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Remove health care from the cost of business

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Remove health care from the cost of business

By Ed Weisbart, M.D.
St. Louis Post-Dispatch, Letters, Oct. 12, 2015

Patriot Coal’s latest bankruptcy success once again draws attention to the desperate measures some employers take to unburden themselves from the financial burdens of employee health (editorial “Shafted,” Oct. 8).

No other modern nation inserts health care into the middle of labor contracts. American workers and businesses both suffer from this accident of history. Workers find their negotiated benefits under constant attack; businesses find the costs an unlevel playing field, driving them to avoid aged and unhealthy employees and still less able to compete with businesses based in countries that have developed more sensible systems.

The United Mine Workers would not need to fight for their right to health care if all Americans, mine workers and the rest of us, were included in a national health insurance program. We have a very popular model for this — Medicare. Beloved by seniors, its flaws could be readily improved (expand the benefit design to include things like dentistry and nutritional counseling; eliminate the financial barriers that have crept in). Expanding Medicare to all Americans would remove health care from the non-productive operating costs borne by American businesses, and introduce free market solutions to the delivery of health care.

Providing all Americans with an improved form of Medicare is the only solution that promises affordable access to the high quality of health care we like to think of as American. The mine workers deserve this; who among us does not?

Dr. Ed Weisbart resides in Olivette. He is chair of the Physicians for a National Health Program-Missouri chapter.

http://www.stltoday.com/news/opinion/mailbag/remove-health-care-from-the-cost-of-business/article_a723b4b4-4fb5-541f-9bb8-fc3f0413956e.html

It’s time to embrace single-payer system

By Andrew D. Coates, M.D.
Times Union (Albany, NY), Oct. 9, 2015

Why won’t “single payer” — the call for one public health insurance program to cover all necessary medical care for every person in the United States — go away? Wasn’t it dismissed already from the mainstream discourse?

Instead of vanishing from the public eye, “single payer” or “Medicare for All” has already entered the 2016 elections. The presidential campaign of Vermont’s longtime single-payer advocate, Sen. Bernie Sanders, deserves much of the credit.

But perhaps “Obamacare” is the larger factor. Although the Affordable Care Act reduced the number of uninsured, after the “overhaul,” health care in the U.S. today is even more about money and even less about the care of patients.

In our present moment, “post-reform,” rising deductibles, rising co-pays and onerous co-insurance costs have become “the usual.” Financial barriers to care are ubiquitous.

The Affordable Care Act did not regulate the rise of premiums. Nor did it prohibit the narrowing networks of providers, as so many plans do. Nor did the “reform” rein in skyrocketing drug prices.

Additionally, about 31 million people in our nation remain inadequately insured. Being “underinsured” is not the same as being uninsured. It is when one’s health insurance fails to protect the household finances in the face of illness.

As for the uninsured, the Census Bureau reports 33 million people lacked any coverage at all last year, a number that is roughly expected to persist for a decade.

By so many measures, Obama’s Affordable Care Act has failed as “reform.”

One of the nation’s top health care journalists, Ricardo Alonso-Zaldivar of The Associated Press, recently highlighted the emerging national discourse (“Again? Health care debate expands for 2016,” Oct. 5). He outlined three basic positions: those for single payer; those for “repeal and replace” (without a credible alternative); and those for maintaining the status quo.

He asked renowned Princeton historian of the American medical system, Paul Starr, to comment. Starr succinctly amplified what both mainstream Democrats and Republicans have been saying about single payer. “It’s a dead end,” Starr said, because its supporters “don’t face up to the significant tax changes that would be necessary.”

Will the old cry “No new taxes!” effectively bury single payer in the upcoming election season — even though a nonprofit, streamlined single-payer system would actually save our nation and people hundreds of billions of dollars annually?

The problem for the establishment is that the fundamental contradiction that drove the passage of the Affordable Care Act — that the wealthiest nation on Earth fails to guarantee health care to all of its inhabitants, that the health of the nation overall is mediocre on a world scale — still drives the American debate.

The health care needs of the American people have yet to become the central focus of our health system.

A meaningful health care overhaul for the United States would be a program that would cover everyone, eliminate profiteering, control costs, improve quality and outcomes, lessen disparities, protect caregiver-patient relationships and guarantee maximum choice of provider.

Single payer could do all of these things.

Under single payer, equitable, progressive taxes would replace premiums, co-pays, deductibles and out-of-pocket costs for necessary care.

One study found that as many as 95 percent of all U.S. households would save money under a single-payer program — after taking into account the “significant tax changes that would be necessary.”

The costs of health care are inescapable. In a democracy, the question should be how to share those costs and to pay for care in the fairest way, so that each person might gain the opportunity to be as healthy as possible.

Perhaps the idea of single payer won’t go away simply because it would work.

On this score, evidence from other nations leaves no doubt. As even Donald Trump quipped this summer: “As for single payer, it works in Canada, it works incredibly well in Scotland.”

It is time to for us to embrace solutions. Further debate will reveal the need for action. We need single payer now.

Dr. Andy Coates of Delmar is immediate past president of Physicians for a National Health Program, chief of hospital medicine at Samaritan Hospital in Troy, and clinical assistant professor of medicine at Albany Medical College.

http://www.timesunion.com/tuplus-opinion/article/It-s-time-to-embrace-single-payer-system-6562071.php

Physician concentration drives up prices

Less Physician Practice Competition Is Associated With Higher Prices Paid For Common Procedures

By Daniel R. Austin and Laurence C. Baker
Health Affairs, October 2015

Abstract

Concentration among physician groups has been steadily increasing, which may affect prices for physician services. We assessed the relationship in 2010 between physician competition and prices paid by private preferred provider organizations for fifteen common, high-cost procedures to understand whether higher concentration of physician practices and accompanying increased market power were associated with higher prices for services. Using county-level measures of the concentration of physician practices and county average prices, and statistically controlling for a range of other regional characteristics, we found that physician practice concentration and prices were significantly associated for twelve of the fifteen procedures we studied. For these procedures, counties with the highest average physician concentrations had prices 8–26 percent higher than prices in the lowest counties. We concluded that physician competition is frequently associated with prices. Policies that would influence physician practice organization should take this into consideration.

Conclusion

The existence of an association between concentration and prices should underscore the importance of continued attention to the challenges posed by provider consolidation, especially given that consolidation among physician groups is likely to continue. Increased health care expenditures attributable to higher prices without improved outcomes for patients would generate inefficiency in the US health care system at a time when the opposite is badly needed. Policies that balance any benefits of larger organizations with the potential for problematic price increases, possibly including appropriate antitrust oversight, are needed as the country seeks to ensure efficient, high-quality patient care.

http://content.healthaffairs.org/content/34/10/1753.abstract

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Comment:

By Don McCanne, MD

Consolidation of physician practices has been promoted as a means of improving efficiency and quality of care by means of integrating health care services. But this has raised the concern that concentration is anticompetitive and thus may result in higher health care prices. This study looks at that possibility.

