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The policy community’s approach to narrow networks

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The policy community’s approach to narrow networks

A better approach to regulating provider network adequacy

By Mark Hall and Paul B. Ginsburg
USC-Brookings Schaeffer Initiative for Health Policy, September 14, 2017

Health care reforms, including those put in place by the Affordable Care Act, are making insurers more competitive. However, in their effort to lower costs, health insurers more often are selling health plans that cover fewer hospitals, and many fewer physicians.

This narrowing of provider networks is a sign that market reforms may be improving consumer value,  but network narrowing also raises a number of concerns. For example, a narrow network may have insufficient capacity to serve the number of people enrolled, or the providers may be too geographically dispersed to be reasonably accessible.

Rules dictating the adequacy of care in these networks have been in place for several decades, but state and federal regulators have begun to assess whether these rules are suited for the modern conditions.

In “A better approach to regulating provider network adequacy,” Mark Hall and Paul B. Ginsburg argue that the current set of regulations are not sufficient to ensure network adequacy without placing undue constraints on market innovation. Instead, the authors argue that a more layered approach is needed, including a form of patient-specific [or case-specific] dispute resolution.

This layered approach to network adequacy consists of the following recommended eight elements:

1. A general qualitative standard for network adequacy is needed

2. Insurers should provide reasonably up-to-date and user-friendly network directories, and network size should be more clearly labeled for consumers.

3. Some basic baseline quantitative standards should be considered that are fairly easy to administer, such as a minimally acceptable number of higher-volume providers in the major areas of primary care and specialty practice, and at least one such provider within a defined distance of most of the plan’s enrolled population.

4. Quantitative standards should be presumptive, but not conclusive.

5. If quantitative standards are adopted, consideration should be given to maximum wait times (rather than simply number and distribution of providers).

6. Regardless of the substantive adequacy standards in place, a backstop dispute resolution process is also needed to protect patients who might face inadequate access due to a restricted network.

7. Patients should be held financially harmless when a reviewer determines there are grounds to receive care out of network.

8. If network adequacy requirements might add substantially to the cost of insurance, then states should consider creating an additional dispute resolution process focused on financial implications.

The authors conclude that a robust dispute resolution process can ease the administrative burden of overseeing network adequacy. “Nevertheless, well-designed regulation of network adequacy is not easy to achieve. Because no single regulatory approach is likely to be sufficient, we need to think more in terms of a layered approach – one that thoughtfully melds together different dimensions and techniques of oversight.”

https://www.brookings.edu…

Full report:
https://www.brookings.edu…

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Comment:

By Don McCanne, M.D.

Why do private insurers establish narrow provider networks? They claim that they contract for higher quality at lower costs, but quality has nothing to do with it. They reduce costs by granting physicians and hospitals greater numbers of patients in return for contracted lower prices. They also lower costs by reducing patient access to care as a result of failure to use the full complement of heath care resources in the community. This not only allows insurers to offer more competitive premiums and thus greater insurance sales, but it also enhances profits and shareholder returns.

Narrow networks are a business tool of for-profit, private insurers. They are detrimental for patients because they lose access to their choices in their health care professionals and institutions. They are also detrimental to care provided by dedicated primary care physicians because they reduce access for their patients to specialists and their specialized services (often without the knowledge of patients when physicians remain silent on potential health care resources that are out-of-network).

Traditional Medicare does not use narrow networks. Medicare’s mission is to enable access to care for the beneficiaries, not to obstruct access to that care. Although entrepreneurial endeavors and public service health programs may superficially appear to have similar goals, their primary targets are quite different – investor returns versus optimal health care.

These differences have been widely recognized. So what should be done about this problem? To see what the policy community recommends, skim through the eight elements listed above. With a little thought, you can immediately recognize the problem, and that is that they have not acknowledged what the real problem is.

The elements listed would hardly tweak the current system, yet they are the type of approaches that are taken when you make the assumption that we are going to leave our health care system under the control of the medical-industrial complex. The real problem is the dysfunctional health care financing system that we continue to support.

If we were to change to a well designed, single payer national health program, the narrow provider networks would be eliminated because they counter the goals of a premier performing health care system. The sooner we do that, the better.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Atul Gawande: Is health care a right?

Is Health Care a Right?

By Atul Gawande
The New Yorker, October 2, 2017

Is health care a right? The United States remains the only developed country in the world unable to come to agreement on an answer. Earlier this year, I was visiting Athens, Ohio, the town in the Appalachian foothills where I grew up. The battle over whether to repeal, replace, or repair the Affordable Care Act raged then, as it continues to rage now. So I began asking people whether they thought that health care was a right.

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“My personal opinion is that anytime the government steps in and says, ‘You must do this,’ it’s overstepping its boundaries,” Joe said. “A father, mother, two kids working their asses off—they’re making minimum wage and are barely getting by—I have no problem helping them. If I have someone who’s spent his whole life a drunk and a wastrel, no, I have no desire to help. That’s just the basics.”

Such feelings are widely shared. They’re what brought the country within a single vote of repealing major parts of President Obama’s expansion of health-care coverage. Some people see rights as protections provided by government. But others, like the Duttons, see rights as protections from government.

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People don’t think about their water, Tim said, but we can’t live without it. It is not a luxury; it’s a necessity of human existence. An essential function of government, therefore, is to insure that people have clean water. And that’s the way he sees health care. Joe wanted government to step back; Tim wanted government to step up. The divide seemed unbridgeable. Yet the concerns that came with each viewpoint were understandable, and I wondered if there were places where those concerns might come together.

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Monna considered herself a conservative. The notion of health care as a right struck her as another way of undermining work and responsibility: “Would I love to have health insurance provided to me and be able to stay home?” Of course, she said. “But I guess I’m going to be honest and tell you that I’m old school, and I’m not really good at accepting anything I don’t work for.”

