UNISON responds to appointment of Simon Stevens as NHS chief executive

UNISON, October 24, 2013 Responding to the announcement that the president of Global Health and group executive vice-president at UnitedHealth, Simon Stevens, will take on the role of chief executive of NHS England in April next year, UNISON Head of Health Christina McAnea said: “The NHS is facing its first serious crisis for the best part of the decade, and it is critical that Simon Stevens respects and shares the values of our NHS – universal healthcare that is free at the point of need. “It is surprising that no one within the NHS has been found to take on this position. We sincerely hope this is not a sign that the government wants to import America-type values into the NHS and look at ways of developing healthcare through an insurance model. If this is the intention there will be massive opposition. “Mr Stevens will have his work cut out for him right from the start. Far from being protected from government cuts, the NHS is being starved of the funds it needs. Thousands of jobs are under threat and accident and emergency departments are creaking under the pressure of cuts, privatisation and upheaval.” (UNISON is a UK trade union of public employees) http://www.unison.org.uk/news/unison-responds-to-appointment-of-simon-stevens-as-nhs-chief-executive

Simon Stevens, new head of NHS England, is in for a rude awakening

Under Labour, Stevens began the culture of competition in health. He will now find out just how perverse this has become

By Polly Toynbee
The Guardian, October 24, 2013
As he sowed, so shall he reap. Simon Stevens will get his just deserts as he takes up the reins of NHS England, only to find this horse has no bridle or bit, galloping out of anyone’s control. That was, of course, precisely the explosive “creative destruction” Andrew Lansley intended. Stevens returns from the biggest US health company to an NHS whose current path he designed as Tony Blair’s adviser. Now he must piece together some coherence from the fragments of what Sarah Wollaston, MP and GP, called “a grenade” tossed into the NHS. As Lansley outlined his scheme in 2010, Stevens wrote a paean of praise in the Financial Times. It reads as a touchingly optimistic vision, where choice and competition in a perfect market deliver everything a patient or GP could desire. When he sees what he’s inherited, he may get a rude awakening. But he shares the blame, claiming authorship: “What makes the coalition’s proposals so radical is not that they tear up (our) earlier plan,” but “move decisively towards fulfilling it – in a way that Mr Blair was blocked from doing by internal opposition”. He lists the plan’s glories: in “the new model NHS, patients are rightly being promised that ‘no decision will be made about me, without me'”. No sign yet of that. He praises “the severing of day-to-day political control of the NHS”, but now he’ll find his own control severed. How will he marry his vouchers for pregnant women with wildly unpopular maternity closures? His hope that “patient power will become real, GP commissioners will fire on all cylinders and hospitals will be liberated to innovate” is a world away from today’s NHS. But his greatest regret may be his praise for “the decision to extend competition law across the health sector and treat the NHS as a regulated utility, with an economic regulator – Monitor”. Faith in competition fills his writings – but reality is biting back. Monitor, engine of NHS competition, has only just understood its destructive force: its chief executive, David Bennett, recently recoiled, saying Monitor would be “mad” to enforce the Lansley competition rules leaving commissioners to “spend all their time running competitive processes because they’re terrified they’re going to get in trouble if they don’t”. Too late now. So far, 63% of contracts have been put out to tender by clinical commissioning groups (CCGs), now run by just a few GPs. The 211 CCGs are widely regarded as no match for the private sector in writing complex contracts. Section 75 of the Health and Social Care Act forces them to put all but a few services out or risk any putative bidder challenging them in court. Bringing competition law into the NHS means no one can control these unleashed forces. Watch Stevens demand more changes to the law if he’s to control the unfolding chaos. Half of NHS trusts have announced a deficit for this year – that’s unprecedented – yet by 2017 the NHS must “save” £30bn. The Care Quality Commission says one in four hospitals are a safety risk, but their inspections aren’t allowed to count numbers of staff: the NHS has haemorrhaged 6,000 nurses since 2010. Many CCGs that control NHS funds are chaotic, with services falling between gaps, no one paying for them. Privatisation rushes on, at least £11bn so far, but private providers escape the NHS duty of openness or freedom for whistleblowers. Waiting times are rising, ambulance and A&E times growing, as the social care crisis blocks NHS beds with winter approaching. Stevens will find many perversities in the competition culturre. He said top-down control was a disaster – but he may find fragmentation and lack of strategic control far worse. Can he make his perfect market work – or admit he might have been wrong? http://www.theguardian.com/commentisfree/2013/oct/25/simon-stevens-nhs-england-rude-awakening

