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Oncologists Make the Case for Single Payer System

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Oncologists Make the Case for Single Payer System

By Tony Berberabe, MPH
OncLive, Jan. 22, 2014

When a patient receives the diagnosis of cancer, regardless of stage or severity of the disease, one of the many questions asked is how to pay for the treatment. And while the diagnosis is arguably the single most catastrophic health care event in an individual’s life, the burden of cost on the patient and their family only adds to the stress of the situation.

Oncologists are in the unenviable position of advising a treatment scheme that the patient can afford, paving the way to consider a single-payer system, writes Ray E. Drasga, MD, and Lawrence H. Einhorn, MD, in the latest issue of the Journal of Oncology Practice. Drasga is a community oncologist who founded a free clinic in Crown Point, IN, and Einhorn is a professor of Medicine at Indiana University Hospital in Indianapolis.

Single-payer systems are systems in which a single public or quasi-public agency handles all health care financing. Delivery of care may remain in public or private hands, depending on the particular system.

Drasga and Einhorn make the case for a regional single-payer system similar to Medicare that would provide universal, comprehensive coverage with free choice of providers. “All medical care would be covered, including provider visits, hospital care, prescription drugs, and rehabilitation. Copayments, deductibles, insurance premiums, and out-of-pocket expenses would be eliminated,” they write.

With the Affordable Care Act (ACA) now firmly established and private insurers firmly at its center, the authors foresee the trend of more high-deductible health plans, underinsurance, and greater cost shifting to patients. In addition, Drasga and Einhorn point out that the ACA does not include any cost-control measures, but rather relies on accountable care organizations, a revised version of the health maintenance organization. The authors write, “There’s no evidence ACOs will be any more effective than HMOs were in containing costs.”

Faced with the crisis of uncontrolled costs and inequitable access to care, Drasga and Einhorn call for a “streamlined, efficient, nonprofit system based on human needs to provide high-quality care to every person,” and ask that their fellow oncologists and their society, ASCO, endorse a single-payer system of national health care insurance.

http://www.onclive.com/news/Oncologists-Make-the-Case-for-Single-Payer-System

High deductibles perpetuate system’s issues

By Jonathan D. Walker, M.D.
The Journal Gazette (Fort Wayne, Ind.), Jan. 14, 2014

“Doc, I need to get this done before my new deductible kicks in.” Physicians hear this a lot; it reflects the increasing use of so-called consumer-directed health plans, where people are responsible for the first several thousand dollars of care before their insurance company has to pay. If you don’t already have one, you probably will soon.

And, believe it or not, this trend has nothing to do with Obamacare. The adoption of high-deductible plans is a symptom of a deeper problem: the fact that everything costs way more in America than anywhere else. For decades, there has been so much money sloshing around the system that there has been an “arms race” over who can charge the most. And for-profit insurance companies have never had the leverage to actually bring those prices down – the system is too fragmented.

There are some good things that come from those prices; part of that money goes to developing new treatments and technology. But a lot of that money ends up being wasted. For instance, a huge amount is thrown away on needless bureaucracy. A 2003 paper in the New England Journal of Medicine estimated that up to 30 percent of our health care costs come from administrative waste.

And it gets even worse. Researchers have shown that some of the care provided may not be as necessary or effective as doctors think. For instance, there is a whole website created by the American Board of Internal Medicine to help doctors and patients decide which tests and treatments actually are useful (choosingwisely.org).

So we have a system that is insanely expensive, that wastes money on needless paperwork and may not always provide the right type of care. But no one can fix it because it is too disjointed and unwieldy. So what do you do if you are a for-profit insurance company? You figure out a way to make someone else pay.

And that is why we have high-deductible plans. The insurance company is off the hook for the first several thousand dollars. Plus, the thinking is that if you have to pay that first big amount, you will somehow be able to control costs and “solve” the system’s problems. Now, there is a bit of truth to that. Studies show that people respond to high deductibles by cutting down on doctor visits for simple things. More importantly, it gets people to be more involved in their care, and that is definitely a good thing.

Unfortunately, it doesn’t solve the fundamental problem of high costs. Once people get really sick, they blast through the deductible and the system ends up right back where it started, with lots of expensive care and no way to control it. And a lot of studies show that when people are worried about their deductibles, they put off being evaluated, ending up much sicker and with more expensive problems. Children can often be the innocent victims of this, as parents struggling with finances try to decide which symptoms need a doctor and which don’t. Finally, women tend to have higher health costs overall, and high-deductible plans amount to more than a $1,000 loss in pay for women compared to men.

But the winners are always the insurance companies. They have managed to shift their costs onto you, yet they can still charge huge premiums and deceptively blame Obamacare (rather than admit that they are perpetuating a broken business model). It would have been so much simpler, and cheaper, if Congress had just raised everyone’s Medicare tax – less than what we pay for private insurance – then we could all have some degree of basic coverage through Medicare. But that concept is kept so far off the table that most Americans don’t realize it is an option.

But even if research suggests that high-deductible plans can’t work, it doesn’t make any difference. They are happening. So in coming years, as you pay thousands of dollars to fulfill your deductible, remember that you are spending all that extra money to help your insurance company survive. Hopefully you will, too.

