PNHP

Spending for privately insured Americans remains high

Spending for privately insured Americans remains high

Center for Studying Health System Change October 2006 Tracking Health Care Costs: Spending Growth Remains Stable at High Rate in 2005

By Paul B. Ginsburg, Bradley C. Strunk, Michelle I. Banker, John P. Cookson

Health care spending per privately insured American increased 7.4 percent in 2005, marking the third year that the cost trend hovered below 8 percent, following a peak increase of 10.4 percent in 2001. Spending data for the first quarter of 2006 suggest continued stability–albeit at a relatively high rate of growth (7.7%). In 2005, health spending growth continued to outpace overall economic growth, despite a robust 5.4 percent increase in the overall U.S. economy as measured by per capita gross domestic product.

Trends in three of the five spending categories–inpatient hospital care, physician services, and other services–accelerated in 2005, while prescription drug spending grew at a slower rate for the sixth year in a row and hospital outpatient care spending growth slowed slightly.

Two key factors will tend to drive cost trends higher. One is the rapid expansion of specialty facilities, including hospital inpatient and outpatient facilities, freestanding centers and additional ancillary service capability in physician offices. The combination of supply creating demand and the effects of increased physician self-referral could mean that these expansions will increase spending. The continuing growth of obesity in this country is also a major cost driver. Kenneth Thorpe and colleagues estimate that 27 percent of real per capita growth in spending from 1987 to 2001 is attributable to increasing rates of obesity and increasing relative spending by those who are obese.

When listening to discussions in policy circles about the potential for a slowing of health care cost trends, one does not hear much about the factors outlined above. Instead, political leaders extol the potential for health information technology to save money by increasing quality of care and curbing duplication of diagnostic procedures, the potential of medical liability reform to reduce defensive medicine, the potential of quality improvements motivated by pay for performance to reduce costs and the potential for increased price transparency to lower health services’ prices substantially.

All or some of these scenarios may come to pass, but the most likely outcome over the next few years is costs continuing to outpace incomes and private health insurance becoming increasingly unaffordable for more people.

http://www.hschange.org/CONTENT/879/

Comment:

By Don McCanne, MD

There are many more factors involved in the increase in health care spending besides the two listed, especially obvious when the problems are framed more appropriately. Of most concern are the flaws that result in a very large amount of wasteful spending, well described in the policy literature.

We need solutions that specifically address these flaws. As this article indicates, current political efforts are neglecting the fundamental defects, but instead are diverting reform efforts by tinkering at the periphery with measures that will have negligible impact compared to the enormity of the problems.

When we know what is wrong and what needs to be done, it is tragic that we merely sit back and watch the tinkerers tinker.

Major surgery is the only cure

By David Lazarus
San Francisco Chronicle
October 1, 2006

Our health care system is a shambles. Here’s yet more proof:

* Insurance premiums paid by employers and workers have nearly doubled since 2000, according to a new report from Menlo Park’s Kaiser Family Foundation. The 7.7 percent increase this year is more than twice the rate of inflation.

* San Pablo’s Doctors Medical Center says it expects to file for bankruptcy protection this week after losing about $1 million a month for the past two years. The obstetrics department is scheduled to close today and the hospital’s 11 emergency-room physicians have given notice that they’ll quit by the end of the month.

* Gov. Arnold Schwarzenegger has vetoed state legislation that would have established universal health coverage for all Californians. He offered no alternative plan to help the state’s roughly 7 million uninsured.

“We’re watching the health care system collapse around us,” said James Kahn, a professor of health policy at UCSF.

The Kaiser report issued last week serves as a frightening reminder for all families that health insurance in the United States is an increasingly costly and, for many, unobtainable goal.

Premiums have increased 87 percent during the past six years, the report shows. Family health coverage now costs an average $11,480 annually, with employers paying the bulk of that amount and workers paying an average $2,973. That’s about $1,354 more than the typical worker had to pay in 2000.

This year’s 7.7 percent hike in premiums is the slowest growth rate in six years but it’s still more than double the annual increase in wages (3.8 percent) and the overall cost of living (3.5 percent).

“The bottom line here is that health care costs are increasing dramatically faster than wages, and that’s why people are feeling pain,” said Drew Altman, president of the Kaiser Family Foundation. “We’re seeing a slow unraveling of the employment-based health insurance system.”

Nationwide, about 47 million Americans lack health coverage — a number that’s steadily rising as more companies abandon health programs for workers. (About 61 percent of businesses now offer coverage to at least some employees, according to Kaiser. That’s down from 69 percent in 2000.)

“Health insurance is becoming increasingly unaffordable for businesses and working people,” Altman said.

The financial woes plaguing Doctors Medical Center in the East Bay illustrate how dysfunctional the U.S. health care system has become.

The hospital, which serves some of the more economically challenged communities of Contra Costa County, was run by Tenet Healthcare until 2004. It lost $24 million that year alone.

The facility was taken over by the West Contra County Healthcare District, which cut the deficit to $15 million in 2005 but now foresees even more red ink due to lower-than-expected patient volume, technology upgrades and other factors.

Perhaps the biggest problem faced by the hospital is the fact that about a third of ER patients have no insurance and can’t pay their bills. About 10 percent of all patients arriving at the facility lack health coverage.

To help turn things around, the hospital’s board last week approved a contract for up to $84 million to treat at least eight San Quentin inmates every day for the next few years.

“The prison contract offsets some of the losses we’re seeing in other areas,” said Gisela Hernandez, a hospital spokeswoman. “But it’s not the entire solution.”

For this reason, she said a bankruptcy filing is all but certain this week. And even then, the future of Doctors Medical Center remains uncertain. “Without an immediate infusion of cash, it’s going to be tough,” Hernandez said.

ER doctors gave notice last week because they say they haven’t been paid for six months.

Hernandez said universal coverage would go a long way toward keeping hospitals like Doctors afloat. “If everyone had health insurance,” she observed, “we wouldn’t have any uninsured people in the emergency room.”

However, it looks like that won’t be happening anytime soon. The governor recently vetoed legislation — SB840 — that would have used taxpayer funds to establish a universal health insurance system for all Californians.

Independent analysts say such a system would be cheaper than existing insurance payments for most businesses and workers. But Schwarzenegger, bowing to pressure from the insurance industry, said the system envisioned by the bill would be tantamount to socialism.

