Speaker – Page 496

Oregon Experiment update: Medicaid works, sort of

The Oregon Experiment — Effects of Medicaid on Clinical Outcomes

By Katherine Baicker, Ph.D., Sarah L. Taubman, Sc.D., Heidi L. Allen, Ph.D., Mira Bernstein, Ph.D., Jonathan H. Gruber, Ph.D., Joseph P. Newhouse, Ph.D., Eric C. Schneider, M.D., Bill J. Wright, Ph.D., Alan M. Zaslavsky, Ph.D., and Amy N. Finkelstein, Ph.D. for the Oregon Health Study Group
The New England Journal of Medicine, May 2, 2013

Our study provides evidence of the effects of expanding Medicaid to low-income adults on the basis of a randomized design, which is rarely available in the evaluation of social insurance programs. We found that insurance led to increased access to and utilization of health care, substantial improvements in mental health, and reductions in financial strain, but we did not observe reductions in measured blood-pressure, cholesterol, or glycated hemoglobin levels.

http://www.nejm.org/doi/full/10.1056/NEJMsa1212321

And…

Protecting Finances and Improving Access to Care with Medicaid

By Richard Kronick, Ph.D., and Andrew B. Bindman, M.D.
Editorial, The New England Journal of Medicine, May 2, 2013

Insurance has three main purposes: to protect financial assets in the event of illness, to improve access to care, and to protect health.

First, Baicker and colleagues found that insurance provided a low-income population with considerable financial protection.

Second, Medicaid was associated with dramatically improved access to care.

It is less clear how well Medicaid accomplished the third goal — improving health.

The minimal effects of Medicaid coverage on measures of physical health are not entirely surprising given the many steps needed between the availability of insurance coverage and the delivery of appropriate care. In addition, the short follow-up period of the study, the small number of persons with chronic conditions in the study sample, and the limited number of outcomes may have contributed to a false negative result. This study did not or could not address many important potential health benefits of health insurance, including early detection of cancer, a reduction in sick days from school or work, and a reduction in mortality.

http://www.nejm.org/doi/full/10.1056/NEJMe1302107

The Oregon Health Insurance Experiment (A concise summary of findings): http://www.nber.org/oregon/

Comment:

By Don McCanne, M.D.

The Oregon Experiment unequivocally demonstrates that Medicaid improves access to care and provides considerable financial protection for the low-income population that it serves. Although it was not powered to demonstrate statistically significant improvements in health outcomes, a multitude of other research studies have already confirmed that the health-care interventions studied here are clinically effective.

Today there is a barrage of responses from conservatives and libertarians attacking Medicaid because this study supposedly shows that Medicaid had no significant effect on health outcomes. Thus they challenge the wisdom of implementing the Affordable Care Act provision that would greatly expand the Medicaid program.

Although there are many reasons to consider better options to Medicaid (e.g. single payer), withholding access to and affordability of care that has already been proven to be effective is certainly not one of them.

Perhaps the most significant set of observations in this study is the reduction in financial barriers to care. Most importantly, catastrophic expenditures (over 30 percent of household income) were reduced from 5.5 percent in the uninsured group to 1.0 percent in the Medicaid group. Those with medical debt were reduced from 57 percent to 44 percent, and those who had to borrow money to pay medical bills, or simply walked away from the bills, were reduced from 24 percent to 10 percent.

These reductions in financial barriers improve access which, in turn, improves health outcomes, although these numbers are still not good enough. With a well-designed single payer system, we could do much better.

Insurance fox guards henhouse of Obamacare

By Jonathan D. Walker, M.D.
The Journal Gazette (Fort Wayne, Ind.), April 26, 2013

Something worrisome just happened in Washington, but hardly anyone has noticed. The occurrence was a striking example of lobbyists exerting influence over our government and winning a profound victory for an industry we don’t need.

Most people don’t spend much time thinking about Medicare. If they do, they probably think of it as some old government insurance system that is too expensive. But the truth is that Medicare can be remarkably efficient. It has served as a model for health care systems in other countries. People eligible for it are much less likely to worry about their health and their money than the rest of us. Of course, Medicare could also be much better, but special-interest groups work hard to prevent improvements from being made. For instance, Medicare is the only health insurance on the planet forbidden to bargain over drug prices thanks to lobbying by the pharmaceutical industry.

However, Medicare’s problems go deeper. Americans have an ingrained attitude that for-profit entities can do things much better than the government, but numerous studies suggest that for-profit insurance companies cannot live up to this. They have too many expenses and they don’t have the market power to control costs. Plus, their business model demands that they do whatever they can to avoid paying for sick people – which is why you are now facing higher deductibles along with more restrictive networks and costlier premiums.

Yet politicians continue to insist that for-profit companies are better, and for that reason they created Medicare Advantage. Medicare Advantage plans are simply Medicare plans run by companies such as Humana and WellPoint but paid for by the taxpayers. Unfortunately, those plans have always cost more to cover people than standard Medicare. Because private insurance companies add so much bureaucracy and complexity, greater costs are inevitable.

We pay these companies on average about 14 percent more to do what Medicare already does. Then we pay an additional 14 percent on top of that because those companies are very good about adding more “diagnoses” to make their patients seem sicker. They get 28 percent more revenue for giving us extra hassles and less service than standard Medicare.

But if you are older than 65 and a smart shopper, these plans can offer you a great deal. Those extra taxpayer dollars allow the company to give you perks and still make a handy profit. If you have a Medicare Advantage plan that hasn’t abused you yet, you need to thank everyone around you who is younger than 65 for paying for your good fortune.

