PNHP

$22 billion taxpayer gift to private Medicare Advantage plans

$22 billion taxpayer gift to private Medicare Advantage plans

Closed-Door Deal Makes $22 Billion Difference
By Jonathan Weisman
The Washington Post
January 24, 2006

House and Senate GOP negotiators, meeting behind closed doors last month to complete a major budget-cutting bill, agreed on a change to Senate-passed Medicare legislation that would save the health insurance industry $22 billion over the next decade, according to the nonpartisan Congressional Budget Office.

Since managed-care companies first began working through Medicare in the 1990s, the government has recognized an issue in the way the companies are paid for their participation. Private insurers attract healthier seniors than the traditional government-run Medicare system, so their payment rates — based on the elderly population as a whole — exceed the actual cost of treatment.

In 2003, the government began lowering payments to Medicare HMOs to account for their healthier population of beneficiaries. But to keep those HMOs from fleeing the system, the Bush administration added a “hold harmless” payment that negated that cut.

http://www.washingtonpost.com/wp-dyn/content/article/2006/01/23/AR2006012301700_2.html

Comment: By Don McCanne, M.D.

Although the details of the CBO analysis are somewhat technical, the fundamental perversity is not. The Medicare Advantage private insurance programs are paid at a rate which assumes that patients enrolled in their programs have the same health care needs as the average patient remaining in the traditional Medicare program. That is not the case. The Medicare Advantage programs are successful in selectively marketing to a healthy subset of Medicare patients. Thus the private plans are overpaid when compared to payments for comparable patients within the traditional program.

This overpayment is vital to the Medicare Advantage plans. Without it, they could not meet their higher administrative costs. New private plans would not enter the market, and once rates are adjusted to match risk, existing plans would exit the market.

Even though Democrats were excluded from the behind-closed-doors sessions, the intent of these overpayments is no secret. In 2010, a process will begin which is designed to reduce payments in the traditional Medicare program. It will be important to have in place a market of private Medicare Advantage plans as patients begin to flee from an underfunded public program. That market of private plans cannot develop unless Congress and the administration pays this $22 billion bribe of taxpayer funds.

The Washington Post article also states, “Republican aides involved in the change dismiss its significance, saying the CBO is reading too much into it.” A $22 billion bribe may be insignificant to Republican aides, but the rest of us certainly should be concerned. That’s our tax money and our Medicare program that they’re messing with!

Health Care Is Broke, How Do We Fix It?

FOR IMMEDIATE RELASE:

Contact:
John Wasik at 847-223-9814, johnwasik@ameritech.net.
Stan Rosenberg at 847-543-1202, bcbarn@prairiecrossing.com.

A Prairie Crossing Public Forum

Saturday, February 4, 2006, 1:00 p.m.
Byron Colby Barn, Route 45 and Jones Point Road, Grayslake, IL

Affordable and accessible health care is a serious national problem that impacts everyone, yet it rarely tops the agenda for most politicians (Note: President Bush will mention health care in his upcoming State of the Union speech). Nevertheless, the topic needs to be aired, focusing on the following questions:

* Why is the U.S. losing the economic battle (jobs, factories) to compete worldwide because of its crippled health care system?

* Why is the single-payer Canadian health-care system being attacked so vigorously by American special-interest groups? What makes the Canadian system work?

* Why does the U.S. provide some of the most extensive healthcare and still lag behind industrialized countries despite having the highest gross domestic product on earth?

* Why are 45 million Americans without health insurance and 20 million underinsured?

* Why is it extremely difficult to find affordable coverage if you’re a part-timer, contract worker, small business employee or have serious pre-existing health conditions or are between jobs?

* Why are most employers cutting back on healthcare benefits, forcing you to pay more out of pocket?

At the Byron Colby Barn, we will have a number of expert speakers who will examine the current situation and propose solutions. There will be a question-and-answer session in which you can ask questions and enter into intelligent discussions concerning the alternatives to our present system. Here are some of the exciting and informed speakers you can expect to hear:

– One of our lead speakers will be Dr. Quentin Young with Physicians for a National Health Care Program. Dr. Young is the former chairman of Medicine at Cook County Hospital and a well-known authority on health care. He is a regular commentator on WBEZ-FM.

– Joining us from Canada will be Dr. Robert McMurtry, an expert on the Canadian health program and orthopedic surgeon (see bio below). Dr. McMurtry is a leader in efforts to reduce waiting times in the Canadian system. This is a great opportunity to learn the facts about health care in Canada, get your questions answered, and discuss evidence-based health care reform with a brilliant, committed, practicing physician from north of the border.

