PNHP

Scare tactics of health insurance industry

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Scare tactics of health insurance industry

By F. Douglas Stephenson, LCSW, BCD
The Gainesville (Fla.) Sun, March 3, 2015

Using manufactured scare tactics, the U.S. health insurance industry successfully lobbied Congress to enact a requirement that most non-elderly Americans become compulsory customers of the insurance industry and approve taxpayer financing of massive subsidies for the private insurance industry.

With establishment of the Affordable Care Act, Americans have been forced to purchase the product of a particular private industry plus the tax-financed subsidies for the insurance industry in the amount of a half-trillion dollars per decade.

U.S. health insurance companies continue to protect their high profits using scare tactics. One very effective tactic is to deliberately confuse the public by conflating the “socialized medicine” label with single-payer, “socialized (public) health insurance”.

Whatever the pros/cons of socialized medicine, national, single-payer health insurance is not socialized medicine. Socialized medicine is a system in which doctors and hospitals work for and draw salaries from the government. Health-care professionals in the U.S.Veterans Administration and the armed services are paid this way. The good health systems in Great Britain and in Spain are other examples.

Most European countries, Canada, Australia and Japan have socialized health insurance, not socialized medicine. The government pays for care that is delivered in the private (mostly not-for-profit) sector. This is similar to how Medicare works in this country. Doctors are in private practice and are paid on a fee-for-service basis from government funds. The government does not own or manage medical, mental health practices or hospitals.

The term “socialized medicine” is often used by the private insurance industry and politicians to manufacture frightening images of government bureaucratic interference in medical care. In countries with socialized health insurance, health and mental health professionals and patients often have more clinical freedom. This is in sharp contrast to the U.S., where private health insurance bureaucrats attempt to direct/interfere with care .

Manufactured confusion by the health insurance industry and their political spokesmen impede the public’s ability to differentiate, and so far have allowed the private health industry to successfully maintain control of the U.S. health care system for its own purposes.

F. Douglas Stephenson lives in Inglis and is former president of the Florida Society for Clinical Social Work.

http://www.gainesville.com/article/2015150309931?tc=ar

URGENT: Explaining MIPS; Action required

Summary of “SGR Repeal and Medicare Provider Payment Modernization Act”

House Committees on Energy & Commerce and Ways & Means, March 19, 2015

Summary: http://energycommerce.house.gov/sites/republicans.energycommerce.house.gov/files/114/Analysis/20150319SGRSectionbySection.pdf
Yesterday’s Quote of the Day: https://www.pnhp.org/news/2015/march/emergency-the-mips-stake-is-plunging-into-the-heart-of-traditional-medicare

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Comment:

By Don McCanne, MD

Yesterday’s Quote of the Day message sounded the alarm on legislation that would replace the flawed Sustainable Growth Rate formula (SGR) for updating Medicare payments with a new Merit-based Incentive Payment System (MIPS) – legislation with strong bipartisan support that will be taken up in Congress this week and is expected to pass.

Yesterday I sent out a link to the actual legislation (minus crucial amendments, likely detrimental, that have not yet been advanced). Since few have the time to plow through the legislative language and make sense of it, I am now providing a link to the eight page summary (above).

Why this concern?

The SGR formula is considered to be flawed primarily because economic factors considered in the formula would result in inappropriate payment reductions in many of the yearly adjustments. Thus there is consensus that the formula should be repealed. However, it did provide an administratively simple process for trying to keep Medicare rates from increasing well beyond the growth in the economy. That is, there was no administrative burden placed on the providers; they merely had to accept adjustments in their payments.

The concern is over its replacement: MIPS. On reading the summary of the “SGR Repeal and Medicare Provider Payment Modernization Act,” you will see that MIPS places a tremendous administrative burden on health care professionals in a health care system that is already overwhelmingly overburdened with administrative excesses. The only way to escape this additional burden is to participate in Alternative Payment Models (APMs) which, in themselves, create further significant administrative burdens (ACOs, PCMHs, etc.). MIPS is an administrative nightmare.

Some might consider the administrative excesses of MIPS to be worth it if it were to result in fair adjustments to Medicare payment rates. But you need to read the “MIPS Payment Adjustment” section of the summary.

Under the MIPS payment system, eligible professionals with higher scores will receive positive payment adjustments (and may be eligible for an additional incentive payment). We have observed repeatedly how such systems are gamed in order to receive these extra payments. The problem is that those who do not game the system, and especially those with practice situations and patient populations that make it very difficult to score higher points, will almost automatically receive performance scores below the threshold since their performances will be compared with the gamers. This will result in negative payment adjustments – reducing payments by up to nine percent. If you think SGR is unfair, MIPS robs from these hard-working professionals who are just trying to make the system work for their patients, and gives the spoils to those who likely have consultants to show them how to game the system. (Consultants? See Sec. 6 that authorizes “qualified entities” to suck more money out of our health care system by selling analyses and claims data to assist providers in their quality improvement activities., i.e., professional gamesters.)

This is serious. And it is being steamrolled through Congress right now! I consider myself an information resource, but I am not an organizer. Those who care about the future of Medicare and who do have organizational skills must immediately inform themselves on what is happening here. Then act. You cannot wait to watch the Congressional vote tally on C-Span, perhaps as early as this week. By then it will be a done deal.

EMERGENCY! The MIPS stake is plunging into the heart of traditional Medicare

H.R. 1470: “SGR Repeal and Medicare Provider Payment Modernization Act of 2015”

114th Congress

A BILL

To amend title XVIII of the Social Security Act to repeal the Medicare sustainable growth rate and improve Medicare payments for physicians and other professionals, and for other purposes.

TABLE OF CONTENTS.—The table of contents of this Act is as follows:

Sec. 1. Short title; table of contents.

Sec. 2. Repealing the sustainable growth rate (SGR) and improving Medicare payment for physicians’ services.

Sec. 3. Priorities and funding for measure development.

Sec. 4. Encouraging care management for individuals with chronic care needs. 

Sec. 5. Empowering beneficiary choices through continued access to information on physicians’ services.

Sec. 6. Expanding availability of Medicare data.

Sec. 7. Reducing administrative burden and other provisions.

Sec. 2 (c) MERIT-BASED INCENTIVE PAYMENT SYSTEM.

