Health Law Concerns for Cancer Centers

By Ricardo Alonso-Zaldivar
Associated Press, March 19, 2014

Cancer patients relieved that they can get insurance coverage because of the new health care law may be disappointed to learn that some the nation’s best cancer hospitals are off-limits.

An Associated Press survey found examples coast to coast. Seattle Cancer Care Alliance is excluded by five out of eight insurers in Washington state’s insurance exchange. MD Anderson Cancer Center says it’s in less than half of the plans in the Houston area. Memorial Sloan-Kettering is included by two of nine insurers in New York City and has out-of-network agreements with two more.

In all, only four of 19 nationally recognized comprehensive cancer centers that responded to AP’s survey (members of the National Comprehensive Cancer Network) said patients have access through all the insurance companies in their state exchange.

Not too long ago, insurance companies would have been vying to offer access to renowned cancer centers, said Dan Mendelson, CEO of the market research firm Avalere Health. Now the focus is on costs.

“This is a marked deterioration of access to the premier cancer centers for people who are signing up for these plans,” Mendelson said.

Those patients may not be able get the most advanced treatment, including clinical trials of new medications.

And there’s another problem: It’s not easy for consumers shopping online in the new insurance markets to tell whether top-level institutions are included in a plan. That takes additional digging by the people applying.

To keep premiums low, insurers have designed narrow networks of hospitals and doctors. The government-subsidized private plans on the exchanges typically offer less choice than Medicare or employer plans.

By not including a top cancer center an insurer can cut costs. It may also shield itself from risk, delivering an implicit message to cancer survivors or people with a strong family history of the disease that they should look elsewhere.

For now, the issue seems to be limited to the new insurance exchanges. But it could become a concern for Americans with job-based coverage too if employers turn to narrow networks.

In a statement, Anthem said its network was based on research involving thousands of consumers and businesses. “What we learned was that people are willing to make trade-offs in order to have access to affordable health care,” the company said. “Our provider networks reflect this.”

http://hosted.ap.org/dynamic/stories/U/US_HEALTH_OVERHAUL_TOP_CANCER_CEN…

Members of the National Comprehensive Cancer Network (http://www.nccn.org/members/network.asp)

****

2015 Letter to Issuers in the Federally-facilitated Marketplaces

CMS, March 14, 2014

Section 3. Network Adequacy

Pursuant to 45 C.F.R. 156.230(a)(2), an issuer of a QHP that has a provider network must maintain a network that is sufficient in number and types of providers… to assure that all services will be accessible to enrollees without unreasonable delay. All issuers applying for QHP certification will need to attest that they meet this standard as part of the certification/recertification process.

CMS will assess provider networks using a “reasonable access” standard, and will identify networks that fail to provide access without unreasonable delay as required by 45 C.F.R. 156.230(a)(2).

If CMS determines that an issuer’s network is inadequate under the reasonable access review standard, CMS will notify the issuer of the identified problem area(s) and will consider the issuer’s response in assessing whether the issuer has met the regulatory requirement and prior to making the certification or recertification determination.

http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/20…

****

Kaiser Health Tracking Poll: February 2014

By Liz Hamel, Jamie Firth and Mollyann Brodie
KFF.org, February 26, 2014

The latest Kaiser Health Tracking Poll finds that, in general, the public leans towards more expensive plans with broader networks. About half (51 percent) say they would rather have a plan that costs more money but allows them to see a broader range of doctors and hospitals, while just under four in ten (37 percent) prefer a plan that is less expensive but allows them to visit a more limited range of providers. While older individuals and those with higher incomes exhibit a clearer preference for more expensive plans with broader networks, younger adults and those with lower incomes are more evenly divided in their preferences. But those who are either uninsured or currently purchase their own coverage – a group that is most likely to be in a position to take advantage of new coverage options under the ACA – are more likely to prefer less costly narrow network plans over more expensive plans with broader networks (54 percent versus 35 percent). Those who currently get their insurance through an employer (and are more protected from the cost of coverage) have the opposite preference: 55 percent prefer a more expensive plan with a broader network, while 34 percent would rather have a cheaper narrow network plan.

Those who prefer narrow network plans may be less likely to prefer them if it means they can’t see their usual providers. When those who prefer a less costly narrow network plan are presented with the possibility that they would not be able to visit the doctors and hospitals they normally use, the share who continue to prefer this option drops from 37 percent to 23 percent among the public overall, and from 54 percent to 35 percent among the uninsured and those who buy their own insurance.

On the other hand, when those who initially prefer a more expensive plan with a broader network are told that they could save up to 25 percent on their health care costs, the share continuing to prefer the more expensive option drops from 51 percent to 37 percent among the public overall, and from 35 percent to 22 percent among those the uninsured and those with non-group coverage.

http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-fe…

For decades we have been hearing heartrending stories of children and adults under 65 who develop cancer but were uninsured. For those of us striving for a comprehensive health care program for everyone, there could not be a greater motivating force than the desire to eliminate forever the twin tragedies of impaired access to care and personal financial ruin for these unfortunate cancer victims.

The Affordable Care Act brought us expanded access to private insurance plans with incentives for the insurers to provide plan innovations to help slow spending on health care. Although plans already were using limited networks to leverage lower prices from the providers, the degree to which they would further narrow networks was not expected, except perhaps by the cynics amongst us.

But the insurers have no shame. Cancer management is expensive. What better place to restrict access could there be than to remove most members of the National Comprehensive Cancer Network from many of their insurance networks. Only four of nineteen of these centers are included in all exchange plan networks within their respective states.

CMS tells us that they will use a “reasonable access” standard when the plans are recertified for the federal exchanges next year. This is a relative rather than an absolute standard. They have no intention of opening up insurer networks to all comers. That would defeat the insurance innovation of controlling costs by blocking access to out-of-network providers, especially the expensive ones such as the members of the National Comprehensive Cancer Network.

The latest Kaiser tracking poll is of concern since it shows that lower-income and uninsured people will select the plans with more restricted networks simply because the premiums are lower. No centers-of-excellence cancer care for them.

Although insurers are prohibited from denying coverage, just think of the advantage they would have in avoiding adverse selection by being able to tell those patients who have cancer that they really don’t want to buy the plans they offer since the nation’s noted cancer institutions are not covered. They can do the cancer victim a favor by sending her to a competitor. Then they can retreat into their headquarters to devise yet more insurance innovations that work this well.