“Socialized medicine is not the solution to our state’s health care problems,” he said in a statement, adding that the proposed system would be “a serious and expensive mistake.”

UCSF’s Kahn countered that the governor has it wrong.

“SB840 is not about socialized medicine,” he said. “You would still have public and private health care providers. What this is really about is simplifying the finances of health care.”

According to researchers at Harvard Medical School, about a third of all health care spending nationwide is squandered on bureaucratic overhead — the result of a vast array of insurance forms and procedures.

“All the evidence suggests that the current system doesn’t work,” Kahn said.

And gradually, business leaders are reaching the same conclusion.

“The (health care) system is out of control, it’s unstable, it’s basically bankrupt, it gets worse each year and all we do is tinker around the edges when what we need are major fixes,” Craig Barrett, chairman of chipmaker Intel Corp., said in a speech last week.

He didn’t call specifically for universal coverage, but he said that employers should demand that hospitals use standardized record systems to keep costs under control.

“The current health care system is economically unsustainable and negatively impacting our nation’s ability to compete globally,” Barrett said. “It’s time for a systemic transformation, and U.S. employers must lead.”

Unless, that is, our politicians can find the courage to do so.

David Lazarus’ column appears Wednesdays, Fridays and Sundays. Send tips or feedback to dlazarus@sfchronicle.com.

ID Theft Infects Medical Records

Victims face bogus bills and risk injury or death. Privacy laws make such fraud hard to pursue

By Joseph Menn
Los Angeles Times Staff Writer
September 25, 2006

After shoulder surgery last year, Lind Weaver was stunned when hospital bill collectors demanded that she pay for the amputation of her right foot.

“Either you didn’t do the surgery, or you did a really [shoddy] job of it,” Weaver told them, sending along notarized photos of her toes, all still attached. “Either way, I’m not paying.”

But the 56-year-old retired schoolteacher quickly discovered she was dealing with something more nefarious than a simple clerical error: An identity thief had obtained medical care under Weaver’s name and had the bill sent to her insurer.

A year later, Weaver is still trying to catch errors in her medical records and clear the hospital bills fraudulently run up in her name.

“It became a 40-hour-a-week job,” Weaver said. “I put my phone to my ear and sat there listening to elevator music.”

Although the most typical of the millions of identity theft cases in the U.S. each year involve credit cards, a 2003 federal report estimated that at least 200,000 instances involved medical identity fraud. Experts believe that the rising cost of healthcare is driving more identity theft, and that many people are unaware they have become victims unless they receive a hospital bill or query from their insurer.

“There’s no reason to assume the patients ever find out,” said Harvard University management professor Malcolm Sparrow, an expert on regulatory agencies who has written books on healthcare fraud. “The bulk presumably remain invisible.”

With their medical records compromised, victims of this kind of fraud face a greater risk of injury or even death if doctors make treatment decisions based on bad information. Files might list incorrect prescriptions or the wrong blood type. Or, as in Weaver’s case, an erroneous diagnosis of diabetes.

Bad information can also put careers and insurance at risk. Many employers, including more than a third of the Fortune 500 companies, demand access to medical records when making hiring, promotion or benefits decisions, according to the nonprofit Patient Privacy Rights Foundation. Health and life insurance companies routinely scan medical files or payout reports before issuing new policies.

Victims, though, often find that clearing their medical records of bad information is much more difficult than fixing credit reports, which are centralized in three major credit bureaus.

Consumers have the right to obtain one free credit report annually, and to demand an investigation of information they believe is fraudulent or incorrect. Unverified reports must be removed promptly.

Medical records, in contrast, can be scattered across dozens of doctors’ offices, hospitals and clinics. And federal privacy rules intended to protect private information can make it difficult for patients to even obtain their own records when identity theft is suspected.

“These privacy rules might put you in a situation where you can’t even investigate,” said Wilma Kidd, chief privacy officer at WellPoint Inc., the largest U.S. health insurer for employees and other groups.

A big reason most people never find out about erroneous records is the Health Insurance Portability and Accountability Act of 1996. The law can make it difficult for patients to see their own medical records, since the penalties for improper disclosure prompt some hospitals to set up roadblocks including demands for multiple forms of identification.

The bitter twist on medical identity theft is that once a person tells a keeper of records that someone else’s data might be intermingled, the file becomes even harder to obtain. Why? Because it includes another person’s medical history, which many hospitals argue can’t be turned over without consent.

Even when patients do see their records, they have no automatic right to fix errors they find.

As she battled collection agencies last year, Weaver fought to see her medical files. She suspected that someone had used her identity to obtain a foot amputation, but hospital officials wouldn’t help.

Weaver marched into the hospital waiting room in Bunnell, Fla., and started shouting that the doctors didn’t know who their patients were.
That got her service in a hurry. After she was shown to a consulting room and given the file, she soon thought she had weeded out her impostor’s medical history.

In May, Weaver suffered a heart attack at her home in Palm Coast, Fla., and was in and out of consciousness.

When she awoke in her hospital room two days later, a nurse asked Weaver what drugs she had been taking to treat her diabetes. Weaver has never had diabetes, a disease that can lead to foot problems severe enough to require amputation.

“They could have given me insulin,” Weaver said. “There’s a whole different heart procedure that covers people with diabetes.”

Diabetes experts said those procedures would have been unlikely to threaten Weaver’s life. A hospital spokeswoman declined to answer questions about Weaver’s case.

Weaver doesn’t know how her identity was compromised, but identity fraud is easy when so many in the medical field have access to intimate records and patients are admitted without having to prove who they are.

At New York homeless shelters, state Medicaid identification cards once could be rented for as little as $2 a day, said Harvard’s Sparrow, who has seen overlapping pregnancies claimed under the same name. In Veterans Affairs hospitals, some eligible veterans have their identities assumed by brothers or cousins who have easy access to their documents, said Richard Ehrlichman, the department’s assistant inspector general.

Sometimes it’s the doctors who commit identity fraud to collect insurance payments for work they didn’t perform.

A Boston-area psychiatrist, Richard Skodnek, was convicted a decade ago of fraud after falsifying diagnoses, treatment sessions and entire patient histories. His victims, some of whom discovered that their insurance benefits had been exhausted, had to struggle to clear their records.

In perhaps the most sensational case, a Chicago podiatrist under grand jury investigation for exaggerating the work he performed shot and killed one of his patients in 2002 when she refused to lie on his behalf. Ronald Mikos was convicted of the murder last year.

