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PNHP comments on Hsiao draft report "Achieving Affordable Universal Health Care in Vermont" 1/19/11

January 21, 2011
William Hsiao, Ph.D.
124 Mt. Auburn Street, Suite 410 South
Cambridge, MA 02138

Dear Dr. Hsiao,

Thank you for this opportunity to comment on your draft report, and for generously volunteering your time and international expertise to this project.

PNHP agrees that the most effective, evidence-based approach to addressing the health care crisis facing Vermont is the adoption of a single payer system, and applauds the work of your team in preparing two models of single payer – with different benefit packages and governance structures – for the Vermont legislature to consider.

We particularly appreciate your recommendation, based on interviews with all the stakeholders, for an Independent Board to determine budgets and payments to providers, to address concerns – real or imagined – about the transparency and accountability of the single payer. That is a valuable contribution to the design of a single payer system for Vermont.

We briefly outline some questions and concerns, below, with the goal of strengthening the single payer model in Option 1 and Option 3 and giving it greater ability to control costs.

We also have concerns about the fiscal analysis of the model, also below, mostly related to what we believe is an underestimate of the potential administrative savings and savings from effective cost-containment with single payer budgeting, and an overestimate of the potential savings from ACO’s. Overall we believe that the projected savings from single payer are in the right range (25 percent of projected health spending 2015-2024), however.

Strengthening the Single Payer, Strengthening Cost Control

1. Medicare and Medicaid should be fully incorporated into the single payer to maximize administrative savings, strengthen cost control, and provide seniors and low-income residents with the superior benefits package of the single payer as well as seamless, continuous coverage. Additional Medicaid benefits (e.g. transportation costs) may continue to be provided separately.

2. With Medicare and Medicaid fully incorporated into the single payer, it will be possible to globally budget hospitals, nursing homes, and other delivery facilities, a measure we strongly recommend both to slash administrative costs at the hospital level and to vastly strengthen cost control. In order to contain costs, it is important to do health planning, particularly with new technology, which is expanding in Vermont more rapidly than hospitals’ physical plant. Thus we recommend that hospitals and other institutions have separate capital and operating budgets.

3. In order to effectively control costs Vermont needs to prohibit participation in the program by investor-owned, for-profit delivery systems. There is solid evidence that investor ownership raises costs and lowers quality of care in nursing homes, hospitals, dialysis clinics, and other facilities.

4. Long-term care is an essential benefit for an aging population. The additional cost of coverage for nursing home care may be reduced by charging an income-based fee for the housing portion of nursing home care, but not for the clinical portion.

5. Other benefit improvements we suggest are:
– use of the “comprehensive” benefit package as the starting point
– coverage of all residents of Vermont (subject to a residency requirement, not citizenship status)
– elimination of all co-pays and cost-sharing (reduces administrative costs and is not necessary for cost control under single payer system with enforceable budgets)

6. While we appreciate the need for time to prepare for a new way of financing care, we suggest that the program be implemented sooner, in 2012, rather than wait until 2015. We believe that the evidence from Taiwan shows that faster implementation, if there is the political will, is possible.

Comments on the fiscal analysis: Single Payer “Bends the Cost Curve”

1. The evidence from savings from administrative waste is very strong and savings from this category are a minimum of 10 percent if the single payer is correctly structured (that is, Medicare and Medicaid are included and hospitals are globally budgeted) and as high as 15 percent or more of total health expenditures.

2. The evidence of savings from using a non-profit delivery system is also very strong; for-profit hospitals are an average of 19 percent more costly than non-profits. There is a large body of evidence showing that investor-owned, for-profit facilities such as dialysis clinics are more costly and have lower quality than non-profits that should be added to the report and fiscal modeling (see references at www.pnhp.org/resources/evidence-based-talking-points).

3. In addition to the one-time savings from slashing administrative waste, if the single payer is strengthened it is able to “bend the cost curve” and reduce the rate of health inflation in Vermont going forward (e.g. with enforceable global budgets for physician care and hospitals as well as total health spending; bulk purchasing of drugs and supplies; and negotiated fees). This is the real source of the majority of savings over time from a single payer plan, and projections of future health spending should reflect this. This finding is well supported by the international evidence from Taiwan and elsewhere.

4. In contrast, we believe that the evidence for ACOs saving money is weak (much of it has not been published in peer-reviewed journals; even CMS does not agree on what an ACO looks like and is only pursuing pilot projects) and there is just as much reason to believe that the consolidation of providers and increased management costs necessitated by the ACO requirement will raise costs as lower them. In fact, dramatically raising administrative costs is precisely what has happened in the British NHS as it has tried ACO-like schemes.

5. We thus strongly recommend a more critical evaluation of the literature on ACOs in the report and reducing the estimate of the potential savings from ACOs. We believe that the savings from effective cost-control as a result of the single payer will more than make up for the savings currently attributed to ACOs.

6. While outsourcing claims processing to the lowest bidder may be more appealing politically and to insurers, we are skeptical of the claim that it will save any more money.

7. Finally, while we understand the justification for the payroll tax on the employer side, we believe that the payroll tax on the employee side should be replaced with a small income tax or surtax on very wealthy families (top 5 percent) or a small tax on unearned income. Income inequality is a major contributor to ill health in its own right, and income inequality has increased dramatically in the U.S. over the past 30 years. A small tax on unearned income (or surtax on those with very high unearned incomes) would be a small step towards reducing this disparity.

We would be happy to review these points with your team or to arrange meetings with PNHP policy experts.

Thank you again for your outstanding contribution to fundamental health care reform in Vermont.

Sincerely yours,

Deborah Richter, MD
Chair, Vermont chapter, PNHP

Ida Hellander, MD
Executive Director, PNHP

Comments by Himmelstein and Woolhandler on Hsiao draft report "Achieving Affordable Universal Health Care in Vermont"

By Drs. Steffie Woolhandler and David Himmelstein

Submitted on Mon, Jan 24, 2011

Dear Dr. Hsiao,

1- We are convinced that hospital global budgeting would generate substantial additional administrative savings. This conviction is based both on strong anecdotal evidence and some systematic studies. Canadian hospitals do little of the internal cost tracking needed to attribute costs and charges to individual patients. Anecdotally, this allows a typical Canadian hospital to employ fewer than 5 billing personnel, vs. 50 or more for a U.S. hospital. Some years ago we learned that Toronto General had about a dozen people in its billing department whose main task was to send bills to Americans who wandered across the border. At that time, the MGH had 352 FTE billing personnel. We’re told that the current number at the MGH is closer to 1000. This is reflected in the 10 percentage point difference in administration’s proportion of hospital costs between the U.S. and Canada, far larger than the roughly 2% that you estimate could be saved under your options 1 or 3 (http://www.masscare.org/wp-content/uploads/2007/05/PNHPAdminCosts.pdf). Our studies of the number of administrative personnel employed in U.S., Canadian and German hospitals yield similar estimates of potential savings through global budgeting, and indicate that a unified per-patient billing system (as in Germany) is far less administratively streamlined (http://ajph.aphapublications.org/cgi/content/abstract/86/2/172 and Himmelstein, D. U., et al., “The Health Care Labor Force: U. S., Canada, and Western Germany,” unpublished contractor report prepared for the Office of Technology Assessment, U.S. Congress, Washington, DC, Mar. 19, 1993.). In the U.K., hospitals also beefed up their administrative staffs when the internal market was promulgated, and the director of the Karolinska Hospital in Stockholm told David that the advent of per-patient payments had caused at least a doubling in that hospital’s administrative costs.

2- We’re very concerned about your failure to recommend that hospital capital budgets be allocated separately from their operating revenues. Deriving hospital capital largely from the surpluses they accumulate out of their operating budgets means that profitability determines investment, negating any real possibility for health planning. Allowing hospitals to divert unspent operating funds to capital investment also provides incentives for hospitals to amplify profitable services such as elective orthopedic and cardiac procedures, and shrink needed but unprofitable ones such as psychiatry and primary care. We’re similarly concerned about the plan to allow ACOs to keep any surplus they don’t spend on their patients. Such incentives will guarantee cherry picking and the neglect of important but unmeasured care. Regulatory efforts and quality measurement are no match for the cleverness of those who will game the system.

