The Sacramento Bee
March 21, 2002
By Lisa Rapaport

Some of the biggest changes could come in CalPERS’ two self-insured plans, which provide benefits to 20 percent of its 1.2 million members. The pension plan has seen financial risk grow in its self-insured plans as sicker, costlier patients flock to them as HMOs abandon outlying counties and some unions with healthier members shop for coverage outside CalPERS.

In response, the pension fund might drop all of its HMO contacts in favor of a single, statewide self-insured plan.

Larry Levitt of the Kaiser Family Foundation:

“You have to be very big to even contemplate fully self-funding and taking the HMOs out of the equation completely. It’s hard to imagine many employers besides CalPERS pulling this off.”

http://www.sacbee.com/content/business/story/1913356p-2025433c.html

Comment: If CalPERS, the nation’s second largest provider of health benefit services (next to FEHBP), recognizes the wisdom of excluding middlemen health plans and establishing a single, statewide program for California state employees and retirees, then when will the rest of us finally recognize that a single, statewide, publicly-administered program will better serve the health care needs for all of us? Would CalPERS consider letting us join in on the initial discussions to consider whether it might be wise to establish a single payer system for the entire state? The California Health Care Options Project has established the credibility of this approach. It is time to look at all options, especially those with credibility.

The New York Times
March 19, 2002
By Paul Krugman

Sunday’s front-page story in The Times on doctors who shun patients with Medicare may have been alarming enough; it seems that recent cuts in Medicare payments are inducing many doctors to avoid treating Medicare recipients at all. But this is just the beginning of a struggle that will soon dominate American politics.

Think of it as the collision between an irresistible force (the growing cost of health care) and an immovable object (the determination of America’s conservative movement to downsize government).

Why don’t we just leave medical care up to individuals? Basically, even in the United States there are limits to how much inequality the public is prepared to tolerate. It’s one thing if the rich can afford bigger houses or fancier vacations than ordinary families; Americans accept such differences cheerfully. But a society in which rich people get their medical problems solved, while ordinary people die from them, is too harsh even for us.

But meeting the public’s expectations for medical care – that is, ensuring that every American, and in particular every retired American, gets essential care – will require a lot of government spending. And the conservative movement in general, and the Bush administration in particular, are not prepared to make the money available; after all, government spending must ultimately be paid for with taxes.

Yet they dare not say openly that they are prepared to deny essential health care to those who cannot afford it.

http://www.nytimes.com/2002/03/19/opinion/19KRUG.html

Paul Krugman, Ph.D., is Professor of Economics and International Affairs at Princeton University.

Comment: “A lot of government spending” does not have to mean more spending. The administrative efficiencies enabled by establishing a publicly administered program of universal insurance would provide enough savings to fund the deficiencies in our current system. The only hurdle has been our reluctance to accept the fact that “public administration” means that the government would collect the “premiums” and distribute those funds equitably and efficiently. That is not a bad thing. We have to get over thinking that it is.

The American public, the Congress and the News Media do not have before them accessible, sense-making comparative costs, figures. Nor do they see/hear/receive/have explained in common sense fashion the elements and considerable benefits to be derived via single payer, regional global budgeting, or the multiple payers that exchange mountains of bills each day, back and forth. Most of the proposals forthcoming are merely the rearrangement of desk chairs on the SS. US HEALTH COSTS DEBACLE.

Health care is too important to be left to the market place. Hopefully not medical and public health academia too.

It is hard enough to find out what one’s insurance pays, how much of the co-payment has or has not been factored in, and whether or not one needs yet another supplementary policy to make certain bankruptcy is not just around the corner.

The ego and energy going into this particular conversation would better be spent on informing the public.

Come on, gentlemen. We are on the same side aren’t we?

Tom Mainor

Uwe Reinhardt again responds to Theodore Marmor:

Ted:

I’m off on a trip over break and have only a few moments to reply, but let me try.

You took a few nice swings at me, which was fair enough, I suppose, but I do not think that you have answered my two fundamental questions I raised in my earlier e-mail, more sincerely than you may surmise:

1. How does democracy work in America? If your life depended on it, Ted, and someone asked you to compress your knowledge on this subject into, say, one written page that might be roughly right, what would you write down?

2. What do the American people, other than the providers or financial intermediaries of health care, want from their health system, and what kind of system would they really like to have?

Do I understand you to say that the people do not have a coherent, logically consistent view on what they want from their health system?

Is it the case that, whatever people may think in this regard at a moment, it takes very little to disinform and confuse them, and to shift their views (as, say, in California)?

Are you saying that, even if people had logically consistent and stable views on health policy, these views would be irrelevant under our system of government in any event, or are relevant only occasionally, in ways that can be predicted only ex post–e.g. by Shields and Brooks?

Having spoken at length on several occasions with Humphrey Taylor of Lou Harris, and having read on the matter, too, I do appreciate that it is very difficult to fathom through surveys what people really think about any issue, if only because the responses given are easily influenced by the way questions are framed. I am not really thinking about that problem. I am after what people actually might be thinking.