– We’ll also feature a speaker from the Illinois Health Care Referendum 2006, a statewide effort to ask the voters if they want lawmakers to improve our health care system. Citizen Action Illinois will also be presenting the “Healthy Illinois” proposal, a plan to provide health care to everyone in the state through partnerships with private insurers. As President Bush and other leaders embark upon a national dialogue to discuss health care, be a part of the discussion and debate.

Bio of Dr. Robert McMurtry

Dr. Robert McMurtry is a graduate of the University of Toronto in Medicine in 1965 and a Fellow of the Royal College of Physicians and Surgeons of Canada.

During his residency in Orthopedic Surgery, he spent 2 years in Africa, first in a mission hospital in Sekhukhuniland (South Africa) and then with the Canadian International Development Agency in Uganda. Following his residency, Dr. McMurtry did a fellowship in Hand Surgery at the University of Iowa. He started his practice at the former Sunnybrook Hospital (now Sunnybrook and Womens Health Centre) in 1975. It was there that Dr. McMurtry founded and directed Canada’s First Trauma Unit and the multi-disciplinary Hand Unit.

In 1987, he was appointed Professor and Chair of Surgery at the University of Calgary and Chief of Surgery at Foothills Hospital. In 1992, he became Dean of Medicine at the University of Western Ontario and subsequently Dean of Medicine and Dentistry, a post he held until 1999. In 1999, he became the first Cameron Visiting Chair at Health Canada – a post carrying the responsibility for providing policy advice to the Deputy Minister and Minister of Health for Canada.

Dr. McMurtry is the founding Assistant Deputy Minister of the Population and Public Health Branch of Health Canada. He was appointed to the Romanow Commission in 2002 as a Special Advisor to Commissioner Romanow.

Presently, Dr. McMurtry is Professor of Surgery at the University of Western Ontario and Orthopedic Consultant at St. Josephs Health Care in London, Ontario. His work involves an active clinical practice as well as teaching and research In December 2003, he was appointed to the Health Council of Canada and is Chair of the Wait Times and Accessibility Work Group. In June of 2003, he received the Presidential Award of Excellence from the Canadian Orthopedic Association.

Tami understands

An email that I received this morning from my daughter-in-law, Tami, who lives in Berkeley:

i thought of you this weekend as i was taking a training workshop for a clinic i will be volunteering at. the clinic serves low income women with cancer. it was extremely heart wrenching to see and hear their stories.

women who had to take public transportation to their chemo appts, living in cars while going through cancer and treatments, etc. and the #1 reason for the current poverty situation was lack of health care or not enough of it.

many or most had good or decent jobs prior to their diagnoses but because of deteriorating health they lost their jobs and then lost their insurance, or some just didn’t have it before and the diagnosis and bills, etc. put them into utter poverty. your mission for the need for universal health care slapped me in the face!

Comment: Tami understands.

'Wal-Mart law' the wrong approach on health care

Don’t mandate coverage by only large companies.
By Register Editorial Board
Des Moines Register
January 17, 2006

While millions of people flock to shop at Wal-Mart every day, the company has also gained a flock of critics for running small stores out of business, paying low wages and forcing many of its employees to turn to taxpayer-financed programs like Medicaid for health care.

It’s easy to throw stones at such a big target. But the Maryland General Assembly went too far last week when it overrode the governor’s veto and required employers with more than 10,000 workers ? i.e., Wal-Mart ? to spend at least 8 percent of their payroll on employee health care or pay into a fund for the uninsured.

Maryland is the first state in the country to pass a “Wal-Mart bill,” but labor unions are pushing legislatures in at least 30 other states – including Iowa – to enact similar requirements. It should end there: The law is unfair because it targets only companies of a certain size. Of the state’s large employers, only Wal-Mart spends less than 8 percent on health care. Other government mandates, such as those requiring companies to pay minimum wage or honor medical leave, apply to all companies.

So why did Maryland do it?

“The taxpayers are giving a health-care subsidy to the largest retailer on Earth,” said Maryland lawmaker Kumar Barve.

But that rationale is misguided because it assumes providing health care is the responsibility of employers. It shouldn’t be. Employers don’t pay workers’ car insurance, homeowners’ insurance or grocery bills. They shouldn’t be responsible for picking up their health care tab, either.

Unfortunately, the twists and turns of this country’s history have led to employer-based health insurance. Following World War II, a labor shortage and wage-freeze led to some companies offering insurance as a “perk.” Now it’s become an expectation that burdens companies financially. Worse, it keeps workers in dead-end jobs they hate. It thwarts entrepreneurial spirit when people are forced to stay with a company solely because it provides health insurance.

