Speaker – Page 1036

Single-payer health system for Maine

By Bob Lodato
Bangor Daily News
Friday, August 25, 2006

In an Aug. 12-13 op-ed piece, [Maine House candidate] Bob Walker wrote about how single-payer health care would never bring about an end to the crisis in heath care spending. I beg to disagree. According to Physicians for a National Health Plan, in 2005, half of all U.S. bankruptcies were at least in part due to medical bills, and more than three fourths of people in “medical bankruptcy” had health insurance at the time they became ill.

The Veterans Health Administration is a shining example of what Single Payer Health Care (a single national health plan) could and should be. Amazingly, just 10 years ago, the VHA was in crisis. Mismanagement and misallocation of resources resulted in surgeons who never operated and some hospitals being half empty while others were overwhelmed.

The solution was a change in management. A physician trained in public health, Ken Kizer, oversaw a radical decentralization of management, implementation of pay-for-performance contracts with top executives, and the right to fire incompetent doctors. One of the most essential components of his strategy, though, was an obsessive attention to systematization of quality and safety improvements.

The U.S. health care system’s private sector is still striving mightily to catch up. In 2003, the New England Journal of Medicine compared the VHA with private- sector hospitals. On all 11 measures of quality assessed, the VHA was “significantly better.” In 2005, the Annals of Internal Medicine showed that the VHA provided better care in seven of seven measures of quality care in the treatment of diabetic patients.

The National Committee for Quality Assurance (NCQA) ranks health care plans. Their seal of approval is the gold standard for quality of care. Last year, the VHA outperformed the best private hospital systems (including the Mayo Clinic, Massachusetts General, and Johns Hopkins) in all 17 performance measures assessed. As for patient satisfaction, a 2005 independent survey shows 81 percent of VHA patients are satisfied, compared with 77 percent of Medicare and Medicaid patients.

The Institute of Medicine considers the VHA’s integrated health information system, which includes performance measures to improve quality, one of the best in the nation. Thus the quality issue is answered: a single-payer system, with good management, can provide quality care that beats the best private institutions. What about cost effectiveness?

The VHA, unlike all private health systems, has a nearly guaranteed lifetime relationship with its patients. Thus, it has an incentive to invest in prevention and effective disease management. The savings accrued actually benefit the VHA, so the interests of both the patient and the system are aligned. In contrast, private systems usually see their patients moving into and out of their plans every year, so disease prevention only benefits the competition.

Unlike Medicare, the VHA is allowed by law to negotiate deep drug discounts, which is why a vet can get most prescriptions for under $10. Also unlike Medicare, it provides nursing home care. Even with these tremendous additional benefits, between 1999 and 2003, when VHA enrollment increased by 70 percent, funding increased by only 41 percent.

Single-payer health care is not only feasible. It will also improve quality and safety and reduce overall costs. But we need a national single-payer system. A patchwork of state systems, while better than the current patchwork of private plans, will still be bogged down by the inefficiencies of inter-relating with a multitude of private plans, each with its own forms, formularies and bureaucracy.

Our state is currently experiencing problems with its Medicaid program, with the purchase of poorly designed claims software and expansion at an inopportune time. However, system mismanagement can be corrected. The VHA is a shining example of the possible.

Don’t expect a Republican administration to make the correction, though. As Bob Walker explains, his party is dead set against any single-payer system. They will ensure, perhaps even better than the Baldacci administration, that it doesn’t work too well. The Democrats still have time to do the right thing, to put a Ken Kizer in charge. If they don’t, perhaps a new Green Independent governor will have the honor of creating a cost-effective and high-quality single-payer health system for Maine.

Bob Lodato, M.D., of Charleston, is an internist practicing in Dexter.

Has Canada Got the Cure?

by Holly Dressel
Yes Magazine
Fall issue, 2006

Publicly funded health care has its problems, as any Canadian or Briton knows. But like democracy, it’s the best answer we’ve come up with so far.

Should the United States implement a more inclusive, publicly funded health care system? That’s a big debate throughout the country. But even as it rages, most Americans are unaware that the United States is the only country in the developed world that doesn’t already have a fundamentally public–that is, tax-supported–health care system.

That means that the United States has been the unwitting control subject in a 30-year, worldwide experiment comparing the merits of private versus public health care funding. For the people living in the United States, the results of this experiment with privately funded health care have been grim. The United States now has the most expensive health care system on earth and, despite remarkable technology, the general health of the U.S. population is lower than in most industrialized countries. Worse, Americans’ mortality rates–both general and infant–are shockingly high.

