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Administrative burden on U.S. physicians

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Administrative burden on U.S. physicians

Administrative Work Consumes One-Sixth of U.S. Physicians’ Working Hours and Lowers Their Career Satisfaction

By Steffie Woolhandler and David U. Himmelstein
International Journal of Health Services, Volume 44, Number 4 / 2014

Abstract:

Doctors often complain about the burden of administrative work, but few studies have quantified how much time clinicians devote to administrative tasks. We quantified the time U.S. physicians spent on administrative tasks, and its relationship to their career satisfaction, based on a nationally representative survey of 4,720 U.S. physicians working 20 or more hours per week in direct patient care. The average doctor spent 8.7 hours per week (16.6% of working hours) on administration. Psychiatrists spent the highest proportion of their time on administration (20.3%), followed by internists (17.3%) and family/general practitioners (17.3%). Pediatricians spent the least amount of time, 6.7 hours per week or 14.1 percent of professional time. Doctors in large practices, those in practices owned by a hospital, and those with financial incentives to reduce services spent more time on administration. More extensive use of electronic medical records was associated with a greater administrative burden. Doctors spending more time on administration had lower career satisfaction, even after controlling for income and other factors. Current trends in U.S. health policy—a shift to employment in large practices, the implementation of electronic medical records, and the increasing prevalence of financial risk sharing—are likely to increase doctors’ paperwork burdens and may decrease their career satisfaction.

From the Discussion

A few studies have examined the amount of time physicians spend on billing and insurance-related paperwork—a narrower definition of administrative work than we used. A 2000 California study estimated billing and insurance-related work consumed 4.9 percent of physician time. In a 2006 survey, physicians reported spending 3 hours per week interacting with private insurance plans, with primary care doctors and solo practitioners reporting slightly higher figures; 81.5 percent perceived that this work was increasing. A companion 2006 survey of office-based private practitioners in Ontario found they spent 2.2 hours per week interacting with insurers (vs. 3.4 hours in the United States when Medicare and Medicaid were included along with private insurers). Differences in the time spent on these tasks by non-physician office staff were even larger; 20.6 hours of nurse time per physician in the United States versus 2.5 hours in Canada; 53.1 hours per week of clerical time in the United States versus 15.9 hours in Canada; and 3.1 hours per week of senior administrators’ time in the United States versus 0.5 hours in Canada.

Much time and money are currently spent on medical billing and paperwork. A simpler system could realize substantial savings, freeing up more resources to expand and improve coverage.

International Journal of Health Services (click on the article for the abstract): https://www.baywood.com/journals/previewjournals.asp?id=0020-7314

Full article: http://org.salsalabs.com/o/307/images/Physician%20admin%20time_IJHS.pdf

PNHP Press Release: https://www.pnhp.org/news/2014/october/administrative-work-consumes-one-sixth-of-us-physicians%E2%80%99-time-and-erodes-their-mor

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Comment:

By Don McCanne, MD

The health care system in the United States is unique for its profound administrative waste. This article by Steffie Woolhandler and David Himmelstein demonstrates the intensity of the administrative burden on physicians – a burden that is correlated with lower career satisfaction.

The good news is that we could reduce that burden and improve satisfaction by adopting a single payer system such as they have in Canada. But then the bad news is that we have left the political agenda in the hands of those who are adept at buying the votes in Congress – especially the insurance and pharmaceutical industries.

It doesn’t have to be this way. After all, we are a democracy, but we have to make the effort to have our voices heard.

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Bureau of International Information Programs, U.S. Department of State

What Is Democracy?

The essence of democratic action is the active, freely chosen participation of its citizens in the public life of their community and nation. Without this broad, sustaining participation, democracy will begin to wither and become the preserve of a small, select number of groups and organizations.

At a minimum, citizens should educate themselves about the critical issues confronting their society–if only to vote intelligently for candidates running for high office.

http://www.ait.org.tw/infousa/zhtw/docs/whatsdem/whatdm3.htm

Single-payer health care is the only sustainable way forward

By Dave Dvorak, M.D.
Duluth News Tribune, Oct. 23, 2014

“Not sustainable.” That was the way PreferredOne CEO Marcus Merz described the circumstances leading to his insurance company’s decision to withdraw from the MNsure exchange.

Now, with double-digit cost increases forecast for many of the plans on the exchange, perhaps it’s time to finally acknowledge what is truly unsustainable: the increasingly costly and complicated patchwork of insurance coverage that passes for an American health care system. 

Spending twice per capita on health care compared to other Western democracies might be defensible if it demonstrated results. But a Commonwealth Fund study earlier this year ranked the U.S. health system dead last among 11 industrialized nations on measures of quality, efficiency and access.

Not sustainable, indeed.

Despite increases in coverage rates under the Affordable Care Act, millions of families on tight budgets are encountering unaffordable deductibles and copays. Take a 60-year-old Minnesota couple earning $63,000 who purchased a specific plan this year on the exchange. If either of them should experience significant illness, they would face more than $25,000 in expenses, including their premium and out-of-pocket costs — 41 percent of their pre-tax income. Not surprisingly, the leading cause of bankruptcy in America is unaffordable health expenses.

The entrenched private insurance industry vigorously promotes the value of choice in our health plans — 84 separate plans will be offered on next year’s exchange — while corralling its “members” (that’s us) into increasingly narrow provider networks. It is our health premiums that pay for those attention-grabbing billboards and commercials, marketing departments, underwriters, lobbyists, eight-figure executive salaries and investor profits. All are costly administrative functions of private insurance that play no role in actual health care.

The good news resides in the ACA’s little-discussed Section1332. Known as the State Innovation Waiver, this provision allows individual states in 2017 to apply for federal waivers to implement their own innovative health systems — provided they can cover at least as many residents as the ACA without adding to the federal deficit. This offers a huge opportunity for Minnesota to get it right.

An increasingly discussed alternative to the status quo is state-based, single-payer reform. Hardly a fringe concept, single-payer was endorsed by 64 percent of Minnesota physicians in a Minnesota Medicine survey in 2007.