She could quit her job and get Medicaid free, she pointed out, just as some of her neighbors had. “They have a card that comes in the mail, and they get everything they need!” she said. “Where does it end? I mean, how much responsibility do tax-paying people like me have? How much is too much?” She went on, “I understand that there’s going to be a percentage of the population that we are going to have to provide for.” When she was a young mother with two children and no home, she’d had to fall back on welfare and Medicaid for three months. Her stepson, Eric, had been on Medicaid and Social Security Disability Insurance before he died. Her eighty-three-year-old mother, who has dementia and requires twenty-four-hour care, was also on Medicaid. “If you’re disabled, if you’re mentally ill, fine, I get it,” Monna said. “But I know so many folks on Medicaid that just don’t work. They’re lazy.” Like the Duttons, she felt that those people didn’t deserve what they were getting.

But then we talked about Medicare, which provided much of her husband’s health care and would one day provide hers. That was different, Monna told me. Liberals often say that conservative voters who oppose government-guaranteed health care and yet support Medicare are either hypocrites or dunces. But Monna, like almost everyone I spoke to, understood perfectly well what Medicare was and was glad to have it. I asked her what made it different.

“We all pay in for that,” she pointed out, “and we all benefit.” That made all the difference in the world. From the moment we earn an income, we all contribute to Medicare, and, in return, when we reach sixty-five we can all count on it, regardless of our circumstances. There is genuine reciprocity. You don’t know whether you’ll need more health care than you pay for or less. Her husband thus far has needed much less than he’s paid for. Others need more. But we all get the same deal, and, she felt, that’s what makes it O.K.

“I believe one hundred per cent that Medicare needs to exist the way it does,” she said. This was how almost everyone I spoke to saw it. To them, Medicare was less about a universal right than about a universal agreement on how much we give and how much we get.

Understanding this seems key to breaking the current political impasse. The deal we each get on health care has a profound impact on our lives—on our savings, on our well-being, on our life expectancy. In the American health-care system, however, different people get astonishingly different deals. That disparity is having a corrosive effect on how we view our country, our government, and one another.

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Arnold, with his code of self-reliance, had eliminated nearly all sources of insecurity from his life. But here was one that was beyond his control. “The biggest worry I have would be some sort of health-care need,” he said. A serious medical issue would cost him his income. As an independent contractor, he isn’t eligible for unemployment benefits. And, having passed the age of fifty, he was just waiting for some health problem to happen.

So did he feel that he had a right to health care? No. “I never thought about it as a matter of rights,” he said. “A lot of these things we think are rights, we actually end up paying for.” He thinks that the left typically plays down the reality of the costs, which drives him crazy. But the right typically plays down the reality of the needs, which drives him crazy, too.

In his view, everyone has certain needs that neither self-reliance nor the free market can meet. He can fix his house, but he needs the help of others if it catches fire. He can keep his car running, but he needs the help of others to pave and maintain the roads. And, whatever he does to look after himself, he will eventually need the help of others for his medical care.

“I think the goal should be security,” he said of health care. “Not just financial security but mental security—knowing that, no matter how bad things get, this shouldn’t be what you worry about. We don’t worry about the Fire Department, or the police. We don’t worry about the roads we travel on. And it’s not, like, ‘Here’s the traffic lane for the ones who did well and saved money, and you poor people, you have to drive over here.’ ” He went on, “Somebody I know said to me, ‘If we give everybody health care, it’ll be abused.’ I told her that’s a risk we take. The roads are abused. A lot of things are abused. It’s part of the deal.”

As he saw it, government existed to provide basic services like trash pickup, a sewer system, roadways, police and fire protection, schools, and health care. Do people have a right to trash pickup? It seemed odd to say so, and largely irrelevant. The key point was that these necessities can be provided only through collective effort and shared costs. When people get very different deals on these things, the pact breaks down. And that’s what has happened with American health care.

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We relied on government to establish a system of compulsory public education, infrastructure for everything from running water to the electric grid, and old-age pensions, along with tax systems to pay for it all. As in other countries, these programs were designed to be universal. For the most part, we didn’t divide families between those who qualified and those who didn’t, between participants and patrons. This inclusiveness is likely a major reason that these policies have garnered such enduring support.

Health care has been the cavernous exception.

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To win passage, the A.C.A. postponed reckoning with our generations-old error of yoking health care to our jobs—an error that has made it disastrously difficult to discipline costs and insure quality, while severing care from our foundational agreement that, when it comes to the most basic needs and burdens of life and liberty, all lives have equal worth. The prospects and costs for health care in America still vary wildly, and incomprehensibly, according to your job, your state, your age, your income, your marital status, your gender, and your medical history, not to mention your ability to read fine print.

Few want the system we have, but many fear losing what we’ve got. And we disagree profoundly about where we want to go. Do we want a single, nationwide payer of care (Medicare for all), each state to have its own payer of care (Medicaid for all), a nationwide marketplace where we all choose among a selection of health plans (Healthcare.gov for all), or personal accounts that we can use to pay directly for health care (Health Savings Accounts for all)?

***

What we agree on, broadly, is that the rules should apply to everyone. But we’ve yet to put this moral principle into practice.

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Two sets of values are in tension. We want to reward work, ingenuity, self-reliance. And we want to protect the weak and the vulnerable—not least because, over time, we all become the weak and vulnerable, unable to get by without the help of others. Finding the balance is not a matter of achieving policy perfection; whatever program we devise, some people will put in more and some will take out more. Progress ultimately depends on whether we can build and sustain the belief that collective action genuinely results in collective benefit. No policy will be possible otherwise.

https://www.newyorker.com…

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Comment:

By Don McCanne, M.D.

Years ago, here in conservative Orange County, I learned not to ask audiences whether they believed health care is a right. The “tis so,” “tis not” that followed was not productive. Nevertheless, the question frequently came up during Q&A, with the same result.

