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Senate Panel Diagnoses Primary Health Care Crisis

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Senate Panel Diagnoses Primary Health Care Crisis

News release from the office of Sen. Bernie Sanders
CommonDreams.org, Jan. 29, 2013

WASHINGTON — A Senate panel today examined a “major crisis” in primary health care at a time when 30 million more patients will soon get health insurance under the Affordable Care Act and worsen an already acute doctor shortage.

One in five Americans today live in areas where they do not have adequate access to primary care due to a shortage of providers, according to Sen. Bernie Sanders (I-Vt.), the chairman of the Senate Primary Care and Aging Subcommittee.

“In our country today we are spending almost twice as much per capita on health care as any other major country yet our health outcomes in terms of life expectancy, infant mortality and disease prevention are not particularly good,” Sanders said. “One of the reasons for that is that we have a major crisis regarding primary health care access which results in lower quality health care for our people and greater expenditures.”

According to a report released at the hearing, as many as 45,000 people die each year because they do not have health insurance and do not get to a doctor on time. A significant reason for the lack of access to care is that less than one-third of all doctors in America today practice primary care, down for half of all physicians 50 years ago. The problem is likely to get worse because many primary care doctors are nearing retirement and fewer and fewer medical students are interested in becoming family practitioners.

Dr. Claudia M. Fegan, the chief medical officer at Cook County Hospital in Chicago, told the subcommittee she sees evidence every day of patients without primary doctors. “Every single day, people without a physician line up across the street from our hospital to be seen in our walk-in clinic … They hope to be one of the lucky ones who will be given a physician of their very own, who will get to know them and take care of them and be available when they have a problem or question, someone to help them meet their medical needs, someone to help them navigate our complicated health care system to get what they need.”

Another witness, Princeton economist Uwe E. Reinhardt, said Medicare and Medicaid payments should be realigned to address the acute shortage of primary care physicians.

Tess Kuenning, executive director of the Montpelier, Vt.-based Bi-State Primary Care Association, testified that community health centers could provide affordable care for more patients. The 2010 health care law included a Sanders provision that authorized $11 billion to double the number of patients cared for at health centers. Funds needed to reach that goal, however, have not been committed.

In Vermont, Kuenning said, more than 110,000 patients receive care at one of eight community health centers throughout the state. With additional funding, she added, three more communities “are fully poised to apply for competitive federal funding to bring medical, dental and behavioral health services to communities in need.”

https://www.commondreams.org/newswire/2013/01/29-2

See also Dr. Don McCanne’s Quote of the Day on the hearing, which includes links to all the witness statements, video, and more:
https://pnhp.org/blog/2013/01/29/senate-help-hearing-on-primary-care/

Senate HELP hearing on primary care

30 Million New Patients and 11 Months to Go: Who Will Provide Their Primary Care?

Subcommittee Hearing, Committee on Health, Education, Labor and Pensions
United States Senate, January 29, 2013

Primary Care Access 
A Report from Chairman Bernard Sanders

Conclusion
 
The primary health care system in America and its workforce is in significant need of a checkup. As the population grows and ages, as more doctors retire, and as the primary care pipeline dries up, we face a severe shortage of providers. The result is that millions of Americans are not getting the care that they need now and the situation may only get worse. Although the ACA took important steps towards expanding access points by increasing funding for community health centers and the National Health Service Corps, for example, the tremendous scope of the problem requires further attention and action. Just like an illness from which it will be more difficult and costly to recover from the longer we wait, we must take steps now to address the primary care access crisis in America.

http://www.sanders.senate.gov/imo/media/doc/PrimaryCareAccessReport.pdf

Video of the hearing (2 hours):
http://www.help.senate.gov//hearings/hearing/?id=dc487385-5056-a032-522c-082a29c4a406

Written testimonies of the witnesses:

Fitzhugh Mullan, MD , Murdock Head Professor of Medicine and Health Policy at the George Washington University School of Public Health and Professor of Pediatrics at the George Washington University School of Medicine, Washington, DC:
http://www.help.senate.gov/imo/media/doc/Mullan1.pdf

Tess Stack Kuenning, CNS, MS, RN , Executive Director, Bi-State Primary Care Association, Montpelier, VT:
http://www.help.senate.gov/imo/media/doc/Kuenning.pdf

Toni Decklever, MA, RN , Government Affairs, Wyoming Nurses Association, Cheyenne, WY:
http://www.help.senate.gov/imo/media/doc/Decklever.pdf

Andrew Wilper, MD, MPH , Acting Chief of Medicine, VA Medical Center, Boise, ID:
http://www.help.senate.gov/imo/media/doc/Wilper.pdf

Uwe Reinhardt, PhD , James Madison Professor of Political Economy and Professor of Economics and Public Affairs, Princeton University, Princeton, NJ:
http://www.help.senate.gov/imo/media/doc/Reinhardt.pdf

Claudia Fegan, MD , Chief Medical Officer, John H. Stroger Jr. Hospital of Cook County, Chicago, IL:
http://www.help.senate.gov/imo/media/doc/Fegan.pdf

Comment:

By Don McCanne, M.D.

We have a crisis in primary care. Unless we improve and expand our primary care infrastructure, we will become more dependent on the alternatives: overuse of emergency departments, fragmented care in walk-in clinics, traveling large distances from rural communities devoid of primary care, excessive use of direct access to specialized services limited to those who can afford it, and, worst of all, limited or no health care access for those who are uninsured and cannot afford it.

Today’s hearing of the Senate HELP Committee is important because it brings attention to the seriousness of this problem, demonstrating that action is an imperative. Although, as you read this, you do not have time to watch a 2 hour video nor read a half dozen testimonies, links are provided so that you can access these resources later – perhaps during the weekend when many of you have more time. If not, these links can be saved for later reference.

Although this session was focused on primary care, a couple of comments from the testimony of Claudia Fegan are apropos because of the larger needs in health care. Claudia is not only Chief Medical Officer of Cook County Hospital, she is also a former President of Physicians for a National Health Program. She understands that primary care would function much better if we had comprehensive health care reform.