Although outrage is often expressed at some of the very high prices that physicians charge for procedures, those prices are rarely paid since Medicare and Medicaid dictate the actual amount they pay, and private insurers contract for allowable charges for their network providers. Only patients who are uninsured or who are using out-of-network providers face the full charges, but, even then, lower prices are often negotiated on an individual basis, or sometimes the patient simply defaults on the bill. So in considering health care costs in general, it is the authorized payments that count and not the list prices.

This study, in fact, confirmed that where physician practices are more concentrated, prices insurers paid for health care are higher. So physician concentration is anticompetitive and results in higher payments. But are physicians the bad guys who are making us pay more for health care than we should be?

Looking closer at this study, the prices analyzed were those paid to in-network physicians in preferred provider organizations (PPOs) representing larger employers. This is where insurers should be able to deliver on their promises of lower prices. By representing larger employers, the insurers contracting with the physicians who would be included in the networks should be able to extract from them their most competitive prices.

But that didn’t happen. The insurers were not able to drive a better bargain in markets with physician concentration. Physicians in less concentrated markets were able to provide their services for lower prices, so that means that insurers actually were paying excessive prices in the concentrated markets.

Some say that the costs of large integrated systems are higher, so the prices had to be higher. But this belies the claim that integration of services increases efficiency, thereby reducing prices. What this actually shows is that the PPOs were not as effective negotiators when faced with provider concentration.

Compare that with the publicly-administered pricing that takes place in a single payer national health program. The amount paid is based on actual costs with fair margins, not on whatever the market will bear. What we don’t need are wimpish insurers who charge us outrageous administrative fees for a job they don’t even do well. Let’s get rid of them.

More on high health spending and poor population health in U.S.

U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries

By David Squires, Chloe Anderson
The Commonwealth Fund, October 8, 2015

This analysis draws upon data from the Organization for Economic Cooperation and Development and other cross-national analyses to compare health care spending, supply, utilization, prices, and health outcomes across 13 high-income countries: Australia, Canada, Denmark, France, Germany, Japan, Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.

Key Findings:

  • The United States is the highest spender on health care.

Data from the OECD show that the U.S. spent 17.1 percent of its gross domestic product (GDP) on health care in 2013. This was almost 50 percent more than the next-highest spender (France, 11.6% of GDP) and almost double what was spent in the U.K. (8.8%). U.S. spending per person was equivalent to $9,086 (not adjusted for inflation).

  • Private spending on health care is highest in the U.S.

 In 2013, the average U.S. resident spent $1,074 out-of-pocket on health care, for things like copayments for doctor’s office visits and prescription drugs and health insurance deductibles. Only the Swiss spent more at $1,630, while France and the Netherlands spent less than one-fourth as much ($277 and $270, respectively). As for other private health spending, including on private insurance premiums, U.S. spending towered over that of the other countries at $3,442 per capita—more than five times what was spent in Canada ($654), the second-highest spending country.

  • U.S. public spending on health care is high, despite covering fewer residents.

Public spending on health care amounted to $4,197 per capita in the U.S. in 2013, more than in any other country except Norway ($4,981) and the Netherlands ($4,495), despite the fact that the U.S. was the only country studied that did not have a universal health care system. In the U.S., about 34 percent of residents were covered by public programs in 2013, including Medicare and Medicaid.7 By comparison, every resident in the United Kingdom is covered by the public system and spending was $2,802 per capita. Public spending on health care would be even greater in the U.S. if the tax exclusion for employer-sponsored health insurance (amounting to about $250 billion each year) was counted as a public expenditure.

  • Despite spending more on health care, Americans have fewer hospital and physician visits.

The U.S. had fewer practicing physicians in 2013 than in the median OECD country (2.6 versus 3.2 physicians per 1,000 population). With only four per year, Americans also had fewer physician visits than the OECD median (6.5 visits). In the U.S., there were also fewer hospital beds and fewer discharges per capita than in the median OECD country.

  • Americans appear to be greater consumers of medical technology, including diagnostic imaging and pharmaceuticals.

The U.S. stood out as a top consumer of sophisticated diagnostic imaging technology. Americans had the highest per capita rates of MRI, computed tomography (CT), and positron emission tomography (PET) exams among the countries where data were available. In addition, Americans were top consumers of prescription drugs.

  • Health care prices are higher in the U.S. compared with other countries.

Data published by the International Federation of Health Plans suggest that hospital and physician prices for procedures were highest in the U.S. in 2013. Other studies have observed high U.S. prices for pharmaceuticals.

  • The U.S. invests the smallest share of its economy on social services.

A 2013 study by Bradley and Taylor found that the U.S. spent the least on social services—such as retirement and disability benefits, employment programs, and supportive housing—among the countries studied in this report, at just 9 percent of GDP.12 Canada, Australia and New Zealand had similarly low rates of spending, while France, Sweden, Switzerland, and Germany devoted roughly twice as large a share of their economy to social services as did the U.S.

The U.S. was also the only country studied where health care spending accounted for a greater share of GDP than social services spending. In aggregate, U.S. health and social services spending rank near the middle of the pack.

  • Despite its high spending on health care, the U.S. has poor population health.

On several measures of population health, Americans had worse outcomes than their international peers. The U.S. had the lowest life expectancy at birth of the countries studied, at 78.8 years in 2013, compared with the OECD median of 81.2 years. Additionally, the U.S. had the highest infant mortality rate among the countries studied, at 6.1 deaths per 1,000 live births in 2011; the rate in the OECD median country was 3.5 deaths. The prevalence of chronic diseases also appeared to be higher in the U.S.

A 2013 report from the Institute of Medicine reviewed the literature about the health disadvantages of Americans relative to residents of other high-income countries. It found the U.S. performed poorly on several important determinants of health. The Institute of Medicine found that poorer health in the U.S. was not simply the result of economic, social, or racial and ethnic disadvantages—even well-off, nonsmoking, nonobese Americans appear in worse health than their counterparts abroad.

  • The U.S. performs well on cancer care but has high rates of mortality from heart disease and amputations as a result of diabetes

One area where the U.S. appeared to have comparatively good health outcomes was cancer care. The opposite trend appears for ischemic heart disease, where the U.S. had among the highest mortality rates in 2013—128 per 100,000 population compared with 95 in the median OECD country. The U.S. also had high rates of adverse outcomes from diabetes, with 17.1 lower extremity amputations per 100,000 population in 2011. Rates in Sweden, Australia and the U.K. were less than one-third as high.

From the Discussion

Health care spending in the U.S. far exceeds that in other countries, despite a global slowdown in spending growth in recent years. At 17.1 percent of GDP, the U.S. devotes at least 50 percent more of its economy to health care than do other countries. Even public spending on health care, on a per capita basis, is higher in the U.S. than in most other countries with universal public coverage.

How can we explain the higher U.S. spending? In line with previous studies, the results of this analysis suggest that the excess is likely driven by greater utilization of medical technology and higher prices, rather than use of routine services, such as more frequent visits to physicians and hospitals.

