PNHP

The Effect Of Physicians’ Electronic Access To Tests: A Response To Farzad Mostashari

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The Effect Of Physicians’ Electronic Access To Tests: A Response To Farzad Mostashari

By Danny McCormick, David Bor, Stephanie Woolhandler, and David Himmelstein
Health Affairs Blog, March 12th, 2012

Our recent Health Affairs article linking increased test ordering to electronic access to results has elicited heated responses, including a blog post by Farzad Mostashari, National Coordinator for Health IT.  Some of the assertions in his blog post are mistaken.  Some take us to task for claims we never made, or for studying only some of the myriad issues relevant to medical computing.  And many reflect wishful thinking regarding health IT; an acceptance of deeply flawed evidence of its benefit, and skepticism about solid data that leads to unwelcome conclusions.

Dr. Mostashari’s use of a government website to critique our paper, will, we hope, open a fruitful dialogue.  We trust that in the interest of fairness he will also post our response on his agency’s site.

Our study analyzed government survey data on a nationally representative sample of 28,741 patient visits to 1187 office-based physicians.  We found that electronic access to computerized imaging results (either the report or the actual image) was associated with a 40% -70% increase in imaging tests, including sharp increases in expensive tests like MRIs and CT scans; the findings for blood tests were similar.  Although the survey did not collect data on payments for the tests, it’s hard to imagine how a 40% to 70% increase in testing could fail to increase imaging costs.

Dr. Mostashari’s statement that “reducing test orders is not the way that health IT is meant to reduce costs” is surprising, and contradicts statements by his predecessor as National Coordinator that electronic access to a previous CT scan helped him to avoid ordering a duplicate and “saved a whole bunch of money.” A Rand study, widely cited by health IT advocates including President Obama, estimated that health IT would save $6.6 billion annually on outpatient imaging and lab testing.  Another frequently quoted estimate of HIT-based savings projected annual cost reductions of $8.3 billion on imaging and $8.1 billion on lab testing.

We focused on electronic access to results because the common understanding of how health IT might decrease test ordering is that it would facilitate retrieval of previous results, avoiding duplicate tests.  Indeed, it’s clear from the extensive press coverage that our study was seen as contravening this “conventional wisdom”.

Nonetheless, Dr. Mostashari criticizes us for analyzing the impact of physicians’ electronic access to imaging and test results, but not other aspects of electronic health record (EHR) use.    We did, however, analyze the relationship of EHRs to test ordering in a subsidiary analysis.  While physicians use of a full EHR was associated with a 19% increase in image ordering, as we noted in the paper this finding was not statistically significant.  While we cautiously (and properly) interpreted this as a “null” finding, these data are inconsistent with Mostashari’s optimistic view that use of a full EHR reduces costs.

He asserts that our 2008 data are passe, and that health IT meeting today’s “meaningful use” criteria definitely saves money. The data we analyzed were the latest available data when we initiated the study.  While the proportion of outpatient physicians utilizing health IT has grown since 2008, we are unaware of any “game changing” health IT developments in the past four years that are would produce substantially different results if the study were repeated today.  The EHR vendors that dominated the market in 2008 remain, by and large, today’s market leaders, and their products have undergone mostly modest tweaks.  Mostashari’s contention that 2012  EHRs  – incorporating decision support and electronic information exchange – save money in ways not possible in 2008 should be tested through additional research but remains merely a hypothesis. We hope that some day his predicted savings can be achieved.

Dr. Mostashari offers his own explanation for our findings, suggesting that doctors who are inclined to order more tests are also inclined to purchase health IT for viewing test results electronically rather than on paper.  He offers no evidence for this assertion and ignores the fact that we explored (and rejected) this explanation by analyzing subgroups of doctors who are unlikely to be the decision maker for IT purchases – e.g. employed physicians, those working in an HMO setting etc.  In other words, electronic access to results predicted more test ordering whether or not the ordering physician was responsible for health IT purchases.

He incorrectly states that our analysis did not take into account patients’ severity of illness, physicians’ level of training, and the nature of physicians’ financial arrangements.  In fact, we reported subsidiary multivariate analyses that included several serious diagnoses; all of our models included physician specialty (which we specified in several different ways); and all models included adjustment for an extensive list of indicators of financial arrangements (e.g. whether the physician owned the practice or was an employee; the type of office; whether the practice was owned by a hospital; whether the physician was a solo practitioner; whether the physician’s compensation was based, in part or whole on “profiling”; and whether the practice was predominantly prepaid).  We also performed a series of subsidiary analyses that explored whether physicians with a proclivity to “self refer” patients for imaging tests accounted for our finding; they didn’t.

Dr. Mostashari criticizes us for failing to assess whether health IT improved the quality or appropriateness of care.  Of course, these were not the topic of our research.  Those are different studies for a different time.  However, we would note that other large-scale studies have found no, or trivial quality improvements associated with HIT outside of a few flagship institutions4-6.

Dr. Mostashari’s strongest claim is that observational studies like ours (and most other health policy studies, including some by Dr. Mostashari himself) cannot prove causation. This is surely true.  As long time teachers of evidence based medicine we took care to couch our conclusions in cautious terms, stating only that “Computerization, whatever its other benefits, remains unproven as a cost control strategy.”