Dr. Jonathan D. Walker is an assistant clinical professor at Indiana University School of Medicine in Fort Wayne and a member of Hoosiers for a Commonsense Health Plan. He wrote this for The Journal Gazette.

http://www.journalgazette.net/article/20140114/EDIT05/301149990/1144

Why we do not want investor-owned health care institutions

Hospital Chain Said to Scheme to Inflate Bills

By Julie Creswell and Reed Abelson

The New York Times, January 23, 2014

Health Management Associates, a for-profit hospital chain based in Naples, Fla., kept tabs on an internal strategy that regulators and others say was intended to increase admissions, regardless of whether a patient needed hospital care, and pressure the doctors who worked at the hospital.

This month, the Justice Department said it had joined eight separate whistle-blower lawsuits against H.M.A. in six states. The lawsuits describe a wide-ranging strategy that is said to have relied on a mix of sophisticated software systems, financial incentives and threats in an attempt to inflate the company’s payments from Medicare and Medicaid.

For H.M.A., the timing could not be worse. Shareholders recently approved the planned $7.6 billion acquisition of the company by Community Health Systems, which will create the nation’s second-largest for-profit hospital chain by revenue, with more than 200 facilities.

Federal regulators have multiple investigations into questionable hospital admissions, procedures and billings at many hospital systems, including the country’s largest, HCA. Community Health Systems, the Franklin, Tenn., company from which H.M.A. hired its former chief executive in 2008, faces similar accusations that it inappropriately increased admissions. 

The practice of medicine is moving more rapidly than ever from decision-making by individual doctors toward control by corporate interests. The transformation is being fueled by the emergence of large hospital systems that include groups of physicians employed by hospitals and others, and new technologies that closely monitor care.

The last year has been particularly tumultuous for H.M.A., starting with the announced departure of Mr. Newsome (chief executive), a battle for control of the board with Glenview Capital Management, the hedge fund founded by Lawrence M. Robbins, and the announcement of the acquisition by Community Health Systems.

When H.M.A. announced the Justice Department’s involvement in the lawsuits, investors and analysts shrugged, and the stocks for both companies involved in the merger barely budged.

Sheryl R. Skolnick, who follows health care for CRT Capital, recently wrote in a note to investors, “Investors seem to think that D.O.J. investigations, qui tam suits and allegations of serious Medicare fraud are simply a cost of doing business.” Many settlements run only into the tens of millions of dollars. That’s a corporate slap on the wrist for companies whose stocks typically soar when executives push the profit envelope. Only if the penalty is at least $500 million, Ms. Skolnick said, are corporations likely to find the cost a deterrent.

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A Giant Hospital Chain Is Blazing a Profit Trail

By Julie Creswell and Reed Abelson

The New York Times, August 14, 2012

During the Great Recession, when many hospitals across the country were nearly brought to their knees by growing numbers of uninsured patients, one hospital system not only survived — it thrived.

In fact, profits at the health care industry giant HCA, which controls 163 hospitals from New Hampshire to California, have soared, far outpacing those of most of its competitors.

The big winners have been three private equity firms — including Bain Capital, co-founded by Mitt Romney, the Republican presidential candidate — that bought HCA in late 2006.

Among the secrets to HCA’s success: It figured out how to get more revenue from private insurance companies, patients and Medicare by billing much more aggressively for its services than ever before.

Many doctors interviewed at various HCA facilities said they had felt increased pressure to focus on profits under the private equity ownership. “Their profits are going through the roof, but, unfortunately, it’s occurring at the expense of patients,” said Dr. Abraham Awwad, a kidney specialist in St. Petersburg, Fla.

Some of HCA’s tactics are now under scrutiny by the Justice Department (2012).

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PRLOG

October 7, 2013

An investigation on behalf of investors in shares of HCA Holdings Inc (NYSE:HCA) was announced concerning whether certain HCA Holdings officers and directors possibly breached their fiduciary duties in connection with certain statements.

http://www.prlog.org/12222266-hca-holdings-inc-nysehca-long-term-stockholder-investigation-over-potential-wrongdoing.html

Comment:

By Don McCanne, M.D.

What is the primary purpose of a hospital? Isn’t it to meet the health care needs of patients that require more care than can be readily provided outside of the hospital? Not according to the expanding for-profit hospital chains. It is to make as much money as possible for the investors, even if that means using patients as economic tools to enhance revenues.

This is not a new problem. In 2003, HCA paid the largest health care fraud settlement in U.S. history – $1.7 billion. http://www.justice.gov/opa/pr/2003/June/03_civ_386.htm

This is why the PNHP model of single payer reform includes not only publicly-administered and publicly-financed health care for everyone, it also includes a conversion of the for-profit health care delivery system to nonprofit.

We need a health care system whose sole mission is to take care of patients, not investors.

In 1965, Medicare Was Rolled Out In 8 Months. How?

By Laurie Tarkan
WellBeeFile, Jan. 24, 2014

Dr. Stephanie Woolhandler, a member of Physicians for a National Health Program, which advocates for a single payer national health program, is professor in the CUNY School of Public Health at Hunter College. WellBeeFile (WBF) interviewed her about her views on the Affordable Care Act and its rollout.

WellBeeFile: As an advocate of single payer national health program, do you think that the Affordable Care Act is a step in that direction?

Steffie Woolhandler: The ACA will expand Medicaid (the joint federal-state program for the poor).  Medicaid is better than no insurance, but does not provide fully adequate coverage. Medicaid reimbursements tend to be so low that many doctors refuse to accept it.  In addition, Medicaid managed care plans tend to have very narrow networks of providers.  So this expansion will ameliorate some of the suffering of poor Americans, but does not provide a model for a universal, high quality health system.

