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Consumer-directed health plans reduce utilization of essential drugs

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Consumer-directed health plans reduce utilization of essential drugs

Patient Responses to Incentives in Consumer-Directed Health Plans: Evidence from Pharmaceuticals

By Peter J. Huckfeldt, Amelia Haviland Ateev, Mehrotra Zachary Wagner, and Neeraj Sood
National Bureau of Economic Research, NBER Working Paper No. 20927, February 2015

Abstract

Prior studies suggest that consumer-directed health plans (CDHPs) – characterized by high deductibles and health care accounts – reduce health costs, but there is concern that enrollees indiscriminately reduce use of low-value services (e.g., unnecessary emergency department use) and high-value services (e.g., preventive care). We investigate how CDHP enrollees change use of pharmaceuticals for chronic diseases. We compare two large firms where nearly all employees were switched to CDHPs to firms with conventional health insurance plans. In the first firm’s CDHP, pharmaceuticals were subject to the deductible, while in the second firm pharmaceuticals were exempt. Employees in the first firm shifted the timing of drug purchases to periods with lower cost sharing and were more likely to use lower-cost drugs, but the largest effect of the CDHP was to reduce utilization. Employees in the second firm also reduced utilization, but did not shift the timing or use of low cost drugs

From the Introduction

Overall, we find evidence that employees in the CDHP with pharmaceuticals subject to the deductible use more low cost drugs and shift the timing of drug purchases to periods with lower cost sharing. The majority of the response, however, is to reduce overall drug utilization. These results imply that enrollees possess some awareness of benefit design and availability of low cost drugs, but also suggest that enrollees either discount or are not cognizant of the adverse consequences of poor adherence. Employees in the CDHP with pharmaceuticals exempt from the deductible also exhibit decreased utilization relative to firms with conventional coverage. The presence of a utilization response may suggest a lack of understanding of plan design or reflect secondary effects where increased cost sharing leads to fewer physician visits where drugs are prescribed. The persistence of the response into the second year of the plan (presumably a sufficient time period for enrollees to understand plan design) may suggest this response is due to cost sharing for physician visits.

From the Conclusion

We investigate the effects of CDHPs on use of pharmaceuticals that treat and prevent chronic diseases including high cholesterol, hypertension, and type 2 diabetes. We compare changes in utilization among employees in two firms that shift all of their employees to CDHPs relative to employees in firms that offered no CDHP; in one firm (CDHP firm 1) pharmaceuticals are subject to the deductible and in the other pharmaceuticals are exempt from the deductible (CDHP firm 2). We find that enrollees in CDHP firm 1 change utilization of pharmaceuticals along each hypothesized margin: enrollees shift the timing of purchase to periods with lower cost sharing, increase the use of lower cost drugs (but only when such drugs were equally or more effective), and reduce overall pharmaceutical utilization. The majority of the response, however, is focused on the reduction in overall utilization. In addition, most of these effects persist into the second year of the CDHP. In CDHP firm 2, we observe insignificant changes in utilization for statins, but statically significant or marginally significant reductions in utilization of antihypertensive drugs and diabetes drugs. We observe no effect, however, on the percentage of days supply purchased or used that were low cost. The utilization effects for CDHP firm 2 are larger and statistically significant for all drug categories in the second year of the CDHP. We interpret the persistence of these effects, combined with the absence of a change in use of low cost drugs, as suggestive evidence of a “gatekeeper” effect, where higher cost sharing for physician visits result in reductions in pharmaceutical use. Moreover, some of the reduction in utilization in CDHP firm 1 could also be driven by a reduction in access to physician visits, a phenomenon observed in the RAND Health Insurance Experiment (Leibowitz, Manning, and Newhouse 1985).

http://www.nber.org/papers/w20927?utm_campaign=ntw&utm_medium=email&utm_source=ntw

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Comment:

By Don McCanne, MD

One of the most important changes taking place in the financing of health care is the widespread adoption of high-deductible health plans, not only with the plans offered in the ACA insurance exchanges, but also with employer-sponsored health plans. When high-deductible plans are combined with a personal health account (health reimbursement arrangement or health savings account) then they are referred to as consumer-directed health plans (CDHPs). This study further informs us on the perverse consequences of this model of health care financing.

Three different paragraphs, each describing this study, were selected for today’s quote to help the reader get through the fog of this fairly complex, technical study. Basically, patient utilization rates for drugs in three chronic conditions (hypercholesterolemia, hypertension, and Type 2 diabetes) were measured under three different scenarios: a large employer with a CDHP in which pharmaceuticals applied to the deductible, requiring full payment until the deductible was reached, a large employer with a CDHP in which pharmaceuticals were exempt from the deductibles, requiring only copayments, and a third group of 19 other firms that offered only traditional coverage and no CDHP.

The primary finding was that patients in CDHP plans decreased utilization of pharmaceuticals for these disorders compared to patients in traditional health plans. This was true whether or not drug purchases applied to the deductible. It is crucial to note that having a personal health account from which funds could be drawn to pay for these drugs did not prevent patients from decreasing utilization of these important drugs.

It is easy to understand why patients declined to purchase drugs for which they had to pay the full cost, even though those drugs were important in their medical management. We have innumerable studies that show that patients will decline care that they should have when they are faced with significant out-of-pocket expenses, demonstrating why high-deductible plans are a such a perverse method of controlling health care spending.

But why would patients with high-deductible plans reduce their use of beneficial drugs if they were exempt from the deductible, requiring them to pay only the copayments? One reason may be that the intrusions and complexities of private insurer cost-shifting arrangements, such as through CDHPs, may be training patients to decline care except in the most dire of circumstances. Another reason may be that the physician visit required to obtain the prescription must be paid in full until the deductible is met, causing patients to drop off of their therapeutic program. Again, the availability of an employer-funded health reimbursement arrangement did not prevent patients from declining to fill their prescriptions (although an empty personal health account is not very helpful).

The bottom line is that too many patients are not receiving drugs and other care that they should have merely because of the increasing transition to CDHPs, with their high-deductible barriers to care. We should abandon CHDPs and shift to first dollar coverage in a program that controls spending through patient-friendly efficiencies – a single payer national health program.