3- Your endorsement of P-4-P is unsupported by any reasonable evidence. The extensive British experience indicates that you get more of what you pay for, but with substantial undesired side effects on aspects of care that are not incentivized. Recent studies from the MGH indicate that P-4-P targets are far harder to achieve when caring for low income, minority or mentally ill patients. Moreover, interesting data from behavioral economics suggests that such schemes may well worsen performance of complex tasks (see the video at: http://www.youtube.com/watch?v=u6XAPnuFjJc for an entertaining introduction to this literature from writer Daniel Pink).

4- Microsimulation models inaccurately predict changes in utilization that result from system-wide changes in the comprehensiveness of coverage because they assume no supply limit. Given the shortage of primary care physicians in much of Vermont it is implausible that the more comprehensive benefit package would cause much increase in primary care visits. Similarly, unless hospital capacity were greatly expanded, dropping financial barriers to hospitalization would not be likely to cause a large increase in inpatient care. The proof of this lies in data from Canada. In Quebec, there was virtually no change in aggregate utilization of physician care with the elimination of financial barriers in 1971. The poor and sick saw doctors more frequently, while the wealthy and healthy waited a bit longer for appointments and saw their doctors a bit less often (http://www.nejm.org/doi/pdf/10.1056/NEJM197311292892206). Similarly, Saskatchewan saw little decrease in aggregate physician visits when co-payments for outpatient care were added, and not much increase when they were subsequently dropped (http://www.jstor.org/pss/3764080). Bob Evans has noted that physicians almost always work the same number of hours, regardless of the MD/Population ratio, and the Dartmouth data make a convincing case that this is so. Hence, we’d suggest that your estimates of the cost of comprehensive benefits are too high.

5- While we find much to like in your Model 1 with comprehensive benefits, even that plan cannot be properly labeled “single payer” since it would retain (at least initially) Medicare and Medicaid (and apparently Medigap plans as well). We’d suggest calling this plan (and Model 3) “Oligopayer” options. If (as we understand that you advocate) Medicare and Medicaid were folded in at a later date and Medigap eliminated, only at this more advanced stage would the system properly be termed single payer.

6- Finally, we are unaware of evidence to support your claim that contracting out claims payment etc. to a private insurer will produce savings, and would urge you to review the evidence to the contrary. The initial Saskatchewan experience (reviewed in: Horne JM, Beck RG. Further Evidence on Public versus Private Administration of Health Insurance. Journal of Public Health Policy 1981) led the Hall Commission that recommended nationwide adoption of the single payer approach to conclude: “Hence the decision which Canadians have to make is whether they wish to pay $1,027 million in 1971 for a programme administered by the insurance industry, or $837 million for a programme administered by government agencies.” At present, Canadian public payers average about 1% overhead, far lower than any of the private contracted payers that you cite. Moreover, it seems likely that after the initial bidding process, barriers to entry for competitors will be steep since the initial winning bidder will have a decisive advantage in having built the payment infrastructure (computer programs, provider rosters etc.). Moreover, a private firm would have strong incentives to increase the complexity and cost of administration, and hence boost its revenues.

Thanks in advance for your consideration. We’d be happy to discuss these issues with you further if you wish.

'How everybody exists' in D.C. doesn’t have to be

By Wendell Potter
The Huffington Post, Jan. 25, 2011

If you want to know how things really get done in Washington — or don’t get done, depending on the desires of America’s corporate executives — all you have to do is read a couple of paragraphs in a Jan. 23 Philadelphia Inquirer story.

Reporter Joe DiStefano quotes a vice president at APCO Worldwide — one of DC’s most powerful and influential PR firms — in response to questions about my book, “Deadly Spin.” Throughout the book I disclose the previously secretive work APCO did for the health insurance industry to manipulate public opinion on health care reform, in part by trying to scare people away from a movie, Michael Moore’s 2007 documentary “Sicko.”

The surprising gem in the Inquirer piece was that APCO VP Bill Pierce essentially agreed with me. He acknowledged that interest-funded pressure groups “are all over the place” in Washington. “That’s how everybody exists here,” Pierce said.

He’s right. That is indeed how the influence peddlers and spinmeisters exist (although a much more accurate word is thrive) in Washington.

Credit Where Credit is Due

Here’s the context. Pierce — an old (and probably now former) friend from my nearly two decades inside the insurance industry — was quoted by DiStefano as saying that I erred when I wrote that APCO set up and operated a fake grassroots front group, Health Care America, to discredit Moore and his movie because insurance company executives were terrified that “Sicko” would convince even more Americans that the government should play a much greater role in the U.S. health care system.

The trend was already going against the industry: In the spring of 2007, a few weeks before Sicko’s U.S. premier, the insurance industry’s pollsters told the executives that for the first time ever, more than half of all Americans were so disillusioned with the way private insurers controlled the health care system that they wanted more government involvement.

My error, according to Pierce, is not in pointing out that APCO was doing the dirty work of the industry through its phony front group — but that I failed to acknowledge the role that other big special interests played in funding Health Care America, as well. (Pierce was listed on the now-defunct group’s press releases as Health Care America’s media contact. If you called the number on the press release for Pierce, you would have reached him at his desk at APCO.)

DiStefano is at least the second reporter to hear Pierce complain that I did the public a disservice by not giving sufficient credit to other big special interests who paid APCO to create and run Health Care America. In November of last year he told PR industry watchdog Jack O’Dwyer the same thing.

In response, I wrote a blog post on Nov. 22 detailing the history and work of the front group. Here’s an excerpt:

O’Dwyer blogged last Tuesday that, ‘Just about every known evil practice that PR has ever engaged in is described in Deadly Spin.’ He noted that I had mentioned APCO — the second biggest firm in the O’Dwyer ranking, with $100.3 million in fees in 2009 — several times in the book. APCO and AHIP must be paying a media monitoring service to alert them immediately when I am mentioned in the media, as they did for Michael Moore and “Sicko” three years ago. Within hours, APCO Senior Vice President William Pierce sent O’Dwyer an email to challenge my credibility because of my failure to disclose Health Care America’s original incarnation. He’s right — partially. I should have pointed out in the book that APCO repurposed Health Care America for the insurance industry and other special interests who were concerned that “Sicko” might lead to reforms that would threaten their profits, too. I would have disclosed it if I had known about it. Unlike PR people who practice the dark arts of PR, I had no intention of misleading anyone.

Textbook Playbook

Had Pierce been more forthcoming, he might have shared with DiStefano the PR plan APCO prepared for America’s Health Insurance Plans (AHIP), the insurance industry’s big lobbying group, to discredit “Sicko” and set the stage for the industry’s campaign to shape health care reform legislation.

Since he didn’t, I will.

Here it is, courtesy of Bill Moyers, who disclosed portions of the APCO/AHIP plan on the July 10, 2009, edition of Bill Moyers Journal, and posted it on his website. As you can see, the plan shows how APCO planned to use Health Care America and other organizations that APCO could press into service in the industry’s campaign against “Sicko.” If you’ve ever wanted to know how to create a PR plan to discredit an enemy and manipulate public opinion, you should take a look at this one. It’s a classic.

Back to Pierce’s comments to DiStefano. Here’s the full quote:

‘Pharma, hospitals, doctors backed Health Care America, not insurers,’ Pierce said. He doesn’t see why Potter thinks such groups are a threat to democracy: In Washington, interest-funded pressure groups ‘are all over the place,’ and many are backed by liberals. ‘That’s how everybody exists here.’

Pierce and I agree on this last point. Pierce admitted in a few words that one of the core truths of my book is indeed true: the near-total control exerted by corporate special interests over the democratic process in America is simply, and in the most literal way possible, business as usual.

The irony seems to be lost on Pierce, however. What’s the big deal, he asks?

