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As Nov. 6 PNHP meeting nears, activity steps up

Oct. 20, 2010

Dear PNHP colleagues and friends,

Momentum is building for PNHP’s Annual Meeting, which is only a couple of weeks away – Saturday, Nov. 6 – in Denver, but it’s still not too late to register. We also have a few spots open for our highly acclaimed Leadership Training Institute the day before (Nov. 5). Please register for one or both today.

You won’t want to miss distinguished speakers like Democracy Now host Amy Goodman, PNHP co-founders Drs. David Himmelstein and Steffie Woolhandler, pharmaceutical industry critics Donald Light (editor of the new book “The Risks of Prescription Drugs”) and Joel Lexchin, American pediatric surgeon practicing in Canada Dr. Sherif Emil, labor activist Rose Roach and journalist T.R. Reid (author of “The Healing of America”), among others.

And you won’t want to miss the chance to compare notes with PNHP activists from all over the country who are continuing the drive for single-payer health reform on the state and national levels.

All events will be held at the Sheraton Denver Downtown Hotel at 1550 Court Place, Denver. To book your room, call 800-325-3535. If you have questions, call the PNHP office at (312) 782-6006. If you are unable to attend, please consider making a donation to help pay for scholarships for medical students to participate.

Meanwhile, PNHP leaders and activists have been active on multiple fronts in recent weeks.

Thirty-nine physicians joined or renewed their membership in PNHP at the recent meetings of the American Academy of Family Physicians and the American Academy of Pediatrics, where we had exhibit booths. Our membership continues to grow – we’re now over 18,000!
Dr. Margaret Flowers and PNHP staffer Ali Thebert just completed a successful chapter visit to North Carolina, where area members arranged for Dr. Flowers give grand rounds, radio interviews and presentations in churches and community halls in Charlotte, Greensboro and Durham-Chapel Hill. In the weeks ahead, similar visits are planned for New Jersey, Wisconsin and Colorado. To arrange a chapter visit, contact Ali Thebert at ali@pnhp.org.
PNHP’s banner at the Oct. 2 “One Nation Working Together” march in Washington calling for “Single payer – improved Medicare for all” was very well received. An estimated 175,000 people attended the event, which is described by Drs. Flowers and Andy Coates here. You can see a picture of our banner here.
Our Washington staff, notably PNHP congressional fellow Dr. Flowers and Ron Hikel, have been meeting with the health legislative assistants of several U.S. senators, aiming to line up more support for single-payer legislation in that chamber. On the House side, the main points of our successful congressional briefing on Sept. 23 are summarized here. The briefing, which focused on the Deficit Commission’s threats to Medicare, drew several dozen health LAs and the participation of Rep. Lynn Woolsey, honorary co-host of the event, and Rep. John Conyers. Rep. Raul Grijalva also co-hosted.
The Nov. 2 midterm elections are just around the corner, and single payer is an issue in many campaigns. You can read the comments of PNHP’s national coordinator, Dr. Quentin Young, on this fall’s political scene at The Huffington Post.
Our physicians continue to engage in a lively debate about health reform on the opinion pages of their regional newspapers. See, for example, the recent op-eds of Dr. Wally Retan in the Birmingham News and Dr. James Mitchiner in the Ann Arbor News. A great resource for evaluating the new health law and making a compelling case for single payer is Dr. John Geyman’s new book, “Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Reform.” You can order it easily through PNHP’s store.

Thanks for your continued support and especially your priceless efforts for reform!

Cordially,

Quentin Young, M.D.
National Coordinator

Mark Almberg
Communications Director

P.S. If you’re a member of CREDO’s phone services or CREDO Action, you can help PNHP by voting on how CREDO distributes its 2010 donations funding. This year PNHP is on the ballot and we need your votes! The more votes we get, the more funding we’ll receive from CREDO. Two years ago we received nearly $65,000 in this way. Voting is easy. Go to http://www.credomobile.com/ballot and vote for us. It’s a quick and effective way to support PNHP — at no extra cost to you. Of course, you can always make a direct, tax-deductible contribution to PNHP online or by mail, too!

State needs single-payer health system

By WALLY RETAN
Birmingham News, Oct. 10, 2010

The cost of health care is out of control. We have to do something about it. Now.

As a nation, we spent about $8,000 per person on health care last year. Tha
t includes premiums, co-payments, deductibles and out-of-pocket payments for what insurance didn’t cover. That’s also the money employers didn’t put into paychecks because they sent it to an insurance company.

It’s also taxes. Medicaid is bankrupting many state governments, including ours, but health care costs also include taxes for the veterans medical system, military medicine and Medicare.

In 1970, health care costs were only $350 per person. Government experts expect the spending to rise to $13,000 per person by 2018, the year the major cost-controlling measures of the new health care law finally become fully effective. That would be more than $30,000 a year for an average family.

We can’t afford to wait for the law to do whatever it’s going to do to control costs.

Medical expenditures in Great Britain, Sweden and Spain are about $3,000 per person each year. The quality of health care in those countries scores very high in international comparisons; in some cases, higher than ours. People who live there are generally well-satisfied with the care they have.

America can follow their example and provide high-quality health care for everyone for about half of what we’re spending now. What it would take is a publicly financed, national health insurance program like those in European countries — a single-payer health care system.

Today, of every U.S. dollar spent for health care, 30 cents or more go to administration, most of it wasted on the paperwork and bureaucracy imposed by private health insurance companies. By comparison, the administrative overhead in the Medicare system is less than 4 cents per dollar.

We need the efficiency of a single, publicly financed health care system, like an improved form of Medicare, providing affordable, high-quality care for everyone. Medicare preserves the right to choose and change one’s physician, fundamental to patient autonomy. Patients would be free to seek care from any licensed health care professional.

Our health facilities should be geared toward optimal patient care, not for optimal return to shareholders. Hospitals should operate as public service organizations, with regional planning agencies setting their global budgets, including their capital expenditures. This would eliminate most of today’s irrational waste.

So, is this the way our country should go?

Doctors would like it. Physicians in single-payer countries live comfortably, much like physicians here. They have much less medical school debt, much lower malpractice insurance and wonderful freedom from hassles with insurance companies.

Patients would like it. We’d all pay a little more Medicare tax, but we’d be free of those sky-high premiums, co-payments and deductibles, and free of wrongful claim denials. We’d know that every one of us could get all of the care we really need, without favoritism and with no one left out.

Businesses would like it. No more double-digit premium increases each year to struggle with. No more worrying about the cost of health care for employees. Employers could get out of the health insurance business and back to doing what they know best.

A single-payer program would also give us powerful tools like the ability to negotiate fees and pharmaceutical prices, thus giving us long-term cost control.

States all across the country are looking hard at what the new health care reform law requires of them. Many states are also looking hard to see if a state single-payer option would make sense for them.

Alabama should be looking at a state single-payer option, too.