Atul Gawande’s long article is interesting because conservatives he interviewed used different framing to express the concept that people should have health care when they need it, without deeming it to be a right. Health care should be a basic service like trash pickup, water, a sewer system, roadways, police and fire protection, and schools. We don’t speak of a right to trash pickup, and we don’t need to anger others by getting into a cat fight over a “right” to health care.

It is no wonder that we are beginning to see conservatives supporting single payer, not as a right but as a necessity.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Our family, friends and communities deserve Medicare for all

By Peter Mahr, M.D.
The Oregonian (Portland, Ore.), September 27, 2017

As a family physician, I was trained to guide patients through difficult times with clinical expertise and emotional support. But I am finding it increasingly difficult to provide this care.

One of my patients without insurance received a $100,000 hospital bill after a heart attack and newly diagnosed congestive heart failure. She has declined all recommended follow up tests, specialist care and cardiac rehabilitation due to the cost. I had a young patient in his 20s who developed worrisome neurological symptoms that warranted tests to rule out a stroke. But he declined hospital admission as his insurance required a $3,000 copay. A father had a bicycle accident requiring life-saving emergency care for a broken pelvis and fractured arm. The emotional toll from his accident was compounded by the shock of a $5,000 deductible bill, and the stress of the resulting collections agency calls and threat of home foreclosure.

Patients’ financial stress has become a routine part of our medical practices. Although we stand by our patients during daunting medical challenges, we were never taught to protect them from bankruptcy when they seek the care they need. These are stories of a broken health care system. They reveal a dark side of medicine we were not trained for and did not choose to participate in.

The United States’ healthcare system is the most expensive in the world, yet 60 million of us remain uninsured or underinsured. Our administrative and drug costs dwarf other nations. Gallup reports that one-third of Americans delay or forgo care due to cost.  Despite spending twice as much per capita on healthcare, the US ranks 81st among 195 nations on mortality prevented by medical care – we’re tied with Estonia and one place above Lebanon.

Fortunately, there is light emerging from darkness. Sen. Bernie Sanders has introduced legislation that would enact a Medicare For All or “single payer” system in the U.S. All current health care financing — taxes, premiums, copayments and deductibles — would be placed into a single fund and pay for all medically necessary services. The vast majority of Americans would receive comprehensive medical coverage and pay less than they currently do. Each patient would have the freedom to go to any doctor or hospital. The dramatic reduction in administrative costs and the ability to negotiate drug prices will allow us to cover everyone and stabilize health care costs.

Single payer health insurance is what our family, friends, neighbors and communities deserve. We deserve continuous, affordable health insurance regardless of income, marital status, age or employment. We deserve to seek medical care when we are sick without fear of financial catastrophe. We deserve to choose our doctors or hospitals based on preference not on insurance networks. And we deserve the peace of mind that we will have access to health care when we need it.

I urge you to support Sen. Sanders’ Medicare For All Act of 2017. Oregon Sen. Jeff Merkely is a co-sponsor. Call Sen. Ron Wyden today and ask him to sign on as well.

Dr. Peter Mahr has practiced as a family physician in the metro area for 16 years and is president of the Portland chapter of Physicians for a National Health Program. He lives in Southeast Portland.

http://www.oregonlive.com…

CaPA’s Tarzynski sets record straight on single payer

Americans have been fighting over government's role in medical care for decades. That fight will continue.

By Steve Tarzynski
Los Angeles Times, September 27, 2017

From my decades of experience as a doctor, it seems to me that no market-driven healthcare system can simultaneously limit costs, guarantee universal coverage and deliver desired outcomes. Overwhelming evidence demonstrates that the best way to reduce costs and guarantee healthcare to everyone is to have the largest risk pool — that is, the entire nation. These facts compel the United States to move to a single-payer system guided by comparisons with other countries’ experiences and by our own American successes, such as Medicare and Medicaid.

The preamble of our Constitution states that government exists to provide “domestic tranquility” and “promote the general welfare,” which certainly suggests constitutional support for healthcare for all.

Steve Tarzynski is a physician and president of the California Physicians Alliance.

http://www.latimes.com…

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Comment:

By Don McCanne, M.D.

Because of an editorial glitch in a previous Los Angeles Times op-ed by Steve Tarzynski, there was some confusion over the relative positions of PNHP California and California Physicians Alliance on the goal of single payer. His followup message could not be more clear. We remain partners in the quest for health care justice for all. In fact, many of us, including me, belong to both organizations.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

How Anthem and Medicare control MRI prices

Need An MRI? Anthem Directs Most Outpatients To Independent Centers

By Michelle Andrews
Kaiser Health News, September 26, 2017

Tightening the screws on pricey imaging exams, health insurer Anthem will no longer allow many patients to get MRIs or CT scans at hospital-owned, outpatient facilities, requiring them to use independent imaging centers instead.

Anthem says the change is aimed at providing high-quality, safe care while reducing medical costs.

But critics say that imposing a blanket rule that gives preference to freestanding imaging centers is at odds with promoting quality and will lead to fragmented care for patients.

Imaging tests are generally subject to preapproval by Anthem to confirm that they’re medically necessary. Under the new policy, AIM Specialty Health, an Anthem subsidiary, will also evaluate where they should be performed. Doctors who request non-emergency outpatient MRI or CT scans that can be done at an independent imaging center rather than one owned by the hospital will be given a list of centers eligible for patient referrals.

Hospital imaging is indeed pricier than imaging at freestanding centers. Average prices for MRI and CT scans ranged from 70 percent to 149 percent higher at hospitals, according to an analysis by the Healthcare Financial Management Association, a membership group for health care finance professionals.

But price isn’t the only important variable, and the perception that all imaging studies conducted by qualified providers generally yield comparable results is wrong, (said Leah Binder, president and CEO of the Leapfrog Group).

This is Anthem’s second coverage change this year attracting attention. Earlier, the company came under fire for a new policy under which it will no longer pay for emergency department visits that it determines after the fact weren’t emergencies. That decision raised concerns it could discourage people who might need emergency treatment from  seeking care.