Endangered Democracy

The big deal is that this dynamic threatens the very foundations of our democracy. It puts the interests of corporations, and the institutional shareholders that own them, above the interests of individual citizens — you and me. It concentrates power in the hands of a few “business leaders” rather than in the people who vote and the people those voters elect to represent them. It gives the loudest voice not to those with the best ideas but to those who can afford the most expensive lobbyists.

In the end, the true will of the people — such as the widely popular but still elusive policy of providing universal access to affordable, quality health care, as do the countries featured in “Sicko” — will continue to be thwarted until this is no longer “how everybody exists” in Washington.

http://www.huffingtonpost.com/wendell-potter/how-everybody-exists-does_b_813532.html

John Goodman: "real" insurance means sick pay more

The Case for Health Insurance

By John Goodman
John Goodman’s Health Policy Blog
January 26, 2011

I’m one of the very few health policy wonks you know (maybe the only one) who believes everyone should have access to health insurance the same way they currently have access to life, disability and homeowner’s insurance. In fact, I often refer to my blog as about the only health policy blog on the Internet that believes real health insurance is a legitimate business.

Wait a minute, Goodman. How can you say that? What about the Commonwealth Fund and Families USA? Don’t they believe everyone should have health insurance? What about everyone in Congress who supported ObamaCare? What about the president himself? Aren’t they all promoting the business of health insurance?

The short answer to all those questions is “no.” Real insurance involves a pooling of risks. The insurer must make sure each new entrant to the pool pays a premium that reflects the expected costs that entrant brings to the pool. Otherwise, the insurer won’t be able to pay claims. The business of insurance is the business of pricing and managing risk.

The organizations and people noted above don’t believe that “pricing and managing risk” is a legitimate activity. In fact, they went a long way toward completely outlawing the practice in the health reform bill. The only legitimate purpose of insurance, in their view, is to collect money and pay bills. For public insurance, this means collecting taxes and paying expenses. Their view of acceptable private insurance is to copy government insurance — a sort of private sector socialism.

Okay, Goodman, let’s accept that distinction for the moment. Doesn’t pricing risk mean charging me a premium that reflects my health status? The less healthy I am, the more I have to pay. Why should I want to buy insurance from a company that does that?

Because if your insurer doesn’t do that, a lot of bad things will happen.

Remember the phrase, “You’re in good hands with Allstate”? It was the voiceover at the scene of an auto accident where there has been catastrophic damage. The ad speaks volumes about what happens in real insurance markets. Basically, insurance is unimportant to you until things go very wrong. It’s at that point that you want good service.

Contrast Allstate’s ad with the kind of ads federal employees are subjected to during the fall open season for choosing a health insurance plan. What you never see in Washington are ads saying, “You are in good hands with [Aetna, Cigna, UnitedHealth, etc.] if you get [AIDS, cancer, heart disease, etc.].” Instead, the typical open season ad pictures young families with healthy children and no apparent health problems. The not-so-subtle message is: “You’ll be in good hands with us if you look like the people in these photos.”

Why is the health insurance market so different from auto insurance? Answer: health insurers are not allowed to charge federal employees premiums that reflect their health status.

Since the health overhaul legislation plans to make the federal employee health benefit system the model for health insurance exchanges nationwide, it’s instructive to stop and consider the incentives the health plans in these systems have. As explained in a previous analysis, if insurers have to take all applicants for the same premium, they will obviously try to attract the healthy (on whom they will make profits) and avoid the sick (on whom they will incur losses). After enrollment, their incentive is to overprovide to the healthy (to keep the ones they have and attract more of them) and to underprovide to the sick (to encourage them to leave and discourage enrollment by others just like them). If a TV ad could summarize how this health insurance market works, it would say, “You’re in good hands with us, unless you really need us — then we hope you will go somewhere else.”

And the reason this works is because people really can go somewhere else if they get sick — paying no extra premium.

So the incentives of the healthy employees are: Find plans that have lots of services for healthy people — knowing that if they get sick, they can always enroll in some other plan. The incentives for employees with a serious health problem (or more likely, a family member with a health problem) are to seek out plans that are the best at treating costly illness. But, as in a game of musical chairs, no insurer wants to be chosen.

In such a world, comparative effectiveness research, FDA rulings on drugs, end-of-life counseling and so many other controversial issues of late become very relevant. Insurance companies can’t just dump their sickest patients out on the street. They need cover. They need reasons not to pay for the latest cancer drug or the latest expensive test. Given the slightest encouragement, denial is in their self-interest.

Okay, Goodman. This is all very persuasive. But if my premium reflects my health status, what happens to people who are too poor or too sick to be able to afford those premiums? And what happens if a healthy person gets really sick (high medical costs) and wants to switch insurers?

These are good questions. I will answer them in a future Health Alert.

http://healthblog.ncpa.org/the-case-for-health-insurance/

Comments

By Don, McCanne, MD (Originally published here)

In pooling risk, the decision to assign premiums based on an individual’s risk is purely arbitrary, albeit it is convenient for those marketing the traditional business model of insurance – “real” health insurance, as John Goodman calls it.

The ultimate pooling of risk would be one national pool that includes everyone. Yet average medical costs for a worker’s family of four is now over $18,000 (Milliman), when median household income is $50,000. A middle-income family can no longer afford an equally-allocated premium plus out-of-pocket costs for that risk pool, much less a premium that is adjusted upward for higher risk.

Many of of us who do believe that everyone should have access to health care free of significant financial barriers understand that the traditional concept of “real” insurance no longer works. If individuals with health problems are priced out of risk pools, then how can they possibly pay premiums for the pools that concentrate high-risk individuals? And don’t say that you merely have to set up state-run high-risk pools. Not only have they already been proven to be ineffective in seriously addressing this problem, they would still have to be funded by us anyway, through the tax system. If we moved most high-risk individuals into these pools, that would consume a major portion of our national health expenditures (i.e., much of the 20 percent of people who consume 80 percent of health care).

In fact, think of our largest risk pool – the collective pools of employer-sponsored plans. These are largely composed of the healthy workforce and their young healthy families (the 80 percent of people who use only 20 percent of health care). Yet these low-cost pools that benefit from favorable selection (opposite of adverse selection) are already straining the budgets of employers and their employees. Isn’t it kind of silly to pool together these massive numbers of healthy people, while leaving out most of those with greater needs, and pretend that somehow we have provided the nation with “real” insurance? That serves the insurance industry well, but not the people.

Since average-income individuals can no longer afford their equally-allocated portion of our national health expenditures, funding will have to be progressive, based on income. The least adminis
tratively complex and a less expensive method of doing that would be to establish a single risk pool, and fund it through progressive tax policies.

If our goal is seeing that everyone gets the care they need, then we really do need to discard the antiquated business model of “real insurance” and adopt a single payer system – an improved Medicare that covers everyone.

Merger of Harvard Pilgrim Health Care and Tufts Health Plan

2 big health plans may merge

By Robert Weisman and Kay Lazar
The Boston Globe
January 25, 2011

Harvard Pilgrim Health Care and Tufts Health Plan are close to signing a memorandum of understanding that would combine their operations in four New England states and make them a stronger competitor to the market leader, Blue Cross Blue Shield of Massachusetts, in their home state. (Update: the memorandum of understanding was signed today.)

Consumer advocates said it is unclear how the insurers’ subscribers might be affected by the union, which would leave Massachusetts with only two major health companies.

“There has been tremendous value in having three strong locally based health plans in terms of choices for consumers,” said Nancy C. Turnbull, associate dean at the Harvard School of Public Health and a former deputy insurance commissioner. “But on the other hand, this could create a consolidated plan that could create a stronger competitor to Blue Cross and it could create a plan that has stronger leverage than either of them individually in negotiating with providers.”