High health care spending has far-reaching consequences in the U.S. economy, contributing to wage stagnation, personal bankruptcy, and budget deficits, and creating a competitive disadvantage relative to other nations. One potential consequence of high health spending is that it may crowd out other forms of social spending that support health. In the U.S., health care spending substantially outweighs spending on social services. This imbalance may contribute to the country’s poor health outcomes. A growing body of evidence suggests that social services play an important role in shaping health trajectories and mitigating health disparities.

Exhibit 8. Health and social care spending as a percentage of GDP

(The first number is the percent of GDP spent on health care, the second is the percent spent on social care, and the third is the percent spent on both combined)

12  21  33  France
12  21  33  Sweden
11  20  31  Switzerland
11  18  29  Germany
12  15  27  Netherlands
16  09  25  United States
09  16  25  Norway
08  15  23  United Kingdom
09  11  20  New Zealand
10  10  20  Canada
09  11  20  Australia

http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective

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Comment:

By Don McCanne, MD

This update, comparing us with 13 high-income countries, confirms that we still spend far more than any other nation on health care, partly because of our very high prices, even though we are not using more health care.  Worse, in spite of our high levels of spending, our population health remains relatively poor.

One exhibit in this report shows that our combined spending on health care and on social care (retirement and disability benefits, employment programs, and supportive housing) is about average (see Exhibit 8, above). Considering that our health care spending is so high, it may be that the comparatively low spending on social services is a significant contributor to our poor population health.

We do need to improve the way we spend our health care dollars so that everyone has affordable access to high quality care, and a single payer system would do that. However, since we are a very wealthy nation, we should be able to increase spending on social services as well. The progressive taxes required to do that would also help to address our crisis in income inequality.

Maine Doctors Support Single Payer

By Julie Keller Pease, M.D.
The Times Record (Brunswick, Maine), Letters, Oct. 7, 2015

I was interested to read the article in Friday’s Times Record about the “Broader health care debate for 2016.” Giving prominence to “single payer” makes sense because only a single-payer plan can cover everyone for all medically necessary care, eliminate financial barriers to care, and allow free choice of doctor and hospital. Single payer healthcare would also control costs. Noted healthcare economist Dr. William Hsiao, when he visited Maine in 2010, estimated that if Maine moved to a single-payer system of health care, the state would save $1 billion during the first year alone.

Currently, the criticism of single payer (mentioned in the article) is that it would require a tax increase. In his fiscal study of H.R. 676, “The Expanded and Improved Medicare for All Act,” economist Dr. Gerald Friedman estimated that 95 percent of all households would actually SAVE money. This is because any increase in taxes would be more than offset by a massive decrease in insurance premiums and out-of-pocket expenses. Further, a streamlined single-payer system would reap about $400 billion annually in savings by slashing wasteful administrative costs, the government would be able to use its negotiating clout to bargain for lower drug and medical supply prices and it would be allowed to take other proven measures to save money.

Maine doctors support single payer. In January 2014, 450 Maine physicians responded to a survey question from the Maine Medical Association: “When considering the topic of health care reform, would you prefer to make improvements to the current public/private system or a single-payer system such as a ‘Medicare for all’ approach’? Nearly 65 percent of Maine doctors preferred the single-payer option, a jump from about 52 percent in a 2008 MMA survey that asked the identical question.

If you’re interested in learning more about health care for all, I urge you to visit the websites of Physicians for a National Health Program (www.pnhp.org) and Maine AllCare (www.maineallcare.org). Please join us in our advocacy for health care for everyone in Maine.

Dr. Julie Keller Pease resides in Brunswick.

http://www.timesrecord.com/news/2015-10-07/Opinion/Maine_Doctors_Support_Singlepayer.html

What lessons can we learn from Europe’s health insurance exchanges?

Risk Selection Threatens Quality Of Care For Certain Patients: Lessons From Europe’s Health Insurance Exchanges

By Wynand P. M. M. van de Ven, Richard C. van Kleef and Rene C. J. A. van Vliet
Health Affairs, October 2015

Abstract

Experience in European health insurance exchanges indicates that even with the best risk-adjustment formulas, insurers have substantial incentives to engage in risk selection. The potentially most worrisome form of risk selection is skimping on the quality of care for underpriced high-cost patients—that is, patients for whom insurers are compensated at a rate lower than the predicted health care expenses of these patients. In this article we draw lessons for the United States from twenty years of experience with health insurance exchanges in Europe, where risk selection is a serious problem. Mistakes by European legislators and inadequate evaluation criteria for risk selection incentives are discussed, as well as strategies to reduce risk selection and the complex trade-off among selection (through quality skimping), efficiency, and affordability. Recommended improvements to the risk-adjustment process in the United States include considering the adoption of risk adjusters used in Europe, investing in the collection of data, using a permanent form of risk sharing, and replacing the current premium “band” restrictions with more flexible restrictions. Policy makers need to understand the complexities of regulating competitive health insurance markets and to prevent risk selection that threatens the provision of good-quality care for underpriced high-cost patients.

Lessons from Europe:

Risk Selection Is A Serious Problem

Examples of selection activities include offering health plans attuned to the preferences of the under- and overpriced insured, opening clinics in regions with healthy populations, closing offices in areas with underpriced high-cost populations, selective marketing to preferred groups, the use of group contracts, and selection of favorable applicants by insurance agents.

The situation is more critical in the United States than in Europe in the short run, because in the United States there are many competing managed care organizations that deliver care themselves and therefore, compared to European insurers, have much more effective and subtle tools to use to distort the level of quality of care. In addition, for-profit insurers in the United States have extensive experience with risk selection.

Risk Adjustment Should Be Improved

Because risk adjusters ideally should fulfill criteria such as appropriateness of incentives, fairness, and feasibility, adding new risk adjusters may involve trade-offs. For example, using a patient’s health care expenses in the previous year as a risk adjuster effectively reduces selection by insurers, but it also reduces the insurers’ incentives for efficiency.

The United States might consider adopting the following risk adjusters that are currently used in Europe: disability, pharmacy-based cost groups, previous use of durable medical equipment, and high costs from multiple prior years.

Invest In Collecting Data

Another lesson for US policy makers is that it is worthwhile to invest in collecting appropriate data. Several of the risk adjusters currently used in Europe required many years of investment in building up appropriate data systems.

Risk Sharing Is An Effective Strategy

Given imperfect risk adjustment, which seems inevitable to a certain extent, an effective strategy for reducing selection incentives is risk sharing. There are several forms of risk sharing. One form is mandatory risk sharing among insurers, which is sometimes referred to as mandatory reinsurance with a community-rated reinsurance premium. Another form is risk sharing between the regulator and the insurers — for example, when a regulator provides cost-based compensations to the insurers for high-cost patients. Because risk sharing also reduces an insurer’s incentive for efficiency, it confronts the regulator with a trade-off between selection and efficiency.

