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AMA med students back state laws to achieve universal care

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AMA med students back state laws to achieve universal care

FOR IMMEDIATE RELEASE, November 11, 2014

Contact: Mark Almberg, communications director PNHP, mark@pnhp.org

DALLAS – The Medical Student Section of the American Medical Association adopted a resolution last Friday that supports state legislation to provide universal health care, including single-payer legislation.

Resolution 13, which was brought to the AMA-MSS Interim 2014 meeting by medical students from Massachusetts, Vermont, New York, and Wisconsin, is the first resolution lending support to a single-payer, nonprofit system of financing health care to be adopted by an official section of the AMA in the organization’s 167-year history.

The resolution calls for the AMA-MSS to support “state-level legislation to implement innovative programs to achieve universal health care, including but not limited to single-payer health insurance.” The full text of the resolution is here.

The resolution points to Section 1332 in the Affordable Care Act, which allows individual states in 2017 to apply for federal waivers to implement their own health systems provided they can cover at least as many residents as the ACA without adding to the federal deficit.

Although the resolution applies only to the student section of the AMA, supporters say it sends a signal to the larger organization that many physicians-in-training think the most recent round of national health reform didn’t go far enough.

“Last Friday’s vote is yet further evidence that physicians – and in this case physicians-in-training – are increasingly angry about private insurance companies that meddle in doctor-patient relationship, deny access to care, balk at payment, and afflict providers and patients alike with costly and unnecessary red tape,” said Bradley Zehr, a second-year medical student at Boston University School of Medicine who helped write the resolution.

“Med students want to practice medicine and to help people get better, not to be part of a corporate enterprise that puts financial gain over our patients’ well-being,” Zehr said. “They see the millions of people who will remain uninsured or underinsured under the Affordable Care Act. That’s why physician opinion is shifting toward a nonprofit, publicly financed, Medicare-for-All-type system that would cover everyone while also controlling costs.”

Earlier this year, the Michigan State Medical Society, an AMA affiliate, appropriated $50,000 for a feasibility study of a single-payer financing system. About the same time, a survey by the Maine Medical Association (also an AMA affiliate) found 64.3 percent of its members support single payer, up 12 percentage-points from just six years ago.

In a 2011 survey of its membership, the Massachusetts Medical Society found that of five options for the U.S. health care system, including the ACA model, far more – 41 percent – preferred single payer to any other option. This reflected a 7 percentage-point increase over the previous year.

In 2008, the Hawaii Medical Association, an affiliate of the AMA, adopted a pair of resolutions in support of single-payer systems on both the state and national levels.

These trends are also congruent with a 2008 study by Drs. Aaron E. Carroll and Ronald Ackerman in the Annals of Internal Medicine showing 59 percent of U.S. physicians “support government legislation to establish national health insurance,” a leap of 10 percentage points in physician support since 2002.

Physicians for a National Health Program (www.pnhp.org) is a nonprofit, 19,000-member research and educational organization of doctors and medical students who support single-payer national health insurance.

The moral hazard of preventive services

An Economic Framework For Preventive Care Advice

By Mark V. Pauly, Frank A. Sloan and Sean D. Sullivan
Health Affairs, November 2014

Abstract

Under the Affordable Care Act, preventive care measures, including vaccinations and screenings, recommended by the Advisory Committee on Immunization Practices and the US Preventive Services Task Force must be covered in full by insurance. These recommendations affect the cost of medical care. Yet neither organization explicitly incorporates measures of efficiency or cost-effectiveness in making its recommendations. To redress this shortcoming, we propose a decision-making framework for these two organizations based on the principles of economic efficiency. Our analysis suggests that routine use of a preventive service should be recommended for full insurance coverage if the service’s cost-effectiveness exceeds a socially determined threshold. For less cost-effective services, we suggest that information about effectiveness and cost should be provided to consumers by physicians or government, but the choice of care and insurance coverage for care should be made by individuals. For the least cost-effective services, the two organizations should discourage public and private insurers from covering such services and report their unfavorable cost-effectiveness.

Health And Cost Trade-Offs

It is crucial to note that the policies of ACIP and the US Preventive Services Task Force are affected by legislative and political constraints. Even with expertise and intent, and with reliance on staff to summarize information on cost-effectiveness, the two organizations are heavily restricted in their ability to incorporate costs in their decisions. Nonetheless, they are given the authority to make recommendations with potentially serious cost consequences. They are being asked to do a task that is impossible to do well. The current structure is thus unworkable as a vehicle for deciding on costly coverage. We therefore propose an alternative that could, in principle, then be implemented either by ACIP and the US Preventive Services Task Force or by some other entity.

An Economic Framework

Preventive care should be made free of user cost for several reasons. The classic reason for requiring immunizations for contagious diseases is concern about the failure of consumers to consider the benefits of prevention to others who might otherwise contract the disease from them. Such use is encouraged by insurance coverage. Another reason is that considerable evidence exists suggesting that some patients do not fully appreciate the benefits from some high-value preventive services, such as the measles vaccine. Finally, future cost reduction for other services that sometimes accompany effective prevention will be overlooked by consumers insured for those services (and by insurers and employers) if there is turnover of insured people from one insurance company to another.

Shorn of technical language and complex mathematics, the fundamental goal of economic efficiency is to provide all services worth more than their cost to users and others who value receipt of these services. In contrast, services should not be provided if they improve health but not by enough to justify their costs.

Categories Of Evaluation And Advice

Here is a way to consider possible policies. A highly desirable service may be “strongly” recommended, with the expectation that physicians will routinely offer and encourage the use of such services and insurance or public subsidies will reduce the user price to zero. Most recommended pediatric immunizations fall into this category.

There are effective preventive services that might be of limited benefit to most people’s health but are sufficiently beneficial for some people to prefer them. We suggest that recommendations in this case be “permissive.” They would emphasize to consumers the positive health benefits of the care and the need to alert them about its availability and cost. Those who attach personal value to the benefit in excess of the societal threshold would be permitted to use them or insure them, but neither subsidies nor insurance would be required.

Finally, there could be a “discouraging” recommendation. In such cases, the service may be effective but insufficiently effective to justify its cost for the great majority of people.