Partly in reaction to the pressure to switch from fee-for-service to global payments, several Massachusetts hospitals have combined operations, while others say they are seeking buyers.

http://www.boston.com/business/healthcare/articles/2011/01/25/tufts_harvard_pilgrim_explore_merger/?page=full

Comment:

By Don McCanne, MD

Choice. Wasn’t that the clarion call during the campaign for health care reform? We could have our choice of keeping the health plan we have, or choosing from a market of plans in the health insurance exchanges. Since Massachusetts had a head start in establishing the model of reform selected for the nation, let’s see what choice has meant to them.

Has health plan competition in the marketplace kept Massachusetts’ health care costs under control? No. They have the highest health care costs in the nation, and costs continue to rise.

Well that didn’t work. So now Massachusetts has begun the process of reducing the competition to two major health plans. That creates an oligopoly, which suppresses competition. Out with the market theory that competition reduces prices. In with the market theory that concentration provides the health plans with leverage to extract greater price concessions from the providers of health care. Of course, choice is a casualty of concentrated markets.

How do the providers fight back? Hospitals are already merging, in an effort to establish market dominance. Physicians are evaluating the concept of accountable care organizations (ACOs) as called for in the Patient Protection and Affordable care Act. Although the intent of the law is that ACOs would control costs (after all, they’re supposed to be accountable), physicians and their health provider partners will certainly use them to leverage their end of price negotiations (i.e., fight for higher prices, not lower).

Fundamental to competition is that when you have winners, you must have losers. That might be appropriate in sporting events, but it is an ethical breach to establish a health care financing system that automatically moves a significant portion of our health care providers into the column of losers. We need a financing system that makes patients winners by providing them access to a health care delivery system that strives for optimal care through cooperation, rather than competition.

That is partly what a single payer system is all about. Using global budgeting and negotiation, the public administrator works with the providers – all providers – to pay legitimate costs and provide fair margins.

Under such a system, competition becomes moot. Eliminating private health plans obviously eliminates health plan competition. If consolidation of health providers improves efficiency, quality and access, then there is no reason to be concerned about a lack of competition there either. Even without consolidation, appropriately compensated providers still can fully engage themselves in serving their patients, unencumbered with the distraction of having to compete.

Funding for health care law next big battle

By Robert Reich
San Francisco Chronicle
Sunday, January 23, 2011

Forget the symbolic vote to repeal health care. Republicans don’t have the votes to override President Obama’s sure veto.

The real move happens later, when Republicans try to cut the money needed to implement the law’s requirement that all Americans buy health insurance.

On its face, it’s a smart tactic. The individual mandate is the linchpin of the heath care law because it spreads the risks. Without the participation of younger or healthier people, private insurers won’t be able to take on older or sicker customers with pre-existing medical conditions, or maintain coverage indefinitely for people who become seriously ill. The result would be to unravel the health care law, which presumably is what many Republicans seek.

The mandate is also the least popular aspect of the law. According to a December 9-12 ABC News/Washington Post survey, 60 percent of the public opposes it. While most want to prevent insurers from dropping coverage when customers become seriously ill, they don’t like the idea of the government requiring them to buy coverage. The mandate not only offends libertarian sensibilities, but it also worries some moderates and liberals who fear private insurers will charge too much because of insufficient competition in the industry.

And the mandate is most vulnerable to legal challenge. In the first major ruling on the new law, announced Dec. 13, Judge Henry E. Hudson of the federal district court in Richmond, Va., struck it down, calling the mandate an “unbridled exercise of federal police powers” and an overreach of the Constitution’s Commerce Clause. The U.S. government is appealing that decision.

There’s a lesson for Democrats in all this.

The federal government wouldn’t be nearly as vulnerable to these political and legal obstacles had the health care law been built upon the framework of Social Security or Medicare – public insurance financed by payroll taxes.

Not only are these programs enormously popular (“Don’t take away my Medicare!” was a rallying cry among some conservative populists during the debates over the health care law), but they also rest on a more widely accepted relationship between the individual, the government and the market.

Americans are accustomed to paying for public insurance through their payroll taxes. Such payments aren’t viewed as federal mandates that encroach upon individual freedoms, or as payoffs to private companies likely to make even more money from mandatory purchases of their products, but as well-deserved entitlements.

Indeed, the biggest problem with Social Security and Medicare is they’re so popular that politicians have had a hard time trimming their benefits to match payroll-tax revenues.

For 60 years, the battle over health care reform has been waged over these two ways of spreading costs and risks: either through payroll taxes and public insurance, or mandated purchases from private insurers.

For most of those six decades, Democrats advocated the former. Harry Truman’s initial plan for adding health insurance to Social Security was defeated, but Lyndon Johnson’s Medicare succeeded. Apart from George W. Bush’s drug benefit, which was also based on this Democratic framework, Republicans have been on the side of mandated purchases from private insurers.

In 1974, Richard Nixon’s proposed Comprehensive Health Insurance Plan would have required private employers to provide their employees with comprehensive health insurance coverage purchased from private insurers. (An employer mandate is tantamount to an individual mandate in that employees are forced to pay it indirectly, via lower wages.) Sen. Edward Kennedy simultaneously proposed universal coverage financed through Social Security taxes, essentially copying Medicare. Neither plan succeeded, but Nixon’s framework redefined the idea of national health insurance from then onward.

Obama and a majority of Democrats in the last Congress opted for the Republican model even though many Democrats preferred a single-payer system – Medicare for all – or at the very least a public option. Most polls showed that the public favored such an option. But the White House hoped for Republican support and wanted to ward off opposition from health insurers and pharmaceutical companies by promising them some 30 million additional customers.

The current Republican attack on mandatory coverage shows that Democrats who wanted a single-payer system should have stuck to their guns.

Perhaps they’ll have another chance. If the Republican attack is successful, single-payer will be the only alternative. And it’s the system Americans seem to prefer – payroll taxes and public insurance.

Robert Reich, former U.S. secretary of labor, is professor of public policy at UC Berkeley and the author of the new book “Aftershock: The Next Economy and America’s Future.” He blogs at www.robertreich.org.

Physicians for a National Health Program Tour Oregon to Promote Single Payer Health Care, February 2011

The Oregon Chapter of Physicians for a National Health Program (PNHP) and Mad As Hell Doctors (MAHD) will follow up on their landmark 2009 national tour and 2010 California tours with spirited rallies in Linn and Lincoln Counties during February. Their program will feature music by bluegrass singer and composer Bob Wickline of Fox Island, Washington; documentary videos by Paul Hochfeld M.D.; testimony by physicians and nurses; and “Mad As Heck Minutes” by audience members on camera and on screen.

The doctors and nurses will start in Albany on Sunday, February 13, 6:30-8 p.m. at the Two Rivers Market, then go to Eugene for a parade starting at 5 p.m. and rally at 6 p.m. (place tba), hit the beach at Florence on Tuesday, Feb. 15, 6-8 p.m. at the Siuslaw Public Library, then Newport on Wednesday, Feb. 16, 7-9 p.m., at the Newport Visual Arts Center 2nd floor conference room, 777 NW Beach Drive (across from the Nye Beach Turnaround). Then it’s on to Lincoln City on Thursday, Feb. 17, 6:30 p.m., at the Lincoln City Cultural Center.2150 NE Oar Place.

PNHP is a group of physicians, nurses, ancillary health providers, and other concerned citizens advocating for an improved and expanded Medicare program to provide financially sustainable universal health coverage for all Americans. In September 2009, PNHP doctors traveled 6,000 miles through America’s heartland from Portland, OR to Washington, D.C., stopping at over 40 venues in 22 states. After appearances on the Ed Schultz Show (MSNBC), Keith Olberman (MSNBC), Democracy Now! and interviews on dozens of other media outlets, the group is continuing its unique approach and activist flair to advocate for Single Risk Pool, Improved Medicare-for-all.

PNHP contends that the Patient Protection and Affordable Care Act (P-PACA) does too little to protect the health and livelihood of patients and their families. P-PACA serves to further entrench the current medical-industrial complex with an unsustainable cost spiral within our health care system.PNHP further contends that, while the Oregon Health Policy Board, a result of House Bill 2009, has proposed critical improvements in Oregon’s health care system, these improvements will be achievable only under a Single Risk Pool, Improved Medicare-for-all plan.