More recently, in August, the Minnesota Medical Association, while not taking a position on single-payer, hosted a policy forum to discuss the pros and cons of moving to a state-based single-payer system.

The chief feature of single-payer is a single, unified funding stream that slashes the inefficiencies of the private insurance industry. Single-payer creates transparent and uniform pricing for health services and products. It replaces the cumbersome and costly practice of itemized hospital billing with global annual budgeting, directing more health care dollars toward actual health care rather than webs of hospital administrators and bloated billing departments.

Meanwhile, single-payer keeps the delivery of health care largely private, encouraging market-based competition where it matters — among health care providers.

In its 2012 economic analysis of single-payer reform in Minnesota, the Lewin Group determined that single-payer could provide quality health and dental coverage to every Minnesotan while saving the state a staggering $65 billion in health spending over 10 years. About

95 percent of Minnesotans would spend less on health care — an average savings of $3,512 per year for a median-income Minnesota family.

The conversation is well underway. Through single-payer reform, Minnesota can guarantee fair, affordable and quality health coverage to every individual and family in the state while saving billions. Now that is sustainable.

Dr. Dave Dvorak of Minneapolis is an emergency department physician and a member of the Minnesota chapter of Physicians for a National Health Program (pnhp.org), which advocates for universal health coverage through single-payer reform.

http://www.duluthnewstribune.com/content/local-view-single-payer-health-care-only-sustainable-way-forward

Zarr appointed president-elect of Physicians for a National Health Program

UT School of Public Health, Oct. 22, 2014

Robert Zarr, M.D., M.P.H., an alumnus of The University of Texas School of Public Health, was recently appointed president-elect of the organization Physicians for a National Program (PNHP). Zarr earned an M.P.H. at the School of Public Health, which is part of The University of Texas Health Science Center at Houston (UTHealth), and an M.D. at Baylor College of Medicine.

Zarr is a board-certified pediatrician at Unity Health Care in Washington, where he cares for a low-income and immigrant population. The clinic is a federally qualified health center. Zarr will be presiding over sessions of PNHP’s Annual Meeting in New Orleans on Nov. 15 and will fully assume the office of president on Jan. 1, 2015.

In addition to his work with Unity Health Care and PNHP, Zarr is a strong supporter of physical activity as a prescription for health problems. He works with the Parks Rx program coordinated with the National Park Service and George Washington University. “From my angle, as a physician, I’m literally prescribing parks, prescribing nature now,” says Zarr. He says the research on that should be published soon. (Read more about that here.)

Physicians for a National Health Program is a nonprofit research and educational organization of more than 19,000 members (physicians, retired physicians and medical students) who support single-payer national health insurance. Surveys show that among U.S. physicians, pediatricians tend to be among the most supportive of national health insurance. “It seemed fitting for me to volunteer my time with PNHP because I personally see so much of the unnecessary lack of access to healthcare and all its consequences,” says Zarr.

Zarr will be working with PNHP’s founders, Dr. David Himmelstein and Dr. Steffie Woolhandler; as well as other supporters such as Quentin Young who was a personal physician for Martin Luther King, Jr. “These are people who have really wonderful hearts, who have done so much work to improve all of our lives,” says Zarr. “I’m just so honored that they would even think of me as a peer and a leader in their organization.”

“We’re really about a single issue—which is, in my opinion and the opinions of thousands of other physicians around the country the most important first step—we’ve got to eliminate this financial barrier to seeking care,” says Zarr about PNHP. Zarr mentioned the Dallas Morning News article written by the nephew of Ebola patient Thomas Eric Duncan, which mentions that Duncan was uninsured. “Whether we want to face that fact or not, we know that it plays a very important part in delaying care and in receiving care. Once a person takes the initiative to receive care, it’s undoubtedly a factor that millions—right now we’re still at 42 million—Americans are still uninsured, which is nearly one in six. That’s a lot of people and is a crisis.”

Zarr spoke more about epidemic-sized infectious diseases, specifically Ebola in 2014, and also severe acute respiratory syndrome (S.A.R.S) and the situation that occurred in Asia in 2002-2004. “When you have a looming disaster like this [Ebola], a public-health disaster, people need to know that they can receive care without the stigma of not being able to pay or in the worst case without being deported,” says Zarr. “If you look at S.A.R.S. in China, the government was having a hard time getting ahold of the outbreak and was trying to prevent pandemic. What they found was that people weren’t going to the hospital because they couldn’t pay the bill—they were scared. One of the first things the government did was say, ‘Listen, we’ll pay all the bills: anybody who comes in with S.A.R.S.-related symptoms—it’s all paid for.’ And it worked. It was a very important measure.”

Zarr says not having health insurance delayed Duncan’s decision to go to the emergency room when he was having Ebola symptoms. “We’ve already had one person who didn’t have health insurance and we don’t know all the reasons why he went in when he did, but we know that care is definitely delayed when one does not have health insurance.” Duncan died two days after returning to the hospital for the second time.

When a country has a national health insurance program, Zarr says it is important for the citizens to remember that it is not “free.” Zarr described the National Health System’s formation in the United Kingdom of Great Britain and Northern Ireland in 1948, a few years after the end of World War II. He said the government helped people understand that it would be paid for through taxes in the same way that roads, police, fire departments and schools are paid for. “I think it was a really important move on their part,” Zarr said. “People tend to understand it shouldn’t be free—we do pay for it. And we’re paying for it now; it’s just that it’s not equitable now. Not everybody has equal access and that is the issue that we’ve been grappling with for so long.”

As a physician, Zarr said that the additional M.P.H. degree has given him a good foundation in public health to be an advocate for his patients and people without access to health insurance. “An M.P.H. is really a fantastic supplement to any physician’s career really. I think when you graduate with your M.P.H., you leave there understanding that big picture, which you really need to have in order to effect change on a big scale.”

