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Is the slowdown in health care spending good news?

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Is the slowdown in health care spending good news?

We still have a health-care spending problem

By Drew Altman and Larry Levitt
The Washington Post, April 21, 2013

For the past several months, analysts at the Kaiser Family Foundation and the Altarum Institute have been analyzing the recent slowdown in health spending. On average, health spending grew by 4.2 percent per year from 2008 to 2012, down from the recent peak of 8.8 percent from 2001 to 2003 and the lowest rate of growth in five decades. Our main conclusion is that most of this slowdown, 77 percent, has been due to years of a weak economy, which causes people to put off health services when they can and prompts employers and states to reduce health spending. The other 23 percent is explained by changes in the health system, including increased consumer cost-sharing, tighter managed care and modifications in payment and delivery (we can’t precisely pinpoint the separate effects of these three factors).

We need to be realistic about the fact that health spending will start going up more rapidly again as the economy improves. But how much costs escalate is at least in part within our control, and that matters a lot for federal and state budgets, employers and families. The place to start is by recognizing that the problem of health-care costs is far from solved.

Drew Altman is president and chief executive of the Kaiser Family Foundation, of which Larry Levitt is senior vice president.

http://www.washingtonpost.com/opinions/we-still-have-a-health-care-spending-problem/2013/04/21/2e105bbc-a854-11e2-8302-3c7e0ea97057_story.html

KFF Snapshot – Assessing the Effects of the Economy on the Recent Slowdown in Health Spending: http://www.kff.org/insurance/snapshot/chcm042213oth.cfm

Comment:

By Don McCanne, M.D.

We are now experiencing the slowest growth in health-care spending in the past half century. Though most agree that the weak economy slowed the rate of growth, many now claim that implementation of the Affordable Care Act is responsible for the protracted slowing while predicting that further implementation will finally bring excessive cost escalation under containment. What is really happening here?

Although the growth of spending – at 4.2 percent – is much lower than recent historical trends, it still represents excess growth since inflation has been flat and the growth of GDP has been very sluggish. Should we return to a more vibrant economy and more typical inflation rates, with no other changes, the rate of growth in health-care costs would be in the higher ranges that we no longer tolerate. So the good news in the slowing of health-care spending may not be such good news after all.

An important finding in this Kaiser Family Foundation report is that over three-fourths of the slowing has been due to the weak economy. We are not only facing a disappointing recovery, this factor in the slowing of health-care spending does not bode well for the future. If the economy recovers fully, high rates of spending increases will return. If, as some economists warn, we remain in a protracted stagnant economy with relatively high unemployment rates – a new “normal” for our economy – rates in the mid-single digits will still represent excess rates of increased health-care spending.

What about the other trends that have slowed spending? Of course, they are not as important as the vibrancy of the economy since they represent less than one-fourth of the slowing, but we can use any help. Or can we?

This study was not able to quantify the effect of the provisions of the Affordable Care Act in reducing spending. What is clear though is that much of the slowing not related to the economy has been due to the imposition of greater cost sharing, especially higher deductibles, and to the ratcheting up of managed care intrusions such as more restrictive provider lists and greater use of tiering of benefits. For containing costs, these are unwise policies because they create barriers that impair access to health-care services that patients should have. That is a terrible way to control spending.

So what hope is there? The policy community seems to be hanging its hat on accountable care organizations ACOs) and bundled payments. Think about what percentage of services delivered would be significantly altered by these tools. There should be very little change in the amount of appropriate care. Teasing out inappropriate care is difficult if for no other reason than there are few guidelines to determine what should be eliminated. Further, how much can you really pare off of the spending, when, even if bundled, most of the services would still have to be rendered? Are you really reducing spending, or just shifting the costs? Even if ACOs and bundled payments worked as intended, the amount of savings would be negligible when considering the magnitude of the problem.

Drew Altman and Larry Levitt write, “The place to start is by recognizing that the problem of health-care costs is far from solved.” If ever there was a time to pull out the drawer and look for proven policy solutions, that time is now. The single payer model is a proven model, and is just what we need. Without it, we can anticipate higher health-care spending and worse health-care access in an economy that is working well for the wealthy, but not very well for the rest of us.

Psychiatrists spend 1 million hours a year awaiting insurance approval, study says

By Amanda Woerner
Fox News, April 23, 2013

One million hours: That’s how long psychiatrists across the country spend each year, waiting to get approval from insurance companies before they’re able to hospitalize suicidal or mentally ill patients from the emergency room, according to estimates from a new study in the Annals of Emergency Medicine.

Unlike other doctors, psychiatrists are required to seek permission from a patient’s insurance company, before admitting anyone to the hospital from an emergency room.