         (1) IN GENERAL.—Section 1848 of the Social Security Act (42 U.S.C. 1395w–4) is amended by adding at the end the following new subsection:

   “(q) MERIT-BASED INCENTIVE PAYMENT SYSTEM.—

       “(1) ESTABLISHMENT.—

         “(A) IN GENERAL.—Subject to the succeeding provisions of this subsection, the Secretary shall establish an eligible professional Merit-based Incentive Payment System (in this subsection referred to as the ‘MIPS’) under which the Secretary shall—

             “(i) develop a methodology for assessing the total performance of each MIPS eligible professional according to performance standards under paragraph (3) for a performance period (as established under paragraph (4)) for a year;

             “(ii) using such methodology, provide for a composite performance score in accordance with paragraph (5) for each such professional for each performance period; and

             “(iii) use such composite performance score of the MIPS eligible professional for a performance period for a year to determine and apply a MIPS adjustment factor (and, as applicable, an additional MIPS adjustment factor) under paragraph (6) to the professional for the year.

       “(2) MEASURES AND ACTIVITIES UNDER PERFORMANCE CATEGORIES.—

          “(A) PERFORMANCE CATEGORIES.—Under the MIPS, the Secretary shall use the following performance categories (each of which is referred to in this subsection as a performance category) in determining the composite performance score under paragraph (5):

              “(i) Quality.

              “(ii) Resource use.

              “(iii) Clinical practice improvement activities.

              “(iv) Meaningful use of certified EHR technology

           “(B) MEASURES AND ACTIVITIES SPECIFIED FOR EACH CATEGORY.—For purposes of paragraph (3)(A) and subject to subparagraph (C), measures and activities specified for a performance period (as established under paragraph (4)) for a year are as follows:

              “(i) QUALITY.—For the performance category described in subparagraph (A)(i), the quality measures included in the final measures list published under subparagraph (D)(i) for such year and the list of quality measures described in subparagraph (D)(vi) used by qualified clinical data registries under subsection (m)(3)(E).

              “(ii) RESOURCE USE.—For the performance category described in subparagraph (A)(ii), the measurement of resource use for such period under subsection (p)(3), using the methodology under subsection (r) as appropriate, and, as feasible and applicable, accounting for the cost of drugs under part D.

              “(iii) CLINICAL PRACTICE IMPROVEMENT ACTIVITIES.—For the performance category described in subparagraph (A)(iii), clinical practice improvement activities (as defined in subparagraph (C)(v)(III)) under subcategories specified by the Secretary for such period, which shall include at least the following:

                 “(I) The subcategory of expanded practice access, such as same day appointments for urgent needs and after hours access to clinician advice.

                 “(II) The subcategory of population management, such as monitoring health conditions of individuals to provide timely health care interventions or participation in a qualified clinical data registry.

                  “(III) The subcategory of care coordination, such as timely communication of test results, timely exchange of clinical information to patients and other providers, and use of remote monitoring or telehealth.

                  “(IV) The subcategory of beneficiary engagement, such as the establishment of care plans for individuals with complex care needs, beneficiary self-management assessment and training, and using shared decision-making mechanisms.

                  “(V) The subcategory of patient safety and practice assessment, such as through use of clinical or surgical checklists and practice assessments related to maintaining certification.

                  “(VI) The subcategory of participation in an alternative payment model (as defined in section 1833(z)(3)(C)).

              In establishing activities under this clause, the Secretary shall give consideration to the circumstances of small practices (consisting of 15 or fewer professionals) and practices located in rural areas and in health professional shortage areas (as designated under section 332(a)(1)(A) of the Public Health Service Act).

              “(iv) MEANINGFUL EHR USE.—For the performance category described in sub-paragraph (A)(iv), the requirements established for such period under subsection (o)(2) for determining whether an eligible professional is a meaningful EHR user.

Sec. 2(e)(6) INTEGRATING MEDICARE ADVANTAGE ALTERNATIVE PAYMENT MODELS.—Not later than July 1, 2016, the Secretary of Health and Human Services shall submit to Congress a study that examines the feasibility of integrating alternative payment models in the Medicare Advantage payment system. The study shall include the feasibility of including a value-based modifier and whether such modifier should be budget neutral.

https://www.congress.gov/bill/114th-congress/house-bill/1470/text

GPO pdf of H.R. 1470: https://www.congress.gov/114/bills/hr1470/BILLS-114hr1470ih.pdf

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Comment:

By Don McCanne, MD

It is URGENT that everyone who cares about the future of Medicare understands what is happening here.

H.R. 1470, the “SGR Repeal and Medicare Provider Payment Modernization Act of 2015,” was formally introduced in the House of Representatives only yesterday (3/19/15), with strong bipartisan support. The 158 pages (GPO pdf) introduced so far provide a mechanism for replacing the Medicare Sustainable Growth Rate (SGR) for determining Medicare payments, with a new Merit-based Incentive Payment System (MIPS).

Next week it is anticipated that the House will act on amendments that allegedly will help offset the cost of canceling payment reductions that would have taken place under the SGR system. Today’s message is limited to the new MIPS, but everyone should be alarmed about the amendments that are to be considered next week. Just two of them – greater means testing of Part B premiums, and requiring Medigap enrollees to start paying deductibles – will be very damaging to the egalitarian nature of our Medicare program.

The excerpts from H.R. 1470,  above, reveal how the government intends to fulfill its goal of supposedly converting Medicare from a system that pays based on volume to a system that is based on value. Since the excerpts represent only a small sampling of this bill, it would be wise to download the full bill. You can gain a better understanding of the bill by skimming through the 158 pages, reading only the lines in full capital letters, while reading in full any section that piques your interest. It takes just a few minutes. That’s too much? Remember, this bill is about to become law and we will have to live with it perhaps for decades (the scorned SGR has been with us for 18 years).

One ominous clause in the bill is Sec. 2(e)(6) on page 101 of the GPO version. It calls for a study of “the feasibility of integrating alternative payment models in the Medicare Advantage payment system.” That is code language to clarify that these onerous requirements of MIPS apply only to the traditional Medicare program and not to the private Medicare Advantage plans. Why is that important?

