Speaker – Page 518

Bill Keller on P4P and single payer

Carrots for Doctors

By Bill Keller
The New York Times, January 27, 2013
With its ambitious proposal to pay doctors in public hospitals based on the quality of their work — not the number of tests they order, pills they prescribe or procedures they perform — New York City has hopped aboard the biggest bandwagon in health care. Pay for performance, or P4P in the jargon, is embraced by right and left. It has long been the favorite egghead prescription for our absurdly overpriced, underperforming health care system. The logic seems unassailable: Reward quality, and you will get quality. Stop rewarding waste, and you will get less waste. QED! P4P!
If only it worked.
For if you spend a little time with the P4P skeptics — a data-bearing minority among physicians and health economists — you will come away full of doubts. In practice, pay for performance does little to improve outcomes or to control costs.
The first problem with P4P is that it does not address the biggest problem. Americans spend more than twice as much per capita as other developed countries on health care — a crippling 18 percent of the country’s economic output, and growing.
But the main reason everything costs less in other countries is that other countries tend to have one big payer — usually the government — with the clout to bargain down prices. A single-payer system has, so far, proven politically unpalatable in this country.
http://www.nytimes.com/2013/01/28/opinion/keller-carrots-for-doctors.htm…

Bill Keller, the former executive editor of The New York Times, explains why pay-for-performance (P4P) is a false solution to the problems of high health care costs and mediocre quality. Although he recognizes the correct solution – a single payer system – he follows the lead of other journalists and politicians in immediately dismissing it as being “politically unpalatable.”
Was Medicare politically unpalatable?
Consider the following oft-expressed concept. “Single payer is the solution that would bring health care to everyone at a cost that we can afford; therefore we shouldn’t adopt it because of concerns about political feasibility.” Phrased this way, obviously this is a non sequitur.
Let’s jam single payer into its proper place in government. The we’ll see how politically unpalatable it is, or rather is not.

HCA hasn't changed

Judge says HCA broke spending promises

By Diane Stafford
The Kansas City Star, January 24, 2013

The Health Care Foundation of Greater Kansas City has won a $162 million judgment against Hospital Corp. of America, owner of the largest hospital system in the Kansas City area.

The lawsuit contended that HCA hadn’t spent what it promised on capital improvements to the former Health Midwest hospitals that HCA bought for $1.13 billion in 2003. The lawsuit further claimed that HCA had not met its charitable health care commitments to help pay for treating indigent people.

The amounts that HCA agreed to spend within certain deadlines were part of the deal transferring the nonprofit Health Midwest hospitals to the for-profit HCA.

As agreed to by parties to the 2003 sale, the for-profit HCA was to make $450 million in capital improvements to the existing Health Midwest hospitals, which had been nonprofit institutions and needed significant upgrades.

HCA had agreed under terms of the sale to spend more than $650 million on charity health care in the Kansas City area, the judge noted in his decision. How far HCA has gone toward meeting that obligation will be scrutinized in the court-ordered audit.

But in his decision Thursday, (Judge John) Torrence said HCA’s financial accounting made it impossible to tell whether the company had met its charitable health care commitments.

http://www.kansascity.com/2013/01/24/4029002/health-care-foundation-wins-major.html

Comment:

By Don McCanne, M.D.

Hospital Corporation of America (HCA) is not only the largest private operator of health care facilities in the United States, it also holds the record for the largest fraud settlement, over $1.7 billion. This current judgement against HCA suggests that they continue to place a priority on profits over patients.

When HCA took over the largest hospital group in the Kansas City area, they agreed to upgrade the hospitals with much needed improvements, plus they agreed to continue to provide charity care as safety net institutions. This was in exchange for allowing them to convert these non-profit hospitals into for-profit facilities under their ownership.

Once gaining ownership, they reverted to business as usual – make money while ignoring the commitments made for charitable care and for improving the facilities. The $162 million judgment that they may have to pay (they are appealing it) to them is not much more than an expense of doing business, especially considering that their 2011 net income was $2.47 billion (adding considerably to Bain’s profits from their investment in HCA).

Although PNHP certainly objects to the diversion of profits to investors – profits that should go for patient care or to help lower costs – the primary reason that we believe that for-profit entities should be expelled from the health care system is the egregious behavior on the part of their corporate executives and board members in using patients as instruments in their quest for profits. In this instance it can be measured by the care that they avoided providing to indigent patients, and by the less than optimal care received by patients in their substandard facilities.

The next time you see a placard stating, “PATIENTS, NOT PROFITS,” keep in mind that it is not just profits, but it is the deeper significance of what corporate greed does to patient care.

