PNHP

Evolving Role of Emergency Departments

Evolving Role of Emergency Departments

The Evolving Role of Emergency Departments in the United States

By Kristy Gonzalez Morganti, Sebastian Bauhoff, Janice C. Blanchard, Mahshid Abir, Neema Iyer, Alexandria Smith, Joseph V. Vesely, Edward Okeke, Arthur L. Kellermann
RAND Health, May 20, 2013

To develop a more complete picture of how EDs (emergency departments) contribute to our modern health care system, the Emergency Medicine Action Fund asked RAND to conduct this mixed-methods study.

Key findings include the following:

• Between 2003 and 2009, inpatient admissions to U.S. hospitals grew at a slower rate than the population overall. However, nearly all of the growth in admissions was due to a 17 percent increase in unscheduled inpatient admissions from EDs. This growth in ED admissions more than offset a 10 percent decrease in admissions from doctors’ offices and other outpatient settings. This pattern suggests that office-based physicians are directing to EDs some of the patients they previously admitted to the hospital.

• In addition to serving as an increasingly important portal of hospital admissions, EDs support primary care practices by performing complex diagnostic workups and handling overflow, after-hours, and weekend demand for care. Almost all of the physicians we interviewed—specialist and primary care alike—confirmed that office-based physicians increasingly rely on EDs to evaluate complex patients with potentially serious problems, rather than managing these patient themselves.

• As a result of these shifts in practice, emergency physicians are increasingly serving as the major decisionmaker for approximately half of all hospital admissions in the United States. This role has important financial implications, not only because admissions generate the bulk of facility revenue for hospitals, but also because inpatient care accounts for 31 percent of national health care spending.

• Although the core role of EDs is to evaluate and stabilize seriously ill and injured patients, the vast majority of patients who seek care in an ED walk in the front door and leave the same way. Data from the Community Tracking Study indicate that most ambulatory patients do not use EDs for the sake of convenience. Rather, they seek care in EDs because they perceive no viable alternative exists, or because a health care provider sent them there.

• Medicare accounts for more inpatient admissions from EDs than any other payer. To gain insight into whether care coordination makes a difference in the likelihood of hospital admission from an ED, we compared ED admission rates among Medicare beneficiaries enrolled in a Medicare Choice plan versus beneficiaries enrolled in Medicare fee-for-service (FFS). We found no clear effect on inpatient admissions overall, or on a subset of admissions involving conditions that might be considered “judgment calls.”

• Irrespective of the impact of care coordination, EDs may be playing a constructive role in constraining the growth of inpatient admissions. Although the number of non-elective ED admissions has increased substantially over the past decade, inpatient admissions of ED patients with “potentially preventable admissions” (as defined by the Agency for Healthcare Research and Quality) are flat over this time interval.

Our study indicates that: (1) EDs have become an important source of admissions for American hospitals; (2) EDs are being used with increasing frequency to conduct complex diagnostic workups of patients with worrisome symptoms; (3) Despite recent efforts to strengthen primary care, the principal reason patients visit EDs for non-emergent outpatient care is lack of timely options elsewhere; and (4) EDs may be playing a constructive role in preventing some hospital admissions, particularly those involving patients with an ambulatory care sensitive condition. Policymakers, third party payers, and the public should be aware of the various ways EDs meet the health care needs of the communities they serve and support the efforts of ED providers to more effectively integrate ED operations into both inpatient and outpatient care.

http://www.rand.org/pubs/research_reports/RR280.html

Comment:

By Don McCanne, M.D.

This RAND Health report provides an excellent perspective on how emergency departments (EDs) have evolved into institutions providing a greater central role in health care delivery. It is a particularly valuable report because it sets aside many misperceptions about ED functions – misperceptions that can lead to flawed policy recommendations.

It is crucial that we continue to assess and recommend improvements in the health care delivery system. This report reflects the benefit of such an approach since EDs have expanded their roles in very beneficial ways. As they continue to evolve, integration with both inpatient and outpatient care should become more efficient, especially from the perspective of benefiting patients.

The current focus of policy reform seems to be not so much on the improvement of health care delivery, but rather on mechanisms that supposedly would slow the growth in health care spending. Accountable care organizations, bundling of payments, innovative insurance designs such as those that erect financial barriers to care, are the types of policy approaches that will have very little impact on overall costs while inappropriately expanding the administrative excesses of our dysfunctional system.

This report is well worth downloading. As you read it, you can see many opportunities to further expand the progress that we have seen through the evolving improvements in the role of EDs in our health care system. Thinking about how further improvement in integrating their role with both inpatient and various community outpatient services can help us envision further opportunities to achieve the goals of a high-performance system.