The House budget introduced this week once again calls for the end of the traditional Medicare program and replacing it with a market of private plans. Although this has been a Republican goal, many Democrats now agree to this MIPS legislation that moves in that direction, and it has the strong support of the AMA and other physician organizations. While loudly proclaiming that we finally have a “doc fix” for the SGR, they are moving forward with changes that will lead us much closer to Medicare privatization, using the excuse that compromise is the way the legislative process works.

Physicians will be mortified by the new requirements and administrative burdens of MIPS. They will be looking for a way out. For those not able to retire, there may be a mass exodus of physicians from the traditional Medicare program into the Medicare Advantage plans. Included in H.R. 1470 is even a ruling change that simplifies the requirements for a physician totally opting out of Medicare indefinitely.

This process is being steamrolled. The bill will pass this month, unless Congress is deafened by a roaring protest.

Are you just going to sit there?

Gov. Brown’s attack on public employee health benefit programs

Unions, retirees blast Jerry Brown’s state worker medical plan

By Jon Ortiz
The Sacramento Bee, March 18, 2015

Unions lined up Wednesday to oppose Gov. Jerry Brown’s proposal to offer high-deductible medical coverage to state employees, suggesting it could hurt workers’ health instead of improving it.

“We think that high-deductible plans are a very bad thing,” SEIU Local 1000 President Yvonne Walker said during a Senate subcommittee hearing into Brown’s plan.

Meanwhile, state experts said it’s not clear whether a plan with high-monthly premiums and a tax-advantaged health savings account would save money in the long run. The most comprehensive studies take in only three years, not nearly long enough to establish a reliable trend.

Brown wants to add at least one health plan to the state’s menu that would give subscribers lower monthly premiums and a tax-advantaged health-savings account in exchange for higher co-pays for visits to doctor significantly larger deductibles for treatments, hospitalization and drugs.

High-deductible plans and health-savings accounts have become common in the private sector as a way for employers to shift more health care cost to their employees. This year the state will pay about $3 billion for employee medical benefits.

CalPERS, which is dominated by union members and politicians with labor ties, has stayed away from offering the kind of low-premium high-deductible health plan Brown has proposed, said Ann Boynton, who is responsible for the fund’s health plan contracting.

For reference, she noted that the lowest-premium plan CalPERS offers members now, PERS Select, has just 17,000 subscribers, fewest of any of its preferred-provider organization plans.

Member surveys show those subscribers are the most dissatisfied with their coverage, Boynton said, due to the steep co-pays and how hospitals in the preferred networks price services.

http://www.sacbee.com/news/politics-government/the-state-worker/article15302201.html

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Retirees Could Lose their ‘Guaranteed’ Health-Care Benefits

By Allison Schrager
Bloomberg Business, March 18, 2015

California’s struggling to pay for health care for retired state employees, with an estimated $72 billion in medical costs coming in the next 30 years. Governor Jerry Brown’s solution: Make workers start contributing money to pay for the health care they’ll need after retiring.

Until recently, the courts had regularly said that health-care benefits must be honored. In January, that changed: The Supreme Court unanimously decided that retiree health benefits are not necessarily guaranteed.

Since 1992, private companies have had to list health-care obligations as a liability on their balance sheets. Being forced to disclose health-care costs led many employers to ditch retiree health care. A Kaiser Foundation report speculates that the remaining plans may soon be eliminated, too.

The Supreme Court’s ruling may finally signal the end of private-sector retirement health benefits. What it means for public-sector retirees is still an open question, although some lawyers say the same ruling will apply. If that’s the case, the consequences may be more far-reaching. Employer health coverage among public-sector retirees is still common. From 2006 to 2010, health plans covered two-thirds of Medicare eligible and three-quarters of early retirees.

http://www.bloomberg.com/news/articles/2015-03-18/retirees-could-lose-their-guaranteed-health-care-benefits

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Comment:

By Don McCanne, MD

Private employers have taken the initiative in slowing the cost increases in their health benefit programs. They have been reducing or terminating their retiree health plans. They have also greatly expanded the use of high-deductible health plans which shift costs of care to their employees. Public employees have been relatively insulated from these reductions, largely due to more favorable plans negotiated by their unions. California’s Governor Jerry Brown is now attempting address the state’s budget issues by reducing the state’s contribution to these plans.

These were not free benefits that the unions negotiated. They were paid for by forgoing wage increases. To reduce these benefits without compensatory wage increases amounts to significant pay cuts for the government employees. That is not right.

Also, high-deductible health plans clearly reduce access to appropriate health care primarily because health care becomes less affordable when the patient is faced with greater out-of-pocket costs. CalPERS has confirmed what was already well known about the high-deductible plans: subscribers to these plans are the most dissatisfied. Today’s payers, whether the government or the private sector, are taking it out on their employees through these undesirable reductions in benefits that create potential financial hardships for their employees.

It would be far better to remove the employer, public or private, from the role of being keeper of the health benefits, and to restore, in full, the wage and salary increases that have been forgone to pay for these programs.

With a publicly-financed and publicly-administered single payer program – an improved Medicare for all – there would be no need for employer-sponsored plans for either active or retired employees. Also, the public program would be designed for the benefit of patients needing care, rather than being used inappropriately as a tool to balance public or private budgets.

Think About It: Democracy or Sausage

By Bertha Cooper
Sequim (Wash.) Gazette, March 18, 2015

Most of us have heard the saying that watching legislation being made is like watching sausage being made. The image brings to my mind watching pigs being sacrificed and seeing some parts going to fine cuts of pork for those that can afford it and less desirable, unappetizing parts being ground into sausage for just about everyone’s breakfast.

The implication is that the process of making laws is a lot like making sausage and so revolting that we would lose our faith in the quality of the final product, that is, if we haven’t already.

I resent this analogy typically used by politicians involved in the process and all-knowing pundits. It comes across too much as an insider reflection that separates us ordinary folk from elite law makers and observers and, I think, might cover up things they don’t want us to know.

After all, we call our legislative process democracy, which should be a transparent process that can be audited at any point by the voting public.

Groups or individuals who wish to influence public policy are at a significant disadvantage when they do not have access to the process. As much as they keep their eye on the process around their bill and attempt to use the system to make their case, they cannot know the deals that are made behind the scenes.