Wally Retan, M.D., of Mountain Brook is state coordinator for the Alabama chapter of Physicians for a National Health Program (www.PNHP.org) and Health Care for Everyone — Alabama (www.HealthCareFor-Everyone-Alabama.org). E-mail: info@healthcareforeveryone-Alabama.org.

http://blog.al.com/birmingham-news-commentary/2010/10/my_view_state_needs_single-pay.html

Model exists to provide health insurance for all – it’s called Medicare

By Dr. James C. Mitchiner
Ann Arbor News, Oct. 3, 2010

The announcement last month by the Census Bureau that the number of uninsured increased last year to a record 50.7 million individuals should come as no surprise to those who understand the uniquely American tradition of linking health insurance to employment.

Combined with the corresponding finding that the rate of employer-based insurance has decreased, the conclusion is obvious: in a declining economy, as unemployment rates increase and employer payrolls tighten, the number of people lacking health insurance goes up.

Why is this? I have never understood why health insurance must be associated with employment. Historically, I recognize how businesses’ response to FDR’s wartime wage and price controls lead to the situation we have now. But I fail to see how a model first applied in the 1940s should continue to operate in the 21st century. Other forms of insurance – car, home, boat, flood, and universal life insurance – are not linked to a job, so why should health insurance have this unique relationship?

Imagine a world where your health care coverage would not be predicated on what you did or where you worked, where you lived under a system that provided continual access to care as you moved from job to job or state to state, and guaranteed your health security even if you were laid off or terminated. Picture yourself in such a world where “choice” refers not to your choice of health insurer, but instead to the freedom to choose your own doctor and hospital, based on whatever criteria you and you alone deem to be personally relevant. And imagine a world where more than 95 percent of your contribution to health insurance was actually spent on health care, with no substantial contributions to a bloated and mindless bureaucracy.

The good news is that such a model exists. It is called a single-payer, Medicare-for-All program. It is a plan modeled on Medicare, a popular program that is universal, portable, affordable, non-profit, non-discriminatory, and administratively efficient. An expanded Medicare program would sever the link between employment and health insurance for all Americans, and use as its sole entry criteria nothing more than U.S. citizenship. Such a program would drastically reduce the number of uninsured, at a total cost much less than what we are paying now. And, under a single-payer system, private insurance firms would be used for simple administrative functions only, and not for decisions that place greedy corporate profits over an individual’s right to medical care.

And the bad news? The United States remains the only western democracy that does not have universal single-payer health insurance. For illogical reasons, we as a country continue to have blind faith in the ability of the private insurance industry to solve the dual problems of access to care and cost containment. If for-profit insurance has not fixed the problems with health care after over 60 years of existence, why would anyone believe it would happen now under the recently passed health care reform act, where private insurance continues to play a dominant role? Clearly, the only logical solution is to insure everyone, and the most efficient way to do that is through single-payer national health insurance.

Dr. James Mitchiner, an Ann Arbor physician, is the fo
rmer president of the Washtenaw County Medical Society and a member of Physicians for a National Health Program.

http://www.annarbor.com/news/opinion/model-exists-to-provide-health-insurance-for-all—its-called-medicare/

Socialized, single payer health care in the U.S. – that works!

By Richard Cranium
Daily Kos, Oct. 15, 2010

Yesterday, I was introduced to a socialized, government-run, single payer health care system that works. And it is working beautifully, right here in America.

It would be almost schadenfreude-ish to see every Republican and blue dog Dem try to take a swipe at this highly efficient model of medical care provision. But they won’t, because it wouldn’t be politically expedient to do so, as it is with “Obamacare”.

If you’re interested in taking a look at what a comprehensive, national health care system might look like – one that is actually operating in the U.S. right now – hop down below the fold.

Toward the end of the health care reform debate, there was a big outcry (championed most publicly by Howard Dean) that the end result should be “Medicare for all”. That’s not a half bad idea, as far as it goes. And it would have been an improvement on what the final HCR bill looked like. I’m wondering, though, if we missed an opportunity. The end result of a comprehensive overhaul of the provision of health care in the United States might actually be closer to the Veterans Administration health care system.

Allow me to explain my own first encounter with the VA model. Now, granted, my experience yesterday was only my first visit, but the coordination of the care I received from the moment I checked in was extremely – and I mean, extremely – efficient.

Here are the bullet points of my day:

12:55 – Arrived at VA medical center, checked in
1:05 – Called by a team nurse, vitals checked, basic information collected, received flu shot
1:15 – Taken to waiting room to see my primary
1:20 – Primary comes to waiting room, introduces herself, we go to her office
2:00 – Leave primary’s office, go to nurse station. Receive Tdap booster.
2:05 – Sign up at lab station
2:10 – Called for lab work
2:15 – Lab samples drawn; head for specialty clinic to make appointment
2:20 – Go to pharmacy to pick up prescriptions; prescriptions are ready
2:25 – Go to radiology clinic
2:45 – Chest Xray and EKG complete
2:55 – Make appointment at another specialty lab
3:00 – Take care of some administrative details at Eligibility station
3:15 – Leave VA medical center

The Details

My primary was very thorough, and took a good amount of time with me to get all of my background, discuss my overall health issues, and conduct a brief physical exam. She was able to write up all of my current meds right from her computer. I can’t emphasize enough how absolutely thorough she was in her data collection and evaluation, and all of this was entered into my profile right on her computer as we talked. More on this in a minute.

During the course of my day, I received a lab workup, a flu shot, Tdap booster, EKG, chest xray, and two specialty referrals (including audiology). By the time I finished the lab, and went to the pharmacy, my prescriptions were ready and waiting – no more than 20 minutes after I had left the primary’s office. I did not wait more than 5 minutes at any one station, from the time I checked in, until the time I checked out. In my 56 years on the planet, that alone made this a unique experience.

I went to Eligibility after everything was complete, and got a form for a hardship request (because I’m out of work) to lower my copays, and to have my picture taken for an ID. And finally, per my primary’s request, I walked the EKG results down to her, knocked on her door, she looked at them and said, “looks great! See you in a month.” I asked her if she wanted the graph. “Not necessary,” she said. “It’s already in the computer and I’ll get a reading sent down by the cardiologist.”

Damn.

The entire process took 2 hours and 15 minutes, from the time I walked in until the time I walked out. I was truly amazed that any health care system that was this efficient, and thorough, was available to me. As I was leaving, I complimented the process to the last woman I spoke with in Eligibility. And I told her: “Every person in America should experience that efficiency and level of caring one time. One time.”

In a two and one quarter hour period, I accomplished more for my medical care than I would have in days with my prior physician, and the outside labs and radiology clinics and specialists. The longest wait time that I had all afternoon was waiting for the elevator after I left the radiology lab.

Here’s the real kicker. Remember that computer stuff the primary was doing? Actually, from the time I first contacted VA about health care, a computer record of me was established. What we did yesterday was to fill in the holes in that record. And now, I can walk into any VA medical clinic or hospital anywhere in the United States, and the medical personnel in that facility will have access to my complete medical history. Talk about records portability.

The cost for all of this? $18 co-pay for each of my 3 prescriptions, and $15 co-pay to see my primary. The efficiency, cost effectiveness, and care that I felt along the way? Priceless.

