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Insurance works, but not for the 36,000 who will die

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Insurance works, but not for the 36,000 who will die

Changes in Mortality After Massachusetts Health Care Reform: A Quasi-experimental Study

By Benjamin D. Sommers, MD, PhD; Sharon K. Long, PhD; and Katherine Baicker, PhD
Annals of Internal Medicine, May 6, 2014

Abstract

Background: The Massachusetts 2006 health care reform has been called a model for the Affordable Care Act. The law attained near-universal insurance coverage and increased access to care. Its effect on population health is less clear.

Objective: To determine whether the Massachusetts reform was associated with changes in all-cause mortality and mortality from causes amenable to health care.

Design: Comparison of mortality rates before and after reform in Massachusetts versus a control group with similar demographics and economic conditions.

Setting: Changes in mortality rates for adults in Massachusetts counties from 2001 to 2005 (prereform) and 2007 to 2010 (postreform) were compared with changes in a propensity score–defined control group of counties in other states.

Participants: Adults aged 20 to 64 years in Massachusetts and control group counties.

Measurements: Annual county-level all-cause mortality in age-, sex-, and race-specific cells (n = 146 825) from the Centers for Disease Control and Prevention’s Compressed Mortality File. Secondary outcomes were deaths from causes amenable to health care, insurance coverage, access to care, and self-reported health.

Results: Reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group (−2.9%; P = 0.003, or an absolute decrease of 8.2 deaths per 100 000 adults). Deaths from causes amenable to health care also significantly decreased (−4.5%; P < 0.001). Changes were larger in counties with lower household incomes and higher prereform uninsured rates. Secondary analyses showed significant gains in coverage, access to care, and self-reported health. The number needed to treat was approximately 830 adults gaining health insurance to prevent 1 death per year.

Limitations: Nonrandomized design subject to unmeasured confounders. Massachusetts results may not generalize to other states.

Conclusion: Health reform in Massachusetts was associated with significant reductions in all-cause mortality and deaths from causes amenable to health care.

From the Discussion

Although we cannot rule out unmeasured confounders, it is challenging to identify factors other than health care reform that might have produced this pattern of results: a declining mortality rate in Massachusetts since 2007 not present in similar counties elsewhere in the country, primarily for health care–amenable causes of death in adults aged 20 to 64 years (but not elderly adults), concentrated among poor and uninsured areas and not explained by changes in poverty or unemployment rates.

http://annals.org/article.aspx?articleid=1867050

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Could Obamacare save 24,000 lives a year?

By Harold Pollack
healthinsurancee.org, May 5, 2014

It is a pleasure to read beautifully conducted studies on important subjects. Annals of Internal Medicine published one such study today by Benjamin Sommers, Sharon Long, and Katherine Baicker, three of the most prominent people researching health reform.

Using ten years of mortality data over the period 2000-2010, these authors compare trends in Massachusetts counties to those observed in similar counties in states that did not expand insurance coverage.

Some details are complicated. The final results are admirably clear. Deaths from causes amenable to health care declined by about 4.5 percent in Massachusetts compared with comparison counties. The annual number of deaths declined by an additional 8.2 per 100,000 non-elderly adults in Massachusetts, with larger results for counties with low average incomes and ones that began with lower rates of insurance coverage.

Sommers, Long, and Baicker then perform an intriguing calculation. They estimate that 830 adults would need to gain health insurance coverage to prevent one death per year.

The absolute numbers are also striking. The Congressional Budget Office estimates that ACA will reduce the ranks of uninsured adults by something like 20 million people. I rather heroically extrapolated the authors’ 1/830 estimate to the entire uninsured population across the U.S. This back-of-the-envelope calculation implies that ACA will prevent something like 24,000 deaths every year. That’s almost the number of Americans who die in auto crashes. It’s more than the number who die of AIDS or the number who are murdered every year.

That’s a crude calculation, of course. The authors understandably avoided such a calculation in their paper. One study of Massachusetts can hardly pin down the mortality reduction we can expect from a huge national policy. Still, the findings allow us to glimpse an order of magnitude, which is pretty impressive.

http://www.healthinsurance.org/blog/2014/05/05/could-obamacare-save-24000-lives-a-year/

Comment:

By Don McCanne, MD

This highly credible study of the changes in mortality before and after health care reform was implemented in Massachusetts indicates that one death was prevented for each 830 adults under age 65 gaining health insurance. The deaths that were prevented were concentrated in conditions most likely to be amenable to health care. Health insurance does save lives.

Prior international studies of deaths due to conditions that a well functioning health care system should prevent have shown that the United States has one of the worst rates of preventable mortality. Using the results of this study, it would be easy to conclude that the fact that we have the lowest rate of insurance coverage of all wealthy nations is a major contributor to our high rate of preventable mortality. 

Although the authors of this paper state that other confounders cannot be excluded as causes, nevertheless, they write, “it is challenging to identify factors other than health care reform that might have produced this pattern of results.” Conservative critics are already discrediting this study, yet they certainly are not providing any other reasonable explanation for the improved mortality.

Professor Harold Pollack of The University of Chicago has extrapolated the ratio of one life saved for each 830 insured and applied that to the estimated 20 million additional people who will be insured when the Affordable Care Act (ACA) is fully implemented. He estimates that 24,000 lives will be saved.

Using the same extrapolation for the roughly 30 million people who will remain uninsured after full implementation of ACA, we can estimate that about 36,000 people will die each year who would not have had they been insured. Do we really have the gall to passively accept these 36,000 deaths each year just because a few audacious individuals keep telling us that an improved Medicare for all is not politically feasible? Come on! It’s an imperative!

New push for state-funded health care

By Kelly Fay
The Legislative Gazette (Albany, N.Y.), May 6, 2014

Lawmakers, patients and health providers are urging the Legislature to pass a bill they say would provide every New Yorker with the basic human right to health care. Advocates rallied outside the Capitol Tuesday demanding the state adopt a single-payer system of health insurance and put “patients before profits.”

The universal health insurance bill, also known as New York Health, would streamline coverage for New Yorkers by replacing existing private and state health care programs with one universal program paid for by the federal and state governments. In order to do so, the state will need a waiver so that federal funding streams for specific programs can be pooled and applied toward statewide health coverage.