From the Conclusion

Given that higher premiums can be a consequence of a recommendation, it seems illogical not to explicitly consider the higher costs compared to the benefit but to be explicit about both benefits and the need to consider the options, as we have recommended. This is a comparison, we admit, that clinical decision makers are reluctant or unable to make because it requires something beyond clinical considerations, and there is no alternative under current law and policies other than inconsistent or undesirable behavior. We have instead recommended a three-tier approach based on cost-effectiveness ratios. The precise dollar values that divide tiers is a political and ultimately a societal judgment.

http://content.healthaffairs.org/content/33/11/2034.full

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Comment:

By Don McCanne, MD

During the crafting of the Affordable Care Act it was decided that prevention should have the highest priority in the delivery of health care services on the basis that it would reduce health care costs by preventing more expensive care, and, more importantly, that preventing disease is better than managing it. Although there is little evidence that preventive care saves money, preventing disease is certainly beneficial.

For that reason it was decided to require that preventive services – including immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) and screening procedures recommended by the US Preventive Services Task Force (USPSTF) – be fully covered by insurance, with no cost sharing, even if the deductible had not been reached.

The concept that all health care should be a prepaid service with no cost sharing was never considered as an option – much as single payer was excluded from consideration.

Mark Pauly, one of the co-authors of this Health Affairs article, popularized the concept of moral hazard in health insurance – that it was important to require patients to directly bear at least a portion of the costs of health care in order to prevent them from obtaining care for free that they would have forgone if they would have had to pay for it in part or in full. This concept has become an absolute given amongst the health policy wonks in this nation. This “skin in the game” consumer-driven notion has so dominated the policy community that it is being expanded by ever-higher deductibles which likely are contributing to the slowdown in health care spending – an undesirable form of cost containment, as will be explained.

The greatest problem with cost sharing (deductibles, co-payments and coinsurance) is that it has been confirmed that people frequently do forgo beneficial health care when they have to pay a portion or all of the costs of that care. Several other nations with universal systems recognize that problem and thus provide first dollar coverage for health care. This problem was also recognized by Congress when it was decided that preventive services should not be discouraged by making them subject to cost sharing (although it has been shown that plans with high deductibles also cause patients to forgo free preventive services).

It appears that Professor Pauly and his colleagues cringe at the thought of dismissing the moral hazard of accepting free preventive services (free at the time of service). Thus they now propose applying the consumer-directed concept of establishing tiers of preventive services – one for full coverage, a second for full payment out-of-pocket, and a third for discouraging the use of those preventive services as not having enough value (due to inordinately high prices) for anyone to pay for them.

It seems to matter little that the ACIP immunization lists and USPSTF screening tests have undergone decades of rigorous scientific investigation and represent the state of the art in preventive services. This begs the question: How do you overuse preventive services? Rather than disrupting these services because they supposedly constitute a moral hazard it would seem much more logical to use public (government) measures to reduce excess prices, just as they do in other nations.

Of course, a single payer national health program is designed to get pricing right – providing optimal health care value for all of us.

OECD/WHO/EOHSP report on P4P

European Observatory of Health Systems and Policies

Paying for Performance in Health Care: Implications for Health System Performance and Accountability

Edited by Cheryl Cashin, Y-Ling Chi, Peter C. Smith, Michael Borowitz and Sarah Thomson
OECD, WHO, October 6, 2014

Forward from the OECD (excerpts):

The problem is that not enough is known about whether and how P4P actually increases value for money in health systems. The evidence that P4P improves health outcomes, or even quality of processes of care, is limited at best.

(This) volume analyses the experience of P4P programmes in 10 OECD countries, selected to reflect the wide range of health system contexts and challenges across the OECD.

The findings of the volume in many ways mirror the findings of the few rigorous systematic reviews of P4P programmes, and the opinions of many leading commentators. Pay for performance does not lead to “breakthrough” quality improvements, and performance measures and other key building blocks of P4P programmes remain highly inadequate.

This volume will not provide answers to questions such as whether or not P4P works, which performance measures are most appropriate, or what is the right level of financial incentive to get results. Instead – and more importantly for real health financing policy in complicated contexts – are the insights about how P4P might be used to strengthen health system governance and strategic health purchasing to continue the shift taking place in many countries from paying for performance to paying for value.

Mark Pearson, Head of Health Division, Directorate of Employment, Labour and Social Affairs
Organisation for Economic Co-operation and Development

Chapter thirteen:

United States: California integrated healthcare association physician incentive programme

By Meredith Rosenthal

One of the first, and perhaps the largest, private pay for performance (P4P) initiatives of this era was launched by the Integrated Healthcare Association (IHA) in 2001 with eight health plans representing ten million members in California. The IHA programme is of particular interest not only because of its size, but also because it has been sustained for more than a decade and has been independently evaluated.

Results of the programme:

Performance related to specific indicators

More generally, IHA’s own monitoring reports give a mixed picture of performance improvement over time. Performance measures included in the IHA P4P programme have improved modestly and unevenly across measures, with no evidence of “breakthroughs” in quality improvement.

Programme monitoring and evaluation

Two controlled studies provide the strongest evidence of impact of the IHA initiative. These studies find that not all targeted clinical process measures of quality improved. Among the measures that could be analysed, only cervical cancer screening improved differentially among the IHA participants, and improvement was modest at best.

Equity

While there has been no systemic analysis of the impact of the IHA programme on equity, several empirical clues suggest that P4P may not have distributed its benefits equally… (I)interviews with physician group leaders revealed some concerns that the P4P programme has caused groups to avoid patients whose health of health behaviour would negatively affect the group’s performance.

Cost and savings

While no formal analyses have been reported, it is unlikely that improvements in clinical quality, health information technology, and patient experience (to the extent they have occurred) would generate saving for payers.