I have absolutely no doubt that if everyone had the opportunity to experience what I experienced yesterday just once, that there would be a nationalized, single payer health care system in the U.S. in a relatively short period of time.

*************

This diary would be incomplete without acknowledging the assistance of several Kossaks who are also VA customers and military vets. The advice and direction that they generously provided in my previous diary (and off-list email) on the VA medical system helped me to understand the process and navigate the bureaucracy a bit more cleanly before I walked in the door for the first time.

http://www.dailykos.com/story/2010/10/15/102527/19

The midterm elections and Medicare for all

By Dr. Quentin Young
The Huffington Post, October 15, 2010

As we approach Nov. 2, it’s fair to say that in many ways the distortion of political discourse in our country has never been worse.

Extreme right-wing personalities – reincarnated Know-Nothings – are elbowing their way into the nightly airwaves via paid advertisements and Fox News. Billionaires are lavishly funding the Tea Party movement and an assortment of anti-government themes.

As our serious economic destabilization continues, and in the absence of vigorous progressive voices offering convincing, evidence-based solutions to our problems, our population is increasingly being abandoned to the clutches of ultra-right yahoos like Sharron Angle in Nevada, Pat Toomey in Pennsylvania, Ed Martin in Missouri and Christine O’Donnell in Delaware, to name just a few.

Pernicious ballot initiatives aiming to turn the clock back on health care and other social issues have been put on several state ballots, often the result of ultra-conservative stealth organizations deploying deliberately misleading language. Arizona’s Proposition 106, which would proscribe a single-payer system (and prohibit various other federal health programs), is a case in point.

These developments are creating a perilous situation for the republic.

It must be said that the quality of political discourse in the run-up to the midterm elections has not been facilitated by the flawed health reform legislation that the administration squeaked through Congress this spring.

While there are some desirable parts of the Obama administration’s new health law – the funding of community health centers, the expansion of Medicaid, the modest but not unimportant efforts to curb insurance company abuses – it is still widely viewed with unease by the public.

In fact, a recent AP/Stanford/Robert Wood Johnson Foundation poll showed twice as many Americans – 40 percent – believe that the law doesn’t go far enough as believe the government should not have a role in health care, and four-fifths of the public favor “making sure that more Americans get the health care they need.”

The recent spate of insurance company premium hikes and their pre-emptive dropping of whole classes of potentially unprofitable policies, such as those that cover individual children, by insurers like WellPoint, UnitedHealth Group, Aetna, Cigna and Humana, haven’t helped build public confidence in the new law’s ability to rein in these corporate profiteers.

Nor have reports that insurance companies and employers are successfully negotiating waivers to evade some of the modest requirements contained in the law.

As a result, skepticism in the law abounds. Polls suggest Republican calls to repeal or defund the new law have gotten some traction, even though their crude scare tactics – e.g. their charge that the administration’s health law is “socialist” – are patently ridiculous.

Big insurers are giving large donations to the GOP again (after having given so generously to Democrats in the run-up to the new law), hoping to dictate the terms of the law’s implementation in a way most favorable to their mercenary interests.

Meanwhile the health care situation in the U.S. is deteriorating at a more rapid pace. The Census Bureau data reported a few weeks ago indicated a startling 4.3 million increase in the number of uninsured since 2008, to 50.7 million people last year. This number would have been much larger if public insurance programs, in the first place Medicaid, hadn’t enrolled an additional 6 million people. The new uninsured numbers represent enormous human suffering.

It’s worth noting that the much vaunted public option, had it been incorporated into the new law, would have had a negligible affect on this number, according to a letter from the Congressional Budget Office. Besides inviting an insurer’s field day of cherry picking, such a provision would have been anything but a step toward single payer, as some of its advocates claimed.

So what to do?

First, it’s important to recognize there are a number of candidates running for office this November who support single-payer legislation, both incumbents and challengers. The candidacy of Dr. David Gill in Illinois’ 15th congressional district is but one example. Building up a single-payer caucus in Congress is an important goal, as is the continuing enlistment of support for single-payer legislation like Rep. John Conyers’ H.R. 676 and Sen. Bernie Sanders’ S. 703.

Second, several state-based movements for single payer are pressing their agenda for local reform. These states include Vermont, where an important Legislature-funded study on state models for reform – including single payer – is well under way, where several candidates have been vying with each other as to who’s more supportive of single payer, including gubernatorial candidate Peter Shumlin. Sen. Sanders has pledged to seek whatever federal waivers are needed should the people of his state declare their preference for a single-payer system.

Third, Medicare, Medicaid and Social Security are under a serious threat from the National Commission for Fiscal Responsibility and Reform. The commission is presumably going to make recommendations for changing these vital social insurance programs in its report to a lame-duck Congress by Dec. 1. Any cuts should be emphatically rejected. Medicare should be strengthened by improving it and expanding it to everyone. That’s also one of the surest ways to control skyrocketing health costs, as a recent congressional briefing by PNHP leaders and others recently pointed out.

Finally, our educational work in support of an improved Medicare for all remains indispensable. There are good reasons to believe that the new health law will be subject to destabilizing pressures from several quarters, including from actions by incorrigible offenders like the insurance industry (which is already complaining about the law’s minimal restraints), and the law may unravel sooner than
many suspect. Single-payer Medicare for all needs to be ready to fill the gap when that happens, and a powerful people’s movement needs to be ready to push it forward in a new, dramatic way.

http://www.huffingtonpost.com/dr-quentin-young/the-midterm-elections-and_b_764305.html

Don’t weaken Medicare – strengthen it and expand it to all

Don’t weaken Medicare – strengthen it and expand it to all

By Margaret Flowers, M.D.

The following article summarizes a Congressional Briefing held on Sept. 23, 2010, titled “An analysis of proposed changes to Medicare before the Deficit Commission and a better alternative: Improved Medicare for all.”

Presenters and honorary hosts:

Tsung-Mei Cheng, distinguished health economist and expert on comparative health systems at Princeton University. Professor Cheng writes and lectures internationally on such topics as single-payer systems, health care quality, financing, pay-for-performance and technology assessment. She also hosts Princeton’s television program, “International Forum.”

Olveen Carrasquillo, M.D., nationally recognized authority on health disparities, minority health, health services research, health policy, access to care and national health insurance. He is presently chief of the Division of General Internal Medicine in the Department of Medicine at the Miller School of the University of Miami and a member of Physicians for a National Health Program.

Michele Evermore, a legislative advocate for National Nurses United. Formerly served as senior legislative officer in the Office of Congressional and Intergovernmental Affairs at the Department of Labor and for 10 years as a congressional staffer for Sen. Tom Harkin in his personal office and on the Health, Education, Labor and Pensions Committee and for then-Ranking-Member George Miller on the House Education and Labor Committee.

