PNHP

eHealth technology not ready for prime time

eHealth technology not ready for prime time

The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview

By Ashly D. Black, Josip Car, Claudia Pagliari, Chantelle Anandan, Kathrin Cresswell, Tomislav Bokun, Brian McKinstry, Rob Procter, Azeem Majeed, Aziz Sheikh
PLoS Medicine
January 18, 2011

Editors’ Summary

Background

There is considerable international interest in exploiting the potential of digital health care solutions, often referred to as eHealth — the use of information and communication technologies — to enhance the quality and safety of health care. Often accompanied by large costs, any large-scale expenditure on eHealth — such as electronic health records, picture archiving and communication systems, ePrescribing, associated computerized provider order entry systems, and computerized decision support systems — has tended to be justified on the grounds that these are efficient and cost-effective means for improving health care. In 2005, the World Health Assembly passed an eHealth resolution (WHA 58.28) that acknowledged, “eHealth is the cost-effective and secure use of information and communications technologies in support of health and health-related fields, including health-care services, health surveillance, health literature, and health education, knowledge and research,” and urged member states to develop and implement eHealth technologies. Since then, implementing eHealth technologies has become a main priority for many countries. For example, England has invested at least £12.8 billion in a National Programme for Information Technology for the National Health Service, and the Obama administration in the United States has committed to a US$38 billion eHealth investment in health care.

Why Was This Study Done?

Despite the wide endorsement of and support for eHealth, the scientific basis of its benefits — which are repeatedly made and often uncritically accepted—remains to be firmly established. A robust evidence-based perspective on the advantages on eHealth could help to suggest priority areas that have the greatest potential for benefit to patients and also to inform international eHealth deliberations on costs. Therefore, in order to better inform the international community, the authors systematically reviewed the published systematic review literature on eHealth technologies and evaluated the impact of these technologies on the quality and safety of health care delivery.

What Did the Researchers Do and Find?

The researchers divided eHealth technologies into three main categories: (1) storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance. Then, implementing methods based on those developed by the Cochrane Collaboration and the NHS Service Delivery and Organisation Programme, the researchers used detailed search strategies and maps of health care quality, safety, and eHealth interventions to identify relevant systematic reviews (and related theoretical, methodological, and technical material) published between 1997 and 2010. Using these techniques, the researchers retrieved a total of 46,349 references from which they identified 108 reviews. The 53 reviews that the researchers finally selected (and critically reviewed) provided the main evidence base for assessing the impact of eHealth technologies in the three categories selected.

In their systematic review of systematic reviews, the researchers included electronic health records and picture archiving communications systems in their evaluation of category 1, computerized provider (or physician) order entry and e-prescribing in category 2, and all clinical information systems that, when used in the context of eHealth technologies, integrate clinical and demographic patient information to support clinician decision making in category 3.

The researchers found that many of the clinical claims made about the most commonly used eHealth technologies were not substantiated by empirical evidence. The evidence base in support of eHealth technologies was weak and inconsistent and importantly, there was insubstantial evidence to support the cost-effectiveness of these technologies. For example, the researchers only found limited evidence that some of the many presumed benefits could be realized; importantly, they also found some evidence that introducing these new technologies may on occasions also generate new risks such as prescribers becoming over-reliant on clinical decision support for e-prescribing, or overestimate its functionality, resulting in decreased practitioner performance.

What Do These Findings Mean?

The researchers found that despite the wide support for eHealth technologies and the frequently made claims by policy makers when constructing business cases to raise funds for large-scale eHealth projects, there is as yet relatively little empirical evidence to substantiate many of the claims made about eHealth technologies. In addition, even for the eHealth technology tools that have proven to be successful, there is little evidence to show that such tools would continue to be successful beyond the contexts in which they were originally developed. Therefore, in light of the lack of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, the authors say that future eHealth technologies should be evaluated against a comprehensive set of measures, ideally throughout all stages of the technology’s life cycle, and include socio-technical factors to maximize the likelihood of successful implementation and adoption in a given context. Furthermore, it is equally important that eHealth projects that have already been commissioned are subject to rigorous, multidisciplinary, and independent evaluation.