From the Conclusions

Another possible explanation for the weak results may be the continued expansion of the measure set and the difficulty physician organizations face in making investments in quality improvement when the targets are continuously moving. There is an obvious tension here with the desire to include a comprehensive set of measures to avoid “teaching to the test,” a narrow focus that causes providers to concentrate on a small subset of tasks at the expense of unrewarded domains, and to incorporate the best available measurement science over time.

http://www.oecd-ilibrary.org/content/book/9789264224568-en

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Designing Smarter Pay-for-Performance Programs

By Aaron McKethan, PhD; Ashish K. Jha, MD, MPH
JAMA, November 6, 2014

The idea behind pay for performance is simple. Because individuals and organizations respond to incentives, physicians whose patients achieve desirable outcomes should be paid more as an incentive to improve their performance. Yet the results of pay-for-performance programs have been largely disappointing. One argument is that neither the right set of incentives nor the right set of metrics has been identified. Another explanation, which has received far less attention, is that the right set of patients has not been identified for targeted efforts.

To the extent that higher-risk patients can be reliably identified prospectively, this information can inform the design of smarter, more targeted pay-for-performance programs. Specifically, a targeted pay-for-performance program would have, at its core, a prediction model that would identify patients who are at elevated risk of failing to meet a meaningful clinical goal or of having a bad outcome. Predictive models are not just risk-adjustment models already in use by payers to create a level playing field. Predictive models can take into account any factor that is likely to affect a patient’s chance of a poor outcome.

There is little doubt that the effectiveness of these programs will be driven, in large part, by the ability to prospectively identify at-risk patients. However, given the failure of recent efforts to meaningfully improve outcomes, testing targeted pay for performance may be worth the effort.

http://jama.jamanetwork.com/article.aspx?articleID=1934599

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Comment:

By Don McCanne, MD

Pay for performance (P4P) continues to be promoted as a means of improving quality while reducing costs. This 338 page OECD/WHO report adds to the abundance of the policy literature that shows that P4P does not achieve these goals, and may actually impair equity.

The policy community never gives up on a bad idea. In this JAMA article (access is free), McKethan and Jha suggest that we improve P4P by applying it only to prospectively-identified at-risk patients. Not only would that be a good study, but it could also result in P4P rewards that are five times the current levels. What? Greatly increase the complexity and uncertainty by testing only at-risk patients, if you could even identify them? And then depend on provider greed to drive the program? Come on!

One thoroughly tested model that would greatly reduce wasteful spending while improving quality by redirecting the savings to more appropriate care is the single payer model – a national health program. We can let the policy people go out in the alley and play their P4P games while we get serious about improving Medicare and providing it to everyone.

What will Vermont’s election mean for single-payer?

By Morgan True
Vtdigger.org, Nov. 6, 2014

MONTPELIER, Vt. — For many observers, Rep. Mike Fisher’s defeat in the Addison 4 district came as a surprise, and as a rebuke of Vermont’s push for single-payer health care.

Fisher, an eight-term incumbent Democrat, serves as Chair of the House Health Care Committee, and helped to craft Act 48, the legislation putting Vermont on a path to single-payer.

“Having him out of the picture is a big loss,” said Dr. Deb Richter, president of Vermont Health Care For All, a single-payer advocacy group.

Gov. Peter Shumlin will likely hold onto the governorship, but many say this election was a referendum on his tenure, and he will be much weakened by his close contest with Republican Scott Milne.

Richter acknowledges that Shumlin’s influence will be diminished, but she doesn’t see the election as a rejection of single-payer.

“If this was a referendum on single-payer then (Libertarian candidate Dan) Feliciano would be governor, because Milne never came and outright opposed single-payer,” Richter said.

House Minority Leader Don Turner agreed, in that he said this election as more of a referendum on the health care reforms already promulgated by Shumlin – by which he means Vermont Health Connect.

But Turner and other conservatives, such as political strategist Darcie Johnston, say that Shumlin’s inability to fix the state’s ailing exchange will undoubtedly give Vermonters pause when they consider his more ambitious health reforms.

“If he can’t handle Vermont Health Connect, he can’t handle single-payer,” Johnston said.

For his part, Shumlin sounded a less bullish note on single-payer at a press conference Wednesday where he declared victory, but acknowledged the close call would cause him to reevaluate his priorities. The governor dodged direct questions about his commitment to single-payer.

But Senate President Pro Tem John Campbell, who appeared to waffle on single-payer last session, said Democrats owe it to voters to follow through.

“The time for talk is over. Now it’s time for us to take this forward,” Campbell said.

“You don’t give up before you see the game plan,” he added, noting that lawmakers still haven’t seen the governor’s financing plan, which Shumlin is expected to present in January.

At the same time, Republicans picked up 9 seats in the House and, according to Minority Leader Don Turner, they could pick up two more on recounts. Republicans also gained two Senate seats.

There are still Democratic majorities in both houses, but the Republicans have picked up enough seats to shift the dialogue around health care reform, said Sen. Joe Benning, R-Caledonia.

“It makes it more challenging, there’s no two ways about it. I won’t sugar coat that,” Richter said, “But we did well enough all around in this state to get it done, I still have confidence in that.”

Peter Sterling of the pro-single-payer group Vermont Leads, said he’s still optimistic as well, noting that many of the seats lost by Democrats were in districts difficult for them to hold in non-presidential elections.

“These were marginal districts for Democrats,” he said, highlighting loses in St. Johnsbury, St. Albans and Enosburg, where it was a Progressive who went down, but nonetheless a single-payer supporter. Both Richter and Sterling are confident that the new Legislature that will be sworn in in January has the capacity to follow through on single payer.

The concern of grassroots activists was revealed in a press release from the Vermont Workers Center and the Health Care is a Human Right campaign, which in the wake of the election called on officials to “recommit to Act 48.”

The frustration expressed by voters with Vermont Health Connect “highlights the need to move beyond the Affordable Care Act,” and press forward with single-payer, they said.

More than meets the eye in Fisher’s defeat

For people in the Addison 4 district, Republican Fred Baser’s win over Mike Fisher was probably less of a surprise than it was for those outside it.

Baser, 67, was the top vote getter, and will join Rep. David Sharpe, D-Bristol, in representing the four-town district that covers Bristol, Lincoln, Monkton and Starksboro.

Baser is the Bristol town moderator, a former selectman, a former member of the school board, a member of Porter Medical Center’s board and a founding member of the Addison County Economic Development Corporation.

Unofficial returns had Baser with 1,878 votes; Sharpe second at 1,767; Fisher third with 1,740 – only 37 votes out of the second seat – and Republican Valerie Mullin trailing with 1,519.