Best regards,

Uwe

Victor Sidel, M.D., Co-Founder and Past President, Physicians for Social Responsibility/USA and Co-Founder and Past Co-President, International Physicians for the Prevention of Nuclear War (1985 recipient of the Nobel Prize for Peace), comments on the debate and on our priorities:

Don:

As you know, I’m off to Moscow to try to make a contribution to lessening the threat of use of nuclear weapons. That may be the reason I have little patience with this kind of argument. It’s clear why economics is called “the dismal science.” In a time when untold billions of additional dollars are being allocated to the US military and to “bioterrorism preparedness” while the DoD makes plans to use nuclear weapons (or threaten to use them), policy arguments about the exact percentage of GDP devoted to medical care (or the false predictions that were made about its rise) are dilatory or worse. Let’s devote our time and energy to discussion of the political action needed for the achievement in our lifetimes of an equitable high-quality universal cost-effective medical care system for the United States.

Cordially, Vic

Dr. Sidel will be in Moscow March 24-26, and will deliver the paper, “Instead of Nuclear Weapons: An IPPNW Perspective on Nuclear Security, Human Security, and Global Security.” The concept of human security is very directly related to our efforts on behalf of health care justice. Dr. Sidel has kindly consented to make this paper available to members of this list. Since it is four pages, it is too long to send it out to everyone with this message, but merely reply to this message and it will be forwarded to you as a Word attachment.

Kip:

I think we can put this baby to bed as follows:

1. It is agreed that, relative to keeping the elderly in the traditional Medicare (enhanced by a drug benefit), funneling the same tax dollars through private health plans will either not buy the elderly the same health care services or the elderly have to put extra money on top. Thus, for the health plans or anyone else to sell that idea, they would have to convince us that for the same money, we will get different services that will represent higher quality care (e.g., through disease management). That is a hope but not a reality.

2. On the role of managed care during the 1990s, I agree that there is something to all of your arguments–the insurance cycle, the Hillary effect, and so on–but I am struck that when I plot real health spending per capita from 1965 to 2000, how smooth that line basically has been, in spite of insurance cycles and preemptive lying-low in the face of cost-containment talk in the past several decades. There has never been such a dramatic bending down of that curve as occurred during 1922-1997-8. Furthermore, I find it hard to believe that the discounts the plans wrung out of providers and the reduction in ALOS did not yield at least some savings.

Thus, I conclude that this argument is not settled and that the data allows us each to our maintain hypotheses.

3. As to Luft and Miller, they presented a truly detailed revisit of their earlier study last year at a conference. Once again, the results were inconclusive. I will not accept it as a working hypothesis that managed care lowered the quality of the patient’s health care, although it did probably lower the quality of some providers’ life.

Best regards,

Uwe

Sullivan responds to Reinhardt Kip Sullivan responds to Uwe Reinhardt:

From Uwe Reinhardt’s last message:

<< As to Luft and Miller, they presented a truly detailed revisit of their earlier study last year at a conference. Once again, the results were inconclusive. >>

Kip Sullivan:

Uwe, Do you know if Luft and Miller’s new review excluded studies that didn’t control for coverage differences? If it did not, why do you give its conclusions any credability

The most galling of the studies cited by Miller-Luft in their 1994 and 1997 reviews were studies that compared doctors treating Medicare patients in HMOs with doctors treating patients in FFS Medicare without controlling for coverage differences. The complete scam works as follows:

(1) Taxpayers overpay Medicare HMOs,
(2) Medicare HMOs use the subsidy to pay for better coverage (e.g., cancer screens),
(3) researchers with a fondness for HMOs come along and examine whether Medicare HMO docs are better than Medicare FFS docs on process measures (e.g., use of cancer screens) and outcome measures (e.g., stage of cancer at diagnosis) likely to be affected by the coverage difference and,
(4) lo and behold, the HMO docs come out looking better.

I think the scholars who wrote these studies, the editors who accepted them for publication, and others like Miller and Luft who describe them as unusually good studies, are guilty of thought processes so flabby their behavior rises to the level of malpractice.

Evidence-based medicine is now the new religion within the American health policy community. But the health policy community has yet to apply the same standard to itself. If a group of doctors conducted a study comparing the effectiveness of Drug A to Drug B, and they deliberately set it up so that the group getting Drug A took drug A on schedule because they had excellent drug coverage, while the group getting Drug B took Drug B erratically because they had no health insurance, they would be laughed out of the profession. Not so in the health policy community. Health policy analysts who design such shabby experiments are held up as scientists par excellence.

Do you agree with my statement that studies that compare docs treating un- or under-insured FFS patients with HMO docs treating fully insured patients are studies so flawed they shouldn’t be published, much less held up by Miller-Luft as among the 44 best studies published between 1980 and 1997? Can you tell me if Miller-Luft’s new review examined only those studies that controlled for coverage differences?

Thanks.

Kip

Kip:

I think we can put this baby to bed as follows:

1. It is agreed that, relative to keeping the elderly in the traditional Medicare (enhanced by a drug benefit), funneling the same tax dollars through private health plans will either not buy the elderly the same health care services or the elderly have to put extra money on top. Thus, for the health plans or anyone else to sell that idea, they would have to convince us that for the same money, we will get different services that will represent higher quality care (e.g., through disease management). That is a hope but not a reality.

2. On the role of managed care during the 1990s, I agree that there is something to all of your arguments–the insurance cycle, the Hillary effect, and so on–but I am struck that when I plot real health spending per capita from 1965 to 2000, how smooth that line basically has been, in spite of insurance cycles and preemptive lying-low in the face of cost-containment talk in the past several decades. There has never been such a dramatic bending down of that curve as occurred during 1922-1997-8. Furthermore, I find it hard to believe that the discounts the plans wrung out of providers and the reduction in ALOS did not yield at least some savings.

