PNHP

Trump on Immigrants and Health Care Costs: Just Plain Wrong

Trump on Immigrants and Health Care Costs: Just Plain Wrong

By Leah Zallman and Steffie Woolhandler
The Huffington Post, May 26, 2016

Throughout the primary season, leading Republican presidential candidates vied over who could bash immigrants the hardest. And they were promising more than border walls. Donald Trump is the most extreme immigrant-blamer; according to his website, “Providing healthcare to illegal immigrants costs us some $11 billion annually. If we were to simply enforce the current immigration laws and restrict the unbridled granting of visas to this country, we could relieve healthcare cost pressures on state and local governments.”

As with many of Trump’s claims, this one is wrong. But unlike some of his other falsehoods, the media has left this one unchallenged. Trump’s $11 billion figure comes from an obviously biased study that’s based on outlandish assumptions.

For instance, it counts as “immigrants” millions of U.S. citizens — children who were born in the U.S. of immigrant parents. It also assumes that immigrant families have high health care costs, ignoring a raft of data showing that immigrants use little care. For instance, nearly half (48 percent) of noncitizen immigrant children never see the doctor in the course of a year.

Finally, Trump’s source assumes that every penny of immigrant kids’ health care costs are borne by the taxpayers. Yet a recent study in the respected journal Health Affairs found that unauthorized immigrants families pay the vast majority of their own health care bills, either out-of-pocket, or by buying private insurance. Indeed, 40 percent of newly arrived immigrants have private insurance.

Trump’s numbers don’t just exaggerate taxpayers’ costs for immigrants’ care, they ignore the billions that immigrants pay in taxes. Compared to other Americans, immigrants are younger, healthier and more likely to be male and part of the workforce. That means that an outsized share of immigrants pay the payroll taxes that support Medicare and Social Security, while few are eligible to draw benefits from these programs.

Employers are required to check a Social Security card when hiring a new worker. But they don’t have to check that it’s valid. The IRS happily accepts (and passes on to Medicare and Social Security) payments made under invalid Social Security numbers.

Consequently, millions of undocumented immigrants work and pay taxes under fake or borrowed Social Security numbers. The Social Security Administration estimates that undocumented immigrants pay $13 billion annually into the Social Security trust funds. And, in studies we did at Harvard and the City University of New York, we found that undocumented immigrants contribute billions more to Medicare.

Without immigrants — and especially unauthorized immigrants — Medicare’s Trust Fund would be broke. Each year, immigrants pay about $11 billion more in Medicare taxes than Medicare pays for their care. And undocumented immigrants contribute the lion’s share of this subsidy.

And, just like everyone else, unauthorized immigrants pay sales taxes every time they shop and property taxes (indirectly) when they pay their rent, contributing $11 billion annually in state and local taxes.

While unauthorized immigrants contribute billions in taxes, they use shockingly little health care. Most of the federal health programs they help pay for (like Medicare, Medicaid and the ACA’s plans) exclude them. And those who pay for private coverage use very little care, so their premiums effectively subsidize other enrollees with private insurance.

As physicians, we believe that medical care must be available to everyone residing in the U.S. However, if Trump and other politicians are concerned about “relieving healthcare cost pressures on state and local governments” they should champion fair immigration policies that assure a steady flow of immigrants who come here wanting to work and willing to pay taxes, and don’t need much medical care.

Leah Zallman, M.D., M.P.H., is a research scientist at the Institute for Community Health, a primary care doctor at Cambridge Health Alliance, and an instructor of medicine at the Harvard Medical School. She is a health services researcher who focuses on health disparities, with specific areas of focus including immigrant health and access to care for vulnerable populations. Steffie Woolhandler, M.D., M.P.H., is an internist in the South Bronx, professor at the City University of New York School of Public Health at Hunter College, and lecturer in medicine at Harvard Medical School. She co-founded Physicians for a National Health Program.The opinions expressed here do not necessarily reflect the views of the authors’ institutions.

http://www.huffingtonpost.com/leah-zallman-md-mph/trump-on-immigrants-and-health-care_b_10146146.html

PNHP note: Physicians for a National Health Program (PNHP) is a nonpartisan educational and research organization. It neither supports nor opposes any candidate for public office.

Medicare’s Hospital Value-Based Purchasing program has not improved mortality outcomes

Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study

By Jose F Figueroa, Yusuke Tsugawa, Jie Zheng, E John Orav, Ashish K Jha
BMJ, May 9, 2016

From the Introduction

Healthcare systems around the world are striving to deliver high quality care while controlling costs. One compelling strategy is the use of financial incentives to reward high value care. The US federal government has made substantial efforts to shift towards value based payments since the passage of the Affordable Care Act in 2010. One key program is Hospital Value-Based Purchasing (HVBP) introduced by the Centers for Medicare and Medicaid Services (CMS) in 2011. HVBP rewards or penalizes hospitals based on their performance on multiple domains of care, including clinical processes, clinical outcomes (eg, 30 day mortality for acute myocardial infarction, pneumonia, and heart failure), patient experience, and, more recently, cost efficiency. Funding for HVBP is designed to be budget neutral; Medicare withholds a percentage of inpatient payments to prospectively paid hospitals and then redistributes this money back to hospitals based on their performance. In fiscal year 2015, HVBP led to penalties for 1360 hospitals and bonus payments to 1700 hospitals.