Many insurance companies have hotlines for reporting fraud against them, and they sometimes refuse to pay suspicious hospital bills. But that often doesn’t do the identity theft victims any good: They still have to make their own cases to the hospitals, the bill collectors and the credit agencies.

In Weaver’s case, getting the insurance company involved made things worse.

After Weaver realized she was being billed for an amputation she never had, she told her insurance company, which refused to pay as well. In the hospital’s eyes, that left Weaver responsible for the whole $66,000 surgery bill, instead of just her deductible.

Collection agencies didn’t care about her explanation. Each tacked on a fee and resold the collection contract to the next agency down the line. That made correcting Weaver’s credit report especially difficult, because after she established that she wasn’t responsible for one amount billed on a certain day, the credit bureau would receive notice of a new amount with a different date, even though it was based on the same bogus debt.

Even when identity theft victims avoid health complications, the legal side effects can be terrible.

Anndorie Sachs of Salt Lake City found that out in April during a phone call from Utah’s social services department. The social worker told Sachs that her hospitalized infant had tested positive for methamphetamine. The state planned to take away the baby, along with her siblings at home.

Sachs, a mother of four, said that she hadn’t delivered a baby in two years.

“I was freaking out,” said Sachs, 27. “She was not going to believe a word. She said: ‘You’re Anndorie Sachs. You’re on the birth certificate. We know your other kids are being exposed to this too.’ ”

After the social worker grilled Sachs’ 7-year-old about whether her mother had been to the hospital lately, the agency relented.

Months earlier, Sachs’ driver’s license was stolen from her husband’s car. It eventually emerged that a woman named Dorothy Bell Moran had used that license when she checked into the hospital to give birth.
Already wanted on other charges related to identity theft, authorities said, Moran hadn’t wanted to use her own name for fear of getting caught. (She was later arrested on the earlier charges.)

Sachs had to hire a lawyer to disentangle the legal and medical records, and she is still fighting a collection agency over the medical bill.

As with Weaver and other victims interviewed, the Utah hospital cited the health insurance law and refused to show Sachs her files after she told them someone else’s paperwork was included. After Sachs went to the local media, officials agreed to delete both women’s records.

Just to be safe, when Sachs contracted a kidney infection, she chose a hospital that neither she nor the impostor had used. But some records had been shared electronically, and the hospital had the impostor’s blood type down as Sachs’ — setting up a possible fatal error.
Fortunately, staffers had drawn blood and double-checked. When they reviewed other data with Sachs, she found they also had the wrong emergency contact name and number.

The increased use of electronic records such as the ones that dogged Sachs could worsen the spread of medical errors caused by identity theft.

In the last year, the Senate and the House have passed broad bills pushing for wider use of electronic health records. Supporters, including many big technology firms and insurers, said the plan would increase efficiency, reduce error rates and provide earlier warnings about public health problems.

Such a system could also make correcting medical errors easier — but only if patients catch them beforehand, and only if the service providers agree to change them.

As the web of electronic distribution expands beyond the current pilot projects, more people will see medical records. That could increase identity theft while making existing errors harder to resolve, said Joanne McNabb, chief of the California Office of Privacy Protection.

“There is added risk that we’ve seen all over the place with electronic data,” McNabb said. “It can go to the wrong place at the wrong time very easily.”

joseph.menn@latimes.com

Keeping tabs on health records

Under the federal law known as the Health Insurance Portability and Accountability Act of 1996, medical providers have wide latitude to disclose records to others in the field, as long as they tell the patient they are doing so. They are also supposed to show the patient most of those files, with limited exceptions such as the notes of mental health professionals. But hospitals worried about fraud often demand multiple forms of identification and set up other bureaucratic hurdles to patient viewing. They can refuse patient access altogether if someone else’s records are intertwined with the patient’s.

To guard against identity theft, patients should:

* Ask to see their medical files from each provider on a regular basis;

* Scan medical and insurance bills for services, medicine and equipment they didn’t receive;

* Demand an annual list from their health insurance company of benefits that have been provided.

If medical records have been compromised:

* Ask the healthcare providers to delete the incorrect information and contact everyone they have shared that information with, as required by the health insurance act;

* Ask the providers for a list of those recipients, and follow up with them;

* Clean up records with the health insurer and make sure the provider has not passed along improper benefit reports to insurance databases;

* Scrutinize credit reports for unpaid medical bills;

* File a police report;

* Contact the Federal Trade Commission and state health and insurance departments.

Sources: World Privacy Forum, Times research

Copyright 2006 Los Angeles Times

America's uninsured children

No Shelter from the Storm: America’s Uninsured Children

Campaign for Children’s Health Care
September 2006

Findings

There were more than 9 million uninsured children (ages 0-18 years) in the U.S. in 2005. One out of every nine children is uninsured.

The majority of uninsured children-88.3 percent-come from families where at least one parent works.

Among uninsured children living with a parent, more than half-59 percent-live in two-parent households.

In more than half of all two-parent families with uninsured children, both parents work.

Overall, uninsured children are nearly five times more likely than insured children to have at least one delayed or unmet health care need.

Over the past 10 years, the advent of the State Children’s Health Insurance Program (SCHIP) and the increased push for children’s coverage that the new program created have led to marked declines in the number of uninsured children. Nevertheless, a great deal of work remains to be done. The most recent Census data show that, for the first time since 1998, the rate of uninsured children increased, from 10.8 percent to 11.2 percent.

Failure to ensure that all children in this country have health coverage is shortsighted and harmful. Children are the future of this country, and the policy choices the nation makes now can have long-term effects on who today’s children grow up to be. At the very least, we must ensure that each child gets the best possible start, which includes high-quality, affordable health coverage.

http://www.childrenshealthcampaign.org/tools/reports/Uninsured-Kids-report.PDF

Comment:

By Don McCanne, MD

Incrementalists have been touting the one health care reform “success” of the past few decades: the State Children’s Health Insurance Program (SCHIP). Yet, after a decade under the program, 9 million children remain uninsured and the numbers are increasing, and those children have five times the amount of unmet health care needs as insured children. If this is the definition of success, then how would they define failure?

We will never have health care coverage for everyone until we establish policies that ensure that it is automatic, life long, and universal. Nothing short of national health insurance will do.

