PNHP

Canada fights privatization

Canada fights privatization

Self-interest over public interest

By Prof. Gordon Guyatt
The Globe and Mail
01/08/07

Any proposed change to health care implies winners and losers.

Take, for instance, a national Pharmacare program. Winners would include poor Canadians who have difficulty affording drugs, middle income Canadians with high drug costs, and anyone facing catastrophic drug expenditures.
Canadian large industry would also benefit by enhanced competitiveness as a result of lower employee health benefits.

The losers? High income Canadians in upper tax brackets and the insurance industry.

The Canadian Medical Association has recently suggested that provincial governments increase reliance on private, for-profit providers to deliver publicly funded health care. Furthermore, they suggest that physicians be allowed to practice in both for-profit and not-for-profit sectors. Who would win and lose if governments accept the proposal?
The CMA claims that the public would benefit from shorter waiting lists. There are many reasons for skepticism about the claim.

Long wait times and suboptimal care are in considerable part a function of doctor and nursing shortages. For-profit clinics would not lead to the training of a single additional doctor or nurse. Indeed, such clinics would suck desperately needed personnel from not-for-profit hospitals and outpatient facilities.

Physicians practicing in public and private settings they have a vested interest in keeping waiting lists long in publicly funded settings. Why would patients pay extra if waiting lists are under control in publicly funded hospitals and out-patient clinics? They would not. For-profit clinics prosper only so long as non-profit provision suffers unacceptable waits.

Could for-profit clinics shorten waiting lists by creating more resources, such as operating room time? Surely, but the government could create those same resources by investment in hospitals or not-for-profit dedicated surgical and diagnostic facilities.

Investing in not-for-profit provision has a major advantage. For-profit providers need to earn a return — typically 15 to 20% – for their investors. Non-profits can devote that money to patient care. That explains the findings from systematic studies comparing for-profit versus non-profit hospital and dialysis care in the U.S. Higher death rates from cutting corners in for-profit hospitals and dialysis facilities, higher charges to third-party payers in for-profit hospitals.

So, too bad, no public win in terms of wait time reduction.

There would, however, be winners. Physician entrepreneurs like incoming CMA President Brian Day who operates a private hospital facility stand to make large sums of money. Many investors have made huge sums of money in U.S. for-profit health care. The proposal would allow them to exploit the enormous public expenditures on Canadian health care. And, if an associated CMA proposal to expand private insurance comes to pass, the insurance industry will cash in.

The losers? The general public who will end up spending more on health care to feed the investors’ profits and — if that market expands – on administrative costs associated with private health insurance. Those patients who can’t afford the substantial direct charges that — as experience in British Columbia and Quebec has shown — will inevitably come with for-profit health care provision. These losers will suffer the consequences of two-tier health care: the long waits in non-profit facilities necessary to allow the for-profits to charge queue-jumpers.

Other losers? Health workers who believe that ethical medical practice requires treating patients according to need, rather than ability to pay. My many visits to American health care institutions have shown me what it is like to practice medicine in a two-tier system. For doctors and nurses who believe that equity is at the heart of ethical care, it isn’t pleasant.

Consideration of winners and loser reveals a sad conclusion. While many doctors are in strong disagreement with proposals that would undermine public health care, the CMA leadership has chosen self-interest over the public interest.

How will politicians respond to the CMA initiative? Stephen Harper has done nothing to rein in expansions of charge-the-patient for-profit care in Quebec and B.C. On the other hand, the Prime Minister sees the situation as it is. In a letter responding to Ralph Klein’s proposal to allow physicians to practice in public and private systems, Mr. Harper wrote:

“Dual practice creates conflict of interest for physicians as there would be a financial incentive for them to stream patients into the private portion of their practice. Furthermore, dual practice legitimizes queue-jumping as it provides an approved mechanism for patients to pay to seek treatment at the front of the line.”

Whether for political expediency or conviction, the federal government may have nothing to do with the CMA’s proposals. If so, the losers will be the doctors and investors eager to turn health care to profit, and the winners will be the Canadian public.

Gordon Guyatt is a Professor of Medicine at McMaster University

New fight looms over medicare

Toronto Star
EDITORIAL
Aug 01, 2007

Once again the Canadian Medical Association, the national lobby group for Canada’s doctors, has started beating the drums for two-tier health care. In a speech Monday in Charlottetown, outgoing CMA president Collin McMillan set out a plan he calls “Medicare Plus.”

It is a blueprint that would see Canadians being allowed more access to private health insurance that could be used in a private system and which operates alongside medicare’s publicly funded coverage for all Canadians. Also under the plan, as set out in a policy paper released by the CMA, doctors would be free to divide their time as they see fit between public practice and a private one for those Canadians with cash or private insurance.

This is nothing short of a recipe for two-tier medicine.