Different paths

Beginning in the 1930s, both the Americans and the Canadians tried to alleviate health care gaps by increasing use of employment-based insurance plans. Both countries encouraged nonprofit private insurance plans like Blue Cross, as well as for-profit insurance plans. The difference between the United States and Canada is that Americans are still doing this, ignoring decades of international statistics that show that this type of funding inevitably leads to poorer public health.

Meanwhile, according to author Terry Boychuk, the rest of the industrialized world, including many developing countries like Mexico, Korea, and India, viscerally understood that private insurance would [never be able to] cover all necessary hospital procedures and services; and that even minimal protection [is] beyond the reach of the poor, the working poor, and those with the most serious health problems.¹ Today, over half the family bankruptcies filed every year in the United States are directly related to medical expenses, and a recent study shows that 75 percent of those are filed by people with health insurance.²

The United States spends far more per capita on health care than any comparable country. In fact, the gap is so enormous that a recent University of California, San Francisco, study estimates that the United States would save over $161 billion every year in paperwork alone if it switched to a singlepayer system like Canada’s.³ These billions of dollars are not abstract amounts deducted from government budgets; they come directly out of the pockets of people who are sick.

The year 2000 marked the beginning of a crucial period, when international trade rules, economic theory, and political action had begun to fully reflect the belief in the superiority of private, as opposed to public, management, especially in the United States. By that year the U.S. health care system had undergone what has been called “the health management organization revolution.” U.S. government figures show that medical care costs have spiked since 2000, with total spending on prescriptions nearly doubling. ⁴

Cutting costs, cutting care There are two criteria used to judge a country’s health care system: the overall success of creating and sustaining health in the population, and the ability to control costs while doing so. One recent study published in the Canadian Medical Association Journal compares mortality rates in private forprofit and nonprofit hospitals in the United States. Research on 38 million adult patients in 26,000 U.S. hospitals revealed that death rates in for-profit hospitals are signifi cantly higher than in nonprofit hospitals: for-profit patients have a 2 percent higher chance of dying in the hospital or within 30 days of discharge. The increased death rates were clearly linked to “the corners that for-profit hospitals must cut in order to achieve a profit margin for investors, as well as to pay high salaries for administrators.”⁵

“To ease cost pressures, administrators tend to hire less highly skilled personnel, including doctors, nurses, and pharmacists…,” wrote P. J. Devereaux, a cardiologist at McMaster University and the lead researcher. “The U.S. statistics clearly show that when the need for profits drives hospital decisionmaking, more patients die.”

The value of care for all

Historically, one of the cruelest aspects of unequal income distribution is that poor people not only experience material want all their lives, they also suffer more illness and die younger. But in Canada there is no association between income inequality and mortality rates–none whatsoever.

In a massive study undertaken by Statistics Canada in the early 1990s, income and mortality census data were analyzed from all Canadian provinces and all U.S. states, as well as 53 Canadian and 282 American metropolitan areas.⁶ The study concluded that “the relationship between income inequality and mortality is not universal, but instead depends on social and political characteristics specific to place.” In other words, government health policies have an effect.

“Income inequality is strongly associated with mortality in the United States and in North America as a whole,” the study found, “but there is no relation within Canada at either the province or metropolitan area level &ndash between income inequality and mortality.”

The same study revealed that among the poorest people in the United States, even a one percent increase inincome resulted in a mortality decline of nearly 22 out of 100,000.

What makes this study so interesting is that Canada used to have statistics that mirrored those in the United States. In 1970, U.S. and Canadian mortality rates calculated along income lines were virtually identical. But 1970 also marked the introduction of Medicare in Canada — universal, singlepayer coverage. The simple explanation for how Canadians have all become equally healthy, regardless of income, most likely lies in the fact that they have a publicly funded, single-payer health system and the control group, the United States, does not.

Infant mortality

Infant mortality rates, which refl ect the health of the mother and her access to prenatal and postnatal care, are considered one of the most reliable measures of the general health of a population. Today, U.S. government statistics rank Canada’s infant mortality rate of 4.7 per thousand 23rd out of 225 countries, in the company of the Netherlands, Luxembourg, Australia, and Denmark. The U.S. is 43rd–in the company of Croatia and Lithuania, below Taiwan and Cuba.

All the countries surrounding Canada or above it in the rankings have tax-supported health care systems. The countries surrounding the United States and below have mixed systems or are, in general, extremely poor in comparison to the United States and the other G8 industrial powerhouses.