Multiple sources have shown that the Medicare Advantage program is a waste of money, including the Medicare Payment Advisory Commission (Congress’ advisory body on Medicare payments), the Congressional Budget Office and the Government Accountability Office. In fact, the one part of Obamacare that everyone agreed with was a plan to cut back on payments to those plans. But the for-profit companies rallied their lobbyists, and they were able to reverse the cut. And last week the private insurance companies were able to get the government to actually increase their payments by an additional 3.3 percent. A program that adds costs and creates more confusion is being rewarded with more money because we think it is better even when it isn’t.

And that is the real problem. Our gut tells us that for-profit companies have to be better, and those companies leverage that feeling to extract money from us. As we move forward into the new world of Obamacare, we need to keep that in mind. Those companies designed the basic principles of Obamacare – the mandate, subsidies and exchanges. A former WellPoint executive even helped draft the law, and back in 2009 Business Week announced that those companies had been able to get exactly what they wanted.

Obamacare actually has some great features, but it is also going to bring complexity, costs and confusion. We need to remember that all those things exist because we feel on a visceral level that for-profit companies can do things better. So much so that, rather than having a public option to buy Medicare, we handed over control of the new law to companies that avoid paying for our health care in order to make money. And they are so good at working the system that they were able to convince our government to pay even more to perpetuate a program that just plain doesn’t work.

Dr. Jonathan D. Walker is an assistant clinical professor at Indiana University School of Medicine in Fort Wayne. He wrote this for The Journal Gazette.

http://www.journalgazette.net/article/20130426/EDIT05/304269984/1144

Racial bias in health care: an interview with Dr. Claudia Fegan

Mississippi Public Broadcasting Radio, April 29, 2013

PNHP note: The following is an unofficial transcript of an interview that took place in the studios of Mississippi Public Broadcasting in Jackson, Miss., on April 19. Dr. Claudia Fegan is past president of Physicians for a National Health Program. Her two-day visit to Jackson included presentations at Tougaloo College and the University of Mississippi Medical Center.

Karen Brown: This is Mississippi Edition on MPB Radio and I’m Karen Brown. The infant mortality rate among educated Black women is higher than among less-educated white women. So says Dr. Claudia Fegan, chief medical officer for Cook County, Illinois. Dr. Fegan was in Mississippi raising awareness on what she says is racial bias in the health care system. She tells us that, statistics aside, disparity in health care boils down to one thing.

Dr. Claudia Fegan: We’re talking about racism, and how racism impacts upon the delivery of health care in this country. Though we would like to pretend that we’re past that, that we’re in a post-racial state, the reality is that in the delivery of health care in this country racism still plays an important role.

KB: Is this Black and white, or is it Hispanic?

CF: It’s all of that. What we know is that people of color in this country, despite their economic status, are less likely to get the care they need. And until we wrap our brains around that, until we come to grips with that, we can’t begin to address the problem.

KB: Is the problem worse in the South, because everyone thinks that racism is more prevalent in the South?

CF: I can’t say that. The data shows that health care providers, be they Black or white, brown or yellow, in the delivery of health care, do not treat people of color the same. And, as a result of that, people of color do not always get the care that they need.

KB: What kind of data have you used to support that assertion?

CF: There’s very blunt data. The idea that Black women are less likely to get breast cancer than white women and yet their mortality rates are 32 percent higher than white women. There’s data that shows …

KB: Wait, I want to stop you there. Is it because Black women don’t seek out medical care, they don’t have access to medical care, or they’re under-treated or not diagnosed properly?

CF: All of those. So it’s a very complicated problem. If you look at the infant mortality rate, you’ll find Black women with college degrees have births that do not have as good an outcome as white women who do not have a high school diploma. So it’s not as simple as socioeconomic status, and the notion that you can earn your way out, or educate your way out of these problems.

KB: That’s a very interesting statistic or example, because I have done many interviews with many experts talking about disparity and in particular about breast cancer being more deadly among Black women than among white women. The infant mortality rate is very high in this state, Mississippi, and I’ve never heard it said that an educated Black woman has a greater chance of having a child die in infancy than a white woman who is not educated.

CF: What I’m saying is that we as a country have not come to grips with all that is involved in the delivery of health care. So, for example, there’s something very important that’s happening between a patient and a physician. I’m boarded in quality; I look at quality a great deal. If you take a patient and a physician in the exam room, and then after that visit you talk to the physician about what he or she thinks happened in that room, and then talk to the patient about what they think happened in that room, there’s a great difference. There’s a gap there. And until we come to grips with that, we tend to focus on what we can quantify, but we need to understand that the way we are delivering health care does not meet the needs of the people to whom we’re trying to deliver it – we’re trying to care of people. Because that’s something we can’t count well. What we can count are things like death, morbidity, illness, complications – we can’t count that non-tangible part of that visit. What did we miss? Why is that when you look at the patient’s perception of what occurred, and the doctor’s perception of what occurred, there’s a disparity?

KB: How do you find that out?

CF: There are no simple answers, but the first thing you do is acknowledge that there’s a problem. That maybe what we’re delivering is not culturally competent care. That maybe we’re not meeting people where they are. Because, despite the amount of education we have, we still have our cultural bias. We still bring to the table whatever we were raised with, whatever we were brought up with.

KB: Tell me if this factors into it. Would a Black individual be likely to be more uncomfortable with a white doctor or a white person uncomfortable with a Black doctor?

CF: Well, that is the assumption. What you have to really understand is that if a … I heard someone yesterday say to me, “We don’t go to the County [hospital], because County care is not good care.” And if they’ve been raised with the impression that the care they would get there by a physician of color is not good and that they would be better served by a white doctor, then that’s where their comfort level is. That’s a bias that they bring to the table.

KB: And we should say that you’re coming at this from the doctor’s point of view, the health care institution’s point of view. You’re charging your fellow doctors to take this on, is that right?

