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Man Turns to Crime for Prison Health Care

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Man Turns to Crime for Prison Health Care

By ROBERT MACKEY
The Lede Blog, New York Times, June 20, 2011

As if conjured up by a presidential speechwriter to star in an anecdote about America’s dysfunctional health insurance system, James Verone, an unemployed 59-year-old with a bad back, a sore foot and an undiagnosed growth on his chest, limped into a bank in Gastonia, N.C., this month and handed the teller a note, explaining that this was an unarmed robbery, but she’d better turn over $1 and call the cops. That, he figured, would be enough to get himself arrested and sent to prison for a few years, where he could take advantage of the free medical care.

Just to make sure that no one was confused about his intentions, Mr. Verone made sure to let the teller know that he would be sitting on a couch in the bank, waiting for the police. Before he set out for the bank that morning, he also mailed a letter explaining his scheme to a local newspaper, The Gaston Gazette.

“When you receive this a bank robbery will have been committed by me. This robbery is being committed by me for one dollar,” the letter read. “I am of sound mind but not so much sound body.”

In a television interview last week with a local news station, WCNC, Mr. Verone explained that he was hoping for a three-year sentence, which would give him a place to live and free health care until he was old enough to collect a Social Security check and buy a condo on the beach. “I’m sort of a logical person and that was my logic, what I came up with,” he said.

According to Diane Turbyfill, a Gazette journalist who also interviewed Mr. Verone, there was one flaw in his cunning plan. “Because he only demanded $1, he was charged with larceny from a person,” not bank robbery, Ms. Turbyfill wrote. “Still a felony, the count doesn’t carry as much jail time as bank robbery.”

http://thelede.blogs.nytimes.com/2011/06/20/man-turns-to-crime-for-prison-health-care/

AMA 2011 Insurer Report Card

New AMA Health Insurer Report Card Finds Increasing Inaccuracy in Claims Payment

AMA
June 20, 2011

According to the AMA’s latest findings, commercial health insurers have an average claims-processing error rate of 19.3 percent, an increase of two percent compared to last year. The increase in overall inaccuracy represents an extra 3.6 million in erroneous claims payments compared to last year, and added an estimated $1.5 billion in unnecessary administrative costs to the health system. The AMA estimates that eliminating health insurer claim payment errors would save $17 billion.

Physicians received no payment at all from commercial health insurers on nearly 23 percent of claims they submitted. There are many reasons a legitimate claim may go unpaid by an insurer. Claims may be denied, edited or deferred to patients. During Feb. and March of this year, the most common reason insurers didn’t issue a payment was due to deductible requirements that shift payment responsibility to patients until a dollar limit is exceeded.

Metric 6: First ERA accuracy:

This metric measured the percentage of claim lines where the payer’s allowed amount was equal to the physician practice’s expected allowed amount. For this metric, it was necessary to obtain the actual contracted allowed amounts (i.e., fee schedule) for each claim line.

81.08% – Aetna
61.05% – Anthem Blue Cross/Blue Shield
83.02% – CIGNA
87.04% – Health Care Services Corporation
81.99% – Humana
88.41% – Regence
90.23% – UnitedHealthcare
96.19% – Medicare

AMA press release:
http://www.ama-assn.org/ama/pub/news/news/ama-health-insurer-report-card.page

2011 National Health Insurer Report Card:
http://www.ama-assn.org/resources/doc/psa/2011-nhirc-results.pdf

Methodology:
http://www.ama-assn.org/resources/doc/psa/2011-nhirc-methodology.pdf

Comment: 

By Don McCanne, MD

The private health insurance industry’s primary product that they are selling us is administrative services. How well are they doing? One-fifth of the claims that they process are in error. Medicare does better, but in using private billing contractors, their claims are still incorrect 4 percent of the time. We’re sure paying a lot to an industry that is doing such a lousy job.

Another finding that is buried in this report is that physicians received no payment at all from commercial health insurers on nearly 23 percent of claims they submitted. Think of the amount of administrative hassle involved here that is producing… nothing! The supposedly legitimate reasons for nonpayment include failure to meet the deductible, insurance policy has been cancelled, employer changed health plans, failure to use a network physician, services are not an included benefit, etc.

Under our current dysfunctional system of financing health care such denied claims are expected, as is the administrative waste entailed. But think of how it would be under a single payer system. None of these would be reasons to deny a claim. With everyone covered under one set of single payer rules, claims payment rate would be close to 100 percent.

Our current health care financing system is highly flawed, and the commercial insurers are incompetent. And we want more of this?!

"Financial toxicity" of cancer, and AHRQ's Effective Health Care Program

Oncologists confront "financial toxicity" of cancer care

By Pamela Lewis Dolan
American Medical News, June 20, 2011

The toxicity of chemotherapy and other drug treatments for cancer has extended beyond side effects such as nausea and nerve pain. It has now extended to a patient’s ability to pay the mortgage and buy groceries while undergoing care, said the author of a study looking at the financial impact of cancer treatment.

Amy Abernethy, MD, associate professor in the Division of Medical Oncology at Duke University Medical Center, helped write one of a handful of studies presented at the June meeting of the American Society of Clinical Oncology that found the rising cost of cancer care could impact treatment decisions and even lead to patients forgoing treatment because they cannot afford it.

The growing financial burden on those undergoing cancer treatment could put physicians in the position of prescribing treatments that could save their patients’ lives but force them into bankruptcy, poverty or even homelessness — if they could scrape up the money to receive the treatment in the first place. This is especially troubling given the fact that advancements are being made in cancer treatments that could lead to much higher survival rates.