An example of the misguided and misdirected emphasis on innovative payment reform is the failure to find any clear effect on inpatient admissions when comparing the public Medicare program with the much more expensive private Medicare Advantage plans. Payment innovation is simply not where it’s at.

We need to get this right. Let’s continue to work on fixing the health care delivery system so that it works best for patients. That is the key to improving value in health care. It will work as long as we adopt a financing system that is designed exclusively to fund a high-performance health care system (single payer), as opposed to one that is designed to keep policy wonks and insurance administrators employed in bringing us ever-expanding payment innovations that we don’t want (Obamacare).

‘We need health care for all’: Dr. Steve Auerbach on Fox News

Dr. Steve Auerbach, a pediatrician in New York City and a member of the executive board of the N.Y. Metro chapter of Physicians for a National Health Program, appeared on the “Stossel Show” on Fox Business News on April 25. This 7-minute video segment, moderated by host John Stossel, features a debate between Dr. Auerbach and Dr. Lee Hieb, an orthopedic surgeon, on the theme of “Free market vs. government health care.”

Some employers, insurers conspire on bare-bones plans

Employers Eye Bare-Bones Health Plans Under New Law

By Christopher Weaver and Anna Wilde Matthews
The Wall Street Journal, May 19, 2013

Employers are increasingly recognizing they may be able to avoid certain penalties under the federal health law by offering very limited plans that can lack key benefits such as hospital coverage.

Benefits advisers and insurance brokers—bucking a commonly held expectation that the law would broadly enrich benefits—are pitching these low-benefit plans around the country. They cover minimal requirements such as preventive services, but often little more. Some of the plans wouldn’t cover surgery, X-rays or prenatal care at all.

Federal officials say this type of plan, in concept, would appear to qualify as acceptable minimum coverage under the law, and let most employers avoid an across-the-workforce $2,000-per-worker penalty for firms that offer nothing.

The idea that such plans would be allowable under the law has emerged only recently. Some benefits advisers still feel they could face regulatory uncertainty. The law requires employers with 50 or more workers to offer coverage to their workers or pay a penalty. Many employers and benefits experts have understood the rules to require robust insurance, covering a list of “essential” benefits such as mental-health services and a high percentage of workers’ overall costs.

But a close reading of the rules makes it clear that those mandates affect only plans sponsored by insurers that are sold to small businesses and individuals, federal officials confirm. That affects only about 30 million of the more than 160 million people with private insurance, including 19 million people covered by employers, according to a Citigroup Inc. C +0.20% report. Larger employers, generally with more than 50 workers, need cover only preventive services, without a lifetime or annual dollar-value limit, in order to avoid the across-the-workforce penalty.

Such policies would generally cost far less to provide than paying the penalty or providing more comprehensive benefits, say benefit-services firms.

Administration officials confirmed in interviews that the skinny plans, in concept, would be sufficient to avoid the across-the-workforce penalty. Several expressed surprise that employers would consider the approach.

Firms now offering low-cost policies known as mini-meds, generally plans that cap benefits at low levels, could favor the tactic. Companies sought federal health department waivers to cover nearly four million with mini-meds and other similar plans, which will be barred next year. Some employers are “thinking of this as a replacement for the mini-med plan,” said Tracy Watts, national leader for health-care reform at Mercer, a consulting unit of Marsh & McLennan Cos.

San Antonio-based Bill Miller Bar-B-Q, a 4,200-worker chain, will replace its own mini-med with a new, skinny plan in July. The new plan… will cover only preventive services, six annual doctors’ visits and generic drugs. X-rays and tests at a local urgent care chain will also be covered. It wouldn’t cover surgeries or hospital stays.

Tex-Mex restaurant chain El Fenix also said it would offer limited plans to its 1,200 workers, covering doctors visits, preventive care and drugs, but not hospital stays or surgery.

http://online.wsj.com/article/SB10001424127887324787004578493274030598186.html

Comment:

By Don McCanne, M.D.

Imagine health insurance not covering hospitalizations nor surgery. Yet this is still possible because the Affordable Care Act applies the essential health benefit requirement only to plans for small businesses and individuals and not to larger employers.

This has opened up the opportunity for a conspiracy between larger employers who could care less whether or not their employees have health insurance and private insurers who are quite willing to sell these almost worthless bare-bones products as long as there is a profitable market for them.

The solution is obvious. Cover all care that people need, and then provide that coverage to everyone, automatically. Maybe these uncaring employers might not like that, but when the taxes to pay for an equitable system are obligatory, they would get used to the idea of their employees being able to obtain health care when they need it. Not such a bad idea after all, especially when their competitors are treated the same.

