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Better communication a good reason to go for single payer

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Better communication a good reason to go for single payer

By James Binder, M.D.
Charleston (W.Va.) Gazette-Mail, July 23, 2015

Medical students are taught empathic, patient-centered interviewing skills during the first two years of medical school. Patient-centered interviewing is strongly linked to better health outcomes in patients.

These interviewing skills erode as students become residents and young practitioners. Why? I believe the most important factor is an adversarial climate that is now pervasive in our health-care system, a climate created by competing private health care insurance companies.

I have noticed a harshness that was not present 30 years ago. Many professionals do provide compassionate care everyday, but the culture has changed.

I didn’t initially appreciate the importance of empathic communication. I learned through clinical experiences, including one incident that hit close to home.

An elderly woman cried as Dr. Tim Campbell made his morning rounds. The distraught woman explained that, during the previous night, she had not been allowed to visit with her gravely ill husband of 50 years (because the nurses were busy caring for him). Dr. Campbell responded with simple compassion. He hugged the woman. She calmed down, and they talked. I remember the incident because that woman was my mother.

Empathy opened the door for Dr. Campbell to be able to talk with her and make plans to transfer my dad to the ICU. The power of empathy to open up patients and collaborate with them in treatment planning is well documented in the medical literature.

Our fragmented health-care system is competitive and adversarial. This is not a surprise to anyone working in the field or to patients receiving care. What is surprising is that we continue to believe competition will improve quality and save money. It does neither.

The evidence of a hostile climate is inescapable: the new patient is asked for her insurance coverage before receiving a simple welcome; a family has to fight with a case manager to obtain needed medical coverage for their mother; a rushed doctor types into a computer and does not really listen to his patient’s concerns.

A combative approach to patient care is the direct result of believing that patients must be stopped from overutilizing the health-care system, since over utilization is considered the primary cause of our high health costs in the U.S. It is misguided.

Excessive bureaucracy is the most important factor for high costs. “A simplified, single-payer system of financing health care similar to Canada’s or the U.S. Medicare program could result in savings of approximately $375 billion annually,” says a 2014 article in BMC Health Services Research.

If we eliminated the needless bureaucracy inherent in a multi-payer system, we would realize enough savings to cover all citizens for all needed care, including mental health, dental and chronic care.

The following consequences of our current adversarial culture are powerful roadblocks to providing compassionate, patient-centered care:

1. Time spent with patients is severely limited to increase profits.

Currently about one-sixth of patient time is devoted to paperwork and red tape. Its takes time to talk, listen and partner with patients. Richard Schwartzstein reflected the thinking of many practicing physicians when he commented in the New England Journal of Medicine that, “Our system forces them (physicians) to have time-constrained interactions that challenge even the most caring doctors to apply their training.”

2. Clinicians burn out at a very high level, largely because of a loss of autonomy, working in an adversarial climate, and the massive paperwork and red tape demands that result from working in our multi-payer system.

Primary care physicians are particularly vulnerable to burnout (around 50 percent), contributing to our primary care physician shortage.

Burnout, a condition of emotional exhaustion, depersonalization, and decreased sense of accomplishment, leads to personal and family losses, with high rates of substance abuse and divorce.

Four-hundred physicians die each year from suicide, according to the American Foundation for Suicide Prevention. Studies show lower quality of care from burned out physicians. A burned out physician is unlikely to be empathic and patient-centered. Health outcomes of patients suffer.

3. Patients view the health-care system and its leaders as adversaries, not advocates.

Although most patients are satisfied with their individual clinicians, there is distrust of the system itself. This distrust does permeate into individual physician-patient relationships. Trust is fundamental to partnership and positive health outcomes. This lack of trust does not affect physicians in many other countries. The level of public trust in U.S. physicians as a group ranks near the bottom of trust levels in the 29 industrial countries recently surveyed by the International Social Survey Programme.

Insurers are well aware of the above information. Overtly, they endorse the concept of patient-centered, compassionate medical care. It is not their priority.

As Joe Biden stated, “Don’t tell me what you value. Show me your budget and I’ll tell what you value.”

We will not create a compassionate culture by legislating it or by checking a box on a computer template that we partnered with our patient. That would require a change in our attitude, our core beliefs.

One belief that would be important to adopt is: There is enough health care resources to go around and treat all patients with care, respect and competence. Imagine the improvement in health care that would result from eradicating the adversarial climate and including everyone automatically with the $375 billion saved by eliminating the excessive bureaucracy of the multi-payer system.

Dr. James Binder works at Cabin Creek Health Systems and is the author of “Pediatric Interviewing: A Practical Relationship-Based Approach and Primary Care Interviewing: Learning Through Role-Play.” He is a member of Physicians for a National Health Program.

 http://www.wvgazettemail.com/article/20150723/GZ04/150729780/1455#sthash.QwloKK4F.dpuf

Underinsured Chicago doctor wants Medicare for all

By James Ronayne, M.D.
Chicago Sun-Times, July 22, 2015

Medicare has become one of our nation’s most beloved social programs. Today it’s part of the U.S. tradition, as American as apple pie.

