Californians support extending Medi-Cal to undocumented residents

Posted by on Wednesday, Aug 26, 2015

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.

Results from the 2015 Cal Wellness–Field Health Policy Survey – Part 1

By Mark DiCamillo, Director, The Field Poll
The Field Poll, August 26, 2015

Increasing voter support for extending Medi-Cal to undocumented residents

The current survey repeated a question first posed to California voters last year about whether the state’s Medi-Cal program should be expanded to provide preventive health services to undocumented residents, who are not currently eligible for coverage under the ACA. The results show that 58% of the state’s registered voters now favor extending Medi-Cal for undocumented residents, while 39% are opposed. This represents a significant increase in voter support from last year when supporters outnumbered opponents by a narrower 51% to 45% margin.

However, there are big differences in voter opinions about this proposal by party. Democrats favor the idea four to one (78% to 19%), while Republicans are opposed nearly three to one (72% to 25%). No party preference voters largely reflect overall voter sentiment, supporting the proposal 60% to 38%.

When examining voter opinions by race and ethnicity, Latinos report the highest level of support for extending Medi-Cal to undocumented immigrants, with 77% in favor. However, the proposal also now receives majority support from the state’s white non-Hispanic, African American and Asian American voters.

Topline findings

10. I am going to read some proposals that have been made to expand or modify the way the health care law is implemented in California, and please tell me whether you favor or oppose each one. Do you favor strongly, favor somewhat, oppose somewhat or oppose strongly this proposal?

a. Expand the state’s Medi-Cal health care program for low income residents to provide preventive health services to undocumented residents who are not eligible for coverage under the current health care law.

35%  Favor strongly

23%  Favor somewhat

14%  Oppose somewhat

25%  Oppose strongly

3%  Don’t know/Refused

One of the major deficiencies in the Affordable Care Act is that undocumented residents were deliberately excluded from mandated coverage. It has been estimated that roughly one-third of the 30 million or so who will remain uninsured are these undocumented residents. Was Congress following the wishes of the people when they excluded these individuals from coverage? Not if you judge by the views of Californians: 58% support expanding Medi-Cal to low-income undocumented residents.

In fact, every racial group of California voters polled is in support: Latino, white non-Hispanic, African American and Asian American voters.  The only group opposed is not racial, but rather political: Republicans, with 72% opposed, while 78% of Democrats are in support.

At Physicians for a National Health Program, we support health care reform that advances health care justice through sound health policies, devoid of politics. Although we can expound on the virtues of those policies, it is unfortunate – no, tragic – that our voice is muffled in the tainted arena of politics.

Conservatives frequently chastise progressives for accusing them of supporting mean-spirited policies. Well? Prove us wrong. You can do that by supporting the replacement of our inequitable, fragmented, dysfunctional system of financing health care with a single payer system that ensures equitable access and affordability for everyone, including our undocumented residents.

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Claxton and Levitt on the Cadillac plan tax

Posted by on Tuesday, Aug 25, 2015

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.

How Many Employers Could be Affected by the Cadillac Plan Tax?

By Gary Claxton and Larry Levitt
Kaiser Family Foundation, August 25, 2015

As fall approaches, we can expect to hear more about how employers are adapting their health plans for 2016 open enrollments. One topic likely to garner a good deal of attention is how the Affordable Care Act’s high-cost plan tax (HCPT), sometimes called the “Cadillac plan” tax, is affecting employer decisions about their health benefits. The tax takes effect in 2018.

The potential of facing an HCPT assessment as soon as 2018 is encouraging employers to assess their current health benefits and consider cost reductions to avoid triggering the tax. Some employers announced that they made changes in 2014 in anticipation of the HCPT, and more are likely to do so as the implementation date gets closer. By making modifications now, employers can phase-in changes to avoid a bigger disruption later on. Some of the things that employers can do to reduce costs under the tax include:

  • Increasing deductibles and other cost sharing;
  • Eliminating covered services;
  • Capping or eliminating tax-preferred savings accounts like Flexible Spending Accounts (FSAs), Health Savings Accounts (HSAs), or Health Reimbursement Arrangements (HRAs);
  • Eliminating higher-cost health insurance options;
  • Using less expensive (often narrower) provider networks; or
  • Offering benefits through a private exchange (which can use all of these tools to cap the value of plan choices to stay under the thresholds).

For the most part these changes will result in employees paying for a greater share of their health care out-of-pocket.…

During the markup process for the Affordable Care Act it was common to hear our legislators talk about patients demanding too much health care as an explanation for why our health care spending was so high. They blamed health plans that provided extra-rich benefits – plans they labeled Cadillac plans. The problem is that their premise was wrong.

These supposedly extra-rich benefits were merely standard benefits characteristic of the older employer-sponsored indemnity plans such as Blue Cross and Blue Shield. These were not plans with Cadillac benefits but rather they were plans with standard benefits, but benefits that are now provided at Cadillac prices because of our failure to adopt a health care financing system that would slow the rate of health care inflation.

In recent decades, plan purchasers in the individual market became less able to afford the high premiums commanded by the ever-increasing health care costs. In order to keep their premiums affordable, insurers reduced benefits and increased patient cost sharing, making health care less affordable even for those who were insured. Medical debt became a significant contributor to personal bankruptcy and having insurance often no longer prevented it.

Our legislators, after being spoon-fed by lobbyists and the policy community, decided that these inferior plans on the individual market would become the new standard, and the more traditional plans that provided more effective coverage would suddenly become Cadillac plans.

Thus the advent of the high-cost plan tax (HCPT) – often referred to by the misnomer, Cadillac plan tax – a 40 percent tax on plan costs above a certain threshold. This tax was intended to disincentivize the selection of full coverage plans. By having out-of-pocket money at stake with less comprehensive coverage, patients would be forced to decide which of their medical problems they would want managed and which they would decide to live with (or die from). What a terrible way to reduce spending.