Obamacare money could be better spent on Medicare for All

By Marvin Malek, M.D.
Times-Argus (Barre, Vt.), Letters, Jan. 25, 2013

Kudos to the grant writers at Vermont’s Dept. of Health Access for obtaining $156 million from the federal government to assist with the implementation of the health exchange, the new insurance marketplace scheduled to go online in October 2013 as part of Obamacare (“Vt. ranks third in federal health exchange money,” Times-Argus, Jan. 5). The $156 million will lead to the creation of a large number of high quality jobs. Obtaining outside money for Vermont helps the economy and adds to our tax base.

Of course, this might have been better news if this money were designated for something other than unnecessary administrative activity in the U.S. health care system. Had President Obama and the U.S. Congress had more courage, they would have voted to simply extend Medicare to the entire U.S. population. Such a proposal would have obviated the need for exchanges. For that matter, extending Medicare to every American would have eliminated the need for the entire private insurance industry, which contributes only excessive cost and human misery to the U.S. health care system.

While the $156 million coming to Vermont is certainly a waste of federal taxpayer money, this waste pales in comparison to the billions of dollars that will be diverted to private insurers by the Obamacare legislation.

With the new health exchange the $156 million creates, Vermonters will be able to search for very expensive private policies providing coverage that would be disdained by citizens of every other developed country. The exchange will also feature policies with slightly less ridiculously expensive premiums. But these policies will have even worse coverage — even higher deductibles and co-pays. No bargains in Obamacare.

What’s really sad is that at the federal level, there is no way to vote for single-payer health care. The Democrats are largely lined up behind Obamacare. And the proposals coming from the Republicans both in Vermont and nationally have at least as much administrative expense and provide vastly less secure coverage compared to Obamacare. The few Republican proposals that actually extend coverage to additional Americans provide the type of coverage that’s really there for you — as long as you don’t get sick.

There never has been a good reason why Americans pay into Medicare throughout their entire lives, but aren’t covered by the program until they turn 65. Single-payer health care — such as the Medicare program — saves lives and money. We shouldn’t rest until the entire U.S. population can enjoy its benefits. State-based, single-payer reform, as we’re attempting here in Vermont, may be the only viable strategy to eventually expand Medicare to every citizen of our country.

Dr. Marvin Malek is an internist working at Central Vermont Hospital in Berlin.

http://www.timesargus.com/article/20130125/OPINION02/701259993/0/FEATURES05

HCA hasn't changed

Judge says HCA broke spending promises

By Diane Stafford
The Kansas City Star, January 24, 2013
The Health Care Foundation of Greater Kansas City has won a $162 million judgment against Hospital Corp. of America, owner of the largest hospital system in the Kansas City area.
The lawsuit contended that HCA hadn’t spent what it promised on capital improvements to the former Health Midwest hospitals that HCA bought for $1.13 billion in 2003. The lawsuit further claimed that HCA had not met its charitable health care commitments to help pay for treating indigent people.
The amounts that HCA agreed to spend within certain deadlines were part of the deal transferring the nonprofit Health Midwest hospitals to the for-profit HCA.
As agreed to by parties to the 2003 sale, the for-profit HCA was to make $450 million in capital improvements to the existing Health Midwest hospitals, which had been nonprofit institutions and needed significant upgrades.
HCA had agreed under terms of the sale to spend more than $650 million on charity health care in the Kansas City area, the judge noted in his decision. How far HCA has gone toward meeting that obligation will be scrutinized in the court-ordered audit.
But in his decision Thursday, (Judge John) Torrence said HCA’s financial accounting made it impossible to tell whether the company had met its charitable health care commitments.
http://www.kansascity.com/2013/01/24/4029002/health-care-foundation-wins…

Physicians for a National Health Program supports not only a much more efficient and equitable single payer financing system, we also support elimination of passive investors from the health care system. Corporate executives and boards that must place priorities of shareholders over patients should have no place in our health care system.
Hospital Corporation of America (HCA) is not only the largest private operator of health care facilities in the United States, it also holds the record for the largest fraud settlement, over $1.7 billion. This current judgement against HCA suggests that they continue to place a priority on profits over patients.
When HCA took over the largest hospital group in the Kansas City area, they agreed to upgrade the hospitals with much needed improvements, plus they agreed to continue to provide charity care as safety net institutions. This was in exchange for allowing them to convert these non-profit hospitals into for-profit facilities under their ownership.
Once gaining ownership, they reverted to business as usual – make money while ignoring the commitments made for charitable care and for improving the facilities. The $162 million judgment that they may have to pay (they are appealing it) to them is not much more than an expense of doing business, especially considering that their 2011 net income was $2.47 billion (adding considerably to Bain’s profits from their investment in HCA).
Although PNHP certainly objects to the diversion of profits to investors – profits that should go for patient care or to help lower costs – the primary reason that we believe that for-profit entities should be expelled from the health care system is the egregious behavior on the part of their corporate executives and board members in using patients as instruments in their quest for profits. In this instance it can be measured by the care that they avoided providing to indigent patients, and by the less than optimal care received by patients in their substandard facilities.
The next time you see a placard stating, “PATIENTS, NOT PROFITS,” keep in mind that it is not just profits, but it is the deeper significance of what corporate greed does to patient care.