OECD report on income inequality and poverty

Growing risk of inequality and poverty as crisis hits the poor hardest

OECD, May 15, 2013

Income inequality increased by more in the first three years of the crisis to the end of 2010 than it had in the previous twelve years, before factoring in the effect of taxes and transfers on income, according to new OECD report and data.

After taxes and transfers, the richest 10 per cent of the population in OECD countries earned 9.5 times the income of the poorest 10 per cent in 2010, up from 9 times in 2007. The gap is largest in Chile, Mexico, Turkey, the United States and Israel, and lowest in Iceland, Slovenia, Norway and Denmark.

Gini Coefficient (higher = greater inequality)
0.316  OECD average (after taxes and transfers)
0.380  United States (after taxes and transfers)
0.499  United States (before taxes and transfers)
0.320  Canada (after taxes and transfers)
0.447  Canada (before taxes and transfers)

Relative Income Poverty Rates
11.1%  OECD average (after taxes and transfers)
17.4%  United States (after taxes and transfers)
28.4%  United States (before taxes and transfers)
11.9%  Canada (after taxes and transfers)
26.0%  Canada (before taxes and transfers)

http://www.oecd.org/newsroom/growing-risk-of-inequality-and-poverty-as-crisis-hits-the-poor-hardest-says-oecd.htm

OECD report (8 pages): http://www.oecd.org/els/soc/OECD2013-Inequality-and-Poverty-8p.pdf

Comment:

By Don McCanne, M.D.

Compared to the average member nation of the Organization for Economic Cooperation and Development (OECD), the United States has higher levels of poverty and a greater inequality in income.

This OECD report does demonstrate that taxes and transfers (social welfare programs) do reduce the gap, but when you compare the United States and Canada on the amount of redistribution that takes place as a result of these policies, you see that we are much less equitable than Canada.

Although our politicians claim that our taxes are too high and that we need to cut social programs, these results suggest the opposite – that we need more progressive taxes and more generous social benefit programs – maybe like Canada’s single payer Medicare program.

Medicare for All?

By Chuck Thompson
PhillyBurbs.com, May 16, 2013

Nearly two years ago, I turned 65 and signed up for Medicare. I was actually dreading this move as one often fears change, particularly when it relates to health care plans. For nearly 16 years, my wife and I operated our own consulting company and paid in excess of $14,000 a year in health care premiums. When the cost threatened to bury us, my wife got a job with a private company that provided health care coverage for her and me. With her company’s plan acting as the supplement for Medicare when I turned 65, I soon learned that I would be receiving basically the same kind of coverage that I had for decades before on private plans.

Recently I took some time to read volumes of material on the development of Medicare. Basically it was part of the general discussion of the need for universal health care in the United States that dated back to 1911 when the British National Health Insurance program was enacted. A concerted effort to pass medical care for the elderly – which led to the enactment of the program known as Medicare – took more than two decades to come to fruition. It was opposed by the usual gang of conservatives employing their typical scare tactics, with a heavy dose of the money needed to employ an army of lobbyists coming from the American Medicine Association, the doctors’ NRA.

Was Medicare immediately hailed as a major tool in the improvement of medical care in America? Not quite. According to a column written by the Washington Post’s Ezra Klein, after Lyndon Johnson was elected and started the final push for Medicare, a Harris poll found only a minority of Americans, 46%, supported a federal plan to extend health care to the aged. “Today, of course,” Klein points out, “Medicare is overwhelmingly popular.” And it has proved to be a major boon to the very doctors who fought against it for so many years. It has also proved, in my estimation, that government can do a much better job regulating and providing quality, affordable medical care than can private industry.

Medicare may have been a major leap forward, but the U.S. continued to stand almost entirely alone among developed nations that lack universal health care. The Affordable Care Act, passed in 2010 and still in the implementation phase, will go a long way in meeting the needs of the rest of the people, without affecting people who are happy with the plans they currently have.

In the final analysis, however, I wonder how long people will be happy with their current health care plans. Flash back to my wife obtaining medical coverage from her employer. Initially, we were very content with the Blue Cross/Blue Shield Personal Choice plan with limited co-pays and the ability to go to any doctor or specialist of our choice. Ultimately, that plan became too expensive for her employer and last year it evolved into a plan with a $4,000 deductible that had to be met before it started to pick up any of the costs for hospitalization, doctors or prescriptions. I learned from my pharmacist that this is becoming very commonplace among employer health care plans. They should be called insurance for catastrophic illnesses and not much else.

Recently, her company downsized and she was laid off. She applied for COBRA insurance for herself and I started looking into supplement plans for me. Through AARP, I got a supplement plan that has very low co-pays for doctor visits (actually none at all for my family physician and no higher than $20 for specialists), and prescription coverage for a premium of less than $160 per month (compared to the almost $500 a month she has to pay for the COBRA plan).