Another study presented at the ASCO meeting was published online June 5 in The New England Journal of Medicine. It found that the experimental drug vemurafenib and the newly approved Yervoy (ipilimumab) can improve survival rates for patients with advanced melanoma, a population that hasn’t had many treatment options in the past. Yervoy will cost $120,000 for a four-dose treatment at $30,000 per dose.

“The move toward increased cost-sharing in high-deductible health plans, increased premiums and tiered formularies all shift the cost burden to patients and force them to make day-to-day decisions on how to integrate health care costs with other discretionary spending,” said (Neal Meropol, MD, chief of the Division of Hematology and Oncology at Case Western Reserve University School of Medicine).

A study conducted by researchers at the Fred Hutchinson Cancer Research Center in Seattle found that as cancer patients’ survival time increases, so do the chances they will declare bankruptcy. Researchers compared U.S. Bankruptcy Court records to cancer registry data from nearly 232,000 adult cancer survivors in western Washington over 14 years. They found that, on average, bankruptcy rates quadrupled within five years of a cancer diagnosis.

http://www.ama-assn.org/amednews/2011/06/20/bil20620.htm

And…

Effective Health Care Program

Agency for Healthcare Research and Quality

The Effective Health Care (EHC) Program partners with networks of researchers and clinical teams across North America, using input from stakeholders throughout the process of comparative effectiveness research, translation, dissemination, and implementation of research findings.

In 2010, AHRQ used funding from the American Recovery and Reinvestment Act of 2009 (ARRA) to establish two important Program initiatives:

* Community Forum to improve and expand public and stakeholder engagement in AHRQ’s comparative effectiveness research and EHC Program.
* Healthcare Horizon Scanning System to identify new and emerging issues for comparative effectiveness review investments.

These initiatives contribute to the work of these Program components:

* Individual investigators and their research groups at academic institutions and other research centers generate new evidence from original research.
* The Evidence-based Practice Centers (EPCs) perform in depth reviews of existing evidence.
* The DEcIDE (Developing Evidence to Inform Decisions about Effectiveness) Research Network gathers new knowledge on specific treatments and health care services.
* The Centers for Education & Research on Therapeutics (CERTs) conduct research and educate clinicians and consumers about drugs, biologicals, and medical devices.
* The Scientific Resource Center provides scientific support for the EHC Program.
* The John M. Eisenberg Center for Clinical Decisions and Communications Science organizes the research results into guides and tools that are useful to clinicians, health care policymakers, and patients.
* The Stakeholder Group provides different perspectives on the EHC Program from individual members of the Group.

http://effectivehealthcare.ahrq.gov/index.cfm/who-is-involved-in-the-effective-health-care-program1/

Comment: 

By Don McCanne, MD

Having cancer and facing the agony of treatment is bad enough without also having to face the financial burdens of treatment. As this and many other reports show, “financial toxicity” can seriously impair the ability to meet other basic needs, and may even result in personal bankruptcy.

We do need some reassurance that the costs and adverse effects of the treatments are worth the benefits provided. We shouldn’t use as our sole source of information an industry that might be reluctant to communicate the full downside of their treatments when that information might reduce their very lucrative profits.

Fortunately, we do have a good start on becoming more informed in our choices for health care. The Effective Health Care Program of the Agency for Healthcare Research and Quality (AHRQ) is providing us with comparative effectiveness and evidence-based research that can be very useful in our clinical decision making. However, we do need to move further forward and use this information to make coverage decisions, certainly to eliminate coverage of detrimental health care, and also to eliminate coverage of care that the overwhelming preponderance of information reveals is not beneficial.

We also need to negotiate the best pricing based on legitimate costs and fair profits, and begin to make decisions on tolerance thresholds for health care payments. Everyone would agree that we can’t use our collective funds to pay say $10 million for a treatment program that would extend the life of one person by three weeks, but with the very high prices that are being introduced, we will have to begin to struggle with cost-effectiveness determinations at levels that we find to be tolerable.

Once we are armed with the very best information, we should use that to obtain the highest quality care that’s feasible for each and every individual with health care needs. We should eliminate “financial toxicity” by providing first dollar coverage for not just cancer patients but for all patients who already have enough burdens heaped upon them without having to face onerous financial burdens as well.

Considering a single-payer model for health reform

By Aldebra Schroll, M.D.
KevinMD.com blog at MedPage Today, June 17, 2011

The Patient Protection and Affordable Care Act is in the process of being rolled out, however many questions remain.

Will it guarantee universal coverage? Will it stand up to the many court challenges? The private insurance industry will receive an estimated 400 billion in taxpayer money to subsidize the purchase of these plans. Is this the best way to spend our money?

Many of us in the health field remain skeptical of the program. The Physicians for a National Health Program estimate that approximately 23 million people will remain uninsured. Many more will find themselves underinsured with high co-payments and deductibles. They will have insurance coverage that still leaves them at risk of financial ruin in the event of serious illness. Medical expenses are now a leading cause for personal bankruptcy, often occurring in families that have health insurance. It simply does not offer them adequate coverage.

America spends $2.4 trillion a year on our health care expenditures, more than any other advanced country. Yet this higher spending does not translate into better health status. Americans have a lower life expectancy, higher infant mortality and poorer access to care when compared to most industrialized nations. In a 2002 report, the Institute of Medicine estimated that eighteen thousand patients die annually due to a lack of health insurance.

Where does all the money go? The private insurance health plans consume approximately thirty percent of their expense in administrative costs, profits and CEO salaries. These costs do not directly benefit the patients, instead keeping insurance unaffordable for many Americans.