Antidote to Growing Inequality = Universal Healthcare: World Health Organization Head

‘We have to evict private insurers and other profiteers from our healthcare system,’ says U.S. doctor and single-payer advocate

By Andrea Germanos
Common Dreams, Feb. 10, 2015

Providing universal health coverage is a key way to address increasing global inequality, the head of the World Health Organization said Tuesday.

WHO Director-General Margaret Chan made the comment—which echoes previous comments she’s made—during a keynote address on the first of a two-day conference on universal health coverage taking place in Singapore.

“Universal health coverage is one of the most powerful social equalizers among all policy options. It is the ultimate expression of fairness,” Agence France-Presse quotes her as saying.

Achieving such coverage demands “deliberate policy decisions,” she said, adding, “At a time when policies in so many sectors are actually increasing social inequalities, I would be delighted to see health lead the world towards greater fairness in ways that matter to each and every person on the planet.”

The WHO defines the goal of universal health coverage as ensuring “that all people obtain the health services they need without suffering financial hardship when paying for them,” and describes such coverage as “the hallmark of a government’s commitment to improve the well-being of all its citizens.”

A fact sheet from the UN body issued in September 2014 states: “At least a billion people suffer each year because they cannot obtain the health services they need.”

In her comments to the 34-member WHO executive board last month, Chan also referred to universal coverage as “one of the most powerful social equalizers,” and stressed the importance of investing in healthcare systems.

“Health systems and supporting infrastructures … are not a luxury to invest in when funds are available or other priorities have been met,” she said at the time. “They are an essential cushion against the shocks our 21st-century societies are delivering with ever greater frequency, whether from a changing climate or a runaway virus.”

Dr. David Himmelstein, a professor at the CUNY/Hunter College School of Public Health and lecturer at Harvard Medical School, agrees with Chan that healthcare coverage is key to tackling inequality — a challenge he says can be helped in the United States by a single-payer healthcare system that puts healthcare security above corporate profits.

“It’s clear that universal and comprehensive health coverage is a key to fighting inequality,” Himmelstein said in a statement to Common Dreams. “Unfortunately, in the U.S. we still have 30 million or more who remain uninsured despite Obamacare, and tens of millions more with such skimpy coverage that a serious illness would bankrupt them,” he stated.

“And Dr. Chan is clearly correct that we won’t get the coverage Americans need until our government is willing to take on the powerful corporate interests that block needed reform. To make care affordable we have to evict private insurers and other profiteers from our health care system. Insurers’ overhead and the paperwork they inflict on hospitals and doctors drains hundreds of billions each year from the healthcare budget, and they add no value to our system. And our government has to ask the wealthy to help pay for the poor,” he continued.

“Only a single payer national health insurance plan can provide the health security Americans need,” he said.

Andrea Germanos is a staff writer at Common Dreams. This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License.

http://www.commondreams.org/news/2015/02/10/antidote-growing-inequality-universal-healthcare-world-health-organization-head

Take profit out of basic health care

By Howie Wolf, M.D.
The Daily Camera (Boulder, Colo.), Feb. 10, 2015

It was refreshing to read the article in The Camera about “Changes in Colorado’s health insurance market,” (Daily Camera, Jan. 16) especially so because it was written by Marguerite Salazar, our state’s insurance commissioner. She cited how health insurance companies can no longer charge higher premiums for women than men or deny coverage for those applicants with pre-existing conditions. In the past, companies selling health insurance weren’t required to cover maternity, preventative care, and other essentials. Now they are. Besides all of that, they cannot spend more than 20 percent of premium dollars on “administrative costs.” As we all know, some of those costs still include the golden parachutes given their retiring millionaire CEOs. Before these changes, more than one U.S. insurance company ran on as much as 32 percent administrative costs, meaning that the dollars they spent on actual health care were but 68 percent of premium dollars. In Marguerite Salazar’s words, the carriers could make as much profit as they wanted.

Contrast those percentages with Medicare, whose administrative costs are usually 3-5 percent. In other countries where taxes are paid to run a type of national health system, insurance companies are not allowed to profit on citizens’ basic health coverage.Yes, higher taxes for most European countries, Canada, Japan, and Australia, but significantly cheaper than average USA insurance premiums. Their administrative costs are also less.

Our “non-system” has improved somewhat under Obamacare. More citizens now have access to care than ever before. Medicaid is now available to 30 million more Americans, but sadly this does not mean better access to our nation’s specialists and surgeons. As a family physician that sees many Medicaid patients, I have witnessed the angst of patients having to wait months just for a consultation.

An analysis by The New York Times shows that the cost of a mid-level silver insurance plan in Colorado rose 36 percent west of the Rockies while another dipped nearly 40 percent in northeast Colorado! The Affordable Care Act (ACA), or Obamacare, is still too insurer-friendly, allowing them to capture certain markets with a low, seductive price, only to be followed by rate increases after the competition has been thinned out.

Pharmaceutical company greed, too, needs to be reined in. The Prescription Drug Act of 2003 allows these companies to charge whatever they want; negotiations are not permitted. What is more remarkable is that countries who buy the same drugs from U.S. manufacturers will receive huge discounts because of the buying power of their national health systems. Our VA and Medicaid formularies are given favorable prices, but not so for the rest of Americans; not even senior citizens.

Despite the many problems with Obamacare, trying for the umpteenth time to repeal it is ludicrous. Certainly it needs fixing and should include a public option. What we need, in my view, is to take the profit out of basic health care and make improvements on what the ACA has started, eventually getting to Medicare for all. An excellent book on this subject is T. R. Reid’s “The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care.”

Howie Wolf, M.D. has practiced in Longmont and Lafayette and now practices in Thornton. He lives in Boulder.

http://www.dailycamera.com/guest-opinions/ci_27500953/dr-howie-wolf-take-profit-out-basic-health-care

A simpler approach to health care

By Aatif Mansoor, Channing James and Jenny Zhang
Minnesota Daily, Letters, Feb. 11, 2015

We are medical students who have devoted eight years of our lives to educating and training ourselves, along with three to seven more years of training left for our chosen specialty.

We don’t put ourselves through all of that because we have a penchant for staying in school, purchasing expensive textbooks and accruing student loans — we do it so we will be able to properly take care of our future patients.

During the application process, we are all asked to write a personal statement about why we want to go medical school. I would wager that 100 percent of the responses from my classmates and from across the nation included some verbiage that referred to wanting to help people.

