PNHP

10 Questions: Steven Nissen, M.D.

10 Questions: Steven Nissen, M.D.

By Todd Neal, Senior Staff Writer
MedPage Today, Dec. 5, 2013

What’s the biggest barrier to practicing medicine today? That’s just the first of 10 questions the MedPage Today staff is asking leading clinicians and researchers to get their personal views on their chosen profession. In this series we share their uncensored responses. Here, answers from Steven Nissen, MD, of the Cleveland Clinic.

There, Nissen is chair of the Robert and Suzanne Tomsich Department of Cardiovascular Medicine. A past president of the American College of Cardiology and former chair of the FDA’s Cardiovascular Renal Drugs Advisory Committee, he has had a leading role in highlighting potential risks associated with certain drugs, including rofecoxib (Vioxx) and rosiglitazone (Avandia). In 2007, Nissen was included on Time Magazine‘s list of “100 men and women whose power, talent, or moral example is transforming the world.”

1. What’s the biggest barrier to your practicing medicine today?

The lack of a single-payer system. We waste enormous amounts of time and energy dealing with insurance companies, whose major goal is figuring out how not to cover patients.

2. What is your most vivid memory involving a patient who could not afford to pay for healthcare (or meds or tests, etc.) and how did you respond?

There are too many to count. I remember a patient who could not afford clopidogrel (Plavix), so he split his pills to stretch the prescription, but subsequently had a catastrophic in-stent thrombosis leading to cardiogenic shock and eventually heart transplantation.

3. What do you most often wish you could say to patients, but don’t?

If you continue to smoke, I would prefer that you see another physician.

4. If you could change or eliminate something about the healthcare system, what would it be?

Fee-for-service medicine. It drives overutilization and leads to poor outcomes.

5. What is the most important piece of advice for med students or doctors just starting out today?

Consider a career in academic medicine. It provides greater diversity and satisfaction than limiting your career to clinical practice.

6. What is your “elevator” pitch to persuade someone to pursue a career in medicine?

I have never regretted my decision. The relationship to patients as well as science makes medicine a unique career choice.

7. What is the most rewarding aspect of being a doctor?

The appreciation we receive from patients and their families. It’s always very special.

8. What is the most memorable research published since you became a physician and why?

I actually think the CAST Trial was most memorable. It continues to resonate. Drugs that suppressed arrhythmias increased the rate of death. It began the ongoing movement away from surrogate endpoints.

9. Do you have a favorite hospital-based TV show?

I don’t watch TV (except the NewsHour on PBS). Television lowers your IQ substantially. There’s a dose-response curve. The more you watch, the more stupid you become.

10. What is your advice to other physicians on how to avoid burnout?

If you can, do what you really enjoy. Then work becomes a pleasure.

Todd Neal is senior staff writer at MedPage Today. http://www.medpagetoday.com/PracticeManagement/PracticeManagement/43257?isalert=1&uun=g441580d398R5538349u&utm_source=breaking-news&utm_medium=email&utm_campaign=breaking-news&xid=NL_breakingnews_2013-12-05

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Wall Street’s view of narrow networks