Adopt A Generic Premium Rate Band

Another effective strategy for US policy makers to use in reducing risk selection is to allow insurers to charge their enrollees, within a band or range of acceptable charges, risk-adjusted health insurance premium rates. As a result, the information surplus about enrollees that insurers have over the regulator might be focused on premium rate variation rather than on risk selection.

Understand The Complexities

An important lesson from European experience with health exchanges is that there are no easy solutions and that regulating competitive health insurance markets involves complex trade-offs among selection (through quality skimping), efficiency, and affordability. Another lesson from Europe is that legislators and policy makers can easily make serious mistakes and be misled by incorrect arguments.

http://content.healthaffairs.org/content/34/10/1713.abstract

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Risk Selection Threatens Quality of Care for Certain Patients: Lessons from Europe’s Health Insurance Exchanges

The Commonwealth Fund, October 6, 2015

The Issue

Beginning in the early 1990s, several European countries, along with Israel, established health insurance exchanges similar to those launched in the U.S. as part of the ACA. For a Commonwealth Fund–supported study in Health Affairs, researchers gleaned lessons from those countries on how to reduce incentives to engage in risk selection. Insurers can engage in risk selection by steering away high-risk patients in a variety of ways, including purposefully contracting with doctors or hospitals that offer mediocre or substandard care or excluding providers with the best reputations for treating certain diseases.

The Big Picture

Risk selection may be a more critical issue in the U.S. over the short run. “[I]n the United States there are many competing managed care organizations that deliver care themselves and therefore, compared to European insurers, have much more effective and subtle tools to use to distort the level of quality of care,” the authors write. U.S. insurers also are experienced at identifying medical risk and may use the information at their disposal to design products that are unattractive to high-risk patients—including those with cancer and substance abuse disorders. The high number of consumers choosing health plans in the insurance exchanges may exacerbate the problem. Solving these vexing issues, the authors say, must be made a priority to prevent sick patients from receiving poorer-quality services or reduced access to care.

http://www.commonwealthfund.org/publications/in-the-literature/2015/oct/risk-selection-threatens-quality-of-care

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Comment:

By Don McCanne, MD

This report, supported by the Commonwealth Fund and published in Health Affairs, looks at European nations that use variations of market exchanges of private insurance plans (Belgium, Germany, Ireland, Switzerland and, especially, the Netherlands) to see what lessons on risk selection they may have for the United States. But are these the right lessons for us?

Private insurers in the United States have long been masters at figuring out ways of insuring the healthy, with their relatively low health care costs, while avoiding insuring individuals with greater health care needs. Although the Affordable Care Act prohibits insurers from refusing to cover individuals anticipated to have higher health care costs, we are seeing insurance innovations in gaming risk selection that substitute for medical underwriting, which sometimes still prevents patients from receiving the care that they should have.

The multi-payer system in the United States is infamous for the very high costs of the wasteful administrative excesses in our health care financing. In fact, some of these excesses are for the very purpose of ensuring the business success of the private insurers. So what efficiencies do the European systems that use marketplace exchanges of private plans have that might help the United States avoid the perversities of favorable risk selection on the part of the insurers?

The authors suggest the introduction of additional risk adjusters (more administration), systems to collect yet more data (more administration), introduction of risk-sharing strategies such as mandatory community-rated reinsurance or risk sharing between the regulator and the insurers (more administration), allowing insurers to charge their enrollees, within a band or range of acceptable charges, risk-adjusted health insurance premium rates (more administration), and balancing trade-offs of quality-skimping selection, efficiency, and affordability (more administration).

Not only would these “lessons” expand the administrative excesses of our system, but because of the trade-offs involved, further compromises in quality and equity would result. No matter what strategies are used, the private insurers will always find a way around them. That is inherent in their business-model DNA.

Instead of us looking for lessons in the European private insurance markets, it seems that these European nations should be looking for lessons from our neighbor to the North: Canada and its single payer model of health care financing. We would do well to do the same.

High-cost patients exit private Medicare Advantage plans

High-Cost Patients Had Substantial Rates Of Leaving Medicare Advantage And Joining Traditional Medicare

By Momotazur Rahman, Laura Keohane, Amal N. Trivedi and Vincent Mor
Health Affairs, October 2015

Abstract

Medicare Advantage payment regulations include risk-adjusted capitated reimbursement, which was implemented to discourage favorable risk selection and encourage the retention of members who incur high costs. However, the extent to which risk-adjusted capitation has succeeded is not clear, especially for members using high-cost services not previously considered in assessments of risk selection. We examined the rates at which participants who used three high-cost services switched between Medicare Advantage and traditional Medicare. We found that the switching rate from 2010 to 2011 away from Medicare Advantage and to traditional Medicare exceeded the switching rate in the opposite direction for participants who used long-term nursing home care (17 percent versus 3 percent), short-term nursing home care (9 percent versus 4 percent), and home health care (8 percent versus 3 percent). These results were magnified among people who were enrolled in both Medicare and Medicaid. Our findings raise questions about the role of Medicare Advantage plans in serving high-cost patients with complex care needs, who account for a disproportionately high amount of total health care spending.

From the Introduction

Each year Medicare beneficiaries can choose between two options for health coverage: traditional Medicare and Medicare Advantage. Although each option covers the same core set of benefits, the two may differ in terms of beneficiaries’ out-of-pocket expenses, choice of providers, and access to additional services. Approximately 30 percent of Medicare beneficiaries in 2014 were enrolled in Medicare Advantage plans.

Because Medicare Advantage plans receive prospective, capitated payments to finance and deliver services for their enrollees, they operate under strong incentives to manage their members’ health care costs. Policy makers have been concerned that capitated payments give Medicare Advantage plans an incentive to enroll healthier beneficiaries and to avoid enrolling those with chronic conditions. Indeed, a large body of literature based on data from the 1990s and early 2000s found that Medicare Advantage plans disproportionately enrolled healthier beneficiaries. This phenomenon, known as favorable risk selection, has historically yielded substantial overpayments to Medicare Advantage plans.

From the Discussion

We examined the relationship between use of hospital, nursing home, and home health care in 2010 and beneficiaries’ switching between Medicare Advantage and traditional Medicare by January 2011. Among traditional Medicare beneficiaries, we observed lower rates of switching into Medicare Advantage among people who used nursing home, home health, or acute inpatient care, compared with beneficiaries who did not use these services. In contrast, among Medicare Advantage beneficiaries, we found increased rates of switching into traditional Medicare among people who used nursing home and home health care, compared with beneficiaries who did not use these services.

Our results are consistent with other studies reporting that beneficiaries who report poorer health, use more health services, and have higher health care spending are more likely than their counterpart Medicare Advantage beneficiaries to leave Medicare Advantage plans, despite the recent reforms to the Medicare Advantage payment formula.

Our results raise questions about whether current Medicare Advantage regulations and payment formulas are designed to meet the needs of Medicare Advantage members who use postacute and long-term care. First, the enhanced payments to Medicare Advantage plans for dual eligibles or people who receive extended nursing home care do not appear to be effective in retaining these beneficiaries in Medicare Advantage plans. The unidirectional flow of these high-risk and often high-spending patients from Medicare Advantage to traditional Medicare appears to transfer responsibility to traditional Medicare just as patients enter a period of intensive health care needs.

