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Improved and expanded Medicare for all: The single-payer option we need

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Improved and expanded Medicare for all: The single-payer option we need

Improved and expanded Medicare for all: The single-payer option we need

By Judith L. Albert, M.D. and Ana Malinow, M.D.
Allegheny County Medical Society Bulletin, April 2018

Dr. Fredric Jarrett’s article in the February Bulletin, “Single-payer health care: Not an option,” offers an opportunity to correct many misperceptions about what the “single-payer option” is and to present instead, the case in favor of “expanded and improved Medicare for all.” 1 Dr. Jarrett initially suggests that proponents of single payer extol the virtues of the Canadian and British systems, a statement that is misleading since these two systems are quite different. While Canada does have coverage for all residents, it is administered at the provincial and federal levels. Health care providers are largely private. In the United Kingdom, a national health service exists, such that providers and hospitals are run by the government, and the government also pays for health care for most residents. There is, however, another option in the United Kingdom that allows wealthier individuals to obtain care outside the national health system, a factor that complicates and dilutes the potential for cost containment and equal access, and disqualifies the U.K. system as a model for a national health program in the United States.

Supporters of expanded and improved Medicare for all favor the following: “Universal coverage for all medically necessary care – health care that is publicly financed but largely privately delivered. Patients no longer face burdensome premiums, copays or deductibles, even as they gain free choice of physician and hospital. Doctors gain clinical autonomy and dramatically reduced paperwork.” 2 Any discussion of the “single-payer option” must use rigorous definitions to avoid confusion.

Dr. Jarrett voiced concerns about allowing the single payer to “make the rules” regarding medical necessity. We would argue that placing the decision-making for medical coverage with a public, single-payer option with public accountability will remove the profit motive for decision-making that exists in our current private insurance system. Do we really want health care decisions to be made by corporate insurance executives whose primary interest is their bottom line? Two current single-payer bills in the House (H.R. 676) 3 and Senate (S. 1804) 4 have explicit provisions that address accountability and transparency in the management of the health care program.

Dr. Jarrett goes on to acknowledge that the health care system in Canada enjoys near universal popularity among Canadians, due to the elimination of “medical bankruptcy,” a condition that is all too common here in the United States when lack of insurance coverage or under-insurance allows huge medical debt to accrue for individuals. 5 One of the advantages of the Canadian system is the ability of the health care program to negotiate with pharmaceutical companies on drug prices. Tremendous savings in health care expenditures would result from the ability of a U.S. national health program to negotiate drug prices and would eliminate at least one cause of medical bankruptcy. 6

Dr. Jarrett alludes to critical differences between the U.S. and Canadian health care infrastructure that make comparisons difficult, and clearly mandate that a single-payer system in the United States must be specific to the needs of our much larger population and complex medical systems. It is true that the United States is far better equipped to handle the need for necessary imaging when compared to Canada (we have three and a half times as many MRI and CT scanners). However, emergency imaging is always available in Canada without delay. While in the United States, we have the capacity, uninsured and underinsured individuals cannot afford CT or MRI scans. Millions of Americans are not even afforded the luxury of a place in line. 7

Dr. Jarrett cites the anecdotal increased mortality from abdominal aortic aneurysm due to patients waiting for approval in the United Kingdom. Compare that to the projected excess annual mortality of 36,000 Americans as a result of the 28 million people who are uninsured. 8 Lack of health insurance is bad for our health and results in increased mortality. The United States spends nearly twice as much for health care than other economically developed countries in the world, yet ranks last among 11 industrialized countries when it comes to quality, efficiency, access, equity and healthy lives. 9 Surely, with our massive healthcare resources, we can do better than this.

Finally, we would disagree that the nearest current prototype to single payer we have is Medicaid, because Medicaid is a means-tested program that varies by state. The current prototype for single payer is Medicare, which insures all adults 65 and older. While Medicaid does provide for the medical care of many non-elderly individuals, it is not universal coverage for that population in the way that Medicare is for the elderly. Dr. Jarrett neglected to mention House Bill H.R. 676, which currently has the support of 122 members of Congress. 10 The bill is 30 pages long and would create a publicly financed, privately delivered health care system that builds on the existing Medicare program. It would improve and expand Medicare to cover all U.S. residents. By replacing our nation’s fragmented patchwork of competing private insurance companies (with their wasteful administrative costs, profits and high executive salaries) with a nonprofit single-payer program, the nation would save more than $500 billion per year, 6 enough to guarantee comprehensive health care to all, with no co-pays or deductibles. Numerous surveys of physicians and health care consumers indicate a majority support the idea of expanding Medicare to provide health insurance to every American, including 59 percent of all physicians 11 and 60 percent of Americans. 12 There is even support for expanding Medicare from 40 percent of Trump voters! 12

As physicians, we have an obligation to advocate for all Americans and their health. As members of our professional organizations, we have a duty to seek evidence and report the facts. There is strong evidence that having health insurance fosters improved health and reduced mortality for all individuals. Our current system is giving us exactly what it was designed to do: increased profits for private insurance companies and the rationing of care based on the ability to pay. Improved and expanded Medicare for all: the single-payer option we need.
 
Dr. Albert is an obstetrician/gynecologist and reproductive endocrinologist who has been in practice in Pittsburgh since 1992. She and Dr. Malinow founded the Pittsburgh chapter of Physicians for a National Health Program with several other physicians in fall 2017.

Dr. Malinow is a general pediatrician in Pittsburgh. She is past president of Physicians for a National Health Program, an organization of more than 20,000 health care providers that support a single-payer, national health program.

The authors can be reached at bulletin@acms.org.