Making sausage

Case in point is an example that dashed the hopes of a singularly dedicated group, Healthcare for All/WA (HCFA-WA), that has been working for over a decade to improve access to health care while reducing health care costs not only for the government, but for the individual and family.

Following the implementation of the Affordable Care Act (Obamacare), they started working with the state Legislature to activate a provision that would allow a waiver to the State of Washington to enact a version of the single payer system that would provide for health care for all Washington residents.

2015 was no different and another bill (HB 1025), sponsored by 23 legislators, one of whom was Steve Tharinger from our district, was submitted to the House. A public hearing for the bill was scheduled for Feb. 20 before the House Health and Wellness Committee on which Tharinger and Kevin Van De Wege, our other representative, sit.

Both Tharinger and Van De Wege have said that there wasn’t a snowball’s chance on Hurricane Ridge in 2015 that it would pass during this legislature session. Still, the group persisted as many do (think women’s right to vote) because they did want to keep the issue before the Legislature for passage in 2016 or 2017.

In order to understand what’s going on in this story, it is important to remember that payment of our nation’s health care system is through commercial insurance predominantly provided as an employee benefit, government payers such as Medicare, Medicaid and Tricare and commercial insurance purchased by individuals through Obamacare.

HCFA-WA’s idea is to eliminate commercial health care insurance for the most part and move to a less complicated single payer system. To make their point, the group pulled together businesses owners and representatives to testify at the hearing to the economic value of a single payer plan to businesses.

Secret sauce

A related bill (HB 1967) was put forth by Health and Wellness Committee asking for a different waiver provided for in Obamacare around Feb. 1. “HCFA-WA only learned about the Bill one week before their scheduled testimony on HB 1025,” according to Patrick Noonan, a member of HCFA-WA who would provide testimony.

The new bill introduced by the committee (HB 1967) would “permit employers to integrate employer health care arrangements with individual market policies and to authorize alternative structures for those participating in medical assistance.” In other words, the bill supported the existing American method of insurance policies for health care and effectively silences any effort toward single payer in the near future years.

The public hearing for the new bill with three sponsors was held on Feb. 11 and executive action was taken on Feb. 17, three days before the scheduled hearing at which HCFA-WA would appear. The Health and Wellness Committee passed the new legislation with a majority, which included Tharinger and Van De Wege, and was sent to appropriations on a relative fast track.

I could have burst into tears hearing this all too familiar story of the long-suffering boyfriend or girlfriend that waited for years only to be left standing at the altar except this bride or groom of democracy was ruthlessly sent into obscurity without so much as an explanation. Sure there was a public hearing for the new bill, but who knew?

Who on the Health and Wellness Committee could not take the time to say we are going in another direction? And why not? No one seemed to have the interest or courtesy to tell this group or, as it turns out, to listen to any more they had to say.

Grind to a humiliating halt

HCFA-WA’s time at the Feb. 20 hearing was reduced to 10 minutes. One HCFA-WA participant reported that they were first on the agenda and although Tharinger and Van De Wege were present, very few legislators were. Other legislators arrived at a leisurely pace during the presentations. Once seated, many of the few made no pretense to listen and turned their attention instead to their electronic device or each other.

There was nothing subtle about the message; they were not interested. Noonan had driven from the Olympic Peninsula and stayed the night so he could participate in the legislative process. He lamented, “The path was already decided,” and added, “I was embarrassed for us and I was embarrassed for them. Mostly, I was embarrassed for democracy.”

So why do it; why waste their time and the time of interested citizens? My guess is that the Health and Wellness committee of the House needed to document that they gave 10 minutes to HCFA-WA in compliance of some sort of rule.

The point is not whether one supports the bill or not; it’s more that the process should allow for transparency and inclusion of differing views. Things that have to be hidden in the sausage can’t be good. In the end, the group and presenters were not allowed at the table making the sausage.

I can’t help but think that someone more influential than this low-budget, nonprofit group was at the table and will get the fine cut of pork.

Bertha D. Cooper is retired from a 40-plus year career as a health care administrator focusing on the delivery system as a whole. She still does occasional consulting. She is a featured columnist at the Sequim Gazette. Reach her at columnists@sequimgazette.com.

http://www.sequimgazette.com/opinion/296782981.html#

How American health care turned patients into consumers

By Philip Caper, M.D.
Bangor (Maine) Daily News, March 19, 2015

A clash of cultures is rapidly developing among those of us who see the mission of the health care system to be primarily the diagnosis and healing of illness and those who see it primarily as an opportunity to create personal wealth.

The concept of health care primarily as a business is uniquely American, and it has gained ascendancy during the last few decades. While there have always been a few greedy doctors, businessmen-wealth-seekers — not doctors — now dominate the medical-industrial complex. They include for-profit insurance, medical device and pharmaceutical companies as well as for-profit and nonprofit corporate providers of health care services, such as the three large hospital systems in Maine.

Partly because of the Affordable Care Act, they also include a rapidly growing army of lawyers, consultants and policy wonks who are creating lucrative businesses helping hapless “consumers” — formerly “patients” — “navigate” their way through the grotesquely byzantine maze our health care system has become.

This shift in emphasis from patient care to money profoundly has affected the practice of medicine and resulted in the clash of cultures within health care. As increasing numbers of “providers” — formerly “doctors” — become employees of large health care corporations — formerly community hospitals — we have come under increasing pressure to diagnose profitable diseases and order profitable tests and procedures without enough regard to the benefits or harm accruing to patients. Hospital “CEOs” — formerly “administrators” — trained in the ethics and practices of business rather than health care are incentivized to configure their “product lines” — formerly “services” — to produce the largest “profits” — formerly “margins.”

Those of us in the health care “business” — formerly “profession” — have been slow to react to this hijacking of our health care calling. Patients, despite sensing something is deeply wrong, feel helpless to push back. That now seems to be changing.

For the past three years The Lown Institute, founded by Dr. Bernard Lown, renowned cardiologist and advocate for universal health care, has held conferences designed to point out the growing problem of overtreatment in medicine. Recently they also have turned their attention to the equally disturbing problem of impaired access to health care and undertreatment. They now advocate for RightCare — not too much treatment and not too little.

