PNHP

Support reforms to cut administrative burdens on doctors

Support reforms to cut administrative burdens on doctors

By Stephen B. Kemble, M.D.
Honolulu Star-Advertiser, Nov. 6, 2014

Health care in the U.S. suffers from severe over-management.

Recent studies have documented high administrative burdens for American doctors and hospitals. The average U.S. physician spends a sixth of their time on administrative tasks that are not integral to patient care, and this is worst for psychiatrists, internists, and family practitioners – the very specialties for which we have the worst shortages. 

Administrative costs for U.S. doctors are about four times those of countries with simpler, universal health care systems. 

U.S. hospitals also spend 25 percent of their budgets on administration, much higher than in any other country and twice as high as countries like Canada and Scotland.  

Since the introduction of managed care in the 1990s, the number or doctors in the U.S. has about doubled, while the number of administrators has increased more than tenfold, to the point that there are now far more administrators than doctors. 

Spurred by the Affordable Care Act, doctors and hospitals are reorganizing into large systems, and hospitals and insurance plans are buying up physician practices all over the mainland, supposedly to improve care coordination and efficiency of care. Actual results are showing the opposite. Large systems bring higher administrative burdens for doctors and raise the total cost of care. 

Pay-for-performance is the latest scheme to micromanage doctors, but the complexity of health care means the validity of “quality” measures is very low, and financial incentives reward the wrong things and encourage gaming of documentation to satisfy “metrics.” 

Conscientious doctors who knows their patients will always know far more about quality of care for individual patients than a health plan administrator with “metrics” from claims and electronic health records. Physicians are increasingly demoralized by micromanagement from clueless administrators, harming actual quality of care.

Hawaii’s health transformation initiative has so far been focused on developing “Accountable Care Organizations” and implementing pay-for-performance schemes, relying on federal health care innovation grants. These efforts are getting us nowhere in the quest for the “Triple Aim” goals of improved quality of care, improved population health, and reduced cost. Once the grants run out, we are left with administratively complex and costly reforms that can’t work in practice.

I hope our next governor will realize the futility of this approach and support reforms that reduce administrative burdens on doctors and empower them to do what they were trained to do – manage the care of their patients based on their professional training balanced with specific knowledge of each patient’s unique illnesses and circumstances. 

Instead of pay-for-performance, physician pay should be incentive-neutral, freeing doctors to focus on the best interest of their patients.

Relief from administrative burdens will also help recruit and retain doctors, making it easier for them to practice in underserved specialties and locations.

If we want to achieve the Triple Aims, we need to assure care for everyone in the most cost-effective settings, simplify and streamline administration, and use administrative savings – not restrictions on care – to reduce the prices paid for health care. 

Dr. Stephen B. Kemble is assistant clinical professor of medicine at the John A. Burns School of Medicine.

http://www.staradvertiser.com/s?action=login&f=y&id=281737321

What the election means for reform, especially single payer

This Is How the New GOP Senate Will Try to Dismantle Obamacare

By Jonathan Cohn
New Republic, November 4, 2014

Most Republicans know that they can’t repeal Obamacare anymore. They’ll start with a symbolic vote for outright repeal. From there, (Ted) Cruz says, Republicans will go after Obamacare provisions “one at a time.” 

Here’s what the GOP has in mind, based on conversations with health care experts and lobbyists:

  • Repealing the individual mandate
  • Repealing or modifying the employer mandate
    • changing the threshold to 40 hours
    • could propose raising (50 employee requirement) to 100 full-time employees
  • Eliminating “risk corridors”
  • Repealing the device tax
  • Abolishing the Independent Payment Advisory Board (IPAB)
  • Introducing “Copper Plans”
    • 50 percent actuarial value

http://www.newrepublic.com/article/120125/republican-plans-obamacare-device-tax-mandates-risk-corridors

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Comment:

By Don McCanne, MD

New Republic’s Senior Editor Jonathan Cohn, an astute and very well-informed observer of the health care reform scene, provides us with a quite plausible response of the new Republican majority in the next session of Congress. They will likely fulfill their promise to introduce legislation to repeal the Affordable Care Act (ACA), though knowing that the effort will end with either a filibuster or a presidential veto. The real action will take place over individual provisions of ACA.

Some of the less objectionable measures they propose could be included in other bills as part of the legislative compromise process. Other less desirable changes could avoid filibuster by being tacked onto reconciliation bills, and avoid veto by being added to must-sign bills ((e.g., bills to prevent shutting down the government).

Since the Republicans have never formed a consensus on the replace part of repeal and replace, it is unlikely that they will try to enact some of their proposed measures such as eliminating the tax preference of employer-sponsored plans, or selling plans across state borders to avoid effective regulatory oversight. Such efforts would create new problems that would be unpopular – not an approach they would likely take when they have their eye on the White House in two years.