“If we think logically about what it would be like if someone came into the ER with a life-threatening illness and they had to wait to get admitted – that would be ridiculous,” study author and child psychiatry fellow at Brown University, Dr. Amy Funkenstein told FoxNews.com. “Our patients have life-threatening illnesses too, and we need to not question whether they deserve the hospitalization.”

After determining a patient needs to be treated – often because he or she is suicidal, psychotic or even homicidal – psychiatrists must call the patients’ insurer and present their case as to why they believe hospitalization is necessary. They present initially to an administrator and then to a social worker. If the case is denied by the social worker, the psychiatrists must present their case to a doctor.

Approval is required for all insured patients – except those on Medicare.

Funkenstein became increasingly frustrated with the insurance approval process while completing her psychiatric residency, so she asked her colleagues to begin recording the amount of time they spent seeking insurance approval – as well as the total time their psychiatric patients spent waiting in the ER, over the course of three months.

The study, published April 23, showed the approval process takes on average, 38 minutes, and with approximately 1.6 million psychiatric admissions requiring approval every year, that translates into 1 million hours of a psychiatrist’s time, which Funkenstein described as “wasted.”

Funkenstein pointed out the process can often take much longer.

“I once had a child who boarded for three days in the ER because the social worker didn’t believe admission was appropriate, while I waited for a doctor from the insurance company to call me back,” Funkenstein said.

The study also revealed the median time psychiatric patients spent in the emergency room before being admitted was 8.5 hours.

Incidentally, Funkenstein noticed that despite all the time spent requesting authorization, only one in 53 cases were denied.

“You’re waiting for 40 minutes to present a five-minute case, and they always said, ‘OK.’ You’re wasting hours every night with no change in the (outcome),” Funkenstein said.

Funkenstein hopes her research will help grant psychiatrists the same freedom that other medical doctors have – to admit patients freely, based on their own clinical expertise.

“Ideally, we would have a similar system to what our medical colleagues have,” Funkenstein said. “We make a decision – (a patient) needs to be admitted, and we don’t have to call the insurance company.”

Funkenstein said she believes psychiatric disorders are often seen as less medically urgent because people don’t understand them. She also pointed out that people suffering from mental illness are often not able to demand better care.

“These are homeless individuals, veterans; this is this disenfranchised group,” Funkenstein said. “We’re stuck as a profession, and the only people to advocate for these patients are us.”

http://www.foxnews.com/health/2013/04/23/psychiatrists-spend-1-million-hours-year-awaiting-insurance-approval-study-says/

1 million hours may be spent annually for insurance approvals for inpatient psychiatric admissions

Psychiatrists spent on average 38 minutes on the telephone getting approval from insurance companies for psychiatric patients in need of inpatient care at the ED, according to a research letter published today in the Annals of Emergency Medicine

Psychiatric Annals, April 23, 2013

Approximately 1.6 million psychiatric patients with private insurance are admitted to the ED every year in the United States, which means that about 1 million hours are spent seeking authorization on their behalf.

During a 3-month period, Amy Funkenstein, MD, of Brown University, and colleagues collected data on 53 patients seeking inpatient psychiatric care at the Cambridge Health Alliance psychiatric ED in Cambridge, Mass. The researchers calculated how long the patients stayed in the ED before hospitalization and the length of time ED psychiatrists spent obtaining their insurance approvals. Patients’ diagnoses spanned the entire psychiatric spectrum, and the most common complaint was suicidal ideation.

In all but one case, authorization was granted to the patients. The average time between first contact with the insurance company until authorization for admission was granted or denied was 38 minutes. According to the researchers, half of the requests were resolved in less than 20 minutes, but for about 10% of patients, the approval process took 1 hour or more to complete. The longest wait for admission was 5 hours. The median time that patients spent in the ED was 8.5 hours; the shortest stay was 3 hours and the longest 20 hours.

According to study researcher J. Wesley Boyd, MD, PhD, of Harvard University, insurers use the authorization process as a deterrent to avoid paying for inpatient care.

“Insurers hope that clinicians will be so hassled by authorization procedures that they won’t seek admission for their patients, saving insurance companies money,” Boyd said in a press release. “Placing profits ahead of the health of patients when mental illness makes them vulnerable is immoral. A single-payer Medicare-for-all health care system would represent a great leap forward for patients and providers alike.”

The researchers noted that reimbursements for psychiatric care are lower compared with that of other health care services, and health care organizations frequently limit the number of psychiatric beds a hospital can have, which in turn increases the demand for mental health care.

“[T]he result is that our nation’s EDs are de facto psychiatric wards, with 79% of emergency physicians reporting that their hospitals board psychiatric patients for whom appropriate treatment resources could not be found, sometimes for days,” the researchers wrote. “The situation is so dire that EDs (are) now being designed and configured to house psychiatric patients awaiting placement.”

Disclosure:The researchers report no relevant financial disclosures.

