PNHP

Woolhandler, Himmelstein and Relman on the right path for Medicare

Woolhandler, Himmelstein and Relman on the right path for Medicare

Sunday Dialogue: The Future of Medicare

The New York Times, February 23, 2013
Readers weigh in on problems with the health care program:
Canada’s Medicare program — phased in at the same time as the American version — shows how we can make Medicare simpler and thriftier, while simultaneously upgrading its coverage. Canada’s program covers all Canadians (not just the elderly) under a single public program in each province, and bans co-payments and deductibles.
Patients can choose any doctor and hospital. Cutting out private insurers and the complexity and fragmentation they impose has simplified paperwork for patients, doctors and hospitals. Administrative costs are roughly half United States levels, saving more than $1,000 per capita.
Over all, Medicare spending on the elderly has grown three times faster in the United States than in Canada since 1980, while life expectancy (for the elderly, as for all age groups) has grown faster in Canada. If American Medicare costs had risen at Canadian rates, we’d have saved more than $2 trillion by now, and Medicare’s trust fund would show a healthy surplus.
STEFFIE WOOLHANDLER
DAVID U. HIMMELSTEIN
New York, Feb. 20, 2013
The writers, internists and professors at the CUNY School of Public Health at Hunter College, co-founded Physicians for a National Health Program.
***
Medicare is headed for bankruptcy because it depends largely on open-ended fee-for-service payment of almost any services providers choose to deliver, at prices mainly determined by the providers. Compounding the problem, most providers act like independent businesses seeking to increase their income, regardless of whether they are for-profit or investor-owned.
An effective Medicare fix would require a new payment system that prospectively pays providers for comprehensive care at a rate set by a single public payer. It would also need a not-for-profit medical care system based on multispecialty doctor groups that pay physicians by salary, thus minimizing incentives to deliver duplicative or unnecessary care.
The new system would have to be mandatory for all citizens, including legislators, and it would have to be financed by a progressive, earmarked health care tax.
Obviously, such reform would be slow and difficult, but so would any other change that threatened vested interests. All reform will depend on an aroused public opinion.
ARNOLD S. RELMAN
Tucson, Feb. 21, 2013
The writer is professor emeritus of medicine and social medicine at Harvard Medical School and a former editor in chief of The New England Journal of Medicine.
http://www.nytimes.com/2013/02/24/opinion/sunday/sunday-dialogue-the-fut…

At a time when Congress and the Obama administration are contemplating a reduction in Medicare spending as a means of paring down our national budget deficit, it is important to remind the nation of the beneficial changes that we could be making to the Medicare program that would bring affordable, high quality care to everyone under a single payer Medicare budget that we could afford. The messages of Steffie Woolhandler, David Himmelstein and Arnold Relman need to drown out the messages of those who would send Medicare down the wrong path.

Impending access crisis for low-income patients

States Can Cut Back on Medicaid Payments, Administration Says

By Robert Pear
The New York Times, February 25, 2013

The Obama administration said Monday that states could cut Medicaid payments to many doctors and other health care providers to hold down costs in the program, which insures 60 million low-income people and will soon cover many more under the new health care law.

The administration’s position, set forth in a federal appeals court in California, has broad national implications as it comes as the White House is trying to persuade states to expand Medicaid as part of the new law.

In a brief filed with the United States Court of Appeals for the Ninth Circuit, in San Francisco, federal officials defended a decision by California to cut Medicaid payments to many providers by 10 percent.

Kathleen Sebelius, the secretary of health and human services, approved the cuts in October 2011 after finding that beneficiaries would still have “adequate access” to the wide range of services covered by Medicaid.

The Obama administration urged judges to uphold those cuts, which are being challenged by patients, doctors, dentists, hospitals, pharmacists and other health care providers in California.

Health care providers said California’s payment rates were inadequate even before the cuts. They pointed to a federal study that said, “California stands out because of its very low Medicaid payment levels.”

In an interview, Gov. Jerry Brown of California, a Democrat, said the Medicaid cuts were essential to his efforts to dig the state out of a budget hole.

Federal law says Medicaid rates must be “sufficient to enlist enough providers” so that Medicaid beneficiaries have access to care at least to the same extent as the general population in the same geographic area.

Moreover, the administration said, Congress gave states “wide discretion” to set Medicaid rates, and courts should not second-guess decisions by Secretary Sebelius on the adequacy of rates.

“There is no general mandate under Medicaid to reimburse providers for all or substantially all of their costs,” the administration said.

http://www.nytimes.com/2013/02/26/us/politics/states-can-cut-back-on-medicaid-payments-administration-says.html?_r=0

And…

Healthcare overhaul may threaten California’s safety net

By Anna Gorman
Los Angeles Times, February 25, 2013

An estimated 3 million to 4 million Californians — about 10% of the state’s population — could remain uninsured even after the healthcare overhaul law takes full effect. The burden of their care will fall to public hospitals, county health centers and community clinics. And those institutions may be in jeopardy.

County health leaders and others say the national health law has had the unintended consequence of threatening the financial stability of the state’s safety net.

And under the federal law, some of the funding that goes to safety-net hospitals is also set to decrease.

Now, as the state scrambles to create the new healthcare infrastructure, Gov. Jerry Brown is proposing to take back another crucial pot of money that counties have depended on for more than two decades to care for the uninsured.

http://www.latimes.com/health/la-me-left-uninsured-20130226,0,3348028.story

Comment:

By Don McCanne, M.D.