The Honorable Raúl M. Grijalva (Honorary Host), Co-chair Congressional Progressive Caucus

The Honorable Lynn Woolsey (Honorary Host), Co-chair Congressional Progressive Caucus

*****

The Deficit Commission has marked Medicare and Medicaid as potential targets for lowering the federal deficit. They are reportedly considering at least three possibilities:

Shifting more seniors into Medicare Advantage
Shifting more of the cost onto the individual through higher co-pays and deductibles
Switching to a voucher program for the purchase of private insurance.

These approaches would be misguided, ineffective and harmful.

Attributing the deficit to Medicare and Medicaid is misguided because these necessary social insurance programs are not the causes of our soaring health care costs, but are rather the result of the lack of a rational health care system.

Medicare, which currently covers 43.4 million people, accounts for 13 percent of total federal outlays (FY 2010) and Medicaid accounts for 8 percent.
Medicare and Medicaid together account for a much smaller proportion of our GDP (< 5 percent) than do our other health care costs and they are rising at a slower rate.

The most effective way to control rising health care costs would be to address the underlying causes which are the large administrative costs of a multi-payer health care financing model and the lack of monopsonistic bargaining power to negotiate fair prices for goods and services.

The changes proposed by the deficit commission will not have a positive effect.

Shifting more seniors into Medicare Advantage will increase federal spending because these are for-profit plans with higher administrative costs, currently 14 percent more expensive than traditional Medicare.
Shifting more of the cost of health care onto individual Medicare beneficiaries through increased co-pays and deductibles or by changing to a voucher system will reduce federal spending. However, the deleterious economic effect on seniors and total health care spending is likely to be significant.
Increasing co-pays and deductibles will place increased financial strain on seniors already burdened with high out-of-pocket costs. According to the Kaiser Family Foundation’s analysis of the CMS Medicare Beneficiary Survey Cost and Use File for 2005, seniors earning less than 200 percent of Federal Poverty Level (FPL) spend 22 percent of their income on health care. Those with incomes between 200 and 400 percent of FPL spend an average of 15 percent of their income on health care.
A recent article published in the New England Journal of Medicine documents that raising Medicare HMO co-pays and deductibles results in fewer outpatient visits and more hospital admissions and days in the hospital. It is reasonable to expect that the savings may be offset by greater hospital costs and will certainly lead to poorer health outcomes for seniors.
Converting Medicare from a defined benefit program to a defined contribution program in which seniors are given vouchers to purchase insurance also seeks to shift more of federal health care spending onto the individual. This will likely increase total health care spending as it further dilutes market power on the demand side by further fragmenting the Medicare population.

Of course, single-payer supporters already know that the best way to preserve and protect our American legacy, Medicare, is to improve it and expand it to everyone: Everybody in, nobody out.

And now let us examine why expanding and improving Medicare to everyone will control total health care costs while protecting individual patients from financial ruin, improving the health of our population and stimulating the economy.

First it is important to understand that health care costs per capita in the United States are the highest in the world. These high costs are due in large part to the use of a fragmented multi-payer (multiple insurance plans) model with associated high administrative costs.

One third of our health care dollars are used for administration rather than direct patient care.
Administrative costs include developing and marketing plans, determining eligibility for the various plans and then processing the claims for the various plans which each have different rules.
Contrast this with the relatively streamlined administrative cost of Medicare which is less than 3 percent.
There are significant costs to providers (both clinicians and health facilities) in terms of both time and money to interact with the various plans. According to Jim Kahn of the University of California San Francisco Philip R. Lee Institute for Health Policy Studies, every full-time physician spends over $85,000 on billing and insurance functions.

Mr. Kahn states that “Overall, for health care funded through the private insurance system, fully 38 cents of each dollar goes to administration and profits, leaving only 62 cents for clinical care. 20 cents is avoidable administration – which would mainly disappear with single payer.”

Simplifying administration by switching to a national single public fund to collect and pay out our health care dollars will save about 15 percent of total health care spending (over $400 billion per year).

Health care costs in the United States are also very high because the prices we pay for medical goods and services are among the highest in the world. This is a result of a profit-driven model and the lack of a single system with which to negotiate for fair prices.

There has been a temptation to blame over-utilization of health care services and goods for soaring health care costs.

Americans have fewer physician visits and fewer days in the hospital than people in other industrialized nations.
Except for some very expensive, highly technical procedures, people in the U.S. use less health care services per capita than people in other nations.

The growth of health care costs has occurred more slowly for Medicare than it has for the private i
nsurance sector. According to the Kaiser Family Foundation, per capita health care costs rose 6.8 percent for Medicare and 7.1 percent for private insurance during the period from 1998 to 2008. This is impressive considering that Medicare is responsible for a population with greater health care needs: those 65 years of age and older and members of the disability community.

We can preserve and protect our American legacy, Medicare, with its lower administrative costs and slower growth in total costs, by

expanding it to the entire population
placing everyone in a single risk pool
using a streamlined payment mechanism
financing the program with progressive taxation that will typically amount to less than what people are paying now for premiums and out-of-pocket medical expenses.

There will be adequate funds to pay for health care for each person when he or she needs it without fear of losing coverage or going bankrupt.

In addition, improving and expanding Medicare to the entire population will create a health system with proven cost controls:

global budgeting for medical institutions
negotiation of fair prices for goods and services.

It is true that Medicare has weaknesses. We can improve Medicare by making it more comprehensive, removing financial barriers to care such as co-pays and deductibles and improving reimbursement rates.

The most recent nation to adopt a single-payer health system is Taiwan in 1995. We look to their experience to see the impact of changing from multiple private payers and a high number of uninsured to a universal single-payer system.

Prior to having a national health insurance system, only 59 percent of people in Taiwan had health care coverage and health care costs were rising by nearly 14 percent each year.

When the new system in Taiwan began, after a planning period, the remaining 41 percent of people had access to coverage overnight. By the end of the first year, 90 percent of people were enrolled. Within nine years, more than 99 percent of people were enrolled and this percentage has remained steady. The current satisfaction rate with the system is 83 percent (similar to the satisfaction rate for Medicare in the U.S.).

The single-payer system in Taiwan has effectively controlled the rise of health care costs.

There was an expected bump the first year of implementation as total health care costs rose 18 percent (compared to almost 14 percent per year prior to the new system).
Within 10 years, the rise of health care costs had fallen to a more manageable 3.5 percent to 4.5 percent per year, despite the fact that there is high use of the system (average of 15 visits/patient/year).
Administrative costs for the system are a low 1.4 percent.

The proven strengths of the Taiwanese system are

the ability to control national health expenditures
the simplicity of uniform rates and fees
a uniform information technology system
a single standard of care for all people
increased choice: patients are able to choose their health provider freely and the system covers some alternative therapies such as Chinese medicine
as it is in the US under traditional Medicare, physicians are able to use their best clinical judgment without interference from either insurance or government administrators
the important physician-patient relationship is not compromised as it is under the current multiple-insurance based model used in the US.

There are important advantages of creating a national single-payer health system in the U.S. A big plus is that it will virtually eliminate bankruptcies due to medical debt.