But it rests on two flawed assumptions: first, that medicare is broken, and second, that it is too expensive for governments to fix.

As former Saskatchewan premier Roy Romanow concluded in 2002 after his exhaustive, 18-month review of Canada’s publicly funded, not-for-profit health-care system, medicare is far from broken. And all the well-known problems with the current system that arose at a time when Ottawa was preoccupied with fighting its deficit can be fixed at a reasonable cost.

In fact, since Romanow reported five years ago, important progress has been made on many fronts, although there is still much to be done.

Both Ottawa and provincial governments have invested heavily in health care, which has resulted in shorter wait times in many key areas, an increase in the availability of sophisticated diagnostic equipment and the introduction of programs of enhanced primary care. These advances, however, have not stopped the champions of private health care from continuing to push for two-tier medicine in Canada.

Indeed, Canada is heading rapidly toward yet another major national fight over the future of medicare.

Defenders of medicare have fought these battles in the past Ć¢ā‚¬ā€œ and will need to speak up again in the coming fight. And they cannot afford to underestimate their opponents.

If anything, McMillan’s speech on Monday is merely the opening salvo in this debate. The next major battleground will be the provincial election in Ontario.

Here, Progressive Conservative Party Leader John Tory’s election platform promises “to involve the private sector where there are opportunities to shorten waiting lists and improve access to high-quality, publicly funded care.” Many in his party want to see widespread use of privately run, but publicly funded clinics. Although such proponents insist that patients would not be allowed to buy their way to the front of the line, their arguments in favour of private delivery have been used repeatedly like a crowbar by those trying to pry open the door to two-tier medicine.

At the national level, the pressure on Ottawa and the provinces to experiment more with private health care will start to increase next month when Brian Day takes over from McMillan at the CMA. A vociferous critic of the public system, Day is also the owner of Canada’s largest private hospital, based in Vancouver.

On the other side of the divide are the vast majority of Canadians, who overwhelmingly support medicare. They will have a critical part to play as this renewed debate unfolds.

To counter those who favour increased privatization, these Canadians must re-energize themselves and prepare once again to take on the claims of affordability and increased efficiency that proponents of private care use to sell their case.

Most importantly, they must continue to press governments to improve the current system and be ready with their own prescriptions for completing the work that still needs to be done to restore the public’s confidence in a system that has served Canada well.

For as Romanow wrote in the introduction to his 2002 report: “Strong leadership and the involvement of Canadians is key to preserving a system that is true to our values and sustainable.”

Rudy Giuliani’s health care proposal

Rudy Giuliani Campaign Announces Health Care Advisors

RUDY
www.JoinRudy2008.com
July 30, 2007

The Rudy Giuliani Presidential Committee today announced key advisors who have been providing input on Rudy Giuliani’s commitment to providing affordable free-market-based solutions to health care aimed at giving Americans more control over and access to their health care.

The Mayor’s group of advisors includes well-known advocates of consumer-driven health care and recognized leaders in their respective areas of expertise.

“Rudy Giuliani strongly believes in limited government and giving American families more control over their health care decisions,” said Steve Goldsmith, the campaign’s Chief Domestic Policy Advisor. “He understands that failed mandates and wasteful, unaccountable bureaucracies lead to the exclusion of millions of Americans from quality care and health insurance.”

The Advisors:

Dan Kessler, Ph.D. – a senior fellow at the Hoover Institution and a professor at the Graduate School of Business at Stanford University, and co-author of Healthy, Wealthy, and Wise (advocates a free market solution to reform).

Scott Atlas, M.D. – a senior fellow by courtesy at the Hoover Institution whose research includes free market solutions to health care.

David Gratzer, M.D. – a senior fellow at the Manhattan Institute whose most recent book, with Foreword by Milton Friedman, is The Cure: How Capitalism Can Save American Health Care.

Sally C. Pipes – president and chief executive officer of the Pacific Research Institute, a San Francisco-based think tank. Previously she was assistant director of the Fraser Institute.

Donald W. Moran – served as the Executive Associate Director for Budget and Legislation at the U.S. Office of Management & Budget under President Ronald Reagan.

http://www.joinrudy2008.com/news/pr/548

And…

Giuliani attacks Democratic health plans as ‘socialist’

By Paul Steinhauser
CNN.com/politics
July 31, 2007

Republican presidential candidate Rudy Giuliani said Tuesday he wants to give American citizens more control over their health care.

“We’ve got to do it the American way,” Giuliani said during a town hall forum in Rochester, New Hampshire. “The American way is not single-payer, government-controlled anything.”

“That’s why when you hear Democrats in particular talk about single-mandated health care, universal health care, what they’re talking about is socialized medicine.”

Giuliani’s health care plan, unveiled at the forum, includes giving taxpayers tax credits to purchase private health insurance. The highlight of Giuliani’s plan: a $15,000 tax deduction for each family to buy private health insurance.