California has been a leader in setting national trends in health care financing. Two developments should have low-income patients very concerned. California’s Medicaid program is critically underfunded, and the state is reducing payment rates by another ten percent. Also, the state is reducing funding for local safety-net institutions which provide critical access for low-income populations.

Perhaps the most alarming of all is the official response of the Obama administration (in an appeals court filing): “There is no general mandate under Medicaid to reimburse providers for all or substantially all of their costs.”

We have said over and over again that Medicaid, as a welfare program, will never have the political support to fund it adequately. The burden of the additional load of Medicaid patients will surely find the health care resources strained beyond the capacity of willing providers, especially when you consider that California already is not meeting the costs of providing care to this vulnerable population. And the 3 to 4 million Californians who will remain uninsured will need to rely on the safety-net institutions, though those institutions also are in jeopardy – again because of the lack of political support for welfare programs.

If California is successful with its cruel budget trimming, it can be anticipated that many more states will follow.

Here’s an amazing fact: Low income patients do not have the money to pay for health care. (What an intuitive stroke of genius!) What they need is an affordable system that removes financial barriers to care while ensuring adequate financing of our entire health care delivery system, thereby removing health system disincentives to providing essential care for this vulnerable population. Make that for all of us.

Impending access crisis for low-income patients

States Can Cut Back on Medicaid Payments, Administration Says

By Robert Pear
The New York Times, February 25, 2013
The Obama administration said Monday that states could cut Medicaid payments to many doctors and other health care providers to hold down costs in the program, which insures 60 million low-income people and will soon cover many more under the new health care law.
The administration’s position, set forth in a federal appeals court in California, has broad national implications as it comes as the White House is trying to persuade states to expand Medicaid as part of the new law.
In a brief filed with the United States Court of Appeals for the Ninth Circuit, in San Francisco, federal officials defended a decision by California to cut Medicaid payments to many providers by 10 percent.
Kathleen Sebelius, the secretary of health and human services, approved the cuts in October 2011 after finding that beneficiaries would still have “adequate access” to the wide range of services covered by Medicaid.
The Obama administration urged judges to uphold those cuts, which are being challenged by patients, doctors, dentists, hospitals, pharmacists and other health care providers in California.
Health care providers said California’s payment rates were inadequate even before the cuts. They pointed to a federal study that said, “California stands out because of its very low Medicaid payment levels.”
In an interview, Gov. Jerry Brown of California, a Democrat, said the Medicaid cuts were essential to his efforts to dig the state out of a budget hole.
Federal law says Medicaid rates must be “sufficient to enlist enough providers” so that Medicaid beneficiaries have access to care at least to the same extent as the general population in the same geographic area.
Moreover, the administration said, Congress gave states “wide discretion” to set Medicaid rates, and courts should not second-guess decisions by Secretary Sebelius on the adequacy of rates.
“There is no general mandate under Medicaid to reimburse providers for all or substantially all of their costs,” the administration said.
http://www.nytimes.com/2013/02/26/us/politics/states-can-cut-back-on-med…
And…

Healthcare overhaul may threaten California’s safety net

By Anna Gorman
Los Angeles Times, February 25, 2013
An estimated 3 million to 4 million Californians — about 10% of the state’s population — could remain uninsured even after the healthcare overhaul law takes full effect. The burden of their care will fall to public hospitals, county health centers and community clinics. And those institutions may be in jeopardy.
County health leaders and others say the national health law has had the unintended consequence of threatening the financial stability of the state’s safety net.
And under the federal law, some of the funding that goes to safety-net hospitals is also set to decrease.
Now, as the state scrambles to create the new healthcare infrastructure, Gov. Jerry Brown is proposing to take back another crucial pot of money that counties have depended on for more than two decades to care for the uninsured.
http://www.latimes.com/health/la-me-left-uninsured-20130226,0,3348028.story

California has been a leader in setting national trends in health care financing. Two developments should have low-income patients very concerned. California’s Medicaid program is critically underfunded, and the state is reducing payment rates by another ten percent. Also, the state is reducing funding for local safety-net institutions which provide critical access for low-income populations.
Perhaps the most alarming of all is the official response of the Obama administration (in an appeals court filing): “There is no general mandate under Medicaid to reimburse providers for all or substantially all of their costs.”
We have said over and over again that Medicaid, as a welfare program, will never have the political support to fund it adequately. The burden of the additional load of Medicaid patients will surely find the health care resources strained beyond the capacity of willing providers, especially when you consider that California already is not meeting the costs of providing care to this vulnerable population. And the 3 to 4 million Californians who will remain uninsured will need to rely on the safety-net institutions, though those institutions also are in jeopardy – again because of the lack of political support for welfare programs.
If California is successful with its cruel budget trimming, it can be anticipated that many more states will follow.
Here’s an amazing fact: Low income patients do not have the money to pay for health care. (What an intuitive stroke of genius!) What they need is an affordable system that removes financial barriers to care while ensuring adequate financing of our entire health care delivery system, thereby removing health system disincentives to providing essential care for this vulnerable population. Make that for all of us.

TIME: Steven Brill's "bitter pill" should wake us up

Bitter Pill: Why Medical Bills Are Killing Us

By Steven Brill
TIME, February 20, 2013

The Way Out Of the Sinkhole

“I was driving through central Florida a year or two ago,” says Medicare’s (Jonathan) Blum. “And it seemed like every billboard I saw advertised some hospital with these big shiny buildings or showed some new wing of a hospital being constructed … So when you tell me that the hospitals say they are losing money on Medicare and shifting costs from Medicare patients to other patients, my reaction is that Central Florida is overflowing with Medicare patients and all those hospitals are expanding and advertising for Medicare patients. So you can’t tell me they’re losing money … Hospitals don’t lose money when they serve Medicare patients.”