In other words, what I have now is actually superior to and costs far less than what we had under Blue Cross/Blue Shield Personal Choice years ago. There is some merit to the argument that the U.S. could have achieved universal health care with much less hue and cry if it had just expanded Medicare to cover all. But, hell, that would have been socialized medicine, and we can’t have that.

Chuck Thompson is a former Middletown Township supervisor, journalist and marketing consultant. He has worked on a number of political campaigns and most recently was a team staging leader for the Obama campaign. He has published his first novel, McCurry’s War, which is based on his experience as a voice intercept operator in Berlin in the late ‘60s. Contact him at chuckthompson@comcast.net.

http://www.phillyburbs.com/blogs/politically_astute/medicare-for-all/article_b9e024ca-ba78-5583-a2c2-bbb8f4b40304.html

Rough sailing ahead for health care reform, but it’s not our only option

By Dr. Philip Caper
Bangor Daily News, May 16, 2013

You know another storm is brewing when Washington politicians start looking for somebody else to blame for problems they themselves created.

That’s what happened recently at a Senate budget hearing when Finance Committee Chairman Max Baucus unloaded on Kathleen Sebelius, President Barack Obama’s health and human services secretary. He berated her for failing to adequately educate the public or competently implement the 2,000-plus page Patient Protection and Affordable Care Act, or Obamacare. During the hearing, Baucus worried aloud about “a huge train wreck coming down” if the Obama administration didn’t clean up its act. Other Democrats soon piled on.

Aside from being known as one of the most prolific producers of lobbyists from among his staffers in the Senate, Baucus is probably best known as one of Obamacare’s prime architects.

Baucus is right to worry that the law may in fact run into extreme turbulence. It is far too complex. It has too many moving and interdependent parts to be smoothly implemented by anybody, no matter how talented or highly motivated, and it is too controversial.

There are a lot of people in and out of Congress — about 50 percent of Americans, according to the latest polls — who do not want to see the law implemented and will find ways to sabotage it. The law itself provides no shortage of opportunities to do so.

First, there is the challenge of setting up the health insurance exchanges in every state, when almost half the states, including Maine, have indicated no interest in doing it themselves. In those states, that job will fall on the federal government.

Then there is the law’s expansion and standardization of Medicaid — optional for each state, since the Supreme Court last year found making it mandatory to be unconstitutional. A large number of Republican governors, including Maine’s, have so far shown little interest in expanding that program.

The law also intends to expand the federal Community Health Center program. Republicans and others opposed to an expansion of government can be relied on to resist funding that program every chance they get. They will also resist expanding funding for the law’s subsidies for the purchase of private insurance.

In addition, the complexity of the law has created a huge number of unknowns. Each unknown creates plenty of opportunities for mischief in the future. Some examples: How many healthy young people will sign up for the exchanges (thus keeping premiums down for others) instead of simply paying or dodging the tax penalties? How many businesses will choose not to hire that 50th employee to avoid the mandatory coverage provisions of the law?

It now appears that federal subsidies in the exchanges may apply only to employees, and not dependents. How will this affect employees’ willingness to sign up for increasingly expensive family health insurance coverage? How will mid-year changes in employment or income affect the operation of the program and those covered by it? How will labor mobility be affected by this new system, and how will that affect the general economy?

There are lots more unknowns, but you get the idea. Complexity, not implementation, is the underlying pathology of Obamacare. Congress, not the administration, bears the brunt of the responsibility for that.

Mr. Baucus surely knew about this at the time of the law’s passage. After his own constituents in Libby, Mont., became uninsurable by private insurance due to industrial pollution with carcinogens and were unable to get the courts to hold the polluters responsible, Baucus came to the rescue. He simply tucked a little provision into the massive health reform bill making affected Montanans eligible for — you guessed it — Medicare.

No health insurance exchanges for these hardworking folks. Nothing but the best for Libby. By taking the simple, direct and most efficient route to expanding health-care coverage, Mr. Baucus did the right thing by his constituents. But Baucus made sure that everybody else had to settle for Obamacare.

It has been observed that “Americans will always do the right thing, once they’ve exhausted all alternatives.” I’m not holding my breath waiting for Congress to revisit health care reform anytime soon. But there is a lot we can do here in Maine to make health care a human right. Under the new law’s provisions we, like Vermont, can begin to move down a path to universal coverage in our state starting in 2017.

In some ways, we’re not as lucky as Vermont. Unlike Vermont, we have a large for-profit insurance presence in Maine. That means there’s a lot of money at stake. There will therefore be a lot of resistance.

But unlike Vermont, in addition to our ability to replace politicians who fail to act in the interests of the majority, we can use the initiative and referendum processes to express the people’s will directly.