The United States is alone in the world in tying jobs to health care.

The country should be moving away from employer-based health care and toward a tax-financed system that provides health care to all Americans, regardless of where or if they’re employed.

What has happened in Maryland should be a wake-up call to businesses all over America to get on board with reforming health care. The best action for employers to take: support the expansion of the existing, tax-financed Medicare program for seniors to cover all Americans.

Companies and workers could contribute to the Medicare fund through payroll taxes the same way they pay into Social Security. Because Medicare has lower administrative costs and covers a larger pool of people, that may be cheaper for companies than the premiums they’re currently paying to private insurance companies to cover workers.

Maryland lawmakers had good intentions. They want more residents to have access to health care. They’re tired of Wal-Mart employees ending up on the public dime. But the move is unfair to large business and, in the long run, detrimental to moving this country toward a single system of health care that covers all Americans.

VA care is rated superior

VA Care Is Rated Superior to That in Private Hospitals
By Rob Stein
The Washington Post
January 20, 2006

The Department of Veterans Affairs medical system once epitomized poor-quality care. But after a series of changes, the system has been hailed in recent years as a model for health care reform.

Now, survey results released this week indicate that those improvements have translated into a high level of satisfaction among veterans getting treated by the rehabilitated VA.

The telephone survey, conducted in October, found inpatient care received a rating of 83 on a 100-point scale; outpatient care got a rating of 80. In comparison, a similar survey of patients receiving private care found they rated their satisfaction at 73 for inpatient care and 75 for outpatient care.

(Veterans Affairs Secretary Jim) Nicholson acknowledged that some veterans do have to wait for care, but he said the waiting time has been improving and continues to improve.

http://www.washingtonpost.com/wp-dyn/content/article/2006/01/19/AR2006011902936.html

Comment: During discussions of national health insurance, how many times have you heard someone say that we don’t want government health care because then we would all have health care like they have at the VA?

Previous studies have shown that the quality of care in the VA system is actually higher than in the private sector, and now this study shows that patient satisfaction is also greater. It is ironic that the VA can still be used as an argument against national health insurance, but in an entirely different way. Imagine this comment: “We don’t want national health insurance that covers lower quality care in the private sector when we can have higher quality and greater patient satisfaction through a government-owned socialized medicine system as exemplified by the VA.”

Of course, you won’t hear such comments because the nation is not supportive of a public buy-out of our entire health care delivery system. They are having enough trouble accepting the concept of public insurance, as persuasive as are the arguments for a social insurance system.

One reason for the VA’s effectiveness is that it is an integrated health care delivery system, but many would prefer care in the private sector rather than in what they perceive to be a less personal, clinic-type environment. However, Kaiser Permanente, as an integrated health delivery system, has many features in common with the VA system, and yet many patients select Kaiser as their provider of choice.

If we had a national health insurance program, individuals would have the freedom to choose integrated health systems. For veterans, that should certainly include the VA. They should not be deprived of the option of higher quality and greater satisfaction with their care.

The VA does have a unique problem. Wars abruptly create new veterans, and a fixed system has limited flexible surge capacity to meet the increased demand. Queues for elective services can be a problem, though they can be moderated through modest capacity adjustments and queue management. Regardless, for those veterans who cannot afford care in the private sector, and who are stuck in a queue, a universal national health insurance program could provide them the option of obtaining their care in the private sector.

The least we could do for our veterans is to give them the additional choice of accessing the poorer quality and less satisfying care that the rest of us have.

Doctor is in — for a price

By David Lazarus
San Francisco Chronicle
Sunday, January 8, 2006

David Ogden, a doctor in Marin County’s affluent Greenbrae, says he wants more time to spend with his nearly 3,000 patients, and he knows his patients want more face time with him.

Ogden’s solution: a $2,400 annual retainer to be paid by “several hundred” patients who want round-the-clock access to his expertise, no waiting for appointments, plus more leisurely visits with him in the examining room.

Everyone else — in other words, at least 2,000 current patients — will no longer see Ogden during routine checkups or for most ailments. Instead, they’ll have to make do with a nurse practitioner.

This is the latest trend in health care — variously called “concierge medicine” or “boutique medicine.” For an additional fee, patients receive more access to, and attention from, their physician, on top of the normal cost of treatment.

For those who can’t (or won’t) pay the extra charge, health care can be less convenient, less comprehensive and possibly less skillful. And that’s if the concierge doctor will still accommodate patients who aren’t paying retainers.