Thus, I conclude that this argument is not settled and that the data allows us each to our maintain hypotheses.

3. As to Luft and Miller, they presented a truly detailed revisit of their earlier study last year at a conference. Once again, the results were inconclusive. I will not accept it as a working hypothesis that managed care lowered the quality of the patient’s health care, although it did probably lower the quality of some providers’ life.

Best regards,

Uwe

Sullivan responds to Reinhardt Kip Sullivan responds to Uwe Reinhardt:

From Uwe Reinhardt’s last message:

<< As to Luft and Miller, they presented a truly detailed revisit of their earlier study last year at a conference. Once again, the results were inconclusive. >>

Kip Sullivan:

Uwe, Do you know if Luft and Miller’s new review excluded studies that didn’t control for coverage differences? If it did not, why do you give its conclusions any credability

The most galling of the studies cited by Miller-Luft in their 1994 and 1997 reviews were studies that compared doctors treating Medicare patients in HMOs with doctors treating patients in FFS Medicare without controlling for coverage differences. The complete scam works as follows:

(1) Taxpayers overpay Medicare HMOs,
(2) Medicare HMOs use the subsidy to pay for better coverage (e.g., cancer screens),
(3) researchers with a fondness for HMOs come along and examine whether Medicare HMO docs are better than Medicare FFS docs on process measures (e.g., use of cancer screens) and outcome measures (e.g., stage of cancer at diagnosis) likely to be affected by the coverage difference and,
(4) lo and behold, the HMO docs come out looking better.

I think the scholars who wrote these studies, the editors who accepted them for publication, and others like Miller and Luft who describe them as unusually good studies, are guilty of thought processes so flabby their behavior rises to the level of malpractice.

Evidence-based medicine is now the new religion within the American health policy community. But the health policy community has yet to apply the same standard to itself. If a group of doctors conducted a study comparing the effectiveness of Drug A to Drug B, and they deliberately set it up so that the group getting Drug A took drug A on schedule because they had excellent drug coverage, while the group getting Drug B took Drug B erratically because they had no health insurance, they would be laughed out of the profession. Not so in the health policy community. Health policy analysts who design such shabby experiments are held up as scientists par excellence.

Do you agree with my statement that studies that compare docs treating un- or under-insured FFS patients with HMO docs treating fully insured patients are studies so flawed they shouldn’t be published, much less held up by Miller-Luft as among the 44 best studies published between 1980 and 1997? Can you tell me if Miller-Luft’s new review examined only those studies that controlled for coverage differences?

Thanks.

Kip

The San Diego Union-Tribune
March 10, 2002
By Tony Fong

A handful of HMOs in California have begun offering plans that steer patients into selected hospitals where no co-payments are required. Patients who use nonpreferred hospitals are charged hefty co-payments, sometimes as much as hundreds of dollars a day.

And, starting next year, the PacifiCare HMO plans to divide medical groups and doctors into similar categories. Members who use “preferred” doctors will have lower co-payments and deductibles than members who don’t.

The new plans are similar to other managed-care models such as preferred-provider organizations plans, or PPOs, and point-of-service plans, or POS, except that they are part of HMOs. In effect, the plans are creating networks within existing networks.

Such a tiering of benefits is designed to funnel more patients to those providers that charge the health plans less, while forcing patients who use the more expensive networks to pay more of the cost themselves.

Health-care analysts say that such plans are here to stay.

Dr. Sam Ho, corporate medical director for PacifiCare, said tiering is viable now because there are more effective ways of measuring the quality of care and consumers are seeking greater choice in their health care.

“Our hospital costs were rising dramatically, and we had several options: We could raise prices to the hospitals, cut hospitals from our networks or cut benefits,” Epstein said (Tom Epstein, a spokesman for Blue Shield). “Or we could raise prices to our members.”

Health-care economists say that shifting costs onto consumers, however, leads to an inequitable health system in which the sickest patients and low-wage earners are most adversely affected financially.

Thomas Rice, a professor at the UCLA School of Public Health, said health insurance has historically operated on the principle that the healthy population should subsidize coverage for the sicker population, making it possible for low-wage earners to get care.

Shifting costs to consumers undermines that, experts said.

Larry Levitt, an analyst at the Kaiser Family Foundation:

“The more you charge patients at the point of service, the more you move away from insurance. It’s a matter of people getting different levels of care. You may get better care at the cheaper hospital than the more expensive one, but you don’t know because it’s based solely on costs.”

http://www.uniontrib.com/news/uniontrib/sun/business/news_1b10tiers.html

Comment: The prevailing rhetoric is that, in this age of consumerism, choice is being delegated to the patient-consumer who will control health care costs by becoming an empowered consumer. Let’s look at how this works.

Let’s begin with the first step, and that is choosing your health plan. What questions does the informed shopper need to ask?

What menu of health plans does my employer offer? Only one plan? So much for shopping!

But let’s assume that there is a menu of plans. Now what questions need to be asked?

Is my physician contracted with the plan? How do I find out? Those lists are difficult to locate and are frequently outdated as contracts continually change.

If my physician is contracted, is he or she in the less expensive tier? If I can’t even find out whether my physician is contracted, how can I find out which tier?

If not contracted in the right tier, are there other physicians in the less expensive tier that I can accept, even though it means leaving my current physician?

