PNHP

St. Louis doctor pushes for single-payer health care system

St. Louis doctor pushes for single-payer health care system

By Michele Munz
St. Louis Post-Dispatch, July 19, 2012

CLAYTON, Mo. — In a meeting room at a St. Louis County public library, Dr. Ed Weisbart started his health insurance reform presentation with pictures of sick people.

One was self-employed who couldn’t afford health insurance and made too much money to get Medicaid. Another was a factory worker who lost coverage when he became too ill to work. Then there were working parents whose bills for their sick infant drove them into bankruptcy.

“The reason I’m here and that you are here, is because you’ve seen patients like this,” Weisbart told the crowd.

About 40 people from diverse fields filled the room. They included doctors, students, a medical office manager, social worker and even a musician.

They were there to learn about a single-payer health care system that makes free-market advocates cringe. Instead of hundreds of insurance companies and billing agencies, one government-run organization would collect the fees and pay all the costs under the single-payer plan. In a system financed by a progressive tax, advocates argue that people would pay less than what they pay now in premiums and out-of-pocket costs.

Each person would receive comprehensive medical care and choose whichever doctor or hospital they want. Patients would receive no bills. Co-payments and deductibles would be eliminated.

“It basically involves just changing two words in the law,” Weisbart said about the current federal insurance program for older Americans. “Instead of saying Medicare is available at age 65, say it’s available starting at birth.”

However, the American Medical Association, the country’s largest physician group, supports the current mix of private and public insurance options.

“The private sector has been leading the way in developing and piloting innovative health care delivery and payment models to better support and reward physicians who provide high-value health care,” said the AMA’s president, Dr. Jeremy Lazarus.

Single-payer may seem like an impossibility in the U.S. Weisbart, 58, had long thought so too, until President Barack Obama began tackling health care reform.

“I had thought single-payer, great idea, but it’s not going to happen. The interests against it are so vested,” he said. “Then that pesky Obama got elected, and I got all hopey-changey.”

Implementation of the president’s Affordable Care Act is now in full swing after last month’s ruling by the Supreme Court upheld its constitutionality. The legislation moves the country closer to universal health care coverage, but single-payer advocates like Weisbart argue it’s not enough.

Weisbart is a member of Physicians for a National Health Program, which has been advocating for a single-payer system since 1987 and now has 18,000 members. In March, he started a St. Louis chapter.

The group’s first meeting included 10 people at Weisbart’s home in Olivette. Since then, the chapter has organized two presentations to more than 125 medical students at Washington and St. Louis universities and the recent meeting at the library.

Weisbart led the meeting along with a panel that included the president of a Barnes-Jewish Hospital physician group that advises administration on patient care, a family physician who served on the national policy committee for the nation’s second-largest physician group and a third-year Washington University medical student who co-authored “The Health Care Handbook,” praised as a clear guide to our health care system.

Weisbart has a lengthy resume as well. He was drawn to become a doctor by new ideas in improving patient care: Health maintenance organizations and family medicine.

After medical school, Weisbart went to work as a family doctor for an HMO at Rush Medical College, eventually becoming chief medical officer. Later, a 200-member group of private practice doctors in suburban Chicago hired him as director of care and quality.

Then in 2003, locally based pharmacy benefit giant Express Scripts recruited him as its chief medical officer. He retired from Express Scripts two years ago.

Weisbart also has a long list of volunteer work, including seeing patients at the Barnes-Jewish Center for Outpatient Health and the Saturday Neighborhood Health Clinic run by Washington University medical students, both which serve the under- and non-insured. He’s also the medical director for Rx Outreach, a nonprofit mail-order pharmacy based in Maryland Heights that provides medicine for low-income patients.

A year after retiring from Express Scripts, he was approached by community activist Linda Lieb, 54, about organizing a local Physicians for a National Health Program chapter. She had just moved to St. Louis after helping organize a chapter in Huntsville, Ala., and had heard of Weisbart.

After a long career of trying to improve care within the system, Weisbart agreed to start recruiting. “I realized if you support incrementalism, you oppose fundamental change,” he said.

In Huntsville, Lieb experienced difficulty in finding doctors.

“It’s encouraging to see so many physicians here in St. Louis who are working toward this goal,” she said. “Ed has pulled together a wonderful leadership committee of physicians and medical students.”

Support among physicians appears to be growing. A poll published in 2008 shows 59 percent of doctors support national insurance, up from 49 percent five years earlier. The American College of Physicians, the nation’s second-largest doctor group, and the American Medical Student Association have both endorsed single-payer.

“We need to be more vocal. We need to tell our patients we support this,” Dr. Christine Jacobs, a family physician who directs St. Louis University’s family medicine residency program, said at the library meeting. “When I tell my patients, they are surprised. They say, ‘You think that?’ “

The panel members discussed fears about long waits and stifled medical research, arguing that the system would be more efficient and focused with less money and time spent on marketing, administration and underwriting. Administrative costs consume 31 percent of U.S. health spending, studies have found.

Lazarus, of the American Medical Association, points to the current problems in determining how much physicians are reimbursed through Medicare.

“One look at the flawed Medicare physician payment formula provides a clear example of the problems that can arise with a government-run health care system — conflicting agendas and budget constraints can dictate policy rather than the health care needs of our nation’s senior citizens,” he said.

Federal legislation to enact single-payer would address those problems by creating separate budgets for care, education and capital improvements, Weisbart said. An independent, diverse board would monitor reimbursement and quality.

Even with the Affordable Care Act, experts estimate that 26 million will remain uninsured and others will still be dealing with gaps in coverage and rising costs.

Weisbart is driven by memories of patients like the 62-year-old grandmother caring for her three grandchildren and facing eviction, who asked how long she could live without taking her blood pressure pills.

“I don’t want anyone to ask me that question again,” he said.

http://www.stltoday.com/lifestyles/health-med-fit/fitness/local-doctor-pushes-for-single-payer-health-care-system/article_79560155-639a-5550-a262-3c0be8f38f69.html#ixzz215mBiZSX

Medicare performs better than private plans

Medicare Beneficiaries Less Likely To Experience Cost- And Access-Related Problems Than Adults With Private Coverage

By Karen Davis, Kristof Stremikis, Michelle M. Doty and Mark A. Zezza
Health Affairs, July 18, 2012

The 2010 survey results indicate that compared to people who are privately insured, Medicare beneficiaries are less likely to have cost-related access problems, high premium and out-of-pocket health care expenses as a share of income, and financial problems because of medical bills. And compared to nonelderly adults with employer-based coverage, Medicare beneficiaries are more likely to have access to a medical home—a primary care provider who knows their medical history well, is accessible, and helps coordinate their care. Studies show that patients with medical homes are less likely to report medical errors or gaps in the coordination of their care and are more likely to be up-to-date with their preventive care.

Given these findings, it is not surprising that Medicare beneficiaries are far less likely than privately insured adults to give their health insurance plan a fair or poor rating, while being far more likely to report excellent quality of care.

Among Medicare beneficiaries, those with Medicare Advantage are more likely than adults with traditional Medicare to give their insurance a fair or poor rating. Although Medicare Advantage enrollees are less likely to spend 10 percent or more of their income on premiums and out-of-pocket expenses, they are more likely to report cost-related access problems than adults with traditional Medicare. This may in part reflect beneficiaries’ experience with private health maintenance organization plans that offer lower premiums in return for limited access to a smaller network of providers.