Most of the estimated 200 concierge doctors nationwide are making such people look elsewhere for primary care. Ogden is one of a relative few attempting to maintain a full practice through expanded use of nurse practitioners.

“This is about spending more time with patients,” he told me. “It’s what I want, and it’s what my patients want.”

Perhaps, but most apparently don’t want to pay thousands more each year for the privilege.

Ogden said he notified most of his patients shortly after Thanksgiving about the switch to what he prefers to call a “retainer practice.” As of last week, only about 1 percent had signed up for the new service.

“I’m very encouraged by the response so far,” Ogden said.

Gordon Schiff, a founder of Physicians for a National Health Program and a doctor at Chicago’s Cook County Hospital, responded that there’s little encouraging about concierge medicine. At least from a patient’s point of view.

“They should resent this,” he said. “Many of the things that doctors are saying they’ll do under concierge medicine should already be expected by patients. It shouldn’t be a privilege that you have to pay extra for.”

In-depth meetings with physicians, personal calls with test results, ready access to treatment — these should be staples of all medical practices, Schiff said.

“Concierge medicine is inherently discriminatory,” he observed. “Poor people will be treated differently from rich people, probably worse.”

But Schiff acknowledged that the U.S. health care system is so dysfunctional that most doctors are prevented from providing concierge-level service to all patients. It’s impossible when a physician is churning through 20 patients a day so he or she can reap sufficient returns from insurers.

This was Ogden’s situation. He said most visits with patients had to be limited to just 15 minutes so he could squeeze in as many as possible during an eight-hour shift.

“It’s not how I want to practice medicine,” Ogden said.

On the other hand, being restricted for the most part to seeing a nurse practitioner, and not their primary-care physician, is probably not what most of his non-retainer patients want either.

Worse, it might violate guidelines laid out by the American Medical Association, which determined in 2003 that concierge medicine raises “ethical concerns that warrant careful attention, particularly if retainer practices become so widespread as to threaten access to care.

“Physicians who engage in mixed practices, in which some patients have contracted for special services and amenities and others have not, must be particularly diligent to offer the same standard of diagnostic and therapeutic services to both categories of patients,” the association concluded.

“All patients are entitled to courtesy, respect, dignity, responsiveness and timely attention to their needs.”

This is why a Florida company called MDVIP, the leading force in concierge medicine, requires participating doctors to shift all non-retainer patients to other physicians.

“The hybrid approach with nurse practitioners is questionable,” said Darin Engelhardt, MDVIP’s chief financial officer. “If you’re providing priority to some patients, that could be detrimental to others.”

MDVIP accounts for about half of all doctors now practicing concierge medicine nationwide. The company essentially helps a physician get a concierge practice up and running. In return, it gets $500 of the doctor’s annual retainer, which typically runs $1,500.

Tommy Thompson, who until January 2005 served as President Bush’s secretary of health and human services, is on MDVIP’s payroll. He’s chairing a committee on preventive medicine.

Engelhardt confirmed that Thompson is being compensated for his role with MDVIP but declined to specify how much he’s being paid.

In 2002, Thompson was asked by members of Congress to clarify the government’s position on concierge medicine in general, especially as it relates to Medicare patients, and on MDVIP’s operations in particular.

Thompson responded that “it is not clear that such annual retainer agreements necessarily violate the law” and that “physicians may proceed with agreements of this type,” thus providing concierge doctors with the administration’s legal blessing.

Thompson didn’t address the lawmakers’ specific questions about MDVIP.

Engelhardt disputed critics’ charges that concierge medicine is responsible for a tiered health care system. He said managed care has already created different levels of service for patients.

“In a perfect world, the services provided by MDVIP physicians would be available to everyone,” he said. “The market reality precludes that.”

At Chicago’s Cook County Hospital, Schiff said, he can sympathize with doctors wanting to spend more time with patients. But he questions the ethics of any physician who demands more money for preferential treatment.

“If medicine is a public service and we’re here to take care of everyone, you don’t limit yourself to people who have money,” Schiff said. “Most people expect to be treated based on need, not on how much money they have.”

In Greenbrae, Ogden said, he feels comfortable that all his patients — retainer-paying and otherwise — will receive appropriate care.

“If someone needs me, I’m here,” he said. “I’m still a doctor.”

And, increasingly, a businessman.