But Dr. Motashari is less cautious, asserting that the case for HIT is closed.  The paper he cites to buttress this claim (authored by members of his own agency) culled studies reporting any impact of HIT on virtually any aspect of care, and accepted authors’ claims of benefit without regard to study quality or statistical niceties.  Thus, a focus group’s impressions of benefit are accorded the same weight as nationwide studies of Medicare data showing virtually no impact of computerization on quality measures.  Reports of a reduction from 70% to 38 % in “missed bi
lling opportunities” or a $7,000 reduction in office supply costs are among the 92% of studies judged “positive”.  While the literature review he cites is interesting, nothing in it contradicts our findings.

Dr. Mostashari is also correct in reiterating that randomized trials are the best way to assess health IT.  In fact, no randomized trial has ever been published that examines patients’ outcomes or costs associated with off-the-shelf health IT systems that dominate the U.S. market.  No drug or new medical device could pass FDA review based on such thin evidence as we have on health IT.  Yet his agency is disbursing $19 billion in federal funds to stimulate the adoption of this inadequately evaluated technology. Dr. Mostashari is perhaps the only person in our nation who commands the resources needed to mount a well done randomized controlled trial to fairly assess the impact of health IT, and the comparative efficacy of the various EHR options.

Finally, Dr. Mostashari’s unbridled faith in technology is mirrored by his belief that ACOs are the next panacea for health costs and quality.  That health policy flavor-of-the-month also remains wholly unproven.

HHS hands exchange control to insurers!

Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers

Department of Health and Human Services
Federal Register publication date: March 27, 2012

Final rule, Interim final rule.

Excerpts from pages 34-37

Summary of Regulatory Changes

If the Exchange is an independent State agency or not-for-profit entity established by the State, we proposed that its governing board meet the standards outlined in §155.110(c)(1) through §155.110(c)(4) of the proposed rule, which included: the Exchange accountability structure must be administered under a formal, publicly-adopted operating charter or by-laws; the Exchange board must hold regular public meetings; representatives of health insurance issuers, agents, brokers, or other individuals licensed to sell health insurance may not constitute a majority of the governing board; and, all members of the governing board must meet conflict of interest and qualifications standards.

Several commenters urged HHS to apply conflict of interest standards to eligible contracting entities.
 
Response: We generally defer to States to establish conflict of interest standards for eligible contracting entities beyond the prohibition of health insurance issuers being eligible contracting entities, as established in section 1311(f)(3) of the Affordable Care Act and codified in §155.110(a)(1)(iii). We believe that many States have existing conflict of interest laws, have appropriate expertise in this area, and can support Exchanges in the development of conflict of interest standards for such entities.

Commenters suggested broadening the list of groups identified as having a conflict of interest in proposed §155.110(c)(3)(ii) to include: health care providers; anyone with a financial interest; anyone with a spouse or immediate family with a conflict of interest; major vendors, subcontractors, or other financial partners of conflicted parties; members of health trade associations and providers; and, health information technology companies. Commenters recommended that such groups be limited or prohibited from participation in an Exchange. Other commenters recommended that individuals with ties to the insurance industry participate through technical panel or advisory group instead of through board membership.

Response: As proposed, §155.110(c)(3)(ii) ensures as a minimum standard that the groups with the most direct conflict of interest cannot form a majority of voting members on a governing board. We believe that further definition of conflict of interest may create inconsistencies with State law and other existing State standards, but note that Exchanges may expand the list or further define conflict of interest. For example, a State may elect to prohibit any conflicted members from serving on the board.

Final rule, Interim final rule. (644 pages):
http://www.kaiserhealthnews.org/~/media/Files/2012/Exchange%20Standards%20For%20Employers%20March%202012.pdf

HHS release:
http://www.healthcare.gov/news/factsheets/2011/07/exchanges07112011a.html

Reulatory impact analysis:
http://www.kaiserhealthnews.org/~/media/Files/2012/Exchange%20Regulatory%20Impact%20Analysis%20March%202012.pdf

Comment:

By Don McCanne, MD

Skim reading this 644 page HHS rule on the state insurance exchanges to be established under the Affordable Care Act makes you realize even more how unnecessarily complicated this legislation had to be merely to accommodate the private insurance industry. If you are suffering from euphoria, read this rule and it will cure you.

As everyone knows, the Affordable Care Act was written by and for the private insurance industry. Just to show how much the insurance industry’s influence extends into the Obama administration you merely need to look at the rule on the governing board composition and conflict of interest, to wit, “representatives of health insurance issuers, agents, brokers, or other individuals licensed to sell health insurance may not constitute a majority of the governing board.”

Absolutely astounding! The private insurance industry can occupy up to one-half of the seats on the governing board! Amongst all of the other members of the board, they need only one friend. Watching the reform process take place it is clear that they have friends everywhere!

During the comment period, many expressed concern about this obvious conflict of interest, suggesting even that insurers participate as an advisory group rather than through board membership. And HHS’s response? “We believe that further definition of conflict of interest may create inconsistencies with State law and other existing State standards.”

This is an outrage! Mobilize the forces!

Primary Care: Can Seeds Of Innovation Take Root?

By Thomas Bodenheimer
Health Affairs, March 2012

“Breaking Point: How The Primary Care Crisis Endangers The Lives Of Americans”
by John Geyman
Friday Harbor (WA): Copernicus Healthcare, 2011
234 pp.; $18.95

Many innovations in health care falter. New drugs, hastily approved, can disappear in a flurry of bad outcomes. Medical devices (some metal-on-metal hip replacements, for instance) turn into disasters for those who have them. Certain attempts to improve quality might be oversold and fail to live up to their initial hype; pay-for-performance comes to mind. In health policy, so-called tipping points[1]— times when new ideas spread rapidly to become the norm—are few and far between.