The evidence reported here from surveys now spanning a decade shows that Medicare is doing a better job than employer-sponsored plans at fulfilling the two main purposes of health insurance: ensuring access to care and providing financial protection.

http://content.healthaffairs.org/content/early/2012/07/16/hlthaff.2011.1357.abstract

Summary by The Commonwealth Fund:
http://www.commonwealthfund.org/~/media/Files/Publications/In%20the%20Literature/2012/Jul/1613_Davis_Medicare_vs_employer_ins_HA_07_18_2012_ITL.pdf

Comment:

By Don McCanne, MD

One of the goals of the Affordable Care Act was to protect private, employer-sponsored health plans – a sector that was considered to be functioning well. In so doing, a less expensive Medicare for all model was rejected. So how do the private plans compare to Medicare?

According to this report, “Medicare beneficiaries are less likely to have cost-related access problems, high premium and out-of-pocket health care expenses as a share of income, and financial problems because of medical bills. And compared to nonelderly adults with employer-based coverage, Medicare beneficiaries are more likely to have access to a medical home – a primary care provider who knows their medical history well, is accessible, and helps coordinate their care,” and are “far more likely to report excellent quality of care.”

Medicare is not perfect and does need improvement, but it performs far better than the best of the private plans – the employer-sponsored health plans. Individual and small group plans have an even worse performance.

Above all, “Medicare is doing a better job than employer-sponsored plans at fulfilling the two main purposes of health insurance: ensuring access to care and providing financial protection.”

Right now, efforts are being made to convert Medicare into a market of private plans. Why should we pay more for less health care choice, greater risk exposure, and poorer quality? Any sane individual who is paying attention should realize that we should be doing the opposite – improve Medicare and then provide it for everyone.

Medicare performs better than private plans

Medicare Beneficiaries Less Likely To Experience Cost- And Access-Related Problems Than Adults With Private Coverage

By Karen Davis, Kristof Stremikis, Michelle M. Doty and Mark A. Zezza
Health Affairs, July 18, 2012
The 2010 survey results indicate that compared to people who are privately insured, Medicare beneficiaries are less likely to have cost-related access problems, high premium and out-of-pocket health care expenses as a share of income, and financial problems because of medical bills. And compared to nonelderly adults with employer-based coverage, Medicare beneficiaries are more likely to have access to a medical home—a primary care provider who knows their medical history well, is accessible, and helps coordinate their care. Studies show that patients with medical homes are less likely to report medical errors or gaps in the coordination of their care and are more likely to be up-to-date with their preventive care.
Given these findings, it is not surprising that Medicare beneficiaries are far less likely than privately insured adults to give their health insurance plan a fair or poor rating, while being far more likely to report excellent quality of care.
Among Medicare beneficiaries, those with Medicare Advantage are more likely than adults with traditional Medicare to give their insurance a fair or poor rating. Although Medicare Advantage enrollees are less likely to spend 10 percent or more of their income on premiums and out-of-pocket expenses, they are more likely to report cost-related access problems than adults with traditional Medicare. This may in part reflect beneficiaries’ experience with private health maintenance organization plans that offer lower premiums in return for limited access to a smaller network of providers.
The evidence reported here from surveys now spanning a decade shows that Medicare is doing a better job than employer-sponsored plans at fulfilling the two main purposes of health insurance: ensuring access to care and providing financial protection.
http://content.healthaffairs.org/content/early/2012/07/16/hlthaff.2011.1357.abstract
Summary by The Commonwealth Fund:
http://www.commonwealthfund.org/~/media/Files/Publications/In%20the%20Literature/2012/Jul/1613_Davis_Medicare_vs_employer_ins_HA_07_18_2012_ITL.pdf

One of the goals of the Affordable Care Act was to protect private, employer-sponsored health plans – a sector that was considered to be functioning well. In so doing, a less expensive Medicare for all model was rejected. So how do the private plans compare to Medicare?
According to this report, “Medicare beneficiaries are less likely to have cost-related access problems, high premium and out-of-pocket health care expenses as a share of income, and financial problems because of medical bills. And compared to nonelderly adults with employer-based coverage, Medicare beneficiaries are more likely to have access to a medical home – a primary care provider who knows their medical history well, is accessible, and helps coordinate their care,” and are “far more likely to report excellent quality of care.”
Medicare is not perfect and does need improvement, but it performs far better than the best of the private plans – the employer-sponsored health plans. Individual and small group plans have an even worse performance.
Above all, “Medicare is doing a better job than employer-sponsored plans at fulfilling the two main purposes of health insurance: ensuring access to care and providing financial protection.”
Right now, efforts are being made to convert Medicare into a market of private plans. Why should we pay more for less health care choice, greater risk exposure, and poorer quality? Any sane individual who is paying attention should realize that we should be doing the opposite – improve Medicare and then provide it for everyone.

The Nation moves to right-center on health care

The Battle for Healthcare Has Just Begun

By the Editors
The Nation, July 11, 2012

If you thought the battle over healthcare reform came to an end when the Supreme Court declared the Affordable Care Act’s individual mandate constitutional, think again. The fight is just beginning. On one side the Republican Party and its big money allies aspire to defeat President Obama, take control of Congress and repeal the largest piece of domestic legislation in forty-five years. Mitt Romney’s plan is even more regressive. He’d not only eliminate insurance for the 30 million Americans covered by the ACA; he would change the way the industry is taxed and regulated, turn Medicare into a voucher program and transform Medicaid into a block grant, which together would strip access to healthcare from as many as 28 million Americans who are currently insured.

On the other side are people-powered progressives determined to implement the law and strengthen its less than ideal aspects to achieve universal coverage (see Wendell Potter, page 4). Under the ACA, for example, states will be empowered to create state-based single-payer systems. Vermont has already passed such legislation, and advocates in California are pushing a similar plan, passed by the legislature twice, only to be vetoed both times by then–Governor Schwarzenegger.

But if the fast and furious attack from the right is any indication, we have our work cut out for us. As many as eight Republican governors—led by Tea Party ideologues like Florida’s Rick Scott, Wisconsin’s Scott Walker, South Carolina’s Nikki Haley, Texas’ Rick Perry and Louisiana’s Bobby Jindal—have refused to implement the law’s expansion of Medicaid to cover some of America’s poorest. In Florida, that would affect some 1.3 million people who make less than 133 percent of the federal poverty level (about $31,000 a year for a family of four). In Texas, where 25 percent of residents are uninsured—the highest rate in the nation—Perry’s intransigence would leave 1.8 million out in the cold.

This cruel, cynical agenda has been enabled by a cabal of groups bankrolled by the 1 percent, such as the Chamber of Commerce and Karl Rove’s Crossroads GPS. Even before the Supreme Court decision came down, these organizations had spent some $235 million on attack ads vilifying “Obamacare,” and they are on track to spend much more by November. Already the Koch-backed Americans for Prosperity has launched a $9 million campaign against the ACA and the Democrats who voted for it. Concerned Women for America has pledged another $6 million.

These ads and the rhetoric emanating from the Tea Party guvs are nothing but open fearmongering and baldfaced lies. They insinuate that the ACA would ration healthcare (in fact, the ACA rations it no more or less than the current system). Governor Scott justified his refusal to expand Medicaid by claiming it would add $1.9 billion to Florida’s budget (though the federal government funds 100 percent of Medicaid expansion in the first three years, and Florida’s own healthcare agency estimates it would cost the state far less). Not to be outdone, Rush Limbaugh hysterically called the ACA the “biggest tax increase in the history of the world” (when, in fact, it contains tax breaks for middle-class Americans).

These lies have done a great deal of damage. Many people are confused about what the act does and does not do, creating a debate that seems to take place in an alternate reality. The stakes in this fight, then, are profound: the health of millions of Americans, of our shared social safety net and—not least—of our democracy itself.