HSC’s 18th Annual Wall Street Comes to Washington Conference

Center for Studying Health System Change, November 21, 2013 From the conference transcript: Paul Ginsburg (President, Center for Studying Health System Change): Let me move on to network innovations. And one thing that came up a little bit in our first session was narrow- or limited-network products. And let me start by asking about how are plans building limited networks? I mean, in a sense, what are they looking for as far as which providers would they like to have? How sophisticated are they in assessing the value of different providers? Carl McDonald (Director and Senior Analyst, Citi Investment Services): I can go quick: Price. I’m done. Paul Ginsburg: Okay. Actually, how sophisticated is the price? Carl McDonald: Sorry? “How sophisticated…” Paul Ginsburg: How sophisticated is the price? Is it price per episode? Is it simply, you know, unit prices? Carl McDonald: Yes, I mean, generally it’s going to be the unit price, or price per episode. Matthew Borsch (Vice President, Goldman Sachs): Let me just offer one thing that’s happening. This is not quite to the tiered-network strategy, or narrow-network strategy, per se, but it’s topical right now in that you’ve seen some of the health plans in Medicare Advantage taking some pretty strong steps to narrow their networks. On the physician side, it’s been the most notable. In fact, there was a, there’s been some communication about that. There was a letter that was posted yesterday from the health insurance industry to CMS, stressing how important it was for the plans to be able to make these network exclusions. But obviously, for doctors who’ve been, you know, contracted in Medicare Advantage to suddenly be, to be terminated, where, in most cases, they continue to participate on the commercial side, has created some real blowback. Paul Ginsburg: I had noticed that, and was wondering, it sounded to me that this was different way that a plan pursues a more limited network. Matthew Borsch: It is. Paul Ginsburg: It seems as though, and I saw The Wall Street Journal article a week or two ago about United, and it almost seemed as though they were trying to get their star quality scores up by culling out the physicians who contribute to low scores. And is that what it’s about, Matt? Matthew Borsch: Well, the truth is we don’t really know. Paul Ginsburg: Yeah. Matthew Borsch: You know, that, that is, from our perspective, somewhat of a black box, in terms of the decision making there. There are multiple criteria. There’s how each physician group feeds into the star quality scores. There are utilization, efficiency metrics that they can run on a broad, you know, larger companies can run on a broad set of claims data. There’s also, frankly, the consideration of which Medicare Advantage members are assigned to those physician groups. And again, I’m not pointing to any one of these three as a factor but there you could possibly have some effort to change the risk distribution of the underlying membership. Sheryl Skolnick (Managing Director & Co-Head of Research, CRT Capital Group): So, just to put this in context, Medicare Advantage rates are coming down very significantly next year. They’re actually going down next year from United’s perspective, what? about 3 1/2 percent or so. And when your rates go down, some of your plans, and some of your providers in those plans will have to be terminated, because you need to essentially shrink to a profitable size, or a sustainable size. So that’s part of what you’re seeing, is instead of the proactive “We’re introducing a new benefit plan, we’re going to build a narrow network,” now you’re seeing the reactive effect of United’s always been a very inclusive and broad based network. They’ve had some issues of adverse publicity in St. Louis and some other places when they’ve tried to narrow the network based on quality. There is a lot less push back on that sort of thing now. But they’re getting some push back on this one because in Connecticut alone, for example, it’s 2,000 providers. That’s a lot in Connecticut. It’s not that big a state. So, what you’re seeing is, first, the unwinding. Second, I agree with you completely, I think it is absolutely a strategy to get their star scores up, because they’re a major embarrassment. And they’re clearly, from their last conference calls, a focus of the company strategy for Medicare Advantage for the next couple of years, is to get the star scores up. But I also, I agree with Matt, that there are many other factors at work, most notably that they need to get all of these markets that they’ve expanded rather broadly to get rid of the marginal plan, to get rid of the marginal provider and, in some cases, the high cost member. Robert Berenson (Institute Fellow, The Urban Institute): But I think it’s important to point to a major difference between the Medicare managed care situation and commercial, which is that in Medicare, out of network services are paid at Medicare rates, so that changes the whole leverage situation. And it’s the reason, I think, that hospitals basically are in network at Medicare rates, or near to Medicare rates, because they don’t have the leverage. Balance billing is a whole different situation. I’m actually surprised that MA plans weren’t more aggressive in the past, because they have the protection for the out of network care. And others, there won’t be such push back from the beneficiaries hit with the complete balance bill, if their physician is not in network, or something like that. Paul Ginsburg: So, getting into the employer based, the commercial space, you know, it looks like there’s been substantial growth in small group plans to have narrow networks. And, of course, so many of the products of the exchanges are narrow networks. And, any comments about that strategy, how it’s going, is there going to be, is there going to be push back by the public? Sheryl Skolnick: For a long time the hospitals were telling us that while Wall Street was busy talking about the narrowing of networks, they weren’t actually seeing it. It was only when the exchange contracts came up that, even in the beginning, there was some concern that some of the contracts that were being signed weren’t narrow-network contracts, in the very beginning of the contracting. Towards the end of the contracting for reform these are commercial, by the way, these are fundamentally commercial contracts. So, by the end of the contracting, though, almost all of the contracts being signed were for some sort of a narrowed network. So, I think there was a very quick evolution in the thought process of the plans in negotiating these things, where they very quickly realized: This is one of the very few levers we have, we better pull it. Paul Ginsburg: Yes. And, to what extent, as they form these networks, to what extent are the savings going to come from keeping high cost providers out, or getting discounts from providers? Sheryl Skolnick: Yes. Yes. Paul Ginsburg: Which is the dominant piece, or are they both very important. Sheryl Skolnick: Very important. Paul Ginsburg: Okay. That’s the answer. http://www.hschange.org/CONTENT/1396/?id_conf=32

Comment:

By Don McCanne, M.D. If insurers were marketing products designed primarily to get their clients the health care that they need, you would think that they would do their best to make sure that they cover essentially all of the physicians that their clients would select. But they don’t, and they are narrowing even further their lists of contracted providers. Why? Wall Street understands. It ’s not about quality or access. It’s about the money.