CF: I’m charging society to take this on. Because while the doctors cannot – while we can lead, I would say we should participate. But we as a society have to accept the notion that everyone should have access to care. Everyone should have access to health care. We accept as a society that everyone should have access to education. We provide access to education. We accept the notion that we don’t expect a single individual to make sure that their water is clean. We as a society make sure they have clean water. We no longer expect someone, if there’s a fire in their house, to put it out by themselves. We realize that you need multiple hands.

KB: How do you focus on doctors who may be showing a bias toward patients? Is there a way, is there a program for doctors to address that or even to recognize that they might have a bias when it comes to treating their patients?

CF: Yes, there’s a wake-up moment: for people to think about the way in which they do their jobs every day, and even though they say I’ve done it this way every year for the last 20 years or 30 years. They’ve always had a reticence to do that.

KB: Let me wrap all this up by asking what, in your mind, is justice in health care?

CF: A patient being able to get what they need when they need it. I always ask: Who does not deserve health care? Is there someone you think who doesn’t deserve health care? And if they deserve health care, who does not deserve the best health care we have to deliver? And how can you ensure that everyone gets the best health care they deserve? And that’s by ensuring that everyone in this country is insured. And until we can guarantee every person coverage for the care they need, when they need it, we will not have justice in health care.

KB: Dr. Claudia Fegan is executive medical director for the Cook County Health and Hospital Systems. I thank you very much for being with us.

CF: Thank you.

You can listen to the broadcast here (Dr. Fegan’s segment starts at the 13:30-minute mark): http://mpbonline.org/mississippiedition/ME042913/

Freestanding emergency departments?

Freestanding emergency department growth creates backlash

By Sue Ter Mat
American Medical News, April 29, 2013

Dr. McLaughlin, part-owner of Texas-based Elite, is among those embracing one of the growing segments of health care — freestanding emergency departments. The stand-alone emergency departments have similar equipment as hospital emergency departments but are usually miles from main hospitals. They can look from the outside like urgent care centers, but freestanding EDs can take more severe cases. If the centers take Medicare or Medicaid, they are subject to the federal Emergency Medical Treatment and Active Labor Act and must accept all patients regardless of their ability to pay.

Centers are opened by hospitals and physicians, sometimes separately, sometimes in alliance. Generally, local hospital EDs have agreements with the centers to take cases too severe for the freestanding centers, or to admit patients.

The centers’ numbers have doubled during the past decade, up to 284 in 45 states.

With that growth, however, has come a backlash over freestanding EDs charging, or attempting to charge, a facility fee, as a hospital ED would. Facility fees are charges that hospitals collect from insurers for operating EDs and cover the cost of running the departments.

Urgent care centers also have viewed freestanding emergency departments as a competitive threat.

Freestanding EDs are more lucrative than urgent care centers. Average net revenue per patient for urgent care centers range from $105 to $135, while average revenue is $350 to $500 for freestanding EDs.

A major concern has been that freestanding EDs take care of minor health problems like urgent care clinics but charge emergency departments fees.

http://www.amednews.com/article/20130429/business/130429966/4/?utm_source=nwltr&utm_medium=heds-htm&utm_campaign=20130429

Comment:

By Don McCanne, M.D.

What is the difference between an urgent care center and a freestanding emergency department?

Urgent care centers are equipped and staffed to provide immediate care for urgent problems which arise when care may not be convenient or accessible at the patient’s primary source of health care. Emergency departments also provide urgent care, but, in addition, they triage patients, admitting patients with more serious disorders to the hospital with which they are associated.

Free standing emergency departments really are not much different from urgent care centers since the latter also can transfer patients to acute care hospitals when necessary. The primary difference seems to be that the freestanding emergency department will have an entrepreneurial arrangement with a hospital in order to be able to gouge patients and insurers with outrageous “facility fees” – a trick used by hospital emergency departments to increase revenues, partly to offset costs of EMTALA requirements that prohibit them from turning away uninsured or underinsured patients with conditions serious enough to require hospital admission. Urgent care centers typically have the facility fee built into their other charges.

Like urgent care centers, freestanding emergency departments do not have the financial responsibility for caring for patients requiring admission, yet they still charge the facility fee as if they did. If they accept Medicare and Medicaid patients, the only extra obligation of the freestanding emergency departments is to arrange transfer to an acute care hospital.

Freestanding emergency departments are established primarily to make money. Hospital emergency departments are established primarily to meet the health care needs of the community. They are different animals, as this scheme to cheat people by charging unwarranted facility fees demonstrates.

Under the PNHP single payer model, two issues presented here are addressed. One is that, through central planning, facilities are planned and developed based on the health-care needs of the community, rather than being based on the greatest opportunity for profit while avoiding communities with fewer resources. The other is that for-profit institutions are prohibited in the PNHP model; all resources go to patient care with none being diverted to investors.

Single payer is not just a matter of shooing away intrusive and wasteful private insurers. It is a matter of redesigning the health-care financing and delivery infrastructures to best meet the health-care needs of the community, while providing the greatest value in health care – for all of us.

Brookings' disappointing recommendations for bending the cost curve

Bending the Curve: Person-Centered Health Care Reform: A Framework for Improving Care and Slowing Health Care Cost Growth

Authors: Joseph Antos, Katherine Baicker, Michael Chernew, Dan Crippin, David Cutler, Tom Daschle, Francois de Brantes, Dana Goldman, Glenn Hubbard, Bob Kocher, Michael Leavitt, Mark McClellan, Peter Orszag, Mark Pauly, Alice Rivlin, Leonard Schaeffer, Donna Shalala, Steve Shortell
Engelberg Center for Health Care Reform, Brookings, April 29, 2013

We propose a framework for health care reform that focuses on supporting person-centered care. With continued innovation toward more personalized care, this is the best way to improve care and health while also bending the curve of health care cost growth.