Arguably some of the most important effects of Obamacare have been the destabilization of our deeply dysfunctional health care system and an order-of-magnitude increase in the amount of attention given to its dysfunction by the media and the public. Elisabeth Rosenthal’s excellent New York Times series “Paying Till It Hurts” and Steven Brill’s Time magazine cover story and book titled “America’s Bitter Pill” are two of the most recent examples. These two factors have created an opportunity for real structural and cultural change.

There are many advocacy groups — Physicians for a National Health Program, HealthCare-NOW, Maine AllCare — trying to highlight these issues and to propose ways to turn this runaway train around.

While they are necessary, attempts at education and persuasion are not sufficient. Unlike past human rights movements, such as women’s suffrage and marriage equality, the fight for the right to health care for all Americans will require redirecting huge sums of money away from deeply entrenched, profit-oriented private corporations to not-for-profit programs that directly promote the public’s health and well-being.

The Institute of Medicine estimates that the convoluted American health care system wastes $750 billion per year in inefficiency and fraud, unnecessary administrative complexity and medical services, unjustifiably high prices and missed prevention opportunities. That waste creates a lot of jobs but does not pay for one Band-Aid or aspirin.

I attended the latest Lown conference, held last week in San Diego, to talk about the “Heal-In” held at Boston City Hospital in 1967 as an example of direct action taken by doctors, nurses and other healers to achieve a political goal without compromising patient care. The capstone of the conference was to announce the expansion of Lown’s mission, previously focused on education and discussion, to include creation of a national grassroots movement that will include direct action. Their first foray will be called RightCare Action week and is scheduled for the fall. Stay tuned.

Changing our health care system is as much about persuasion through power as it is about the power of persuasion. We as patients have power through the ballot box, and we as health care workers have power through our key roles in the “business” of health care to return and redirect its mission toward healing and away from its increasingly singular obsession with profitability.

All we have to do is summon the will and the courage to exercise that power.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com or through his website at philcaper.net.

http://bangordailynews.com/2015/03/19/health/blogs-and-columns/how-american-health-care-turned-patients-into-consumers/?ref=search

Blue Shield of California loses its state tax-exempt status

With billions in the bank, Blue Shield of California loses its state tax-exempt status

By Chad Terhune
Los Angeles Times, March 18, 2015

Authorities have revoked the tax-exempt status of nonprofit Blue Shield of California, potentially putting it on the hook for tens of millions of dollars in state taxes each year.

The move by the California Franchise Tax Board comes as the state’s third-largest health insurer faces fresh criticism over its rate hikes, executive pay and $4.2 billion in financial reserves.

The highly unusual action comes after a lengthy state audit that looked at the justification for Blue Shield’s taxpayer subsidy.

Now, a company insider has sided with critics. Michael Johnson, who resigned as public policy director last week after 12 years at the company, said the insurer has been “shortchanging the public” for years by shirking its responsibility to Californians and operating too much like its for-profit competitors.

On Wednesday, Johnson plans to launch a public campaign calling on executives to convert the insurer into a for-profit company and return billions of dollars to the public that could be used to bolster the state’s healthcare safety net. He estimates the company could be worth as much as $10 billion.

In 1996, a similar conversion of Blue Cross of California — now part of Anthem — generated $3 billion to establish the California Endowment and the California HealthCare Foundation.

The company defends its work on behalf of Californians. It cites its long-standing support of health reform and numerous efforts to make coverage more affordable.

“Blue Shield as a company and management team firmly believes it is fulfilling its not-for-profit mission and commitment to the community,” said company spokesman Steve Shivinsky.

In 2011, amid a backlash over rate increases, the insurer capped its profits at 2% of annual revenue and gave back about $560 million to customers and community groups from 2010 to 2012. Blue Shield has also contributed more than $325 million over the last decade to its own charitable foundation.

But some consumer advocates and health-policy experts say those gestures are lacking in light of the company’s stockpile of cash.

Blue Shield’s surplus of $4.2 billion at the end of 2014 is four times as much as the Blue Cross and Blue Shield Assn. requires its member insurers to hold to cover future claims.

Critics also note the company hasn’t served the state’s poorest residents on Medi-Cal and it has frequently run afoul of state regulators. The 2011 disclosure of a nearly $5-million salary for its former chief executive drew protests.

Some consumer groups have also questioned whether certain Blue Shield spending is out of line with its nonprofit mission.

For instance, the company contributed about $10 million to defeat a ballot measure last year seeking rate regulation. It spent $2.5 million for a luxury box at the new professional football stadium in Santa Clara, Calif.

Critics have also long complained about Blue Shield’s lack of disclosure.

Blue Shield was founded by the California Medical Assn. as part of a national movement by hospitals and doctors to form prepaid health plans.

The company is a “mutual benefit” nonprofit — “dedicated to charitable, religious or public purposes,” according to California corporation law.

http://www.latimes.com/business/la-fi-blue-shield-california-20150318-story.html

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Comment:

By Don McCanne, MD

Many of us in California were very upset when Blue Cross of California converted to a for-profit (WellPoint, then Anthem) and immediately changed its behavior to fulfill its responsibilities to its shareholders as a profit-making business. We immediately saw “insurance innovations” that redirected its business goals from taking care of patients to taking care of shareholders.

It was particularly disappointing to see non-profit Blue Shield of California adopt similar insurance innovations in order to remain competitive in the California insurance market. From the perspective of health care “consumers,” Blue Shield and Blue Cross remained virtually indistinguishable.

Blue Shield of California has annihilated the dream of those who believed that the United States could adopt a universal system of private, non-profit insurance companies like they have in Switzerland. There are many serious problems with the Swiss model, but some believed that a market of well-regulated, non-profit insurers would make optimal patient care a priority. Blue Shield of California has now demonstrated to us that this pipe dream would only become another nightmare in the saga of private insurance markets in the U.S.

We need to banish them and establish our own public program – an improved Medicare for all.

“Paying for value” could mean the end of small family practices

A Boehner-Pelosi prescription for Medicare doc fixes

By Jennifer Haberkorn and David Rogers
Politico, March 15, 2015

In a rare display of bipartisanship, House leaders are actively pursuing a deal to permanently change the way Medicare pays doctors and to extend a children’s health program for two years.