WBF: What do you think is good about the ACA?

SW: As mentioned above, Medicaid expansion will be an improvement over what we have in 2013. In addition, the ACA places some good new regulations on private insurers, such as the elimination of pre-existing condition exclusions and the removal of lifetime caps.  Previously, several thousand privately insured Americans each year reached their cap (typically $500,000 to $1 million) and then their insurance stopped paying their medical bills.  Banning these grossly unfair private insurance practices is particularly important for non-elderly people who experience severe illness such as cancer.

WBF: Do you think the website problems have occurred because of the sheer number of private companies on the exchanges?

SW: The website problems reflect the immense complexity of health financing under the ACA.  This is not just a problem of a multiplicity of insurers (indeed, in some markets there are just one or two insurers), but also the byzantine complexity of the eligibility, coverage, and subsidy rules.  We know that a single payer would entail dramatically lower administrative burdens and costs. Traditional Medicare was rolled out in just eight months during the fall of 1965 and spring of 1966, in an era before computers.  Traditional Medicare (i.e. excluding the private Medicare Advantage plans) has overhead of about 2 percent, as does Canada’s national health insurance program.  Private insurance plans are allowed to have overhead of 15 percent to 20 percent under the ACA.

WBF: What do you think is problematic about the ACA?

SW: The worst aspect of the ACA is that 32 million Americans will remain uninsured after the ACA is fully implemented.  The ACA reinforces the role of the private insurance industry which is responsible for the complexity and high administrative costs of the current system.

WBF: Do you think older individuals will be able to find affordable health insurance?

SW: Some middle-class people 50-64 years old will be able to afford the new coverage; some won’t. People with incomes within 250 percent of the poverty line will receive substantial subsidies to help them afford coverage.  Above 250 percent (and particularly above 400 percent) of poverty, insurance will be quite expensive.

WBF: Do you have any recommendations for people when sorting through the different medal plans?

SW: On some exchanges, there are many variations of similar plans. First of all, if your income is between 138 percent and 250 percent of poverty, you must purchase a Silver plan to be eligible for a second set of subsidies to offset co-payments and deductibles.  For anyone else, lower cost premiums will almost always translate into higher out-of-pocket costs.  Unfortunately, it is almost impossible to figure out what your total costs (including premiums and out-of-pocket costs) will be under any given plan, since that depends so much on what illnesses or injuries befall you in the next year.

http://wellbeefile.com/will-obamacare-offer-universal-health-coverage/

Medicare for all ensures excellent health care

By Michael Binder, M.D.
The Enquirer (Cincinnati), Letters, Jan. 22, 2014

Martin Luther King Jr. said, “Of all the forms of inequality, injustice in health care is the most shocking and inhuman.” Sadly, the problem of massive inequality in health care persists to the present day. I saw a patient in clinic in the past week who is going through personal financial bankruptcy due to overwhelming medical bills. This is someone who actually has health coverage, but it was not enough to prevent him from going into tens of thousands of dollars in debt.

The Affordable Care Act has many noble aims, but it is not the solution to our current health care crisis. A fix to our current crisis would take a commitment similar to the one made when Medicare was introduced in 1965. The introduction of Medicare was in many ways the opposite of the recent ACA rollout. Whereas simplicity is “baked in” to Medicare, complexity is “baked in” to the ACA. The website is one example of that complexity. A Medicare-for-all plan (also known as a single-payer plan) would ensure excellent health care for all Americans.

Dr. Michael Binder resides in downtown Cincinnati.

http://cincinnati.com/blogs/letters/2014/01/22/medicare-for-all-ensures-excellent-health-care/

Wyden’s S.1932 – “Better Care, Lower Cost Act”

The Better Care, Lower Cost Act

Senator Ron Wyden

January 15, 2014

Medicare is not doing enough to take care of chronically ill patients, and the limitations of the fee-for-service system inhibit a needed focus on these patients and their needs. This is critically important because most Medicare enrollees suffer from multiple chronic conditions and account for almost all of its costs.

Our Solution:

The Wyden-Isakson-Paulsen-Welch Better Care, Lower Cost Act removes the barriers that prevent Medicare providers from building on existing successful delivery models, and provides a framework for encouraging innovative chronic care delivery across the country. Specifically, the bill:

Provides Critical Support for Providers

To support providers and plans wanting to actively engage and care for this population, this proposal: does not include any form of the attribution rule, encourages specialized team-based care with rewards for improving patient’s outcomes, uses telemedicine and knowledge networks to increase access in rural areas, and includes vital case management services proven to increase medical compliance.

Focuses on the Unique Needs of Medicare Enrollees

To help transition Medicare from a program that simply treats sickness to one that promotes wellness, this proposal identifies the patients most in need and provides them with better care before becoming the most acutely and persistently ill. To improve standards of care for Medicare enrollees, the bill provides for changes to medical school curricula in order to better respond to the evolving needs of the chronically ill.

Ends Geographic Disparities in Integrated Care

This proposal creates incentives for higher quality, lower cost Medicare coverage nationwide that is open to Medicare beneficiaries regardless of income or place of residence. With a “Better Care Plan” (BCP) designation, a state-licensed and certified provider may practice at the top of his/her license, removing barriers to care that currently exist in parts of the country with provider shortages.