From the Discussion

Three years after the introduction of the US national pay for performance program — Hospital Value-Based Purchasing (HVBP) — we find no evidence that it has led to better patient outcomes. The trends in mortality for the target conditions among hospitals participating in HVBP actually slowed after the program’s introduction, although that slowing was also seen among hospitals not participating in the program. Even among hospitals with worst patient mortality at baseline, a group of hospitals that had arguably more motivation to improve to avoid penalties, we found no evidence that HVBP drove improvement beyond secular trends observed in a matched group of non-HVBP hospitals. Taken together, these findings call into question the effectiveness of the national hospital pay for performance program and whether it is having the desired effect on patient outcomes.

This study has important implications for international efforts using financial incentives to drive improvements in hospital quality of care. The program on which HVBP was based, the US Premier Hospital Quality Incentive Demonstration, also failed to improve patient outcomes. Some critics argued that prior pay for performance programs based purely on attainment did not motivate poor performers to improve (since they were unlikely to improve enough to earn bonuses) and also did little for higher performers who would have received bonuses even by maintaining their status. However, HVBP was modified to include financial incentives for both achievement and improvement to ensure that all hospitals had some motivation to improve. Further, as a national non-voluntary program, HVBP was posited to be more impactful because it was not focused on a voluntary group of hospitals that might have been high performers at baseline. Despite these advantages, we found no evidence that HVBP improved patient outcomes. Given the amount of time and resources spent in its design and implementation, these findings are discouraging and should motivate policymakers to consider changes in the structure and size of incentives in ways that may lead to meaningful improvements in patient care versus completely rethinking the utility of pay for performance programs that target hospital quality.

Comparison with other studies

These results add to a growing body of literature that suggest many pay for performance programs are largely ineffective in improving patient outcomes. As further emphasis on value-based programs continues to grow, healthcare policymakers should carefully consider the costs of investing in these pay for performance programs and the potential unintended consequences. Ultimately, these programs need to be evaluated based on weighting the benefits and harms they create — and our work suggests that the benefits seem to be small, if present at all.

http://www.bmj.com/content/353/bmj.i2214.full

***

Comment:

By Don McCanne, M.D.

Pay for performance programs add to the administrative burden of our health care system and contribute to physician burnout, and now we have yet one more study that shows that they are ineffective in improving patient outcomes.

The thrust of health care reform is currently directed towards paying for quality instead of quantity, with an emphasis on measurement and process, resulting in greater administrative waste. Current cost containment has been largely confined to cost sharing which erects financial barriers to beneficial care and can only result in worse outcomes.

Now people are talking about what we really do need instead – a well designed single payer system, an improved Medicare for all – but the legislators, public administrators, and stakeholders are ignoring the conversation. This should be a call for organized protests. Why aren’t they happening?

Medicare’s Hospital Value-Based Purchasing program has not improved mortality outcomes

Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study

By Jose F Figueroa, Yusuke Tsugawa, Jie Zheng, E John Orav, Ashish K Jha
BMJ, May 9, 2016

From the Introduction

Healthcare systems around the world are striving to deliver high quality care while controlling costs. One compelling strategy is the use of financial incentives to reward high value care. The US federal government has made substantial efforts to shift towards value based payments since the passage of the Affordable Care Act in 2010. One key program is Hospital Value-Based Purchasing (HVBP) introduced by the Centers for Medicare and Medicaid Services (CMS) in 2011. HVBP rewards or penalizes hospitals based on their performance on multiple domains of care, including clinical processes, clinical outcomes (eg, 30 day mortality for acute myocardial infarction, pneumonia, and heart failure), patient experience, and, more recently, cost efficiency. Funding for HVBP is designed to be budget neutral; Medicare withholds a percentage of inpatient payments to prospectively paid hospitals and then redistributes this money back to hospitals based on their performance. In fiscal year 2015, HVBP led to penalties for 1360 hospitals and bonus payments to 1700 hospitals.

From the Discussion

Three years after the introduction of the US national pay for performance program — Hospital Value-Based Purchasing (HVBP) — we find no evidence that it has led to better patient outcomes. The trends in mortality for the target conditions among hospitals participating in HVBP actually slowed after the program’s introduction, although that slowing was also seen among hospitals not participating in the program. Even among hospitals with worst patient mortality at baseline, a group of hospitals that had arguably more motivation to improve to avoid penalties, we found no evidence that HVBP drove improvement beyond secular trends observed in a matched group of non-HVBP hospitals. Taken together, these findings call into question the effectiveness of the national hospital pay for performance program and whether it is having the desired effect on patient outcomes.

This study has important implications for international efforts using financial incentives to drive improvements in hospital quality of care. The program on which HVBP was based, the US Premier Hospital Quality Incentive Demonstration, also failed to improve patient outcomes. Some critics argued that prior pay for performance programs based purely on attainment did not motivate poor performers to improve (since they were unlikely to improve enough to earn bonuses) and also did little for higher performers who would have received bonuses even by maintaining their status. However, HVBP was modified to include financial incentives for both achievement and improvement to ensure that all hospitals had some motivation to improve. Further, as a national non-voluntary program, HVBP was posited to be more impactful because it was not focused on a voluntary group of hospitals that might have been high performers at baseline. Despite these advantages, we found no evidence that HVBP improved patient outcomes. Given the amount of time and resources spent in its design and implementation, these findings are discouraging and should motivate policymakers to consider changes in the structure and size of incentives in ways that may lead to meaningful improvements in patient care versus completely rethinking the utility of pay for performance programs that target hospital quality.

Comparison with other studies

These results add to a growing body of literature that suggest many pay for performance programs are largely ineffective in improving patient outcomes. As further emphasis on value-based programs continues to grow, healthcare policymakers should carefully consider the costs of investing in these pay for performance programs and the potential unintended consequences. Ultimately, these programs need to be evaluated based on weighting the benefits and harms they create — and our work suggests that the benefits seem to be small, if present at all.

http://www.bmj.com/content/353/bmj.i2214.full

Pay for performance programs add to the administrative burden of our health care system and contribute to physician burnout, and now we have yet one more study that shows that they are ineffective in improving patient outcomes.