The concept for the bill (A.5389-a/S.2078-a) was initially introduced 23 years ago, and passed in the Assembly in 1992. However, it has not been brought to the floor for a vote since. Currently, New York Health has received the official support of 72 assembly members, but activists are confident it would pass if a vote is allowed.

Chair of the Assembly Health Committee and sponsor of the legislation Richard Gottfried said great strides were made with the passage of the federal Affordable Care Act, but more needs to be done.

“What is now crystal clear to everyone is that while you can patch it up, the system still does not work,” said Gottfried, D-Manhattan. “We do not need health insurance companies. We need to recognize that health care is a human right, not a commodity.”

Similar measures have been introduced in 26 states, but only one — Vermont — has passed legislation instituting a single-payer program. Vermont is expected to launch the program in 2017 once it has received the proper federal waivers. In California, the Legislature has passed universal health care bills twice, but the legislation did not receive the support of Gov. Arnold Schwarzenegger.

According to a 2009 study by the Urban Institute and funded by the New York state Legislature, the state could cut health care expenses — whether agency, employer or individual — by $20 billion if a single payer program were adopted.

According to Laurie Wen, executive director of the NY-Metro chapter of Physicians for a National Health Program, under a single payer system, some people, primarily wealthier individuals, may see an increase in taxes. However, she explained, other costs such as deductibles, premiums, out-of-network charges and co-pays would no longer be an issue.

More importantly, she said, the system would save the lives of six people a day who die because they do not have health coverage, and provide everyone with the same freedom of choice when choosing a physician.

“This is the most momentum we have had for this campaign in the last 22 years,” Wen said. “What we really need right now is for Speaker Silver to do the right thing. We had the majority last year for 6 months but speaker has not allowed it to come for a vote.”

Dr. Daniel Lugassy, a member of Physicians for a National Health Program, pointed out that medical bills are the leading cause of personal bankruptcy in the nation and said he encounters first-hand the problems presented by the current, profit-driven health insurance system at his job in the emergency room.

He shared a story of a woman who was experiencing a heart attack, but tried to refuse care because she was concerned she did not have adequate coverage and said many under-insured and uninsured New Yorkers face the same dilemma daily.

“I never went to medical school to practice business — I went to school to practice medicine,” Lugassy said. “A single payer system is the only way I’ll be able to do the job I was meant to do.”

New York Health is endorsed by more than 75 physician, labor and social justice groups as well as Green Party candidate for governor Howie Hawkins. It is sponsored in the Assembly by Health Committee Chair Richard Gottfried, D-Manhattan, and in the Senate by Bill Perkins, D-Harlem.

The New York State Black, Puerto Rican, Hispanic and Asian Legislative Caucus is scheduled to endorse the legislation during an event in the Capitol on Wednesday.

http://www.legislativegazette.com/Articles-Top-Stories-c-2014-05-06-87812.113122-New-push-for-statefunded-health-care.html

PNHP note: The May 6 Lobby Day was endorsed by Single Payer New York, 1199SEIU United Healthcare Workers East, American Academy of Pediatrics-District II, Capital District Alliance for Universal Healthcare, Central Labor Council – Albany, NY, Capital District Area Labor Federation, Citizen Action of New York, Committee of Interns and Residents/SEIU, Communications Workers of America District 1, Doctors Council/SEIU, Doctors for America—New York, Downtown Manhattan HCV Support Group, Finger Lakes for New York Health – Ithaca, NY, Granny Peace Brigade, Gray Panthers NYC Network, Green Party New York, Green Party of Onondaga, Labor-Religion Coalition New York State, New York HCV & HBV Support Group at O’Connor Hospital, Healthcare-NOW! NYC, Hunger Action Network of New York State, IATSE—Local 1, Interfaith Health Care Coalition of Rochester, Interfaith Impact of New York State, League of Women Voters of New York State, Metro Justice of Rochester, Move On, National Physicians Alliance—New York, New York State Academy of Family Physicians, New York State Labor Religion Coalition, New York State Nurses Association, New York State AFL-CIO, Metro New York Health Care for All Campaign, New York Lawyers for the Public Interest, Physicians for a National Health Program – Finger Lakes Chapter, Physicians for a National Health Program – NY Metro Chapter, Rekindling Reform, Single Payer New York, Statewide Senior Action Council, Sullivan County Legislature, Troy Area Labor Council, UAW Regions 9 and 9A, United University Professions, Upstate Hepatitis Awareness Project, VOCAL-NY, Westchester for Change, Working Families Party.

Single-payer health care seems to be inevitable

By Pat Barcas
Fox Valley Labor News, April 5, 2014

CHICAGO — Single-payer health care, or universal health care, is care paid for by the government through taxation. The United States does not offer this, falling woefully behind other industrialized nations in health care, and advocates want to change that through legislation.

“I think single payer is inevitable in America,” said Anne Scheetz, M.D., of the Illinois Single Payer Coalition. “Health care right now in America isn’t sustainable. It’s a terrible system and it’s going to fall apart.”

The Labor News sat down with Scheetz, and another advocate, Hale Landes of IBEW Local 134. Landes said even though many unions offer privatized health care, single payer would still benefit them.

“Health care is a huge bargaining chip in union negotiations. Take that away and we have more power. No one likes negotiating, but the thing is, the health insurance company doesn’t care, because they always win,” said Landes.

Single payer would allow for older people only working for insurance coverage to retire and open up the market, and workers comp insurance industry would vanish, because everyone would be covered.

“It really eliminates a lot of problems,” he said.

People who don’t want to pay the increased tax for covering strangers may not know they are already covering the cost. The existing system is operating extremely inefficiently, and hospitals have to raise prices for those uninsured who get treated at the emergency room.

“The vast majority of people would pay less in taxes than they pay now in premiums, co-pays, and services,” said Sheetz, who added the system we have now only serves those at the top, and snubs those at the bottom.

“Low-wage workers pay the same now as high wage-workers. It’s a huge disparity. And no one has the responsibility now of putting health care where it’s needed, so low income and rural areas have either one choice or no choice at all in an emergency,” she said.