As she states, “If we would enact a single-payer national health program, where everyone was entitled to health care as a right, we could focus on delivering to our patients the best care in the world and relieve our physicians of the administrative hassles…”

And her plea to the members of the Senate HELP Committee, “I urge you to work to make a difference, not for me or you, but for the patients I have the privilege of serving, who desperately need their elected officials to care about what happens to them.”

And isn’t her advocacy truly representative of the essence of primary care?

PNHP note: One of our members, Dr. Deborah Schumann of Washington, D.C., attended the hearing. Here are her notes and observations from the hearing room.

Notes from the Senate hearing room

By Deborah Schumann, M.D.

Senator Bernie Sanders (I-Vt) chaired the standing-room-only subcommittee hearing, which drew an audience of around 100 people. Sen. Mike Enzi (R-Wy.) co-chaired the meeting, which was attended by seven more senators: Elizabeth Warren (D-Mass.), Tammy Baldwin (D-Wis.), Al Franken (D-Minn.), Chris Murphy (D-Conn.), Bob Casey (D-Pa.), Kay Hagan (D-N.C.) and Sheldon Whitehouse (D-R.I.).

Sen. Sanders summarized some of the problems with the U.S. health care system, particularly with regard to inadequate access to primary care. He pointed out that the U.S. spends 18 percent of GDP on health care but doesn’t measure up to other developed countries on outcomes. With 1 in 5 patients unable to see a primary care doctor when they need to, not only do medical conditions get worse, but also some of these patients resort to expensive treatment in a hospital E.R. The problem of inadequate access to primary care is worst in rural areas such as Wyoming and Idaho, but even small states like Vermont and Connecticut have areas that are affected, particularly for low-income or minority populations.

It is estimated that about half of doctor visits need a primary care provider, but in the U.S. only about 30 percent of physicians practice primary care. Furthermore, it is estimated that one quarter of them are nearing retirement and only 7 percent of medical students are currently choosing primary care.

The reasons why the U.S. is deficient in primary care and over-supplied with specialists were discussed:

* The number one reason was felt to be financial disparities between specialist reimbursement and primary care reimbursement. On average a specialist can expect to earn double that of a primary care doctor.

* Since students come out of medical school with a median debt of $160,000 there is an increased incentive to choose a highly-reimbursed specialty such as radiology or gastroenterology.

* Dr. Fitzhugh Mullan stated that medical schools are “specialty focused,” and that they create a “toxic culture” for primary care.

* Senator Murphy commented that there is a prestige factor involved in choice of practice.

* Senator Baldwin pointed out the lifestyle implications of the choice. For example a rural primary care doctor taking care of 3500 patients in Wyoming is looking at a much more difficult work life than a radiologist who practices in a suburb of Boston.

The consequences of lack of primary care were discussed:

* Senator Hagan stated that in her state of North Carolina a million patients can’t access management of chronic disease because of a shortage of providers.

* Dr. Andrew Wilper reminded the committee that 45,000 patients per year die for lack of health care coverage and that good primary care costs less and improves outcomes.

* Dr. Claudia Fegan described the scene outside of her clinic in Chicago where hundreds of patients line up every day hoping that they will find a doctor.

* Toni Decklever, R.N., described how lack of primary care follow-up can lead to long
er institutional stays and higher readmission rates after hospitalization.

Senator Casey stated that the “goal is for everyone to have a primary care provider” just like members of Congress do.

Possible policy changes that could improve the situation were presented:

* Increase the number of community health centers similar to Blue Ridge Community Health Center, a federally qualified health center, as described by Senator Hagan. Also have community health centers open evenings and weekends.

* Increase the number of non-physician providers. Uwe Reinhardt suggested that a federal licensing system could be set up to increase this workforce.

* Senator Enzi suggested increased use of telemedicine to help reach underserved rural areas.

* Encourage more medical students to choose primary care through programs such as the National Health Service Corps, loan forgiveness and greater parity of compensation between primary care and specialties.

* Dr. Andrew Wilper suggested that the Medicare funding stream that goes to hospitals for residency programs be made contingent on developing more robust training programs in primary care. Some of these residents could work in the expanded community health center sector, for example.

* Reform the Relative Value Scale Update Committee (RUC). This AMA committee is overwhelmingly controlled by specialty groups who keep their own reimbursement high at the expense of primary care doctors. Uwe Reinhardt recommended outside auditors to deal with this issue.

* Recruit more medical students from underserved areas such as rural parts of the country and low-income urban areas. Senator Franken commented, “there is nothing good about the high cost of education.” The astronomical cost of medical education bars many from entry.

Everyone on the committee seemed motivated to do something about the problem of inadequate access to primary care, but there are huge challenges ahead. While the Affordable Care Act (ACA) expands coverage to an estimated 30 million patients, “coverage does not equal access,” said Tess Kuenning, R.N. Health care costs are on an accelerating curve, Senator Whitehouse said. “We need better outcomes at lower costs,” Senator Warren emphasized. There was consensus that primary care providers are indispensable.

Not only are patients suffering from lack of access to health care, but providers are “being driven to distraction or exiting the profession” because of onerous billing and administrative responsibilities, said Dr. Fegan. She pointed to the hundreds of insurance companies that her clinic has to deal with in addition to the fact that current electronic health records are aimed more at billing and coding than at continuity of patient care.

Dr. Mullan commented that the ACA is a moral victory but presents a technical challenge. Dr. Fegan stated that “health care is a right,” and that a single-payer, improved-Medicare-for-all approach would bring everyone in, leave nobody out, be affordable to the country and lead to better outcomes.

Why a Maine doctor becomes a senator

By Geoff Gratwick
Bangor Daily News, Jan. 27, 2013

For the first time in recent memory there are four doctors in the Maine State Legislature, and I am honored to be one of them. It is extraordinarily exciting to be part of this small group bent on returning medicine to its original goal: the care of patients.

I have spent the last 40 years caring for people one at a time. Sadly, over these years I have seen medicine change from a profession focused on patients to a big business driven more and more by money issues. We need to return medicine to its original purpose: promoting wellness and taking care of the sick. Health care should be for people, not stockholders.

