By Ann Settgast, M.D., and Elizabeth Frost, M.D.
PNHP note: The following letter is an official “Draft Recommendation” from PNHP Minnesota that was submitted to Minnesota’s Care Integration and Payment Reform Work Group, a body created to oversee the state’s implementation of health reform.
November 11, 2012
Dear Care Integration and Payment Reform Work Group:
Thank you for the opportunity to submit public comment on your draft recommendations. We share the workgroup’s acknowledgement that the cost of care in Minnesota is unaffordable. Our physician group also shares your goals of improving the health of Minnesotans, improving the experience of patients, and improving the affordability of health care.
However, our proposed solution is quite different. 31 percent of the U.S. health care dollar is spent on administration (NEJM 2003;349:768-75). This is double the administrative spending of other industrialized nations. The driver of our administrative spending is our unique reliance on U.S.-style private insurance which profits dramatically while patients in Minnesota and the nation continue to die due to lack of coverage. The majority of the workgroup’s recommendations rely on the assumption that care here is so unaffordable because patients use too much care and/or their doctors provide too much uncoordinated or inefficient care. Certainly, some of this is true, but the reality is that among OECD nations, the U.S. has among the lowest utilization rates for hospital and physician services (Commonwealth Fund, May 2012). It is in our administrative spending that we are so vastly different from the rest of the industrialized world, and a focus here rather than payment reform would be the most effective way to reduce Minnesota health care spending.
We advocate for a single-payer system. Canada is a case in point. As you know, this nation manages to provide comprehensive, high-quality care to ALL of its residents while spending about half what we do. They do this while paying their doctors via the fee-for-service mechanism. In fact, just last month, new data from the Archives of Internal Medicine (2012:1-2. doi:10.1001/2013) revealed that since 1980, Canada’s costs in caring for their expensive elderly have risen 75 percent versus our 200 percent. Consequently, we do not believe the best way to reduce spending in Minnesota is via payment reform and improved care coordination. This simply is not going to get the job done. The recently released Lewin report, with which you are familiar, showed Minnesota could reduce health care spending by nearly 10 percent by adopting a unified funding mechanism that comprehensively covered all Minnesotans. These savings were seen despite greatly expanded coverage and using a fee-for-service model. More details on the report can be found on the Growth and Justice website.
Our group is not opposed to care coordination or to evidence-based payment reform but we believe the cart is being put before the horse. Until we have a unified system with everyone in and no one out, can we really make true progress toward the triple aim? How can we really work toward providing more patient-centered care when there are patients who remain outside the system? Can care integration and a health care home improve the experience of a patient who is uninsured and has no access? What about a patient who is underinsured and has limited access due to a high co-pay? We ask the workgroup to seriously consider how much more valuable and successful your care integration and payment reform work would be if it was done in the context of a truly unified system that left no Minnesotan out.
We would like to address two items in your draft specifically:
One of the five major strategies you propose is to, “Enhance the market availability of health insurance products that foster consumer accountability for health behaviors and create incentives for consumers to use high value providers.” Although not stated explicitly in your recommendations, we are concerned that by “products that foster consumer accountability” you may be referring to high-deductible insurance plans. If so, this is a misguided approach. There is ample peer-reviewed evidence available showing us that high-deductible plans harm patients by encouraging less care-seeking by those who need it. To our knowledge, there is no evidence revealing improved health outcomes in those using high-deductible plans. Furthermore, the reference to incentivize patients to use “high value providers” is troubling. There is, to our knowledge, no evidence that we have yet attained an accurate or useful method for measuring physician quality. Physician report cards are notoriously imprecise and have great potential for harm in that they can incentive physicians to avoid caring for sick and difficult patients. Is this really what we are striving for in Minnesota?
Finally, we request you change the following statement at the end of your Executive Summary because it is quite misleading. You state, “Above all other issues, Minnesotans have expressed concern about affordability of care and are eager to take more responsibility for their health, which they consider to be a balance of physical and emotional health.” Your footnote references the “Final Report: Citizen Solutions, a different conversation about fixing health care.”
In reviewing the actual poll data of the Minnesotans who participated in the community conversations, publicly available in the appendix of this report, we have difficulty understanding from where your summary statement derives. While the poll data does indeed reveal Minnesotans find affordability to be the biggest challenge, your summary statement implies that Minnesotans said they wanted to address it by taking more responsibility for their health. In actuality, as you can see from a simple review of the data, when asked what solution they would choose, practicing healthy behaviors received far fewer votes than single payer. In fact, on page 3, you can see that Minnesotans chose single payer as their clear first choice for a solution. If you still would like to summarize this report, we suggest you use the following statement which more accurately reflects the available data: “Above all other issues, Minnesotans have expressed concern about affordability of care, and they believe the best solution to this problem is a single-payer system.” Incidentally, if you read on in the poll data, you’ll also note that when asked about spending, Minnesotans felt administrative expenses were the biggest driver.
Thank you for your work, and also for your time in considering our comments.
Ann Settgast, MD and Elizabeth Frost, MD
Co-chairs, Physicians for a National Health Program – Minnesota