The PNHP supports two Congressional bills: House bill H.R. 676 and the Senate companion bill 1782. “It’s an important step we need to take so that we can reach the level of outcomes and equity that we haven’t seen ever in this country,” said Zarr about the bills. “We’ve had a lot of discussion about ACA [Affordable Care Act] within our organization [PNHP] and there are a lot of things about ACA that are very good: the expansion of Medicaid, the extension of benefits up to age 26 for a young adult to be on his or her parents’ plan, the elimination of preexisting conditions—but at the end of the day, even by 2016 when it’s supposed to be fully implemented, there’s still going to be around 30 million uninsured and many millions more underinsured. Even though people have an insurance card, they’re still going not to have access to the care they need primarily because they won’t be able to afford the copays and the deductibles. They’re very high, even with the silver plan.”

Zarr is a past president of the Washington, D.C. chapter of the American Academy of Pediatrics and served as a CATCH facilitator in D.C. for five years. He holds adjunct professorships at Children’s National Medical Center and George Washington University.

In addition to his work with PNHP and Parks Rx, he is active in a variety of quality improvement initiatives including asthma management, injury prevention, literacy promotion, breastfeeding awareness, youth advocacy, tuberculosis prevention and compliance with early and periodic screening, diagnostic and treatment standards.

https://sph.uth.edu/2014/10/uthealth-alumnus-zarr-appointed-president-elect-of-physicians-for-a-national-health-program/

Important: Uwe Reinhardt on health care price transparency and economic theory

Health Care Price Transparency and Economic Theory

By Uwe E. Reinhardt, PhD
JAMA, October 22/29, 2014

Citizens in most economically developed nations have health insurance coverage that results in only modest cost sharing at the time health care is used. Furthermore, physicians, hospitals, and other clinicians and entities that provide health care within most systems outside the United States are paid on common fee schedules uniformly applied to all clinicians, health care organizations, and insurers. That approach spares the insured the need to seek out lower-priced health care and obviates the need for transparency on the prices charged by individual clinicians and organizations that provide health care.

Not so in the United States, where every private health insurer negotiates prices with every health care practitioner and organization, where large public health insurance systems such as Medicaid and Medicare pay fees that do not cover the full cost of treating patients covered by these programs, and where uninsured, self-paying patients can often be asked to pay whatever can be extracted from their household budgets, sometimes with the help of debt collectors and the judiciary. Economists call the approach price discrimination, which means the identical service is sold to different buyers are different prices.

This approach to pricing health care has led in the United States to a system in which, at one end of the spectrum, hospitals and physicians are expected by society to treat low-income patients free of charge, on a charitable basis, or for modest fees that do not cover the cost of those treatments and then to finance that informal catastrophic health insurance system for the poor out of the other part of their enterprises that they can operate as profit-maximizing business firms. This is true even in some of the large segment of institutions referred to as not-for-profit. The harsh excesses that this quest for profits in health care can unleash—even among not-for-profit hospitals—have been well reported in various articles in the popular press.

Private employers in the United States have played a pivotal role in the evolution of this system. They hired as their agents in health care the private insurers who helped put that system into place, and they supported it. To gain better control over the growth of their health spending, employers have of recent resorted to a technique long recommended to them by the market devotees among health economists, namely, putting the patient’s “skin in the game,” as the jargon goes. It is done with health insurance policies imposing on the insured very high annual deductibles before insurance coverage even begins, followed by significant coinsurance, perhaps requiring patients to pay 10% to 20% of every medical bill, up to a maximum total annual out-of-pocket expenditure that can potentially exceed $10 000 for a family.

This approach of shifting more of the cost of employment-based health insurance visibly and directly into the household budgets of employees amounts to rationing parts of US health care by price and ability to pay and delegates the bulk of the hoped-for belt-tightening to low-income families. Because the word rationing is anathema in the US debate on health policy, the strategy has been marketed instead under the felicitous label of consumer-directed health care, presumably designed to empower consumers in the health care market to take control of their own health care. However, this strategy, based mainly on economic theory, so far has put the cart before the horse.

In virtually all other areas of commerce, consumers know the price and much about the quality of what they intend to buy ahead of the purchase. This information makes comparison shopping relatively easy and is the sine qua non of properly functioning markets. By contrast, consumer-directed health care so far has led the newly minted consumers of US health care (formerly patients) blindfolded into the bewildering US health care marketplace, without accurate information on the prices likely to be charged by competing organizations or individuals that provide health care or on the quality of these services. Consequently, the much ballyhooed consumer-directed health care strategy so far has been more a cruel hoax than a smart and ethically defensible health policy.

http://jama.jamanetwork.com/article.aspx?articleid=1917413

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Association Between Availability of Health Service Prices and Payments for These Services

By Christopher Whaley, BA; Jennifer Schneider Chafen, MD, MS; Sophie Pinkard, MBA; Gabriella Kellerman, MD; Dena Bravata, MD, MS; Robert Kocher, MD; Neeraj Sood, PhD
JAMA, October 22/29, 2014

Conclusions

Use of price transparency information was associated with lower total claims payments for common medical services. The magnitude of the difference was largest for advanced imaging services and smallest for clinician office visits.

http://jama.jamanetwork.com/article.aspx?articleid=1917438

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Comment:

By Don McCanne, MD

In a JAMA editorial commenting on an article about price transparency and health care spending, Uwe Reinhardt first describes the ridiculous system we currently have, concluding, “the much ballyhooed consumer-directed health care strategy so far has been more a cruel hoax than a smart and ethically defensible health policy.”

He then discusses the article by Christopher Whaley and his colleagues in which they describe price savings resulting from health care price shopping: an average of a mere $1.18 for clinician office visits, $3.45 for laboratory tests, and a more impressive average savings of $124.74 for advanced imaging services.

Imaging aside, think about that one dollar saved by shopping office visit prices. Does that one dollar really pay for the labor involved in price shopping, much less the additional transportation costs and other inconveniences of going to a different doctor, not to mention the disruption in care provided by a primary care medical home? Not exactly a shopper’s paradise.

Even the more significant savings in advanced imaging can have drawbacks if it results in non-coordinated care outside of a system functioning as an integrated unit, whether or not it is technically a single integrated health care entity.

But what is really important here lies in Uwe Reinhardt’s comments. As he states, “other clinicians and entities that provide health care within most systems outside the United States are paid on common fee schedules uniformly applied to all clinicians, health care organizations, and insurers. That approach spares the insured the need to seek out lower-priced health care and obviates the need for transparency on the prices charged by individual clinicians and organizations that provide health care.”