If that’s the case, I asked, why not just extend the program to everyone and pay for it all by charging people under 65 the kinds of premiums they would pay to private insurance companies? “That’s not for me to say,” Blum replied.

In the debate over controlling Medicare costs, politicians from both parties continue to suggest that Congress raise the age of eligibility for Medicare from 65 to 67. Doing so, they argue, would save the government tens of billions of dollars a year. So it’s worth noting another detail about the case of Janice S., which we examined earlier. Had she felt those chest pains and gone to the Stamford Hospital emergency room a month later, she would have been on Medicare, because she would have just celebrated her 65th birthday.

If covered by Medicare, Janice S.’s $21,000 bill would have been deeply discounted and, as is standard, Medicare would have picked up 80% of the reduced cost. The bottom line is that Janice S. would probably have ended up paying $500 to $600 for her 20% share of her heart-attack scare. And she would have paid only a fraction of that — maybe $100 — if, like most Medicare beneficiaries, she had paid for supplemental insurance to cover most of that 20%.

In fact, those numbers would seem to argue for lowering the Medicare age, not raising it — and not just from Janice S.’s standpoint but also from the taxpayers’ side of the equation. That’s not a liberal argument for protecting entitlements while the deficit balloons. It’s just a matter of hardheaded arithmetic.

As currently constituted, Obamacare is going to require people like Janice S. to get private insurance coverage and will subsidize those who can’t afford it. But the cost of that private insurance — and therefore those subsidies — will be much higher than if the same people were enrolled in Medicare at an earlier age. That’s because Medicare buys health care services at much lower rates than any insurance company. Thus the best way both to lower the deficit and to help save money for people like Janice S. would seem to be to bring her and other near seniors into the Medicare system before they reach 65.

Meanwhile, adding younger people like Janice S. would lower the overall cost per beneficiary to Medicare and help cut its deficit still more, because younger members are likelier to be healthier.

If that logic applies to 64-year-olds, then it would seem to apply even more readily to healthier 40-year-olds or 18-year-olds. This is the single-payer approach favored by liberals and used by most developed countries.

***

Yet while Medicare may not be a realistic systemwide model for reform, the way Medicare works does demonstrate, by comparison, how the overall health care market doesn’t work.

Unless you are protected by Medicare, the health care market is not a market at all. It’s a crapshoot. People fare differently according to circumstances they can neither control nor predict. They may have no insurance. They may have insurance, but their employer chooses their insurance plan and it may have a payout limit or not cover a drug or treatment they need. They may or may not be old enough to be on Medicare or, given the different standards of the 50 states, be poor enough to be on Medicaid. If they’re not protected by Medicare or they’re protected only partly by private insurance with high co-pays, they have little visibility into pricing, let alone control of it. They have little choice of hospitals or the services they are billed for, even if they somehow know the prices before they get billed for the services. They have no idea what their bills mean, and those who maintain the chargemasters couldn’t explain them if they wanted to. How much of the bills they end up paying may depend on the generosity of the hospital or on whether they happen to get the help of a billing advocate. They have no choice of the drugs that they have to buy or the lab tests or CT scans that they have to get, and they would not know what to do if they did have a choice. They are powerless buyers in a seller’s market where the only sure thing is the profit of the sellers.

Indeed, the only player in the system that seems to have to balance countervailing interests the way market players in a real market usually do is Medicare. It has to answer to Congress and the taxpayers for wasting money, and it has to answer to portions of the same groups for trying to hold on to money it shouldn’t. Hospitals, drug companies and other suppliers, even the insurance companies, don’t have those worries.

http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/

Comment:

By Don McCanne, M.D.

Steven Brill’s TIME article, “Bitter Pill: Why Medical Bills Are Killing Us,” seems to be awakening those who have, until now, accepted the very high prices of health care as an inevitability for having a technologically advanced health care system here in the United States.

In his 36 page article – which will surely be required reading in many health policy courses – Brill makes it clear that we no longer need to take the “bitter pill” of medical bills that are killing us. Clearly, Medicare already has several tools to control costs and has the potential for further improving value in the nation’s health care purchasing.

At the end of his article, Brill seems to be advancing a non sequitur when he writes, “The real issue isn’t whether we have a single payer or multiple payers. It’s whether whoever pays has a fair chance in a fair market… We don’t have to scrap our system and aren’t likely to.” This certainly does not follow from what he had to say as the central theme of his article.

He then recommends some tired or inadequate remedies that would have very little impact on the problems that we face in health care. What is ironic is that he has built a tremendous case for the logical solution – an improved Medicare for all – and then he seems to dismiss it. You cannot read his article and escape the conclusion that a single payer national health program is an absolute imperative, that is, if we really do want affordable care for everyone.

Download this article (the full 36 pages is available for free at the link above), and share it with others. But put a Post-it note on it that states: WARNING! For the health of our nation, ignore the section at the end titled “Changing Our Choices” (that’s the tired remedies section), but concentrate on what an improved Medicare system could do for all of us.

Readers react: The future of Medicare

The New York Times, Letters, Feb. 24, 2013

PNHP note: The following two letters were published as part of a “Sunday Dialogue” in response to a Feb. 19 letter by Thomas M. Cassidy titled “Fix Medicare to save it” in The New York Times. The complete set of letters is available here.

Lessons from Canada’s program

By Steffie Woolhandler, M.D., and David U. Himmelstein, M.D.
 