A single payer national health program would not have networks. Patients could go anywhere. With an improved primary care infrastructure, they would receive assistance in obtaining the best care for their medical condition. For those with cancer, there would be no private insurers profiting off of discount cancer care, though the single payer system would take care to see that the services are priced right for the benefit of us taxpayers who would be financing our health care system.

Medical Home: An Evolving Model of Primary Care

By Melinda K. Abrams
Commonwealth Fund Blog, February 25, 2014

Today, the Journal of the American Medical Association (JAMA) released a study, cofunded by The Commonwealth Fund, evaluating a three-year medical home pilot in Pennsylvania. The study, led by RAND’s Mark Friedberg and colleagues, found the program was not associated with significant improvements in quality of care or cost reductions. ….

While some may be ready to hand medical homes a failing grade, the study’s findings underscore what we already knew about this team-based model of primary care: we need to continue to improve how care is delivered, how providers are paid, and how the model is implemented in different settings.

Since the Pennsylvania initiative was launched in 2008, we have learned more about how best to implement an effective patient-centered medical home. For example, it’s become clear that the payment model needs to reward cost savings as well as quality improvement. ….

In addition, evidence suggests that sites targeting patients with complex medical conditions are more likely to see an impact on outcomes and utilization than those serving patients with more routine needs. ….

But this study also raises questions about whether recognition criteria used by NCQA and other accrediting organizations need to better reflect meaningful practice transformation….

http://www.commonwealthfund.org/Blog/2014/Feb/Medical-Homes-Evolving-Primary-Care.aspx

Comment:

By Kip Sullivan, JD

The February 25 edition of JAMA published a study of “patient-centered medical homes” (PCMH) by Mark Friedberg et al. The authors reported that PCMHs had no effect on costs and almost no effect on quality (PCMHs outperformed the control clinics on only one of 11 quality measures). In fact, it appears that PCMHs raised costs when the costs associated with setting up PCMHs and rewarding PCMH doctors is taken into account. 

The PCMH may not survive much longer if research continues to show that it cannot cut costs. The loss of the “medical home” metaphor will be inconsequential, but if the termination of the PCMH experiment sets back the campaign to strengthen the primary care sector, that will be a significant loss. To avoid that outcome, PCMH proponents should cease hyping the PCMH as a cost containment device applicable to entire “populations” and instead focus on specific services for specific patients. 

Cutting costs has always been one of the primary goals of PCMH advocates. For private insurers, it is not merely a goal – it is a precondition. Unless it is ordered to do otherwise by state legislatures or Congress, the American insurance industry will not, over the long haul, subsidize clinics to provide “home” services if those services do not reduce the industry’s net costs – their subsidies to PCMHs plus their expenditures on claims. Nor will clinics certified as PCMHs provide, over the long term, the services PCMHs are expected to provide if insurers refuse to compensate them for those services. And if insurers and PCMHs refuse to pay for those services, it is extremely unlikely patients can be persuaded to pay for them.

The “medical home” label was originally coined to refer to clinics which held all the records of children with special needs. But in 2007 the concept was greatly expanded by the American Academy of Family Physicians and three other primary care specialty groups and promoted as a means to bring more resources into the entire primary care sector while simultaneously cutting costs http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf. As Robert Berenson et al. put it in a 2008 paper, “[T]he medical home can be viewed as an alternative way to recognize and support primary care activities, particularly those that are not considered to be part of evaluation and management service codes….” http://content.healthaffairs.org/content/27/5/1219.abstract As Ed Wagner and other PCMH advocates put it in a 2012 paper for the Commonwealth Fund, “Among the experts, stakeholders, and patients consulted for this report, there was broad agreement that … sustaining the PCMH model and making the case for increased primary care payments hinge on success in reducing health care costs.” http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2012/Feb/1582_Wagner_guiding_transformation_patientcentered_med_home_v2.pdf

Promoting the “medical home” as a cost-containment tool rather than simply calling for more resources for primary care may turn out to have been a mistake. It is becoming increasingly apparent that the cost-cutting prowess of the “home” was vastly exaggerated by its proponents. It should have been described only as an approach or model that might cut costs if applied to specific categories of chronically ill patients. Thanks to research like the paper by Friedberg et al., that realization seems to be dawning on PCMH advocates.  The comment on the Commonwealth Fund blog quoted above is one example. An editorial accompanying the JAMA paper, aptly entitled “One size does not fit all,” is another. Even the ever-optimistic Patient-Centered Primary Care Collaborative (which last year added Liz Fowler to its board http://www.pcpcc.org/2013/07/23/liz-fowler-jill-hummel-hal-lawrence-and-adrienne-white-faines-join-pcpcc-board-directors) said of the JAMA paper, “There was no targeting and/or analysis of chronically ill patients.” http://www.pcpcc.org/2014/02/26/pcpcc-leadership-responds-jama-article-medical-home-pilot-study

The “medical home” movement would be well advised to stop exaggerating the cost-containment powers of the PCMH and instead call for experimentation and research on specific services for specific types of chronically ill patients. Let me offer one example suggested by the Friedberg paper. The PCMH model studied by Friedberg et al. focused on diabetes care – six of the 11 quality measures measured some aspect of diabetes treatment. The one measure at which the PCMH clinics excelled turned out to be a diabetes measure (kidney exams). How did the PCMH clinics achieve this laudable outcome? We don’t know, but it is reasonable to infer that the high percentage of diabetes measures in the quality measurement set caused the clinics to “teach to the test” – to concentrate resources on diabetes patients, possibly at the expense of patients without diabetes. Did they use some or all of the diabetes disease management techniques that have been shown to improve the health of diabetics and pre-diabetics? We don’t know.  

If instead of testing the impossibly amorphous, one-size-fits-all “home” concept, the PCMH clinics had tested their ability to improve the health of diabetics with specific treatments and interventions, we might now be reading a paper with useful information about what treatments work for diabetics and whether those treatments cost more to deliver than they saved in future medical costs. Instead we are left to scratch our heads about why the latest over-hyped managed care fad with the saccharine name isn’t working.

The AAFP and other proponents of the “medical home” should never have burdened the concept with the expectation of cost containment. If they were serious about cost containment, they should have endorsed single-payer legislation. If they were serious about strengthening the primary care sector, they should have called for more money for primary care, period.