The thrust of health care reform is currently directed towards paying for quality instead of quantity, with an emphasis on measurement and process, resulting in greater administrative waste. Current cost containment has been largely confined to cost sharing which erects financial barriers to beneficial care and can only result in worse outcomes.

Now people are talking about what we really do need instead – a well designed single payer system, an improved Medicare for all – but the legislators, public administrators, and stakeholders are ignoring the conversation. This should be a call for organized protests. Why aren’t they happening?

Aetna and Anthem shareholders condone secrecy of dark money contributions

Shareholders vote down dark money disclosure at Aetna, Anthem

By Bob Herman
Modern Healthcare, May 26, 2016

Health insurers Aetna and Anthem won’t have to tell shareholders how much money they send to tax-exempt political organizations, at least for another year.

Shareholder resolutions that would’ve required Aetna and Anthem to disclose how much they spend on 501(c)(4) “social welfare” organizations and other business association groups failed to gain approval last week at the companies’ respective annual shareholders meetings. Approximately 91% of Anthem investors rejected the proposal, and 75% of the votes were cast against Aetna’s resolution.

Political not-for-profit organizations, also called dark money groups, do not have to reveal their donors, and they can receive unlimited amounts of money, much of which is routed toward influencing elections.

http://www.modernhealthcare.com/article/20160526/NEWS/160529926

***

Comment:

By Don McCanne, M.D.

The shareholders of Aetna and Anthem, by voting down disclosure of dark money contributions, are co-conspirators with the corporate executives in the efforts to prevent transparency of their financial contributions to dark money organizations that use their funds to influence elections.

Once we replace the private insurers with a publicly-owned Medicare for all program, we need show no special sympathy for the displaced insurance executives, and that goes for their rent-seeking shareholders as well. Our sympathies should be directed to the displaced employees of the insurance corporations who will need assistance in job training and in creating new employment opportunities.

Aetna and Anthem shareholders condone secrecy of dark money contributions

Shareholders vote down dark money disclosure at Aetna, Anthem

By Bob Herman
Modern Healthcare, May 26, 2016

Health insurers Aetna and Anthem won’t have to tell shareholders how much money they send to tax-exempt political organizations, at least for another year.

Shareholder resolutions that would’ve required Aetna and Anthem to disclose how much they spend on 501(c)(4) “social welfare” organizations and other business association groups failed to gain approval last week at the companies’ respective annual shareholders meetings. Approximately 91% of Anthem investors rejected the proposal, and 75% of the votes were cast against Aetna’s resolution.

Political not-for-profit organizations, also called dark money groups, do not have to reveal their donors, and they can receive unlimited amounts of money, much of which is routed toward influencing elections.

http://www.modernhealthcare.com/article/20160526/NEWS/160529926

The shareholders of Aetna and Anthem, by voting down disclosure of dark money contributions, are co-conspirators with the corporate executives in the efforts to prevent transparency of their financial contributions to dark money organizations that use their funds to influence elections.

Once we replace the private insurers with a publicly-owned Medicare for all program, we need show no special sympathy for the displaced insurance executives, and that goes for their rent-seeking shareholders as well. Our sympathies should be directed to the displaced employees of the insurance corporations who will need assistance in job training and in creating new employment opportunities.

Progress in covering low- and moderate-income populations falters

Americans’ Experiences with ACA Marketplace and Medicaid Coverage: Access to Care and Satisfaction

By Sara R. Collins, Munira Gunja, Michelle M. Doty, Sophie Beutel
The Commonwealth Fund, May 25, 2016 

Abstract

The fourth wave of the Commonwealth Fund Affordable Care Act Tracking Survey, February–April 2016, finds at the close of the third open enrollment period that the working-age adult uninsured rate stands at 12.7 percent, statistically unchanged from 2015 but significantly lower than 2014 and 2013. Uninsured rates in the past three years have fallen most steeply for low-income adults though remain higher compared to wealthier adults. ACA marketplace and Medicaid coverage is helping to end long bouts without insurance, bridge gaps when employer insurance is lost, and improve access to health care. Sixty-one percent of enrollees who had used their insurance to get care said they would not have been able to afford or access it prior to enrolling. Doctor availability and appointment wait times are similar to those reported by insured Americans overall. Majorities with marketplace or Medicaid coverage continue to be satisfied with their insurance.

Exhibit 2: Uninsured Rates Among Low-Income Adults Have Fallen the Most But Remain Substantially Higher Than Those For Adults with Higher Incomes

People with low and moderate incomes — the population targeted in particular by the ACA’s reforms — had the highest uninsured rates prior to the law’s enactment and subsequently have experienced the greatest gains in coverage by far. But after declining steeply in 2014, uninsured rates for adults with incomes below 138 percent of the federal poverty level ($16,243 for an individual and $33,465 for a family of four) have remained about the same. Similarly, uninsured rates for those with incomes between 138 percent and 249 percent of poverty ($29,425 for an individual and $60,625 for a family of four) had fallen by half by 2015 but remain nearly the same this year. Consequently, low- and moderate-income adults are uninsured at rates as much as 10 times higher as those for adults with higher incomes.

Conclusion and Policy Implications

After falling sharply in 2014 upon rollout of the ACA’s major coverage expansions, the uninsured rate for U.S. working-age adults has been declining at a slower pace. The chasm in insurance coverage between lower- and higher-income adults remains troubling. We will explore the possible reasons for this in a forthcoming brief.