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More health care regulations mean more middlemen, fewer doctors

By Stephen B. Kemble, M.D.
Honolulu Star-Advertiser, Nov. 27, 2013 I attended the recent Hawaii 2013 Healthcare Summit, on how Hawaii is implementing the Affordable Care Act and transforming health care. The keynote address by Dr. Abraham Verghese was inspiring — all about the sanctity of the doctor-patient relationship and how health care should be focused on the living patient, not the “iPatient” in the computer.
 
In panel discussions, Hawaii’s health plans and hospitals told us how they will guide us away from fee-for-service payment that rewards volume of services to value-based payment systems that reward quality and care coordination. The goals are the “triple aims” of improved quality, improved population health, and improved value/reduced cost. However, dig deeper and the conference was full of contradictions and confusion.
 
Information presented included:
 
* Hawaii has a low rate of medical procedures compared to the rest of the country.
 
* We have the lowest per capita fee-for-service Medicare expenditures in the country.
 
* Thanks to relatively broad coverage under our Prepaid Health Care Act, Hawaii covers more of our population than any state besides Massachusetts — our benefits are already at the “gold” and “platinum” levels for Obamacare plans, better than any other state — yet we have the third lowest insurance premiums in the country, and all of this under a fee-for-service system.
 
* Hawaii has 20 percent fewer physicians than needed for our population and this is projected to get worse. Shortages are especially severe on the neighbor islands.
 
* Two-thirds of Hawaii psychiatrists no longer accept new Medicaid patients, many dropping out in the past four years, and our ER and hospital costs for mental illness have risen 30 percent in that time.
 
Hospitals and health plans were well represented on panels, but no practicing doctors. Doctors were shaking their heads as panelists told us that solo and small-group medical practices will soon become extinct, replaced by competing “accountable care organizations.” Every health plan and hospital now has multiple “partners” deploying computerized systems to enable them to better manage health care. Doctors are going to be rewarded for meeting quality metrics and punished with financial penalties if they fail to purchase computer systems that achieve “meaningful use,” or if they fail to meet quality metrics.
 
You would think from these presentations that the problem is doctors who don’t care about quality and just want to do more procedures and see more patients to make more money. The health insurance plans and hospitals are going to make sure doctors get paid for “quality,” not “volume.” However, there is no evidence for the alleged problem with excessive “volume” of services here, and if you look at the actual “quality” metrics, they are either very narrow, focusing on those limited aspects of health care that can be easily measured, or they are seriously flawed and don’t actually measure “quality.”
 
The managers and middlemen in health care are proliferating while our supply of doctors is dwindling. The evidence shows that doctors in Hawaii are not actually delivering much unnecessary care, but there are not enough of them and the ones we have are overworked and overburdened with administrative requirements. We are apparently pursuing Dr. Verghese’s “iPatients” at the expense of real patients.
 
Doctors agree that time spent on charting and administration is increasing, so they must work longer hours, spend less time with each patient, or see fewer patients. They are restricting their practices to fewer insurance plans to control administrative burdens, leaving more patients with inadequate access to care. Many are talking about early retirement or dropping participation with health insurance entirely, converting to “concierge” practices for those who can afford it. All of this is taking us in the opposite direction from the “triple aim” goals.
 
Most of our problems are problems with inadequate access to care, especially for those with Medicaid, not fee-for-service incentives or lack of concern for quality.
 
Hawaii’s experience with our Prepaid Health Care Act shows that broader coverage and improved access to care actually reduce health care costs. Let’s take this further and expand coverage to everyone, build our health care provider work force, simplify and streamline administration, pay doctors the same for everyone, and eliminate barriers to access care. Single payer, anyone?
 
Stephen B. Kemble, M.D., is a psychiatrist, an assistant professor at the John A. Burns School of Medicine and immediate past president of the Hawaii Medical Association.
 
http://www.staradvertiser.com/s?action=login&f=y&id=233570491

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Pritzker students explore single-payer health care at PNHP national conference