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000387#pmed.1000387-Garg1

Digital health care solutions, or eHealth, include electronic health records, picture archiving and communication systems, ePrescribing, associated computerized provider order entry systems, and computerized decision support systems. These researchers performed a systematic review of the systematic reviews of eHealth published since 1997, providing us with a perspective of the impact that eHealth has had on the quality and safety of health care.

What did they find?

“Our systematic review of systematic reviews on the impact of eHealth has demonstrated that many of the clinical claims made about the most commonly deployed eHealth technologies cannot be substantiated by the empirical evidence. Overall, the evidence base in support of these technologies is weak and inconsistent, which highlights the need for more considered claims, particularly in relation to the patient-level benefits, associated with these technologies. Also of note is that we found virtually no evidence in support of the cost-effectiveness claims.”

This is of particular importance right now as health care providers and institutions are gearing up to establish accountable care organizations (ACOs), as called for in the Patient Protection and Affordable Care Act (PPACA). Although various models of ACOs are being developed, all of them have in common interconnectivity through eHealth. In fact, the simplest form is the so-called virtual ACO which is nothing more than isolated, independent practices connected through eHealth.

Since eHealth provides the fundamental framework through which ACOs function, it is important to be sure that we have it right. But we’re not certain. The authors report that eHealth systems have proven to be beneficial when carefully designed in house for a handful of large institutions, but the evidence is simply not there for most systems in use today.

The reason that our politicians included ACOs in the PPACA is that theoretically they would help to control health spending primarily through the transparencies, efficiencies and error reduction of eHealth. Yet there is “virtually no evidence in support of the cost-effectiveness claims.”

We have to get health care costs under control. Maybe someday eHealth will help with that, but we’re definitely not there now. It is certainly fine to continue with studies of ACOs and eHealth, but for cost containment, we should move immediately to policies that have been proven to be effective – a single payer national health program, aka an improved Medicare for all.

Insurance Execs Not Happy with Hsiao’s Single Payer

By Russell Mokhiber
Single Payer Action, January 20, 2011

Harvard Professor William Hsiao is a single payer supporter.

Twenty years ago, he helped push through a single payer system for Taiwan.

And now, he wants to do something similar in Vermont.

Over the past couple of months, Hsiao has been working feverishly – with a team of 20 researchers – to finish a report to the Vermont legislature on how to best implement a single payer system for the state.

Yesterday, he delivered his 132-page report.

And at the beginning of his one hour presentation to the legislature in Montpelier, he made it clear that “what I’m going to present is not necessarily popular for everyone.”

“Recently I was talking to an insurance executive,” Hsiao said.

“And I asked him if he was in favor of spending $50 billion to manufacture a new shuttle to the moon.”

“And he says – yes, if you will go.”

That got a chuckle out of the gathered legislators.

But clearly, the insurance industry is not at all pleased with Hsiao.

They are watching events in Vermont carefully.

The newly elected Governor – Peter Shumlin – ran on a single payer platform.

Shumlin said that in his first conversation with Hsiao last year, Hsiao told him that he had “given up on America.”

“I told him we are Vermonters,” Shumlin said. “We think independently. We take care of each other, and we do things that others dare not do.”

The Vermont legislature tasked Hsiao with putting forth and analyzing three proposals.

A pure single payer government run system.

The current system with a public option.

And Hsiao’s preferred system – a single payer system run by an independent board.

While Hsiao is not explicit about this in his report, the bottom line is clear – under Hsiao’s single payer proposals, the private health insurers in Vermont would be out of the business of marketing and selling basic health insurance.

That’s why the insurance industry would prefer to see Hsiao headed to the moon than on the ground speaking before the Vermont state legislature.

“Our analysis of the three health insurance companies with significant operations in Vermont – Blue Cross Blue Shield of Vermont, MVP, and Cigna – was much more limited than our analysis of other groups, partly because much of Act 128 has fairly clear implications for those companies,” Hsiao writes in his report.