PNHP is hitting the road again over the next several months to carry its message throughout Oregon. More information is available at www.pnhp.org/states/oregon and www.madashelldoctors.com.

You can also interact with 11,000 friends on www.facebook.com/MadDrs.

Mike Huntington, Physicians for a National Health Program, (541) 745-5635, mchuntington@comcast.net

Single-payer advances from Vermont to California to D.C.

January 24, 2011

Dear PNHP colleagues and friends,

The movement for fundamental health reform is making important advances “on the ground” in Vermont and elsewhere. Here’s a roundup of recent developments.

1. Vermont – draft report on single payer released, doctors speak out

2. H.R. 676 national single-payer bill reintroduced

3. California – medical students lobby for single payer

4. “Deadly Spin” author, former Cigna executive, on book tour

5. Kentucky honors MLK with single-payer forum

1. Harvard economist and architect of Taiwan’s single-payer health care system, William Hsiao, Ph.D., testified before the Vermont Legislature last week in support of a single-payer-like system. Hsiao was commissioned by the Legislature to design three options for health care reform for Vermont. Read the comments of Dr. Don McCanne, PNHP’s senior health policy fellow, on Hsiao’s report here.

Vermont’s congressional delegation (Senators Bernie Sanders and Patrick Leahy, along with Rep. Peter Welch) announced plans to introduce federal legislation that would allow Vermont to get waivers from the new federal health law and implement a single-payer health reform as soon as 2014. Vermont’s new governor, Peter Shumlin, also reiterated his strong support for a single-payer system.

PNHP’s Dr. Deb Richter, a Vermont family physician who has spent more than two decades working for single payer, said “the stars are aligned” for fundamental health care reform in Vermont. “The broad outlines of Dr. Hsiao’s single-payer proposals are very promising,” she said. “They represent a major step in the right direction.” (Read the comments of Richter and other Vermont doctors about the excessive paperwork in practicing medicine here.)

ACTION:

If you haven’t already signed the physicians’ petition to the Vermont Legislature to enact single payer, please do so today.

Vermont physicians are gathering at the Statehouse this Thursday, Jan. 27, to make the case for single payer with state lawmakers. For more information, visit www.vermontforsinglepayer.org. Medical students are rallying in Vermont on March 26. Contact Jenny@pnhp.org for more information.

2. H.R. 676, the “Expanded and Improved Medicare for All Act,” will be reintroduced by Rep. John Conyers (D-Mich.) early this week.

ACTION:

PNHP activists are encouraged to speak with their congresspersons about becoming co-sponsors of this hallmark national single-payer legislation, H.R. 676. (Each congressional session requires fresh co-sponsorship. Sponsors in the last session are listed here.) The congressional switchboard number is (202) 224-3121.

3. In California, hundreds of medical students and other health professionals-in-training flooded the steps of the Capitol for Student Lobby Day, urging state lawmakers to support the state single-payer bill sponsored by Sen. Mark Leno, SB 810. Californians are continuing to press forward with their single-payer bill and are encouraged by the recent departure of Gov. Arnold Schwarzenegger, who twice vetoed the Legislature’s approval of the legislation.

4. “Deadly Spin” author and insurance industry whistle-blower Wendell Potter spoke at a very successful event hosted by PNHP’s Indiana chapter, Hoosiers for a Commonsense Health Care Plan. The event, featuring Potter and a showing of Michael Moore’s movie “Sicko,” drew over 415 people.

Potter is on a speaking tour on his book “Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans.” PNHP chapters in New York City, Tennessee and several other states have also hosted or helped build impressive turnouts for Potter’s events.

5. PNHP President Dr. Garrett Adams and Kentuckians for Single Payer Health Care observed Dr. Martin Luther King Jr.’s birthday with a forum on single payer at the Louisville Urban League. The forum featured former PNHP president Dr. Claudia Fegan (“Dr. King said the time is always right to do what’s right”), Mayor Greg Fischer, Rep. John Yarmuth, and the head of the Falls City Medical Society, Dr. Joyce Howell, among others. Dr. Fegan also spoke to enthusiastic audiences at the Presbyterian Theological Seminary, a physicians’ luncheon and a potluck for activists. See this article in the Louisville Courier-Journal and visit www.kyhealthcare.org for more details.

There’s much more that we could report, both from chapters and from tasks forces like our Divestment group, but for the moment we want to stress that PNHP is continuing to make progress – and that we rely on you and others like you for support. Everything we do hinges on your continuing support. If you haven’t made a tax-deductible donation to PNHP recently, please do so today.

Cordially,

Quentin Young, M.D.
National Coordinator

Mark Almberg
Communications Director

Vermont doctors say patient needs are buried in paperwork

By Kevin O’Connor
Times Argus (Barre-Montpelier, Vt.), Jan. 23, 2011

RUTLAND — Middlebury’s Dr. Jack Mayer knows that most patients want health care reform to cut rising prices. But he, along with a growing group of Vermont medical providers, hopes to point a scalpel at piles of related paperwork.

Back in 1976 when Mayer opened his first pediatric office in the tiny northernmost town of Enosburg Falls, the Bronx native often bartered his services for eggs, firewood or knitted afghans.

In a larger community and practice 35 years later, Mayer now works with two fellow physicians, a nurse practitioner and two full-time billing clerks who process claims for more than 200 insurance plans.

“Every company has its own paperwork, payment schedules and policies about what it will cover,” says Mayer, who notes that such overhead eats upward of 30 percent of U.S. medical expenses. “The administrative costs of my practice are enormous and don’t go toward improving health or patient care.”

Mayer isn’t alone in his assessment. So many Vermont medical professionals have similar concerns, the Legislature — now contemplating several plans to change the state’s health care system — will hold a public hearing in Montpelier this week to receive their testimony.

“What I hear from all my colle
agues is, ‘For every hour I put into clinical care, I put another into paperwork,’” says Dr. Deborah Richter, a Cambridge physician. “They can’t give the care that patients need because of these obstacles.”

Richter is president of the Vermont Health Care for All campaign, which for almost a decade has pushed for what a state consultant proposed last week: a single-payer system to provide medical coverage to all residents.

Richter wasn’t sure if her peers would respond when the Legislature — welcoming public comment through Feb. 3 — invited them to speak Thursday from noon to 2 p.m. at the Statehouse. So far 50 colleagues have confirmed they’ll be there.

“These are busy doctors,” she says, “but they’re willing to talk.”

Nothing but billing

Take Dr. Adam Sorscher, an 18-year primary care physician who juggles work at Central Vermont Medical Center in Berlin, Dartmouth-Hitchcock Medical Center in Lebanon, N.H., (the New Hampshire hospital is Vermont’s second-largest health care provider) and the Good Neighbor Health Clinic in White River Junction. He finds problems wherever he goes.

“I see people at the clinic who have neglected preventive care because of the high cost,” Sorscher says, “and then we have to provide therapies that are more expensive and wouldn’t have been necessary if the health care system was better organized.”

Or consider Dr. William Eichner, an eye specialist who opened his Middlebury practice in 1976 and has added branches in Rutland and Ticonderoga, N.Y. To do so, he has increased his staff to 20 — three of whom focus solely on financial paperwork.

“They don’t greet patients, they don’t handle charts,” the ophthalmologist says. “They do nothing but handle billing and insurance claims.”

That frustrates more and more doctors. Richter points to a 2006 survey she sent to Vermont’s 840 primary care physicians. Of the 300 who responded, four out of five agreed with such statements as “Unnecessary paperwork increasingly is taking away more of my time from my patients” and “I don’t find the intrusion from outside managers and companies helpful.”

Providers say the resulting costs are pricing out more and more patients.

“I feel ashamed we’re the last developed country in the world not to have universal health care,” Eichner says. “I feel a moral imperative that everyone has access and that it be affordable.”