The health insurance program covers 55 million Americans — people older than 65, along with younger people with disabilities. It has made health care accessible to many millions and has reduced health inequalities based on race and socioeconomic status. Moreover, under traditional Medicare, patients can go to the doctor and hospital of their choice – something unheard of in today’s health care scene.

On July 30 Medicare will turn 50, and celebrations will take place nationwide. I will celebrate Medicare’s achievements but also call for improving and expanding it to cover everyone in the country.

That’s right — I think we need an efficient, nonprofit, improved Medicare for All.

Unfortunately, just a few days later, I have plans to experience another American tradition that I’m less enthusiastic about – going to see my doctor and paying out of pocket. You see, I don’t have insurance to cover my visit.

What makes my situation unusual is that I’m a doctor at one of Chicago’s hospitals. I’m also a researcher, and I also work in private practice. Because I have three different part-time jobs, I’ve become ineligible for insurance through my workplace.

Now, I don’t want to mislead – I just got insurance through my wife’s plan. However, my doctor is now “out of network.” My costly medication isn’t covered either.

I couldn’t find an appointment with a doctor who takes my wife’s insurance until August. I like my doctor, but I am being forced to find another, and to change medications, because I cannot afford to pay the full freight.

Keep in mind that I have a detailed understanding of the medical system.

Many of my patients can no longer come to my clinic because of insurance changes, and some have lost everything — house, car, college funds for the kids — due to illness.

Indeed, ours is the only developed country where it’s commonplace for medical bills to result in bankruptcy.

In contrast, consider this: when I was a medical student in England, I was treated by that country’s National Health Service. I had zero out-of-pocket costs. 

While a politician in Illinois, Barack Obama supported expanding Medicare to all. As president, he bowed to pressure from the insurance companies and instead elected to mandate that Americans buy private health insurance, or enroll in Medicaid, a substandard plan compared to Medicare. 

Private insurance puts 30 percent of every health dollar into administration (UnitedHealth’s CEO took  $66 million last year). The insurance companies like it this way, and spend lots of money to keep politicians in line. Contrast that with Medicare, where only 2 percent of each dollar goes to administration. 

So next time you hear a politician demanding we cut or dismantle Medicare, and you think to yourself, “That’s got nothing to do with me,” I want you to think again.

I know I will. If a doctor in this country can struggle to pay for medical care, so can the rest of us — if not today, then tomorrow.

The simplest solution, though the hardest politically, is to improve and expand Medicare to cover all of us. There is legislation in the U.S. House and the Illinois General Assembly that would do this. Urge your lawmakers to sign on.

By passing these bills, we can restore confidence in our medical system, and all of us can enjoy healthier, richer lives.

Dr. James Ronayne, a pediatrician in Chicago, is a member of Physicians for a National Health Program and the Illinois Single-Payer Coalition.

http://chicago.suntimes.com/opinion/7/71/814283/opinion-doctor-gains-deeper-appreciation-medicare

You went to medical school to do what!?

Dropout Docs: Bay Area Doctors Quit Medicine to Work for Digital Health Startups

By Christina Farr
KQED, July 17, 2015

New data provided exclusively to KQED shows that Bay Area-based medical students have among the very lowest rates of applying to residency programs after graduation compared to the rest of the country. Rather than pursuing a career in traditional medicine, many of these doctors-in-training are drawn to entrepreneurship.

Bay Area-based medical students from Stanford and UCSF have among the very lowest rates of pursuing residency programs after graduation compared to the rest of the country. Stanford ranked 117th among 123 U.S. medical schools with just 65 percent of students going on to residencies in 2011, according to Doximity, a physician-network that generates data for the U.S. News Best Hospitals rankings. UCSF is 98th on the list, with 79 percent of its graduating students going on to residency. (Some students may have opted to apply to residency after taking a few years off. The 2011 figures haven’t yet been updated to reflect that.)

“We’ve seen that many of these Bay Area-based medical students are drawn to startup opportunities — it used to be biotech, and now it’s more often digital health,” said Jeff Tangney, CEO of Doximity. Tangney said many of the top digital health companies are more than willing to hire new grads straight out of medical school, who lack years of clinical experience.

Tangney said dropout doctors are well-positioned for a career in digital health as they have an insider’s view of the industry — and ideas about how to fix it.

Many of the students at the top Bay Area medical schools, Stanford and UCSF, are exposed to entrepreneurial thinking during the course of their education, which can be a major draw.

Other dropout docs said they felt pushed out of medicine, due to the lack of career opportunities or earning potential. Family practitioners, who serve at the front lines of health care, are paid the least.

Recent studies have also shown rising levels of discontent among primary care doctors. Nearly half of 7,200 doctors who responded to a Mayo Clinic survey in 2012 said they felt a lack of enthusiasm about medicine or cynicism about it. A decade ago, one quarter of doctors reported feeling burnt out.

“I loved working with patients but I looked around me and realized that I didn’t want the jobs of anybody who had ‘succeeded’ as a clinician,” said Rebecca Coelius, who graduated with an MD from UCSF.

http://ww2.kqed.org/futureofyou/2015/07/17/increasingly-young-bay-area-doctors-leave-medicine-for-digital-health/

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Comment:

By Don McCanne, MD

Of medical school graduates in 2001, one-fifth of those graduating from UCSF and one-third from Stanford did not proceed into residency training for clinical medicine. Many of them instead were drawn into entrepreneurship, especially digital health.