Pays for a Medicare Program Taxpayers Want and Beneficiaries Need

In response to the need to move away from fee-for-service, this proposal makes BCP providers and plans fully responsible for the cost, care and outcomes of their enrolled patients, and directs CMS to determine spending based on the experience of similar patients that are not enrolled in a BCP.

http://www.wyden.senate.gov/chroniccare

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Wyden Plan May Be Vision For Future Medicare Reforms

By Mary Agnes Carey

Kaiser Health News, January 21, 2014

Sen. Ron Wyden, the Oregon Democrat widely expected to be the next Senate Finance Committee chairman, last week led a bipartisan group of lawmakers, health care experts and seniors’ advocates backing a plan to better coordinate care given to Medicare beneficiaries.

The proposal is part of the ongoing health policy conversation over shifting Medicare away from paying per service provided to paying for the quality of that care.

Health insurers and providers who want to specialize in chronic care would receive a set amount of money to care for patients and would be responsible for the cost, care and outcomes of their enrolled patients.

It’s unclear what happens next. Elements of the bill may be included in legislation to repeal and replace Medicare’s “sustainable growth rate,” the formula used to pay Medicare physicians.  Maybe the legislation will be attached to another bill or pass on its own. Even if it goes nowhere, it may well be the pathway to Congress finding consensus on Medicare changes in the future.

Reader response: Don McCanne

Before you come to any conclusions, read the actual bill. Google “S.1932 – Better Care, Lower Cost Act”

From the Act: “The qualified BCP (Better Care Program) shall be accountable for the quality, cost, and overall care of enrolled BCP eligible individuals and agree to be at financial risk for that enrolled population.”

Much of the rest of the legislation involves efforts to define the nature of the Better Care Program provider teams, the patient populations, their risks, and how to establish capitation rates that will reduce spending while increasing quality. Such efforts would be administratively intensive and not very effective.

Primary care already plays a very important role in providing chronic care. Our efforts would be better directed to reinforcing the primary care infrastructure. Fragmenting Medicare’s risk and shifting it to the providers might be therapeutic for the federal budget, but it places the providers in conflict with their patients over who will come out ahead – the exact opposite of what we want in our health care system.

http://capsules.kaiserhealthnews.org/index.php/2014/01/wyden-plan-may-be-vision-of-future-medicare-reforms/#more-25372

Comment:

By Don McCanne, M.D.

S.1932, the Better Care, Lower Cost Act, is important since the concept is being considered as an offset to the cancellation of the accrued deficits related to the sustainable growth rate (SGR), which is a flawed formula for adjusting Medicare payments. Congress has given itself a three month window to enact an SGR fix. This is apt to slip through as attention is directed to celebrating SGR relief while ignoring the actual SGR fix.

The bill can be accessed at congress.gov. It is somewhat complex, which is not a surprise since it empirically segregates chronic care patients and then sets up an administratively complex “Medicare Better Care Program” that “promotes accountability and better care management for chronically ill patient populations and coordinates items and services under parts A, B, and D, while encouraging investment in infrastructure and redesigned care processes that result in high quality and efficient service delivery for the most vulnerable and costly populations.”

Although vague, the program seems to set up a variation of an accountable care organization, with bundling of services, while transferring financial risk to the providers so that they, in essence, also serve as the insurers. The wasteful administrative complexity and the perversity of the incentives alone should cause us to question this concept. As if caring for a patient with multiple chronic disorders wasn’t enough, we need yet additional government rules and bureaucratic oversight of an artificial chronic care construct that seems to be designed primarily to shift risk from the government to the providers?

We do need an improved Medicare that would serve all of us well as a single payer program, but this certainly isn’t it.

The Costs of a Trip to the Doctor

By Winthrop Dillaway, M.D.
The New York Times, Letters, Jan. 21, 2014

Re “Patients’ Costs Skyrocket; Specialists’ Incomes Soar” (“Paying Till It Hurts” series, front page, Jan. 19):

The American health care system fails irrefutably and unacceptably with its economics and its ethics. How is it acceptable that the other leading countries of the world provide universal health care at half the cost and generally with higher quality?

The increasing national recognition of single-payer (improved Medicare for all) offers a singular and simple solution to both the economics and the ethics of our health care system. Single payer is simple, economical and humane, and it is desperately needed in the United States.

The writer, a retired family medicine specialist, is New Jersey chapter president of Physicians for a National Health Program. He resides in Morristown, N.J.

Vt. Lawmakers Tap Consultant For Health Care Finance Review

By Peter Hirschfeld
Vermont Public Radio, Jan. 21, 2014

Vermont lawmakers are at a critical juncture in their quest for a publicly financed health care system. And they’re bringing aboard a $10,000-a-month consultant to help them get it right.

The Legislature already has a small staff of fiscal analysts to call on. But as lawmakers undertake the most ambitious health care reform agenda in state history, they’re spending some money on outside experts.

“When you’re talking about doing a $1.6 billion or $2 billion project or program, I think it’s appropriate to spend a couple hundred thousand dollars to look at whether we’re moving in the right direction,” said House Speaker Shap Smith.

Smith said the Legislature has some serious questions to answer before it can move ahead with single-payer.

The Shumlin Administration will use its considerable executive branch resources to design the governor’s single-payer proposal. But Smith said the Legislature has to do its own due diligence when it comes to figuring out how much the system will cost, and how taxpayers should pay for it.

So they’ve brought in a health care economist from Emory University to help them out. Ken Thorpe is no stranger to the Vermont Statehouse. Seven years ago, he helped the Legislature put together an insurance subsidy that would later become known as Catamount Health.