Landes cited the efficiency of the VA in delivering quality care to those who say the government is too sloppy to handle single payer.

“The Obamacare rollout was done with private companies. It’s not always the most efficient way,” he said.

The points for single payer are staggering — a 2013 study alone showed massive savings during the first year alone if the United States switches to single payer.

Gerald Friedman, a professor of economics at the University of Massachusetts, Amherst, found that upgrading the nation’s Medicare program and expanding it to cover people of all ages would yield more than a half-trillion dollars in efficiency savings in its first year of operation, enough to pay for high-quality, comprehensive health benefits for all residents of the United States at a lower cost to most individuals, families and businesses.

Friedman said the savings would come from slashing the administrative waste associated with today’s private health insurance industry ($476 billion) and using the new, public system’s bargaining muscle to negotiate pharmaceutical drug prices down to European levels ($116 billion).

“We want people to know they can do something about this,” said Scheetz, who said representatives from the Illinois Single Payer Coalition are available for educational speaking engagements.

“Learn about single payer, contact your state senator or representative. This will help a lot of people,” Scheetz stressed.

Visit the Illinois Single Payer Coalition website to join, to obtain more information or to schedule a speaking engagement.

http://foxvalleylabornews.com/

Health insurance CEO pay skyrockets in 2013

Some see their compensation double

Healthcare-NOW!, May 5, 2014

Chief executive officers at Fortune 500 health insurance companies, who have opposed new regulations under the Affordable Care Act, emerged this month as one of the ACA’s greatest beneficiaries. Recently filed financial reports show that average compensation for these top nine health insurance CEOs rose by more than 19 percent in 2013, while several of the nation’s largest insurers more than doubled CEO pay.

The biggest winner was Aetna CEO Mark Bertolini, who received a staggering $30.7 million compensation package in 2013. This marks the largest payout to any health insurance executive since passage of the ACA and exceeded the compensation of the next two highest paid health insurer CEOs combined. The Bertolini pay package, which included a large “special one-time performance-based retention award,” represented a 131 percent increase over his $13.3 million compensation in 2012. (See table below.)

Molina Healthcare and Centene, both Fortune 500 insurers that specialize in privately managed Medicaid plans, roughly doubled CEO compensation in 2013. J. Mario Molina received $11.9 million, up from $5 million in 2012, while Centene’s CEO Michael Neidorff made $14.5 million, up from $8.5 million. Overall, average CEO pay across Fortune 500 health insurers rose from $11.6 million in 2012 to $13.9 million in 2013.

The disclosures of higher CEO pay coincided with several of the same companies announcing better-than-expected earnings in the first quarter of 2014, even as they signaled that patients and businesses should prepare for increased insurance premiums in 2015.

“For far too long, private health insurance executives have received outsized compensation packages – subsidized by the ever-increasing premiums of hardworking Americans – while millions of low-income individuals and those with pre-existing conditions went uninsured,” says Representative John Conyers, Jr. (D-Mich.). “The United States’ healthcare sector has been in need of repair for decades, and over the top executive compensation is emblematic of the failure of our private health insurance system. While the Affordable Care Act is a good first step, truly universal coverage and meaningful reform to our healthcare system can be provided only through a single-payer system. I have introduced H.R. 676 – the Expanded and Improved Medicare for All Act – since 2003 to live up to this aim of universal care and establish health insurance as a basic right rather than a for-profit industry,” he continued.

“Families and patients are being asked to tighten their belts in the face of rising healthcare costs, while our premiums are being used to subsidize even more astronomical compensation for the already wealthy,” said Benjamin Day, director of organizing at Healthcare-NOW!, a nonprofit group that advocates for a single-payer system, sometimes called “an improved Medicare for all.”

“In contrast, the top administrator of Medicare – our public, universal health plan for all seniors, which is more efficient, provides better financial protection, and receives higher marks from patients than private health insurers – is paid less than $200,000 per year. The culture of excess at these for-profit corporations is incompatible with the goals of an efficient, ethical health care system, where every dollar diverted from patient care represents a loss of access for real families.”

Day continued: “We face the highest healthcare costs and have among the worst health outcomes of any country in the developed world because we allow private health insurers and dozens of other intermediaries to act as for-profit middlemen in the health care system. Although many backers of the Affordable Care Act said it would rein in insurance company excesses, the law clearly hasn’t curtailed top executive pay.”

“Thirty-million-dollar CEO paychecks – millions that should be spent on saving lives, not making the rich richer – should be a stark reminder that a single-payer, Medicare-for-All program would lower costs by spending every available dollar on patient care, and making access to care an inalienable right for everyone in the United States,” Day said.

Graphics:

Chart: 2012 and 2013 Health Insurance CEO and Average Worker Compensation

https://salsa.wiredforchange.com/o/6055/images/2013CEOPayChart1.jpg

Bar Graph: 2013 Health Insurance CEO, CMS Administrator, and Average Worker Compensation

https://salsa.wiredforchange.com/o/6055/images/2013CEOWages1.jpg

Sources:

  1. Securities and Exchange Commission, 10-K Annual Reports
  2. Securities and Exchange Commission, DEF 14A Proxy Statements

(Both available at https://www.sec.gov/edgar/searchedgar/companysearch.html)

Embracing Fee-For-Non-Service – Again!

Report of The National Commission on Physician Payment Reform

Society of General Internal Medicine, March 2013

Recognizing that the level of spending on health care in the United States is unsustainable, the return on investment is generally poor, and the way that physicians are paid contributes substantially to the high cost of health care, The Society of General Internal Medicine (SGIM) convened The National Commission on Physician Payment Reform in March 2012 to recommend new ways to pay physicians that will ultimately improve patient outcomes but also rein in health care costs.