While details are still being ironed out, the basic contours are clear: The plan would permanently eliminate the Sustainable Growth Rate, the outdated formula that calls for frequent and deep cuts to Medicare providers, and replace it with a new payment system. This is a priority for both parties to end the need for frequent “doc fixes.”

The replacement policy agreed to by the House Energy and Commerce and Ways and Means committees and the Senate Finance Committee would move away from volume-based payments, in which physicians are paid based on the number of tests or procedures ordered, into a value-based system. That would reward them with higher payments when they meet performance thresholds on improved care and quality.

This new system would set up a series of quality measures that physicians will have to meet and would incentivize care coordination, particularly for patients with chronic care needs in which multiple doctors are involved.

The replacement policy is widely supported by medical organizations. But some critics argue the bill is too vague and that its reporting requirements could be ruinous to small practices.

“Aspirationally, it is correct, but we don’t know enough about how to measure value,” said Robert Berenson, the former vice chairman of the Medicare Payment Advisory Commission. “This could mean the end of small general practices for all practical purposes.”

http://www.politico.com/story/2015/03/medicare-doctors-john-boehner-nancy-pelosi-116097.html

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Comment:

By Don McCanne, MD

The rhetoric sounds great. We are moving away from paying for the volume of health care provided, and we are going to pay for value instead.

In reality, volume will always be an important factor in determining health care costs. Maybe there are marginal expenses that can be reduced, but most services are clinically appropriate and do have relatively fixed costs involved. Reducing volume has really been code language for using various schemes such as accountable care organizations and bundling of payments to reduce prices. These schemes have an almost negligible impact on reducing volume.

What is this increased value that the industry envisions? Usually they are referring to quality measures. Yet those measurements are very primitive. As Robert Berenson says, “we don’t know enough about how to measure value.” Yet reducing payments for volume and giving rewards for Mickey Mouse quality scores increases administrative complexity – increasing busy work without increasing value.

Do we really want to do this? Again, quoting Robert Berenson, “This could mean the end of small general practices for all practical purposes.” My personal primary care physician is a solo practitioner. I should have to give him up simply because some policy people believe that we should continue down this path when there is very little support that these measures will either reduce costs or increase quality?

What the policy people do know is that an improved Medicare that covered everyone for the same amount that we are spending today is the most effective way to improve value. We should go where the action is. Once there, we can tweak the system for quality and volume.

Feds Knew About Medicare Advantage Overcharges Years Ago

By Fred Schulte
NPR, March 13, 2015

Federal health officials were advised in 2009 that a formula used to pay private Medicare plans triggered widespread billing errors and overcharges that have since wasted billions of tax dollars, newly released government records show.

Privately run Medicare Advantage plans offer an alternative to standard Medicare, which pays doctors for each service they render. Under Medicare Advantage, the federal government pays the private health plans a set monthly fee for each patient based on a formula known as a risk score, which is supposed to measure the state of their health. Sicker patients merit higher rates than those in good health.

Health insurer Humana Inc. disclosed that its Medicare Advantage plans are being looked at by the feds.

The program is a good fit for many seniors. Some 16 million people have signed up — about a third of people eligible for Medicare — and more are expected to follow. Supporters argue that Medicare Advantage improves care while costing members less out of pocket than standard Medicare. The Medicare Advantage industry is lobbying hard to block budget cuts sought by the Obama administration.

Medicare Advantage plans are “clearly an important force to be reckoned with when it comes to making public policy,” said Dr. Robert Berenson, a former government health official, who is now at the Urban Institute.

But overspending tied to rising risk scores has cost taxpayers billions of dollars in recent years, as the Center for Public Integrity reported in a series of articles published last year. And concerns that some health plans overstate how sick their patients are date back years, according to records recently released to the Center for Public Integrity under the Freedom of Information Act.

The documents include an unpublished study commissioned by the agency that runs Medicare and the Centers for Medicare and Medicaid Services, and dated Sept. 29, 2009; the study tracked growth in risk scores starting in 2004, the year after Congress created the billing tool.

The study found that risk scores for Medicare Advantage enrollees grew twice as fast between 2004 and 2008 as they would have had the same person remained in standard Medicare. The study said it was “extremely unlikely” that people who enrolled in the plans actually got sicker and noted that coding inflation “results in inappropriate payment levels.”

The lead author was Richard Kronick, then a researcher at the University of California, San Diego. Kronick now heads the federal Agency for Healthcare Research and Quality, a research arm of the Department of Health and Human Services. He had no comment. Other authors listed included three CMS employees.

A CMS spokesman said on Thursday that the agency sought to publish the findings on a government run research site, but was told it needed to be “substantially shortened” to be considered. “Given competing workload demands we were not able to revise and resubmit the article,” the official said in a statement.

The study cited diabetes as an example of the billing problem.

The private Medicare Advantage health plans reported rates of diabetes with medical complications more than twice as often as for people in standard Medicare. “It seems extremely unlikely that the actual distribution of diabetics changed substantially in MA plans … and almost surely reflects MA efforts to more fully document members’ diagnoses,” the study said.

The authors noted that “a number of companies have successfully marketed services to help MA plans increase their risk scores.” They also said that the problem was worsening over time.

The study said that a number of large Medicare health plans, which were not named, raised risk scores far above their peers. But the agency chose not to ferret out the worst offenders and discipline them. Instead CMS cut rates industrywide in 2010 by 3.41 percent to offset the jump in risk scores.

Berenson, of the Urban Institute, said cutting rates across the board was a kind of “rough justice.”

“It seems to me that they need to identify the plans that are bending the rules,” Berenson said. “It’s not so easy to focus in on plans that are overly aggressive [in billing],” he said.

Medicare Advantage plans are currently mounting an aggressive lobbying effort to stave off proposed new federal budget cuts. Fifty-three senators signed a recent letter opposing the cuts. The Coalition for Medicare Choices, run by the health insurance industry, even rolled out a “Medicare Advantage”-themed food truck that parceled out free cookies and coffee near the U.S. Capitol. Utah Sen. Orrin Hatch was among those who stopped by.

Separately, an advocacy group called the Better Medicare Alliance on March 10 unveiled a pair of advertisements arguing any cuts would cause seniors to pay more for their medical care.

