PNHP

Single-payer would fix health care

Single-payer would fix health care

By Bob Fischer
Register Guard (Eugene, Ore.), Letters, June 2, 2014

In his May 24 letter Roger Russell said the serious problems at Veterans Affairs hospitals have to do with allegations of veterans waiting weeks or months to see a doctor, malpractice, fraud and even unnecessary deaths.

Those are symptoms of serious problems related to the VA’s size and financing. It’s too small to handle the enormous need, and it doesn’t receive the resources it needs to do the job.

Russell said having a single-payer system would mean the federal government would take over and control the nation’s health care system. That’s wrong, too, with the error due to confusing health care financing with health care delivery.

Single-payer is about financing health care. It’s like Medicare. Under a single-payer system, the government pays the bills and health care delivery is left in the hands of doctors, nurses and other health care professionals, a matter between patients and their doctors. Unlike private insurance companies, the government doesn’t intrude or interfere.

Single-payer means the for-profit insurance industry is taken out of the health care equation. Private insurance companies are the reason Americans pay twice as much for health care as people of other industrialized nations, and they’re the reason we get worse health care outcomes.

If we want to fix our health care system, single-payer is the only way to do it.

Bob Fischer resides in Bandon, Ore.

http://registerguard.com/rg/opinion/31640663-78/care-health-eugene-system-payer.html.csp

Wake-up call for reform

By Arthur J. Sutherland III, M.D.
The Commercial Appeal (Memphis, Tenn.), Letters, May 31, 2014

Your May 18 article “City health plan: Changes could cost retirees, employees” shows just how broken our health care delivery system has become. Employer-based commercial health insurance is not working. This way of financing access to health care has persisted in spite of the evidence that the U.S. has the most complex, chaotic and costly health care system in the developed world. We do not cover everyone in America and most people with insurance are underinsured. Your article gave dramatic examples of gaps in coverage for both active city employees and retirees.

The sad part of this story is that America spends twice as much per capita on health care as other countries, but gets inadequate results. We are the only developed country in the world not to provide universal coverage, and the World Health Organization ranks the U.S. 37th in overall health status compared to other nations.

The 2010 Patient Protection and Affordable Care Act was just “health insurance reform.” We are already seeing that this law will not cover everyone in America or control long-term costs. In essence, it is not sustainable because it added more cost and complexity, plus reduced the patients’ choice of providers and hospitals to narrow networks controlled by the insurance industry.

What we need is a public single-payer national health insurance system — a “Medicare for all” model. We were never able to get this debate on the table during the health care reform debate because of the excessive corporate influence that rendered our government incapable of making policy on the basis of evidence and the public good.

Your story should be our early warning, and a wake-up call to restructure our health care payment and delivery system.

Dr. Arthur J. Sutherland III resides in Memphis.

http://www.commercialappeal.com/news/2014/may/31/letter-wake–call-reform/

VA: Do we awfulize, or do we fix it?

Chairman Sanders Lays Out Legislative Action Plan for Veterans

Senator Bernie Sanders, June 1, 2014

Senate Veterans’ Affairs Committee Chairman Bernie Sanders (I-Vt.) today outlined a comprehensive legislative package to address “reprehensible” behavior by VA officials and to correct underlying problems in access to medical care.

“There must be a culture of honesty and accountability within the VA and people who have lied or manipulated data must be punished. But we also have to get to the root causes of the problems that have been exposed. The simple truth is that with 2 million more veterans coming into the system in recent years there are many facilities within the VA that do not have the doctors, nurses and other personnel that they need to provide quality care in a timely way.”

Sanders said a Thursday hearing of the veterans committee will consider the Restoring Veterans’ Trust Act of 2014. The measure then could be put on a fast track for consideration by the full Senate. It would give the VA authority to immediately remove senior executives based on poor job performance while preventing wholesale political firings. It would provide veterans who can’t get timely appointments with VA doctors the option of going to community health centers, military hospitals or private doctors. It would authorize VA to lease 27 new health facilities in 18 states. It would authorize emergency funding to hire new doctors, nurses and other providers in order to address system-wide health care provider shortages and to take other steps necessary to ensure timely access to care.  To address primary care doctor shortage for the long-term, the bill would authorize the National Health Service Corps to award scholarships to medical school students and to forgive college loans for doctors and nurses who go to work at the VA.

Altogether, the bill would provide education, retirement security and other benefits for millions of veterans and their families. Virtually all of the provisions already have been approved by the Senate committee, many of them by unanimous votes, during previous legislative markup sessions.

Sanders said the need for congressional action was underscored last Wednesday when the VA’s independent Office of Inspector General found that officials had lied about wait times for appointments at the Phoenix VA and other medical facilities. A separate audit delivered to President Barack Obama on Friday disclosed attempts by VA employees at two-thirds of VA hospitals and clinics to cover up delays in providing patient care.

http://www.sanders.senate.gov/newsroom/press-releases/chairman-sanders-lays-out-legislative-action-plan-for-veterans

THE RESTORING VETERANS’ TRUST ACT OF 2014: http://www.sanders.senate.gov/download/restoringveteranstrustact2014?inline=file

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VA Scandal Gives Single-Payer Opponents Ammunition

By Brianna Ehley
The Fiscal Times, May 27, 2014

The ongoing scandal at the Veterans Affairs Department has forced the idea of government-managed health care into the spotlight, with opponents pointing to the VA’s failures as an example of what could happen if the country were to adopt government run health care or a single payer insurance policy on a larger scale.

Larry Kudlow of the Kudlow Report was quick to pounce on the VA scandal as testament to what goes wrong when you adopt socialized medicine. “This VA scandal is a reminder that government-run single-payer health care does not work.”

However, single payer advocates say what’s happening at the VA isn’t relevant to single payer at all, since the VA is completely government-run and in a single- payer system, the delivery of care would remain largely in the private sector’s hands.