The commission’s recommendations focus on the near-term, calling for drastic changes to the current fee-for-service payment system and a five-year transition to a physician- payment system that rewards quality and value-based care. The recommendations pertain to the way physicians are paid throughout the health care system — both public and private payers.

http://physicianpaymentcommission.org/wp-content/uploads/2013/03/physician_payment_report.pdf

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Do We Get What We Pay For? Transitioning Physician Payments Towards Value and Efficiency

By Malathi Srinivasan and Mark D. Schwartz
Editorial, Journal of General Internal Medicine, May 2014

In March 2013… the National Commission on Physician Payment Reform (NCPPR), released a report with twelve recommendations to reform how physicians are paid, linking incentives to quality in patient care to curtail rising health care costs.

In this issue, SGIM ad hoc Committee members offer three Comments addressing the Commission’s recommendations. First, Selker and colleagues review the first three recommendations, which argue for phasing out the current volume-based, fee-for service (FFS) reimbursement model over 5 years, to be replaced by a system emphasizing value and efficiency, with incentives that promote high quality, coordinated, and cost-effective, patient-centered care. Then Siddiqui et al., addressing Commission recommendations four through nine, contend that while transitioning away from FFS, the US must strengthen the primary care foundation of high performing healthcare systems, notably evaluation, management and preventive services. Finally, Patel and Nadel examine the Commission’s last three recommendations, arguing that Medicare’s Sustainable Growth Rate (SGR) formula be repealed and replaced with policy that rewards value rather than volume, and that is based on a valuation of physician work that rectifies the current relative value unit (RVU) bias in favor of procedural compared with cognitive-based services.

http://link.springer.com/article/10.1007/s11606-014-2818-9/fulltext.html

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Global Amnesia: Embracing Fee-For-Non-Service — Again

By David U. Himmelstein, MD and Steffie Woolhandler, MD, MPH
Editorial and Comment, Journal of General Internal Medicine, May 2014

Now SGIM’s Commission has joined the growing policy bandwagon to reanimate the HMO strategy. There are semantic changes — ACO has replaced HMO, and when insurers drop expensive doctors (e.g. the 1,000-member Yale Medical Group5), it’s called “network optimization” not “delisting”. In a new twist on gag clauses, today’s ACO patients (e.g. seniors in Medicare’s Pioneer ACOs) aren’t told they’re enrolled. But the diagnosis and prescription are unchanged.

As in 1971, fee-for-service is the culprit. A shift to “bundled payment, capitation, and increased financial risk sharing” is the solution, with “risk adjustment… to avoid physicians and other providers cherry-picking the healthiest patients”; and “quality measures… to assure that evidence- based care is not denied as a cost-saving mechanism.”

Twentieth century risk adjustment and quality monitoring were overmatched by HMOs’ gaming and deception. Despite additional decades of work to devise bullet-proof risk adjustment, gaming remains so powerful and pervasive that cost and quality rankings are often distorted, or even inverted. No solution is on the horizon.

Conclusion

Like the SGIM Commission, we rue the toxic incentives of the current fee-for-service system. But in the profit-maximizing milieu of American medicine, capitation risks making things even worse. “Risk-sharing” too often means that physicians earn bonuses for denying care — a danger perceived by patients, who take a dim view of capitation. Risk-sharing is not simply the inverse of fee-for-service, but of fee splitting, the illegal practice of kickbacks for referrals.

There are many bad ways to pay doctors, and no particularly good ones. Other nations have achieved better outcomes, lower costs and fairer compensation of physicians using a variety of methods: fee-for-service, capitation, and salary; none is clearly best. The common theme isn’t mode of payment, but a universal system with regulations that restrain costs and minimize the opportunities for profit and the risk of loss.

Payment reform should focus not on manipulating greed, but on dampening it. Then the real motivations for good doctoring — altruism, social duty, and the glow we feel when we help our patients — can flourish.

Use the following link to read the entire article or to download the PDF: http://link.springer.com/article/10.1007/s11606-013-2745-1

Comment:

By Don McCanne, MD

Regarding controlling health care spending, the meme of this decade seems to be that we must start paying based on value and not volume, as if the greatest value would be realized by reducing the volume of health care to as close to zero as possible.

There are plenty of articles on how this might be accomplished, many of them centering on concepts such as accountable care organizations and bundling of payments. What seems to be missing are comprehensive discussions of how unrealistic and misdirected these proposals are.

That is why it is important that you download the article by Himmelstein and Woolhandler. It should be used in your advocacy work to move us away from the empty managed-care promise of supposedly replacing volume with value, so that we can move forward with reform that actually will improve value – a single payer national health program.

Singular solution

By Ana Malinow, M.D.
Pittsburgh Post-Gazette, Letters, May 4, 2014

Kudos to Bill Toland for his April 27 piece “How Did America End Up With This Health Care System?” To briefly summarize 100 years of our patchwork, dysfunctional health care system is almost as remarkable as finding a real solution for it. Mr. Toland gets all the particulars right, but the solution will not be found in the Affordable Care Act, no matter how long we wait for it to change.

As Americans gain more experience with the ACA, they will become disappointed when they realize that plans in the marketplace have low actuarial value and high deductibles. Narrow provider networks will prevent Americans from having choices in physicians and hospitals. Those previously satisfied with their employer-sponsored coverage will find they, too, have fewer options at greater cost. This incremental step will put billions in the pockets of insurance companies, entrenching them further in our system.

The solution today as in 1915, when the first national health insurance bill was introduced in Congress, is a health care system that is truly universal, affordable, accountable, accessible, sustainable and just.

Only with a single-payer system or improved and expanded Medicare for all will we ever have a health care system worth $2.8 trillion — something that cannot be said for what we have today or what we are getting under the ACA.

Dr. Ana Malinow resides in Shadyside.

Read more: http://www.post-gazette.com/opinion/letters/2014/05/04/Singular-solution/stories/201405040080#ixzz30lTqtxS7

Obamacare’s Empty Victory

By Margaret Flowers, M.D.
The Indypendent (Brooklyn, N.Y.), May 2, 2014

It feels truly Orwellian that progressives are applauding the forced purchase of private health insurance — one of the most hated industries in the United States — while the right is opposing a model that originated from their political leaders. The Affordable Care Act (ACA) is a step farther on the path to total privatization of our health care system, not towards the health care system that most Americans support: single payer Medicare for all.