Funkenstein A. Ann Emerg Med. 2013;doi: 10.1016/j.annemergmed.2012.10.033.

http://www.healio.com/psychiatry/practice-management/news/online/%7BBAEF6E1F-5DCB-4071-86AB-15A6ED917A09%7D/1-million-hours-may-be-spent-annually-for-insurance-approvals-for-inpatient-psychiatric-admissions

NHS: Section 75 of the health act is an engine for destruction

Section 75 of the health act is the mechanism that locks in privatisation of the health service: the Lords must amend it

By Kailash Chand 
The Guardian (U.K.), April 22, 2013

Andrew Lansley’s Health and Social Care Act, which came into effect on 1 April, had a troubled passage through parliament, including an unusual legislative “pause”. This was to allow the government time to “listen” to its many critics, including most healthcare professionals and a majority of the public, who believed the plans would create and lock in rights for private providers to make a profit from the NHS. Lansley gave assurances that these voices had been heard, and that clinical commissioning groups would be able to decide “when and how competition should be used”.

However, concerns about privatisation return to centre stage this week, when the regulations governing procurement and competition are debated in the Lords. As Lucy Reynolds, a research fellow at the London School of Hygiene and Tropical Medicine, puts it, if the act itself was the aircraft of privatisation, the structure that gave the idea the potential to fly, section 75 of the regulations is the engine that will allow take off.

The wording of section 75 requires commissioners to put out to tender everything that could be provided by an organisation other than the NHS. Private contractors are more likely to win these tenders than doctors, many of whom will never have even seen a tender notice. The regulations would create rights for commercial providers under rules originally devised by US corporations to promote their commercial interests. If implemented, they will drag the NHS into a competition law regime which creates obligations for governments to compensate private providers in the event of services being brought back into public provision.

The British Medical Association, along with many other health organisations including the Royal College of General Practitioners, are calling for the regulations to be withdrawn, as is the Labour party. The BMA says they must be replaced with new regulations that “unambiguously reflect previous government assurances that commissioners will not be forced to use competition when making their commissioning decisions”, and explicitly state this principle.

As contracts are lost by public sector bidders, the teams that would have delivered them will be made redundant because funds will not be available to pay them. Under the proposed regulations, the government is not permitted to rescue such a service unless all other competitors are equally subsidised, in the interests of non-discrimination.

The competitive tendering forced by the current draft of the regulations requires a large amount of administration, which will divert funds away from frontline care. Thanks to market-driven changes that have already taken place administrative costs have risen to at least 16%, in contrast to the pre-1980 figure of less than 5%.

These regulations will act as the motor of the NHS privatisation by giving companies a mechanism to force their way into NHS service provision for the patients, procedures and places wherever they see profits. The likes of Care UK or Virgin Care will try to cherry-pick easy and profitable services – diagnostics, routine elective surgery, and simple treatments, for example – leaving behind A&E, care of the elderly, mental health services and anything that is unpredictably expensive.

Seeking the withdrawal and replacement of these regulations is not scaremongering; there is plenty of evidence that market-driven health services lead to limited choice, escalating costs, and reduced quality. There is no evidence to support the idea that competition breeds excellence in healthcare. According to Robert Evans, professor of economics at the University of British Columbia, market innovations in the NHS over the last 40 years have led to greater inequity, increased inefficiency, cost inflation and higher levels of public dissatisfaction. It is time to reject the market ideology that has plagued the NHS for more than a quarter of a century, wasting billions of pounds in the process.

http://www.guardian.co.uk/commentisfree/2013/apr/22/section-75-health-act-destruction-engine

1 million hours of psychiatrist time wasted yearly on phone approvals for hospitalization

Harvard researchers find lengthy waits for severely ill psychiatric patients

FOR IMMEDIATE RELEASE
April 23, 2013

A study published today in Annals of Emergency Medicine reports lengthy waits for severely ill psychiatric patients in need of immediate hospitalization in the Boston area, due in part to time-consuming prior authorizations required by insurance companies.

Psychiatrists spent, on average, 38 minutes on the telephone getting authorization. In 10 percent of cases it took more than one hour to obtain insurance authorization; in one case authorization took five hours of psychiatrist time.

Mental health disorders are common, affecting nearly 1 in 4 adults annually, less than a third of whom receive psychiatric care. Better access to care might reduce the harms mental illness imposes on the mentally ill, their families and communities.

For the present study, over a three-month period, researchers tabulated how long psychiatric patients who were deemed in need of inpatient admission stayed in the emergency department (ED) prior to being hospitalized, and the amount of time that the ED psychiatrists spent obtaining authorization from the patient’s insurer. A group of 11 psychiatric residents at Cambridge Health Alliance (CHA) working in the psychiatric ED with acutely ill psychiatric patients collected the data.

Most patients required hospitalization because they were suicidal or, in a few cases, homicidal.