So how does single payer activism fit into all of this? With one caveat, there should be no change in our mission to educate our colleagues and the public on a vastly superior alternative – a single payer national health program. As patients experience the deficiencies of our current dysfunctional system, they have to understand that it doesn’t have to be this way – that everyone can have their choices in essential health care without having to negotiate financial barriers to that care.

During the next session of Congress, it is clear that we will not see any movement on single payer legislation. Even if a wave of Republican Enlightenment were to flood Congress and they decided that single payer really was the preferred model, they would not allow President Obama to receive any credit by signing the bill, but rather would wait until a Republican President took office in 2017. Lest this seem like a fantasy, F.A. Hayek supported “a comprehensive system of social insurance.”

Our education process is two-fold: 1) describing the very positive features of the single payer model, and 2) exposing the severe inequities and deficiencies of our fragmented system which has only been perpetuated by ACA. The former is obvious, but the caveat applies to the latter.

Until we can move forward on single payer, it is important to take care of what we do have. We should not criticize the efforts of those who are still in the process of implementing ACA. They are doing the best they can under current laws and regulations. If Congress tries to enact measures that are clearly detrimental we should join our friends in opposing such actions. If beneficial patches to ACA are proposed, we should not oppose them merely because they perpetuate ACA, but rather support them as transitional improvements until we can achieve single payer.

But this is where we have a problem. We need to let the public know why these measures are inadequate – how they merely perpetuate our highly flawed system. But we must make a clear distinction between our efforts to make our health care system work well for everyone and the efforts of some members of Congress who would destroy as much of ACA as they can, and walk away leaving too many people exposed to yet more health and financial insecurity. When we are accused of helping the enemy of reform by opposing ACA we have to correct that misperception by letting them know that we support ACA as a transitional program that provides some relief until we can enact single payer, but that we cannot accept decades of incremental changes to ACA that can never lead to a rational, comprehensive system of health care financing.

Based on the simplistic messages that carried the election, it is obvious that we have a formidable task ahead of us. Our messages are not simple, but they need to be clear. Everyone can have affordable, high quality health care, but we do not have that with ACA nor would we with the anticipated Republican actions. We have to let people know.

The high administrative costs in U.S. health care

Health Affairs, Letters, November 2014

PNHP note: The following letters appeared in the November issue of the journal Health Affairs in connection with a feature article in the September issue titled “A Comparison Of Hospital Administrative Costs In Eight Nations: US Costs Exceed All Others By Far,” by David U. Himmelstein, Miraya Jun, Reinhard Busse, Karine Chevreul, Alexander Geissler, Patrick Jeurissen, Sarah Thomson, Marie-Amelie Vinet, and Steffie Woolhandler.

High Administrative Costs At US Hospitals

By Samuel Metz

David Himmelstein and coauthors (Sep 2014) show that administrative costs in US hospitals exceed those in hospitals in seven other developed nations and indicate that this extra spending buys more administrators, not more benefits. This raises the question of why American hospitals need more administrators than foreign hospitals do.

The authors say that the extra administrators in the United States determine patients’ insurance benefits and their ability to pay costs that are not covered by insurance. These functions are unnecessary elsewhere.

Unlike nations with national insurance plans, the United States spends billions of dollars to fragment our population into thousands of insurance pools and then to fragment those pools into tens of thousands of subsets with differing benefits. This format generates substantial administrative challenges. For example, physician offices in Chicago might deal with 17,000 different payment schedules.[1]

It costs more money to exclude patients and restrict benefits that it would to provide comprehensive care to all patients without fragmentation. Two authors of the September article previously estimated that replacing our multipayer system with a national health program would recover $320 billion in administrative costs.[2] This exceeds the estimated $220 billion in additional costs needed to provide comprehensive care to everyone.[3]

The message is clear: Barriers to health care cost more than universal access to health care.

Notes:
1.  Kagel R. Blue crossroads: insurance in the 21st century. Amednews.com [serial on the Internet]. 2004 Sep 20 [cited 2014 Sep 15]. Available from: http://www.amednews.com/article/20040920/business/309209993/4
2. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med. 2003;349(8):768–75.
3. Sheils J, Haught RA. The Health Care for All Californians Act: cost and economic impacts analysis [Internet]. Falls Church (VA): Lewin Group; 2005 Jan 19 [cited 2014 Sep 15]. Available from: http://www.lewin.com/~/media/Lewin/Site_Sections/Publications/3015.pdf

Portland, Ore.

http://content.healthaffairs.org/content/33/11/2081.1.full

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High Administrative Costs: The Authors Reply

By David U. Himmelstein and Steffie Woolhandler

Samuel Metz aptly characterizes the wasteful complexity of US health care financing, compared to a single-payer system — for example, an improved version of Medicare for all Americans. His estimate of administrative savings achievable through such reform is too low, however, because it’s based on an analysis of 1999 data. Our study (Sep 2014) found that since 2000, US hospitals’ administrative costs have risen from 0.98 percent of gross domestic product to 1.43 percent. And per capita annual insurance overhead costs have tripled since 2006, reaching $731.[1] Switching to a single-payer system today could save more than $400 billion annually on bureaucracy.