In the months leading up to the March 31 deadline to obtain health insurance, ACA supporters united around their mission to enroll people. Volunteers knocked on doors and tabled in their communities. Celebrities and athletes tweeted and labor unions ran robocalls. The media buzzed with speculation about whether the ACA would succeed or fail. March 31 felt like election night. And after it was over, ACA supporters clapped each other on the back and celebrated.

Obamacare survived. But now that the law is implemented and the dust is settling, it’s time to question what this actually means for health care and what we should do now.

Before President Obama was elected in 2008, Drs. David Himmelstein and Steffie Woolhandler, two of the co-founders of Physicians for a National Health Program, raised a crucial question in their report, “Our Health Care System at the Crossroads: Single Payer or Market Reform?” They outlined the health care crisis and how past reforms were taking us toward increasingly “threadbare insurance coverage.” Knowing that health care reform would be front and center for the next few years, they argued that as a nation, we had a choice to make. We could stay on the same path toward a market-based health care system or take an evidence-based approach and create national single payer health insurance.

With the ACA, we have now passed that crossroads and are headed down the road to a completely market-based system of privatized health care. This is not something to celebrate. Dr. Adam Gaffney recently wrote an excellent history in Jacobin on the turn we have taken away from the concepts of universal health care and economic justice to a neoliberal model. We are inundated with market rhetoric telling us how wonderful it is to have the choice of shiny silver insurance in the brand new marketplace. Insurance plans are called products and we are consumers of them.

The problem with these public relations messages is that having health insurance doesn’t guarantee access to health care and health care doesn’t belong in the marketplace. As patients, we do not have a choice of whether or not to purchase health care when we need it. Delaying or avoiding necessary care can and does have serious consequences. And we can’t predict how much health care we will need or when we’ll need it. In a market-based system, profits are the bottom line and people receive only the amount of health care they can afford, not what they need.

The ACA is transferring hundreds of billions of public dollars to the private insurance industry to subsidize plans that leave people underinsured, unable to afford care and at risk of financial ruin if they have a serious accident or illness. And even at its best, tens of millions of people will remain without insurance.

Most of the 7.5 million people who purchased health insurance on the exchanges were already insured. More than 80 percent bought the lower-tier silver, bronze or catastrophic plans with the hope that they would not get sick. These plans have the lowest premiums but require that patients pay thousands of dollars out of pocket before insurance kicks in, and then pay 30 to 40 percent of the cost of covered care. The result is that underinsured people will continue to self-ration, delay or avoid care due to cost, as 80 million of us did in 2012.

The ACA includes regulations, but as usual the insurance industry has ways to work around them. Many insurers had caps on out-of-pocket costs waived. Insurers also found a way to “cherry pick” the healthiest customers by leaving cancer centers and major medical centers out of their networks. In fact, most of the new plans have narrow and ultra-narrow networks that shift more of the cost of care onto patients because care outside of insurance networks isn’t covered. And while insurance companies cannot drop individuals when they get sick, they can stop selling their plans in areas that don’t make a profit. Some are already doing this, which means the competition that was supposed to emerge did not. Instead, in 515 of the poorest counties in 15 states, only one insurance company is available on the health exchange. And greater consolidation of the health care system is underway through mergers and acquisitions.

Our public insurances, Medicaid and Medicare, are being increasingly taken over by private insurances in the form of Managed Care Organizations and Medicare Advantage. They compete for the healthiest patients and siphon more of the health dollars for profit, salaries and administration than public insurances. Top advisors to the White House expect our public plans to be rolled into the health exchanges in the near future with subsidies, a plan similar to Congressman Paul Ryan’s voucher proposal.

Nations that treat health care as a public good and not a commodity have universal coverage that costs less and produces better health outcomes. And in polls, some two thirds of Americans support single payer. Now our tasks is to shift the national debate away from how many people have insurance to what type of health care system we support. Efforts to do this are taking place at both state and national levels.

State efforts to educate and organize for universal health systems are using a human rights framework. This started with the Health Care is a Human Right campaign in Vermont that is working to create universal coverage, and similar organizing is happening in Maine, Pennsylvania and Maryland. An essential component of this organizing model is to develop leadership within communities that are uninsured or underinsured. States such as Washington, Oregon, Colorado and New Mexico also use human rights messaging in their campaigns.

State health reform faces significant barriers because federal legislation is needed to allow the creation of a state single payer system. However, state campaigns are essential because they push state health policy to be the strongest it can be and build an informed and organized grassroots movement that can also push for solutions at the national level.

Legislation for single payer health systems exists in Congress. In the House, Congressman John Conyers (D-MI) has introduced HR 676, “The Expanded and Improved Medicare for All Act,” in every session since 2003. So far it has 56 co-sponsors. In late 2013, Senator Bernie Sanders (I-VT) introduced SB 1782, “The American Health Security Act,” in the Senate. National organizations are working together to encourage more members to sponsor them and a national lobby day is happening in Washington, D.C., on May 22.

On a personal level, I have chosen to be a conscientious objector to the ACA. I cannot in good conscience give my support to the very industry I am trying to eliminate. Being a conscientious objector is a decision that people have to make for themselves. So far nearly 500 people have joined me by signing a petition at PopularResistance.org.

Some people speculate that the ACA will bring us to single payer some day because it will fail. This will only happen if we fight for it. Every day that we delay, people suffer and die in this country unnecessarily. Neil H. Buchanan says it best, “The ACA is as good as it gets, when it comes to basing a health care system on private insurance, and it is simply not good enough. Even as the ACA takes effect, therefore, we need to start planning to make it disappear.”

Margaret Flowers is a pediatrician and co-chair of the Maryland chapter of Physicians for a National Health Plan. She serves on the board of Healthcare-Now and of the Maryland Health Care is a Human Right campaign. She is also an editor at popularresistance.org.

http://www.indypendent.org/2014/05/02/obamacare%E2%80%99s-empty-victory

Is The Commonwealth Fund serious about searching for disruptive breakthroughs?

Searching for the Next Breakthrough in Health Care

By Anne-Marie J. Audet, M.D, M.Sc., S.M.
The Commonwealth Fund, May 5, 2014

It is well documented that health care in the United States is not just expensive; it’s world-class expensive, and unsustainably so. And although many would like to believe that all that spending buys us the safest, most effective care to be found anywhere on the planet, it is equally well documented that our health care system, on many levels, doesn’t measure up on a global scale. We’re simply not getting what we pay for.