“It is reasonably safe to assume that health insurance companies would oppose any major health system reform that reduces their autonomy in financing and paying for health care, increases government’s role, and/or introduces new competitors to their market.”

“However, given Vermont’s history with reforms such as guaranteed-issue, community-rating, and the Blueprint program, it must be noted that the remaining health insurers in Vermont – especially those run as non-profits – are likely more accustomed and potentially more open than insurers elsewhere to working with state-led regulations. In addition, a continued market for supplementary insurance would generate ongoing opportunities for private insurance in the state.”

“It is possible that one or more companies may be interested in partnering with the state and substantially reforming their business model in order to continue to operate in Vermont.”

And in fact, Vermont’s largest insurer – Blue Cross Blue Shield – with 75 percent of the state’s health insurance business – signaled yesterday that it might be interested in taking Hsiao at his word.

“If there’s a single payer system, we’d like to be the single payer,” Leigh Tofferi, the Blue Cross-Blue Shield lobbyist in Vermont told vtdigger.org.

But Hsiao warned of another possible insurance industry reaction.

“Of course, the opposite is also possible – that an industry with deep pockets nationally will oppose reforms due to the threats they pose to the Vermont market and other markets that could follow Vermont’s lead,” Hsiao wrote.

There’s not a mention of the report in today’s big three newspapers – the New York Times, the Wall Street Journal or the Washington Post.

Early indications are that supporters of a pure government run single payer system are willing to accept Hsiao’s public/private compromise.

Physicians for a National Health Program’s (PNHP) Deb Richter told vtdigger.org that while a government administered system “makes the most sense in terms of good policy,” the system doesn’t have to be controlled by the government to be effective.

And PNHP’s Don McCanne said that “although advocates of the pure single payer model will find some problems with this report on a reform proposal for Vermont, there is very good news in this analysis. The report emphatically confirms the superiority of the single payer model in ensuring that everyone is included while containing health care costs.”

“One very serious deficiency is that they decided to leave in place Medicare and Medicaid, primarily because of existing barriers to move them into a single payer system,” McCanne wrote. “Thus their proposal is not a single payer system. Leaving these programs in place sacrifices some of the important single payer efficiencies.”

“Within the next couple of days, we’ll have a clearer concept of where the single payer community should be on this report. Tentatively, it seems that it deserves our support, but support that is qualified by strong advocacy to make it right by such measures as including comprehensive benefits, and rolling in and eliminating Medicare and Medicaid,” McCanne said.

Governor Shumlin’s office is reportedly drafting legislation that will be introduced soon.

Clearly, Shumlin hasn’t given up on America.

Or at least on Vermont.

http://www.singlepayeraction.org/blog/?p=2687

Medicare Advantage plans work the float

Rollup Review of Impact on Medicare Program for Investment Income That Medicare Advantage Organizations Earned and Retained From Medicare Funds in 2007

Office of Inspector General
U.S. Department of Health & Human Services
January 18, 2011

If Federal requirements had been established to delay prepayments to Medicare Advantage organizations (MA organizations) until after the beginning of the beneficiary’s coverage period by the same number of days that we estimated that MA organizations held Medicare funds, the Medicare Part A and Part B trust funds (which finance the Medicare Advantage program) could have earned approximately $450 million of interest income in calendar year (CY) 2007. Alternatively, if Federal requirements had been established to require MA organizations to reduce their revenue requirements in their bid proposals to account for anticipated investment income, the Medicare program could have saved an estimated $376 million that the 457 MA organizations that were included in our sampling frame earned in CY 2007.

We recommended that CMS evaluate these audit results and either (1) pursue legislation to adjust the timing of Medicare’s prepayments to MA organizations to account for the time that these organizations invest Medicare funds before paying providers for medical services or (2) develop and implement regulations that require MA organizations to reduce their revenue requirements in their bid proposals to account for anticipated investment income. CMS did not concur with our recommendation.

http://oig.hhs.gov/oas/reports/region7/71001080.asp

Comment: 

By Don McCanne, MD

Simply stated, the private Medicare Advantage plans receive hundreds of millions of dollars by investing advance payments of taxpayer funds used to pay their health care claims. This is not unusual since all insurers work the float. The longer they can hold on to premiums before they pay out benefits, the greater the returns from investing those funds. It is so commonplace that the Centers for Medicare and Medicaid Services did not concur with the Inspector General’s recommendation to pursue changes to recover that investment income.