In retrospect, both Republicans and Democrats in Congress have decided that this tax should be repealed, but for different reasons. Republicans are simply opposed to any taxes, and Democrats are concerned about additional tax burdens on lower income individuals with employer-sponsored plans that provide reasonable coverage (assuming the tax is paid by forgone wage increases). Hurdles to the repeal of this tax include reluctance to compensate for the loss of these government revenues by either assessing new taxes (Republicans opposed) or by cutting spending on other programs (Democrats opposed), plus a reluctance for a highly polarized Congress to work together on anything.

The important policy issue is not the tax, it is the decision to control spending by erecting financial barriers to care through the design of the insurance product – consumer-directed health care. This prevents patients from getting care that they should have while exposing them to financial hardship. Instead we should be providing everyone with prepaid health care while controlling spending through more humane, proven policies that are in use in many other nations. Of course, these are the policies that are inherent in a well-designed single payer national health program.

Forget the Cadillac imagery. Let’s talk about providing affordable health care for everyone.

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“Direct primary care” and the future of family medicine

Posted by on Tuesday, Aug 25, 2015

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.

New Program in Coachella Valley Seeks Affordability in Personalized Primary Care

By Lauren McSherry
California Healthline, August 24, 2015

Joseph Scherger, a primary care physician at Eisenhower Medical Center in Rancho Mirage, opened an email one morning earlier this month with an update on one of his patients who had recently suffered a heart attack.

The email had been sent directly by the patient, who wanted to put Scherger in touch with the cardiologist who had treated him while he had been traveling out of state.

Scherger, Eisenhower’s vice president of primary care, often uses email to correspond with his patients. In fact, email tends to be a big part of the day-to-day job for some of Eisenhower’s primary care physicians. Through a program called Eisenhower Primary Care 365, patients pay an annual fee to have direct email access to their doctors and other benefits.

Scherger calls the E365 program a new direct primary care model, one of many that have been popping up across the nation in recent years. It is intended to be a more-affordable version of expensive concierge medicine, in which patients pay a fee, unlimited access to their primary care doctors.

Jay W. Lee, California Academy of Family Physicians president, said doctors involved in the program see it as a way to equalize and democratize care.

“What I’m most excited about is that we’re starting to innovate,” he said. “It’s clear that this has resonated with a population of clinical physicians. What I’ve seen is that there is growing interest, not only in California but across the country.”

With direct primary care, patients pay a subscription fee — either annually or monthly — that enables them to have immediate access to their doctors, scheduling same-day visits and bypassing the long wait times.

But rather than paying $1,800 to $5,000 a year for that privilege, as they would for concierge medicine, patients pay $395-$595 per year, depending on their age, in the E365 model.

“The real story is that alternatives to concierge medicine are emerging that are going to cause concierge medicine to recede,” Scherger said.

Scherger began developing the program in 2009, when a new outpatient clinic, the Eisenhower George and Julia Argyros Health Center, was about to open. He was faced with a recruitment challenge “because too many of the good primary care doctors were going into high-cost concierge medicine” in the Coachella Valley. So he developed a hybrid model, one that accepts most insurance and Medicare and covers the cost of non-visit communications through a fee.

Since launching, the program has gained steam and now has 14 doctors treating 6,500 patients at four locations in the Coachella Valley.

Personalized Care, Longer Visits

Direct primary care has several characteristics that are attractive to doctors, such as having fewer patients and being able to spend more time with them, Lee said.

“In many ways, the promise of it is that there is an opportunity to control flow and pace,” he said.

A typical primary care doctor may have 90-120 patient visits per week and can only spend 10-15 minutes with each patient. In contrast, an E365 doctor will have around 50 visits per week and can spend 20 minutes with a patient, Scherger said.

The average panel size for a primary care doctor is 2,000 to 3,000 patients. Concierge practices usually limit their physicians to 200 or 300 patients. Direct primary care models fall somewhere in between. In the case of the E365 program, physicians each take care of 850 to 950 patients, Scherger said.

Scherger says direct primary care models began emerging about 10 years ago because primary care physicians were getting burned out under the traditional private practice model. One early model was GreenField Health, launched in 2001. Another model, Qliance, reportedly has 35,000 patients, with about half of whom are enrolled in Medicaid.

According to a 2014 survey by the American Academy of Family Physicians, about 2% of members were currently working in direct primary care settings and 7.2% reported they were currently determining if they would transform their practices to that model.

“The direct primary care model is slowly gaining momentum,” said Robert Wergin, the group’s president. He said the model is increasing in popularity because it moves away from the acute, episodic, fragmented care that is common with volume-based medical services, and it allows doctors more time to focus on quality of care rather than paperwork and billing.

Could Direct Primary Care Exacerbate a Physician Shortage?

One of the looming issues surrounding direct primary care is whether it will exacerbate the shortage of primary care doctors in California, particularly in the Coachella Valley where the shortage is severe.

The Coachella Valley has a cluster of nine cities, including Palm Springs in eastern Riverside County, a region containing both incredible wealth and far-reaching poverty.

“The question I have is around scale,” Lee said. “If everyone is doing this, are we going to meet the needs of the population?”

He is concerned because more patients are now covered by Medi-Cal as a result of the Affordable Care Act, and it’s unclear whether the direct primary care model will serve those patients.

Beth Capell, a policy advocate with Health Access California, said the direct primary care model eases physician workloads but doesn’t solve the issue of access to primary care for all populations in the Coachella Valley. The Coachella Valley and Merced are two of the most underserved regions in California, she said.

Nearly 40% of Coachella adults live in households below the federal poverty line, according to the Health Assessment and Research for Communities’ 2013 Executive Report. The report also estimates that about one-third of adults in the region, roughly 74,600 people, lack health insurance.

“The disparity in health resources only compounds the underlying reality that people who are low income need more access to care,” Capell said.

People who are affluent are generally healthier, while people with lower incomes are disproportionately likely to be in poorer health, often with multiple chronic conditions that are more difficult to manage, Capell said.

The UC-Riverside School of Medicine has launched several programs to expand the physician workforce in the region.

“We have a profound shortage, and our shortage is understated because of the number of concierge practices that exist in the Coachella Valley,” said John Heydt, the medical school’s senior associate dean of clinical affairs.