‘Have to kowtow’

Burlington’s Dr. Peggy Carey recalls when, lacking health insurance in her 20s, she was diagnosed with diabetes. Inspired by a nutrition course she took to deal with her diagnosis, she went to medical school and now works as a family doctor in a group practice.

“I wanted to change the system,” says the former English teacher turned 19-year physician.

Carey belongs to the doctor-led Vermont for Single Payer campaign and Physicians for a National Health Program. But she fights her biggest battles inside her practice.

“The majority of the paperwork that comes to me is not in reference to patient care,” she says, “but to what insurance plans allow or don’t allow.”

The problem isn’t limited to physical health. Psychiatrist Dr. Alice Silverman moved to St. Johnsbury two decades ago because the state’s rural Northeast Kingdom lacked enough mental health workers. Today she’s president of the Vermont Psychiatric Association — yet remains one of her region’s few resources.

“I’ve had a waiting list for years,” she says, “and there’s no one else I can refer to.”

Even so, insurance hurdles keep more people out of Silverman’s office.

“I may have someone who’s suicidal, but insurers say they have to see a provider in network, even when there is no one in network,” she says. “In psychiatry, people feel embarrassed enough — to have to call and get approval is a real obstacle. I spend 30 percent of my time trying to get care authorized.”

Burlington’s Dr. Joe Lasek, another psychiatrist, can relate. He works at the Howard Center, a private, nonprofit human service agency that takes care of his billing paperwork. But he still must tackle other insurance issues.

“If I try to get diagnostic tests or follow-up treatment for my patients, insurance companies can say no,” he says. “I have sick and sometimes suicidal patients who aren’t getting care.”

Such problems are keeping other professionals out of the business. Lasek’s wife has a medical degree.

“One of the main reasons she’s not practicing is these hassles,” her husband says. “I have other friends who are pulling back their hours or retraining in another field.”

Berlin’s Dr. Stuart Williams says a growing number of his colleagues support change. The 30-year practitioner is on the board of the Vermont Academy of Family Physicians, which found that a majority of members surveyed favor a single-payer system.

“It seems that physicians have capitulated responsibility to insurers,” Williams says. “We’ve become second tier when we recommend a procedure to a patient and have to kowtow to prior approval and paperwork to put that care in place.”

Different answers

Doctors may agree on the problem, but they aren’t united on the solution. While the Vermont Psychiatric Association has endorsed a single-payer plan, Williams — a member of the council of the Vermont Medical Society — says other medical specialists haven’t voiced a formal position.

Single-payer supporters believe state involvement will eliminate private insurers’ profit motives for questioning care. But they know that skeptics fear government interference.

“People worry that outsiders would be making decisions,” Sorscher says, “but important decisions already are being made by corporate entities.”

Proponents also point to the federal Medicare health insurance program, which, even with its own funding problems, estimates its overhead to be about 3 percent — a tenth of that of private insurers.

“It works for everyone over 65,” Eichner says. “Why not make it universal?”

Back in Middlebury, Mayer says physicians of all political opinions may complain about paperwork, but ultimately they’re most concerned about patients.

“If we as a nation take as a basic premise that health care should be a universal right of all citizens, equally, like Medicare, we will figure out an equitable way to pay for that,” he says. “My decision-making is impacted when I have to think about a person’s personal economics and how much some treatment will cost them. It’s just not fair for those financial considerations to get between me and the care my pediatric patients deserve.”

Global hospital payments by private insurers?

Blue Cross CEO says providers must control costs, or else

By Robert Weisman
The Boston Globe
January 23, 2011

The chief executive of Blue Cross Blue Shield of Massachusetts, the state’s largest health insurer, is calling on hospitals and doctors to step up efforts to contain health care costs, warning that those insisting on traditional fee-for-service contracts will face level or reduced payments from his company.

Andrew Dreyfus, who took the helm at Blue Cross Blue Shield in August, last week sent a letter to more than 400 leaders of hospitals and physicians practices, applying pressure on them to switch to a global payment plan.

Dreyfus’s letter acts as “both a threat and a promise,’’ said Stuart H. Altman, health policy professor at Brandeis University. “He’s saying to the hospitals, you can do better under global payments. But he’s also saying, if you don’t want to do it, if you’re more comfortable with the fee-for-service system, forget it, we’re going to come down on you.’’

http://www.boston.com/business/healthcare/articles/2011/01/23/blue_cross_ceo_says_providers_must_control_health_care_costs_or_else/

Comment:

By Don McCanne, MD

One of the advantages of a single payer system, as envisioned by PNHP, is that hospitals can be placed on global budgets. They are paid periodically a flat budgeted amount based on legitimate operating expenses, just as other public service institutions, such as the fire department, are funded. This relieves the hospital of the high costs and administrative burden of itemizing a multitude of charges for each individual patient – not to mention that it does away with the $15 charge for a Tylenol or $35 charge for a Band-Aid.

Considering the efficiencies of global budgeting it might seem that the decision of Blue Cross Blue Shield of Massachusetts to switch to global payments for hospitals is a giant step toward single payer. It might seem that, but it isn’t.

Under a single payer system, all legitimate costs are budgeted (with separate budgeting of capital improvements), and payments made accordingly. With a global payment made by a single insurer in a multi-payer system, it is difficult to decide which costs should be allocated to that insurer. Furthermore, the insurer really doesn’t care.

A large insurer like Blue Cross Blue Shield will use its leverage to negotiate down its global payments in a secretive, proprietary process, while leveraging risk adjustment to its own advantage (“our privately insured patients are healthier than your sick Medicare patients”). Smaller insurers would be at a competitive disadvantage because of a lack of leverage and an excessive administrative burden per beneficiary. Public payers such as Medicare and Medicaid would continue to do what they already do, regardless of any agreements the hospitals work out with the private payers. Thus the inefficiencies, inequities, and administrative excesses of our current, fragmented, public and private financing system would be perpetuated.

We keep hearing that if we don’t do this, or if we don’t do that, we are going to have single payer. The problem is that if we do this, or do that, anything as long as it isn’t single payer, we’re only going to delay the inevitable. Wouldn’t it be much smarter to end the suffering and hardship now by enacting a single payer system, especially since it’s inevitable anyway?

Vermont doctors say patient needs are buried in paperwork

By Kevin O’Connor
Times Argus (Barre-Montpelier, Vt.), Jan. 23, 2011

RUTLAND — Middlebury’s Dr. Jack Mayer knows that most patients want health care reform to cut rising prices. But he, along with a growing group of Vermont medical providers, hopes to point a scalpel at piles of related paperwork.

Back in 1976 when Mayer opened his first pediatric office in the tiny northernmost town of Enosburg Falls, the Bronx native often bartered his services for eggs, firewood or knitted afghans.

In a larger community and practice 35 years later, Mayer now works with two fellow physicians, a nurse practitioner and two full-time billing clerks who process claims for more than 200 insurance plans.

“Every company has its own paperwork, payment schedules and policies about what it will cover,” says Mayer, who notes that such overhead eats upward of 30 percent of U.S. medical expenses. “The administrative costs of my practice are enormous and don’t go toward improving health or patient care.”

Mayer isn’t alone in his assessment. So many Vermont medical professionals have similar concerns, the Legislature — now contemplating several plans to change the state’s health care system — will hold a public hearing in Montpelier this week to receive their testimony.

“What I hear from all my colleagues is, ‘For every hour I put into clinical care, I put another into paperwork,’” says Dr. Deborah Richter, a Cambridge physician. “They can’t give the care that patients need because of these obstacles.”

Richter is president of the Vermont Health Care for All campaign, which for almost a decade has pushed for what a state consultant proposed last week: a single-payer system to provide medical coverage to all residents.

Richter wasn’t sure if her peers would respond when the Legislature — welcoming public comment through Feb. 3 — invited them to speak Thursday from noon to 2 p.m. at the Statehouse. So far 50 colleagues have confirmed they’ll be there.

“These are busy doctors,” she says, “but they’re willing to talk.”