There could be several reasons for the switching of high-risk Medicare Advantage enrollees. One possibility is that Medicare Advantage plans may not have sufficient incentives to spend their enhanced payments on better services for their beneficiaries.

Second, our findings suggest that Medicare Advantage members who use home health or nursing home services might be dissatisfied with the Medicare Advantage program. Medicare Advantage beneficiaries may find that their plans’ network restrictions make it harder to access these services that would be the case in traditional Medicare, creating an incentive to switch.

Additionally, some Medicare Advantage plans have been criticized for imposing high cost sharing for services such as the skilled nursing facility care that can be necessary for seriously ill beneficiaries.

Conclusion

We observed substantial switching from Medicare Advantage to traditional Medicare by beneficiaries who used nursing home and home health care, particularly those who were also eligible for Medicaid, and virtually no entry into Medicare Advantage plans by traditional Medicare beneficiaries who used these services or acquired dual eligibility. We found that a high proportion of beneficiaries with nursing home or home health care use choose to exit the Medicare Advantage program by the start of the next plan year. Thus, our study raises questions about the role of Medicare Advantage plans in serving high-cost patients with complex health care needs that span acute, postacute, and long-term care settings.

http://content.healthaffairs.org/content/34/10/1675.abstract

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The Medicare-HMO Revolving Door — The Healthy Go in and the Sick Go Out

By Robert O. Morgan, Ph.D., Beth A. Virnig, Ph.D., M.P.H., Carolee A. DeVito, Ph.D., M.P.H., and Nancy A. Persily, M.P.H.
The New England Journal of Medicine, July 17, 1997

Enrollment in Medicare health maintenance organizations (HMOs) is encouraged because of the expectation that HMOs can help slow the growth of Medicare costs.

Results

The rate of use of inpatient services in the HMO-enrollment group during the year before enrollment was 66 percent of the rate in the fee-for-service group, whereas the rate in the HMO-disenrollment group after disenrollment was 180 percent of that in the fee-for-service group.

http://www.nejm.org/doi/full/10.1056/NEJM199707173370306

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Comment:

By Don McCanne, MD

In 1997, The New England Journal of Medicine published a landmark article that showed that Medicare patients who enrolled in private Medicare HMOs exited them when they developed a need for a greater amount of health care: “The Medicare-HMO Revolving Door — The Healthy Go in and the Sick Go Out”

After nearly two decades of refinement of payment methods for the private Medicare Advantage plans, this new study from Health Affairs shows that “a high proportion of beneficiaries with nursing home or home health care use choose to exit the Medicare Advantage program.” Specifically, “Our results are consistent with other studies reporting that beneficiaries who report poorer health, use more health services, and have higher health care spending are more likely than their counterpart Medicare Advantage beneficiaries to leave Medicare Advantage plans, despite the recent reforms to the Medicare Advantage payment formula.”

The healthy go in and the sick go out. With Medicare Advantage plans, the patients and the taxpayers end up as losers.

Not Much to Show for Nation’s High Cost of Care

System must change dramatically to improve outcomes, physician says

By Caroline Poplin, M.D., J.D.
MedPage Today, Sept. 28, 2015

For the last 30 years or so, Americans have pondered the U.S. healthcare cost conundrum: all other developed countries spend significantly less than we do on healthcare — whether that’s measured as a percentage of Gross Domestic Product or per capita — yet achieve better outcomes and cover all their residents. What is our problem?

As readers know, one needs a correct diagnosis to achieve a successful treatment.

In recent years, U.S. health policy experts have advanced a novel explanation: our over-generous insurance plans, our fee-for-service reimbursement system, and our failure to manage healthcare providers all generate huge waste — up to 30% of total spending — mostly in overutilization of services that are of low value, or no value, to anyone.

For example, classical economics predicts that if a product is free at the point of service, consumers will demand an unlimited amount. (Of course, even fully insured patients don’t regard healthcare as exactly free — they have already paid substantial premiums, and may wish to get something for their money besides peace of mind.)

Nevertheless, analysts on both sides of the political spectrum insist that “healthcare consumers” — that is, patients — need more “skin in the game” at the point of service — hence policy leaders firmly oppose “first-dollar” coverage, Medigap plans (they cover co-pays and deductibles for Medicare beneficiaries who purchase them), and so-called “Cadillac” employer-sponsored insurance plans, which under the Affordable Care Act (ACA) will be taxed at 40% starting in 2018.

With their own money at risk, the theory goes, patients will request only truly valuable services, and will shop for the best price — just like buying a car.

On the supply side, policymakers call for radical reform of the reimbursement and delivery of healthcare. Reformers believe that fee-for-service reimbursement encourages doctors and hospitals to maximize the volume of services. Instead, they should be paid only for “value.” Ideally, payers should pay providers “capitated” fees — a fixed fee (maybe risk-adjusted) for each patient to cover the cost of his or her care — which will force providers to practice with maximum efficiency.

The great appeal of this approach is that less care is better care: reducing care generates great outcomes while simultaneously lowering costs. Note that American analysts rarely mention price: they assume that market competition will drive down prices, or that fewer services will reduce overall cost even if prices stay the same.

Reformers wasted no time putting their theories into practice: both Medicare and the ACA authorize pilot projects based on this novel, market-based theory.

So far, results have been mixed: some improvement in selected “quality” measures, less success on reducing cost. This should not come as a surprise. While American reform theory may be elegant, its underpinnings are weak.

For example, a 2012 comparative study by the Commonwealth Fund raised serious questions about the overutilization hypothesis: the fund found that the U.S. “ranked at the bottom for the number of [per capita] doctor consultations … had shorter hospital stays,” and “a smaller number of hospital beds.”

Nor do increased out-of-pocket costs to patients selectively reduce their use of low-value services. In fact, a classic RAND study in 1982 demonstrated that when costs go up, consumers cut back on all medical services, valuable and wasteful alike. (This is not a problem for insurers, of course.)

Finally, competition rarely reduces the price of healthcare services or health insurance in the U.S.

In general, competition only drives prices down to marginal cost under specific conditions: there are so many suppliers and consumers that no one can affect price; consumers can easily switch from one supplier to another; everyone has complete information; and the product is fungible (all the same — think gasoline) or easily compared (groceries).

In many parts of the U.S., however, healthcare markets are limited (only one or two hospitals), or health insurance markets are limited, or both. Products are complex and difficult to compare. There may be competition, but it is usually on “quality,” not price. Indeed, patients often pay different prices for the same service, based on their insurance plans. And the situation is only getting worse as mergers among large health insurers and hospital chains increase consolidation in both markets.

American health costs are high because the for-profit system has only driven prices higher: radically restructuring healthcare delivery and reimbursement is unlikely to change that. Indeed, one could argue that the U.S. healthcare community favors the new theory precisely because it allows prices — and profits — to stay high.