Although obtaining insurance authorization delayed care and took clinicians away from other duties, only 1 of the 53 requests for authorization was denied. Median total time in the ED was 8.5 hours, with the shortest stay lasting 3 hours and the longest recorded stay lasting 20 hours.

These numbers don’t include a handful of patients who boarded in the ED over the weekend while waiting for an inpatient bed to become available for them. They exclude uninsured patients and those with Medicare, which doesn’t require prior authorization.

With approximately 1.6 million psychiatric admissions among people with private insurance nationwide each year, 38 minutes of phone time to obtain authorization translates into about 1 million hours of wasted psychiatrist time.

Lead author Dr. Amy Funkenstein, a child psychiatry fellow at Brown University, led the study while she was a psychiatric resident at CHA and Harvard Medical School. She said: “Society pays for inadequate psychiatric care; more than half of all prison inmates and a third of all homeless people are mentally ill. Massachusetts is considered a model for health reform, yet we found that seriously ill patients routinely spent hours stranded in the ED due to insurance bureaucracy. The hours psychiatrists spend obtaining those authorizations could be far better spent treating our patients.”

Senior author Dr. J. Wesley Boyd, attending psychiatrist at CHA and assistant clinical professor of psychiatry at Harvard Medical School, commented: “Private insurers are obstructing care by requiring authorizations before a qualified psychiatrist can hospitalize a dangerously ill patient. With doctors, nurses and emergency departments already overburdened, adding a time consuming bureaucratic task that doesn’t help patients is unconscionable.

“Insurers hope that clinicians will be so hassled by authorization procedures that they won’t seek admission for their patients, saving insurance companies money,” he said. “Placing profits ahead of the health of patients when mental illness makes them vulnerable is immoral. A single-payer Medicare-for-all health care system would represent a great leap forward for patients and providers alike.”

*****

“Insurance Prior Authorization Approval Does Not Substantially Lengthen the Emergency Department Length of Stay for Patients with Psychiatric Conditions,” Amy Funkenstein, M.D., Monica Malowney, B.A., and J. Wesley Boyd, M.D., Ph.D. Annals of Emergency Medicine, April 23, 2013.

The doi for this article is 10.1016/j.annemergmed.2012.10.033.

A copy of the manuscript of the study, which takes the form of a clinical observations research letter, is available here.

*****

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization of more than 18,000 doctors who advocate for single-payer national health insurance, an improved Medicare for all. PNHP had no role in funding or otherwise supporting the study described above. To speak with a physician/spokesperson in your area, visit www.pnhp.org/stateactions or call (312) 782-6006.

Businessman Allan Tweddle responds to Uwe Reinhardt on "one size fits all"

Allan Tweddle responds to Uwe Reinhardt on "one size fits all"

(Quote of the Day for April 16, 2013 https://pnhp.org/news/2013/april/uwe-reinhardt-on-one-size-fits-all):

I am no expert, just a Canadian born US Citizen with family still north of the border.  I have seen the personal value of their system many, many times.  From horrific cancer in children, to heart and cancer in elderly, to total hip replacements, all covered at zero expense to the citizen patient.
 
And even that needs clarification.  In the Canadian Immigration web page, once a person is accepted by their immigration department, a new arrival into Canada will get full coverage within 3 months after arrival.  That is remarkable, considering that that person has not yet contributed one dime to the system.
 
Their system, like in Britain, provides basic health care for all and lets the private insurers pick up the tab for luxury items like fancy hospital suites, Viagra, etc.
 
The Canadian system is controlled, designed and managed by each province.  It has Federal dollars in each plan, so while their experience is NOT “One size fits all”, they have made it work for 30 years or more.  Did we make any attempt to study their success and learn from their mistakes?  I doubt it.
 
However, there are only 10 provinces.
 
Our ACA plan that tries to take into consideration 50 States does look far too complicated. I’ve been in briefings for the West Virginia plan alone, and it’s too complicated.  We need to just lower the eligibility age of Medicare to age zero less 9 months!
 
We need a single payer for the basics so we eliminate bankruptcy due to unexpected and financially catastrophic health care costs to individuals.  It is my understanding that in the U.S., medical debt contributes to 62% of all bankruptcies. In Canada that number is ZERO!
 
Shouldn’t we be protecting the citizens and not the greed-driven insurance industry?

****

Our emerging manufacturing company has been considering a location for our production operations.  We have concluded, like so many automobile companies* have, that Southern Ontario would be financially attractive due, among other reasons, to the differential in payroll burden.  Aerospace payroll burden here is about 36%, whereas it is 15 to 18% in Ontario.  That’s a significant differential…20%!  And from everything we have been able to determine, the difference is health care expense. (*Did you know that the expense of health care is almost always cited as a primary reason for the announcement of new plants in Ontario, so that now more cars are made and assembled in Ontario than Michigan?)
 