Over half a century ago, as students at UCSF School of Medicine, my twin and I learned early on not discuss our intent to become general practitioners (as family physicians were then known). UCSF was above producing LMDs (local medical doctors – the source of all the screwed up cases that the specialists at UCSF had to bail out). Fast forwarding, at our 50th class reunion a couple of years ago, we were shown the utopian edifices and superstars representing the epitome of the medical-industrial complex.

In the last half century I was dedicated to primary care and, during the past couple of decades, to advancing health care justice through advocacy for a single payer national health program. Boy, did I feel out of place at our UCSF 50th reunion.

Stanford was “the other school” in the bay area. When I was a student, there was a feeling that UCSF was training specialized clinicians whereas Stanford was positioning their students to cater to the elite carriage trade. That is, in my view, Stanford was even worse than UCSF in glorifying the prestige and income in medicine, and apparently it remains so today based on the numbers that are moving into entrepreneurial ventures.

Under a well designed single payer system, primary care would be expanded, and the rewards for specialists would be based not on wealth acquisition but on the satisfaction of being a team member that protects and enhances the health of our patients. The medical school admissions committees at UCSF and Stanford apparently are not filtering out those whose career goals are business success in the industrial side of the medical-industrial equation.

So a single payer system would not only reform the financing infrastructure, it would also reorient the health care delivery system in a direction that would attract students who are truly dedicated to the healing arts. The selection process should continue to grant entry to the majority who are so oriented, but it should filter out those who see medical school as an opening to join the exclusive club of the one-percenters.

Despite critics, Medicare turns 50

By C.V. Allen, M.D.
Modesto (Calif.) Bee, July 16, 2015

Happy 50th birthday, Medicare!

You were a long time coming. With the Great Depression of the 1930s came demand for both health insurance and old-age pensions. Conservatives and the American Medical Association raised the cry of “socialized medicine” – threatening to sink both efforts.

Bowing to reality, reformers cut the health insurance portion adrift and the pension benefits of Social Security became law in 1935.

In the 1940s, President Harry S. Truman proposed a national health care program, but this time it was a casualty of the Cold War – a frightened public was told government medicine was communism, guaranteed to destroy all our freedoms. Again, that propaganda came from the AMA and a growing health care industry.

Among the opponents was Ronald Reagan, then still an actor and unofficial messenger boy for the conservatives and the AMA, who saw in a national health plan the eventual invasion of “every freedom we have known.” Again, reform failed.

The early ’60s brought convergence of three forces – increasing cost and effectiveness of medical care, increasing public demand for health solutions and the leftward shift of the electorate. It was a time when “liberal” was not a dirty word and reform found new life.

So Medicare became law on July 30, 1965. But its passage came with a concession. There would be no national health care system. Period.

Partial reform came in two layers – Medicaid, a state program for the poor, and Medicare for the aged. Thus did the commercial health insurers fix responsibility for the poor and aged on government, retaining for themselves the affluent, employed, under-65 population from which profits could be made. Moreover, the health insurance industry initially demanded – and got – compensation guaranteed to be “usual, customary and reasonable” – which eventually became none of these things.

Over the next 50 years, Medicare proved its critics wrong. It became, along with Social Security, the most effective social program in America’s history.

With low administrative expenses, all-inclusive philosophy and unrestricted choice of providers, Medicare is the most popular medical insurance system in the nation – and the most efficient. But problems abound, including the annual increase in per-capita expenses (higher than inflation, but lower than the private sector), congressional restrictions on reasonable cost containment policies, a high rate of consumer fraud and an uncanny ability of the private insurance sector to find ways to divert public money into private hands.

Even 50 years later, critics see in Medicare a financial tsunami waiting to happen. Others see it as a solution to our present dysfunctional, fragmented health care system – the most expensive in the industrial world despite failing to insure a sixth of its population.

An updated and improved “Medicare for all” could well be the template for radical reform required to lower costs and provide universal coverage – “everybody in, nobody out,” a single set of regulations, low administrative expenses, and a partnership between a private delivery system and a government assuming administrative and financial responsibilities. An impossible dream? So was Medicare five decades ago.

Either way, 50 million Americans go to bed each night knowing medical care will be there if needed. Well done, Medicare, and many happy returns.

C.V. Allen is a semi-retired Modesto doctor.

Read more here: http://www.modbee.com/opinion/opn-columns-blogs/article27435397.html#storylink=cpy

Medicare for All should be the goal

By Eve Shapiro, M.D., and Richard Wahl, M.D.
Arizona Daily Star, July 21, 2015

Medicare, one of our nation’s most valuable and popular social programs, turns 50 on July 30. Medicare is a federal health insurance program that covers 55 million Americans — those over 65 and younger people with permanent disabilities, currently 17 percent of the population.

It was originally conceived as a first step toward covering everyone in the United States under a national health insurance program. Medicare has been a success — it has sharply reduced poverty among seniors and has reduced health disparities related to race, ethnicity and socioeconomic status.