In each year since the coverage expansions, our survey findings have indicated that overall enrollment has been propelled by people who were previously uninsured — a year or longer for the vast majority. Consistent with other national surveys and Congressional Budget Office analyses, enrollment has not been driven by people shifting out of employer coverage: the share of adults insured through an employer has declined only slightly since 2013. The survey findings do suggest that for people who lose their job-based health benefits, the expanded insurance options may be helping to bridge the coverage gap.

http://www.commonwealthfund.org/publications/issue-briefs/2016/may/ACA-tracking-survey-access-to-care-and-satisfaction

***

Comment:

By Don McCanne, M.D.

The Affordable Care Act (ACA) has been effective in reducing the numbers of uninsured, particularly amongst low-income adults. Although that is good news, we should be alarmed that “low- and moderate-income adults are uninsured at rates as much as 10 times higher as those for adults with higher incomes,” and that there has been little improvement in enrollment for these lower income levels since the initial steep decline in 2014.

When ACA was constructed, it was decided that the employer-sponsored plans should be left largely alone to continue to fulfill the role of covering the majority of middle- and higher-income individuals and families. The greatest need was for the uninsured low-income and uninsured moderate-income sectors of the population. Thus two of the more important design features of ACA were to expand Medicaid for low-income individuals and to offer income-indexed tax credits and subsidies for private plans offered through the ACA exchanges (Marketplace).

How successful has the plan to cover those with greater financial needs been? As stated, uninsurance for those with low and moderate incomes has stabilized at a rate 10 times higher than those with higher incomes. Except for an initial surge, ACA has failed to achieve the goal of covering these more vulnerable populations.

They would have all been covered under a single payer system. Not only that, the ACA model of reform is the most expensive model of all, yet falls miserably short in universality, efficiency and equity. The least expensive comprehensive models of reform that would have actually achieved these goals are single payer Medicare for all or a government owned and operated national health service.

Although “socialism” has become less of a pejorative in the United States, the majority of residents would prefer the social insurance model of Medicare for all rather than socialized medicine through a national health service model. Now that ACA has been demonstrated to be an over-priced failure, we should move on with establishing an Improved Medicare for All.

Progress in covering low- and moderate-income populations falters

Americans’ Experiences with ACA Marketplace and Medicaid Coverage: Access to Care and Satisfaction

By Sara R. Collins, Munira Gunja, Michelle M. Doty, Sophie Beutel
The Commonwealth Fund, May 25, 2016 

Abstract

The fourth wave of the Commonwealth Fund Affordable Care Act Tracking Survey, February–April 2016, finds at the close of the third open enrollment period that the working-age adult uninsured rate stands at 12.7 percent, statistically unchanged from 2015 but significantly lower than 2014 and 2013. Uninsured rates in the past three years have fallen most steeply for low-income adults though remain higher compared to wealthier adults. ACA marketplace and Medicaid coverage is helping to end long bouts without insurance, bridge gaps when employer insurance is lost, and improve access to health care. Sixty-one percent of enrollees who had used their insurance to get care said they would not have been able to afford or access it prior to enrolling. Doctor availability and appointment wait times are similar to those reported by insured Americans overall. Majorities with marketplace or Medicaid coverage continue to be satisfied with their insurance.

Exhibit 2: Uninsured Rates Among Low-Income Adults Have Fallen the Most But Remain Substantially Higher Than Those For Adults with Higher Incomes

People with low and moderate incomes — the population targeted in particular by the ACA’s reforms — had the highest uninsured rates prior to the law’s enactment and subsequently have experienced the greatest gains in coverage by far. But after declining steeply in 2014, uninsured rates for adults with incomes below 138 percent of the federal poverty level ($16,243 for an individual and $33,465 for a family of four) have remained about the same. Similarly, uninsured rates for those with incomes between 138 percent and 249 percent of poverty ($29,425 for an individual and $60,625 for a family of four) had fallen by half by 2015 but remain nearly the same this year. Consequently, low- and moderate-income adults are uninsured at rates as much as 10 times higher as those for adults with higher incomes.

Conclusion and Policy Implications

After falling sharply in 2014 upon rollout of the ACA’s major coverage expansions, the uninsured rate for U.S. working-age adults has been declining at a slower pace. The chasm in insurance coverage between lower- and higher-income adults remains troubling. We will explore the possible reasons for this in a forthcoming brief.

In each year since the coverage expansions, our survey findings have indicated that overall enrollment has been propelled by people who were previously uninsured — a year or longer for the vast majority. Consistent with other national surveys and Congressional Budget Office analyses, enrollment has not been driven by people shifting out of employer coverage: the share of adults insured through an employer has declined only slightly since 2013. The survey findings do suggest that for people who lose their job-based health benefits, the expanded insurance options may be helping to bridge the coverage gap.

http://www.commonwealthfund.org/publications/issue-briefs/2016/may/ACA-tracking-survey-access-to-care-and-satisfaction

The Affordable Care Act (ACA) has been effective in reducing the numbers of uninsured, particularly amongst low-income adults. Although that is good news, we should be alarmed that “low- and moderate-income adults are uninsured at rates as much as 10 times higher as those for adults with higher incomes,” and that there has been little improvement in enrollment for these lower income levels since the initial steep decline in 2014.

When ACA was constructed, it was decided that the employer-sponsored plans should be left largely alone to continue to fulfill the role of covering the majority of middle- and higher-income individuals and families. The greatest need was for the uninsured low-income and uninsured moderate-income sectors of the population. Thus two of the more important design features of ACA were to expand Medicaid for low-income individuals and to offer income-indexed tax credits and subsidies for private plans offered through the ACA exchanges (Marketplace).