He says his program for private insurance would replace coverage from employers.

While outlining his plan, Giuliani offered few details.

http://www.cnn.com/2007/POLITICS/07/31/giuliani.democrats/

Comment:

By Don McCanne, MD

Rudy Giuliani’s choice of health care advisors is all you need to know to understand his positions on reform. His decision to trump rational health policy with extremist libertarian ideology does tend to make you question his political skills. He obviously isn’t poll driven.

Presbyterian Health fought Whipple at M. D. Anderson

Doing Battle With the Insurance Company in a Fight to Stay Alive

By Denise Grady
The New York Times
July 29, 2007

A glorious blend of forces came together to save Gordon HendricksonĆ¢ā‚¬ā„¢s life: smart doctoring, luck, kindness, and his own wisdom and abundant grit.

Only his insurance company tried to stand in the way.

His doctors thought he was among the lucky few with pancreatic cancer found early enough to be cured by surgery. But they warned him not to have the surgery in his home city, Albuquerque. They said the operation he needed, a Whipple procedure, was so risky and complicated that it should be done only by a surgeon who performed it often and at a hospital with many similar cases. But neither was available locally.

…his internist, Dr. Kristine Bordenave… canceled her other appointments to spend hours on the phone finding a major cancer center that would quickly admit him. It turned out to be the M. D. Anderson Cancer Center in Houston.

But his insurer, the Presbyterian Health Plan, refused to pay for treatment in Houston. The company insisted that the operation be done in Albuquerque and sent him a list of five local surgeons.

He went to M. D. Anderson anyway.

Mr. Hendrickson had the surgery. It went well. But he was left with more than $80,000 in medical bills, which Presbyterian Health Plan refused to pay.

Mr. Hendrickson waged a long battle with Presbyterian.

After Presbyterian rejected two appeals, he took his case to a state review board, where he represented himself because he could not afford a lawyer.

Ultimately, Mr. Hendrickson won the case, and Presbyterian Health Plan paid the entire bill.

http://www.nytimes.com/2007/07/29/health/29OBSTACLES.html?adxnnl=1&adxnnlx=1185712600-tpCl49Yqw7WlMUs6wqw8Gg

About Presbyterian Healthcare Services:
http://www.phs.org/admin/about_us.shtml

Comment:

By Don McCanne, MD

The appropriate medical decision could not be more straightforward. A Whipple procedure should always be done in a center with an experienced team. To attempt this operation at a local level with an inexperienced team is almost tantamount to a death sentence.

Had Mr. Hendrickson been covered by the traditional Medicare program, the referral would have been made promptly to M. D. Anderson Cancer Center without the need to consider any other referral options, the operation would have been completed, and Medicare would have paid the bills. End of story.

But no. His coverage was through Presbyterian Health Plan, an intrusive third party payer that held contracts with the patient on the consumer side, and with a specific list of physicians and hospitals on the provider side. The contracts allowed Presbyterian Health Plan to use a basic business decision to overrule a crucial medical decision. This clearly caused Mr. Hendrickson considerable distress, and could have cost him his life.

One irony is that Presbyterian Health Plan is part of Presbyterian Healthcare Services which is a private, nonprofit statewide healthcare system with several hospitals, plus primary and specialty care through Presbyterian Medical Group. Single payer model proposals usually include coverage for integrated healthcare delivery systems, as long as their mission is providing health care rather than providing insurance services.

Suppose we adopted a single national health insurance program covering everyone for all reasonable beneficial services. Presbyterian Health Plan would be superfluous and could be eliminated. Payment for services could be made directly by the public insurance program. The patient could be free to continue to use Presbyterian Healthcare Services, but could also be free to use any other healthcare providers such as M. D. Anderson Cancer Center. Neither the patient nor the providers necessarily would be locked in by a contract.

But what if the integrated healthcare delivery system elected to be funded through capitation, as some single payer models would permit? That returns some of the financial risk to the delivery system, and locks the patient back in (otherwise the government would be paying, for the same patient, both a capitation fee for comprehensive services and fee-for-service costs outside of the system). The single payer model does call for funding hospitals through global budgets, so the hospital component of the integrated delivery system could be funded by global budgets as well. The medical group component could then be funded either by fee-for-service, or also by a global budget negotiated to cover legitimate costs plus fair compensation. Paying physicians by salary reduces the incentives to either withhold beneficial care or provide excessive services (although it risks sloth).

At any rate, Mr. Hendrickson’s experience provides us with yet one more example of why we need to remove private insurers from our financing of health care. Health care needs to be based strictly on medical need rather than on business decisions made by private insurers.