Mullin finished fourth even though she outspent her opponents by more than $2,000 in a race where no one spent more than $10,000.

Mullin drew the ire of her Democratic opponents by sending out a late-campaign direct mail piece that accused them of attempting to take over Medicare as part of the state’s planned single-payer program.

Fisher chalked his loss up to a confluence of factors, including an anti-Democratic, anti-incumbent sentiment across the state in Tuesday’s midterm election. There was a great deal of frustration with Vermont Health Connect, “which I’m sure was tied to me in some way,” he said.

Fisher did not discount Baser’s popularity, but he said he does wonder if the attacks hurt his chances.

Baser said would like to think that the mailers weren’t a factor. The former financial planner described his Republicanism as moderate.

He supports universal health care that gives all Vermonters coverage, but Baser said he’s skeptical of financing such a program with taxes. But he would like to work in a bipartisan manner to find solutions for health care reform, he said.

When Sharpe told him what the Mullin mailer said, he remembers shaking his head.

“That’s not my style,” he said “I wouldn’t do something like that.”

But Johnston, director of the anti-single-payer group Vermonters for Health Care Freedom, said she thinks the mailers resonated in the district and acknowledged it was one she crafted for Mullin.

Addison County is the second oldest in the state, and according to Johnston, the four towns in the district have a “very old population,” increasing the Medicare mailer’s efficacy.

“Valerie Mullin made that a centerpiece of her campaign, the strategy of it, and she wasn’t the beneficiary, but she’s thrilled as we all are that Mike Fisher was defeated,” Johnston said.

Fisher said the loss stings, but at the same time “there’s also this opening in front of me that feels really freeing.”

He wouldn’t say whether he plans to run for office again in two years, but Fisher said he does want to remain engaged in health care reform in some fashion. Fisher congratulated Sharpe and Baser, and said he was honored to have served 14 years in the Legislature.

Single-payer was going to be a difficult undertaking before the election, Fisher said, and while his loss isn’t a bad omen for its future, it was a rough election “across the board” for single-payer supporters.

http://www.reformer.com/state/ci_26879576/what-will-vermonts-election-mean-single-payer

Canada and U.S. ration health care differently

By Trudy Lieberman
The Star Phoenix (Saskatoon, Sask.), Nov. 6, 2014

As an American journalist sitting in a Toronto coffee bar, I began to chat with people about their healthcare system.

One employee taking people’s orders was about to go off duty and sat down to visit. “I’m tired of hearing you Americans talk about rationing in Canada,” he said. “Let me tell you how many MRIs I had when I was riding my bike and got hit by a motorcyclist.”

He had been injured and received an MRI when he was admitted to the emergency room, plus a couple of more during his hospital stay. Nobody put him on a waiting list; nobody argued that he didn’t need the procedure. He didn’t have to worry whether the doctors who gave him emergency care or the doctor who interpreted the MRIs were in his insurer’s network or out of it.

He made a full recovery and paid nothing for the service when he received it. No $250 or $500 co-payment for an ER visit, now customary in the United States. The server’s injuries warranted some quick MRIs.

Another patient suffering from a less serious mishap or seeking diagnostic testing might have to wait for a while. That’s when other countries’ waiting lists grab headlines in the U.S. That’s when opponents of other countries’ health systems point to their shortages and long wait times and claim we don’t ration health care in America.

As narrower insurance networks begin to limit where we can get our care and contradict the American notion of abundant choices, I thought about the Canadian bicyclist and the waiting lists in his country for some non-emergency MRIs.

Yes, Canadians do wait for some procedures in some provinces because provincial and federal governments have chosen not to fund MRIs or CT scans for everyone who wants or demands one on the spot. It’s one way the country controls medical expenditures.

Even in Canada where patient prioritizing allocates which patients will get care first, new evidence shows that MRIs are still being overused, with no therapeutic benefit to patients. MRIs for lower back pain are among the most frequently requested scans in the Canadian system.

Yet researchers found that more than half of the scans at two big hospitals were inappropriate or were of uncertain value to the patient. When that happens, those who really need them may wait longer.

No country can afford to give every citizen every health-care service that comes along. Narrow insurance networks are one way America controls its medical costs. Insurers choose only providers who agree to accept what the insurers want to pay — in theory pushing down the price of care. If patients want to go to the high-priced cancer hospital, for example, they pay out of their own pocket or go without.

That’s also the American theory behind sky-high deductibles, co-insurance and co-payments for commonly used services such as emergency room visits, diagnostic tests, and outpatient care, or limitations on number of physical therapy visits covered by an insurance policy.

If patients want these services, they pay more out of pocket, postpone them or skip them altogether. Instead of rationing with waiting lists, America rations with price. If some patients don’t have $600 for an MRI co-pay, they may not get it, and studies have shown that people do forgo care when cost-sharing increases.

Like Canada, the U.S., too, overuses medical technology. CT scans in emergency rooms come to mind. But when there’s talk of using this type of service more rationally, cries of rationing ring through the media.

That rhetoric may be changing. The case of the hepatitis C drug Sovaldi, with its $84,000 price tag, and other similarly expensive drugs now waiting in drug makers’ pipelines, may mean the U.S will have no choice but to look to its northern neighbour on how it allocates care.

Those high drug prices are unsustainable for the health-care system, says John Rother, who heads the National Coalition on Healthcare, which is raising awareness of high-priced drugs. Some state Medicaid programs are considering limiting Sovaldi to the sickest patients. Arizona has already done this.

Yes, we do ration health care in America. It’s just that those affected the most are those who have the least income. But the mere hint that a needs — or evidence-based — process might be used to allocate scarce or high-priced health care raises an outcry from those accustomed to getting what they want, when they want it.

Something’s gotta give.

Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She is also a media adviser to EvidenceNetwork. ca. This article was distributed by Troy Media.

http://www.thestarphoenix.com/health/Canada+ration+health+care+differently/10357872/story.html

What is the evidence for access and quality in Medicare Advantage versus traditional Medicare?

What Do We Know About Health Care Access and Quality in Medicare Advantage Versus the Traditional Medicare Program?