By Pamela Peters, MS1
Pritzker News, University of Chicago Pritzker School of Medicine, December 4, 2013 With the recent enactment of key portions of the Affordable Care Act, health care reform has increasingly become a hot-button issue. Six students from Pritzker explored the option of single-payer health care reform by attending the annual meeting for the advocacy group Physicians for a National Program (PNHP) on November 2, 2013 in Boston. PNHP is a non-profit research and education organization of 19,000 physicians, medical students, and health professionals based in Chicago with chapters in almost every state. The turnout at the meeting set a new record for the organization, with 404 registrants from 38 states. “The conference was a great opportunity to discuss the economic and medical realities of health care going forward under the ACA, as well as the role of physicians in pushing for change in how medical care is financed,” commented Brandon Berger, MS1. “To me, single payer is a solution to the prohibitive cost of health care, an opportunity to provide medical care in a way that doesn’t discriminate based on ability to pay, and a public health initiative of enormous potential impact.” At the meeting, Pritzker students had the opportunity to listen to presentations from a variety of speakers, such as Vermont Governor Peter Shumlin, who outlined progress and barriers in creating a single-payer health care system for his state. Dr. Marcia Angell, former editor of the New England Journal of Medicine, gave a talk entitled, “Patients and Profits,” and PNHP co-founders Dr. David Himmelstein and Dr. Steffie Woolhander updated attendees with the most recent statistics about the status of health care in America. Pritzker students also had the opportunity to attend many student-specific workshop sessions, where medical students from around the country shared inspiring stories of activism and counseled newcomers on how to become more involved in the single-payer movement. Pritzker’s very own Scott Goldberg, MS2, who is a student delegate on the PNHP national board of directors, led a session entitled “Heroism vs. Evil in Medicine: Transitioning from Sympathizer to Activist.” Scott also founded the University of Chicago student chapter of PNHP, and spent time working with PNHP California this past summer to advocate for movement towards a state-based, single-payer health care system there. “I have seen the medical student movement for single-payer grow significantly in just one year since the last PNHP annual meeting, commented Scott. “The 140 students in attendance were organized, inspired, and committed to fighting for truly universal health insurance. The Affordable Care Act has a few strengths, but it does not fundamentally reform our costly, inefficient, unjust health care system. It still treats health care as a commodity to be traded not a public good. While single-payer reform may seem inevitable to some, it will only occur through the tireless efforts of medical students, physicians, and health professionals. I was honored to lead a workshop that could offer students some tools and insights into making that leap from advocate to activist.” The conference included an additional day of Leadership Training for those who were new to single payer or wanted to learn how to better discuss it with others. The Leadership Training was held on November 1 and began with instruction on how to present the concept of single payer health care in a Grand Rounds format. Three Pritzker students (Brandon Berger, MS1; Rachel Stones, MS1; Pamela Peters, MS1) were able to attend this workshop through generous scholarships from either the Nicholas Skala Student Activist Scholarship fund or the Illinois Single Payer Coalition.

“It was refreshing to be around so many doctors and students who are passionate and actively working towards a more equitable health care system,” said Rachel. “I became much more informed about single-payer and I will definitely be continuing the learning process. I was also inspired by the things that medical students are doing and the activism they are involved with around the country.”

Whether new to activism or a health policy and advocacy veteran, all who attended the conference benefited greatly from the thought-provoking presentations and the equally stimulating dialogues that followed them. http://pritzker.uchicago.edu/about/news/PNHP-Conf.shtml

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Nobody Should Get Rich Off Obamacare

By Evan Soltas
Bloomberg, The Ticker, Dec. 3, 2013

For an industry that’s supposed to be burdened by the launch of Obamacare, the health-care business is doing pretty well. Stocks of health-care companies are up almost 40 percent this year, the strongest performance of any sector in the S&P 500.

This is despite, for insurers, new regulations on the “medical loss ratio” which require them to spend at least 80 percent of premiums on health care — in practice, capping their profits and administrative expenses such as advertising at 20 percent. How about the medical-technology manufacturers that were slapped with an excise tax? Doing just fine. The hospital chains that face lower reimbursement rates from Medicare patients? They’re doing well, too.

Health care is a business, and businesses are supposed to make money. Still, it’s a bit concerning that health-care investors are so upbeat just as President Barack Obama’s health-reform law goes into effect.

It makes you wonder where the new profits are expected to come from. If they’re earned in a competitive market, great — but health care in the U.S. hasn’t been a free market in decades, so it’s worth turning a skeptical eye.

The law will give the insurance industry millions of new customers and subsidizes its products. It brings millions of others into the market for health-care services through its Medicaid expansion. If health-care investors are throwing a party, it might be because the rest of us are paying for it.

Economists call profits in excess of what would be earned in a competitive market “rents.” Often it’s hard to tell the difference — but the expected increase in health-care profits has a whiff of rent about it. After all, Obama passed his law with the support of the health-care industry. The insurers signed on. Pharma signed on. Doctors signed on. It would be shocking if this law reduced their rents.

Regulation is the usual remedy. Public utilities commissions, for example, determine the “fair profit” of electric utilities and prevent them from squeezing customers. In health care, this hasn’t been the Obama administration’s approach. A headline on a recent piece by Adam Davidson put it best: “The President Wants You To Get Rich On Obamacare.” It said that Tom Scully, a private-equity executive who has been pitching health-care investments, leaves investors expecting a gold mine:

No matter what investors thought about Obamacare politically — and surely many there did not think much of it — the law was going to make some people very rich. … With the right understanding of the industry, private-sector markets and bureaucratic rules, savvy investors could help underwrite innovative companies specifically designed to profit from the law. Billions could flow from Washington to Wall Street, indeed.