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

John Sweeney on covering everybody

John J. Sweeney, President of the AFL-CIO
National Press Club
January 18, 2006

… if I were President of the United States, I’d use this State of the Union speech to… challenge Congress to quit stalling and pass universal health coverage this year …

(Later in the speech…)

We need a simple national health care plan that covers everybody…

http://www.aflcio.org/mediacenter/prsptm/sp01182006.cfm

Comment: Everyone across the political spectrum supports “universal health coverage,” even though for some that means only providing everyone with the option of being able to purchase a low-cost, stripped-down plan of “basic” benefits, while excluding those who fail underwriting requirements. Individuals claiming to support universal coverage can be ignored unless they present specifics on a plan for comprehensive coverage that would automatically include absolutely everyone. The problem is that most people who speak about universal coverage really mean covering the most people we can with our fragmented system of public and private programs, recognizing that “we’ll never be able cover absolutely everyone,” often said with a wink and a nod.

What about “a simple national health care plan that covers everybody”? If this is a truly sincere statement, it says much more.

“Everybody” is much more specific than that abused term: “universal.” Presumably “everybody” really does mean everybody.

“National” means federal, as opposed to state and local programs that tend to be patchwork attempts to cover more (or sometimes less) under a shredded system. A national program presumably would be a standardized, equitable program that would cover everyone in the nation.

“Simple” is a term that you don’t hear from most individuals speaking about universal coverage. That is likely because their proposals are complex modifications of our fragmented system, such as the touted consumer-directed health plans that actually reduce coverage. On the other hand, “simple” is a term used by advocates of reform who would replace our complex, highly inefficient and wasteful system of administering health care funds with a simple, publicly-administered single payer system. Could that be what John Sweeney meant?

There is no doubt that John Sweeney’s words were chosen very carefully for this important speech before the National Press Club. As to the meaning behind his words, we anxiously await signals to see if AFL-CIO’s actions will quickly evolve beyond their current efforts to merely target a few large employers.

PNHP Board Member on How to Fix the Medicare Drug Benefit

New York Times of Sunday, January 15.

To the Editor:

“States Intervene After Drug Plan Hits Early Snags” (front page, Jan. 8) reports that Medicare recipients are being denied promised prescription help. I would add that this has already increased hospitalizations.

I was outraged last week when one of my patients required hospital admission after stopping her medications because she couldn’t afford the new $45.57 co-payment demanded by her assigned private pharmaceutical benefit management company. Medicaid had previously covered her prescriptions.

The administration has designed a drug benefit to protect the pharmaceutical industry and discredit Medicare, our one single-payer health insurance program. Today’s mess could have been avoided if Congress had included the pharmacy benefit in Medicare and allowed Medicare to negotiate prices.

Congress should make changes in the drug benefit, instead of letting it serve as an opening wedge to privatizing and thus undermining original Medicare. Then it should extend Medicare coverage to everyone.

Oliver Fein, M.D.
New York, Jan. 9, 2006

The writer is chairman of the Metro New York chapter of Physicians for a National Health Program.

Citizens' Health Care Working Group

Citizens’ Health Care Working Group
“Health Care that Works for All Americans”

Note: This message is a call for action on your part. If you are already well informed on the Citizens’ Health Care Working Group, then skip to the three asterisks in the latter half of this message to take action. It is important that as many citizen voices as possible be heard during this process.

Background:

Senators Ron Wyden (D-Ore.) and Orrin Hatch (R-Utah) authored the “Health Care that Works for All Americans Act,” legislation designed to launch a national dialogue on health policy and bring quality care within the reach of every American. “Through open, public community meetings, the bill seeks to make citizen input the cornerstone of the reform process, giving citizens an opportunity to make hard decisions and voice their priorities for how to reshape the health care system. It would also guarantee a vote by Congress on the recommendations that result from the discussions.”

The bill was enacted as an amendment to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). Sec. 1014 of the MMA describes “Health Care that Works for All Americans: Citizens’ Health Care Working Group,” and is available at the following link:
http://www.citizenshealthcare.gov/about/law.php

The process described in Sec. 1014 has begun. The Citizens’ Health Care Working Group has been established, and the initial steps have been completed. An informative website is accessible online:
http://www.citizenshealthcare.gov/

Hearings have been held to gather information to prepare “The Health Report to the American People.” That report has been completed (though subject to
revision) and can be downloaded at the following link:
http://www.citizenshealthcare.gov/healthreport/hrtap_full.php

Beginning in mid-January, “community meetings” will be held throughout the nation to receive citizen input on reforming our health care system. The Working Group is also accepting other input, including public responses to a web-based questionnaire. Further information on what you can do to participate follows the three asterisks below.

After the community meetings are completed, the Working Group shall prepare and make available to the public through the Internet and other appropriate public channels, an interim set of recommendations on health care coverage and ways to improve and strengthen the health care system based on the information and preferences expressed at the community meetings. There shall be a 90-day public comment period on such recommendations.