These savings would make it possible to provide universal coverage without copayments or deductibles and with no increase in health expenditures. In contrast, the Affordable Care Act has added another layer of bureaucracy — the health insurance exchanges — that cost $6 billion to get up and running, or $750 per new enrollee.

Economics texts preach that markets breed efficiency, but the most market-oriented health systems are the least efficient. The transformation of American health care into a business has sharply increased transaction costs and rewarded entrepreneurs for financial games that add no value.

One hospital that we know paid upcoding consultants $600,000 to advise interns on the best language for chart notes. Typing “moderately malnourished” instead of “malnourished” apparently ups diagnosis-related group payments (and also improves risk-adjusted mortality scores). That useless expenditure garnered an extra $3 million in revenues for the hospital.

A simple national health insurance program is the best way to meet both the moral imperative to care for the sick and the economic imperative to do so efficiently.

Note:
1. Centers for Medicare and Medicaid Services. National health expenditure data, historical data [Internet]. Baltimore (MD): CMS. Table 4: national health expenditures by source of funds and type of expenditures: calendar years 2006–2012; [cited 2014 Sep 17]. Available from: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/tables.pdf

City University of New York, New York, N.Y.

http://content.healthaffairs.org/content/33/11/2081.2.full

EHR Use Adds To Administrative Duties

Electronic health records are meant to simplify a physician’s workload, right? Not so, according to an article published in the International Journal of Health Services.

By Katie Wike
Health IT Outcomes, Nov. 5, 2014

Drs. Steffie Woolhandler and David Himmelstein, who serve as professors of public health at the City University of New York and lecturers in medicine at Harvard Medical School, recently studied data from over 4,700 physicians. According to the International Journal of Health Services, this data came from the most recent 2008 Health Tracking Physician Survey.

Woolhandler and Himmelstein found the average doctor spent 8.7 hours per week – 16.6 percent of their working time – on administrative duties. This includes time spent on billing, obtaining insurance approvals, financial and personnel management, and negotiating contracts. It does not include patient related tasks, such as charting, ordering labs, and consulting with other physicians.

Fierce EMR explains Woolhandler and Himmelstein also discovered doctors using electronic health records (EHRs) averaged about 17 percent of their time on administrative duties, while those using paper records spent about 15.5 percent of their time doing the same. For those who used both an EHR and paper records, this number rose to 18 percent. This difference may stem from the fact that EHR documentation often takes longer.

“American doctors are drowning in paperwork,” said lead author Woolhandler. “Our study almost certainly understates physicians’ current administrative burden. Since 2008, when the survey we analyzed was collected, tens of thousands of doctors have moved from small private practices with minimal bureaucracy into giant group practices where bureaucracy is rampant. And under the accountable care organizations favored by insurers, more doctors are facing HMO-type incentives to deny care to their patients, a move that our data shows drives up administrative work.”

iHealth Beat reports the study also found correlations between administrative duties and professional satisfaction. Those who spent more time on such tasks had lower moral. Doctors who reported they were “very satisfied” spent an average of 16.1 percent of their time doing administrative tasks, while doctors who reported being “very dissatisfied” spent 20.6 percent doing such work.

“Our crazy health financing system is demoralizing doctors and wasting vast resources. Turning health care into a business means we spend more and more time on billing, insurance paperwork and the bottom line. We need to move to a simple, nonprofit national health insurance system that lets doctors and hospitals focus on patients, not finances,” said Himmelstein.

http://www.healthitoutcomes.com/doc/ehr-use-adds-to-administrative-duties-0001

Don’t pay for ‘nothing,’ fund universal care

By Samuel Metz, M.D.
Portland (Ore.) Tribune, Nov. 4, 2014

What are the saddest parts of the Cover Oregon debacle?

The first is that our state government spent $250 million for software development that, in the end, left us with … nothing.

Not only nothing, but with a hostile and very wealthy software development company intent on compelling Oregon to pay even more for … nothing.

Actually, that big loss is neither unexpected nor unprecedented. The majority of software development projects, both government and private, ultimately fail to produce the expected product. Oregon’s government is not immune to these catastrophes: In the 1990s, Oregon spent more than $100 million on Department of Motor Vehicles software that ultimately produced … nothing. So Cover Oregon did not break new ground in failed projects, not even for failed government projects.

The saddest part of Cover Oregon, however, is that a universal health plan in Oregon would have rendered Cover Oregon, plus its software, its website and indeed its entire mission, totally unnecessary. Matching four million Oregonians with a specific insurance policy is expensive. But universal health care is not.

Why was Cover Oregon so expensive? The Affordable Care Act compels Oregon, like the rest of the country, to spend millions of dollars assigning us into one of hundreds of insurance pools, based on employer, age, number of coworkers, military status, residence, family size and a host of other factors.

Our assigned insurance pool then determines which insurance plans we might qualify for and which physicians we can see. These insurance plans are further subdivided into hundreds of benefit plans, which could be unaffordable, inadequate or both.