A study published in June, 2009 found that 62 percent of personal bankruptcies in the U.S. were due to medical costs.
Nearly 80 percent of those who became bankrupt due to medical costs had health insurance.
In a single-payer system, all medically necessary care is covered throughout the life of the patient.
People pay into the system based on their ability to pay.
There is an end to the loss of coverage with the loss of employment.
There is an end to higher charges based on age, gender or medical condition.

A national single-payer health system will create conditions that will stimulate our economy. In some ways, single payer is a jobs bill.

For small businesses, single payer means relief from the increasing burden of providing health benefits to employees.
Single payer ends job-lock, providing greater security for those who may choose to open their own business.
Single payer enables those who are staying in jobs until they are eligible for Medicare to retire early, which opens jobs for those who are younger.
By controlling rising health care costs, single payer will allow large businesses to be more competitive in the global market.

The changes to Medicare that are being considered by the Deficit Commission are misguided and harmful. Rather than cutting our important social insurance programs, Congress could address both our health care crisis and our federal deficit woes by improving and expanding Medicare to all people in our nation.

Reimbursing based on process and outcomes?

Basing Pay-for-Performance on Outcomes

By Uwe E. Reinhardt
The New York Times
October 15, 2010

In last week’s post I presented the flow chart (at link below), exhibiting the path from the production of health care proper to human well-being, and I asked where in this process one should monitor the performance that we might seek to encourage through financial incentives.

I noted that adherence to what is thought to be best clinical practice for given medical conditions is the most widely used approach to measuring performance, even though it is generally agreed that a better way is to measure performance by clinical outcomes — that is, changes in the health status of patients (Box B in the chart). Much work is now under way to move in that direction.

Unfortunately, measuring performance by clinical outcome is easier said than done.

All of these experiments (mentioned in the article) with pay-for-performance are fledgling efforts, because the science of outcome measurement has yet to scale many methodological hurdles. Furthermore, in practice the approach will work only if the providers of health care find them sufficiently accurate and fair to sign on. And economic theory tells us that to make the approach effective, it must be backed with significant financial incentives. So far, in many instances, the sums of money at stake have been rather small.

Several readers of last week’s post saw in my enumeration of the difficulties of measuring performance a rejection of the idea. Not at all. The task is indeed daunting, but that does not mean we should back away from it. Rather, we must be patient and not expect too much too soon.

Basing Pay-for-Performance on Outcomes (Oct. 15):
http://economix.blogs.nytimes.com/2010/10/15/basing-pay-for-performance-on-outcomes/

The Uncertainties of Pay-for-Performance (Oct. 8):
http://economix.blogs.nytimes.com/2010/10/08/the-uncertainties-of-pay-for-performance/

Two published responses to Professor Reinhardt:

2. Don McCanne
San Juan Capistrano, CA
October 15th, 2010

Where are the science and art of medicine headed? Is the health care professional’s role to asses the needs of the patient and try to meet those needs? That alone is a daunting task when you consider studies that show that patients are receiving only about half of the care that they should be receiving.

Will the guidelines for medical care become a complex algorithm of process and outcomes, with the health care professional understanding that the goal and rewards will be found in mastering and optimally executing the measurement junctures within that massive maze? Will these measurements be samplings, or will almost everything be measured (a not so far-fetched concept in this day of computerization)? What burden in time and effort will this entail?

How about the real world? When the child with diabetes who you have been caring for comes in because of being depressed over the fact that her parents just split up, are you going to ignore her immediate overwhelming concern because you are too busy checking to see that you are complying with the glycohemoglobin and whatever other process and outcome junctures on which you will be rewarded?

When the goal is to do our best to see that everyone has the highest quality care that we can manage to pay for, it would be sad to see us caught up in the science of measurements when the greater need is in the art of medicine.

http://community.nytimes.com/comments/economix.blogs.nytimes.com/2010/10/15/basing-pay-for-performance-on-outcomes/?permid=2#comment2

9. Dr. Robert Centor
Birmingham
October 15th, 2010

We must thank Dr. Reinhardt for 2 stimulating posts on P4P. He has pointed out the problems of P4P. But I fear he still believes that P4P could work, despite growing evidence to the contrary. Physicians have multidimensional tasks with each patient. We must make accurate diagnoses; we must treat diagnoses and symptoms; we must communicate with patients and help them make diagnostic and treatment decisions. We must balance the treatment of multiple diseases and weigh the risks and benefits each potential treatment decision.

Implementing a P4P scheme focuses attention on the measurables and decreases attention to those things that are not measured. The NHS P4P project demonstrates that very well. Focusing on prompt visits led to a decrease in physician-patient continuity. Focusing on some parameters led to a degradation in other parameters.

P4P sounds like it should work, but many physicians believe that it cannot work, because no metric can evaluate the extent of our professional responsibilities.

We could look at preventable errors (such as central line infections) and penalize hospitals for unacceptable rates. But we should only do that when we can establish that we have a proven method to achieve the goal. I picked this example because of Dr. Peter Provonost’s excellent work on this particular issue.

Dr. Reinhardt suggests that we use outcomes, but what outcomes should we measure. How do we place a metric on accurate diagnosis? We can study the reasons for diagnostic error, but measuring diagnostic errors represents a most complex and perhaps unsolvable problem?

How do we measure the physician patient interaction? This interaction includes history taking, patient education and patient motivation. Some suggest we use patient satisfaction scores, but those have major flaws and suffer from intense grade inflation.

How do we measure an appropriate balancing for the management of 5 (or more) diseases? How do we assess the appropriate prioritization of medications? How do we value decreasing polypharmacy by not treating every performance indicator to its fullest?

How do we value appropriate referrals to palliative care? How do we put a number on excellent comfort care?

I thank Dr. Reinhardt for shining a light on this problem. While I disagree with his belief that P4P is a solvable problem, I agree that we have not yet solved the problem.

http://community.nytimes.com/comments/economix.blogs.nytimes.com/2010/10/15/basing-pay-for-performance-on-outcomes/?permid=9#comment9

Comment:

By Don McCanne, MD

As part of the current fervor over implementing reform, considerable attention has been directed to controlling spending and improving quality by changing reimbursement methods from those based on volume and complexity of services to models based on measurements of clinical practices and health care outcomes.

Professor Reinhardt suggests that we must not expect too much out of these efforts in the immediate future; I indicate that the science and art of medicine provide far greater benefits than those measurements of process and outcomes could ever adequately assess; and Dr. Centor provides a precise explanation of why current concepts of P4P (pay for performance) miss the target.

The magic of the highly touted accountable care organizations seems to be based on these same principles. It is likely that the magic will turn out to be only sleight-of-hand, at best.

Our policymakers would be much more productive if they would shift their attention from dinking around with P4P to crafting
a financing system that would ensure that everyone would have affordable access to an efficient health care delivery system with a robust primary care infrastructure. PNHP can help our policymakers define that system, if only they will finally listen.

These physicians are ticked

The Mad as Hell Doctors make a stop in Chico

By Evan Tuchinsky
Chico News and Review, Oct. 14, 2010

“I’m mad as hell, and I’m not going to take it anymore!”

