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Respond to the NYT on insurers further limiting choice of health care

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Respond to the NYT on insurers further limiting choice of health care

Insurers Push Plans That Limit Choice of Doctor

By Reed Abelson
The New York Times
July 17, 2010

As the Obama administration begins to enact the new national health care law, the country’s biggest insurers are promoting affordable plans with reduced premiums that require participants to use a narrower selection of doctors or hospitals.

The plans, being tested in places like San Diego, New York and Chicago, are likely to appeal especially to small businesses that already provide insurance to their employees, but are concerned about the ever-spiraling cost of coverage.

But large employers, as well, are starting to show some interest, and insurers and consultants expect that, over time, businesses of all sizes will gravitate toward these plans in an effort to cut costs.

The tradeoff, they say, is that more Americans will be asked to pay higher prices for the privilege of choosing or keeping their own doctors if they are outside the new networks. That could come as a surprise to many who remember the repeated assurances from President Obama and other officials that consumers would retain a variety of health-care choices.

But companies may be able to reduce their premiums by as much as 15 percent, the insurers say, by offering the more limited plans.

Many insurers also expect the plans to be popular with individuals and small businesses who will purchase coverage in the insurance exchanges, or marketplaces that are mandated under the new health care law and scheduled to take effect in 2014.

Prominent officials like Mr. Obama and Hillary Rodham Clinton learned to utter the word “choice” at every turn as advocates of overhauling the system.

But choice — or at least choice that will not cost you — is likely to be increasingly scarce as health insurers and employers scramble to find ways of keep premiums from becoming unaffordable. Aetna, Cigna, the UnitedHealth Group and WellPoint are all trying out plans with limited networks.

The size of these networks is typically much smaller than traditional plans. In New York, for example, Aetna offers a narrow-network plan that has about half the doctors and two-thirds of the hospitals the insurer typically offers. People enrolled in this plan are covered only if they go to a doctor or hospital within the network, but insurers are also experimenting with plans that allow a patient to see someone outside the network but pay much more than they would in a traditional plan offering out-of-network benefits.

The insurers are betting these plans will have widespread appeal in the insurance exchanges as individuals gravitate toward the least expensive options.

The new health care law offers some protection against plans offering overly restrictive networks, said Nancy-Ann DeParle, head of the office of health reform for the White House. Any plan sold in the exchanges will have to meet standards developed to make sure patients have enough choice of doctors and hospitals, she said.

How widespread these plans will become is anybody’s guess, and some benefits consultants wonder if these plans represent any real solution to high medical costs. The narrow network, if it is based on the insurers’ ability to demand low prices, may be “just another short-term fix,” warned Barry Schilmeister, a consultant at Mercer.

But many insurers say they are still figuring out how to persuade people to choose these plans rather than force them to enroll. “What’s not changed are the old techniques of black-belt managed care,” said Mark T. Bertolini, Aetna’s president. “We have to create the same kind of model without the ‘Mother, may I.’ What we want is the ‘Mother, should I.’ ”

http://www.nytimes.com/2010/07/18/business/18choice.html?pagewanted=all

Comment: 

By Don McCanne, MD

The managed care revolution brought us restricted networks of physicians, hospitals and other health care services. These restrictions, which limited patients’ choices of their health care professionals and facilities, did produce a one-time notch in the curve of rising health care costs. The insurers did this by contracting lower rates with health care providers, and then imposing financial penalties on patients who chose their care outside of the networks.

Patients were not pleased with limitations placed on their choices, but generally were not rebellious since they were often able to continue to see their own physicians, or, if not, were usually satisfied with their in-network substitutes.

The major insurers have been experimenting for some time with much more restrictive networks – networks in which they could contract for much lower rates in exchange for a higher patient volume. Individuals and employers have not responded to these market efforts because the restrictions were too severe. They excluded popular health care professionals and hospitals, sometimes completely, or sometimes by requiring unaffordable coinsurance payments by the patients.

But the environment has changed. The premiums for health plans are now very close to being truly unaffordable for most individuals and employers. With individuals being mandated to purchase insurance, and employers being exposed to penalties if their employees purchase plans in the exchanges, the market for plans with affordable premiums is being forced. The insurers must come up with plans that will meet the test of the market. The deeply-discounted, more tightly restricted plans are now finding their market.

These plans are terrible. Many will lose their primary care professionals. They will often not be able to use their local hospitals and many of their local specialists. Most referrals to centers of excellence will be prohibited. Although the Patient Protection and Affordable Care Act (PPACA) will require that provider networks provide choice, the law does not prohibit intolerably Spartan networks.

This, of course, is a setup for the death spiral of adverse selection for the plans with more adequate networks. Individuals with more significant problems will select plans that can better meet their needs, while the healthy will flee to the plans with Spartan networks once the premiums skyrocket.

When individuals shift to the more restricted plans, what will happen to the large number of physicians and hospitals that are denied contracts? Obviously their financial viability would be threatened, and many would shut down. As if we didn’t already have enough problems with the deterioration in our primary care infrastructure, much of the entire health care delivery infrastructure could begin to crumble.

PPACA contains many measures designed to improve the functioning of the private insurers, but most of them will drive premiums even higher. Insurance innovations such as the Spartan provider networks were fully predictable.