References

1. Jarrett F. Single-payer health care: Not an option. Allegheny County Medical Society, February 2018 Bulletin.

2. Physicians for a National Health Program, Single Payer FAQ, https://pnhp.org…

3. H.R. 676 Expanded and Improved Medicare for All Act, 115th Congress (2017-2018) https://www.congress.gov…

4. S. 1804 Medicare for All Act of 2017, 115th Congress (2017-2018) https://www.congress.gov…

5. Himmelstein DU, Thorne D, Warren E. Medical Bankruptcy in the US, 2007: Results of a National Study. The American Journal of Medicine. Vol 122, Issue 8, August 2009: 741-746. https://pnhp.org…

6. Woolhandler S, Himmelstein DU. Savings of $500 B/year. Woolhandler S and Himmelstein D. Single-Payer Reform: The Only Way to Fulfill the President’s Pledge of More Coverage, Better Benefits, and Lower Costs. Annals of Internal Medicine, April 18, 2017. http://annals.org…

7. Papanicolas I, Woskie LR, Jha AK. Health Care Spending in the United States and Other High-Income Countries. JAMA. 2018;319(10):1024-1039. https://jamanetwork.com…

8. Wilper, AP, et al. Health Insurance and Mortality in US Adults. American Journal of Public Health. 2009;99:2289-2295. https://pnhp.org…

9. The Commonwealth Fund. US Health System Ranks Last Among Eleven Countries on Measures of Access, Equity, Quality, Efficiency, and Healthy Lives. June 16, 2014. http://www.commonwealthfund.org…

10. H.R. 676 Expanded and Improved Medicare For All Act 115th Congress (2017-2018) Cosponsors https://www.congress.gov…

11. Carroll A, Ackerman R, Support for National Health Insurance Among American Physicians: Five Years Later. Annals of Internal Medicine April 1 2008. http://annals.org…

12. The Economist/YouGov Poll. April 2-4, 2017. https://d25d2506sfb94s.cloudfront.net…

https://www.acms.org…

Single-payer health insurance advocates launch chapter in Greenville

By Liv Osby
Greenville (S.C.) News, April 29, 2018

There was the uninsured truck driver in his 50s who skimped on his blood pressure medication because of the cost and wound up having a stroke.

And the housekeeper in her early 60s who couldn’t afford health insurance on her meager wages and had no way to pay for breast cancer treatment.

Over the years, there have been thousands of other patients like these, said Dr. David Keely, a family physician who spent his career caring for people who had trouble affording health care.

“I’ve seen it over and over,” he told The Greenville News. “Either their illness got worse because they were unable to afford their medication or they presented uninsured with hardly any money and had a medical condition that had to be treated.”

Now semi-retired from a community health clinic in rural Rock Hill, Keely is trying to make healthcare something that all Americans — poor, uninsured and underinsured included — can access by establishing a chapter of Physicians for a National Health Program in Greenville.

“The goal is to mount an awareness campaign about the inequities (of) our current system,” he said, “and try to get a grass roots movement to … make our health care system better with the ultimate goal of single-payer financed, privately delivered universal care.”

PNHP is a nationwide nonprofit made up of 20,000 physicians, medical students and health professionals who support single-payer national health insurance.

Also known as Medicare for All, it would operate the way Medicare insurance does now, paying for care by private providers. It would cover doctors, hospitals, mental health, dental and vision care, prescription drugs and more, according to the group, and be funded by the savings from replacing the current system.

Surveys show most Americans favor the idea of Medicare for All, including 75 percent of Democrats and 46 percent of Republicans, according to PNHP.

Affording health care

As the first physician in his family, Keely started a practice in Chester County to repay his obligation to the National Health Service Corps, which helped pay his tuition to medical school in return for practicing in a high-need area.

Seeing the hardships his patients endured, Keely attended a PNHP presentation where a speaker said that 45,000 people in the United States die every year because they lack access to affordable health care.

“It was the equivalent of a jetliner crashing every other day and nobody surviving,” he said. “I thought ‘That’s immoral.’ ”

So Keely helped launch a chapter of PNHP in the Palmetto State. Called Healthcare for All – South Carolina, it has branches in Charleston, Columbia and Florence.

And now a regional group is getting started in Greenville.

“There are many reasons why a single-payer system would be better for us,” said Greenville psychiatrist Dr. Patrick Mullen, who is among the supporters.

For example, he said, dealing with only one insurer instead of many would be less complicated and save money.

Desperate need

“One simpler system to deal with — and I don’t see how it could be any more complicated than it is,” he said. “And I can’t think of anything bad from the standpoint of the health of the population.”

One of the group’s first events in Greenville is a May 2 presentation by Dr. Ed Weisbart, assistant professor of clinical medicine at Washington University in St. Louis, Missouri, and chair of the Missouri chapter of PNHP.

A family physician who volunteers at safety net clinics, he’s also seen his share of patients in desperate need.

One 63-year-old woman supporting three grandchildren stopped taking her blood pressure medicine to make the rent so the family wouldn’t be homeless, he said.

Another patient with warning signs of a massive stroke couldn’t afford an expensive test and surgery, so she rolled the dice and waited until she was eligible for Medicare about six months later.

“That’s not what should happen,” Weisbart said. “If she had had this stroke, and then been disabled, it would have been even more expensive to take care of. It’s not even a good business strategy to have people make these trade-offs.”

Yet all over the country, Weisbart said, people are going bankrupt and losing their homes because of medical bills.

Four in 10 Americans are fearful of having to pay for a serious illness, according to PNHP. Even the insured have difficulties, said Weisbart, noting that he and his wife pay $2,000 a month in insurance premiums and have a deductible of $12,000.

‘Opened my eyes’

Michelle Hunt and her husband have three young daughters, and the 6-year-old has been battling severe asthma most of her life.

The doctor just prescribed a medicine that costs $245 a month in addition to her $115 rescue inhaler, Michelle Hunt said. But with insurance premiums of $550 a month, that was going to be hard for the Rock Hill couple.

“I reached out … to see if there were any other cheaper medications, but there weren’t,” she said. “We have found a coupon that will bring it down to about $200. So I guess we will have to cut back on other things.”

Among them is her own allergy medication, which costs about $50 a month, she said. They may also cut out cable TV and other things they can live without. Her mother has also offered to help with the costs of Emily’s medicine.

“This is something she has to have to breathe better,” said Hunt, 38, a risk management administrator for a telecommunications company.

“We’ve never had anything like this happen before,” she said. “But even with insurance, this really opened my eyes. We need something to help out with these costs.”

Covering everyone

Weisbart said insurance overhead makes up 15 to 20 percent of health care costs. In addition, he said, the average independent physician has $85,000 worth of staff that does nothing but deal with insurance.

“I see this as a problem that’s affecting Americans and I believe the most prudent way to solve it is to take Medicare, improve a few things, and provide it to everybody,” he said.

Most research shows that a single-payer option  – which is not socialized medicine but an insurance plan – would result in a dramatic savings or at least break even with everyone covered, including the 28.8 million Americans who are uninsured now, he said.

“Other countries with single-payer systems spend half of what we do,” he said, “and they live longer.”

Keely, who still spends about 20 hours a week as a volunteer physician, said he isn’t unrealistic about the headwinds the group faces, but adds that the current system is unsustainable.

“We don’t think we have our heads in the wrong place, but it’s certainly a marathon and not a sprint,” he said. “It’s heartening to be able to reach people and get them be able to say, ‘I just hadn’t thought about this and what you say makes sense.’