The Affordable Care Act: What to Expect in 2013

By John Geyman, M.D.
The Huffington Post, Jan. 24, 2013

The Affordable Care Act (ACA), crafted in large part by corporate stakeholders who are themselves responsible for the high costs of U.S. health care, is more secure with President Obama’s win last November. But regrettably, the law will fail to control costs or prices, will not provide universal access to care, and at best will provide low-value, high-premium “insurance” that will still make essential health care unaffordable for many millions of patients and families.

The ACA’s fundamental flaw is that it props up an inefficient and exploitative private health insurance industry while not recognizing that deregulated markets can’t fix systemic problems of access, costs, quality, equity, accountability and sustainability.

President Obama gained an impressive victory, and Democrats have held control of the Senate. Most importantly, corporate money, power, lies and deception on the right have not prevailed. But of course, the Republican-controlled House is likely to bring continued political gridlock. Overemphasis on austerity and deficit control threaten Medicare, Medicaid and safety net programs.

Going forward, we can expect to see wild battles across the health care landscape, including these examples:

* Continued mergers among the major players, including insurance companies, hospital systems, medical groups and others, which will end up increasing costs and prices while limiting patients’ choices of physician and hospital.

* Continued lobbying by the insurance industry to mold accountable care organizations and insurance exchanges in their interests (i.e. cherry-pick enrollees and pass along sicker patients to public programs).

* Further privatization and exploitation of Medicare and Medicaid.

* Efforts by insurers to limit definitions of minimal essential benefits.

* Further fragmentation and increasing bureaucracy of our market-based health care system with worse health outcomes.

Under this onslaught, the ACA will not hold up. Health care reform needs to be more progressive than how it ended up with the ACA. The only real fix for our problems is single-payer, improved Medicare for All, a proposal introduced by Rep. John Conyers (D-Mich.), H.R. 676, coupled with a private delivery system.

Health care is just one more example of the 99/1 percent challenge facing the country. These are some of the directions that we, the citizens of this great country, can take in restoring hope that all Americans can gain their rightful access to the health care that they deserve:

* Speaking out, individually and collectively, at community, state and federal levels to expose the abuses and cruelty of what passes for health care in its under-regulated state.

* Fighting for a defined benefit program that covers all Americans in a single risk pool with full choice of physicians, other health professionals and institutions, as H.R. 676 would provide.

* Supporting efforts at the state level for single-payer financing in the event that reform may first need to be demonstrated at the state level before a national program can be passed by Congress.

* Pushing for a more responsible government oversight of health care at state and federal levels to oversee health care, including an independent, well-funded national institute to deal with coverage and cost-effectiveness issues on the basis of scientific evidence, not upon which profit-based interest group can scream the loudest.

* Supporting and participating in divestiture efforts against abusive insurers and other stakeholders in the health care marketplace.

Despite what we are being told by politicians on both sides of the aisle, our deregulated health care marketplace is not sustainable, and there is no real fix short of single-payer financing reform coupled with a more accountable private delivery system.

Other advanced nations around the world learned many years ago that one or another form of public financing is fundamental to a good health care system. The U.S. remains an outlier among these nations in having the most expensive system that still does not provide universal access to essential health care — even at that we have variable quality and worse outcomes. It is long overdue to learn from the experience of other countries that have coped more successfully with the same health policy issues that we face in this country.

John Geyman, M.D. is professor emeritus of family medicine at the University of Washington, author of “Health Care Wars: How Market Ideology and Corporate Power Are Killing Americans,” past president of Physicians for a National Health Program (PNHP), and a member of the Institute of Medicine.

http://www.huffingtonpost.com/john-geyman/the-affordable-care-act_b_2537411.html

PNHP Annual Meeting Slide Sets

For slides from the most recent Annual Meeting (2024, Chicago) click HERE.

For slides from previous Annual Meetings, see below:

A Different Model — Medical Care in Cuba

By Edward W. Campion, M.D., and Stephen Morrissey, Ph.D.
The New England Journal of Medicine, Jan. 24, 2013

For a visitor from the United States, Cuba is disorienting. American cars are everywhere, but they all date from the 1950s at the latest. Our bank cards, credit cards, and smartphones don’t work. Internet access is virtually nonexistent. And the Cuban health care system also seems unreal. There are too many doctors. Everybody has a family physician. Everything is free, totally free — and not after prior approval or some copay. The whole system seems turned upside down. It is tightly organized, and the first priority is prevention. Although Cuba has limited economic resources, its health care system has solved some problems that ours has not yet managed to address.[1,2]

Family physicians, along with their nurses and other health workers, are responsible for delivering primary care and preventive services to their panel of patients — about 1000 patients per physician in urban areas. All care delivery is organized at the local level, and the patients and their caregivers generally live in the same community. The medical records in cardboard folders are simple and handwritten, not unlike those we used in the United States 50 years ago. But the system is surprisingly information-rich and focused on population health.