What should really alarm us is that the business world thrives on innovation. Think of the possibilities that the private insurance industry can devise. Actually, it is very difficult for us who are trying to figure out how to get patients the care they need to come up with innovative concepts that will protect the business model of the private insurance industry, no matter the cost to patient care. It isn’t in our DNA.

But there is absolutely no doubt whatsoever that we will see innovation, and it won’t be healthy for patients, nor for their health care professionals.

TAKE ACTION:  The article provoked a large number of responses on The New York Times website, many supportive of Medicare for all, single payer, national health program, and health care justice in general. ADD YOUR RESPONSE. Go to the article and post your opinion, even if only a sentence or two. If you are not registered, it is easy to do, so don’t let that deter you. The New York Times needs to hear from us so that they will investigate why there is such broad support for a national health program. (At least click “Recommend” on response #232.)

Public sector workers now seeing deterioration in their health plans

Public sector workers paying more of their health care costs

By Bobby Caina Calvan
The Sacramento Bee
July 15, 2010

Workers in private industry have felt the sting of rising health insurance premiums and out-of-pocket costs for decades. Now, as government budgets bleed, public employees are starting to share the pain.

In the past year, Sacramento’s largest school districts have trimmed health care coverage. Local and state government officials also are looking for ways to save.

And while public employee unions have made preserving health benefits a priority, they have been pressed to give ground or face more layoffs.

In his proposed budget, Gov. Arnold Schwarzenegger is seeking to cut $152.8 million in health premium expenses by requiring the California Public Employees’ Retirement System to offer lower-cost coverage, possibly with fewer benefits, or give the state authority to do so.

Health insurance costs have “reached the point where we can’t sustain those benefits,” said Lynelle Jolley, spokeswoman for the state Department of Personnel Administration.

http://www.sacbee.com/2010/07/15/2891358/public-sector-workers-paying-more.html

Comment: 

By Don McCanne, MD

Private employers have continued to shift more of the costs of health care to their individual employees. This has had deleterious financial and health impacts since it has made health care access less affordable. Now, even with union representation, public employees also are experiencing deterioration in their coverage.

That’s a one-way street. Plans for public employees will never improve but will likely further deteriorate to match the 60 to 70 percent actuarial value plans to be offered by the state insurance exchanges.

“After all, why should we taxpayers have to buy these people good insurance when we have to put up with our lousy plans?” But those who express this sentiment have it backwards. Why should they have put up with crappy insurance when we could all have a program that works even better than most plans for public employees?

As we’ve said many times, the private insurance model doesn’t work anymore. We can have that program that works for all of us, if we, as voters, demand it.

Policy issues for the health insurance exchanges

Health Insurance Exchanges and the Affordable Care Act: Key Policy Issues

By Timothy Stoltzfus Jost, J.D.
The Commonwealth Fund
July 15, 2010

Health insurance exchanges are the centerpiece of the private health insurance reforms of the Patient Protection and Affordable Care Act of 2010 (ACA). If they function as planned, these exchanges will expand health insurance coverage, improve the quality of such coverage and perhaps of health care itself, and reduce costs. Previous attempts at creating health insurance exchanges, however, produced only mixed results. This report identifies the earlier attempts’ problems, enumerates the key issues that are critical for overcoming those problems, analyzes in detail the ACA’s provisions addressing these issues, and discusses further policy options.

As part of successfully implementing the new exchanges, the U.S. Department of Health and Human Services (HHS) and the states must address issues that undermined the earlier attempts. These issues are:

• Adverse selection.
• Numbers of participants.
• Market coverage and structure.
• Choice without complexity.
• Transparency and disclosure.
• Competition.
• Administrative costs.
• Market or regulator?
• Administering subsidies and mandates.
• State, regional, or national exchanges?
• Governance.
• Relationships with employers.
• Cost control.

http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2010/Jul/1426_Jost_hlt_insurance_exchanges_ACA.pdf

Comment: 

By Don McCanne, MD

“Health Insurance Exchanges and the Affordable Care Act: Key Policy Issues,” by Timothy Stoltzfus Jost, should be read in full (44 pages) by everyone who cares about the future of our health care system. The Executive Summary alone is not adequate to understand the implications of the issues he discusses. Every page requires attentive reading since each is covered with red flags, far too many to cover in a qotd commentary.

It is an especially important report for those who believe that the health insurance exchange model is a satisfactory compromise for moving forward, while dismissing further efforts to create a public national health program. It is also important for single payer advocates (improved Medicare for all) since it is important to understand the red flags raised by this report, and be able to debate them with others.

Many of the issues listed would disappear under a single payer system. For instance, in spite of the measures in the law, adverse selection (concentrating high-cost patients in health plans) cannot be eliminated by the insurance exchanges, yet it would disappear in a single universal risk pool. That is especially important since adverse selection has destroyed previous insurance exchanges in numerous states.

The numbers of participants in the exchange plans are also crucial. A few unhealthy individuals can wipe out a plan if there isn’t a large number of healthy individuals to absorb the costs through the plan premiums. It has been estimated that 24 million people will obtain their coverage through the exchanges. Distribute that amongst the fifty states, and then divide those numbers up amongst the “large” selection of plans in the “robust” markets of the exchanges, and you can see that many plans would likely fail due to the small numbers of insured.