Other nations pay the right amount to sustain he system, without the waste of overpaying some nor the threat of inequitable access caused by underpaying others. No matter how much price transparency we have in the United States, our highly dysfunctional, fragmented system of financing health care will never get pricing right.

Yes, we need a single payer national health program. Under such a system the pricing would be transparent to our public administrators, and who better could determine whether or not the price is right? We surely can’t.

Pharmacy benefit managers moving to narrow networks?

CVS Smoke-Free Pharmacy Benefit Excludes Tobacco-Selling Rivals

By Bruce Japsen
Forbes, October 20, 2014

CVS Health (CVS) confirmed its Caremark pharmacy benefit management subsidiary would sell a smoke-free drugstore network to employers and health plans that would provide subscriber discounts for using “tobacco-free” pharmacies.

The move, which would benefit CVS Health pharmacies given the company’s decision to stop selling tobacco, could at the same time hurt rivals like Walgreens, Wal-Mart and others because a health plan subscriber that would use pharmacies outside the Caremark smoke-free network would pay higher co-payments and related cost-sharing.

CVS Health is able to exact some control on customer choices of prescription purchases through its Caremark pharmacy benefit management (PBM) subsidiary, which has contracts with CVS pharmacies as well as myriad other drugstore chains and independent pharmacies.

“Following our announcement that we would no longer be selling tobacco at CVS/pharmacy, a number of our pharmacy benefit management clients approached us about developing a tobacco-free pharmacy network,” Carolyn Castel, vice president of corporate communications at CVS Health said in an e-mailed statement to Forbes.

“As a result, CVS Health is in the process of identifying pharmacies that do not sell tobacco products to participate in such a new offering. We look forward to making this new pharmacy network available to our clients who choose this offering and providing their plan members with an option to select a tobacco-free environment for their prescription fulfillment needs.”

The Wall Street Journal’s Pharmalot blog reported CVS Health’s Caremark PBM would require a co-pay of “up to $15,” but CVS Health wouldn’t confirm any specifics on a cost-sharing structure.

It’s believed to be a first, according to health benefits analysts who see CVS Health’s move as a narrow network strategy, which is becoming more common from insurance companies and pharmacy benefit managers.

Insurers and benefit managers can better control costs by limiting plan subscriber choices to a smaller group of medical-care providers. By limiting choices, insurers say they can better focus on quality of medical care that is delivered to plan customers.

http://www.forbes.com/sites/brucejapsen/2014/10/20/cvs-smoke-free-pharmacy-network-would-exclude-tobacco-selling-rivals/

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Comment:

By Don McCanne, MD

Last month CVS announced, with considerable fanfare, that it would discontinue sales of tobacco products at its drugstores – a move that would cost it $2 billion in annual sales. After a month-long publicity campaign touting its altruistic action in support of a healthier America, we learn of the not-so-noble purpose of their decision.

They are claiming that in response to this move, numerous pharmacy benefit manager (PBM) clients approached them to request that they develop “a tobacco-free pharmacy network.” Sure they did. One month ago, they announced the end of tobacco sales one, but making that announcement one month ahead of their intended schedule. By splitting the announcements, they a get a twofer: favorable publicity for ending tobacco sales, and then publicity for a new PBM program that would allow them to “focus on quality of medical care” by selling drugs in a tobacco-free environment (as if there were a difference in identical pills sold in their tobacco-free stores versus the stores of their competitors that still carried tobacco products).

They are clearly being dishonest when that say that this concept arose only as an afterthought when their PBM clients suggested that it would be a good idea to segregate tobacco-free chains in their PBM plans. Obviously this was a carefully thought out marketing plan. Tobacco-free was a ruse. Their obvious deception in their releases should make us question the integrity of their entire organization.

So what are they really doing? Two of the most important moves in health insurance products have been to shift more costs to the consumers (whom we call patients) and to establish narrow networks that are anti-competitive, benefiting the insurer financially. CVS now owns one of the nation’s largest PBMs: Caremark.

What they are doing is to establish a narrow network of tobacco-free pharmacies (primarily CVS) which will be dominated by CVS’s own Caremark PBM. If the customers (patients) obtain their prescriptions outside of their narrow network, they will be required to pay larger out-of-pocket costs. Wow! With their own PBM they are introducing the health insurer innovations of higher patient cost-sharing and narrow networks. We’re screwed again!

How would it be under single payer? We would have a national formulary that included all appropriate medications. Pharmaceuticals would be priced properly through bulk purchasing and other forms of administered pricing, and they would be paid for through equitable public financing. There would be no crooks controlling the gates that would otherwise impair access to the medications that we need.

Not a threat to Medicare

By Ellen Oxfeld
Rutland (Vt.) Herald, Letters, Oct. 21, 2014

Recent letters have expressed the fear that a Vermont-based single-payer system would be a threat to Medicare. This is simply untrue and here is why. The law which set Vermont on the path to single payer specifies on its very first page that Green Mountain Care will cover all Vermonters “regardless of income, assets, health status, or availability of other health coverage.” Also, federal law does not allow for any state to take away Medicare or change Medicare benefits for seniors.

This provides an answer to the queries about Medicare. People on Medicare, or retirees, can keep their coverage. Nothing in Vermont’s law changes how people sign up for Medicare or what benefits seniors would receive. However, Green Mountain Care will be there for them as well, because it will cover all Vermonters regardless of any other coverage they have.

Rather than Green Mountain Care, Vermont’s future single-payer plan, being a threat to Medicare, it will actually ensure that all Vermonters have the same kind of protection that seniors have with Medicare.

Ellen Oxfeld resides in Middlebury.

http://www.rutlandherald.com/article/20141021/OPINION02/710219988

Covered California demonstrates the administrative complexity in renewing exchange plans

California spends $13.4 million to fix Obamacare service woes

By Chad Terhune
Los Angeles Times, October 17, 2014

California’s health insurance exchange hired two outside firms for $13.4 million to address long wait times for consumers calling about their Obamacare coverage.