“That’s what keeps me going.”

https://www.greenvilleonline.com…

Angus Deaton: Self-assessment of well-being and policy ethics

NBER Working Paper No. 24369; What do Self-Reports of Wellbeing Say about Life-Cycle Theory and Policy?

By Angus Deaton
National Bureau of Economic Research, March 2018

Abstract

I respond to Atkinson’s plea to revive welfare economics, and to considering alternative ethical frameworks when making policy recommendations. I examine a measure of self-reported evaluative wellbeing, the Cantril Ladder (a tool for self-assessment of wellbeing with ladder steps numbered 0 to 10), and use data from Gallup to examine wellbeing over the life-cycle. I assess the validity of the measure, and show that it is hard to reconcile with familiar theories of intertemporal choice. I find a worldwide optimism about the future; in spite of repeated evidence to the contrary, people consistently but irrationally predict they will be better off five years from now. The gap between future and current wellbeing diminishes with age, and in rich countries, is negative among the elderly. I also use the measure to think about income transfers by age and sex. Policies that give priority those with low incomes favor the young and the old, while utilitarian policies favor the middle aged, and men over women.

Conclusions

This paper takes up Atkinson’s challenge to bring back welfare into economics, and to do so in a way that does not have to deny the findings of modern behavioral economics. It also thinks about how policy varies with different ethical assumptions. It uses Gallup’s data on the Cantril Ladder measure of life evaluation as a measure of (period) utility, and examines the implications for welfare variations by age. I find a midlife dip in wellbeing in rich countries, but less or no evidence of it elsewhere.

Overall, only some features of the ladder are consistent with life cycle theory if it is interpreted as a period, or age-specific wellbeing measure; it is much harder to interpret it as a lifetime measure. People’s expectations of the ladder five years ahead are grossly inconsistent with those reports being the mathematical expectations of future period utility; throughout the world, people are generally over-optimistic about the future, except for the elderly in rich countries, who are generally over-pessimistic about the future. These findings are of considerable interest, but cast doubt on the idea that people arrange their consumption and labor supply to maximize the expected integral of age-specific utilities, at least if utilities are well measured by the Cantril Ladder as recorded in Gallup’s surveys. This does not, by itself, invalidate the ladder itself as a measure of period age-specific wellbeing.

Finally, I illustrate what the ladder measure would imply for distributing income by age, and how the choice of the ladder versus income interacts with different ethical frameworks. In the United States, income prioritarians will tend to favor redistribution towards elderly or young adults, whose incomes or per capita incomes are lowest. By contrast, utilitarians will favor those for whom marginal utility is highest, which turns out to be those in midlife, and especially men over women, a prescription that would be enhanced by giving additional priority to those whose wellbeing is lowest, also those in midlife. Both approaches would favor men over women. I make no prescriptions here, but am concerned only to show the possibilities that arise from having a direct measure of wellbeing. I also am responding to Atkinson’s challenge by emphasizing and illustrating that policy prescriptions depend, not just on measurement, but on ethics, a point that is not always given the weight that it should be when economists discuss policy.

As in the happiness literature in general, my findings are mixed; the Cantril Ladder is clearly useful, is not obviously inconsistent with standard notions of period utility, and allows us to say things about welfare and distribution that we could not say using standard revealed preference methods. It does not assume that people do not make mistakes. Reported expectations of future wellbeing are consistent with the widespread finding of optimism bias in psychology, but inconsistent with the rational expectations formulation that is standard in much of economics. Whether this is an advantage or a disadvantage will surely differ according to preference and disciplinary background.

http://www.nber.org…

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Comment:

By Don McCanne, M.D.

Although this NBER working paper by Nobel laureate Angus Deaton is quite wonkish it is an interesting analysis of self-assessment of current and anticipated future well-being under variables of age, sex, wealth, and nationality. For a blog on single payer reform, this paper does have some application since perception of well-being might be an important attribute related to a nation’s health care system.

But that is not why this paper was selected for a Quote of the Day, rather one sentence extracted from the paper expresses a truth that is too often neglected in the policy community:

“I also am responding to Atkinson’s challenge by emphasizing and illustrating that policy prescriptions depend, not just on measurement, but on ethics, a point that is not always given the weight that it should be when economists discuss policy.”

We hear a lot of policy recommendations, but all too often it is difficult if not impossible to identify the ethical imperative. In contrast, the ethical imperative permeates the single payer model of reform.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

The deficiencies of Trump’s short-term health insurance plans

Understanding Short-Term Limited Duration Health Insurance

By Karen Pollitz, Michelle Long, Ashley Semanskee, and Rabah Kamal
Kaiser Family Foundation, April 23, 2018

Late last year, Congress repealed the Affordable Care Act’s individual mandate penalty, the requirement that individuals have minimum essential health coverage or face a tax penalty.  Starting in 2019, the tax penalty will be reduced to $0.  It is possible this change could lead more consumers to consider purchasing short-term policies.  In addition, late last year, President Trump issued an executive order directing the Secretary of Health and Human Services to take steps to expand the availability of short-term health insurance policies, and a proposed regulation to increase the maximum coverage term under such policies was published in February.  This brief provides background information on short-term policies and how they differ from ACA-compliant health plans.

Background

As the name suggests, short-term health insurance policies are not renewable.  Whereas federal law since 1996 has required all other individual health insurance to be guaranteed renewable at the policyholder’s option, coverage under a short-term policy terminates at the end of the contract term.  To continue coverage beyond that date requires applying for a new policy.  As a result, an individual who buys a short-term policy and then becomes seriously ill will not be able to renew coverage when the policy ends.

The Affordable Care Act (ACA) exempted short-term policies from market rules that apply to most major medical health insurance policies sold to individuals in the non-group market: rules that prohibit medical underwriting, pre-existing condition exclusions, and lifetime and annual limits, and that require minimum coverage standards.  By contrast, short-term policies:

* are often medically underwritten – applicants with health conditions can be turned down or charged higher premiums, without limit, based on health status, gender, age, and other factors;

* exclude coverage for pre-existing conditions – policyholders who get sick may be investigated by the insurer to determine whether the newly-diagnosed condition could be considered pre-existing and so excluded from coverage;

* do not have to cover essential health benefits – typical short-term policies do not cover maternity care, prescription drugs, mental health care, preventive care, and other essential benefits, and may limit coverage in other ways;

* can impose lifetime and annual limits –  for example, many policies cap covered benefits at $2 million or less;

* are not subject to cost sharing limits – some short term policies, for example, may require cost sharing in excess of $20,000 per person per policy period, compared to the ACA-required annual cap on cost sharing of $7,350 in 2018; and

* are not subject to other ACA market requirements – such as rate review or minimum medical loss ratios; for example, while ACA-compliant non-group policies are required to pay out at least 80% of premium revenue for claims and related expenses, the average loss ratio for individual market short-term medical policies in 2016 was 67%; while for the top two insurers, who together sold 80% of all short-term policies in this market, the average loss ratio was 50%.