It won’t be easy. But all we need is for most of us to have a common understanding of what to do and the will to do it. Are we up for it?

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com.

http://bangordailynews.com/2013/05/16/health/rough-sailing-ahead-for-health-care-reform-but-its-not-our-only-option/

Redistributive function of Canada's single payer

Publicly Financed Health Care in Canada: Who Pays and Who Benefits Over a Lifetime?

Canadian Institute for Health Information, May 2013

Conclusion

All Canadian taxpayers contribute to publicly financed health care, regardless of their use of the system. Publicly funded health care services are available to all on the basis of need, regardless of ability to pay. When we look at the relationship over a lifetime, only the most affluent (the top 20%) contribute significantly more to health care than they receive. For other income groups, the value received from publicly funded health care is approximately the same as or more than the value of taxes paid to fund those services. The redistributive effect of publicly funded health care in Canada is a 16% reduction in the income gap between the highest- and lowest-income groups. Without the publicly financed health system, the lowest-income Canadians would be at risk of going without needed health care or of being impoverished by paying for it.

https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC2192

Comment:

By Don McCanne, M.D.

This report from Canada demonstrates one of the more important functions of a well designed single payer system. To ensure access while preventing impoverishment, financing must be redistributive, because health care costs are unaffordable for moderate and low income individuals and families. Not only does the redistributive financing ensure universal access, it also ameliorates, to a limited extent, the impact of the worsening Gini coefficient (measure of income inequality).

Oregon's single-payer activists keep dream of universal health care alive

A separate measure, giving state sponsorship of a comprehensive study on universal healthcare financing, makes its way through the Committee on Ways & Means

By Christopher David Gray
The Lund Report, May 15, 2013

SALEM, Ore. — Wes Brain was uninsured last winter when a tonsillectomy showed signs of throat cancer. He qualified for the high-risk Oregon Medical Insurance Pool, which the state has administered through Regence BlueCross BlueShield.

But gaining access to that insurance soon proved a big obstacle for the Ashland resident, when Regence erroneously told him he hadn’t submitted his driver’s license.

“Denial and delay, denial and delay are the way these insurance companies work. They make money this way,” Brain vented to the House Health Committee on Tuesday. He had previously lost his daughter after a nine-year struggle with leukemia while contending with insurance companies over access to necessary health care services.

Eventually, his policy was approved. He paid $2,400 — three month’s premium. His doctor ordered a PET scan for March 1. But then Regence came back and told him no, he’d have to wait until March 1 to even begin authorization.

His clock was ticking. His throat cancer could be spreading.

He enlisted his local Rep. Peter Buckley, D-Ashland, to help him. He got the state Insurance Division on his case.

They came through. He received his PET scan, and spent four days at Oregon Health & Science University, receiving additional tonsil surgery. “They cut the hell out of me,” said Brain, who’s now cancer-free.

“There is no way that Regence should have delayed my care at all,” Brain added. “That’s how they do business. They kill people doing it. Let’s get them the hell out of it, and let’s pass this bill.”

Buckley and 23 other Democrats have signed on to support House Bill 2922, which would throw out the private health insurance industry and set up a single-payer health insurance system administered by the Oregon Health Authority.

The bill has no chance of passage this session, but House Health Committee Chairman Rep. Mitch Greenlick allowed fellow Portland Democrat and chief sponsor Rep. Michael Dembrow to lead single-payer health care advocates in an informational public hearing.

Brain and other activists aired their support for a privately delivered, government-sponsored health system that would revolutionize Oregon health care and make it similar to health systems in Japan, Europe, Canada and the rest of the developed world.

HB 2922 closely parallels House Bill 3510 from the 2011 session, but at 76 pages, it’s 30 percent longer than the previous measure, repealing newly acted reforms such as Cover Oregon, which offers subsidized private insurance for people with moderate incomes.

No Republicans have yet come on board as supporters, but the single-payer bill has twice as many sponsors this session from Democrats across the state, including rural districts as well as Portland and Eugene. Two of the state’s largest unions – the Oregon Nurses Association and the Oregon Education Association – have also thrown their support behind the measure.

Study Bill Moves Forward

Dembrow has also sponsored House Bill 3260, which had a budget hearing on Tuesday. That bill, which passed unanimously earlier this session from the House Health Committee, would solicit $250,000 to $600,000 in private funds to comprehensively study how best to implement universal health care in Oregon.

The study will look at several different options, including single-payer, a public option and the basic health plan envisioned for low-income people who wouldn’t qualify for Medicaid by the Affordable Care Act.