Medical Home: An Evolving Model of Primary Care

By Melinda K. Abrams
Commonwealth Fund Blog, February 25, 2014

Today, the Journal of the American Medical Association (JAMA) released a study, cofunded by The Commonwealth Fund, evaluating a three-year medical home pilot in Pennsylvania. The study, led by RAND’s Mark Friedberg and colleagues, found the program was not associated with significant improvements in quality of care or cost reductions. ….

While some may be ready to hand medical homes a failing grade, the study’s findings underscore what we already knew about this team-based model of primary care: we need to continue to improve how care is delivered, how providers are paid, and how the model is implemented in different settings.

Since the Pennsylvania initiative was launched in 2008, we have learned more about how best to implement an effective patient-centered medical home. For example, it’s become clear that the payment model needs to reward cost savings as well as quality improvement. ….

In addition, evidence suggests that sites targeting patients with complex medical conditions are more likely to see an impact on outcomes and utilization than those serving patients with more routine needs. ….

But this study also raises questions about whether recognition criteria used by NCQA and other accrediting organizations need to better reflect meaningful practice transformation….

http://www.commonwealthfund.org/Blog/2014/Feb/Medical-Homes-Evolving-Pri…

The February 25 edition of JAMA published a study of “patient-centered medical homes” (PCMH) by Mark Friedberg et al. The authors reported that PCMHs had no effect on costs and almost no effect on quality (PCMHs outperformed the control clinics on only one of 11 quality measures). In fact, it appears that PCMHs raised costs when the costs associated with setting up PCMHs and rewarding PCMH doctors is taken into account.

The PCMH may not survive much longer if research continues to show that it cannot cut costs. The loss of the “medical home” metaphor will be inconsequential, but if the termination of the PCMH experiment sets back the campaign to strengthen the primary care sector, that will be a significant loss. To avoid that outcome, PCMH proponents should cease hyping the PCMH as a cost containment device applicable to entire “populations” and instead focus on specific services for specific patients.

Cutting costs has always been one of the primary goals of PCMH advocates. For private insurers, it is not merely a goal – it is a precondition. Unless it is ordered to do otherwise by state legislatures or Congress, the American insurance industry will not, over the long haul, subsidize clinics to provide “home” services if those services do not reduce the industry’s net costs – their subsidies to PCMHs plus their expenditures on claims. Nor will clinics certified as PCMHs provide, over the long term, the services PCMHs are expected to provide if insurers refuse to compensate them for those services. And if insurers and PCMHs refuse to pay for those services, it is extremely unlikely patients can be persuaded to pay for them.

The “medical home” label was originally coined to refer to clinics which held all the records of children with special needs. But in 2007 the concept was greatly expanded by the American Academy of Family Physicians and three other primary care specialty groups and promoted as a means to bring more resources into the entire primary care sector while simultaneously cutting costshttp://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiati…. As Robert Berenson et al. put it in a 2008 paper, “[T]he medical home can be viewed as an alternative way to recognize and support primary care activities, particularly those that are not considered to be part of evaluation and management service codes….”http://content.healthaffairs.org/content/27/5/1219.abstract As Ed Wagner and other PCMH advocates put it in a 2012 paper for the Commonwealth Fund, “Among the experts, stakeholders, and patients consulted for this report, there was broad agreement that … sustaining the PCMH model and making the case for increased primary care payments hinge on success in reducing health care costs.”http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report…

Promoting the “medical home” as a cost-containment tool rather than simply calling for more resources for primary care may turn out to have been a mistake. It is becoming increasingly apparent that the cost-cutting prowess of the “home” was vastly exaggerated by its proponents. It should have been described only as an approach or model that might cut costs if applied to specific categories of chronically ill patients. Thanks to research like the paper by Friedberg et al., that realization seems to be dawning on PCMH advocates.  The comment on the Commonwealth Fund blog quoted above is one example. An editorial accompanying the JAMA paper, aptly entitled “One size does not fit all,” is another. Even the ever-optimistic Patient-Centered Primary Care Collaborative (which last year added Liz Fowler to its board http://www.pcpcc.org/2013/07/23/liz-fowler-jill-hummel-hal-lawrence-and-…) said of the JAMA paper, “There was no targeting and/or analysis of chronically ill patients.” http://www.pcpcc.org/2014/02/26/pcpcc-leadership-responds-jama-article-m…

The “medical home” movement would be well advised to stop exaggerating the cost-containment powers of the PCMH and instead call for experimentation and research on specific services for specific types of chronically ill patients. Let me offer one example suggested by the Friedberg paper. The PCMH model studied by Friedberg et al. focused on diabetes care – six of the 11 quality measures measured some aspect of diabetes treatment. The one measure at which the PCMH clinics excelled turned out to be a diabetes measure (kidney exams). How did the PCMH clinics achieve this laudable outcome? We don’t know, but it is reasonable to infer that the high percentage of diabetes measures in the quality measurement set caused the clinics to “teach to the test” – to concentrate resources on diabetes patients, possibly at the expense of patients without diabetes. Did they use some or all of the diabetes disease management techniques that have been shown to improve the health of diabetics and pre-diabetics? We don’t know.

If instead of testing the impossibly amorphous, one-size-fits-all “home” concept, the PCMH clinics had tested their ability to improve the health of diabetics with specific treatments and interventions, we might now be reading a paper with useful information about what treatments work for diabetics and whether those treatments cost more to deliver than they saved in future medical costs. Instead we are left to scratch our heads about why the latest over-hyped managed care fad with the saccharine name isn’t working.

The AAFP and other proponents of the “medical home” should never have burdened the concept with the expectation of cost containment. If they were serious about cost containment, they should have endorsed single-payer legislation. If they were serious about strengthening the primary care sector, they should have called for more money for primary care, period.

Warning: Opting Out Of Your Insurance Plan’s Provider Network Is Risky

By Michelle Andrews
Kaiser Health News, March 18, 2014

Many plans sold on the health insurance marketplaces offer a tradeoff: lower premiums in exchange for limited networks of providers. But consumers who opt for a narrow network plan with the idea that they’ll go out of network when necessary may be taking a big financial risk.