The financial/economic value of a universal single payer system is obvious to us.  And when you learn that the system they have there has better health results, then the choice becomes clear.  And if any right-wing free enterprise enthusiast who has an open mind would pay attention to the sheer economic advantages, they would join us on a bandwagon to get it here.
 
But we cannot wait for that to happen, so we will in all probability be locating there.

Allan Tweddle, of Charleston, West Virginia, is Chairman and CEO of an aerospace manufacturing firm. His email address: allantweddle@msn.com

Comment:

By Don McCanne, M.D.

We should listen to this Canadian-born, U.S. businessman who is very familiar with the health-care systems and the business climates in both the United States and Canada. The lure of Canada’s health-care system may be too great for his company to establish production operations here in the United States. That should awaken us all, especially the business community.

Much less important, a comment on “one size fits all” is warranted. That phrase has been used endless times to dismiss single payer reform. Used this way, it implies that there are many “sizes” in health care. In reality, when you need health care, you aren’t checking out “sizes.” You merely want unrestricted access to the health care delivery system that we have.

The “sizes” they speak of usually refer to different insurance products, ranging from almost worthless mini-med plans to comprehensive, integrated HMOs. (For purposes this discussion, integrated health care delivery systems such as Kaiser and Group Health are considered components of our health care delivery system rather than as intermediary insurers.)

When individuals select their own insurance plans, which do they choose most often? They select high-deductible, preferred provider organizations. That is, they select a “size” that works if they stay healthy. Should they develop significant health problems, that particular “size” will prevent them from being able to have free choice of their health care professionals and institutions, and it will leave them with out-of-pocket financial burdens – neither of which is the “size” that they really wanted, especially when they find out too late that it didn’t fit.

Mr. Tweddle points out that Canada’s single payer system is not “one size fits all” since it is separately administered in each of their ten provinces. But, refocusing, the Canada Health Act does pull all of the provinces together into one “size” that is universal, comprehensive, accessible, portable, and publicly administered. Quite clearly, this is not a “size” that is inflexible to varying needs, but rather it is a comprehensive program that fits all.

When you shop for health insurance, it is important to keep in mind that all of the private insurance choices are the wrong size, to varying degrees. The only right size out there is the health care delivery system which can be readily accessed by getting all of the wrong-sized insurers out of the way, except for the one right-sized program that really does fit everyone – a single payer national health program, or improved Medicare for all.

Single-payer plan is best health care solution

By Thomas P. Clairmont, M.D.
Portsmouth (N.H.) Herald, Letters, April 20, 2013

The Chidester (op-ed) correctly identifies the problems in health care today: uncontrolled costs and the rising number of uninsured.

He advocates for a simple solution, but fails to deliver one.

His numbers are absolutely wrong. A review of the Census Bureau Web site clearly states that the uninsured number for 2010 was 49,904,000. His number is one-sixth of that. However, it doesn’t really matter. At Physicians for a National Health Program, we feel that one uninsured person is too many. This is reflected in our motto: Everybody In, Nobody Out.

He then advocates for free markets as the solution, comparing buying health insurance to purchasing cell phones and computers. Free markets have been around for a long time, giving us premium increases multiple times inflation for the past decade. Just this week, the Herald reported the York School Department is facing a 13 percent increase in health care premiums. Health care inflation for 2012 was only 3.7 percent.

Free markets don’t work in health care. Every business wants more customers. In health insurance, however, that isn’t true. They only want the healthy, who won’t hurt their bottom line of excessive profits, inordinate executive compensation and returns to stockholders.

Chidester then says he wants a simple solution. OK, so does everyone else. Let’s look at the Vermont Plan, authored by Harvard economics Professor William Hsiao. He outlined four goals:

(1) Universal health insurance coverage; (2) provision to every Vermont resident of an adequate standard benefits package and equal access to health care; (3) control of the rapidly escalating costs of health care in Vermont; and (4) establishment of a system that prioritizes community-based preventive and primary care, as well as integrated health care delivery.

He accomplishes this with a single-payer plan that dramatically reduces administrative expenses. In fact, his plan will immediately reduce health care costs in Vermont by 8-12 percent and reduce health care costs by an additional 12-14 percent over time. Keep in mind that every resident is covered and they won’t have to decide which policy they want, with what combination of co-payments, deductibles and other out-of-pocket costs that are a deterrent to good health. Now that is a simple plan. Do you want the Chidester plan or complete health care security for you and your family?

Dr. Thomas P. Clairmont resides in Portsmouth, N.H.

http://www.seacoastonline.com/articles/20130420-OPINION-304200304

Hawaii should end Medicaid managed-care model

By Stephen Kemble, M.D.
Honolulu Star-Advertiser, April 21, 2013

Hawaii was recently awarded a $937,691 State Innovation Model grant to plan health care reform for Medicare and Medicaid.