An innovation that “tipped” successfully into place in the recent past is the hospitalist movement, in which hospital-based general physicians handle care for hospitalized patients in place of the patients’ primary care physicians. It took the nation by storm in the 1990s and, for better or worse, changed the way both in- and outpatient care are delivered. Coming now to the innovation forefront is the patient-centered medical home—also known as “transformed primary care,” “twenty-first-century primary care,” and “the primary care of the future.”

John Geyman is someone whose opinion on this new innovation counts. In the 1970s he was one of the founders of the new specialty of family medicine, and he has enjoyed a long and productive career in his beloved primary care.

“Breaking Point,” Geyman’s new book about primary care, reviews the promise and problems of primary care. His analysis leads the reader to wonder whether the medical home will reach a tipping point (success) and permanently transform primary care or a breaking point (failure) and be a short-lived blip on the health policy radar screen. Despite the book’s title and recounting of the difficulties facing primary care, the author seems cautiously optimistic that primary care will grow and thrive. The book has a clear point of view, which is that a single-payer system is a prerequisite to a strong primary care sector. It is well written, informative, evidence-based— and an important book for everyone concerned about the U.S. health care system.

Geyman begins by reviewing the evidence base and essential elements of primary care—much of it on the basis of work by the field’s intellectual giant, the late Barbara Starfield[2]—and primary care’s role as the foundation of any health care system. From there, Geyman turns to the serious barriers facing primary care today in the United States: a growing physician workforce shortage in the area of adult primary care, poorly organized primary care practices, and the impossibility of primary care’s being able to provide accessible, high-quality care when doctors have overly large patient workloads.

But “Breaking Point” is not a despairing or complaining book. After laying out the challenges to building a viable primary care foundation for U.S. health care, Geyman goes on to highlight examples of the enormous energy for improvement that infuses hundreds, if not thousands, of primary care practices around the United States: “The Organized Team Model is ideal for building primary care capability to care for populations in a wide range of practice settings.…[It] offers concrete ways by which year round 24/7 primary care can be provided to populations on a sustained basis.” He continues, “Despite decades of deterioration, some promising developments portend a brighter future.”

This outpouring of innovation and energy that Geyman writes about leads primary care advocates like me to believe that the patient-centered medical home—by whatever name it is called—will, indeed, reach a tipping point and spread widely and well throughout the country.

The early adopters of transformed primary care are community health centers and integrated health care delivery systems. Programs such as the Vermont Blueprint for Health and Group Health in Washington State—both known for their improvements in access, prevention, and quality—are two of the innovations described by Geyman that are showing the way. Yet Geyman is cautious about innovation alone, noting that although “these new grassroots efforts to bring primary care into the 21st century give us some hope of their success, much broader system reform will be required to gain that result.”

His larger prescription includes single-payer universal health insurance, primary care teams, giving doctors a generalist orientation during their medical education, and payment reform. On the specifics of payment reform, Geyman argues that insurers’ payments to primary care practices should not reimburse doctors alone but should also should pay for the work of the entire team. Payments also should recognize primary care’s contribution equally with that of specialty practices.

Geyman does not provide details on how primary care practices might transform themselves. A useful addition to the book might have been a more detailed description of high-performing, well-organized practices—whether a small community health center in South Carolina or a huge integrated system in California—because they are remarkably similar in how they transform themselves.[3]

The bedrock needed for this transformation to succeed is continuity of care, which is well known to improve patients’ and clinicians’ satisfaction, improve quality outcomes, and reduce costs. Patients are affiliated with a specific primary care clinician (a physician, nurse practitioner, or physician assistant) within a group practice, and as often as possible they see that clinician, forming a relationship of trust that also improves outcomes.

Not only does this transformed primary care practice place a priority on continuity, it also ensures prompt access for patients. The capacity needed to meet the growing demand for primary care services is created by having a team—consisting of both professional and nonprofessional providers—deliver health care for a group of patients. In high-performing practices, patients transfer their trust in the doctor to trust in the entire team.

Yet, as Geyman emphasizes, these changes are not easy to accomplish; they require the larger system change cited earlier. “Breaking Point” provides information on both the promise and the challenges of primary care and then gives readers the confidence that transformed primary care can reach a tipping point and become the standard way in which primary care is provided in the United States.

Thomas Bodenheimer (TBodenheimer@fcm.ucsf.edu) is a primary care internist who was in full-time practice for thirty-two years. He is a professor of family and community medicine at the University of California, San Francisco.

NOTES

1 Gladwell M. The tipping point: how little things can make a big difference. Boston (MA): Little Brown and Company; 2002.

2 Starfield B. Primary care: balancing health needs, services, and technology. New York (NY): Oxford University Press; 1998.

3 Bodenheimer T. Lessons from the trenches—a high-performing primary care clinic. N Engl J Med. 2011;365:5–8.

doi: 10.1377/hlthaff.2011.1389

Regional health care approach is needed

By Alan A. Pfeffer and Richard Propp
Letters, Albany (N.Y.) Times Union, March 9, 2012

The Feb. 26 articles “State to reclaim patients” and “Superior care comes at a cost” demonstrate one of the misdirections taken by the state Medicaid Redesign Team.