Clearly, it’s going to take more than minor tweaks or adjustments to change our course. It’s going to take a real breakthrough.

What do we mean by a breakthrough? Though incremental change is valuable, and The Commonwealth Fund pursues this in many of its other programs, that’s not what we’re looking for here. We mean an idea, a paradigm, a strategy that positively and profoundly disrupts the status quo.

The Commonwealth Fund’s new Breakthrough Health Care Opportunities program aims to discover and vet transformative ideas that have the potential to expand access to care, dramatically simplify the delivery of care, decrease costs, and improve health outcomes.

We’ve set the bar high. Here are our working criteria for a breakthrough:

  • How much does it disrupt the status quo? We’re looking for major disruption—a whole new approach that represents a break with what we do now.
  • How big a difference will it make? Broad societal impact is the goal, with large numbers of people benefiting nationwide. To gauge impact, we’re using a 20/20 rule for screening breakthroughs: the potential must be at least a 20 percent improvement in health care quality and/or a 20 percent reduction in costs nationally.
  • How quickly can it become a reality? The timeframe we envision is up to 10 years to achieve impact.

Our work in exploring breakthrough opportunities is just beginning. We will seek ideas from a broad network of colleagues, and communicating what we find along the way. Please share your thoughts with us here or Tweet them with the hashtag #hcbreakthrus.

http://www.commonwealthfund.org/Blog/2014/May/Searching-for-the-Next-Breakthrough-in-Health-Care.aspx

Breakthrough Health Care Opportunities: http://www.commonwealthfund.org/Program-Areas/Breakthrough-Health-Care-Opportunities.aspx

Comment:

By Don McCanne, MD

The Commonwealth Fund’s new Breakthrough Health Care Opportunities program is looking for “major disruption – a whole new approach that represents a break with what we do now.” They aim to “discover and vet transformative ideas that have the potential to expand access to care, dramatically simplify the delivery of care, decrease costs, and improve health outcomes.”

Uh, there is a great idea already out there that would seem to be just what they are looking for – a well designed single payer system. It is highly unlikely that anyone will come up with any other idea that does not yet exist which is a truly disruptive, transformative breakthrough that will achieve their goals. It is much more likely that proposals will be for incremental tweaks or adjustments which they say they are not looking for.

But are they serious? As one example of “the scale and ambition we believe are needed to achieve dramatic improvements in U.S. health care” they suggest “the massive and widespread implementation of financial risk-sharing arrangements to encourage more careful allocation of resources and create incentives to keep patients healthy.” Yikes! We already have introduced that with accountable care organizations and their predecessors, and the results to date indicate that improvements are negligible or worse. A special form of risk sharing – requiring patients to pay more of the costs of the care they obtain – might slow spending very modestly but at a cost of increasing financial hardship and impairing health care access.

Although single payer is not a new concept, it would certainly be a beneficial, disruptive breakthrough for the United States. It will be interesting to see if they are really serious about considering all ideas, or if this will be yet another ABSP proposal. (ABSP – Anything But Single Payer).

Getting serious about single payer

Getting serious about a single payer system 

By James F. Burdick
The Baltimore Sun, May 1, 2014

A single payer system — where the government pays for health costs — is now recognized by many in the U.S. as the best solution for our health care problems. It was taken “off the table” in 2009 by Sen. Max Baucus, A Montana Democrat who reportedly received more money from the pharmaceutical and health insurance industries than any other Congressman. But now the flood of single payer advocacy cannot be turned off by vested business interests. It is time to progress from the stereotype of single payer to having a serious discussion about it.

Ironically, even after its recent success in covering millions more Americans, the problems with the Affordable Care Act serve to illuminate the advantages of single payer. The public, although confused by the divisive rhetoric around health care reform, is coming to realize that the complexity of the law and the pursuit of insurance company profits are major problems for the ACA. Back in 2009, a majority of Americans favored a single payer-like system. The country may now lose patience with the protracted process of ACA implementation, with Republicans yapping at its heels, until 2020 when the final provision closing the Medicare prescription drug doughnut hole fully kicks in.

The 30-page H.R. 676, the single payer bill of Rep. John Conyers Jr., a Michigan Democrat, shows how simple it is to cover everyone. It provides savings through quality care — including protection from harmful overuse and efficient, timely management of chronic disease — as well as savings through national monopsony buying power and freedom from insurance business profits.

Most politicians and health policy experts with national reputations remain silent. Some may have too great a stake in the ACA to join in the single payer adventure right away. But the country did just pass this valuable law. Even recognizing the tight political maneuvering required, this attests that the political potential for major change to our health care system is there. Luminaries who have asserted the wisdom of single payer include political commentator Bill Maher, former U.S. Secretary of State Colin Powell, Nobel-prize winning economist Paul Krugman, Sen. Bernie Sanders of the Vermont Progressive Party and former U.S. Labor Secretary Robert Reich. With even conservative columnist Ross Douthat alluding to the unspeakable in the April 5th New York Times “(ahem, single payer)” and a number of states trying to establish it on their own, supporting single payer nationally no longer appears out of reach.

The paper by Drs. Ray Drasga and Lawrence Einhorn, both of Indiana, in the Journal of Oncology Practice from January showing how their cancer patients would benefit from single payer is a beacon for all of medicine. Other prominent doctors recently supporting it include Dr. Nancy Snyderman of NBC and Dr. James Mitchiner of The American College of Emergency Physicians. The Physicians for a National Health Program promoting single payer is now 19,000 members strong. American nurses strongly support single payer.

Soon candidates who wish to be seen as working for all Americans will support single payer, or they will have some explaining to do.

Dr. James Burdick is Professor of Surgery at Johns Hopkins University School of Medicine.

http://www.baltimoresun.com/news/opinion/oped/bs-ed-single-payer-20140501,0,2307598.story

Comment:

By Don McCanne, MD

As the serious deficiencies of the Affordable Care Act become ever more obvious, people will be looking for solutions to our health care crisis that will actually work. As they begin to better understand the single payer model, the groundswell of support will drive the reform process. By then, the “economic elite” will no longer be able to stop us.