There are no major industrialized countries near the United States in the rankings. The closest is Italy, at 5.83 infants dying per thousand, but it is still ranked five places higher.⁷

In the United States, infant mortality rates are 7.1 per 1,000, the highest in the industrialized world — much higher than some of the poorer states in India, for example, which have public health systems in place, at least for mothers and infants. Among the inner-city poor in the United States, more than 8 percent of mothers receive no prenatal care at all before giving birth.

Overall U.S. mortality

We would have expected to see steady decreases in deaths per thousand in the mid-twentieth century, because so many new drugs and procedures were becoming available. But neither the Canadian nor the American mortality rate declined much; in fact, Canada’s leveled off for an entire decade, throughout the 1960s. This was a period in which private care was increasing in Canadian hospitals, and the steady mortality rates reflect the fact that most people simply couldn’t afford the new therapies that were being offered. However, beginning in 1971, the same year that Canada’s Medicare was fully applied, official statistics show that death rates suddenly plummeted, maintaining a steep decline to their present rate.

In the United States, during the same period, overall mortality rates also dropped, reflecting medical advances. But they did not drop nearly so precipitously as those in Canada after 1971. But given that the United States is the richest country on earth, today’s overall mortality rates are shockingly high, at 8.4 per thousand, compared to Canada’s 6.5.

Rich and poor

It has become increasingly apparent, as data accumulate, that the overall improvement in health in a society with tax-supported health care translates to better health even for the rich, the group assumed to be the main beneficiaries of the American-style private system. If we look just at the 5.7 deaths per thousand among presumably richer, white babies in the United States, Canada still does better at 4.7, even though the Canadian figure includes all ethnic groups and all income levels. Perhaps a one-per-thousand difference doesn’t sound like much. But when measuring mortality, it’s huge. If the U.S. infant mortality rate were the same as Canada’s, almost 15,000 more babies would survive in the United States every year.

If we consider the statistics for the poor, which in the United States have been classified by race, we find that in 2001, infants born of black mothers were dying at a rate of 14.2 per thousand. That’s a Third World figure, comparable to Russia’s.⁸

But now that the United States has begun to do studies based on income levels instead of race, these “cultural” and genetic explanations are turning out to be baseless. Infant mortality is highest among the poor, regardless of race.

Vive la différence! Genetically, Canadians and Americans are quite similar. Our health habits, too, are very much alike — people in both countries eat too much and exercise too little. And, like the United States, there is plenty of inequality in Canada, too. In terms of health care, that inequality falls primarily on Canadians in isolated communities, particularly Native groups, who have poorer access to medical care and are exposed to greater environmental contamination. The only major difference between the two countries that could account for the remarkable disparity in their infant and adult mortality rates, as well as the amount they spend on health care, is how they manage their health care systems.

The facts are clear: Before 1971, when both countries had similar, largely privately funded health care systems, overall survival and mortality rates were almost identical. The divergence appeared with the introduction of the single-payer health system in Canada.

The solid statistics amassed since the 1970s point to only one conclusion: like it or not, believe it makes sense or not, publicly funded, universally available health care is simply the most powerful contributing factor to the overall health of the people who live in any country. And in the United States, we have got the bodies to prove it.

Holly Dressel was born south of Chicago and lives in Montreal, Quebec. She is a writer/researcher and the best-selling co-author, with David Suzuki, of Good News for a Change and other works.

This article was adapted from Holly Dressel’s book God Save the Queen–God Save Us All: An Examination of Canadian Hospital Care via the Life and Death of Montreal’s Queen Elizabeth Hospital, to be published in 2007 by McGill/Queen’s Press.

^{1 Terry Boychuk. The Making and Meaning of Hospital Policy in the United States and Canada. University of Michigan Press, Ann Arbor: 1999.}

2 David U. Himmelstein, et al. Health Affairs, Jan.–June 2005, http://content.healthaffairs.org/cgi/reprint/hlthaff.w5.63v1

3 Professor James Kahn, UCSF, quoted in Harper’s Magazine, “Harper’s List,” Feb. 2006.

4 National Health Expenditure Data, www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf.

5 Devereaux, Dr. P.J., et al. “A Systematic Review and Meta-Analysis of Studies Comparing Mortality between Private For-Profit and Private Not-For-Profit Hospitals,” Canadian Medical Association Journal, May, 2002.