The opportunity cost of interest-free cash advances to private insurers is yet one more cost of our flawed system of health care financing. It is a very real cost, amounting to hundreds of millions of dollars just for the private Medicare Advantage plans alone. This is just one more reason that we should establish our own public insurance program – an improved Medicare for all.

No Room in NYT for Single-Payer Doctors, but Right-Wing Cranks Are OK

By Peter Hart
Fairness & Accuracy in Reporting, 01/20/2011

When I saw the headline (1/19/11), “Vocal Physicians Group Renews Health Law Fight,” I thought maybe–just maybe–the New York Times might be talking about Physicians for a National Health Program, the group comprised of “18,000 physicians, medical students and health professionals who support single-payer national health insurance.”

But no. The Times story is about the Association of American Physicians and Surgeons, a 3,000-member organization that is on the far right of the healthcare debate, and is garnering coverage now because they support repeal of the new healthcare law. How far? These excerpts from the Times piece should give you some idea:

Founded in 1943, the Association of American Physicians and Surgeons opposed the creation of Medicaid and Medicare. A decade ago, it was among groups that unsuccessfully urged the United States Supreme Court to release post-mortem photographs of a former Clinton administration official, Vincent Foster. In its brief, the group argued that an independent inquiry was necessary to confirm that Mr. Foster, whose death was attributed to suicide, was not murdered.

And:

Its internal periodical has published studies arguing that abortion increases breast cancer risks, a tie rejected by an expert panel of the National Cancer Institute, as well as reports linking child vaccinations to autism, a discredited theory. Another report, “Illegal Aliens and American Medicine,” contended that illegal immigrants not only brought disease into this country but benefited if their babies were born with disabilities.

“Anchor babies are valuable,” that 2005 report stated, using a negative term for children born in America to illegal immigrants. “A disabled anchor baby is more valuable than a healthy one.”

Now perhaps the angle here is that since repeal is in the news, this group deserves coverage. And citing their extremist positions on an array of subjects might be useful for readers who want to know what sorts of folks are backing repeal.

But in the broader debate over healthcare, single-payer advocates like PNHP are largely sidelined. A search of Times coverage in the Nexis news database shows that PNHP usually shows up only in the letters section. A June 11, 2009 article, “Doctors’ Group Opposes Public Insurance Plan,” focused on opposition to the public option from the likes of the American Medical Association; it included a passing reference to PNHP.

It makes sense for the healthcare debate to include the voices of doctors and other caregivers. But that discussion needs to include those who support single-payer.

Medicare Advantage plans work the float

Rollup Review of Impact on Medicare Program for Investment Income That Medicare Advantage Organizations Earned and Retained From Medicare Funds in 2007

Office of Inspector General
U.S. Department of Health & Human Services
January 18, 2011

If Federal requirements had been established to delay prepayments to Medicare Advantage organizations (MA organizations) until after the beginning of the beneficiary’s coverage period by the same number of days that we estimated that MA organizations held Medicare funds, the Medicare Part A and Part B trust funds (which finance the Medicare Advantage program) could have earned approximately $450 million of interest income in calendar year (CY) 2007. Alternatively, if Federal requirements had been established to require MA organizations to reduce their revenue requirements in their bid proposals to account for anticipated investment income, the Medicare program could have saved an estimated $376 million that the 457 MA organizations that were included in our sampling frame earned in CY 2007.