Sen. Bernie Sanders, the independent Senator from Vermont and potential 2016 presidential contender, has been a leading advocate of a single-payer health care system for years. Last week, Sanders led a panel discussion on Capitol Hill over the future of single payer, since his home state of Vermont is expected to serve as a single payer guinea pig for other states.

http://www.thefiscaltimes.com/Articles/2014/05/27/VA-Scandal-Gives-Single-Payer-Opponents-Ammunition

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Comment:

By Don McCanne, MD

To no surprise, opponents of government involvement in health care have jumped on the malfeasance exposed at the Veterans Health Administration as proof that the government can’t do anything right. Many have expanded that by saying that this is proof that a single payer health care system cannot work – a non sequitur if there ever was one. This nonproductive awfulizing that is taking place (imagining horrific situations and outcomes that don’t yet exist) is a totally inappropriate response when what we need is intervention to correct the deficiencies. Fortunately Sen. Bernie Sanders understands that.

The problem provoking the current furor is the tolerance and mismanagement of excessive queues. It is well within our capabilities to reduce queues to acceptable levels. More attention should be given to queue management (the process that reduced long lines at airports after 9/11). Capacities within the system need to be adjusted. Often small expenditures directed to increasing capacity can dramatically reduce queues. Reinforcing primary care has long been recognized as a priority, yet members of Congress sit on their duffs. Perhaps this will awaken some members to the need to fulfill their responsibilities to the people.

In February, Sen. Sanders submitted a bill to Congress designed to improve the functioning of the VA health system. It was blocked by the Republican Senators. Sen. Sanders is now using the political capital created by this mismanagement in an effort to enact The Restoring Veterans’ Trust Act of 2014. It not only addresses the queues, but it also establishes other important policies designed to improve the functioning of the VA health system. Although he may be able to gain enough Republican support to pass this bill in the Senate, some Republican members of the House this weekend said that we do not have the money required to implement the proposals. Of course that is nonsense. With midterm elections around the corner, the Republicans are going to have to decide whether they want to take the blame for refusing to act on behalf of our veterans.

This really is about what we are as a country. Do we take care of our veterans, or do we move forward with efforts to defund the government so it will drown in a bathtub? We have our choice of politicians who will align themselves with one side or the other. In a democracy, it is up to the voters to decide which politicians we want representing us. So, what do we support, social solidarity or trashing of our revered government institutions?

Simpler, better

By George Dyck, M.D.
The Wichita Eagle, Letters, May 20, 2014

As we still hear about confusion surrounding the Affordable Care Act, I think about how different it is in Canada. I go there to work in the summer and see how much simpler things can be for the person who needs medical care. Residents of Canada can go to the Manitoba Health website and see the following:

“Medicare has become culturally and politically important to Canadians as a reflection of, and as a defining influence on, our national identity. Shared principles of equity, fairness and compassion are embodied in the health care system, and the services it provides are now regarded as a basic right.

“In order to receive medical attention, Canadians need only go to the physician or clinic of their choice and present the health insurance card issued to all eligible residents of a province or territory. There are no charges, deductibles or dollar limits for insured medical services (physician, hospital and surgical-dental), and there are no forms for patients to fill out.”

What is it that prevents Americans from embracing this kind of system? We hear voices saying we do not want to give up our freedoms. But what kind of freedom is this for those who cannot figure out how to get their medical care?

I do not hear people in Manitoba complaining about lost freedom. They shake their heads in disbelief about how complicated it is south of the border. And statistics show they have better health and greater longevity, as well as better overall satisfaction with their health care.

Dr. George Dyck resides in North Newton, Kan.

http://www.kansas.com/2014/05/20/3464064/letters-to-the-editor-on-rps-promoting.html#storylink=cpy

The VA scandal, and the ones beyond

By Inge De Becker, M.D.
Star Tribune (Minneapolis), May 31, 2014

True, the VA has waiting lists, real and fake. We spend fortunes to send youngsters to war, yet underfund their care when they come home. They suffer for no good reason.

That is unacceptable.

Here’s what else is unacceptable. Even with the Affordable Care Act, 30 million U.S. people will remain uninsured. No one keeps their waiting lists, but each year tens of thousands will die because they lack adequate access to medical care. Nearly half of the states refuse to expand Medicaid, effectively condemning more than 7,000 uninsured each year to preventable deaths. Medical bills remain the leading cause of bankruptcy. We don’t have enough primary care physicians, both inside and outside the VA.

Even the best programs could be better, and doctoring waiting lists must stop, but patient surveys still make the VA the highest-rated health care program in the country. Let’s face it. The VA is a public, single-payer health care program. The day the United States and Minnesota choose an adequately funded, public single-payer system, everyone will have access to timely care, and everyone will be protected from financial disaster in time of illness.

Now that is acceptable.

Dr. Inge De Becker resides in St. Paul.

http://www.startribune.com/opinion/letters/261324261.html

VA: Do we awfulize, or do we fix it?

Chairman Sanders Lays Out Legislative Action Plan for Veterans

Senator Bernie Sanders, June 1, 2014

Senate Veterans’ Affairs Committee Chairman Bernie Sanders (I-Vt.) today outlined a comprehensive legislative package to address “reprehensible” behavior by VA officials and to correct underlying problems in access to medical care.

“There must be a culture of honesty and accountability within the VA and people who have lied or manipulated data must be punished. But we also have to get to the root causes of the problems that have been exposed. The simple truth is that with 2 million more veterans coming into the system in recent years there are many facilities within the VA that do not have the doctors, nurses and other personnel that they need to provide quality care in a timely way.”

Sanders said a Thursday hearing of the veterans committee will consider the Restoring Veterans’ Trust Act of 2014. The measure then could be put on a fast track for consideration by the full Senate. It would give the VA authority to immediately remove senior executives based on poor job performance while preventing wholesale political firings. It would provide veterans who can’t get timely appointments with VA doctors the option of going to community health centers, military hospitals or private doctors. It would authorize VA to lease 27 new health facilities in 18 states. It would authorize emergency funding to hire new doctors, nurses and other providers in order to address system-wide health care provider shortages and to take other steps necessary to ensure timely access to care.  To address primary care doctor shortage for the long-term, the bill would authorize the National Health Service Corps to award scholarships to medical school students and to forgive college loans for doctors and nurses who go to work at the VA.