That cry echoed through Harlen Adams Theatre Tuesday night (Oct. 12) as a capacity crowd, exhorted by a physician from the Pacific Northwest, channeled the movie Network in expressing their frustration with health-care economics in America.

Again and again that phrase came up, which only makes sense considering the occasion was a visit from the Mad as Hell Doctors, who capped their three-week tour of California by rolling their medicine show into Chico State.

They shared video clips and stories of gaps in the health-care system—actually, as one described it, “a sick-care non-system.” Joining their call for single-payer insurance, a Chico physician and two local nurses also had inspirations for change.

“I’m mad as hell,” cardiac-care nurse David Welch said, “because of the memory of the 42-year-old man who endured two days of crushing pain before he came into the E.R. and had a heart attack.”

“I’m mad as hell,” Dr. Faraj Walid said, “because not a day goes by that I don’t see patients suffer from a lack of insurance or are underinsured.”

Same for nurse practitioner Paul O’Rourke-Babb, who has had nine patients die “because they didn’t have access to care and insurance.”

The Chico crowd was the largest on the MAHD tour, but the complaints aren’t unique. They’re all too common across the country, where—as signs in the theater starkly noted—50 million Americans lack health insurance, 14,000 lose their coverage each day, and 120 die daily for lack of care.

Moreover, with an emphasis on treating diseases as opposed to preventing them, the majority of health-care funds go to technology and specialties rather than primary care.

Dr. Paul Hochfeld, one of the four visiting MAHD physicians, joked that coffins have nails “so the oncologists can’t get in to give one more round of chemo.” A morbid joke, for sure, but not too detached from a reality in which treatments and tests get lucratively reimbursed while consultations with doctors don’t.

Another MAHD visitor, Dr. Mike Huntington, asked the audience, “How many of you think we have a broken health-care system?” After hands went up and a voice called out, “Trick question,” Huntington pointed to that person and concurred: “We don’t have a system.”

As Hochfeld later put it, “We have a $2.5 trillion health-care factory and there’s nobody in charge.”

Single-payer health insurance is not a new concept, though it’s one that’s not always understood. It gets lumped into the term “government health care” and branded as “socialized medicine” like the national systems in, for example, Canada and Great Britain. However, as Hochfeld noted, the proposals for the U.S. call for publicly funded, privately delivered care.

The major issue, he explained, is the segregation of “risk pools.” Government plans cover many of the neediest Americans: seniors, veterans, individuals with disabilities and those from destitute families.

Private insurance companies, already insulated from these risk pools, further protect their profit margins. “They’re gamblers,” Hochfeld explained. “They gamble that what they collect is more than what they pay out. And they try to fix the odds.” They do so through selective enrollment, contributing to the totals of 50 million uninsured and 75 million underinsured.

Single-payer coverage would put all patients in one risk pool, administered by a public entity instead of myriad private businesses. That insurer would pay the private doctors, hospitals, clinics, pharmacies and others delivering care. One system, one set of policies—no more mazes of administration for providers and patients.

If everyone went into the same pool, Dr. Marc Sapir said, Americans collectively would “save $400 billion the first year after the single-payer system” was established.

“I want one system,” Dr. Katherine Ottaway declared. “Health care for all, one set of rules—that’s why I’m a Mad as Hell Doctor.”

MAHD has 11,500 fans on Facebook (www.facebook.com/MadDrs) and countless followers of its blog (at http://madashelldoctors.com). The group came to California heartened by how far a single-payer bill got in the Legislature, yet aware it didn’t get far enough to become law.

The effort continues. Locally, for instance, the Butte County Health Care Coalition lobbies for a single-payer system.

Sapir, noting that the organization Physicians for a National Health Program came out of the civil-rights movement of the 1960s, called for just that sort of mobilization. “Health care is a human right—don’t believe for a minute anything in the media that says most Americans don’t believe this,” Sapir stated.

“Our plea to you,” Huntington said, “is get mad and stay mad. Call your legislators and talk to your neighbors…. We need to turn this from a welfare system into a health-care system.”

http://www.newsreview.com/chico/content?oid=1858352

PPACA isn't protecting UC Santa Cruz

UCSC employees face tough health care decisions as popular plan changes

By Tovin Lapan
Santa Cruz Sentinel
October 13, 2010

UC Santa Cruz employees think they have been unfairly burdened by the systemwide changes to health care coverage made for 2011.

Faculty, staff and unions representing UCSC workers have all raised concerns that one of the most popular plans on the Santa Cruz campus is no longer offered at a discounted rate and is in some cases 150 percent more expensive than the other alternative being offered, which would require switching physicians.

When the details of the new coverage options were released earlier this week UCSC employees immediately noticed that in many cases it would be difficult to maintain their current doctors at a similar cost to years past. The plan that is no longer discounted covered physicians under the Sutter Health Network, which includes the Palo Alto Medical Foundation and Santa Cruz Medical Clinic. Approximately 60 percent of UCSC employees are affiliated with Sutter Health Network, according to UCSC spokesman Jim Burns.

Open enrollment for UCSC employees will begin Oct. 25, at which point many people will have to choose between paying higher premiums or leaving their doctor.

“The staff members I’ve talked to are pretty furious, and that frustration comes from lack of representation at the level of the office of the president,” UCSC Graduate Program Coordinator Marissa Maciel said. “In order for my premium not to go way up I have to leave my doctor of the last 10 years and change my child’s pediatrician.”

UCSC Campus Provost and Executive Vice Chancellor Alison Galloway called the increases in health care costs “disappointing” and expressed that the UCSC administration has pointed out the difficult situation its employees face to the Office of the President.

“I’m particularly concerned about our many employees who are currently enrolled in the HealthNet HMO plan,” Galloway wrote in an e-mail. “While an alternative version of that plan is being made available, it apparently will offer fewer providers. A sizable number of employees will face the prospect of finding new doctors. We’ve expressed our concerns about these issues – more than once – to UC leaders.”

http://www.santacruzsentinel.com/ci_16329342

Comment:

By Don McCanne, MD

When Congress wrote the Patient Protection and Affordable Care Act (PPACA), they did not want to disturb the very large sector of health insurance coverage that seemed to be working well – the employer-sponsored health plans. It was decided that high-quality plans, such as that of the employees of the University of California at Santa Cruz, should be protected so that the plans would always be there when the employees needed them, that is if they wouldn’t mind choosing between paying much higher premiums or losing their established physicians.

Jerking around provider lists, dramatically increasing premiums, pumping up deductibles and other forms of cost sharing, and manipulating benefits are all market tools used liberally by the private insurers. They are used to benefit the insurers, even if at the expense of the insured.

Compare that to our public insurance program – Medicare. Medicare doesn’t even have provider lists. You can go anywhere and see any physician who is willing to see you. Adjustments in premiums are very modest, unlike the double digit increases typical of the private insurers. Medicare cost-sharing adjustments are also very modest, unlike the financial barriers to care being erected by the private insurers. Medicare benefits do not diminish but have actually increased through the years. Medicare needs further improvement, but at least it’s not headed downward in the same direction as the private plans are.