Patients in Medicare can go to the physician and hospital of their choice. It is also economical — overhead costs are about 2 percent compared with 12 to 20 percent for the private insurance market and even higher for the individual market.

Medicare costs are going up due to an aging population and the higher costs of healthcare, including pharmaceutical prices. These higher costs can be easily met by an upturn in the economy, generating greater tax receipts, and tweaks to the payroll tax, which has not increased in 30 years.

In comparison to Medicare, the health insurance options for all other Americans are problematic. Despite the improved access to care with the Affordable Care Act and the recent U.S. Supreme Court decision affirming people’s access to federal subsidies, the Congressional Budget Office estimates that 27 million Americans will remain uninsured.

In addition, many more Americans are feeling the effect of the cost shift to employees in the form of higher deductibles and copays. This creates underinsurance, defined as out-of-pocket costs more than 10 percent of income, which now faces more than 21 percent of adults. In addition, more than half of all bankruptcies in the U.S. are due to overwhelming health care costs.

What’s the solution? We need Medicare for All to ensure universal, comprehensive coverage with no copays and deductibles. This would include freedom of choice of one’s doctor and hospital, the ability to negotiate for more competitive drug prices, and the elimination of the approximately $400 billion administrative costs in our current system.

This system would be financed by a progressive tax that would cost the average family far less than they are paying now in health care costs. This is not “socialized medicine” because doctors would remain in private practice. Only the financing would change. It would not introduce rationing but would prevent the rationing we have now based on ability to pay.

A pipe dream? No. There is legislation in Congress, The Expanded and Improved Medicare for All Act, HR 676, which would put such a single-payer system in place. All other developed countries in the world have such a system, and provide for coverage for their citizens at a cost far lower than ours and at least equal in quality. Canada, for example, has had a system in place since 1971. Since then, they have spent far less than us on per capita health care costs (close to half), while living longer.

Let’s enable all Americans to take advantage of a single payer system, not just the elderly, and enact HR 676.

Eve Shapiro and Richard Wahl have been pediatricians in Tucson for many years and are members of Physicians for a National Health Program.

http://tucson.com/news/opinion/eve-shapiro-medicare-for-all-should-be-the-goal/article_6374c3c9-ebbf-50fe-9564-5eea664d13eb.html

Beware the fine print in private health plans

‘Illegal Activity’ Fine Print Leaves Some Insured, but Uncovered

By Roni Caryn Rabin
The New York Times, July 20, 2015

There’s no video of the altercation between Monroe Bird III, a 21-year-old sitting in a car with a friend, and Ricky Leroy Stone, 56, a security guard who found them one night in the parking lot of an apartment complex in Tulsa, Okla.

Mr. Stone, the security guard, told police he approached the car because he had been instructed to look out for couples having sex in the parking lot.

But the tragic culmination of their encounter is not disputed: Mr. Stone drew his gun and shot Mr. Bird, leaving him paralyzed from the neck down.

Three months later, as he lay in the hospital hooked to a ventilator, Mr. Bird’s insurance company declined to cover his medical bills. The reason? His injuries resulted from “illegal activity.”

Yet Mr. Bird was not convicted of any crime in connection with the incident. He was not even charged.

Without insurance, Mr. Bird’s family could not move him to a rehabilitation center specializing in spinal cord injuries. He was discharged from the hospital and died at home last month from a preventable complication often seen in paralyzed patients.

But Mr. Bird’s story comes with a particularly bitter sequel relevant to Americans of any background: The plan’s refusal to pay has left his family owing as much as $1 million in medical bills and, experts say, shines a light on a little-known loophole buried in the fine print of many health plans.

There are no firm numbers on how often insurers deny medical coverage based on allegations of illegal activity. But cases like Mr. Bird’s “are more common than people think,” said Crystal Patterson, an attorney in Minneapolis and chairwoman of the American Bar Association’s committee on fiduciary litigation.

Insurers have long relied on allegations of illegal activity to deny coverage to patients injured in a variety of contexts, from traffic infractions to gun accidents. The judicial rationale is that “we don’t want to reward illegal activity,” she said.

Insurance exclusions for illegal activity have been outlawed in some states, but state laws do not apply to health plans administered under the federal Employee Retirement Income Security Act, which sets standards for most pension and health plans in private industry.

Even after passage of the Affordable Care Act, self-insured plans regulated under Erisa maintain wide latitude to determine coverage. These plans “can do pretty much what they want to do,” said Robert Laszewski, an insurance industry consultant in Washington.

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Comment:

By Don McCanne, MD

If a person is insured and needs medical care, is there any circumstance under which the health plan should not pay for that care when it is covered by the plan?

Insurers have always used loopholes to avoid paying for appropriate care. Some of these loopholes, such as rescissions, were patched by the Affordable Care Act. But as long as private insurance is based on a business model rather than a patient service model, insurers will continue to stealthily approach patients in need as being the enemy.

Health financing policies supported by conservatives often factor in blame-the-victim as an excuse to limit or deny private coverage, or at least to assess penalties. Examples include being overweight, smoking, drug dependency, or failure to achieve treatment goals in hypertension, diabetes, and other chronic conditions.