The health-care reform gives health-care suppliers one of the benefits enjoyed by utilities: safe profits. But the quid pro quo — that those profits should be moderate — seems to be missing. That’s the assessment of investors, anyway. For now, at least, they aren’t looking at Aetna the way they look at Con Ed.

Evan Soltas is a contributor to the Ticker.

http://www.bloomberg.com/news/2013-12-03/nobody-should-get-rich-off-obamacare.html?alcmpid=view

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Who wins under Obamacare?

Nobody Should Get Rich Off Obamacare

By Evan Soltas
Bloomberg View, December 3, 2013 For an industry that’s supposed to be burdened by the launch of Obamacare, the health-care business is doing pretty well. Stocks of health-care companies are up almost 40 percent this year, the strongest performance of any sector in the S&P 500. How about the medical-technology manufacturers that were slapped with an excise tax? Doing just fine. The hospital chains that face lower reimbursement rates from Medicare patients? They’re doing well, too. Health care is a business, and businesses are supposed to make money. Still, it’s a bit concerning that health-care investors are so upbeat just as President Barack Obama’s health-reform law goes into effect. The law will give the insurance industry millions of new customers and subsidizes its products. It brings millions of others into the market for health-care services through its Medicaid expansion. If health-care investors are throwing a party, it might be because the rest of us are paying for it. http://www.bloomberg.com/news/2013-12-03/nobody-should-get-rich-off-obamacare.html?alcmpid=view

Comment:

By Don McCanne, M.D. To pass the Affordable Care Act, President Obama was convinced that he had to gain the support of the health financing and health care industries. He did. Look who’s profiting. Who loses? Those who will have to pay much more out of pocket for health care because of higher deductibles. Those who lose choice of their physicians and hospitals because of narrower provider networks, and end up losing catastrophic protection because of care inadvertently received out of network. Those who will be contributing through taxes or insurance premiums far more than they should have to because of the profoundly wasteful administrative excesses of our dysfunctional financing system. That’s most of us. The improvements in insurance plans for the few – guaranteed issue and community rating – do not begin to offset the deterioration that is beginning to take place in the employer-sponsored plans where most of us receive our health care coverage. There are a few of us who will gain, some by being enrolled in Medicaid and some by receiving subsidies for exchange plans, but the numbers of us who will lose is far greater than the numbers who will win. We could have had reform in which we would all be winners – an improved Medicare that covers everyone. Even those who will gain through Medicaid or subsidies would gain much more under a single payer system. But no, political feasibility dictated that the vested stakeholders of the medical-industrial complex be the ones who get the money, while the rest of us pay more and get less.

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Medicare for all is the solution

By Andrew Rock
Tampa Bay Times, Letters, Nov. 3, 2013

Re “New dispute arises: policy cancellations” (Oct. 30)

All the recent hoopla about the Affordable Care Act has generated a lot of heat but not much light. In all the angry finger-pointing, both parties have missed the main point. Obamacare is flawed and cumbersome for the same reason that our existing “system” doesn’t work: It is a health insurance system, not a health care system. The obvious answer is a single-payer health care system, Medicare for all

The administration is running into problems with technology and with cancellation of existing policies precisely because Obamacare is an insurance-based program. So we have to navigate insurance exchange websites, that must then connect up with insurance company databases, that must then correlate with existing insurance coverage, and so on. It’s bound to be inefficient and confusing, and also costly.

Insurance companies take at least 20 cents out of every dollar Americans spend on health care; Medicare takes only 2 or 3 cents on the dollar. Health insurance companies are massively profitable, yet most Americans either can’t afford health insurance or are very dissatisfied with the coverage they have, which is not only expensive but often not there for us when we need it most.

Those Americans fortunate enough to be on Medicare are very happy with it. Most of us, including President Barack Obama, knew that a single-payer Medicare for all system was by far the best way to reform American health care. But it didn’t happen because it wasn’t “politically doable.” Most of our congressmen and state legislators are more responsive to the corporate interests who pay for their election campaigns than the people they claim to represent. This is true of both Republicans and Democrats. So single payer was never on the table because the health insurance lobby is simply too powerful.

If Obamacare ever gets off the ground, it will be helpful to many low-income Americans who will be able to afford health insurance. But it is a huge windfall for the health insurance industry, just as the Bush administration’s prescription drug benefit was a huge windfall for the pharmaceutical industry.