PNHP Debates Incoming AMA President

Is single-payer health care a good idea? A debate between Dr. Nancy Nielsen, president-elect of the American Medical Association and Dr.Don McCanne, Senior Policy Fellow for Physicians for a National Health Program. To hear the show, click HERE

Single payer debate with AMA President-Elect Nancy Nielsen

Is single-payer health care a good idea?

A debate between Dr. Nancy Nielsen, president-elect of the American Medical Association and Dr. Don McCanne, Senior Policy Fellow for Physicians for a National Health Program.
KALW, San Francisco
July 29, 2007

Hosted by Marty Nemko

Halfway through the debate:

Marty Nemko: You know, as I’m kind of stepping back and listening to this debate, at this moment in time in the debate, it’s seeming as though the advantages of lower costs that would accrue from reduced administrative costs that would come from single payer, the simplification of life that would come from single payer, and retention of choice in the single payer program that you’re advocating, that is choice of doctors and hospitals, right now makes it look like you’re winning. So I’d like to ask you, Don, some tough questions that I think will at least allow our listeners to hear the best answers to these kind of tough questions…

To hear the hour-long broadcast, click on “HERE” for the 7/29 archive:
http://www.martynemko.com/past-and-upcoming-radio-shows

Comment:

By Don McCanne, MD

Because of my obvious bias, I’ll not comment here on our respective opinions on the health care reform policies debated. The listeners can draw their own conclusions.

But I would like to mention one point of disagreement that could not be clarified during the limited time of the broadcast. I mentioned that the AMA’s version of choice was the choice of private health plans, allowing individuals to purchase plans with lower premiums, but at a cost of reducing the insurance function of the private plans. Those plans work for the healthy, but not for those who later develop significant medical problems. She replied that this does not at all represent the AMA’s proposal. She used the analogy that you would never buy an unsafe car, but rather you would choose a car with all of the safety features. But the 2007 AMA proposal for reform specifically states: “Benefit mandates should be minimized to allow markets to determine benefit packages and permit a wide choice of coverage options.” This point is absolutely crucial because it further demonstrates how poorly private plans would serve us in a universal system of health care coverage.

The best of the Blues

CMA Appalled by Blue Shield of CaliforniaĆ¢ā‚¬ā„¢s Failure to Settle RICO Lawsuit

California Medical Association
CMA Alert
July 26, 2007

CMA is outraged that Blue Shield of California has refused to settle a class-action lawsuit filed in 2003 that would have meant tens of millions of dollars to California physicians who were harmed by the insurer’s previous failures to provide and pay for patient care.

Despite the association’s best efforts to work amicably with this nonprofit insurance company — a company CMA founded — Blue Shield is demonstrating a disappointing unwillingness to provide its enrollees with the care for which they’ve paid.

Though not a plaintiff in this case, CMA has been working with the parties involved over the past several months to reach a fair settlement. Unfortunately, the Blue Shield of California board of directors recently decided it was not willing to pay the pro rata shares owed to doctors who provided tens of millions of dollars in uncompensated care to Blue Shield enrollees.

The case, Rick Love, M.D. v. Blue Cross Blue Shield Association, was filed in May 2003 in federal district court in Miami. The suit accused the insurers of a pattern and practice of denying and delaying care, including intentionally programming computer billing databases to automatically down-code physician claims. The suit was filed under the federal civil RICO (Racketeering Influenced and Corrupt Organizations) statutes.

http://www.calphys.org/html/alert072607.asp?anchorID#3

Comment:

By Don McCanne, MD

Those who believe that private insurers should continue to have a prominent role in health care financing often point to the Blue Cross and Blue Shield companies as effective, efficient and ethical insurers. How has that played out in California?

Blue Cross of California has a well deserved reputation for being the heavy in the havoc wreaked in California’s insurance market. They led the way by transforming themselves from a traditional, non-profit insurer serving patients, into a for-profit insurer serving investors. The ugly story will not be repeated here other than to say that their financial success has been due primarily to their business model that has allowed them to offer competitive premiums by limiting their medical losses. The innumerable devious methods used to avoid paying for health care are what offend our sensibilities.

In contrast, Blue Shield of California, founded by the California Medical Association, has remained non-profit, and has had a reputation a representing the noble traditions of the Blues. But is that reputation deserved?

To remain competitive, Blue Shield had to adopt many of the same nefarious measures that Blue Cross uses to limit medical losses. According to this lawsuit, they established “a pattern and practice of denying and delaying care,” and even resorted to the dishonest practice of using computers to automatically change service code numbers. Thus physicians were not being paid the already-discounted fees for which they contracted. Blue Shield is serving neither the patients nor the providers well. The take-home point is that even the best of the private insurers engage in devious practices.

Physicians and hospitals might have their differences with the Medicare program, but at least reimbursements are determined by an open an honest process (a process that requires continual refinement). More importantly, Medicare policies are designed to promote affordable access to care for everyone qualified, whereas private insurer policies are designed to hinder access to care and to exclude those with the greatest needs.