But as we have learned more and more about the system in place to take care of people in this country, we have become more concerned.

Yes, the Affordable Care Act has gotten more Americans insurance coverage — but what kind of coverage? Increasingly, ultra-high deductibles and copays are making patients reluctant to seek care when they need it — and vulnerable to financial ruin when they do.

America spends plenty on health care — twice per capita as other industrialized nations — but with staggering inefficiency. Administrative overhead devours 31 percent of our health spending.

It’s our health insurance premiums that pay for those catchy health-maintenance organization commercials, ads that cover an entire light-rail car, marketing departments, underwriters, lobbyists, eight-figure insurance executive salaries and handsome investor profits. None of this has helped us take care of our patients.

What if we redirected those wasted health care dollars into actual health care, while ensuring that all citizens have access to quality care?

This is the case for single-payer health reform.

The power of single-payer health care is its efficiency.

It replaces the dizzying labyrinth of private insurance plans with a single, unified public-financing stream. Yet it maintains the private practice of medicine, encouraging market-based competition where it matters — among providers.

Single-payer care streamlines payment for health services and products by establishing uniform, transparent pricing.

It replaces the costly, cumbersome practice of itemized hospital billing with global annual budgeting, removing layers of hospital administrators and bloated billing departments.

Most importantly, single-payer care guarantees quality coverage to all, removing crippling out-of-pocket liabilities.

The win-win is that we as future physicians would be compensated fairly for every patient we treat, while our patients no longer fear crushing medical bills and visits by debt collectors.

Because we believe single-payer care is the most sensible, equitable and sustainable way forward, we are members of the Minnesota chapter of Physicians for a National Health Program, which advocates for universal coverage through single-payer reform.

We currently have support from over 1,000 fellow Minnesota physicians, medical students and other health professionals who have signed the resolution in support of single-payer.

We encourage all University of Minnesota students at our institution to learn more about the single-payer system and consider supporting the movement.

The authors are University of Minnesota Medical School students.

PNHP note: The text above was originally published in two parts, one on Feb. 10 and the other on Feb. 11. They’ve been combined here for the reader’s convenience.

http://www.mndaily.com/opinion/letters-editor/2015/02/09/simpler-approach-health-care
http://www.mndaily.com/opinion/letters-editor/2015/02/10/simpler-approach-health-care

How far can we go with Sec. 1332 waivers?

Understanding the Affordable Care Act’s State Innovation (“1332”) Waivers

By Jessica Schubel and Sarah Lueck
Center on Budget and Policy Priorities, February 7, 2015

Considerable uncertainty surrounds the potential scope of the “waivers for state innovation” authorized under the Affordable Care Act (ACA), which allow states to modify how they implement key elements of health reform beginning in 2017. Also known as “1332 waivers” for the section of the ACA creating them, the waivers are attracting attention as a way states may pursue their own approaches to expand coverage, including alternatives that would represent a significant departure from the ACA’s standards and requirements.

Many aspects of the ACA, however, cannot be waived. Moreover, the ACA establishes several conditions that states must satisfy if they diverge from ACA standards and requirements. These conditions ensure that states using the ACA’s waiver authority continue to meet the overarching goals of health reform, such as extending access to affordable health coverage that provides a basic level of benefits.

In addition, section 1332 waiver authority doesn’t extend to Medicaid or the Children’s Health Insurance Program (CHIP). If a state wants to change these programs at the same time that it changes how it implements health reform, it can simultaneously request approval of a Medicaid or CHIP demonstration project under section 1115 of the Social Security Act. Section 1332 waivers aren’t themselves “super waivers” that give states sweeping new authority over Medicaid or CHIP (or Medicare), as some have suggested.

This paper describes key elements of 1332 waivers, how states may use them, what conditions states must satisfy to receive federal approval, and how they interact with existing waiver authority related to other federal health programs.

http://www.cbpp.org/files/2-5-15health1.pdf

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Comment:

By Don McCanne, MD

“Forget about our gridlocked Congress. We’ll get an ACA waiver and enact our own state-level single payer system, just like Saskatchewan did in Canada.” Great idea. The problem is that the Sec. 1332 waivers authorized in the Affordable Care Act are extremely limited in their scope. This very helpful article from CBPP explains the uses and limitations of the Sec. 1332 waivers.

Although the limitations are disappointing, single payer activists should vigorously proceed on two fronts. While Congress remains non-receptive to legislation moving us toward single payer, efforts should continue on a state level to enact whatever single payer policies are possible. That not only would make the eventual transition to a single payer system smoother, but it would also improve access and affordability for those who need relief now.

The more important front is to immediately step up advocacy for federal legislation, using John Conyers’ H.R. 676 – the Expanded and Improved Medicare for All Act – in educating the public as to reform that would really work. Although the Republican-controlled 114th Congress is preoccupied with responding to the Affordable Care Act and will not advance a single payer bill, nevertheless it is essential that we use this time to educate, form coalitions, educate, initiate grassroots efforts, and educate. As people discover how severe the deficiencies in our current system are, they will want to hear about a system that does not take away their choices while exposing them to financial hardship.

So understand the limitations of Sec. 1332 waivers as you continue your advocacy for state reform, but, by all means, simultaneously intensify your efforts for federal legislation that will enable not only your state, but all states, to ensure that everyone in the nation will have access to all essential health care services, free of financial barriers.

Med student: Activism for single payer, equality on the rise

The following is an unofficial transcript of an interview that Vanessa Van Doren, a first-year medical student at Case Western Reserve University School of Medicine, gave to Ed “Flash” Ferenc, host of the labor-oriented, Cleveland-based “America’s Work Force Radio” on WERE-AM 1490, on Feb. 9, 2015. You can listen to the audio recording of this interview beginning at the 39:44 minute mark here:http://awfradio.com/todays-show-2-9-15/

HOST ED ‘FLASH’ FERENC: When we come back we’re going to talk with a medical student at Case talk about a single-payer health care system in America. Other countries have it; it’s about time we have it here. … Let’s go to Vanessa now. Vanessa Van Doren is a first-year medical student at Case Western Reserve University School of Medicine. She is a native of Boston. You’re probably glad you’re not in Boston — I heard they’re getting nailed with snow today. Did you know that?

VANESSA VAN DOREN: Oh, yeah. My mom works downtown and she emailed me and told me she doesn’t have work. I wouldn’t mind that.