One reform proposal gaining momentum across the nation is single payer health. Vermont recently passed a single-payer plan after their legislature commissioned Harvard economist Dr. William Hsiao. His analysis determined that a single-payer model would be 25 percent cheaper than continuing the current model that depends heavily on private insurers. In signing the bill, Vermont Governor Peter Shumlin emphasized health care as a right, not a privilege; a feeling shared by many of us working in the front lines of health care.

Under a single-payer plan, physicians and other health care institutions would operate independently and collect payments from a single entity, which would significantly reduce the expense and challenges of collecting from a variety of payers. It would also reduce the administrative costs and the profits that motivate major insurers.

This model was not seriously considered during the national health reform discussions. The tide is turning however; recent surveys of physicians have found 59 percent favor a national health insurance plan. As we continue to move forward on the path of reform, it is crucial we understand where we have been and consider all our options, including the single payer model.

Aldebra Schroll is a family physician.

http://www.kevinmd.com/blog/2011/06/single-payer-model-health-reform.html

Single-payer coverage eyed in New York State

By Douglas Turner
The Buffalo News, June 20, 2011

WASHINGTON — Conservative House Republicans, flush from their 2010 victory over the perceived overreach of the Obama health care law, flooded the Capitol with heroic-sounding legislation last winter.

The titles include the No Taxpayer Funding for Abortion Act, the Reclaiming Individual Liberty Act and my favorite, the Revoke Excessive Policies that Encroach on Individual Freedom Act. There are scores of these ideological bills, most written by health insurance lobbyists or special interest groups. None will become law this session because of the Democratic-controlled Senate and President Obama.

Momentum is moving in a very different direction in liberal Vermont, and maybe in New York State. A month ago, Vermont Gov. Peter Shumlin signed a law that will create a single-payer health care system, parallel to Canada’s.

In New York, Assemblyman Richard Gottfried, D-Manhattan, has introduced legislation creating a single-payer plan for all residents of the state. Gottfried is Health Committee chairman. His bill has more than 60 Assembly and Senate co-sponsors. Among them are Democratic Assembly Members Sam Hoyt, Crystal Peoples-Stokes and Mark F. Schroeder, of Buffalo.

The bill creates the State Health Plan, which would become an authority, drawing revenues from the State Health Trust Fund. The fund would get its money from federal and other funds already going to the state from Medicaid and other sources, plus new payroll taxes. The payroll taxes would be 2 percent on employees, 8 percent on employers and 10 percent on the self-employed. Private health insurance premiums now are about 22 percent to 25 percent of payroll.

New York and Vermont have this in common — both states have a much higher share of their residents covered by either Medicare or Medicaid. In New York, it’s 41 percent and in Vermont, it’s 43 percent, according to the Kaiser Family Foundation. Nationally, the number is 34 percent. The Kaiser data is two years old, so the percentages of public coverage are probably much higher now.

“We can get better coverage, get all of us covered and save billions by having New York provide publicly sponsored single-payer health coverage,” Gottfried said.

He said this may be the closest New York could get to an economic silver bullet, making the state much more “job friendly” by eliminating the need for employers to pay for health insurance.

Right now, the state is in the cellar as a place to do business. Health care costs are at least 16 percent of all goods and services produced statewide, or nationally. Most other industrialized nations spend 8 percent to 10 percent on health care and get better quality.

More importantly, a single-payer system would provide coverage for individuals, as more and more private employers say they are planning to end paying for this defined benefit when the weaker federal plan becomes effective in 2014.

Gottfried’s bill has miles to go before becoming law.Gov. Andrew M. Cuomo has no known position on it. Cuomo was by turns friendly and critical of the insurance industry as attorney general. The bill at least has early strong support from some Democrats from across the state.

In Congress, most Democrats are scared to death of the term “single-payer.” This is because of the propaganda blanket the insurance industry has spread over Washington, huge amounts the health business invests in elections, and the infiltration of ultra-rightists into the national tea party movement.

The Commonwealth Fund notes that Sen. Bernie Sanders, IVt., has a bill calling on all states to create a single-payer system. It has no co-sponsors. Only veteran Rep. John Conyers, D-Mich., has introduced a comprehensive federal single-payer bill called Medicare for All. Among the 60 co-sponsors of the bill, six are from New York; but none from Erie-Niagara.

dturner@buffnews.com

http://www.buffalonews.com/editorial-page/columns/douglas-turner/article460758.ece

Universal health care for New York?

By Trevor T. Alford
The Legislative Gazette (Albany, N.Y.), June 13, 2011
  
Looking to follow in the footsteps of Vermont, which passed legislation May 26 leading toward a single-payer health care system in that state, two lawmakers are pushing for the adoption of a public health option in New York.

Sen. Thomas Duane and Assembly Health Committee Chairman Richard Gottfried were joined at a press conference June 7 by a number of advocates who support a single-payer health care system. Physicians, nurses, religious leaders and labor representatives all appeared with the lawmakers to support legislation they are sponsoring to create a publicly funded and government-managed health care system in New York state.

Their bill (S.5425/A.7860) would enact the New York State Health Plan, which would create a single, government-run agency to oversee the financing of health care throughout the state. On May 19, the bill was referred to the Senate Finance Committee and to the Assembly Health Committee.

The bill has been introduced by Gottfried, D-Manhattan, in every consecutive session since 1992, the only year it passed in the Assembly. It was first picked up in the Senate by New York’s Attorney General Eric Schneiderman in 1999 when he was a state senator. Duane, D-Chelsea, has stepped up in Schneiderman’s absence.

“Let’s see whether a public option can compete with private insurance,” said Duane. “We believe a public option will be cheaper and more efficient and provide better health care. The private sector says that’s not true, but you know what, we’re willing to compete.”

“Our current health care coverage system is overwhelmingly accountable to insurance company stockholders,” said Gottfried. “We think we can do a whole lot better if it is accountable to the public.”