Canada’s Medicare program — phased in at the same time as the American version — shows how we can make Medicare simpler and thriftier, while simultaneously upgrading its coverage. Canada’s program covers all Canadians (not just the elderly) under a single public program in each province, and bans co-payments and deductibles.

Patients can choose any doctor and hospital. Cutting out private insurers and the complexity and fragmentation they impose has simplified paperwork for patients, doctors and hospitals. Administrative costs are roughly half United States levels, saving more than $1,000 per capita.

Over all, Medicare spending on the elderly has grown three times faster in the United States than in Canada since 1980, while life expectancy (for the elderly, as for all age groups) has grown faster in Canada. If American Medicare costs had risen at Canadian rates, we’d have saved more than $2 trillion by now, and Medicare’s trust fund would show a healthy surplus.

The writers, internists and professors at the CUNY School of Public Health at Hunter College, co-founded Physicians for a National Health Program.

Needed: a nonprofit, integrated delivery system and single payer

By Arnold S. Relman, M.D.

Mr. Cassidy’s proposed fix is sensible but is far short of what is needed.

Medicare is headed for bankruptcy because it depends largely on open-ended fee-for-service payment of almost any services providers choose to deliver, at prices mainly determined by the providers. Compounding the problem, most providers act like independent businesses seeking to increase their income, regardless of whether they are for-profit or investor-owned.

An effective Medicare fix would require a new payment system that prospectively pays providers for comprehensive care at a rate set by a single public payer. It would also need a not-for-profit medical care system based on multispecialty doctor groups that pay physicians by salary, thus minimizing incentives to deliver duplicative or unnecessary care.

The new system would have to be mandatory for all citizens, including legislators, and it would have to be financed by a progressive, earmarked health care tax.

Obviously, such reform would be slow and difficult, but so would any other change that threatened vested interests. All reform will depend on an aroused public opinion.

The writer is professor emeritus of medicine and social medicine at Harvard Medical School and a former editor in chief of The New England Journal of Medicine.

Free-market fantasy on health care

By Caroline Poplin, M.D.
The New York Times, Letters, Feb. 21, 2013

Re “The Health Benefits That Cut Your Pay” (Sunday Review, Feb. 17):

With the best intentions, David Goldhill has described a free-market fantasy of health care. Market prices are based on power. In the United States today, hospitals and large doctor groups wield enormous market power, and they exercise it ruthlessly; consumers have none. Hospitals charge whatever the market will bear; uninsured patients pay the highest prices.

Large insurers bargain for “discounts” from prices set high enough so that hospitals still profit, and pass some of the “savings” on to large employers, who also have market power, but not to small businesses or individuals.

Whatever their faults, single-payer systems using government leverage, like the Canadians’ — or Medicare — deliver decent quality care to more people at lower cost. Mr. Goldhill makes the best the enemy of the good.

Dr. Caroline Poplin is a primary care physician. She resides in Bethesda, Md.

http://www.nytimes.com/2013/02/22/opinion/how-can-we-make-health-care-work.html?emc=eta1

Reducing Administrative Costs

By Samuel Metz, M.D.
New England Journal of Medicine, Correspondence, Feb. 14, 2013

In their Perspective article, Cutler et al. (Nov. 15 issue)[1] describe methods for reducing administrative costs in our health care system. The authors acknowledge that single-payer systems eliminate many administrative expenses, but they omit those estimated savings and dismiss the adoption of a national single-payer system as “unlikely.”

Estimates of administrative costs that could be recovered by a national single-payer system have been reported as $204 billion,[2] $230 billion,[3] $350 billion,[4] and ranging from $400 billion to $500 billion.[5] These numbers can be compared with the authors’ estimates of $23 billion in recoverable costs without a single-payer system.

American single-payer health care is not impossible — it is a reality. More than 120 million Americans currently receive care through single-payer plans, both private (multiemployer plans and self-funded plans) and public (e.g., Veterans Affairs, TRICARE, and Indian Health Service). That’s 39% of our population. All these single-payer plans provide better care to their populations for less money than private health insurance.

We physicians should not underestimate the cost-effectiveness of a single-payer system. We should not dismiss our ability to convince the authors and our national leaders that single payer is not “unlikely”; it is inevitable. We are already 39% of the way there.

References
1. Cutler D, Wikler E, Basch P. Reducing administrative costs and improving the health care system. N Engl J Med 2012;367:1875-1878
2. Institute for Health and Socio-Economic Policy. Single payer/Medicare for all: an economic stimulus plan for the nation. 2009 (http://nurses.3cdn.net/c6fb9a313be501086e_1vm6y1duy.pdf).
3. Kahn JG, Kronick R, Kreger M, Gans DN. The cost of health insurance administration in California: estimates for insurers, physicians, and hospitals. Health Aff (Millwood) 2005;24:1629-1639
4. Rodberg L, McCanne D. Upgrading to national health insurance (Medicare 2.0): the case for eliminating private health insurance. Chicago: Physicians for a National Health Program, July 13, 2007 (https://pnhp.org/news/2007/july/_health_insurance_fo.php).
5. Kuttner R. Market-based failure — a second opinion on U.S. health care costs. N Engl J Med 2008;358:549-551

Samuel Metz, M.D., resides in Portland, Ore. He can be reached at s@samuelmetz.com.