After the expiration of the public comment period, the Working Group shall submit to Congress and the President a final set of recommendations.

Not later than 45 days after receiving the final recommendations of the Working Group, the President shall submit a report to Congress which shall contain– (1) additional views and comments on such recommendations; and (2) recommendations for such legislation and administrative actions as the President considers appropriate.

Not later than 45 days after receiving the report submitted by the President, each committee of jurisdiction of Congress, the Committee on Finance of the Senate, the Committee on Health, Education, Labor, and Pensions of the Senate, the Committee on Ways and Means of the House of Representatives, the Committee on Energy and Commerce of the House of Representatives, Committee on Education and the Workforce of the House of Representatives, shall hold at least one hearing on such report and on the final recommendations of the Working Group.

***

What you can do to contribute to the national dialogue on reform:

(1) Provide your answer to each of the following four questions (framed by the Working Group):

What concerns you most about health care in America today?

Our current way of paying for health care includes payments by individuals, employers, and government. Are there any changes you think should be made to this system?

What trade-offs do you think the American public is willing to make in either benefits or financing to ensure access to affordable, high quality health care?

What is your single most important recommendation to make to improve health care for all Americans?

Submit your answers online at the following link:
http://www.citizenshealthcare.gov/speak_out/public_comment.php?pguid=e73766d8-f911-4ad1-af6c-45b2b461cf8f

(2) Attend a community meeting. For an overview, with links to meeting dates and locations, registration materials, etc.:
http://www.citizenshealthcare.gov/community/overview.php

(3) Tell your friends and members of organizations to which you belong to add their input to this process. For those without computers, please assist them in this process. Public libraries can provide computer access.

(4) For those willing to expand their efforts to advance this important national dialogue, further suggestions are listed at this link:
http://www.citizenshealthcare.gov/community/invitation.pdf

N.B.: The President, in his report to Congress, will make the final recommendations for any legislation and administrative actions. If we disagree with his recommendations, we will have no right to complain unless we have provided our input. If we do participate, then we have the right to expect from the President recommendations for “Health Care that Works for All Americans.”

No kidding – wealth improves access to specialized services

Inequalities in access to medical care by income in developed countries
By Eddy van Doorslaer, Cristina Masseria, Xander Koolman for the OECD Health Equity Research Group
CMAJ
January 17, 2006

The member states of the Organization for Economic Cooperation and Development (OECD) represent the wealthiest and healthiest countries in the world. Most of them achieved nearly universal coverage of their populations for a fairly comprehensive package of medical services decades ago. Their governments are committed not only to pursuing the efficient delivery of high-quality medical care but also to ensuring equitable access to that care. In most OECD countries, access to good-quality physician services is ensured at relatively low and sometimes zero financial cost at the point of delivery. This is mainly the result of a variety of public insurance arrangements aimed at ensuring equitable access. The increasing tension between affordability and equity has spurred a number of countries to reconsider their public-private mix and to study reforms that may enhance efficiency while maintaining equity.

Like the World Health Organization, the OECD is committed to a watchful monitoring and comparison of the performance of its members’ health care systems, and equity in access is regarded as a key objective. In 2002, the OECD Health Project commissioned a cross-country comparative study to assess how the very diverse health care delivery systems of its members fare in terms of equitable access. This article summarizes some of the main results of this study.

Results: We found inequity in physician utilization favouring patients who are better off in about half of the OECD countries studied. The degree of pro-rich inequity in doctor use is highest in the United States and Mexico, followed by Finland, Portugal and Sweden. In most countries, we found no evidence of inequity in the distribution of general practitioner visits across income groups, and where it does occur, it often indicates a pro-poor distribution. However, in all countries for which data are available, after controlling for need differences, people with higher incomes are significantly more likely to see a specialist than people with lower incomes and, in most countries, also more frequently. Pro-rich inequity is especially large in Portugal, Finland and Ireland.