It’s interesting to note that more recent releases from the Department of Health & Human Services and other public agencies have shortened the name of the Patient Protection and Affordable Care Act (PPACA) to simply Affordable Care Act (ACA). Just as they gave up on insuring everyone, it looks like they also have given up on patient protection. If we had an improved Medicare for all, everyone would be covered and patients actually would receive the protection they need. It’s not too late to change.

PPACA isn’t protecting UC Santa Cruz

UCSC employees face tough health care decisions as popular plan changes

By Tovin Lapan
Santa Cruz Sentinel
October 13, 2010

UC Santa Cruz employees think they have been unfairly burdened by the systemwide changes to health care coverage made for 2011.

Open enrollment for UCSC employees will begin Oct. 25, at which point many people will have to choose between paying higher premiums or leaving their doctor.

http://www.santacruzsentinel.com/ci_16329342

Comment:

By Don McCanne, MD

Sen. Coburn and Prof. Feldstein predict single payer

Coburn: Private health insurance may end soon

By Randy Krehbiel
Tulsa World
October 12, 2010

“There will be no insurance industry left in three years,” Coburn told the Republican Women’s Club of Tulsa County.

“That is by design. You’re going to make insurance unaffordable for everyone — which is what they want. Because if there’s no private insurance left, what’s left? Government-centered, government-run, single-payer health care.”

http://www.tulsaworld.com/news/article.aspx?subjectid=262&articleid=20101012_262_0_hrimgs995333

Senator Tom Coburn, M.D.
http://coburn.senate.gov/public/

And…

Nursing Economics: Is U.S. Health Care Evolving Toward a Single-Payer System? An Interview with Health Care Economist Paul Feldstein, PhD

Interview by Peter I. Buerhaus, PhD, RN, FAAN
Medscape Family Medicine
October 13, 2010

Peter Buerhaus: Looking to the future, do you think the passage of health reform legislation and its implementation could eventually lead to the adoption of a single-payer system?

Paul Feldstein: It is hard to say where we are going, particularly because the legislation creates health insurance exchanges which will be overseen by an insurance regulator. The insurance regulator will have the authority to set the benefit package and influence whether a state approves or denies rate hikes by insurance companies. I can see a scenario where there is very little cost containment and little pressure to keep insurance premiums from rising substantially. And, if there is a weak mandate for individuals to purchase health insurance, then the resulting adverse selection is likely to cause insurers to increase their premiums. People will become dissatisfied with the premium increases and some may become more supportive of a government-funded public insurance option. By heavily subsidizing government-provided health insurance and undercutting private insurers, many people will switch to lower-cost public insurers because studies show that people are willing to switch insurers for not much of a price difference. Eventually, if many individuals purchase public insurance, we could end up with a single-payer system or something close to one.

http://www.medscape.com/viewarticle/726680_5

Paul J. Feldstein, Ph.D.
http://merage.uci.edu/Faculty/FacultyDirectory/FacultyProfiles.aspx?FacultyID=18

Comment:

By Don McCanne, MD

The majority of progressives predict that a single payer system is inevitable because the nation will no longer tolerate the increasing costs of health care. On the other side, many conservatives and libertarians predict that a single payer system may be inevitable because health plans will no longer be affordable in a regulated insurance market. Senator Tom Coburn and Professor Paul Feldstein represent the latter view.

Senator Coburn has been nicknamed “Dr. No” because of his conservative, anti-government, obstructionist approach to legislation. His views can be dismissed as those of a right-wing ideologue.

Prof. Feldstein, on the other hand, presents a more intellectual discourse of his position on health care financing. In a conversation we had during a forum at which we both appeared (Eighth Tamkin Symposium at the University of California at Irvine), Prof. Feldstein indicated to me that he was a dedicated follower of the teachings of his mentor at the University of Chicago – Milton Friedman. I probably need not say more.

The full interview of Prof. Feldstein (link above) is worth reading if you wish to better understand the sincere framing of single payer concepts from the perspective of a free-market intellectual. Although I say that his framing is sincere, it is distorted by what I believe to be exaggerated potential adverse consequences of single payer and by his failure to include certain inescapable benefits of single payer which, specifically, more than offset the deficiencies. He also repeats many of the trite criticisms of single payer that are based more on ideology and less on solid policy science, supposedly proving points by citing what are actually exceptions.

So while those on the right threaten us with the inevitability of single payer, the supporters of health care justice preach the inevitability of single payer. It looks like it’s not if we’ll have single payer, but when. But it won’t happen until we all understand that the financing mechanism of the Patient Protection and Affordable Care Act is not an avenue to reform, but a barrier that must be displaced. What we put in its place is where we totally disagree.

I might add that my conversation with Prof. Feldstein was in 2006, long before the recent reform process was underway, and at that time he told me that he believed that eventually we would have a single payer system, as much as he lamented the prospect. He is a very bright individual.

Election 2010 Health care question on Nov. ballot

By David Pepose
Berkshire Eagle, Oct. 12, 2010

PITTSFIELD — Voters in the 2nd and 4th Districts will test the waters for single-payer health care in a ballot question in November’s elections.

According to Ben Day, executive director of the statewide advocacy group Mass-Care, the non-binding ballot question is meant to allow voters to “instruct their representative whether they should support a single-payer health care system.”

“It doesn’t have any impact on the law, but it gives something for representatives to listen to,” said Day.

Question 4, which made it into 10 districts across the state in 2008, will be on 14 district ballots in 2010.

This will be the first time any Berkshire districts have had the question on their ballots, which required 200 signatures from registered voters in each district.

Single-payer health care is designed to promote “universal health care” to a state by means of a single, taxpayer-funded source. Governments in Canada, England and Australia all subscribe to single-payer health care systems.

“Almost every country in the developed world, except for the United States, establishes health care for everyone. It’s paid through the tax system, sort of like we pay for firefighters and the police,” Day said. “We’re basically the only country in the developed world were people can slip through the cracks.”

Likening a single-payer health care system to “expanding Medicare” to all ages, Day said that by
“eliminating the middlemen” of the health insurance industry, the state could eliminate rapidly increasing health costs — particularly those in legal fees between doctors and insurance companies — while promoting high success rates with patients in need.

State representative candidates in the 2nd and 4th districts spoke about the measure with largely positive responses.

“I’ve been a leading co-sponsor for that for six years,” said state Rep. William “Smitty” Pignatelli, D-Lenox, who is running as an incumbent for the 4th Berkshire District. “We have to find affordable, reasonable products if [the state’s health care] mandate is going to continue.”

Pignatelli’s competitor, Lee Scott Laugenour, agreed.

“I have lived in several countries where they have single-payer health care. Over there, there’s no such thing as deductibles or co-pays, there’s no such thing as people going bankrupt because they got sick,” Laugenour said.

“The Massachusetts reforms that have been passed and the national reforms based on Massachusetts don’t look to be very sustainable. … The plans are already falling apart,” he added. “In countries with this sort of insurance system, people spend far less on health care than we do — and they get better results.”