Patient advocates and health care providers have also expressed concerns about the new imaging rule’s potential impact on patients.

Cancer patients who often are being treated at cancer centers within hospitals would feel the effect, noted Dr. J. Leonard Lichtenfeld, deputy chief medical officer for the American Cancer Society.

“They have to go to a new outpatient facility, get the film, get it read and transmitted back to the cancer center,” Lichtenfeld said. If, as often happens, the hospital and the imaging center’s computer systems don’t talk to each other, the patient may have to bring the results back to the doctor on a CD. “For that patient who’s in a lot of stress to begin with, it adds another level of stress,” he said.

Anthem isn’t the only insurer trying to find a way around hospitals’ steeper outpatient imaging costs, said Lea Halim, a senior consultant at the Advisory Board, a health care research and consulting company. The Medicare program is taking steps as well, although its approach doesn’t directly influence patient care in the same way.

In recent years, hospitals have been snapping up independent physician practices, outpatient imaging and testing facilities and then charging Medicare higher hospital outpatient fees for their services. In a bid to equalize payments, in January the Medicare program reduced by 50 percent the amount it pays some hospital-owned outpatient facilities, including imaging centers, that are located away from a hospital’s campus. A further reduction is proposed for 2018.

“So Medicare is doing something that’s in a way very similar to what Anthem’s doing,” Halim said.

http://khn.org…

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CMS Finalizes Hospital Outpatient Prospective Payment System Changes to Better Support Hospitals and Physicians and Improve Patient Care

CMS.gov, November 1, 2016

Focusing Payments on Patients Rather than Setting

CMS is finalizing policies to implement section 603 of the Bipartisan Budget Act of 2015, which requires that certain items and services furnished by certain off-campus hospital outpatient departments will no longer be paid under the OPPS beginning January 1, 2017. Currently, Medicare pays for the same services at a higher rate if those services are provided in a hospital outpatient department rather than a physician’s office. This payment differential has provided an incentive for hospitals to acquire physician offices in order to receive the higher rates. This acquisition trend and difference in payment has been highlighted as a long-standing issue of concern by Congress, the Medicare Payment Advisory Commission, and the Department of Health and Human Services Office of Inspector General. This difference in payment also increases costs for the Medicare program and raises the cost-sharing liability for beneficiaries.

This final rule with comment period describes which off-campus hospital outpatient departments are subject to this requirement and which items and services are “excepted” from application of these payment changes and will continue to be paid under the OPPS.

CMS is issuing an interim final rule with comment period (IFC) in conjunction with this final rule with comment period to establish new payment rates under the Medicare Physician Fee Schedule (MPFS) for the items and services provided by certain off-campus provider-based departments for CY 2017.

These new interim final rates being adopted in the IFC will permit hospitals to be paid for the furnishing of items and services that may no longer be paid under the OPPS, and we believe will reduce incentives for hospitals to acquire independent physician practices and convert the same service into more highly paid OPPS services.

https://www.cms.gov…

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Comment:

By Don McCanne, M.D.

Prices charged for MRI scans in hospitals and outpatient departments are higher than those charged in freestanding facilities. Both Medicare and the private, for-profit insurer Anthem are taking measures to correct this imbalance. Health care consultant Lee Halim says that “Medicare is doing something that’s in a way very similar to what Anthem’s doing.” But are they really similar?

The problem to be addressed is that the prices are too high. What is not a problem is the location of the facility. Hospital and outpatient facilities are located conveniently, enabling them to provide services integrated with the mothership.

Obtaining MRI scans in unrelated freestanding facilities can be disruptive. Imagine a patient receiving outpatient care in a cancer center having to go across town to obtain an MRI from a radiologist that is not part of the integrated team. Imagine the confusion as to the precise imagining features desired, the transfer of the images to incompatible equipment, and the communication difficulties between the patient’s cancer team and an outsider. Yet this is Anthem’s solution to obtaining lower prices.

What does Medicare do? It does not change the location, but rather it uses administered pricing to reduce the costs to appropriate levels. As the Medicare release states, they are “focusing payments on patients rather than setting.”

Medicare made these patient-friendly changes almost a year ago, and now Anthem is following through in the most patient-unfriendly manner – disrupting health care to save a buck.

There really is a difference in the patient service culture of our Medicare program and the strict business ethic of the for-profit insurers, not to mention that Medicare is providing us with a better deal anyway.

Medicare still doesn’t have everything quite right, and that is why we need an improved Medicare. But then we’ll have a program that will be nearly ideal for all of us, and one that we can afford.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Why I’m the last happy doctor

By Marsha Fretwell, M.D.
The Charlotte Observer, September 26, 2017

When I retired at 70 years old as a practicing geriatrician in Wilmington and said farewell to my medical colleagues, I slowly began to realize that I might be “The Last Happy Doctor” in town. Why is this and how did it happen? First, let me lay out some of the realities of practicing medicine today.

The surgeon general has declared that, second only to opioid addiction, “burned out” physicians is our most critical issue in health care. In a recent survey of N.C. physicians, the most prominent reason given for their “burnout” was erosion of clinical authority and the requirement of excessive insurance paperwork in order to get paid. Only 11 percent of physicians felt they had the time they needed to provide the highest standards of care. In the next one to three years, 44 percent plan to cut back on direct delivery of care, retire, or seek work in non-clinical jobs.

So, how did I end up as the “Last Happy Doctor”? It was a series of responses I made as the insurance industry began to reshape health care as a for-profit efficiency driven business. The first choice was to resist reducing the time spent with my patients. When I refused to schedule less than one half hour per patient, it became obvious that I would need to start and manage my own practice. Because of my choice to focus primarily on caring for older patients, my revenue stream was approximately 96 percent Medicare funded. Unaware, I had wandered into a “Medicare for All” financed healthcare practice.