The state knew that the needs of people on ventilators, people suffering from traumatic brain injuries and people with Huntington’s disease could not be met by the nursing homes within the state. Instead of first creating the needed special units that are required, it decided to try and “repatriate” them back into regular nursing homes.

This was done at the request of the Healthcare Association of New York State, a lobbying organization, so its clients will have a greater stream of business. We argue that people are not business commodities.

This situation would not exist if we had a national single-payer health care system where all people, regardless of their age, employment status or disability, have access to long-term care.

Plans for this were published by the Physicians for a National Health Program 20 years ago. Their plan called for a right to long-term care, universal coverage and a continuum of social and medical services aimed at maximizing functional independence.

The entire population would finance it. Instead, we are burdened with state rivalries rather than what we need, regional interstate consortiums.

Alan A. Pfeffer of Glenmont and Richard Propp of Albany are members of the Capital District Alliance for Universal Healthcare Inc.

http://www.timesunion.com/opinion/article/Letter-Regional-health-care-approach-is-needed-3395854.php#ixzz1ojFjhR8v

Health care 'reform' doesn't solve deep-seated problems

Single-payer system is better option for U.S.

By Bernie Fetterly
Ithaca (N.Y.) Journal, March 9, 2012

We know that the Affordable Health Care Act was written by the insurance companies for the insurance companies. It does not deal with the rising cost of health care and it increases under- insurance for just about everybody. Also, 23 million Americans will remain uninsured. Can we really wait two more years and still have a bad health care plan that will cause many to die needlessly and also cause many to go bankrupt?

President Barack Obama is trying to make his bad health care plan look good in his campaign for re-election. We may be forced to re-elect him, but we should not make the mistake of thinking his Affordable Health Care Act is a good one.

Unaffordable under-insurance

Americans are being confronted with the emergence of a new stage in America’s downward slide on health care. “‘Unaffordable under-insurance” is rapidly becoming the new standard in the United States.

One of the most telling symptoms of the “new normal” is that visits to physicians’ offices have dropped a stunning 17 percent from the second quarter of 2009 to the second quarter of 2011, according to a recent Kaiser Family Foundation report. This drop illustrates how the ever-growing burden of health care costs — in the form of out-of-pocket deductibles and co-pays — is making Americans reluctant to seek care despite having the supposed protection of health insurance. We know that a lot of people are foregoing beneficial treatments for conditions such as diabetes, or not getting vital preventive services such as Pap smears. It’s scary.

As people’s health conditions deteriorate because of a lack of preventive care, the eventual cost of treatment will be much more costly and the chances of a healthy outcome reduced. With high- deductible insurance plans proliferating among pattern-setting large employers, a pattern of unaffordable under-insurance will be well-established by the time the Affordable Care Act, which will include state-level health care exchanges, is fully implemented in 2014.

The various levels of coverage offered under the ACA will leave working families with the same problem of increasingly skimpy insurance coverage that is too expensive to actually utilize.

The “bronze plan” will have an “actuarial value” of 60 percent, meaning that people will be paying 40 percent of their health care costs. Government subsidies and maximums on out-of-pocket costs will provide some assistance, but it still appears that the “bronze plan” will mean that consumers pay about 40 percent.

“The silver plan” covers 70 percent (in other words, it does not cover 30 percent) of health care costs, but the premiums will be higher and most consumers will probably be drawn to the bronze plan. But there is little likelihood that health insurance premiums will remain stable under the bronze plan or any other option under the new federal legislation.

Even with usage of insurance declining, fueling huge profits, insurers in California and elsewhere have been jacking up premiums. Corporations have been able to force workers to swallow the premium increases, with workers’ share of health care costs rising 63 percent between 2003 and 2007. With no effective cost controls contained in the Affordable Care Act — which, after all, was drafted by Wellpoint insurance lobbyist Liz Fowler working alongside the insurers’ pets in Congress — the problem of “unaffordable under- insurance” is only going to snowball as we enter the new era of “reform.”

Disappointing so far

While the ACA has raised hopes that some of the worst abuses of the for-profit insurance industry will be curbed, most “improved Medicare for all” supporters caution that insurers are likely to circumvent regulations and that the ACA won’t be able to keep health care affordable.

The much-vaunted insurance regulations — for instance, ending denials on the basis of pre-existing conditions — are riddled with loopholes, thanks to the central role that insurers played in crafting the legislation. For example, the ACA’s program for people with pre-existing conditions has enrolled a mere fraction of those expected to sign up, as insurance remains prohibitively expensive.

Many single-payer (“improved Medicare for all”) supporters say we appear to be headed toward a new health crisis in which most people find themselves among the ranks of the “unaffordable under-insured” and health care is increasingly delivered in a rigidly tiered system based on ability to pay.

Poor people depending on Medicaid will be especially hard hit as the cash-strapped conservative governors and some Democrats slash Medicare and Medicaid rolls. The limitations of ACA-style reform — which the Obama administration chose to build around the mammoth and unproductive bureaucracy of the for-profit insurance industry — are becoming increasingly apparent.

Some of the most highly-touted features of the ACA features contain built-in problems, Physicians for a National Health Program leaders noted last year. For example, older people can be charged up to three times more than their younger counterparts, and large companies with a predominantly female workforce can be charged higher gender-based rates at least until 2017. Moreover, about 23 million people will remain uninsured nine years into ACA’s existence.

At the same time, the affordability and coverage of those with insurance will continue to deteriorate until the bottom 99 percent start to rebel against a health system shaped to maximize the profits of insurers who seek to minimize care. The Occupy movement offers a hopeful sign that Americans are recognizing that the health care system, like other U.S. institutions, functions to benefit the top 1 percent at the expense of the vast majority.