Duane says New York already engages in single-payer insurance through programs such as Medicare and Child Health Plus, which New Yorkers pay into and get health care as a result.

“Public health care already exists in our state and in our nation,” said Duane. “There’s nothing to be feared. In fact the great experiment would be to let us compete against private insurers, and I think we’ll stand up and do better.”

The legislation would establish the New York Health Plan as a public-benefit corporation and establish the New York Health Trust Fund, which would provide the funding for health care costs.

State and local money from Medicaid and Medicare would be pooled into the fund, along with payroll premiums — 8 percent by the employer and 2 percent by the employee — and any funds that previously went into health-based services that would be covered by the single-payer health plan.

According to the sponsors, removing private insurance companies from the system would free up more than $5 billion in the health care system currently used to pay for administrative positions and for the billing and collecting of debt for hospitals.

“This legislation is not just slapped together,” said Dr. Garrett Adams, the national president of Physicians for a National Health Program. “I looked at it, and it’s very carefully thought out. The bottom line — the best part of it is — it will help New York people, it will help everyone.”

Laurie Wen, the executive director of the New York Metro Chapter of Physicians for a National Health Program, said the physicians from her local chapter are stifled by the insurance companies.

“The No. 1 complaint I hear from my physician members is ‘my hands are tied,'” Wen said. “The private insurance industry will not let me do the job I was trained to do. I went to medical school to help people, to treat people, to give them care, but I spend all my time fighting the insurance industry doing paperwork, and my patients come in much sicker than they need to be.'”

According to Shaun Flynn, director of governmental affairs of the New York State Nurses Association, nurses have come to the conclusion that single-payer health care is necessary to control escalating costs for their patients.

“One of the things that we’ve found in talking with our members who interact with patients every day is that there’s a common theme here,” Flynn said. “Over the last decade people have seen the value of their health insurance coverage diminish while their costs have skyrocketed.”

Omar Kutty, a spokesman with Healthcare NOW! of New York City, says popular opinion polls in the United States should be an indication of the wide support for a single payer system.

“Single payer, or the concept of single payer, consistently polls at over 50 percent. We can assume that in a blue state like New York it has considerably higher support than that,” Kutty said.

In July 2009 a poll taken by the Kaiser Family Foundation, which researches health trends, found that 58 percent of those polled supported a “Medicare-for-all” program, while 38 percent opposed such a measure. This poll surveyed 1,205 Americans and has a margin of error of 3 percentage points.

The Rev. Harlan E. Ratmeyer, pastor of the First Reformed Church of Bethlehem and manager of the Department of Pastoral Care at Albany Medical Center, spoke about the inappropriateness of private insurance companies being involved in medicine.

Ratmeyer said he believed that medicine has been taken a hold of by “some forces that really distort the joy of medicine and the vocation of medicine. It all turns into business and profit margins.”

“This is a no-brainer for labor because one of the first things you do in contract negotiations, is negotiate against yourselves,” said Wayne Bayer, a representative of the Public Employee Federation. “What do you want, a better wage or do you want health care benefits? This would take health care benefits off the table.”

Bayer also said such a bill would free up entrepreneurs to leave a job and pursue independent careers because they would no longer need to fear losing their employee health coverage.

http://www.legislativegazette.com/Articles-c-2011-06-13-78267.113122-Universal-health-care-for-New-York.html

British fear 'American-style' healthcare system

As leaders debate ways to reform healthcare, politicians repeatedly tell a worried public that Britain will not turn the National Health Service into an 'American-style' private system.

By Henry Chu
Los Angeles Times, June 13, 2011

LONDON — Two years ago, Britons were outraged when U.S. politicians like Sarah Palin, in the debate over healthcare reform, turned this country’s National Health Service into a public whipping boy, denouncing it as “evil,” “Orwellian” and generally the enemy of everything good and true.

It’s time for some payback.

Britain is now embroiled in a healthcare argument of its own, prompted by a proposed shake-up of the NHS. And the phrase on everyone’s lips is “American-style,” which may not be as catchy as the “death panels” that Palin attributed to socialized medicine but which, over here, inspires pretty much the same kind of terror.

Ask a Briton to describe “American-style” healthcare, and you’ll hear a catalog of horrors that include grossly expensive and unnecessary medical procedures and a privatized system that favors the rich. For a people accustomed to free healthcare for all, regardless of income, the fact that millions of their cousins across the Atlantic have no insurance and can’t afford decent treatment is a farce as well as a tragedy.

But critics here warn that a similarly bleak future may await Britain if a government plan to put more power in the hands of doctors and introduce more competition into the NHS succeeds — privatization by stealth, they say.

So frightening is the Yankee example that any British politician who values his job has to explicitly disavow it as a possible outcome. Twice.

“We will not be selling off the NHS, we will not be moving towards an insurance scheme, we will not introduce an American-style private system,” Prime Minister David Cameron emphatically told a group of healthcare workers in a nationally televised address last week.

In case they didn’t hear it the first time, Cameron repeated the dreaded “A”-word in a list of five guarantees he offered the British people at the end of his speech.

“If you’re worried that we’re going to sell off the NHS or create some American-style private system, we will not do that,” he said. “In this country we have the most wonderful, precious institution and also precious idea that whenever you’re ill … you can walk into a hospital or a surgery and get treated for free, no questions asked, no cash asked. It is the idea at the heart of the NHS, and it will stay. I will never put that at risk.”

Cameron’s eagerly declared devotion to the NHS illustrates the totemic role it plays in British society, an institution so cherished that some describe it as the closest thing here to a truly national religion. Created in 1948, as the country struggled to rise from the ashes of World War II, the NHS is widely hailed as the welfare state’s biggest triumph.