Andrew Rock lives in Tampa.

http://www.tampabay.com/opinion/letters/vote-for-november-letter-of-the-month/2155085

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Bone Marrow as a commodity

Why It’s OK to Pay Bone-Marrow Donors

By Sally Satel
Bloomberg View, December 1, 2013 Locating a marrow donor is often a needle-in-a-haystack affair. The odds that two random individuals will have the same tissue type are less than 1 in 10,000, and the chances are much lower for blacks. Allowing compensation for donations could enlarge the pool of potential donors and increase the likelihood that compatible donors will follow through. So the ruling by a three-judge panel of the U.S. Court of Appeals for the Ninth Circuit was promising news for the 12,000 people with cancer and blood diseases currently looking for a marrow donor. Shaka Mitchell, a lawyer in Nashville, Tennessee, and co-founder of the nonprofit MoreMarrowDonors.org… invited a team of economists to evaluate the effects of the ruling on people’s willingness to join a registry and to donate when they are found to be a match. The researchers were to specifically assess whether cash payments would be any more or less persuasive than noncash rewards or charitable donations. Now comes the bad news. On Oct. 2, the U.S. Department of Health and Human Services proposed a new rule that would overturn the Ninth Circuit’s decision. The government proposes designating a specific form of bone marrow — circulating bone-marrow stem cells derived from blood — as a kind of donation that, under the 1984 National Organ Transplant Act, cannot be compensated. The strongest opposition to compensation comes from the National Marrow Donor Program, the Minneapolis-based nonprofit that maintains the nation’s largest donor registry. Michael Boo, the program’s chief strategy officer, says of reimbursement, “Is that what we want people to be motivated by?” HHS is presumably under pressure from the National Marrow Donor Program. The department does not otherwise explain its proposed rule except to claim that compensation runs afoul of the transplant act’s “intent to ban commodification of human stem cells” and to “curb opportunities for coercion and exploitation, encourage altruistic donation and decrease the likelihood of disease transmission.” Each year, 2,000 to 3,000 Americans in need of marrow transplants die waiting for a match. Altruism is a virtue, but clearly it is not a dependable motive for marrow donation. (Sally Satel, is a psychiatrist and a resident scholar at the American Enterprise Institute.) http://www.bloomberg.com/news/2013-12-01/why-it-s-ok-to-pay-bone-marrow-donors.html

Comment:

By Don McCanne, M.D. Imagine trading bone marrow in the commodities market. It could be very lucrative. In no time at all, the prices could be driven over what we are now paying for the newer cancer drugs – $100,000 and more – maybe much more. And don’t stop at bone marrow. Think of the trade that could be generated in other human organs. Is there no end to the commodification of health care? How did we end up here? Is the compulsion to look for market solutions so great that we abandon all sense of humanity? People who think like this – do they have a soul?

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The real fix for Obamacare's flaws: Medicare for all

There’s no reason to rollback the progress the ACA has made. But we should go all the way and dump the for-profit system

By RoseAnn DeMoro
The Guardian (U.K.), Nov. 27, 2013

Lost amidst the well-chronicled travails of the Affordable Care Act rollout are the long term effects of people struggling to get the health coverage they need without going bankrupt.

If that sounds familiar, it’s because that’s been the main story line of the US healthcare system for several decades. Sadly, little has changed.

Still, with all the ACA’s highly publicized snafus, and less discussed systemic flaws, there’s no reason to welcome the cynical efforts to repeal or defund the law by politicians whose only alternative is more of the same callous, existing market-based healthcare system.

US nurses oppose the rollback and appreciate that several million Americans who are now uninsured may finally get coverage, principally through the expansion of Medicaid, or access to private insurance they’ve been denied because of their prior health status.

At the same time, nurses will never stop campaigning for a fundamental transformation to a more humane single-payer, expanded Medicare for all system not based on ability to pay and obeisance to the policy confines of insurance claims adjustors.

Website delays – the most unwelcome news for computer acolytes since the tech boom crashed – are not the biggest problem with the ACA, as will become increasingly apparent long after the signup headaches are a distant memory.

What prompted the ACA was a rapidly escalating healthcare nightmare, seen in 50 million uninsured, medical bills plunging millions into un-payable debt or bankruptcy, long delays in access to care, and record numbers skipping needed treatment due to cost.

The main culprit was our profit-focused system, with rising profiteering by a massive health care industry, and an increasing number of employers dropping coverage or just dumping more costs onto workers.

The ACA tackles some of the most egregious inequities: lack of access for many of the working poor who will now be eligible for Medicaid or subsidies to offset some of their costs for buying private insurance through the exchanges, a crackdown on several especially notorious insurance abuses, and encouragement of preventive care.

But the law actually further entrenches the insurance-based system through the requirement that uncovered individuals buy private insurance. It’s also chock full of loopholes.

Some consumers who have made it through the website labyrinth have found confusing choices among plans which vary widely in both premium and out of pocket costs even with the subsidies, a pass through of public funds to the private insurers.