All patients are categorized according to level of health risk, from I to IV. Smokers, for example, are in risk category II, and patients with stable, chronic lung disease are in category III. The community clinics report regularly to the district on how many patients they have in each risk category and on the number of patients with conditions such as hypertension (well controlled or not), diabetes, and asthma, as well as immunization status, time since last Pap smear, and pregnancies necessitating prenatal care.

Every patient is visited at home once a year, and those with chronic conditions receive visits more frequently. When necessary, patients can be referred to a district polyclinic for specialty evaluation, but they return to the community team for ongoing treatment. For example, the team is responsible for seeing that a patient with tuberculosis follows the assigned antimicrobial regimen and gets sputum checks. House calls and discussions with family members are common tactics for addressing problems with compliance or follow-up and even for failure to protect against unwanted pregnancy. In an effort to control mosquito-borne infections such as dengue, the local health team goes into homes to conduct inspections and teach people about getting rid of standing water, for example.

This highly structured, prevention-oriented system has produced positive results. Vaccination rates in Cuba are among the highest in the world. The life expectancy of 78 years from birth is virtually identical to that in the United States. The infant mortality rate in Cuba has fallen from more than 80 per 1000 live births in the 1950s to less than 5 per 1000 — lower than the U.S. rate, although the maternal mortality rate remains well above those in developed countries and is in the middle of the range for Caribbean countries.[3,4] Without doubt, the improved health outcomes are largely the result of improvements in nutrition and education, which address the social determinants of health. Cuba’s literacy rate is 99%, and health education is part of the mandatory school curriculum. A recent national program to promote acceptance of men who have sex with men was designed in part to reduce rates of sexually transmitted disease and improve acceptance of and adherence to treatment. Cigarettes can no longer be obtained with monthly ration cards, and smoking rates have decreased, though local health teams say it remains difficult to get smokers to quit. Contraception is free and strongly encouraged. Abortion is legal but is seen as a failure of prevention.

But one should not romanticize Cuban health care. The system is not designed for consumer choice or individual initiatives. There is no alternative, private-payer health system. Physicians get government benefits such as housing and food subsidies, but they are paid only about $20 per month. Their education is free, and they are respected, but they are unlikely to attain personal wealth. Cuba is a country where 80% of the citizens work for the government, and the government manages the budgets. In a community health clinic, signs tell patients how much their free care is actually costing the system but no market forces compel efficiency. Resources are limited, as we learned in meeting with Cuban medical and public health professionals as part of a group of editors from the United States. A nephrologist in Cienfuegos, 160 miles south of Havana, lists 77 patients on dialysis in the province, which on a population basis is about 40% of the current U.S. rate — similar to what the U.S. rate was in 1985. A neurologist reports that his hospital got a CT scanner only 12 years ago. U.S. students who are enrolled in a Cuban medical school say that operating rooms run quickly and efficiently but with very little technology. Access to information through the Internet is minimal. One medical student reports being limited to 30 minutes per week of dial-up access. This limitation, like many of the resource constraints that affect progress, is blamed on the long-standing U.S. economic embargo, but there may be other forces in the central government working against rapid, easy communication among Cubans and with the United States.

As a result of the strict economic embargo, Cuba has developed its own pharmaceutical industry and now not only manufactures most of the medications in its basic pharmacopeia, but also fuels an export industry. Resources have been invested in developing biotechnology expertise to become competitive with advanced countries. There are Cuban academic medical journals in all the major specialties, and the medical leadership is strongly encouraging research, publication, and stronger ties to medicine in other Latin American countries. Cuba’s medical faculties, of which there are now 22, remain steadily focused on primary care, with family medicine required as the first residency for all physicians, even though Cuba now has more than twice as many physicians per capita as the United States.[4] Many of those physicians work outside the country, volunteering for two or more years of service, for which they receive special compensation. In 2008, there were 37,000 Cuban health care providers working in 70 countries around the world.[5] Most are in needy areas where their work is part of Cuban foreign aid, but some are in more developed areas where their work brings financial benefit to the Cuban government (e.g., oil subsidies from Venezuela).