Legal challenge threatens Canada’s medicare

No evidence that for-profit health care results in better outcomes

By Monika Dutt and Rachel Tutte
Vancouver Sun, May 1, 2014

We are just four short months away from an unprecedented legal challenge to Canadian public health care that will put the fundamental Canadian principle of care based on need, not ability to pay, on trial.

The legal case is being driven by Dr. Brian Day, owner of the Vancouver-based for-profit Cambie Surgery Centre, infamous for unlawfully billing patients for health care services.

Dr. Day hopes to strike down the rules that prevent a U.S.-style system in Canada, where some people get to pay privately to jump the queue. His claim is that B.C.’s Medicare rules violate the Canadian Charter of Rights and Freedoms.

It is hard to overstate the significance of this challenge. If Dr. Day wins, the public system that Canadians rely on — and overwhelmingly support — will be dismantled across the country. We will be left with a system that looks very much like that of the United States — physicians will be permitted to charge patients any amount they like for services, and the rich elite will get care faster than the rest of us.

Evidence shows that the kind of system Dr. Day is seeking via the courts would result in longer wait times and poorer health outcomes for Canadians.

An abundance of evidence shows that for-profit hospitals reduce access to care for everyone but the wealthy elite. Studies in Canada, Europe, and the UK show that patients who can’t pay, and whose doctors work in both public and private systems, have the longest waits. Australian research shows that private for-profit clinics drain the limited supply of doctors and other health professionals from the rest of the health care system, lengthening waiting times for all but those who can afford expensive private insurance.

This bears emphasizing: A second, for-profit tier does not relieve pressure on the public system; instead, evidence shows wait times actually increase.

Similarly, there is no evidence that private for-profit care results in better outcomes — not anywhere in the world.

There is no doubt we are in need of improvements to our system. Those improvements need to reflect the Canadian values of equity and cost-effectiveness. We need to scale up evidence-based innovations that have been proven to reduce wait times and improve health outcomes. Across Canada, there are dozens of innovative projects improving access, quality, and cost-effectiveness while protecting equitable access to care. For example, the Alberta Bone and Joint Institute reduced wait times from 11 months to nine weeks for hip and knee surgery.

Dr. Day’s true motives are clear. A provincial audit of Day’s Cambie Surgery Centre and the associated Specialist Referral Clinic found that patients were unlawfully extra-billed $491,654 in just 30 days. In one case, a Cambie patient was billed $7,215.00 for services that would only have cost $1,288.04 in the B.C. health care system. Auditors also found over $66,000 in overlapping claims — evidence that suggests double dipping for the same services.

Charging patients nearly six times the actual cost of a procedure is not about human rights, and it’s not about system improvement. It’s about profit.

For the good of all Canadians, let’s hope this dangerous legal challenge is struck down and we can get on with the work of improving a system that cares for all of us.

Dr. Monika Dutt, chair of Canadian Doctors for Medicare, is a Medical Officer of Health, Cape Breton District and Family Physician. Rachel Tutte is co-chair of the BC Health Coalition and a physiotherapist.

http://www.vancouversun.com/news/Legal+challenge+threatens+medicare/9797988/story.html#ixzz39X4LRPiy

Medicine and Money

On Medicine and Money

By Eli Y. Adashi, MD, MS
JAMA Forum, April 30, 2014

As might have been anticipated, much of the media coverage of the release of the CMS data focused attention on health care professionals dubbed “Medicare millionaires” and their practice patterns. Tantalizing as such details might be, more profound issues were being sidestepped. In particular, little has been said with respect to the uncomfortable relationship between medicine and money.

This is an unfortunate state of affairs, because the ethical and moral challenges associated with the juxtaposition of medicine and money are highly deserving of our attention.

Many see the pairing of money and medicine as a nonissue, and instead view it as capitalism at its best, with medicine being just another market in which competition reigns supreme. For proponents of this point of view, health care professionals might be seen as operatives in a retail business, wherein the volume of sales (of health services) carries the day, creating a vibrant health care market that sparks the scientific innovations upon which we have all come to depend. They see the business model of medicine as no different than that of any other field of pursuit, naturally rooted in foundational libertarian principles. Viewed in this light, the intersection of medicine and money is as American as apple pie. Exemplified by the time-honored “private practice” of medicine, this all-out embrace of the business principles of a market economy remains undiminished—if increasingly untenable.

But there’s a potential flaw in this line of reasoning: the presumption of a fail-safe firewall between financial considerations and clinical decision making. Sadly, that may not always be the case.

Clearly, opinions vary widely as to the ethical and moral wisdom of mixing medicine with money. Some would favor a lightly regulated, self-policing field, wherein unfettered entrepreneurship and Medicare millionaires are bound to thrive. According to this outlook, infractions perpetrated by a select few do not warrant the imposition of blanket, heavy-handed oversight.

But those who consider medicine and money to constitute a volatile mix may express preference for another model, such as a national health care system buttressed by a single governmental payer, in which value rather than volume of services determine provider compensation. Under this system, Medicare millionaires are unlikely to flourish.

JAMA Forum: On Medicine and Money

****

Comment:

By Don McCanne, MD

Physician. Seeing that word, what comes into your mind? Do you think of a person who is dedicated to promotion of health and healing of the sick? Or do you think of an occupation that is as American as apple pie in its dedication to retail business within the entrepreneurial health care marketplace?

Medicine is different. Those favoring unfettered entrepreneurship with the chance to become a Medicare millionaire really do not belong in the field. Most physicians find the imposition of money considerations into the relationship between the physician and the patient to be a great nuisance, if not outright repulsive.

Dr. Adashi reminds us that there is another model that would be preferred by most physicians who would rather be healers than entrepreneurial businessmen. That preferred model is “a national health care system buttressed by a single governmental payer.”

Isn’t it time for us to change our model?

P4P harms poor patients

Health law’s pay policy is skewed, panel finds

By Robert Pear
The New York Times, April 28, 2014

Federal policies to reward high-quality health care are unfairly penalizing doctors and hospitals that treat large numbers of poor people, according to a new report commissioned by the Obama administration that recommends sweeping changes in payment policy.