Thorpe is a national expert on health care policy, and he visited several legislative committees Tuesday to introduce himself and offer some initial thoughts on the work ahead. Thorpe said that if Vermont can’t reduce the chronic diseases responsible for skyrocketing health care costs, then financing reforms like single-payer aren’t going to solve the problem.

“So at the end of the day, no matter where you want to go in terms of cost containment, if we don’t have a statewide capacity to really prevent the growth in chronic disease and more effectively engage and manage chronically ill patients, the only other option you have for controlling costs is just by slashing payment rates,” Thorpe said.

With programs like the Blueprint for Health, Thorpe said that Vermont is already beginning to lower the enormous health care bills racked up by people suffering from conditions such as diabetes and high blood pressure.

Smith said he’ll be looking to Thorpe to determine whether Vermont’s current reform programs are reducing the rate of growth in health care spending fast enough. And if they aren’t, then Smith said lawmakers need to reassess whether single-payer is such a good idea.

“Everybody agrees that we want to make sure that we have quality health care, we’re doing things to bring down the rate of growth for costs,” Smith said. “And if we don’t have those two things, we don’t want to move forward with the single payer.”

Thorpe’s four-month contract will keep him in Montpelier through most of the 2014 legislative session.

http://digital.vpr.net/post/lawmakers-tap-consultant-health-care-finance-review

Supreme Court upholds government’s right to negotiate drug prices for all of us (2003 decision)

Remember the MaineRx

By Robert Kemp

Applied Health Economics and Health Policy, February 2014

Abstract

In 2000, Maine became the first state in the US to enact a law to establish maximum retail prices for prescription drugs for all qualified state residents—MaineRx. The purpose was to lower prescription drug prices for all eligible residents of the state. The state was to have the ability to negotiate manufacturer rebates and pharmacy discounts. Major drug manufacturers, represented by the Pharmaceutical Research and Manufacturers of America, challenged MaineRx in the courts, going to the Supreme Court where it was upheld in 2003. Fifteen other states enacted, proposed, or filed price-control bills in their state legislatures. The result would have been downward pressure on prices outside of the public programs, and the first instance of state-sponsored monopsony power in the US. MaineRx is viewed as one of the proximate causes of the pharmaceutical industry’s successful lobbying effort to implement Medicare Part D in 2004. Medicare Part D is administered through private Pharmacy Benefit Managers (PBMs); it made administration via state government PBMs illegal. The lower prices that could have resulted from MaineRx-type laws did not occur and the magnitude of these reductions is commented upon.

Conclusion

Politics play an important role in health policy. In this case, pharmaceutical companies, represented by the PhRMA, were able to influence Congress to introduce a national solution to the threat of state-run PBMs and the negotiation of positive lists. The companies were instrumental in formulating Medicare Part D and lobbying for its passage. It is speculated that Medicare Part D came about to put a stop to state rebate programs such as MaineRx in fear of reduced profits for the pharmaceutical companies. Thus, Medicare Part D terminated the existence of state-run PBMs. The historical importance of MaineRx is that it was an attempt of the state trying to contain healthcare cost and expand prescription coverage. Had MaineRx been implemented, it might have been a milestone on the path to reduced healthcare cost.

Robert Kemp, Ph.D. is Associate Professor, Clinical and Administrative Sciences, School of Pharmacy, The University of Louisiana at Monroe

http://link.springer.com/article/10.1007/s40258-013-0076-3

Comment:

By Don McCanne, M.D.

Government works for the benefit of the people, sometimes. The government of Maine almost brought under control our outrageous drug pricing in the United States. The Supreme Court even upheld Maine’s legislation that would do so. But then, with the conservatives in charge, Medicare Part D was enacted which prohibited Maine or any other state, or even the federal government itself, from using its monopsony power to demand fair pricing of drugs by the pharmaceutical firms. This time the government worked to the benefit of the plutocrats rather than the people. We have to change that.

Cancer, costs and single payer

Oncologists call for single payer in leading cancer journal

Physicians for a National Health Program, January 17, 2014

A feature article published today in the Journal of Oncology Practice contains an evidence-based appeal by two oncologists, including a past president of the American Society of Clinical Oncology (ASCO), for their colleagues to endorse a single-payer health system.

They say they do not believe that the Affordable Care Act, or “Obamacare,” will be able to solve the health care crisis that cancer patients face.

https://www.pnhp.org/news/2014/january/oncologists-call-for-single-payer-in-leading-cancer-journal

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Why Oncologists Should Support Single-Payer National Health Insurance

By Ray E. Drasga, MD and Lawrence H. Einhorn, MD

Journal of Oncology Practice, January 2014

Cancer leaves a patient in his or her most vulnerable state not only physically but financially. Oncologists are in a unique position to champion the cause of improving access to care for patients with cancer and easing the financial burden they and their families face.

With ACA now the law of the land, and its retention of the private insurance industry at the center of the health system, the trend toward high-deductible health plans, underinsurance, and cost shifting to patients will almost certainly worsen. 59 Years of private-sector solutions have failed. There needs to be a major paradigm shift in our approach to funding health care in the United States.

Because ACA will fail to remedy the problems of the uninsured, the underinsured, rising costs, and growing corporate control over caregiving, we cannot in good conscience stand by and remain silent. Life is short, especially for some patients with cancer; they need help now. We call on the American Society of Clinical Oncology (ASCO) to advocate for a single-payer national health insurance program. Our medical system must be oriented toward caregiving, not toward maximizing investors’ profits.