Comment:

By Don McCanne, M.D. The National Health Service in England currently exemplifies the greatest problem with publicly-administered and publicly-financed national health programs: They become subject to privatization efforts whenever conservatives gain control of the government. Selecting UnitedHealth’s Simon Stevens as chief executive of NHS England surely advances Conservative Prime Minister David Cameron’s privatization scheme. When do you suppose UnitedHealth will put in a bid to purchase the NHS? It would be great for Cameron’s budget, though the people would lose out.

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Health Care Law Fails to Lower Prices for Rural Areas

By Reed Abelson, Katie Thomas and Jo Craven McGinty
The New York Times, October 23, 2013 As technical failures bedevil the rollout of President Obama’s health care law, evidence is emerging that one of the program’s loftiest goals — to encourage competition among insurers in an effort to keep costs low — is falling short for many rural Americans. While competition is intense in many populous regions, rural areas and small towns have far fewer carriers offering plans in the law’s online exchanges. Those places, many of them poor, are being asked to choose from some of the highest-priced plans in the 34 states where the federal government is running the health insurance marketplaces, a review by The New York Times has found. Of the roughly 2,500 counties served by the federal exchanges, more than half, or 58 percent, have plans offered by just one or two insurance carriers, according to an analysis by The Times of county-level data provided by the Department of Health and Human Services. In about 530 counties, only a single insurer is participating. The Obama administration, while not disputing the findings, responded to the analysis in a statement that the marketplaces “allow insurers to compete for customers based on price and quality.” Observers cautioned against drawing too many conclusions from the current landscape, noting that several major insurers were waiting to see what happens next. http://www.nytimes.com/2013/10/24/business/health-law-fails-to-keep-prices-low-in-rural-areas.html?hp&pagewanted=all

Polis fights sky-high rates as ski town signups stall

By Katie Kerwin McCrimmon
Solutions, October 23, 2013 Health insurance rates are so high in Colorado’s mountain resort areas that U.S. Rep. Jared Polis plans to seek waivers from the federal government so people who skip buying insurance in 2014 won’t face financial penalties. Health coverage guides working to enroll Summit County residents in new health plans through Colorado’s health exchange have been deeply disappointed. They have not enrolled a single new client since Colorado’s health exchange launched on Oct. 1. http://www.healthpolicysolutions.org/2013/10/23/congressman-fights-sky-high-rates-as-ski-town-signups-stall/

Comment:

By Don McCanne, M.D. Another flaw in Obamacare is the failure in rural areas to make premiums affordable through health plan competition, primarily because the markets are too small to attract enough insurers to promote competition. An example is found in the Colorado mountain resort areas such as Summit County where not one person has been enrolled through the exchange. How many times do we have to say it? The Affordable Care Act was the wrong model for reform. It leaves in place our profoundly expensive, administratively inefficient, fragmented, dysfunctional health care financing system. Compared to what needed to be done, the improvements were only marginal, and some of the problems actually increased, such as underinsurance – plans that provide less health security and less financial security than many of us had before. Besides, even in areas with greater plan competition, health care costs are still out of control. A publicly-administered single payer program is far more effective in getting health spending right than is health insurer competition.

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The Restive Single Payer Tribe

By Ed Kilgore
Washington Monthly, Political Animal, October 21, 2013 But if I were in the White House, I’d keep an eye on one issue they might not have thought much about in quite some time: the revival of progressive hostility to Obamacare on grounds that the law reflected a “sell-out” of the obvious single-payer solution to the problems of the health care system. I’m not going to relitigate the whole single-payer-versus-managed-competition debate that’s been going on for decades, or even the argument that a managed competition model requires a “public option” to function properly. But whatever else it is, a single-payer system is a whole lot simpler and more predictable than anything that not only accepts but insists upon a publicly regulated and subsidized private health insurance marketplace. Single-payer fans (or those strongly favoring a public option in a hybrid system) are never going to have much in common with conservatives who don’t believe in universal access to affordable health care and want to disable or repeal the public programs we already have. But if the one thing they do have in common — disdain for the messy hydraulics of any hybrid system — becomes the center of attention and stays there, watch out! Ed Kilgore is a contributing writer to the Washington Monthly. He is managing editor for The Democratic Strategist and a senior fellow at the Progressive Policy Institute. http://www.washingtonmonthly.com/political-animal-a/2013_10/the_restive_single_payer_tribe047438.php