However, no reforms can be effective without good physician participation and good access to care for patients, and we have serious problems with both in our Medicaid managed care program. If we don’t fix these problems, Hawaii will waste almost a million dollars and several years on ineffective reforms.

Hawaii converted our state-run, fee-for-service Medicaid program to managed care via competing private plans, in stages, in 1994 and 2009. This conversion has demonstrably increased the cost of the Medicaid program while reducing patient access to care and quality of care.

Hawaii’s Medicaid costs have been rising around 3 percent faster than the national average since Medicaid managed care was introduced here in the mid-1990s, according to Kaiser Family Foundation State Health Facts. Regardless of what the managed care companies will tell the state, privatization of Medicaid has led to increased cost and declining access and quality of care wherever it has been studied.

The managed-care model relies on restriction and denial of care. Escalating administrative burdens imposed by managed care plans are literally driving doctors out of treating Medicaid patients, and it has become almost impossible to find a private-sector doctor who will accept new Medicaid patients. Access to outpatient care is getting worse, undoubtedly leading to increased preventable hospitalizations.

Competing managed-care plans add substantially higher administrative costs, much of which are misleadingly counted as “health care” for reporting purposes, adding to the total cost that the state must pay for Medicaid.

Failures in care coordination are largely due to fragmentation of Medicaid and excessive managed-care restrictions. Each plan has its own restricted network of doctors and its own formulary and prior authorization policies. This means increased administrative hassles for doctors, fragmentation of the data needed for health information technology and care coordination, declining physician participation, and disruption in care when patients switch plans.

The Medicaid managed-care plans talk about “integrated, coordinated care,” but in practice this is true only for Kaiser, where Medicaid patients have the same access to care as any other Kaiser member, and to some degree for HMSA, which has better acceptance among doctors than the other Medicaid plans.

Payment and delivery system reforms cannot be effective without access to cost-effective care. There is nothing in the governor’s Health Transformation Initiative that addresses the reasons doctors are refusing Medicaid patients. The managed-care policies that obstruct and deter care and associated administrative hassles for doctors are being left in place. Doctors may complain about low fees, but that is not the reason they have been fleeing Medicaid. Medicaid fees relative to commercial rates have not changed significantly in the past 20-30 years, but physician acceptance of Medicaid patients declined only after Medicaid was broken into competing private plans.

The state actually ran Medicaid much more cost-effectively than the private plans do now, but a consolidated Medicaid program could use a single third-party administrator to run the program in lieu of re-creating the administrative structures that were in place before conversion to Medicaid managed care.

Hawaii could markedly reduce Medicaid administrative costs while increasing physician participation and access to care simply by terminating our Medicaid managed-care program when the contracts expire at the end of this year, and go back to fee-for-service Medicaid. Then we could add care coordination programs funded with the State Innovation Model planning grant, including patient-centered medical homes and community care teams, and see if they help improve the cost-effectiveness of care.

Dr. Stephen Kemble is president of the Hawaii Medical Association; he also serves on the Hawaii Health Authority and was on the executive committee of the Hawaii Health Project.

Labor council, plumbers local in Alabama endorse H.R. 676

Actions bring total labor organization endorsements to 600 nationwide

By Kay Tillow

On April 15, the Northeast Alabama Labor Council in Gadsden endorsed H.R. 676, national single-payer health care legislation sponsored by Congressman John Conyers.

President Garry “Gabby” Frost brought the resolution before the council in response to an appeal from the All Unions Committee for Single Payer Health Care – H.R. 676 and from Pippa Abston, M.D., Ph.D., a board member of Physicians for a National Health Program and a Huntsville, Ala., pediatrician.

“Health care is a necessity not a privilege,” said President Frost after the adoption of the resolution for H.R. 676. “Everybody’s got to have it. This is the only industrialized nation that does not have it.”

The Northeast Alabama Labor Council is the 145th Central Labor Council to endorse H.R. 676. The council represents workers in nine counties: Calhoun, Chambers, Cherokee, Cleburne, DeKalb, Etowah, Marshall, Randolph, and St. Clair. The Southwest Alabama Labor Council in Mobile and the Alabama State AFL-CIO had previously endorsed H.R. 676.

President Frost, who is the business manager of Local 498, United Association of Plumbers and Pipefitters, reports that Local 498 has also endorsed H.R. 676. That brings the total of union organizations that have endorsed H.R. 676 to 600.

Dr. Pippa Abston commented on the importance of these union endorsements of H.R. 676. She said, “As an Alabama physician and Physicians for a National Health Program board member, I am thrilled to hear this news! Medicare for All is an achievable, practical way to address our health care needs and would go a long way towards relieving our state’s constant budget struggles. Thank you to our friends in Labor for helping bring H.R. 676 a step closer to success.”