The health law generally places limits on how much consumers can be required to pay out of pocket for medical care (not including premiums). In 2014, the limit for an individual plan is $6,350 and for a family plan, $12,700. But those limits apply only to care provided by doctors and hospitals in a plan’s provider network. There may be a separate out-of-pocket maximum for services provided out of network in marketplace plans, or no cap at all.

Similarly, the health law requires that preventive care such as vaccines, cancer screenings and annual checkups be covered at no cost to consumers in most health plans. If someone uses an out-of-network provider, however, they can be charged.

Going out of network opens the door to higher costs in other ways as well. Plans may require patients to pay a higher copayment or coinsurance for an out-of-network provider. In addition, since the doctors, hospitals and other providers are not under contract with the insurance company, in many states those providers may bill patients for any charges not covered by the insurance, a practice known as “balance billing.” The contracts signed by providers who join plan networks generally contain provisions that prohibit them from balance billing enrollees.

Plans sold on the marketplace are divided into four levels based on the amount of consumer cost sharing required. On average, a bronze plan pays for 60 percent of covered medical services, a silver plan pays for 70 percent, a gold plan, 80 percent, and a platinum plan, 90 percent. But those percentages don’t take any out-of-network care into account.

A McKinsey & Co. analysis of 120 silver-level exchange plans found that 70 percent were narrow network plans, in which at least 30 percent of the area’s largest hospitals are not in the plan, or ultra narrow network plans, in which that number grows to at least 70 percent.

Narrow networks can be a particular problem in HMO-style plans that don’t cover any out-of-network care except for emergency services. According to the analysis by Breakaway Policy Strategies, roughly a third of mid-level silver plans are of this type, typically leaving consumers on the hook for the entire bill if they get care from an out-of-network provider.

The health law does provide protection for consumers when they receive emergency care from a hospital that’s not in their provider’s network. In such instances, health plans can’t charge consumers higher coinsurance or copayments.

However, patients placed on observation status or admitted to the out-of-network hospital from the emergency department are no longer shielded from higher out-of-pocket costs.

“Once the patient is stabilized, the patient will be responsible for whatever the insurer doesn’t pay for that observation or admittance,” says Jeffrey Bettinger, an emergency physician who is chairman of the reimbursement committee of the American College of Emergency Physicians.

Whichever type of plan they choose, the onus is on consumers to dig into the details and make sure they understand what they’re signing up for. There’s a tremendous amount of variability in exchange plans, even among silver level plans, says Richard Smith, executive vice president at Breakaway Policy Strategies.

“I don’t see a lot of standardization,” he says. “Consumers need to be really cognizant. There are design features of these plans that consumers need to be aware of.”

http://www.kaiserhealthnews.org/Stories/2014/March/18/Michelle-Andrews-opting-out-insurer-provider-network-risky.aspx

Comment:

By Don McCanne

Most people who have been paying any attention at all are quite aware that health plans inside and outside of the exchanges limit coverage to physicians and hospitals within their contracted networks. Although some plans may also offer limited coverage outside of the networks, it is less clear as to the extent and adequacy of that coverage. This article helps to clarify that issue by showing how muddled the coverage is.

Some of the traps include care provided outside of HMOs, care provided after an emergency patient is stabilized, free preventive services that may not be free outside of the network, services provided within network that are not benefits of the specific plan selected, and so forth. What is particularly treacherous is that, not only do you usually have to pay in full for these services, but your payments may not apply to your maximum out-of-pocket expenses, which can be unlimited out-of-network. The ACA promise that out-of-pocket expenses will be capped for the year ($6,350 for an individual and $12,700 for a family) comes from the same book of promises that gave us “you can keep your plan if you like it.” It is possible to end up with expenses over six figures. That is quite a whack for the person who was trying to do the right thing by buying a qualified insurance plan.

The precise out-of-network coverage depends on the specifications of the plan selected, and there are very few standards with which the plans must comply. So how do you select the right plan?

When people purchase their plans, they usually look first at the premium. Then they look at the deductibles and then the copayments or coinsurance. Usually, when assisted by a plan navigator or equivalent, they will also look at the tax credits for the premiums and the subsidies for cost sharing. Since many benefit from these they often select a silver plan because that is the only tier that includes cost-sharing subsidies.

The next step is to check the list of providers to see if your physician(s) or hospital(s) are on the list. This is where it becomes more tricky since those lists are often difficult to access, and they can be quite unreliable. Even physicians can be confused since they may be included on an insurer’s plan outside of the exchanges, but excluded from the exchange plans, and yet they may not be aware of the exclusion.

Finally, just try to find out the precise rules for coverage of care obtained outside of the network. Since there are very few standards, it is important to know this. The various insurers may approach such charges quite differently. You could end up with only modest additional expenses, but it is not too difficult imagining a six-figure bill when you are admitted to an out-of-network hospital. The insurer may cover the charges in the emergency room, but once the stabilized patient is admitted, she may well be on her own for all additional charges.

Think of how administratively complex the private insurers have already made our system. Then think of the administrative excesses that arise just from handling the muddled out-of-network care. The insurers are forcing upon us even more of their primary product – administrative services – while evading the very purpose of health care coverage by not paying for medical services that the patient needs.

If we had a single payer national health program with first dollar coverage (like many other nations with much lower health care costs) then this out-of-network nonsense would go away. What is really perplexing is why haven’t our people demanded this before now? Don’t facts matter?

In fairness, when we, as experts, think of how much effort we have to put in just to understand these issues, it is no wonder the the insurers and the rest of the medical-industrial complex have been so successful in bamboozling the public at large. We can use the political process to overcome this, but it would require a massive effort. After a couple of decades of working on this, I don’t see it happening. Prove me wrong.

Warning: Opting Out Of Your Insurance Plan’s Provider Network Is Risky

By Michelle Andrews
Kaiser Health News, March 18, 2014

Many plans sold on the health insurance marketplaces offer a tradeoff: lower premiums in exchange for limited networks of providers. But consumers who opt for a narrow network plan with the idea that they’ll go out of network when necessary may be taking a big financial risk.

The health law generally places limits on how much consumers can be required to pay out of pocket for medical care (not including premiums). In 2014, the limit for an individual plan is $6,350 and for a family plan, $12,700. But those limits apply only to care provided by doctors and hospitals in a plan’s provider network. There may be a separate out-of-pocket maximum for services provided out of network in marketplace plans, or no cap at all.