6 Nancy A. Ross et al. “Relation between income inequality and mortality in Canada and in the United States: cross sectional assessment using census data and vital statistics,” Statistics Canada, reprinted in Health Geography, GEOG-303, ed. Nancy Ross, McGill University, 2005, pp. 109-117.

7 CIA World Fact Book. www.cia.gov/cia/publications/factbook/rankorder/2091rank.html

8 See, among many studies blaming race, Child Health USA 2003, Health Status — Infants; HRSA, with graphs such as “Breastfeeding Rates by Race/Ethnicity, 2001”; “Very Low Birth Weight Among Infants, by Race/Ethnicity 1985-2001”; http://www.mchb.hrsa.gov/chusa03.

Queue management in U.S. emergency departments

Hospitals slash emergency room wait times By Marie-Anne Hogarth
East Bay Business Times
August 11, 2006

Sutter Delta Medical Center in Antioch says it has reduced emergency room waiting times from an average of four to six hours to one to two hours in just two months by adopting a new system for prioritizing patients.

For a hospital that expects to see 54,000 patients this year in its emergency department – the only one in eastern Contra Costa County – those shorter waits represent a big boost in efficiency.

Rapid Medical Evaluation, the new system at Sutter Delta, is not entirely original. It was developed by Emeryville-based California Emergency Physicians Medical Group, which staffs more than 50 emergency departments in the state.

The RME system is one example of a nationwide push for emergency room efficiency. Hospitals are seeking ways to reduce “door to doc” times, which in turn impact patient satisfaction scores. Strategies include using providers earlier in triage, bedside registration and setting up separate areas to treat noncritical patients quickly.

http://www.bizjournals.com/eastbay/stories/2006/08/14/story4.html?b=1155528000^1329775

Comment:

By Don McCanne, MD

Excessive queues (wait times), whether for acute problems in emergency departments or for non-urgent specialized services, are often claimed by opponents of reform to be an inevitable consequence of universal, publicly-financed health systems. The truth is that they are an inevitable consequence of any health care system that is not monitoring patient flow and making appropriate adjustments when warranted.

When excessive queues develop, two approaches may be appropriate. If the system is truly deficient in capacity, minor adjustments in capacity may be required with a very modest increase in marginal costs. Much more often, excessive queues can be moderated simply by application of queue management techniques, often with no significant increase in costs.

This article demonstrates that even the seemingly insolvable problem of excessive emergency department queues here in the United States can respond dramatically to simple queue management (even though other issues such as surge capacity may have complex solutions). Establishing policies to ensure that everyone has comprehensive health care coverage should never be a reason to abandon principles of queue management.

Some countries, but not all, have lagged in queue oversight and management.
The following Canadian website provides links to presentations on queue management. They have acknowledged their problem, and they are addressing it.

http://www.cprn.com/en/doc.cfm?doc=1447

The U.S. spends more for less because of its fragmented financing system

In this survey, a team of respected researchers lead by Gerard Anderson examines health spending and health system capacity in 30 OECD nations. Although the U.S. has by far the highest per capita health spending, it is near or below average in the number of doctors, nurses, hospital beds and hospital admissions per capita. As the authors point out, this disparity illustrates the much higher prices charged for health care in the United States.

The authors conclude that other nations control rising health costs more effectively because of their collective purchasing of health services, and attribute the United States’ high costs directly to our fragmented system of financing health care. Only collective purchasing of health care (such as provided by a single-payer system) can control rising health costs. Reform options that do not address this aspect are bound to fail.

Read “It’s The Prices, Stupid: Why The United States Is So Different From Other Countries” (pdf)

U.S. Care Quality is No Better Than Other Countries

What does the United States get for its exceptionally high health spending? The answer from Johns Hopkins researcher Peter S. Hussey is “not much.” In this study, Hussey led a distinguished team in developing a set of 21 indicators to evaluate health system quality in five industrialized nations: Australia, Canada, England, New Zealand, and the United States. Although the U.S. spends roughly twice per capita on health care what the other nations do, it received a significantly higher standardized score on only two of the quality measures (breast cancer survival and cervical cancer screening rates).

The U.S. health system does not provide higher quality care despite our high spending. Instead, our resources are diverted into the administrative waste inherent in our private insurance payment system and expensive interventions that are often of dubious value. Only a single-payer system has the potential to reallocate our plentiful health resources to high-quality care for all.