Although an important goal of reform was administrative simplification, insurers will still have most of their administrative costs, as will the physicians and hospitals, and yet another layer of administration is added in the operation of the exchanges.

The premium subsidies, cost-sharing subsidies, and the mandates and penalties, in a system with ever-shifting eligibilities, creates a complex financing structure that is totally unnecessary. It is far simpler to finance the entire health care system through equitable taxes.

The reform act was designed to perpetuate the employer role in providing health care coverage, but increasing costs and increasing fragmentation through various public and private programs is increasing the complexity of the decision process for employers, creating an uncertain future for employer-sponsored plans. It would be far easier to remove the employer as keeper of the health plan, and simply provide a single, comprehensive public plan for everyone.

And cost control? It didn’t happen.

You likely don’t have time to read the full report now, but download it and read it this weekend, or at any other time that you have a break.

Preparing Slideshows

By Gordon Schiff, MD
   
Be selective
Weed and re-weed the slides. Then, the night before your presentation, take out another 5 slides. It is better to cover fewer topics richly and in depth, grabbing the audience to be engaged by the ideas/data you are presenting them, than to quickly flash through scores of slides they will barely absorb.

Slide transitions are key
This can make the difference between a slide show that is easy to follow and logically flows from one convincing idea to the next versus one that is constantly losing the audience.

Keep it fresh
Vary slides and their order. Always add a new slide or two or more to keep it interesting and fresh for you, and timely for your audience, so that you both don’t feel like you’re giving a canned talk.

Grab attention
Use stories that are engaging and interesting. Dig up examples about local hospitals or managed care firms for example. Or, magazine covers, dramatic patient stories, headlines, etc. Be enthusiastic.

Quote “them”
Use “their” own literature, ads, journals, etc. to quote “their” language, crassness, profit goals, etc. I love reading Medical Economics or quotes from Wall St Journal for this.

Don’t use slides as a script
Don’t stand with your back to the audience “reading” your slides. This prevents you from facing the audience and making the talk engaging. (It is fine to use a pointer and refer back-and-forth, though do beware of shaky hands). If using a LCD, set up your laptop on a podium high enough to position it correctly so that you can see the slides Attach and use a mouse on your laptop as your pointer.  I bring an extra 25-50 foot VGA cable extension cord (expensive and hard to find but worth owning) so I am free to place my laptop wherever I care to stand (rather than be tied to where the projector is located). Also, don’t forget a power extension cord as well.

Beware of equipment, software, and power failure, and be prepared
Sometimes when you least expect it the projector will not work (it will break, the bulb will blow, the computer will fail, the room is too bright, etc.). Ensure that you get to your speaking location early enough to do everything possible to set every up perfectly  (I won’t even get into matters like VGA screen size settings or output toggle on/off but be prepared for these gremlins.)

Know more than your slides
You must be armed with supplementary information for your slides. Immerse yourself with timely clippings from newspapers or good quotes. This will help you come off like a professional during the Q&A.
 
Revised 5/05 Gordy Schiff, MD. Revised 11/09

Public Speaking Tips

By Gordon Schiff, M.D.

Emphasize 2-3 key points
They don’t have to be all that you talk about, buy you need to identify key “take away” points and ensure that you convey them so strongly that no-one leaves without understanding these well enough to describe them themselves.

Say things that the audience would be interested in learning
Don’t remind them of what they already know and agree with. Take them higher and farther on the topic.

Keep a bin to collect and prepare for your next talk
Keep a folder or file where you toss or cut-and-paste any interesting article/clipping from newspapers, PNHP mailings, quotes from meetings, etc. This way, your next talk will be continuously incubating itself. The pile will be ready for perusal when you are about to give your next talk; you’ll be amazed how many of the articles and points you would have otherwise forgotten.

Make the talk timely and serve as a learning experience for yourself
Talks are for you as much as your audience. Giving a talk is an opportunity to get caught up on this latest news and force yourself to read or master that stack in your “bin.” Check The New York Times, The New England Journal of Medicine, your local paper, AMA News, PNHP, the Commonwealth Foundation or Kaiser Health Policy websites, and etc., for three days prior to your talk. They will always have a relevant article.

Over-prepare rather than under-prepare
There’s only one Dr. Quentin Young in PNHP – only he can give a great talk off the top of his head. For the rest of us, good talks are not born, they’re efforts of perspiration and preparation. Ensure that your preparations are cumulative (i.e., keep notes, computerize, etc.).

“Reverse-outline”
Although we learn in high school to prepare an outline before writing a paper, I do the opposite. I shovel bits of information and ideas onto a paper/computer first, then organize them into the key points I want to make. Thus the outline comes later, but you’ve ensured that you have all the content you would like to include. (However do what works best for you, as we all work differently.)

Remember that your audience probably hasn’t heard you before
Don’t forget that although you may have given the same or a similar talk a dozen times before, it will still be new for your audience. Don’t be inhibited from refining and repeating yourself.

Don’t talk down: Always err on the side of “overestimating” your audience
People are intelligent, and it doesn’t take too much to connect with their understanding of the health care situation.  Don’t assume that they know the details you do, but do assume that they will catch on to what you are on about if you explain it well.