Clare Krusing, a spokeswoman for America’s Health Insurance Plans, said in a statement:

“Seniors enrolled in Medicare Advantage have already faced year-over-year cuts to the coverage they rely on. Now, CMS is proposing another cut at a time when beneficiaries, policymakers, providers are all calling for stability in the program. Preventing any further cuts to Medicare Advantage will ensure seniors can continue to rely on this critical lifeline.”

Though Medicare Advantage has built formidable support in Congress, the risk-based payment system has critics in other areas of government.

Earlier this week, the Government Accountability Office, the audit arm of Congress, cited more than $12 billion in improper payments to Medicare Advantage plans among a total of nearly $60 billion in misspent Medicare funds for 2014. A broader GAO audit of how well federal officials have monitored the industry to curb overbilling is underway; it’s due to be released later this year.

The industry has a good track record when it comes to building the political support to silence its critics. For instance, an ad campaign run by the industry in 2013 turned a proposed 2 percent cut in rates into a 3 percent rate hike. In backing down, CMS officials said the revised rates would give patients “more value in the care they receive and greater protections against increasing costs.”

President Obama’s proposed 2016 budget seeks more than $36 billion in Medicare Advantage cuts over the next decade, mainly by taking aim at risk scoring.

A final decision on the payment rates for 2016 is due in April.

This piece comes from the Center for Public Integrity, a nonpartisan, nonprofit investigative news organization. For more, follow the center on Twitter @Publici, or sign up for its newsletter.

http://www.npr.org/blogs/health/2015/03/13/392755143/feds-knew-about-medicare-advantage-overcharges-years-ago

Report: Medical loss ratio has no impact on private insurers’ overhead

Plans met MLR limit before Affordable Care Act was in place

By Dori Zweig
Fierce Health Payer, March 16, 2015

The Affordable Care Act seemingly has had little or no impact on health insurers’ overhead, according to a new report from the International Journal of Health Services.

The report’s authors examined medical loss ratios (MLRs) using the pre-2011 definition set by the Department of Health and Human Services: Total premium income divided by total medical payments. The authors analyzed this data for risk-bearing plans for every insurer listed in the Fortune 500 for three years prior to and after implementation of the MLR rule in 2012. The rule requires an MLR of at least 80 percent in the individual and small-group markets and 85 percent in the large-group market.

Here’s what the authors found:

The average MLR of the nine Fortune 500 insurers assessed did not change before and after the new regulation: 83.04 percent for 2009-2010 and 83.05 percent for 2011-2013. (Cigna was excluded from the study due to changes in accounting practices that made an accurate assessment impossible.)

MLRs dropped at three of the four largest insurers. UnitedHealth’s MLR from 2008-2010 was 81.6 and fell to 80.9 percent for 2011-2013. Humana’s was 83.4 percent and dropped to 83.2 percent, while Aetna’s was 83.0 percent and fell to 81.6 percent.

Centene experienced the most significant increase in MLR. From 2008-2010, the average was 83.3 percent; it rose to 88.5 percent for 2011-2013.

“Although overhead was reduced at some insurers, with one exception these reductions were within the range of year-to-year fluctuations commonly seen in the past,” the authors pointed out. Additionally, these results are consistent with trends in the National Health Expenditure Accounts, which found medical spending decreased slightly as a proportion of private insurance premiums two years into ACA implementation. Finally, the report concluded that overhead at private insurers remains six times as high as traditional Medicare overhead.

As of late, insurers have pushed for change to MLR requirements, FierceHealthPayer previously reported. The industry wants payments to brokers and agents excluded from administrative costs, claiming that their inclusion in MLR calculations hurts insurers’ bottom lines and drives up premiums.

For more – here’s the report.

http://www.fiercehealthpayer.com/story/report-medical-loss-ratio-has-no-impact-private-insurers-overhead/2015-03-16

Medicare works; open it to everyone

By Larry Donohue, M.D.
The Daily Herald (Everett, Wash.), March 15, 2015

Is our social contract obsolete, only a fond memory of a simpler time? Some, perhaps many, on the political right who embrace a libertarian view hold that their successes are self-made and so should be yours.

As conservatives legislatively seek its repeal and the U.S. Supreme Court again reviews the constitutionality of the Affordable Care Act, or Obamacare, it is possible that we could return to the shame that in this affluent country so many of our citizens could again be without affordable access to even basic health care.

If we could get past polarized political positions, there is no question that Obamacare can be and indeed needs to be improved. Legislative compromises left Obamacare less than it could be. Quality improvement opportunities include:

First, the costs of health care are not optimally curtailed.

There is no question that we should pay for quality of care not quantity of care, as we have traditionally done, easy in concept but more difficult in operation.

The low hanging fruit of cost containment is the administrative costs of our commercial insurers. There is up to 20 percent of the premium dollar going for advertising, high executive salaries and other items that don’t contribute to improving health care. But this low hanging fruit is not as easy to harvest as it might be.

Bloomberg Business stated it clearly.

“But the thing that few people talk about, and that no serious policy proposal attempts to fix — the arrangement that accounts for much of the difference between health spending in the U.S. and other places — is the enormous administrative overhead costs that come from lodging health-care reimbursement in the hands of insurance companies that have no incentive to perform their role efficiently as payment intermediaries.”

Second, commercial health insurance rules and regulations introduce expensive-to-administer complexity, not value. Each health insurance plan contractually assembles its own networks of providers, benefits and rules. It need not contract with providers that it judges expensive, despite the providers expertise. An example is Seattle Children’s Hospital, a locally cherished and nationally respected health care facility. Several insurers are reported to have not contracted with Children’s, citing cost. Their insureds are denied access to these renowned physicians. With pressure from the Office of the Insurance Commissioner, more insurers are now including Seattle Children’s Hospital in their networks, but with each contract year the problem can return.

A University of Washington Medical School Professor opined that one of the problems of our health care system is that strategy decisions are now being crafted by masters of business administration rather than by health care professionals. The bottom line trumps the common good.

A second example, arguably the premier cancer research and treatment center in the country, The Seattle Cancer Care Alliance (The Fred Hutchinson Cancer Research Center, University of Washington Medicine and Seattle Children’s Hospital) and the largest provider of commercial health insurance in the state, Regence BlueShield, covering some 1.1 million people, have failed to reach contractual agreement, thus denying these 1.1 million fellow Washingtonians affordable access to world-class cancer experts.