The minimum benefits are also somewhat illusory. Insurance companies have decades of experience at gaming the system and warehouses full of experts to design ways to limit coverage options.

The ACA allows insurers to cherry pick healthier enrollees by the way benefit packages are designed, and as a Washington Post article noted on 21 November, consumers are discovering insurers are restricting their choice of doctors and excluding many top ranked hospitals from their approved “network”.

The wide disparity between the healthcare you need, what your policy will cover, and what the insurer will actually pay for remains.

Far less reported is what registered nurses increasingly see – financial incentives within the ACA for hospitals to prematurely push patients out of hospitals to cheaper, less regulated settings or back to their homes. It also encourages shifting more care delivery from nurses and doctors to robots and other technology that undermines individual patient care, and that may work no better than the dysfunctional ACA websites.

Is there an alternative? Most other developed nations have discovered it, a single-payer or national healthcare system.

Without the imperative of prioritizing profits over care, Medicare for all streamlines the administrative waste and complex insurance billing operations endemic to private insurance. That waste is a major reason why the US has more than double the per capita cost of healthcare of other developed nations, yet lower life expectancies than many.

Medicare for all eliminates the multi-tiered health plans that plague both the individual and group insurance markets that are tied to the girth of your wallet not your need for care. Class, gender, and racial disparities in access and quality of care vanish under Medicare for all.

It’s beyond time that we stop vilifying government and perpetuating a corporatized healthcare system that has abandoned so many. We can, with a system of Medicare for all, we can cut healthcare costs and promote a much more humane society.

http://www.theguardian.com/commentisfree/2013/nov/27/obamacare-flaws-medicare-for-all

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Grading a Physician's Value — The Misapplication of Performance Measurement

Grading a Physician’s Value — The Misapplication of Performance Measurement

By Robert A. Berenson, M.D., and Deborah R. Kaye, M.D.
The New England Journal of Medicine, November 28, 2013 Perhaps the only health policy issue on which Republicans and Democrats agree is the need to move from volume-based to value-based payment for health care providers. Rather than paying for activity, the aspirational goal is to pay for outcomes that take into account quality and costs. In keeping with this notion of paying for value rather than volume, the Affordable Care Act (ACA) created the “value-based payment modifier,” or “value modifier,” a pay-for-performance approach for physicians who actively participate in Medicare. By 2017, physicians will be rewarded or penalized on the basis of the relative calculated value of the care they provide to Medicare beneficiaries. Although we agree that value-based payment is appropriate as a concept, the practical reality is that the Centers for Medicare and Medicaid Services (CMS), despite heroic efforts, cannot accurately measure any physician’s overall value, now or in the foreseeable future. The value modifier is meant to provide differential payment to a physician or physician group under the Medicare Physician Fee Schedule on the basis of the quality of care furnished as compared with the cost. To reduce the burden on physicians, CMS has based the value modifier on the Physician Quality Reporting System (PQRS). The meager rate of physician participation in the PQRS suggests that something is fundamentally wrong — physicians simply do not respect the measures, and for good reason. PQRS measures reflect a vanishingly small part of professional activities in most clinical specialties. A handful of such measures can provide a highly misleading snapshot of any physician’s quality. Research shows that performance on specific aspects of care does not predict performance on other components of care. Primary care physicians manage 400 different conditions in a year, and 70 conditions account for 80% of their patient load. Yet a primary care physician currently reports on as few as three PQRS measures. The challenge of accurately assigning costs to an individual physician is similarly daunting. Current methods for case-mix adjustment do not adequately capture variations in patients’ illness severity, complicating coexisting conditions, or relevant socioeconomic differences — differences beyond the physician’s control that affect the cost of care. And we currently don’t know how to attribute to an individual physician the costs that Medicare beneficiaries generate across the health care system. Even if we had better measures, behavioral economists would still challenge the pay-for-performance concept, at least for professionals such as physicians and teachers, who must manage complex situations and creatively solve problems. These critics argue that rewarding professionals on the basis of a particular performance measure has the potential to crowd out the intrinsic motivation to perform well across the board, not just on the few activities being measured. http://www.nejm.org/doi/full/10.1056/NEJMp1312287?query=TOC

Comment:

By Don McCanne, M.D. The “value-based payment modifier” – an adjustment in payments to reward physicians for improving value in the health care they provide, or to punish them for providing lower value – is yet another example of the often misguided measures in the Affordable Care Act allegedly designed to improve our health care system, when, in fact, the fundamental reforms in the health care financing system that we really needed were barely touched upon, in deference to the private insurance industry. It will be difficult to change from a volume-based system (fees based on volume of services provided) to a value-based payment system when we still do not know how to define the value of physician services, as Drs. Berenson and Kaye explain to us in this NEJM article, though they do suggest some other modest measures that might have some benefit. It is fine to continue research on measures that have a potential for improving value in health care, but it is almost criminal to ignore a concept that has already been proven in other nations to dramatically increase value – potentially a far greater increase than all of the other measures combined that are included in the Affordable Care Act. Of course, that concept is single payer financing. Let’s first enact an improved Medicare for all, and then we could tweak the system with measures that might provide incremental improvements in value. But first things first.