We really do need to eliminate the inefficient, intrusive private insurers from our health care system. Even the Blues have to go.

Prescription mining raises millions for doctors' group

By Robert Restuccia and Lydia Vaias
San Francisco Chronicle
Wednesday, July 25, 2007

Drug companies care about what your doctor prescribes just as much as you do – and they’re paying big money to find out. They are paying so much, in fact, that even though the vast majority of physicians disapprove of the sale of their personal prescribing data for marketing purposes, the American Medical Association persists in selling detailed physician information to the pharmaceutical industry. This data must be used for legitimate public health research – not brand promotion.

Drug ads cover doctors’ offices, coating everything from wall calendars and paperweights to stethoscopes and prescription pads. The numbers show that these advertisements work: doctors are prescribing more brand-name, higher-cost drugs than ever before.

One of the less obvious but more intrusive marketing tools is the drug rep’s hand-held computer, which contains a detailed profile of your doctor’s prescribing history. Armed with the knowledge of each doctor’s individual prescribing habits, pharmaceutical sales representatives tailor their pitches to each physician. This strategy has resulted in new, costlier drugs replacing established medications that have proven histories of safety and effectiveness. Industry profits swell, as do the nation’s health care costs.

Few people recognize the role the AMA plays in making physician information available to companies that use it for pharmaceutical marketing purposes. The AMA sells information from its physician “Masterfile” to health information organizations that pair the identifying information with prescribing records from pharmacies and sell the whole package to pharmaceutical companies, a practice commonly called “prescription data-mining.”

The AMA profits handsomely from this agreement. In 2005, the AMA made more than $44 million from the sale of database products, approximately 16 percent of its budget. It comes as no surprise, then, that the sale of prescriber information failed to make the formal agenda when AMA delegates met in Chicago last month.

Yet among physicians there is a growing and vigorous debate about the appropriateness of this practice and its enhancement of pharmaceutical marketing. Despite representing less than 30 percent of all U.S. doctors, the AMA keeps identifying information on all licensed physicians – and sells it all. Even so, only 60 percent of physicians surveyed by the Kaiser Family Foundation were aware of the sale of their information. Once told, 74 percent disapproved. Even a survey by the AMA itself found a 66 percent disapproval rate.

A number of policymakers, physician groups and medical societies have come out against this practice in recent years. Leaders include the National Physicians Alliance, the American Medical Student Association, the Vermont Medical Society and the New Hampshire Medical Society. Unfortunately, the AMA has a financial incentive to keep selling this information without regard to how it is being used or the impact it has on patient care and health-care costs.

A growing number of states have taken measures to end data mining because the AMA will not. Maine and Vermont recently passed legislation banning the sale of information detailing what drugs doctors are prescribing their patients while New Hampshire, the first state to pass such legislation, saw the data mining companies challenge the law. A federal court overturned the law banning the sale of prescription information “on free speech” grounds and the case in now being appealed by New Hampshire.

Last year, in response to this growing pressure, the AMA created an “opt-out” measure, called the Prescribing Data Restriction Program. Difficult to navigate, poorly publicized, with only a quarter of physicians are aware of it, and used by less than 1 percent of doctors, the opt-out program is a step toward reform, but a small and inadequate one. The program does not bar the sale of prescriber information to pharmaceutical companies; it merely requests and then relies on the industry to prevent the transmission of this data to its sales teams.

By continuing to profit from the sale of physician data, the AMA has shown itself to be at best, slow-to-act, and at worst, opportunistic at the expense of professional boundaries. The AMA should put medical ethics before profits and stop licensing its Physician Masterfile for pharmaceutical marketing purposes.

Robert Restuccia is the executive director of the Prescription Project, a national initiative supported by the Pew Charitable Trusts to end conflicts of interest created by the pharmaceutical industry’s marketing to physicians. Lydia Vaias serves as president of the National Physicians Alliance and is a board-certified general surgeon on staff at Kaiser Permanente Hospital in Bellflower (Los Angeles County).

This article appeared on page B – 9 of the San Francisco Chronicle

Prescription mining raises millions for doctors’ group

By Robert Restuccia and Lydia Vaias
San Francisco Chronicle
Wednesday, July 25, 2007

Drug companies care about what your doctor prescribes just as much as you do – and they’re paying big money to find out. They are paying so much, in fact, that even though the vast majority of physicians disapprove of the sale of their personal prescribing data for marketing purposes, the American Medical Association persists in selling detailed physician information to the pharmaceutical industry. This data must be used for legitimate public health research – not brand promotion.

Drug ads cover doctors’ offices, coating everything from wall calendars and paperweights to stethoscopes and prescription pads. The numbers show that these advertisements work: doctors are prescribing more brand-name, higher-cost drugs than ever before.