All of our patients deserve dignity. It is our moral and ethical obligation as physicians to advocate for universal access to health care. Oncologists, working in conjunction with ASCO, are well positioned to educate legislators about single-payer national health insurance. The time to start is now.

http://jop.ascopubs.org/content/10/1/7.extract

http://org.salsalabs.com/o/307/images/Drasga%20Einhorn%20authors%20proof-edited%20(1).pdf

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Patients’ Costs Skyrocket; Specialists’ Incomes Soar

By Elisabeth Rosenthal

The New York Times, January 18, 2014

Many specialists have become particularly adept at the business of medicine by becoming more entrepreneurial, protecting their turf through aggressive lobbying by their medical societies, and most of all, increasing revenues by offering new procedures — or doing more of lucrative ones.

That math explains why the incomes of dermatologists, gastroenterologists and oncologists rose 50 percent or more between 1995 and 2012, even when adjusted for inflation, while those for primary care physicians rose only 10 percent and lag far behind, since insurers pay far less for traditional doctoring tasks like listening for a heart murmur or prescribing the right antibiotic.

Oncologists benefit from the ability to mark up (and profit from) each dose of chemotherapy they administer in private offices, a practice increased dramatically in the late 1990s. The median compensation for oncologists nearly doubled from 1995 to 2004, to $350,000, according to the M.G.M.A. One study last year attributed 65 percent of the revenue in a typical oncology practice to such payments.

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New Truths That Only One Can See

By George Johnson

The New York Times, January 20, 2014

It has been jarring to learn in recent years that a reproducible result may actually be the rarest of birds. Replication, the ability of another lab to reproduce a finding, is the gold standard of science, reassurance that you have discovered something true. But that is getting harder all the time.

Fears that this is resulting in some questionable findings began to emerge in 2005, when Dr. John P. A. Ioannidis, a kind of meta-scientist who researches research, wrote a paper pointedly titled “Why Most Published Research Findings Are False.”

His work was just the beginning. Concern about the problem has reached the point that the journal Nature has assembled an archive, filled with reports and analyses, called Challenges in Irreproducible Research.

Among them is a paper in which C. Glenn Begley, who is chief scientific officer at TetraLogic Pharmaceuticals, described an experience he had while at Amgen, another drug company. He and his colleagues could not replicate 47 of 53 landmark papers about cancer. Some of the results could not be reproduced even with the help of the original scientists working in their own labs.

Given what is at stake, it seems like a moral failing that the titles of the papers were not revealed. That was forbidden, we’re told, by confidentiality agreements imposed by the labs.

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Drug development: Raise standards for preclinical cancer research

By C. Glenn Begley and Lee M. Ellis

Nature, March 28, 2012

What reasons underlie the publication of erroneous, selective or irreproducible data? The academic system and peer-review process tolerates and perhaps even inadvertently encourages such conduct. To obtain funding, a job, promotion or tenure, researchers need a strong publication record, often including a first-authored high-impact publication. Journal editors, reviewers and grant-review committees often look for a scientific finding that is simple, clear and complete — a ‘perfect’ story. It is therefore tempting for investigators to submit selected data sets for publication, or even to massage data to fit the underlying hypothesis.

Improving preclinical cancer research to the point at which it is reproducible and translatable to clinical-trial success will be an extraordinarily difficult challenge. However, it is important to remember that patients are at the centre of all these efforts. If we in the field forget this, it is easy to lose our sense of focus, transparency and urgency.

http://www.nature.com/nature/journal/v483/n7391/full/483531a.html

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Oncology Market Access

By Jill Sackman, D.V.M., Ph.D. & Michael Kuchenreuther, Ph.D

eyeforpharma

Confronted with unsustainable costs and inconsistent quality of patient outcomes, the U.S. healthcare segment has been embroiled in a national debate over healthcare reform. While nearly every division of the industry has come under fire because of high healthcare costs, one therapeutic area that has continued to win premium reimbursement is oncology. Historically, cancer drugs have enjoyed premium pricing and widespread off-label usage because of their designation for patients with generally incurable diseases. Furthermore, new drugs have been rapidly adopted despite weak clinical evidence and overall questionable value. Thus, it is not surprising that spending on these drugs in the U.S. has risen at twice the rate of total drug spending in recent years.

http://www.eyeforpharma.com/oncologyusa/numerof-whitepaper.php

Comment:

By Don McCanne, M.D.

Cancer has become outrageously expensive to manage. A major factor in the increased spending is the use of high-priced cancer drugs. The newest drugs are priced at about $10,000 per month – a level at which coinsurance payments by patients may not be affordable, if the drug is even covered by the patient’s plan.

What is particularly disconcerting is that the science behind these new drugs is particularly weak. We are paying a lot for drugs that often are not particularly effective and that frequently make people sick. Many of these drugs are introduced into the market after showing scant improvement but were approved because the nominal benefit reached the level of statistical significance. Factors determining the prices of these drugs include costs of research and marketing, like other drugs, but the firms also include “what is a life worth” adjustments – capitalizing on the grief of cancer patients and their families.

Of course there are therapeutic interventions in cancer that are very effective, sometimes curative. With today’s emphasis on outcomes, should the oncologists be paid very high fees for the successful outcomes while being paid little for futile therapy? Of course not. Their incomes should depend on their provision of professional services regardless of the prognosis of their patients.