A diagnosis of cancer is enough of a psychological assault without adding the additional burden of having to choose between paying for locally available, internationally recognized cutting edge care and risking personal bankruptcy or choosing to forgo potentially life saving state-of-the-art care.

Both of these quality improvement opportunities can be addressed by adopting a “Medicare for all” program to administer health care payment.

The Medicare program is efficient and popular with users. In the heat of argument a few years ago, an impassioned speaker said “Keep your government hands off my Medicare!” Go figure!

The major obstacle to accomplishing these quality improvements is the untoward influence of health care industry lobbyists. More than 2,400 individuals are registered as lobbyists for the health care sector. The National Journal’s “Influence Alley” reported that health insurance lobbyists funneled $102.4 million to the Chamber of Commerce during the health care reform debate. Health care industry lobbyists regularly spend $500 million each year influencing Congress.

If the only dialogue is between the lobbyists and politicians, affordable, efficient, quality health care for all will not happen. It is up to us to get involved and make our voices heard. The wisdom of the people can figure it out.

Larry Donohue has worked as a physician with the U.S. Army, UW and Harborview medical centers and a small group practice, served on the governing board of Swedish Medical Center and was an ombudsman and associate medical director for Regence BlueShield. He lives in Seattle. He is also a cancer patient.

http://www.heraldnet.com/article/20150315/OPINION03/150319541

Patients lack enough assets to pay insurance cost sharing

Consumer Assets and Patient Cost Sharing

By Gary Claxton, Matthew Rae, and Nirmita Panchal
Kaiser Family Foundation,  March 11, 2015

While concerns about cost sharing are not new, the recent coverage expansions under the ACA put a new focus on what it means for coverage to be affordable. The goal of the law was to cover more of the uninsured, many of whom have limited means. The law requires most people to have health insurance, if they can afford to pay the premium, or to pay a penalty. The issue for some families, however, is that the policies with affordable premiums may have cost sharing requirements that would be difficult for them to meet when they access services. Many of the policies in the state and federal marketplaces have significant cost sharing, as do many policies provided to people at work. The ACA provides cost-sharing assistance to some, primarily to those with incomes below 200 percent of poverty purchasing through a state or the federal marketplace. Others potentially face much higher out-of-pocket expenses.

Deductibles

Overall, three in five (63%) households have enough liquid financial assets to meet the lower deductible amounts ($1,200 single/$2,400 family) while one-half (51%) can meet the higher deductible amounts ($2,500 single/$5,000 family). These percentages are similar for single-member and multi-member households, but vary significantly by family income. Only 32% of households with incomes between 100% and 250% of poverty can meet the lower deductible amounts, while one-in-five can meet the higher deductible amounts. In contrast, 88% of households with incomes over 400% of poverty can meet the lower deductible amounts and three-in-four (79%) can meet the higher amounts.

Out-of-Pocket Limits

Out-of-pocket limits are higher than deductibles and meeting them is more difficult for many families. Forty-eight percent of households have enough liquid financial assets to meet the lower out-of-pocket limits ($3,000 single/$6,000 family) and 37% can meet the higher limits ($6,000 single/$12,000 family). The percentages are quite low for households with incomes between 100% and 250% of poverty, with 18% having enough liquid financial assets to meet the lower out-of-pocket limits and 11% being able to meet the higher limits. Among households with incomes over 400% of poverty, 75% have enough liquid financial assets to meet the lower out-of-pocket limits while just 62% can meet the higher limits.

Discussion

Many non-elderly, non-poor households lack the resources to meet the deductibles and out-of-pocket limits that they may encounter in the private insurance market. Many households have insufficient liquid financial assets to meet the specified cost sharing measures, and the situation for net financial assets is no better. Not surprisingly, the difficulties are greater in households with lower incomes and with someone who lacked health insurance.

While the ACA provides for reduced cost sharing for some people with incomes below 250% of poverty that purchase coverage in a state or the federal marketplace, there is no assistance with cost sharing for those with higher incomes or for those obtaining coverage through a job. Substantial shares of households with incomes between 250% and 400% of poverty would be unable to meet even the lower out-of-pocket limits with their current resources, and meaningful shares of households with incomes over 400% of poverty would have problems as well.

http://kff.org/health-costs/issue-brief/consumer-assets-and-patient-cost-sharing/

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Comment:

By Don McCanne, M.D.

This important study demonstrates one of the most serious deficiencies in our dysfunctional system of health care financing: the mismatch between the personal financial assets that most Americans have and the cost sharing in the form of deductibles and out-of-pocket limits required by their insurance plans. Far too many individuals, should they have significant medical needs, do not have adequate liquid assets to cover the level of cost sharing required by most plans today.

Look at the most favorable example above: 25% of higher-income families (families with incomes over 400% of poverty) do not have enough liquid financial assets to pay lower out-of-pocket limits of $3,000 single/$6,000 family. Worse, 38% of these higher-income families do not have enough liquid assets to pay higher out-of-pocket limits of $6,000 single/$12,000 family (the 2015 out-of-pocket limits for plans in the ACA exchanges are even higher: $6,600 individual/$13,200 family). Further, net financial assets are usually lower than liquid financial assets because of family debt; families are even more broke than their cash on hand would indicate.

Except for those with the very highest incomes, our current flawed system of financing health care through private plans creates financial hardship for far too many of us who require significant amounts of health care. Today’s private insurance products are inadequate.

What is the source of support for this deficient coverage? Private insurers want to maintain access to markets by keeping their premiums competitive. They do this partly by shifting costs to patients’ pockets. Neoliberal and conservative politicians want to keep spending on government premium subsidies to a minimum, so they support cost sharing policies that reduce premiums. Libertarian and conservative ideologues want to place health care consumers in charge of spending their own money. If they don’t have enough funds, well, that’s too bad. They should have had enough personal responsibility to establish their own health savings accounts and fully fund them before medical needs arose. Sure.

Private insurers we can certainly do without. But what about the ideologues? Is there no place in this country for egalitarianism and social solidarity? I cringe when I think about current trends advancing income and wealth inequality as the social fiber continues to shred.

We desperately need a single-payer, improved Medicare for all, with first dollar coverage. Let’s harness the forces of social solidarity so we can achieve that goal.