Inspire your audience with your commitment and enthusiasm
Each of us should take pride in ourselves: an inspiring clinician, a dedicated physician, a nurse, and etc. Modestly playing off this by connecting our activism with our jobs helps audiences connect with us as colleagues and appreciate where we’re coming from. This always contrasts favorably with a drug or insurance company hack or bureaucrat.

Learn opponents’ arguments: Know them better than they do
Become an expert on your opponent’s arguments so that you can better refute them. There is no need to introduce them yourself (though sometimes that may prove useful), but be prepared to catch them when they are pitched – even rephrase them more articulately that your opponents. You can then hit a home run through your carefully planned responses.

Use both rational and emotional appeals
Both data and moving anecdotes are important: mix them freely.

Keep a cheat sheet of key sound-bites
Whether participating in a debate, doing a radio/television interview, or just giving a standard talk or presentation, ensure that you keep a 1-2 page sheet of key points, data figures, and quotes ready for immediate citation. This will also remind you to address all of your main ideas.

Don’t fear debate
The best and brightest opponents on the other side are no match for the truth and data of our case. I recall attending a series of debates with national managed care medical directors, absolutely terrified of the opposition. I however wrote up a “12 points” article (later reprinted in the ACP Observer) in preparation, and argued these so well that my opponent in one of these debates said “I pretty much agree with what Dr. Schiff said.”

Hecklers/opponents
Don’t allow yourself to get thrown off by them. Keep cool and listen to their points so you can respond to them by rephrasing their contentions and refuting them. Don’t get defensive or take them as personal attacks. You should shield your self with many of the above weapons, especially by drawing on your personal commitment and experience. Use each instance of a heckler or an opponent as a learning and surveillance opportunity to be better prepared for the next.

Visual props
Use props (e.g. a hat advertising “American HMO, a foreign-owned plan marketing to poor people on Chicago’s West Side, where they had no providers; hospital bills; health security cards).

Don’t pretend to be the all-knowing expert
It’s fine to acknowledge what you don’t know about; there’s no reason why your audience would expect you to know everything (you’re a doctor just like them.) Talk about what your understanding is and what makes sense to you (and allow them to do the same.)

Revised 5/05 Gordy Schiff, MD. Revised 11/09

Building the Movement with Public Speaking

By Gordon Schiff, MD

Know the values, needs, and issues of the audience/organization
Be sure to have a good conversation before your talk with someone from the organization (perhaps the person arranging the talk), and read up on the group’s literature. One highly effective practice is to come early, listen to their issues at their (business/residency) meeting, and refer back to these issues while you talk. Every organization you speak with is a potential ally in a coalition.

Use humor and modesty to win over the audience
So many of our opponents are arrogant, uncaring, thoughtless, and non-clinical. This often makes it easy and important to distinguish them from ourselves.

If possible, go in a pair
Bring a partner. If you are more experienced, bring along someone new to help you and learn from you. If newer, go along with someone more experienced and take notes on their tricks and audience responses. Share constructive criticism and feedback when you debrief each other.

Be self-critical, and honestly introspective 
Identify the weaknesses of single payer (past strategic miscalculations, Canadian weaknesses) – without being apologetic. However there is nothing worse than a speaker who begins by apologizing and persists in doing so throughout the talk. Don’t apologize for any speaking weaknesses and certainly don’t be apologetic for your bold ideas – put these forward distinctly and forcefully.

Get names
Sign-in sheets allow the local chapter to continually build its list of names and contact information. If you are speaking with physicians who would like more information or to become a member, feel free to contact the national PNHP office for assistance. If you are with another single-payer activist, they may be able to pass around a clipboard during your presentation. Be sure to follow-up on all requests in a timely manner.

Pass out information
Bring pamphlets and brochures with you to each talk. If you are speaking to physicians, PNHP can supply you with physician-targeted information. If you are speaking to community group, Healthcare Now can assist in providing materials. PNHP will donate $100 for lunches to any medical student organization that hosts a PNHP speaker.

Solicit other speaking engagements
Many people are involved in more than one organization. Feel free to let your audience know that you are available to speak with other groups on the importance of single payer. If you can’t meet a request, you can always forward the request to the national office for follow-up.

Revised 5/05 Gordy Schiff, MD. Transcribed/revised 11/09

A Ph.D’s Quick, Populist PNHP Talk

By Martha Livingston, Ph.D.

1. I have a Ph.D. and teach health policy. But you don’t need a degree to understand this issue: we all need health care, a lot of us are dying without it, and we have all the money it would take to give it to everybody. Plenty of people will try to confuse you about this and make the issue more complex than it needs to be: that is, make you feel as thought you don’t know what you’re talking about and that you’re not capable of understanding such a complex question. Don’t believe them: of course you understand this issue – it’s about health care justice, and you can speak about that!

2. We are the richest country on the planet, and we spend way more on health care than any other country does ($2.5 trillion, 17.7% of GDP; more than 1/6 of the economy, $8,160 per person; other countries spend no more than roughly 10% of their GDP, or more than $4,000 a person, and they cover everyone!). In fact, our government spends more on health care (60% of this $2.5 trillion) than any other government on the planet!

3. And yet 46 million people in the US are insured, and tens of millions are underinsured. About 45,000 people died last year because they couldn’t access health care when they needed it. Millions more walk around with serious conditions like diabetes, hypertension, or high cholesterol undiagnosed, and millions have to choose between paying the rent or filling their prescriptions. Medical bills are the main reason for personal bankruptcy in America – more than half were caused by them!