Comment:

By Don McCanne, M.D. It is fair to say that Ed Kilgore represents the views of neoliberals who have taken control of the Democratic Party and moved it to the right: that is, he represents centrist views. What is striking about his message is that the intensive political attacks on Obamacare by the conservatives are assisting single payer advocates who are busy exposing its profound policy deficiencies. With their noise, and our reasoned policy prescriptions, middle America may be ready to move to single payer much sooner than expected.

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Predicting ACO Formation: Two Studies With More In Common Than It Might Seem

By Valerie Lewis, Carrie Colla, and Elliott Fisher
Health Affairs Blog, October 22, 2013 At a time when policy makers, providers and payers are all trying to make high stakes decisions about how respond to the proliferation of Accountable Care Organizations (ACOs), divergent research findings might feel as welcome as rain on the fourth of July. Two recently published studies, one by our group at Dartmouth and one by David Auerbach and coauthors in Health Affairs, both examined predictors of ACO formation.  On the surface, they appear to have some inconsistent findings.  Their core conclusions, however, are similar, and differences in the results are readily explained.  Most importantly, policy implications are well aligned: there is much we can do to help the transition to accountable care succeed. A common set of policy implications The findings in both studies also point to challenges that deserve further attention by policy makers.  How can providers without experience in risk-based contracts or who are in smaller, more fragmented practices get the additional support they may need to become an ACO?  Models like the Medicare Advance Payment model are one move to support these types of providers, but our results here and elsewhere suggest that policymakers should be further developing programs to support the financing of these systems, along with the development of analytic and care coordination capabilities that are likely necessary for ACO success. Another important question How can spending and quality benchmarks be refined to encourage broader participation?  Some (including us) have suggested that paying for improvement rather than absolute performance on quality may encourage underperforming systems to join the ACO model. Careful thinking is necessary from health economists and health care finance experts on how to set cost targets that do not penalize providers already on the low end of the cost spectrum. The imperative of continued learning Perhaps the most important conclusion, however, is to acknowledge the many uncertainties that remain.  The transition to performance-based payment systems has barely begun – and better information on what is working and what isn’t would make successful reform more likely. http://healthaffairs.org/blog/2013/10/22/predicting-aco-formation-two-studies-with-more-in-common-than-it-might-seem/

Comment:

By Don McCanne, M.D. If you are holding your breath to see if accountable care organizations (ACOs) are the answer to our quality and cost issues, I have some life-saving advice for you. Don’t wait, but breathe immediately! Elliott Fisher from the Dartmouth Institute has been credited with coining the term, accountable care organization. Look at what he and his colleagues have to say: The most important conclusion is that many uncertainties remain. One of the more important reasons for the uncertainties is that there remains a conflict between those who support better integration of health care (a noble goal) and those who support a business model that smacks of MBA-driven managed care (an ignoble goal). There are no uncertainties with the single payer model. We should proceed immediately to the enactment of an improved Medicare for all, and then we can afford to take years to study variations of the ACO model to see if we can improve health care delivery.

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Obamacare vs. Canada: Five key differences

By Antonia Maioni
The Globe and Mail, October 2, 2013 Despite the partisan war in Washington that shut down the federal government this week, President Barack Obama has succeeded in implementing the first major health reform in the United States in nearly 50 years, as the Patient Protection and Affordable Care Act goes into effect. Even though its most virulent critics raise the spectre of “Canadian-style” health care, “Obamacare” does little to change the enduring differences between the two health care system. What, exactly, does “Obamacare” look like compared to Canada? Not single-payer Canadian critics tend to rail against “two-tiered” medicine, but in fact, the U.S. has a multi-tiered system. And despite the hype on both sides of the Congressional aisles, Obamacare keeps the same complex structure in place, while adding another layer through the introduction of health care “exchanges” for uninsured Americans. But the majority of Americans will continue to access care through a variety of health insurance plans made available or subsidized by their employer; nearly 50 million elderly and disabled through the federal Medicare program; another 60 million lowest-income through state-federal Medicaid arrangements. Not universal coverage Health care in Canada is based on a simple proposition: every legal resident is covered through a publicly-financed provincial or territorial plan. The individual mandate, derived from a Republican precedent in Massachusetts, stands in stark contrast to Canada’s universality principle. Even though Obamacare broadens coverage, the individual mandate relies on a fundamental insurance principle – care depends on type of coverage – and compels Americans to purchase insurance to access care. Americans now have more affordable insurance options and subsidies to cover their costs, and the lowest-income may be eligible for public coverage through the expansion of Medicaid. Still, despite the crush of online traffic as enrolment began Tuesday, only half of the estimated 40-plus million uninsured will be affected by Obamacare.