By Marsha Gold and Giselle Casillas
Kaiser Family Foundation, November 6, 2014

This literature review synthesizes the findings of studies that focus specifically on Medicare and have been published between the year 2000 and early 2014. Forty-five studies met the criteria for selection, including 40 that made direct comparisons between Medicare health plans and traditional Medicare. An additional five studies are included, even though they have no traditional Medicare comparison group.

Summary

Despite great interest in comparisons between traditional Medicare and Medicare Advantage, studies comparing overall quality and access to care between Medicare Advantage plans and traditional Medicare tend to be based on relatively old data, and a limited set of measures.

On the one hand, the evidence indicates that Medicare HMOs tend to perform better than traditional Medicare in providing preventive services and using resources more conservatively, at least through 2009. These are metrics where HMOs have historically been strong. On the other hand, beneficiaries continue to rate traditional Medicare more favorably than Medicare Advantage plans in terms of quality and access, such as overall care and plan rating, though one study suggests that the difference may be narrowing between traditional Medicare and Medicare Advantage for the average beneficiary. Among beneficiaries who are sick, the differential between traditional Medicare and Medicare Advantage is particularly large (relative to those who are healthy), favoring traditional Medicare. Very few studies include evidence based on all types of Medicare Advantage plans, including analysis of performance for newer models, such as local and regional PPOs whose enrollment is growing.

As the beneficiary population ages, better evidence is needed on how Medicare Advantage plans perform relative to traditional Medicare for patients with significant medical needs that make them particularly vulnerable to poorer care. The ability to assess quality and access for such subgroups is limited because many data sources do not allow subgroups to be identified or have too small a sample size to support estimates. Also, in many cases, metrics employed may not be specific to the particular needs or the way a patient’s overall health and functional status or other comorbid conditions influence the care they receive.

At a time when enrollment in Medicare Advantage is growing, it is disappointing that better information is not available to inform policymaking. Our findings highlight the gaps in available evidence and reinforce the potential value of strengthening available data and other support for tracking and monitoring performance across Medicare Advantage plans and traditional Medicare as each sector evolves.

http://kff.org/medicare/report/what-do-we-know-about-health-care-access-and-quality-in-medicare-advantage-versus-the-traditional-medicare-program/

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An Emerging Consensus: Medicare Advantage Is Working And Can Deliver Meaningful Reform

By Thomas Miller and James Capretta
Health Affairs Blog, November 6, 2014

The success of Medicare Advantage in recent years is changing the conversation on Medicare reform.  It is now possible to envision genuine bipartisan support for fair competition between MA plans and FFS.  The “premium support” concept still engenders highly politicized opposition in some quarters.  But support for the idea has also begun to cross ideological divides. 

Premium support is of course a complex reform.  It requires risk adjustment of payments and regulation of plans to ensure fair competition.  But the risk adjustment system and the regulation need not be perfect for the reform to work; indeed, the system already in place today for MA plans should provide sufficient confidence that a competitive reform model would be beneficial for the program’s participants.

The main obstacle to more intensive competition in Medicare has been distrust.  MA advocates believe the bureaucracy will tilt the playing field toward FFS; and FFS defenders believe private plans will find new ways to risk select and game the system or to influence policymakers to provide them with overly generous terms on their payment rates.

http://healthaffairs.org/blog/2014/11/06/an-emerging-consensus-medicare-advantage-is-working-and-can-deliver-meaningful-reform/

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Comment:

By Don McCanne, MD

Today two new papers were released designed to give us greater insight on the relative value of the traditional Medicare program and the private Medicare Advantage plans. What can we learn from these reports?

It is well established that Medicare Advantage plans are paid more per patient than the costs of providing care for comparable patients in the traditional Medicare program. They continue to market their plans to healthier patients and yet they artificially magnify a touch of illness for purposes of receiving greater payments based on risk adjustment. Although the Affordable Care Act requires a gradual reduction in these overpayments, concessions have been made by the Obama administration to reduce the impact of these adjustments. The taxpayers continue to receive inferior value from their investment in the private Medicare Advantage plans.

The comprehensive literature review from Kaiser Family Foundation concludes that the information available unfortunately is quite limited. They do conclude that Medicare HMOs are able to achieve higher scores in providing preventive services – likely because of their IT systems that flag items that would improve their quality rating scores. Medicare HMOs also use resources more conservatively, which raises the concern that they could be withholding appropriate care.

Perhaps the most important conclusion from the Kaiser review is the finding that the differential in quality and access for beneficiaries who are sick is particularly large, relative to those who are healthy, between traditional Medicare and Medicare Advantage. Medicare Advantage plans may have learned how to score well on teach-to-the-test quality measures, but they fall far short of traditional Medicare in patients’ real world health care experiences.

The Health Affairs Blog article by Miller and Capretta needs to be recognized for what it is – a political tract. They claim that “evidence mounts that MA plans can deliver more efficient and higher quality care than FFS” – a claim based more on their ideological preferences for a privatized Medicare rather than on a comprehensive review of the health policy literature. They then use that conclusion to advocate for a premium support proposal that would further privatize Medicare.

They state that the main obstacle to increasing public and private Medicare plan competition is distrust. They say that Medicare Advantage advocates believe that bureaucrats will tilt the playing field toward traditional Medicare, yet the facts are that the Obama administration has been tilting the field towards the Medicare Advantage plans instead. They also say that the traditional Medicare advocates “believe private plans will find new ways to risk select and game the system or to influence policymakers to provide them with overly generous terms on their payment rates.” Of course, those are not just beliefs but are well documented facts. We are paying more for private insurers to game the system at our expense.

Although neither of these reports provides new evidence that would change our opinions on private Medicare Advantage plans, they do reinforce our view that we should not listen to ideologues who care more about markets than about patients. Instead we should continue to support our traditional Medicare program that puts patients first, although we do need to improve it and then expand it to cover everyone.

Support reforms to cut administrative burdens on doctors

By Stephen B. Kemble, M.D.
Honolulu Star-Advertiser, Nov. 6, 2014

Health care in the U.S. suffers from severe over-management.

Recent studies have documented high administrative burdens for American doctors and hospitals. The average U.S. physician spends a sixth of their time on administrative tasks that are not integral to patient care, and this is worst for psychiatrists, internists, and family practitioners – the very specialties for which we have the worst shortages. 

Administrative costs for U.S. doctors are about four times those of countries with simpler, universal health care systems. 