4. Where does all the money go? Into the pockets of the rich: the insurance companies, Big PhRMA, the HMOs, and health care CEOs are making killing. And while Medicare spends less than 4% of its budget on administration costs, private health care companies spend anywhere from 15-33% of theirs – all while denying many the care they need!

5. Too many politicians are in the pockets of the health care industry – and we have to remember that they need our votes. We need them to accept the only solution that saves money and covers everyone: Medicare-for-All! That’s right, the same old Medicare – just that it will start at age zero, rather than 65. And with all the money we’ll save, we’ll be able to improve Medicare’s coverage so that it covers all the care that people need – drugs, glasses, long-term care, and so forth.

6. How can we get Medicare for all? Get on your elected representatives, get them behind H.R. 676, the Medicare-for-All bill, and vote ‘em out if they’d rather support health-care profiteers (or, if they are health-care profiteers themselves, like Senator Bill Frist!)

By Martha Livingston, Ph.D., NYC speakers’ training 4//2005. Statistics updated by Nic Miller 11/2009

Planning a House Party for Single-Payer Health Reform

Before the event:

Plan ahead. Start planning 6 weeks ahead of time so that you’ll never feel like you’re in a rush. If you’re hosting a PNHP speaker, make a list of everyone that you would like to invite, and then double it. Don’t forget to include people you know from your place of worship, neighborhood association, and any civic organization. Decide if you would like to include other entertainment, food, or beverages.
 
Send out an invite about a month ahead of time. Invitations can be sent by regular mail, email, or even Facebook, depending on your audience. It’s important to include basic information about the event, including RSVP information, food or drink offerings, the time and date, and directions to the house. If working by email or Facebook, it’s a good idea to send out a reminder message 2 weeks before the event.

Call up the people that you still haven’t heard from a week before the event and personally invite them. The time and effort of a phone conversation can make all the difference for the event.

During the House Party:

Have a table set up near guests that has 2-3 informational handouts, a sign-in sheet, pens, and name tags (if guests are unlikely to already know each other).

Once everyone has arrived, introduce the speaker (if you’re the host) and ask people to sign in. If you’re the speaker, try and present the case for single payer in less than 20 minutes and give some time for people to ask questions. Be sure to mention “action items” people can do to advocate for single payer in their communities. 

After the talk, consider asking for money. Either the host or the speaker can do this. It’s a great practice for building up our efforts. When people contribute money to a cause, their chances of donating again, volunteering in the future, and talking with their friends and family about the issue dramatically increase. See the PNHP handout on fundraising for more information.

Afterward:

Compile all the sign-ins for the event and send them a quick thank-you note (ideally via email). This is also your chance to say anything you may have forgotten to add during the event. Add the sign-ins to your local chapter list and then send the list to the appropriate national group, either PNHP or Healthcare Now. We’ll add them to our lists and follow-up with them.

Complete all your follow-up work, such as sending more information, or answering lingering questions. This is the hardest part of any event, and the easiest to forget. The main purpose of a House Party is to build for the future, and following-up is essential to get — and keep — new people involved.

For a PNHP speaker, information, or assistance, please contact Emily Henkels at e.henkels@pnhp.org, (312) 782-6006.  

Drew Altman on what conservatives are winning

What Conservatives Are Winning

By Drew Altman, Ph.D., President and CEO
Kaiser Family Foundation
July 14, 2010

But for all of the frustration and even anger within the conservative movement about where health care is headed, the fact of the matter is that they are winning more than even they may realize in the current health care equation. That’s because the nature of health insurance itself is being redefined and moving gradually but seemingly inexorably in the direction conservatives have long advocated: more consumer “skin in the game” through higher patient deductibles.

Item: In our recent survey of people in the non-group insurance market, we found that the average deductible for an individual policy is now $2,498, and for families it’s $5,149. These are very high thresholds by any standard. Consider, for example, that a family with median income facing such a deductible would be spending almost 10% of their annual income just for their deductible before their insurance kicked in.

Item: The percentage of workers facing high deductibles — $1,000 or more for single coverage —  has been growing rapidly. It doubled from 10 percent to 22 percent between 2006 and 2009, and increased from 16 percent to 40 percent in small firms.

Item: Indications are that the share of workers with high deductibles is continuing to grow, a trend I expect our 2010 employer survey to confirm when we release it in September as we have every year for more than a decade now. And a substantial number of these high deductible plans are paired with tax-advantaged savings accounts, which conservatives have long advocated. Facing cost pressures without alternative answers, employers are moving to plans with less comprehensive coverage to reduce their expenses for employee benefits.

Item: Health reform is unlikely to reverse these trends. Large employers will continue to look for ways to address the rising cost of health care. And, for the basic “bronze” insurance plan that people will be required to buy, deductibles could run several thousand dollars for individuals and double that for families. To be sure, other aspects of health reform cut the other way. For example, there will be no cost sharing for preventive services in newly-purchased plans, and insurers will be required to cap consumer out-of-pocket costs at defined levels. And, of course, there are substantial subsidies to reduce premium and out-of-pocket costs for lower-income people. But, for the first time, the government will be defining the threshold that decent insurance must meet, and that minimum coverage will have the kind of high deductibles that conservatives favor.