The tragic case of Monroe Bird III adds to this list injuries that result from illegal activity – an exclusion often found in the fine print of employer-sponsored health plans. In Monroe’s case, the illegal activity proved to be equivocal – shot in the back while fleeing a security guard (who had cannabinoids in his system) investigating him to see if he and a young lady were having sex in his car. The claim of “illegal activity” was so flimsy that, on appeal, the insurance administrator claimed that it was “hazardous activity,” another blame-the-victim reason for denial.

There is absolutely no question that Monroe Bird was insured and that he desperately needed medical care. The question came down to whether or not the health plan could get away with not paying for that care, based on a blame-the-victim clause in the fine print of his health plan.

We are often accused of challenging the ethics of the private insurance industry when they are simply businesses following standard business practices. But on the face of it, the refusal by the health plan administrator to pay the million dollar medical tab for Monroe’s injury is a contemptible act. It proves that the private insurance industry will commit evil acts if it furthers their own business interests.

If we close this blame-the-victim loophole the plans will find other innovative measures to chisel away at patient health care benefits. Narrow networks and unaffordable deductibles are only the beginning.

What we need is a universal system, serving the public, designed to remove financial barriers to care for patients in need – a single payer national health program, an improved Medicare for all. What we do not need are private administrators who deny us our plan benefits through the non sequitur that having sex in a car is a hazardous activity.

Charlotte doctors host advocate of Medicare for all

Despite ACA, doctor says need for reform remains * Says Medicare could expand to all ages * Free talk is 6 p.m. Thursday at Myers Park Baptist

By Karen Garloch
The Charlotte (N.C.) Observer, July 21, 2015

Dr. Andrew Coates agrees with some critics of the Affordable Care Act. In many ways, he says the federal law “reinforced or worsened some of the most egregious inequalities and injustices in the health system.”

Coates, a New York physician and immediate past president of Physicians for a National Health Program, suggests that the United States, like other developed nations of the world, should adopt a single-payer plan, such as Medicare. The federal program could be expanded to all citizens, not just those 65 and over or disabled.

He’ll be in Charlotte on Thursday, at the invitation of Health Care Justice-North Carolina, to make his case for expanding Medicare. His free talk is 6-7:30 p.m. at Myers Park Baptist Church, Heaton Hall, 1900 Queens Road.

As Medicare marks its 50th anniversary this year, Coates said it’s interesting to note the contrast between that popular “model of publicly financed comprehensive” health insurance compared with the “current mess” in the private health insurance market, “including the exacerbation of that mess by the Affordable Care Act.”

Like many others, Coates praises the ACA for expanding insurance coverage to many who previously had none or who were excluded because of pre-existing medical conditions. But he added that it “entrenched the interests of the private insurance companies.” He said that the mandate for electronic medical records was a good idea but has not produced the projected cost savings.

“In terms of sweeping health reform, we did not get that with the Affordable Care Act,” said Coates, chief of hospital medicine at Samaritan Hospital in Troy, N.Y., and assistant professor of medicine and psychiatry at Albany Medical College.

Coates acknowledges that a single-payer plan is not popular with leaders of either major political party. But he said there is agreement in the country that everyone should have comprehensive health insurance. “In Main Street America, that is absolutely a consensus. I’ve talked to big groups and small groups. Republican town councilmen and liberal Catholic clergy. The idea that everyone should have access to health care is not a real debate.”

Despite arguments to the contrary, Coates said a single-payer plan would not be “a government takeover.” Services would still be provided by private hospitals and doctors. The payment system would be administered by the federal government, and that would save millions of dollars in administrative costs that could then be spent on services, Coates said.

As Americans face higher deductibles and co-pays for insurance, the need for reform remains great, he says. “A health care crisis is still very likely to cause personal bankruptcy,” Coates said. And when that happens, it’s seen as a personal failure rather than a societal one.

“It’s kind of a private shame. You see the collection jars at the fire company or the church. It’s not seen as a collective shame and a scandal.”

You can reach Karen Garloch at kgarloch@charlotteobserver.com.

http://www.charlotteobserver.com/living/health-family/karen-garloch/article28011271.html#storylink=cpy

Gerard Anderson on new payment models

Will Hospitals Lose Money Under Obamacare?

By Kimberly Leonard
U.S. News & World Report, July 17, 2015

The portion of President Barack Obama’s health care law aimed at lowering the number of uninsured in the country has largely rolled out, leaving the administration increasingly turning its attention to another goal of the Affordable Care Act: controlling health care costs. It doesn’t appear, however, that the proposals will make a significant dent in government spending, and questions remain over whether providers – particularly hospitals – could see any benefit from the initiatives.

In recent months, Obama and Sylvia Burwell, the secretary for Health and Human Services, have touted a move toward payment models that reward better quality of care, rather than the current model that compensates health care providers for the number of medical services they provide.

The government has been testing several initiatives aimed at slowing or reducing health care spending, which grows faster than the rest of the economy and makes up one-fifth of the country’s expenditures. By 2018, the administration plans to place half of payments on Medicare – the government’s program for adults 65 and older – under new models.