One of the less obvious but more intrusive marketing tools is the drug rep’s hand-held computer, which contains a detailed profile of your doctor’s prescribing history. Armed with the knowledge of each doctor’s individual prescribing habits, pharmaceutical sales representatives tailor their pitches to each physician. This strategy has resulted in new, costlier drugs replacing established medications that have proven histories of safety and effectiveness. Industry profits swell, as do the nation’s health care costs.

Few people recognize the role the AMA plays in making physician information available to companies that use it for pharmaceutical marketing purposes. The AMA sells information from its physician “Masterfile” to health information organizations that pair the identifying information with prescribing records from pharmacies and sell the whole package to pharmaceutical companies, a practice commonly called “prescription data-mining.”

The AMA profits handsomely from this agreement. In 2005, the AMA made more than $44 million from the sale of database products, approximately 16 percent of its budget. It comes as no surprise, then, that the sale of prescriber information failed to make the formal agenda when AMA delegates met in Chicago last month.

Yet among physicians there is a growing and vigorous debate about the appropriateness of this practice and its enhancement of pharmaceutical marketing. Despite representing less than 30 percent of all U.S. doctors, the AMA keeps identifying information on all licensed physicians – and sells it all. Even so, only 60 percent of physicians surveyed by the Kaiser Family Foundation were aware of the sale of their information. Once told, 74 percent disapproved. Even a survey by the AMA itself found a 66 percent disapproval rate.

A number of policymakers, physician groups and medical societies have come out against this practice in recent years. Leaders include the National Physicians Alliance, the American Medical Student Association, the Vermont Medical Society and the New Hampshire Medical Society. Unfortunately, the AMA has a financial incentive to keep selling this information without regard to how it is being used or the impact it has on patient care and health-care costs.

A growing number of states have taken measures to end data mining because the AMA will not. Maine and Vermont recently passed legislation banning the sale of information detailing what drugs doctors are prescribing their patients while New Hampshire, the first state to pass such legislation, saw the data mining companies challenge the law. A federal court overturned the law banning the sale of prescription information “on free speech” grounds and the case in now being appealed by New Hampshire.

Last year, in response to this growing pressure, the AMA created an “opt-out” measure, called the Prescribing Data Restriction Program. Difficult to navigate, poorly publicized, with only a quarter of physicians are aware of it, and used by less than 1 percent of doctors, the opt-out program is a step toward reform, but a small and inadequate one. The program does not bar the sale of prescriber information to pharmaceutical companies; it merely requests and then relies on the industry to prevent the transmission of this data to its sales teams.

By continuing to profit from the sale of physician data, the AMA has shown itself to be at best, slow-to-act, and at worst, opportunistic at the expense of professional boundaries. The AMA should put medical ethics before profits and stop licensing its Physician Masterfile for pharmaceutical marketing purposes.

Robert Restuccia is the executive director of the Prescription Project, a national initiative supported by the Pew Charitable Trusts to end conflicts of interest created by the pharmaceutical industry’s marketing to physicians. Lydia Vaias serves as president of the National Physicians Alliance and is a board-certified general surgeon on staff at Kaiser Permanente Hospital in Bellflower (Los Angeles County).

This article appeared on page B – 9 of the San Francisco Chronicle

Lessons from Massachusetts on affordability

Massachusetts Health Reform: Employers, Lower-Wage Workers and Universal Coverage

By Laurie E. Felland, Debra A. Draper, Allison Liebhaber
Center for Studying Health System Change
July 2007

In rapid fashion, Massachusetts has made efforts to both ignite demand for health insurance and establish a marketplace for individuals and small employers to purchase coverage.

Perhaps the most fundamental challenge is the issue of affordability. While most market observers agree that the primary goal of the reform is to improve access to health insurance, they contend that its ultimate success depends on affordability–both in the short term, as well as the long term. If affordable coverage is not available, it is unlikely that small employers on the cusp of offering insurance to their workers will be motivated to do so.

Affordability is also a concern of individuals and, despite the individual mandate to have health insurance, there are likely to be some people who will forgo coverage and pay the tax penalty. They may decide this based on individual assessments that they cannot afford coverage, which for lower-income individuals, in particular, may mean that basic needs such as housing and food take precedence over obtaining health insurance. Efforts in other states to reduce the number of uninsured by creating purchasing pools, offering insurance subsidies to employers and employees, tax credits or limited benefits often have struggled for precisely this reason–individuals’ perceptions that they cannot afford coverage or that what they are buying is not worth the cost. In April, the Connector board reported plans to exempt nearly 20 percent of uninsured adults (approximately 60,000 people) ineligible for state subsidies from the individual mandate after determining that even the lowest cost insurance is unaffordable for them. The Connector board currently is revisiting the premium levels that will be considered affordable for people at all income levels, after learning that its proposed schedule would exempt significantly more people from the individual mandate than originally intended.