HOST: We occasionally get dumped on — we had a pretty good one last week — but nothing like what they got in Boston or in Buffalo back in November. That was ridiculous. Getting back to Vanessa, she graduated from Brown University, good school, in 2007 with a degree in anthropology, worked as a genetics researcher for several years before deciding to pursue a career in medicine. So you want to be a doctor, right?

VAN DOREN: Yes, after a lot of thinking about it, I guess I do.

HOST: What, specific, I mean, everything is specialized in medicine today. What field do you want to go into?

VAN DOREN: It’s pretty early now, and every time I shadow a new doctor I get excited about another thing, but I think I’m leaning toward infectious disease. I’m interested in global health, too, so there’s a lot of overlap between the two.

HOST: With the Ebola scare, I can understand why. That’s scary stuff. And that doesn’t bother you. You can get exposed. We’ve seen nurses, we’ve seen other things happen here, that kind of stuff doesn’t bother you?

VAN DOREN: No, I actually think we’re pretty safe in the United States. We have much better protocols and better health overall. Especially given how many people are still dying from that, there are thousands who have died in West Africa. I feel that it would be a good thing to get behind.

HOST: Well, we’ve got a good health care system here, we just can’t pay for it. That’s the problem. That’s what you’re here to talk about.

VAN DOREN: Yes.

HOST: You’re with an organization that’s called Students for a National Health Program, right? And you have a number of students at Case? Talk to us about the organization. It’s part of a bigger organization, right?

VAN DOREN: Yes. We’re student chapter of Physicians for a National Health Program. That’s an organization of about 19,000 physicians in the United States who are advocating for universal, single-payer health care in the U.S. So our group is a student chapter of that. We started in January and we’ve already got about 50 members that have joined the group so far — so we’re pretty excited about that.

HOST: What about nationwide? How large is just your organization nationwide, just the students’ part?

VAN DOREN: The student part, I believe there are thousands of students who are involved. About 160 of us are going to a big conference in Chicago next weekend to talk about what we’re going to be doing on a national level a little bit.

HOST: Now that’s going to be in Chicago? Talk to me about that.

VAN DOREN: Yes, that’s in Chicago this weekend, actually. And so eight of us are going from this new group and we’ll be getting together as med students from across the country that want to advocate for universal coverage and for single payer, and how to get more students and physicians involved and the intersections between the goals other groups that are focused on issues of equality and social justice and our own, and members of Congress who support the single-payer bill. Yes, I’m pretty excited about it.

HOST: So, is the discussion on how to implement this kind of thing? Because we’ve often heard it’s Medicare for All.

VAN DOREN: Yes.

HOST: Do you want to take the Medicare system as we know it and expand it? Because right now you don’t go on Medicare until you’re 65. So just take that — and there’d be no age limits? Is that what we’re talking about?

VAN DOREN: Yeah. It would cover every citizen in the United States, much like just about every other developed country in the world does. It would be universal, and the single- payer part of it is how to finance it. So that means that instead of having dozens of different for-profit insurance companies reimbursing hospitals and physicians, the government would be the single payer, it would be streamlined, a lot more efficient, a lot more cost-effective. So they would be responsible for reimbursing.

HOST: So, get the insurance companies out if then, altogether?

VAN DOREN: Yeah, definitely. I don’t think that health care, human lives, should be a commodity like that. That’s something that should be covered for everyone in a developed country.

HOST: Because the insurance companies are the ones kind of dictating who gets what — medicines, certain health care, or if you have a horrible disease, they can say “You’re not worth saving.” That kind of stuff goes on, doesn’t it?

VAN DOREN: Yes. I mean the Affordable Care Act has improved that. They’ve eliminated exclusions for pre-existing conditions, and tried to standardize some forms of health insurance, so that some things have to be covered now, but it doesn’t go far enough. There are still tens of millions of people who have no coverage whatsoever. 44,000 people die each year due to lack of access to care: that’s just unconscionable. We’re the richest country in the world. We should be able to do that.

HOST: 44,000 people every year.

VAN DOREN: Yes, from unexpected things, from not being able to pay. If you have some kinds of cancer, the medications for that are hundreds of thousands a year a lot of the time. So even if you have health insurance that covers 80 percent of your bills, you’re going to be in a lot of trouble. The leading cause of bankruptcy in the United States is medical bills, which is outrageous. And of people filing for bankruptcy for medical bills, over half of them had insurance, they just didn’t have very good coverage.

HOST: OK. To expand Medicare to all, there’s a Medicare tax. Are you advocating raising that tax to cover everybody and do you know what that tax would be, or is it too premature right now?

VAN DOREN: I think it’s too hard to give exact numbers right now, but the main cost-savings would be from streamlining the system. Instead of having all of these different payers, all these different insurance companies, and this massive bureaucracy and red tape that goes along with that, you’d have one system, one payer. You could eliminate billing departments in hospitals, and if you’re only interacting with one set of rules and one payer, and everyone was covered. The cost savings from that would be enormous, and that would be the primary way we’d be funding the system.

HOST: Yes. I remember the stats on Medicare. Isn’t there, as far as administration, something between 2 and 3 percent, where you have private insurance companies, the margin is something like 15 to 20 percent. Isn’t it something like that?

VAN DOREN: Yeah. It’s much higher.

HOST: So by eliminating that, you would encompass more people getting health care. I that what you’re saying?

VAN DOREN: Yes. Right now we spend about 17 percent of our GDP on health care, but we don’t have universal coverage. We pay about double per capita of what other countries pay. It doesn’t make any sense.

HOST: And we’re the only major industrialized country that doesn’t have a single-payer system — that’s the crazy thing about this. OK, Vanessa, let’s go back here. I see you had this “White Coat Die-In” on Dec. 10. It caught my attention. What was that all about?

VAN DOREN: So, the die-in was a national event in December at about 90 med schools across the country and over 2,000 med students participated. It started off as response to the Eric Garner and Michael Brown verdicts, and the point of it initially was to recognize that institutionalized racism is a public health crisis, and that it affects all area of society, I mean law enforcement and the courts, as we saw with those cases, but also in medical care. So the focus originally was primarily on institutionalized racism in medicine. And that’s been getting some attention recently. There have been a number of studies coming out recently, showing that white physicians spend less time with black patients.  There’s a particularly study that shows physicians treat white patients versus black patients for a fracture differently. So anyone who’s had a broken leg knows that these are excruciating injuries that require serious pain medication, but this study showed physicians were twice as likely to prescribe Tylenol to black patients and twice as likely to prescribe opiates to white patients. So with all this stuff coming out, and what we’ve learned as med students, we identified this overlap between institutionalized racism in law enforcement and racism in medicine.