From the Discussion

Short-term health insurance policies offer lower monthly premiums compared to ACA-compliant plans because short-term policies offer less insurance protection.  Medically underwritten policies can only be purchased by people when they are healthy.  Individuals who buy short-term policies and then develop health conditions will lose coverage when the contract ends.  Short-term policies typically do not cover essential benefits, such as prescription drugs, and often apply dollar caps and higher deductibles on coverage that are no longer allowed under ACA-compliant individual market and group health plans.  As a result, people who buy short-term policies today in order to reduce their monthly premiums take a risk that, if they do need medical care, they could be left with uncovered bills and/or find themselves “uninsurable” under such plans in the future (though they would be able to buy ACA-compliant policies at the next open enrollment period).

To the extent that healthy individuals opt for cheaper short-term policies instead of ACA-compliant plans, such adverse selection contributes to instability in the reformed non-group market and raises the cost of coverage for people who have health conditions.  Income-related premium subsidies in the non-group market offset the cost differential, and so help correct for adverse selection to a significant extent.  Lower-income people would be protected by the premium subsidies, but middle-income people not eligible for subsidies who buy ACA-compliant plans would likely see premium increases.  So far, the individual mandate penalty also has helped offset the cost differential between short-term plans and ACA-compliant plans, though this will disappear starting in 2019.  The combined effect of repealing the individual mandate penalty and the administration’s efforts to promote the sale of short-term plans could result in fewer people signing up for ACA-compliant plans and higher premiums in the ACA-compliant individual market, potentially adversely affecting the stability of the ACA-compliant individual market.

https://www.kff.org…

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Comment:

By Don McCanne, M.D.

President Trump has issued an executive order directing that steps be taken to expand the availability of short-term health insurance plans. Although there is a general recognition that these short-term plans are more limited than plans regulated by the Affordable Care Act, this policy brief from Kaiser Family Foundation explains just how severe the deficiencies in coverage are and the negative impact that they will likely have on more comprehensive plans that are compliant with the Affordable Care Act.

People will buy these plans because the premiums will be less, but most will suffer significant financial hardship should they be faced with severe acute or chronic conditions.

Why are President Trump, HHS Secretary Azar and CMS Administrator Verma not only supporting but actually encouraging these plans? Is there a rational reason, or do they share some form of psychopathology? Whatever it is, we need to fix the problem by enacting and implementing a single payer national health program – an improved Medicare for all – and do it as soon as possible.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Ipsos survey shows concern over paying for health care

Consumers for Quality Care, Ipsos Survey, March 13-25, 2018

From the executive summary

* Americans are acutely worried about paying for health care – even more than they worry about costs associated with retirement, college, housing, or child care.

* What people pay is the main pain point: Americans are more concerned about premiums, deductibles, and co-pays than they are about access to care or quality of care.

* When asked who is responsible for their out-of-pocket costs, Americans mostly blame insurance companies, pharmaceutical companies, and the federal government.

Q20: I am going to read you a series of statements. For each one, please tell me if it makes you more or less likely to support a candidate for Congress.

Would vote for candidates who support…

Health care companies disclosing costs
84% – Democrats
84% – Republicans
83% – Independents

Lowering out-of-pocket costs for Rx drugs
83% – Democrats
85% – Republicans
80% – Independents

Passing pharma discounts to customers
80% – Democrats
83% – Republicans
84% – Independents

Improving and funding Obamacare
77% – Democrats
15% – Republicans
52% – Independents

Repealing Obamacare
28% – Democrats
68% – Republicans
48% – Independents

Single-payer health care
59% – Democrats
44% – Republicans
53% – Independents

https://consumers4qualitycare.org…

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Comment:

By Don McCanne, M.D.

This Ipsos survey confirms that Americans are still very much concerned about health care costs. What is perhaps of more interest here is what people think we should do about it.

There is still a sharp political divide on Obamacare with Republicans favoring repeal, Democrats favoring improving it, and Independents evenly divided. The divide seems to be based more on politics rather than policy.

The support for single payer seems to be about the same as other surveys have reported, though usually more Democrats than the 59% reported here are in support. Of note is that 44% of Republicans support single payer indicating that the single payer message should be targeted more broadly than just to progressives since there also is some significant support amongst conservatives for the concept.

What deserves special attention in this survey is the very strong support across the political spectrum for health care companies disclosing costs, lowering out-of-pocket costs for prescription drugs, and passing drug discounts on to patients. Although some might suggest that this indicates that Americans prefer incremental change, it more likely reflects the fact that it is easier to express support for one single beneficial policy issue at a time.

The nation needs to hear repeatedly just a couple of the specific policy issues that make single payer the moral imperative. We should work on that message, especially regarding affordability. For those whose attention we gain, we can elaborate on the full package.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Top US medical schools failing to reflect minorities, social justice group says

White Coats for Black Lives calls on elite schools to improve race bias shortcomings and help eliminate disparities in US healthcare

By Amanda Holpuch
The Guardian, April 25, 2018

Ten of the top US medical schools including Harvard and Yale do not have faculty and staff that reflect the country’s black, Native American and Latino population, according to a report by the social justice group White Coats for Black Lives (WC4BL).

The medical student-run group, which came together in response to the Black Lives Matter movement, on Wednesday published a 129-page report that grades medical schools on their work to combat racism.

The report, shared first with the Guardian, found that schools fell short of the activist group’s standards for 15 metrics, including providing robust anti-racism training and paying all workers a living wage for the local area.

Kathryn Himmelstein, one of nine people on White Coats for Black Lives’ national working group, told the Guardian they wanted to: “Turn a light on those 10 schools but also open up questions about what other academic medical centers do, and encourage folks at those places to inquire, to research, to question what their institutions could be doing better.”

For the inaugural report, WC4BL assessed:

  • Harvard Medical School in Boston
  • Icahn School of Medicine at Mount Sinai in New York
  • Johns Hopkins School of Medicine in Baltimore
  • Perelman School of Medicine at the University of Pennsylvania in Philadelphia
  • Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia
  • University of California in San Francisco
  • University of Michigan Medical School in Ann Arbor
  • University of Pittsburgh School of Medicine
  • Washington University School of Medicine in St Louis
  • Yale School of Medicine in New Haven

WC4BL selected the first 10 schools for its inaugural report because of their prominence and student interest in attending these schools and it plans to grade more schools in the future.