Since then, it has bloomed into a behemoth that gobbles up nearly $170 billion a year in taxpayer money — an amount set to grow along with Britain’s aging population — and is one of the nation’s largest employers.

Governments of all stripes have taken office pledging to reform the system, to streamline it and make it more efficient, but none has fully succeeded, knowing that they tinker with the NHS at their peril. The current Conservative Party-led coalition, which has embarked on the most radical public spending cuts in a generation, has promised not to take a penny from the health service.

To each other, Britons love to complain about the NHS, retailing gruesome tales of substandard care, of long waiting lists for simple operations like hip replacements, of snotty surgeons and naughty nurses. But when Americans began citing the NHS as the epitome of socialized medicine gone wrong, people here bristled.

Fear that Britain is becoming more like the U.S. extends beyond healthcare. “American-style” is also the epithet of choice to describe the direction of Britain’s higher-education system.

To make up for lost state funding, many public universities, including Oxford and Cambridge, have decided to take advantage of a new law allowing them to charge students a maximum of $14,750 in annual tuition, nearly triple the current price tag. Shelling out huge sums for college may be part of the American way, but Britons don’t like it.

Last week, well-known philosopher A.C. Grayling caused a stir by announcing the creation of a private university, featuring top British and U.S. academics, that will charge nearly $30,000 a year.

There have also been demonstrations over the proposed NHS overhaul. Britons are so uneasy about the changes that a sheepish Cameron was forced to put them on hold and ordered his ministers to go on a two-month listening tour to hear out voters.

“We recognize that many people have had concerns about what we were doing,” Cameron said. “This has been a genuine chance for people … to work together to strengthen the institution we all love and hold dear.”

The results of the review, and the government’s expected concessions, are to be unveiled this week.

The changes will be debated in the public arena and fought over in Parliament. Doctors’ groups will no doubt say one thing, patients’ advocates another. In the end, lawmakers will probably approve a messy healthcare compromise that will anger many and please few.

Which just goes to show that maybe Britain and America aren’t so different after all.

henry.chu@latimes.com

http://www.latimes.com/health/la-fg-britain-health-care-20110613,0,1237142.story

Delaying Medicare eligibility is bad for health

By Austin Frakt and Aaron Carroll
The Incidental Economist, June 10, 2011

By now most of the blogosphere has weighed in on Joe Lieberman’s idea of increasing Medicare eligibility from age 65 to 67 (see Frakt, Klein, Volsky, Drum, Krugman). Most of the focus has been on how the delayed eligibility will affect overall health costs. Though federal costs may go down, overall costs would not, because most would just be shifted to seniors themselves. Cost isn’t everything, though. There’s something else delay would do: harm health.

This is not guesswork on our part; there’s clear evidence in the literature. In several papers, Michael McWilliams and colleagues found that utilization, spending, and outcomes for age-eligible Medicare beneficiaries differed for those who had been uninsured prior to turning 65 vs. those who had been insured. Their work was based on survey data, sometimes merged with Medicare claims. This is a relatively strong analytic approach since it exploits a discontinuity in coverage that potentially applies to nearly all individuals: the vast majority of the population enrolls in Medicare at age 65.

The authors found that, relative to those with insurance before age 65, those without insurance prior to Medicare eligibility spent much more money on health care after they became Medicare eligible. In other words, people wait to get care until their Medicare kicks in.  This is bad both for health and for the federal government’s bottom line.

Delaying Medicare even longer would likely make this worse. People would forego care longer, health would suffer, and Medicare would pay for the consequences later.

Here’s the evidence in charts, extracted from McWilliams et al.’s papers (references listed at the end). First, from [1], we see that after age 65, uninsured adults with (chart A) and without (chart B) hypertension, heart disease, stroke, or diabetes all have a significant and improved change in trend in health status after obtaining Medicare. Insured adults, however, do not experience a change in trend. Medicare improved the health of the uninsured; delaying Medicare would delay that help.

Next, from [2] we see a similar phenomenon in doctor visits. Relative to the insured, those uninsured prior to age 65 visit the doctor more after obtaining Medicare eligibility.

From the same paper ([2]), here are the results on hospital admissions.

This shouldn’t surprise anyone. It makes sense. It’s hard to get affordable insurance as you approach age 65. If you’re lucky enough to have insurance, then you’re getting the care you need, so getting Medicare is nice, but not a huge change in your life. If you’re uninsured, though, then getting Medicare is a huge change. If you know you need care, and it’s expensive, then you will likely try and wait until the Medicare kicks in to get it. People do this all the time; the evidence above confirms it.

Raising the eligibility age will just force these people to wait longer.* If this somehow saved us money, then we suppose you could have a debate about its benefits and harms. Knowing that it will likely cost Medicare more, however, means that it’s entirely possible that delaying Medicare eligibility will cost more and lead to worse outcomes. That’s the worst of both worlds.

* McWilliams et al.’s analysis does not take into consideration the effect of health reform. Provided it stays on the books, the non-elderly will have different options in 2014. Still, the analysis shows the value of health insurance, and in particular of universal coverage.

References

[1] McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Health of previously uninsured adults after acquiring Medicare coverage. JAMA. 2007;298:2886-94.

[2] McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Use of health services by previously uninsured Medicare beneficiaries. N Engl J Med. 2007;357:143-53.

http://theincidentaleconomist.com/wordpress/delaying-medicare-eligibility-is-bad-for-health/

Nurses Union Keeps Pressure On Health Care Overhaul

By Jessica Marcy and Shefali S. Kulkarni
Kaiser Health News, June 10, 2011

Nurses converged on Washington in their fight against Wall Street this week.