We recommended that CMS evaluate these audit results and either (1) pursue legislation to adjust the timing of Medicare’s prepayments to MA organizations to account for the time that these organizations invest Medicare funds before paying providers for medical services or (2) develop and implement regulations that require MA organizations to reduce their revenue requirements in their bid proposals to account for anticipated investment income. CMS did not concur with our recommendation.

http://oig.hhs.gov/oas/reports/region7/71001080.asp

Simply stated, the private Medicare Advantage plans receive hundreds of millions of dollars by investing advance payments of taxpayer funds used to pay their health care claims. This is not unusual since all insurers work the float. The longer they can hold on to premiums before they pay out benefits, the greater the returns from investing those funds. It is so commonplace that the Centers for Medicare and Medicaid Services did not concur with the Inspector General’s recommendation to pursue changes to recover that investment income.

The opportunity cost of interest-free cash advances to private insurers is yet one more cost of our flawed system of health care financing. It is a very real cost, amounting to hundreds of millions of dollars just for the private Medicare Advantage plans alone. This is just one more reason that we should establish our own public insurance program – an improved Medicare for all.

Top 10 Reasons Why the Health Repeal Vote Is Inane

By Rose Ann DeMoro
The Huffington Post, January 19, 2011

At a time when so many Americans continue to fall through the gaping holes in our healthcare system, it’s hard to imagine a more dysfunctional debate in Washington than the charade this week over the Republican effort to repeal President Obama’s healthcare law.

Consider that, to name just a few points:

• The number of officially uninsured tops 50 million,
• Half of all Americans are considered to have pre-existing conditions and thus subject to rampant insurance denials (and ways big insurers will surely find to game the system even if the law remains as is),
• Arizona is denying life-saving transplants to poor people on Medicaid,
• Blue Shield is ignoring protests and pushing through premium rate hikes in California of up to 59 percent for individuals
• A UNICEF report ranked the U.S. a pathetic 22nd in health well-being for our children.

Yet Congress is going a though a Kabuki theater that will end without repeal or real, comprehensive solutions to the ongoing healthcare crisis.

Here’s a Top 10 list for the inanity of the repeal debate:

1. The public is already rightfully confused. A Kaiser Family Foundation poll last month found that nearly as many people (20%) favor expanding the law as favor repealing it entirely (26%). And, perhaps, most significantly, 43% of the public said they were still “confused” about the law.

2. Despite the rhetoric from the right, the law was not a “government takeover,” much less “socialized medicine.” In fact, it serves to prop up and protect the broken private system from a more fundamental reform, single-payer/expanding Medicare to cover everyone, just as President Nixon pushed HMOs as an alternative to single-payer 40 years ago (as Talking Points Memo noted last week).

3. Many Republicans do not really care if people are covered, they care about business making money. The “alternatives” discussed by the repeal crowd would unleash more of the same “magic” of the market that created the current crisis in access, cost, and quality.

4. Democrats and liberals have, ironically, become the foremost champions of “individual mandate,” a concept first proposed by Republicans and adopted in Massachusetts by a Republican Governor Mitt Romney (with a law which has been steadily unraveling in rising costs with the state reducing eligibility and covered services). Yet Democrats now promote the deception that forced purchase of private insurance constitutes “universal” healthcare, while Republicans wail that idea they once loved is unconstitutional.

5. Though the Republicans publicly say they oppose the law in part because it is unfriendly to business, nearly all the giants in the healthcare industry backed the law.

6. Despite a desperate need for fundamental change, proponents of the most far-reaching reform are dismissed as “naive” and “not serious”. Only those who support an unsustainable status quo in corporate control of our health were granted a seat at the table by the Democrats, and anything more than the most token coverage in the media.

7. In an environment where “objectivity” is defined as letting both sides have their say – as long as you stay within the parameters of the story as defined by the media – the side that is willing to tell bigger lies wins the most ink. Thus the debate was distorted by deliberate deceptions about “death panels,” seniors being cut off Medicare, and similar fantasies.

8. Challenging the efficacy of healthcare as a commodity is off the table no matter how many lives are compromised and discarded. Thus, we have a law that is not universal, does little to control costs in rising premiums and un-payable medical bills, improve quality or reduce disparities. And the repeal fans want it to do even less.