Which hospital does my physician use? Is it a contracted hospital? If so, which tier is it? But if we have only one hospital in our community and it is in the wrong tier, doesn’t that mean that I really don’t have any choice? Assuming there are a few hospitals, why do I have to go across town to that hospital with the bad reputation to qualify for the lower tier? But my physician isn’t on the staff of that hospital anyway? Do I really have any choice here?

And my employer has just announced that they are changing the health insurance contract in January? I have to start all over again!?

And those that do not have access to coverage through their employers and are dependent on the private market in health plans? Premiums are 30% higher than those for the employers. And the plans are rapidly shifting more costs to the beneficiary. Is an unaffordable policy with inadequate coverage really a choice?

Informed shoppers? Choice? When looking at what should be the simple process of merely choosing a health plan, we see that consumers in reality have very little choice. And now the health plans are shifting more costs to the consumers when they “choose” the more expensive tier when they often had no other option.

The health plans are not only nailing the patient-beneficiaries, but they are also going after the providers. One of the successes of managed care was to ratchet down the rates of the providers. The effectiveness of this strategy was so great that it drove many physician groups into bankruptcy. That left fewer groups that were now able to negotiate rates which would assure solvency. This is one of the reasons that we are seeing large premium increases again. Now the health plans are back with their ratchets to extort agreements selectively within their own list of cooperating, contracted providers. Ratchets are designed to move in one direction only. We can anticipate that health plans will only expand application of these policies that will further shift costs and risks to patients and their providers, making them useless as “insurers.” The health plans have literally become cut-throat organizations.

Choice is a good thing when it means that you can choose your physician and your hospital. But as long as we leave control in the hands of the health plans, we will not have choice, and we will be subjected to the extorting, cut-throat business practices of this worthless industry of middleman leeches.

All efforts at reform today continue to build on this nefarious industry. Enough! Let’s throw them out! Let’s adopt an equitable, publicly-administered program of universal health insurance. Then patients will have true choice within an industry of health care providers that are motivated to please patients rather than health plan executives.

Kip Sullivan responds to Uwe Reinhardt’s comments on Medicare HMOs, then Reinhardt responds to Sullivan, and then one more response by Sullivan:

Kip Sullivan:

Since we seem to agree on this question of whether managed care saved money for Medicare, let’s dispose of that issue first. When I said Medicare HMOs have driven up Medicare’s costs, I meant that Medicare HMOs are less efficient than the traditional Medicare program — that a dollar invested in Medicare HMOs buys less health care than a dollar invested in classical FFS Medicare. Are we in agreement about that? Your first sentence suggests you agree with me, but your second sentence citing the additional coverage most Medicare HMOs provide suggests you disagree or are unsure.

Uwe Reinhardt:

It is known from studies by Mathematica, MedPAC and others, that during the 1990s the HMOs did benefit from a favorable risk selection-whether it was deliberate cherry picking or accidental matters not. The benefits of favorable risk selection helped fund extra benefits–such as vision care, prescription drugs or the elimination of the Part B premium–that was bestowed on Medicare beneficiaries. Add support for these benefits may have come from some utilization control and, in California, from fees sometimes at 90% or so of Medicare’s own fee schedule. Aside from PacifiCare, most HMOs did not flow much added benefit to their bottom line. In general, having Medicare patients hurts an HMO’s stock–now even PacifiCare.

That was then. At this time, the mounting cost of these added benefits has outstripped whatever benefits HMOs may receive from favorable risk selection. Furthermore, whatever economies or price discounts the HMOs may have reaped in the 1990s have been harvested. It is the reason why so many HMOs are pulling out of Medicare+Choice.

I agree though that, as we look to the future, the cost of serving a given set of elderly patients through Medicare, enhanced by a drug benefit, is likely to be lower than giving the same elderly the same benefits through Medicare+Choice. Why? Because Medicare can probably do this at a loss ratio of 97%-98%, while HMOs are lucky to make any profit at a loss ratio of 90%. They will burn an extra 8-10 cents per dollar just on their higher SG&A and the profits they need to offer investors.

Consequently, if the HMOs want to play in this market, they must be able to look society in the eye and say: yes, going with us will raise somewhat the total annual health care cost per risk-adjusted elderly, but we will be able to offer a superior health care experience to the elderly for it. I have challenged many HMO executives to tell me what those added quality dimensions might be. Sadly, many of them still run on the cliché that anything the private sector does is, ipso facto, more efficient than anything government does, and therefore have not thought beyond it to rationalize a move towards Breaux-Frist.

I have found it as frustrating as you probably find it unsurprising.

Kip Sullivan:

When I suggested we debate your assumption that managed care has saved money and maintained or improved health, I was thinking we’d exchange perhaps a half dozen emails on these complex issues. But Don tells me that that much discussion is more than many members on this list are going to want to read, and has asked me to limit my rejoinder to just this email. To do that in one email, I’m going to have to cite two articles I wrote and leave it to you and other readers either to accept my conclusions or dig up the articles. That was not my original intention, though.

Does managed care save Medicare money?

We agree that managed care plans (MCPs) have not saved Medicare any money, and, because they have overheads that are extremely high compared to FFS Medicare’s, they are utterly incapable of ever saving Medicare any money. The only change I would make to your comments is that the overheads of MCPs probably average closer to 20 to 30 percent, not 10 percent.

Does managed care save the private sector money?

In your previous email, you based your claim that “managed care” saves money for the private sector solely on the lull in health care inflation that America enjoyed between 1992 and 1996. This strikes me as a very thin reed upon which to base the assertion that “managed care” saves money. If this is all you have to rely on, then I believe you should adopt my position, which is that the evidence on whether managed care saves money is inconclusive.