For several years we have seen moderate increases in premiums for employment-based health insurance. I suspect that rising deductibles and other out-of-pocket costs are one explanation for this. It’s simple arithmetic that employers can buy down premium increases by switching to less comprehensive coverage and shifting more costs to workers. Plus, these higher out-of-pocket costs exert downward pressure on utilization – in some cases for the better, in some cases for the worse — and thus on premiums as well. At the same time, people have never been more upset about their own rising health care costs, as the coverage they get offers less and less financial protection.

Looked at through a political lens, liberals have gained through passage of major health reform legislation, including expanded coverage and increased government oversight of the health insurance system. But increasingly, the insurance itself is looking more and more like the vision advanced by conservatives – less comprehensive with more skin in the game. That’s where conservatives may be winning more than they realize in the ongoing battle over the future of health care.

http://www.kff.org/pullingittogether/071410_altman.cfm

Comment: 

By Don McCanne, MD

Regular readers of the Quote of the Day have seen this theme expressed relentlessly in these weekday messages: We are experiencing a massive shift to underinsurance products, and this policy of making individuals sensitive to health care costs through greater out-of-pocket spending has long been on the agenda of the conservatives.

The importance of today’s message is that it comes from a highly credible individual, Drew Altman, President and CEO of Kaiser Family Foundation, which serves as a “non-partisan source of facts, information, and analysis for policymakers, the media, the health care community, and the public.” It is a very objective observation of the reality of the reform that is now law, and it’s the same message that we have been delivering over and over.

Building on the current system, which we just did, is the most expensive and one of the least effective models of achieving the goal of affordable, high quality care for everyone. Yet one of the least expensive and most effective models is a single payer national health program – an improved Medicare for all. Most of the measures in the enacted legislation have not yet taken place. We can still change course and do it the right way.

England's liberation of the NHS

Conservative leader David Cameron on the NHS

Quote of the Day
August 17, 2009

“One of the wonderful things about living in this country is that the moment you’re injured or fall ill – no matter who you are, where you are from, or how much money you’ve got – you know that the NHS will look after you. That’s why we as a Party are so committed not just to the principles behind the NHS, but to doing all we can to improve the way it works in practice.”

(Since this quote, Conservative David Cameron was elected Prime Minister.)

https://pnhp.org/blog/2009/08/17/conservative-leader-david-cameron-on-the-nhs/

And…

NHS shake-up grants new powers to doctors and patients

By Rebecca Smith
Telegraph.co.uk
July 12, 2010

GPs are to be handed £80bn of the NHS budget to buy care from hospitals and other doctors for patients in their area, as hundreds of middle-management organisations are swept away.

Family doctors will be responsible, in consortiums, for commissioning the care for patients in their area by buying treatment from hospitals, charities and other doctors.

Under the new Coalition government’s health white paper, ministers will step back from the day-to-day running of the health service and hand power to the front line.

Andrew Lansley, Health Secretary, said the white paper represented a “vision based on the principles of freedom, fairness and responsibility”.

However, there was immediate criticism from Labour and the unions, saying handing £80bn to GPs who are private contractors was a mistake and that the plan was a ‘Trojan horse’ for widespread privatisation.

The document entitled Equity and Excellence: Liberating the NHS includes wide-ranging reforms covering all aspects of the NHS and healthcare.

Mr Lansley said ‘process-driven’ Labour government targets, such as the 18-week waiting time between GP referral and hospital treatment, will be scrapped and the focus will instead be on quality of outcomes for patients.

All hospitals are to become a Foundation Trust or part of one, giving them far greater freedoms from Whitehall and allowing them to earn more money from private patients.

Management costs are to be cut in half but the Government has already admitted that the NHS would be forced to make staff redundant. It is estimated that around 25,000 jobs could be lost.

Nigel Edwards, acting chief executive of the NHS Confederation, which represents all NHS organisations, said the changes would represent a huge upheaval.

“It is hard to stress just how radical this is. The NHS will look much more like the gas, electricity or telecom’s market than it will the monolithic state bureaucracy we have come to understand,” he said.

Dr Jennifer Dixon, director of the think thank, the Nuffield Trust, said handing billions of pounds of taxpayer’s money to GPs was ‘risky’ and is a significant change from their current role.

Andy Burnham, Shadow Health Secretary, called the white paper a ‘giant political experiment’ and warned that the government were taking an ‘£80bn gamble with the great success story that is out National Health Service today’.

“At a stroke, you are removing public accountability and opening the door to unchecked privatisation; you are demoralising NHS staff at just the time you need them at their motivated best,” he told Mr Lansley in the House of Commons.

David Fleming of Unite, said: “This is an untested, expensive Trojan Horse in political dogma that will give private companies an even greater stake in the NHS – this way of operating has already happened in the USA.

“Before the election, the Tories promised no major reorganisation of the health service – within three months that pledge to the British people, the majority of whom did not vote for further privatisation of the NHS – has been broken. So much for the ‘new politics’.”

http://www.telegraph.co.uk/health/healthnews/7885753/NHS-shake-up-grants-new-powers-to-doctors-and-patients.html

And…

Equity and excellence: Liberating the NHS

Department of Health (England)
July 2010

5. Cutting bureaucracy and improving efficiency

The scale of the NHS productivity challenge may prompt calls during this Parliament for even bigger increases in NHS resources; but the reality is that there is no more money.