Simplify and Standardize Administrative Requirements

The time cost to clinicians of interacting with health plans has been estimated to be as high as $23 to 31 billion annually. Further, clinicians, health plans, and other participants in health care reform are currently subject to a wide range of diverse reporting requirements that add to costs and reduce the availability of actionable information. Some steps have been taken recently to reduce these administrative costs through standardization. Further administrative simplification steps should include the following, all of which can be accomplished through existing standard-setting entities and public-private implementation initiatives:

* Implementation of an updated standardized claim form.

* Standard methods for quality reporting by providers and plans, including clinical, outcome, and patient-level measures — this would be an administrative benefit for providers that adopt value-based payment reforms across all of their payment systems and would lead to reduced reliance on cumbersome coding for specific types of providers.

* Standard methods for timely data sharing by plans with health care providers and patients who are involved in the financing reforms described in this report. Data sharing accomplished according to consistent standards would reduce the burden on providers and patients, and the it vendors who serve them, for implementing the analytic tools needed to achieve greater improvements in care.

* Support for state investments to update their Medicaid information systems including standard quality measure reporting and access to CMS data for quality improvement.

Reforms for Private Health Insurance Markets and Coverage

* Support employer efforts to engage employees in reducing overall health care costs through Employment Retirement Income Security Act (ERISA) and other health plan regulations that promote value-based insurance designs and tiered benefit designs, narrow networks of providers that demonstrate high performance, and employees’ ability to share in the savings from health care choices and changes in behavior that reduce costs.

Bending the Curve (49 pages):
http://www.brookings.edu/~/media/research/files/reports/2013/04/person%20centered%20health%20care%20reform/person_centered_health_care_reform.pdf

Comment:

By Don McCanne, M.D.

This newest report on recommending changes to control health care costs is being presented as a “bipartisan” consensus representing “broad agreement” on reform. Those who have followed the national policy dialogue will recognize that the list of authors does, in fact, include representatives of both major political parties. Nevertheless, the views presented in the report confirms the presumption that these Democratic authors have moved into the Republican camp in the policy debate.

As an example, their recommendations for reducing administrative waste totally ignores the well documented sources of that waste, resulting in recommendations that will have no impact at all on the problem, when recovery of administrative waste should be front and center in reform.

As another an example of their right-wing approach, they recommend “value-based insurance designs and tiered benefit designs, narrow networks of providers that demonstrate high performance, and employees’ ability to share in the savings from health care choices and changes in behavior that reduce costs.” This is code language for consumer-driven approaches that shift more costs to those needing health care – terrible policies that defeat principles of health care justice.

The only good thing about this report is that you can quickly dump it with the “delete” button, without the environmental consequences of wasting 49 pages of paper.

Universal health care advocacy group readying for local rally

By Rachel Roubein
Carroll County Times, April 29, 2013

What started as the formation of an about eight-person book club spiraled into the creation of a local grassroots effort to advocate for universal health care in Maryland.

The club members read one book: “The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care” by T.R. Reid. Afterward, they readied themselves to take on the cause, which they accomplished by contacting Healthcare is a Human Right Maryland.

At Birdie’s Cafe in Westminster Friday, three members of Carroll County’s chapter of Healthcare is a Human Right Maryland and statewide organizer Sergio España told of the formation of the grassroots campaign locally. They told of their excitement for the state’s first speakout — a rally to share health-care stories — which will be held in Carroll County on Saturday.

They spoke passionately about making health care a public good.

“No one should not have health care,” group member Frank Reitemeyer said. “For me, that’s the biggest thing, and it’s getting to the point where it’s unaffordable for everybody, and we’re all suffering because of it.”

So it’s time to take action, to take care of family, friends and neighbors who might be uninsured, he said.

From 2010 to 2011, about 771,500 people were uninsured in Maryland, which is 13 percent of the state’s population, according to www.statehealthfacts.org, a product of the Kaiser Family Foundation that analyzes Census Bureau data.

Nearly 7 percent of Carroll adults were uninsured in 2011, according to The Partnership for a Healthier Carroll County community dashboard. Additionally, more than 2 percent of children were without insurance that same year.

This wouldn’t be the case with a universal health-care system. It works like this: Health care would be publicly funded and treated like a public good, such as education. No one would have to pay when they go see a doctor, as it would be funded through taxpayer dollars, according to the group.

The campaign is looking to Vermont as an example, which became the first state to pass a publicly funded health-care system in 2011. Under the law, the state will set up a universal health-care system for all residents, likely by 2017, according to www.vermont.gov. Through banding together, Healthcare is a Human Right Maryland — which has chapters in Howard, Montgomery, Baltimore and Frederick counties — strives to set up a similar system, according to España.

“Everybody quietly knows that something’s wrong with our health-care system,” he said, “but how do we connect with each other?”

The Carroll chapter hopes to make those connections locally — and to put a face on the uninsured and others burdened by the cost of medical bills, group member Sandy Wright said.

It’s an expense that can be a struggle, she said. She’s not only read about it but watched the frustration firsthand. Wright and her husband pay for her daughter and grandson’s insurance to help them out.

“We’re not going to live forever,” Wright said, “so we need to get [universal health care] set up so she can get insured.”

The campaign officially kicked off statewide in December, and members are in the midst of collecting surveys from state residents. Questions include asking an individual if they’ve had to forgo medical care because of costs and if they’ve ever had an issue receiving the care they need.

The group also aims to foster dialogue on the issue throughout the state this year, according to España.