****

H.R. 676, the Expanded and Improved Medicare for All Act, would institute a single-payer health care system by expanding a greatly improved Medicare to everyone residing in the U.S.

H.R. 676 would cover every person for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental (including oral surgery, periodontics, endodontics), mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care and correction, hearing services including hearing aids, chiropractic, durable medical equipment, palliative care, podiatric care, and long-term care.

H.R. 676 ends deductibles and co-payments. H.R. 676 would save hundreds of billions annually by eliminating the high overhead and profits of the private health insurance industry and HMOs.

In the current Congress, H.R. 676 has 41 co-sponsors in addition to Conyers.

H.R. 676 has been endorsed by 600 union organizations including 145 Central Labor Councils/Area Labor Federations and 41 state AFL-CIO’s (KY, PA, CT, OH, DE, ND, WA, SC, WY, VT, FL, WI, WV, SD, NC, MO, MN, ME, AR, MD-DC, TX, IA, AZ, TN, OR, GA, OK, KS, CO, IN, AL, CA, AK, MI, MT, NE, NJ, NY, NV, MA & RI).

For further information, a list of union endorsers, or a sample endorsement resolution, contact:

Kay Tillow, All Unions Committee for Single Payer Health Care—H.R. 676, c/o Nurses Professional Organization (NPO), 1169 Eastern Parkway, Suite 2218, Louisville KY 40217. Phone: (502) 636 1551; e-mail: nursenpo@aol.com; website: http://unionsforsinglepayer.org

Hospital Head Warns of Racism in U.S. Health Care System

By Jeffrey Hess
Mississippi Public Broadcasting News, April 19, 2013

JACKSON, Miss. — The head of a major U.S. hospital is warning that the health care industry in the U.S. is ignoring embedded racism.
 
Dr. Claudia Fegan is the chief medical officer of a major Chicago hospital.  She talks about what she views as a major problem in the current health care system.
 
“The reality is, in the delivery of health care in this country racism still plays an important role,” says Fegan.
 
She says evidence shows that minority patients have worse health care outcomes in most situations, a disparity that transcends class and education level.
 
“Black women with college degrees whose birth do not have as good an outcome as white women who do not have a high school diploma. It is not as simple as socio-economic status or the notion that you can earn or educate yourself out of these problems,” continues Fegan.
 
For example, In Mississippi black babies are twice as likely to die as infants compared to white babies.
 
Fegan says doctors and patients often have very different perceptions of the quality of a doctor’s visit, which she says contributes to doctors not understanding how race impacts health care.
 
She says doctors and hospitals need to do more to recognize the cultural differences and acknowledge the worse outcomes to begin fixing the issue.

http://mpbonline.org/News/article/hospital_head_warns_of_racism_in_u.s._healthcare_system

Uwe Reinhardt on "one size fits all"

Author Interview

JAMA, April 16, 2013

Uwe E. Reinhardt, PhD, economics professor at Princeton:  On this point, I’m very disappointed that we Americans couldn’t even get the exchanges right. As Atul said, an exchange is really just like the personnel benefit department at General Motors. It’s just an electronic market to buy health insurance. I could show you the Swiss or the German exchanges. We have now made a horrendous mess of these exchanges. It cost close to a billion dollars to implement the California exchange, and heaven knows what’s happening in the other states. I was thinking if this generation of Americans had to plan the Normandy invasion, I think they would never have gotten there, or by the time they got there, the Russians would have been there. It is just unbelievable what an administrative nightmare the Affordable Care Act has become. Americans always tell me – I’m just an immigrant trying to learn about this country – they always tell me, oh, one size doesn’t fit all. Well, tell that to McDonald’s or to the Holiday Inn. In fact, Americans invented the idea that one size fits all, and built great industries on it – the auto companies, the food services, the hotels, the department stores – they’re all one size fits all.

Ed Livingston, deputy editor of JAMA:  You mentioned that companies like McDonald’s and Holiday Inn have been very successful in building large industries with uniformities, but those are private industries. Is the problem that when the government tries to take on something this complex they just can’t seem to get it done?

Uwe Reinhardt:  Well, it’s for the reason that Atul mentioned, that somehow we give enormous respect to regional variations, and, because we do, we make everything enormously complex. Imagine if you ran the U.S. Army that way. Soldiers from every state could pick their own rifles, and so on and so forth. Sometimes you have to do national things. I recently wrote a Health Affairs piece and said, every American is a dual citizen. He has citizenship in the state that they live in and citizens in America. And it really depends when you draft federal legislation, which citizenship do you make supreme. Typically you find Democrats put American citizenship up on top. The idea being that a baby in Mississippi should have the same rights to access to health care as a baby in Massachusetts, because they are both Americans. I think more on the Republican side they would say, no, what happens to a Mississippi baby is up to the people down there, and you can do what you want to a Massachusetts baby up there in Massachusetts. Now, that’s a different conception, neither right or wrong, but I’m saying on some issues we really, in my view, should have national policies because it would be much more easy to administer. After all, that’s what we said in Medicare. We said no matter where the elderly live, they should have the same deal in health care, and we created Medicare. Has Medicare been that much of a disaster?