So our first task is to increase the proportion of resource available for front-line services, by cutting the costs of health bureaucracy. Over the past decade, layers of national and regional organisations have accumulated, resulting in excessive bureaucracy, inefficiency and duplication. The Government will therefore impose the largest reduction in administrative costs in NHS history. Over the next four years we will reduce the NHS’s management costs by more than 45%.

The Department will shortly publish a review of its arm’s-length bodies. Subject to Parliamentary approval, we will abolish organisations that do not need to exist. We will streamline those functions that need to remain, to cut cost and remove duplication and burdens on the NHS. In future, the Department will impose tight governance over the costs and scope of all its arm’s-length bodies.

The Government will cut the bureaucracy involved in medical research. We have asked the Academy of Medical Sciences to conduct an independent review of the regulation and governance of medical research. In the light of this review we will consider the legislation affecting medical research, and the bureaucracy that flows from it, and bring forward plans for radical simplification.

We are moving to a system of control based on quality and economic regulation, commissioning and payments by results, rather than national and regional management. Within that context, we are committed to reducing the overall burdens of regulation across the health and social care sectors. We will therefore undertake a wide-ranging review of all health and social care regulation, with a view to making significant reductions.

Equity and excellence: Liberating the NHS (61 pages):
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117352.pdf

Comment: 

By Don McCanne, MD

The British National Health Service (NHS) is one of the most effective health care systems in the world. That is a remarkable achievement considering that they devote only half as much funds to their health care as does the United States (percent of GDP in 2008: UK 8.7% versus US 16.0%). Yet in their white paper, “Equity and excellence: Liberating the NHS,” the Conservative government of Prime Minister David Cameron states, “the NHS productivity challenge may prompt calls during this Parliament for even bigger increases in NHS resources; but the reality is that there is no more money.”

No more money!? Excuse the vulgarity, but… bullshit!

The Cameron government is using this false claim to dramatically pull back the government’s role in the NHS, and to push privatization. They are not only cutting back on essential government administrative functions (as opposed to the profound administrative waste in the U.S. system), but they are also failing to honor their duty as stewards of the taxpayers’ funds to maintain adequate regulatory oversight of their public health care system.

They are even going so far as to reduce the governme
nt’s role in medical research. Could you imagine the Congress of the United States defunding our National Institutes of Health merely because it is a composite of government bureaucracies?

Is this really what the people of England voted for?

England’s liberation of the NHS

Conservative leader David Cameron on the NHS

Quote of the Day
August 17, 2009

“One of the wonderful things about living in this country is that the moment you’re injured or fall ill – no matter who you are, where you are from, or how much money you’ve got – you know that the NHS will look after you. That’s why we as a Party are so committed not just to the principles behind the NHS, but to doing all we can to improve the way it works in practice.”

(Since this quote, Conservative David Cameron was elected Prime Minister.)

https://pnhp.org/blog/2009/08/17/conservative-leader-david-cameron-on-the-nhs/

And…

NHS shake-up grants new powers to doctors and patients

By Rebecca Smith
Telegraph.co.uk
July 12, 2010

GPs are to be handed £80bn of the NHS budget to buy care from hospitals and other doctors for patients in their area, as hundreds of middle-management organisations are swept away.

Family doctors will be responsible, in consortiums, for commissioning the care for patients in their area by buying treatment from hospitals, charities and other doctors.

Under the new Coalition government’s health white paper, ministers will step back from the day-to-day running of the health service and hand power to the front line.

Andrew Lansley, Health Secretary, said the white paper represented a “vision based on the principles of freedom, fairness and responsibility”.

However, there was immediate criticism from Labour and the unions, saying handing £80bn to GPs who are private contractors was a mistake and that the plan was a ‘Trojan horse’ for widespread privatisation.

The document entitled Equity and Excellence: Liberating the NHS includes wide-ranging reforms covering all aspects of the NHS and healthcare.

Mr Lansley said ‘process-driven’ Labour government targets, such as the 18-week waiting time between GP referral and hospital treatment, will be scrapped and the focus will instead be on quality of outcomes for patients.

All hospitals are to become a Foundation Trust or part of one, giving them far greater freedoms from Whitehall and allowing them to earn more money from private patients.

Management costs are to be cut in half but the Government has already admitted that the NHS would be forced to make staff redundant. It is estimated that around 25,000 jobs could be lost.

Nigel Edwards, acting chief executive of the NHS Confederation, which represents all NHS organisations, said the changes would represent a huge upheaval.

“It is hard to stress just how radical this is. The NHS will look much more like the gas, electricity or telecom’s market than it will the monolithic state bureaucracy we have come to understand,” he said.

Dr Jennifer Dixon, director of the think thank, the Nuffield Trust, said handing billions of pounds of taxpayer’s money to GPs was ‘risky’ and is a significant change from their current role.

Andy Burnham, Shadow Health Secretary, called the white paper a ‘giant political experiment’ and warned that the government were taking an ‘£80bn gamble with the great success story that is out National Health Service today’.