Rep. Justin Ready, R-District 5A, said he’d be willing to engage in conversation on the topic but thinks making health care a public good isn’t the right way to address the system’s affordability.

“It’s important to look at it from the cost side — what can we do both in government and the community to bring down the cost of care?” said Ready, who sits on the state House’s Health and Government Operations Committee. “I think that should be the most important focus.”

The transition to universal health care in the state won’t be immediate, group member Becky Powel said, but it’s a cause she’s willing to fight for.

For Reitemeyer, it comes down to morality.

“Just because you’re rich doesn’t mean that you are allowed to be healthy,” he said, “and that the guy who’s busting his butt with two or three jobs or the woman who’s doing that can’t afford to have their children raised with good health care. It’s just — it’s immoral. That’s the whole point of the campaign.”

If You Go

What: Local residents will share health care stories at this event, called a Speakout, hosted by the Carroll County chapter of Healthcare is a Human Right Maryland

When: 2 to 5 p.m., May 4
Where: St. Paul’s United Church of Christ, 17 Bond St., Westminster

For more information, contact CarrollCountyHCHR@gmail.com, www.facebook.com/HealthcareIsAHumanRightMaryland or 240-478-8193.

http://www.carrollcountytimes.com/news/local/universal-health-care-advocacy-group-readying-for-local-rally/article_cbecc8c2-e561-5dbb-8b86-4d795afe0f08.html

Relegating Medicaid patients to lower-tier care

Hammurabi’s Code and U.S. Health Care

By Uwe E. Reinhardt
The New York Times, April 6, 2013

I recall addressing a group of New Jersey State legislators on this point a few years ago as follows:

“I teach my students that the price a buyer is willing to pay for a thing signals to suppliers of that thing the monetary value the prospective buyer puts on it. It is a basic tenet of economics. Leaning on that tenet, I conclude that the value you in your role as state legislators put upon the professional work of, say, a pediatrician, if applied to a poor child on Medicaid, is less than a quarter of the value you put upon that same professional work it applied to your own commercially insured children.”

Physicians clearly understand this relative valuation being signaled to them. According to a recent estimate, almost a third of American physicians are unwilling to accept any new patients covered by Medicaid.

Naturally, New Jersey’s legislators were not well pleased by my comment. To be fair, I doubt they had ever thought of their Medicaid budgets in that way. More probably, they tacitly assume that our health care system will give patients covered by Medicaid the same health care for a given medical condition that would be given a commercially insured patient, regardless how much legislators are willing to pay for that care.

Perhaps these legislators believe that the Hippocratic Oath, sworn to by all physicians at the onset of their careers, compels that egalitarian approach. In fact, neither the ancient nor modern version of the oath imposes on healers an obligation to treat patients at a monetary loss.

Americans today have a more, shall we say, “nuanced” view of the matter. One the one hand, we signal to our health care professionals vastly different valuations of their work. On the other, we expect them to be punctiliously egalitarian on their job.

In conclusion, I note that under the Affordable Care Act of 2010, the federal government is willing to pick up the added cost of raising physician fees paid by Medicaid for primary services to equality with the usually higher fees paid by Medicare for those services.

Alas, for the states, the federal government will pick up the bill for this policy only during 2013 and 2014. It is anybody’s guess, therefore, how many states will retain the more generous and to them costly payment policy after 2014.

Comment:

By Don McCanne, M.D.

Soon the nation be spending $3 trillion for health care. That is certainly more than enough to provide everyone with all essential health care services; that is, we can easily afford an egalitarian system.

Having spent a career attempting to provide care on an egalitarian basis, there is no doubt in my mind that it is impossible in our fragmented, dysfunctional system of financing care.

This is precisely why so many of us have become passionate in our advocacy for a single payer system. Yes, it would make life easier for dedicated health care professionals, but, far more important, it would ensure that all of us would have the health care that we need. The Affordable Care Act falls woefully short.

No system is perfect, but some are a whole lot more humanitarian than others.

http://economix.blogs.nytimes.com/2013/04/26/hammurabis-code-and-u-s-health-care/?ref=healthcarereform

Will Obamacare end medical bankruptcies? Probably not.

By Sarah Kliff
Washington Post, April 26, 2013

Welcome to Health Reform Watch, Sarah Kliff’s regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Sarah with questions, comments and suggestions here. Check back every Monday, Wednesday and Friday afternoon for the latest edition, and read previous columns here.

There’s pretty widespread agreement, on both sides of the aisle, that the health-care law will expand insurance coverage. The nonpartisan Congressional Budget Office estimates that 30 million more Americans will have health insurance by the end of a decade.

What’s become more of a debate though, is how good that health insurance coverage will be. Two new academic studies raise the possibility that many Americans will still face big financial burdens after they gain insurance coverage.

“The Affordable Care Act will reduce the number of uninsured by a little more than half, which is a good thing,” says Stephanie Woolhandler, a professor at the CUNY School of Public Health. “But it’s going to increase the problem of underinsurance: People who have insurance but still can’t afford care.”

The whole point of buying health insurance coverage is to make care affordable. Millions of Americans pay monthly premiums with the expectation that, should a horrible illness or accident occur, the insurance company will cover the majority of some pretty expensive hospital bills.

Some experts and health advocates have begun to question whether the health-care law can deliver on that promise. Woolhandler wrote an editorial earlier this week, in the Journal of General Internal Medicine, contending that “the new private coverage offered to the near-poor and middle income individuals through insurance exchanges will also leave many underinsured.”

Much of this has to do with the type of plans that insurers will sell on the health insurance exchange. Health insurers will offer consumers a “bronze” plan that will, on average, cover 60 percent of an enrollee’s costs. This, in health insurance-speak, is known as “actuarial value.” Using actuarial values can make it easier to compare plans, and understand what part of the bill the insurer will likely cover — and how much the enrollee can expect to be on the hook to pay.