Similarly, the health law requires that preventive care such as vaccines, cancer screenings and annual checkups be covered at no cost to consumers in most health plans. If someone uses an out-of-network provider, however, they can be charged.

Going out of network opens the door to higher costs in other ways as well. Plans may require patients to pay a higher copayment or coinsurance for an out-of-network provider. In addition, since the doctors, hospitals and other providers are not under contract with the insurance company, in many states those providers may bill patients for any charges not covered by the insurance, a practice known as “balance billing.” The contracts signed by providers who join plan networks generally contain provisions that prohibit them from balance billing enrollees.

Plans sold on the marketplace are divided into four levels based on the amount of consumer cost sharing required. On average, a bronze plan pays for 60 percent of covered medical services, a silver plan pays for 70 percent, a gold plan, 80 percent, and a platinum plan, 90 percent. But those percentages don’t take any out-of-network care into account.

A McKinsey & Co. analysis of 120 silver-level exchange plans found that 70 percent were narrow network plans, in which at least 30 percent of the area’s largest hospitals are not in the plan, or ultra narrow network plans, in which that number grows to at least 70 percent.

Narrow networks can be a particular problem in HMO-style plans that don’t cover any out-of-network care except for emergency services. According to the analysis by Breakaway Policy Strategies, roughly a third of mid-level silver plans are of this type, typically leaving consumers on the hook for the entire bill if they get care from an out-of-network provider.

The health law does provide protection for consumers when they receive emergency care from a hospital that’s not in their provider’s network. In such instances, health plans can’t charge consumers higher coinsurance or copayments.

However, patients placed on observation status or admitted to the out-of-network hospital from the emergency department are no longer shielded from higher out-of-pocket costs.

“Once the patient is stabilized, the patient will be responsible for whatever the insurer doesn’t pay for that observation or admittance,” says Jeffrey Bettinger, an emergency physician who is chairman of the reimbursement committee of the American College of Emergency Physicians.

Whichever type of plan they choose, the onus is on consumers to dig into the details and make sure they understand what they’re signing up for. There’s a tremendous amount of variability in exchange plans, even among silver level plans, says Richard Smith, executive vice president at Breakaway Policy Strategies.

“I don’t see a lot of standardization,” he says. “Consumers need to be really cognizant. There are design features of these plans that consumers need to be aware of.”

http://www.kaiserhealthnews.org/Stories/2014/March/18/Michelle-Andrews-o…

Most people who have been paying any attention at all are quite aware that health plans inside and outside of the exchanges limit coverage to physicians and hospitals within their contracted networks. Although some plans may also offer limited coverage outside of the networks, it is less clear as to the extent and adequacy of that coverage. This article helps to clarify that issue by showing how muddled the coverage is.

Some of the traps include care provided outside of HMOs, care provided after an emergency patient is stabilized, free preventive services that may not be free outside of the network, services provided within network that are not benefits of the specific plan selected, and so forth. What is particularly treacherous is that, not only do you usually have to pay in full for these services, but your payments may not apply to your maximum out-of-pocket expenses, which can be unlimited out-of-network. The ACA promise that out-of-pocket expenses will be capped for the year ($6,350 for an individual and $12,700 for a family) comes from the same book of promises that gave us “you can keep your plan if you like it.” It is possible to end up with expenses over six figures. That is quite a whack for the person who was trying to do the right thing by buying a qualified insurance plan.

The precise out-of-network coverage depends on the specifications of the plan selected, and there are very few standards with which the plans must comply. So how do you select the right plan?

When people purchase their plans, they usually look first at the premium. Then they look at the deductibles and then the copayments or coinsurance. Usually, when assisted by a plan navigator or equivalent, they will also look at the tax credits for the premiums and the subsidies for cost sharing. Since many benefit from these they often select a silver plan because that is the only tier that includes cost-sharing subsidies.

The next step is to check the list of providers to see if your physician(s) or hospital(s) are on the list. This is where it becomes more tricky since those lists are often difficult to access, and they can be quite unreliable. Even physicians can be confused since they may be included on an insurer’s plan outside of the exchanges, but excluded from the exchange plans, and yet they may not be aware of the exclusion.

Finally, just try to find out the precise rules for coverage of care obtained outside of the network. Since there are very few standards, it is important to know this. The various insurers may approach such charges quite differently. You could end up with only modest additional expenses, but it is not too difficult imagining a six-figure bill when you are admitted to an out-of-network hospital. The insurer may cover the charges in the emergency room, but once the stabilized patient is admitted, she may well be on her own for all additional charges.

Think of how administratively complex the private insurers have already made our system. Then think of the administrative excesses that arise just from handling the muddled out-of-network care. The insurers are forcing upon us even more of their primary product – administrative services – while evading the very purpose of health care coverage by not paying for medical services that the patient needs.

If we had a single payer national health program with first dollar coverage (like many other nations with much lower health care costs) then this out-of-network nonsense would go away. What is really perplexing is why haven’t our people demanded this before now? Don’t facts matter?

In fairness, when we, as experts, think of how much effort we have to put in just to understand these issues, it is no wonder the the insurers and the rest of the medical-industrial complex have been so successful in bamboozling the public at large. We can use the political process to overcome this, but it would require a massive effort. After a couple of decades of working on this, I don’t see it happening. Prove me wrong.

Hearing: “Access and Cost: What the U.S. Health Care System Can Learn from Other Countries”

Testimony of Sally C. Pipes, President and CEO, Pacific Research Institute
U.S. Senate Committee on Health, Education, Labor and Pensions, Subcommittee on Primary Health and Aging, March 11, 2014

Those Canadians who can afford to do so have simply opted out of their healthcare system. An enormous number jump the queue for care in their native land and travel to the United States to receive medical attention. In 2012, over 42,000 Canadians crossed the border to get treated.

http://www.help.senate.gov/imo/media/doc/Pipes.pdf

****

Frasier Institute Reports:

Leaving Canada for Medical Care 2010
Estimated number of patients receiving treatment outside Canada, 2010: 44,794
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/articles/leaving-canada-for-medical-care.pdf

Leaving Canada for Medical Care 2011
Estimated number of patients receiving treatment outside Canada, 2011: 46,159
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/articles/leaving-canada-for-medical-care-2011-ff0712.pdf