N Engl J Med 2013; 368:683February 14, 2013DOI: 10.1056/NEJMc1215485

http://www.nejm.org/doi/full/10.1056/NEJMc1215485?query=TOC

Corruption and scandal in the NHS: What happens when you introduce private incentives to public services

By Josh Freeman, M.D.
Medicine and Social Justice blog, Feb. 23, 2013

The United Kingdom has a National Health Service which covers everyone (although it allows those with private insurance to access care elsewhere). While not perfect – nothing is – and historically underfunded, it is one very reasonable model for how we could ensure access to health care for everyone. It goes back to the post-WW II period, when the British Labor Party made the decision to expand the existing National Health Insurance program to create the NHS through the political process, while in the US the emphasis among unions was to use collective bargaining to get health insurance as a member benefit.

But the NHS, while profoundly supported by the vast majority of British people, has been a target of attacks by Conservative governments since the Thatcher years. One of the big changes was the creation of several regional “trusts”, quasi-public entities that were invested with NHS funds and made responsible for the provision of care in their regions. This was consistent with the Tory assertion (held even more strongly in the US) that the private sector, or as close as they could get politically to the private sector, would be more efficient and effective than a public “bureaucracy”. Success at meeting “targets” (often high production with inadequate resources) could lead a trust to “foundation” status, where they would have even more control.

Many in Britain had their doubts, certainly among those to the left of the Conservatives. There was concern that the trusts might not be responsive to the health care needs of the people and might be more concerned with enhancing their own salaries, perks, and power. Conservatives (small ‘c’) tend to believe that government bureaucracies are more inefficient; those on the left see more evidence that privatization is much more likely to serve the self-interest of those in control than the interests of those who are supposed to be served.

I recently read the 1996 mystery novel “Quite Ugly One Morning” by the Scottish writer Christopher Brookmyre. One of the major plot lines involves corruption in the Edinburgh-based regional NHS trust. I don’t want to spoil the plot, and I do recommend the book, but the portrayal of self-serving, stealing, and lack of attention to the actual care of the patients of the NHS was scary. Of course, it was a novel; there were not actual patients being harmed by corruption in the actual regional NHS trusts in the actual United Kingdom. After all, I thought, the British don’t do such things. We do, but that is because so much of our system is private and for-profit. Surely the British value the NHS too much for such things to really happen.

Wrong. It appears, however, that this in fact has been happening. In “English hospital report cites ‘appalling’ suffering”, NY Times February 6, 2013, Sarah Lyall describes conditions cited in a government report on Stafford Hospital, operated by the Mid-Staffordshire Trust: “Shockingly bad care and inhumane treatment at a hospital in the Midlands led to hundreds of unnecessary deaths and stripped countless patients of their dignity and self-respect, according to a scathing report published on Wednesday…. The report, which examined conditions at Stafford Hospital in Staffordshire over a 50-month period between 2005 and 2009, cites example after example of horrific treatment: patients left unbathed and lying in their own urine and excrement; patients left so thirsty that they drank water from vases; patients denied medication, pain relief and food by callous and overworked staff members; patients who contracted infections due to filthy conditions; and patients sent home to die after being given the wrong diagnoses.”

HUNDREDS of people. Maybe as many as 1200 people died unnecessarily. And, in the followup of this scandal, there are investigations into at least 14 other trusts, reported across the British press such as this article in the Telegraph, “Head of NHS ignored warning that patients were in danger, alleges whistleblower”. One of these trusts is United Lincolnshire, whose former chief executive has turned whistleblower, accusing the head of the entire NHS, Sir David Nicholson, of ignoring warnings that substandard care was being provided there. The whistleblower, Gary Walker, was fired from his job and paid off to the tune of about a half-million pounds, to keep quiet.

This would be a great example of “life imitating art” if it weren’t for all the people who died or suffered serious morbidity as a result of “…its efforts to balance its books and save $16 million in 2006 and 2007 in order to achieve so-called foundation-trust status, which made it semi-independent of control by the central government, the hospital laid off too many people and focused relentlessly on external objectives rather than patient care,” (NY Times).  As further documented in the report, this was essentially “speed up”, a condition familiar to assembly-line workers.

“Speaking in the House of Commons,” the NY Times article goes on, “Prime Minister David Cameron apologized for the way the system had allowed ‘horrific abuse to go unchecked and unchallenged’ for so long. So deeply rooted was the trouble, he said, that ‘we cannot say with confidence that failings of care are limited to one hospital.’” Apparently not, given the accusations at Lincolnshire. However, despite these accusations, and perhaps more damningly, the fact that he was the Chief Executive of the Mid-Staffordshire trust during much of the time that the scandalous activities were occurring there, Nicholson is staying put, and so far the government is backing him. (more coverage in the Mail (Feb 13 and 17).

Well, he is staying put so far, but people in Britain far and wide are calling for his resignation, as well they might. Demonstrations in support of the NHS as a system designed to serve the people, not its administrators, have broken out across Britain; an example is this wonderful “Youtube” video of a “flash mob choir” (!) at King’s Cross railroad station in London singing in support of National Health (h/t Alex Scott-Samuel).

It would be possible to pin these atrocities on the National Health Service, as an example of the failing of socialized medicine, but that would be wrong. It would even be wrong to point out that the problem is chronic under-funding of the NHS. The problem, in fact, is a public good being run for private benefit, for the temptation of even great “autonomy” (read: potential for exploitation) by becoming a “foundation” led to deaths far in excess of the scale fictionally portrayed by Brookmyre in the mid-90s. The NHS does not suffer because it is tasked with providing health care to all of the British people; it suffers when a lack of adequate regulation and supervision allow such abuses to go unchecked.