The exchange will also have other plans with different actuarial values: Silver plans will cover 70 percent of an average enrollee’s costs, and gold plans would be expected to foot 80 percent of the bill. The bronze plans are expected to attract a high number of enrollees, since they will likely have smaller premiums — because consumers are buying less robust financial coverage.

Woolhandler, who is the co-founder of Physicians for a National Health Program, has previously conducted research on rates of medical bankruptcy in Massachusetts, before and after the state expanded health insurance access. She found that in 2009, two years after the insurance expansion took effect, just about half the debtors (52 percent) attributed their bankruptcy at least in part to medical bills. In 2007, before the expansion, the number stood at 59 percent.

Allison Gailbrath, an assistant professor at Harvard Medical School, has also looked at the Massachusetts’s insurance expansion to better understand how access to health insurance affects the financial burden of medical costs.

She published a paper this month in the journal Health Affairs, which looked at which costs were faced by families who had gained insurance through the Connector, Massachusetts’s version of a health-care exchange. She found that 38 percent reported a financial burden (defined as having difficulty paying medical bills) and 45 percent said costs were higher than they had expected.

Numbers were slightly higher for those earning less than 400 percent of the poverty line and for those with children.

It’s worth noting that the Massachusetts bronze plans had a lower actuarial value than those that will be sold on the exchanges. They covered, on average, 40 to 50 percent of enrollees’ costs. That means, to Gailbraith, that underinsurance is still a concern in the federal exchanges—but perhaps not as much as it has been in the Massachusetts experience.

“The exchanges will provide coverage and that will help the uninsured but there’s still an underinsured problem,” Galbraith says. “People will have plans, but they will still have cost issues involved.”

Galbraith contends that this creates an impetus for better consumer education — that there’s space for better education about how much health insurance will cover, and what consumers might be expected to pay. Some employers, for example, will provide cost calculators where enrollees can input some data on what type of health-care spending they expect and get a sense of which plan might provide the best deal.

That can move consumers away from just comparing premiums, and towards thinking about all the other costs they could incur from various co-payments and cost-sharing. That could lead consumers to pick different plans, which might come with higher premiums — but also lower cost-sharing down the line.

KLIFF NOTES: Top health policy reads from around the Web.

Senate Democrats are concerned about Obamacare’s roll out. “Democrats in both houses of Congress said some members of their party were getting nervous that they could pay a political price if the rollout of the law was messy or if premiums went up significantly. President Obama’s new chief of staff, Denis R. McDonough, fielded questions on the issue for more than an hour at a lunch with Democratic senators.” Robert Pear in The New York Times.

As time runs out, Florida’s Medicaid expansion hangs in limbo. “House Republicans rejected a bipartisan Senate proposal to accept $51 billion in federal health care money on Thursday, diminishing hopes that lawmakers will reach a health care compromise before the legislative session ends next week.” Tia Mitchell in the Miami Herald.

Mid-level health care jobs are disappearing. ”Positions such as licensed practical nurses and medical-records clerks are being eliminated or pushed out of hospitals into lower-paying corners of the field such as nursing homes. Meanwhile, positions that were once an accessible first rung on the career ladder, such as registered nursing, increasingly require at least a bachelor’s degree.” Ben Casselman in The Wall Street Journal.

Correction: This story originally misstated the actuarial value of the bronze plans in the Massachusetts Connector. It is between 40 to 50 percent.

http://www.washingtonpost.com/blogs/wonkblog/wp/2013/04/26/will-obamacare-end-medical-bankruptcies-probably-not/

A Near Miss

By Andrew D. Coates, M.D.
WAMC Northeast Public Radio, April 26, 2013

Many years back during my residency training, on my first overnight as the senior admitting resident, I got a call from an emergency physician at a tiny rural hospital. Her patient had pulmonary emboli — blood clots to arteries of the lungs. She proposed to transfer the patient to our hospital, where closer monitoring would be available.

When the patient arrived I hurried to the her bedside, for pulmonary emboli kill as many as 100,000 people each year in the United States.

She asked if she might die. It occurred to me that she might. But I sought to reassure her, explaining that she was not only stabilizing but already receiving treatment.

As I gestured to the “treatment” she was getting, I looked at the bag of heparin hanging at her bedside. I was thinking that I should recheck the rate of the drip, to make sure the emergency physician had chosen the correct dose of the anticoagulant.

But there was no pump attached to the IV. In fact the bag of heparin was empty. With horror I recognized a life-threatening medical error.

A bag of intravenous heparin had been hung earlier, at the rural hospital, before the patient’s transfer. The doctor who ordered the heparin meant for the contents to infuse slowly, by a pump to control the drip rate, over about 28 hours. Instead the entire bag had been infused into the patient all at once, by gravity, over a few minutes.

The ambulance crew had transported the patient with an IV pump. At the first hospital, to avoid the need to return, the ambulance crew had substituted a pump that belonged to their company. When they got to us, they simply unhooked their pump and took it with them, without taking time for our nurses to switch to a different pump.

Our patient who had just suffered blood clots to the lungs suddenly faced a profound risk of bleeding. I asked the patient not to get out of bed, to eliminate her risk of falling, and informed her nurses.

I then rushed to order the antidote, a medication called protamine.

That we might need it some day had been drilled into us as medical students but I had never seen it used. Quickly I phoned the pharmacist for help. The pharmacist that night was just like me, recently out of school. Just like me, it was her first overnight and she too had never seen protamine used.