“We had call response times that were far too long,” said Peter Lee, the exchange’s executive director. “We were swamped.”

Lee said the exchange is nearly doubling its service-center staff to 1,300 to help more than 1 million Californians renew their health-law policies by Jan. 1. The first batch of renewal notices for 2015 went out this week.

Covered California said more than 200,000 people have signed up for Obamacare coverage since regular enrollment ended in April under the Affordable Care Act.

But in a sign of the churn in the individual insurance market, an additional 150,000 people dropped out of the exchange after getting health benefits at work or failing to pay their premium.

People who move, lose their employer coverage or have some other qualifying event in their life can enroll outside the normal sign-up period.

Overall, Covered California said it has 1.1 million people enrolled now, down from its previous tally of 1.2 million.

Part of that was because the exchange said 81% of enrollees paid their initial premium compared with its earlier estimate of 85%.

http://www.latimes.com/business/healthcare/la-fi-obamacare-california-enrollment-20141016-story.html

Comment:

By Don McCanne, M.D.

When the Affordable Care Act (ACA) was being crafted, it was almost as if the designers thought that they were developing a relatively static system. They would simply cover the lowest-income individuals with Medicaid, make available subsidized private plans for moderately-low-income individuals, and then use individual and employer mandates, under threat of penalty, to force the rest of the uninsured into private plans. Although a limited amount of churning in and out of various plans and programs was expected, what they did not seem to understand was how unstable these categories actually are. The churning is massive.

California’s health insurance exchange – Covered California – provides an example of only one part of the churning – that within the exchanges. Just look at some of the numbers:

*  The 1.2 million enrolled in Covered California dropped to 1.1 million, though the instability is much more than the 100,000 difference

*  After open enrollment ended, 200,000 more enrolled in the several months following, allowable only because they had some qualifying event that changed their eligibility status

*  Only 81 percent of enrollees paid their initial premium, so the other 19 percent were dropped

*  150,000 dropped out of the exchange for reasons such as gaining health benefits at work, or failing to pay the premium for the exchange plans

*  1,300 Covered California staff members are required to help about 1 million Californians renew their coverage

Although this amount of churning did not seem to be expected by the designers of ACA, it was thought that at least those remaining in the exchanges would have stable coverage – a static situation for them. No, not really. Because of the variable bids of the private insurers, the benchmark plan – the second lowest cost silver plan – is changing for many exchange participants. Since most premiums are going up, not down, the change in the benchmark plans will change the portion  of the premium for which most of the exchange enrollees will be responsible. To keep their share of the premium lower, many will have to change plans. That means that they will have to shop not only the premiums but also shop the amount of the deductibles, and, as if that weren’t enough, they will have to shop the provider network lists which have been notorious for their inaccuracies, if you can even find a list. Even if the provider lists were accurate, they too are not a static as these lists continue to change as well, with providers moving onto and off of the lists.

If nothing changes, enrollees can accept automatic renewal. That means that nothing could have happened that would change eligibility – no change in employment, income, residence, family size, etc. Also it means that the insurer must be offering the same plan, and yet we know that plan designs change frequently. Nevertheless, everyone enrolled through the exchange plans should enquire as to their options for next year if for no other reason than that the benchmark plan will likely have changed, changing the amount of the premium they will have to pay. Some patients may be dismayed that shopping for premiums may cause them to lose their established health care providers.

There are about 1.7 million Californians who are eligible for coverage but who remain uninsured. This does not count the undocumented. For both logistical and administrative reasons, this will be a more difficult group to insure. Combine this with the fact that perhaps 1 million people already enrolled in Covered California will have to revisit their options means that the task will inevitably necessitate extensive administrative services.

And next year? This static system is not so static after all. And remember that here we are discussing only the administrative hassles of the exchanges. This does not count all of the hassles with Medicaid, employer-sponsored plans, private plans purchased outside of the exchanges, and the administrative nightmare of determining which of the uninsured must pay penalties, how much they must pay, and how the penalties are to be collected when they are linked to income tax refunds.

Suppose we had a single payer national health program. This annual renewal, with all of the administrative costs, hassle, and especially the grief, disappears. Why is nobody in power seriously considering an improved Medicare for all?

Unable to Meet the Deductible or the Doctor

By Abby Goodnough and Robert Pear
The New York Times, Oct. 17, 2014

Patricia Wanderlich got insurance through the Affordable Care Act this year, and with good reason: She suffered a brain hemorrhage in 2011, spending weeks in a hospital intensive care unit, and has a second, smaller aneurysm that needs monitoring.

But her new plan has a $6,000 annual deductible, meaning that Ms. Wanderlich, who works part time at a landscaping company outside Chicago, has to pay for most of her medical services up to that amount. She is skipping this year’s brain scan and hoping for the best.

“To spend thousands of dollars just making sure it hasn’t grown?” said Ms. Wanderlich, 61. “I don’t have that money.”

About 7.3 million Americans are enrolled in private coverage through the Affordable Care Act marketplaces, and more than 80 percent qualified for federal subsidies to help with the cost of their monthly premiums. But many are still on the hook for deductibles that can top $5,000 for individuals and $10,000 for families — the trade-off, insurers say, for keeping premiums for the marketplace plans relatively low. The result is that some people — no firm data exists on how many — say they hesitate to use their new insurance because of the high out-of-pocket costs.

Insurers must cover certain preventive services, like immunizations, cholesterol checks and screening for breast and colon cancer, at no cost to the consumer if the provider is in their network. But for other services and items, like prescription drugs, marketplace customers often have to meet their deductible before insurance starts to help.

While high-deductible plans cover most of the costs of severe illnesses and lengthy hospital stays, protecting against catastrophic debt, those plans may compel people to forgo routine care that could prevent bigger, longer-term health issues, according to experts and research.

“They will cause some people to not get care they should get,” Katherine Hempstead, who directs research on health insurance coverage at the Robert Wood Johnson Foundation, said of high-deductible marketplace plans. “Unfortunately, the people who are attracted to the lower premiums tend to be the ones who are going to have the most trouble coming up with all the cost-sharing if in fact they want to use their health insurance.”