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Major physician organizations concerned about impaired access through exchange plans

Doctors: New Health Care Plans Raise Red Flags

By Louise Radnofsky
The Wall Street Journal, November 26, 2013 Physicians groups told Obama administration officials Tuesday that they are worried that new insurance plans under the Affordable Care Act offer only limited networks of providers and low reimbursement rates for doctors, and that could make it difficult for millions of those enrolled to actually get health care. As the Journal has reported, some health plans don’t include big brand-name health providers in their networks and are slashing how much they’ll pay medical practices for treating the newly covered. Representatives from the major physician lobbying groups raised these issues Tuesday in a White House meeting with health officials including Chris Jennings and Jeanne Lambrew of the White House, and Chiquita Brooks-LaSure of the Centers for Medicare & Medicaid Services. “Some of the things were not a surprise to them… they’re acutely aware,” Shawn Martin, a top lobbyist for the American Academy of Family Physicians, said after the noon meeting. The American Medical Association, the American Academy of Family Physicians, American Academy of Pediatrics, and American College of Physicians, the American Osteopathic Association, the American Medical Group Association and the American Association of Nurse Practitioners were among the groups present, participants said. http://blogs.wsj.com/washwire/2013/11/26/doctors-new-health-care-plans-raise-red-flags/

Comment:

By Don McCanne, M.D. The new health plans to be offered in the exchanges are avoiding excessive premium increases by using narrow networks of physicians and by lowering payment rates for health services. The leaders of our nation’s leading organizations of health care professionals are concerned enough about what this might do to patient access that they met with Obama administration officials at the White House. The administration officials were already “acutely aware” of these problems. Of course, they were. They result from fundamental design flaws in the financing model of the Affordable Care Act. The model was designed by and for the private insurance industry. It is likely that members of these professional organizations are not only concerned about the patients, narrow networks and lower payments have a direct effect on their livelihoods. In a well designed system, patients must always come first, but the professionals taking care of the patients should be content as well. Grumpy doctors and nurses detract from an optimal patient care environment. There will be more discontentment as the Obamacare model of high-deductibles, narrow networks, and payment restrictions extend to employer-sponsored private plans. These trends will no doubt expand with the proliferation of private insurance exchanges catering to employers – exchanges outside of the government-operated Obamacare exchanges. Even the private Medicare Advantage plans are being modified in response to their overpayments being pared back. UnitedHealth, the nation’s largest private insurer, has notified thousands of physicians that they are being dropped from their Medicare Advantage network. Do we really want to keep headed in this direction? The traditional Medicare program does not use narrow networks. Patients have their choice of their health care professionals. Medicare payment rates are higher than the rates expected to be offered by most of the exchange plans. It would not take much to improve Medicare, and then it would be an ideal program for covering everyone. You can bet that the representatives of these professional groups didn’t ask for single payer to be put on the table. Too bad.

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Obama put faith in house of cards

By Eric Naumburg, M.D.
The Baltimore Sun, Letters, Nov. 26, 2013

President Obama is reaping what he sowed by relying on the health insurers when he supported the Affordable Care Act. The health insurers literally wrote the law, in the person of Liz Fowler, a former VP at WellPoint, and clearly they know Obamacare better than the President, whose ill-fated promise about keeping your health insurance if you are happy with it blew up in his face.

But the reality is the American people never wanted their favorite health insurance plan what they want is affordable, accessible healthcare. In fact a majority of Americans want a government funded healthcare system similar to traditional Medicare.

The complexity of the Affordable Care Act undoubtedly contributed to its difficult launch; but the real weakness of the law is that once you have health insurance you are still not protected from bankruptcy due to illness or guaranteed access to the doctor and hospital of your choice.

We need a humane healthcare system, not a profit-driven one. In a rich country like America, healthcare should be a public good, not a privilege. If we expanded traditional Medicare to everyone, there would be no need to figure out if you can afford a bronze, silver, gold or platinum plan; instead there’d be one standard of care for everyone.

Dr. Eric Naumburg is co-chair of the Maryland chapter of Physicians for a National Health Program.

http://www.baltimoresun.com/news/opinion/readersrespond/bs-ed-health-insurance-20131126,0,4649646.story

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