Awed, if not frightened, by the responsibility we shared, we independently calculated the dose of the antidote (protamine) and then took a minute to compare our results. Too much and the patient would be back at a risk of more blood clots. Too little and she would remain at a risk of bleeding. The pharmacist quickly delivered the protamine and the nurses immediately gave it. (And we notified our supervisors of the situation.)

By morning we learned that we had chosen just the right dose. The patient remained stable — and also therapeutically anti-coagulated, without risk of further clotting. And remembering that night … so many lessons learned!

But I’d focus for a minute on the question of the medical error as well as how thinking about it shaped my consciousness. Events like this “near miss” deserve careful review. As one of the world’s experts in health care quality, Dr. Gordy Schiff, points out, these experiences should be treated like treasure. Careful study of a problem can allow us to unearth its roots, and in turn build systems that will save lives.

The ambulance crew members were good people with a sincere desire to serve the community. Of course they swore never to make the same mistake again. Yet fixing blame will not, ultimately, fix errors. When we discussed a team-building system fix the Director of Nursing pointed out that in a fundamental way, the ambulance crew was not quite part of our team.

The ambulance was run by for a for-profit company with a corporate headquarters thousands of miles away. Naturally the goal of the company was to get the crew to transport as many patients as possible across our landscape. That night, I later learned, they were racing off to another patient waiting at another rural hospital. The paramedics were amid a “speed-up” like … well, like just about everybody else in our country.

These days just about any aspect of health care delivery can be subcontracted out or made into a business. Local health care businesses are increasingly joined by the tendrils of international conglomerates. In fact the corporation that owned the rural ambulance in this essay was recently bought by a global private equity firm.

But a local ambulance crew should serve the needs of the local community, not private equity investors.

For the sake of patient safety we should work to remove profiteering from the care of the sick. A public single payer system would a giant step in the right direction. Most of all it would be the beginning of a system in which health priorities were set by the people, by patients and their caregivers, something every modern democracy should have.

Dr. Andrew Coates practices internal medicine in upstate New York. He is president of Physicians for a National Health Program.

You can listen to Dr. Coates’ radio broadcast here: http://www.wamc.org/post/andrew-coates-near-miss

ACA's negative impact on employment

Governments may push workers out of employer health care and into health exchange

By Associated Press
The Washington Post, April 24, 2013

In a quest to save money, political leaders in Washington state are exploring a proposal that would shift some government workers out of their current health plans and onto the insurance exchange developed under President Barack Obama’s health care law.

Lawmakers believe the change, which could affect thousands of part-time state employees and education workers, would save the state $120 million over the next two years.

The Washington proposal has been advanced as a way to help deal with a $1.2 billion budget shortfall. Under it, Washington state would make policy changes and secure agreements in which staffers who work between 20 and 30 hours a week would get extra compensation but lose their current health coverage. They would then be eligible to get health care in the federal plan, without any consequence for the state.

“I think it’s a great way to fully take advantage of the Affordable Care Act,” said Republican Sen. Andy Hill, one of the state’s top budget writers.

While few states are following Washington’s path at the moment, there has been concern about how private employers will handle the new health care law and the possibility that some may shed insurance coverage. The owner of Olive Garden and Red Lobster restaurants, for example, began experimenting last year with putting more workers on part-time status.

Virginia is doing something similar, with Republican Gov. Bob McDonnell directing that all part-time state employees work less than 29 hours weekly. That is creating a financially crippling problem for many of Virginia’s 9,100 adjunct faculty members at the state’s 23 community colleges on 40 campuses statewide.

“I’ve never anticipated getting rich off being a teacher,” said J. Gabriel Scala, an adjunct English professor at J. Sargeant Reynolds Community College in Richmond.

“But the rent has to be paid. And I have to eat. And gas has to be put in the car — and $17,000 a year isn’t going to do it,” she added.

http://www.washingtonpost.com/business/governments-may-push-workers-out-of-employer-health-care-and-into-health-exchange/2013/04/24/fed10f26-acb4-11e2-9493-2ff3bf26c4b4_story.html

Comment:

By Don McCanne, M.D.

One of the most important design features of the Affordable Care Act was that the employer-sponsored sector of health care coverage was to be largely left alone since allegedly it was functioning so well – not only covering the largest sector of our population, but also an important source of health care financing that was already in place. What could possible go wrong with this strategy?

What are employers to think when they see that the two primary features of the Affordable Care Act – the expansion of Medicaid and the establishment of exchanges of private insurance plans – were to be partially or completely financed with government funds? If lower-income employees could be shifted into the exchanges, the federal government would provide subsidies that would help fund the health care needs of employees. The only condition is that the employee must be part time, not working more than 30 hours per week.

Private employers have already begun to reduce their employees’ hours to qualify them for the exchange plans, and now we see that state governments are considering the same approach.

The important point is that employees in this sector that was to be left intact – those with employer-sponsored plans – are not only experiencing changes in their health insurance coverage, they are also experiencing a major loss of income due to the requirement of sharply limiting the hours worked per week. Since many of these individuals already have very low incomes, the cutback will be financially catastrophic.

It is really tragic that a program theoretically designed to expand health care coverage is having such a negative impact on employment itself. This would never have happened had we enacted a single payer system. We still can, you know.

Physician says Affordable Care Act an 'experiment' that will fail

By Lori Kersey
The Charleston Gazette, April 25, 2013

DAWES, W.Va. — The Affordable Care Act is an experiment that will fail, the head of an organization that advocates for a single-payer health system argued Thursday.

“People will not be able to afford the health insurance that they’re being pushed to buy,” Dr. Andrew Coates, president of Physicians for a National Health Program (PNHP), said during a visit to West Virginia on Thursday. “And when they do buy it, it won’t be good enough to cover health-care calamity.”