The British people deserve much better. So, for that matter, do Americans. Let’s listen to the “flash mob choir” again!

http://medicinesocialjustice.blogspot.com/2013/02/corruption-and-scandal-in-nhs-what.html

TIME: Steven Brill's "bitter pill" should wake us up

Bitter Pill: Why Medical Bills Are Killing Us

By Steven Brill
TIME, February 20, 2013
The Way Out Of the Sinkhole
“I was driving through central Florida a year or two ago,” says Medicare’s (Jonathan) Blum. “And it seemed like every billboard I saw advertised some hospital with these big shiny buildings or showed some new wing of a hospital being constructed … So when you tell me that the hospitals say they are losing money on Medicare and shifting costs from Medicare patients to other patients, my reaction is that Central Florida is overflowing with Medicare patients and all those hospitals are expanding and advertising for Medicare patients. So you can’t tell me they’re losing money … Hospitals don’t lose money when they serve Medicare patients.”
If that’s the case, I asked, why not just extend the program to everyone and pay for it all by charging people under 65 the kinds of premiums they would pay to private insurance companies? “That’s not for me to say,” Blum replied.
In the debate over controlling Medicare costs, politicians from both parties continue to suggest that Congress raise the age of eligibility for Medicare from 65 to 67. Doing so, they argue, would save the government tens of billions of dollars a year. So it’s worth noting another detail about the case of Janice S., which we examined earlier. Had she felt those chest pains and gone to the Stamford Hospital emergency room a month later, she would have been on Medicare, because she would have just celebrated her 65th birthday.
If covered by Medicare, Janice S.’s $21,000 bill would have been deeply discounted and, as is standard, Medicare would have picked up 80% of the reduced cost. The bottom line is that Janice S. would probably have ended up paying $500 to $600 for her 20% share of her heart-attack scare. And she would have paid only a fraction of that — maybe $100 — if, like most Medicare beneficiaries, she had paid for supplemental insurance to cover most of that 20%.
In fact, those numbers would seem to argue for lowering the Medicare age, not raising it — and not just from Janice S.’s standpoint but also from the taxpayers’ side of the equation. That’s not a liberal argument for protecting entitlements while the deficit balloons. It’s just a matter of hardheaded arithmetic.
As currently constituted, Obamacare is going to require people like Janice S. to get private insurance coverage and will subsidize those who can’t afford it. But the cost of that private insurance — and therefore those subsidies — will be much higher than if the same people were enrolled in Medicare at an earlier age. That’s because Medicare buys health care services at much lower rates than any insurance company. Thus the best way both to lower the deficit and to help save money for people like Janice S. would seem to be to bring her and other near seniors into the Medicare system before they reach 65.
Meanwhile, adding younger people like Janice S. would lower the overall cost per beneficiary to Medicare and help cut its deficit still more, because younger members are likelier to be healthier.
If that logic applies to 64-year-olds, then it would seem to apply even more readily to healthier 40-year-olds or 18-year-olds. This is the single-payer approach favored by liberals and used by most developed countries.
***
Yet while Medicare may not be a realistic systemwide model for reform, the way Medicare works does demonstrate, by comparison, how the overall health care market doesn’t work.
Unless you are protected by Medicare, the health care market is not a market at all. It’s a crapshoot. People fare differently according to circumstances they can neither control nor predict. They may have no insurance. They may have insurance, but their employer chooses their insurance plan and it may have a payout limit or not cover a drug or treatment they need. They may or may not be old enough to be on Medicare or, given the different standards of the 50 states, be poor enough to be on Medicaid. If they’re not protected by Medicare or they’re protected only partly by private insurance with high co-pays, they have little visibility into pricing, let alone control of it. They have little choice of hospitals or the services they are billed for, even if they somehow know the prices before they get billed for the services. They have no idea what their bills mean, and those who maintain the chargemasters couldn’t explain them if they wanted to. How much of the bills they end up paying may depend on the generosity of the hospital or on whether they happen to get the help of a billing advocate. They have no choice of the drugs that they have to buy or the lab tests or CT scans that they have to get, and they would not know what to do if they did have a choice. They are powerless buyers in a seller’s market where the only sure thing is the profit of the sellers.
Indeed, the only player in the system that seems to have to balance countervailing interests the way market players in a real market usually do is Medicare. It has to answer to Congress and the taxpayers for wasting money, and it has to answer to portions of the same groups for trying to hold on to money it shouldn’t. Hospitals, drug companies and other suppliers, even the insurance companies, don’t have those worries.
http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-…

Steven Brill’s TIME article, “Bitter Pill: Why Medical Bills Are Killing Us,” seems to be awakening those who have, until now, accepted the very high prices of health care as an inevitability for having a technologically advanced health care system here in the United States.
In his 36 page article – which will surely be required reading in many health policy courses – Brill makes it clear that we no longer need to take the “bitter pill” of medical bills that are killing us. Clearly, Medicare already has several tools to control costs and has the potential for further improving value in the nation’s health care purchasing.
At the end of his article, Brill seems to be advancing a non sequitur when he writes, “The real issue isn’t whether we have a single payer or multiple payers. It’s whether whoever pays has a fair chance in a fair market… We don’t have to scrap our system and aren’t likely to.” This certainly does not follow from what he had to say as the central theme of his article.
He then recommends some tired or inadequate remedies that would have very little impact on the problems that we face in health care. What is ironic is that he has built a tremendous case for the logical solution – an improved Medicare for all – and then he seems to dismiss it. You cannot read his article and escape the conclusion that a single payer national health program is an absolute imperative, that is, if we really do want affordable care for everyone.
Download this article (the full 36 pages is available for free at the link above), and share it with others. But put a Post-it note on it that states: WARNING! For the health of our nation, ignore the section at the end titled “Changing Our Choices” (that’s the tired remedies section), but concentrate on what an improved Medicare system could do for all of us.