Knowing that all my patients had coverage was a great relief to me and my office staff. That allowed us to focus on truly caring for and about them. Having a predictable reimbursement allowed me to create a budget. The greatest bonus was the lower overhead. Because my practice did not need to spend hours on the phone with agents of the for-profit insurance companies, I could hire fewer staff. Additionally, not only was I making clinical decisions based on patients’ needs, I got to decide on clinician-friendly computer software for data collection. This reduced the other major reason physicians are “burned out” and leaving practice: spending excessive time using computer software that does not actually serve any meaningful purpose for clinical care.

The introduction of widespread for-profit insurance financing of health care in the 1970s is a major factor in the demoralization of physicians. The percentage of the health care insurance market served by for-profits rose from 16 percent in 1981 to 65 percent in 1997. In the for-profit setting, physicians are required to care for patients under constant time pressure and with the knowledge that the cost of care may send their patients into bankruptcy. This model does not work in health care at the practitioner level because it requires reduction of human contact time. Without this human contact, a loss of satisfaction occurs for both the physicians and patients. Critical to the discussion is the significant lowering of survival rates and desired patient outcomes since 1950, all in the context of rapidly rising costs.

In a humane society, universal health care is a given, and those involved in health care optimally come with a calling. Helping individuals improve their health requires trusting relationships over time. Creating a “Medicare for All” financing system and removing for-profit insurers from the equation is an appropriate pathway to less expensive care, better health outcomes, happier patients and happier doctors. I know because I have been there.

Dr. Fretwell is retired from active practice in geriatric medicine. She is now activity working with Healthcare for All of Western North Carolina seeking fundamental change in the financing of health care.

http://www.charlotteobserver.com…

Bernie Sanders is right – why not Medicare for all?

Private doctors and hospitals would still provide care under Bernie Sanders' Medicare for All plan, offering better care at lower cost.

By James E. Dalen, M.D., M.P.H., Sc.D. (hon)
Arizona Republic, September 26, 2017

Bernie Sanders is introducing a bill that would ensure that all Americans have access to health care. It is called “Medicare for all.”

Is this a wild socialist scheme?

Nearly every industrialized nation (except the U.S.) provides universal access to health care. They spend less on health care than the U.S., and nearly all have better health care outcomes because they provide ongoing primary and preventive care to all their citizens.

There are two ways to ensure care

There are two ways that a nation may ensure health care for all its citizens. It may directly provide the health care by employing all physicians and health-care workers, and owning all hospitals and clinics. The cost of health care is paid by taxes.

This is the English system established as the National Health Service in 1948. This is socialized medicine. There may be rationing or significant waiting times for certain tests or procedures. Many Scandinavian countries also have this system. Socialized medicine works well for them, but it would never be accepted in the U.S.

The second way to provide universal care is mandatory national health insurance paid by a payroll tax shared by the employee and the employer. Health care is provided by the private sector: private physicians and private hospitals and clinics. The government does not provide the care.

This system has worked well in Germany, France and many other European countries for decades. There is no rationing of care and no long waits for care. Health-care costs are lower and the quality of care is equal to or exceeds the U.S’s.

Nations with universal health care have a single payer for health care: either the government itself or a national health insurance plan.

Sanders’ plan offers a single payer

In the U.S. we have multiple payers. Most Americans have employment based insurance. Employers contract with various insurance companies to pay the medical bills of their employees. Physicians and hospitals send their bills to hundreds of different insurance companies, each company has its own forms and fee schedules. It is a very complex and very expensive system.

The other major payors are Medicare and Medicaid. Again, they have different fees and different billing procedures.

Sanders proposes that all U.S. health-care bills would have a single payer: Medicare. Medicare would set fees and pay health providers in much the same way it currently pays for care to Medicare patients. Billing would be much simpler: a single billing form and a single fee schedule. The administrative costs of Medicare are about 2 percent, compared to about 17 percent for U.S. private insurance. Medicare as a single payer would decrease U.S. health-care costs by billions of dollars.

Many Americans will object to the Sanders plan because they believe that the government should not be involved in health care. Yet our government is already heavily involved in health care. More than half of U.S. health care – Medicare, Medicaid, military and VA care – is provided by or administered by federal or state governments.

Government is already involved in care

Many Americans oppose mandatory health insurance, yet we have had it for more than 50 years. Medicare is mandatory health insurance administered by the federal government.

Health care to Medicare patients is provided by private physicians and private hospitals and clinics; not the government as in England or Scandinavia. Patients have free choice of hospitals and physicians. All surveys have shown that quality of care is excellent and that seniors are pleased with their care. There is no rationing of care and no long waiting times for care.

Polls since 1945 have shown that most Americans favor national health insurance. A poll in 2007 showed that most U.S. physicians also favor national health insurance.

If we are looking for a way to provide comprehensive health care to all our citizens at less cost, it is in plain sight: Medicare for all.

Dr. James E. Dalen is dean emeritus at the University of Arizona Medical School and executive director of Weil Foundation in Tucson, which serves to advance integrated medicine.

http://www.azcentral.com…

USA TODAY: Obamacare or single payer?

Focus on Obamacare, not single-payer pipe dreams

By The Editorial Board
USA TODAY, September 25, 2017

Our view: Bernie Sanders’ Medicare for all is an unwieldy manifesto

Providing a Medicare-like public option alongside private insurers in ACA exchanges is another idea worth trying, particularly in any counties that go down to one or zero sellers. Allowing people 55 and older to buy into Medicare at the actual cost to government is another option.

But now, even with the Graham-Cassidy measure on life support, is the wrong time for Democrats to be focusing on Berniecare.

Reader Poll: What do you think of our view?