Market Forces May Be Driving Change

Heydt believes market forces are driving the rise of concierge and hybrid models. He predicts these models will gain even more popularity if insurers continue to expect doctors to see high volumes of patients for lower reimbursement rates.

“There are tremendous physician shortages on the horizon,” he said. “When anything is in short supply, the demand is high. And if you look at the day-to-day life of some physicians, they are run by their practices.”

Christopher Flores, who runs an independent direct primary care practice in Palm Desert, says E365 has filled a niche, and he expects the model to grow in coming years because doctors are feeling burnt out.

“The way the system is going, it’s becoming much more of an impersonal assembly line,” he said.

Whether direct primary care will succeed or evolve into something entirely different is up for debate.

“There is still a little uncertainty as to what the regulatory environment dictates,” Lee said. “I think those nuances have yet to be figured out.”

He stressed, though, that creating new models of care is critical given the pressures that primary care physicians are facing, such as high patient volumes and declining reimbursements. He sees new models that are not tied to in-person visits but that incorporate email, telemedicine, or telephone calls as the way forward.

“It’s pretty clear we don’t have enough supply to meet demand,” he said. “We can grow a workforce — but there’s a long tail on that — or we can practice better.”…

Today’s article is presented in its entirety since it is important to view the topic from a broad perspective as opposed to simply considering isolated policy topics contained in the article.

Weariness and burnout are common amongst overworked family physicians. It is no wonder that some physicians are exploring other models of medical practice. Concierge practices are based more on a business model – extracting additional fees from patients in order to lighten the workload. Direct primary care practices differ in that they increase access through electronic communication and at fees that are much more modest than with concierge practices – more of a patient service model and less of a business model. But they both have a serious defect – by sharply reducing the patient load, they decrease the productivity of family physicians at a time when we already have a profound shortage of family physicians in underserved regions.

A model which is designed to increase productivity is the primary care medical home. Such a model can certainly include improved electronic access for patients, but that would be only one feature of the wide variety of integrated services characteristic of well designed medical homes. The medical home would be ideal for balancing the overworked physician with the health care needs of the underserved residents in the community. The other health professionals in the primary care team not only could make work schedules more reasonable for everyone, but they could and should be used to adjust capacity so that the community health care needs at large are well served.

As it is, the label, “direct primary care,” is at risk of becoming just another label for concierge practices, just as “medical home” is at risk of becoming a label for managed care IPOs. To counter these trends we must always place first the health care needs of the patient and the community at large. If we do that, family physicians and other health care professionals working together as a team would have a great future ahead.

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What do insured patients see as financial burdens of health care?

Posted by on Friday, Aug 21, 2015

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.

Financial Burden of Health Care Costs Among Insured: Kaiser Health Tracking Poll: August 2015

By Bianca DiJulio, Jamie Firth, and Mollyann Brodie
Kaiser Family Foundation, August 20, 2013

Among insured:  Thinking about your own health care costs, which of the following do you find to be the greatest financial burden?

17%  The deductible you pay before insurance kicks in
14%  Your health insurance premiums
11%  Your prescription drugs
7%   Your doctor visits
3%   Some other health care cost
44%  Paying for health care and health insurance is not a financial burden

(Note: “All equally” and “Don’t know/Refused” responses not shown)…

It is nice to know that health insurance and paying for health care do not create a financial burden for 44% of those who are insured. The system is working well for the almost half of the insured who have decent incomes who remain in good health. But what about the other half?

Being insured is no assurance that you will not face significant financial burdens. The most common are high deductibles, high insurance premiums, high costs of prescription drugs, and, to some extent, physician fees. But shouldn’t the health care financing system be designed to remove financial burdens whenever people need health care? Our system is not working well for patients who have modest incomes and current significant health care needs.

Under a single payer system, there is no need for deductibles to save money by discouraging the use of beneficial health care services, because spending is controlled though other less intrusive, more patient-friendly economic measures. Physician fees are negotiated and paid by the single payer administrator, and prescription drug spending is controlled through negotiation and bulk purchasing. Insurance premiums are eliminated and replaced with equitable, progressive taxes that place a burden on no one. Instead of deliberately building financial barriers into the system, shouldn’t we eliminate them?

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NCQA’s ‘medical home’ baffles RAND

Posted by on Friday, Aug 21, 2015

Evaluation of CMS FQHC APCP Demonstration: Second Annual Report

By Katherine L. Kahn et al.
RAND Corporation, July 2015

In December 2009, President Barack Obama directed … the Centers for Medicare and Medicaid Services (CMS) … to implement a three-year demonstration intended to support the transformation of federally qualified health centers (FQHCs) into advanced primary care practices (APCPs) in support of Medicare beneficiaries. … For the demonstration, CMS recognizes as advanced primary care (APC) the type of care that is offered by FQHCs that have achieved Level 3 recognition as a patient-centered medical home (PCMH) from the National Committee for Quality Assurance (NCQA).

RAND is conducting an independent evaluation of the FQHC APCP demonstration for CMS. The evaluation includes studying the processes and challenges involved in transforming FQHCs into APCPs and assessing the effects of the APCP model on access, quality, and cost of care provided to Medicare and Medicaid beneficiaries currently served by FQHCs. [p. xi]

As of the end of the demonstration’s ninth quarter, we know that costs for demonstration [PCMH] sites are higher than for comparison sites. [p. xvii]

In July the RAND Corporation released a report on the second year of CMS’s three-year “medical home” experiment with federally qualified health centers (FQHCs). The report concluded the clinics in the “medical home” arm of the experiment were spending more money than clinics in the control arm, and that this was unlikely to change by the end of Year 3.

Sad to say, we’re never going to know what it was the experimental clinics did that raised their costs. It may well be those clinics used their “care management fees” to hire more social workers who in turn persuaded more people living near the clinics to make appointments, and that in turn led to greater utilization of medical goods and services. Or perhaps the fees were used to hire more patient educators, and the patient education induced existing patients to visit their clinic more often, and that in turn caused more hospitalizations.