How successful has the plan to cover those with greater financial needs been? As stated, uninsurance for those with low and moderate incomes has stabilized at a rate 10 times higher than those with higher incomes. Except for an initial surge, ACA has failed to achieve the goal of covering these more vulnerable populations.

They would have all been covered under a single payer system. Not only that, the ACA model of reform is the most expensive model of all, yet falls miserably short in universality, efficiency and equity. The least expensive comprehensive models of reform that would have actually achieved these goals are single payer Medicare for all or a government owned and operated national health service.

Although “socialism” has become less of a pejorative in the United States, the majority of residents would prefer the social insurance model of Medicare for all rather than socialized medicine through a national health service model. Now that ACA has been demonstrated to be an over-priced failure, we should move on with establishing an Improved Medicare for All.

Working families of four now average over $25,000 for health care

Milliman Medical Index: Healthcare costs for a typical American family will exceed $25,000 in 2016 and have tripled since 2001

Healthcare costs reach $25,826 for the typical American family of four, compared to $8,414 in 2001.

PRNewswire
May 24, 2016

Milliman, Inc., a premier global consulting and actuarial firm, today released the 2016 Milliman Medical Index (MMI), which measures the cost of healthcare for a typical American family of four receiving coverage from an employer-sponsored preferred provider plan (PPO). In 2016, costs for this family will increase by 4.7% — the lowest rate of increase in the history of this study — though the total dollar increase of $1,155 marks the 11th consecutive year that the total dollar increase has exceeded $1,100. The employer pays $14,793 of the total healthcare costs and the employee — through payroll deductions and cost sharing at the time of service — pays $11,033.

http://www.prnewswire.com/news-releases/milliman-medical-index-healthcare-costs-for-a-typical-american-family-will-exceed-25000-in-2016-and-have-tripled-since-2001-300273940.html

***

2016 Milliman Medical Index

In 2016, the cost of healthcare for a typical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan is $25,826, according to the Milliman Medical Index (MMI).

Milliman Medical Index is an actuarial analysis of the projected total cost of healthcare for a hypothetical family of four covered by an employer-sponsored preferred provider organization (PPO) plan. Unlike many other healthcare cost reports, the MMI measures the total cost of healthcare benefits, not just the employer’s share of the costs, and not just premiums. The MMI only includes healthcare costs. It does not include health plan administrative expenses or profit loads.

Key findings of the 2016 MMI include:

1. Our lowest annual increase in 15 years still pushes the MMI over $25,000. The cost of care for the typical American family of four has more than tripled since its value of $8,414 in 2001. And the current level of $25,826 is just an average. Healthcare spending for any given family can range from $0 into the millions of dollars.

2. The percentage increase in the MMI is at its lowest rate ever. However, even at 4.7%, which is the lowest annual increase since we first measured the MMI in 2001, the rate of increase is still well above growth in the consumer price index (CPI) for medical services, and far surpasses the average 2% annual increase in median household income between 2004 and 2014. More than ever before, health insurance is a critical component of a family’s financial security, and yet it continues to become less and less affordable.

3. Employee expenses increase at rates higher than total healthcare spending. At $11,033, the employee’s total cost increased by 5.3% from 2015, while the employer’s cost increased 4.2%. In fact, only once in the past 10 years have employee costs increased at a lower rate than employer costs. Back in 2001, the first year we measured the MMI, employers paid 61% of costs while employees paid 39%. In 2016, the same split is 57% and 43%. Employees are shouldering more of the healthcare cost burden than they were 15 years ago.

4. Prescription drugs, the most rapidly growing MMI component, are nearly 17% of total healthcare spend. In 2016, the MMI family’s prescription drug costs will reach $4,270. That’s almost four times as much as the $1,111 in prescription drug expenditures the family had in 2001. Prescription drug expenses grew at 9.1% from 2015 to 2016, a lower rate than last year’s 13.6% increase.

http://us.milliman.com/uploadedFiles/insight/Periodicals/mmi/2016-milliman-medical-index.pdf

***

Comment:

By Don McCanne, M.D.

The Milliman Medical Index (MMI) is the cost of health care for a typical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan. It is now over $25,000 ($25,826).

Although the annual percentage increase in the MMI has been declining – this year down to 4.7% – the dollar increase has exceeded $1,100 for each of the last 11 years. Though some of that is paid by forgone wage increases, that is quite a bite to being taking each year out of the wages for a typical worker’s family of four.

Nor should the declining rate of increase in the MMI be celebrated as a success of the Affordable Care Act. It is in excess of four times the rate in the increase in the CPI over the last 12 months (1.1%). Families on the average are ending up further and further behind because of the increases in our health care costs.

Doctor-Workers: Unite!

Could Disobedience Be the Path Ahead?

By Howard Waitzkin, M.D., Ph.D.
Medscape, May 20, 2016

“A person can become free through acts of disobedience by learning to say no to power…. At this point in history the capacity to doubt, to criticize and to disobey may be all that stands between a future for mankind and the end of civilization.”

– Erich Fromm, On Disobedience1

Disobedience

I confess: I am a disobedient doctor.

After a career in academic medicine and public health, I decided to work part-time in a rural health program. There I began to understand the loss of control over the conditions of medical practice that has affected so many doctors. Administrative demands multiplied and constrained my ability to care for my patients in the ways I thought best.

So I decided to disobey. A seemingly minor training requirement for the International Classification of Diseases, 10th edition (ICD-10), became the administrative demand that pushed me over the line to disobedience. But the struggle might have involved any other segment of clinical medicine, where employer mandates infringe on a doctor’s freedom to practice.