27% – Strongly agree

30% – Agree

6% – Don’t know

17% – Disagree

21% – Strongly disagree

(113 votes as of 2:20 PM Eastern)

https://www.usatoday.com…

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Bernie Sanders: Time is ripe for Medicare for all

By Bernie Sanders
USA TODAY, September 25, 2017

Opposing view: Eliminate insurance industry profits and reduce waste

The truth is that the only reason we, among all major countries, do not have universal health care has everything to do with politics and greed.

Now is the time to tell members of Congress that their job is to protect the American people, not the insurance companies and the drug companies. Now is the time for Medicare for all.

Reader Poll: What do you think of Sen. Sanders’ commentary?

69% – Strongly agree

11% – Agree

4% – Don’t know

4% – Disagree

12% – Strongly disagree

(745 votes as of 2:20 PM Eastern)

https://www.usatoday.com…

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Comment:

By Don McCanne, M.D.

This poll is not scientific, but it is interesting. As of this posting, 80 percent agree with Bernie Sanders position on single payer, whereas 57 percent agree with the USA TODAY editorial board that we should focus on Medicare instead of single payer “pipe dreams.” But make of it what you will, as of the moment this is written, almost seven times as many readers elected to vote on Bernie’s Sanders’ commentary (745) as voted on the USA TODAY editorial (113). That netted 597 votes for Sanders’ position to 66 votes for The Editorial Board position.

There is certainly more passion behind the single payer movement than there is behind skipping single payer and focusing on Obamacare. Let’s turn that passion into action.

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Five lessons from Canada on single-payer health care

By Colleen M. Flood and Allan Rock
Chicago Tribune, September 24, 2017

The United States is about to debate the merits of Bernie Sanders’ proposal for a single-payer health care system. While cost will be an issue, evidence shows that many countries provide access to quality care for all their citizens through a single-payer model while spending far less than the U.S. does now.

How can this be?

Single-payer systems are often promoted as a means to achieve social justice. But they are also more economically efficient than the private market alternative. Having one payer simplifies the administration of health care by avoiding multiple insurers processing claims.

Costly administration is one reason why the U.S. spends by far the greatest percentage of gross domestic product on health care in the Organization for Economic Co-operation and Development (while having the largest percentage of uninsured).

But not all single-payer models are created equal.

As Americans consider Sanders’ proposal, they should examine the successes and failures of single-payer systems elsewhere. Canada’s actual experience (and not the make-believe version portrayed by idealogues) might help Americans craft their own, better version.

We offer five lessons from Canada that Americans should take to heart.

‱ First and most important, a single-payer system does not and should not cover everything — just everybody. All health systems have their limits. But there must also be a process for deciding what services are insured. That list must change to keep pace with innovations and emerging needs.

Canada’s single-payer system is weak in this respect. It was created when health care meant doctors and hospitals, and so the Canada Health Act reflects that long-ago world.

The Sanders proposal is more modern, including long-term care [1], prescription drugs and other items important today (not covered in the Canadian model). But Sanders’ plan should include a fair process to periodically re-evaluate the services and treatments that are insured.

‱ Second, a single-payer system need not mean bleak government hospitals staffed by underpaid doctors. Single-payer can include a vibrant private sector both within and ancillary to the public plan.

Mythmaking aside, Canada’s system accommodates a major role for the private sector within the public system. Nothing in the Canadian model prohibits the private delivery of publicly paid services.

Indeed, most Canadian doctors are not salaried state employees but private contractors who are well remunerated — and who don’t have to manage multiple payers, chase accounts receivable and treat patients who can’t pay.

The private sector is also a complement to Canada’s public system, insuring services left out of the public plan. Some Canadians would prefer an even greater level of privately-insured care, which is an ongoing debate. Each single-payer system manages the public-private balance to best suit that country’s needs, values and priorities. Americans should consider how others have established that balance before determining their own.

‱ Third, single-payer need not mean reduced patient choice and increased wait times. Canadian patients can choose their own physicians and hospitals without the restrictions imposed by American “managed care.” While it is sadly true that Canada has struggled with wait times that are too long for some services, the problems derive not from the single-payer system itself but rather from issues of system management. The proof is found in many other single-payer systems that do not face the same issues.

Concerns with wait times should be addressed up-front in a U.S. single-payer plan, emulating successful models and setting maximum wait-times based on clinical evidence.

‱ Fourth, single-payer need not mean funding the system only from taxes. Canada’s experience is that tax funding alone can make the system vulnerable when economic downturns require steep government cuts. Wisely, the Sanders plan is in line with European models with a mix of funding sources, including premium payments by employers and employees together with some funding from tax revenues.

‱ Finally, the U.S. can learn from Canada’s vexed experience with federal-provincial negotiations about health care. If the federal government goes it alone in funding health care — as the Sanders plan seems to suggest — the difficult dynamic of federal-state negotiations will be avoided. But if the final plan involves federal grants to states, federal funding must have a guaranteed floor and be adjusted over time to fairly account for changing needs and technologies. There must also be a way to speedily resolve federal-state disputes when they arise.

As Canadians can attest, the single-payer health care model has enormous social and economic advantages. But its success in meeting the needs of a nation depends on its wise design and deployment. By considering the experience elsewhere, Americans have the historic opportunity to create a model that will be uniquely their own while capturing best practices everywhere.

Colleen M. Flood is associate vice president of research and director of the Centre for Health Law Policy and Ethics at the University of Ottawa. Allan Rock is president emeritus of the University of Ottawa and is a former Canadian minister of health.

PNHP Endnote:

1. In Sen. Sanders’ plan, long-term care would be administered by the states only for low-income individuals, similar to Medicaid today. PNHP believes long-term care should be provided to all as part of a national health plan.

http://www.chicagotribune.com…

Readmissions down; deaths up

While U.S. heart failure readmissions fall, deaths rise

By Mitchel L. Zoler
Internal Medicine News, September 20, 2017

U.S. hospitals have recently shown a consistent and disturbing disconnect between reductions in their heart failure hospital readmission rates and heart failure mortality. Readmissions have dropped while mortality has risen.