We’re never going to know. RAND may produce some anecdotal evidence that the hypotheses I suggested above are true, or any of numerous other hypotheses could be accurate. But RAND will not produce empirical evidence. The primary reason is the maddeningly vague definition of “medical home.” The “features” that “medical homes” are said to possess are so poorly defined they cannot be reduced to measurable components.

It didn’t have to be this way. When President Obama ordered CMS to study the “medical home,” CMS could have used its discretion to test a version of the “home” that was much more clearly defined than the amorphous version adopted by the Agency for Healthcare Research and Quality, the National Committee for Quality Assurance (NCQA), and other self-appointed arbiters of what the phrase means. Instead, CMS punted – they said a “medical home” would be whatever the NCQA says clinics must do to qualify as a “level 3 patient-centered medical home” (PCMH). But NCQA’s requirements for PCMH certification are as vague as the features NCQA and other PCMH advocates claim PCMH’s possess, and in most cases the requirements bear no relation to the alleged features.

The RAND Corporation either could not or would not insist that CMS or NCQA define the PCMH more precisely before signing a contract with CMS to “evaluate” the FQHC PCMH demonstration.

Thus did the impossible challenge of evaluating the amorphous, elusive PCMH bounce down from Obama to CMS to RAND.

To grasp the impossibility of the challenge RAND signed up for, run your eye over the two tables below. Table 1 lists the seven “features” of the PCMH according to NCQA. Table 2 lists NCQA’s ten “must-pass” requirements for PCMH certification. Put yourself in RAND’s shoes and ask yourself two questions: First, how would you operationalize (reduce to measurable components) the “features” listed in Table 1; second, can you discern any relationship between the ten “must-pass elements” and the seven “features”?

Table 1: Seven “features” of the PCMH according to NCQA

(1)    Personal physician: Each patient has an ongoing relationship with a personal physician
(2)    Physician directed medical practice: The personal physician leads a team of individuals … who collectively take responsibility for ongoing patient care
(3)    Whole person orientation
(4)    Care is coordinated and integrated
(5)    Quality and safety are hallmarks of the medical home
(6)    Enhanced access to care is available through … innovative options for communication
(7)    Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home


Table 2: NCQA’s ten “must-pass elements” for certification as a Level 2 or 3 PCMH

(1)    Written standards for patient access and patient communication
(2)    Use of data to show standards for patient access and communication are met
(3)    Use of paper or electronic charting tools to organize clinical information
(4)    Use of data to identify important diagnoses and conditions in practice
(5)    Adoption and implementation of evidence-based guidelines for three chronic or important conditions
(6)    Active support of patient self-management
(7)    Systematic tracking of tests and follow-up on test results
(8)    Systematic tracking of critical referrals
(9)    Measurement of clinical and/or service performance
(10)  Performance reporting by physician or across the practice

Table 1 is riddled with mushy, sometimes tautological phrases such as “ongoing relationship,” “physician-directed,” “whole person” and “hallmarks” (I have italicized amorphous phrases). How is RAND supposed to distinguish, for example:

* a doctor-patient relationship that is “ongoing” from one that is not going,
* a “personal physician” from an impersonal physician,
* a “team of individuals” from a plain-vanilla staff, or
* “whole person orientation” from, say, “half-person orientation”?

How does RAND determine when “quality and safety” have become “hallmarks”? If we stumbled upon a “hallmark” in a clinic, how would we know?

When you’re done struggling with the questions generated by the happy talk in Table 1, then ask yourself whether the ten requirements in Table 2 answer any of the questions generated by Table 1. The answer is no, they just add to the clutter.

There are two reasons for this. The first is that the ten requirements are almost as vaguely described as the seven “features” (I have italicized mushy phrases in Table 2). What sense, for example, is RAND supposed to make of requirement 6, the one about “active support of patient self-management”? How is RAND supposed to know:

* what a “self-managed” patient is as opposed to whatever the opposite of “self-managed” is,
* what constitutes “support,” and once that has been defined, what constitutes “active support” as opposed to (help me out here) inactive support?

What do “important diagnoses” (requirement 4) and “critical referrals” (requirement 8) mean? Why would some diagnoses be unimportant and some referrals uncritical?

The second reason for the disconnect between Tables 1 and 2 is that there is no obvious relationship between the seven “features” and most of the ten requirements. Which of the ten requirements would you say “transforms” a mere staff into a “team,” “transforms” an ordinary doctor-patient relationship into an “ongoing relationship,” or is remotely related to “appropriate payment”? Answer: None.

What I see in the ten requirements is an obsession with measuring and reporting. Nine of the ten requirements mandate measurement and/or reporting. (Only the “active support of patient self-management” requirement does not clearly require measurement, but it might. The phrase is just too vague to say for sure).[1] It is reasonable to conclude that the most accurate “definition” of a “medical home,” according to NCQA, is a clinic that agrees to measure and report on a few vaguely defined policies and activities. This would be like defining a “cargo-centered” trucking company as one that signs a document with the National Committee on Trucking Quality to obey the speed limits, to stop by the side of the road now and then to be weighed, and to limit the number of hours its drivers can go without sleep. These promises tell us nothing about what a “cargo-centered” trucking company does.

My characterization of NCQA’s “definition” is supported by RAND’s finding that PCMH staff felt overwhelmed by NCQA’s documentation requirements. As RAND put it at page 37:

The problem of documentation in general for the NCQA application process was mentioned as an overarching concern for a majority of the FQHC respondents. Not only was there a concern about documenting the specifics of the … NCQA PCMH standards, the respondents also described the demanding nature of documenting every task that a clinician or provider engages in during a patient encounter.

To return to the problem I raised at the outset: If NCQA’s “definition” of a PCMH is essentially a clinic that agrees to document vaguely defined standards and policies that have no obvious relationship with the “features” NCQA says PCMHs possess, how is a CMS contractor like RAND supposed to determine why PCMH clinics raised Medicare’s costs? They can’t. RAND can ask the same questions NCQA asks during its audits – do PCMHs have a document on file explaining their “standards for patient communication,” for example. But since this standard will vary by clinic (thanks to the vague definition of this NCQA requirement), and because it might not even be implemented effectively or at all, RAND has no usable data on this variable.  Ditto for the other requirements. With no useful data on the “standards for patient communication” and the other requirements, RAND cannot test these variables to assess their impact on the dependent variable – Medicare expenditures.