Of150 grades allotted across the 15 metrics for 10 universities, only eight were As, denoting the best record.

Johns Hopkins, UCSF, Thomas Jefferson, University of Pittsburgh and University of Pennsylvania said they embraced diversity and welcomed WC4BL’s report, but felt the analysis overlooked initiatives or had a questionable methodology.

Joseph Hill, senior vice president and chief diversity officer at Thomas Jefferson University’s Enterprise Office of Diversity, Inclusion and Community Engagement, said he was concerned information was missing from the report and highlighted that the school offered the only scholarship in the country for African-American males in medical school.

“We would welcome a discussion with our student members of White Coats for Black Lives about the many ways we are working to address these important issues,” Hill said.

Mary Masson, a University of Michigan medical spokesperson, said the school was looking forward to continued conversations with the group. “We were happy to provide additional details about our diversity, equity and inclusion efforts in several areas that were rated prior to receiving this information,” the statement said. “Together, we hope to continue elevating our shared values for the next generation of physicians, nurses, health professionals and scientists.”

Harvard, Mt Sinai, Washington University and Yale did not respond to requests for comment.

A call to colleges to fight US healthcare disparities

That race bias pervades medical institutions, research and care has been highlighted in studies showing black infants in the US are twice as likely to die as white infants, while black patients are less likely to be prescribed pain medicine. Black life expectancy is 3.6 years lower than white life expectancy in the US.

But only in recent decades has the impact of this bias been extensively researched.

With the report, WC4BL sought to use its power as a force within medical schools to outline how these elite institutions could leverage their power to help disadvantaged people and eliminate disparities in US healthcare.

Since December 2014, the group has led “die-in” protests at medical schools and Black Lives Matter demonstrations, including one held across the country last week in honor of unarmed black man Stephon Clark, who was killed by Sacramento police in March.

Himmelstein, a fourth-year medical student at the University of Pennsylvania’s Perelman School of Medicine, said WC4BL focused its first major report on medical schools because they are often the largest employers in their region, receive government funding for research and medical care and are gatekeepers to joining the medical profession. “Given they control so many resources and have this important social role, there was shockingly little accountability for how medical schools were or were not promoting social justice,” said Himmelstein.

In the report, each school was given a letter grade on 15 metrics, such as its policies toward immigrant patients. A is the best, B is middle and C is the worst.

The first metric assessed in the report is URM representation, the Association for American Medical Colleges term for the populations underrepresented in medicine.

Under the WC4BL criteria, schools receive an A if their student and faculty URM representation was proportionate to the US: at least 13% Black, 1% Native American and 17% Latinx – a gender-neutral term for people of Latin American descent. If a school met the minimum percentage for one of these groups, WC4BL gave it a B. If the school does not have a proportionate amount of any of these groups, WC4BL gave it a C – which is what all of the 10 schools were designated.

Colleges’ strongest at race discrimination reporting

On average, the 10 schools performed best in the area of discrimination reporting, with no school receiving a C because they all had racial discrimination policies. The University of Michigan, Washington University School of Medicine in St Louis and Yale School of Medicine were awarded As because they offer continued, documented support to people who make discrimination claims.

Grades were also handed out based on how the school recognizes people of color; how it involves community health leaders in the coursework; whether it calls race a social, not biological, construct; if it makes data about racial grade disparities public; what support is given to the URM population; if staff are compensated in line with the region’s minimum living wage; if it offers alternatives to police and security forces and what its standards are for how racial and ethnic minorities are incorporated into research.

WC4BL was inspired in part by the Black Panthers’ work to provide alternative healthcare for underrepresented communities.

“We hope there will be greater discussion both within the medical community as well as outside the medical community, about how are we leveraging the resources of academic medical centers to promote racial justice,” said Himmelstein.

WC4BL provided a copy of the report card to each university before the report’s release.

The group said that many of the schools provided additional information that was not previously publicly available to help build out the report, even if they disagreed with some of the assessments.

https://www.theguardian.com…

Healing an ailing pharmaceutical system: prescription for reform for U.S. and Canada

Our pharmaceutical systems are broken, and only fundamental reform can ensure universal access to safer, more innovative, and more affordable drugs

Pharma Proposal Graphic

By Adam Gaffney, instructor in medicine 1, Joel Lexchin professor emeritus 2, US, Canadian Pharmaceutical Policy Reform Working Group
BMJ, Analysis, May 2018

To read the full proposal, see below or visit the BMJ website.

To access our economic analysis and supplemental materials, click here.

To read PNHP’s press release, click here.

To read and view media coverage of the proposal, click here.

Click on each section to see text.

Author credentials: 1. Department of Medicine, Cambridge Hospital/Harvard Medical School, Cambridge, MA 02139, USA; 2. School of Health Policy and Management, York University, Toronto, Ontario, Canada

WARNING: CMS request for information (RFI) on direct primary care (DPC)

What is Direct Primary Care?

Direct Primary Care Coalition

Direct Primary Care (DPC) is an innovative alternative payment model improving access to high functioning healthcare with a simple, flat, affordable membership fee. No fee-for-service payments. No third party billing. The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider.

https://www.dpcare.org

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Feedback on New Direction Request for Information (RFI) Released, CMS Innovation Center’s Market-Driven Reforms to Focus on Patient-Centered Care

CMS.gov, April 23, 2018

Today, the Centers for Medicare & Medicaid Services (CMS) announced that it has released the comments submitted by patients, clinicians, innovators, and others in response to the CMS Innovation Center’s New Direction Request for Information (RFI). Last fall, CMS released the RFI to collect ideas on a new direction for the agency’s Innovation Center to promote patient-centered care and test market driven reforms that: empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, reduce costs, and improve outcomes. The Innovation Center is a central focus of the Administration’s efforts to accelerate the move from a healthcare system that pays for volume to one that pays for value and encourages provider innovation.

CMS is sharing the feedback received to promote transparency and facilitate further discussion of how to move the Innovation Center in a new direction.

Today, CMS is also taking a next step to develop a potential model in the area of direct provider contracting, informed in part by the RFI. A direct provider contract model would allow providers to take further accountability for the cost and quality of a designated population in order to drive better beneficiary outcomes. Such a model would have the potential to enhance the doctor-patient relationship by eliminating administrative burden for clinicians and providing increased flexibility to provide the high-quality care that is most appropriate for their patients, thus improving quality while reducing expenditures.