Employer-sponsored premium increases

Health Benefits In 2006: Premium Increases Moderate, Enrollment In Consumer-Directed Health Plans Remains Modest

By Gary Claxton, Jon Gabel, Isadora Gil, Jeremy Pickreign, Heidi Whitmore, Benjamin Finder, Bianca DiJulio, Samantha Hawkins
Health Affairs
September 26, 2006

Abstract

Based on a survey of 2,122 randomly selected public and private employers, this paper reports on the state of employer-sponsored health insurance in spring 2006, including recent changes. Premiums increased 7.7 percent from spring 2005 to spring 2006 and have risen 68 percent since 2001. About 4 percent of workers are enrolled in high-deductible health plans with savings options. The percentage of workers covered by their own employer did not statistically change from 2005 to 2006.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w476

Comment:

By Don McCanne, MD

Some reports of this study suggest that this is good news because employer-sponsored premium increases are now down to only twice the rate of inflation, as if a “down” isn’t an “up.”

Remember the magic of compounded interest? Modest amounts of funds, with time, grow to very large amounts not only because of the interest, but also because of the interest on the interest. With insurance premiums, not only are the rate increases high, but the rates are applied to prior high rate increases, compounding year after year. That has resulted in a rate increase of 68 percent since 2001.

Although this report is about increased costs of insurance premiums, the real issue is the increase in actual health care costs. Our current pseudo-market mechanisms of slowing spending increases have been ineffective. It is not as if we don’t know what can be done. Establishing a public monopsony would enable us to obtain value in health care purchasing though single payer mechanisms. What is astounding is that we continue to tolerate these outrageous cost increases with a complacency that the market will take care of it for us.

Same question as before: Are we a nation of dimwits?

Final Recommendations of the Citizens' Health Care WorkingGroup

Health Care that Works for All Americans Final Recommendations

Citizens’ Health Care Working Group

Bipartisan legislation created the Citizens’ Health Care Working Group to go to the American people, to explore their values and aspirations for the American health care system, and to bring their ideas and energy for health reform back to Washington.

Appointed by the Comptroller General of the United States, the Citizens’ Health Care Working Group is a nonpartisan body made up of 14 citizens plus the Secretary of Health and Human Services – all from very different backgrounds, experiences within the health care system, and communities across the nation.

Guarantee Financial Protection Against Very High Health Care Costs

By establishing protection against very high medical costs for all, the Working Group’s Recommendation 2 responds to two major messages from the American people. First, people believe that no one should be financially ruined by health care costs. Further, there was overwhelming public support for a new dynamic in American health care where everyone is protected, not just select portions of the population. This Recommendation can be implemented in the short term and provide a basic level of financial protection to those who do not already possess this coverage. Building this system will provide some level of immediate protection for everyone, and also has the potential to stabilize existing employer-based health insurance markets and expand the private individual and small group health insurance markets to more Americans.

After listening to and analyzing the needs and ideas of the American people and discussing the topic with experts, the Working Group developed two possible frameworks that would meet the requirements of universal protection and guard against very high health care costs: The Market-Based and the Social Insurance models.

The Market-Based Model

The basics of the market-based model are as follows:

* All Americans would have to obtain coverage against high out-of-pocket costs.
* Individuals would be offered a choice of standardized high-cost insurance products, whose details would be easy to understand and easy to compare.
* The products would offer protection at different levels of out-of-pocket costs to individuals.
* Individuals would be free to purchase the policy that best suits their needs. Since individuals with the lowest incomes also face impoverishment with all but the most expensive plans, premium subsidies would be provided based on ability to pay, and would diminish with increasing income levels.
* Employers would retain a role in paying for or providing health plans.

The Market-Based Model: An Example

For illustrative purposes only, consider three policies covering the same set of services: (1) Policy A with a deductible of $4,000 in out-of-pocket expenses prior to full coverage of covered services, (2) Policy B with a deductible of $12,000, and (3) Policy C with a deductible of $30,000. These deductible levels are similar to policies currently offered in the individual insurance market. Based strictly on coverage offered, Policy A would have the highest premium, Policy C the lowest premium.

The Social Insurance Model

A second approach is based on a social insurance model:

* All Americans would be required to participate in a federal government program protecting against very high out-of-pocket costs.
* The program, like Medicare, would be administered by the federal government through private-sector contractors.
* The program would be funded through a combination of premiums and earmarked federal revenues. Premiums would be structured to be fair and affordable, based on a sliding scale or surcharges related to income.
* Federal subsidies, based on ability to pay, would be provided to pay premiums.

The Social Insurance Model: An Example

In an illustration of this coverage approach, protection would be provided against out-of-pocket costs for covered services that exceed some percentage of income-such as 20 percent of taxable income above the federal poverty level-or that exceed a fixed dollar amount of individual liability-such as $30,000-whichever is lower.

Final Recommendations (access page):
http://www.citizenshealthcare.gov/recommendations/finalrecs.php

Executive Summary:
http://www.citizenshealthcare.gov/finalrecs/ppd_execsumm.pdf

Recommendations report:
http://www.citizenshealthcare.gov/finalrecs/ppd_recommendations.pdf

Comment:

By Don McCanne, MD

I followed this process closely, and personally participated in it. One common theme I heard repeatedly was that comprehensive health care must be affordable for all Americans. At no time did I ever hear support for the concept that we only need to “guard against VERY HIGH health care costs” (emphasis mine). Even the few who supported high-deductible health plans also supported covering initial costs with health savings accounts. And never did I hear a suggestion that the deductible be in the range of $30,000. Although there was very strong support for single payer social insurance, none of the advocates suggested a deductible of 20 percent of income over the federal poverty level.

I am not surprised by this recommendation. At the start of the process I stated the following in a Quote of the Day:

“It is crucial that we closely observe this process that will result in a vote in Congress on systemic health care changes theoretically designed to bring quality care to every American. The current Comptroller General, David Walker, will appoint 14 of the 15 members and the Chairperson of the Working Group. Since David Walker will be able to control the ideological complexion of the Working Group, we should try to understand his views. Based on his health care forum presentation this month, it appears that he supports incremental reforms in the marketplace that place a greater emphasis on increasing price sensitivity for patients while decreasing the financial insulation provided by insurance.”

(https://pnhp.org/news/2004/january/medicare_bill_calls_.php)

I think that it is safe to say that nothing in the process warranted the “very high costs” recommendation, but it is also safe to say that the Comptroller General achieved his goal of producing a report that places “a greater emphasis on increasing price sensitivity for patients while decreasing the financial insulation provided by insurance.”