RAND offers no solution. Its analysts merely state they will compare outcomes of PCMH with non-PCMH clinics using claims data and answers from patient surveys about their “experiences with care.”[2] Claims data will tell RAND whether expenditures were higher for PCMH clinics, and patient surveys will answer general questions about patient perceptions, e.g., “satisfaction” with the timeliness of care and whether doctors were clear in their instructions or good listeners. But claims data and patient survey responses contain no information about what it is PCMHs do that makes them different from non-PCMHs.

This quandary is, of course, not peculiar to CMS’s FQHC “medical home” demo. It is afflicts every test of the “medical home” that uses NCQA’s flabby definition.

The inability of RAND, CMS or anyone else to determine what it is PCMH clinics do raises another obvious problem: If we cannot determine what PCMHs do, how do we know what PCMHs do with the “care management fees” CMS pays them? I’ll address that question shortly on this blog.


1. If evidence supported NCQA’s assumption that measuring and reporting improves quality, we could at least say the requirements have some link with the “quality and safety” feature in Table 1. But the evidence on that issue is mixed.

2. Here is a quote from the RAND study: “Key Policy Question 2 focuses on differences between demonstration and comparison sites. … To answer this policy question, the evaluation focuses on metrics spanning 12 research questions … including: (1) continuity, (2) timeliness, (3) access to care, (4) adherence to evidence-based guidelines, (5) beneficiary ratings of providers, (6) effective beneficiary participation in decision making, (7) self-management, (8) patient experiences with care, (9) coordination of care, (10) disparities, (11) utilization, and (12) expenditures. Some of these metrics are evaluated using claims data, others by beneficiary report.” (p. xvi)

Kip Sullivan, J.D., is a member of the board of Minnesota Physicians for a National Health Program. His articles have appeared in The New York Times, The Nation, The New England Journal of Medicine, Health Affairs, the Journal of Health Politics, Policy and Law, and the Los Angeles Times.

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Over 2 million exchange enrollees forgo cost-sharing reductions

Posted by on Thursday, Aug 20, 2015

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.

More than 2 Million Exchange Enrollees Forgo Cost-Sharing Assistance

By Elizabeth Carpenter
Avalere, August 19, 2015

A new Avalere analysis finds that more than 2 million exchange enrollees eligible for cost-sharing reductions (CSRs) are not receiving the subsidies because they have selected a non-qualifying plan. In addition to the more publicized tax credits that lower consumers’ monthly premiums, exchange enrollees with incomes between 100 and 250 percent ($11,770 – $29,425) of the federal poverty level are eligible for CSRs. Exchange consumers must enroll in a plan on the silver metal level to access CSRs.

Specifically, the analysis finds that of the 8.1 million individuals enrolled in exchanges in 2015 who earn incomes that make them eligible for CSRs to reduce out-of-pocket costs, only 5.9 million are actually receiving them. This leaves 2.2 million consumers who may be paying more out-of-pocket than intended under the Affordable Care Act (ACA) because they have selected a plan that does not qualify.

“Consumers are picking plans on exchanges based on premiums, rather than out-of-pocket costs,” said Dan Mendelson, CEO at Avalere.

The difference between the number of exchange enrollees eligible for CSRs and those enrolled may be a result of consumers’ focus on premiums. For example, some CSR-eligible consumers are likely enrolling in lower-premium bronze plans, rather than the required silver plans. Meanwhile, other consumers may not be aware that CSRs are available and the benefits they offer.

The Congressional Budget Office (CBO) estimates that consumers will continue to forgo CSRs in the future. Indeed, the CBO projects 3 million individuals  who are eligible for CSRs will forgo subsidies by signing up for a bronze plan in the years after 2015.…

One of the more prominent problems with our dysfunctional system of financing health care is that the first decision faced by health care “consumers” is how much they are willing to pay towards the insurance premium, whether paying in full or sharing the cost with an employer or public program. People who are relatively healthy and do not expect to need much health care and whose incomes are limited will tend to select a plan with a lower premium regardless of the plan benefits.

A prime example is found in this report from Avalere. More than 2 million people who would be eligible for cost-sharing reductions if they selected qualifying silver level plans instead select bronze plans with their lower premiums, disqualifying them for the cost-sharing reductions. If they either have or should develop significant medical conditions, they are much worse off financially by having selected a bronze plan.

Another example of selecting plans based on the premiums has been the increase in the prevalence of high-deductible plans, selected because of their lower premiums. Once again, those who develop significant problems are worse off financially with high-deductible plans.

Shopping for cheaper premiums does not exist in a single payer system since the entire system is financed through equitable taxes rather than being financed on an individual basis, and there is no need to shop for plan benefits since everyone receives the same comprehensive benefits.

Instead of having a system wherein individuals are cornered into selecting a plan that is not in their best interests, everyone could participate in a system that is efficient, equitable, comprehensive and affordable for all – a single payer national health program.

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Fundamental flaw of Republican health reform proposals

Posted by on Wednesday, Aug 19, 2015

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.

Scott Walker, Marco Rubio Propose ‘Plans’ to Replace Obamacare

By Jonathan Chait
New York Magazine, August 18, 2015

Today, Scott Walker and Marco Rubio have published plans — really, not so much plans as skeletal descriptions of planlike concepts — to replace Obamacare. Appealing to the general election requires them to promise something to compensate the victims of repeal. How will they fund that something? This is the basic problem that for decades has prevented Republicans from offering a health-care plan. Rubio and Walker show that they still have no answer.

The main reason people lacked insurance before Obamacare is that they did not have enough money to afford it. Some of those uninsured people had unusually high health costs. Some of them had unusually low incomes. Boiled down, Obamacare transferred resources from people who are rich and healthy to people who are poor and sick, so the poor and sick people can afford insurance.