Proletarianization

Intrinsically, I have nothing against being a proletarian. I supported much of my education by working as a proletarian—for instance in a tire factory, where I learned first-hand about life as a worker in our capitalist society. Throughout my medical career, I have befriended many “nonprofessional” health workers—wonderful people whose services usually go underappreciated. Such people spend most of their waking lives doing tasks assigned by supervisors, and they enjoy little or no control over the conditions and rhythm of their work.

Medicine, I thought, would provide a way to seize control of my own work process and creativity by organizing at least a large part of the work week as I preferred. A position in academic medicine actually did allow me that liberty, despite the challenges of university bureaucracies—though there, too, autonomy started to erode, a phenomenon usually linked to financial shortfalls and measures of productivity.

However, entering the world of a nonacademic medical employee revealed the awesome scope of proletarianization—a change in doctors’ previous social class position. Until the 1980s, doctors for the most part owned or controlled their means of production and conditions of practice. Although their work often was challenging, they could decide their hours of work, the staff members who worked with them, how much time to spend with patients, what to write about their visits in medical records, and how much to charge for their services.

Now the corporations for which doctors work as employees usually control those decisions. Loss of control over the conditions of work has caused much unhappiness in the profession. Early on, an esteemed clinician and mentor described medical proletarianization when it was first emerging as “working on the factory floor.”2 Most doctors have become highly paid employees of hospital and health system corporations,3 and around one half of doctors report feeling burned out.4,5 Owing to the mystique of professionalism and their relatively high salaries, doctors often do not realize that their discontent reflects in large part their changing social class position.

Deciding to Disobey

As a doctor-worker, I got into trouble by expressing concerns about the training that our health network (hereafter, referred to as “OHN”) was requiring for ICD-10 implementation. Until then, I had received praise and little negative feedback, and had just been reappointed.

OHN had contracted with a corporation (hereafter, “$Corp”) to help cope with the transition to ICD-10. This corporation was one of hundreds that have emerged to sell consulting services to healthcare organizations facing the challenges of information technology. Such challenges include electronic health records (EHRs), quality assurance, accountable care, and similar arenas. All involve “metrics” that try to make quality quantifiable, a goal that has generated wide debate.

$Corp’s training for ICD-10 took multiple hours of unpaid time, and I decided to disobey the requirement. One reason involved my desire to spend time with a dying friend, which made me even more aware that each moment of life is too precious to waste.

After I previewed the $Corp training, I concluded that its educational quality was poor and that it implicitly encouraged “upcoding,” which could generate more payments for OHN. Brief discussions with other practitioners confirmed universal contempt for the training, as well as disgruntled universal compliance. I decided to protest the training.

The Slippery Slope to Fascism

My subsequent interactions with OHN administrators surprised me, despite my knowledge about medical proletarianization. The chief medical information officer (CMIO) at OHN wrote that “Practitioners with incomplete ICD-10 coursework at midnight on 10/7/15 will be suspended until the coursework is completed.” In response, I sent an email message asking him to explain the rationale for the training requirement. Copying the chief executive officer (CEO), the CMIO pasted his responses into the text of my original message:

1. Please provide evidence that additional training in ICD-10…improves any measurable patient outcomes, costs, or collections.

Not a debatable point. This is a requirement by OHN, so, sorry to say, whether you agree with it or not, it must be done.

2. Please provide the costs to OHN for the training.

Not relevant, as this is a requirement.

3. Please provide quantitative estimates of the financial benefits of the training for OHN.

Not relevant, as this is a requirement.

4. Please give a concrete description of the process by which you concluded that “completion of this training allows us to achieve both appropriate care and remain fiscally responsible—part of OHN stewardship.”

Not relevant, as this is a requirement.

This response pressed one of my alarm buttons, which I might call the “fascism button.” In my response, I explained the slippery slope to fascism,6 when people do what they are ordered in their jobs without understanding why. Such unjustified requirements, I argued, deserve our conscientious questioning and sometimes noncompliance.

Standardization

The CMIO was unimpressed with my argument about incipient fascism in the workplace, so I next appealed to practicality. I proposed coming to the office, unpaid, and practicing ICD-10 within our EHR. His reply? “OHN’s transformation is a movement to ensure process consistency and standardization…. Therefore, your request for an ‘exception’ is outside the organization’s expectation.”

Again, the CMIO’s reply pressed an alarm button. I must behave like an automaton in a medical assembly line, “the factory floor” foreseen by my mentor.

I then requested a face-to-face meeting and details about my forthcoming suspension—including, most importantly, a plan of coverage for my patients. I repeated my concerns about authoritarianism in the medical workplace and the extensive evidence that standardization actually may reduce quality, creativity, and productivity.

Punishment

My moral predicament deteriorated quickly. On the next morning, the CEO sent an email message asking for my resignation effective within 1 week, despite packed schedules that included many unstable patients. Then, 5 days before the deadline for suspension, I received a letter stating that my office hours with patients had been canceled until further notice. Because I needed to respond to lab results and urgent messages, I tried to connect with the EHR but found that I had been cut off.

I now faced the apparent abandonment of hundreds of my patients, many of them unstable, who had not received any alternative plan of care. Medical abandonment is unethical according to the American Medical Association Code of Ethics7 and is illegal in many states. I contacted the chief of the medical staff, who got me reconnected to the EHR so that I could manage acute problems for my unstable patients.

Because I was not willing to abandon my patients, I also persuaded an administrator to get me reconnected to the ICD-10 training, which I completed under protest late the next night. On the following morning, a Sunday, I received an email message from the CEO thanking me for completing the training and stating that my breach of contract had been “cured.”