Under the ACA, health insurance premiums and deductibles will not be affordable, Coates argued.

“I think it’s a big experiment to drive people to [the health insurance] marketplace but the health insurance marketplace hasn’t worked for years now and I don’t see any evidence that’s going to change,” he said.

Coates, an assistant professor of medicine and psychiatry at Albany Medical College, practices at a community hospital in upstate New York. During a visit to the Charleston area Thursday, he spoke to the staff at the Cabin Creek Health Center in Dawes.

Later on Thursday, Coates spoke about the pros and cons of the Affordable Care Act at the University of Charleston, where he shared a platform with Perry Bryant, executive director of West Virginians for Affordable Health Care.

Coates’ visit was sponsored in part by the West Virginia chapter of PNHP.

“People say [a single-payer system] can’t work here,” said Dr. James Binder of the West Virginia chapter. “That’s not true.”

Instead of the Affordable Care Act, which would potentially expand Medicaid to millions of low-income Americans, Coates is campaigning for expanded Medicare for all Americans. That would include an expansion of what Medicare covers. For instance, dental care should be covered, he said.

Research shows that this would actually help provide comprehensive care to everybody and also reduce costs, Coates said.

He argues that by eliminating private insurance and using a single-payer model, the United States could save more than $400 billion a year used for paperwork.

Private insurers, Coates said, do not contribute to the health-care system.

“It’s really not a legitimate or justifiable way to make money,” Coates said. “We’re talking about human illness. Think of the morality.”

The government is already raising and spending enough public money to cover everyone, Coates said.

“Health care is such a necessity of modern life and it’s so unaffordable in many ways for working people,” Coates said. “If everyone could not have to worry about their loved ones getting the care they deserve, it would be liberating for the whole country.”

Coates said the single-payer system differs from socialized medicine because private physicians would care for patients.

The U.S. Department of Veterans Affairs, in which the federal government owns the hospitals and pays the medical staff, is a better example of socialized medicine, he said.

“The veterans administration is working very well,” Coates said. “Being under public control is a very good thing. The attention that Congress puts in to improving the quality of care for veterans is completely appropriate.”

The single-payer system is a small step to a socialized health system, not a big one, Coates said.

“Any reform effort in health care — for decades now — someone has shouted ‘socialism,'” Coates said.

He added that in countries like Canada and New Zealand, where single-payer systems have been put in place, it hasn’t been a threat to democracy.

Reach Lori Kersey at lori.ker…@wvgazette.com or 304-348-1240.

http://www.wvgazette.com/News/201304250121

A noted Republican physician executive talks about single payer

I Am A Republican… Can We Talk About A Single Payer System?

By David May
ACC-in-Touch Blog, American College of Cardiology, April 23, 2013

I am a Republican. For those who know me that is not a surprise. I live in a red state. I have never voted for a Democratic presidential candidate. I can field strip, clean and reassemble a Remington 12-gauge pump blindfolded. And on top of it, I think we should talk about having a single payer national health care plan. The reason is quite simple. In my view, we already have one; we just don’t take advantage of it.

Firstly, Medicare and the Center for Medicare and Medicaid Services (CMS) are de facto setting all of the rules now. They are a single payer system. When we go to lobby the Hill, we lobby Congress and CMS. Talking to Blue Cross, Aetna, Cigna and United Health care is essentially a waste of time. All the third party payers do is play off the Medicare rules to their advantage and profit. They have higher premiums, pay a somewhat higher benefit and have a significantly higher level of regulation which impedes the care of their customers. This is no longer consumer choice but effectively extortion, a less than hidden shake down in which the “choice” for a family of four is company A at $900 per month or company B at $1100 per month. The payers are simply taking advantage of the system, playing both ends against the middle.

Secondly, in order to move forward with true health care finance we need complete transparency in cost and expense… and we need it now. As was noted in a recent Time magazine piece on the hidden cost of health care, our current system is a vulgar, less than honorable construct more akin to used car sales than medical care, cloaked under the guise of generally accepted accounting principles and hospital cost shifting.

Thirdly, with a single payer system would potentially come real utilization data, real quality metrics and real accountability. The promise of ICD-10 with all of its difficulties is that of a much more granular claims-made data. We could use some granularity in health care data and we will never achieve it in big data quantities without a single payer system.

Lastly, I think that the physicians should be in charge of health care and not the insurance companies and hospital systems. With a single price structure, it becomes all about medical decision making, efficiency, the provision of care to our patients, and shared decision making, all of which we do well.

How, you might say, could a Republican come to such a position? The simple answer is I really think it is quite Republican. Oh, I know there will be many raised eyebrows and many critics. I accept that. I understand the fact that no single payer system is perfect, that it is “socialist,” that it is “un-American.”

I would submit to you, however, that it is un-American to allow many of our citizens to be uninsured, that it is un-American to shunt money away from a strong military in order to support a bloated, inefficient and fraud-laden health care system, that it is un-American not to be open and above board with the cost of what we do, the expense of that service and the profit that we make. Mostly, it is un-American to let this outrageous health care injustice continue.

(David May, MD, PhD, FACC, is chair of the Board of Governors of the American College of Cardiology. He invites responses to his comments at the link below.)

http://blog.cardiosource.org/post/I-Am-A-Republicane280a6-Can-We-Talk-About-A-Single-Payer-System.aspx

Comment:

By Don McCanne, M.D.

David May provides an important lesson for those who think that the single payer concept falls on the far left of a linear political spectrum. Society is not linear; it’s four dimensional. If we look at all dimensions, single payer clearly prevails. We can thank Dr. May for shattering the traditional but flawed construct of health care ideology.

Protecting Finances and Improving Access to Care with Medicaid

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