Read “How Does The Quality Of Care Compare In Five Countries?” (pdf)

Another view: SB 840 will cure state's struggles with health care

By Sheila Kuehl — Special to The Bee
Published 12:01 am PDT Sunday, August 20, 2006

I couldn’t agree more with the editorial that health care reform must start on the common ground that our current system is failing everyone involved.

However, the increasing costs of health insurance premiums are bankrupting our state, our businesses and working families. One in five Californians has no health insurance today, and increasing numbers of businesses are planning to drop their health insurance by next year.

Nibbling around the edges with incremental change is not enough. We need courageous and thoughtful reform that provides what all Californians want — affordable access to good-quality health care. This is what SB 840 achieves.

The current health care system and attempts at “reform” fail because they simply bicker about who is going to pay instead of addressing the underlying reasons for out-of-control health care costs. The Sacramento Bee highlights the approach taken in Massachusetts, which, if applied in California, would legally require everyone to purchase private health insurance policies and pay endlessly increasing premiums into the current system that is completely broken. Proponents of the model in Massachusetts even say the reform is not workable in California.

We are spending $186 billion a year on health care right now. With caps on administrative overhead, these monies are more than enough to provide every California resident with excellent health care. We don’t need to spend more on health care; we need to stop wasting our health care dollars on insurance company administration.

Insurance companies do not improve the quality of health care we receive, and they do not provide choices. Instead, insurance companies limit the choices we have. They oppose legislation extending coverage to lifesaving health screenings for infants, hearing aids for children and effective Alzheimer’s medications. Instead of providing simple, straightforward health care coverage, they waste billions of dollars on complicated insurance schemes designed to screen out patients who need health care and to reduce payments to doctors.

Universal health care is the best answer, and it is possible now. SB 840 works by pooling our health care resources so that everyone — state and federal government, income earners and employers — all pay in, and Californians all get quality coverage. SB 840 reduces costs and guarantees your right to choose your own doctor. It saves businesses money and is affordable for families.

Polls show that a majority of Californians support universal health care — there is no more common ground than that.

About the writer: Sen. Sheila Kuehl, D-Santa Monica, is responding to The Bee’s Aug. 13 editorial “Health reform must start on common ground.” She can be reached at senator.kuehl@sen.ca.gov

Groups Form Coalition Focused on "Healthcare Crisis"

Carole Mikita Reporting
August 22nd, 2006 @ 3:34pm

Six community groups formed a coalition to bring awareness to what they call the healthcare crisis. The coalition called this event ‘CHALK IT UP’; the chalk outlines of bodies are still on the sidewalk, each one representing a Utahn.

Dozens of people stopped at Washington Square, 400 S. State St., during their lunch hours to be ‘chalked.’

Tess Bonham, Age 10: “Because people don’t have health insurance.”

Their outlines represent individuals without health insurance who will die.

Fred Gurney, age 11: “I think people should have health care because it’s not really good to die.”

Groups gathered in downtown Salt Lake today say that’s exactly what will happen in the next twelve months. By the end of the afternoon, this coalition of groups hopes to have 132 chalk outlined bodies.

Linda Parsons, Utah Jobs with Justice: “It’s probably a lot more than that. Statistics will show that, and we hope it will bring some attention to our politicians about health care and our crisis.”

Politicians and candidates did show up… using the event to promote their platforms.

Pete Ashdown, (D) U.S. Senate candidate: “This is becoming an economic issue in America. It’s not just small businesses that are suffering, big businsses like Delta and GM. We need some imagination by our federal government to deal with this problem.”

Bob Brister, Utah Green Party candidate for 2nd District: “Every other industrialized country in the world doesn’t let their citizens go without healthcare.”

Scott McCoy, (D) State Senator: “We have almost 300-thousand in the state of Utah, 70-odd-thousand of those are children. And so it should be a priority for the legislature.”

Each group believes the United States needs a national health insurance system that covers everyone.

Barbara Toomer, The Disabled Rights Action Committee: “We joined the coalition, mainly because we have healthcare problems also. And healthcare is extremely important to a person with a disability.”

The coalition members all support a bill H.R. 676, the United States National Health Insurance Act, a publicly financed, privately delivered health care program that uses already existing Medicare.

What will happen to me if I get sick or injured and can't pay my bills?

Katrina vanden Heuvel
BLOG | Posted 08/22/2006 @ 11:13am

On the domestic front, that’s a key question on voters’ minds as the November elections approach. A poll of working women, released on August 8 by the AFL-CIO, indicated that concern about access to quality medical coverage was rated the top issue by 97 percent of respondents, outpolling the income gap between women and men for the first time. MoveOn members, asked to vote on issues that they believe should define a “new positive agenda” ranked healthcare for all persons at the top of the list.