We then recalculate everything with every change in employer, age, etc. That’s why we need Cover Oregon (or a federal website) to keep track of this massive paperwork.

It doesn’t have to be this way. And it isn’t this way for health care systems that successfully provide better care to more people for less money than we do in Oregon.

These successful health care systems (around the world and in our own country) possess one common characteristic — they assign everyone to just one insurance pool (human beings), with just one set of benefits (treatable conditions are treated), and with just one network (all licensed physicians).

No successful system spends money on websites like Cover Oregon in order to sort sick from healthy, poor from wealthy and employed from jobless. They spend money on health care.

Cover Oregon is necessary only if we want to restrict care and limit benefits. If we instead commit to comprehensive care for everyone, Oregon saves money. How much? The money we now spend on software development, website design, insurance administration, marketing, lobbying and provider overhead that deals with all this would be more than enough to provide every Oregonian with access to comprehensive care.

We know this because every health care system that provides universal comprehensive care also spends less money with better results than we do now.

What does the Cover Oregon debacle teach us? Restricted care costs more than universal care.

Oregon doesn’t need to spend more to provide better care to more people. We just need to spend our money on health care, not Cover Oregon.

Successful systems tell us how to achieve that: Universal care.

Samuel Metz is a Portland anesthesiologist and a member of Physicians for a National Health Program and Mad As Hell Doctors, organizations that advocate for universal health care in Oregon and nationally. 

http://portlandtribune.com/pt/10-opinion/239284-104460-my-view-dont-pay-for-nothing-fund-universal-care

Fox: Patients who can’t use their exchange plans

Some ObamaCare patients with high deductibles turning to community care centers

By Jim Angle
Fox News, November 4, 2014

When ObamaCare patients learn their deductible is so high they’re unlikely to get any reimbursement, they often wind up in places like the Denton, Texas Community Care Center.

“There are quite a few, and I saw another one today, where their deductibles are so elevated that they can’t afford them,” said Dr. Flippo Masciarelli, chief physician at the center, which was designed to treat indigent patients.

Robert Laszewski of Health Policy and Strategy Associates noted, “You’re going to the doctor, you’re paying (a) premium, and because of this really high deductible, you’re not getting any benefits.”

The administration pushed insurance companies to keep premiums low, but that also created high deductibles, about $5,000 per person for the least expensive plan, as well as narrow networks of providers.

But most people buy based only on premiums.

“They don’t even look at what their deductible is going to be,” said Dan Mendelson, CEO of Avalere Health. “They don’t look at the cost of the medications that they’re on. And they don’t look at the…network that they have.”

Masciarelli said,”one of the ladies we saw said she called eight primary care offices before she found us…” The rest would not treat people on her plan. 

If the doctor these patients find orders additional tests or treatment, even those with ObamaCare are sometimes forced to go without.

Health economist John Goodman said, “They go to community health centers because it’s free or almost free and or very low charges. And that’s why they’re doing it. So they were coaxed to go into the ObamaCare system, they’re paying premiums over there. And now they’re asking what did I get for my premium? I’m having to go outside the system to get health care.”

Masciarelli agreed. “We do get asked that question at times, yes, wondering you know, I have this product. I can’t even use it. ” 

http://www.foxnews.com/politics/2014/11/04/some-obamacare-patients-with-high-deductibles-turning-to-community-care-centers/

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Comment:

By Don McCanne, MD

Although this is a typical Fox News anecdotal report not based on any scientific study and designed to discredit “ObamaCare,” nevertheless it does make a very valid point. People obtaining their coverage through the insurance exchanges are finding that, with the narrow networks and high deductibles, they “can’t even use” their plans.

Fortunately these patients do have the backup that the 30 million people who will remain uninsured have – community health centers. But they will still have impaired access to specialized services because of unaffordable cost sharing, and because of a lack of specialists who are willing to provide services through the community health centers.

Although these plans do provide coverage for catastrophic events, it is primarily the providers rather than the patients who benefit. Because of EMTALA regulations, the patients would receive the care anyway, but the providers will be paid rather than having to write the care off as a loss. It is just one more example of how the system was designed to take care of the medical-industrial complex rather than placing the patient at the pinnacle.

Single payer would get rid of the narrow networks and unaffordable cost sharing, so no patient would be rejected based on the limitations imposed by the private insurers. But then that would deprive Fox News of these anecdotal reports that they use to bash President Obama. So what is our priority here?

Single-payer health plan would be best for patients

By Robert A. Milch, M.D.
The Buffalo News, Letters, Nov. 1, 2014

The News reported Oct. 25 that the national head of BlueCross BlueShield said the United States “spends too much” for health care, stakeholders need to “work” together and reimbursement must shift to one that “rewards best outcomes.”

Belaboring the well-known obvious, his comments are superficial and self-serving. Costly administrative bureaucracies such as his with arbitrary limitations have made health insurance unavailable or unaffordable for too many Americans while fueling a system producing substandard results.