Altogether, the bill would provide education, retirement security and other benefits for millions of veterans and their families. Virtually all of the provisions already have been approved by the Senate committee, many of them by unanimous votes, during previous legislative markup sessions.

Sanders said the need for congressional action was underscored last Wednesday when the VA’s independent Office of Inspector General found that officials had lied about wait times for appointments at the Phoenix VA and other medical facilities. A separate audit delivered to President Barack Obama on Friday disclosed attempts by VA employees at two-thirds of VA hospitals and clinics to cover up delays in providing patient care.

http://www.sanders.senate.gov/newsroom/press-releases/chairman-sanders-l…

THE RESTORING VETERANS’ TRUST ACT OF 2014:http://www.sanders.senate.gov/download/restoringveteranstrustact2014?inl…

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VA Scandal Gives Single-Payer Opponents Ammunition

By Brianna Ehley
The Fiscal Times, May 27, 2014

The ongoing scandal at the Veterans Affairs Department has forced the idea of government-managed health care into the spotlight, with opponents pointing to the VA’s failures as an example of what could happen if the country were to adopt government run health care or a single payer insurance policy on a larger scale.

Larry Kudlow of the Kudlow Report was quick to pounce on the VA scandal as testament to what goes wrong when you adopt socialized medicine. “This VA scandal is a reminder that government-run single-payer health care does not work.”

However, single payer advocates say what’s happening at the VA isn’t relevant to single payer at all, since the VA is completely government-run and in a single- payer system, the delivery of care would remain largely in the private sector’s hands.

Sen. Bernie Sanders, the independent Senator from Vermont and potential 2016 presidential contender, has been a leading advocate of a single-payer health care system for years. Last week, Sanders led a panel discussion on Capitol Hill over the future of single payer, since his home state of Vermont is expected to serve as a single payer guinea pig for other states.

http://www.thefiscaltimes.com/Articles/2014/05/27/VA-Scandal-Gives-Singl…

To no surprise, opponents of government involvement in health care have jumped on the malfeasance exposed at the Veterans Health Administration as proof that the government can’t do anything right. Many have expanded that by saying that this is proof that a single payer health care system cannot work – a non sequitur if there ever was one. This nonproductive awfulizing that is taking place (imagining horrific situations and outcomes that don’t yet exist) is a totally inappropriate response when what we need is intervention to correct the deficiencies. Fortunately Sen. Bernie Sanders understands that.

The problem provoking the current furor is the tolerance and mismanagement of excessive queues. It is well within our capabilities to reduce queues to acceptable levels. More attention should be given to queue management (the process that reduced long lines at airports after 9/11). Capacities within the system need to be adjusted. Often small expenditures directed to increasing capacity can dramatically reduce queues. Reinforcing primary care has long been recognized as a priority, yet members of Congress sit on their duffs. Perhaps this will awaken some members to the need to fulfill their responsibilities to the people.

In February, Sen. Sanders submitted a bill to Congress designed to improve the functioning of the VA health system. It was blocked by the Republican Senators. Sen. Sanders is now using the political capital created by this mismanagement in an effort to enact The Restoring Veterans’ Trust Act of 2014. It not only addresses the queues, but it also establishes other important policies designed to improve the functioning of the VA health system. Although he may be able to gain enough Republican support to pass this bill in the Senate, some Republican members of the House this weekend said that we do not have the money required to implement the proposals. Of course that is nonsense. With midterm elections around the corner, the Republicans are going to have to decide whether they want to take the blame for refusing to act on behalf of our veterans.

This really is about what we are as a country. Do we take care of our veterans, or do we move forward with efforts to defund the government so it will drown in a bathtub? We have our choice of politicians who will align themselves with one side or the other. In a democracy, it is up to the voters to decide which politicians we want representing us. So, what do we support, social solidarity or trashing of our revered government institutions?

Health policy experts versus everyone else: Why do the experts believe themselves?

Unnecessary Tests and Procedures In the Health Care System: What Physicians Say About The Problem, the Causes, and the Solutions: Results from a National Survey of Physicians

ABIM Foundation, May 1, 2014

Nearly three-quarters (73 percent) of physicians say the frequency of unnecessary tests and procedures in the health care system is a very (29 percent) or somewhat (44 percent) serious problem. ….

The top reasons physicians say they order unnecessary tests and procedures are concern about malpractice issues (52 percent say a major reason), just to be safe (36 percent), and wanting more information for reassurance (30 percent). …

The second-tier influences are patients’ insistence (28 percent) and wanting to keep patients happy (23 percent). Third-tier reasons include other factors such as … the fee-for-service system (5 percent)…. [p 5]

http://www.choosingwisely.org/wp-content/uploads/2014/04/042814_Final-Choosing-Wisely-Survey-Report.pdf

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Phasing out fee-for-service payment

By William Frist and Steven Schroeder
New England Journal of Medicine, 2013; 368:2029-2032

The fee-for-service mechanism of paying physicians is the major driver of higher health care costs in the United States [citation omitted] ….. The long-range solution is [to] shift from a payment system based on a fee-for-service model to one based on value through mechanisms such as bundled payment, capitation, and increased financial risk sharing.

http://www.nejm.org/doi/full/10.1056/NEJMsb1302322

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Comment:

By Kip Sullivan, JD

There is an enormous gap between the opinions of the health policy elite in this country and those of the public, including physicians. The health policy elite find this gap too boring to analyze. They know why this gap exists. The problem is not them, it’s the hoi polloi and the doctors. Patients are bewitched by “technology” and think “more is better,” and doctors’ minds are warped by the incentives of the fee-for-service system. It does not occur to health policy experts that there might be something very wrong with their culture. The idea that there is even a “culture” within the health policy establishment would strike the establishment as at best uninteresting and at worst silly. That this culture might be dysfunctional is unthinkable. In their view, the only “culture” that needs analysis is that of the medical profession and of the unwashed masses.