Nothing but billing

Take Dr. Adam Sorscher, an 18-year primary care physician who juggles work at Central Vermont Medical Center in Berlin, Dartmouth-Hitchcock Medical Center in Lebanon, N.H., (the New Hampshire hospital is Vermont’s second-largest health care provider) and the Good Neighbor Health Clinic in White River Junction. He finds problems wherever he goes.

“I see people at the clinic who have neglected preventive care because of the high cost,” Sorscher says, “and then we have to provide therapies that are more expensive and wouldn’t have been necessary if the health care system was better organized.”

Or consider Dr. William Eichner, an eye specialist who opened his Middlebury practice in 1976 and has added branches in Rutland and Ticonderoga, N.Y. To do so, he has increased his staff to 20 — three of whom focus solely on financial paperwork.

“They don’t greet patients, they don’t handle charts,” the ophthalmologist says. “They do nothing but handle billing and insurance claims.”

That frustrates more and more doctors. Richter points to a 2006 survey she sent to Vermont’s 840 primary care physicians. Of the 300 who responded, four out of five agreed with such statements as “Unnecessary paperwork increasingly is taking away more of my time from my patients” and “I don’t find the intrusion from outside managers and companies helpful.”

Providers say the resulting costs are pricing out more and more patients.

“I feel ashamed we’re the last developed country in the world not to have universal health care,” Eichner says. “I feel a moral imperative that everyone has access and that it be affordable.”

‘Have to kowtow’

Burlington’s Dr. Peggy Carey recalls when, lacking health insurance in her 20s, she was diagnosed with diabetes. Inspired by a nutrition course she took to deal with her diagnosis, she went to medical school and now works as a family doctor in a group practice.

“I wanted to change the system,” says the former English teacher turned 19-year physician.

Carey belongs to the doctor-led Vermont for Single Payer campaign and Physicians for a National Health Program. But she fights her biggest battles inside her practice.

“The majority of the paperwork that comes to me is not in reference to patient care,” she says, “but to what insurance plans allow or don’t allow.”

The problem isn’t limited to physical health. Psychiatrist Dr. Alice Silverman moved to St. Johnsbury two decades ago because the state’s rural Northeast Kingdom lacked enough mental health workers. Today she’s president of the Vermont Psychiatric Association — yet remains one of her region’s few resources.

“I’ve had a waiting list for years,” she says, “and there’s no one else I can refer to.”

Even so, insurance hurdles keep more people out of Silverman’s office.

“I may have someone who’s suicidal, but insurers say they have to see a provider in network, even when there is no one in network,” she says. “In psychiatry, people feel embarrassed enough — to have to call and get approval is a real obstacle. I spend 30 percent of my time trying to get care authorized.”

Burlington’s Dr. Joe Lasek, another psychiatrist, can relate. He works at the Howard Center, a private, nonprofit human service agency that takes care of his billing paperwork. But he still must tackle other insurance issues.

“If I try to get diagnostic tests or follow-up treatment for my patients, insurance companies can say no,” he says. “I have sick and sometimes suicidal patients who aren’t getting care.”

Such problems are keeping other professionals out of the business. Lasek’s wife has a medical degree.

“One of the main reasons she’s not practicing is these hassles,” her husband says. “I have other friends who are pulling back their hours or retraining in another field.”

Berlin’s Dr. Stuart Williams says a growing number of his colleagues support change. The 30-year practitioner is on the board of the Vermont Academy of Family Physicians, which found that a majority of members surveyed favor a single-payer system.

“It seems that physicians have capitulated responsibility to insurers,” Williams says. “We’ve become second tier when we recommend a procedure to a patient and have to kowtow to prior approval and paperwork to put that care in place.”

Different answers

Doctors may agree on the problem, but they aren’t united on the solution. While the Vermont Psychiatric Association has endorsed a single-payer plan, Williams — a member of the council of the Vermont Medical Society — says other medical specialists haven’t voiced a formal position.

Single-payer supporters believe state involvement will eliminate private insurers’ profit motives for questioning care. But they know that skeptics fear government interference.

“People worry that outsiders would be making decisions,” Sorscher says, “but important decisions already are being made by corporate entities.”

Proponents also point to the federal Medicare health insurance program, which, even with its own funding problems, estimates its overhead to be about 3 percent — a tenth of that of private insurers.

“It works for everyone over 65,” Eichner says. “Why not make it universal?”

Back in Middl
ebury, Mayer says physicians of all political opinions may complain about paperwork, but ultimately they’re most concerned about patients.

“If we as a nation take as a basic premise that health care should be a universal right of all citizens, equally, like Medicare, we will figure out an equitable way to pay for that,” he says. “My decision-making is impacted when I have to think about a person’s personal economics and how much some treatment will cost them. It’s just not fair for those financial considerations to get between me and the care my pediatric patients deserve.”

Time For A New Debate On Health Care

By John Nichols
National Public Radio, Jan. 21, 2011

Americans are divided over the question of how best to reform a dysfunctional health care system.

But the new Republican majority in the U.S. House of Representatives entertains no doubt about what must be done: the for-profit insurance industry must be restored to its “proper” place as the determiner of who gets care — and how much they will have to pay.

In the first major vote of the new Congress, the House voted 245-189 in favor of repealing the modest health care reforms implemented last year. All 242 House Republicans voted for repeal, as did three Democrats. All 189 “no” votes were cast by Democrats.

House Speaker John Boehner and his fellow Republican caucus leaders claimed that the vote represented the will of the American people.

But did it?

Survey research suggests that, while Americans are overwhelmingly supportive of health care reform, they are not sure the reform cobbled together by President Obama and the last Congress is the proper fix. According to a new Washington Post/ABC News poll, the country is divided three ways: 33 percent for complete repeal of the measure adopted last year, 35 percent for partial repeal and 30 percent for no repeal.

A new poll conducted for Associated Press finds that “strong opposition to the law stands at 30 percent, close to the lowest level registered in…surveys dating to September 2009.”

All the surveys suggest that the American people are deeply divided with regard to the debate about repeal — not feverishly determined to scrap the existing law, as so many House Republicans are claiming as they argue this week in favor of a symbolic repeal vote.

But those “headline” numbers don’t begin to tell the whole story, however.

What about the tens of millions of Americans who are dissatisfied with the current law but who recognize that the whole debate about repealing it is a political show primarily designed to satisfy talk-radio hosts while exciting insurance-industry campaign donors?

The Americans who oppose repeal but who refuse to buy into the fantasy that the health care system has been sufficiently reformed are right. And there are a lot of them. According to the Associated Press poll, 43 percent of Americans want the government to do more to re-engineer the existing health care system.

That’s millions more than favor the repeal proposed by Republican leaders.

That level of support for more radical reform is the great untold story of the current debate.

The American people are not fools.

Substantial numbers of them understand that what is called “health care reform” by Democrats and “Obamacare” by Republicans is, in fact, a compromise proposal that, at most, addresses the worst abuses of the nation’s for-profit insurers and health providers while outlining a framework for genuine reform.

Unfortunately, Congress did not take the next and necessary step toward creation of a system that provides all Americans with high-quality health care while holding down costs — which now eat up 17 percent of the country’s GDP.

Rather, Republicans in the House used their new majority to push for a return to the bad old days when insurance companies executives were deemed to have an absolute right to their multimillion-dollar bonuses but children and people with pre-existing conditions were deemed to have a right only to beg for charity.

If the House debate on repeal of health care served a purpose, it was to illustrate the deep divide between those who believe the highest priority is to preserve insurance-industry profits and those who worry about sick kids.

Congresswoman Sheila Jackson Lee (D-Texas) summed the whole charade up with her usual precision, when she invited House Republicans to consider their responsibility to represent not just corporations but the common good. “So I would argue that my good friends — some of them are new and I appreciate their newness — I appreciate their desire to keep a commitment to constituents — but when you come to the Congress, you have to govern, you have to look at the whole of America,” she declared during the extended debate on repealing the legislation that the House approved by a narrow margin last year. “And therefore, looking at the whole of America, you need to look at the crux; the crux is saving lives.”