9. Few are discussing that the healthcare crisis will grow if the law is repealed or left as is. Insurers, drug companies, and providers will continue to price gouge, insurers will continue to cherry pick healthier customers and find pretexts to deny needed care, the medical technology both sides promote as a panacea will put more patients at risk by eroding professional caretaker judgment, long waits for care will remain, and the ongoing recession will produce a further shredding of the frail safety net, especially as more public hospitals and clinics are forced to close.

10. While everyone talks about a global economy, no substantive consideration was given by policy makers or the media to the way other industrialized countries assure health coverage with lower costs and better outcomes through national or single payer systems, all while failing to challenge those who falsely claim “we have the best healthcare system in the world” (we don’t).

Instead of repealing the law, let’s urge Congress to expand it by opening up the cost-efficient, universal, equitable Medicare program to everyone.

http://www.huffingtonpost.com/rose-ann-demoro/top-10-reasons-why-the-he_b_811118.html

Americans want single-payer system

Letters
Seattle Times, Jan. 19, 2011
 
U.S. Secretary of Commerce Gary Locke’s defense of the new health-care law had the usual fatal flaw: He still allows it to feed a callous health-insurance middleman [“Repealing new health-care law will make America less competitive,” Opinion, Jan. 15].
 
The law itself recognizes the immoral abuses of the health-insurance industry. It then immediately gives the industry hundreds of billions of taxpayer dollars every year to continue to deny care and bankrupt Americans.
 
Meanwhile, single-payer insurance systems have been proven to cost half as much as we spend. These single-payer insurance systems also cover everyone, eliminating bankruptcies. Our own government statistics prove single-payer insurance systems are the best at controlling costs. All of Locke’s numbers pale in comparison with the $400 billion we would save each year by simply eliminating the health-insurance middleman.
 
Give all of this, it seems Locke is defending entrenched political donors, not a health-care law. Until we get a single-payer insurance system, we will never see an affordable health-care act.
 
William McQuaid
Seattle

William Hsiao's single payer proposal for Vermont

Statement by William C. Hsiao

Vermont State Legislature
January 19, 2011

Act 128 calls upon our team to develop three options. The Legislature requires that we evaluate a state government-administered and publicly-financed single-payer health benefits system. This system, which we refer to as Option 1, would provide all Vermonters with a uniform benefits package. Within those parameters, we looked at costs of both a “comprehensive” benefits package and a leaner, “essential” benefits package, which I will define and discuss later. The second option is a state government-administered, public option that would allow Vermonters to choose between public and private insurance coverage. Option 2 is designed to allow for and promote competition between the public and private plans, while keeping in place the current multiple payer system. Act 128 allows our team to develop a third option that we design after analyzing all aspects of Vermont’s health care and assessing the positions of key stakeholders across the State of Vermont. We call Option 3 a public/private single-payer system. It provides an “essential” benefits package, is administered by an independent board with diverse representation, and it employs a competitively-selected third party to manage provider relations and claims adjudication and processing.

In analyzing the three options, we determined that all will yield significant savings. However, our research and analysis indicate that the single-payer options will have a more dramatic impact on reducing cost than the public option because they incorporate a uniform benefits package and reduce much of the administrative structure needed to compensate multiple payers. Therefore, we estimate that Option 1 will produce savings of 24.3% of total health expenditure between 2015 and 2024. Option 2 will produce savings of 16.1% of total health expenditure between 2015 and 2024. Finally, Option 3 will produce savings of 25.3% of total health expenditure between 2015 and 2024. Option 3 produces additional savings as compared to Option 1 because it incorporates a public/private partnership in governance and administration.

In 2015, the first full year of implementation, PPACA would reduce the number of uninsured by 18,000 people; however 32,000 Vermont residents will remain uninsured. Ultimately in 2019, PPACA will reduce the number of uninsured by 22,000 in 2019. PPACA will likely add an additional $240 million of federal funds in 2015 to the State of Vermont, which will eventually rise to $420 million in 2019. All of these dollar values are expressed in 2010 dollars.

In comparison with option 1 and 3, Option 2 would still leave approximately 30,000 Vermonters uninsured. Option 2 would not expand the current benefits to cover some dental and vision care nor bring up the benefits for those who are currently under-insured.

