the enthusiasm for a federal Medicare for All as he explains in his op-ed. But he joins other members of Congress in qualifying his support by saying, “In the short term, Congress should shore up the Affordable Care Act with bipartisan, commonsense improvements.” “But in the longer term, the time is right to think about ways to make access to health care truly universal and cover those who are still left behind.” Now is not that time?

“Single payer but not now” has become the byword of the incrementalists. If we move forward with an emasculated public option or an unaffordable Medicare buy-in, the process will come to halt, likely for decades, while we “see how this works.” We do not need more policy experimentation. We know what works. Single payer, Medicare for all, or whatever you want to call it, but let’s do it now!

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Senate defeats single payer amendment

Posted by on Thursday, Jul 27, 2017

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.

In the Senate an amendment to the Republican repeal and replace legislation was introduced by Sen. Steve Daines (R-MT) that would establish a single payer system in the United States – an expanded and improved Medicare for all – using the exact same language as in HR 676 introduced in the House by Rep. John Conyers.

The vote:
0 – Yes
57 – No
43 – Present

All Republicans, including Sen. Daines, voted against it. Democratic Senators Donnelley, Manchin, Tester, and Heitkamp, along with Independent Senator King, voted against it. All other Democrats voted Present.

Sen. Bernie Sanders had said before the vote that failure of Sen. Daines and other Republicans to vote for their amendment would demonstrate that this was a sham to be used to campaign against moderate Senators in the next election. When no Republican voted for it, most Democrats plus Independent Sen. Sanders voted Present.

It is a sad commentary that the most important health policy legislation ever introduced in Congress – legislation that would have brought health care justice to all – was used by the Republicans as a tool for political chicanery.

Do they think this was some kind of a joke? They just rejected legislation that would have prevented hundreds of thousands of people over the years from facing physical suffering due to lack of medical care, financial hardship, and even death. Death!

We could forgive them for a bad joke, but this?

Mobilize the forces. This is war! Not the guns and bombs type of war but a war against man’s inhumanity to man.


Man was made to mourn: A Dirge

Many and sharp the num’rous ills
Inwoven with our frame!
More pointed still we make ourselves
Regret, remorse, and shame!
And man, whose heav’n-erected face
The smiles of love adorn, –
Man’s inhumanity to man
Makes countless thousands mourn!

–  Robert Burns, 1784

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