Leaving Canada for Medical Care 2012
Estimated number of patients receiving treatment outside Canada, 2012: 42,173
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/articles/leaving-canada-for-medical-care-2012.pdf

Waiting Your Turn: Wait Times for Health Care in Canada 2011
Average Percentage of Patients Receiving Treatment Outside of Canada, 2011: 1.0%
(See Page 58, Table 11)
https://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/publications/waiting-your-turn-2011.pdf

Waiting Your Turn: Wait Times for Health Care in Canada 2012
Average Percentage of Patients Receiving Treatment Outside of Canada, 2012: 0.9%
(See Page 62, Table 11)
https://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/publications/waiting-your-turn-2012.pdf

Waiting Your Turn: Wait Times for Health Care in Canada 2013
Average Percentage of Patients Receiving Treatment Outside of Canada, 2013: 0.9%
(See Page 64, Table 11)
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/publications/waiting-your-turn-2013.pdf

****

Phantoms In The Snow: Canadians’ Use Of Health Care Services In The United States

By Steven J. Katz, Karen Cardiff, Marina Pascali, Morris L. Barer and Robert G. Evans
Health Affairs, May 2002

Abstract

To examine the extent to which Canadian residents seek medical care across the border, we collected data about Canadians’ use of services from ambulatory care facilities and hospitals located in Michigan, New York State, and Washington State during 1994–1998. We also collected information from several Canadian sources, including the 1996 National Population Health Survey, the provincial Ministries of Health, and the Canadian Life and Health Insurance Association. Results from these sources do not support the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home.

Phantoms in the snow.

Despite the evidence presented in our study, the Canadian border-crossing claims will probably persist. The tension between payers and providers is real, inevitable, and permanent, and claims that serve the interests of either party will continue to be independent of the evidentiary base. Debates over health policy furnish a number of examples of these “zombies”—ideas that, on logic or evidence, are intellectually dead—that can never be laid to rest because they are useful to some powerful interests. The phantom hordes of Canadian medical refugees are likely to remain among them.

http://content.healthaffairs.org/content/21/3/19.abstract

Comment:

By Don McCanne, M.D.

Each year the Fraser Institute of Canada issues a report claiming that over 40,000 patients leave Canada for medical care. Yet a highly credible study done over a decade ago revealed that many of these supposed patients were merely “phantoms in the snow” and that this is another “zombie idea” that, on logic or evidence, is “intellectually dead” but “can never be laid to rest because (the concept is) useful to some powerful interests.” So it is important to understand the source of the Fraser numbers.

Warning: The following is wonkish

As part of their annual survey of specialists to determine waiting times in Canada, the Fraser Institute asks the following question (the last question of their survey):

12. Approximately what percentage of your patients received non-emergency medical treatment in the past 12 months:

In another province? ______ % Outside of Canada? ______ %

Then, within each of twelve specialties in each of the ten provinces, they average the percent of patients who reportedly obtain care outside of Canada, as estimated by the practitioners of those specialities. If you look at Table 11 in any of the “Waiting Your Turn” reports listed above (choose 2013 as the latest example), you will see that this creates a grid of 120 percentages. Averages are obtained for each province (bottom line) and for each specialty (column on the right). These are then averaged to get the final percentage for all of Canada – 0.9% for 2013.

Stop here and think about that. Each practitioner was asked to estimate a percentage of his or her patients who left Canada for care (not specifically for care in the United States as Canada has a very large immigrant population – about one-fifth were born outside of Canada). If they had been asked for specific numbers, each may have been able to make a fairly reasonable guesstimate. But they were asked for a percentage. If there were not very many then the lowest full integer might come to mind – one percent (“Oh, it can’t be more than one percent”). In fact, 37% of the 120 sections of the grid reported zero percentages of patients leaving the country for care – probably a more realistic assessment since those specialists likely couldn’t remember any patients who left. Nevertheless, the majority estimated percentages well below one percent, i.e., there weren’t very many.

But look at Table 11 for 2013. There is quite a wide variation in the 120 results listed. For 2013 that ranged from 0.0% (the most common response) to 5.0%. The responses of 1.0% and higher were the outliers. With the outliers, it is difficult to imagine why a given specialty in a given province would have such a high number of patients leaving the country for health care. When we hear about delays in care in Canada, the most common one is orthopedics – joint replacement, etc. Yet in all of Canada, orthopedics is listed at 0.7%, below the 0.9% average for all specialties combined. It is suspicious that some physicians, intentionally or unintentionally, may be making high estimates which would skew the numbers upwards.

Let’s look at Table 11 for 2011 and 2012 as well as 2013. Urology in British Columbia was 1.3% in 2011, 2.0% in 2012, and 3.8% in 2013. Plastic surgery in British Columbia was 7.8%, 1.3%, and 0.4% in those same years. Cardiovascular survey in New Brunswick was 0.0%, 3.0%, and 0.5%. Internal Medicine in Manitoba was 3.4%, 0.5%, and 0.3%. Radiation oncology in New Brunswick was 0.5%, 7.0%, and zero. Obviously there is a large scatter in the high outliers that changes from year to year. Further, the entire population of specialists surveyed in 2013 totaled only 2,160 physicians scattered amongst 120 categories in the grid. It is quite obvious that only a few individual outliers, who either guessed high or wanted to make a political point, were able to skew the percentages upward. Eliminating the outliers likely would reduce the net percentage in half and maybe more.

For the next step, the Fraser Institute “(combined) these percentages with the number of procedures performed in each province and in each medical specialty (to give) an estimate of the number of Canadians who actually received treatment outside the country.” The results are in Table 1 of each of the three reports, “Leaving Canada for Medical Care.” If their percentages were correct (which they likely are not) and the tally of the procedures were correct (uncertain) then this calculation might give a very rough approximation of the number of procedures performed outside of Canada for each of the 120 categories of the grid. But talk about soft numbers.

They then add a “residual” number of procedures for which people are waiting. “To estimate this residual number, the number of non-emergency operations not contained in the survey that are done in each province annually must be used” – using CIHI and other data which they “pro-rated.” This “residual” for 2012 was 18,265 of the 42,173 total estimated to have exited Canada for health care. It’s a convenient number to boost the figures, even if they are “operations not contained in the survey.”

Talk about phantoms in the snow. This data is almost useless for estimating the number of Canadians who leave Canada for health care, much less whether or not they received it in the United States.