“Despite reductions in 30-day heart failure readmissions in 89% of U.S. hospitals” during 2009-2016, “30-day heart failure mortality rates increased at 69% of these ‘successful’ hospitals” during the same period,” Ahmad A. Abdul-Aziz, MD, said at the annual scientific meeting of the Heart Failure Society of America.

“The most concerning question we can ask is whether inappropriate discharges from emergency rooms and observation units” is a driving factor behind the mortality rise despite a readmissions drop, said Dr. Abdul-Aziz, a cardiologist at the University of Michigan in Ann Arbor.

These shifts in the outcomes of U.S. patients hospitalized for acute heart failure episodes are tied to the penalties that the Centers for Medicare & Medicaid Services began slapping on hospitals in 2013 for excess 30-day readmissions for heart failure patients and in 2014 for excess mortality. A problem with these two CMS programs is that the penalty on inferior readmissions performance is a lot stiffer than for excess mortality, Dr. Aziz noted: a 0.2% penalty on payments for high mortality, compared with a 3% penalty for excess readmissions, a disparity that can make hospitals focus more on the readmissions side, he suggested.

Dr. Aziz’s report isn’t the first to make this observation. Study results published earlier in 2017 used CMS Medicare data from 2008 to 2014 to show that during that period, heart failure 30-day mortality rates following hospital discharge rose by 1.3%, while 30-day readmissions fell by 2.1% (JAMA. 2017 July 18;318[3]:270-8). On the basis of these numbers, as many as 5,200 additional deaths to U.S. heart failure patients in 2014 “may be related to the Hospital Readmission Reduction Program” of CMS, Gregg C. Fonarow, MD, said during a separate talk at the meeting.

“CMS thinks that policy reform is the way to improve outcomes of patients hospitalized for heart failure. There was no evidence, no results from randomized trials, but they pushed it on the country. And it has reduced readmissions. But there have been unintended consequences of gaming the system, of keeping patients out of the hospital and giving them outpatient status, and these data raise concerns because 30-day mortality went up,” said Dr. Fonarow, professor and cochief of cardiology at the University of California, Los Angeles. “We should all be extremely concerned about the unintended consequences of payment reform strategies” that aim to improve the management of patients with heart failure.

http://www.mdedge.com…

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Comment:

By Don McCanne, M.D.

Supposedly application of policy science provides higher quality care at lower costs, but in the case of heart failure, with no evidence, policy decisions were made to penalize hospitals 3 percent of their payments if their 30-day readmission rates went up, but only 0.2 percent if the patients died. Thus CMS rewards hospitals that follow the dictum, “Don’t readmit them, let them die.”

One of the criticisms of using Medicare as the model for a single payer system is its large centralized bureaucracy. Policy decisions often seem quite distant from decisions that should be made between health care professionals and their patients.

The Canada Health Act is only 14 pages and it would be half that except the text was repeated in French. The Canadian Medicare system is administered on the provincial level rather than through Ottawa. Likewise, in the United States it is recommended that administration be more decentralized – moving it from Washington, DC to greater state or regional control. That is one of the major reasons that we refer to an Improved Medicare for All.

Imagine making a decision for readmitting a patient with heart failure. Wouldn’t it be far better making that decision based on clinical need rather than being based on a penalty system out of Washington? Not that physicians would do such a thing, but then why do the numbers suggest that they do? An obvious solution is to shoo away the policy bureaucrats and simply do what is right for the patient.

Canada Health Act:
http://laws-lois.justice.gc.ca…

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Single payer ‘concern trolls’

There are 3 types of single-payer 'concern trolls' — and they all want to undermine universal healthcare

By Adam H. Johnson
Los Angeles Times, September 21, 2017

With momentum building for single-payer healthcare among Democratic voters and a growing number of 2020 hopefuls, Sen. Bernie Sanders unveiled a “Medicare for All” bill last week. Immediately, a number of pundits denounced the legislation as an “unrealistic” “bloated” “disaster” full of “magic math.”

Some of the naysayers are conservatives who simply abhor “big government.” Some have perfectly valid reasons to question the merits of single payer in general or Sanders’ methods in particular. Yet others claim they support universal healthcare in theory (one day, perhaps) but cannot do so now because of a “concern.” They are “concern trolls” — broadly defined as “a person who disingenuously expresses concern about an issue with the intention of undermining or derailing genuine discussion.”

The nuance troll: ‘We need more details!’

Less than 24 hours after the bill’s introduction, New York Magazine’s Jonathan Chait lamented that the bill gets America “zero percent” closer to single payer. While saying he agrees with single payer in theory, he insisted that the 155 million Americans who already have healthcare represent an insuperable barrier, and that the issue of how to move them all to a government-run system “is not a detail to be worked out. It is the entire problem.” After all, as he noted, Lyndon Johnson failed and Hillary Clinton failed and Barack Obama failed to undo the private system. So why bother? It’s too hard; everyone go home.

Nuance trolling is argument by way of tautology, an attempt to pass off power-serving defeatism as savvy pragmatism.

Even if Sanders did lay out how a single-payer transition would work in a technical sense, nuance trolls would find other nits to pick. Where would the money come from? How would you manage all the corporations disturbed? There’s always some essential detail that needs solving before Senate Democrats earn the right to support a bold policy.

And if the demand for nuance seems reasonable enough, consider that pundits rarely require it when it comes to military interventions — Chait and others set this issue aside when it came to invading Iraq in 2003, for instance.

The deficit troll: ‘How do you pay for it?’

Of all the water-muddying tactics, this one is the easiest to set aside. As I’ve noted in these pages before, deficit scare-mongering is used, almost exclusively, as a bludgeon to smear progressive policy proposals. When it comes to launching wars or bailing out banks, these fears vanish.

Money for war is magically always there; money for healthcare must be counted bean by bean.

The feasibility troll: ‘What about the GOP?’