Although the gap between public and expert opinion was documented by the early 1990s, the health policy community has shown no interest in understanding its cause. For the health policy elite, there is nothing to explain: The public is wrong and they are right. Pollster Daniel Yankelovich articulated the establishment point of view in a 1995 paper on the muddled debate about the Clintons’ Health Security Act. “The nation’s leadership and the public are carrying out a bizarre dialogue of the deaf,” Yankelovich wrote. “The nation’s elites have little trouble conversing with one another, but when it comes to engaging the public, there is an astonishing lack of dialogue.” [p. 8]

http://content.healthaffairs.org/content/14/1/7.full.pdf+html?sid=fa42b84d-5f51-458f-bde1-d42bcbd15855  

The problem, said Yankelovich, is the public does not agree with the experts’ diagnosis of the health care crisis. Virtually the entire health policy establishment thinks US expenditures are high because the volume of health care is excessive. But the public disagrees. As Yankelovich put it, “[M]ost Americans attribute the rising costs of health care to waste, fraud, greed, and inefficiency, [and] they assume that whatever is wrong can be fixed by cracking down on these expressions of venality….” [p. 14] The public, Yankelovich concluded, is “on a collision course with the majority of experts”. [p. 14] Yankelovich’s explanation for this standoff was “lack of realism” and “wishful thinking” by the masses. The elite couldn’t possibly be wrong.

The health policy cognoscenti treat the gap between physician and expert opinion with the same incuriosity and arrogance. The latest evidence of how drastically physician opinion departs from that of the establishment appeared in a poll published by the ABIM Foundation (created by the American Board of Internal Medicine) on May 1. The poll found that only 5 percent of physicians believe the fee-for-service payment method is a major cause of overuse of medical care. The three most common explanations doctors offered were variations on the same theme: Reducing uncertainty. Other polls report similar results http://www.unitedhealthgroup.com/~/media/UHG/PDF/2012/UNH-Working-Paper-8.ashx (see p. 8) http://jama.jamanetwork.com/article.aspx?articleid=1719740 (see Table 3).

The health policy elite emphatically disagrees. “The fee-for-service model is like asking a butcher how much steak you should eat,” Jonathan Gruber, a prominent advisor to the Obama administration, “explained” to NPR.

http://www.npr.org/templates/story/story.php?storyId=106859968

According to former Senator William Frist and Steven Schroeder (see article quoted above), the “fee-for-service mechanism is the major driver of higher health care costs.”

How do we explain this divergence of opinion? I propose a modest hypothesis: That the health policy community is as deeply influenced by incentives peculiar to their profession as physicians are by incentives peculiar to their profession. I propose that researchers both inside and outside the health policy community begin their analysis of my hypothesis by documenting the pattern I have outlined above – the experts’ habit of issuing pronouncements on the allegedly irresponsible behavior of doctors as the chief cause of the health care crisis – and comparing that pattern with analogous patterns in physician explanations. Investigators would then examine the evidence behind the different world views.

Let me offer an illustration.  The paper from the New England Journal of Medicine quoted above – “Phasing out fee-for-service payment” – contained one of those extremely rare instances in which proponents of the FFS-is-to-blame diagnosis tried to document their claim. The authors, Frist and Schroeder, cited one and only one paper – a paper published in 2011 by Laugeson and Glied entitled, “Higher fees paid to US physicians drive higher spending for physician services compared to other countries.” http://content.healthaffairs.org/content/30/9/1647.abstract The paper didn’t merely fail to support Frist and Schroeder’s claim, it contradicted it. It demonstrated that volume of services (in other words, overuse) could not explain why expenditures on physicians are so much higher in the US than in other countries that also rely primarily on the FFS method, and that higher physician fees in the US explained the difference. To paraphrase Gerard Anderson et al. http://content.healthaffairs.org/content/22/3/89.full.pdf+html, it’s the prices stupid, not FFS.

Researchers investigating my hypothesis might ask, What incentives are Frist and Schroeder exposed to that would incline them to make such a sloppy mistake? Do proponents of the FFS-is-to-blame mantra and managed care in general make more money, publish more often, advance faster within the ranks of politics and academia, have greater access to the media, or have more luck raising money from foundations than, say, single-payer advocates or observers who are less passionate about their criticism of doctors and patients?

I’m not proposing to exempt doctors and patients from similar scrutiny. I’m proposing that the scrutiny, at long last, become even-handed. I have little doubt even-handed scrutiny would either force the health policy illuminati to honor the rules of scientific discourse and stop promoting diagnoses and solutions with little or no evidence, or it would lower the credibility of the illuminati in the eyes of the public and the media. In either event, the decks would be cleared for a real debate about single payer. Then the most profound gap between the public (including physicians) and the experts would become more visible: By large majorities the public supports single-payer. https://www.pnhp.org/sites/default/files/docs/2011/Kip-Sullivan-Two-thirds-support-medicare-for-all.pdf

Blue Cross parent firm sued over big profits, big bonuses

By Mike Dennison
Independent Record (Helena, Mont.), May 28, 2014

The parent firm of Blue Cross and Blue Shield of Montana has been sued by a benefits-administration group that says the Chicago-based insurance giant is hoarding excess profits and unduly enriching its executives.

The lawsuit, filed last week in federal court in Chicago, said Health Care Service Corp. is breaching its contract with customers by running up excess profits of nearly $5 billion.

The Chicago Tribune first reported on the lawsuit, which said that money should have been distributed to HCSC customers as a paid dividend, reduced prescription drugs costs or lower premiums. Instead, HCSC used some of the money to pay nearly $100 million in bonuses to its top executives from 2011-2013, the suit said.

The Lee Newspapers State Bureau reported last year that HCSC Chief Executive Patricia Hemingway Hall received $16 million in compensation in 2012, including a $14.9 million bonus.