The “best” outcomes for the individual patient and community as a whole are produced by a single-payer, universal coverage such as by an expanded Medicare, which minimizes or eliminates private insurance plans. This has been demonstrated time and again by every developed country instituting such a policy – outcomes measured as life expectancy, infant and maternal death rates, countless others.

We should no longer be tolerant of unresponsive, empty posturing such as his or our elected representatives, resistant to meaningful change. Health is not just a commodity, and its care requires more than a transaction.

Dr. Robert A. Milch resides in Williamsville.

http://www.buffalonews.com/opinion/letters-to-the-editor/letter-single-payer-health-plan-would-be-best-for-patients-20141101

Using Ebola Care as a National Health Model

By Carol C. Nadelson and Howard Corwin
The New York Times, Letters, Oct. 31, 2014

The Ebola crisis could be a test case for health care management on a national scale. It may provide an extraordinary opportunity to improve the adequacy of our national health care.

The Centers for Disease Control and Prevention, after its initial failure, swiftly mobilized to meet a public health emergency threat. It coordinated communication to all health care facilities, standardized education for health care personnel and created protocols for improved quality of care in emergency situations.

It has demonstrated that scientifically informed rather than politically tinged state efforts are effective. Just as with national defense, only a coordinated, unified response by the federal government is capable of meeting such an emergency.

Fortunately such a model is translatable not just for medical emergency situations, but to all levels of medical care. The Affordable Care Act remarkably has had the foresight to focus on prevention and public health as well as individual treatment.

Ebola has focused our government’s role in the delivery of health care. We can implement universal single-payer health care insurance that incorporates the A.C.A.’s principles of preventive medicine and public health by expanding Medicare, a proven high-quality, reliable insurance delivery system.

Not only would this improve the nation’s health care, but through its effectiveness and savings, it could also be a stimulus for improving the health of the economy.

Dr. Nadelson is a professor of psychiatry at Harvard Medical School and past president of the American Psychiatric Association. Dr. Corwin is a retired clinical professor at Tufts University School of Medicine.

Insurance shopping without health insurance literacy

A Little Knowledge Is a Risky Thing: Wide Gap in What People Think They Know About Health Insurance and What They Actually Know

By Kathryn A. Paez and Coretta J. Mallery
American Institutes for Research, October 2014

Health insurance is among the most complicated and costly products that consumers buy. Lacking health insurance-related knowledge and skills — or health insurance literacy — puts people at risk of choosing an insurance product that could fail to provide needed benefits or protect them financially.

More than half of all people surveyed were moderately or very confident in their ability to choose and use a health plan that is best for their family, but their actual knowledge was less.

Because many people believe they know more than they do about health insurance, they may not fully understand their options before committing to a particular health plan for an entire year, or they may have an unpleasant surprise when they use health care services and end up owing a larger amount out of pocket than expected.

Understanding Plan Type and Calculating Cost Sharing

When comparing and selecting health plans, 61 percent of people said they were moderately or very confident that they could choose the best health plan for themselves. Only 23 percent could identify characteristics of a preferred provider organization (PPO) — for example, “you may have to pay a percentage of the bill.”

Three out of four people said they were moderately or very confident that they have the knowledge to use health insurance. However, only 20 percent could accurately calculate how much they would pay for a visit to an in-network doctor when presented with a cost-sharing scenario that included a copayment, deductible and coinsurance.

Skills Differ by Age, Care Use, Race, Income, Education

Generally younger people were less health-insurance literate — for example, people aged 22 to 34 got an average of 55 percent of knowledge and skills items correct.

Likewise, people who use health care less frequently had more difficulties.

Health insurance knowledge and skills also varied greatly by race, with blacks and Hispanics on average having less knowledge about health insurance.

Knowledge and skills also decreased with income and education.

Implications

Choosing and using a health insurance plan can be daunting, especially for people with little experience with the health care system and health insurance. According to the 2013 AIR Health Insurance Literacy Survey, many Americans are unprepared to make informed choices when selecting and using health plans — especially younger people, minorities, people with lower incomes and those with less education.

At the same time, health insurance and benefit structures are becoming even more complex. As mentioned previously, consumers likely don’t need to know the exact differences between an HMO and PPO, but they do need to consider important health plan characteristics — such as patient cost sharing, which hospitals and doctors are in network, and the rules for out-of-network coverage — when choosing a plan.

Without efforts to increase health insurance knowledge and skills, many insured people will remain at risk of forgoing needed care if they don’t understand how their health insurance works or how to estimate out-of-pocket costs.

At a minimum, counseling efforts could stress that once people are enrolled, they should contact their health plan member services department to get questions answered.

http://aircpce.org/wp-content/uploads/2014/10/11801-451-05_Issue_Brief_102014.pdf

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Comment:

By Don McCanne, MD

Great. The insurance exchanges established by the Affordable Care Act have created a shoppers paradise for health insurance. People can choose from different premiums, different plans, at different levels of coverage, with different benefits, and different cost-sharing deductibles, co-payments and coinsurance, with different networks of physicians and hospitals, and different rules on out-of-network coverage, not to mention different insurance structures such as PPOs, HMOs, EPOs, and ACOs, whatever they are.