Posted reader comment:

By Don McCanne, MD

It is disappointing to see that the editorial position of The Nation has framed the current status of the health care debate as, on the left, a determination to “implement” and “strengthen” the Affordable Care Act, and, on the right, an effort to “repeal” ACA.

The objection is not with the characterization of the right, but with the implication that the left has settled on a right-center approach designed by conservatives. Token mention is made of the Vermont and California efforts to enact single payer, but, in fact, states do not have the option of diverting federal funds from programs such as Medicare and Medicaid into a state-based single payer program, nor can they bypass federal requirements such as the ERISA restrictions, usurping funds from employer-sponsored self-insured plans.

All the tweaking in the world cannot repair the highly-flawed, fragmented, and egregiously administratively wasteful model of ACA. It needs to be replaced with a bona fide model of social insurance – the most appropriate for the United States being a single payer, improved and expanded Medicare that covers everyone.

Also, it is a mistake to be hung up on a left-right linear polarity when the issue of health care justice should be much more inclusive. In an article this week in the Des Moines Register, retired health executive Jack Bernard stated, “If we Republicans took the Medicare-for-all approach, it would thrust us into the vanguard of reform. Instead of the Democrats stealing our ideas, we could steal theirs.”

The Democrats did steal the Heritage model which was originally introduced by Republicans as a conservative response to the Clinton proposal. Democrats have now succeeded in enacting it, but what a terrible model. It will leave tens of millions uninsured while creating a new standard of underinsurance, imposing financial hardship on those with health care needs.

Everyone should read Jack Bernard’s article, and then we should see if we can get past the simplistic polarization to bring us together to improve our health as individuals and to improve the health of the nation.

Jack Bernard, “Head-in-the-sand ‘solution’ is killing GOP”:
http://www.desmoinesregister.com/article/20120716/OPINION01/307160040/

The Nation editorial:
http://www.thenation.com/article/168844/battle-healthcare-has-just-begun

Nurses Union Will Keep Fighting for Medicare for All

By Rose Ann DeMoro
The Nation, July 17, 2012

Now that the Supreme Court has upheld the Affordable Care Act, former insurance company executive Wendell Potter’s appeal to single payer advocates to “bury the hatchet,” recently published in The Nation, is both misdirected and shortsighted.

Potter argues that insurance industry pirates will exploit left critiques of the ACA to subvert implementation of the law. He calls on proponents of more comprehensive reform to forgive and forget, embracing the massive concessions made by the Obama administration and its liberal allies.

But there are some gaping holes in this thinking.

First, the insurers hardly need to rely on the single-payer movement to sabotage elements of the law they don’t like. They have office towers full of high-priced lawyers who are adept at identifying loopholes in the much-touted consumer protection provisions, like the bans on pre-existing condition exclusions or dropping coverage when patients get sick, or limiting how much money can be siphoned off for profits and paperwork.

Second, let’s not have illusions about the history of the ACA.

Before he was elected, President Obama, an advocate of single-payer when he was in the Senate, called on progressives to push him. Instead, most of the liberals reduced themselves to cheerleading while all the pressure came from the right.

So when the healthcare bill was introduced, the President, with the active encouragement of groups like Health Care for America Now, blocked single payer from consideration. Persuading people through consent, rather than coercion, to accept inadequate solutions for societal needs has long been a key feature of the neoliberal agenda.  It’s one reason so many people vote against their own interests.

To get any hearing from Sen. Max Baucus, who was running the Senate side of the debate, nurses, doctors, and single-payer healthcare activists had to get arrested in a Senate Finance Committee hearing. On the House side, Democrats who proposed single payer amendments endured heavy-handed threats from then-White House chief of staff Rahm Emanuel. Meanwhile, then-Press Secretary Robert Gibbs publicly attacked the “professional left” who will only “be satisfied when we have Canadian healthcare and we’ve eliminated the Pentagon.”

It should not come as a surprise that negotiating with your supporters before engaging political opposition, and lecturing, hectoring and seeking to silence healthcare activists who have worked for years for real reform, Obama and the Democrats ended up with a weaker bill. That bill lacked the public option HCAN and other liberals had claimed would be their bottom line, while HCAN and other liberals embraced the individual mandate – the brainchild of the rightwing Heritage Foundation – as high principle.

Even with its positive elements – yes, it does have some – the Affordable Care Act uses public money to pad insurance profits (the subsidies to buy private insurance), prevents the government from using its clout to limit price gouging by the pharmaceutical giants, does little to effectively control rising healthcare costs for individuals and families that have made medical bankruptcies and self-rationing of care a national disgrace, and falls far short of the goal of universal coverage.

We can, as Michael Moore has said, acknowledge that the Supreme Court decision was a defeat for the opponents of any reform of our healthcare system without pretending that our nation’s health care crisis is over.

For three weeks in June and July, the California Nurses Association/National Nurses United sponsored a tour that drew about 1,000 people to free basic health screenings and another 2,000 to town hall meetings in big cities and rural communities across California. We heard a lot of stories like this one, from Carolyn Travao of Fresno:

I worked for Aetna health insurance for 15 years. When I took early retirement, I thought my Cobra would be manageable. Then they sent me a bill in January for $1,300 a month and I couldn’t pay it.

Soon after,

I had a heart attack. I knew I didn’t have health insurance. I have a mortgage. I had a 401(k) that I knew would get wiped out, so I didn’t go to the hospital. I stayed at home for 16 hours, suffering chest pains, praying that I would die because my son would be left homeless and I do have insurance to pay off my mortgage so if I die he would at least have a home. I couldn’t take the pain any longer and I kept passing out, and he kept saying “Mom, you’re going to die.”

“OK,” I said, “take me to emergency.” So we went to emergency. But when I got home, my bill was $135,000. I have $13,000 left in my 401k. I don’t think I can even start [paying].  I never thought I would lay there and want to die. But I would have rather died knowing that my son would be left homeless with no job.

Since the ACA’s cost control mechanisms for insurance companies are so weak – for example permitting insurers to charge far more based on age and where you live – and hospitals will still largely have free reign to impose un-payable bills, will Carolyn and millions like her really have guaranteed healthcare under the ACA?

Sadly, nurses who have seen far too many patients like Carolyn know the answer all too well. That is why nurses and our organization will never stop fighting for guaranteed healthcare based on a single standard of quality care for all that is not based on ability to pay and is not premised on protecting the profits of healthcare corporations that long ago wrote off patients like Carolyn Travao.

Unlike Wendell Potter and many of the liberals, nurses see the ACA as a floor, not a ceiling. It’s time now for those who say they recognize its limitations and believe in genuinely universal healthcare to join us in pushing for an improved and expanded Medicare for all.