“At a stroke, you are removing public accountability and opening the door to unchecked privatisation; you are demoralising NHS staff at just the time you need them at their motivated best,” he told Mr Lansley in the House of Commons.

David Fleming of Unite, said: “This is an untested, expensive Trojan Horse in political dogma that will give private companies an even greater stake in the NHS – this way of operating has already happened in the USA.

“Before the election, the Tories promised no major reorganisation of the health service – within three months that pledge to the British people, the majority of whom did not vote for further privatisation of the NHS – has been broken. So much for the ‘new politics’.”

http://www.telegraph.co.uk/health/healthnews/7885753/NHS-shake-up-grants-new-powers-to-doctors-and-patients.html

And…

Equity and excellence: Liberating the NHS

Department of Health (England)
July 2010

5. Cutting bureaucracy and improving efficiency

The scale of the NHS productivity challenge may prompt calls during this Parliament for even bigger increases in NHS resources; but the reality is that there is no more money.

So our first task is to increase the proportion of resource available for front-line services, by cutting the costs of health bureaucracy. Over the past decade, layers of national and regional organisations have accumulated, resulting in excessive bureaucracy, inefficiency and duplication. The Government will therefore impose the largest reduction in administrative costs in NHS history. Over the next four years we will reduce the NHS’s management costs by more than 45%.

The Department will shortly publish a review of its arm’s-length bodies. Subject to Parliamentary approval, we will abolish organisations that do not need to exist. We will streamline those functions that need to remain, to cut cost and remove duplication and burdens on the NHS. In future, the Department will impose tight governance over the costs and scope of all its arm’s-length bodies.

The Government will cut the bureaucracy involved in medical research. We have asked the Academy of Medical Sciences to conduct an independent review of the regulation and governance of medical research. In the light of this review we will consider the legislation affecting medical research, and the bureaucracy that flows from it, and bring forward plans for radical simplification.

We are moving to a system of control based on quality and economic regulation, commissioning and payments by results, rather than national and regional management. Within that context, we are committed to reducing the overall burdens of regulation across the health and social care sectors. We will therefore undertake a wide-ranging review of all health and social care regulation, with a view to making significant reductions.

Equity and excellence: Liberating the NHS (61 pages):
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117352.pdf

Comment: 

By Don McCanne, MD

The British National Health Service (NHS) is one of the most effective health care systems in the world. That is a remarkable achievement considering that they devote only half as much funds to their health care as does the United States (percent of GDP in 2008: UK 8.7% versus US 16.0%). Yet in their white paper, “Equity and excellence: Liberating the NHS,” the Conservative government of Prime Minister David Cameron states, “the NHS productivity challenge may prompt calls during this Parliament for even bigger increases in NHS resources; but the reality is that there is no more money.”

No more money!? Excuse the vulgarity, but… bullshit!

The Cameron government is using this false claim to dramatically pull back the government’s role in the NHS, and to push privatization. They are not only cutting back on essential government administrative functions (as opposed to the profound administrative waste in the U.S. system), but they are also failing to honor their duty as stewards of the taxpayers’ funds to maintain adequate regulatory oversight of their public health care system.

They are even going so far as to reduce the government’s role in medical research. Could you imagine the Congress of the United States defunding our National Institutes of Health merely because it is a composite of government bureaucracies?

Is this really what the people of England voted for?

AHIP on “plan-provider collaborations”

Plan-Provider Collaborations Promise Improved Care Delivery

By Louise Kertesz
America’s Health Insurance Plans
July 12, 2010

“Despite many challenges, health plans are well positioned to drive improvements” in care delivery through collaborations with providers. “Health plans have an enormous amount of assets” in the form of data and relationships they can leverage to improve care, said Jeremy Nobel, MD, adjunct lecturer, health policy and management, Harvard School of Public Health.

To drive improvement, plans can contract with providers to deliver value-based care, with reimbursement linked to performance. Plans can help establish medical homes, accountable care organizations, and episode pricing, he said.

They can also offer providers online tools to improve care delivery effectiveness and efficiency, such as e-prescribing, registries, computerized order entry, and electronic health records. Plans can “be an active infomediary between members and providers, supporting collaborative and value-based care through care gap alerts and shared personal health records.”

Rushika Fernandopulle, MD, a principal at Renaissance Health, has been involved in installing disease management processes for patients with chronic conditions in physician practices in Seattle and Atlantic City. His group has used predictive modeling to identify patients, brought in health coaches, and set up a three-tier payment model (in Seattle) and global budgets (in Atlantic City).

Putting DM processes – usually reserved for health plans and DM vendors – into physician offices is “next-generation disease management,” he said.

“This sort of close payer-provider partnership is not easy, but it is very rewarding when done right. It’s a very active process—more than writing a check and walking away. Plans need to be willing to invest enough, and be patient. There needs to be strong, ongoing connections at multiple levels, including personal relationships; one person needs to own this and go between” physicians and plan, he said.

http://www.ahiphiwire.org/News/Default.aspx?channel=HealthIT&doc_id=617027&utm_source=7/12/2010&utm_medium

Comment:

By Don McCanne, MD

Now that Congress has codified a permanent role in health care for the private insurance industry, what will be the next entrepreneurial innovations of the private insurance/managed care industry? “Plan-provider collaborations” that are “not easy” but “very rewarding when done right.”  Be afraid. Be very afraid!