As you recall, I wrote an article for Health Affairs in which I reviewed the literature on whether managed care saves money (the literature doesn’t support that conclusion, not even for HMOs as opposed to PPOs), and then I presented an explanation for the 1992-96 inflation lull that did not rely on the never-documented assumption that managed care saves money (“On the ‘efficiency’ of managed care plans,” Health Affairs 2000; 19(4):139-148). I presented evidence that the inflation lull was caused by three factors: (1) a huge, record-breaking decline in the general inflation rate that began in 1991; (2) the predictable downturn in the three-year underwriting cycle that began in 1992; (3) merger fever that began late in 1992, triggered by a rush of endorsements of managed competition by state and federal politicians between the fall of 1992 and the spring of 1993, and the resulting low-balling of prices by players throughout the health-care industry; and (4) the delayed effects of the 1990-91 recession.

The rapid return of torrid premium and total-expenditure inflation in the late 1990s, despite the persistence of a low underlying inflation rate, adds weight to my conclusion that managed care had little or nothing to do with the mid-90s inflation lull. I predict we will see a slight reduction in the inflation rate in the next year or so, but this reduction will not be anything like the unusually long 1992-96 lull (precisely because three of the four factors I listed above will not be operative), and this decline will be temporary because it will merely reflect one of the four causes I listed above — a downturn in the underwriting cycle.

Does managed care improve quality of care?

Your claim that managed care improved the quality of health care in America (you made that statement to this list a year ago, and your recent emails imply you still adhere to) is not supported by any of the three big categories of evidence — anecdotal, polling and focus group data, and good research. Here I’ll just focus on the last category.

In 1994 and 1997, Robert Miller and Harold Luft published literature reviews claiming to find that medical care offered by FFS and MCP docs was equivalent. The 1997 Miller-Luft literature review was financed by the American Association of Health Plans, no less, and still Miller and Luft couldn’t bring themselves to conclude that quality of MCP care was superior, as you have argued. These reviews were, as of 2000, the most thorough literature reviews ever done on this question. (I haven’t been doing my homework as assiduously as I should have over the last 18 months, so I would appreciate being notified of any reviews published recently that members of this list believe are thorough and well done.)

I located and read every one of the 44 studies Miller-Luft cited in their two reviews to see for myself if I thought the studies used reasonable methodologies. To my surprise, I discovered that the great majority of these studies failed to control for differences in coverage between FFS and MCP patients. In all the studies, MCP patients had coverage for the type of treatment under consideration, but in many studies some or all of the FFS patients had inferior coverage (e.g., coverage for doctor visits but no drug coverage) or lacked any insurance at all.

Can you imagine my astonishment? How the heck does one draw any conclusions about the quality of care given to arthritis patients, for example, by HMO and FFS doctors if the FFS doctors are seeing large numbers of patients with no prescription drug coverage and $250 deductibles while the HMO docs are seeing patients with no copays for office visits and no drug coverage? But that’s what one of the studies cited by Miller-Luft did.

So, I weeded out all studies cited by Miller-Luft that failed to control for coverage differences (in doing this, I used a criterion favorable to MCPs). This reduced the number of comparisons from 57 to 44 (and the number of studies from 44 to 34). The outcomes of these 44 comparisons are shown below: __________________________________ MCP care was better than FFS care 4 MCP and FFS care were equivalent 19 MCP care was worse than FFS care 21 Total number of comparisons 44

Source: Kip Sullivan, “Managed care plan performance since 1980: Another look at two literature reviews,” American Journal of Public Health 1999;89:1003-1008. ____________________________________

You can see that MCP care was rarely superior to FFS care and often inferior to FFS care. I concluded, “the quality of care provided by MCPs tends to be equal or inferior to that provided by FFS plans.”

I sent Miller and Luft a copy of my article before I submitted it and asked for their thoughts. They never replied. But after my article was published, they asked the Am J Pub Health to publish an incoherent, rambling rejoinder, filled with euphemisms and cryptic phrases (e.g., “prototypical choices,” and “inherent aspect of the [FFS] ‘package'”), in which they defended studies that compared uninsured FFS patients with insured MCP patients. I tore their funny little letter to shreds with language my editor described as “caustic” (Miller and Luft, “A reply to Sullivan’s reanalysis of managed care plan performance since 1980;” Sullivan, “Sullivan responds,” Am J Pub Health 2000;90:984-986).

I believe the two Miller-Luft articles and my review of them constitute the most thorough reviews of the scientific literature on the question of quality of MCP and FFS care as of 2000. If you or anyone on this list would like to suggest literature reviews that you think were more thorough than the Miller-Luft reviews, and used more rigorous criteria than I did, I’d love to know about them.

You may wish to argue that 44 studies is not a lot to go on, and I would agree with you. But that’s not the issue before us. The issue is whether you or anyone else is justified in claiming that evidence indicates MCP care is superior. That evidence, slim though it is, supports the opposite conclusion.

Conclusions

So that’s my case in a nut shell. You claim Americans “trashed managed care.” I say, Bravo, they had every reason to trash managed care. Managed care has not demonstrated an ability to save money, and it has demonstrated an ability to damage quality of care and destroy patient privacy. If I had more time, I would argue that common sense tells us all three of these bad outcomes had to happen. But I’ll save that line of argument for your next email praising managed care.