More importantly, the premise of those who use these unreliable numbers of patients exiting Canada for care is that single payer financing results in excessive queues which then triggers this exit. That should not necessarily follow since queues can be tamed if the stewards of the system are attentive to system capacity and queue management. Many nations with comprehensive systems do not have problems with queues.

In contrast, in the United States, the financial barriers to care (that do not exist in Canada) are so great that tens of millions who need care do not even gain a place in the queue – rationing based on ability to pay. Only a fool would recommend our callous system over Canada’s egalitarian single payer system.

****

For those who read this far, it might be worth your time to look at one more item. The “Waiting Your Turn” reports are the same reports that are used each year to claim that Canadians have intolerable delays in accessing their health care. For the 2013 Waiting Your Turn report, look at Chart 6 on page 10. Except for plastic surgery, orthopedics and internal medicine (not primary care), the actual median time between an appointment with a specialist and treatment is quite close to the median time that the specialists deemed to be a reasonable wait. And where there are problems, they are working on it.

More reliable data on wait times in Canada is available through the Canadian Institute for Health Information:

http://www.cihi.ca/CIHI-ext-portal/internet/EN/subtheme/health+system+performance/access+and+wait+times/cihi010647

Hearing: “Access and Cost: What the U.S. Health Care System Can Learn from Other Countries”

Testimony of Sally C. Pipes, President and CEO, Pacific Research Institute
U.S. Senate Committee on Health, Education, Labor and Pensions, Subcommittee on Primary Health and Aging, March 11, 2014

Those Canadians who can afford to do so have simply opted out of their healthcare system. An enormous number jump the queue for care in their native land and travel to the United States to receive medical attention. In 2012, over 42,000 Canadians crossed the border to get treated.

http://www.help.senate.gov/imo/media/doc/Pipes.pdf

****

Frasier Institute Reports:

Leaving Canada for Medical Care 2010
Estimated number of patients receiving treatment outside Canada, 2010: 44,794
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-…

Leaving Canada for Medical Care 2011
Estimated number of patients receiving treatment outside Canada, 2011: 46,159
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-…

Leaving Canada for Medical Care 2012
Estimated number of patients receiving treatment outside Canada, 2012: 42,173
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-…

Waiting Your Turn: Wait Times for Health Care in Canada 2011
Average Percentage of Patients Receiving Treatment Outside of Canada, 2011: 1.0%
(See Page 58, Table 11)
https://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research…

Waiting Your Turn: Wait Times for Health Care in Canada 2012
Average Percentage of Patients Receiving Treatment Outside of Canada, 2012: 0.9%
(See Page 62, Table 11)
https://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research…

Waiting Your Turn: Wait Times for Health Care in Canada 2013
Average Percentage of Patients Receiving Treatment Outside of Canada, 2013: 0.9%
(See Page 64, Table 11)
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-…

****

Phantoms In The Snow: Canadians’ Use Of Health Care Services In The United States

By Steven J. Katz, Karen Cardiff, Marina Pascali, Morris L. Barer and Robert G. Evans
Health Affairs, May 2002

Abstract

To examine the extent to which Canadian residents seek medical care across the border, we collected data about Canadians’ use of services from ambulatory care facilities and hospitals located in Michigan, New York State, and Washington State during 1994–1998. We also collected information from several Canadian sources, including the 1996 National Population Health Survey, the provincial Ministries of Health, and the Canadian Life and Health Insurance Association. Results from these sources do not support the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home.

Phantoms in the snow.

Despite the evidence presented in our study, the Canadian border-crossing claims will probably persist. The tension between payers and providers is real, inevitable, and permanent, and claims that serve the interests of either party will continue to be independent of the evidentiary base. Debates over health policy furnish a number of examples of these “zombies”—ideas that, on logic or evidence, are intellectually dead—that can never be laid to rest because they are useful to some powerful interests. The phantom hordes of Canadian medical refugees are likely to remain among them.

http://content.healthaffairs.org/content/21/3/19.abstract

Each year the Fraser Institute of Canada issues a report claiming that over 40,000 patients leave Canada for medical care. Yet a highly credible study done over a decade ago revealed that many of these supposed patients were merely “phantoms in the snow” and that this is another “zombie idea” that, on logic or evidence, is “intellectually dead” but “can never be laid to rest because (the concept is) useful to some powerful interests.” So it is important to understand the source of the Fraser numbers.

Warning: The following is wonkish

As part of their annual survey of specialists to determine waiting times in Canada, the Fraser Institute asks the following question (the last question of their survey):

12. Approximately what percentage of your patients received non-emergency medical treatment in the past 12 months:

In another province? ______ % Outside of Canada? ______ %

Then, within each of twelve specialties in each of the ten provinces, they average the percent of patients who reportedly obtain care outside of Canada, as estimated by the practitioners of those specialities. If you look at Table 11 in any of the “Waiting Your Turn” reports listed above (choose 2013 as the latest example), you will see that this creates a grid of 120 percentages. Averages are obtained for each province (bottom line) and for each specialty (column on the right). These are then averaged to get the final percentage for all of Canada – 0.9% for 2013.

Stop here and think about that. Each practitioner was asked to estimate a percentage of his or her patients who left Canada for care (not specifically for care in the United States as Canada has a very large immigrant population – about one-fifth were born outside of Canada). If they had been asked for specific numbers, each may have been able to make a fairly reasonable guesstimate. But they were asked for a percentage. If there were not very many then the lowest full integer might come to mind – one percent (“Oh, it can’t be more than one percent”). In fact, 37% of the 120 sections of the grid reported zero percentages of patients leaving the country for care – probably a more realistic assessment since those specialists likely couldn’t remember any patients who left. Nevertheless, the majority estimated percentages well below one percent, i.e., there weren’t very many.

But look at Table 11 for 2013. There is quite a wide variation in the 120 results listed. For 2013 that ranged from 0.0% (the most common response) to 5.0%. The responses of 1.0% and higher were the outliers. With the outliers, it is difficult to imagine why a given specialty in a given province would have such a high number of patients leaving the country for health care. When we hear about delays in care in Canada, the most common one is orthopedics – joint replacement, etc. Yet in all of Canada, orthopedics is listed at 0.7%, below the 0.9% average for all specialties combined. It is suspicious that some physicians, intentionally or unintentionally, may be making high estimates which would skew the numbers upwards.