In California, one of the country’s largest states and a decisive election-year battleground, the growing momentum behind healthcare reform is pushing two sharply different approaches into public view.

The first, a proposal for universal healthcare coverage, is presented in Senate Bill 840, authored by Southern California’s State Senator Sheila Kuehl (D-23). SB 840 would provide universal, comprehensive healthcare insurance to Californians while protecting consumers’
ability to choose their own doctors. Under the SB 840 model, consumers and businesses would pay an income or payroll-based premium for a “solid, comprehensive plan” that includes medical, dental, vision, prescription drug, hospitalization and emergency coverage. Medical care provision would remain as the mix of private and not-for-profit business that it is now. SB 840 would also mandate that California use its purchasing power to negotiate bulk rates for prescription drugs and medical equipment. (The administrative costs for medical care in California would drop below 5 percent of total costs, compared to the whopping 25 to 30 percent currently being spent.)

On the other side, on June 16, Sandra Shewry, Governor Schwarzenegger’s Director of the Department of Health Services hosted a meeting of journalists to discuss the possibility of “Massachusetts-style health reform” in California. As it turned out, uninvited healthcare experts and advocates showed up, as well, to deliver an early warning: Massachusetts’ so-called universal healthcare plan is already bad news for the people of Massachusetts and would be a disaster for California.

The heart of the Massachusetts plan is this: every resident of Massachusetts must have health insurance by July 1, 2007 or pay a fine–but costs of health insurance and medical care itself are not controlled, nor are there adequate standards for what health insurance is supposed to cover. Big insurance wins; consumers lose.

The Massachusetts plan offers subsidies for the very poor–as it should, and allows those who can afford it to buy insurance pre-tax–but this plan squeezes middle class people who don’t qualify for subsidies and can’t afford to buy insurance pre-tax. The plan subsidizes people who earn up to 300 percent of the poverty level. But a typical group policy in Massachusetts costs about $4,500 annually for an individual and more than $11,000 for family coverage. Many families and business would be forced to choose between complying with the law and other vital necessities. Young and healthy people might be able to buy low premium plans, but even these are now typically considered affordable only to people whose income is greater than 499 percent of the poverty level. Furthermore, such high-deductible, low-coverage plans often don’t offer even adequate coverage.

The sort of plans available to middle-class consumers– those with deductibles that run into the thousands of dollars–mean that most consumers would wind up footing the bill for most of their own yearly healthcare in addition to the premiums that such a law would force them to pay. If such consumers found themselves truly needing extensive coverage–if they get hit by a car or contract a serious illness–they may find out that their cut-rate plan will leave them in terrible financial trouble. (About half of all bankruptcies sustained in the United States today are the result of medical expenses incurred by people who had health insurance they thought they could trust). Middle class consumers will not be able to choose the doctors they most trust but will be forced to decide among the doctors whose services are covered by the plan they can afford.

The sad joke is that plans like this are being marketed as “consumer driven.” Healthcare consumers (that is to say, everybody) please take note: any so-called ‘consumer-driven’ health plan is really an anti-consumer hit and run. California State Senator Sheila Kuehl is offering a real alternative. Her bold legislative initiative would bring truly affordable healthcare to all.

SB 840 has already been passed by the California State Senate and the Assembly Appropriations Committee. It will likely be up for a floor vote by the Assembly later this week or next Monday. Ask your California friends to support this bill–and to contact their Assembly representatives to vote “yes’ on SB 840. And urge your own state legislators to put forth similarly bold proposals.

Salinas throws support behind universal health care

By GEORGE B. SÃNCHEZ
Herald Salinas Bureau

The Salinas City Council this week endorsed a state Senate bill to provide universal health care for California residents.

The council voted 6-0 to support the California Health Insurance Reliability Act, which calls for the creation of a state health insurance agency that would be overseen by an elected commissioner. Councilwoman Janet Barnes abstained from the vote.

If the bill is enacted, the commissioner would be appointed by the governor and confirmed by the state Senate.

The resolution of support was brought to the council by the Salinas Action League, a local activist group, and introduced by Councilman Sergio Sanchez.

“One in five people in California do not have health insurance,” said Salinas Action League member Dr. Carolee Bull. “In a few years, it will be one in four.”