Health professionals from PNHP say the downward spiral in health care will finally end only when the United States installs a Canadian-style “Medicare for All” single-payer system. It is ideal for the United States, with its very large risk pool, which includes the rich, the middle class, the poor and the elderly. The solution is to have everybody involved and working together.

Hopefully, Obama will change once re-elected, but we don’t have to believe and should not believe that the Patient Protection and Affordable Care Act is a good health care plan for America. A single-payer plan is what we need; it’s a job stimulus and it saves billions of dollars. We can do better. We have to do better.

Bernie Fetterly is director of the Tompkins County Health Care Task Force.

http://www.theithacajournal.com/article/20120310/VIEWPOINTS02/203100307/Guest-Viewpoint-Health-care-reform-doesn-t-solve-deep-seated-problems

Health care ‘reform’ doesn’t solve deep-seated problems

Single-payer system is better option for U.S.

By Bernie Fetterly
Ithaca (N.Y.) Journal, March 9, 2012

We know that the Affordable Health Care Act was written by the insurance companies for the insurance companies. It does not deal with the rising cost of health care and it increases under- insurance for just about everybody. Also, 23 million Americans will remain uninsured. Can we really wait two more years and still have a bad health care plan that will cause many to die needlessly and also cause many to go bankrupt?

President Barack Obama is trying to make his bad health care plan look good in his campaign for re-election. We may be forced to re-elect him, but we should not make the mistake of thinking his Affordable Health Care Act is a good one.

Unaffordable under-insurance

Americans are being confronted with the emergence of a new stage in America’s downward slide on health care. “‘Unaffordable under-insurance” is rapidly becoming the new standard in the United States.

One of the most telling symptoms of the “new normal” is that visits to physicians’ offices have dropped a stunning 17 percent from the second quarter of 2009 to the second quarter of 2011, according to a recent Kaiser Family Foundation report. This drop illustrates how the ever-growing burden of health care costs — in the form of out-of-pocket deductibles and co-pays — is making Americans reluctant to seek care despite having the supposed protection of health insurance. We know that a lot of people are foregoing beneficial treatments for conditions such as diabetes, or not getting vital preventive services such as Pap smears. It’s scary.

As people’s health conditions deteriorate because of a lack of preventive care, the eventual cost of treatment will be much more costly and the chances of a healthy outcome reduced. With high- deductible insurance plans proliferating among pattern-setting large employers, a pattern of unaffordable under-insurance will be well-established by the time the Affordable Care Act, which will include state-level health care exchanges, is fully implemented in 2014.

The various levels of coverage offered under the ACA will leave working families with the same problem of increasingly skimpy insurance coverage that is too expensive to actually utilize.

The “bronze plan” will have an “actuarial value” of 60 percent, meaning that people will be paying 40 percent of their health care costs. Government subsidies and maximums on out-of-pocket costs will provide some assistance, but it still appears that the “bronze plan” will mean that consumers pay about 40 percent.

“The silver plan” covers 70 percent (in other words, it does not cover 30 percent) of health care costs, but the premiums will be higher and most consumers will probably be drawn to the bronze plan. But there is little likelihood that health insurance premiums will remain stable under the bronze plan or any other option under the new federal legislation.

Even with usage of insurance declining, fueling huge profits, insurers in California and elsewhere have been jacking up premiums. Corporations have been able to force workers to swallow the premium increases, with workers’ share of health care costs rising 63 percent between 2003 and 2007. With no effective cost controls contained in the Affordable Care Act — which, after all, was drafted by Wellpoint insurance lobbyist Liz Fowler working alongside the insurers’ pets in Congress — the problem of “unaffordable under- insurance” is only going to snowball as we enter the new era of “reform.”

Disappointing so far

While the ACA has raised hopes that some of the worst abuses of the for-profit insurance industry will be curbed, most “improved Medicare for all” supporters caution that insurers are likely to circumvent regulations and that the ACA won’t be able to keep health care affordable.

The much-vaunted insurance regulations — for instance, ending denials on the basis of pre-existing conditions — are riddled with loopholes, thanks to the central role that insurers played in crafting the legislation. For example, the ACA’s program for people with pre-existing conditions has enrolled a mere fraction of those expected to sign up, as insurance remains prohibitively expensive.

Many single-payer (“improved Medicare for all”) supporters say we appear to be headed toward a new health crisis in which most people find themselves among the ranks of the “unaffordable under-insured” and health care is increasingly delivered in a rigidly tiered system based on ability to pay.

Poor people depending on Medicaid will be especially hard hit as the cash-strapped conservative governors and some Democrats slash Medicare and Medicaid rolls. The limitations of ACA-style reform — which the Obama administration chose to build around the mammoth and unproductive bureaucracy of the for-profit insurance industry — are becoming increasingly apparent.

Some of the most highly-touted features of the ACA features contain built-in problems, Physicians for a National Health Program leaders noted last year. For example, older people can be charged up to three times more than their younger counterparts, and large companies with a predominantly female workforce can be charged higher gender-based rates at least until 2017. Moreover, about 23 million people will remain uninsured nine years into ACA’s existence.

At the same time, the affordability and coverage of those with insurance will continue to deteriorate until the bottom 99 percent start to rebel against a health system shaped to maximize the profits of insurers who seek to minimize care. The Occupy movement offers a hopeful sign that Americans are recognizing that the health care system, like other U.S. institutions, functions to benefit the top 1 percent at the expense of the vast majority.