How many times have you heard physicians, nurses, health policy wonks, and knowledgeable others say that they have trouble figuring out their own insurance plans. Most end up waiting until they receive their Explanation of Benefits to find out just what was covered. How on earth can we ever expect people with little prior exposure to the intricacies of health insurance to be able to shop intelligently for plans offered in the exchanges? We can’t.

The tragedy is that poor choices in plan selection can have major impacts on both the physical and financial well being of the health plan purchasers. But when you think about it, virtually every plan offered has significant deficiencies, especially in limiting access through narrow networks and in increasing risk of financial hardship through excessive cost sharing. The subsidies may help some, but they are inadequate for most. Not only are the choices difficult to make, they are mostly all bad choices.

Those concerned about lack of “health insurance literacy” – an almost universal phenomenon – suggest that the solution is to increase transparency in the exchanges. But the authors of this report suggest that we need much more. Health insurance shoppers need additional training to “increase health insurance knowledge and skills.” Is that the answer?

What we want is a system wherein whenever we need health care, we go get it. Period. What we have is a conglomeration created by private and public intermediaries that make it difficult to decide where you can go when you need health care and how to pay for it ex-ante (premiums) and ex-post (cost sharing). And we end up paying much more for all of the administrative excesses that these intermediaries have created.

Do we want to make it all go away so that each of us can simply get the health care that we need? Easy – single payer.

Obamacare a Successful Failure

By Samuel Metz, M.D.
Gastroenterology & Endoscopy News, Oct. 29, 2014

Is the Affordable Care Act a failure? For some of us, the answer is simple: If you voted for President Obama, it must be a success. If you voted against the president, it must be a failure.

But if you think the legacy of Barack Obama is irrelevant to health care reform, the answer gets more complex.

Will the Affordable Care Act (ACA) achieve anything at all? Maybe. More Americans will own health insurance policies, especially if they are young and employed. Government spending on health care will decrease, despite the added cost of new computer programs and 17 different state insurance exchanges. Also, the financial burden of Medicare patients who have excessively costly diseases will move from the payer (the U.S. government) to the providers (us).

But these changes hardly qualify as reform. For patients, physicians and employers, none of these potential achievements has the slightest bearing on health care reform.

Patient Expectations

What do patients want from reform? Simple: access, lower costs and better health outcomes. The ACA misses all three.

Access? According to the Congressional Budget Office (CBO), despite the new law, the ACA will leave 10 million to 30 million Americans under-insured, putting them at risk for bankruptcy or death if they get the wrong disease at the wrong time. Another 30 million will be left with no insurance at all. In other words, when their incomes end, so does their health care — and maybe their lives. And that’s if the ACA works perfectly.

Lower costs? Although the CBO anticipates a $100 billion annual decrease in government health care spending, it also predicts a net increase of $100 billion in total health care spending. That means patients and employers will pay $200 billion more annually than they pay now. And that’s if the ACA works perfectly.

Improved outcomes? The Massachusetts experience says no. Six years after implementing its version of the ACA (Jonathan Gruber, the Massachusetts Institute of Technology economist who worked on both the Massachusetts program and the ACA, called them “the same [expletive deleted] bill”), 95% of state residents own insurance policies. Yet outcomes are unchanged, medical bankruptcies are 30% higher, and costs are increasing faster than anywhere else in the country.

(This is not entirely true. Those Massachusetts residents newly covered by Medicaid expansion now enjoy better health and lower medical debt. The same can’t be said, however, for those with private insurance.)

If you’re a patient, the ACA is a failure.

Physician Expectations

What do physicians want from reform?

First, payment. Given the amount of pro bono work that physicians provide, sometimes unwillingly, payment is not a slam dunk. It’s one thing to voluntarily perform charity care in Third World countries to prevent patients from dying of easily treatable diseases. But it’s a real tragedy to realize that without our charity work, many Americans similarly will die of easily treatable diseases.

In no other industrialized country do the poor and sick get charity care — physicians caring for them get paid the same amount as the physicians would if they cared for the rich and the famous. Only in the United States do physicians go unreimbursed if they care for the wrong patients.

Second, our payment should reflect the value of our services, not the value of the insurance policies of our patients. If we are paid more for patients with pearls than we are for those with tattoos, then financial motive favors care for the pearls.

Lastly, physicians want easy billing and prompt payment. Most of us haven’t seen that for decades. The ACA makes no pretense of simplifying either.

Physician-Employer Expectations

What should health care reform provide to employers?

First, employers want healthy employees. When office staff call in sick, it doesn’t matter if they are full-time or part-time — it’s lost productivity.

Next, employers want out of the health benefit management business. Just to manage the complexities of employee benefits costs employers an extra 2% of payroll. Can we rid ourselves of this added cost of doing business? Employers want health care benefits removed from labor–management negotiations.