Bull said federal, state and local money already spent on health care, along with low premium rates by employees and employers, would go into a state fund proposed by Sheila James Kuehl, D-Los Angeles.

The cities of Berkeley, Santa Cruz and Watsonville, as well as Alameda, Marin and Los Angeles counties, have also passed resolutions in support of the bill.

“We need universal health care in this county,” said Councilwoman Gloria de la Rosa.

“Health care is like housing,” said Councilman Maria Giuriato, a social services worker. “It’s the foundation and infrastructure to leverage health and hold a good job.”

Giuriato asked the Salinas Action League to seek support for the bill from the Monterey County Board of Supervisors as well as other cities in Monterey County.

Carole Erickson, director of Student Health Services at Monterey Peninsula College, told the board about a Salinas student who had to be hospitalized for scabies, a skin-burrowing mite. If the student had access to preventive health care, Erickson said, the infection could have been properly diagnosed and treated.

Access to preventive health care is more cost effective than hospitalization, she said.

“If it’s cheaper to treat up front, then what are we doing?” said Erickson.

Jeff Richman, a school nurse who works in Salinas and the Pajaro Valley, said it is common to find students who need vision, dental and mental health care but have no access to a doctor other than the school nurse.

The proposed bill, he said, would help them.

George B. SÃ¡nchez can be reached at 753-6771 or gesÃ¡nchez@montereyherald.com.

MedPAC on the increase in volume of physician services

Statement of Mark E. Miller, Ph.D., Executive Director, Medicare Payment Advisory Commission
U.S. House of Representatives
Subcommittee on Health, Committee on Energy and Commerce July 25, 2006 Medicare payment to physicians

Medicare expenditures for physician services are growing rapidly. In 2005 spending on physician services increased 8.5 percent, while the number of beneficiaries in FFS Medicare increased only 0.3 percent. To get good value for the Medicare program, the payment system should set the relative prices for services accurately. Providing incentives to control unnecessary growth in volume and intensity would be desirable, but it is much more difficult.

Measuring physician resource use

For Medicare beneficiaries living in regions of the country where physicians and hospitals deliver many more health care services there is no clear relationship with better quality of care or outcomes. Moreover, they do not report greater satisfaction with care than beneficiaries living in other regions. This finding, and others by researchers such as Wennberg and Fisher, are provocative. They suggest that the nation could spend less on health care, without sacrificing quality, if physicians whose practice styles are more resource intensive moderated the intensity of their practice.

MedPAC recommends that Medicare measure physicians’ resource use over time, and feed back the results to physicians. Physicians could then start to assess their practice styles, and evaluate whether they tend to use more resources than their peers. Moreover, when physicians are able to use this information with information on their quality of care, it will provide a foundation for them to improve the efficiency of the care they and others provide to beneficiaries. Once greater experience and confidence in this information is gained, Medicare might begin to use the results in payment, for example as a component of a pay-for-performance program.

Creating new incentives in the physician payment system

MedPAC has consistently raised concerns about the SGR as a volume control mechanism and recommended its elimination. We believe that the other changes discussed previously-pay for performance, encouraging use of IT, measuring resource use, setting quality standards for imaging services, and improving payment accuracy-can help Medicare beneficiaries receive high-quality, appropriate services and help improve the value of the program. Although the Commission’s preference is to directly target policy solutions to the source of inappropriate volume increases, we recognize that the Congress may wish to retain some budget mechanism linked to volume. An ideal volume control mechanism would overcome the incentive under fee-for-service to increase volume and instead create incentives for physicians to practice in ways that improve care coordination and quality while prudently husbanding Medicare resources. The Congress has tasked the Commission to evaluate several alternative volume control mechanisms including differing levels of application such as group practice, hospital medical staff, type of service, geographic areas, and outliers. We will report on these alternatives in March 2007.

http://www.medpac.gov/publications/congressional_testimony/072506_Testimony_physician.pdf?CFID=2415800&CFTOKEN=28943302

Comment:

By Don McCanne, MD

One of the most important features of a well-functioning national health insurance program is that it can use budgets to slow the growth in health care costs to a level closer to the growth in GDP. But what a nightmare that creates.

In a predominantly fee-for-service system, physicians respond to a slowing of rate increases by increasing the frequency and intensity of services provided (volume of services). To maintain a growth rate near that of the GDP, the rate per unit of service must be decreased to offset the increases in the number of units of services provided. This is the flaw in MedPAC’s SGR formula (sustainable growth rate). Medicare’s fee per unit of service must be reduced to slow the growth rate to a “sustainable” level.