The arrival of four members of a usually nonpolitical profession in Augusta is no accident. The election of physicians to the Legislature was not a coordinated effort by some outside group. It shows instead that we are witnessing a sea change in the way Mainers are thinking about health care. And doctors are only the tip of the needle. There are now 14 health care professionals in the Legislature, as well as many others who heard from the citizens of Maine as they went door-to-door that the cost of health care is ruinous.

Change will not happen easily because medical care is dominated by the for-profit sector. The medical-industrial complex is made up of insurance companies, big pharma and megacorporations. It is immensely powerful and has undermined reform efforts many times in the past. But virtually all Americans now recognize that our current health care system is catastrophically expensive, unsustainable and close to being terminally broken. We need to reframe the conversation so that once again we are talking about health, not profit.

As always the question is how. The immediate goal for the 126th Legislature is to make the Affordable Care Act (also known as Obamacare) work for Maine. Whatever its flaws (and I think I know many of them), the ACA is the law of the land. It is a first step in the right direction, a step toward accessible and affordable health care for all. To disregard it will deprive many middle class and working people of health care and cost the state hundreds of millions of dollars.

The ACA can be adapted to fit the needs of Maine. We need health care exchanges that function, expanded coverage for those now denied it and a transition from a system based heavily on financial gain to one driven by best practices and compassion. We face a further challenge because thus far there has not been an executive branch task force in Augusta leading the way. A better health system will require all three branches of government to work together to devise the best plan for Maine.

There are many other problems facing our state: not enough jobs, the need for more skilled workers, a shortage of educational funding and environmental and social service issues. But if we can heal our ailing health care system we will free up resources we need to tackle these other issues. The Legislature has a steep path ahead, but the medical contingent looks forward to the challenge.

Geoff Gratwick is a rheumatologist and state senator representing District 32, encompassing Bangor and Hermon.

http://bangordailynews.com/2013/01/27/opinion/why-a-maine-doctor-becomes-a-senator/

Bill Keller on P4P and single payer

Carrots for Doctors

By Bill Keller
The New York Times, January 27, 2013

With its ambitious proposal to pay doctors in public hospitals based on the quality of their work — not the number of tests they order, pills they prescribe or procedures they perform — New York City has hopped aboard the biggest bandwagon in health care. Pay for performance, or P4P in the jargon, is embraced by right and left. It has long been the favorite egghead prescription for our absurdly overpriced, underperforming health care system. The logic seems unassailable: Reward quality, and you will get quality. Stop rewarding waste, and you will get less waste. QED! P4P!

If only it worked.

For if you spend a little time with the P4P skeptics — a data-bearing minority among physicians and health economists — you will come away full of doubts. In practice, pay for performance does little to improve outcomes or to control costs.

The first problem with P4P is that it does not address the biggest problem. Americans spend more than twice as much per capita as other developed countries on health care — a crippling 18 percent of the country’s economic output, and growing.

But the main reason everything costs less in other countries is that other countries tend to have one big payer — usually the government — with the clout to bargain down prices. A single-payer system has, so far, proven politically unpalatable in this country.

http://www.nytimes.com/2013/01/28/opinion/keller-carrots-for-doctors.html?hp&_r=0&pagewanted=all

Comment:

By Don McCanne, M.D.

Bill Keller, the former executive editor of The New York Times, explains why pay-for-performance (P4P) is a false solution to the problems of high health care costs and mediocre quality. Although he recognizes the correct solution – a single payer system – he follows the lead of other journalists and politicians in immediately dismissing it as being “politically unpalatable.”

Was Medicare politically unpalatable?

Consider the following oft-expressed concept. “Single payer is the solution that would bring health care to everyone at a cost that we can afford; therefore we shouldn’t adopt it because of concerns about political feasibility.” Phrased this way, obviously this is a non sequitur.

Let’s jam single payer into its proper place in government. The we’ll see how politically unpalatable it is, or rather is not.

Carrots for Doctors

By Bill Keller
The New York Times, January 27th, 2013

With its ambitious proposal to pay doctors in public hospitals based on the quality of their work — not the number of tests they order, pills they prescribe or procedures they perform — New York City has hopped aboard the biggest bandwagon in health care. Pay for performance, or P4P in the jargon, is embraced by right and left. It has long been the favorite egghead prescription for our absurdly overpriced, underperforming health care system. The logic seems unassailable: Reward quality, and you will get quality. Stop rewarding waste, and you will get less waste. QED! P4P!

If only it worked.

For if you spend a little time with the P4P skeptics — a data-bearing minority among physicians and health economists — you will come away full of doubts. In practice, pay for performance does little to improve outcomes or to control costs. But if you look hard enough at why this common-sense approach doesn’t deliver, you find some clues to what might.

The New York plan would give hospitals bonuses to distribute to their doctors based on such indicators as patient satisfaction, speeding the flow of cases through the system and administering specific therapies. It is an attempt to get ahead of the federal law we all know as Obamacare, which includes rewards for hospitals that peg pay to a list of quality metrics. I’ve said before that I consider Obamacare an important leap forward, mainly for extending the basic safety net to millions of Americans. And there are aspects of the law, notably the Medicare Independent Payment Advisory Board, that may help bring down costs, if Congress can resist the temptation to interfere. But the pay-for-performance provisions are a triumph of theory over experience.

The first problem with P4P is that it does not address the biggest problem. Americans spend more than twice as much per capita as other developed countries on health care — a crippling 18 percent of the country’s economic output, and growing. Before studying the statistics, I assumed the root of the problem was doctors who, paid piecemeal for the services they provide, load up patients with marginal tests and treatments. In fact, America’s health care system is not much different from other developed countries in the volume of service. Our doctors prescribe more or less the same number of pills and X-rays, perform similar numbers of blood tests and surgeries, as doctors in the best European countries. While there are undoubtedly savings to be had by cutting unnecessary services (shortening hospital stays, for example), the main problem is that our system charges far more for each service — each office visit, each hip replacement, each day in a hospital bed, each dose of antibiotic. “The facile explanation is that doctors do too much,” said Peter Bach, a doctor at Memorial Sloan-Kettering who studies quality of cancer care. “But if you compare us to other countries on volume, we’re not leading in any category. The flip side is, we pay double for a lot of stuff.” (Actually, we lead in tonsillectomies and knee replacements, but his point is generally right.)