In all, the company’s top 10 executives took home $53 million in bonuses for 2012, when the company reported $1 billion in net revenue.

Figures on HCSC’s executive pay for 2013 weren’t immediately available Wednesday.

HCSC, which has 8.5 million fully insured customers, owns Blue Cross plans in Montana, Texas, Illinois, New Mexico and Oklahoma.

The company bought Blue Cross and Blue Shield of Montana last year for $40 million. In Montana, HCSC has about 250,000 customers.

John Doran, a Blue Cross spokesman in Montana, said Wednesday that HCSC is “in the process of analyzing the pending litigation and will determine (its) next steps.”

The suit was filed by Babbit Municipalities Inc., a Chicago-based benefits administration company that does business as Group Benefits Associates, working primarily with labor unions. The company asked the court to certify the lawsuit as a class-action that would include all of HCSC’s fully insured business.

The Chicago law firm representing Babbit is one of the largest consumer class-action firms in the country, according to the Tribune, and has brought dozens of consumer lawsuits against large, prominent companies.

The lawsuit said HCSC had a $10.3 billion reserve at the end of last year when it needs only $5.4 billion in reserves.

Holding such a large reserve “obliterates (the company’s) purpose as a nonprofit mutual corporation and exceeds the bounds of proper business judgment,” the lawsuit said, and makes the company effectively a for-profit firm that provides “no substantial mutual benefit to its members.”

HCSC posted net income of $684 million last year and $1 billion a year in 2010, 2011 and 2012, the Tribune reported.

http://helenair.com/news/local/blue-cross-parent-firm-sued-over-big-profits-big-bonuses/article_fa4b9036-e6a9-11e3-8a18-0019bb2963f4.html

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2013 salaries for Blue Cross executives in Montana

By IR State Bureau
Independent Record (Helena, Mont.), May 29, 2014

While Blue Cross and Blue Shield of Montana’s parent company is being sued over allegedly excessive bonuses paid to its executives, its top executives in Montana actually saw a pay cut last year.

Mike Frank, who’s now president of the Montana Division of Health Care Service Corp., received about $228,000 in compensation last year, including a $224 bonus.

In 2012, the year before Montana Blue Cross was purchased by HCSC, Frank was paid $635,000 as president and CEO of the Montana health insurer, including a $213,000 bonus.

HCSC, based in Chicago, bought Blue Cross and Blue Shield of Montana last year. A lawsuit filed last week alleges that HCSC has made excessive profits and used some of that money to pay millions of dollars in bonuses to its executives.

Last year, after HCSC bought Montana Blue Cross, its highest-paid executive in Montana was Mark Burzynski, the vice president for provider services. He received $334,700 in compensation, including a $190,000 bonus. That amount is $14,000 less than he was paid the previous year by Blue Cross.

Other top HCSC Montana executives’ salaries last year were:

  • Frank Cote, vice president of Montana sales, $184,000 – about $37,000 less than he received in 2012.
  • Monica Berner, vice president and chief medical officer, $164,000, or $47,000 less than in 2012.
  • James Spencer, chief actuary, $159,300 – about $121,000 less than in 2012.

http://helenair.com/news/local/salaries-for-blue-cross-executives-in-montana/article_2ac38e18-e6f4-11e3-ba31-0019bb2963f4.html

Health policy experts versus everyone else: Why do the experts believe themselves?

Unnecessary Tests and Procedures In the Health Care System: What Physicians Say About The Problem, the Causes, and the Solutions: Results from a National Survey of Physicians

ABIM Foundation, May 1, 2014

Nearly three-quarters (73 percent) of physicians say the frequency of unnecessary tests and procedures in the health care system is a very (29 percent) or somewhat (44 percent) serious problem. ….

The top reasons physicians say they order unnecessary tests and procedures are concern about malpractice issues (52 percent say a major reason), just to be safe (36 percent), and wanting more information for reassurance (30 percent). …

The second-tier influences are patients’ insistence (28 percent) and wanting to keep patients happy (23 percent). Third-tier reasons include other factors such as … the fee-for-service system (5 percent)…. [p 5]

http://www.choosingwisely.org/wp-content/uploads/2014/04/042814_Final-Ch…

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Phasing out fee-for-service payment

By William Frist and Steven Schroeder
New England Journal of Medicine, 2013; 368:2029-2032

The fee-for-service mechanism of paying physicians is the major driver of higher health care costs in the United States [citation omitted] ….. The long-range solution is [to] shift from a payment system based on a fee-for-service model to one based on value through mechanisms such as bundled payment, capitation, and increased financial risk sharing.

http://www.nejm.org/doi/full/10.1056/NEJMsb1302322

There is an enormous gap between the opinions of the health policy elite in this country and those of the public, including physicians. The health policy elite find this gap too boring to analyze. They know why this gap exists. The problem is not them, it’s the hoi polloi and the doctors. Patients are bewitched by “technology” and think “more is better,” and doctors’ minds are warped by the incentives of the fee-for-service system. It does not occur to health policy experts that there might be something very wrong with their culture. The idea that there is even a “culture” within the health policy establishment would strike the establishment as at best uninteresting and at worst silly. That this culture might be dysfunctional is unthinkable. In their view, the only “culture” that needs analysis is that of the medical profession and of the unwashed masses.

Although the gap between public and expert opinion was documented by the early 1990s, the health policy community has shown no interest in understanding its cause. For the health policy elite, there is nothing to explain: The public is wrong and they are right. Pollster Daniel Yankelovich articulated the establishment point of view in a 1995 paper on the muddled debate about the Clintons’ Health Security Act. “The nation’s leadership and the public are carrying out a bizarre dialogue of the deaf,” Yankelovich wrote. “The nation’s elites have little trouble conversing with one another, but when it comes to engaging the public, there is an astonishing lack of dialogue.” [p. 8]

http://content.healthaffairs.org/content/14/1/7.full.pdf+html?sid=fa42b8…

The problem, said Yankelovich, is the public does not agree with the experts’ diagnosis of the health care crisis. Virtually the entire health policy establishment thinks US expenditures are high because the volume of health care is excessive. But the public disagrees. As Yankelovich put it, “[M]ost Americans attribute the rising costs of health care to waste, fraud, greed, and inefficiency, [and] they assume that whatever is wrong can be fixed by cracking down on these expressions of venality….” [p. 14] The public, Yankelovich concluded, is “on a collision course with the majority of experts”. [p. 14] Yankelovich’s explanation for this standoff was “lack of realism” and “wishful thinking” by the masses. The elite couldn’t possibly be wrong.