Chunhuei Chi, a professor at Oregon State University’s College of Public Health and Human Sciences, told The Lund Report the study would aim for transparency, be replicable and available for peer review. The Oregon Health Authority could either choose Oregon State or another entity to conduct the study.

Previously, Health Care for All Oregon, which supports the single-payer bill, had considered asking the Northwest Health Foundation to conduct such a study. But according to Dembrow, a state-sanctioned study would lend more credibility.

Earlier, he told The Lund Report that while he expects single payer the best route to universal health care, he believes the underlying bill is written well enough to turn into the best solution for Oregon, and he will support its recommendations.

“This is exactly the way it’s done,” said Sen. Elizabeth Steiner Hayward, D-Portland, who favors doing such a study but has not come out in support of the single-payer option. “I like that you’ve laid out a menu of options, and that it doesn’t make a predetermined decision,” she added, calling the study outcome-based rather than motivated by political ideology.

Contrasting Systems

Alan Journet, a retired professor and dual British-U.S. citizen, pointed out that in Great Britain, socialized medicine is so popular even Conservative icon, former Prime Minister Margaret Thatcher, was a big supporter.

While living in the U.S., he came down with cancer and was given two months to live, absent treatment. “Thanks to insurance, I didn’t have to worry much about the cost of treatment, but I did constantly have to worry about the insurance company approving doctor-recommended treatment,” Journet said.

Journet said he felt lucky — his insurance company approved his treatment, unlike his sister-in-law who fell ill earlier.

“Her insurance company denied treatment, and she died,” Journet said. “We often hear the complaint that we should fear government functionaries making decisions on treatment, as though we are better served having insurance company functionaries make such decisions, employees whose income encourages denying treatment and generating a sizable profit.”

Dembrow said his passion for single-payer health care started following the birth of his two children. His daughter, who was born in France, received exemplary care, including house calls from physicians for just a small co-payment and a tax taken out of the family paychecks.

His son, on the other hand, was born in Indiana. At the time, insurance companies weren’t required to cover infants for the first 30 days of their life. His son had a digestive abnormality called pyloric stenosis that required surgery. A graduate student at the time, Dembrow and his wife had to deplete their savings to pay for the care.

“The contrast of those experiences have committed me to try to do things differently in this country,” Dembrow said.

Dembrow praised the reform efforts of Gov. Kitzhaber to deliver health care for the poor through coordinated care organizations and also lauded many of the aspects of the Affordable Care Act, including the expanded Oregon Health Plan and the insurance exchange. Yet, he said these reforms fall far short of an equitable universal health care system.

“We’ll continue to have jobs kept temporary or part-time for no good reason other than to keep workers from being eligible for coverage,” he said. “Our system will still rely on private insurance companies who charge high administrative fees, create administrative burdens for doctors and other health care professionals, and whose primary interest is their own profits. … At best what we’re going to continue to have an expensive, complicated patchwork system.”

http://www.thelundreport.org/resource/single_payer_activists_keep_dream_of_universal_healthcare_alive

CBO now estimates 31 million will remain uninsured

CBO’s Estimate of the Net Budgetary Impact of the Affordable Care Act’s Health Insurance Coverage Provisions Has Not Changed Much Over Time

Congressional Budget Office, May 14, 2013

Proposed regulations recently issued by the Department of Health and Human Services and the Department of the Treasury expanded the number of people who will be exempt from paying a penalty for being uninsured relative to our previous expectations. CBO and JCT now expect that, as a result of those regulations, between 500,000 and 1 million fewer people will obtain health insurance coverage each year. In our current projections for 2023, the ACA reduces the number of people without health insurance by 25 million, leaving 31 million uninsured (compared with 30 million in our February estimate).
http://www.cbo.gov/publication/44176

Comment:

By Don McCanne, M.D.

After the Affordable Care Act is fully implemented ten years from now, the number of people who will remain uninsured is estimated to be 31 million. Since there will be a net gain of 25 million with insurance, that means that Obamacare – a plan to cover everyone – will have been only 45 percent effective in the goal of reducing the net number of uninsured. Pretty lousy.

This result on the uninsured will put us just about where we were when the Clintons began their effort to achieve universal coverage. It was a crisis then, and it will still be a crisis after we’ve expended far too much money and time on this terribly flawed effort.

Forget repeal, REPLACE!

Psychiatrists Waste Millions of Hours Obtaining Prior Auths

Health Insurers Require Time Consuming Prior Auths for Emergent Psych Admissions

By J. Wesley Boyd, M.D., Ph.D.
Psychology Today, Almost Addicted blog, May 14, 2013

My colleagues and I recently tabulated how long psychiatric patients who were deemed in need of inpatient admission — overwhelmingly because of suicidal thoughts or plans — stayed in the emergency department prior to being hospitalized, as well as the amount of time that the emergency department psychiatrists spent obtaining authorization from the patient’s insurer.