As part of its process to gain further insight from the public in this area and ask more focused questions, CMS is issuing a follow up RFI. The information being requested is detailed in nature and is intended to provide CMS the data needed to potentially design and release a model in this area. CMS is excited to continue to evaluate the concept of direct provider contracting and is also focusing its attention on other areas guided by input and feedback from the New Direction RFI as well as the public.

https://www.cms.gov…

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Direct Provider Contracting Models – Request for Information

CMS.gov

The Centers for Medicare & Medicaid Services (CMS) is seeking broad input on direct provider contracting (DPC) between payers and primary care or multi-specialty groups to inform potential testing of a DPC model within the Medicare fee-for-service (FFS) program (Medicare Parts A and B), Medicare Advantage program (Medicare Part C), and Medicaid.

A DPC model would aim to enhance the beneficiary-physician relationship by providing a platform for physician group practices to provide flexible, accessible, and high quality care to beneficiaries that have actively chosen this type of care model.

The public is encouraged to provide feedback on their experiences with, and perspectives on, DPC and how CMS can use DPC models to reduce expenditures and preserve or enhance the quality of care for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries.

Please submit your comments to the CMS Innovation Center at DPC@cms.hhs.gov through 11:59pm EDT May 25, 2018.

https://innovation.cms.gov…

Request for Information on Direct Provider Contracting Models (9 pages):
https://innovation.cms.gov…

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Comment:

By Don McCanne, M.D.

This CMS notice is important. CMS is requesting public input on factors that should be considered in including a direct primary care model (DPC) in traditional FFS Medicare, Medicare Advantage, Medicaid, and CHIP.

DPC is a model in which a retainer (membership fee) is paid by a patient to a primary care provider to cover all included primary care services. No insurer or third party payer is involved although it is usually recommended that the patient obtain catastrophic (high deductible) insurance for expensive, specialized care beyond what would be provided in a primary care practice.

From the physician’s perspective, DPC eliminates controls on fees, whether by a government program or commercial insurance. The physician does not contract with an insurer, does not bill an insurer, and does not accept any limitations demanded by an insurer. From the patient’s perspective, direct access to the primary care professional is supposedly much more readily available.

Keep in mind that today’s high deductible health plans are quite expensive; the premium added to a significant retainer fee would not be affordable for the majority. The RFI will be important for the government to design its portion of a retainer fee plus costs of catastrophic insurance that it will pay for with Medicare or with the other government programs.

Also note that the retainer is a form of capitation rather than fee-for-service. For individual physicians or small groups, capitation poses a risk should the practice attract a larger percentage of patients with chronic diseases.

In the request for information (RFI) on DPC, CMS states that the goal of DPC would be to reduce expenditures (presumably for the government) while maintaining quality. Since government programs already pay less than commercial insurance, the prospect of further reductions in payments (inadequate retainer fee) should raise alarms for health care professionals.

But what should be even more alarming is that CMS states that DPC incorporated into the public programs would eliminate the administrative burden and provide increased flexibility in the provision of care. Their RFI suggests that, under this model, a retainer could be provided in which the primary care professional will bear all upside and downside risk in an environment with greatly reduced regulatory oversight. In a program designed to reduce spending, you can be sure that patients with greater health care needs – downside risk – would be avoided, shifting those patients to what is left of the traditional, taxpayer-funded Medicare program. And reduced oversight? The temptation would be very great to market a comfy, patient-friendly practice environment while remaining silent on more costly primary care services that are not being provided.

This obviously represents an attempt of the administration to decrease the role of the government as a payer and a regulator. This program, driven by conservative ideology, poses a great hazard to our traditional government health programs, especially Medicare.

Everyone who cares should look at the nine page RFI (last link above) and consider submitting a response, or, even better, have your various professional or advocacy organizations submit a formal response. Deadline is May 28, 2018.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

HHS Secretary Azar joins notorious list of 30 day readmissions

Alex Azar's medical woes shine a light on readmissions

By Dan Diamond
POLITICO Pulse, April 20, 2018

On Monday, the HHS secretary was discharged from the hospital with a common intestinal infection known as diverticulitis. By Wednesday, he was back — the most high-profile hospital readmission in some time.

More than a few PULSE readers noted the irony: HHS is actively working to curb readmissions, even as the agency’s leader needed one himself.

The Affordable Care Act created a program to penalize hospitals with high readmission rates, which Obama officials argued would boost quality and cut costs.

And readmission rates have fallen — but there’s evidence that it’s partly because hospitals changed how they document patients, not necessarily improved care quality.

“I’ve always found the focus on readmissions to miss the bigger point,” says Harvard’s Ashish Jha, arguing that the real issue is how the U.S. health care system encourages hospitals to quickly send patients home. That approach has positives (many patients would prefer to recover at home) and drawbacks (some patients’ illnesses inevitable get worse).

Diverticulitis is also a common condition with a relatively straightforward course of care, notes Jha, a practicing internist. When a patient gets readmitted, “it’s almost never a failure of care coordination or fragmentation,” he adds.

https://www.politico.com…

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Comment:

By Don McCanne, M.D.

People who have conditions that require hospitalization frequently develop related problems after they are discharged from the hospital and then require readmission. Most of these readmissions are unavoidable.

Occasionally readmission is avoidable if lapses in followup occur such as ensuring that patients receive medications that are required to control their medical conditions. But even in those instances it often is not the fault of the hospital. The patient can have many reasons for being non-compliant, and the hospital can do only so much to improve that compliance. Of course, some hospitals, especially those serving as safety nets, have a greater population of patients who are less likely to be compliant regardless.

Yet hospitals are being penalized when their 30 day rates of readmissions are above a modest threshold. Many of these penalties are unfair since they are based on mere chance of falling on the wrong side of the bell curve.

Patients who return may not be formally readmitted, often to avoid the risk of a penalty, even though they may be treated as if they were. This has potential financial consequences for the patient since coverage is based on outpatient rather than inpatient payment rules. It may also disqualify a patient for convalescent facility care should it be required.

Why don’t we just pay fair prices for care that patients need? That is what a well designed single payer system should do. HHS Secretary Alex Azar should contemplate whether or not it was fair to potentially penalize his hospital simply because his physician thought that he should be readmitted.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Health Industry CEOs’ Compensation in 2017

America’s largest private health insurance and pharmaceutical companies continued to take home millions in profits in 2017. And while the compensation for those at the top is outrageous, it is only the tip of the iceberg. Administrative waste – money spent on billing, coding, paperwork, and profits – totaled $504 billion in 2017. Pharmaceutical price gouging cost us an additional $113 billion. By implementing a single-payer national health program, we could direct these dollars where they are needed most: patient care.