Hundreds of nurses from across the country rallied to support broader access to health care and to call for higher taxes on corporations and the wealthy.

They gathered Tuesday near the White House and then picketed the U.S. Chamber of Commerce with large red banners that read: “RNs say Heal America, Tax Wall Street.” National Nurses United, the nation’s largest nurses union, sponsored the event to promote its “Main Street Contract for the American People,” a campaign that broadly calls for improved living conditions, including guaranteed health care, better wages and quality education.

They plan to rally on Wall Street later this month.

In response to the Washington rally, Blair Latoff, director of communications for the U.S. Chamber of Commerce, released the following statement: “The Chamber welcomes all voices to the debate, but the debate has to remain focused on creating American jobs and keeping our economy growing. Right now U.S. businesses are saddled with one of the highest corporate tax rates in the world, which is undercutting our global competitiveness.”

Some nurses spoke about the need for improved working conditions by increasing pay and enforcing adequate nurse-patient ratios. Many held signs that read: “I am a patient advocate” and “Medicare for all.” Participants finished the rally by gathering at a park near the Capitol, where Sen. Barbara Boxer, D-Calif., spoke about the need to protect Medicare and Sen. Bernie Sanders, I-Vt., told the crowd of red-shirted nurses that the nation needs a single payer system like that recently promoted in his own state.

Rose Ann DeMoro, executive director of National Nurses United, suggested that nurses offer a unique perspective on the struggles that patients and their families face because of the direct care they provide. “Everywhere the fallout of this system is felt, and it’s felt and experienced by the registered nurse,” she said.

Sue Gray, 51, who has been a nurse for more than 30 years and cares for cardiac surgery patients at Minneapolis Children’s Hospital, says that her own experience as a cancer patient has given her insight into the financial and emotional pressures that patients and their families experience. Diagnosed with breast cancer 12 years ago, Gray continues to work two days a week despite her cancer, which returned five years ago and has spread to her liver and bones. She does so to provide financial support and health insurance to her self-employed husband and three children.

“We really need to get some type of universal health care so that people going through my situation or families that I see at work that are struggling don’t have to worry about not getting health care,” Gray said.

Web version includes slideshow and audio of nurses’ demonstration in Washington: http://www.kaiserhealthnews.org/Slide-Shows/2011/National-Nurses-United-Washington.aspx

Request for candidates for Green Mountain Care Board

Most of you are aware of the important role that Deb Richter has played in advancing health care reform in the state of Vermont, where every effort is being made to bring Vermont in compliance with the policies and goals of a single payer system. The road in that direction has been rough and challenging, but that has not stopped the dedicated advocates of reform from moving forward.

Deb Richter is a member of the nominating committee for the Green Mountain Care Board. She has asked me distribute the following notice. Many members of this list either are or know people who are highly qualified to serve on this board. Applicants do not have to be Vermonters.

This is a great opportunity for qualified, dedicated individuals to contribute to these groundbreaking efforts to advance health care justice.

GREEN MOUNTAIN CARE BOARD MEMBER

State of Vermont
 
The State of Vermont is seeking candidates for the independent, five-member, Green Mountain Care Board that was established by Vermont’s landmark health care health reform law. The Board consists of a full-time Chair and four members. 
 
Vermont’s health care reform law (Act 48, 2011 Session) sets out a process to move the state through several stages of health care system change leading to a publicly financed, universal health benefits program, Green Mountain Care, by 2017. When completed, the program will provide affordable access to high quality health care for all Vermonters, separate from their employment.
 
Board members will be exempt state employees. The Chair, who will be responsible for leading the process, will be a full time employee and will be paid $122,866. Side members will be .8 FTE (32 hours) and will be paid $81,910. Required qualifications can be found in the job description below. The Governor will make appointments to the Green Mountain Care Board by October 1, 2011 from a list of qualified candidates submitted to him by the Nominating Committee. 
 
How to Apply
To obtain a complete job description, application form and find complete details about the application process, please visit:
http://humanresources.vermont.gov/GMCB_Search
 
Completed applications must be received no later than 2:00 p.m. on July 11, 2011.

Green Mountain Care Board Member Search:
http://humanresources.vermont.gov/GMCB_Search

Green Mountain Care Board Member Job Description:
http://humanresources.vermont.gov/sites/dhr/files/pdf/GMCB%20Job%20Description.pdf

Application for Candidates for Green Mountain Care Board:
http://humanresources.vermont.gov/sites/dhr/files/pdf/APPLICATION%20FOR%20GMCB%20CANDIDATES.pdf

(Although this is not an official message from PNHP, it is being distributed nevertheless because the Vermont effort represents significant progress towards the goal of achieving health care justice for all – a goal we share with the Vermont organizers. PNHP will continue its mission of advocating for a single payer national health program, without compromise.)

The Coming Crash Of The American Health Care System

By Rick Ungar
Forbes on-line, Jun. 9 2011

The American health care system, as we currently know it, is well into its final days.

Don’t get too excited, conservatives. It’s not Obama’s fault. Likewise, the final death throes of the status quo will not be the doing of Paul Ryan Medicare plan.

Indeed, none of this inevitability will be the result of the drama we Americans so love to inject into our politics.

It’s about the end of a business model that really hasn’t worked very well for at least a decade coupled with government’s responsibility-for better or for worse- to step in and provide essential services when nobody else can do so.

With all the complaining about Obamacare, social entitlements, etc., the truth is that government and private health insurers have played a cooperative role in how health care has been delivered to most Americans for nearly half a century.

In the process, they have learned how to regulate one another.