Any visitor can see that Cuba remains far from a developed country in basic infrastructure such as roads, housing, plumbing, and sanitation. Nonetheless, Cubans are beginning to face the same health problems the developed world faces, with increasing rates of coronary disease and obesity and an aging population (11.7% of Cubans are now 65 years of age or older). Their unusual health care system addresses those problems in ways that grew out of Cuba’s peculiar political and economic history, but the system they have created — with a physician for everyone, an early focus on prevention, and clear attention to community health — may inform progress in other countries as well.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

References

1. Keck CW, Reed GA . The curious case of Cuba. Am J Public Health 2012;102:e13-e22
2. Drain PK, Barry M . Fifty years of U.S. embargo: Cuba’s health outcomes and lessons. Science 2010;328:572-573
3. World population prospects, 2011 revision. New York: United Nations (http://esa.un.org/unpd/wpp/Excel-Data/mortality.htm).
4. The world factbook. Washingto
n, DC: Central Intelligence Agency, 2012 (https://www.cia.gov/library/publications/the-world-factbook).
5. Gorry C . Cuban health cooperation turns 45. MEDICC Rev 2008;10:44-47

N Engl J Med 2013; 368:297-299 January 24, 2013 DOI: 10.1056/NEJMp1215226

Two Events, One Argument: The Case for Single-Payer Health Care

Debra Street, Andrew Coates speak in Buffalo

By George Sax
Artvoice (Buffalo, N.Y.), Jan. 24, 2013

Thirty years ago, soon after she arrived in Fort Walton Beach, Florida, from her native Canada, Debra Street found herself in a hospital emergency room with a painful kidney stone problem. This unpleasant situation quickly became more unpleasant, and something of a cultural shock.

She was asked how she would pay by an intake interviewer. Street, currently the chair of the sociology department at the University at Buffalo, had no insurance, or job. Her husband had both, but his insurance hadn’t kicked in yet during a probationary period. She had no checks with her name printed on them since the bank hadn’t yet sent them. She had no credit card. “It was a perfect storm” of misfortune, she told a meeting of the League of Women Voters at an Amherst restaurant last Friday. She was told to seek treatment at a “charity hospital” 40 miles away. “I hadn’t thought of this before,” she said. “I’m a Canadian. We get health care.”

And they get it without this kind of scrutiny. The Canadian government is billed for service. Canadians pay for it through premiums or taxes, depending on which province they live in.

Street might encounter a different response today because of a federal law that mandates emergency room treatment without regard for a patient’s fiscal resources. But maybe not. As she pointed out in a telephone interview this week, she might be turned down because hospitals are only required to stabilize emergencies and they judge whether a case is one. They also need not give preventive or longer-term service. (This is true despite the blithe assurance of the Buffalo News’ editors several years ago that everyone is protected by a care “safety net” because of access to emergency rooms. The News was engaging in a long-running opposition to President Barack Obama’s health care proposal and its limited insurance mandate.) None of this would have mattered to Street in Canada. As she said, Canadians get health care, in a single-payer system, where treatment isn’t approved or disallowed by private interests, as in this country.

“In Canada,” she told League members, “corporations don’t make the important decisions about health; public officials do.”

The night before Street spoke, more than 80 people crowded into a basement meeting room at Buffalo’s Lafayette Presbyterian Church for a community forum on “Poverty, Disparities and Healthcare,” organized by the Community Health Worker Network of Buffalo. At least a third of the attendees were young people, a result of outreach to medical students and undergraduates, according to Jessica Bauer Walker, the Network’s director.

The lead speaker was Andrew D. Coates, the newly elected president of Physicians for a National Health Program. Coates is an assistant professor at Albany Medical College and the medical director at an Albany County-owned nursing home. The PNHP is a 18,000-member organization dedicated to the institution of a single-payer system in this country, rather than what it regards as the unwieldy, piecemeal, and inadequate Obamacare program.

Thursday night, in his talk, Coates effectively functioned not only as a physician but also as a political economist, a historian, and a sociologist. For about an hour he deftly sped through data compilations and comparisons, succinctly and sometimes aphoristically commenting on the dismal state of American health care. The poor results of the American system haven’t been a secret for years, although a large portion of the American public has seemed confused about or unaware of the situation, an ignorance created at least in part by powerful political and private interests.

The U.S. ranks at or near the bottom of a list of 20 of the most advanced nations around the world in such categories as infant mortality, incidence of serious illness, and life expectancy. It is at the top in the cost of its system. “Our health delivery systems have created the dismal results and ill-health,” Coates said.

The two central themes of the Coates presentation—and of two co-speakers—were “the social determinants” of health, and the probable failures of Obamacare. There are at least 50 million uninsured Americans, and millions more of the underinsured. This glaring lack accounts for much of the bad outcomes, Coates said. He noted a recent finding by Harvard researchers that there are 45,000 “excess deaths” each year because of a lack of access to medical services.