Doctors cite a number of reasons our medical treatments cost more — the high price of malpractice insurance being a favorite, and genuine, culprit. But the main reason everything costs less in other countries is that other countries tend to have one big payer — usually the government — with the clout to bargain down prices. A single-payer system has, so far, proven politically unpalatable in this country. And even Medicare, which has the power of scale and uses it to drive down prices, wields its power sparingly, because doctors threaten to stop serving Medicare patients if the reimbursements fall too low. As hospitals merge into mightier megachains, they may be able to bargain down the payments to doctors and drug companies and device-makers, and create economies of scale by standardizing treatments. (The physician and New Yorker writer Atul Gawande proposed in a provocative August article that hospitals could drastically improve productivity by studying the example of restaurant chains like the Cheesecake Factory.) But that’s not what P4P is about.

Instead of leverage, P4P employs incentives. Reduce the length of stay for acute-care patients, cut the rate of readmission for pneumonia cases, make sure heart-attack victims get a talk about diet before they are discharged, and you stand to find a little windfall in your paycheck.

Critics, who have evidence from a host of pilot programs, say that the bonuses are typically too small to change behavior; New York’s would be a maximum of 2.5 percent of a doctor’s salary, and most P4P programs pay less than that. Often the performance indicators measure things that are not within the doctor’s control. Luis Marcos, a former president of the agency that runs New York’s public hospitals, plucked several examples from the list of 13 metrics proposed for New York. Reducing waits in the emergency room (No. 4) is a worthy goal, he said, but it depends on a whole cast of people, from the clerk who greets the patient to the orderly who makes the bed ready. Shortening hospital stays (No. 13) requires having someone in the community — family, a social worker — to receive the patient; that’s an especially hard requirement for hospitals that treat a lot of low-income or homeless people.

Another problem with P4P is that providers learn how to manipulate the results. “Once you define performance, people manage toward those metrics and neglect other things that don’t get counted,” said the Princeton health economist Uwe Reinhardt, who writes for The Times’s Economix blog. New York doctors have a favorite, possibly apocryphal, story of medical providers gaming the system: Miami hospitals that use patient feedback as a performance measure wait until spring to do their surveys, because that’s when the cranky, hard-to-please New Yorkers go home from their winter refuge.

Ashish Jha, a doctor at the Harvard School of Public Health, argues that P4P might get results if the incentive payments to hospitals were substantially bigger, the formulas were simplified and the performance indicators were kept to a few, clear measures that doctors and patients agree matter: mortality rates, infection rates, recurrence of heart attacks. “If hospitals achieve great outcomes, it matters little how they did so,” Jha wrote in the latest Journal of the American Medical Association. And death rates are harder to game than administrative procedures.

Jha also proposes a little experiment in behavioral psychology: give hospitals 100 percent of the bonus at the beginning of the year, but require them to send a refund at the end of the year to pay for any shortcomings. Givebacks really focus the mind.

Peter Provonost, a physician and professor at Johns Hopkins, says that rather than bribe doctors to adopt better practices, we should play to doctors’ professionalism. Pronovost is famous for a scheme that drastically reduced infections associated with catheters by disseminating to doctors and nurses a simple, five-point operating-room checklist of reminders: Wash your hands, wear a sterile mask, etc. No pay incentives were involved, just an appeal to professional pride — and, later, public reporting of the results. “I wouldn’t rule out economic incentives,” Pronovost told me. “But you can do a lot just working with professional norms.”

Pronovost has a more radical piece of common sense to offer. He proposes that the United States create an agency that would do for medicine what the Securities and Exchange Commission does for securities markets: compile and audit information about the performance of hospitals, and make it public. Rankings of hospitals now come either from news organizations or consumer groups working with untested and inconsistent data, or they are propaganda p
roduced by medical providers themselves. “There are stronger regulations about what a company can say about toothpaste than what a hospital can claim about quality,” Pronovost said.

For image-conscious doctors and hospitals, pride and shame might be the most effective kind of carrots and sticks.

HCA hasn't changed

Judge says HCA broke spending promises

By Diane Stafford
The Kansas City Star, January 24, 2013

The Health Care Foundation of Greater Kansas City has won a $162 million judgment against Hospital Corp. of America, owner of the largest hospital system in the Kansas City area.

The lawsuit contended that HCA hadn’t spent what it promised on capital improvements to the former Health Midwest hospitals that HCA bought for $1.13 billion in 2003. The lawsuit further claimed that HCA had not met its charitable health care commitments to help pay for treating indigent people.

The amounts that HCA agreed to spend within certain deadlines were part of the deal transferring the nonprofit Health Midwest hospitals to the for-profit HCA.

As agreed to by parties to the 2003 sale, the for-profit HCA was to make $450 million in capital improvements to the existing Health Midwest hospitals, which had been nonprofit institutions and needed significant upgrades.

HCA had agreed under terms of the sale to spend more than $650 million on charity health care in the Kansas City area, the judge noted in his decision. How far HCA has gone toward meeting that obligation will be scrutinized in the court-ordered audit.

But in his decision Thursday, (Judge John) Torrence said HCA’s financial accounting made it impossible to tell whether the company had met its charitable health care commitments.

http://www.kansascity.com/2013/01/24/4029002/health-care-foundation-wins-major.html

Comment:

By Don McCanne, M.D.

Physicians for a National Health Program supports not only a much more efficient and equitable single payer financing system, we also support elimination of passive investors from the health care system. Corporate executives and boards that must place priorities of shareholders over patients should have no place in our health care system.

Hospital Corporation of America (HCA) is not only the largest private operator of health care facilities in the United States, it also holds the record for the largest fraud settlement, over $1.7 billion. This current judgement against HCA suggests that they continue to place a priority on profits over patients.