We found both lengthy waits for severely ill psychiatric patients in need of immediate hospitalization as well as time consuming prior authorizations required by insurance companies and published our findings in Annals of Emergency Medicine.

In our study psychiatric personnel spent, on average, 38 minutes on the telephone getting authorization. In 10% of cases it took more than one hour to obtain insurance authorization; in one case authorization took five hours of psychiatrist time. On top of the time required to obtain authorization, psychiatric patients who need admissions wait a long time for inpatient beds to open up. The total time that patients remained in the ER in our study averaged 8.5 hours.

Our data don’t include a handful of patients who boarded in the ED over the weekend while waiting for an inpatient bed to become available for them and also excluded uninsured patients and those with Medicare, which doesn’t require prior authorization.

A much larger study published just before ours found even longer wait times — more than 11 hours while awaiting placement into an inpatient facility.

Out of 53 requests, we had only one prior authorization request denied, so basically the process of calling the insurance company, relaying patient information, and obtaining her authorization to pay for admission, is a needless, time consuming process given that the end result — namely, the insurance company saying they will in fact pay for the admission — is a foregone conclusion provided I jump through the proper hoops.

Imagine if women in labor required this kind of authorization or if children with ruptured appendices did? There would be a public outcry and the practice would end immediately.

Given that there are approximately 2.5 million inpatient psychiatric admissions annually in the US, if two-thirds of them require some form of prior authorization (which is likely an underestimate), then roughly a million hours of time annually is wasted by psychiatric clinicians obtaining these authorizations. Add to that the many day hospital admission and psychiatric medication requests that also require prior authorization from insurance companies, and the total number of psychiatric clinician hours spent on the phone asking for authorization of service is staggering.  

Just today, for example, I spent 25 minutes on the phone obtaining authorization for a psychiatric medication I prescribed for a 50-ish-year-old professional male. Knowing the call would take a chunk of time, I thought about not making the call and just having him pay out of pocket for the medication instead of taking my time to make the call, but I just couldn’t bring myself to concede defeat to his insurance company so, ultimately, I made the call.

This is a travesty. It is demoralizing to psychiatric clinicians. For me to have to calculate whether my time is worth it for an insurer to pay for medications it is supposed to pay for is pathetic.

It also testifies to the fact that psychiatric patients are singled out for this kind of scrutiny because they are vulnerable and often unwilling to publicly advocate for themselves, the way that pregnant or pediatric patients and their allies might. I’d wager that insurance companies hope to profit off this vulnerability, given that overworked clinicians might opt to, if they are on the fence about how to proceed, do something other than admitting their patients given the hassle of seeking authorization. My co-authors and I call this “rationing this by hassle factor.”

The humanity of societies is judged by how well they take care of their most vulnerable, and we undoubtedly need to do better.  Health insurance needs to provide real coverage and assurance to those in need, not set up roadblocks to needed care that deter clinicians from seeking care when it is life-saving.

If we had a health care system that was not profit driven — an improved Medicare for all would be ideal — then I’d wager such impediments to urgent care would not be present and patients could receive the care they need without unnecessary hurdles for healthcare clinicians to jump through, set up only to generate greater profit for insurers.
 
References:
Amy Funkenstein, MD, Monica Malowney, BA, J. Wesley Boyd, MD, PhD.  Insurance Prior Authorization Approval Does Not Substantially Lengthen the Emergency Department Length of Stay for Patients With Psychiatric Conditions.  Annals of Emergency Medicine, Volume 61, Issue 5, May 2013:  596–597

J. Wesley Boyd is on faculty at Harvard Medical School and is an Attending Psychiatrist at Cambridge Health Alliance and Children’s Hospital Boston.

http://www.psychologytoday.com/blog/almost-addicted/201305/psychiatrists-waste-millions-hours-obtaining-prior-auths

Can we talk about the ACA train wreck?

GOP Candidates' Top Campaign Issue Will Be Obamacare 'Train Wreck'

By Wendell Potter
The Huffington Post, May 6, 2013

Will the implementation of some of the most important provisions of ObamaCare this fall and next year result in the “train wreck” Senate Finance Chairman Max Baucus (D-Mont.) predicted a few days ago?

No. But you can be certain that there will be no shortage of political candidates and high-powered political spin doctors who will be working relentlessly between now and the 2014 midterms to convince us that it will be.

If the Democrats and consumer advocates who support ObamaCare are not at work developing their own strategies to counter the coming barrage of misleading spin, the GOP will have an excellent chance of controlling Capitol Hill after the next elections.

http://www.huffingtonpost.com/wendell-potter/gop-candidates-top-campai_b_3222876.html

Comment:

By Don McCanne, M.D.