This process had great potential. We could have seen the best of the American political process at work – a process expressing the will of the American people. Instead it turned out to be another partisan hack job.

Illinois Health Care Justice Act

Taming a medical monster
By William H. Albers
Peoria Journal Star
September 24, 2006

In 2004, the Illinois Legislature enacted the Health Care Justice Act (HCJA). A 29-member task force was appointed to gather information about the uninsured and to issue a report by this December. The committee hired a consultant to recommend solutions. Public hearings have been held. Six proposed solutions have been submitted. The committee, which meets Tuesday, is now attempting to reach consensus on a plan to recommend to the Legislature.

Any solution must satisfy at least three major criteria. First, there must be universal, affordable coverage. Second, cost containment should be built in. Third, coverage should be comprehensive and fair.

Possible solutions for the uninsured take several approaches. Several attempt to increase the number of individuals covered by private insurance, including an employer mandate, individual mandate, tax incentives, health savings accounts (HSAs), purchasing cooperatives and vouchers. All of these would increase health care costs.

Other plans would seek to expand enrollment in Medicare or Medicaid by lowering eligibility requirements. Finally, some propose a single-payer system, similar to Canada’s, in which a government agency receives funds from individuals and employers, and reimburses providers for care.

Six proposals have been submitted to the task force. The consultant, rating each on a point system based on essential ideals, ranked single-payer the highest. It is the only solution which meets each of the criteria. Because of low administrative costs and simple reimbursement policies, a government-managed system can cover all citizens for no more than is now being spent on health care.

This alternative is highly controversial because it would eliminate private insurance. Not only would it be opposed by insurance companies, but others oppose it philosophically. “I do not favor national health insurance because it is not the American way,” one elected official recently said.

Unregulated private insurance has not and will not solve the current problems of excess cost and 46 million uninsured. Health care is unlike any other commodity in our economy. Demand is inelastic and society tells us that everyone is entitled to the same care, regardless of the ability to pay. However, private insurance, because it needs to generate profit, tries to exclude those at high risk, thus limiting the pool and reducing payouts.

The old and the poor are covered by public plans, but many middle-class working families are unable to afford private insurance (premiums for a family of four exceed $10,000 annually), and many others with chronic conditions are denied coverage and fall into the ranks of the uninsured.

To reach consensus, the task force may recommend a compromise. A hybrid proposal has been drafted which includes an employer mandate (employers above a certain size must offer health insurance) and an individual mandate (all individuals must have health insurance; those who cannot afford it may receive subsidies). Any proposal using either mandate will reduce the numbers of uninsured only if there is also an insurance mandate (insurance companies must expand the risk pool by offering insurance at the same rates to all).

The ideal solution to our health-financing problem is a federal single-payer system. Realistically, that is not going to happen for a while. A state-by-state approach is not optimal. There could be 50 different systems.

The Legislature must seriously consider the final recommendations of the task force and pass legislation. Any action which reduces the number of uninsured in Illinois (currently about 1.8 million people) will improve the health and well being of our citizens. This problem has been ignored by our leaders for far too long, and Illinois now has a chance to lead the way.

William H. Albers is a pediatric cardiologist and professor emeritus of pediatrics at the University of Illinois College of Medicine at Peoria.

http://www.pjstar.com/stories/092406/OP__BB0EJLGN.059.shtml

Comment:

By Don McCanne, MD

Once again, the single payer model ranked the highest based on the ideals of a universal system. Yet the voices still clamor for a compromise merely to protect the private insurance industry that has failed miserably in achieving the ideals we are seeking.

Compromise!? Why do we insist that the insurance industry must be allowed to continue to compromise the health and financial security of the people of our nation?

Are we a nation of dimwits!?

Private insurers offering traditional Medicare coverage

Luring Customers From Medicare
By Milt Freudenheim
The New York Times
September 22, 2006

For years, private insurers have offered alternatives to the federal Medicare program that are meant to give patients lower-cost options than the government coverage provides.

But suddenly a type of private insurance plan is gaining ground that looks very similar to the basic coverage long available to anyone with a federally issued Medicare card.

And the government is paying the private insurance industry a subsidy of 11 percent per patient, on average, to provide it.

The fee-for-service plans, the focus of the current controversy, are in many ways similar to the government’s own Medicare. Under the industry version, patients have the right to choose their own doctors and hospitals – as they have long been able to do with their federally issued Medicare cards.

And as with the federal program, enrollees in the private fee-for-service plans typically pay a monthly $88.50 premium to the government.

Under the industry plans, moreover, the hospitals and doctors receive the same rates as when they are paid through the basic federal Medicare program.

Experts say that because the administrative costs of providing the private policies are minimal, they represent easy income for the insurance companies, with profit margins of 4 percent or so.

But many see the private fee-for-service Medicare plans as mainly a feeder program in which insurance companies hope to gradually convert members into even more complex, more profitable private Medicare offerings that the government also subsidizes.

The more lucrative plans, like Medicare health maintenance organizations or doctor-network managed care programs, which have been available longer, can yield profits in the 10 percent range, analysts say.

While insurers do run a risk of losing money on a patient if he or she has unexpectedly large health costs, the companies can consult county-by-county Medicare cost data and decide where to offer coverage and which high-cost areas to avoid.

Under Medicare’s complicated rules, though, the amount actually paid to a company for a patient can vary. Around the nation, depending on local medical costs and the health profile of Medicare-eligible residents, the monthly federal subsidy to the insurance company can range from $400 to $2,500, said Dr. Scott Latimer, a Humana executive based in Tampa, Fla.

Marilyn Moon, a longtime Medicare researcher who served as a public trustee of the program… said she was “unconvinced by the logic that says, ‘If we are overpaying the health plans now, they will save us money later.'”

It is a “back-door way of trying to privatize Medicare,” said Dr. Jack Lewin, the chief executive of the California Medical Association.

http://www.nytimes.com/2006/09/22/business/22medicare.html?_r=1&adxnnl=1&oref=slogin&adxnnlx=1158948710-wp9HSSVwV+nFHUNNWRwPiA&pagewanted=all

Comment:

By Don McCanne, MD

Why would Congress do this? They are paying more money to private insurers for the same fees as traditional Medicare and for the same providers (all willing physicians). They also allow them to market exclusively in more lucrative markets. In addition, patients currently in treatment programs will be less likely to change coverage, whereas less expensive, healthy patients may be attracted by potential incentives such as a single package which adds a Part D drug benefit.