Deductibles for the most popular health plans sold through the new marketplaces are higher than those commonly found in employer-sponsored health plans, according to Margaret A. Nowak, the research director of Breakaway Policy Strategies, a health care consulting company. A survey by the Kaiser Family Foundation found that the average deductible for individual coverage in employer-sponsored plans was $1,217 this year.

In comparison, the average deductible for a bronze plan on the exchange — the least expensive coverage — was $5,081 for an individual and $10,386 for a family, according to HealthPocket, a consulting firm. Silver plans, which were the most popular option this year, had average deductibles of $2,907 for an individual and $6,078 for a family.

Jon R. Gabel, a health economist at NORC, a research organization affiliated with the University of Chicago, said that employer-sponsored plans had lower deductibles, in part, because they provided more generous coverage than the most popular exchange plans. The typical employer-sponsored health plan would qualify as a gold-level policy under the standards of the Affordable Care Act, Mr. Gabel said.

The website for the federal insurance marketplace serving 36 states, HealthCare.gov, strongly encourages consumers to focus on premiums: When consumers search for a plan online, the results are ranked by premium price, with plans offering the lowest premiums listed first.

But insurance plans with lower premiums generally have higher deductibles. Gina Brown, 37, of Nashville, was paying about $155 a month for a Blue Cross Blue Shield of Tennessee plan, after taking account of her subsidy. But her deductible was $4,000, she said, and so she avoided going to the doctor even when she got an ear infection over the summer.

“I attempted to treat it with over-the-counter and homeopathic meds,” she said. “Eventually it went away.”

Ms. Brown recently got a job with health benefits, so she canceled the marketplace plan. Her new insurance has a deductible of $1,000, but primary care visits and prescriptions are not subject to the deductible.

“Now that I know I can go and safely just pay a co-pay,” she said, “it makes me feel better.”

Mark Yuschak, 57, of Jackson, N.J., said he had a silver plan with an annual deductible of $3,000. He discovered its limits in March.

“My wife had an incident, a digestive disorder, and we had to go to the emergency room of a hospital in Freehold, N.J.,” Mr. Yuschak said. “We presented our insurance card and filled out all the forms. They told us, ‘You don’t have a co-payment, you’re free to go.’ ”

Later, though, they received a bill “that could choke a horse,” Mr. Yuschak said — for more than $1,000. “Our insurance wouldn’t cover any of it because we had not met our deductible.”

Carol Payne, a respiratory therapist in Gilbert, Ariz., signed up through HealthCare.gov for a Blue Cross Blue Shield plan with a $6,000 deductible. She pays $91 toward her monthly premium and gets a subsidy of $353 to cover the rest.

The plans she could have chosen with lower deductibles were from insurers that “were not as reputable,” Ms. Payne said. She has used the insurance for preventive care and an emergency room visit after a car accident.

“I’m just doing what I can to keep myself healthy,” she added. “I mean, $6,000 — do they think I’ve just got that under my mattress?”

People with low incomes may qualify for subsidies that reduce their deductibles, co-payments and other out-of-pocket costs. The assistance is available to people with incomes from 100 percent to 250 percent of the poverty level (from $23,550 to $58,875 for a family of four), but only if they choose a silver plan.

Consumers also benefit from a provision of the Affordable Care Act that limits out-of-pocket costs, which include deductibles. The limit this year is $6,350 for an individual and $12,700 for a family plan. But in general, the limits apply only to care provided by doctors and hospitals in a plan’s network and do not cap charges for out-of-network care.

Dr. Rebecca Love, of Moab, Utah, is well on her way to passing that limit. Dr. Love, 63, who has degenerative arthritis and a host of other health problems, pays $422 a month in premiums for a plan that has a deductible of $6,000. But she has already paid more than $6,000 in medical costs this year that did not count toward her deductible because the doctors and hospitals — more than 100 miles away in Grand Junction, Colo. — were not in her network.

To see certain specialists in her network, Dr. Love said, she would have had to travel to Salt Lake City, which is much farther away and requires driving through a treacherous mountain pass.

“Medical care costs too much and health insurance as it stands doesn’t address this,” she said. “What have we become?”

Ms. Wanderlich, who had suffered the brain hemorrhage, was even avoiding preventive care until last month, when she had to get a prescription renewed and her doctor’s office required her to be seen first. Grudgingly, she went for an annual physical exam on Sept. 12. She was relieved to learn that she owed only $30 for the visit; the provider billed her insurer more than $1,200.

When the next open enrollment period begins on Nov. 15, Ms. Wanderlich said, she will probably switch to a plan with a narrower network of doctors and a smaller deductible. It will probably mean losing her specialists, she said, but at this point she is resigned.

“A $6,000 deductible — that’s just staggering,” she said. “I never thought I’d say this, but how many minutes until I get Medicare?”

A version of this article appears in print on October 18, 2014, on page A1 of the New York edition with the headline: Unable to Meet the Deductible or the Doctor.

http://www.nytimes.com/2014/10/18/us/unable-to-meet-the-deductible-or-the-doctor.html?_r=0

Americans still need a national health plan for everyone

An expanded Medicare program would save enough money in reduced bureaucracy to cover every uninsured American

By Johnathon Ross, M.D.
The Blade (Toledo, Ohio), Oct. 19, 2014

America’s 57 highest-paid health insurance executives collected a total of $300 million in salary and bonuses last year. The complex medical insurance market and the profit motive make private insurers a bad bargain.

Doctors and hospitals waste enormous sums on insurance paperwork and bureaucracy. More competition generates more administrative expenses, as well as astronomical salaries for insurance CEOs.

These money-changers thrive by chasing money to pay for care, not by delivering it. Meanwhile, nearly 2,000 Americans go bankrupt every day because of medical crises and debt, even though most were insured against illness or injury.

Republican governors in 21 states — not including Ohio and Michigan — still refuse to expand their states’ Medicaid programs under the federal Affordable Care Act. Medicaid covers the poorest of uninsured Americans, including the working poor. As many as 17,000 unnecessary deaths are likely to occur each year because of these governors’ political failure, a new Harvard University study estimates.