The health policy cognoscenti treat the gap between physician and expert opinion with the same incuriosity and arrogance. The latest evidence of how drastically physician opinion departs from that of the establishment appeared in a poll published by the ABIM Foundation (created by the American Board of Internal Medicine) on May 1. The poll found that only 5 percent of physicians believe the fee-for-service payment method is a major cause of overuse of medical care. The three most common explanations doctors offered were variations on the same theme: Reducing uncertainty. Other polls report similar resultshttp://www.unitedhealthgroup.com/~/media/UHG/PDF/2012/UNH-Working-Paper-…(see p. 8) http://jama.jamanetwork.com/article.aspx?articleid=1719740 (see Table 3).

The health policy elite emphatically disagrees. “The fee-for-service model is like asking a butcher how much steak you should eat,” Jonathan Gruber, a prominent advisor to the Obama administration, “explained” to NPR.

http://www.npr.org/templates/story/story.php?storyId=106859968

According to former Senator William Frist and Steven Schroeder (see article quoted above), the “fee-for-service mechanism is the major driver of higher health care costs.”

How do we explain this divergence of opinion? I propose a modest hypothesis: That the health policy community is as deeply influenced by incentives peculiar to their profession as physicians are by incentives peculiar to their profession. I propose that researchers both inside and outside the health policy community begin their analysis of my hypothesis by documenting the pattern I have outlined above – the experts’ habit of issuing pronouncements on the allegedly irresponsible behavior of doctors as the chief cause of the health care crisis – and comparing that pattern with analogous patterns in physician explanations. Investigators would then examine the evidence behind the different world views.

Let me offer an illustration.  The paper from the New England Journal of Medicine quoted above – “Phasing out fee-for-service payment” – contained one of those extremely rare instances in which proponents of the FFS-is-to-blame diagnosis tried to document their claim. The authors, Frist and Schroeder, cited one and only one paper – a paper published in 2011 by Laugeson and Glied entitled, “Higher fees paid to US physicians drive higher spending for physician services compared to other countries.”http://content.healthaffairs.org/content/30/9/1647.abstract The paper didn’t merely fail to support Frist and Schroeder’s claim, it contradicted it. It demonstrated that volume of services (in other words, overuse) could not explain why expenditures on physicians are so much higher in the US than in other countries that also rely primarily on the FFS method, and that higher physician fees in the US explained the difference. To paraphrase Gerard Anderson et al. http://content.healthaffairs.org/content/22/3/89.full.pdf+html, it’s the prices stupid, not FFS.

Researchers investigating my hypothesis might ask, What incentives are Frist and Schroeder exposed to that would incline them to make such a sloppy mistake? Do proponents of the FFS-is-to-blame mantra and managed care in general make more money, publish more often, advance faster within the ranks of politics and academia, have greater access to the media, or have more luck raising money from foundations than, say, single-payer advocates or observers who are less passionate about their criticism of doctors and patients?

I’m not proposing to exempt doctors and patients from similar scrutiny. I’m proposing that the scrutiny, at long last, become even-handed. I have little doubt even-handed scrutiny would either force the health policy illuminati to honor the rules of scientific discourse and stop promoting diagnoses and solutions with little or no evidence, or it would lower the credibility of the illuminati in the eyes of the public and the media. In either event, the decks would be cleared for a real debate about single payer. Then the most profound gap between the public (including physicians) and the experts would become more visible: By large majorities the public supports single-payer.https://pnhp.org/system/assets/drupal/docs/2011/Kip-Sullivan-Two-third…

It’s time for single-payer, universal health care

By Pat Barcas
Fox Valley Labor News, May 15, 2014

CHICAGO — Discussion about single payer, universal health care has been ongoing for the last 100 years. Now, Dr. Andrew Coates says the fight is about to come to an impasse — this country needs universal health care to move forward.

“This is something that every first world, civilized country has,” said Coates at a special Chicago conference entitled “Beyond Obamacare” May 8.

Dr. Coates is president of Physicians for a National Health Program. He is chief of hospital medicine at Samaritan Hospital in Troy, N.Y., and an assistant professor of medicine and psychiatry at Albany Medical College. He previously served on the statewide executive board of the Public Employees Federation, AFL-CIO, and founded Single Payer New York, a statewide grassroots coalition of single-payer organizations and activists.

He criticized the Affordable Care Act, saying it will leave 30 million uninsured once fully implemented. It’s also wasteful, costing $368 million just to set up the New York state marketplace.

Under the current system, Coates said, 60 percent of those filing for bankruptcy due to health care bills have health insurance. Deductibles eat up savings. Households have to pick which bills to pay, or permanently forgo necessary surgeries.

There are fewer people going to the emergency room now, said Coates, but admissions into the hospital are on the rise.

“There are fewer ER visits because it’s so expensive, but people are becoming much sicker,” he said.

Coates said there are no legitimate downsides to single-payer: It’’s cheaper in the long run, it levels racial and wealth disparities, it makes for a healthier populace, and there’s a reliable model right next door in Canada.

“Imagine the liberation of working people. It’s very profound,” he said. “We’re up against the whole establishment. They don’t want it. This is a basic economic right.”

He called on unions to lead the charge in changing public opinion, and turn the political tide toward voting for single-payer.

“Unions have the expertise — how to organize, how to lead the fight,” he said.

A major argument against the single-payer system in Canada, Coates said, is that there can be a waiting list for non life-threatening surgery, such as knee surgery.