When HCA took over the largest hospital group in the Kansas City area, they agreed to upgrade the hospitals with much needed improvements, plus they agreed to continue to provide charity care as safety net institutions. This was in exchange for allowing them to convert these non-profit hospitals into for-profit facilities under their ownership.

Once gaining ownership, they reverted to business as usual – make money while ignoring the commitments made for charitable care and for improving the facilities. The $162 million judgment that they may have to pay (they are appealing it) to them is not much more than an expense of doing business, especially considering that their 2011 net income was $2.47 billion (adding considerably to Bain’s profits from their investment in HCA).

Although PNHP certainly objects to the diversion of profits to investors – profits that should go for patient care or to help lower costs – the primary reason that we believe that for-profit entities should be expelled from the health care system is the egregious behavior on the part of their corporate executives and board members in using patients as instruments in their quest for profits. In this instance it can be measured by the care that they avoided providing to indigent patients, and by the less than optimal care received by patients in their substandard facilities.

The next time you see a placard stating, “PATIENTS, NOT PROFITS,” keep in mind that it is not just profits, but it is the deeper significance of what corporate greed does to patient care.

Obamacare money could be better spent on Medicare for All

By Marvin Malek, M.D.
Times-Argus (Barre, Vt.), Letters, Jan. 25, 2013

Kudos to the grant writers at Vermont’s Dept. of Health Access for obtaining $156 million from the federal government to assist with the implementation of the health exchange, the new insurance marketplace scheduled to go online in October 2013 as part of Obamacare (“Vt. ranks third in federal health exchange money,” Times-Argus, Jan. 5). The $156 million will lead to the creation of a large number of high quality jobs. Obtaining outside money for Vermont helps the economy and adds to our tax base.

Of course, this might have been better news if this money were designated for something other than unnecessary administrative activity in the U.S. health care system. Had President Obama and the U.S. Congress had more courage, they would have voted to simply extend Medicare to the entire U.S. population. Such a proposal would have obviated the need for exchanges. For that matter, extending Medicare to every American would have eliminated the need for the entire private insurance industry, which contributes only excessive cost and human misery to the U.S. health care system.

While the $156 million coming to Vermont is certainly a waste of federal taxpayer money, this waste pales in comparison to the billions of dollars that will be diverted to private insurers by the Obamacare legislation.

With the new health exchange the $156 million creates, Vermonters will be able to search for very expensive private policies providing coverage that would be disdained by citizens of every other developed country. The exchange will also feature policies with slightly less ridiculously expensive premiums. But these policies will have even worse coverage — even higher deductibles and co-pays. No bargains in Obamacare.

What’s really sad is that at the federal level, there is no way to vote for single-payer health care. The Democrats are largely lined up behind Obamacare. And the proposals coming from the Republicans both in Vermont and nationally have at least as much administrative expense and provide vastly less secure coverage compared to Obamacare. The few Republican proposals that actually extend coverage to additional Americans provide the type of coverage that’s really there for you — as long as you don’t get sick.

There never has been a good reason why Americans pay into Medicare throughout their entire lives, but aren’t covered by the program until they turn 65. Single-payer health care — such as the Medicare program — saves lives and money. We shouldn’t rest until the entire U.S. population can enjoy its benefits. State-based, single-payer reform, as we’re attempting here in Vermont, may be the only viable strategy to eventually expand Medicare to every citizen of our country.

Dr. Marvin Malek is an internist working at Central Vermont Hospital in Berlin.

http://www.timesargus.com/article/20130125/OPINION02/701259993/0/FEATURES05

The Affordable Care Act: What to Expect in 2013

By John Geyman, M.D.
The Huffington Post, Jan. 24, 2013

The Affordable Care Act (ACA), crafted in large part by corporate stakeholders who are themselves responsible for the high costs of U.S. health care, is more secure with President Obama’s win last November. But regrettably, the law will fail to control costs or prices, will not provide universal access to care, and at best will provide low-value, high-premium “insurance” that will still make essential health care unaffordable for many millions of patients and families.

The ACA’s fundamental flaw is that it props up an inefficient and exploitative private health insurance industry while not recognizing that deregulated markets can’t fix systemic problems of access, costs, quality, equity, accountability and sustainability.

President Obama gained an impressive victory, and Democrats have held control of the Senate. Most importantly, corporate money, power, lies and deception on the right have not prevailed. But of course, the Republican-controlled House is likely to bring continued political gridlock. Overemphasis on austerity and deficit control threaten Medicare, Medicaid and safety net programs.

Going forward, we can expect to see wild battles across the health care landscape, including these examples:

* Continued mergers among the major players, including insurance companies, hospital systems, medical groups and others, which will end up increasing costs and prices while limiting patients’ choices of physician and hospital.

* Continued lobbying by the insurance industry to mold accountable care organizations and insurance exchanges in their interests (i.e. cherry-pick enrollees and pass along sicker patients to public programs).

* Further privatization and exploitation of Medicare and Medicaid.

* Efforts by insurers to limit definitions of minimal essential benefits.

* Further fragmentation and increasing bureaucracy of our market-based health care system with worse health outcomes.

Under this onslaught, the ACA will not hold up. Health care reform needs to be more progressive than how it ended up with the ACA. The only real fix for our problems is single-payer, improved Medicare for All, a proposal introduced by Rep. John Conyers (D-Mich.), H.R. 676, coupled with a private delivery system.

Health care is just one more example of the 99/1 percent challenge facing the country. These are some of the directions that we, the citizens of this great country, can take in restoring hope that all Americans can gain their rightful access to the health care that they deserve:

* Speaking out, individually and collectively, at community, state and federal levels to expose the abuses and cruelty of what passes for health care in its under-regulated state.

* Fighting for a defined benefit program that covers all Americans in a single risk pool with full choice of physicians, other health professionals and institutions, as H.R. 676 would provide.

* Supporting efforts at the state level for single-payer financing in the event that reform may first need to be demonstrated at the state level before a national program can be passed by Congress.

* Pushing for a more responsible government oversight of health care at state and federal levels to oversee health care, including an independent, well-funded national institute to deal with coverage and cost-effectiveness issues on the basis of scientific evidence, not upon which profit-based interest group can scream the loudest.