To remain competitive, employers want costs for employee health care to be no more than what our competitors pay. Similarly, our employee benefits should be no worse than what our competitors offer.

Lastly, employers want health care costs to be predictable and consistent.

The ACA addresses none of these needs.

Health Care Basics

Whatever else the ACA may achieve, it completely fails to address the basic health care needs of patients, physicians and employers. Whether we voted for or against our current president, whether we register to vote as Republicans or Democrats, whether we are in private practice or academics, the ACA leaves our health care landscape in the same shape as before: a complete shambles.

It’s disappointing that this massive opus strives so valiantly to make a difference, yet falls so short of achieving what we really need. Is the ACA a well-intended piece of legislation? Yes. Is it reform? Sadly, no.

Maybe Congress will have better luck next time, if there is a next time. Let’s hope so.

Dr. Metz is a private practice anesthesiologist who lives and works in Portland, Oregon. He can be reached at s@samuelmetz.com.

http://www.gastroendonews.com/ViewArticle.aspx?d=Opinions+%26+Letters&d_id=189&i=October+2014&i_id=1115&a_id=28486

Medicare Advantage plans are lying about their networks

The Accuracy of Dermatology Network Physician Directories Posted by Medicare Advantage Health Plans in an Era of Narrow Networks

By Jack S. Resneck Jr, MD; Aaron Quiggle, BA, MS; Michael Liu, BS; David W. Brewster, BA
JAMA Dermatology, October 29, 2014

In the evolving health insurance marketplace, many health plans have increasingly deployed “narrow networks,” reducing the number of contracted physicians or hospitals in a given metropolitan area. Whereas the use of these narrow networks in exchange plans offered under the Affordable Care Act (ACA) might have been expected given pressures to control costs and limit premiums, insurers have taken similar actions in several states to reduce the number of participating physicians in private plans offered as alternatives to Medicare patients known as Medicare Advantage (MA) plans.

Whereas some inaccuracies in ACA exchange plan directories may be expected given the novelty of those products in 2014 and the last-minute contracting that occurred, the MA marketplace is more mature and should have more stable physician listings. Accurate physician lists are particularly important at a time when MA plans are increasingly deploying narrow networks, making determinations of network adequacy critical for both primary care and many difficult-to-access specialties.

Methods 

Using MA enrollment data from July 2014, we determined the 3 largest insurers in each of the 12 MSAs by enrollment.

A scripted telephone call was placed by one of us (A.Q. or M.L.) to each unique physician listing. All calls were placed during varied times of the day and days of the week for each MSA and occurred between August 5 and September 4, 2014.

He asked whether the listed physician accepts the relevant MA plan(s) and sees patients with itchy rashes and, if so, when the next available new-patient appointment was.

Results

For the largest MA plans in the 12 MSAs… there were 4754 physician listings (4408 MDs, 346 DOs) meeting inclusion criteria.

Within health plans, a large number of these listings represented duplicates (2164 [45.5%]).

Among the 2590 remaining unique listings, there were many that our callers were unable to contact (464 [17.9% of unique listings]). Some of these were nonworking or wrong telephone numbers, and others were offices that reported that they had never heard of the listed physician. Several more (221 [8.5% of unique listings]) reported that the listed physician had died, retired, or moved out of the geographic area.

Many of the listed physicians whose offices we reached were not accepting new patients (221 [8.5% of unique listings]). There were also several who were subspecialized and were not willing to make an appointment for a patient with an itchy rash.

Fewer than half of listed physicians for each plan (1266 [48.9% of unique listings]) were reached, accepted the listed plan, and offered an appointment for a patient with an itchy rash. Because of the large number of duplicate listings, this translates to only 26.6% of individual directory listings being unique, taking the listed plan, and offering a medical dermatology appointment.

Wait times for the appointments offered by those listed physicians were relatively long (median, 30 days; mean, 45.5 days).

Discussion

Our findings of inaccurate physician directories and long dermatology appointment wait times in many areas come at a time when many health plans are narrowing their MA networks by reducing the number of in-network physicians. There has been concern voiced about the proprietary methods that health plans are using to select physicians for termination and whether those methods themselves may limit access for patients with more costly health conditions. Our study cannot address those specific concerns, but our data do support the hypothesis that the large physician directories posted by many health plans exaggerate perceived access to dermatologists for MA patients. Furthermore, the long in-network appointment wait times observed for many of these plans suggest a lack of capacity that can only be exacerbated by further network narrowing.

http://archderm.jamanetwork.com/article.aspx?articleid=1919439

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Comment:

By Don McCanne, MD

One of the more alarming trends in health insurance innovation is the increasing use of narrower provider networks. Patients are losing their choice of their health care professionals and hospitals. Not only can this result in impaired access and longer wait times, it also can unfairly benefit the insurers by discouraging sicker patients from enrolling because of concerns about being unable to access the care that they need – especially specialized services.