“In Canada, sure, you may wait weeks to get elective surgery, but it’s free at the point of service. Here in America, the wait time is infinity if you can’t afford it,” he said. “Imagine if you don’t have to worry about paying for you or your child’s care — we have the expectation that we’re free, but we aren’t until we all have health care. We just don’t have the political will.”

The event was co-sponsored by Physicians for a National Health Program and the Illinois Single Payer Coalition.

It’s time for single-payer, universal health care

Is the Urban Institute asking the right question on ending the employer mandate?

Why Not Just Eliminate the Employer Mandate?

By Linda J. Blumberg, John Holahan, and Matthew Buettgens
Urban Institute, May 2014

Controversy over the Affordable Care Act’s employer mandate continues. The requirement’s implications for coverage are small, and yet the negative labor market effects of keeping it in place could harm some low-wage workers.

Under the law, employers of 50 or more workers are subject to a penalty if at least one of their full-time workers obtains a Marketplace subsidy. Employees offered coverage deemed affordable and adequate are prohibited from obtaining subsidies, as are their family members, and employers can avoid penalties by offering coverage to at least 95 percent of workers. However, the Administration has delayed the requirements until 2016 for employers of 50-99, for larger employers until 2015, and softened requirements for that first year. Yet there are anecdotal reports of employers changing labor practices even though penalties have yet to be implemented.

Our analyses as well as that of others find that eliminating the employer mandate will not reduce insurance coverage significantly, contrary to its supporters’ expectations. Eliminating it will remove labor market distortions that have troubled employer groups and which would harm some workers. However, new revenue sources will be required to replace that anticipated to be raised by the employer mandate.

Conclusion

In summary, eliminating the employer mandate would eliminate labor market distortions in the law, lessen opposition to the law from employers, and have little effect on coverage. Alternative sources of revenue would have to be found to compensate for the federal loss of penalties. Both the elimination of the mandate and creating a new source of revenue to replace it will require legislation. Current legislation before Congress proposes to move the employer requirement from employers of 50 or more workers to employers of 100 or more. While this approach would help those firms between 50 and 99 employees and decrease the exposure to adverse incentives within that group, it shifts the threshold where labor market effects could take place to a different point and does not address the concerns of large, low-wage firms. The individual mandate, together with the Medicaid expansion and income related subsidies, is, as we have shown elsewhere,14 critical to expanding coverage under the ACA; the employer mandate is not.

http://www.urban.org/UploadedPDF/413117-Why-Not-Just-Eliminate-the-Employer-Mandate.pdf

****

Study Questions Need For Employer Health Care Requirement

By John Ydstie
NPR, May 28, 2014

A study called “Why Not Just Eliminate the Employer Mandate?” has been published by the Urban Institute, a center-left think tank based in Washington, D.C. It lists a number of reasons why dropping the mandate might be a good idea.

Linda Blumberg, one of the authors, says first of all, requiring firms to offer health insurance could be a bad deal for lots of low-wage workers.

“A lower-income worker is going to do better, most likely — financially — by getting subsidized coverage through one of the health insurance marketplaces instead of through their employer,” she says.

That’s because many of those workers make so little that they qualify for free coverage under Medicaid. Even workers making as much as 2 1/2 times poverty-level wages would get subsidies in the Obamacare exchanges, and that could make it a better deal than the coverage provided by their company.

Employer-sponsored plans do make sense for lots of workers because they allow those workers to buy their insurance with tax-free dollars. But for low-income workers who may not pay any income tax, there’s little benefit.

The Urban Institute study also concludes that the employer mandate won’t be very helpful in increasing insurance coverage. It finds that only about 200,000 more people will be covered under the mandate.

So, with these kinds of negatives, what’s the incentive for hanging on to the employer mandate?

Jon Gruber is an economist at the Massachusetts Institute of Technology who helped design the Massachusetts health care exchange under then-Gov. Mitt Romney. Gruber, who also consulted with the Obama administration on the Affordable Care Act, says that the most important incentive is money.

“The right way to think about the employer mandate is really as a revenue-raising tool,” Gruber says. “It does raise a lot of money.”

Gruber says the mandate has its pluses and minuses, but he says there’s about an even chance it won’t ever take effect.

“The strongest argument probably for getting rid of this is political, which is that while this is really not a very fundamental piece of the law, it’s catching a huge share of the flak around the law,” he says.

The Obama administration continues to stand behind the employer mandate, arguing that it will help get health insurance to more people and save taxpayers money.

http://www.npr.org/2014/05/28/316692125/study-questions-need-for-employer-health-care-requiremen

****

Comment:

By Don McCanne, MD

The Affordable Care Act is a highly inefficient, expensive, and administratively complex method of expanding health care coverage. One of the complexities is the mandate for employers to provide health insurance for their employees. The Urban Institute asks if the employer mandate should be eliminated, but is this the right question?

Once it was decided to use a multi-payer model of a multitude of private health plans and public programs to expand health care coverage, it was recognized that the funds provided by employers for their health benefit programs were an important revenue source in funding our national health expenditures. To ensure that those funds would still be there, the mandate for employer participation was included in the legislation.

This analysis by experts at the Urban Institute reveals that eliminating the employer mandate would result in only a modest increase in the numbers of uninsured – maybe 200,000 – though other estimates are higher. Of course, those individuals who would not be covered may not agree that this would be only a “modest” impact of this policy change.

The primary benefit would be to end the opposition of the business community. Some businesses would encourage their employees to obtain their coverage though government-subsidized exchange plans or the government-financed Medicaid program.

The Obama administration is opposed to this change since it would reintroduce the problem they were trying to avoid – finding new sources of government revenue to pay for the increases in enrollment in these tax-supported programs. But Jonathan Gruber suggests that the politics behind this unpopular provision may force the change.

So should we be asking if eliminating the employer mandate is a wise decision? It would be only one tweak in a highly complex system which supporters agree requires a great multitude of tweaks. The problem with incremental repair of this system is that the basic structure will still remain highly inefficient and will continue to waste tremendous resources, while falling short on on the goals of universality, equity, and affordability.