What has been the source of the volume increase? Part of it has been that patients are brought back for return visits more frequently, and the levels of services have been increased from basic to moderate complexity. Another very important component has been the increased utilization of high-tech services, especially medical imaging. The explosion of spending in imaging has pulled a significant amount of funds away from physicians, especially family physicians and general internists just at a time that we are trying to reinforce the primary care infrastructure.

Virtually everyone agrees that the current rate of growth is not sustainable indefinitely. Costs will not be controlled without controlling volume. How do you do that? One possibility presented in this testimony is to identify the non-beneficial excesses and then educate physicians who, in response, would likely modify their practice patterns. This can be effective as has been demonstrated by the decline in the use of antibiotics in childhood viral respiratory infections once physicians were convinced that they were of no value. That approach will help, but it alone likely will not be sufficient. New innovations will continue to present new challenges.

MedPAC is currently evaluating several volume control mechanisms and will report their findings to Congress in March, 2007. Volume will be controlled, but how will they do that, and can we live with it? This is a process that requires intensive citizen oversight by the policy community. Heads up!

Affordability concerns are moving up the income ladder

The Commonwealth Fund Commission on a High Performance Health System August 2006 Public Views on Shaping the Future of the U.S. Health System
By Cathy Schoen, Sabrina K. H. How, Ilana Weinbaum, John E. Craig, Jr., and Karen Davis
The Commonwealth Fund

Abstract:

On behalf of The Commonwealth Fund Commission on a High Performance Health System, Harris Interactive surveyed U.S. adults to determine the public’s perspectives on ways to improve patient care and on health policy priorities facing the President and Congress. Overall, the representative sample of 1,023 adults ages 18 and older revealed strong public support for efforts to improve care coordination and access to information. There is a shared belief that expanded use of information technology, care teams, and improved delivery of preventive services could improve the quality of care. Patients reported recent experiences of wasteful, inefficient, or unsafe care. In addition, half of middle-income and lower-income families reported serious problems paying for care and insurance coverage. Three-quarters of all adults said the U.S. health care system needs either fundamental change or complete rebuilding. Expanding insurance and controlling costs, they said, should be top priorities for federal action.

Affordability concerns are moving up the income ladder

Half of middle-income ($35,000-$49,999 annually) and lower-income (less than $35,000 annually) families said they have had serious problems paying for care in the past two years. With the median U.S. household income at $44,000, the findings indicate that more than half of all households are experiencing stress when paying for medical care.

A similarly high proportion of middle- and lower-income adults reported difficulties paying for health insurance.

Affordability is a now a concern at even higher-income levels. One-third of adults with annual incomes between $50,000 and $74,999 reported serious problems in paying for care.

Shared Views, Values and Concerns

Across income groups and regions of the country, there was resounding agreement that ensuring reliable health insurance and controlling rising costs are the most pressing health policy issues for the President and Congress to tackle. The majority consistently ranked coverage and costs as their top two priorities.

http://www.cmwf.org/publications/publications_show.htm?doc_id=394606

Comment:

By Don McCanne, MD

This report is highly credible (Harris Interactive) and is current (survey conducted June, 2006). It confirms many other reports about pubic views on the U.S. health care system.

From the perspective of reforming health care financing in the United States, the most important finding in this report is that the concerns about affordability of health insurance and health care have moved up the income ladder. The concerns of average-income families are now as great as lower-income families (more than half!), and now even higher-income families are concerned (one-third!).

The other issues addressed are very important, especially the need for a medical home. But they will be very difficult to address until we fix the financing of health care by providing comprehensive coverage for everyone.

U.S. capacity for mammograms adequate, but…

United States Government Accountability Office (GAO) July 2006 Mammography Current Nationwide Capacity Is Adequate, but Access Problems May Exist in Certain Locations

Closures of certified mammography facilities outpaced openings during a recent 3-year period, and financial considerations were most often cited as the reason for facility closures.

Although key elements that make up mammography capacity have decreased and the use of screening mammography has grown, current nationwide capacity is adequate.

The loss or absence of machines in certain locations may have resulted in access problems, including problems for women who are medically underserved, such as those who have a low income or lack health insurance.

http://www.gao.gov/highlights/d06724high.pdf

Comment:

By Don McCanne, MD

So the United States has the capacity to provide every women with appropriate mammography screening, except for those who have low income or lack health insurance.

How much longer are we going to sit back and just talk about this. Have we no decency?

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