This study looked at provider lists of dermatologists offered by a representative group of major private Medicare Advantage plans. Although the plans offered in the new insurance exchanges under the Affordable Care Act can plead being victims of transitional logistical complexities causing errors in their network lists, the private Medicare Advantage plans have been around for many years in an expansionary market and thus should represent the best of network administration. So how are they doing?

This study was completed less than two months ago and thus represents the current state of the art. When contacted, only one-fourth (26.6%) of the total number of dermatologists listed in the Medicare Advantage provider networks offered new appointments, and the mean wait time was 45 days. Only one-fourth! And with a 45 day wait!

This narrow network thing has really caught on. Some of these same Medicare Advantage plans are now cutting more providers from their networks, including dermatologists. And the newer ACA exchange plans are starting out with even narrower networks.

How can this benefit patients? Take away choice? Hiding true providers in otherwise worthless lists? Moving patients further back in the queues? And they want to give us more of this?

Traditional Medicare doesn’t have any networks. They are a creation of the private insurance industry, designed to serve their own nefarious interests. Enough! Time to get rid of them and enact an improved Medicare that takes care of all of us.

One way Medicare Advantage plans game risk scores

Another whistleblower suit alleges Medicare Advantage fraud

By Fred Schulte
The Center for Public Integrity, October 29, 2014

A new whistleblower lawsuit accuses a California health care firm of diagnosing “false and fraudulent” medical conditions that several Medicare Advantage plans allegedly used to overcharge the federal government by $1 billion or more.

The suit was filed by Anita Silingo, a former compliance officer for Mobile Medical Examination Services, Inc., or MedXM. The Santa Ana, California-based firm sends medical professionals to the homes of Medicare Advantage members to assess their health.

The suit also names four Medicare Advantage insurance plans which, Silingo alleges, “turned a blind eye” to the practices. The health plans named in the suit are: Molina Healthcare of California; WellPoint, Inc., which operates  Anthem Blue Cross and Blue Shield; Health Net of California, Inc. and Alameda Alliance for Health.  None would comment.

MedXM chief executive officer Sy Zahedi called the allegations “categorically not true.”

Critics argue that federal officials waste billions of tax dollars every year by failing to crack down on health plans that game the arcane payment system.  At least five other whistleblower cases accusing Medicare Advantage of fraudulently inflating risk scores are winding through federal courts, records show.

The four health plans “turned a blind eye to the truth” because the MedXM health assessments made them money, according to the suit. Medicare Advantage plans argue that the in-home health assessments can help members stay fit and in their homes as long as possible by spotting untreated diseases and dangerous living conditions. While the doctors and nurses don’t offer any treatment during their visit, they report their exam findings to the patient’s primary care physician.

But home visits also are controversial, largely due to their impact on Medicare costs.

The lawsuit names nearly 70 nurse practitioners and physician assistants whom she claims were not properly supervised by doctors. Some evaluations were conducted over the phone rather than in person, as required by federal regulations. In other cases, Silingo alleged, medical coders directed the health professionals to “modify” medical records “in order to increase the severity of the patients’ diagnosis.”

Some doctors and nurses were scheduling 20 to 25 of the home visits per day. The suit names three doctors whom it says scheduled at least 20 of the visits in a single day.

In December of 2012 about 750 Molina patients had “identical vital statistics for age, weight, sex height, blood pressure and heart rate” as well as similar medical findings, all done by the same doctor.

That doctor was “routinely” completing more than 22-25 assessments per day “traveling over a wide geographic area making it implausible that he actually performed the work that he claimed,” according to the suit.

Another whistleblower suit alleges Medicare Advantage fraud

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Comment:

By Don McCanne, MD

Assuming the allegations of this lawsuit prove to be true, it appears that private Medicare Advantage insurers contracted with a private company that hired health care professionals to do in-home health assessments, not for treatment purposes but merely to collect data that, combined with innovative coding, could be used to increase government payments based on inflated risk scores.

These questionable visits were not only useful for increasing profits, they also served as a marketing tool in which the plans could claim that they were providing “coordinated care” not available in the traditional Medicare program, even if these visits were not much more than a sham.

It was already known that private Medicare Advantage insurers were gaming risk scores to increase profits. The revelation in this lawsuit demonstrates one of the mechanisms apparently used to cheat the Medicare program.

Medicare Advantage plans are paid more yet take away choice by limiting care to provider networks. So why do people enroll in them? It is primarily because of the lower cost sharing of the plans that have premiums that are much lower than the Medigap plans, which also offer similar cost sharing reductions. To reduce out-of-pocket spending, Medicare Advantage plans take away choice and Medigap plans charge excessive premiums.

If the same out-of-pocket cost reductions were rolled into the traditional Medicare program then patients could receive the same level of benefits as in Medigap or Medicare Advantage, while preserving free choice of hospitals and health care professionals. Even better, if the other flaws in Medicare were also fixed then we could use it for health care coverage for everyone – an improved Medicare for all.