Walker and Rubio are fairly clear about their plans for regulating the insurance market. They want to go back to the pre-Obamacare, deregulated system. They’d eliminate the requirements that insurance plans cover essential benefits, and let them charge higher prices to sicker customers. That’s good for people who have very limited medical needs (as long as they never obtain a serious medical condition, or have a family with somebody with a serious medical condition). It’s bad for people who have, or ever will have, higher medical needs.

Both Walker and Rubio promise to take care of people with preexisting conditions by creating separate “high-risk pools.” That is a special kind of insurance market for people with expensive medical conditions. As you may have guessed, insurance for people with expensive medical needs is, well, expensive. Making that insurance affordable therefore requires lots of subsidies from the government. Where would Walker and Rubio get the money for that? They don’t say.

Both Walker and Rubio propose to cut funding for Medicaid, but this doesn’t create much room to subsidize coverage, since Medicaid is already much cheaper than Medicare or private insurance. Republicans are willing to cut Medicaid because they’re generally willing to cut programs for term paper that focus on the very poor, but there’s not much blood to be drawn from this stone.

It is tempting to treat the lack of specifics in the Republican health-care plans as a problem of details to be filled it. But it is not a side problem. It is the entire problem. They will not finance real insurance for the people who have gotten it under Obamacare, nor will they face up to the actual costs they’re willing to impose on people. The party is doctrinally opposed to every available method to make insurance available to people who can’t afford it. They have spent six years promising to come up with an alternative plan, and they haven’t done it, because they can’t.…

Much has been written this week about the proposals of presidential candidates Gov. Scott Walker and Sen. Marco Rubio for replacing the Affordable Care Act (ACA or Obamacare) once it is repealed. Most articles discuss the few specifics of their proposals that they have provided, but Jonathan Chait’s stands out because he describes the underlying fundamental flaw common to all conservative proposals for reform: for everyone to have affordable access to health care, there must be a large transfer from the healthy to the sick and from the wealthy to those with lower incomes, and the conservative proposals fall far short on the size and direction of the transfers that are needed.

Chait exits the topic leaving ACA in place, but there is more to be said. Although ACA actually did expand the necessary transfers, it still falls short of what is needed, plus too many inequities are perpetuated. Patches to ACA would still leave in place the fundamentally flawed infrastructure, and the Republican replacements are even more fundamentally flawed because they would worsen the financial barriers to care, especially by failing to include adequate transfers in their models.

A much more efficient and equitable method of achieving the necessary transfers would be to enact a single payer national health program. If the Republicans really do want a better replacement for Obamacare, maybe they should seriously consider single payer.

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PolitiFact accurate but misleading on Sanders’s claim of U.S. spending twice as much

Posted by on Tuesday, Aug 18, 2015

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.

Bernie Sanders repeats flawed claim about U.S. health care spending compared to other countries

By Will Cabaniss
PolitiFact, August 16, 2015

Democratic presidential candidate Bernie Sanders is on a campaign for “Medicare for all” — or at least something like it.

Sanders, an independent senator from Vermont who identifies as a socialist, told NBC’s Meet the Press moderator Chuck Todd to look at how much the country spends compared to the rest of the world as a reason for a single-payer system.

“We spend almost twice as much per capita on health care as do the people of any other country,” Sanders said.

It’s a striking claim, and one we heard from Sanders six years ago.

We rated the claim False then, and it’s still wrong now.

We looked at data from the Organization for Economic Cooperation and Development (OECD), widely cited by experts as an authoritative source for this information.

In 2007, the United States led the world in health care spending at $7,167 per capita, according to the OECD. Norway and Switzerland followed at $4,579 and $4,568, respectively.

The United States maintained its spending lead in the years that followed. But Sanders puts the difference too strongly when he says U.S. spending is “almost twice” per capita of “any other country.”

According to the OECD’s most recent data, U.S. spending grew to $8,713 per capita in 2013. Switzerland and Norway came in second and third at $6,325 and $5,862 per capita, respectively.

Had Sanders fine-tuned his talking point by claiming that the United States spends twice as much per capita as the average developed country, his statement would been accurate. Average per capita spending is less than $3,500 across the 32 countries listed in the OECD database. That’s 40 percent of what the United States spends per person.

Our ruling

Sanders said that “we spend almost twice as much per capita on health care as do the people of any other country.”

The United States spends more on health care per capita than other countries, but not always twice as much. Sanders’ comment suggests the United States outpaces all other countries more than it actually does. European countries with extensive social service networks aren’t so far behind the United States.

We rate his statement False.…

OECD Health Statistics 2015:

Sen. Bernie Sanders told NBC’s Chuck Todd, “We spend almost twice as much per capita on health care as do the people of any other country.” You’ve probably heard, or thought you heard, similar statements from others, including some of the PNHP leadership. But this specific statement is technically incorrect.

Sanders did include the important specification that he was referring to “per capita” spending, but by specifying that our per capita spending was almost twice that of any other country, that would place the second highest spending country at slightly over half of our spending. That is not correct.

What he likely intended to say was, “We spend almost twice as much per capita on health care as the average of developed nations,” or, “… industrialized nations,” or, “… wealthy nations,” or, more specifically, “… as the average of all OECD nations.” PolitiFact indicates that such a statement would have been accurate.

Yet this statement still isn’t quite accurate. In 2013, the latest year for which we have full data, the United States spent $8713 per capita, whereas the OECD average was $3453 per capita. That is not “almost twice” the OECD average, but rather the United States is spending over TWO AND A HALF TIMES AS MUCH PER CAPITA as the average per capita spending of OECD nations (2.52 times as much).

PolitiFact rules, “Sanders’ comment suggests the United States outpaces all other countries (in spending) more than it actually does.” In fact, the United States outpaces the average per capita spending of other developed dissertation writing nations by even more than what Sanders intended to say.


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Health care injustice for California’s high-needs children

Posted by on Monday, Aug 17, 2015

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

California’s Plan To Absorb Medically Fragile Children Into Managed Care Proves Controversial

By Barbara Feder Ostrov and Anna Gorman
Kaiser Health News, August 17, 2015

When Kausha King’s son Christian was born with cerebral palsy, along with a seizure disorder and lung disease, doctors told her he would not live past the age of three. Today, Christian is 18, and although he cannot walk or speak, he is happy and thriving, King says.