The article in the Journal of Oncology Practice by Ray Drasga and Lawrence Einhorn explains the rationale of a single payer system – a rationale that should appeal to all oncologists who have faced the dilemma of being able to offer only very expensive drugs that provide unwarranted hope in a futile clinical situation, especially when the drugs may impose a major financial hardship on the patient.

Imagine a situation in which money is removed from that scenario, made possible by a single payer system. The patient does not have to consider out-of-pocket costs when discussing options with her physician. The physician receives the same income regardless of what clinical course the patient selects. Clinical decisions are made by the patient using the best information available, provided to her by her physician. Cost decisions are made by the public administrator, including negotiated pricing for cancer drugs, in an environment totally removed from the clinical scene.

Cancer can be a very cruel disease over which physicians frequently agonize, acutely aware of the physical and emotional pain of the patient. We really need a system in which all of our attention can be devoted to obtaining the very best care for the patient, totally removed from the “business” aspect of medicine. A well designed single payer system would do that.

The only way out

By Louis Balizet, M.D.
Health Policy Solutions (Denver), Jan. 9, 2014

The Affordable Care Act, while providing some short-term benefits, is, on the whole, unworkable. Quite apart from website failures, its approach to health care is fundamentally flawed. It is exceedingly complex. It perpetuates and entrenches the inefficient insurance model of payment for health care. It does nothing to address the rapacious pricing of pharmaceuticals. It ignores hospitals’ “medical arms race,” in which they expand facilities and services based not on community need, but on potential for profit. It still burdens doctors and hospitals with multiple payers, abstruse coding and insecurity about payment for delivered services. It is subject to state-by-state sabotage. At its most optimistic projection it leaves at least 25 million people uncovered.

Despite three years of preparation, the Affordable Care Act (ACA) is beset by delays, multiple exemptions and computer failures. The Obama Administration celebrates the enrollment of 2.1 million persons in private insurance through the exchanges.

The Centers for Medicare and Medicaid Services, meanwhile, has been cagey about how many of these 2.1 million have actually established a contractual arrangement with an insurance company. This has led to speculation that the number is quite small.

As recently as two months ago, the digital conduit that connects exchanges to insurance companies was described as “under construction.” Repeatedly postponed deadlines have insurance companies scrambling to send bills, register payment and validate coverage. With opening day now behind us, it is likely that hundreds of thousands will find themselves stranded at second base – exchanges negotiated, but insurance not issued.

Many of those who have secured coverage will discover that it is very thin coverage indeed, especially those with bronze plans. These plans approximate “junk insurance”: prohibitively high deductibles and co-pays combined with shrinking provider lists. Insurance companies that have elected to participate in the exchanges may find themselves in actuarial hot water and will raise premiums, further trim provider lists or fold altogether (especially the newly-formed co-ops). This year and especially 2015, may make October through December 2013 look like halcyon days.

The multiple failures of the ACA should come as no surprise to anyone familiar with its sordid political history. Sen. Ted Kennedy’s untimely death deprived the U.S. Senate of a powerful member who was at once its chief expert on health care policy and a decades-long advocate for universal health care. Health care leadership defaulted to Montana Sen. Max Baucus, ill-suited by inclination and background to fashion true reform.

Barack Obama acted less like a president and more like a community organizer as he failed to propose a coherent plan of his own. Into this policy breach stepped special interests, most prominently insurers and Big Pharma; any pretense of universal coverage and bona fide cost controls soon disappeared. What emerged was the euphemistically entitled the Patient Protection and Affordable Care Act, a Rube Goldberg contraption that befuddles experts to this day while richly rewarding those who got in on the ground floor.

What are the alternatives if the ACA craters? This is not a hard question to answer; examples of much better systems abound.

Virtually all other developed nations provide universal health care at two-thirds or less than our cost, with equal or better outcomes. The U.S. spends 17.7 percent of its GDP on health care, and its residents experience a life expectancy of 78.7 years. The corresponding values for France are 11.6 percent and 82.7 years, for Canada 11.2 percent and 81.0 years, and Australia 8.9 percent and 82.0 years.

What these and more than a dozen other countries with similar figures have in common is government-provided or facilitated universal health care, financed by a variety of taxes (income, payroll, sales) without reliance on American-style insurance companies. America should learn from these countries, not ignore or deride them.

The only way out of our currently costly and shameful health care quagmire is single-payer, tax-supported, improved Medicare for all. Medicare is a tax supported single-payer plan that has provided access to health care to tens of millions of Americans over 65 or with disabilities, with 3 percent overhead for close to 50 years. It would need to be altered, however, before universal application. Right now it is partially privatized, with Part B supplements, Part D drug coverage and Medicare Advantage. Involvement of private insurance companies makes it unnecessarily complex and unacceptably expensive. These concessions to private industry have to be eliminated and benefits expanded to include more complete outpatient care and drug coverage.

The statutory prohibition of system-wide government drug purchasing, embedded in George W. Bush’s Part D legislation, would have to be repealed. Medicare must be empowered to pay hospitals by an annual global budgeting process rather than the complex, costly piecemeal process currently in place. Doctors would have to be fairly compensated and not threatened annually with draconian cuts in income. For all the alterations that would be necessary, Medicare is still a far superior foundation on which to build a universal health care system, compared to the cacophony of hundreds of insurance companies we now contend with.

The flagrant failures of Obamacare, past and yet to come, would seem to argue against trusting the federal government to run a project with the scope of Medicare-based universal health care.