Uwe Reinhardt responds to the comments of Theodore Marmor:

(The original comments of Dr. Marmor are reproduced, with the comments of Dr. Reinhardt added.)

Dr. Marmor:

Uwe–your arithmetic was helpful to see what is at work with projections of future national income and what one scenario forecasts for health expenditures as a proportion of that national income. But arithmetic neither produces plausible predictions (as against conditional forecasts) and, more important, does not provide the grounds for analysis of that future. (Were CBO forecasts in 1993 l8% of GNP for health by 2000? That was their forecast!)

Dr. Reinhardt:

It was projected to be 19.7%, Ted (October, 1993–I still have the paper). How could you err by so much!

Dr. Marmor:

I particularly want to contest your claim (repeated often by you) that “Americans have signaled that they don’t want any cost control at all….” Kip challenges your claims about the effects of what is called managed care.

Dr. Reinhardt:

I attach a chart on real health spending per capita (not included in this message). Either you or Kip must explain to us all what caused the trend line to bend. We know it was not Medicare, because that kept right on its growth path until the BBA ’97. So I shall temporarily concede–against superior authority–that managed care had nothing to do with it and await yours or Kip’s explanation.

Dr. Marmor:

I want to challenge your interpretation of the connection between what mass American wants and both public and private policy. It is decades too late to continue to repeat the fallacy of revealed preference in politics. It does not follow that because outcome A takes place, the citizens of that jurisdiction ‘wanted’ A. It might be, but the use of the effect to specify the cause is a logical fallacy. Until and unless you can find reason to believe mass opinion shaped events decisively, stop blaming the victim.

Dr. Reinhardt:

Again, I must defer here to superior authority. I am not a political scientist. What I await from you, Ted–perhaps all of us do–is a concise, short explanation of how democracy works in America. As an example, explain to me why the election of 1994 had nothing to do with voter preferences–among others about government’s role in health care. Throw in a convincing–but concise–explanation of why the referendum in California on a single-payer plan did not work. Always eager to learn.

Dr. Marmor:

I don’t for a moment believe the American mass public has any clear idea about the extent to which cost control arguments are true, false, or misleading.

Dr. Reinhardt:

And how do you know that?

Dr. Marmor:

Our political system is far too structured against mass majority rule to explain health policy outcomes as the result of their ‘wishes.’ Sure, a different distribution of wants and attitudes might make some policies more likely, but the locomotive conception you use is genuinely misleading and unsupported, as I have mentioned before, by the public opinion literature.

Dr. Reinhardt:

Too vague, Ted. Too vague. This is you in your old mode. As you know, I don’t groove on it. For example, I could simply assert that your statement here is genuinely misleading and unsupported, and leave it at that.

No, Ted, I would like you to explain to me why voters’ attitudes about the role of government in health care has nothing to do with the demise of the Clinton plan and the ascendancy of Republican rule in the House.

Finally, Ted, since you infer that you may know, please tell me once and for all what the American people really want in health care. I suggest a concise list. In return I shall compose what I think they want.

March 8, 2002

“Human dignity, private property, free speech, equal justice, education, and health care – these rights must be guaranteed throughout the world.”

http://www.whitehouse.gov/firstlady/news-speeches/speeches/fl20020308.html

Yesterday, Dr. Reinhardt commented on the projections of health care expenditures made by the Office of the Actuary at the Centers for Medicare and Medicaid Services. That report is now available online at:

http://www.hcfa.gov/stats/nhe-proj/proj2001/Proj2001.pdf

The abstract of the Health Affairs article is also now available (the full article is available only to subscribers or by purchase):

http://130.94.25.113/1130_abstract_c.php?ID=http://130.94.25.113/Library/v21n2/s25.pdf

One quote from the Health Affairs article is noteworthy:

“After 2002, growth is projected to gradually slow to 5.9 percent by 2011. This deceleration can be primarily attributed to slower projected per capita real income growth, a move toward more restrictive forms of managed care, a rise in the uninsured population, and an increase in the use of consumer cost sharing.”

Comment: We don’t have much control over per capita income growth, but the other three factors are cruel and inhumane mechanisms of slowing the growth of health care costs. Instead of continuing to erect more financial barriers to care, we could replace those mechanisms with a globally-budgeted, publicly administered program of universal health insurance. Excess growth would be constrained, but in an equitable and humane manner.

Theodore Marmor responds to Uwe Reinhardt:

Uwe–your arithmetic was helpful to see what is at work with projections of future national income and what one scenario forecasts for health expenditures as a proportion of that national income. But arithmetic neither produces plausible predictions (as against conditional forecasts) and, more important, does not provide the grounds for analysis of that future. (Were CBO forecasts in 1993 l8% of GNP for health by 2000? That was their forecast!)

I particularly want to contest your claim (repeated often by you) that “Americans have signaled that they don’t want any cost control at all….” Kip challenges your claims about the effects of what is called managed care. I want to challenge your interpretation of the connection between mass American wants and both public and private policy. It is decades too late to continue to repeat the fallacy of revealed preference in politics. It does not follow that because outcome A takes place, the citizens of that jurisdiction ‘wanted’ A. It might be, but the use of the effect to specify the cause is a logical fallacy. Until and unless you can find reason to believe mass opinion shaped events decisively, stop blaming the victim. I don’t for a moment believe the American mass public has any clear idea about the extent to which cost control arguments are true, false, or misleading. Our political system is far too structured against mass majority rule to explain health policy outcomes as the result of their ‘wishes.’ Sure, a different distribution of wants and attitudes might make some policies more likely, but the locomotive conception you use is genuinely misleading and unsupported, as I have mentioned before, by the public opinion literature.

