Health Affairs
January/February 2003
The Road To Meaningful Reform: A Conversation With Oregon’s John Kitzhaber
The first step is to call into question the basic inequities and
contradictions in our current health care system-the things we will not
openly defend.
by Jeff Goldsmith

John Kitzhaber, M.D., former governor of Oregon:

“Let’s write a health care bill which describes the policy underlying the
current system and see how many votes we get for it.”

http://www.healthaffairs.org/readeragent.php?ID=/usr/local/apache/sites/heal thaffairs.org/htdocs/Library/v22n1/s15.pdf

Comment: Given what we now know, would we create our current system of
funding health care? Tweaking this system will never right the wrongs of our
current policies. Obviously we really do need comprehensive reform based on
sound policy.

The Washington Post
April 10, 2003
Medicare HMO Benefits Down, Premiums Up
By Theresa Agovino, The Associated Press

Medicare HMO premiums are rising while the benefits they offer are diminishing for the fourth year in a row, according to a new study by a nonprofit health research firm.

“Plans don’t want to scare healthy people away with high premiums. You are seeing the plans trying to raise money in different ways like charging more for hospital stays and drug copays.” said Marsha Gold, a senior fellow at Washington-based Mathematica Policy Research who co-wrote the study using government data on the plans.

“The government shows no indication that they want to make this a profitable business for the private sector,” said Clifford Hewitt, an analyst at Legg Mason Wood Walker Inc. in Baltimore.

http://www.washingtonpost.com/wp-dyn/articles/A1944-2003Apr10.html

Comment: Perhaps “the government” has the wisdom to not only end the waste of resources on health plan middlemen, but also the wisdom to add a desperately needed prescription benefit to the traditional Medicare program.

The Washington Post
April 10, 2003
Medicare HMO Benefits Down, Premiums Up
By Theresa Agovino, The Associated Press

Medicare HMO premiums are rising while the benefits they offer are diminishing for the fourth year in a row, according to a new study by a nonprofit health research firm.

“Plans don’t want to scare healthy people away with high premiums. You are seeing the plans trying to raise money in different ways like charging more for hospital stays and drug copays.” said Marsha Gold, a senior fellow at Washington-based Mathematica Policy Research who co-wrote the study using government data on the plans.

“The government shows no indication that they want to make this a profitable business for the private sector,” said Clifford Hewitt, an analyst at Legg Mason Wood Walker Inc. in Baltimore.

http://www.washingtonpost.com/wp-dyn/articles/A1944-2003Apr10.html

Comment: Perhaps “the government” has the wisdom to not only end the waste of resources on health plan middlemen, but also the wisdom to add a desperately needed prescription benefit to the traditional Medicare program.

Houston Chronicle
April 6, 2003
President promises one health policy, proposes another

In his State of the Union address in January, Bush said the nation must move to a system in which “all Americans have a good [health] insurance policy and choose their own doctors,” with seniors and low-income Americans receiving the help they need. The president urged the nation to take control of health care away from the bureaucrats, trial lawyers and HMOs and return it to doctors, nurses and patients.

However, the Medicare reform plan Bush proposed just before the start of the Iraq war would force the elderly to choose among these goals, thus preventing Americans’ attainment of a majority of those goals.

Since January, President Bush has been preoccupied with regime change in Iraq. Perhaps he has forgotten the words of assurance he spoke to Americans in his State of the Union message. If the president relies on aides to prevent him from making empty promises or contradicting himself, his aides have failed him.

http://www.chron.com/cs/CDA/story.hts/editorial/1853344

Comment: This is simply one more reminder that health care proposals must be based on sound policy rather than on the politics of those who place their lesser agendas above that of the health of our people.

Houston Chronicle
April 6, 2003
President promises one health policy, proposes another

In his State of the Union address in January, Bush said the nation must move to a system in which “all Americans have a good [health] insurance policy and choose their own doctors,” with seniors and low-income Americans receiving the help they need. The president urged the nation to take control of health care away from the bureaucrats, trial lawyers and HMOs and return it to doctors, nurses and patients.

However, the Medicare reform plan Bush proposed just before the start of the Iraq war would force the elderly to choose among these goals, thus preventing Americans’ attainment of a majority of those goals.