Yet even if the ACA were fully implemented, 31 million Americans would remain uninsured. In this wealthy country, with the best doctors, nurses, and hospitals in the world, we allow tens of thousands of people to die every year from lack of health insurance coverage.

As a primary care physician in Toledo, I can tell you this human toll is real. I see patients who are at grave risk, but cannot afford blood pressure or diabetes medicine. I see them die after the heart attack or stroke they would not have had if they had been able to afford care.

Individual market forces, such as high co-payments or medical savings accounts, will not lower health-care costs because the most expensive services are the least negotiable. Can a patient with a ruptured appendix, who is on morphine, haggle over fees?

Health care is a human need that should be available to every American. A national health insurance program — an expanded Medicare program for all Americans — would save enough money in reduced paperwork and bureaucracy to cover every uninsured American and improve coverage for all of us.

It would eliminate the high co-payments and deductibles of the present system. It would allow each of us to choose our own doctor and hospital, not force us to pick from a narrow provider network that profits an insurance company.

The Affordable Care Act includes provisions for experimentation. Any new approach cannot cost more than the ACA, and must cover just as many people with equivalent or better benefits. For nearly 50 years, Medicare has done that for tens of millions of uninsured elderly and disabled Americans.

Powerful, monied interests would oppose Medicare expansion. The same ideologues who would deny medical coverage to the poorest of the poor, and who lied to us about “death panels,” would call this the biggest tax increase in history.

They will not mention that improved, expanded Medicare would also lead to an even larger decrease in premiums, co-pays, and deductibles. About 95 percent of Americans would pay less for care than they do now.

Critics will say that the government cannot do anything as well as the private sector, but Medicare works where private insurance does not. It is just too complex and costly to administer 300 million individual policies, with different co-pays, deductibles, and coverage networks. What we have now costs too much and will never cover everyone.

This is a political fight as well as a moral one. We must insist that our elected officials understand that our lives are literally at stake, and that we will defend ourselves from their negligence.

Improved and expanded Medicare for all will save lives and money. It is the right thing to do. Being uninsured is worse than being at war. Americans will have to fight politically to end this travesty.

Johnathon Ross, M.D., of Toledo is past president of Physicians for a National Health Program.

http://www.toledoblade.com/Opinion/2014/10/19/Americans-still-need-a-national-health-plan-for-everyone.html

Top Doc Says Ebola Shows Skewed Priorities

By Amitabh Pal
The Progressive, Oct. 17, 2014

The Ebola crisis has revealed severe deficiencies in how the American health care system works, experts say.

Dr. Walter Tsou, past president of the American Public Health Association and the former health commissioner for Philadelphia, says that the Ebola crisis shows the skewed priorities of the U.S. health care system.

“Our chronic disease-oriented health care system is ill-equipped to address an acute infectious disease outbreak,” Dr. Tsou, a board adviser to Physicians for a National Health Program, tells The Progressive. “We don’t have enough biocontainment units, sufficiently trained experts on how to control for highly infectious disease agents, trained sanitation crews who can clean up and properly handle waste disposal.”

Tsou says that the Ebola epidemic has uncovered big flaws in the global health system, too.

“We have known about Ebola since 1976 and yet we still have no vaccine or treatment,” he points out. “The fact that we are now scrambling to find some type of vaccine and  treatment only speaks to the paucity of research that we have invested in the developing world. In the cruel economics of the pharmaceutical industry, unless the drugs promise a significant return on investment, they are unwilling to invest in it essentially condemning most of the developing world.”

The Ebola crisis has also made apparent the impact of drastic health budget cuts. Bloomberg News reports that there’s been a nearly one-fifth reduction in public health employees at the state and local levels in just the last six years, with 60,000 fewer people employed than in 2008. This manifests itself in many ways.

“There are fewer people to deploy to take care of education, training, public service messages, and other information,” Johns Hopkins Professor Albert Wu tells Bloomberg. “Ebola is not the first and is not the last challenge to our public health system.”

Dr. Tsou says that the lack of sufficient resources is not confined to the United States.

“The World Health Organization is a shadow of what it should be and is unable to mount a ‘boots on the ground surveillance, mitigation and quarantine program,” he says. “The United Nations has called for the world to donate $1 billion to confront the Ebola crisis, but we only have $100,000 in the bank so far.”

National Nurses United Executive Director RoseAnn DeMoro has commended the recent appointment of an Ebola czar, but has asked the Obama Administration to go further.

“What we need is a real czar to assure public safety, not a communicator, and the power to cut the hospitals’ Medicare and Medicaid funding if they still refuse to adhere to those standards and leave their patients, nurses and other caregivers at extreme risk,” she states in a press release.

For Dr. Tsou, one key public policy measure is necessary to combat such public health emergencies.

“All residents, including immigrants regardless of legal or financial status, should be able to access the health care system to be diagnosed and treated,” he says. “Our health care system already excludes over 42 million who are uninsured and erroneously denies insurance to millions of immigrants, many who are the most likely to bring Ebola into the country. A single payer system, open to all, offers the best mechanism to ensure early detection of illnesses.”

– See more at: http://www.progressive.org/news/2014/10/187889/top-doc-says-ebola-shows-skewed-priorities#sthash.HWi8BPmb.dpuf

Ebola didn’t have to kill Thomas Eric Duncan, nephew says

By Josephus Weeks
The Dallas Morning News, Oct. 14, 2014

On Friday, Sept. 25, 2014, my uncle Thomas Eric Duncan went to Texas Health Presbyterian Hospital Dallas. He had a high fever and stomach pains. He told the nurse he had recently been in Liberia. But he was a man of color with no health insurance and no means to pay for treatment, so within hours he was released with some antibiotics and Tylenol.

Two days later, he returned to the hospital in an ambulance. Two days after that, he was finally diagnosed with Ebola. Eight days later, he died alone in a hospital room.

Now, Dallas suffers. Our country is concerned. Greatly. About the lack of answers and transparency coming from a hospital whose ignorance, incompetence and indecency has yet to be explained. I write this on behalf of my family because we want to set the record straight about what happened and ensure that Thomas Eric did not die in vain. So, here’s the truth about my uncle and his battle with Ebola.