* Supporting and participating in divestiture efforts against abusive insurers and other stakeholders in the health care marketplace.

Despite what we are being told by politicians on both sides of the aisle, our deregulated health care marketplace is not sustainable, and there is no real fix short of single-payer financing reform coupled with a more accountable private delivery system.

Other advanced nations around the world learned many years ago that one or another form of public financing is fundamental to a good health care system. The U.S. remains an outlier among these nations in having the most expensive system that still does not provide universal access to essential health care — even at that we have variable quality and worse outcomes. It is long overdue to learn from the experience of other countries that have coped more successfully with the same health policy issues that we face in this country.

John Geyman, M.D. is professor emeritus of family medicine at the University of Washington, author of “Health Care Wars: How Market Ideology and Corporate Power Are Killing Americans,” past president of Physicians for a National Health Program (PNHP), and a member of the Institute of Medicine.

http://www.huffingtonpost.com/john-geyman/the-affordable-care-act_b_2537411.html

A Different Model — Medical Care in Cuba

By Edward W. Campion, M.D., and Stephen Morrissey, Ph.D.
The New England Journal of Medicine, Jan. 24, 2013

For a visitor from the United States, Cuba is disorienting. American cars are everywhere, but they all date from the 1950s at the latest. Our bank cards, credit cards, and smartphones don’t work. Internet access is virtually nonexistent. And the Cuban health care system also seems unreal. There are too many doctors. Everybody has a family physician. Everything is free, totally free — and not after prior approval or some copay. The whole system seems turned upside down. It is tightly organized, and the first priority is prevention. Although Cuba has limited economic resources, its health care system has solved some problems that ours has not yet managed to address.[1,2]

Family physicians, along with their nurses and other health workers, are responsible for delivering primary care and preventive services to their panel of patients — about 1000 patients per physician in urban areas. All care delivery is organized at the local level, and the patients and their caregivers generally live in the same community. The medical records in cardboard folders are simple and handwritten, not unlike those we used in the United States 50 years ago. But the system is surprisingly information-rich and focused on population health.

All patients are categorized according to level of health risk, from I to IV. Smokers, for example, are in risk category II, and patients with stable, chronic lung disease are in category III. The community clinics report regularly to the district on how many patients they have in each risk category and on the number of patients with conditions such as hypertension (well controlled or not), diabetes, and asthma, as well as immunization status, time since last Pap smear, and pregnancies necessitating prenatal care.

Every patient is visited at home once a year, and those with chronic conditions receive visits more frequently. When necessary, patients can be referred to a district polyclinic for specialty evaluation, but they return to the community team for ongoing treatment. For example, the team is responsible for seeing that a patient with tuberculosis follows the assigned antimicrobial regimen and gets sputum checks. House calls and discussions with family members are common tactics for addressing problems with compliance or follow-up and even for failure to protect against unwanted pregnancy. In an effort to control mosquito-borne infections such as dengue, the local health team goes into homes to conduct inspections and teach people about getting rid of standing water, for example.

This highly structured, prevention-oriented system has produced positive results. Vaccination rates in Cuba are among the highest in the world. The life expectancy of 78 years from birth is virtually identical to that in the United States. The infant mortality rate in Cuba has fallen from more than 80 per 1000 live births in the 1950s to less than 5 per 1000 — lower than the U.S. rate, although the maternal mortality rate remains well above those in developed countries and is in the middle of the range for Caribbean countries.[3,4] Without doubt, the improved health outcomes are largely the result of improvements in nutrition and education, which address the social determinants of health. Cuba’s literacy rate is 99%, and health education is part of the mandatory school curriculum. A recent national program to promote acceptance of men who have sex with men was designed in part to reduce rates of sexually transmitted disease and improve acceptance of and adherence to treatment. Cigarettes can no longer be obtained with monthly ration cards, and smoking rates have decreased, though local health teams say it remains difficult to get smokers to quit. Contraception is free and strongly encouraged. Abortion is legal but is seen as a failure of prevention.

But one should not romanticize Cuban health care. The system is not designed for consumer choice or individual initiatives. There is no alternative, private-payer health system. Physicians get government benefits such as housing and food subsidies, but they are paid only about $20 per month. Their education is free, and they are respected, but they are unlikely to attain personal wealth. Cuba is a country where 80% of the citizens work for the government, and the government manages the budgets. In a community health clinic, signs tell patients how much their free care is actually costing the system but no market forces compel efficiency. Resources are limited, as we learned in meeting with Cuban medical and public health professionals as part of a group of editors from the United States. A nephrologist in Cienfuegos, 160 miles south of Havana, lists 77 patients on dialysis in the province, which on a population basis is about 40% of the current U.S. rate — similar to what the U.S. rate was in 1985. A neurologist reports that his hospital got a CT scanner only 12 years ago. U.S. students who are enrolled in a Cuban medical school say that operating rooms run quickly and efficiently but with very little technology. Access to information through the Internet is minimal. One medical student reports being limited to 30 minutes per week of dial-up access. This limitation, like many of the resource constraints that affect progress, is blamed on the long-standing U.S. economic embargo, but there may be other forces in the central government working against rapid, easy communication among Cubans and with the United States.

As a result of the strict economic embargo, Cuba has developed its own pharmaceutical industry and now not only manufactures most of the medications in its basic pharmacopeia, but also fuels an export industry. Resources have been invested in developing biotechnology expertise to become competitive with advanced countries. There are Cuban academic medical journals in all the major specialties, and the medical leadership is strongly encouraging research, publication, and stronger ties to medicine in other Latin American countries. Cuba’s medical faculties, of which there are now 22, remain steadily focused on primary care, with family medicine required as the first residency for all physicians, even though Cuba now has more than twice as many physicians per capita as the United States.[4] Many of those physicians work outside the country, volunteering for two or more years of service, for which they receive special compensation. In 2008, there were 37,000 Cuban health care providers working in 70 countries around the world.[5] Most are in needy areas where their work is part of Cuban foreign aid, but some are in more developed areas where their work brings financial benefit to the Cuban government (e.g., oil subsidies from Venezuela).