The comprehensive benefit package under option 1 covers all health services with minimum cost sharing. As a result, it costs more and requires more funds to finance it. Under a payroll contribution scheme of financing, employers and workers will have to pay more than what they would pay if no reform takes place. This comprehensive benefit option would also increase the total health spending in Vermont which would make this option less feasible.

The essential benefit package under option 1 and 3 have leaner benefits and they can be financed through payroll contributions without increasing the amount that most employers and workers would have to pay as compared to if no reform takes place. It would reduce the total health spending in Vermont slightly in 2015 when the proposed reforms are implemented.

Statement (10 pages):
http://WWW.leg.state.VT.us/jfo/healthcare/FINAL%20VT%20Hsiao%20Written%20Statment%20for%20Jan1911_1.pdf

Full report – William Hsiao, Steven Kappel and Jonathan Gruber (138 pages):
http://www.leg.state.vt.us/jfo/healthcare/FINAL%20VT%20Draft%20Hsiao%20Report.pdf

Comment:

By Don McCanne, MD

Although advocates of the pure single payer model will find some problems with this report on a reform proposal for Vermont, there is very good news in this analysis. The report emphatically confirms the superiority of the single payer model in ensuring that everyone is included while containing health care costs.

In an analysis of the impact of the Patient Protection and Affordable Care Act (PPACA), the authors demonstrated that far too many would still be left without insurance, and it would have a negligible impact in controlling health care costs. As we have said all along, the financing system in PPACA is grossly inadequate and needs to be replaced.

The authors’ Option 2 is essentially PPACA with a “public option” added – a public insurance plan that competes with the private plans. Their analysis shows that it would have only a very modest impact on reducing costs, and an almost negligible impact on reducing the numbers of uninsured. Thus the bluster in support of the public option was misdirected. That energy should have been redirected to supporting single payer instead.

Options 1B and 3 are almost identical. They are both single payer models that totally replace the private insurance plans. They have an “Essential Benefits Package” with an actuarial value of about 87 percent which is close to the typical employer-sponsored plans before they began introducing high deductibles. Their analyses shows that these plans would cover everyone without any increase in spending since the single payer efficiencies would be enough to pay for those currently uninsured or under-insured. So this is the really good news – single payer works (though read on).

The primary difference in 1B and 3 is that 1B is publicly administered whereas 3 is administered by an independent board that contracts with a competitively-selected third party to manage provider relations and claims adjudication and processing. The authors state a preference for Option 3 claiming that it saves a little bit more money by requiring potential managers to compete for the contract. That is highly dubious and more likely was inserted to appease the market ideology of a sector of the twenty some odd contributors to this study. Considering this, I think that we can extrapolate the fact that the authors would also endorse Option 1B, since it is otherwise identical.

Option 1A is like 1B except that it provides a “Comprehensive Benefits Package” – virtually all health care services and products – achieving approximately an actuarial ratio of 97% for medical and mental health services, 90% for drugs and vision care, and 85% for dental, nursing homes and home care. It would cost more than Option 1B, but not that much more. It was not selected by the authors since one of the goals of study was to cover everyone without increasing spending over current levels. In a single payer system the benefits should be comprehensive.

One very serious deficiency is that they decided to leave in place Medicare and Medicaid, primarily because of existing barriers to move them into a single payer system. Thus their proposal is not a single payer system. Leaving these programs in place sacrifices some of the important single payer efficiencies.

They also tout accountable care organizations (ACO), suggesting that capitation should apply to primary care and salaries should apply to specialists. Yet by questions that they pose, they recognize that ACOs are not well defined. For instance, how can they effectively manage the care of a patient that PPACA grants the right to move in and out of the ACO at any and all times?

Within the next couple of days, we’ll have a clearer concept
of where the single payer community should be on this report. Tentatively, it seems that it deserves our support, but support that is qualified by strong advocacy to make it right by such measures as including comprehensive benefits, and rolling in and eliminating Medicare and Medicaid.