Private Health Insurance Company CEOs

Aetna Meme 2017

Mark T. Bertolini, Aetna ($225,744 per day)
Separately, Bertolini was given $14.9 million in stock and option awards, which will provide value in future years. Should CVS Health acquire Aetna (pending regulatory approval), the Wall Street Journal estimates that Bertolini could receive a golden parachute worth approximately $500 million.

Anthem Meme 2017

Joseph Swedish, Anthem ($101,605 per day)
Separately, Swedish was given $12.6 million in stock and option awards, which will provide value in future years.

Cigna Meme 2017

David Cordani, Cigna ($168,677 per day)
Separately, Cordani was given $12.0 million in stock and option awards, which will provide value in future years.

Humana Meme 2017

Bruce Broussard, Humana ($131,493 per day)
Separately, Broussard was given $15.5 million in stock and option awards, which will provide value in future years.

Molina Meme 2017

J. Mario Molina, Molina ($117,416 per day)
Note: J. Mario Molina was terminated effective May 2. His compensation total includes the severance package he received.

United Health Meme 2017

Stephen Hemsley, UnitedHealth Group ($103,754 per day)
Separately, Hemsley was given $11.1 million in stock and option awards, which will provide value in future years.

Pharmaceutical Company CEOs

Abbvie Meme 2017

Richard Gonzalez, AbbVie ($146,588 per day)
Separately, Gonzalez was given $12.2 million in stock and option awards, which will provide value in future years.

Bristol Meme 2017

Geovanni Caforio, Bristol-Myers Squibb ($44,032 per day)
Separately, Caforio was given $12.7 million in stock awards, which will provide value in future years.

Gilead Meme 2017

John Milligan, Gilead ($80,237 per day)
Separately, Milligan was given $10.6 million in stock and option awards, which will provide value in future years.

Johnson Meme 2017

Alex Gorsky, Johnson & Johnson ($88,301 per day)
Separately, Gorsky was given $17.6 million in stock and option awards, which will provide value in future years.

Merck Meme 2017

Kenneth Frazier, Merck ($57,641 per day)
Separately, Frazier was given $12.6 million in stock and option awards, which will provide value in future years.

Pfizer Meme 2017

Ian Read, Pfizer ($101,818 per day)
Separately, Read was given $21.1 million in stock and option awards, which will provide value in future years.

Note: Annual CEO compensation includes salary, non-equity incentive pay, “all other compensation,” and the value of stock options exercised and stock awards that vested and were realized. (Sources: DEF 14A schedules, Securities and Exchange Commission; Bureau of Labor Statistics; Current Population Survey.) For reference, the median earnings of full-time wage and salary workers in 2017 was $44,720 ($172 per day).

The US is entering a golden age of corporate medicine

The recent slew of mergers and acquisitions is part of a larger corporate transformation that is remaking American healthcare – for the worse

By Adam Gaffney, M.D.
The Guardian, April 22, 2018

A golden age of corporate medicine may be dawning. A slew of mergers and acquisitions looks set to transform American healthcare, drawing health insurance giants, pharmacy benefit managers, physicians’ practices, drugstores, surgical centers and “retail clinics” in pharmacies and supermarkets together into giant corporate healthcare blobs. Whether you view this as a positive development may depend on your stock portfolio: good for industry profits, perhaps, but almost certainly detrimental to the public’s health.

Last week, health insurance giant Humana bought a large physicians’ group based in Florida, which comes on the heels of recent news that retail behemoth Walmart may be angling to buy Humana. Meanwhile, drugstore giant CVS, which already runs a pharmaceutical benefits program and the nation’s largest chain of retail clinics, is buying insurer Aetna for $69bn even as it expands into the dialysis game. And health insurer UnitedHealth Group has been gobbling up physicians’ practices from coast to coast, building a powerful “army of tens of thousands of physicians”, as Bloomberg puts it, alongside more than 200 surgical facilities and 230 urgent care centers.

Some contend that assembling different healthcare enterprises under one roof might sometimes deliver value to “consumers”. By buying Aetna and “more closely aligning management of drug benefits and other types of benefits in one organization”, health policy expert Austin Frakt noted in the New York Times, “CVS could be acting in ways that ultimately benefit consumers”. And as Craig Garthwaite, professor of strategy at Northwestern University’s Kellogg School of Management, said of another deal to Bloomberg: “You can see the strategy by which they could make investments that make people healthier for a patient that’s both a Humana enrollee and a Walmart customer.”

But whatever the purported efficiencies of vertical integration may be, these deals should be seen as part of a larger corporate transformation that is remaking American healthcare – for the worse.

Consider corporate medicine’s track record. Dialysis is dominated by corporations – the two largest are DaVita and Fresenius – that do a comparatively poor job keeping their patients alive. A 2011 study in Health Services Research found that for-profit chains had 13% higher risk of mortality than not-for-profits. DaVita, meanwhile, has paid out hundreds of millions in recent years to settle claims including Medicare fraud and overuse of a potentially harmful medication.

Evidence of corporate medicine’s paltry performance goes beyond dialysis. A 2014 study found that although there were gaps in the literature, for-profit providers overall achieved inferior outcomes, while a 2002 meta-analysis found that patients at for-profit hospitals had a higher risk of death as compared with not-for-profits.

Why? The investigators of the latter study offer one theory. For-profit institutions have unique expenses (eg profits and high executive salaries) but receive similar reimbursements, which creates a challenge: “They must achieve the same outcomes … while devoting fewer resources to patient care.” Not surprisingly, they often fail.

Corporate providers also seem prone to unsavory behavior. A decade and a half ago, the Hospital Corporation of America (HCA), the nation’s largest for-profit hospital chain, reached settlements with the federal government totaling $1.7bn for what the Department of Justice called the “largest health care fraud case in US history”. And a 2012 New York Times investigation found that HCA has more recently shaved costs by deciding “not to treat patients who came in [to the emergency room] with nonurgent conditions, like a cold or the flu or even a sprained wrist, unless those patients paid in advance”.