And when underlying racism manifests itself in law enforcement, the consequences are very obvious — a person being choked to death, or grand juries that decide not to indict the perpetrators — but when a patient dies of diabetes complications due to lack of access to care, or a misdiagnosis because a physician dismissed that patient’s symptoms because of these underlying biases, it’s not as dramatic as killing someone in cold blood but the impact on that person and their family and community is the same.

HOST: Yes.

VAN DOREN: So that’s the rationale for why we had this demonstration.

HOST: And a single-payer system would alleviate that kind of thing because costs would be taken out of it then, right?

VAN DOREN: Yeah, single payer — I mean it wouldn’t eliminate institutionalized racism, but it would help reduce the burden by providing access to care for all people. And we would still have a long way to go beyond that, to treat patients with the same attention and compassion that they deserve, but single payer would be a crucial step. And actually the group that started the die-in helped identify single payer as a key component in eliminating racism in medical care. So there’s a big overlap between the two.

HOST: So that happened on Dec. 10 at the Case campus, and did you get a good turnout for that? And what about the university. Did the university go along with that?

VAN DOREN: Well, they were pretty involved. We only had about two days to plan it. It was mostly done through Facebook and we simply started inviting people. We had 70 people out there with this quick turnaround, which was exciting. And it wasn’t just students — there were members of the community, physicians from the university hospitals, there were deans — a couple of our deans came. My dean, Dr. Haynie, was out there holding a sign — that was exciting. A big part of Case’s curriculum is talking about the social determinants of health, health policy, and that kind of stuff, so it was exciting to see our faculty members practicing what they preach and out there supporting us. We were lucky.

HOST: And this was part of a national effort, too. I see there were 2,000 medical students at 90 schools?

VAN DOREN: Yeah, and this was all organized through Facebook over about two days. It was pretty amazing to see it broaden out like that.

HOST: Thank god for social media today. It’s amazing.

VAN DOREN: Yes, it was the most Facebooking I’ve ever done on my life, I think.

HOST: Are you going to do something like that again, perhaps?

VAN DOREN: So that group has started chapters at different schools and we’re trying to keep the movement going and the conversation going. One of the big things we’re trying to do now is to have roundtable discussions with med students and physicians who supported the concepts but didn’t want to come out and participate, just to kind of discuss what of roles med students and physicians should have in addressing these kinds of issues. I think that’s an important conversation to have.

HOST: Social media is big and I also see you’re getting into the mainstream media. I see you had a response as a letter to the editor in replying to an Ohio libertarian. Now the libertarians, they don’t want any government intervention, do they?

VAN DOREN: No. Yes, how that letter happened is that Joshua Niforatos, he another first-year medical student at Case – he’s one of the founders of the chapter — saw the op-ed by Sarah Bevins, one of the leaders of the Libertarian Party in Ohio. Her op-ed was arguing against the Medicaid expansion in Ohio. She argued that government safety-net programs like Medicaid should be totally overhauled and replaced by “free market” solutions. So we wrote just a short letter, just a few hundred words, a letter to the editor, explaining why her argument was wrong — from any perspective, but predominately financial and ethical perspectives, and to explain why single payer is a better solution to address the problems of high costs, red tape, and lack of access to care — hallmarks of our current system.

HOST: They don’t seem to understand those 44,000 people who are dying because they don’t have that program that you just referred to. It doesn’t seem to make a difference, though, does it?

VAN DOREN: Yes. That’s the thing that really gets to me, it’s totally unconscionable to say that. I mean that’s what we have with Medicare and Medicaid and CHIP, which is for lower-income kids. If we pull those safety-net programs, what are people going to do? The poverty line for an individual right now is set at $11,670 a year, and Medicaid covers people making under this amount. And in states that are expanding Medicaid, that line is set at about $16,000 a year. So this is a group that Bevins was saying that people should be paying for care just out-of-pocket, which is ridiculous. Private insurance premiums are thousands of dollars a month, and these are people who are struggling to pay rent and put food on the table. Medicaid is not a complete solution, but I just can’t see how a free-market approach would help these people get access to care.

HOST: No. They have a “let them die” attitude. That’s the sad part about it, it really is. Well Vanessa, I think you’re on the right track on this issue. I’d like to keep in touch with you. So you’re a first-year medical student so you have a little way to go, don’t you?

VAN DOREN: Oh, yeah, a long road. But it’s exciting. I’m really glad to be in this field.

HOST: So let’s check in with you, to see how things are going. If you have another demonstration or something like that, feel free to send it over our way to BMA Media and we’ll get it on the show, OK?

VAN DOREN: That would be great. Thank you so much.

HOST: And the national website is pnhp.org. Vanessa, thank you so much, keep up the fight, we’ll be in touch, all right?

VAN DOREN: Thanks a lot.

Single payer criticism often untruthful

By James Burdick, M.D.
The Baltimore Sun, Feb. 9, 2015

After discouraging election results, Vermont Gov. Peter Shumlin abandoned his effort to establish a single payer health system. This is bad news not only for the Green Mountain State but for all Americans. Governor Shumlin had been one of the only major U.S. office holders with the backbone to advocate this remedy for our ailing health care system.

The single payer system is already working well in Canada. The Canadian Medical Association strongly supports the system and is working to improve it. But some enemies of reform here are using Canadian stats and the Shumlin setback to decry the single payer system.

Arch-conservative Sally Pipes, president of the Pacific Research Institute and a prominent foe of single payer, claims that Vermont dodged a bullet. In the National Review, Ms. Pipes noted that “78 percent of Canadians over 45 are worried that they won’t be able to access care when they need it.”

So what? It is the rare Canadian who wants to cancel his or her health care system.

In fact, the 78 percent number she cites is from a Canadian Medical Association report, advising a change in funding strategy. The report is an endorsement of continuing the system by improving it. Of course any national system needs updating and other tinkering to keep it running smoothly. But we do not even have a functioning system in the U.S. to evaluate.