As to state Medicaid programs, a crucial element of the Obama plan that is supposed to provide for those unable to pay for the insurance policies offered by private companies on the Internet “exchanges” that are to be established, Coates expressed biting skepticism: “Medicaid may be indefensible, but it’s better than nothing.”

It may also prove unavailable. (Dis)qualifying standards are usually stringent and a large number of the 50 states will apparently opt out of Obamacare’s expanded Medicaid with liberalized requirements despite a federal subsidy to them, according to William P. Keefer, a health law practitioner at the Buffalo law firm Phillips, Lytle LLP.

Coates dismissed the prospects of Obamacare insuring a majority of the uninsured. In an interview before the event, he cited a recent Congressional Budget Office projection that there will be 36 million people left out of the program at the end of 2016. The cost of policies offered will be too great for many people, he said. The sector of the population that will benefit the most from Obamacare are corporate interests: insurance, managed care, medical device and pharmaceutical companies. (Last June, USA Today quoted insurance executives who were relieved that the U.S. Supreme Court had sustained the program because it would create an expanded market for them.)

Coates scoffed at so-called market-driven reforms, quoting Harvard professor David Himmelstein: “Consumer-driven plans are driven like cattle are driven.” High co-pays and deductibles cause people with meager resources to deny themselves care, he said. “People delay care, even for heart attacks, one-fifth more if they’re underinsured,” he reported.

Sam Magavern, co-director of the Partnership for the Public Good, told the audience that for all the talk of Buffalo’s extreme poverty, the problem isn’t really the city’s poverty rate: “It’s not poverty, it’s inequality,” he said. The metropolitan area around Buffalo has a poverty rate at the national median. The national health care crisis isn’t due to “lack of resources. It’s the politics of who is willing to pay for what.”

Dr. Myron Glick, founder and chief executive at the nonprofit Jericho Road Family Practice in Buffalo, pointedly recalled how he has marvelled at the new and lavish suburban offices of insurance companies and medical groups he has visited for meetings. And he remembered a prominent cardiologist who declined a referral from Glick because the patient had only Medicaid. “It was the first question he asked,” Glick said. “He said I should send him to the county hospital. ‘They need patients to practice on.’”

Glick said he later saw the doctor at a medical conference. “I hold it against him,” he went on, “but it’s really the system. But the system won’t be changed by altruism.”

“I’m an incrementalist,” Coates said. “I’m not asking for a social revolution, but to get rid of a private-profit health system.” A single-payer system, he said a few minutes later, would “eliminate the most parasitical portion of finance capital” from health care.

Artvoice is Buffalo’s oldest and largest weekly newspaper, providing in-depth coverage of local politics, event information and reviews.

http://artvoice.com/i
ssues/v12n4/week_in_review/case_for_single_payer

Managed care needs a better watchdog

The Star Tribune failed that role in a story about UnitedHealth

By Kip Sullivan
Star Tribune (Minneapolis), Jan. 23, 2013

So UnitedHealth Group has figured out a way to cut Medicare’s costs “without cutting services”? That is how the Star Tribune characterized the organization’s self-serving claims in a recent story (“UnitedHealth says Medicare can save big without big cuts,” Jan. 20).

The Star Tribune has long had a policy of clearly distinguishing advertisements from news reporting. That policy was violated by the story on United, which characterized the firm’s claims as a fresh perspective in the debate about how to cut Medicare’s costs. In fact, United and every other large health insurance company has been peddling similar hype for decades.

The reader had to wade through 15 paragraphs to find a dissenting view, expressed by the Congressional Budget Office. The Star Tribune relegated the CBO’s views to this single sentence: “The Congressional Budget Office … tends to downplay or even ignore numbers like the ones UnitedHealth now offers, experts said.” It would have been helpful if the article had gone on to explain why.

The reason is that CBO requires supporting evidence before it will report back to Congress that a health care reform proposal will save money. The evidence the CBO looks for is not news releases and “studies” from health insurance companies but papers based on the principles of science and published in peer-reviewed journals. To date, the scientific literature does not support the cost-containment claims made by United and the rest of the managed-care insurance industry.

Neither the CBO nor professional journals are infallible. But they have no financial stake in the debate.

United thinks “private success stories need to drive public reforms.” In other words, that self-serving anecdotes from the health insurance industry should mean more to lawmakers than the scientific literature does. How does the state’s largest newspaper let such nonsense go unexamined?

Minnesota badly needs the equivalent of a CBO. I urge the Star Tribune to consider playing the role. That would require regular reporting on the evidence for the cost-containment claims made for “payment reform,” “pay for performance,” “report cards,” “bundled payments,” “disease management,” and the other health care reform fads collectively known as “managed care.”