The comparative performance of physicians’ practices operating under new corporate roofs, “retail clinics” sprouting up in pharmacies and supermarkets and for-profit free-standing emergency rooms and urgent care centers is not yet entirely clear. However, there is reason to believe that they are increasing costs (such as by inducing excess healthcare use where it may not be needed), while doing little to increase healthcare access. A 2016 study in Health Affairs, for instance, found that retail clinics increased spending for “low-acuity conditions”, like colds, by 21%. And both free-standing ERs and retail clinics are disproportionately located in high-income areas, where new healthcare facilities are least needed.

It’s still too early to know if these new, vertically integrated corporate healthcare ventures will succeed financially. Squeezing profits from sick people is, after all, a tricky business.

But whatever their financial future, the advancing corporatization of American healthcare will fail for a more fundamental reason: cutthroat corporate profiteering and the humane provision of healthcare don’t mix. As healthcare reform returns to the national political discussion, we should be talking about cutting corporate America out of the healthcare system altogether – not welcoming them in.

Dr. Adam Gaffney is an instructor in medicine at Harvard Medical School, a pulmonary and critical care doctor at the Cambridge Health Alliance, and president-elect of Physicians for a National Health Program.

https://www.theguardian.com…

Industry expert discusses misplaced role of consumerism in health care

The Type of Consumerism Healthcare Really Needs

By Sachin H. Jain
Forbes, April 17, 2018

For decades, many have been dreaming of a revolution in healthcare based on the premise that making patients more accountable for healthcare costs—making them “consumers”—will result in higher quality and lower costs. It’s a brilliant vision. And smart people believe it makes sense. Except for one little detail: For many patients, it’s not a dream, it’s a nightmare.

Misplaced Conventional Wisdom

There is a conventional wisdom about patients that is inconsistent with the reality that many patients live. It starts with the premise that patients want to shop for healthcare like they shop for other goods and services. We assume patients want to go on-line and manage their health and make all of their own healthcare decisions. We assume they want to use rating ranking sites to make decisions about where to get their primary care and medicines. We assume they want to shop like it’s Black Friday.

The conventional wisdom continues with assumptions about the literacy, engagement, capability, and wealth. For many healthcare entrepreneurs, the median patient is assumed to be an MBA graduate with significant disposable income. The imagined patient has a “Type A” personality and wants to be obsessively engaged in every aspect of their health or healthcare.

And, on a related note, the conventional wisdom assumes high levels of digital literacy. The average patient has a sophisticated smartphone and multiple paired Bluetooth devices and knows how to use them. And would be able to improve their health if they just had the right tools to do so.

The implementation of this view is the proliferation of point solutions that aim to solve problems that we assume that patients prioritize: transparency of lab data, access to on-line medical records and easy access to appointment scheduling. While these are wonderful convenience features that we should undoubtedly adopt, they do very little to fundamentally change the healthcare cost or quality for consumers.

And they’re oddly implemented as an endless maze of disconnected portals, tools, and apps—few of which speak to each other and few of which delivers anything close to the value that we believe that they will. Either because patients don’t use them as intended, or they fail to capture the complexity of the broader ecosystem in which our patients live.

Masked Incrementalism

And there are many companies and startups that excite the people that are built on this vision of consumerism with clever tag lines that mask the incrementalism that underlies them. These are healthcare solutions that are really good for the 80% of patients who account for 20% of our healthcare costs. But the question is whether this perspective on the empowered consumer works for the 20% of patients who account for 80% of the costs.

Because if you are really trying to change the cost or quality equation in healthcare—you need to imagine a different consumer profile. One where the patient doesn’t want to be engaged in the traditional sense of the term—but where everything just works right for the patient. Where needs are anticipated and addressed before the patient or family can articulate them. One where we push beyond the superficial causes for problems—and dig far deeper into their root causes.

A Different View of Consumerism

CareMore, the company I lead, espouses a very different vision of consumerism. By way of introduction CareMore is a $1.4B Medicare and Medicaid delivery system that focuses on the care of more than 150,000 high-cost, high-need and vulnerable patients in 10 states. Our mission is to make health care more accessible, affordable and simple for the patients we are privileged to serve.

CareMore’s View

CareMore’s view of consumerism is grounded in the following simple ideas: 1) Healthcare should anticipate and deliver on consumers’ needs proactively. 2) Sick people should not have to shop for the care they need. 3) Consumers should not pay out of pocket for the things that they need.

Sick Patients Shouldn’t Have to Shop

Probably most controversial notion is the idea that sick people shouldn’t shop. But think about it. You’ve just been diagnosed with breast cancer. Multiple sclerosis. Diabetes. Do you want to be flipping through directories to find a doctor? Or do you want the appointment to be set up for you urgently with exactly the right specialists for your condition? Do you want the right durable medical equipment needed for your delivery to just show up or do you want to look through a website to pick your equipment? While I recognize there are a number of consumers—who given the opportunity to make these choices, would want to be in the driver seat—I would argue that most would not. They would want, most simply to just be cared for.

There is poverty in thought and intellectual laziness when we simply say consumers want to make these decisions.

https://www.forbes.com…

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Comment:

By Don McCanne, M.D.

In this article, Sachin Jain presents the fallacy of consumer-directed health care, that somehow the patient has the desire to use their own expertise and control of their own funds to shop for the best care available and in doing so will improve the quality and reduce the costs of health care. Jain explains that, instead, patients do not want to shop for their health care but would prefer that beneficial care be offered proactively without financial barriers that impair access to that care.

In other words, patients want the health care they need when they need it without having to shop in a complex health care environment in which they have little or no expertise. This is an argument for supporting a robust and efficient primary care infrastructure. Such a system should provide easy entry to appropriate technological and specialized services for patients with medical needs, not to mention being a source of preventive services.

It should be noted that the conclusion presented by the author, but not included in the excerpts above, is quite biased. Sachin Jain, MD, MBA is President and CEO of CareMore Health, a subsidiary of Anthem that provides Medicare Advantage and Medicaid managed care plans. Rather than framing the solution as primary care, in the rest of the article he essentially is marketing their private Medicare and Medicaid plans.

Although many of us at PNHP support integrating health care through a primary care infrastructure, we remain opposed to private Medicare Advantage and Medicaid managed care plans, especially those offered through a for-profit Wall Street corporation. The primary care professionals collectively, loosely arranged within a community and interacting with the specialized services and facilities available, or a community health center, or an integrated delivery system such as Kaiser Permanente, would be examples of the type of primary care infrastructure that would serve us well.

This comment clearly is not an endorsement of privatized Medicare or Medicaid, but it is a recognition that an individual representing the medical-industrial complex can still have the wisdom to recognize what a con the consumer-directed movement in health care has been. So we should to listen to everyone but reject the bad while implementing the good.

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