The congresswoman bluntly rejected the notion that repeal is the economic necessity Republicans suggest. Instead, she proposed, preserving reforms that protect the most vulnerable is a life-and-death necessity. “Frankly, I would just say to you, this is about saving lives. Jobs are very important; we created jobs,” explained Jackson Lee. “But even the title of their legislation, H.R. 2, ‘job-killing’ — this is killing Americans if we take this away, if we repeal this bill.”

That’s a credible argument, to be sure.

But what of real reform? What about the changes that might get to the heart of the matter of ending the profiteering that makes health care so expensive and inaccessible?

Congressman Dennis Kucinich (D-OH) brought the right perspective to the debate when he reminded the House that “everyone knows that health insurance companies make money by not providing health care. After all, they are in the insurance business. They are not charities. With as many as 129 million Americans suffering from pre-existing conditions, insurance companies want Congress to repeal health care reform. The provisions which require covering people with pre-existing conditions would eventually cut into insurance company profits.”

Kucinich warned that: “Repeal means Americans will continue to pay more for insurance but get less, that is, if they can afford health care insurance in the first place.”

But the co-author of “Medicare for All” legislation that would extend the Medicare system to all Americans, regardless of age, did not stop there.

“The very idea of health care reform solely within the context of a for-profit system has been more than problematic. Today, 50 million Americans have no health insurance. What are we going to do for them?” said Kucinich. “Rather than waste time on debating how much reform insurance companies will permit — if any — it is time to change the debate. It is time to end the for-profit health care model. It is time for not-for-profit health care, single-payer, universal, Medicare for All — with an emphasis on wellness and personal responsibility.”

John Nichols writes about politics for The Nation magazine as its Washington correspondent. He is a contributing writer for The Progressive and In These Times and the associate editor of the Capital Times, the daily newspaper in Madison, Wisconsin.

http://www.npr.org/2011/01/20/133074314/the-nation-time-for-a-new-debate-on-health-care

eHealth technology not ready for prime time

The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview

By Ashly D. Black, Josip Car, Claudia Pagliari, Chantelle Anandan, Kathrin Cresswell, Tomislav Bokun, Brian McKinstry, Rob Procter, Azeem Majeed, Aziz Sheikh
PLoS Medicine
January 18, 2011

Editors’ Summary

Background

There is considerable international interest in exploiting the potential of digital health care solutions, often referred to as eHealth — the use of information and communication technologies — to enhance the quality and safety of health care. Often accompanied by large costs, any large-scale expenditure on eHealth — such as electronic health records, picture archiving and communication systems, ePrescribing, associated computerized provider order entry systems, and computerized decision support systems — has tended to be justified on the grounds that these are efficient and cost-effective means for improving health care. In 2005, the World Health Assembly passed an eHealth resolution (WHA 58.28) that acknowledged, “eHealth is the cost-effective and secure use of information and communications technologies in support of health and health-related fields, including health-care services, health surveillance, health literature, and health education, knowledge and research,” and urged member states to develop and implement eHealth technologies. Since then, implementing eHealth technologies has become a main priority for many countries. For example, England has invested at least £12.8 billion in a National Programme for Information Technology for the National Health Service, and the Obama administration in the United States has committed to a US$38 billion eHealth investment in health care.

Why Was This Study Done?

Despite the wide endorsement of and support for eHealth, the scientific basis of its benefits — which are repeatedly made and often uncritically accepted—remains to be firmly established. A robust evidence-based perspective on the advantages on eHealth could help to suggest priority areas that have the greatest potential for benefit to patients and also to inform international eHealth deliberations on costs. Therefore, in order to better inform the international community, the authors systematically reviewed the published systematic review literature on eHealth technologies and evaluated the impact of these technologies on the quality and safety of health care delivery.

What Did the Researchers Do and Find?

The researchers divided eHealth technologies into three main categories: (1) storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance. Then, implementing methods based on those developed by the Cochrane Collaboration and the NHS Service Delivery and Organisation Programme, the researchers used detailed search strategies and maps of health care quality, safety, and eHealth interventions to identify relevant systematic reviews (and related theoretical, methodological, and technical material) published between 1997 and 2010. Using these techniques, the researchers retrieved a total of 46,349 references from which they identified 108 reviews. The 53 reviews that the researchers finally selected (and critically reviewed) provided the main evidence base for assessing the impact of eHealth technologies in the three categories selected.

In their systematic review of systematic reviews, the researchers included electronic health records and picture archiving communications systems in their evaluation of category 1, computerized provider (or physician) order entry and e-prescribing in category 2, and all clinical information systems that, when used in the context of eHealth technologies, integrate clinical and demographic patient information to support clinician decision making in category 3.

The researchers found that many of the clinical claims made about the most commonly used eHealth technologies were not substantiated by empirical evidence. The evidence base in support of eHealth technologies was weak and inconsistent and importantly, there was insubstantial evidence to support the cost-effectiveness of these technologies. For example, the researchers only found limited evidence that some of the many presumed benefits could be realized; importantly, they also found some evidence that introducing these new technologies may on occasions also generate new risks such as prescribers becoming over-reliant on clinical decision support for e-prescribing, or overestimate its functionality, resulting in decreased practitioner performance.

What Do These Findings Mean?

The researchers found that despite the wide support for eHealth technologies and the frequently made claims by policy makers when constructing business cases to raise funds for large-scale eHealth projects, there is as yet relatively little empirical evidence to substantiate many of the claims made about eHealth technologies. In addition, even for the eHealth technology tools that have proven to be successful, there is little evidence to show that such tools would continue to be successful beyond the contexts in which they were originally developed. Therefore, in light of the lack of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, the authors say that future eHealth technologies should be evaluated against a comprehensive set of measures, ideally throughout all stages of the technology’s life cycle, and include socio-technical factors to maximize the likelihood of successful implementation and adoption in a given context. Furthermore, it is equally important that eHealth projects that have already been commissioned are subject to rigorous, multidisciplinary, and independent evaluation.

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000387#pmed.1000387-Garg1

Comment:

By Don McCanne, MD

Digital health care solutions, or eHealth, include electronic health records, picture archiving and communication systems, ePrescribing, associated computerized provider order entry systems, and computerized decision support systems. These researchers performed a systematic review of the systematic reviews of eHealth published since 1997, providing us with a perspective of the impact that eHealth has had on the quality and safety of health care.

What did they find?

“Our systematic review of systematic reviews on the impact of eHealth has demonstrated that many of the clinical claims made about the most commonly deployed eHealth technologies cannot be substantiated by the empirical evidence. Overall, the evidence base in support of these technologies is weak and inconsistent, which highlights the need for more considered claims, particularly in relation to the patient-level benefits, associated with these technologies. Also of note is that we found virtually no evidence in support of the cost-effectiveness claims.”

This is of particular importance right now as health care providers and institutions are gearing up to establish accountable care organizations (ACOs), as called for in the Patient Protection and Affordable Care Act (PPACA). Although various models of ACOs are being developed, all of them have in common interconnectivity through eHealth. In fact, the simplest form is the so-called virtual ACO which is nothing more than isolated, independent practices connected through eHealth.

Since eHealth provides the fundamental framework through which ACOs function, it is important to be sure that we have it right. But w
e’re not certain. The authors report that eHealth systems have proven to be beneficial when carefully designed in house for a handful of large institutions, but the evidence is simply not there for most systems in use today.

The reason that our politicians included ACOs in the PPACA is that theoretically they would help to control health spending primarily through the transparencies, efficiencies and error reduction of eHealth. Yet there is “virtually no evidence in support of the cost-effectiveness claims.”

We have to get health care costs under control. Maybe someday eHealth will help with that, but we’re definitely not there now. It is certainly fine to continue with studies of ACOs and eHealth, but for cost containment, we should move immediately to policies that have been proven to be effective – a single payer national health program, aka an improved Medicare for all.

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