Of those who are serious about health care reform, some want to abandon the Affordable Care Act (ACA) and immediately enact single payer, and others want to abandon the single payer cause and move full steam ahead with implementation of the ACA. But should we really abandon either approach?

It is clear that ACA alone will be grossly deficient. Thirty million people will remain uninsured, inadequate low actuarial value plans will become the new standard, and wasteful spending will continue because of the highly flawed, administratively complex model of ACA. So single payer should not be abandoned since it is an imperative if we want to have affordable health care for everyone.

Why shouldn’t we abandon ACA? Because, quite simply, it is all that we have right now, and it will provide some limited relief for millions of people. If we were to abandon ACA now, mobilizing a social movement and then enacting and implementing single payer would still take many years – too long for those who would receive some benefit from ACA now.

So we should do both. Let the ACA enthusiasts continue with the implementation, while single payer forces step up the social movement for health care justice though advocacy for an improved Medicare for everyone.

So where is the train wreck? There isn’t any. But Wendell Potter is right. The opponents of reform will latch onto every ACA implementation glitch, real or imagined, and onto the criticisms which will inevitably follow. They will attempt to frame the implementation as a debacle, and run with that in their effort to use election politics to advance their anti-government agenda.

This complicates the message for the single payer camp. We need to educate people as to why ACA will fall intolerably short of reform goals, but we do not want that to become part of the Repeal ACA message. The opponents initially supported Repeal and Replace, but they have largely abandoned Replace, concentrating on Repeal. So how do we counter the Repeal message?

We need to emphasize the positive message of single payer – truly affordable health care for everyone. We can add that we don’t need to repeal ACA since it can help some during the transition to single payer. But our action message should be Replace – letting the public know that we really do have a much better program that will work for everyone, whereas the opponents do not.

So perhaps a unifying message for the supporters of health care justice should be:

Forget Repeal, REPLACE!

Economist to speak in Charlotte about single payer health plan

By Karen Garloch
The Charlotte Observer, May 13, 2013

Dr. Gerald Friedman, a professor of economics at the University of Massachusetts at Amherst, will be in Charlotte May 23 to make the case for single payer, universal health care in the United States.

He won’t argue for that approach because health care is a human right – even though that’s what he believes.

Instead, he’ll make the case that it’s the only plan that makes economic sense.

To those who think we can’t afford it, Friedman responds: “What we can’t afford is the current system. The only thing we can afford in the long run is a universal, single payer system. That’s the only thing that will bring down the cost.”

Friedman’s talk is sponsored by Health Care Justice, a local chapter of Physicians for a National Health Program.

His analysis centers on the nation’s health insurance system, where competition among private payers leads to administrative redundancy that increases costs without improving anyone’s health.

In the early 1970s, when there was little competition and most people got private insurance from one organization (Blue Cross), U.S. health care spending amounted to about 7.5 percent of the gross national product, he said. Today, with dozens of competing insurers, health care costs have risen to nearly 18 percent of GDP.

Eighty percent of that difference “can be explained by rising administrative costs,” Friedman said.

The average U.S. doctor spends 22 hours a week interacting with insurance representatives, and the largest occupation in health care is billing clerks, he said.

Many economists believe competition is good. Offer the best product at the best price, and you’ll sell more. But health care is different, Friedman said.

“Health insurers don’t try to sell more product. They try to sell less … When you get sick, and they pay for an X-ray or chemotherapy, that’s a cost to them … I’m not saying they’re evil, but the incentive is in the direction of making life difficult for people who get sick.”

A single payer system would get rid of duplicate billing operations and the incentive to cherry pick patients.

Even though the Affordable Care Act, the law championed by the Obama administration, will expand insurance coverage, it won’t cover everyone, and it won’t contain costs, Friedman said.

In five or 10 years, he predicted, health costs will be even higher. Private employers and state and local governments will again feel squeezed and demand a solution.

Despite gridlock in Washington, Friedman is optimistic that single payer, universal health care will one day be law in the United States, as it is in so many other nations.

When asked why, he referred to a quote often attributed to Winston Churchill: “Americans will always do the right thing, after exhausting all the alternatives.”

More Information:
Free talk: “Sustainable Quality Health Care for North Carolina: Single Payer is not an Answer – it is the Answer”
Speaker: Dr. Gerald Friedman, professor of economics, University of Massachusetts at Amherst
When: May 23, 7 p.m.
Where: Midwood International and Cultural Center, 1817 Central Ave.

Read more here: http://www.charlotteobserver.com/2013/05/13/4039209/economist-to-speak-in-charlotte.html#storylink=cpy