Health professionals from PNHP say the downward spiral in health care will finally end only when the United States installs a Canadian-style “Medicare for All” single-payer system. It is ideal for the United States, with its very large risk pool, which includes the rich, the middle class, the poor and the elderly. The solution is to have everybody involved and working together.

Hopefully, Obama will change once re-elected, but we don’t have to believe and should not believe that the Patient Protection and Affordable Care Act is a good health care plan for America. A single-payer plan is what we need; it’s a job stimulus and it saves billions of dollars. We can do better. We have to do better.

Bernie Fetterly is director of the Tompkins County Health Care Task Force.

http://www.theithacajournal.com/article/20120310/VIEWPOINTS02/203100307/Guest-Viewpoint-Health-care-reform-doesn-t-solve-deep-seated-problems

Krauthammer and Kahn convinced; Salam wants to hear more

Columnist: If 'Obamacare' implemented, single-payer is next

By Don Finley
San Antonio Express-News, March 9, 2012

If President Obama’s health care reform act is fully implemented over the next two years, it will evolve into a Canadian-style single-payer system that will forever change the social contract between Americans and their government, a nationally syndicated columnist and physician predicted.

“It will change the country. If it is not repealed, we will be a different country when ‘Obamacare’ is fully implemented,” (Washington Post columnist and Fox News commentator Charles) Krauthammer said in an interview after speaking Thursday to a receptive crowd of mostly physicians and other health care professionals at a breakfast sponsored by the San Antonio Medical Foundation.

In his speech, Krauthammer predicted the complexity of the law eventually would doom it to failure, which would lead to a single-payer system within a decade.

“This is a new reform that when it kicks in within a couple of years will make the practice of medicine a nightmare,” he said. “If it’s not repealed, I guarantee you that within a decade we will have a single-payer system. And if I had to choose between Obamacare and a Canadian or British system, I’d choose the single-payer system. At least it would be rational.”

http://www.mysanantonio.com/news/local_news/article/Columnist-If-Obamacare-implemented-single-payer-3392700.php

And…

On the $1,000 Genome and the Future of Health Systems

By Reihan Salam
National Review Online, March 8, 2012

Back in 2009, I wrote a column that pivoted off of a really good 2007 column by economist Stephen Cecchetti which argued that the genomics revolution made single-payer inevitable. At the time, I argued that while the genomics revolution didn’t make single-payer inevitable, it would push health systems in the advanced market democracies towards a more coherent system for protecting against chronic illnesses and catastrophic medical expenditures.

Razib Khan, my go-to writer on these matters, adds the following: (Comments on the $1000 genome available at the link below)…

That is, the $1,000 genome will accelerate the growth of a broader innovative ecology that will transform medicine. Razib, incidentally, is a rare right-of-center supporter of single-payer health systems, and I’d love to hear his thoughts on the subject.

http://www.nationalreview.com/agenda/293003/1000-genome-and-future-health-systems-reihan-salam

Comment: 

By Don McCanne, MD

Many conservatives have a good understanding of the beneficial features of the single payer model of health care financing, and several believe that it may be an inevitable imperative. As Charles Krauthammer states, “And if I had to choose between Obamacare and a Canadian or British system, I’d choose the single-payer system. At least it would be rational.”

Paid-off medical bills can still ruin credit

Medical bills can wreck credit, even when paid off

By Carla K. Johnson
Associated Press, March 4, 2012

The Commonwealth Fund, a private foundation that sponsors health care research, estimates that 22 million Americans were contacted by collection agencies for unpaid medical bills in 2005. That increased to 30 million Americans in 2010.

Surprisingly, even after the bills have been paid off, the record of the collection action can stay on a credit report for up to seven years, dragging down credit scores and driving up the cost of financing a home. An estimated 3.4 million Americans have paid-off medical debt lingering on their credit reports, according to the Access Project, a research group funded by health care foundations and advocates of tougher laws on medical debt collectors.

Medical bills make up the majority of collection actions on credit reports, and most are for less than $250, according to Federal Reserve Board research.

Matt Ernst, a vice president at Mortgage Lenders of America in Overland Park, Kan., said medical collections frequently turn up on credit reports.

“We see a ton of them,” Ernst said. They have an impact on financing, he said, but even he didn’t realize how much until he learned that someone with a FICO score of 680 — which is considered good, but not excellent — will see their score drop up to 65 points because of a medical collection.

“I didn’t know a medical collection would hammer it that hard,” Ernst said.

It’s a problem for insured and uninsured alike. Outright billing mistakes, confusion over whether a claim will be paid by insurance and disputes between insurance companies and doctors — all can lead to medical bills being sent to collection agencies.

http://news.yahoo.com/medical-bills-wreck-credit-even-paid-off-183216201.html

Comment:

By Don McCanne, MD

In 2010, 30 million Americans were contacted by collection agencies for unpaid medical bills. Even if paid off, the resulting reduction in scores on credit reports often have serious negative financial consequences because of the perceived lower level of creditworthiness.

Imagine this occurring with a health care financing system that provides first dollar coverage, as with a single payer national health program. It wouldn’t. Bill collectors would be joining insurance administrators in trying to find more productive occupations that would provide greater value for our nation.