Second Berkshire District candidate Stefan Racz said if a single-payer system was implemented, it ought to be measured.

“I would do it on a gradual basis,” Racz said. “If you do single-payer heath care as an immediate transfer, you’re going to bankrupt the state. We can’t do that.”

Pushing for a “more gradual” institution of single-payer health care that would take two to three years, Racz said, and “a lot of small businesses would love single-payer health care because it would be a lot cheaper for them.”

Response to the question was not universally positive.

Mike Case, a Republican candidate for the 2nd District, said that while he would need specifics to make a strong decision, “right off the cuff I’d say I don’t like single-payer health care.”

“Just the massive costs — our tax rate would skyrocket with that,” Case said. “And it wouldn’t do anything to address the problems of the cheating and the overpricing and the gouging.”

Yet 2nd Berkshire District candidate Paul Mark disagreed, saying that the ultimate cost would be far less than the current health care system.

“I think what they’re overlooking is … we’re paying more in the United States per capita than any of the other developed nations,” Mark said.

He said he believes universal health care would ultimately lower costs across the board.

“We’re already paying for this,” he said.

http://www.berkshireeagle.com/ci_16323409

Prescription abandonment

Pharma Insight 2009

Wolters Kluwer Pharma Solutions

Sample represents more than 80% of the dispensing activity within the United States for retail prescriptions, inclusive of largest retail chains.

While payers still greatly influence patient access to treatment, increasingly, patients are weighing treatment cost and benefit, especially of new prescriptions.

2009: Commercial Rx Claims – New Rx

85.59% – Dispensed to patient
8.08% – Denied by health plans
6.33% – Abandoned by patients
Brand Rx – 9.30% abandoned
Generic Rx – 5.50% abandoned

http://www.wolterskluwerpharma.com/Press/Pharma%20Insight%202009%20-%20Media.pdf

Comment:

By Don McCanne, MD

This study covered 80 percent of the retail dispensing activity within the United States. It included patients for whom our health care system is working, at least theoretically. These individuals gained access to a physician, received one or more prescriptions, and then attempted to have the prescription filled by a retail pharmacy.

Private health plans that should be assisting patients in receiving the care that they should have, denied over 8 percent of the new prescriptions recommended by physicians.

Of all new prescriptions, over 6 percent were prepared but then abandoned by patients, primarily because of the high out-of-pocket costs of the prescription.

We need a health care system that ensures that all of us receive the health care that we need, including prescription drugs. A single payer national health program – an improved Medicare for all – would do just that. No one would walk away from a pharmacy empty handed.

Lessons from Bangladesh

Health System in Bangladesh

World Health Organization
(Accessed October 11, 2010)

Bangladesh has made significant progress in recent times in many of its social development indicators particularly in health. This country has made important gains in providing primary health care since the Alma Ata Declaration in 1978. All health indicators show steady gains and the health status of the population has improved. Infant, maternal and under-five mortality rates have all decreased over the last decades, with a marked increase in life expectancy at birth.

Like most transitional societies, a wide range of therapeutic choices are available in Bangladesh, ranging from self care to traditional and western medicine. The public sector is largely used for in-patient and preventive care while the private sector is used mainly for outpatient curative care.

The Public Sector

The primary care in the public sector is organized around the Upazila Health Complex (UHC) at sub-district level which works as a health-care hub. These Units have both in- and out-patient services and care facilities. Most commonly, they have in-patient care support with 31 beds, while some UHC have over 50 beds. Many UHC Units have a package service called “comprehensive emergency obstetric care services” (EOC) available, with an expert gynaecologist, an anaesthetist and skilled support nurses on duty round-the-clock, and basic laboratory facilities. At a lower tier, the Union Health and Family Welfare Centre (UHFWC) are operational, constituted with two or three sub centers at the lowest administrative level, and a network of field-based functionaries. The public sector field-level personnel are comprised of Health Assistants (HAs) in each union who supposedly make home visits every two months for preventive healthcare services, and Family Welfare Assistants (FWAs) who supply condoms and contraceptives pills during home visits. Recently some of the female HAs and FWAs have been trained as birth attendants (skilled birth attendants – SBAs), to provide skilled services within a household setting.

The Private Sector

In the private sector, there are traditional healers (Kabiraj, totka, and faith healers like pir / fakirs), homeopathic practitioners, village doctors (rural medical practitioners RMPs/ Palli Chikitsoks-PCs), community health workers (CHWs) and finally, retail drugstores that sell allopathic medicine on demand. In addition to dispensing medicine, sellers at these mostly unlicensed and unregulated retail outlets also diagnose and treat illnesses despite having no formal professional training.

http://www.whoban.org/health_system_bangladesh.html

And…

Physician’s obligations to patients

By Dr. Delwar Hossain
The New Nation – Bangladesh’s Independent News Source
October 10, 2010

Doctors of medical background are usually brilliant and talented groups of people of our country. They are the cream of the society and pride of this country.

High moral values and strict ethical practice should be observed in the physicians simply because they are considered next to Allah by the sick people. In true sense they are the deputy of almighty Allah in this world. Unfortunately with the few exceptions they are indulged in immoral activities and unethical practices of all sorts. I think it is not too late to rectify ourselves now.

Malpractices of all sorts have engulfed the physicians of all categories and money appears as the single most important driving factor. Money is an important factor but should not be the only factor for our profession.

Cesarean operation is a life saving method for mother and baby. It was invented only for selective and complicated labor. It is still used as such in the West. But quite different picture is seen in our country. When this facility was first available in our country several decades ago hardly 10% labor was done by it. It was used only in cases of its valid indications. But now around 50% (varies 40% to 95%) labors are done by it across the country and in majority cases injudiciously. It becomes the easiest method of earning a lot of money within shortest possible time! If we become an exploiter instead of a perfect technical person how can we be able to protect the interest of a patient?

Cases of gross negligence on the part of physicians are being reported in paper now and then. These are nothing but the tip of the ice-burg only. One of my known persons decided to deliver their baby by Cesarean section. He managed to get the best anesthesiologist and gynecologist. Patient started muscle twitching on the operation table during later part of operation. On inquiry it was found that Oxygen cylinder ran out of oxygen! And the anesthetist was found upstairs in computer game! By this time patient incurred irreparable brain damage. Then she was transferred to Dhaka to Singapore and attended by both the British and the American specialists. But did not get any benefit. Now she is deeply unconscious, has been bed-ridden for last one and a half decades, on life saving measures. She and her family life had gone to hell.

http://nation.ittefaq.com/issues/2010/10/10/news0680.htm

Comment:

By Don McCanne, MD

Can a health care system in a transitional society such as Bangladesh provide lessons for a modern industrialized nation like the United States? Well, yes. See how many lessons you can find here.

pnhpf3a

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UCSC employees face tough health care decisions as popular plan changes

Comment:

Nursing Economics: Is U.S. Health Care Evolving Toward a Single-Payer System? An Interview with Health Care Economist Paul Feldstein, PhD

Comment:

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Physician’s obligations to patients

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