Clearly Congress did not intend that the private plans would continue to receive higher rates and continue to indirectly avoid adverse risk. Their intent was to establish painless private Medicare insurance options even though it requires a subsidy. The next step is ominous. Congress will slash the funding of the “unsustainable” traditional program requiring a reduction in provider funding with a massive exit of providers from the program.

Once the traditional program can no longer float (except as an under-funded welfare program), the private insurers will be granted more leeway to keep their products affordable, but not with more government money. What does that mean? The insurance industry has defined affordability to mean higher deductibles and coinsurance, greater premiums, and innovative benefit programs that reduce services covered.

The intent of Congress is not really to encourage more of the abusive practices of the private insurance industry. They passively accept that as being the markets at work (though they will want to see options for comprehensive products in the private market that take care of themselves and their wealthy supporters). Their intent is simply to destroy political support for the traditional program so they can shrink it “down to the size where we can drown it in the bathtub.”

Evil, evil, evil!

Luring Customers From Medicare

By MILT FREUDENHEIM
New York Times, business section

For years, private insurers have offered alternatives to the federal Medicare program that are meant to give patients lower-cost options than the government coverage provides. More than 7 million people now subscribe to such plans, out of a total Medicare population of 42.5 million.

But suddenly a type of private insurance plan is gaining ground that looks very similar to the basic coverage long available to anyone with a federally issued Medicare card.

And the government is paying the private insurance industry a subsidy of 11 percent per patient, on average, to provide it.

Since the government substantially increased the subsidies two years ago for these most basic private industry plans — known as private fee-for-service — enrollment in the plans has grown tenfold to 820,000. About 18,000 people signed up in August alone, Medicare said yesterday in its latest update. And some analysts expect enrollments to double or even triple by 2009.

The $7 billion that Medicare will pay private industry this year to provide this fee-for-service coverage is at least $770 million higher than the government would spend covering those patients itself, based on the 11 percent calculation.

Critics see the trend as further evidence that the government is paying private industry to take Medicare off its hands.

It is a “back-door way of trying to privatize Medicare,” said Dr. Jack Lewin, the chief executive of the California Medical Association, a physicians’ group. But the Bush administration’s Medicare chief, Dr. Mark B. McClellan, insisted yesterday that the trend “is definitely not a ‘push to privatization,’ ” but simply a way to give people with Medicare more choices. “The original Medicare program is and remains an option for those who prefer it,” said Dr. McClellan, who plans to step down next month.

Private insurers can offer more choices and cost breaks to patients, he said, while providing overall better health care that will end up saving the government money.

The 11 percent calculation comes from the Medicare Payment Advisory Commission, an independent federal research body that advises Congress. And some insurance executives say the figure is an exaggeration. But there is little dispute that federal subsidies are encouraging the insurance industry to recruit members for the plans.

And while the current industry coverage can be a good deal for some patients, critics worry that Medicare patients reliant on private insurers could be left stranded if the federal money is eventually cut.

“We are very concerned that Congress is going to pull back on the funding,” Dr. Lewin said, “and we will be left with a private system that offers fewer benefits and is going to be influenced by Wall Street.”

Critics say the growing transfer of the nation’s $342 billion Medicare program to private industry has already been playing out through other means, like the new Medicare Part D drug program and various Medicare-linked managed care plans and H.M.O’s offered by private insurers.

Providing Medicare coverage in all its guises has become a $60 billion-a-year business and one of the few profitable growth areas for insurers. Medicare enrollees look especially attractive to insurers, as the industry’s other main clientele — corporate America — struggles to meet the growing cost of providing health benefits to working people.

The fee-for-service plans, the focus of the current controversy, are in many ways similar to the government’s own Medicare. Under the industry version, patients have the right to choose their own doctors and hospitals — as they have long been able to do with their federally issued Medicare cards.

And as with the federal program, enrollees in the private fee-for-service plans typically pay a monthly $88.50 premium to the government.

Under the industry plans, moreover, the hospitals and doctors receive the same rates as when they are paid through the basic federal Medicare program.

Experts say that because the administrative costs of providing the private policies are minimal, they represent easy income for the insurance companies, with profit margins of 4 percent or so.

But many see the private fee-for-service Medicare plans as mainly a feeder program in which insurance companies hope to gradually convert members into even more complex, more profitable private Medicare offerings that the government also subsidizes.

The more lucrative plans, like Medicare health maintenance organizations or doctor-network managed care programs, which have been available longer, can yield profits in the 10 percent range, analysts say.

The more basic private fee-for-service plans, around for less than a decade, were authorized through an amendment to the 1997 balanced budget act as a way to ensure that elderly people could obtain adequate health insurance. Now the plans are envisioned as primarily for rural Americans who typically have few medical choices.

The insurance industry largely ignored the fee-for-service plans until the insurers’ subsidies were increased by $14 billion over 10 years by the 2003 Medicare overhaul legislation. Insurance lobbyists had argued that expanding private Medicare programs would eventually lower the government’s costs.

But insurers “are not really being asked to do anything for additional subsidies,” said Marilyn Moon, a longtime Medicare researcher who served as a public trustee of the program — a watchdog role — during the Clinton years. She is now at the American Institutes for Research, a nonpartisan research center in Washington.

Insurers, though, say they provide benefits that basic Medicare does not cover.

The leader by far in private Medicare fee-for-service, with more than half the total members, is Humana. UnitedHealth and WellPoint are also big players.

John M. Bertko, a Humana vice president, says benefits included having nurses stay in touch with discharged hospital patients with chronic diseases to make sure they were following doctors’ orders.

Other selling points for the private insurance plans include predictable out-of-pocket co-payments — typically $5 to $20 for doctor visits. That compares with the uncertainties patients face under traditional federal Medicare, in which they are responsible for 20 percent of whatever the doctor charges.

Martin Smith and his wife, Donna, of Bristol, Ind., chose a fee-for-service plan from UnitedHealth’s Secure Horizons Medicare unit earlier this year.

The monthly premiums of $12.50 each for Mr. Smith, 68, and Mrs. Smith, 70, are in addition to their government Medicare premiums of $88.50 each. But the Smiths say the private plan is paying off.