Ms. Pipes has joined other naysayers of health care reform in pointing to lengthy waiting times for care in Canada. Americans need to be aware that this is harmful propaganda. Yes, Canadians have to wait a few months for some elective procedures. They recognize this and are working on it. But Canadians typically find that if they get sick they will be well taken care of without a big bill afterward.

The truth about such comparisons with the U.S. was highlighted when a Canadian newspaper responded with indignation to Sen. Mitch McConnell’s claim that the U.S. health care system was superior to Canada’s because of the waiting times. A spokesperson for the Republican senator’s home state of Kentucky, asked by an Ontario newspaper reporter what waiting times were typical in the U.S., admitted to not knowing what these were but said “anyway, they can always go to an E.R.”

A country’s waiting times represent averages for all citizens. In the U.S., our citizens without insurance would have to be included in our averages for comparison with other countries that do have national health coverage. In effect, the skewed comparison with other countries would be so distorted as to be meaningless.

This sort of disinformation is common in the health care debate: Statistics are applied manipulatively, leading to grossly incorrect generalizations being used to criticize “universal” health care systems. This is not civic discourse. It is nothing but a big lie.

But let’s look further ahead. Given the extensive benefits for many from the Affordable Care Act, how do business interests vested in the status quo argue that more comprehensive reform is not the answer? For that big lie, proponents of the status quo say we must blame the ACA. In truth, the political impediments that prevented more complete legislation in 2010 are the cause of the trouble we’ve had.

With the ACA we made a good start, but there is much more to be done in order to enable our health care system to work for everyone. It is critical to recognize and neutralize malicious misinformation directed against further health care reform. The real fix lies in the prospect of a single payer system along the lines of the Vermont legislation.

Although moving directly to a national system such as single payer would be the most prompt and effective next step, the present political climate provides little hope for this. Perhaps gradual coalescence of state programs would work. After all, gradual provincial participation is the way the federal Canadian health care system grew to maturity. Efforts such as those in Vermont, and the similar “Health Care is a Human Right” campaign in Maryland, provide encouraging steps toward that goal.

But even that is a political fight few of our politicians seem to have the gumption to wage right now. Keeping the debate truthful will at least level the playing field.

Dr. James Burdick is a professor of surgery at Johns Hopkins University School of Medicine. He is writing a book detailing his plan for patient-centered health reform. His email is jburdic1@jhmi.edu.

http://www.baltimoresun.com/news/opinion/oped/bs-ed-single-payer-20150209-story.html

Dr. Robert Zarr on ‘The Big Picture’

PNHP President Dr. Robert Zarr appeared on Thom Hartmann’s “The Big Picture” on RT America on Feb. 9, 2015, to discuss the limitations of the Affordable Care Act and the continuing need for single-payer reform — an improved Medicare for all.

Republicans can take the lead on health care

By James Fieseher, M.D.
Concord (N.H.) Monitor, Feb. 10, 2015

As much as we’ve prospered as a nation under the “free market” system, one size doesn’t fit all. There are just some things that don’t belong in a free-market system, particularly when it comes to an integration of services.

For example, our national security is a government-run system that integrates a standing Army, Navy, Air Force, Marine Corps and Coast Guard. Outsourcing our military would create competing networks that would drive up costs and lose the efficiency of a coordinated military campaign. Similar arguments can be made for our police and firefighting departments.

Modern medicine now requires a system of integration that rivals our military. Coordination of care is now an integral part of our medical process, whether we’re fighting infection, cancer, mental illness or the ravages of aging.

Yet, there are many in this country and this state who insist it’s okay to buy and sell health care. “That’s different,” they say. “You can live without health insurance.”

Maybe we can’t. Last year, more than 48,000 Americans died unnecessarily because they couldn’t get health care in a timely manner. More than 100 of those were from New Hampshire. Of the 1.7 million Americans who filed for bankruptcy last year, more than 60 percent of them were due to medical expenses. Finally, which of us, when confronted with a loved one with a terminal disease, wouldn’t give everything we had to get their loved one’s health back? Without some type of health insurance, what are our chances?

The fact remains, our health is the most precious and personal thing we have. So why should our health care be bought and sold on the free market?

It shouldn’t. If the ethical argument doesn’t convince you, the fiscal argument should. The United States has had “free market” health insurance since the early 1970s. In 1980, health care spending accounted for 9 percent of our GDP, which was comparable to other industrialized nations. By 2008, health care spending rose to 16 percent and in the last seven years it now stands at 18 percent of our GDP. This means that the cost of health care isn’t just rising, the rate of growth is increasing as well.

If we don’t find a different solution to free-market health care, then the cost of health care will price itself out of that market.

There is one free market where health care does belong: the free market of ideas. We need to change our mode of thinking about health care. We should think about our health care as it was intended: a right for all Americans, not a commodity to be bought or sold.

Currently, there is a bill before the state Legislature (HB 686) sponsored by Reps. Richard McNamara, Suzanne Smith and Marcia Moody to bring a single-payer system of health care to New Hampshire. The bill was written by a group of New Hampshire physicians who are part of a national organization: Physicians for a National Health Program. PNHP represents a growing trend among health care providers (not just doctors, but nurse practitioners, nurses, physician assistants, etc.) who have firsthand knowledge of how badly the free market and for-profit motive is hampering the effectiveness of our health care system.

Single payer is the general system of care controlled either directly through the government or indirectly through government oversight. Single-payer health care is universal, meaning all residents have it, and comprehensive, meaning it reasonably covers most health problems and is affordable.

All other industrialized nations have a form of a single-payer system, and most of them have health care costs below 10 percent of their GDP (none are above 12 percent).

Is this the right time to bring a single-payer bill such as HB 686 before a Republican Legislature? The physicians of the New Hampshire chapter of PNHP think it is.

Health care is a bipartisan issue. No one political party has exclusive rights to it. The Affordable Care Act was passed without Republican participation and while it begins to address some aspects of our health care dilemma, it still relies on marketplace economics and hasn’t fulfilled the promise of meeting most of America’s health care needs.

HB 686 gives the Republicans an opportunity to take the leadership position on health care. The bill itself needs work in areas such as funding, which should enable the Republicans to put their fiscal stamp on such an important piece of legislation.