What is indisputable is that neither our government nor any other should attempt to implement a fatally flawed project. The U.S. military provides valuable lessons in this regard. When given an achievable goal and a sound strategy, it produces remarkable results (World Wars I and II). On the other hand, when it is asked to execute a flawed policy, disaster ensues (Vietnam, Iraq, Afghanistan).

No one can discredit the U.S. military on the basis of these failures; rather, blame is rightfully placed on the elected officials who asked the military to attempt the impossible. Likewise, our government should be reasonably expected to achieve what other governments have shown to be achievable – universal health care without breaking the bank. Obamacare’s failings should not blind us to this realization. In fact, there is no option other than improved Medicare for all. It is that, or fiscal and moral Armageddon.

Louis Balizet, M.D., is a recently retired oncologist from Pueblo. He’s a member of the advocacy group, Physicians for a National Health Program, and a leader of Health Care for All Colorado.

http://www.healthpolicysolutions.org/2014/01/09/opinion-the-only-way-out/

Maine lawmakers to consider single-payer health care system

Supporters of the bill want to adopt a government-run program, but a critic calls that unwise and expensive

By Joe Lawlor
Kennebec (Maine) Journal, Jan. 21, 2014

Jim Miller, president of WoodenBoat Publications in Brooklin, wants the decisions about how to provide health insurance for his employees taken out of his hands.

“I hate playing God,” he said. “Every spring I am forced into that position.”

Spring is when his company’s health insurance policies come up for renewal and he has to balance rising costs against being fair to his 30 employees.

Miller supports a legislative proposal for Maine to adopt a system that would replace employer-sponsored health insurance with a government-run program.

Starting in 2017, states can adopt such single-payer systems under the Affordable Care Act, using federal funding that now goes to states for programs such as the health insurance marketplace.

Maine’s bill will be discussed by a legislative committee Thursday in Augusta.

“The ACA is the first step toward a single-payer system,” said Rep. Charles Priest, D-Brunswick, the bill’s sponsor.

Priest concedes that it will be hard to get the bill passed this year, with opposition from Republican Gov. Paul LePage.

“Obviously, it’s a new concept for Maine,” Priest said. “I look at now as a time to educate people about single-payer.”

While there are many ways to create a single-payer system, a simple analogy is that Medicare would be expanded to everyone. Other countries, including Canada and the United Kingdom, operate single-payer health care systems.

Priest said details for the funding and operation of Maine’s single-payer system would be worked out later, if the bill became law. Vermont has already approved a single-payer system, but has not yet decided how to implement it.

Miller, at WoodenBoat Publications, said he would rather spend time on his core business – which includes publishing magazines, operating a mail order business and running a sailing school – than on health insurance paperwork. He was one of about 50 people who testified in favor of the bill before the Legislature’s Insurance and Financial Services Committee on Jan. 9.

But Rep. Joyce Fitzpatrick, R-Houlton, a member of the committee, said she doesn’t believe it’s a good idea. She said she doubts the system would save money, despite advocates’ claims that a streamlined system that de-emphasizes insurance companies would be more cost-efficient.

“We all know how much things cost when the government gets involved,” Fitzpatrick said.

Considering all of the work being done to get the Affordable Care Act working properly, she said, it would be unwise for Maine to switch gears and install a massive new system.

“I think there’s too much going on in health care to try to do something different,” Fitzpatrick said. “The ACA is the law of the land, so why would we try to re-create the wheel?”

In a single-payer system, insurance companies would be eliminated or greatly reduced. The Maine Medical Association, an advocacy group for physicians, has reservations about that.

“We support universal access to health care coverage,” said Gordon Smith, the association’s executive vice president. “We’re not prepared to throw the commercial insurance carriers, at this point, out the door.”

Representatives of the insurance industry testified against Priest’s bill, arguing that single-payer systems limit competition, and choice for consumers.

Smith noted that doctors are reimbursed at higher rates for patients with private insurance, making up for lower reimbursements for patients on Medicare or Medicaid. A new system would have to smooth out the discrepancies and ensure that doctors are paid fairly for their services, he said.

But Joe Lendvai of Maine AllCare, an advocacy group that supports a single-payer system, said he believes that businesses would flock to states with single-payer systems because they would no longer have to carry insurance for their workers.

“Imagine if small businesses, or any business, could be entirely focused on the products and services they provide, and not worrying about insurance,” he said.

Maine AllCare is poised to gather signatures to put the issue on the statewide ballot by 2017, if the Legislature doesn’t act by then.

A written statement from the governor’s office details why LePage believes single-payer is not the answer.

“A single-payer health care system will not fix the problem,” said Holly Lusk, senior policy adviser for LePage. “Making care free to people means they will use more of it. Using more care will accelerate cost growth even more.”

LePage’s opponents in this year’s race for governor, Democratic U.S. Rep. Mike Michaud and independent Eliot Cutler, were noncommittal in statements issued to the Portland Press Herald.

Michaud wrote, “I would be interested in exploring a single-payer system down the road, but right now the most important thing we can do is fully implement the Affordable Care Act by expanding access to health care to 70,000 eligible Mainers (by expanding Medicaid) and creating a state-run exchange.”

Cutler wrote that the “important issue is less who pays than what we pay for.”

“Truly universal access to preventive care is the key. We will decide with the Legislature whether the structure ought to be single- or multi-payer,” Cutler wrote. “We must focus on keeping people healthy, so that we are not just paying for costly procedures after people get sick.”

http://www.kjonline.com/politics/Maine_lawmakers_to_look_into_single-payer_health_care_.html