Audio (April 16,2013): http://jama.jamanetwork.com/multimedia.aspx#AuthorInterviews

Comment:

By Don McCanne, M.D.

Hmmm.

“It is just unbelievable what an administrative nightmare the Affordable Care Act has become.”

“…they always tell me, oh, one size doesn’t fit all. Well, tell that to McDonald’s or to the Holiday Inn.”

“…but I’m saying on some issues we really, in my view, should have national policies because it would be much more easy to administer.”

“We said no matter where the elderly live, they should have the same deal in health care, and we created Medicare. Has Medicare been that much of a disaster?”

So can we draw the conclusion that we should adopt the administrative simplicity of a national, one-size-fits-all Medicare that gives everyone the same deal in health care? Seems like a really good idea.

Upstate New York Greece

By Andrew D. Coates, MD, FACP
WAMC Northeast Public Radio, April 19, 2013

I live in upstate New York. If you’re hearing this, chances are you do too.

One of my great friends at the university once casually remarked that it seemed the whole world came through our community. “Look deeply enough into anyone’s family history and you will find a connection,” she said. “Some part of everyone has been here one way or another.”

Her consciousness about the connectedness of one community to the whole world reminded me of a fragment by Franz Kafka:

“You do not need to leave your room. Remain sitting at your table and listen. Do not even listen, simply wait, be quiet, still and solitary. The world will freely offer itself to you to be unmasked, it has no choice, it will roll in ecstasy at your feet.”

When the world is busy rolling up at our feet it reveals that upstate New York, like anywhere, has its own distinct and proud culture. From it, our own William Kennedy, Richard Russo, Lauren Groff and many others have spun great literature. Just think, for example, of the extraordinary catalogue of people who have come through Yaddo or Caffe Lena, both in Saratoga, or Bard College, just down the Hudson, and all that these people have shown us, collectively, about life and our world.

In other words, knowing one’s community well can be, as my friend was pointing out, a way to understand the whole world.

We physicians have earned great scientific insight into health and illness in our patients. But we also gain great human insight — how the conditions of everyday life impact the fate of our patients. Ultimately an understanding the culture and the economy of our community is inescapable if we are to serve our patients and our profession. This leads to a sense of connectedness with the whole world.

Lately I’ve been struggling to overcome a sense of shock as I learn about the living conditions and the daily life distress faced by my patients.

I feel a bit like Rip Van Winkle, for after several years away from hospital medicine I returned to full time. In the hospital an entire slice of life, a cross section of all cultures and classes and ages, streams into the building, for we all face a risk of acute medical illness. It has opened my eyes.

The ravages of drug addiction — how it can tear families asunder; the weight of a serious illness upon a spouse — how people forfeit their homes and their jobs because of a family health crisis; how temporary and part-time jobs, always with no sick time, force the postponement of necessary medical care, not only for the person with the difficult job, but for their children, their parents, anyone who depends upon them. These issues arise again and again and in the most personal way. Things have gotten worse in our community over recent decades — and I am a frontline witness.

To illustrate our connectedness to the world, a study published this week in the American Journal of Public Health looked at the adverse health consequences of the economic recession and subsequent austerity measures in Greece over recent years. The team of Greek and American researchers found, for example, that between 2007 and 2009, suicide rates among men rose 22.7 percent.  Homicide mortality rates among men increased by 27.6 percent.

Mental disorders, substance abuse, and infectious diseases showed worsening trends. In turn, the government cut public health spending dramatically.

In short, government austerity is bad for our health.

Meanwhile UNICEF published a study of child well-being in the 29 wealthiest nations. My friend Dr. Don McCanne pointed out that out of 29 nations, Greece was ranked number 25. The United States was behind Greece at 26.

As I read these studies the tears and sobs of my patients and their loved ones leapt to mind. The human stress of illness in the context of difficult economic times has been worsened by austerity here, just like Greece.

The same schemes of privatization, deregulation and cuts to public programs that have happened in Greece can be found in every community in upstate New York.

The people who make the decisions don’t seem to understand the human consequences of austerity policies on top of the difficult economy.  But for those of us who know and love our home communities and our local culture — whether upstate New York or Greece or anywhere — the tragic health effects tear a hole in our hearts and our future.

Andrew D. Coates, M.D., F.A.C.P., practices internal medicine in upstate New York. He is president of Physicians for a National Health Program.

You can listen to Dr. Coates’ radio broadcast, which was titled “The Human Consequences of Austerity” by WAMC, here:
http://www.wamc.org/post/andrew-coates-human-consequences-austerity