This year, we are seeing a trend in many Republican states where taxes are being raised to fulfill essential governmental services. If properly done, HB 686 should eliminate health insurance premiums across the board in exchange for a comparatively modest tax increase, a potential net savings of several billion dollars to businesses, individuals and the state.

It remains to be seen whether New Hampshire’s Republican-controlled Legislature will seize the opportunity to move forward in some manner with HB 686. It’s time for the party of Lincoln to emancipate our health care from the free market way of thinking.

Dr. James Fieseher is a primary care physician and lives in Dover.

http://www.concordmonitor.com/news/politicalmonitor/15611672-95/my-turn-republicans-can-take-the-lead-on-health-care

Elisabeth Rosenthal’s “Insured, but Not Covered”

Insured, but Not Covered

By Elisabeth Rosenthal
The New York Times, February 7, 2015

The Affordable Care Act has ushered in an era of complex new health insurance products featuring legions of out-of-pocket coinsurance fees, high deductibles and narrow provider networks. Though commercial insurers had already begun to shift toward such policies, the health care law gave them added legitimacy and has vastly accelerated the trend, experts say.

The theory behind the policies is that patients should bear more financial risk so they will be more conscious and cautious about health care spending. But some experts say the new policies have also left many Americans scrambling to track expenses from a multitude of sources — such as separate deductibles for network and non-network care, or payments for drugs on an insurer’s ever-changing list of drugs that require high co-pays or are not covered at all.

For some… narrow networks can necessitate footing bills privately. For others, the constant changes in policy guidelines — annual shifts in what’s covered and what’s not, monthly shifts in which doctors are in and out of network — can produce surprise bills for services they assumed would be covered. For still others, the new fees are so confusing and unsupportable that they just avoid seeing doctors.

(B)y endorsing and expanding the complex new policies promoted by the health care industry, the law may in some ways be undermining its signature promise: health care that is accessible and affordable for all.

Readers Comments:

Don McCanne
San Juan Capistrano, CA

The private insurance industry will always place a priority on optimizing its business model, which means maximizing revenues (premiums) and minimizing expenses (payments for patient care). Earlier managed care models proved unpopular because of denial of care, but now they have devised innumerable methods of denying payment instead, in full or in part. Many examples are found in this article.

In sharp contrast, an insurer owned by the public, such as Medicare, has a mission of serving patients. That is, our own public stewards are there to help us get the care we need. They are not there to try to produce a profit for the government; after all, its our own tax dollars.

We are close to the threshold wherein the public will no longer tolerate private insurers shifting ever more costs onto patients with health care needs, while taking away our choice of our health care professionals.

What is our way out? Improve Medicare and expand it to include everyone.

Len Charlap
Princeton, NJ

Some conservative commenters have pointed to Switzerland as a country which only uses private insurance companies and appears to have a system that works.

  1. The Swiss government writes a basic policy that all companies are required to offer with no change. Thus all the chicanery reported in the article is avoided. The policy is accepted by all doctors. People know exactly what they are getting. Everyone must have the basic policy.
  2. The private insurance companies may make no profit on the basic policy.
  3. The health care results of Switzerland are about average among the 10 or 12 wealthiest countries which is to say they are considerable better than we get.
  4. If the cost of insurance is more than 8% of a family’s income. they receive a subsidy from the government. About 40% receive such subsidies.
  5. We pay about 50% more for health care than the Swiss, but the Swiss pay almost 50% more than the other wealthy countries most of which use a variation of single payer.
  6. The Swiss government and insurance companies pay careful attention to the practices of its physicians wrt to poor practice, unnecessary tests, and overcharges. A suspected doctor will receive a dreaded “blue letter” from the insurance company requiring him to justify his practice.

If we can’t have an efficient single payer system like the UK or Canada, for example, I would settle for something like the Swiss system. It would do away with most of the scams illustrated in Rosenthal’s great series.

Don McCanne
San Juan Capistrano, CA

In Reply to Len Charlap

The Swiss health care system is certainly superior to what we have in the United States, precisely because of the reasons cited by Dr. Charlap. However, a comprehensive report by OECD and WHO of the Swiss system was released in 2011, and, if you read it carefully, you will also find these features of the Swiss system – features they share with us:

  • Highly inefficient and fragmented
  • Profound administrative waste
  • Inequitably funded
  • Regressive financing
  • Wide variations in premiums
  • Highest out-of-pocket costs
  • Increasing managed care intrusions
  • Insurers game the system

Because of the inadequacies of the Affordable Care Act we need to return to the negotiating table to fix our health care system. But when we do, let’s not start from a position of compromise, thereby allowing private insurers to continue to inflict these abuses on us. Let’s begin with a bona fide single payer system – an improved version of Medicare that covers everyone.

****

Comment:

By Don McCanne, MD

This may be the most important article in Elisabeth Rosenthal’s outstanding series on health care costs and pricing in the United States. She shows that the Affordable Care Act failed to prevent private insurers from reducing their own risks by shifting much more of the costs onto patients, while reducing patient choice by further limiting their networks of approved providers.

Both access and affordability are worse now than they were with typical plans available a generation ago. The nation expanded the numbers covered by insurance, but at a cost of of leaving too many patients broke and without adequate access to care.

In my first posted response to her article, I repeated our oft-expressed view that it makes a difference on whether we finance health care through private insurers structured to optimize their business success or though public insurance designed specifically to serve patients. Elisabeth Rosenthal shows that what is good for insurers is bad for patients.

Some may wonder why I included two responses on the Swiss health care system when this article is on the poor quality of private health plans in America.

First I want to say that Len Charlap is one of the more astute and ethically-driven commentators in the readers’ response sections of The New York Times. His highly appropriate response to this article explains that our private insurance products could be greatly improved if we adopted the policies that the Swiss have in their country to regulate and control the excesses of the private insurance industry. Such a system theoretically would be more politically feasible in the United States since it is supported by a few prominent conservatives such as Harvard Professor Regina Herzlinger. 

We definitely do need to return to the negotiating tables since the ACA reforms are intolerably flawed. Although I certainly agree with Len Charlap that the Swiss system definitely would be superior to what we have, I do have a problem supporting a Swiss-style private insurance model as our opening position on renegotiating reform. Imagine having to compromise with those on the far right who would insist that patients have greater financial exposure to the health care that they receive. They would perpetuate and make even worse the very problems that Elisabeth Rosenthal discusses in her article.