Nurses respect the president.  But they love their patients far too much not to go the distance for their patients’ health and survival.

http://www.thenation.com/article/168928/nurses-union-will-keep-fighting-medicare-all

The Nation moves to right-center on health care

The Battle for Healthcare Has Just Begun

By the Editors
The Nation, July 11, 2012
If you thought the battle over healthcare reform came to an end when the Supreme Court declared the Affordable Care Act’s individual mandate constitutional, think again. The fight is just beginning. On one side the Republican Party and its big money allies aspire to defeat President Obama, take control of Congress and repeal the largest piece of domestic legislation in forty-five years. Mitt Romney’s plan is even more regressive. He’d not only eliminate insurance for the 30 million Americans covered by the ACA; he would change the way the industry is taxed and regulated, turn Medicare into a voucher program and transform Medicaid into a block grant, which together would strip access to healthcare from as many as 28 million Americans who are currently insured.
On the other side are people-powered progressives determined to implement the law and strengthen its less than ideal aspects to achieve universal coverage (see Wendell Potter, page 4). Under the ACA, for example, states will be empowered to create state-based single-payer systems. Vermont has already passed such legislation, and advocates in California are pushing a similar plan, passed by the legislature twice, only to be vetoed both times by then–Governor Schwarzenegger.
But if the fast and furious attack from the right is any indication, we have our work cut out for us. As many as eight Republican governors—led by Tea Party ideologues like Florida’s Rick Scott, Wisconsin’s Scott Walker, South Carolina’s Nikki Haley, Texas’ Rick Perry and Louisiana’s Bobby Jindal—have refused to implement the law’s expansion of Medicaid to cover some of America’s poorest. In Florida, that would affect some 1.3 million people who make less than 133 percent of the federal poverty level (about $31,000 a year for a family of four). In Texas, where 25 percent of residents are uninsured—the highest rate in the nation—Perry’s intransigence would leave 1.8 million out in the cold.
This cruel, cynical agenda has been enabled by a cabal of groups bankrolled by the 1 percent, such as the Chamber of Commerce and Karl Rove’s Crossroads GPS. Even before the Supreme Court decision came down, these organizations had spent some $235 million on attack ads vilifying “Obamacare,” and they are on track to spend much more by November. Already the Koch-backed Americans for Prosperity has launched a $9 million campaign against the ACA and the Democrats who voted for it. Concerned Women for America has pledged another $6 million.
These ads and the rhetoric emanating from the Tea Party guvs are nothing but open fearmongering and baldfaced lies. They insinuate that the ACA would ration healthcare (in fact, the ACA rations it no more or less than the current system). Governor Scott justified his refusal to expand Medicaid by claiming it would add $1.9 billion to Florida’s budget (though the federal government funds 100 percent of Medicaid expansion in the first three years, and Florida’s own healthcare agency estimates it would cost the state far less). Not to be outdone, Rush Limbaugh hysterically called the ACA the “biggest tax increase in the history of the world” (when, in fact, it contains tax breaks for middle-class Americans).
These lies have done a great deal of damage. Many people are confused about what the act does and does not do, creating a debate that seems to take place in an alternate reality. The stakes in this fight, then, are profound: the health of millions of Americans, of our shared social safety net and—not least—of our democracy itself.

Originally posted as a reader comment:
It is disappointing to see that the editorial position of The Nation has framed the current status of the health care debate as, on the left, a determination to “implement” and “strengthen” the Affordable Care Act, and, on the right, an effort to “repeal” ACA.
The objection is not with the characterization of the right, but with the implication that the left has settled on a right-center approach designed by conservatives. Token mention is made of the Vermont and California efforts to enact single payer, but, in fact, states do not have the option of diverting federal funds from programs such as Medicare and Medicaid into a state-based single payer program, nor can they bypass federal requirements such as the ERISA restrictions, usurping funds from employer-sponsored self-insured plans.
All the tweaking in the world cannot repair the highly-flawed, fragmented, and egregiously administratively wasteful model of ACA. It needs to be replaced with a bona fide model of social insurance – the most appropriate for the United States being a single payer, improved and expanded Medicare that covers everyone.
Also, it is a mistake to be hung up on a left-right linear polarity when the issue of health care justice should be much more inclusive. In an article this week in the Des Moines Register, retired health executive Jack Bernard stated, “If we Republicans took the Medicare-for-all approach, it would thrust us into the vanguard of reform. Instead of the Democrats stealing our ideas, we could steal theirs.”
The Democrats did steal the Heritage model which was originally introduced by Republicans as a conservative response to the Clinton proposal. Democrats have now succeeded in enacting it, but what a terrible model. It will leave tens of millions uninsured while creating a new standard of underinsurance, imposing financial hardship on those with health care needs.
Everyone should read Jack Bernard’s article, and then we should see if we can get past the simplistic polarization to bring us together to improve our health as individuals and to improve the health of the nation.
Jack Bernard, “Head-in-the-sand ‘solution’ is killing GOP”:
http://www.desmoinesregister.com/article/20120716/OPINION01/307160040/
The Nation editorial:
http://www.thenation.com/article/168844/battle-healthcare-has-just-begun

Jack Bernard's message for his fellow Republicans

Head-in-the-sand 'solution' is killing GOP

By Jack Bernard
DesMoinesRegister.com, July 16, 2012

We Republicans have ourselves to blame for the Affordable Care Act, or Obamacare.

Our reaction to the Clinton health reform proposals in the early 1990s was to have conservative think tanks come up with a free competition model based on expansion of private insurance and Medicaid. That idea became Romneycare, which evolved into Obamacare.

It is our baby, ugly or not.

It is the height of hypocrisy for us now to criticize our own idea unless we have something better to replace it. And, the replacement needs to be comprehensive, not just a series of unacceptable statements and proposals based on doing away with traditional Medicare by turning it into a voucher program and gutting Medicaid by making it into a block grant.

Using vouchers for Medicare just dumps the cost problem into the lap of the powerless patient, rather than the federal government that has clout, making the cost escalation problem worse. The block grants for Medicaid idea just shifts the cost issue onto the states rather than the federal government, which once again solves nothing and only makes things worse.

States will just cut services and people from their Medicaid roles, creating more uninsured. Don’t Iowa hospitals serve enough uninsured in their emergency rooms now?

This gets us to what we as Republicans should do: throw out our rule book and be innovative. People my age will remember how we Republicans were 100 percent against recognizing China before Richard Nixon, the anti-communist crusader, came out for it. We must do the same with health care.

There is only one way to control health care costs and insure universal access — and that is by first admitting that the U.S. system has failed and then adopting ideas that have been proven to work elsewhere. We should take a look at how health care is financed and delivered in other developed nations with lower cost and better morbidity and mortality rates.

A Commonwealth Fund study was issued in May 2012 which did just that for 13 countries. The bottom line is that we spend 17.4 percent of our gross national product on health care, far more than other developed nations, which averaged 9.5 percent. Our per-capita spending was $7,960 versus $3,182 for the group as a whole.

Why? One key factor is prices. For example, U.S. pricing on the 30 most commonly prescribed brand name drugs is one-third higher than Canada and double France, both of which have a form of Universal Medicare.

From looking at the international data, if we Republicans really want to dump the Affordable Care Act, the way to go is Medicare for all. Studies show that the nations with universal health care have better overall health care outcomes than we do, not worse.

And, according to the respected Physicians for a National Health Program, www.pnhp.org, yearly savings generated under Medicare for all would be $400 billion. That would go a long way towards paying for universal coverage, versus the Affordable Care Act, which will increase systemic costs because it relies on private insurance.

The canard about waiting times to see doctors is just a tactic to scare the public. If you need a knee replacement for a knee that has been going bad for years, waiting a little longer for an operation should not be a major issue for the patient. Despite the scare tactics, no one who needs immediate care in Canada is ever left to sit in a line. In any case, there should be no waiting lists at all here. Canada spends just $4,363 per capita on health care versus our $7,960.

If we Republicans took the Medicare-for-all approach, it would thrust us into the vanguard of reform. Instead of the Democrats stealing our ideas, we could steal theirs. When it was implemented and turned out to be widely accepted, as was Medicare in the 1960s, we would be the party the public would look to for the future.

Of course, there is an alternative. We can stick our heads in the sand and push for infeasible actions. That approach is killing us regarding immigration and will work just as well for health care.

(JACK BERNARD of Monticello, Ga., is a retired health care executive who worked extensively with Iowa health care providers, including Iowa Health System. He now is a member of the Jasper County (Ga.) Board of Commissioners and Jasper County Board of Health. Contact: bernard_jack@hotmail.com)

http://www.desmoinesregister.com/article/20120716/OPINION01/307160040/

Comment: 

By Don McCanne, MD

This article should be distributed widely. Although it is written by a Republican, targeting his fellow Republicans, if his party can understand this message, then the Democrats and others who bailed on Medicare for all should be able to understand it as well.