Not “national” health insurance One of the hallmarks of health care in Canada is that, although each province and territory administers a health plan, everyone can expect to be covered for a comprehensive range of services, no matter where they live. And the federal government is expected to chip in to provincial coffers to make this happen. There’s plenty of intergovernmental friction as a result, but nothing like the fractured federalism of the United States. The implementation of Obamacare will further exacerbate regional and state differences, mainly as a result of the Supreme Court decision to curtail the federal government’s obligation for states to expand their Medicaid coverage. As a result, only about half of the states have chosen to sign on to the new Medicaid program. Not equal access There’s been some controversy in Canada lately over wait times and access to timely care, but this pales in comparison to the wide gulf that exists in access to care in the United States. Obamacare tries to address this in its provisions for insurance reform, such as lifting pre-existing conditions and limits on co-payment. But for all of the emphasis on affordable care, the new law reinforces the notion that access depends on how much you can afford, not how much you need. In the health insurance exchanges, the price of premiums will depend on your age, health, income, and on whether you opt for a bronze, silver, gold or platinum coverage. In Canada, access to necessary health care services is not a competitive sport. Not cost containment The sharpest critics of Obamacare argue it does little to address the fundamental challenge of cost control. The new law includes a review of Medicare reimbursement and the expansion of Accountable Care Organizations to reward cost-effective care. But it doesn’t grapple in a systematic fashion with the overall inefficiencies in health care delivery and financing, the administrative burden of multiple payers, providers and plans, and the cost pressures of defensive medicine. Governments in Canada know that health care is a searing financial responsibility, but they have at their disposal cost containment measures – monopoly fee negotiations with providers, global budgets for hospitals – that remain unfathomable in the American context. Obamacare is a huge step in American health reform and, if it seen to improve the system, will represent a major victory for Democrats. Like other major reforms of the past, however, it will entrench the private nature of the system, and likely render national health insurance, or anything remotely like “Canadian-style” health care, impossible to attain. Antonia Maioni is an associate professor at McGill University http://www.theglobeandmail.com/commentary/obamacare-vs-canada-five-key-differences/article14657740/ Brief bio of Professor Maioni: http://www.mcgill.ca/politicalscience/sites/mcgill.ca.politicalscience/files/antonia_maioni_bio_en_2012.pdf

Comment:

By Don McCanne, M.D. It is frequently said that Obamacare will lead to a Canadian-style single payer system – a statement of optimism by some supporters, and a threat by opponents. McGill University Professor Antonia Maioni explains why Obamacare will do no such thing. Many of the Quote of the Day messages describe very serious flaws in the Obamacare model – flaws that perpetuate high costs, administrative excesses, impairments in access, and many other unjust inequities inherent in our system. I frequently receive messages stating that I should cease criticizing Obamacare, and, instead, I should be supporting Obamacare measures as incremental steps leading to single payer. Although we do not want to reject even minimal improvement in our system, most of the serious structural flaws cannot be corrected with simple remedial legislation. Professor Maioni explains some of the fundamental structural defects in the U.S. financing system that cannot be merely tweaked to get it right. As Professor Maioni states, “Obamacare… will entrench the private nature of the system, and likely render national health insurance, or anything remotely like ‘Canadian-style’ health care, impossible to attain.” The incremental path to single payer through Obamacare has no bridge across the chasm. It would be a tragedy to spend a decade or two, standing on one edge of the chasm, looking across and trying to figure out how legislative patches can build a bridge to the other side, when patches cannot repair a bridge that doesn’t even exist. Only a new infrastructure will do. We must begin building a single payer system with all due haste.

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