Private health insurers have kept government in check by spreading around huge sums of cash to fund political campaigns in order to get elected officials to do their bidding. When, from time to time, the public outcry against private health insurance’s abuses overwhelmed a politician’s ability to turn a blind eye, government imposed the occasional regulation to keep insurers from their most offensive practices.

But let’s not kid ourselves. The insurance companies have always been in the driver’s seat.

That’s about to end – not because public sentiment is deeply in favor of turning all health care over to the government, but because the private insurance companies no longer really care.

This from a recent Kaiser Family Foundation report –

Here’s one change few were talking about when the health overhaul law passed: It’s sent insurers – worried the law could stunt profits and growth – looking for new types of business.Where are they investing? In less-regulated companies that could yield strong profits and make the main business – insurance – more lucrative. The purchases also could increase insurers’ control over more parts of the health system.

Insurers have moved into technology, health-care delivery, physician management, workplace wellness, financial services and overseas ventures in wide-ranging efforts to mitigate the new rules imposed by the law. Since June 2009, seven of the nation’s largest insurers have made 25 major deals, and only six of those acquisitions run health plans, according to an analysis of data collected by FactSet Research Systems, a private company. At an investors meeting in February, Rick Jelinek, UnitedHealth Group’s top executive for emerging businesses, said the company’s future growth would be in services that are “much less regulated” than insurance plans.

In 2010, UnitedHealth Group bought ChinaGate, which helps bring medical treatments to market in China; Picis, a technology vendor specializing in clinical and financial management systems for hospital emergency departments and intensive care units; the medical screening company Wellness; and six other firms. In December, Aetna acquired Medicity, a business that helps hospitals share patient information. The federal government will reward hospitals and doctors with more than $30 billion in increased Medicaid and Medicare payments by 2015 for adopting electronic medical records, but only if they can share their data. Also in December, Humana bought Concentra, a Texas-based urgent- and occupational-care provider with clinics in 40 states. More than one-third of Humana members live within 10 miles of a Concentra clinic, making its services convenient for the insurer’s members. Last year it also bought a health coaching firm that helps employers keep workers healthy, and in February it partnered with a South African company to launch new wellness services in the United States.

The Humana story is particularly interesting. Once upon a time, Humana was a major player in the business of owning hospitals. Some years ago, they made a corporate decision to get out of the hospital business and focus on health insurance as that is where they believed the real profits were to be found.

Now, we see them going back in the other direction as they pursue businesses that will earn them more money than selling health insurance.

Get used to this – it will not be long until our major health insurers are no longer playing the game.

No doubt, some of you are already cussing out Obamacare for pushing the health insurance companies over the line.

But, if that is what you are thinking, you’re missing the real issue.

Obamacare, for all the bombast and baloney about socialism, etc., was really little more than a bill that followed much of the practices of the past. The government cracked down on some of the more distressing practices of the insurers – spending too little paying for actual health care while spending too much for advertising, administrative fees, big salaries, etc. – and, in return, the ACA cleared the way for many more people to enter into the private insurance market, particularly should the mandate hold up, creating many more customers for the insurers.

Depending upon whom you ask, the deal was either too good for the health insurance companies because we should have passed a public option or, better yet, Medicare for all, or the health insurance companies got hosed because they will no longer be able to earn the huge profits to which they’ve grown accustomed.

In many respects, both sides are right.

With the requirement that insurers be required to take on customers with previous medical problems – and the higher risk that comes from the same – plus the requirement that insurers spend 80% of every dollar they take in from their customers on actual health care benefits- the insurers are now freaked out over how they will earn enough profit to support their share prices – – and they are right to worry.

Does that mean that Obamacare was a mistake? Did the law push the private health insurance industry too far?

It was not a mistake.

If you follow health care insurance as closely as some of us do, you are all too aware of what the insurers were forced to get into in order to maintain profitability in the face of dramatically rising costs.

They found themselves having to play a very dirty game of hard ball. They would take a customer’s money, with pleasure, right up until the moment the customer had to call upon the insurer to pay off when the customer fell seriously ill. At that point in time, the health insurer would shift its focus to finding ways not to pay for the care the customer had always believed she would get each and every time she sent in a large premium check.

It was ugly – but the only way the health insurers figured they could keep their profits where they needed to be.

This is precisely what led to the element of Obamacare that requires insurers to now spend 80% of each premium dollar paying for actual health care. By so doing, the law disincentivizes insurers from cheating. If they don’t spend the 80%, the law forces them to repay a percentage of premiums to all of its customers.

Should Congress not have done this?

If you have never been sick, and just cannot believe that you or a family member on your policy will ever get sick, it’s easy to say that it was a mistake. If you don’t much care because you receive your health insurance as a benefit of employment and figure that the insurance company won’t mess with the group policy by refusing to pay your claim, you might not want to get too comfortable. Jobs go away and health care goes with them.

Of course this had to be done. To do otherwise would have been to allow insurers to continu
e cheating people at the very moment when they are most vulnerable.

That brings us to pre-existing conditions.

Should the government have cotinued to turn it’s back on the growing number of people who cannot get insurance at any price because the insurers business model cannot handle the risk in their business models?

Again, if you don’t think you’re ever going to be sick, maybe you aren’t concerned. If you are on a corporate policy, you can’t be denied your coverage so it’s all good. But, as noted, jobs disappear and if you believe that nobody in your family can ever fall seriously and expensively ill and lose the opportunity to be insured in the future, I have some junk real estate I’d like to discuss with you.

Further, that whole meme that suggests that if people don’t take care of themselves they should be forced to suffer the consequences, is complete nonsense. Serious and expensive illness is every bit as likely to be the result of genetic pre-disposition as it is likely to result from poor eating and exercising habits.

The government had to impose this requirement on the health insurers to forestall a genuine crisis.