Jack Bernard’s message for his fellow Republicans

Head-in-the-sand ‘solution’ is killing GOP

By Jack Bernard
DesMoinesRegister.com, July 16, 2012

We Republicans have ourselves to blame for the Affordable Care Act, or Obamacare.

Our reaction to the Clinton health reform proposals in the early 1990s was to have conservative think tanks come up with a free competition model based on expansion of private insurance and Medicaid. That idea became Romneycare, which evolved into Obamacare.

It is our baby, ugly or not.

It is the height of hypocrisy for us now to criticize our own idea unless we have something better to replace it. And, the replacement needs to be comprehensive, not just a series of unacceptable statements and proposals based on doing away with traditional Medicare by turning it into a voucher program and gutting Medicaid by making it into a block grant.

Using vouchers for Medicare just dumps the cost problem into the lap of the powerless patient, rather than the federal government that has clout, making the cost escalation problem worse. The block grants for Medicaid idea just shifts the cost issue onto the states rather than the federal government, which once again solves nothing and only makes things worse.

States will just cut services and people from their Medicaid roles, creating more uninsured. Don’t Iowa hospitals serve enough uninsured in their emergency rooms now?

This gets us to what we as Republicans should do: throw out our rule book and be innovative. People my age will remember how we Republicans were 100 percent against recognizing China before Richard Nixon, the anti-communist crusader, came out for it. We must do the same with health care.

There is only one way to control health care costs and insure universal access — and that is by first admitting that the U.S. system has failed and then adopting ideas that have been proven to work elsewhere. We should take a look at how health care is financed and delivered in other developed nations with lower cost and better morbidity and mortality rates.

A Commonwealth Fund study was issued in May 2012 which did just that for 13 countries. The bottom line is that we spend 17.4 percent of our gross national product on health care, far more than other developed nations, which averaged 9.5 percent. Our per-capita spending was $7,960 versus $3,182 for the group as a whole.

Why? One key factor is prices. For example, U.S. pricing on the 30 most commonly prescribed brand name drugs is one-third higher than Canada and double France, both of which have a form of Universal Medicare.

From looking at the international data, if we Republicans really want to dump the Affordable Care Act, the way to go is Medicare for all. Studies show that the nations with universal health care have better overall health care outcomes than we do, not worse.

And, according to the respected Physicians for a National Health Program, www.pnhp.org, yearly savings generated under Medicare for all would be $400 billion. That would go a long way towards paying for universal coverage, versus the Affordable Care Act, which will increase systemic costs because it relies on private insurance.

The canard about waiting times to see doctors is just a tactic to scare the public. If you need a knee replacement for a knee that has been going bad for years, waiting a little longer for an operation should not be a major issue for the patient. Despite the scare tactics, no one who needs immediate care in Canada is ever left to sit in a line. In any case, there should be no waiting lists at all here. Canada spends just $4,363 per capita on health care versus our $7,960.

If we Republicans took the Medicare-for-all approach, it would thrust us into the vanguard of reform. Instead of the Democrats stealing our ideas, we could steal theirs. When it was implemented and turned out to be widely accepted, as was Medicare in the 1960s, we would be the party the public would look to for the future.

Of course, there is an alternative. We can stick our heads in the sand and push for infeasible actions. That approach is killing us regarding immigration and will work just as well for health care.

(JACK BERNARD of Monticello, Ga., is a retired health care executive who worked extensively with Iowa health care providers, including Iowa Health System. He now is a member of the Jasper County (Ga.) Board of Commissioners and Jasper County Board of Health. Contact: bernard_jack@hotmail.com)

http://www.desmoinesregister.com/article/20120716/OPINION01/307160040/

Comment: 

By Don McCanne, MD

This article should be distributed widely. Although it is written by a Republican, targeting his fellow Republicans, if his party can understand this message, then the Democrats and others who bailed on Medicare for all should be able to understand it as well.

Head-in-the-sand 'solution' is killing GOP

By Jack Bernard
Des Moines Register, July 16, 2012

We Republicans have ourselves to blame for the Affordable Care Act, or Obamacare.

Our reaction to the Clinton health reform proposals in the early 1990s was to have conservative think tanks come up with a free competition model based on expansion of private insurance and Medicaid. That idea became Romneycare, which evolved into Obamacare.

It is our baby, ugly or not.

It is the height of hypocrisy for us now to criticize our own idea unless we have something better to replace it. And, the replacement needs to be comprehensive, not just a series of unacceptable statements and proposals based on doing away with traditional Medicare by turning it into a voucher program and gutting Medicaid by making it into a block grant.

Using vouchers for Medicare just dumps the cost problem into the lap of the powerless patient, rather than the federal government that has clout, making the cost escalation problem worse. The block grants for Medicaid idea just shifts the cost issue onto the states rather than the federal government, which once again solves nothing and only makes things worse.

States will just cut services and people from their Medicaid roles, creating more uninsured. Don’t Iowa hospitals serve enough uninsured in their emergency rooms now?

This gets us to what we as Republicans should do: throw out our rule book and be innovative. People my age will remember how we Republicans were 100 percent against recognizing China before Richard Nixon, the anti-communist crusader, came out for it. We must do the same with health care.

There is only one way to control health care costs and insure universal access — and that is by first admitting that the U.S. system has failed and then adopting ideas that have been proven to work elsewhere. We should take a look at how health care is financed and delivered in other developed nations with lower cost and better morbidity and mortality rates.

A Commonwealth Fund study was issued in May 2012 which did just that for 13 countries. The bottom line is that we spend 17.4 percent of our gross national product on health care, far more than other developed nations, which averaged 9.5 percent. Our per-capita spending was $7,960 versus $3,182 for the group as a whole.

Why? One key factor is prices. For example, U.S. pricing on the 30 most commonly prescribed brand name drugs is one-third higher than Canada and double France, both of which have a form of Universal Medicare.

From looking at the international data, if we Republicans really want to dump the Affordable Care Act, the way to go is Medicare for all. Studies show that the nations with universal health care have better overall health care outcomes than we do, not worse.

And, according to the respected Physicians for a National Health Program, www.pnhp.org, yearly savings generated under Medicare for all would be $400 billion. That would go a long way towards paying for universal coverage, versus the Affordable Care Act, which will increase systemic costs because it relies on private insurance.

The canard about waiting times to see doctors is just a tactic to scare the public. If you need a knee replacement for a knee that has been going bad for years, waiting a little longer for an operation should not be a major issue for the patient. Despite the scare tactics, no one who needs immediate care in Canada is ever left to sit in a line. In any case, there should be no waiting lists at all here. Canada spends just $4,363 per capita on health care versus our $7,960.

If we Republicans took the Medicare-for-all approach, it would thrust us into the vanguard of reform. Instead of the Democrats stealing our ideas, we could steal theirs. When it was implemented and turned out to be widely accepted, as was Medicare in the 1960s, we would be the party the public would look to for the future.

Of course, there is an alternative. We can stick our heads in the sand and push for infeasible actions. That approach is killing us regarding immigration and will work just as well for health care.

Jack Bernard of Monticello, Ga., is a retired health care executive who worked extensively with Iowa health care providers, including Iowa Health System. He now is a member of the Jasper County (Ga.) Board of Commissioners and Jasper County Board of Health. Contact: bernard_jack@hotmail.com

http://www.desmoinesregister.com/article/20120716/OPINION01/307160040/

Head-in-the-sand ‘solution’ is killing GOP

By Jack Bernard
Des Moines Register, July 16, 2012

We Republicans have ourselves to blame for the Affordable Care Act, or Obamacare.