Thomas Eric Duncan was cautious. Among the most offensive errors in the media during my uncle’s illness are the accusations that he knew he was exposed to Ebola — that is just not true. Eric lived in a careful manner, as he understood the dangers of living in Liberia amid this outbreak. He limited guests in his home, he did not share drinking cups or eating utensils.

And while the stories of my uncle helping a pregnant woman with Ebola are courageous, Thomas Eric personally told me that never happened. Like hundreds of thousands of West Africans, carefully avoiding Ebola was part of my uncle’s daily life.

And I can tell you with 100 percent certainty: Thomas Eric would have never knowingly exposed anyone to this illness.

Thomas Eric Duncan was a victim of a broken system. The biggest unanswered question about my uncle’s death is why the hospital would send home a patient with a 103-degree fever and stomach pains who had recently been in Liberia — and he told them he had just returned from Liberia explicitly due to the Ebola threat.

Some speculate that this was a failure of the internal communications systems. Others have speculated that antibiotics and Tylenol are the standard protocol for a patient without insurance.

The hospital is not talking. Until then, we are all left to wonder. What we do know is that their error affects all of society. Their bad judgment or misjudgment sent my uncle back into the community for days with a highly contagious case of Ebola. And now, officials suspect that a breach of protocol by the hospital is responsible for a new Ebola case, and that all health care workers who care for my uncle could potentially be exposed.

Their error set the wheels in motion for my uncle’s death and additional Ebola cases, and their ignorance, incompetence or indecency has created a national security threat for our country.

Thomas Eric Duncan could have been saved. Finally, what is most difficult for us — Thomas Eric’s mother, children and those closest to him — to accept is the fact that our loved one could have been saved. From his botched release from the emergency room to his delayed testing and delayed treatment and the denial of experimental drugs that have been available to every other case of Ebola treated in the U.S., the hospital invited death every step of the way.

When my uncle was first admitted, the hospital told us that an Ebola test would take three to seven days. Miraculously, the deputy who was feared to have Ebola just last week was tested and had results within 24 hours.

The fact is, nine days passed between my uncle’s first ER visit and the day the hospital asked our consent to give him an experimental drug — but despite the hospital’s request they were never able to access these drugs for my uncle. (Editor’s note: Hospital officials have said they started giving Duncan the drug Brincidofovir on October 4.) He died alone. His only medication was a saline drip.

For our family, the most humiliating part of this ordeal was the treatment we received from the hospital. For the 10 days he was in the hospital, they not only refused to help us communicate with Thomas Eric, but they also acted as an impediment. The day Thomas Eric died, we learned about it from the news media, not his doctors.

Our nation will never mourn the loss of my uncle, who was in this country for the first time to visit his son, as my family has. But our nation and our family can agree that what happened at Texas Health Presbyterian Hospital Dallas must never happen to another family.

In time, we may learn why my uncle’s initial visit to the hospital was met with such incompetence and insensitivity. Until that day comes, our family will fight for transparency, accountability and answers, for my uncle and for the safety of the country we love.

Josephus Weeks, a U.S. Army and Iraq War veteran who lives in North Carolina, wrote this piece exclusively for The Dallas Morning News. Reach him at josephusweeks@yahoo.com.

http://www.dallasnews.com/opinion/latest-columns/20141014-josephus-weeks-ebola-didnt-have-to-kill-my-uncle.ece

Complexity of the 90 day grace period for paying exchange plan premiums

The Ninety-Day Grace Period

Health Affairs, Health Policy Briefs, October 16, 2014

To help enrollees new to the system keep their insurance, the ACA provides a ninety-day grace period before an insurer can discontinue someone’s coverage for failure to pay a monthly premium. This applies only to those who have received an advance premium tax credit to purchase health insurance through the Marketplaces and have previously paid at least one month’s full premium in that benefit year.

The grace period allows for continuity of care for patients by preventing people from shifting or “churning” in and out of coverage when they fail to make a monthly premium payment.

In final regulations, CMS said issuers must pay all appropriate claims for medical services rendered to the enrollee during the first month of the grace period, and the insurer may put on hold claims for services rendered to the enrollee in the second and third months. Issuers must also notify HHS of such nonpayment and notify providers of the possibility for denied claims when an enrollee is in the second and third months of the grace period.

During these second and third months of the grace period, because the patient is still insured, he or she cannot be billed by the provider for any remainder that is owed for medical services that the enrollee received. But if an enrollee fails to pay his or her premiums and the entire grace period elapses, providers are allowed to seek payment for the medical services they gave to that patient and for which the insurance company did not reimburse claims.

Patient assistance programs: Some providers have expressed interest in providing premium and cost-sharing assistance for their patients enrolled in coverage through the Marketplaces. By helping their patients maintain coverage and avoid the grace period in the first place, providers hope to reduce the risk that medical claims for care they provide will go unpaid.

However, questions continue to swirl about the legality of such an approach. Although federal anti-kickback regulations might seem to prohibit this type of practice, HHS has stated that such regulations do not apply to the Marketplaces, their plans, and premium tax credits because they are not considered “federal health care programs.”

The ACA’s uniform grace period could prove to play an important role in keeping people enrolled in their plans. But big questions remain unanswered about the financial risks to which physician practices or hospitals could be exposed, as well as how much risk insurers face for claims in the grace period and how that might affect premium growth for all enrollees over time.

http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=128

Comment:

By Don McCanne, M.D.

The Affordable Care Act provides a 90 day grace period during which health care coverage through exchange plans is continued before insurers can cancel the plans for non-payment of premiums. However, the insurers must pay claims for only the first 30 days, whereas providers are not allow to collect from the patient during the remaining 60 days. After 90 days of nonpayment of premiums, the patient can be retroactively billed, though collection can be difficult since most of these patients do not have enough funds to pay their premiums, much less their health care bills.

If you read the full Health Policy Brief, you will see that the issues are even more complex. The 90 day rule is yet one more unnecessary administrative burden that ACA added to our already highly complex system of financing health care. Under a single payer system there would be no such thing as a 90 day grace period. Financing of the health care system would be as automatic as it is now with Medicare.