Recommend reading list for Angel-Relman-Schoen visit

Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance

Drug Companies & Doctors: A Story of Corruption by Marcia Angell, New York Review of Books, January 15, 2009

Big Pharma, Bad Medicine: How corporate dollars corrupt research and education by Marcia Angell, Boston Review, MAY/JUNE 2010

Your Dangerous Drugstore by Marcia Angell, New York Review of Books, June 8, 2006

Health Reform You Shouldn’t Believe In by Marcia Angell, American Prospect, April 18, 2008

Health Care: The Disquieting Truth by Arnold Relman New York Review of Books, September 30, 2010

How Doctors Could Rescue Health Care by Arnold Relman, New York Review of Books, October 27, 2011

In Dire Health by Arnold Relman, The American Prospect, January 13, 2012

Measuring The Health Of Nations: Updating An Earlier Analysis by Ellen Nolte and C. Martin McKee, Health Affairs, 27, no.1 (2008):58-71

Summary – Measuring the Health of Nations: Updating an Earlier Analysis prepared Deborah Lorber, Commonwealth Fund, January 2008

New 2011 Survey Of Patients With Complex Care Needs In Eleven Countries Finds That Care Is Often Poorly Coordinated by Cathy Schoen, Robin Osborn, David Squires, Michelle Doty, Roz Pierson, and Sandra Applebaum, Health Affairs, 30, no.12 (2011):2437-2448

How Health Insurance Design Affects Access To Care And Costs, By Income, In Eleven Countries by Cathy Schoen, Robin Osborn, David Squires, Michelle M. Doty, Roz Pierson, and Sandra Applebaum Health Affairs, 29, no.12 (2010):2323-2334

Electronic Health Records: A Study and Perspective

By Steve Lohr
The New York Times, Bits blog, March 6, 2012

I wrote an article in Tuesday’s New York Times, which was based on a study published Monday in the journal Health Affairs that casts doubt on the widespread claim that computerized patient records will cut health care spending.

The study found that doctors who were able to electronically track a patient’s recent imaging tests, like X-rays and MRIs, were more likely to order new imaging tests than doctors with paper records. That is sobering news for advocates of electronic health records, whose adoption is getting a big push from federal incentive payments to physicians.

But the study is another piece of evidence, among many, in the debate surrounding electronic health records. And it’s worth keeping in mind that the debate is really about the best way to adopt the technology, and at what pace — not whether moving from paper records to the computer age makes sense.

A lot of physicians complain that the advantages of electronic health records are oversold, and that they can be complex and confusing. Yet when well designed, the technology can improve the practice of medicine.

Dr. Danny McCormick, the lead author of the study, practices at the Cambridge Health Alliance, which made the switch to a modern electronic health record system in 2005.

As Dr. McCormick said at the end of The Times article, “I’m a primary care doctor, and I would never go back.”

So what to make of the new study in Health Affairs? First, there are limitations in the data set of more than 28,000 patient visits to more than 1,100 physicians in 2008 — limitations noted in the article. And the study did not address why physicians with computer technology were more likely to order tests, though Dr. McCormick suggested that the digital technology makes it easier to order and follow-up on tests, so they do more of it.

As I noted in the article, Dr. David J. Brailer, former national coordinator for health information technology in the Bush administration, questioned the conclusions of the study because they were based on a correlation in the data rather than a controlled test.

He elaborated in a paragraph cut from the article, reasonably, for space: Still, if a controlled test reached a similar conclusion, Dr. Brailer said he would not be surprised. “An electronic health record is only part of the solution,” he said. “The real gains come from improving the quality of the information that the doctor receives, so it is more accurate, complete and timely.”

Dr. Brailer’s comment suggests a larger point. An electronic health record is a tool, one that will be used by people in response to the incentives they are given. The American health care system is predominantly fee-for-service. Doctors and hospitals are reimbursed delivering more treatment, so we get more of everything — tests, surgeries, pills.

The drive to pay health providers based more on what economists call outcomes — healthier people — instead of inputs, like tests, is under way.

The big savings in American health care, most experts agree, will come from making sure people with chronic conditions like diabetes and heart disease, manage their conditions, stay healthy and out of hospitals. My colleague Reed Abelson recently wrote an article on programs to manage the care of the 1 percent of patients who account for 25 percent of health spending — nearly $100,000 a year each.

Most of these patients are complex cases, with several chronic conditions, seeing primary care physicians and specialists, taking a series of drugs. Managing those cases efficiently is nearly impossible without the information collection, monitoring and recommendations that a modern electronic health record makes possible.

Finally, two of the four co-authors of the study in Health Affairs are co-founders of Physicians for A National Health Program, which advocates a single-payer national health care system. They are Dr. Stephanie Woolhandler, a professor at the City University of New York School of Public Health at Hunter College, and Dr. David U. Himmelstein, also a professor at the CUNY School of Public Health at Hunter College.

In an interview last weekend, Dr. Himmelstein said, “For decades, there has been this hype about how computers were going to fix everything in health care. All those predictions have been wrong. It’s vaporware.”

If technology is not the answer, that can arguably strengthen the case for other solutions, like a single-payer system.

But Dr. Himmelstein’s and Dr. Woolhandler’s views on how to pay for health care seem to have no direct effect on the study, which was analysis of national data published in a peer-reviewed journal.

Besides, the evidence worldwide suggests that electronic health records are seen as part of the long-term answer to improving care and controlling costs, according to Dr. David Blumenthal, who stepped down last year as the Obama administration’s national coordinator for health information technology.