Our reaction to the Clinton health reform proposals in the early 1990s was to have conservative think tanks come up with a free competition model based on expansion of private insurance and Medicaid. That idea became Romneycare, which evolved into Obamacare.

It is our baby, ugly or not.

It is the height of hypocrisy for us now to criticize our own idea unless we have something better to replace it. And, the replacement needs to be comprehensive, not just a series of unacceptable statements and proposals based on doing away with traditional Medicare by turning it into a voucher program and gutting Medicaid by making it into a block grant.

Using vouchers for Medicare just dumps the cost problem into the lap of the powerless patient, rather than the federal government that has clout, making the cost escalation problem worse. The block grants for Medicaid idea just shifts the cost issue onto the states rather than the federal government, which once again solves nothing and only makes things worse.

States will just cut services and people from their Medicaid roles, creating more uninsured. Don’t Iowa hospitals serve enough uninsured in their emergency rooms now?

This gets us to what we as Republicans should do: throw out our rule book and be innovative. People my age will remember how we Republicans were 100 percent against recognizing China before Richard Nixon, the anti-communist crusader, came out for it. We must do the same with health care.

There is only one way to control health care costs and insure universal access — and that is by first admitting that the U.S. system has failed and then adopting ideas that have been proven to work elsewhere. We should take a look at how health care is financed and delivered in other developed nations with lower cost and better morbidity and mortality rates.

A Commonwealth Fund study was issued in May 2012 which did just that for 13 countries. The bottom line is that we spend 17.4 percent of our gross national product on health care, far more than other developed nations, which averaged 9.5 percent. Our per-capita spending was $7,960 versus $3,182 for the group as a whole.

Why? One key factor is prices. For example, U.S. pricing on the 30 most commonly prescribed brand name drugs is one-third higher than Canada and double France, both of which have a form of Universal Medicare.

From looking at the international data, if we Republicans really want to dump the Affordable Care Act, the way to go is Medicare for all. Studies show that the nations with universal health care have better overall health care outcomes than we do, not worse.

And, according to the respected Physicians for a National Health Program, www.pnhp.org, yearly savings generated under Medicare for all would be $400 billion. That would go a long way towards paying for universal coverage, versus the Affordable Care Act, which will increase systemic costs because it relies on private insurance.

The canard about waiting times to see doctors is just a tactic to scare the public. If you need a knee replacement for a knee that has been going bad for years, waiting a little longer for an operation should not be a major issue for the patient. Despite the scare tactics, no one who needs immediate care in Canada is ever left to sit in a line. In any case, there should be no waiting lists at all here. Canada spends just $4,363 per capita on health care versus our $7,960.

If we Republicans took the Medicare-for-all approach, it would thrust us into the vanguard of reform. Instead of the Democrats stealing our ideas, we could steal theirs. When it was implemented and turned out to be widely accepted, as was Medicare in the 1960s, we would be the party the public would look to for the future.

Of course, there is an alternative. We can stick our heads in the sand and push for infeasible actions. That approach is killing us regarding immigration and will work just as well for health care.

Jack Bernard of Monticello, Ga., is a retired health care executive who worked extensively with Iowa health care providers, including Iowa Health System. He now is a member of the Jasper County (Ga.) Board of Commissioners and Jasper County Board of Health. Contact: bernard_jack@hotmail.com

http://www.desmoinesregister.com/article/20120716/OPINION01/307160040/

Fee-For-Service is Not the Problem

By Stephen Kemble, M.D.
OpEd News, July 14, 2012

There is a widespread assumption among health policy experts that the key problem with runaway health care costs is unnecessary care driven by the incentive to over-treat that is inherent in fee-for-service payment of doctors. Therefore, the argument goes, we need to improve financial incentives for care coordination and reorganize doctors into “Accountable Care Organizations,” forcing primary care, specialist physicians, and hospitals into shared financial arrangements that shift at least some insurance risks onto providers, countering the fee-for-service incentive to over-treat.

While there are certainly some doctors providing unnecessary procedures due to fee-for-service financial incentives, it is extremely unlikely that this is the root of our health care cost problem. The argument that fee-for-service incentives are the driver of excess health care cost is based on a fundamental misdiagnosis of the reasons for unsustainable cost escalation in U.S. health care.

If one attempts to quantify the sources of excess U.S. health spending by looking at actual evidence, it is apparent that exorbitant and unnecessary administrative costs are the biggest driver (around 20-25 percent of National Health Expenditures[1,2]), followed by unnecessary care due to over-treatment[3,4](perhaps 10 percent of NHE, of which only a fraction is attributable to fee-for-service incentives), and expensive complications of under-treatment due to lack of access (perhaps 5-10 percent of NHE, plus a lot of suffering and death that does not show up in health spending figures). About half of over-treatment is due to unreasonable demands for care by patients, most of which is actually driven by providers (direct-to-consumer advertising for drugs, ads by hospitals, and by the recommendations of doctors.) Malpractice costs and defensive medicine are only a few percent at most.[5]

There is a problem with lack of coordination of care for certain patients, but the far bigger problem is inadequate access to necessary care. There is a nation-wide shortage of doctors in primary care and also in many specialties. This is compounded by the problems of un-insurance and under-insurance, and the refusal of many doctors to accept patients with insurance plans that are onerous, pay low fees, or both. Care coordination is meaningless without access.

According to a recent CBO report[6], all 34 pilot care coordination projects funded by CMS either failed to save any Medicare spending at all, or if they did save on health care spending, they cost more in administrative expenses than they saved, for a net increase in total cost for all of them. Three of four payment reform demonstration projects that relied on pay-for-quality incentives failed to save money, and the only successful one negotiated a discounted, bundled fee for coronary bypass surgeries and did not use pay-for-performance incentives. After three years, the PROMETHEUS project on bundled payments for episodes of care has failed to implement any actual contracts due to the complexities of defining a “bundle.”[7] Just about all the “cost saving” initiatives in the Affordable Care Act (ACA) are along the same lines and will fail for the same reasons.

There are only a few U.S. health reform programs that have actually achieved significant cost savings without relying on “cherry picking” healthier populations and avoiding sicker ones. Major examples are Community Care of North Carolina[8] and Rocky Mountain Health Plans in Colorado[9]. The common denominator is not elimination of fee-for-service, which both still employ; it is physician leadership, high levels of physician participation and buy-in, significantly improved access to outpatient care for sicker high-risk patients, and a shared commitment to quality improvement.

Part of the problem is indeed the imbalance in pay between certain specialties and primary care, rooted in the flawed Medicare SGR physician fee schedule, and we do need to re-think how the money is distributed between “cognitive services” and procedures. Increased payment for primary care and care-coordination is part of the solution, but does not require shifting insurance risk onto doctors via HMOs or ACOs.

Administrative costs

If we want to “bend the cost curve,” we should focus first and foremost on administrative simplification. The drivers of excess administrative costs are primarily due to use of competing insurance plans to finance health care. Insurance works fine for expensive, infrequent, and unpredictable risks like house fires. However, when insuring health care for a population, a large percentage of whom have known risks (pre-existing conditions and risk factors), then the overriding incentive for competing plans is not to offer a better plan; it is to identify higher risk (sicker) individuals and groups and avoid insuring them or avoid paying for their care if they get sick. The attempts in the ACA to counter the perverse incentives due to competition among insurance plans have been watered down and will fail to achieve adequate control of the problem, and are adding even more administrative costs. The only definitive way around these perverse incentives would be to establish a social insurance model with a single risk pool covering an entire population. This means eliminating competing private health insurance plans, at least for medically necessary health care. Competing private health plans also carry approximately six times the administrative cost of a social insurance system.