Physician says Obamacare not the answer to full coverage

By Nicole Back
The Morehead (Ky.) News, Feb. 22, 2013

Is health care a human right? Dr. Ewell Scott, a retired physician, emphatically says the answer is “yes.”

He delivered that message Tuesday during a town hall meeting at the Center for Health, Education and Research (CHER).

Scott was speaking about HR 676, also known as the Expanded and Improved Medicare for All Act, which has been reintroduced in Congress by Rep. John Conyers, Jr.

“If we had a single payer Medicare for all plan – from life to death – it would reduce the expenses of our healthcare by $400 billion a year,” Scott said. “No disputing that figure and we would cover everybody.”

Scott said the Patient Protection and Affordable Care Act (PPACA), more commonly known as Obamacare, will reduce the number of uninsured persons in America but the law won’t help much with the cost of health insurance. The new law will go into effect fully in 2014.

There currently are 50 million uninsured Americans, according to Scott.

“The PPACA is going to insure a lot more people in this country,” he said. “It’s going to bring the 50 million figure down – and the figures are disputed – to somewhere between 20 and 30 million that still won’t have health care insurance for a variety of reasons.”

He said the PPACA will expand Medicaid to 139 percent of the federal poverty level.

“If I remember correctly, it’s like $11,000 for an individual and $32,000 for a family,” Scott said.

“If your income level is below that, you’re going to be eligible for Medicaid, not Medicare, but Medicaid.”

The problem with Medicaid, Scott said, is that it covers only 75 percent of hospital costs. Many specialists will not accept it and benefits vary state by state.

Fifty percent of the PPACA’s funding will come from new taxes, he said.

The other fifty percent will come from a reduction in payments to Medicare.

The answer, he said, is HR 676, which would establish expanded and improved Medicare for all. Comprehensive coverage would include outpatient, inpatient, emergency department, medications, durable medical equipment, long term care, mental health, dental care, substance abuse, chiropractic care, basic vision care and hearing. There would be no cost sharing, deductibles or co-pays.

“Insurance is basically voluntary socialism with a surcharge,” Scott said.

He added that lack of insurance leads to bankruptcy and the market is not the solution.

The country with the 40th highest life expectancy is the United States, where people live to be 77.8-years-old. There are 50,000 deaths each year due to lack of access to adequate care.

The PPACA would rely on Medicaid and private health insurance. Relying on private health insurance would mandate the purchase of a bad product, according to Scott.

He encouraged the audience of 85 persons to contact their congressmen about voting for HR 676.

After Scott’s speech, there was a panel discussion involving Dr. Bob Albert, dean of Morehead State University’s College of Business and Public Affairs; Sonny Jones, chief financial officer and vice president of St. Claire Regional Medical Center; Dr. Anthony Weaver of St. Claire’s medical staff; and Dr. Bo Shi, assistant professor of finance at MSU.

In Dr. Weaver’s opening statement, he said, “Insurance companies have too much money to be phased out.”

“We are unwilling to accept the lifestyles of people. Let’s face it, if we’re all under a single plan, we’re all responsible for the stupidity of each other and we just can’t handle that,” Weaver said. “Insurance companies have allowed us to escape from that by changing our rates.”

Questions ranged from how Medicare works to how wellness plans do not save money for health insurance companies.

One audience member asked what chance she has of seeing any valid changes in America’s health care system in her lifetime.

“The people who seem to be in the know say by 2017, when the Affordable Care Act has really kicked in, and all these things have taken place, [health care’s share of the] gross domestic product consumption is going to be about 20 percent,” Scott said. “And I’m told that’s the absolute breaking point for our country.”

Nicole Back is a staff writer at The Morehead News.

http://themoreheadnews.com/local/x564659446/Scott-says-Obamacare-not-the-answer-to-full-coverage

CMS limits innovative designs to multi-payer models

State Innovation Models Initiative: General Information

Centers for Medicare and Medicaid Services
Center for Medicare and Medicaid Innovation, February 2013

The State Innovation Models Initiative is providing up to $300 million to support the development and testing of state-based models for multi-payer payment and health care delivery system transformation with the aim of improving health system performance for residents of participating states. The projects will be broad based and focus on people enrolled in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP).

Background

The Innovation Center created the State Innovation Models initiative for states that are prepared for or committed to planning, designing, testing, and supporting evaluation of new payment and service delivery models in the context of larger health system transformation. The Innovation Center is interested in testing innovative payment and service delivery models that have the potential to lower costs for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP), while maintaining or improving quality of care for program beneficiaries. The goal is to create multi-payer models with a broad mission to raise community health status and reduce long term health risks for beneficiaries of Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).

For more information, click on “Fact Sheet: State Innovation Models Initiative” at this link: http://innovation.cms.gov/initiatives/State-Innovations/

And…

State Receives $937,691 Grant to Continue Healthcare Transformation Efforts

State of Hawaii, February 21, 2013

The State of Hawaii once again has an opportunity to demonstrate its leadership in healthcare transformation. The Centers for Medicare and Medicaid Services (CMS) today announced that Hawaii was awarded a planning grant worth $937,691 as part of the agency’s State Innovations Model (SIM) initiative.

Beginning April 1, the state will have six months to design and submit a State Healthcare Innovation Plan, built around multipayer payment and healthcare delivery system transformation.