Attempts at changing payment models in the past, however, have yielded only modest savings at best. Also, what remains unclear is why hospitals would buy into a payment system voluntarily that likely would reduce their bottom lines.

“The answer is: They wouldn’t,” says Gerard Anderson, director of the Center for Hospital Finance and Management at the Johns Hopkins Bloomberg School of Public Health.

Hospitals do participate in different payment models, he says, so they can be prepared if there is a change in the way payments are delivered.

There has been scant evidence that accountable care organizations can significantly reduce health care costs. Anderson points out that hospitals may not want to partake because the more they save, the less they ultimately make. “If I’m a hospital, why would I cut anything, because I’d rather have all of it? Most of them don’t, and that’s why it’s not working well,” he says.

Not everyone is optimistic that these various experiments can bring about significant savings. These alternative payment models are far from the norm. “There is a lot of confidence, and most of it is not warranted,” Anderson says. “There is nobody with significant power [in the health care industry] who wants to control health care costs. Until we have that, we will muddle along in terms of coming up with good ideas, implementing them and getting lukewarm results.”

Still, it’s difficult to say how much the country will suffer as a result of health care spending. Government officials warn decade after decade, year after year, that the country cannot sustain anymore spending on medical services. “We keep addressing the goal line of what’s acceptable as we reach it and pass it,” Anderson says. “It is cannibalizing other budgets, causing us to spend less on programs like education and housing.”

“The Affordable Care Act was really about coverage,” Anderson says. “It wasn’t about affordable care.” 

http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2015/07/17/hospitals-have-little-to-gain-from-new-payment-models

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‘It’s the Prices, Stupid’: An Interview with Health Policy Expert Gerard Anderson

By Gerard Anderson, Elizabeth Palmberg
Sojourners, June 2011

Sojourners: What are some of the most important causes for why the U.S. is paying a lot more than other wealthy countries [in the OECD] for health care without getting improved results?

Anderson: A higher health-care cost is pretty much because of what I call, “It’s prices, stupid.” We just pay approximately twice as much for each good and service that we utilize in the U.S. vis-a-vis other industrial countries. In fact, for a hospital visit it’s about three times more than other industrialized countries for a similar visit — in a shorter period of time that you’re in the hospital, we still spend about three times more. So it seems to be that we just pay more for identical services compared to other industrialized countries.

Sojourners: Why?

Anderson: Because, in most other countries they have a single purchaser, which is a very tough negotiator, whereas in the United States we have so many different purchasers that nobody has a lot of power.

Sojourners: If you didn’t have to think about political realities at all, what health-care policies would you suggest the U.S. adopt?

Anderson:  Basically, that everybody has the same health care and access to the same health care.

Sojourners: Through a single-payer system?

Anderson:  Well, that’s the payment side. And then access to the same delivery system as well.

Sojourners: So, both single-payer and a standardized quality of care?

Anderson:  Correct.

https://sojo.net/magazine/june-2011/its-prices-stupid-interview-health-policy-expert-gerard-anderson

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Comment:

By Don McCanne, MD

Gerard Anderson is a professor of health policy and management and professor of international health at the Johns Hopkins University Bloomberg School Public Health, and professor of medicine at the Johns Hopkins University School of Medicine. He may be most famous as co-author of the 2003 landmark Health Affairs article, “It’s the Prices, Stupid,” demonstrating that prices are much more important than quantity of services in explaining why health care spending is so high in the United States. He is as qualified as anyone to comment on the anticipated impact of the new payment models in health care.

The new models will pay for quality rather than quantity, thus supposedly controlling health care spending while maintaining quality.

What does Professor Anderson have to say about this? “There is a lot of confidence, and most of it is not warranted. There is nobody with significant power [in the health care industry] who wants to control health care costs. Until we have that, we will muddle along in terms of coming up with good ideas, implementing them and getting lukewarm results.”

As Anderson says, “The Affordable Care Act was really about coverage. It wasn’t about affordable care.”

What could we do? In an interview a year after the Affordable Care Act was signed into law, he indicated that the United States needed a single purchaser that could negotiate prices, providing everyone with the same health care and health care access – a single payer on the payment side, with ensured access on the delivery side.

These new models that attempt to convince providers that they need to reduce the volume of services, when the greater problem is prices, simply are not going to gain traction, other than token participation. Providers may be willing to work less, but they are not going to give up significant revenues.

Under single payer, we would receive the right volume, at the right prices. As long as the prices are fair, providers will participate.

Medicare expanded for all would be better than ACA

By Kathryn Dean, M.D.
The Olympian (Wash.), Letters, July 18, 2015

“I need to admit you to the hospital for pneumonia,” I told my patient. He had reluctantly driven himself to the emergency room as his symptoms worsened. In between gasps, he asked, “How much will it cost?”

Many patients have asked me that question in moments where their health should have been the number one concern. But it is an important question. Sixty-two percent of all personal bankruptcies in the U.S. are linked to medical bills or illness. Three quarters of those bankrupted had health insurance when they got sick. One hospital bill could lead to the unraveling of your life.