Interpretation: Although in most OECD countries general practitioner care is distributed fairly equally and is often even pro-poor, the very pro-rich distribution of specialist care tends to make total doctor utilization somewhat pro-rich. This phenomenon appears to be universal, but it is reinforced when private insurance or private care options are offered.

http://www.cmaj.ca/cgi/content/full/174/2/177

And…

Commentary (on the article above)
By Jeremiah Hurley and Michel Grignon

The international comparison carries some potentially important lessons for health care policy debates in Canada. The most important is perhaps the link between equity of utilization and a country’s system of financing. It should not be surprising that the 2 countries in the study that lack universal health care insurance coverage (Mexico and the United States) have both some of the lowest overall visit rates and the greatest income-related inequity of utilization. More subtle appears to be the effect of parallel private insurance (private insurance that covers publicly insured services) among those countries with universal public insurance coverage. Such private insurance is disproportionately purchased by the wealthy and is particularly targeted at specialist services. Countries in which parallel insurance plays an important role in financing (e.g., Ireland, Spain and Portugal) achieve equitable utilization of general practitioner services across income groups – indeed, there is a tendency toward a pro-poor bias – but utilization for specialist services displays some of the highest degrees of inequity. The results of this study do not allow any definitive conclusions in this regard, but they caution against any illusion that parallel private insurance will increase access for anyone except the higher-income people who purchase it.

http://www.cmaj.ca/cgi/content/full/174/2/187

Comment: This OECD study has some very good news, some bad news, and some terrible news.

The very good news is that nations with universal systems (all industrialized nations except the United States) have relatively equitable access to primary care services – the foundation of a well-functioning health care system.

The bad news is that access to specialized services is not equitable in most countries, but it is certainly no surprise that wealth opens doors to specialized services. This differential is exaggerated in nations with parallel private insurance systems. This is not to begrudge the wealthy their improved access to specialized services (which are not always beneficial), but rather it is to express alarm over the fact that the remaining population has even greater impairment in access to specialized services merely because of stratification of the masses into the universal public insurance program, while granting the wealthy the option of using the red-velvet-roped First Class entrance to health care.

The terrible news is that the United States, lacking universal health insurance, has amongst the lowest overall visit rates and the greatest income-related inequity of utilization. There is not much consolation in the fact that Mexico shares that honor. Mexico, a relatively poor country, spends 6 percent of its GDP on health care whereas the United States, a very wealthy nation, spends 16 percent. Where is that greater quality at lower cost that the market enthusiasts keep talking about?

A brief OECD statement on the health system of Mexico:
http://www.oecd.org/dataoecd/35/19/34685343.doc

Kitzhaber's proposal doesn't go far enough

Friday, January 13, 2006
The Oregonian

Former Gov. John Kitzhaber has offered a proposal to extensively reform America’s health-care system. The plan would have the state collect Medicaid money (it does this already), Medicare money (federal insurance through Social Security) and tax savings that employers get when they pay for health insurance for their employees. He would do this by having the federal government “waive” existing restrictions on states (this could apply only to Medicaid; Medicare benefits belong to workers). The resulting pool of money ($6 billion) would support preventive care and care for “other common but often costly ailments.”

Presumably, existing services would remain (although this was not specified).

The flaws in this proposal are huge. Federal limitations in many instances serve valuable purposes. Medicare and Medicaid have very different purposes (insurance vs. welfare), structures (federal payment vs. federal/state payment) and beneficiaries (retired workers vs. the poor). Constitutionally, the federal government could not assign retirees’ Medicare benefits (earned through decades of work) to a state, nor could they constitutionally deny federal tax deductions to the employers in one state (Oregon) while extending them to the other 49 (or consider the deterrence of out-of-state or interstate employers).

Most importantly, the proposal does not increase the funding for services or expand covered people or services at a time when 43 million Americans lack health insurance.

The analogy Kitzhaber draws is to his Oregon Health Plan efforts, which were admirable and innovative. But this is different. OHP was limited to Medicaid, a federal/state program, specifically contemplating waivers. And even then, we have watched the failure of the Oregon Health Plan during the past five years. There are no state dollars in Medicare or federal taxes. The Kitzhaber proposal would require national legislation; there is no chance for a single state to lead in this way. And, as national legislation, it is far too little to address major needs.

But the critics, too, have it wrong. The proposal would not create a “single-payer” program. But it should. Our health-care failure is not that we have covered too many health services, but too few. The flaw is not that we pay too much — $1.3 trillion — but that we get too little for what we pay.

And Kitzhaber himself has it wrong in saying that health care is not as important as education or the economy. It is central to both.

In the end, Kitzhaber’s proposal is not, contrary to many commentators, nearly bold enough. We need adequate funding; national planning for health facilities and services (we had this for a decade in the 1970s and ’80s); effective cost control (especially through bulk buying of drugs, as the Veterans Administration does); a broad definition of health to address smoking, obesity and alcoholism and to offer preventive health care; and a single-payer system retaining employers and insurers as delivery mechanisms, along with state agencies to reach the uninsured and the unemployed.