U.S. hospitals also spend 25 percent of their budgets on administration, much higher than in any other country and twice as high as countries like Canada and Scotland.  

Since the introduction of managed care in the 1990s, the number or doctors in the U.S. has about doubled, while the number of administrators has increased more than tenfold, to the point that there are now far more administrators than doctors. 

Spurred by the Affordable Care Act, doctors and hospitals are reorganizing into large systems, and hospitals and insurance plans are buying up physician practices all over the mainland, supposedly to improve care coordination and efficiency of care. Actual results are showing the opposite. Large systems bring higher administrative burdens for doctors and raise the total cost of care. 

Pay-for-performance is the latest scheme to micromanage doctors, but the complexity of health care means the validity of “quality” measures is very low, and financial incentives reward the wrong things and encourage gaming of documentation to satisfy “metrics.” 

Conscientious doctors who knows their patients will always know far more about quality of care for individual patients than a health plan administrator with “metrics” from claims and electronic health records. Physicians are increasingly demoralized by micromanagement from clueless administrators, harming actual quality of care.

Hawaii’s health transformation initiative has so far been focused on developing “Accountable Care Organizations” and implementing pay-for-performance schemes, relying on federal health care innovation grants. These efforts are getting us nowhere in the quest for the “Triple Aim” goals of improved quality of care, improved population health, and reduced cost. Once the grants run out, we are left with administratively complex and costly reforms that can’t work in practice.

I hope our next governor will realize the futility of this approach and support reforms that reduce administrative burdens on doctors and empower them to do what they were trained to do – manage the care of their patients based on their professional training balanced with specific knowledge of each patient’s unique illnesses and circumstances. 

Instead of pay-for-performance, physician pay should be incentive-neutral, freeing doctors to focus on the best interest of their patients.

Relief from administrative burdens will also help recruit and retain doctors, making it easier for them to practice in underserved specialties and locations.

If we want to achieve the Triple Aims, we need to assure care for everyone in the most cost-effective settings, simplify and streamline administration, and use administrative savings – not restrictions on care – to reduce the prices paid for health care. 

Dr. Stephen B. Kemble is assistant clinical professor of medicine at the John A. Burns School of Medicine.

http://www.staradvertiser.com/s?action=login&f=y&id=281737321

What the election means for reform, especially single payer

This Is How the New GOP Senate Will Try to Dismantle Obamacare

By Jonathan Cohn
New Republic, November 4, 2014

Most Republicans know that they can’t repeal Obamacare anymore. They’ll start with a symbolic vote for outright repeal. From there, (Ted) Cruz says, Republicans will go after Obamacare provisions “one at a time.” 

Here’s what the GOP has in mind, based on conversations with health care experts and lobbyists:

  • Repealing the individual mandate
  • Repealing or modifying the employer mandate
    • changing the threshold to 40 hours
    • could propose raising (50 employee requirement) to 100 full-time employees
  • Eliminating “risk corridors”
  • Repealing the device tax
  • Abolishing the Independent Payment Advisory Board (IPAB)
  • Introducing “Copper Plans”
    • 50 percent actuarial value

http://www.newrepublic.com/article/120125/republican-plans-obamacare-device-tax-mandates-risk-corridors

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Comment:

By Don McCanne, MD

New Republic’s Senior Editor Jonathan Cohn, an astute and very well-informed observer of the health care reform scene, provides us with a quite plausible response of the new Republican majority in the next session of Congress. They will likely fulfill their promise to introduce legislation to repeal the Affordable Care Act (ACA), though knowing that the effort will end with either a filibuster or a presidential veto. The real action will take place over individual provisions of ACA.

Some of the less objectionable measures they propose could be included in other bills as part of the legislative compromise process. Other less desirable changes could avoid filibuster by being tacked onto reconciliation bills, and avoid veto by being added to must-sign bills ((e.g., bills to prevent shutting down the government).

Since the Republicans have never formed a consensus on the replace part of repeal and replace, it is unlikely that they will try to enact some of their proposed measures such as eliminating the tax preference of employer-sponsored plans, or selling plans across state borders to avoid effective regulatory oversight. Such efforts would create new problems that would be unpopular – not an approach they would likely take when they have their eye on the White House in two years.

So how does single payer activism fit into all of this? With one caveat, there should be no change in our mission to educate our colleagues and the public on a vastly superior alternative – a single payer national health program. As patients experience the deficiencies of our current dysfunctional system, they have to understand that it doesn’t have to be this way – that everyone can have their choices in essential health care without having to negotiate financial barriers to that care.

During the next session of Congress, it is clear that we will not see any movement on single payer legislation. Even if a wave of Republican Enlightenment were to flood Congress and they decided that single payer really was the preferred model, they would not allow President Obama to receive any credit by signing the bill, but rather would wait until a Republican President took office in 2017. Lest this seem like a fantasy, F.A. Hayek supported “a comprehensive system of social insurance.”

Our education process is two-fold: 1) describing the very positive features of the single payer model, and 2) exposing the severe inequities and deficiencies of our fragmented system which has only been perpetuated by ACA. The former is obvious, but the caveat applies to the latter.

Until we can move forward on single payer, it is important to take care of what we do have. We should not criticize the efforts of those who are still in the process of implementing ACA. They are doing the best they can under current laws and regulations. If Congress tries to enact measures that are clearly detrimental we should join our friends in opposing such actions. If beneficial patches to ACA are proposed, we should not oppose them merely because they perpetuate ACA, but rather support them as transitional improvements until we can achieve single payer.

But this is where we have a problem. We need to let the public know why these measures are inadequate – how they merely perpetuate our highly flawed system. But we must make a clear distinction between our efforts to make our health care system work well for everyone and the efforts of some members of Congress who would destroy as much of ACA as they can, and walk away leaving too many people exposed to yet more health and financial insecurity. When we are accused of helping the enemy of reform by opposing ACA we have to correct that misperception by letting them know that we support ACA as a transitional program that provides some relief until we can enact single payer, but that we cannot accept decades of incremental changes to ACA that can never lead to a rational, comprehensive system of health care financing.

Based on the simplistic messages that carried the election, it is obvious that we have a formidable task ahead of us. Our messages are not simple, but they need to be clear. Everyone can have affordable, high quality health care, but we do not have that with ACA nor would we with the anticipated Republican actions. We have to let people know.