Lyndon Johnson began to address this problem exactly 50 years ago when he signed Medicare into law in July 1965. President Johnson said, “There are those fearing the terrible darkness of despairing poverty -– despite their long years of labor and expectation –- who will now look up to see the light of hope and realization.”

The Affordable Care Act increased the number of Americans with insurance, but many still remain uninsured and far more are under-insured. Insurance companies have significantly contributed to the skyrocketing costs of U.S. health care as health outcomes have worsened.

A better solution would be to improve and expand Medicare to cover everyone. Legislation like “The Expanded and Improved Medicare for All Act,” H.R. 676, could make our health care system less costly and more fair. I look forward to the day when my patients and I can focus on health instead of health insurance.

Dr. Kathryn Dean resides in Olympia.

http://www.theolympian.com/opinion/letters-to-the-editor/article27459355.html

Medicare turns 50, and we have much to celebrate

By Theresa Chalich, R.N.
Pittsburgh Post-Gazette, Letters, July 19, 2015

Nicholas Kristof’s commentary “Poverty: Yes, It’s About Personal Responsibility but It’s Also About the Choices We Make as a Society” (July 12 Forum) on the need for collective responsibility was written at an opportune time. This July we celebrate the 50th anniversary of Medicare. What an impact this social program has made on improving health and financial stability.

This publicly funded program financed by our employee Medicare taxes has been and is a practical solution to a severe need. Fifty years ago one-half of seniors were without hospital insurance. One in three lived in poverty. Today nearly all seniors and younger people with permanent disabilities have access to affordable health care.

Mr. Kristof wrote about our nation’s blame-the-victim mentality. It is important to know that Medicare addressed our systemic problem of racism by stopping payments to segregated hospitals and by allowing African-American doctors to get hospital admitting privileges. For these doctors, the legacy of discrimination held back their economic growth. Medicare has truly been a collective response.

On July 14 Pittsburgh City Council recognized the 50th anniversary of Medicare and its goals with a proclamation sponsored by Councilman Corey O’Connor.

So, happy birthday, Medicare! May our birthday wish be that we will have Medicare for all!

Theresa Chalich, R.N., resides in Squirrel Hill. She is a member of HealthCare 4 All PA.

http://www.post-gazette.com/opinion/letters/2015/07/19/Medicare-turns-50-and-we-have-much-to-celebrate/stories/201507170176

PNHP note: The text of the Pittsburgh City Council resolution cited in the letter above is as follows.

Resolution on Medicare’s 50th Anniversary

WHEREAS, on July 30, 1965, President Lyndon Johnson signed into law the Medicare program to provide health care insurance for the elderly with the intent purpose to reduce poverty among seniors and significantly improve the financial security of American families;

WHEREAS, the passage of Medicare led to the rapid desegregation of 99.6% of U.S. hospitals and continues to reduce health disparities related to race, ethnicity and socioeconomic status, and as a result, 55 million seniors and people with disabilities have access to guaranteed health care benefits; and,   

WHEREAS, Medicare is a model of how a publicly financed care program can assure millions of Americans access to medically necessary care while controlling costs, spending only about 2% on administration which is about 6 times less than what commercial insurers spend on overhead; and,

WHEREAS,  Medicare’s guaranteed benefit is a lifeline to millions of Americans. The evolution of the Medicare legislation has been built on President Johnson’s vision to “assure availability and accessibility to the best healthcare to all Americans, regardless of age or geography or economic status.”

NOW, THEREFORE BE IT RESOLVED that the Council of the City of Pittsburgh does hereby recognize and reflect on the critical role that Medicare plays in protecting the health and well-being of millions of families, setting standards for how care is delivered and having the ability to strengthen and improve health care for future generations. The Council of the City of Pittsburgh salutes Medicare on its 50th Anniversary and urges residents to find creative ways to celebrate this monumental Anniversary for our nation.

Passed in Council on Tuesday, July 14, 2015.

Bruce A. Kraus
President of Council

Attest: Mary Beth Doheny
City Clerk

Expand Medicare to improve nation’s health care system

By William M. Fogarty Jr., M.D.
St. Louis Post-Dispatch, Letters, July 20, 2015

On July 30, Medicare will celebrate its 50th birthday. This program has been a resounding success for the elderly and disabled of our country and is firmly embedded in our culture and medical care system. It has improved the health of the nation’s elderly and removed the threat of medical impoverishment that loomed over them before its enactment.

Medicare is not perfect and fails to cover many necessary services, but it is the basis upon which we can build a health care system that would cover all  Americans, improve the health, economy and security of the country and save billions of dollars every year.

We have a mechanism to replace our incredibly inefficient, wasteful and complex system right before our eyes. It is improved and expanded Medicare for All.

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

http://www.stltoday.com/news/opinion/mailbag/expand-medicare-to-improve-nation-s-health-care-system/article_65b6c3c7-75a7-5fc4-844f-1519d0b8ccd7.html

Single-Payer Health Reform: A Step Toward Reducing Structural Racism in Health Care

By Dominic F. Caruso, MD/MPH Candidate, David U. Himmelstein, MD, and Steffie Woolhandler, MD
Harvard Public Health Review, July 20, 2015

Racial and income equality are too often absent from conversations about health care financing. Research continually exposes alarming health disparities in the United States, particularly impacting African Americans and Native Americans. These groups have lower life expectancies than non-Hispanic white Americans, and experience higher rates of most major causes of death including infant mortality, trauma, heart disease, and diabetes. Yet despite their greater need, access to care is worse for minority populations by most measures.