The end result is that these items will prove to be the final straw in a failing private health insurance model that can no longer afford to be in the business – and it isn’t going to be long until the insurers bail out entirely leaving us all exposed and in trouble.

What then?

I only know one bank large enough to step in and take over the business.

It’s called the United States government.

So, whether your ideologically in favor of government single-payer care or ideologically convinced that is means Communism will have arrived, deal with it and start thinking about how to best perfect it. It won’t be long until it is the only system we have when it comes to America’s health care.

http://blogs.forbes.com/rickungar/2011/06/09/the-coming-crash-of-the-american-health-care-system/

Disturbing New Statistics Show Huge Percentage Of Financial Fraud Against U.S. Government Comes From Healthcare Industry

By Don Soeken
MichaelMoore.com, June 10, 2011

Ever wondered who the biggest culprits are, when it comes to defrauding the taxpayers of the United States?

The answer to that question may surprise you.

According to some shocking new statistics from the nonprofit Taxpayers Against Fraud (TAF) public interest group, the ranks of the admitted federal cheaters are occupied almost entirely by health insurers and the healthcare pharmaceutical industry.

That’s the clear and thoroughly disturbing conclusion to be found in a revealing TAF study of the “Top 20” fraud lawsuits (ranked by dollar amounts) to have been decided by court judgments or agreed-upon settlements in recent years. Amazingly, the list of penalty awards – as adjudicated under legal procedures mandated by the U.S. False Claims Act – contains no fewer than 19 healthcare or health insurance entities . . . and only a single financial entity who isn’t engaged in the business of health insurance or medical care.

Astonishing? You bet it is. Even a quick look at the list of recent fraud convictions and fraud case settlements involving the U.S. healthcare industry (to review them for yourself: www.taf.org) should be enough to make any alert taxpayer ask: Why haven’t all of these obvious fiscal abuses by healthinsurers and the pharmaceutical industry been reported in the news media . . . even as the entire nation continues to debate the future of healthcare reform?

As the Taxpayers Against Fraud website makes chillingly clear, some of America’s most best known and most trusted healthcare industry corporations are heading up the list of despicable cheaters whose conscienceless manipulation of federal health dollars has resulted in convictions or financial settlements with Uncle Sam.

Some appalling examples from the TAF “Top 20” list:

No. 1 Fraud Offender: Pfizer — $1 billion under the False Claims Act. Pfizer paid a total of $2.3 billion, of which $1.3 billion was a criminal fine for kickbacks and off-label marketing and $1 billion was paid under the False Claims Act.

No. 2 Fraud Offender: Tenet Heathcare — $900,000,000 under the False Claims Act. In July 2006, Tenet Healthcare agreed to pay the Federal Government $900 million for billing violations that included manipulation of outlier payments to Medicare, as well as kickbacks, upcoding, and bill padding.

No. 3 Fraud Offender: HCA — $731,400,000 under the False Claims Act.?In December 2000, HCA The Healthcare Company (formerly known as Columbia HCA), the largest for-profit hospital chain in the United States, pled guilty to criminal conduct and agreed to pay more than $840 million in criminal fines, civil penalties and damages for unlawful billing practices.

No. 4 Fraud Offender: Merck – $650,000 under the False Claims Act.?In January of 2008, Merck settled the very first nominal pricing fraud case in which the company was accused of taking kickbacks and violating Medicaid best price regulations for Vioxx (an arthritis drug), Zocor (a cholesterol drug), Pepcid (an acid-reflux drug), Cozaar (a hypertensive medication), Fosamax (a bone loss drug) Maxalt (a migraine medication) and Singulair (an asthma medication).

****

As you read through the “Top 20” list of fiscal malefactors who were either found guilty or agreed to settle in fraud cases against Uncle Sam, one fact stands out with startling clarity: 95 percent of these massively unprincipled cheaters were healthcare players . . . including some of the most venerated names in the pharmaceutical, hospital and health insurance industries.

Unfortunately, however, the taxpayers who are so frequently being bilked by these unscrupulous players haven’t been told that the record already shows how willing the U.S. healthcare industry is to stretch the rules and cheat the public in its ceaseless quest for grotesquely swollen profits.

As a Ph.D. social worker who has spent much of the past 30 years counseling and defending whistleblowers who dare to speak out against fraud against the U.S. government, I learned a long time ago that the U.S. healthcare industry can’t be trusted to provide adequate medical care for the citizenry, or even to obey the laws and regulations that protect the taxpayers from being defrauded.

Make no mistake: That disturbing list of “Top 20” awards against healthcare insurers and the Pharmaceutical industry shows clearly that we cannot leave healthcare to the “profit-oriented” insurance companies and the hospital chains whose greed and willingness to short-change consumers on care is now common knowledge everywhere.

The record shows clearly that allowing the insurers to dictate healthcare policy and healthcare costs can only produce disastrous results. A massive Harvard University study of treatment patterns among patients who were treated in hospital emergency rooms showed that “uninsured” patients were much more likely to die while in the hospital than those who were able to pay the sky-high premiums for adequate healthcare coverage. (To learn more about the study, click on: http://news.yahoo.com/s/hsn/uninsuredtraumapatientsmorelikelytodiestudy).

The first step on the road to getting healthcare reform right is to understand that we are not on a “level playing field,” and that the health industry will stop at nothing to protect its immense profits, regardless of the needless death and the needless suffering their behavior may cause the rest of us.

Donald R. Soeken,is a social worker with 40 years of professional experience; he is also founder of the nonprofit Whistleblower Support Fund – a public service organization that supports whistleblowers.

http://www.michaelmoore.com/words/mike-friends-blog/disturbing-new-statistics