Let’s look at Table 11 for 2011 and 2012 as well as 2013. Urology in British Columbia was 1.3% in 2011, 2.0% in 2012, and 3.8% in 2013. Plastic surgery in British Columbia was 7.8%, 1.3%, and 0.4% in those same years. Cardiovascular survey in New Brunswick was 0.0%, 3.0%, and 0.5%. Internal Medicine in Manitoba was 3.4%, 0.5%, and 0.3%. Radiation oncology in New Brunswick was 0.5%, 7.0%, and zero. Obviously there is a large scatter in the high outliers that changes from year to year. Further, the entire population of specialists surveyed in 2013 totaled only 2,160 physicians scattered amongst 120 categories in the grid. It is quite obvious that only a few individual outliers, who either guessed high or wanted to make a political point, were able to skew the percentages upward. Eliminating the outliers likely would reduce the net percentage in half and maybe more.

For the next step, the Fraser Institute “(combined) these percentages with the number of procedures performed in each province and in each medical specialty (to give) an estimate of the number of Canadians who actually received treatment outside the country.” The results are in Table 1 of each of the three reports, “Leaving Canada for Medical Care.” If their percentages were correct (which they likely are not) and the tally of the procedures were correct (uncertain) then this calculation might give a very rough approximation of the number of procedures performed outside of Canada for each of the 120 categories of the grid. But talk about soft numbers.

They then add a “residual” number of procedures for which people are waiting. “To estimate this residual number, the number of non-emergency operations not contained in the survey that are done in each province annually must be used” – using CIHI and other data which they “pro-rated.” This “residual” for 2012 was 18,265 of the 42,173 total estimated to have exited Canada for health care. It’s a convenient number to boost the figures, even if they are “operations not contained in the survey.”

Talk about phantoms in the snow. This data is almost useless for estimating the number of Canadians who leave Canada for health care, much less whether or not they received it in the United States.

More importantly, the premise of those who use these unreliable numbers of patients exiting Canada for care is that single payer financing results in excessive queues which then triggers this exit. That should not necessarily follow since queues can be tamed if the stewards of the system are attentive to system capacity and queue management. Many nations with comprehensive systems do not have problems with queues.

In contrast, in the United States, the financial barriers to care (that do not exist in Canada) are so great that tens of millions who need care do not even gain a place in the queue – rationing based on ability to pay. Only a fool would recommend our callous system over Canada’s egalitarian single payer system.

****

For those who read this far, it might be worth your time to look at one more item. The “Waiting Your Turn” reports are the same reports that are used each year to claim that Canadians have intolerable delays in accessing their health care. For the 2013 Waiting Your Turn report, look at Chart 6 on page 10. Except for plastic surgery, orthopedics and internal medicine (not primary care), the actual median time between an appointment with a specialist and treatment is quite close to the median time that the specialists deemed to be a reasonable wait. And where there are problems, they are working on it.

More reliable data on wait times in Canada is available through the Canadian Institute for Health Information:

http://www.cihi.ca/CIHI-ext-portal/internet/EN/subtheme/health+system+pe…

Health Care: U.S. vs. Canada

YouTube, March 12, 2014

On March 11, 2014, several authorities on single payer health care systems of other nations testified before a committee of the United States Senate, chaired by Sen. Bernie Sanders. The hearing was not only the topic of a recent Quote of the Day (March 12), it also has been covered extensively in the media and on the Internet throughout the United States and Canada.

It was the responses of Dr. Danielle Martin of Canada to the questions from Committee Ranking Member Sen. Richard Burr, that caused this story to go viral. For those who missed it, the 7 minute segment that includes the exchange between Dr. Martin and Sen. Burr can be viewed at this YouTube link: http://www.youtube.com/watch?v=iYOf6hXGx6M

You can read more about this exchange by Googling “Danielle Martin.” Some of the other coverage:

National Post: “Toronto doctor smacks down U.S. Senate question on Canadian waitlist deaths”: http://news.nationalpost.com/2014/03/12/toronto-doctor-smacks-down-u-s-senate-question-on-canadian-waitlist-deaths/
Los Angeles Times: “Watch an expert teach a smug U.S. senator about Canadian healthcare”: http://www.latimes.com/business/hiltzik/la-fi-mh-watch-a-canadian-20140312,0,2995139.story
Huffington Post: “Watch This Doctor Totally School An Anti-Obamacare Senator On Health Care”: http://www.huffingtonpost.com/2014/03/13/danielle-martin-richard-burr_n_4958164.html
Huffington Post Canada: “Canadian Doctor Gives U.S. Senator A Clinic On Public Health Care”: http://www.huffingtonpost.ca/2014/03/13/canadian-doctor-us-senator-health-care_n_4956468.html
CBC.ca (audio): “Canadian doctor schools U.S. Senator on public health care”: http://www.cbc.ca/asithappens/features/2014/03/12/canadian-doctor-schools-us-senator-on-public-health-care/
MSNBC: The Rachel Maddow Show (3/14/14, Ari Melber, guest host): http://www.msnbc.com/rachel-maddow-show
The Maddow Blog: “Martin 1, Burr 0″: http://www.msnbc.com/rachel-maddow-show/martin-1-burr-0#break
Salon: “Canadian doctor makes anti-Obamacare senator look like a buffoon”: http://www.salon.com/2014/03/13/canadian_doctor_makes_anti_obamacare_senator_look_like_a_buffoon/
Toronto Star: “Toronto doctor smacks down U.S. senators’ myths about Canadian health care”: http://www.thestar.com/life/health_wellness/2014/03/13/toronto_doctor_smacks_down_us_senators_myths_about_canadian_health_care.html
Canada.com: “Watch: Canadian doctor schools American senator on health care”: http://o.canada.com/health/danielle-martin-richard-burr-health-care-410599/
Huffington Post Canada: “Republicans Ruin Health Care By Ignoring Jesus (And Canada)”: http://www.huffingtonpost.ca/michael-bolen/canada-america-health-care-christian-nation_b_4957509.html

Well, you get the point.

For those interested in viewing the entire hearing (1 hour, 45 minutes), or wish to download witness statements: http://www.help.senate.gov/hearings/hearing/?id=8acab996-5056-a032-522e-e39ca45fcfbe