Unequal medical care is often viewed as a consequence of broader social inequalities, but the current health financing system also reinforces and institutionalizes inequality; unequal care may be viewed as a form of structural racism.

While most Americans rely on private insurance, rates of private coverage are much lower for minorities and the poor.

The Patient Protection and Affordable Care Act (ACA) offered subsidies to expand private coverage, making insurance more affordable for many families. However, many of these new private plans carry high deductibles and co-payments. Deductibles for the ACA’s bronze and silver plans average over $5000 and $2900, respectively, for single coverage, and over $10,000 and $6,000, for family coverage.

Deductibles have also soared in employer-sponsored plans; in 2014, more than 40% of such plans carried a deductible of more than $999, up from just 10% in 2006. Moreover, while Medicaid traditionally imposed virtually no cost-sharing, several conservative state governors have extracted waivers from the Centers for Medicare and Medicaid Services allowing the imposition of cost-sharing on recipients as a condition for implementing the ACA’s Medicaid expansion.

High cost-sharing particularly impacts minority families, whose average incomes are far lower than those of non-Hispanic whites. Yet even figures on income disparities understate minorities’ disadvantage when confronted with high out-of-pocket costs. With medical bills often reaching into the thousands for even routine care such as childbirth and appendectomy, many families must tap savings or other assets like housing equity, and racial/ethnic disparities in assets dwarf the differences in income. African American and Hispanic median household income was 58 percent and 70 percent, respectively, that of non-Hispanic whites in 2011.  In contrast, the median net worth of black and Hispanic householders was $6,314 and $7,683, respectively, vs. $110,500 for non-Hispanic whites, a 15-fold difference. Hence, the average family deductibles for bronze and silver plans would bring financial ruin to most African American and Hispanic households. Even the lower cost-sharing now increasingly common under Medicaid may be prohibitive for poor families, many of whom have zero or negative net worth.

The ACA’s drafters erred in relying on private, for-profit insurers to fund health care. Health insurance’s social purpose is to pay for care in order to promote access to health services and prevent financial hardship. For-profit insurers’ purpose is to maximize shareholders’ profits, a goal that provides strong incentives to maximize premiums and minimize the health care they pay for. Historically, this incentive led to such practices as denying coverage for pre-existing conditions and canceling policies for expensive enrollees. Although the ACA prohibits these tactics, recent evidence indicates that insurers are finding ways to subvert these regulations, e.g. through tiered pharmacy benefits that discriminate against enrollees with potentially expensive illnesses such as HIV, Parkinson’s, seizures, psychosis and diabetes.

The persistence of our corrupt and irrational insurance system may stem in part from the way Americans (and particularly health professional students) are taught to think about health care. In a recent conversation with a Canadian student at Harvard’s school of public health, he expressed surprise that many of his U.S. classmates perceive health care interactions as business transactions, and reflected that Canadians, who have a publicly-funded universal coverage system, view health care as a fundamental right to be provided for all.

Should we in the U.S. continue to treat health care as a commodity distributed according to financial ability, or shift to a financing system that assures it as a right equally available to all without regard to income, health status, race or ethnicity? While market theorists might claim that a commodity-based approach to care breeds efficiency, facts on the ground argue otherwise. At present, we have the world’s highest per-capita health care expenditures, yet tens of millions remain un- and under-insured, and our health outcomes trail most other wealthy nations.

This isn’t just an indication of failed policy, it’s a national embarrassment. We have the resources to provide everyone in the U.S. with access to health care. And Canada provides a working model for how to put those resources to good use: a public, single-payer, national health insurance program, similar to an expanded and improved Medicare for all.

In our view a national single-payer health insurance program offers the best possibility for equitable financing of U.S. health care. It would eliminate the motive to deny needed care or discriminate against the expensively ill for the sake of profit. A national public insurance system would provide coverage based on residence in the U.S., not employment status, income level or ability to pay, as in the current regime. A program that abolished co-payments and deductibles would level the playing field for minorities and the poor who generally lack the assets to surmount these barriers.

A single-payer system would also offer economic benefits. A federally-run financing system would have far lower administrative costs than private insurance, as the Medicare program consistently demonstrates. A universal public model would lift a significant financial burden from businesses that currently fund health insurance for their employees. Finally, a single-payer program would largely eliminate the financial burden of illness, a leading cause of bankruptcy and debts sent to collection.

Perhaps most importantly, a single-payer system would make a clear statement that health care is a human right. This framework recognizes health care as a universal necessity, not a commodity reserved for those lucky enough to have won the economic lottery, and most definitely not a scheme for denial and discrimination. While implementing a single-payer insurance program will not solve all of our nation’s health, racial or social inequities, it is clearly a step in that direction.

Single-Payer Health Reform: A Step Toward Reducing Structural Racism in Health Care