Ted Marmor

Theodore R. Marmor Professor of Public Policy & Management Professor of Political Science Yale University School of Management

Beth Capell, Ph.D., responds to the Reinhardt and Sullivan comments:

As one of the prime architects of the California HMO Patient Bill of Rights (with much guidance from our CaPA leaders), one key observation:

The HMOs had promised to deliver all medically necessary and appropriate care–and were required by California law to do so. Every dime of cost they attributed to the Patient Bill of Rights was proof that they were denying necessary and appropriate care.

Time and again in the negotiations over the Patient Bill of Rights the HMOs were caught in this trap: if HMOs were giving people the care they needed, what was the problem with requiring them to do so? Contraceptives, diabetes management, independent medical review, second opinion, you name it: if consumers were getting the care they should, the reform cost nothing. If the reform cost money, it demonstrated a denial of care. An analysis by a Senate Insurance Committee skeptical about so-called mandates found little if any cost associated with most of them.

The one exception to this case was mental health parity where plainly consumers were not getting care they should have. This provision unquestionably cost purchasers money—because by failing to provide decent mental health coverage, the purchasers and the HMOs had shifted costs to the public sector and simply failed to provide needed care.

And costs in California were rising well before HMO reform was fully enacted in late 1999.

Beth Capell, on behalf of the California Physicians Alliance.

Theodore Marmor on the predictions of the Office of the Actuary:

Watch out for the idea that projections are anything but forecasts whose validity is utterly dependent on the accuracy of the premises. They can be useful for sensitivity analysis. But anyone who thinks you can predict economic and medical life 10 years hence needs medical care.

Theodore R. Marmor Professor of Public Policy & Management Professor of Political Science Yale University School of Management

The Center for Medicare and Medicaid Services, in new projections released today in Health Affairs, estimates that health spending will more than double to $2.8 trillion by 2011 and climb to more than 17 percent of the GDP over the next decade, up from 13.2 percent currently.

Uwe Reinhardt, Ph.D., James Madison Professor of Political Economy, Princeton University, comments:

$2.8 trillion sounds like an awesome lot; but Americans better get used to the idea. Several factors drive that spending figure:

1. There’s expensive new technology on the horizon, and not all of it is money saving. Much of it enhances the quality of care and life, at greater expense.

2. We are facing a growing labor shortage in health care, and not only in nursing. There is likely to be even a renewed physician shortage. We must get used to paying health workers more.

3. By trashing managed care as they did, Americans have signaled that they do not want to have any cost control at all in health care. They seem willing to spend (more correctly: to have someone else spend) whatever it takes, even on care that is known to be only marginally useful or even useless. Yes, Americans do sincerely believe that, if insured, they have a Constitutional right even to useless care. It’s the American way.

All of these factors spell increased health spending, and I see nothing on the horizon to slow it down, short of seriously rationing health care by ability to pay even for insured Americans (e.g., through MSAs). And even that may not work, because with MSAs the piece of health spending called “catastrophic” would be likely to increase more rapidly.

Even so, there’s a brighter side. We have no cause to jump off a bridge.

According to the CBO, GDP in 2001 was $10.193 trillion. It is projected to be $16.676 trillion in 2011. According to the most recent CMS data, total national health spending in 2001 was $1.378 trillion. It is projected to be $2.8 trillion by 2011. Thus, in 2001 we had (10.193 – 1.378) = $8.815 trillion of non-health GDP left over after the health sector took its slice of 31.2% of the GDP pie. In 2011 we are projected to have (16.676-2.8) = $13.876 trillion of non-health GDP left over. This is an increase of (13.876-8.815) = $5.061 trillion in non-health GDP, or a percentage increase of (5.061/8.815) = 57.4%. It is equivalent to an average annual compound growth rate of 4.6% over the period 2001-2011. That ain’t bad, is it? We can live with it.

I see it in your eyes: you are asking me, “But what about inflation?” Ok, here are the numbers. The CBO projects an average annual increase in the GDP deflator of about 2% over the period 2001-2011. If we deflate the non-health GDP projected for 2011 by that inflation factor, the $13.876 in 2001 dollars projected above becomes $11.383 in constant year-2001 dollars. Thus, in terms of real purchasing power, non-health GDP in 2011 is projected to be (11.383-8.815) = $2.568 trillion more than it was in 2001. This represents an increase in real non-health GDP of 2.568/8.815 = 29%. It is equivalent to an average annual compound increase of 2.589% over the period 2001-2011. Still ain’t bad, is it?

I sense that you are still not happy. You wonder about population growth. “Aren’t there more people to claim all that extra non-health GDP? May there be less per capita, then?” you wonder. Ok–here it goes. Our population is projected to grow at an average annual compound rate of slightly less than 1% (0.9% really). Therefore, we can say that real (constant dollar) non-health spending per capita in the US is projected by the CBO to increase by about 2.589% – 1% = 1.589% per year between 2001 and 2011 (1.6% between friends). That ain’t bad either, is it?

Can we really look up to God and cry over it? Can we tell God that, in view of the looming $2.8 trillion in health spending in 2001, we cannot possibly give the elderly prescription drug coverage or extend health insurance coverage to all uninsured Americans, because that would spend us into the poorhouse?