Other developed countries fare better than we do because they keep healthcare prices reasonable, by regulation or negotiation. Insurance is public, non-profit, or tightly regulated. Insurance benefits are comprehensive and largely standardized, reducing transaction costs and confusion, while ensuring necessary care. Meanwhile, reimbursement remains mostly fee-for-service, and healthcare delivery remains decentralized.

We can’t achieve European results without European methods. We should build on traditional Medicare, which currently regulates fees for doctors and hospitals. Congress should authorize the Centers for Medicare and Medicaid Services to negotiate prices for drugs and other medical services, and then gradually extend Medicare to younger Americans.

Indeed, if we believe that all Americans should receive adequate healthcare, “Medicare for all” may be the only system we can afford.

Caroline Poplin, M.D., J.D., is an attorney and internist in Bethesda, Md. She is a former staff internist for the National Naval Medical Center, and currently practices medicine part-time at the Arlington Free Clinic in Virginia. She also consults for law firms on Medicare and Medicaid fraud.

http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/53745

Need a real discussion on humane, cost-effective health care system

By William M. Fogarty Jr., M.D.
St. Louis Post-Dispatch, Letters, Oct. 6, 2015

In his article (“Again? Health Care Debate Expands for 2016,” online Oct. 2) Ricardo Alonso-Zaldivar outlines the three approaches that the various candidates for the presidential nomination offer on health care. They range from the single-payer approach espoused by Bernie Sanders, through the middle ground basically supporting the status quo offered by Hillary Clinton, to the “repeal and replace” position of the Republican contenders. Unfortunately, the Republicans offer no details of their replacement and also attack Medicare and Medicaid, which serve some 100 million Americans, without offering a viable alternative.

The writer states that the single-payer option would call for “a massive tax increase” not allowing for the fact that that increase would be more than offset by replacing the premiums now paid to insurance companies and the $400 billion that would be saved in administrative costs and insurance company profits, not to mention the savings in drug and device costs that would result from competitive purchasing.

Hopefully, we will move beyond the circus we are now enduring in the Republican primary run-up to a real discussion of the issues important to this country. Among those is how we are going to craft a humane, cost-effective, high-quality heath care system that serves everyone. Among the options being discussed, the single-payer system is the only one with the potential to fulfill that goal.

Dr. William M. Fogarty Jr. resides in Webster Groves.

http://www.stltoday.com/news/opinion/mailbag/need-a-real-discussion-on-humane-cost-effective-health-care/article_c0017049-ab9c-56fb-9514-238d4e4e37d7.html

Risk corridor stabilization fund – another ACA failure

Big shortfall in Obamacare risk program could hurt insurers

By Tami Luhby
CNN Money, October 2, 2015

A key federal program designed to cushion health insurers’ risks in the Obamacare exchanges has a massive shortfall, which could throw some insurers into financial turmoil.

Insurers requested $2.87 billion in so-called “risk corridors” payments for 2014, but will only receive $362 million, or 12.6%, said the Centers for Medicare & Medicaid Services, which oversees Obamacare.

The risk corridors program’s goal is to help insurers transition into the individual exchanges, which opened in 2014. Insurers had a tough time setting premiums since they didn’t know how sick their new customers would be.

Under the three-year program, insurers whose premiums exceeded claims pay into the fund, while their peers who didn’t charge enough premiums to cover claims could draw from it.

But too many insurers miscalculated when they set their rates for 2014.

“Insurers underestimated the riskiness of their customer base and set their premiums too low,” said Tim Jost, a health law professor at Washington and Lee University School of Law.

The shortfall could put a financial strain on some insurers, especially some smaller ones who were counting on the funds. Some firms have reported losses in their Obamacare line of business, while four health insurance cooperatives are shutting down because of financial pressures.

Obamacare insurers have already set their premiums for 2016 and can’t adjust them now. The shortfall in risk corridor payments could prompt insurers to raise premiums in future years or exit the program.

The administration said the remaining 2014 risk corridor claims will be paid out of the 2015 and, if needed, the 2016 collections.

Insurers are still getting billions from two other Obamacare risk programs. They will receive $7.9 billion from the reinsurance program, designed to spread the cost of very large insurance claims across all insurers. And they will receive $4.6 billion from the risk adjustment program, which requires insurance companies with healthier consumers in a state to help offset some of the costs of those insurance companies with sicker customers in that state.

http://money.cnn.com/2015/10/02/news/economy/obamacare-insurers/index.html

***

Health Policy Briefs

Health Affairs, February 19, 2015

With the new restrictions on premium setting and the unpredictability of medical expenses from the newly insured, insurers faced a high level of uncertainty when setting their premiums. To buffer insurers from high losses in the initial years, keep premiums affordable, encourage insurers to participate in the Marketplaces, and minimize year-to-year premium fluctuations, the ACA authorized three premium stabilization programs: risk adjustment, reinsurance, and risk corridors.

The risk corridor program has proven to be one of the more controversial aspects of the ACA with critics, including a number of Republicans in Congress, characterizing the program as an insurer bailout. They argue that as a result of HHS and state officials putting pressure on insurers to keep premiums low in the Marketplaces, the federal government will end up picking up the tab to bail out insurers if they underpriced.

Critics also claim that the program encourages insurers to underprice their plans in order to gain market share, knowing the government will offset their losses.

While the Consolidated and Further Continuing Appropriations Act of 2015, which funded the government for the 2015 fiscal year, did give HHS the authority to collect user fees, an amendment was included that specifically prohibited HHS from transferring money from either trust fund. The amendment did not eliminate the risk corridor program, nor did it prevent HHS from using payments received from insurers to pay out claims under the program (that is, user fees), but it effectively made the risk corridor program budget neutral unless HHS can find another source of funding.

If risk corridor claims exceed receivables and HHS does not find an alternative source of funding, it seems likely it will revert to its earlier proposal to prioritize paying off shortfalls from previous years before making new payments. If the shortfalls were great enough, this could effectively eliminate payments to insurers for the final two years of the program.

http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=134

***

Comment:

By Don McCanne, MD

Although the media are covering this story as a shortfall in the risk corridor stabilization funds, the real story here is about the behavior of private insurers competing in the insurance exchanges established under the Affordable Care Act (ACA). An explanation is in order.

So what are the risk corridors and why do they exist? It was understood that insurers could be exposed to significant losses if they attracted more than an expected number of enrollees who had greater health care costs. So for the first three years, a portion of losses above a certain threshold (the upper margin of the corridor) would be covered by a stabilization fund. Likewise, if the insurers were successful in enrolling more individuals with very low health care costs (below the lower margin of the corridor), those insurers would be required to pay a portion of their net gain into the stabilization fund (“user fees”).