Many pundits seem to believe that leftist politicians must preemptively agree internally to some assumed compromise that is “practical” even before attempting to change the conversation, much less the law. Thus feasibility trolls argue that GOP opposition to government-run health insurance renders futile any such proposal.

That’s ahistorical. Maximalist demands aren’t all or nothing, they’re about establishing broad moral goals that people can rally around.

Progressives lose nothing by setting bold targets right out of the gate. Why not make every Republican lawmaker go back to his or her constituents in 2018 and explain opposition to free healthcare? Force the issue, shift the debate, just as the far right has been doing for years.

President Eisenhower — an early practitioner of concern trolling — told the New York Times in 1957 that he supported integration “in principle” but said activists in the South risked going “too far, too fast.” Give it more time. We need more details.

All meaningful changes to society have been met with these types of objections. But the game of politics isn’t won by waiting for the ideal. Its most successful actors establish a moral goal and fight for it until reality catches up to them.

Adam H. Johnson is a media analyst for Fairness and Accuracy in Reporting.

http://www.latimes.com…

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Comment:

By Don McCanne, M.D.

The concern trolls – nuance trolls, deficit trolls, and feasibility trolls – counter the vast superiority of the single payer model of health care reform with arguments that seem almost trivial (though sounding quite serious) when compared to the extraordinary social benefit that single payer would bring to America.

Why do they do that? What benefit is there in acknowledging that there is a far better alternative for reform, yet rejecting it based on a search for nuances, or based on hypothetical deficits that would not exist in a well designed program, or, even worse, based on supposed lack of political feasibility for a program that continues to grow in popularity?

Homo sapiens is a weird species.

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The benefits of Bernie Sanders’ ‘Medicare for All’ plan

By Marcia Angell, M.D.
The Boston Globe, September 21, 2017

Bernie Sanders is right. Given the growing costs and shrinking benefits of Obamacare, and the flame-out of “repeal and replace,” America should transition to Medicare for All. Last week he introduced his Medicare for All Act of 2017, which would do exactly that, while retaining and improving Obamacare during a four-year transition.

Medicare, the current program for Americans over age 65, is a single-payer system, which means it is financed and overseen by the government, even though most providers are private. It is by far the most popular and efficient part of our health care system. In fact, many 64-year-olds can hardly wait to be 65 so they are eligible for it. Unlike private insurers, it doesn’t pick and choose which patients it will cover and for what medical conditions. All seniors are covered for the same package of benefits.

But Medicare isn’t perfect. Benefits aren’t comprehensive (for example, there is no dental coverage), copayments are rising, and there is profiteering by providers. Sanders’ plan would introduce reforms that would help with those problems. It would expand benefits greatly, and out-of-pocket costs would be eliminated except for a small copay for prescription drugs.

Even people who think this all sounds wonderful are concerned about the costs. Won’t taxes increase? How can we possibly afford single-payer health care? But in fact, this concern stems from a misunderstanding. Yes, income taxes and government expenditures would increase, but those increases would be offset by the enormous savings in premiums and out-of-pockets costs. This trade-off is not sufficiently understood, because the Congressional Budget Office estimates only costs to the federal government, not to patients. The fact is that if out-of-pocket costs are included, we would probably break even in the first year and in later years we would come out ahead, because inflation would be curbed.

Obamacare has many virtues. It expanded access to about 20 million people, and it ended some of the worst abuses of the private insurance companies, such as denying coverage because of preexisting conditions. But it did little to rein in cost inflation, because it left our health system in the hands of private insurance companies, profit-oriented providers, and the pharmaceutical companies, all of which could pretty much name their price. As expenses rose for employers who provide health insurance, their answer was to cap their contributions. And as expenses rose for insurance companies, their answer was to shrink benefits and increase deductibles and copayments. Americans found that having insurance was not the same thing as getting adequate health care. Moreover, about 30 million Americans remain uninsured.

The fundamental problem, the problem that underlies all the others, is that the United States has a market-based system. We’re the only advanced country that does. The systems in the other countries vary in details — some have single-payers like Medicare, others have tightly regulated private insurers — but they all have in common universal coverage in predominately nonprofit systems. In all of them, government sets benefits and prices in one way or another, including prices of prescription drugs, and administrative costs are much lower. And it works. Their health systems spend on average less than half as much per person as we do (that gap is growing), and their health outcomes are generally much better.

In contrast, we have chosen to entrust our health care mainly to the commercial market. But while markets are good for many things, they are terrible for health care. Markets seek to expand, and each element in a market (think cars) tries to grow its share of the total by attracting more paying customers. But we want the health care system to shrink, not to keep growing. Health markets also can’t distribute care rationally. The people who most need care are usually the least able to pay for it. So providing it according to the ability to pay instead of medical need inevitably introduces inefficiencies and inequities. Moreover, health businesses usually don’t compete on price, but by marketing to affluent customers.

Sanders’ Medicare for All Act envisages a four-year transition, which would begin by dropping Medicare eligibility from age 65 to 55, and enrolling all children 18 and under. Then, over the next two years, eligibility would be dropped one decade at a time, and in year four it would be extended to everyone. There would be no out-of-pocket costs, and the benefit package would be expanded. The system could be financed by an ear-marked 4 percent income tax. A family of four with an annual income of $50,000 would pay $844 a year, which is about $4,400 less than the average premium working families paid last year to private health insurance companies. I believe we would also need to move to a nonprofit provider system.

Health care is a social good, not a commodity, just as primary education, fire and police protection, and clean water are. A market-based system is not only wasteful, it’s immoral. Winston Churchill famously said, “The Americans always do the right thing, but only after they’ve tried everything else.” In health care, we’ve tried everything else. The time has come for the right thing.

Dr. Marcia Angell, former editor in chief of the New England Journal of Medicine, is a member of the Department of Global Health and Social Medicine at Harvard Medical School.

https://www.bostonglobe.com…