Since the insurance industry does not want to be pushed out of health care, they have a strong incentive to blame providers and patients for rising health care costs, hence the focus on fee-for-service and unnecessary care, and on increasing cost sharing for patients to deter care. The result is ever rising administrative costs and ever decreasing access to care for sick people.

Over-treatment and fee-for-service

Perhaps 10 percent of national health expenditures is attributable to unnecessary care (over-treatment). Some of this is not due to financial incentives at all, but rather to lack of effort or skill on the part of doctors to persuade patients that further care or the requested treatment is ineffective or would only prolong suffering. Major examples are futile end of life care and antibiotics for colds. Some unnecessary care is also driven by direct to consumer ads for drugs and specialized hospital services, which don’t involve financial incentives for doctors. Only a fraction is attributable to fee-for-service incentives.

Fee-for-service physician payment cannot be a root cause of high U.S. health care costs. Other countries with much less expensive health care systems pay doctors with fee-for-service and seem to have fewer problems with unnecessary care, and in studies of regional variation in Medicare spending, high and low cost areas use fee-for-service equally. It takes a combination of fee-for-service and other factors to generate a lot of unnecessary care, such as for-profit hospitals pushing doctors to do unnecessary procedures, and doctors who start for-profit facilities and therefore have incentives beyond getting paid for professional services.

There are pros and cons to paying physicians with either fee-for-service or salaried arrangements that need to be clearly understood in health care planning. Fee-for-service motivates doctors to work harder than they do under salaried arrangements, but can be an incentive to unnecessary care. Salaried arrangements have no incentive to over-treat, but do introduce an incentive to under-treat and may skimp on necessary care. Salaried doctors also tend to work less hard and have to be pushed to maintain high productivity. Where there is a shortage of doctors, fee-for-service can encourage higher productivity. In urban areas where there is an over-supply of doctors,
salaried arrangements may be better. For patients with straightforward chronic diseases, integrated systems that can enforce protocols for best practice are probably superior. For “complex” patients (around 25 percent of a primary care doctor’s practice[10]) with unclear diagnoses, unusual or complex problems, or poor compliance, fee-for-service is probably superior because doctors will be more motivated to put in the extra time required if they can get paid more for it.

Integrated, capitated health plans such as Kaiser pay doctors on salary, so they have no financial incentive to over-treat. Kaiser does a good job of treating patients with established chronic diseases, but their system can be quite unfriendly to patients with unclear diagnoses, complex interacting problems, or complicating psychosocial problems. Kaiser in Hawaii limits their exposure to Medicare and Medicaid. They accept some Medicaid patients under General Assistance and Aid For Dependent Children, but they declined to bid on a plan for the higher risk Aged, Blind, Disabled population. Their ads are entirely targeted to healthy people. In other words, a good portion of their “success” in delivering cost-effective care is actually attributable to cherry picking healthier populations and avoiding sicker ones.

What does motivate doctors?

Doctors are indeed motivated by financial incentives, and they do expect to achieve an income commensurate with the rigors and expense of the training necessary to do what they do. However, they are also motivated by professionalism: putting the needs of their patients first, quality improvement, and individualizing care for complex and difficult patients.

There are two broad ethical paradigms in the world of economics: commercial ethics and “guardian” ethics.[11] The commercial paradigm assumes a seller and buyer of goods or services, whose power and interests are balanced through the marketplace and the laws of supply and demand, with financial incentives as a primary motivator. Guardian ethics are applicable to socially necessary services that require specialized training not available or achievable by the general public, so that there is an inherent imbalance of power between the provider and recipient of services. Classic examples are the military, medicine, and other specialized professions. In these cases, the interests of the public are protected by a tradition of professionalism and concern for the welfare of the public, or patient, or client, which is held to be a higher ethical value than financial considerations.

There has been a movement in this country for the past 50 years to de-professionalize medicine, with an underlying assumption that commercial ethics are the only valid and trustworthy ethics. This justifies increasing interference in health care decisions by insurance plans and government, and a reliance on financial incentives to “fix” problems in health care, and especially its high cost. However, if doctors are stripped of their professional autonomy and treated as if financial considerations are paramount, they actually do start to abandon professional ethics for commercial ones. They start responding to financial considerations above patient needs; they select patients according to their insurance status; and they look for ways to game the system and make more money from things other than professional services. They begin to try to maximize income by any available means, helping drive the cost of health care higher. Sometimes this leads to outright fraud.

My opinion is that the real cause of much of the physician-controlled unnecessary care in the U.S. is abandonment of traditional professional ethics for commercial ethics — “medicine as a business, patients as consumers” — that when combined with fee-for-service leads to excessive and unnecessary care. If my diagnosis is correct, then the further commercialization of medical practices into competing corporate entities will only make the problem worse.

On the other hand, promotion of professionalism among doctors and harnessing it to make care more cost effective through quality improvement programs is the antidote to both the incentive to over-treat under fee-for-service and to under-treat under salaried arrangements.

Quality Improvement

Payment reform initiatives that rely on financial incentives tied to individual quality and performance ratings of doctors and hospitals carry a serious risk of unintended adverse consequences. Much of health care is too complex to be amenable to valid quality ratings anyhow. Rating individual providers will quickly induce them to game the ratings by up-coding diagnoses or avoiding sicker, atypical, and more complex patients, or it will drive them to refuse plans that impose such ratings. Attempts to correct for these problems require complex information from computerized health records and are fraught with problems. Many older, less tech-savvy physicians are likely to retire rather than accept enforced computerization, and with our nation-wide physician shortage we cannot afford to drive a large number of physicians out of practice.

Instead of rating individual doctors for pay-for-performance, quality improvement efforts should be based on the Continuous Quality Improvement (CQI) model, as exemplified by Intermountain Healthcare in Utah.[12] This model defines problems as systems problems, not problems with individual doctors, and engages all doctors cooperatively in improving care. It means focusing on processes of care and transitions between care settings. It encourages reduced variation in practice patterns without punishing doctors for deviating from guidelines when there are good clinical reasons to do so. It means health IT is not focused on measuring for selection, but on measuring for relative improvement. It does not require all doctors to have an EHR, and it requires less disruption in physician workflow. CQI harnesses physician professionalism to improve care and make it more cost effective, rather than relying primarily on financial incentives.

Achieving cost-effective, sustainable health care

We must abandon the idea that competition among health plans can make care more cost-effective. Competition adds administrative complexity and cost for both plans and providers, and interferes with efficient delivery of health care. It does not reduce total health care costs, but does push plans to try to exclude the sick from coverage, reduce benefits, and increase administrative burdens, all of which are destructive to health care. Fragmentation in health care financing also impairs quality improvement efforts, which work best in a universal system. We need consolidation of health plans under an administrative structure that is accountable to effective delivery of health care.

Universal access to care is crucial to ensuring that health care is delivered in the most cost effective setting, minimizing use of emergency rooms and hospitals. Significant savings from administrative simplification depend on universal access, and quality improvement is much more effective when everyone in a community is included.

Solving our physician workforce problems will require improved pay for care coordination and cognitive services, and correcting the imbalance in pay between procedural specialties and primary care. With a universal system, CPT procedure codes could be replaced with a simplified time-based system, with multipliers for training and overhead costs needed to practice a given specialty. An expanded program like the National Health Service, with government subsidies for medical education in exchange for a commitment to practice in under-served specialties and under-served areas, could remove medical education debt as a deterrent to entering less lucrative specialties such as primary care, psychiatry, and general surgery.