Any visitor can see that Cuba remains far from a developed country in basic infrastructure such as roads, housing, plumbing, and sanitation. Nonetheless, Cubans are beginning to face the same health problems the developed world faces, with increasing rates of coronary disease and obesity and an aging population (11.7% of Cubans are now 65 years of age or older). Their unusual health care system addresses those problems in ways that grew out of Cuba’s peculiar political and economic history, but the system they have created — with a physician for everyone, an early focus on prevention, and clear attention to community health — may inform progress in other countries as well.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

References

1. Keck CW, Reed GA . The curious case of Cuba. Am J Public Health 2012;102:e13-e22
2. Drain PK, Barry M . Fifty years of U.S. embargo: Cuba’s health outcomes and lessons. Science 2010;328:572-573
3. World population prospects, 2011 revision. New York: United Nations (http://esa.un.org/unpd/wpp/Excel-Data/mortality.htm).
4. The world factbook. Washingto
n, DC: Central Intelligence Agency, 2012 (https://www.cia.gov/library/publications/the-world-factbook).
5.  Gorry C . Cuban health cooperation turns 45. MEDICC Rev 2008;10:44-47

Copyright © 2013 Massachusetts Medical Society. All rights reserved.

N Engl J Med 2013; 368:297-299 January 24, 2013 DOI: 10.1056/NEJMp1215226

Two Events, One Argument: The Case for Single-Payer Health Care

Debra Street, Andrew Coates speak in Buffalo

By George Sax
Artvoice (Buffalo, N.Y.), Jan. 24, 2013

Thirty years ago, soon after she arrived in Fort Walton Beach, Florida, from her native Canada, Debra Street found herself in a hospital emergency room with a painful kidney stone problem. This unpleasant situation quickly became more unpleasant, and something of a cultural shock.

She was asked how she would pay by an intake interviewer. Street, currently the chair of the sociology department at the University at Buffalo, had no insurance, or job. Her husband had both, but his insurance hadn’t kicked in yet during a probationary period. She had no checks with her name printed on them since the bank hadn’t yet sent them. She had no credit card. “It was a perfect storm” of misfortune, she told a meeting of the League of Women Voters at an Amherst restaurant last Friday. She was told to seek treatment at a “charity hospital” 40 miles away. “I hadn’t thought of this before,” she said. “I’m a Canadian. We get health care.”

And they get it without this kind of scrutiny. The Canadian government is billed for service. Canadians pay for it through premiums or taxes, depending on which province they live in.

Street might encounter a different response today because of a federal law that mandates emergency room treatment without regard for a patient’s fiscal resources. But maybe not. As she pointed out in a telephone interview this week, she might be turned down because hospitals are only required to stabilize emergencies and they judge whether a case is one. They also need not give preventive or longer-term service. (This is true despite the blithe assurance of the Buffalo News’ editors several years ago that everyone is protected by a care “safety net” because of access to emergency rooms. The News was engaging in a long-running opposition to President Barack Obama’s health care proposal and its limited insurance mandate.) None of this would have mattered to Street in Canada. As she said, Canadians get health care, in a single-payer system, where treatment isn’t approved or disallowed by private interests, as in this country.

“In Canada,” she told League members, “corporations don’t make the important decisions about health; public officials do.”

The night before Street spoke, more than 80 people crowded into a basement meeting room at Buffalo’s Lafayette Presbyterian Church for a community forum on “Poverty, Disparities and Healthcare,” organized by the Community Health Worker Network of Buffalo. At least a third of the attendees were young people, a result of outreach to medical students and undergraduates, according to Jessica Bauer Walker, the Network’s director.

The lead speaker was Andrew D. Coates, the newly elected president of Physicians for a National Health Program. Coates is an assistant professor at Albany Medical College and the medical director at an Albany County-owned nursing home. The PNHP is a 18,000-member organization dedicated to the institution of a single-payer system in this country, rather than what it regards as the unwieldy, piecemeal, and inadequate Obamacare program.

Thursday night, in his talk, Coates effectively functioned not only as a physician but also as a political economist, a historian, and a sociologist. For about an hour he deftly sped through data compilations and comparisons, succinctly and sometimes aphoristically commenting on the dismal state of American health care. The poor results of the American system haven’t been a secret for years, although a large portion of the American public has seemed confused about or unaware of the situation, an ignorance created at least in part by powerful political and private interests.

The U.S. ranks at or near the bottom of a list of 20 of the most advanced nations around the world in such categories as infant mortality, incidence of serious illness, and life expectancy. It is at the top in the cost of its system. “Our health delivery systems have created the dismal results and ill-health,” Coates said.

The two central themes of the Coates presentation—and of two co-speakers—were “the social determinants” of health, and the probable failures of Obamacare. There are at least 50 million uninsured Americans, and millions more of the underinsured. This glaring lack accounts for much of the bad outcomes, Coates said. He noted a recent finding by Harvard researchers that there are 45,000 “excess deaths” each year because of a lack of access to medical services.

As to state Medicaid programs, a crucial element of the Obama plan that is supposed to provide for those unable to pay for the insurance policies offered by private companies on the Internet “exchanges” that are to be established, Coates expressed biting skepticism: “Medicaid may be indefensible, but it’s better than nothing.”

It may also prove unavailable. (Dis)qualifying standards are usually stringent and a large number of the 50 states will apparently opt out of Obamacare’s expanded Medicaid with liberalized requirements despite a federal subsidy to them, according to William P. Keefer, a health law practitioner at the Buffalo law firm Phillips, Lytle LLP.

Coates dismissed the prospects of Obamacare insuring a majority of the uninsured. In an interview before the event, he cited a recent Congressional Budget Office projection that there will be 36 million people left out of the program at the end of 2016. The cost of policies offered will be too great for many people, he said. The sector of the population that will benefit the most from Obamacare are corporate interests: insurance, managed care, medical device and pharmaceutical companies. (Last June, USA Today quoted insurance executives who were relieved that the U.S. Supreme Court had sustained the program because it would create an expanded market for them.)