Here are two questions to investigate:

First, how can United claim to have discovered methods that will lower Medicare costs when the health insurance industry, including United, has a long track record of raising, not lowering, Medicare’s costs? A steady stream of research has shown that it costs more to insure seniors through health insurance companies than it does through the traditional fee-for-service (FFS) Medicare program.

The current name for the private-sector branch of Medicare is Medicare Advantage (MA). The Medicare Payment Advisory Commission, which is very sympathetic to managed care, had this to say in a recent report to Congress: “Currently, Medicare spends more under the MA program for similar beneficiaries than it does under FFS.”

The second question to investigate is United’s claim that “health improvement programs such as diabetes prevention and weight control could save $53 billion” for Medicare and Medicaid. The peer-reviewed literature on this claim currently supports the opposite conclusion — that the cost of administering “disease management” programs in general, and diabetes and obesity prevention programs in particular, exceeds the savings in medical costs achieved by these programs.

There are a few exceptions to this rule, but diabetes and obesity are not among them. It remains possible that such programs targeted at a very small number of diabetics and overweight people (for example, those who are highly motivated to get well) will someday prove to save more than they cost the health care system, but in that event the total savings will be small compared with total health care spending.

The Star Tribune is capable of good reporting on managed-care hype. It has done so infrequently in the past. But it needs to do so regularly.

Kip Sullivan is a member of the steering committee of Physicians for a National Health Program, Minnesota chapter.

http://m.startribune.com/opinion/?id=188131581&c=y

Profit-Driven Health Care

By Leonard Rodberg
The New York Times, Letters, Jan. 21, 2013

Re “Health Care and Profits, a Poor Mix,” by Eduardo Porter (Economic Scene, Jan. 9):

The way we Americans provide health care is actually far worse than Mr. Porter suggests. It is not just that for-profit health insurance is more costly and less efficient than the nonprofit or government alternatives; it is inherently contradictory. The more health care the insurance companies provide — the more they respond to the needs of patients — the less profit they make. That’s why they cherry-pick the healthy and avoid the sick. That’s why we patients face denials and delays when we try to receive care.

The results are predictable; we have some of the worst health statistics of any advanced country. Other countries make health care a government responsibility, with the result that their people are healthier and they spend far less.

When will we learn, as your headline suggested, that health care and profits don’t mix?

Leonard Rodberg is a professor and chairman of the urban studies department, Queens College, CUNY. He resides in Flushing, Queens.

http://www.nytimes.com/2013/01/22/opinion/profit-driven-health-care.html?ref=opinion

The second managed care revolution

HMO-Like Plans May Be Poised To Make Comeback In Online Insurance Markets

By Julie Appleby
Kaiser Health News, January 22, 2013

It’s back to the future for insurers, which plan to sharply limit the choice of doctors and hospitals in some policies marketed to consumers under the health law, starting next fall.

Such plans, similar to the HMOs of old, fell into disfavor with consumers in the 1980s and 1990s, when they rebelled against a lack of choice.

But limited network plans — which have begun a comeback among employers looking to slow rising premiums — are expected to play a prominent role in new online markets, called exchanges, where individuals and small businesses will shop for coverage starting Oct. 1. That trend worries consumer advocates, who fear skimpy networks could translate into inadequate care or big bills for those who develop complicated health problems.

Because such policies can offer lower premiums, insurers are betting they will appeal to some consumers, especially younger and healthier people who might see little need for more expensive policies.

Insurers, who are currently designing their plans for next fall, “will start with as tight a network control as they can,” says Ana Gupte, a managed care analyst with Sanford Bernstein.

Plans may also benefit from offering such policies because they are less attractive to those with medical problems, who can no longer be turned away beginning in January 2014.

Driven by consumer and employer demand for lower-cost plans, insurers are already rolling out narrow network policies that have shaved premiums 10 percent or more. A recent survey by benefit firm Mercer found that 23 percent of large employers offered such plans this year, usually among a choice of plans, up from 14 percent in 2011.

Many policies that currently offer a limited network of doctors and hospitals generally allow patients to go to out-of-network providers, with whom they do not have negotiated prices. But patients who seek such care face significant co-payments, which often start at 30 percent of the bill and can go as high as 50 percent.

It is often hard for consumers to figure out how much they might be charged if they go out of network, says Lynn Quincy, senior policy analyst at Consumers Union, publisher of Consumer Reports magazine. In addition to meeting separate annual deductibles for out-of-network care, patients can be “balance-billed” by doctors or hospitals for the difference between what the insurer pays them and their total charges.

That doesn’t change under the federal health law, so consumers could be left on the hook for tens of thousands of dollars.

http://www.kaiserhealthnews.org/Stories/2013/January/23/HMO-limited-networks-comeback-in-exchanges.aspx

Comment:

By Don McCanne, M.D.