Medicare and private insurers are increasingly paying health care providers according to their performance as measured by the quality of the care they provide. But, the draft report by an expert panel says, the measures of quality are fundamentally flawed because they do not recognize that it is often harder to achieve success when treating people who do not have much income or education.

Low-income people may be unable to afford needed medications or transportation to doctor’s offices and clinics, the panel said. If they have low levels of formal education or literacy, they may have difficulty understanding or following written instructions for home care and the use of medications. In addition, the clinics and hospitals they use may lack the resources and high tech equipment needed to diagnose and treat illnesses.

The panel found that existing payment policies unintentionally worsen disparities between rich and poor by shifting money away from doctors and hospitals that care for “disadvantaged patients.”

Measures of health care quality and performance — widely used by Medicare and private insurers in calculating financial rewards and penalties — should be adjusted for various “sociodemographic factors,” the expert panel said. The panel was created by the National Quality Forum, an influential nonprofit, nonpartisan organization that endorses health care standards.

….The Obama administration commissioned the study, but is not entirely comfortable with the recommendations, officials acknowledged. The existing policies of the National Quality Forum and the government say performance scores should generally not be adjusted or corrected to reflect differences in the income, race or socioeconomic status of patients.

…. “We do not want to hold hospitals to different standards of care simply because they treat a large number of low-socioeconomic-status patients,” said Dr. Kate Goodrich, the director of quality measurement programs at the federal Centers for Medicare and Medicaid Services. “Our position has always been not to risk-adjust for socioeconomic status within our measures because of concern about masking disparities, and potentially rewarding providers who provide a lower level of care for minorities or poor patients.”

Comment:

By Kip Sullivan

The notion that doctors and hospitals are screwing up and will behave if they are subjected to punishment and reward by third parties is not new. The Code of Hammurabi (1750 BC) subjected Mesopotamian doctors to a combination of reward (more shekels) and punishment (cutting off of doctors’ hands)  http://economix.blogs.nytimes.com/2013/04/26/hammurabis-code-and-u-s-health-care/.  But even Hammurabi didn’t recommend punishing the patients.

But that is effectively the position taken by the National Quality Forum (NQF), the Obama administration, and the numerous private-sector firms and groups that peddle pay-for-performance (P4P) as a solution to the health care crisis. By refusing to adjust scores on report cards to reflect patient socioeconomic status (SES), P4P proponents are guaranteeing that the P4P fad will punish clinics and hospitals that serve poorer patients.

It is widely known that report cards on clinics and hospitals that are used in P4P schemes are, with rare exceptions, poorly adjusted to reflect differences in patient health. It is also widely known that report cards are almost never adjusted for income, insurance status and other SES indicators. But what was not widely known until Monday’s report in the New York Times was that the NQF and the Obama administration have actually endorsed a policy of prohibiting the use of SES data to adjust scores on report cards.

Why would the NQF go to the trouble of explicitly outlawing the use of SES adjusters and thus draw attention to a serious defect in virtually all P4P schemes in use in America today?

As is always the case with managed care propositions, finding a well-documented argument for the NQF’s position is impossible. All we have is this tiny remark in footnote 15 in an NQF document:

“Risk models should not obscure disparities in care for populations by including factors that are associated with differences/inequalities in care, such as race, socioeconomic status, or gender (e.g., poorer treatment outcomes of African American men with prostate cancer or inequalities in treatment for CVD risk factors between men and women).” http://www.qualityforum.org/docs/measure_evaluation_criteria.aspx

Like most report-card proponents, the NQF gives at least lip service to the necessity of adjusting scores to reflect differences in patient health because (a) these differences affect quality measures and (b) they are beyond provider control. Why, then, wouldn’t the NQF treat SES factors the same way? Patients’ low income, their lack of health insurance, their illiteracy and other factors subsumed under the concept of low SES status affect the outcome of medical care, and they are all way beyond the control of providers.

The basic premise of the NQF and the Obama administration is that the only way for policy makers to know if medical care has worse outcomes in poor people is via report cards. This premise is so foolish its mere statement constitutes a rebuttal.

The NQF “argument” then goes on to claim that the benefits of revealing disparities in health care outcomes via report cards outweighs the damage done to providers who treat poor people and to poor people themselves. Or at least that’s what we have to imagine went through the minds of the folks at NQF. As I said, the proponents of this bizarre policy apparently did not feel compelled to leave a paper trail that would help the rest of us comprehend their thinking.

It was the existence of this strange policy that led to the convening of the expert panel described in the Times article. http://www.qualityforum.org/Risk_Adjustment_SES.aspx The panel rejected the NQF-administration rationale by huge margins. According to the panel’s report:

“There is a clear and expanding body of evidence to suggest that providers serving ‘low-socio-demographic’ populations and communities are more likely to be identified as ‘poor performers’ and either be less likely to receive financial rewards, or be more likely to face financial penalties, in pay-for-performance programs.”

“The net effect,” said the panel, “could worsen rather than ameliorate healthcare disparities.”  To avoid this outcome, said the panel, the NQF should “reconsider” its policy. If the NQF remains concerned that lawmakers may remain in the dark about disparities in health outcomes, it should seek evidence for such disparities through other, more traditional means. In the future, the panel concluded, “purchasers, policymakers and other users of performance measures should assess the potential impact on disadvantaged patient populations …. (p. 10)” before imposing P4P schemes.

How did it come to this? Why do our country’s top health policy makers have to be told to honor the fundamental principles of science and medicine, namely, make sure whatever you recommend is safe and effective before administering it?

There are some big obstacles to achieving universal coverage in the US under a single-payer system. None is more serious than the sloppiness of managed care think – the refusal of the health policy elite to honor the equivalent of evidence-based medicine and the equivalent of the Hippocratic Oath. It encourages lawmakers to buy cheap, snake oil health policy in place of real medicine. All of us who care about an efficient and humane health care system in the US must redouble our efforts to shine a light on the establishment’s cavalier attitude toward science and ethics in health policy.