No, the correct question is, should we replace our highly dysfunctional health care financing system with an efficient, equitable, truly universal, affordable single payer national health program? Presumably only uncaring ideologues would answer in the negative.

Is the Urban Institute asking the right question on ending the employer mandate?

Why Not Just Eliminate the Employer Mandate?

By Linda J. Blumberg, John Holahan, and Matthew Buettgens
Urban Institute, May 2014

Controversy over the Affordable Care Act’s employer mandate continues. The requirement’s implications for coverage are small, and yet the negative labor market effects of keeping it in place could harm some low-wage workers.

Under the law, employers of 50 or more workers are subject to a penalty if at least one of their full-time workers obtains a Marketplace subsidy. Employees offered coverage deemed affordable and adequate are prohibited from obtaining subsidies, as are their family members, and employers can avoid penalties by offering coverage to at least 95 percent of workers. However, the Administration has delayed the requirements until 2016 for employers of 50-99, for larger employers until 2015, and softened requirements for that first year. Yet there are anecdotal reports of employers changing labor practices even though penalties have yet to be implemented.

Our analyses as well as that of others find that eliminating the employer mandate will not reduce insurance coverage significantly, contrary to its supporters’ expectations. Eliminating it will remove labor market distortions that have troubled employer groups and which would harm some workers. However, new revenue sources will be required to replace that anticipated to be raised by the employer mandate.

Conclusion

In summary, eliminating the employer mandate would eliminate labor market distortions in the law, lessen opposition to the law from employers, and have little effect on coverage. Alternative sources of revenue would have to be found to compensate for the federal loss of penalties. Both the elimination of the mandate and creating a new source of revenue to replace it will require legislation. Current legislation before Congress proposes to move the employer requirement from employers of 50 or more workers to employers of 100 or more. While this approach would help those firms between 50 and 99 employees and decrease the exposure to adverse incentives within that group, it shifts the threshold where labor market effects could take place to a different point and does not address the concerns of large, low-wage firms. The individual mandate, together with the Medicaid expansion and income related subsidies, is, as we have shown elsewhere,14 critical to expanding coverage under the ACA; the employer mandate is not.

http://www.urban.org/UploadedPDF/413117-Why-Not-Just-Eliminate-the-Emplo…

****

Study Questions Need For Employer Health Care Requirement

By John Ydstie
NPR, May 28, 2014

A study called “Why Not Just Eliminate the Employer Mandate?” has been published by the Urban Institute, a center-left think tank based in Washington, D.C. It lists a number of reasons why dropping the mandate might be a good idea.

Linda Blumberg, one of the authors, says first of all, requiring firms to offer health insurance could be a bad deal for lots of low-wage workers.

“A lower-income worker is going to do better, most likely — financially — by getting subsidized coverage through one of the health insurance marketplaces instead of through their employer,” she says.

That’s because many of those workers make so little that they qualify for free coverage under Medicaid. Even workers making as much as 2 1/2 times poverty-level wages would get subsidies in the Obamacare exchanges, and that could make it a better deal than the coverage provided by their company.

Employer-sponsored plans do make sense for lots of workers because they allow those workers to buy their insurance with tax-free dollars. But for low-income workers who may not pay any income tax, there’s little benefit.

The Urban Institute study also concludes that the employer mandate won’t be very helpful in increasing insurance coverage. It finds that only about 200,000 more people will be covered under the mandate.

So, with these kinds of negatives, what’s the incentive for hanging on to the employer mandate?

Jon Gruber is an economist at the Massachusetts Institute of Technology who helped design the Massachusetts health care exchange under then-Gov. Mitt Romney. Gruber, who also consulted with the Obama administration on the Affordable Care Act, says that the most important incentive is money.

“The right way to think about the employer mandate is really as a revenue-raising tool,” Gruber says. “It does raise a lot of money.”

Gruber says the mandate has its pluses and minuses, but he says there’s about an even chance it won’t ever take effect.

“The strongest argument probably for getting rid of this is political, which is that while this is really not a very fundamental piece of the law, it’s catching a huge share of the flak around the law,” he says.

The Obama administration continues to stand behind the employer mandate, arguing that it will help get health insurance to more people and save taxpayers money.

http://www.npr.org/2014/05/28/316692125/study-questions-need-for-employe…

The Affordable Care Act is a highly inefficient, expensive, and administratively complex method of expanding health care coverage. One of the complexities is the mandate for employers to provide health insurance for their employees. The Urban Institute asks if the employer mandate should be eliminated, but is this the right question?

Once it was decided to use a multi-payer model of a multitude of private health plans and public programs to expand health care coverage, it was recognized that the funds provided by employers for their health benefit programs were an important revenue source in funding our national health expenditures. To ensure that those funds would still be there, the mandate for employer participation was included in the legislation.

This analysis by experts at the Urban Institute reveals that eliminating the employer mandate would result in only a modest increase in the numbers of uninsured – maybe 200,000 – though other estimates are higher. Of course, those individuals who would not be covered may not agree that this would be only a “modest” impact of this policy change.

The primary benefit would be to end the opposition of the business community. Some businesses would encourage their employees to obtain their coverage though government-subsidized exchange plans or the government-financed Medicaid program.

The Obama administration is opposed to this change since it would reintroduce the problem they were trying to avoid – finding new sources of government revenue to pay for the increases in enrollment in these tax-supported programs. But Jonathan Gruber suggests that the politics behind this unpopular provision may force the change.

So should we be asking if eliminating the employer mandate is a wise decision? It would be only one tweak in a highly complex system which supporters agree requires a great multitude of tweaks. The problem with incremental repair of this system is that the basic structure will still remain highly inefficient and will continue to waste tremendous resources, while falling short on on the goals of universality, equity, and affordability.

No, the correct question is, should we replace our highly dysfunctional health care financing system with an efficient, equitable, truly universal, affordable single payer national health program? Presumably only uncaring ideologues would answer in the negative.