The high administrative costs in U.S. health care

Health Affairs, Letters, November 2014

PNHP note: The following letters appeared in the November issue of the journal Health Affairs in connection with a feature article in the September issue titled “A Comparison Of Hospital Administrative Costs In Eight Nations: US Costs Exceed All Others By Far,” by David U. Himmelstein, Miraya Jun, Reinhard Busse, Karine Chevreul, Alexander Geissler, Patrick Jeurissen, Sarah Thomson, Marie-Amelie Vinet, and Steffie Woolhandler.

High Administrative Costs At US Hospitals

By Samuel Metz

David Himmelstein and coauthors (Sep 2014) show that administrative costs in US hospitals exceed those in hospitals in seven other developed nations and indicate that this extra spending buys more administrators, not more benefits. This raises the question of why American hospitals need more administrators than foreign hospitals do.

The authors say that the extra administrators in the United States determine patients’ insurance benefits and their ability to pay costs that are not covered by insurance. These functions are unnecessary elsewhere.

Unlike nations with national insurance plans, the United States spends billions of dollars to fragment our population into thousands of insurance pools and then to fragment those pools into tens of thousands of subsets with differing benefits. This format generates substantial administrative challenges. For example, physician offices in Chicago might deal with 17,000 different payment schedules.[1]

It costs more money to exclude patients and restrict benefits that it would to provide comprehensive care to all patients without fragmentation. Two authors of the September article previously estimated that replacing our multipayer system with a national health program would recover $320 billion in administrative costs.[2] This exceeds the estimated $220 billion in additional costs needed to provide comprehensive care to everyone.[3]

The message is clear: Barriers to health care cost more than universal access to health care.

Notes:
1.  Kagel R. Blue crossroads: insurance in the 21st century. Amednews.com [serial on the Internet]. 2004 Sep 20 [cited 2014 Sep 15]. Available from: http://www.amednews.com/article/20040920/business/309209993/4
2. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med. 2003;349(8):768–75.
3. Sheils J, Haught RA. The Health Care for All Californians Act: cost and economic impacts analysis [Internet]. Falls Church (VA): Lewin Group; 2005 Jan 19 [cited 2014 Sep 15]. Available from: http://www.lewin.com/~/media/Lewin/Site_Sections/Publications/3015.pdf

Portland, Ore.

http://content.healthaffairs.org/content/33/11/2081.1.full

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High Administrative Costs: The Authors Reply

By David U. Himmelstein and Steffie Woolhandler

Samuel Metz aptly characterizes the wasteful complexity of US health care financing, compared to a single-payer system — for example, an improved version of Medicare for all Americans. His estimate of administrative savings achievable through such reform is too low, however, because it’s based on an analysis of 1999 data. Our study (Sep 2014) found that since 2000, US hospitals’ administrative costs have risen from 0.98 percent of gross domestic product to 1.43 percent. And per capita annual insurance overhead costs have tripled since 2006, reaching $731.[1] Switching to a single-payer system today could save more than $400 billion annually on bureaucracy.

These savings would make it possible to provide universal coverage without copayments or deductibles and with no increase in health expenditures. In contrast, the Affordable Care Act has added another layer of bureaucracy — the health insurance exchanges — that cost $6 billion to get up and running, or $750 per new enrollee.

Economics texts preach that markets breed efficiency, but the most market-oriented health systems are the least efficient. The transformation of American health care into a business has sharply increased transaction costs and rewarded entrepreneurs for financial games that add no value.

One hospital that we know paid upcoding consultants $600,000 to advise interns on the best language for chart notes. Typing “moderately malnourished” instead of “malnourished” apparently ups diagnosis-related group payments (and also improves risk-adjusted mortality scores). That useless expenditure garnered an extra $3 million in revenues for the hospital.

A simple national health insurance program is the best way to meet both the moral imperative to care for the sick and the economic imperative to do so efficiently.

Note:
1. Centers for Medicare and Medicaid Services. National health expenditure data, historical data [Internet]. Baltimore (MD): CMS. Table 4: national health expenditures by source of funds and type of expenditures: calendar years 2006–2012; [cited 2014 Sep 17]. Available from: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/tables.pdf

City University of New York, New York, N.Y.

http://content.healthaffairs.org/content/33/11/2081.2.full

EHR Use Adds To Administrative Duties

Electronic health records are meant to simplify a physician’s workload, right? Not so, according to an article published in the International Journal of Health Services.

By Katie Wike
Health IT Outcomes, Nov. 5, 2014

Drs. Steffie Woolhandler and David Himmelstein, who serve as professors of public health at the City University of New York and lecturers in medicine at Harvard Medical School, recently studied data from over 4,700 physicians. According to the International Journal of Health Services, this data came from the most recent 2008 Health Tracking Physician Survey.

Woolhandler and Himmelstein found the average doctor spent 8.7 hours per week – 16.6 percent of their working time – on administrative duties. This includes time spent on billing, obtaining insurance approvals, financial and personnel management, and negotiating contracts. It does not include patient related tasks, such as charting, ordering labs, and consulting with other physicians.

Fierce EMR explains Woolhandler and Himmelstein also discovered doctors using electronic health records (EHRs) averaged about 17 percent of their time on administrative duties, while those using paper records spent about 15.5 percent of their time doing the same. For those who used both an EHR and paper records, this number rose to 18 percent. This difference may stem from the fact that EHR documentation often takes longer.

“American doctors are drowning in paperwork,” said lead author Woolhandler. “Our study almost certainly understates physicians’ current administrative burden. Since 2008, when the survey we analyzed was collected, tens of thousands of doctors have moved from small private practices with minimal bureaucracy into giant group practices where bureaucracy is rampant. And under the accountable care organizations favored by insurers, more doctors are facing HMO-type incentives to deny care to their patients, a move that our data shows drives up administrative work.”

iHealth Beat reports the study also found correlations between administrative duties and professional satisfaction. Those who spent more time on such tasks had lower moral. Doctors who reported they were “very satisfied” spent an average of 16.1 percent of their time doing administrative tasks, while doctors who reported being “very dissatisfied” spent 20.6 percent doing such work.