King credits much of her son’s progress to a little-known state program known as California Children’s Services (CCS), which pays for specialized medical care for children with severe illnesses or birth defects.

Beginning next year, state officials essentially want to fold the $2 billion program, which serves an estimated 180,000 children younger than 21, into its vast system of Medi-Cal managed care.

But families like King’s, along with children’s advocates and pediatric medical centers, are strenuously opposed. They say Medi-Cal managed care hasn’t worked well for vulnerable populations and is particularly risky for fragile kids whose lives depend on access to highly specialized care.

“It feels like our children are going to be dumped in to this system that doesn’t even seem to be working for healthier children,” said King, who lives in Concord, Calif. and works as a liaison for families of children with special needs. “Children like Christian require a different level of support than your average child.”

At issue are two separate programs whose beneficiaries overlap. About 90 percent of children served by CCS also qualify for Medi-Cal, the public insurance program for low-income Californians. Medi-Cal covers their general medical care, while CCS covers services related to specific conditions such as spina bifida, cancer, cystic fibrosis and sickle cell disease.

CCS pays a fee for each service provided, whereas Medi-Cal increasingly is switching to a managed care approach, in which medical services are coordinated and covered under a single health plan for a fixed monthly payment.

Many parents and consumer advocates are skeptical. Similar transitions of elderly, disabled and child populations from traditional fee-for-service Medi-Cal into managed care programs have proved controversial.

These critics point to a scathing report from the California State Auditor in June, which found that the state could not assure that its Medi-Cal managed care networks were adequate and that thousands of calls to an ombudsman’s office went unanswered every month. They also refer to a lawsuit pending in Los Angeles, alleging disabled people were denied crucial medications, tests and treatment by Medi-Cal managed care plans.

(Ann-Louise Kuhns, president and CEO of the California Children’s Hospital Association) said the state’s proposal threatens children’s access to the pediatric specialists who are most familiar with them and their rare diseases.

“These (managed care) plans typically don’t have these specialty providers in their networks,” she said.…

The origins of California Children’s Services (CCS) (formerly Crippled Children’s Services) date back almost a century (1927). It has been a phenomenal program ensuring care for these children with special needs. Now the state wants to transfer these children into Medi-Cal managed care programs (Medicaid). Ouch!

CCS is part of the traditional culture of California health care. Children’s hospitals, academic institutions, specialists and sub-specialists are readily available to meet the needs of these unfortunate children, simply because it’s always been that way. Well, really more than that, because that is what they do. But no thought is ever given to turning these children away.

In contrast, Medi-Cal has been chronically underfunded and has one of the lowest payment rates in the nation. Many providers refuse to accept Medi-Cal patients (and they are “providers” when they let money issues trump their professional obligation to care for the infirm). Now it is even worse in that the Medi-Cal managed care organizations limit patient access to their own contracted networks. Experience to date suggests that these networks are inadequate for basic, primary care services, and access to more specialized services is much worse.

California Department of Health Care Services director Jennifer Kent said that this is not about saving money, but rather that children can benefit by being managed in a system where the whole child is treated by one plan. But when the decision was made to transfer Medi-Cal patients to managed care programs it was about saving money, according to state announcements at that time.

CCS was all about getting the care that these children needed when they needed it. Medi-Cal managed care is about keeping patients away from “excessive” specialized care by coordinating their care through overworked primary care professionals who do not have the time nor expertise to meet many of the needs of these children with their complex disorders.

This should not to be construed as a statement condemning integrated health care. Just the opposite. Under a single payer system, our entire health care delivery system can be considered to be a single integrated system. Primary care provides an entry into a system in which the most appropriate care can be arranged – the best of integrated health care.

It was a wise move when the precursor of CCS was established early in the last century. It was a wise moved when they abandoned the label, “crippled.” It was a wise move when they perpetuated the program instead of folding it into California’s overworked and underfunded Medi-Cal program. But is was a terrible move when, for cost-saving reasons, they transferred Medi-Cal patients into managed care plans. Moving CCS patients into the same program is nothing short of tragic.

We need a single payer system so that we can get the bureaucrats and their private third party payers out of our way as we medically manage health care based on patient needs, rather than us managing health care dollars. Yes, we need public administrators to manage distribution of the funds, but we need to be free to advocate for our patients in a system designed to ensure access, not to prevent it.

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Do Amy Finkelstein and colleagues show that Medicaid has little value?

Posted by on Friday, Aug 14, 2015

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 Value of Medicaid: Interpreting Results from the Oregon Health Insurance Experiment

By Amy Finkelstein, Nathaniel Hendren & Erzo F.P. Luttmer
National Bureau of Economic Research, Working Paper 21308, June 2015


We develop a set of frameworks for valuing Medicaid and apply them to welfare analysis of the Oregon Health Insurance Experiment, a Medicaid expansion for low-income, uninsured adults that occurred via random assignment. Our baseline estimates of Medicaid’s welfare benefit to recipients per dollar of government spending range from about $0.2 to $0.4, depending on the framework, with at least two-fifths – and as much as four-fifths – of the value of Medicaid coming from a transfer component, as opposed to its ability to move resources across states of the world. In addition, we estimate that Medicaid generates a substantial transfer, of about $0.6 per dollar of government spending, to the providers of implicit insurance for the low-income uninsured. The economic incidence of these transfers is critical for assessing the social value of providing Medicaid to low-income adults relative to alternative redistributive policies.


Valuing Medicaid

By Harold Pollack, Bill Gardner & Timothy Jost
The American Prospect, July 26, 2015

How Valuable Is Medicaid?