Mrs. Smith recently had heart bypass surgery. And though the bill has not yet arrived, she knows that the hospital deductible for her Secure Horizons plan is $600, compared with the $952 she would be responsible for under traditional Medicare.

And instead of 20 percent of the approved doctors’ fees in traditional Medicare, the Smiths pay only $10 to a primary care doctor and $20 for specialists. Secure Horizons pays the rest out of its subsidies from Medicare — which are $692.29 a month, on average, for each fee-for-service member in that part of the country.

The Smiths chose to sign up for Medicare Part D drug coverage from a separate insurer, Humana.

Like the Smiths, more than half of the private fee-for-service enrollees so far have also chosen drug coverage, and many are choosing a plan that combines both.

One is Cathy Watts, 58, of Decatur, Ill., a former nurse who says she had to retire four years ago because of Parkinson’s disease and partial paralysis. Last January she signed up for a fee-for-service offering from Humana that included Part D drug coverage.

Other than the government’s $88.50 Medicare premium that is deducted from her monthly Social Security check, Ms. Watts pays no premium to Humana.

She says the drug coverage was the main lure for her because her drug bill last year was $6,000.

“I will probably pay $3,600 this year” for drugs, she said. “So that will be better.” And she can still see the doctors of her choice.

While insurers do run a risk of losing money on a patient if he or she has unexpectedly large health costs, the companies can consult county-by-county Medicare cost data and decide where to offer coverage and which high-cost areas to avoid.

In southern Illinois, where Mrs. Watts lives, the average monthly rate the government is paying an insurer to provide Medicare fee-for-service is $692.29 — the same as in Mr. Martin’s town in Indiana.

Under Medicare’s complicated rules, though, the amount actually paid to a company for a patient can vary. Around the nation, depending on local medical costs and the health profile of Medicare-eligible residents, the monthly federal subsidy to the insurance company can range from $400 to $2,500, said Dr. Scott Latimer, a Humana executive based in Tampa, Fla.

Enrollments in the fee-for-service plans are still primarily, though not exclusively, concentrated in rural and small cities. Before the Medicare subsidies were increased in 2003, insurers had little incentive to focus on such places. With few doctors and sometimes only one or two hospitals in such areas, insurers typically have little bargaining power. And the health care providers have often balked at accepting the lower fees and second-guessing often associated with managed care insurance networks. But when enough patients in a local area have been enrolled in the private fee-for-service plans, the companies say local health care providers may have little choice but to join the insurers’ Medicare networks.

Rick Jelinek, the chief executive of UnitedHealth’s Secure Horizons Medicare business, acknowledged that the company’s strategy was “in the longer term, to build networks around our programs.”

With such networks in place, he said, the company could help manage patients’ health — and the insurer’s costs — through techniques like having nurses provide telephone health counseling aimed at helping keep patients with heart disease and diabetes avoid hospitalization.

Dan Mendelson, a former Clinton administration health official who is now the president of Avalere Health, a Washington research and consulting firm that advises insurance companies, said the private fee-for-service trend “should save money for Medicare by improving patient care.”

But Ms. Moon, the Medicare researcher, said she was “unconvinced by the logic that says, ‘If we are overpaying the health plans now, they will save us money later.'”

IOM report on rewarding performance

Rewarding Provider Performance: Aligning Incentives in Medicare
Institute of Medicine
September 2006

The health of senior citizens in the United States is not as good as it should be, given the billions of dollars spent on health care each year. This raises concerns that Medicare is not getting the best value for the services it purchases. Medicare’s current payment system places no emphasis on whether the care delivered is of high or low clinical quality or is appropriate. The system provides few disincentives for overuse of often high cost medical services and does little to encourage coordinated, preventive and primary care that could save money and produce better health outcomes.

This study is the third in the IOM’s Pathways to Quality Health Care series, which offers tools for implementing the vision of improved health care delineated in the Quality Chasm report. The first report in the Pathways series, Performance Measurement: Accelerating Improvement, recommended a strategy for developing and implementing a comprehensive performance measurement system, including a national board to coordinate that effort.
The second report, Medicare’s Quality Improvement Organization Program: Maximizing Potential, recommended an emphasis on technical assistance to providers for quality improvement. The present report builds on those studies and offers an operational plan for introducing into Medicare payment incentives that would encourage and reward high-quality care. While alignment can occur in many areas, this report is limited to examining the link between payment incentives and provider performance.

Recommendation 1: The Secretary of the Department of Health and Human Services (DHHS) should implement pay for performance in Medicare using a phased approach as a stimulus to foster comprehensive and systemwide improvements in the quality of health care.

Recommendation 2: Congress should derive initial funding (over the next 3-5
years) for a pay-for-performance program from existing funds.
* Congress should create provider-specific pools from a reduction in the base Medicare payments for each class of providers (hospitals, skilled nursing facilities, Medicare Advantage plans, dialysis facilities, home health agencies, and physicians.
* Congress should ensure that these pools are large enough to create adequate motivation for improved performance on selected measures. Because of unique challenges of physician payment relating to the SGR, investment dollars may be necessary to create adequate resources to effect change.
* Initial funding should be budget conscious in taking into account the resources needed for both funding the pools and implementing the program.

Recommendation 3: Congress should give the Secretary of DHHS the authority to aggregate the pools for different care settings into one consolidated pool from which all providers would be rewarded when the development on new performance measures allows for shared accountability and more coordinated care across provider settings.

Recommendation 4: In designing a pay-for-performance program, the Secretary of DHHS should initially reward care that is of high clinical quality, patient centered, and efficient.

Recommendation 5: The Secretary of DHHS should design a pay-for-performance program that initially rewards both providers who improve performance significantly and those who achieve high performance.

Recommendation 6: Because public reporting of performance measures should be an integral component of a pay-for-performance program for Medicare, the Secretary of DHHS should offer incentives to providers for the submission of performance data, and ensure that information pertaining to provider performance is transparent and made public in ways that are both meaningful and understandable to consumers.

Recommendation 7: The Secretary of DHHS should develop and implement a strategy for ensuring that virtually all Medicare providers submit performance measures for public reporting and participate in pay for performance as soon as possible. Initially, measure sets may need to be narrow, but they should evolve over time to provide more longitudinal and comprehensive assessments of provider and system performance. For many institutional providers, participation in public reporting and pay for performance can and should begin immediately. For physicians, a voluntary approach should be pursued initially, relying on financial incentives sufficient to ensure broad participation and recognizing that the initial set of measures and the pace of expansion of measure sets will need to be sensitive to the operational challenges faced by providers in small practice settings. Three years after the release of this report, the Secretary of DHHS should determine whether progress toward universal participation is sufficient and whether stronger actions – such as mandating provider participation – are required.