So how would private insurers respond? For the first year of marketing plans on the exchanges, they would want to have lower, competitive premiums in order to corner market share. Their losses for high cost enrollees would be largely covered (up to 80%) so they could accept some losses for those with average health care needs, knowing that they could later adjust fees modestly upwards after having gained market dominance (a version of the insurance underwriting cycle). As would be expected of the private insurers who are masters at gamesmanship, they were able to show that not many of their enrollees fell under the lower margin of the corridor, thus their payments to the stabilization fund (user fees) were kept to a minimum.

As a result, the stabilization fund is able to cover only about 13% of of the losses above the upper margin of the corridor. Although HHS says that they would find the funds, Congress has created barriers to using funds other than the user fees authorized by the risk corridor stabilization program. Since they are budgeting 2015 and 2016 user fees to pay for 2014 losses, obviously the funds will be rapidly depleted, with little or none available for the second and third years of the program.

Risk corridors, risk adjustment, and reinsurance are not for the benefit of patients, rather they are to protect the insurers. Not only do they add to our profound administrative waste, they also open up opportunities for insurers to profit even more through chicanery and gamesmanship.

We could completely do away with this and all of the other insurer excesses by simply enacting a single payer national health program. Why not now? Are not the voters in charge?

Time for single-payer health care

By Katie Myers
The Albuquerque Journal, Oct. 4, 2015

When I decided that I was going to be a doctor, I had many preconceived notions about what that meant.

I pictured myself coming upon a mass casualty accident and saving everyone’s lives single-handedly. I thought that I would make a difference every day by curing people’s ailments.

Obviously, I realize now, that saving everyone in a mass casualty accident is a bit grandiose, and as I progress further in my education I have come to the harsh realization that making a difference is often going to be out of my hands as a physician due to our current health care system.

The system is funded by more than 17 percent of our GDP – more than any other nation in the world – and it still leaves 29 million people in America uninsured.

This does not include the 31 million Americans that are underinsured, meaning that they pay over 10 percent of their household income on out-of-pocket medical expenses, even though they have insurance. And that doesn’t include premiums.

This leads to people not going to the doctor due to out-of-pocket costs that they cannot afford. It leads to debt and bankruptcy in families that are already dealing with the overwhelming stress that comes with illness.

These injustices are too real for those of us in the medical field and for our patients who are attempting to navigate this system.

Fortunately, there is a solution to this issue: single-payer health care.

Single-payer health care is the expansion and improvement of Medicare to everyone.

Often the topic of single-payer health care causes a negative reaction and people are quick to say, “This would never work in the U.S.” But, before you dismiss it, I urge you to take a moment and think about it.

Think about the last time you went to the doctor for yourself or with a loved one. During the visit, did you find yourself concerned with the cost of the treatment or test that had to be done? Were you worrying about whether your insurance was going to cover the procedure that you or your loved one needed to have done to feel better?

If you’re like me, you answered yes to these questions and you are directly affected by our failing health care system.

Now imagine going to the doctor and not worrying about these things. Imagine going to the doctor and worrying only about you or your loved one getting better.

Students for a National Health Program (SNaHP) is a growing organization in medical schools across the country. We are students that rally together to find new ways to advocate for this single-payer system.

We do this because every day we see the results of this failing health care system.

We do this for our future patients as well as our families, and our communities.

We do this because, when we received our white coats, we took an oath that we would consecrate our lives to the service of humanity and that the health of our patients would be our first consideration.

Our current health care system is hindering our ability to keep this oath.

For all of these reasons, SNaHP chapters across the country came together on Oct. 1st for a national day of action and demanded a system where our citizens will not go bankrupt paying for their medical bills. A system that is accessible to all. A system that is fair.

We held teach-ins, rallies, and a luminaria vigil to pay our respects to the tens of thousands of people who die each year due to lack of insurance.

This is not the end of our fight for an equitable health care system. We ask that you write your representatives and urge them to vote for the Expanded and Improved Medicare for All Act – H.R. 676.

We hope that you will be as inspired about this issue as we are so that we can all work together for a better, more just health care system. 

Katie Myers is a University of New Mexico medical student.

http://www.abqjournal.com/653709/opinion/time-for-singlepayer-health-care.html

#BlackLivesMatter: Physicians Must Stand for Racial Justice

By White Coats for Black Lives (WC4BL) National Working Group
American Medical Association Journal of Ethics, October, 2015

Racism is one of the major causes of health problems in the United States. Between 1970 and 2004, the Black-white mortality gap resulted in more than 2.7 million excess Black deaths1, making racism a more potent killer than prostate, breast, or colon cancer2. Physicians are intimately involved with institutions that contribute to the victimization of Black people and other people of color. As is widely documented, Black and Latino patients are less likely to receive the care they need, including adequate analgesia, cancer screening, and organ transplants3-6. This is due both to physician bias and to the health care payment structure’s financial disincentives for the care of people of color7—clinicians are paid less to care for patients who are uninsured, underinsured, or publicly insured, and these patients are disproportionately people of color. As a consequence, people of color are often denied access to the health care they need8,9.

These disparities in access to health care exacerbate the harm that social structures and policies cause to the health of people of color. Black and Latino people are disproportionately victimized by police violence, mass incarceration, and poverty10-12. Moreover, despite perceived improvements, rates of racial segregation across the country remain comparable to levels in the 1940s, and people of color face discrimination in their efforts to access adequate housing, quality education, and meaningful employment13-16. The harmful effects of structural inequity are augmented by the subjective experience of racism: for example, awareness of one’s race is correlated with increased diastolic blood pressure among Black patients17.

Addressing racism and its consequences, therefore, should be a central task of American medicine; physicians must work both within and outside the health care system to eliminate inequities in access to and delivery of care. Health professionals and community organizations ranging from the Black Panther Party to the National Latina Institute for Reproductive Health have long proposed effective strategies for addressing racism to improve the health of people of color, including expansion of free clinics, increased research on diseases affecting people of color, and legislative establishment of paid parental leave18,19. Recent incidents and protests in Charleston, Baltimore, New York, and other cities across the country have reminded us of the urgency of acting on these and other proposals to address racism in medicine.

In particular, we, as members of the National Working Group of the medical student organization White Coats for Black Lives, suggest four ways that physicians and other health professionals can immediately pursue racial justice. The first is to more aggressively recruit, support, and promote Black, Latino, and Native American people in medicine to ensure that the physician workforce reflects the diversity of the United States. Black and Latino people represent roughly 30 percent of our nation’s population but make up only 8.5 percent of the physician workforce20. Physicians of color are more likely to provide care for America’s underserved communities, and patients of color report higher satisfaction when their doctor shares their racial background21-23. Despite the Association of American Medical Colleges’ Project 3000 by 200024, the past three decades have witnessed little growth in the population of Latino, Black, and Native American physicians20. Increasing the numbers of Black, Latino, and Native American doctors is a key step in eliminating health inequities.

Secondly, hospitals and practices must take action to eliminate the significant impact of implicit racial biases on the care of patients of color7. To counteract these subtle forms of racism, institutions must routinely administer implicit association tests to their medical staffs to make them cognizant of their unconscious biases and then train their medical staffs to consciously overcome those biases when delivering care25. Furthermore, hospitals should create formal and informal structures to encourage accountability for incidents that may have involved racism. This can be done by fostering a work environment that makes it safe for colleagues to question each other’s biased actions and by using structured venues such as morbidity and mortality conferences to discuss ways that racism may have impacted the quality of patient care.