Since January, President Bush has been preoccupied with regime change in Iraq. Perhaps he has forgotten the words of assurance he spoke to Americans in his State of the Union message. If the president relies on aides to prevent him from making empty promises or contradicting himself, his aides have failed him.

http://www.chron.com/cs/CDA/story.hts/editorial/1853344

Comment: This is simply one more reminder that health care proposals must be based on sound policy rather than on the politics of those who place their lesser agendas above that of the health of our people.

Jonathon Ross, MD, MPH, immediate past president of PNHP, comments on administrative costs:

One should not forget the unmeasured administrative costs in the personnel offices of the businesses. They must deal with all the fuss and bother of contracting with and dealing with the service issues for their employees. This is measured as a business cost but is really a health administrative cost passed on to business that must deal with the added costs in the personnel office. I have informally interviewed about 10 personnel officers at a range of different size businesses and they estimate that about 25-50% of the time spent in the personnel office has to do with health insurance issues including enrollment and disenrollment, service issues, and time spent on decisions involving benefits, purchasing, negotiating with unions or insurers, etc. Lastly, there are the unmeasured costs of the individual trying to sort out health insurance issues such as which coverage to choose, insurance co-payments and deductibles, what doctor to choose when coverage changes and your doctor is no longer in the network, etc.

American Journal of Public Health
April 2003
Primary Care: Is There Enough Time for Prevention?
By Kimberly S. H. Yarnall, MD, Kathryn I. Pollak, PhD, Truls Østbye, MD,
PhD, Katrina M. Krause, MA and J. Lloyd Michener, MD

Abstract

Objectives: We sought to determine the amount of time required for a primary care physician to provide recommended preventive services to an average patient panel.

Methods: We used published and estimated times per service to determine the physician time required to provide all services recommended by the US Preventive Services Task Force (USPSTF), at the recommended frequency, to a patient panel of 2500 with an age and sex distribution similar to that of the US population.

Results: To fully satisfy the USPSTF recommendations, 1773 hours of a physician’s annual time, or 7.4 hours per working day, is needed for the provision of preventive services.

Conclusions: Time constraints limit the ability of physicians to comply with preventive services recommendations.

Discussion (excerpt):

Choosing the best available services is a laudable goal in light of the time pressures faced by physicians. It would be preferable, however, to pursue solutions that do not require clinicians to abandon applicable and effective services. Alternatives that extend beyond the current model of face-to-face patient care, such as group visits with physicians and nurses, use of health educators or dietitians for counseling, and various forms of patient education through telephone or print or electronic media, should be explored further.

It has also been suggested that physicians and nonphysician clinicians should work together, providing illness care and wellness care, respectively. This is perhaps the most promising model currently available, especially because the number of nurse practitioners and physician assistants is expected to increase. This form of practice will require new relationships among physicians, nurse practitioners, and physician assistants that build on their complementary strengths. Delivery of services through other health care professionals or new media will require changes in the current method of reimbursement for preventive services, as well as further research to develop strategies for organizing such delivery.

Currently recommended preventive services for the US population require an unreasonable amount of physician time. The magnitude of the problem is likely to increase as new genetic tests become available. Our current system of preventive care delivery-provided by physicians seeing patients for acute visits and for periodic preventive health evaluations-no longer meets national needs. New methods of preventive care delivery are required, as well as a clearer focus on which services can be best provided, and by whom.

http://www.ajph.org/cgi/content/abstract/93/4/635

Comment: There is no argument about the benefit of evidence-based preventive services and that they should be included in any system of healthy care delivery. There is some dispute about the cost of such services. A frequent claim is that such services reduce costs by preventing more costly medical problems. Considering the tremendous amount of resources that would have to be devoted to this effort brings into question whether cost savings can be achieved, especially when you consider that preventing some disorders will not prevent individuals from eventually developing other costly pathological conditions. Nevertheless, the benefit of prevention in maintaining a better quality of life makes it imperative that we should pursue methods of providing access to proven preventive services.

It is quite clear that our current system has been incapable of meeting this challenge, and, as structured, will never find enough resources to fund these services, not when we continue with policies that prioritize funding administrative waste over “unnecessary” preventive services.