So we didn’t get single payer, but at least we got a bill that brought us an end to insurance company abuses, so they say. But did we really?

Most people purchasing plans through the insurance exchanges will select plans with lower premiums which means the bronze and silver plans that have actuarial values of 60 or 70 percent. To achieve these low values, the plans will require large deductibles and other cost sharing – expenses that may not be affordable for many who actually need health care.

This article and others have reported on the strategy of insurers to rely more heavily on “narrow network” plans – plans that greatly limit your choice of health care professionals and institutions. Obtaining care outside of the network can result in greater cost sharing plus balance-billing for charges that normally would be disallowed. Current networks are already restrictive enough, but these new super skimpy networks will leave patients even more dissatisfied than they were at the peak of the managed care revolution. And we thought we got away from that.

Although insurers would be prohibited from deliberately excluding more costly, sicker patients, the very design of these plans motivates the healthy to buy them and the sick to shun them. Thus cherry picking and lemon dropping will still be with us, even if not overt.

Can you imagine the celebrations in the board rooms of the insurance and pharmaceutical firms? Officers and directors dancing around the table Don McNeill-style, singing, “Happy days are here again!”

The second managed care revolution

HMO-Like Plans May Be Poised To Make Comeback In Online Insurance Markets

By Julie Appleby
Kaiser Health News, January 22, 2013
It’s back to the future for insurers, which plan to sharply limit the choice of doctors and hospitals in some policies marketed to consumers under the health law, starting next fall.
Such plans, similar to the HMOs of old, fell into disfavor with consumers in the 1980s and 1990s, when they rebelled against a lack of choice.
But limited network plans — which have begun a comeback among employers looking to slow rising premiums — are expected to play a prominent role in new online markets, called exchanges, where individuals and small businesses will shop for coverage starting Oct. 1. That trend worries consumer advocates, who fear skimpy networks could translate into inadequate care or big bills for those who develop complicated health problems.
Because such policies can offer lower premiums, insurers are betting they will appeal to some consumers, especially younger and healthier people who might see little need for more expensive policies.
Insurers, who are currently designing their plans for next fall, “will start with as tight a network control as they can,” says Ana Gupte, a managed care analyst with Sanford Bernstein.
Plans may also benefit from offering such policies because they are less attractive to those with medical problems, who can no longer be turned away beginning in January 2014.
Driven by consumer and employer demand for lower-cost plans, insurers are already rolling out narrow network policies that have shaved premiums 10 percent or more. A recent survey by benefit firm Mercer found that 23 percent of large employers offered such plans this year, usually among a choice of plans, up from 14 percent in 2011.
Many policies that currently offer a limited network of doctors and hospitals generally allow patients to go to out-of-network providers, with whom they do not have negotiated prices. But patients who seek such care face significant co-payments, which often start at 30 percent of the bill and can go as high as 50 percent.
It is often hard for consumers to figure out how much they might be charged if they go out of network, says Lynn Quincy, senior policy analyst at Consumers Union, publisher of Consumer Reports magazine. In addition to meeting separate annual deductibles for out-of-network care, patients can be “balance-billed” by doctors or hospitals for the difference between what the insurer pays them and their total charges.
That doesn’t change under the federal health law, so consumers could be left on the hook for tens of thousands of dollars.
http://www.kaiserhealthnews.org/Stories/2013/January/23/HMO-limited-netw…

So we didn’t get single payer, but at least we got a bill that brought us an end to insurance company abuses, so they say. But did we really?
Most people purchasing plans through the insurance exchanges will select plans with lower premiums which means the bronze and silver plans that have actuarial values of 60 or 70 percent. To achieve these low values, the plans will require large deductibles and other cost sharing – expenses that may not be affordable for many who actually need health care.
This article and others have reported on the strategy of insurers to rely more heavily on “narrow network” plans – plans that greatly limit your choice of health care professionals and institutions. Obtaining care outside of the network can result in greater cost sharing plus balance-billing for charges that normally would be disallowed. Current networks are already restrictive enough, but these new super skimpy networks will leave patients even more dissatisfied than they were at the peak of the managed care revolution. And we thought we got away from that.
Although insurers would be prohibited from deliberately excluding more costly, sicker patients, the very design of these plans motivates the healthy to buy them and the sick to shun them. Thus cherry picking and lemon dropping will still be with us, even if not overt.
Can you imagine the celebrations in the board rooms of the insurance and pharmaceutical firms? Officers and directors dancing around the table Don McNeill-style, singing, “Happy days are here again!”

Carrots for Doctors

Comment:

Judge says HCA broke spending promises

Comment:

HMO-Like Plans May Be Poised To Make Comeback In Online Insurance Markets

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