Paradoxically, we are getting there a bit at a time, and have been since 1970. Contrary to Kitzhaber’s proposal, incremental steps work. In the past 35 years, we have added health care for the poor, the aged, children, veterans and workers. We have improved hospitals, doctors, insurance and drugs. We now need to pull them together, fund them adequately and make them work. If we fail, the fault will be ours.

Arthur B. LaFrance is a law professor at Lewis & Clark Law School who teaches Bioethics, Health-Care Delivery and Health, Poverty and the Law.

Bush's Turn to Health Care

Is the President Ready to Expand the Public Role?
By Sebastian Mallaby
Washington Post
Monday, January 16, 2006; A17

This time last year, President Bush was preaching Social Security reform; that got nowhere. This time six months ago, his team was thinking tax reform; it soon got cold feet. Now the new theme is health reform. “This is a big priority for the president,” Al Hubbard, the White House national economic adviser, told me Friday. “The system has got to be reformed.”

He’s right, of course. The U.S. economy as a whole is extraordinarily efficient: Since 1995 productivity has grown twice as fast as in the 1980s and 50 percent faster than in euro land. But U.S. health care is the opposite. It’s notoriously inequitable, it generates tens of thousands of fatal errors annually, and it’s unbelievably wasteful. It achieves shorter life expectancy than the British, French, German, Canadian or Japanese systems, but it eats up 16 percent of the resources in the economy, compared with between 8 and 11 percent in those other countries. The difference — 6 percent or so of economic output — suggests that the waste in the American system comes to $700 billion a year.

Back before Bush was elected, Hubbard convened a private-sector group to wrestle with this challenge. He recruited three academics — R. Glenn Hubbard of Columbia University and John F. Cogan and Daniel P. Kessler of the Hoover Institution — who continue to influence Hubbard as he ponders what Bush should say about health care in the forthcoming State of the Union address. Conveniently, the trio’s thoughts are not a secret. Their five fixes for health care have just been published as a short book.

Some look at the U.S. health mess and see a failure of the market, but the authors insist that government clumsiness prevents the market from working. Modest tort reform would free doctors from practicing expensive defensive medicine. Tougher antitrust policies would prevent price-raising alliances among hospitals. Pruning mandates on health insurers — which often reflect lobbying by doctors’ groups — might free insurers to cover only the most cost-effective procedures.

So far, so plausible: Nonpartisan health experts agree that these ideas push in the right direction. But they don’t push to the goal line, nor anywhere near it. By the authors’ own estimates, the proposals eliminate only a fraction of the waste in the American system.

Enter the authors’ really big idea — the one on which the White House is likely to build a story about its grand health-reform vision. To make the health market work, the trick is to create and then empower consumers. You create them by making individuals pay more out of pocket. And you empower them by forcing hospitals and doctors to publish information on quality and price.

The idea appeals to Al Hubbard, a bluff, no-nonsense business type with a genial, uncomplicated style. Hubbard invited me to imagine a world in which companies paid for their staffs’ groceries: Employees would load up with more food than they needed; supermarkets would seize the chance to mark up groceries; pretty soon, they wouldn’t even bother posting their prices. So it is today with medicine. You don’t know the cost of your hospital visit until a few days later, when the bill arrives.

There’s a weakness in this thinking. The country has moved far enough already toward out-of-pocket payments, which promise hardship for low-income people without much reduction in waste. Health is simply too complex for people to make smart, waste-reducing decisions; when you go to the hospital with screaming stomach pains, you have no idea how many tests you need — and you’re not in a fit state to embark on comparative shopping. A celebrated study by the Rand Corp. showed that out-of-pocket payments deter needed health consumption as much as wasteful consumption, confirming the point that ordinary people aren’t going to become savvy health shoppers.

But the White House is right to press hospitals and doctors for better information on price and quality. Limited state-level experiments suggest that public ratings shame the poorest performers into rethinking their procedures; doctors want to help their patients, and if they are confronted with evidence that they are failing to do so they are willing to shake themselves up. A few health plans have begun paying bonuses to hospitals and doctors that score well on quality and price measures. A recent study led by Harvard’s Meredith B. Rosenthal found that these incentives work.

So the White House is half right. If it sticks to the good bits of its program, it could help bring down health care inflation — which in turn would create more space for wage gains and would also stem the growth in the ranks of the uninsured. But this still raises a nagging question.

Beyond the imperative of restraining prices, the biggest challenges in health care are to get insurance to everyone and to create incentives for preventive treatment — even though prevention may pay off 30 years later, by which time the patient will have gone through multiple switches in health plans. The most plausible subsidizer of universal insurance is government, and the only entity with a stake in lifelong wellness is the government. Is the administration ready to see that?

mallabys@washpost.com