Thirdly, physicians should join community members in advocating for a single-payer health care system as a means of eliminating cost-associated barriers to care. In addition to improving access for all patients, a single-payer system would eliminate insurance-status discrimination and ensure that reimbursements for services provided to white patients and patients of color are equal.

Finally, health care workers must recognize that our responsibility to our patients goes beyond physical exams, prescriptions, and surgical interventions; we must work to alter socioeconomic and environmental factors, including structural racism, that directly affect our patients’ health. The manifestations of structural racism are varied and ubiquitous; addressing them will require joining movements to increase the minimum wage, end criminalizing school discipline practices, and develop mixed-income housing, among many others. In doing so, physicians will need to partner with and take direction from community members who have experienced systemic oppression and are dedicated to working to dismantle it. We will not be able to solve the problems of racism in our society and in our health care system without the input of those most affected by it. In working to combat structural racism, physicians must not only listen to people of color in their practices and communities, but also amplify those voices while advocating for equitable social structures. Theprivilege that physicians possess within society and within the professional hierarchy of medicine provides them with power that can be used to spearhead policy changes to advance racial justice locally and nationally. Using this “physician privilege” to advocate for social change is necessary if we are to eradicate the systemic illness that is racism.

References

  1. Rodriguez JM, Geronimus AT, Bound J, Dorling D. Black lives matter: differential mortality and the racial composition of the US electorate, 1970-2004. Soc Sci Med. 2015;136-137:193-199.
  2. American Cancer Society. Estimated deaths for the four major cancers by sex and age group, 2015. http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044509.pdf. Accessed June 28, 2015.
  3. Agency for Healthcare Research and Quality. 2014 National healthcare quality and disparities report. Rockville, MD: Agency for Healthcare Research and Quality; May 2015. http://www.ahrq.gov/research/findings/nhqrdr/nhqdr14/2014nhqdr.pdf. Accessed June 28, 2015.
  4. Tamayo-Sarver JH, Hinze SW, Cydulka RK, Baker DW. Racial and ethnic disparities in emergency department analgesic prescription.Am J Public Health. 2003;93(12):2067-2073.
  5. Agency for Healthcare Research and Quality. 2013 National Healthcare Quality Report. Rockville, MD: Agency for Healthcare Research and Quality; May 2014. http://www.ahrq.gov/research/findings/nhqrdr/nhqr13/2013nhqr.pdf. Accessed June 28, 2015.
  6. Churak JM. Racial and ethnic disparities in renal transplantation. J Natl Med Assoc. 2005;97(2):153-160.
  7. Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013;28(11):1504-1510.
  8. Hing E, Decker S, Jamoom E. Acceptance of new patients with public and private insurance by office-based physicians: United States, 2013. NCHS Data Brief. 2015;(195):1-8.
  9. Kaiser Family Foundation. Health coverage by race and ethnicity: the potential impact of the Affordable Care Act. March 13, 2013. http://kff.org/disparities-policy/issue-brief/health-coverage-by-race-and-ethnicity-the-potential-impact-of-the-affordable-care-act/. Accessed June 28, 2015.
  10. Sadler MS, Correll J, Park B, Judd CM. The world is not black and white: racial bias in the decision to shoot in a multiethnic context. J Soc Issues. 2012;68(2):286-313.
  11. Kramer MR, Hogue CR. Is segregation bad for your health?Epidemiol Rev. 2009;31(1):178-194.
  12. The Sentencing Project. Reducing racial disparity in the criminal justice system: a manual for practitioners and policymakers. Washington, DC: The Sentencing Project; 2008. http://www.sentencingproject.org/doc/publications/ rd_reducingracialdisparity.pdf. Accessed June 28, 2015.
  13. Shapiro T, Meschede T, Osoro S. Research and policy brief: the roots of the widening racial wealth gap: explaining the black-white economic divide. Waltham, MA: Brandeis University Institute on Assets and Social Policy; February 2013. http://iasp.brandeis.edu/pdfs/Author/shapiro-thomas-m/racialwealthgapbrief.pdf. Accessed June 28, 2015.
  14. Fryer RG Jr, Pager D, Spenkuch JL. Racial disparities in job finding and offered wages. J Law Econ. 2013;56(3):633-689.
  15. American Psychological Association Presidential Task Force on Educational Disparities. Ethnic And Racial Disparities in Education: Psychology’s Contributions to Understanding and Reducing Disparities. August 3, 2012. http://www.apa.org/ed/resources/racial-disparities.pdf. Accessed June 28, 2015.
  16. Williams DR, Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Rep.2001;116(5):404-416.
  17. Brewer LC, Carson KA, Williams DR, Allen A, Jones CP, Cooper LA. Association of race consciousness with the patient-physician relationship, medication adherence, and blood pressure in urban primary care patients. Am J Hypertens. 2013;26(11):1346-1352.
  18. Nelson A. Body and Soul: The Black Panther Party and the Fight Against Medical Discrimination. Minneapolis, MN: University of Minnesota Press; 2013.
  19. Center for Reproductive Rights; National Latina Institute for Reproductive Health; SisterSong Women of Color Reproductive Justice Collective. Reproductive injustice: racial and gender discrimination in US health care: a shadow report for the UN Committee on the Elimination of Racial Discrimination. 2014. http://www.reproductiverights.org/sites/crr.civicactions.net/files/documents/CERD_Shadow_US.pdf. Accessed July 24, 2015.
  20. Association of American Medical Colleges. Diversity in the physician workforce: facts & figures 2014. http://aamcdiversityfactsandfigures.org. Accessed June 28, 2015.
  21. Marrast LM, Zallman L, Woolhandler S, Bor DH, McCormick D. Minority physicians’ role in the care of underserved patients: diversifying the physician workforce may be key in addressing health disparities. JAMA Intern Med. 2014;174(2):289-291.
  22. Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient-physician racial concordance and the perceived quality and use of health care.Arch Intern Med. 1999;159(9):997-1004.
  23. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139(11):907-915.
  24. Nickens HW, Ready TP, Petersdorf RG. Project 3000 by 2000: racial and ethnic diversity in US medical schools. New Engl J Med. 1994;331(7):472-476.
  25. Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231-1238.

White Coats for Black Lives (WC4BL) is a national medical student organization devoted to safeguarding the lives of patients through the elimination of racism. The WC4BL National Working Group endeavors to raise awareness of racism as a public health concern that threatens the lives and health of people of color, end racial discrimination in the delivery of health care, and prepare future physicians to be advocates for racial justice. WC4BL encourages medical professionals to create a physician workforce that reflects the diversity of our nation by actively recruiting and supporting Black, Latino, and Native American people through medical school and into their careers.

http://journalofethics.ama-assn.org/2015/10/sect1-1510.html