The reason that I am reposting our responses here is that Len Charlap’s comment received very high exposure since it was selected and displayed as a “NYT Picks” and at the top of the list of “Readers’ Picks.” On the other hand, my response to him was held until some time after the comments section was closed, and then, when it was posted, it was buried under 300 plus responses, and thus had virtually no visibility.

My response to him listed findings from a OECD/WHO report that revealed that the Swiss private insurance plans, though certainly better than ours, still had many serious deficiencies that we should reject as we go back to the tables to fix our sick system. Many NYT readers may assume from Len Charlap’s comment that the Swiss system is the answer, or at least a reasonable compromise with broad political support (except that the current Republican proposals move even further away from the highly regulated Swiss system).

So the point of discussing these comments on the Swiss system is found in my concluding remark in my second post above:

“Because of the inadequacies of the Affordable Care Act we need to return to the negotiating table to fix our health care system. But when we do, let’s not start from a position of compromise, thereby allowing private insurers to continue to inflict these abuses on us. Let’s begin with a bona fide single payer system – an improved version of Medicare that covers everyone.”

Insured, but Not Covered

By Elisabeth Rosenthal
The New York Times, Feb. 7, 2015

When Karen Pineman of Manhattan received notice that her longtime health insurance policy didn’t comply with the Affordable Care Act’s requirements, she gamely set about shopping for a new policy through the public marketplace. After all, she’d supported President Obama and the act as a matter of principle.

Ms. Pineman, who is self-employed, accepted that she’d have to pay higher premiums for a plan with a narrower provider network and no out-of-network coverage. She accepted that she’d have to pay out of pocket to see her primary care physician, who didn’t participate. She even accepted having co-pays of nearly $1,800 to have a cast put on her ankle in an emergency room after she broke it while playing tennis.

But her frustration bubbled over when she tried to arrange a follow-up visit with an orthopedist in her Empire Blue Cross/Blue Shield network: The nearest doctor available who treated ankle problems was in Stamford, Conn. When she called to protest, her insurer said that Stamford was 14 miles from her home and 15 was considered a reasonable travel distance. “It was ridiculous — didn’t they notice it was in another state?” said Ms. Pineman, 46, who was on crutches.

She instead paid $350 to see a nearby orthopedist and bought a boot on Amazon as he suggested. She has since forked over hundreds of dollars more for a physical therapist that insurance didn’t cover, even though that provider was in-network.

The Affordable Care Act has ushered in an era of complex new health insurance products featuring legions of out-of-pocket coinsurance fees, high deductibles and narrow provider networks. Though commercial insurers had already begun to shift toward such policies, the health care law gave them added legitimacy and has vastly accelerated the trend, experts say.

Full article: http://www.nytimes.com/2015/02/08/sunday-review/insured-but-not-covered.html

Pharmaceutical manufacturers create distrust of vaccinations

By Ed Weisbart, M.D.
St. Louis Post-Dispatch, Letters, Feb. 7, 2015

Children should get vaccinated. The evidence is overwhelming that this is a safe and effective vital strategy for our nation’s health.

Why is there such distrust of vaccinations today?

The answer is simple: Pharmaceutical manufacturers have repeatedly proven themselves as undeserving of our trust.

In 2010, AstraZeneca was fined $520 million for an array of illegal promotions of antipsychotics for children, elderly, veterans and prisoners. That fine sounds large, but it amounted to only 2.4 percent of the $21.6 billion that they made on Seroquel sales the preceding 12 years.

They’re not alone. Glaxo was fined $3 billion for the illegal promotion of two antidepressants and for hiding safety problems with a diabetes drug. Johnson and Johnson was fined $2.2 billion for the illegal marketing of Risperdal. Again: just tiny fractions of their total sales.

Their strategy seems to be “pay the ticket, but keep on speeding.”

We should be able to rely on the Food and Drug Administration to protect us, but the FDA’s advisory boards are now stacked with people who have a financial interest in the very drugs being regulated. Moreover, the FDA’s funding is dependent on the pharmaceutical companies.

Until we achieve a nonprofit national health program where medications are provided as a public good and not sold as commodities for the highest profit, trust in medicine will continue to erode.

Vaccinate your children. Urge financial and clinical independence for the FDA. And tell your lawmakers you want patient-oriented, not profit-oriented, health care. That will help bring trust back.

Dr. Ed Weisbart is chairman, Missouri chapter of Physicians for a National Health Program. He resides in Olivette.

http://www.stltoday.com/news/opinion/mailbag/pharmaceutical-manufacturers-create-distrust-of-vaccinations/article_f799633c-a861-5cbf-b072-462eca90afda.html

Congress shares the blame for high drug prices

By Suzanne Hagan
St. Louis Post-Dispatch, Letters, Feb. 11, 2015

Dr. Ed Weisbart is correct with the letter “Pharmaceutical manufacturers create distrust of vaccinations” (Feb. 7). Pharmaceutical manufacturers have many sins for which they must atone when it comes to the fleecing of American consumers.

But our spineless Congress has to shoulder a share of the blame. Sen. John McCain is the co-sponsor of a bill that enables a few Americans who live in a state bordering Canada to go to our northern neighbor to legally purchase their American-made drugs at a big discount. But Americans as a whole do not share in this benefit. That’s because the powerful lobbyists for Big Pharma made sure that Congress legislated that Americans pay full retail price for drugs we purchase.

Big Pharma tries to justify this position by citing the high cost of research and development for new drugs. But these companies receive tax breaks and other inducements that help defray costs, all subsidized by the American taxpayer. And why should we Americans subsidize the rest of the world’s drug costs? There should be global support of pharmaceutical R&D. Let’s face it: If these companies weren’t making huge profits, they couldn’t afford their army of well-funded lobbyists.

We need journalists to expose these outrages before we have any hope of correcting them. And as Dr. Weisbart pointed out, if we had a national single-payer health plan like Canada’s, we wouldn’t be in this position.

Suzanne Hagan resides in Ballwin, Mo.

http://www.stltoday.com/news/opinion/mailbag/congress-shares-the-blame-for-high-drug-prices/article_5b8dd359-d19b-5ee2-aeed-363b1b356a58.html