“Transforming our state’s healthcare system continues to be a focus of my New Day plan, and under the leadership of Beth Giesting, the state’s healthcare transformation coordinator, we’ve made great strides over the last year,” said Gov. Neil Abercrombie.

http://governor.hawaii.gov/state-receives-937691-grant-to-continue-healthcare-transformation-efforts/

Comment:

By Don McCanne, M.D.

Section 3021 of the Affordable Care Act establishes the Center for Medicare and Medicaid Innovation. Its purpose is “to test innovative payment and service delivery models to reduce program expenditures under the applicable titles (Medicare and Medicaid) while preserving or enhancing the quality of care furnished to individuals under such titles.”

The law lists “opportunities” for models to be tested, including “allowing states to test and evaluate systems of all-payer payment reform for the medical care of residents of the state.” Of note, nowhere does section 3021 limit the innovative testing to “multi-payer models.” Yet CMS now states that “the goal is to create multi-payer models.”

To show how important this administrative decision is, look at Hawaii. Gov. Neil Abercrombie has been a single payer supporter. He was a cosponsor of H.R. 676, John Conyers’ single payer bill, when he was a member of Congress. Efforts have recently been underway to move Hawaii towards becoming a single payer state. But now with this grant, Hawaii is going to “design and submit a State Healthcare Innovation Plan, built around multipayer payment and healthcare delivery system transformation.”

The CMS fact sheet (link above) list other states receiving funds under this program, including states that were thought to be in a position to lead the way on single payer reform, such as Vermont and California.

According to the fact sheet, Vermont has been awarded a $45 million grant to establish “three models: a shared-savings ACO model that involves integration of payment and services across an entire delivery system; a bundled payment model that involve integration of payment and services across multiple independent providers; and a pay-for-performance model aimed at improving the quality, performance, and efficiency of individual providers.” That doesn’t exactly have a single payer ring to it.

Although the law did not limit the innovations to be developed and tested to multi-payer models, the Obama administration has. Once again, single payer advocates have been denied a seat at the table. What are we going to do about it?

CMS limits innovative designs to multi-payer models

State Innovation Models Initiative: General Information

Centers for Medicare and Medicaid Services
Center for Medicare and Medicaid Innovation, February 2013
The State Innovation Models Initiative is providing up to $300 million to support the development and testing of state-based models for multi-payer payment and health care delivery system transformation with the aim of improving health system performance for residents of participating states. The projects will be broad based and focus on people enrolled in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP).
Background
The Innovation Center created the State Innovation Models initiative for states that are prepared for or committed to planning, designing, testing, and supporting evaluation of new payment and service delivery models in the context of larger health system transformation. The Innovation Center is interested in testing innovative payment and service delivery models that have the potential to lower costs for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP), while maintaining or improving quality of care for program beneficiaries. The goal is to create multi-payer models with a broad mission to raise community health status and reduce long term health risks for beneficiaries of Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).
For more information, click on “Fact Sheet: State Innovation Models Initiative” at this link: http://innovation.cms.gov/initiatives/State-Innovations/
And…

State Receives $937,691 Grant to Continue Healthcare Transformation Efforts

State of Hawaii, February 21, 2013
The State of Hawaii once again has an opportunity to demonstrate its leadership in healthcare transformation. The Centers for Medicare and Medicaid Services (CMS) today announced that Hawaii was awarded a planning grant worth $937,691 as part of the agency’s State Innovations Model (SIM) initiative.
Beginning April 1, the state will have six months to design and submit a State Healthcare Innovation Plan, built around multipayer payment and healthcare delivery system transformation.
“Transforming our state’s healthcare system continues to be a focus of my New Day plan, and under the leadership of Beth Giesting, the state’s healthcare transformation coordinator, we’ve made great strides over the last year,” said Gov. Neil Abercrombie.
http://governor.hawaii.gov/state-receives-937691-grant-to-continue-healt…

Section 3021 of the Affordable Care Act establishes the Center for Medicare and Medicaid Innovation. Its purpose is “to test innovative payment and service delivery models to reduce program expenditures under the applicable titles (Medicare and Medicaid) while preserving or enhancing the quality of care furnished to individuals under such titles.”
The law lists “opportunities” for models to be tested, including “allowing states to test and evaluate systems of all-payer payment reform for the medical care of residents of the state.” Of note, nowhere does section 3021 limit the innovative testing to “multi-payer models.” Yet CMS now states that “the goal is to create multi-payer models.”
To show how important this administrative decision is, look at Hawaii. Gov. Neil Abercrombie has been a single payer supporter. He was a cosponsor of H.R. 676, John Conyers’ single payer bill, when he was a member of Congress. Efforts have recently been underway to move Hawaii towards becoming a single payer state. But now with this grant, Hawaii is going to “design and submit a State Healthcare Innovation Plan, built around multipayer payment and healthcare delivery system transformation.”
The CMS fact sheet (link above) list other states receiving funds under this program, including states that were thought to be in a position to lead the way on single payer reform, such as Vermont and California.
According to the fact sheet, Vermont has been awarded a $45 million grant to establish “three models: a shared-savings ACO model that involves integration of payment and services across an entire delivery system; a bundled payment model that involve integration of payment and services across multiple independent providers; and a pay-for-performance model aimed at improving the quality, performance, and efficiency of individual providers.” That doesn’t exactly have a single payer ring to it.
Although the law did not limit the innovations to be developed and tested to multi-payer models, the Obama administration has. Once again, single payer advocates have been denied a seat at the table. What are we going to do about it?