The challenge of affordability extends to a policy debate about what should be the balance between the financial obligations of individuals and the state. The less affordable coverage is for consumers, the more likely the state will have to commit additional monies to subsidize people to achieve near universal coverage.

There is also the issue of whether the Connector adds additional administrative costs to the system. Evidence from other states’ purchasing pool initiatives suggest that the administrative costs of marketing, enrollment processing and premium collection, for example, can be significant.

What happens, however, if people forgo health insurance coverage, but still receive care?

The reform is being implemented during a time when the state’s economy is strong and unemployment is low. What happens if there is an economic downturn?

The issue for Massachusetts may come down to how close to the goal of universal coverage is realistically attainable. The state has a lower percentage of uninsured people compared to most other states, which increases the feasibility of achieving near universal coverage. But at what point do the costs to the state getting one additional individual insured outweigh the benefits?

http://www.hschange.org/CONTENT/939/

Comment:

By Don McCanne, MD

It is an appropriate time to revisit the new Massachusetts program for universal coverage since it went into effect on July 1, and we now have this assessment from the Center for Studying Health System Change, a highly credible source of unbiased information. It is important that we understand this program since it is being touted as a model for other states to emulate.

The issue of affordability was of primary concern from day one. But rather than addressing the crucial problem of the affordability of health care, the architects of the program decided to tackle the problem of the affordability of private insurance plans.

It rapidly became clear that the private insurers could not provide a comprehensive product with premiums that average-income individuals could afford. Although the program subsidizes premiums for low-income individuals, they did not consider extending subsidies to average-income individuals. That wouldn’t make sense. Why would you subsidize inefficient private plans for the majority of individuals when a single publicly-funded program would be much more efficient and more equitable?

Insisting that the program must be administered through private plans, the architects tinkered with the policies behind the concept. They gave up on enacting standard comprehensive benefits for everyone, and established four levels of coverage: bronze, silver, gold, and young adult. Since the less expensive plans were still unaffordable for many, they tinkered with numbers that would excuse many from the penalty that would be assessed for not buying the insurance that they could not afford. But in trying to come up with reasonable numbers, it turns out that a great many more will have to be excused from the penalty. Thus their universal program is not universal, and it will be even less so as the health care financing crisis deteriorates further.

Of all states, Massachusetts had the most favorable health care environment to enact an individual mandate to purchase private insurance. It is not working in Massachusetts, and the outcome would be worse in any other state that tried the same.

The primary flaw in most reform proposals is that they begin with the assumption that we must include private insurance plans in any system of universal coverage, no matter how much is wasted in administrative excesses. Not only is it the most expensive model of administering health care funds, private plans also diminish our choice of providers, limit benefits, and shift more costs to those with health care needs. Talk about flawed assumptions. All objective criteria would indicate that we should begin with the assumption that private plans must be eliminated in order to recover much of the profound administrative waste of our fragmented system of financing health care.

By transferring the affordability concern from individuals to the administrators of a national health insurance program, we could begin to address seriously the real cost drivers of excessive health care spending. Nothing short of structural reform will work.

Queues in the U.S. – for the uninsured

Uninsured adults face yearlong delays for some surgeries

By Mary Engel
Los Angeles Times
July 25, 2007

Adults with no health insurance face waits up to a year or longer for gallbladder or hernia surgery in Los Angeles County.

Community clinics rely on five county-owned hospitals to provide virtually all specialty care, including hernia and gallbladder surgery, for their uninsured patients.

With a quarter of the county’s adult population lacking insurance, patients have always had to wait a long time. But delays are growing longer as the population ages and suffers complications from such chronic conditions as diabetes and obesity.

More than a decade ago, the county partnered with nonprofit clinics to give the uninsured a place to go besides emergency rooms, which must see patients regardless of their ability to pay. Health officials also hoped that regular visits to primary care clinics would keep illnesses from getting worse and turning into real emergencies.

With funding help from the county, 43 nonprofit groups operate 117 community clinics throughout Los Angeles County. The clinics collectively see about 600,000 low-income patients a month for asthma and flu, diabetes and prenatal care, gynecological exams and immunizations.

But people without insurance also get hernias and gallstones, suffer failing hearts and ailing livers that, though not technically emergencies, are beyond the skills of the clinics’ primary care doctors, physician assistants and nurse practitioners.

(A table published with this article reveals that patients of the Southside Coalition of Community Health Centers have a typical wait time of six months to one year for most specialty services.)

http://www.latimes.com/news/local/la-me-wait25jul25,1,788861,full.story?coll=la-headlines-california

Comment:

By Don McCanne, MD

The opponents of reform frequently claim that a program of national health insurance would introduce queues into the United States. But they’re already here. As an example, for one quarter of the adult population in Los Angeles, excessive queues are already very much a fact of life.