It is impossible for primary care physicians to devote over seven hours a day to preventive services. But a single, integrated system, funded with a global budget, could allocate resources specifically to these services. It is also clear that these services could be delivered at a lower cost if we changed from primary physician micromanagement of the preventive services to “specialists” in this field. Such specialists might include nurse practitioners, physician assistants, or even a new category of prevention professionals, working within the integrated health care team. Establishing streamlined protocols that could efficiently process large numbers of individuals, supervised by individuals specifically trained in preventive services, could greatly expand access to these beneficial services in a much more cost-effective manner.

This is yet one more reason to abandon our inefficient, fragmented system of funding health care and adopt a single publicly-administered program of health care coverage.

Kaiser Commission on Medicaid and the Uninsured
March 2003
Health Insurance Premiums and Cost-Sharing:
The Impact on Low-Income Populations

Cost-sharing has a disproportionate impact on low-income people. A number of the research studies have used data from the RAND Health Insurance Experiment (HIE) – a randomized, controlled experiment supported by the federal government in the 1970s that remains the most comprehensive, rigorous study of cost-sharing, health care utilization and outcomes that exists. Analysis of RAND data showed that low-income children in cost-sharing plans had only a 56% likelihood (85% for higher-income children) of receiving highly effective care for acute conditions relative to those with no cost-sharing (Lohr et al, 1986). Similarly, low-income adults in cost-sharing plans had a 59% likelihood of receiving highly effective care relative to those with no cost-sharing. Higher income adults in cost-sharing plans fared better – they had a 71% likelihood of receiving highly effective care.

Conclusions

Research shows that premiums can discourage enrollment in health insurance programs and cost-sharing disproportionately affects low-income people, reduces the use of beneficial, cost-effective services, preventive care and prescription drugs and can result in worse health outcomes. Limiting access to services through cost-sharing, particularly outpatient care, may result in higher costs overall, if more expensive services, such as hospital care, are used instead. In view of the greater health needs and limited resources of low-income individuals, these findings warrant caution as policymakers consider the use of premiums and cost-sharing in public programs for people with modest or low incomes.

Fact sheet: http://www.kff.org/content/2003/4072/4072.pdf

For the full report: http://www.kff.org/content/2003/4071/4071.pdf

Comment: Much discussion regarding controlling health care costs has centered around the theory that patients waste resources by obtaining care that they don’t really need, and that they wouldn’t do so if they had to share in the costs of that care. But this report confirms that studies have shown that cost-sharing reduces the likelihood of receiving “highly effective” medical care. This impact is severe for low-income individuals, but it is important to realize that it negatively impacts higher-income individuals as well.

Other studies have confirmed that over-utilization is a very real problem. But in the physician-patient relationship, it is the physician who has the knowledge and expertise to decide on optimal use of our resources. The patient is not deliberately seeking ways to over-utilize the system, but rather is turning to the physician for the best advice on health care. A better approach to over-utilization (and under-utilization, also a problem) is to have an integrated system which can identify provider outliers. Then a corrective educational process can be instituted. Punitive measures would be considered only for those providers who fail to respond to the educational process.

We need policies that contain costs through mechanisms that do not prevent people from accessing effective health care. Rather than erecting financial barriers in the form of financial disincentives, we can corral costs through global budgeting. The funds would still end up in the hands of the providers, but, in an integrated system, patients would receive the care that they really need.

Radiology
April, 2003
Rationing in Health Care: Changing the Patterns of Health Care
By Richard M. Friedenberg, MD

Managed care has been our first attempt at cost-efficient medicine. It has achieved many of its goals and in many ways has improved upon the cost-effectiveness of third-party insurance. However, it has failed totally in producing universal health coverage, and as a nation, we cannot afford to allow this to continue. More than 1.4 million Americans lost their health insurance last year, with our uninsured population exceeding 41 million (18). Health care insurance rates increased 12.2% in 2001 and 8.1% in 2002, and they are projected to increase 13.6% in 2003 (18). It is time for a change. We have two choices; we can attempt a blend of private insurance and government subsidies or go directly to a single-payer system.

http://radiology.rsnajnls.org/cgi/content/full/227/1/5 (controlled access)

Comment: To see a call for universal coverage in this leading journal for radiologists is a major step forward. We do have the two choices mentioned, but the better one would eliminate the source of much of the grief in our system today – the private insurance plans. But Dr. Friedenberg is certainly correct when he says that it is time for a change.