An important recent paper by Amy Finkelstein, Nathaniel Hendren, and Erzo Luttmer, “The Value of Medicaid,” tries to determine how much it is worth, but in a narrow way whose baseline assumptions understate the value of the program. The authors use data from the Oregon Health Insurance Experiment. The experiment worked like this: Oregon had more poor and uninsured people than they could insure under Medicaid. So they held a lottery for who could apply for Medicaid coverage. Finkelstein and her colleagues realized that this lottery was in effect an experiment that would allow them to study the impact of Medicaid coverage on the previously uninsured.  Following a reasonable — but contestable — economic methodology, Finkelstein and colleagues estimated an equivalent dollar-value to the improved health observed among lottery winners. The authors then explored what happened to a dollar that was spent on providing Medicaid: Who actually benefited and by how much? And would recipients have been willing to pay for their Medicaid benefits if they had to?

The study’s major findings, widely reported in The Wall Street Journal, Vox, Forbes, and many other media outlets, can be summarized as follows:

  1. Uninsured people who get Medicaid only gained from 20 to 40 cents in value from each dollar spent by the government.
  2. A principal reason why the benefit of getting insured was so small is that when uninsured people received care, they typically paid only 20 cents on the dollar for those services. Safety-net providers, state or local government, friends, relatives, or someone else absorbed the remaining costs. When a recipient became insured, Medicaid paid some of these costs at the rate of about 60 cents per dollar.
  3. Because a large fraction of Medicaid expenditures financed care that recipients would have received anyway (for example, by leaving bad debt at hospitals), it is unclear whether recipients themselves would have been willing to pay the full costs of Medicaid.

While the Oregon Health Insurance Experiment was a well-designed study, too few of the study participants experienced serious medical conditions to investigate how Medicaid affected their health or quality of life. In addition, the experiment — and thus Finkelstein, Hendren, and Luttmer’s study — did not examine how Medicaid affected recipients’ families or the health-care institutions that care for low-income uninsured patients. Medicaid’s long-term benefits as an investment in infants and children were also beyond the scope of the Oregon experiment.

But perhaps the most important limitation of the study stems from an assumption that many readers would be unlikely to notice. Finkelstein and her colleagues placed a very low value — $25,000 — on a year of additional life for Medicaid beneficiaries. The typical threshold used in health services research is much larger, in recent studies far above $100,000 per additional year of (healthy) life. Yet because the median income of the Oregon study participants was about one-fourth of the median income in the United States, the researchers chose to value an additional life-year at about one-fourth of the usual threshold. This assumption powerfully frames everything that follows in this analysis. After all, if you start out by assuming that Medicaid beneficiaries’ lives are worth very little, you will find that it is not worth spending much money to prolong them.

Although Finkelstein, Hendren, and Luttmer’s baseline assumptions are methodologically defensible, they have radical implications that are rarely so bluntly applied in other domains of health-policy research. Choices about how to financially value the health of poor people relative to the health of others are inevitably both politically and morally freighted. It strains credulity, for example, to imagine American policymakers using this low a value for life when analyzing mammography, prostate cancer treatment, or implantable cardiac defibrillators for seniors.

The authors are careful not to make any normative statements based on these findings, but others such as Michael Cannon, Tyler Cowen, and John Graham have done so. They make two arguments: First, Medicaid is an inefficient way to benefit the poor. If a Medicaid dollar results in only 20 cents in benefit to a previously uninsured person, wouldn’t it be more efficient to simply give that person a dollar? And, second, Medicaid is actually a subsidy for people other than those it ostensibly helps.

We see matters rather differently. Economists have long understood that poor people would prefer cash to subsidized health insurance (especially if they can still get health care for free). So why does every developed country, including the United States, subsidize health insurance for the poor? Part of the reason is that those countries have broader moral and public-health criteria for thinking about health insurance and poor people’s lives. Universal health care expresses a commitment to the well-being of fellow citizens. Everyone should have access to a decent minimum of care; caring for others in distress is a primary expression of human solidarity.


Quotes from conservatives cited above:

Michael Cannon: “The (Finkelstein et al) trio found that Medicaid enrollees receive very little benefit from each dollar spent on Medicaid.”

Tyler Cowan:  “An implication of this is that the poor would be better off getting direct cash transfers.”

John Graham:  “Only 20 to 40 cents of Medicaid spending actually goes towards patients’ welfare.”

This NBER study by Amy Finkelstein and her colleagues on the value of Medicaid is important in that it is being used by conservatives to discredit Medicaid, giving fodder to opponents of this program. For that reason, it is important to understand the limitations of the narrow assumptions used in the study, and that is why the article by Harold Pollack and his colleagues is so important.

The Finkelstein article is challenging for the non-economist, but one assumption stands out as a basis for countering the claims of the conservatives who would use this to diminish support for Medicaid. That assumption in this study is that a year of life is worth about $25,000 for Medicaid beneficiaries when most studies assign a value closer to $125,000 per quality-adjusted life year ($100,000 to $150,000). When private insurance extends life by a year it is worth about five times what that same year of life would be worth for a low-income Medicaid beneficiary, so this study seems to assume. According to Pollack, et al., “… if you start out by assuming that Medicaid beneficiaries’ lives are worth very little, you will find that it is not worth spending much money to prolong them.”

Another bizarre line of reasoning is that much of the Medicaid money does not benefit the patient because it goes to physicians, hospitals, and Medicaid managed care organizations. The assumption seems to be that if the patient was not covered by Medicaid, the care would be provided anyway on a charity basis. Thus the patient does not receive any benefit from Medicaid because charity care and care under Medicaid are supposedly the same (not true), whereas the physicians and hospitals would benefit by receiving Medicaid income for what would otherwise be charity care. Would these conservatives seriously contend that private insurance provides little value for patients since the money goes to the physicians, hospitals and insurers and not to the patient? Of course not. Private insurance funds are used to purchase health care, providing considerable value for the patient. So how can they say that Medicaid funds are simply diverted to the health care delivery system, providing little value for the patient?

This is yet one more study to come out of the Oregon Health Insurance Experiment. The raw data in these studies are valid but the assumptions made and the interpretations extrapolated from them are being used to make claims such as, “Medicaid enrollees receive very little benefit from each dollar spent on Medicaid.” Medicaid saves lives, reduces suffering, and prevents financial hardship. That has real value.

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