What would happen if these individuals were covered by Medicare? Obviously they would receive their care in as timely a manner as is logistically possible, like the rest of us who are insured. They would not be limited to obtaining their care in over-crowded and under-funded community clinics and county-owned hospitals, a problem which would be somewhat alleviated by the infusion of Medicare funds that would pay for the care that is now delivered without compensation.

That does not mean that we can be inattentive to our health care infrastructure. Yesterday the Massachusetts Medical Society released a report in response to their state’s mandate for (pseudo-) universal coverage.

From the report:

“The inevitable increase in patient demand is occurring in the midst of an increasing physician shortage. Among the new specialties showing strain are family practice and internal medicine, two of the most important to providing adequate preventive care and minimizing the use of emergency departments. Newly insured residents may find it difficult to get timely appointments with physicians due to these shortages.”

What should be our response? Do we make appropriate capacity adjustments, introduce queue management techniques, and prioritize our health care spending so that everyone can have timely access to all reasonable care? Or do we abandon the concept of comprehensive insurance for everyone, and tell those without adequate funds that they’re just going to have to wait and see if they will ever be able to be seen?

Choosing the latter would perpetuate our uniquely American, anti-egalitarian stance. But isn’t that sort of Sicko?

Massachusetts Medical Society, “Physician Workforce study:”
http://www.massmed.org/Content/NavigationMenu/NewsandPublications/ResearchReportsStudies/PhysicianWorkforceStudy/2007Workforce_ExecSummary.pdf

Private card, huge deductible? No way

Letter to the Editor
Atlanta Journal Constitution
07/08/07

Don’t be fooled by all the politicians claiming to support “universal” health care. If you read the fine print, most of their proposals dictate that everyone should buy a private health care card. What good is your card if it commits you to a $5,000 deductible and 50 percent co-pay before you receive any of your (limited) benefits?

We should reject a mandate that everyone must contribute to the coffers of the big insurance corporations. No, thanks. That sort of “universal” plan could mainly bankrupt the middle class and further enrich the private insurance manipulators.

We need a universal plan that is compassionate and sustainable. The clearest way is to eliminate the role of for-profit insurance companies. Having been practicing medicine for 35 years, after seeing “Sicko” I’m convinced we need — and will eventually demand — a single payer, universal, health insurance system.

Thanks, Michael Moore, for pointing the way.

HENRY S. KAHN
Kahn is emeritus professor of family and preventive medicine at Emory University School of Medicine.

UnitedHealth turns to public sector for profits

UnitedHealth Profit Rises on Government Medical Plans

By Avram Goldstein
Bloomberg.com
July 19,2007

UnitedHealth Group Inc., the largest U.S. health insurer, said profit rose 22 percent on gains from government-sponsored medical programs.

The costs of paying health claims from employer-sponsored plans rose to 81.8 percent of revenue, from 81.2 percent a year earlier. These expenses may offset the boon UnitedHealth has seen from increasing the profitability of its Medicare programs for the elderly and adding 290,000 members in state Medicaid programs for the poor in the 12 months through June 30.

Because commercial enrollment is unlikely to go up for the health insurance industry, the company is turning to publicly financed programs for growth, (Chief Executive Officer Stephen) Hemsley said.

“Some 100 million Americans are expected to participate in some government program by 2016, and we’re exceptionally well positioned to serve them,” he said.

Medicare Advantage was a “bright spot” for UnitedHealth in the quarter, said Carl McDonald, an analyst with CIBC World Markets in New York, in a note to clients today.

“This is likely a function of the benefit changes UnitedHealth made to its Medicare Advantage product this year, as it raised premiums, cut benefits and exited unprofitable counties,” McDonald said.

http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aPZqBSLNWSy8

Comment:

By Don McCanne, MD

Those who still insist that health care reform cannot be achieved without continuing to include private insurers should take a closer look at this report.

UnitedHealth, the largest private health insurer, is having problems servicing the private commercial market and so is turning to our publicly financed programs.

And what are they doing for patients in the publicly-funded Medicare Advantage program? They are increasing out-of-pocket spending through higher premiums, cutting benefits covered, and abandoning patients in less lucrative markets! And for this the Bush administration has granted them an extra subsidy over the costs in the traditional Medicare program.

Haven’t we been exposed to enough negative studies and reports on this parasitical industry? Have you seen ANY objective reports of redeeming values that would effectively offset the profound waste and gross injustices that this industry advances?

We really do have to rid ourselves of the private insurance industry if we honestly want to provide affordable, efficient, comprehensive coverage for everyone. But it looks like we’ll first have to rid ourselves of the policymakers who insist that political expediency mandates that we continue to support the private insurers in spite of their adverse impact on patients. Talk about Sicko!