Redemption

As a doctor-worker, I faced a challenging ethical situation that included loss of professional autonomy, authoritarian practices in the workplace, and apparent abandonment of patients. My first suspension in more than 40 years of practice also raised concerns, such as: Would a report about the suspension from OHN to the National Practitioner Data Bank affect my medical licenses or ability to practice in other settings? Was it my responsibility to blow the whistle on OHN’s practices to licensing, accreditation, and insurance agencies?

My small act of conscientious disobedience eventually led to some unexpected responses. My contract and state law required that OHN convene an external review to examine possible interference with my professional judgment, and the coordinator of the state agency that licenses health facilities expressed willingness to investigate this issue and the abandonment of patients.

Facing the probability of external review, the CEO finally met with me in person, and I proposed a formal mediation process. Instead, the CEO composed a document that included an apology, a statement that information about breach of contract would be removed from my personnel file, a commitment to consider individual physicians’ preferences in meeting future training requirements, and a promise to meet individually with a physician when a suspension is considered so that patient care would not be disrupted.

Where is the path toward a noncorporatized vision of what we know medicine can be at its best? I don’t think that path involves our continuing acquiescence. I confess that I have decided to approach these problems through personal acts of disobedience. For a person like me, closer to the end of my medical career than the beginning, such acts don’t risk much. For others, overcoming the risk will require a more organized approach to disobedience.8 Dare I encourage disobedience in unison? To paraphrase someone else: Doctor-workers of the world, unite!

Dr. Howard Waitzkin is Distinguished Professor Emeritus of Sociology at the University of New Mexico and Adjunct Professor of Internal Medicine at the University of Illinois.

http://www.medscape.com/viewarticle/863297

Supplementary Material

“eDocuments of Disobedience,” available on request, includes memoranda intended as illustrations for doctor-workers to use when contemplating or executing acts of disobedience.

“Resources for Organizing Among Doctor-Workers” is available upon request and contain links to additional readings and pertinent organizations.

Acknowledgments

I am deeply indebted to my deceased friend, Mark Teismann, PhD, who provided inspiration, encouragement, and critical feedback for me as I wrote this article while he was dying; and to my partner and co-conspirator, MiRa Lee, MD, who offered constructive suggestions and reminders that disobedience can transform the world.

References

1. Fromm E. On Disobedience. New York, NY: Harper; 2010.

2. Stoeckle JD. Working on the factory floor. Ann Intern Med. 1987;107:250-251.

3. Peckham C. Medscape physician compensation report 2016. Medscape. April 1, 2016. http://www.medscape.com/features/slideshow/compensation/2016/public/overview?src=ppc_google_rem_salary&gclid=CJ_si83OqMwCFZKCaQodSlAH5w#page=1 Accessed April 24, 2016.

4. Peckham C. Medscape lifestyle report 2016: bias and burnout. Medscape. January 13, 2016. http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview#page=1 Accessed April 24, 2016.

5. Caplan AL. Physician burnout is a public health crisis, ethicist says. Medscape Business of Medicine. March 4, 2016. http://www.medscape.com/viewarticle/859300 Accessed April 24, 2016.

6. Arendt H. Eichmann in Jerusalem: A Report on the Banality of Evil. New York, NY: Viking; 1968.

7. American Medical Association. Opinion 8.115—termination of the physician-patient relationship. In: Code of Medical Ethics. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion8115.page Accessed April 24, 2016.

8. Scheiber N. Doctors unionize to resist the medical machine. New York Times. January 9, 2016. http://www.nytimes.com/2016/01/10/business/doctors-unionize-to-resist-the-medical-machine.html?_r=0 Accessed April 24, 2016.

Working families of four now average over $25,000 for health care

Milliman Medical Index: Healthcare costs for a typical American family will exceed $25,000 in 2016 and have tripled since 2001

Healthcare costs reach $25,826 for the typical American family of four, compared to $8,414 in 2001.

PRNewswire
May 24, 2016

Milliman, Inc., a premier global consulting and actuarial firm, today released the 2016 Milliman Medical Index (MMI), which measures the cost of healthcare for a typical American family of four receiving coverage from an employer-sponsored preferred provider plan (PPO). In 2016, costs for this family will increase by 4.7% — the lowest rate of increase in the history of this study — though the total dollar increase of $1,155 marks the 11th consecutive year that the total dollar increase has exceeded $1,100. The employer pays $14,793 of the total healthcare costs and the employee — through payroll deductions and cost sharing at the time of service — pays $11,033.

http://www.prnewswire.com/news-releases/milliman-medical-index-healthcare-costs-for-a-typical-american-family-will-exceed-25000-in-2016-and-have-tripled-since-2001-300273940.html

***

2016 Milliman Medical Index

In 2016, the cost of healthcare for a typical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan is $25,826, according to the Milliman Medical Index (MMI).

Milliman Medical Index is an actuarial analysis of the projected total cost of healthcare for a hypothetical family of four covered by an employer-sponsored preferred provider organization (PPO) plan. Unlike many other healthcare cost reports, the MMI measures the total cost of healthcare benefits, not just the employer’s share of the costs, and not just premiums. The MMI only includes healthcare costs. It does not include health plan administrative expenses or profit loads.

Key findings of the 2016 MMI include:

1. Our lowest annual increase in 15 years still pushes the MMI over $25,000. The cost of care for the typical American family of four has more than tripled since its value of $8,414 in 2001. And the current level of $25,826 is just an average. Healthcare spending for any given family can range from $0 into the millions of dollars.

2. The percentage increase in the MMI is at its lowest rate ever. However, even at 4.7%, which is the lowest annual increase since we first measured the MMI in 2001, the rate of increase is still well above growth in the consumer price index (CPI) for medical services, and far surpasses the average 2% annual increase in median household income between 2004 and 2014. More than ever before, health insurance is a critical component of a family’s financial security, and yet it continues to become less and less affordable.