We need to promote professionalism among doctors. I am in favor of requiring all physicians
to be members of a professional organization, tied to licensure, to ensure their participation in system-wide quality improvement, peer review, and continuing education. Physician professionalism, not pay-for-performance, should be the primary driver of quality improvement and cost containment efforts. It is more effective and costs less than managed care administered by an insurance plan.[8,9,12]

Cost-effective, sustainable health care will require a much simpler administrative structure, universal access to necessary care, and organization of doctors to promote quality improvement. Accountability must always be to the health care needs of the population served.

References
1.      Woolhandler S, Campbell T, Himmelstein D. Costs of Health Care Administration in the United States and Canada. N Engl J Med 2003;349:768-75.
2.      Morra D, Nicholson S, Levinson W, Gans DN, Hammons T, Casalino LP. US Physician Practices vs. Canadians: Spending Nearly Four Times as Much Money Interacting With Payers. Health Affairs 30 , No. 8 (2011): doi: 10.1377/hlthaff.2010.0893.
3.      Fisher ES, Bynum JP, Skinner JS. Slowing the Growth of Health Care Costs — Lessons From Regional Variation. N Engl J Med. 2009 Feb 26;360(9):849-52.
4.      White C. Health Status and Hospital Prices Key to Regional Variation in Private Health Care Spending. National Institute for Health Care Reform. Research Brief No. 7 (February 2012).
5.      Mello MM, Chandra A, Gawande AA, Studdert DM. National Costs Of The Medical Liability System. Health Affairs 29, No. 9 (2010): 1569–1577.
6.      Congressional Budget Office. Lessons from Medicare’s Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment. January 18, 2012 http://www.cbo.gov/ftpdocs/126xx/doc12663/01-18-12-MedicareDemoBrief.pdf .
7.      Hussey PS, Ridgely MS, and Rosenthal MB. The PROMETHEUS Bundled Payment Experiment: Slow Start Shows Problems In Implementing New Payment Models. Health Affairs 30, No. 11 (2011): 2116–2124.
8.      Community Care of North Carolina: Putting Health Reform Ideas into Practice in Medicaid. The Kaiser Family Foundation Publication #7899, May 2009. ( http://www.kff.org/medicaid/7899.cfm )
9.      Bodenheimer, T, West D. Low-Cost Lessons from Grand Junction, Colorado. N Eng J Med 2010; DOI:10.1056/NEJMp1008450.
10.   Grant, RW, Ashburner, JM, Hong, CC, Chang Y, Barry MJ, Atlas, SJ. Defining Patient Complexity From the Primary Care Physician’s Perspective. Ann Int Med 155, No 12 (2011): 797-804.
11.   Jacobs J. Systems of Survival: A Dialogue on the Moral Foundations of Commerce and Politics. New York: Random House; 1992
12.   James BC and Savitzdoi LA. How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts. Health Affairs 30, no. 6 (2011); DOI:10.1377/hlthaff.2011.0358.

http://www.opednews.com/articles/1/Fee-For-Service-is-Not-the-by-Stephen-Kemble-120706-547.html

Primary care a primary concern: Thousands of new patients will stress already burdened health care system

By Charles McMahon
Portsmouth (N.H.) Herald, July 15, 2012

When more than 100,000 state residents are thrust into the health care system on Jan. 1, 2014 — the date the Affordable Care Act will go into full effect — local primary care physician Dr. Thomas Clairmont said he has only one piece of advice.

Be prepared.

Clairmont, who specializes in geriatric care and is the New Hampshire chairman of Physicians for a National Health Program, said the expected addition of approximately 134,000 uninsured residents into the system will likely be burdensome on a system already struggling to meet patients’ needs.

“Adding that many more patients will be a real problem,” Clairmont said, adding his office in Portsmouth has few openings for new patients.

With his specialty focused around elderly care, Clairmont said he believes there are several things that will need to happen before the floodgates open.

“We need more people doing geriatrics and primary care,” he said.

Clairmont said perhaps the biggest challenge to attracting more people into his line of work is the amount of debt tomorrow’s doctors carry when graduating from medical school.

Having paid $375 a semester when he was in school, Clairmont said he knows of some who are borrowing $75,000 just for the first year of their education. When it’s all said and done, Clairmont said it seems graduates end up with so much debt that most of them only consider high-paying areas of the medical field.

“It’s not because primary care isn’t fun or challenging,” he said. “It’s a matter of income.”

Clairmont said he believes one way the health care law can be improved is by including mandates for raises in salaries for primary care physicians.

This is where someone like Jeanne Ryer comes into play.

As a member of the state’s Primary Care Workforce Commission, Ryer is on the front lines of helping develop strategies to address expected shortages in the field of primary care.

Ryer, who is also director of the New Hampshire Citizens Health Initiative, said she was focused on the issue long before the Affordable Care Act came into play.

Having been in the field for some time now, Ryer said New Hampshire has struggled with shortages in the primary care workforce for years.

“New Hampshire has gone through spasms where it has had problems with primary care and provider shortages in the past,” she said.

Those shortages occurred in the 1990s and in the middle of the last decade, according to Ryer.

Despite the historical trends, Ryer said she believes the fear of a shortage may be exaggerated. She said the more than 100,000 chronically uninsured people in New Hampshire pales in comparison to other states.

“I don’t think we’ll see these floodgates open up,” she said.

The reason being, according to Ryer, is that those who are uninsured will likely fall back on the community health centers, rather than on primary care practitioners.

Ryer said that is the reason why if the state wants to prepare itself, it will invest in community health centers.

“We should be better supporting the community health centers now so they can recruit and retain people now,” she said.

Ryer said another important issue that must be addressed is the creation of more preceptor sites to train nurse practitioners and physician assistants.

“There needs to be places for people to train and practice,” she said. “Where people train is where people stay.”

All in all, Ryer said it’s clear that the state needs to do more.

Ned Helms, director of the Institute for Health Policy and Practice at the University of New Hampshire, said if the state wants to prepare itself it should look to Massachusetts.

Helms, who is also a presidential appointee to the National Prevention Strategy Advisory Group, which is part of the Affordable Care Act, said what happened in Massachusetts was that more and more people ended up filtering into the system than anticipated. When that happened, Helms said it became harder and harder for people to find a primary care practitioner.

With more than 30 years of experience in New Hampshire health policy and politics, Helms said he agrees there aren’t enough primary care physicians because of the compensation.

“We do not pay for and focus on primary care,” he said. “Historically our system is more specialty focused.”

Helms said despite there being uncertainty, the Affordable Care Act is loaded with incentives for people to go into primary care, including grants and incentives for loan repayment if a prospective doctor chooses to go into that field.

“There’s a lot of reform taking place at the local level, in that people are realizing that we have to put a heck of a lot more emphasis on primary care and that we need to start getting folks into the doctor’s office instead of the emergency rooms,” Helms said.

Dr. James Fieseher, a board-certified family practitioner who works with Clairmont, said over the last two years there has been an uptick of medical students going into primary care. However, even if a slight uptick continues, Fieseher said New Hampshire still won’t be nearly prepared enough to meet the demand in 2014. Fieseher said he imagines his office will likely need to add more physicians, but agrees with Ryer that some patients will continue to rely on health centers rather than primary care doctors.

“I already know a number of people that aren’t my patients, who want to be, but don’t have the money to come into the office,” he said.

Looking toward 2014, Fieseher said he believes the uninsured will be a tad “skittish” about how to use the new health care law, meaning the immediate influx of new patients won’t be as bad as most anticipate.

“I think 2014 will be a little bit of a shock,” he said. “But in 2015 and 2016, we won’t be able to churn out primary care physicians fast enough.”

http://www.seacoastonline.com/articles/20120715-NEWS-207150338