“There is not a single-payer system in the world that is not going all out to adopt electronic health records,” said Dr. Blumenthal, a professor at Harvard Medical School.

http://bits.blogs.nytimes.com/2012/03/06/electronic-health-records-a-study-and-perspective/

1 in 5 U.S. families say they struggle to pay medical bills

Half say they can’t pay a cent

By The Associated Press
The Washington Post, March 6, 2012

ATLANTA — A survey shows 1 in 5 Americans say their families are having trouble paying their medical bills. Worse, half of those who are struggling say they are unable to pay a single dime toward those debts.

The survey of 52,000 people was conducted by the Centers for Disease Control and Prevention from January through June of last year. It’s the first time the government agency has looked at the issue in such a comprehensive way.

Peter Cunningham, who studies the issue for an independent health policy research group, says it may be the largest such study ever done on the matter.

Lower-income people struggled the most. They were three times more likely to have difficulty paying their medical bills over the past year. It’s the first time the CDC has asked the medical debt question in its long-standing, in-person health survey, so there is no previous data to compare it with.

But another organization — the nonpartisan Center for Studying Health System Change, where Cunningham works — believes the number of people struggling with medical debt actually has been stable in the last five years.

The statistic of 1 in 5 who struggle with medical bills was reported by Cunningham and his colleagues in a smaller study in 2007 at the start of the recession. That figure remained the same in their 2010 survey, and that’s surprising since the ranks of the unemployed and uninsured grew by millions.

“As the number of uninsured increased, and there was higher unemployment, you’d expect that more people would report having problems paying medical bills,” Cunningham said.

However, he and other experts believe there’s something else at play here: Many Americans are likely just cutting back on doctor visits, prescription purchases and other health care spending.

http://www.washingtonpost.com/business/1-in-5-us-families-say-they-struggle-to-pay-medical-bills-half-say-they-cant-pay-a-cent/2012/03/06/gIQAdu9IvR_story.html

Online CDC report: http://www.cdc.gov/nchs/

Financial Burden of Medical Care: Early Release of Estimates From the National Health Interview Survey, January–June 2011

By Robin A. Cohen, Ph.D.; Renee M. Gindi, Ph.D.; and Whitney K. Kirzinger, M.P.H., Division of Health Interview Statistics, National Center for Health Statistics

The highlights of the study are as follows:

* In the first 6 months of 2011, 1 in 3 persons was in a family experiencing financial burden of medical care. One in 5 persons was in a family having problems paying medical bills, 1 in 4 persons was in a family paying medical bills over time, and 1 in 10 persons was in a family that had medical bills they were unable to pay at all.

• Chances of being in families having problems paying medical bills, paying medical bills over time, and having medical bills that could not be paid at all, decreased with age. Almost 24 percent of children aged 0–17 years were in families having problems paying medical bills compared with 21 percent of adults aged 18–64, 10 percent of adults aged 65–74, and 7 percent of adults aged 75 and over.

• Among persons under age 65, those who were poor and those who were near poor were more likely to be in families having problems paying medical bills and to have medical bills they were unable to pay at all than those who were not poor.

• More than 1 in 5 poor and more than one in five near poor persons under age 65 were in families that had medical bills they were unable to pay at all.

• Among adults aged 65 and over, those who were poor and those who were near poor were more than three times as likely as those who were not poor to be in families that had problems paying medical bills in the past 12 months.

For the full report:

http://www.cdc.gov/nchs/data/nhis/earlyrelease/financial_burden_of_medical_care_032012.pdf

More on the financial burden of medical care

Financial Burden of Medical Care: Early Release of Estimates From the National Health Interview Survey, January–June 2011

By Robin A. Cohen, Ph.D.; Renee M. Gindi, Ph.D.; and Whitney K. Kirzinger, M.P.H.
CDC, National Center for Health Statistics, March 2012

Previous work has shown that in 2010, more than one in five Americans were in families reporting problems paying medical bills. In 2011, three new questions addressing financial burden of medical care were added to the National Health Interview Survey (NHIS) Family component. These questions addressed problems paying medical bills, paying medical bills over time, and having medical bills that cannot be paid at all.

In the first 6 months of 2011, one in three persons was in a family experiencing financial burden of medical care. One in 5 persons was in a family having problems paying medical bills, 1 in 4 persons was in a family paying medical bills over time, and 1 in 10 persons was in a family that had medical bills they were unable to pay at all.

http://www.cdc.gov/nchs/data/nhis/earlyrelease/financial_burden_of_medical_care_032012.pdf

Comment: 

By Don McCanne, MD

This new report adds to the profusion of policy studies confirming that Americans continue to experience financial burdens in paying their medical bills. Unfortunately, this problem will not go away after the Affordable Care Act is fully implemented.

Well over 20 million people will remain uninsured, and perhaps a third or more of our population will be under-insured, due to the low actuarial value plans to be offered in the exchanges, and especially due to the increasing prevalence of high-deductibles in employer-sponsored plans. In fact, under-insurance likely will soon be the norm.

Contrast that with John Conyers’ HR 676, the “Expanded and Improved Medicare for All Act,” which states, “The health care benefits under this Act cover all medically necessary services… No deductibles, copayments, coinsurance, or other cost-sharing shall be imposed with respect to covered benefits.”

For those who say we can’t afford this, many other nations provide all of their people comprehensive care with no out-of-pocket expenses, at an average cost of only half of what we are spending on health care.

We can’t afford not to do it.