3. Employee expenses increase at rates higher than total healthcare spending. At $11,033, the employee’s total cost increased by 5.3% from 2015, while the employer’s cost increased 4.2%. In fact, only once in the past 10 years have employee costs increased at a lower rate than employer costs. Back in 2001, the first year we measured the MMI, employers paid 61% of costs while employees paid 39%. In 2016, the same split is 57% and 43%. Employees are shouldering more of the healthcare cost burden than they were 15 years ago.

4. Prescription drugs, the most rapidly growing MMI component, are nearly 17% of total healthcare spend. In 2016, the MMI family’s prescription drug costs will reach $4,270. That’s almost four times as much as the $1,111 in prescription drug expenditures the family had in 2001. Prescription drug expenses grew at 9.1% from 2015 to 2016, a lower rate than last year’s 13.6% increase.

http://us.milliman.com/uploadedFiles/insight/Periodicals/mmi/2016-milliman-medical-index.pdf

The Milliman Medical Index (MMI) is the cost of health care for a typical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan. It is now over $25,000 ($25,826).

Although the annual percentage increase in the MMI has been declining – this year down to 4.7% – the dollar increase has exceeded $1,100 for each of the last 11 years. Though some of that is paid by forgone wage increases, that is quite a bite to being taking each year out of the wages for a typical worker’s family of four.

Nor should the declining rate of increase in the MMI be celebrated as a success of the Affordable Care Act. It is in excess of four times the rate in the increase in the CPI over the last 12 months (1.1%). Families on the average are ending up further and further behind because of the increases in our health care costs.

Students make their voices heard with ink

Resolution writing to spur change

By Anna Zelivianskaia
Chicago Medicine, April 2016

In a world with rapid news cycles and constant updates, medical students have found a way to make lasting change. Through the Chicago Medical Society they are introducing and advocating for resolutions on issues that are important to them. James Curry, an MD/MPH candidate at the University of Illinois at Chicago, submitted four resolutions for CMS Council approval. All were adopted on February 9. When a resolution is adopted, it becomes part of the CMS policy and advocacy agenda. Depending on the goals of a resolution, its outcome may be a research initiative, lobbying agenda, support for legislation, or another mechanism.

Curry describes this process: “To begin the process, you should ask yourself three questions: ‘what problem exists, what are we already doing about it, and what can or should we do to address it?’ The first and most important step is having an issue you are passionate about. Without that, everything seems like work.” Next, he recommends learning what the current CMS policy is and finding relevant language: “This answers, ‘what are we already doing?’ My process has always been to write the best supported resolution for the problem, regardless of current policy. Then, go back and tailor the resolution around existing policy.”

This process may require you to add a completely new policy, amend, or strike existing policy. Each resolution calls for a general type of outcome and has a specific structure. “There are three outcomes a resolution can seek to accomplish: an action, a position statement, or both. An action is anything that will be done by the organization. A position statement helps solidify or establish policy on what the organization believes. There are two parts to a resolution: the preamble and the resolves. Preambles or Whereas clauses explain the need for the resolution, while the Resolved clauses state what the new policies should be or what actions the organization should take. Resolved statements become the adopted policy; they must be written to stand alone, as self-contained, self- explanatory statements. Each clause is short, clear, and to the point, with appropriate citations.

One of Curry’s resolutions called for support of a single-payer healthcare system in the United States. This issue has been debated vigorously, and he did not feel it was controversial: “I was unaware that a single-payer style resolution was needed at CMS because the majority of medical organizations (student or physician) support so many of its core principles already. We should strive for a clear understanding, endorsement and action to accomplish healthcare for all and health justice. Resolutions and policy are the best starting point to address and materialize single-payer – not just give the impression.”

He based his resolution on one already proposed by Dr. Peter Orris, but with some amendments. Curry was thrilled that “the resolve (action) that survived and was adopted commits CMS to study the “benefits and difficulties of instituting and maintaining a single-payer healthcare system, in Illinois, and in the United States. This study will consider economic costs along with outcomes and improvements in health and health disparities.” Thus, the outcome is a CMS research initiative.

The resolution was subsequently considered by the Illinois State Medical Society, which recently voted to study a single-payer healthcare system.

Resolutions like this provide an example of CMS representing the policy interests of Chicago-area health professionals. These are fluid as medicine and policy constantly change, but guiding change requires speaking up.

Many health professionals and members of the public still feel healthcare reform is needed. It is a fact that the U.S. spends more per capita on healthcare than other developed nations in spite of having some of the worst health outcomes. When asked why he believes single-payer is the best strategy to bring about positive change, Curry answers: “Whether it’s family, friends, or ourselves, we have all fallen victim to thinking our health insurance is good, until we need it most (all the while, suffocated by enormous costs). After succumbing to the traps of bills, denials, approvals, changing physicians and care each year, I see the exact same thing from the other side of the table as a medical student, looking up to residents and attending physicians.”

Many people doubt change will come if there is no catalyst – if no one stands up and asks for it. That is simply untrue because many forces make change inevitable and we, as students and physicians, must work with them to transform our healthcare system into one we will still want to work in 10 or 20 years from now. Curry aptly summarizes: “Classes of health insurance mean classes of health. How am I to determine who to treat based on anything other than need?” Writing CMS resolutions is a powerful way to get heard.

Anna Zelivianskaia is fourth-year medical student at the University of Illinois at Chicago. Anyone with comments about this article may reach her at azeliv2@uic.edu.

http://www.cmsdocs.org/news-publications/chicago-medicine-magazine/2016-issues/April2016.pdf