Recommendation 8: CMS should design the Medicare pay-for-performance program to include components that promote, recognize, and reward improved coordination of care across providers and through entire episodes of illness. Thus, CMS should (1) encourage beneficiaries and providers to identify providers who would be considered their principle responsible source of care, and (2) pay for and reward successful care coordination that meets specified standards for providers who take on that role.

Recommendation 9: Because electronic health information technology will increase the probability of a successful pay-for-performance program, the Secretary of DHHS should explore a variety of approaches for assisting providers in implementation of electronic data collection and reporting systems to strengthen the use of consistent performance measures.

Recommendation 10: The Secretary of DHHS should implement a monitoring and evaluation system for the Medicare pay-for-performance program in order to:
* Assess early experiences with implementation so timely corrective action can be taken.
* Evaluate the overall impact of pay for performance on clinical quality, patient-centeredness and efficiency.
* Identify the best practices of high-performing delivery settings that should be shared with others to improve care throughout the nation.

Report brief (4 pages):
http://www.iom.edu/CMS/3809/19805/37232/37236.aspx

Rewarding Provider Performance (full text):
http://darwin.nap.edu/books/0309102162/html/R2.html

Comment:

By Don McCanne, MD

Until now, conceptualizations of pay for performance have not proffered much more than the introduction of additional administrative intrusions that might motivate minimal tweaking of a few practice parameters, but would have a negligible impact on overall health care outcomes.

This Institute of Medicine report sheds further light on the subject. In elaborating on the pay-for-performance concept, the Institute of Medicine makes it very clear that the administrative burden is significant and will divert time and resources away from patient care. But what will that effort attain for us? Sampling of performance will always provide a very incomplete picture of overall performance, and it will favor those who master gaming of the system. The IOM proposal would attempt to improve provider behavior through public humiliation and financial penalties as funds are shifted to those who play the games better. There are already enough pressures on health care professionals without adding this insult.

Pay for performance eventually may become a valuable tool to improve efficiency, quality, and health care outcomes, if anyone can figure out an effective model for doing that. Unfortunately, the gifted individuals at the Institute of Medicine have not yet provided us with that model. Until they do, we should proceed with reform that we know will dramatically improve resource allocation: single payer national health insurance.

Health care scorecard assigns numbers to our national disgrace

U.S. Health System Performance: A National Scorecard

by Cathy Schoen, Karen Davis, Sabrina K. H. How, and Stephen C. Schoenbaum
Health Affairs
September 20, 2006

This paper presents the findings of a new scorecard designed to assess and monitor multiple domains of U.S. health system performance. The scorecard uses national and international data to identify performance benchmarks and calculates simple ratio scores comparing U.S averages to benchmarks. Average ratio scores range from 51 to 71 across domains of health outcomes, quality, access, equity, and efficiency. The overall picture that emerges from the scorecard is one of missed opportunities and room for improvement. The findings underscore the importance of policies that take a coherent, whole-system approach to change and address the interaction of access, quality, and cost.

Access And Affordability

Studies repeatedly find that the single most important determinant of whether patients obtain essential health care is having health insurance. With insurance premiums rising at higher rates than wages and consumer cost sharing up sharply, the affordability of insurance and care is of increasing concern to middle- and low-income families and employers.

The insurance indicator tracks the percentage of adults who are adequately insured all year. Inadequate protection or being underinsured is defined as having expenses that exceed 10 percent of family income (5 percent for those with incomes below 200 percent of the federal poverty level) or being exposed to deductibles that alone constitute 5 percent of income. As of 2003, sixteen million U.S. adults (ages 19-64) were underinsured, and sixty-one million adults (35 percent) were either uninsured or underinsured. In 2004, 40 percent of U.S. adults reported that they went without care because of costs during the year, a rate four times higher than in the United Kingdom, the benchmark country.

Only 58 percent of the nonelderly population lives in a state where employer insurance premiums average less than 15 percent of this population’s median household income. One-third of nonelderly adults report having problems with medical bills, collection agencies, or medical debt. High out-of-pocket and premium costs compared to income affect 17 percent of all nonelderly families. Time trends on all three indicators have been moving toward less affordability.

Overall picture

Within the United States, there is often a substantial spread between the top and bottom groups of states, hospitals, or health plans as well as wide gaps between the national average and top rates. As a result, the U.S.
performance relative to benchmarks averages near 50 for efficiency to 70 for healthy lives, quality, access, and equity, for an overall average score of 66 across the main domains of performance. On multiple indicators, the United States would need to improve its performance by 50 percent or more to reach benchmark countries, regions, states, hospitals, health plans, or targets.

Interrelatedness of deficits

The results provide evidence of the potential net gain from strategies focused simultaneously on improving access, quality, and efficiency. Policies are needed that address the interaction of access, quality, and cost and take a coherent, whole-system view rather than a fragmented approach to change. Universal coverage and participation are essential to improving health care quality and cost performance. High and rising rates of the population that is under- and uninsured destabilize the delivery system, fuel inefficient use of resources, and put families and the nation at risk of losing ground on past gains in health and workforce productivity.

Fragmented and unstable coverage not only increases insurance overhead costs, it also undermines the nation’s ability to assess outcomes or costs over time. Medicare is often the only national program with the stability to track outcomes and costs over episodes of care and follow patients over multiple years.

In sum, the scorecard indicates that the United States has broad opportunities to improve. It can do better, given the level of resources it has committed to health care. There is also much risk in failing to act: Cost and coverage vital signs are moving in the wrong direction. To assure a healthy, productive nation, transformation of the health system is of great urgency.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w457

For the release and helpful links from The Commonwealth Fund:
http://www.cmwf.org/publications/publications_show.htm?doc_id=401577

Comment:

By Don McCanne, MD

For the next two weeks, the article about this important new scorecard can be downloaded for free from the Health Affairs website. You should do so now. Also keep the link to The Commonwealth Fund’s page that provides important scorecard resources.

The first annual scores are now in. They’re not good. We need to address immediately the “single most important determinant” by eliminating the scourge of uninsurance and underinsurance.