My conjecture is that God won’t be impressed, nor will President Bush’s most highly regarded philosopher: Jesus Christ. I think we had better do the Judeo-Christian thing vis a vis the uninsured, lest there be locusts and frogs and stuff all over the country, as once it was in Egypt.

Kip Sullivan responds to Uwe Reinhardt:

Uwe Reinhardt’s previous statement:

<< By trashing managed care as they did, Americans have signaled that they do not want to have any cost control at all in health care. They seem willing to spend (more correctly: to have someone else spend) whatever it takes, even on care that is known to be only marginally useful or even useless. Yes, Americans do sincerely believe that, if insured, they have a Constitutional right even to useless care. It's the American way. >>

Kip Sullivan’s response:

Uwe,

I agree with your demand that Congress insure the uninsured. But I disagree with the remarks above about Americans’ attitudes toward managed care. These remarks rest on two assumptions: (1) That managed care has been demonstrated to cut national health care expenditures or, at minimum, total health spending by the private sector, and (2) that managed care cuts out only “useless care,” not necessary care, and, therefore, has not damaged quality of care.

You didn’t articulate these assumptions, so I’m asking you if you endorse those assumptions. Do you? If you say yes, I will challenge you on both of them. I believe the evidence supports the following conclusions:

(1)(a) the evidence that managed care saved money for the private sector is inconclusive; (b) the evidence indicates permitting managed care companies to enroll Medicare beneficiaries has added to, rather than reduced, Medicare’s costs; and

(2) the evidence supports the conclusion that the spread of managed care damaged quality of care.

These are complex issues, and I’m pressed for time these days, so I might take awhile responding to you. But I think these issues are too important, and your view too incorrect, to let your comment go by unquestioned.

Thanks much.

Kip Sullivan

Uwe Reinhardt responds to Kip Sullivan:

The original remarks are reproduced, and Dr. Reinhardt’s additional comments are marked ***

Kip Sullivan responds to Uwe Reinhardt:

Uwe Reinhardt’s previous statement:

<< By trashing managed care as they did, Americans have signaled that they do not want to have any cost control at all in health care. They seem willing to spend (more correctly: to have someone else spend) whatever it takes, even on care that is known to be only marginally useful or even useless. Yes, Americans do sincerely believe that, if insured, they have a Constitutional right even to useless care. It's the American way. >>

Kip Sullivan’s response:

Uwe,

I agree with your demand that Congress insure the uninsured. But I disagree with the remarks above about Americans’ attitudes toward managed care. These remarks rest on two assumptions: (1) That managed care has been demonstrated to cut national health care expenditures or, at minimum, total health spending by the private sector, and (2) that managed care cuts out only “useless care,” not necessary care, and, therefore, has not damaged quality of care.

You didn’t articulate these assumptions, so I’m asking you if you endorse those assumptions. Do you? If you say yes, I will challenge you on both of them. I believe the evidence supports the following conclusions:

(1)(a) the evidence that managed care saved money for the private sector is inconclusive;

*** What, then, is your explanation for the deceleration of the growth in health spending during the 1990s?

(b) the evidence indicates permitting managed care companies to enroll Medicare beneficiaries has added to, rather than reduced, Medicare’s costs; and

*** I can buy that. it also, of course, has added benefits. If you don’t believe me, ask the elderly. Why else would they whine when they have to go back to Medicare?

(2) the evidence supports the conclusion that the spread of managed care damaged quality of care.

*** I don’t buy that one.

These are complex issues, and I’m pressed for time these days, so I might take awhile responding to you. But I think these issues are too important, and your view too incorrect, to let your comment go by unquestioned.

Thanks much.

Kip Sullivan

North County Times
3/10/02
By Bruce Kauffman

OCEANSIDE —- An advocate for reform of the nation’s health care system said Saturday that medical bills will become the number one cause of bankruptcy in America if administrative costs are not curbed and insurance coverage is not made more available.

Speaking at a conference presented by the North Coast chapter of the League of Women Voters, Don McCanne, a retired Orange County physician who is active in Physicians for Social Responsibility, criticized insurers and the health-care industry for spending up to roughly one of every four dollars in resources on administration.

“Just handling the money burns up a lot of funds,” McCanne said.

McCanne said bringing administrative overhead down to 10 percent would save a quarter of a trillion dollars, money that could pay the health care needs of a “rapidly expanding group” of people with inadequate or no insurance. That group may include some 85 million Americans, he said.

Said another speaker, Gregory Knoll, director of the consumer center for health education and advocacy of the Legal Aid Society of San Diego: “Here’s the deal —- access to quality health care ought to be a constitutional right. If we don’t look at how we’re going to change this system and delve into it and make it work for everybody, we’ve got a problem.”

http://www.nctimes.net/news/2002/20020310/53941.html

Comment: At the conference the point was made that employers and insurers were shifting more costs and risks to employee-beneficiaries. For individuals with significant medical problems, the out-of-pocket expenses are beginning to exceed disposable income. An continuation of this trend may result in insolvency for enough individuals such that unpaid medical bills could move into first place as a cause of bankruptcy.

Also, the shifting of costs from administration to patient care was shown to be achievable based on the preliminary results of the California Health Care Options Study. Replacing the fragmented, inefficient system of private and public plans and no health plans at all, with a single, publicly administered insurance program, would save enough to pay for comprehensive health care benefits for everyone.