Coates scoffed at so-called market-driven reforms, quoting Harvard professor David Himmelstein: “Consumer-driven plans are driven like cattle are driven.” High co-pays and deductibles cause people with meager resources to deny themselves care, he said. “People delay care, even for heart attacks, one-fifth more if they’re underinsured,” he reported.

Sam Magavern, co-director of the Partnership for the Public Good, told the audience that for all the talk of Buffalo’s extreme poverty, the problem isn’t really the city’s poverty rate: “It’s not poverty, it’s inequality,” he said. The metropolitan area around Buffalo has a poverty rate at the national median. The national health care crisis isn’t due to “lack of resources. It’s the politics of who is willing to pay for what.”

Dr. Myron Glick, founder and chief executive at the nonprofit Jericho Road Family Practice in Buffalo, pointedly recalled how he has marvelled at the new and lavish suburban offices of insurance companies and medical groups he has visited for meetings. And he remembered a prominent cardiologist who declined a referral from Glick because the patient had only Medicaid. “It was the first question he asked,” Glick said. “He said I should send him to the county hospital. ‘They need patients to practice on.’”

Glick said he later saw the doctor at a medical conference. “I hold it against him,” he went on, “but it’s really the system. But the system won’t be changed by altruism.”

“I’m an incrementalist,” Coates said. “I’m not asking for a social revolution, but to get rid of a private-profit health system.” A single-payer system, he said a few minutes later, would “eliminate the most parasitical portion of finance capital” from health care.

Artvoice is Buffalo’s oldest and largest weekly newspaper, providing in-depth coverage of local politics, event information and reviews.

http://artvoice.com/i
ssues/v12n4/week_in_review/case_for_single_payer

Managed care needs a better watchdog

The Star Tribune failed that role in a story about UnitedHealth

By Kip Sullivan
Star Tribune (Minneapolis), Jan. 23, 2013

So UnitedHealth Group has figured out a way to cut Medicare’s costs “without cutting services”? That is how the Star Tribune characterized the organization’s self-serving claims in a recent story (“UnitedHealth says Medicare can save big without big cuts,” Jan. 20).

The Star Tribune has long had a policy of clearly distinguishing advertisements from news reporting. That policy was violated by the story on United, which characterized the firm’s claims as a fresh perspective in the debate about how to cut Medicare’s costs. In fact, United and every other large health insurance company has been peddling similar hype for decades.

The reader had to wade through 15 paragraphs to find a dissenting view, expressed by the Congressional Budget Office. The Star Tribune relegated the CBO’s views to this single sentence: “The Congressional Budget Office … tends to downplay or even ignore numbers like the ones UnitedHealth now offers, experts said.” It would have been helpful if the article had gone on to explain why.

The reason is that CBO requires supporting evidence before it will report back to Congress that a health care reform proposal will save money. The evidence the CBO looks for is not news releases and “studies” from health insurance companies but papers based on the principles of science and published in peer-reviewed journals. To date, the scientific literature does not support the cost-containment claims made by United and the rest of the managed-care insurance industry.

Neither the CBO nor professional journals are infallible. But they have no financial stake in the debate.

United thinks “private success stories need to drive public reforms.” In other words, that self-serving anecdotes from the health insurance industry should mean more to lawmakers than the scientific literature does. How does the state’s largest newspaper let such nonsense go unexamined?

Minnesota badly needs the equivalent of a CBO. I urge the Star Tribune to consider playing the role. That would require regular reporting on the evidence for the cost-containment claims made for “payment reform,” “pay for performance,” “report cards,” “bundled payments,” “disease management,” and the other health care reform fads collectively known as “managed care.”

Here are two questions to investigate:

First, how can United claim to have discovered methods that will lower Medicare costs when the health insurance industry, including United, has a long track record of raising, not lowering, Medicare’s costs? A steady stream of research has shown that it costs more to insure seniors through health insurance companies than it does through the traditional fee-for-service (FFS) Medicare program.

The current name for the private-sector branch of Medicare is Medicare Advantage (MA). The Medicare Payment Advisory Commission, which is very sympathetic to managed care, had this to say in a recent report to Congress: “Currently, Medicare spends more under the MA program for similar beneficiaries than it does under FFS.”

The second question to investigate is United’s claim that “health improvement programs such as diabetes prevention and weight control could save $53 billion” for Medicare and Medicaid. The peer-reviewed literature on this claim currently supports the opposite conclusion — that the cost of administering “disease management” programs in general, and diabetes and obesity prevention programs in particular, exceeds the savings in medical costs achieved by these programs.

There are a few exceptions to this rule, but diabetes and obesity are not among them. It remains possible that such programs targeted at a very small number of diabetics and overweight people (for example, those who are highly motivated to get well) will someday prove to save more than they cost the health care system, but in that event the total savings will be small compared with total health care spending.

The Star Tribune is capable of good reporting on managed-care hype. It has done so infrequently in the past. But it needs to do so regularly.

Kip Sullivan is a member of the steering committee of Physicians for a National Health Program, Minnesota chapter.

http://m.startribune.com/opinion/?id=188131581&c=y

Profit-Driven Health Care

By Leonard Rodberg
The New York Times, Letters, Jan. 21, 2013

Re “Health Care and Profits, a Poor Mix,” by Eduardo Porter (Economic Scene, Jan. 9):

The way we Americans provide health care is actually far worse than Mr. Porter suggests. It is not just that for-profit health insurance is more costly and less efficient than the nonprofit or government alternatives; it is inherently contradictory. The more health care the insurance companies provide — the more they respond to the needs of patients — the less profit they make. That’s why they cherry-pick the healthy and avoid the sick. That’s why we patients face denials and delays when we try to receive care.

The results are predictable; we have some of the worst health statistics of any advanced country. Other countries make health care a government responsibility, with the result that their people are healthier and they spend far less.

When will we learn, as your headline suggested, that health care and profits don’t mix?

Leonard Rodberg is a professor and chairman of the urban studies department, Queens College, CUNY. He resides in Flushing, Queens.

http://www.nytimes.com/2013/01/22/opinion/profit-driven-health-care.html?ref=opinion