“Our crazy health financing system is demoralizing doctors and wasting vast resources. Turning health care into a business means we spend more and more time on billing, insurance paperwork and the bottom line. We need to move to a simple, nonprofit national health insurance system that lets doctors and hospitals focus on patients, not finances,” said Himmelstein.

http://www.healthitoutcomes.com/doc/ehr-use-adds-to-administrative-duties-0001

Don’t pay for ‘nothing,’ fund universal care

By Samuel Metz, M.D.
Portland (Ore.) Tribune, Nov. 4, 2014

What are the saddest parts of the Cover Oregon debacle?

The first is that our state government spent $250 million for software development that, in the end, left us with … nothing.

Not only nothing, but with a hostile and very wealthy software development company intent on compelling Oregon to pay even more for … nothing.

Actually, that big loss is neither unexpected nor unprecedented. The majority of software development projects, both government and private, ultimately fail to produce the expected product. Oregon’s government is not immune to these catastrophes: In the 1990s, Oregon spent more than $100 million on Department of Motor Vehicles software that ultimately produced … nothing. So Cover Oregon did not break new ground in failed projects, not even for failed government projects.

The saddest part of Cover Oregon, however, is that a universal health plan in Oregon would have rendered Cover Oregon, plus its software, its website and indeed its entire mission, totally unnecessary. Matching four million Oregonians with a specific insurance policy is expensive. But universal health care is not.

Why was Cover Oregon so expensive? The Affordable Care Act compels Oregon, like the rest of the country, to spend millions of dollars assigning us into one of hundreds of insurance pools, based on employer, age, number of coworkers, military status, residence, family size and a host of other factors.

Our assigned insurance pool then determines which insurance plans we might qualify for and which physicians we can see. These insurance plans are further subdivided into hundreds of benefit plans, which could be unaffordable, inadequate or both.

We then recalculate everything with every change in employer, age, etc. That’s why we need Cover Oregon (or a federal website) to keep track of this massive paperwork.

It doesn’t have to be this way. And it isn’t this way for health care systems that successfully provide better care to more people for less money than we do in Oregon.

These successful health care systems (around the world and in our own country) possess one common characteristic — they assign everyone to just one insurance pool (human beings), with just one set of benefits (treatable conditions are treated), and with just one network (all licensed physicians).

No successful system spends money on websites like Cover Oregon in order to sort sick from healthy, poor from wealthy and employed from jobless. They spend money on health care.

Cover Oregon is necessary only if we want to restrict care and limit benefits. If we instead commit to comprehensive care for everyone, Oregon saves money. How much? The money we now spend on software development, website design, insurance administration, marketing, lobbying and provider overhead that deals with all this would be more than enough to provide every Oregonian with access to comprehensive care.

We know this because every health care system that provides universal comprehensive care also spends less money with better results than we do now.

What does the Cover Oregon debacle teach us? Restricted care costs more than universal care.

Oregon doesn’t need to spend more to provide better care to more people. We just need to spend our money on health care, not Cover Oregon.

Successful systems tell us how to achieve that: Universal care.

Samuel Metz is a Portland anesthesiologist and a member of Physicians for a National Health Program and Mad As Hell Doctors, organizations that advocate for universal health care in Oregon and nationally. 

http://portlandtribune.com/pt/10-opinion/239284-104460-my-view-dont-pay-for-nothing-fund-universal-care

Fox: Patients who can’t use their exchange plans

Some ObamaCare patients with high deductibles turning to community care centers

By Jim Angle
Fox News, November 4, 2014

When ObamaCare patients learn their deductible is so high they’re unlikely to get any reimbursement, they often wind up in places like the Denton, Texas Community Care Center.

“There are quite a few, and I saw another one today, where their deductibles are so elevated that they can’t afford them,” said Dr. Flippo Masciarelli, chief physician at the center, which was designed to treat indigent patients.

Robert Laszewski of Health Policy and Strategy Associates noted, “You’re going to the doctor, you’re paying (a) premium, and because of this really high deductible, you’re not getting any benefits.”

The administration pushed insurance companies to keep premiums low, but that also created high deductibles, about $5,000 per person for the least expensive plan, as well as narrow networks of providers.

But most people buy based only on premiums.

“They don’t even look at what their deductible is going to be,” said Dan Mendelson, CEO of Avalere Health. “They don’t look at the cost of the medications that they’re on. And they don’t look at the…network that they have.”

Masciarelli said,”one of the ladies we saw said she called eight primary care offices before she found us…” The rest would not treat people on her plan. 

If the doctor these patients find orders additional tests or treatment, even those with ObamaCare are sometimes forced to go without.

Health economist John Goodman said, “They go to community health centers because it’s free or almost free and or very low charges. And that’s why they’re doing it. So they were coaxed to go into the ObamaCare system, they’re paying premiums over there. And now they’re asking what did I get for my premium? I’m having to go outside the system to get health care.”

Masciarelli agreed. “We do get asked that question at times, yes, wondering you know, I have this product. I can’t even use it. ” 

http://www.foxnews.com/politics/2014/11/04/some-obamacare-patients-with-high-deductibles-turning-to-community-care-centers/

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Comment:

By Don McCanne, MD

Although this is a typical Fox News anecdotal report not based on any scientific study and designed to discredit “ObamaCare,” nevertheless it does make a very valid point. People obtaining their coverage through the insurance exchanges are finding that, with the narrow networks and high deductibles, they “can’t even use” their plans.

Fortunately these patients do have the backup that the 30 million people who will remain uninsured have – community health centers. But they will still have impaired access to specialized services because of unaffordable cost sharing, and because of a lack of specialists who are willing to provide services through the community health centers.

Although these plans do provide coverage for catastrophic events, it is primarily the providers rather than the patients who benefit. Because of EMTALA regulations, the patients would receive the care anyway, but the providers will be paid rather than having to write the care off as a loss. It is just one more example of how the system was designed to take care of the medical-industrial complex rather than placing the patient at the pinnacle.

Single payer would get rid of the narrow networks and unaffordable cost sharing, so no patient would be rejected based on the limitations imposed by the private insurers. But then that would deprive Fox News of these anecdotal reports that they use to bash President Obama. So what is our priority here?