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The public option ain’t what it used to be

There’s almost nothing left to give away in a healthcare compromise

By Robert Reich
Salon
Thursday, Nov 19, 2009

First there was Medicare for all 300 million of us. But that was a nonstarter because private insurers and Big Pharma wouldn’t hear of it, and Republicans and “centrists” thought it was too much like what they have up in Canada — which, by the way, cost Canadians only 10 percent of their GDP and covers every Canadian. (Our current system of private for-profit insurers costs 16 percent of GDP and leaves out 45 million people.)

So the compromise was to give all Americans the option of buying into a “Medicare-like plan” that competed with private insurers. Who could be against freedom of choice? Fully 70 percent of Americans polled supported the idea. Open to all Americans, such a plan would have the scale and authority to negotiate low prices with drug companies and other providers, and force private insurers to provide better service at lower costs. But private insurers and Big Pharma wouldn’t hear of it, and Republicans and “centrists” thought it would end up too much like what they have up in Canada.

So the compromise was to give the public option only to Americans who wouldn’t be covered either by their employers or by Medicaid. And give them coverage pegged to Medicare rates. But private insurers and … you know the rest.

So the compromise that ended up in the House bill is to have a mere public option, open only to the 6 million Americans not otherwise covered. The Congressional Budget Office warns this shrunken public option will have no real bargaining leverage and would attract mainly people who need lots of medical care to begin with. So it will actually cost more than it saves.

But even the House’s shrunken and costly little public option is too much for private insurers, Big Pharma, Republicans and “centrists” in the Senate. So Harry Reid has proposed an even tinier public option, which states can decide not to offer their citizens. According to the CBO, it would attract no more than 4 million Americans.

It’s a token public option, an ersatz public option, a fleeting gesture toward the idea of a public option, so small and desiccated as to be barely worth mentioning except for the fact that it still (gasp) contains the word “public.”

And yet Joe Lieberman and Ben Nelson mumble darkly that they may not even vote to allow debate on the floor of the Senate about the bill if it contains this paltry public option. And Republicans predict a “holy war.”

But what more can possibly be compromised? Take away the word “public”? Make it available to only 12 people?

Our private, for-profit health insurance system, designed to fatten the profits of private health insurers and Big Pharma, is about to be turned over to … our private, for-profit healthcare system. Except that now private health insurers and Big Pharma will be getting some 30 million additional customers, paid for by the rest of us.

Upbeat policy wonks and political spinners who tend to see only portions of cups that are full will point out some good things: no preexisting conditions, insurance exchanges, 30 million more Americans covered. But in reality, the cup is 90 percent empty. Most of us will remain stuck with little or no choice — dependent on private insurers who care only about the bottom line, who deny our claims, who charge us more and more for co-payments and deductibles, who bury us in forms, who don’t take our calls.

I’m still not giving up. I want every senator who’s not in the pocket of the private insurers or Big Pharma to introduce and vote for a “Ted Kennedy Medicare for All” amendment to whatever bill Reid takes to the floor. And if this fails, a “Ted Kennedy Real Public Option for All” amendment. Let every Senate Democrat who doesn’t have the guts to vote for either of them be known and counted.

The public option ain't what it used to be

There's almost nothing left to give away in a healthcare compromise

By Robert Reich
Salon
Thursday, Nov 19, 2009

First there was Medicare for all 300 million of us. But that was a nonstarter because private insurers and Big Pharma wouldn’t hear of it, and Republicans and “centrists” thought it was too much like what they have up in Canada — which, by the way, cost Canadians only 10 percent of their GDP and covers every Canadian. (Our current system of private for-profit insurers costs 16 percent of GDP and leaves out 45 million people.)

So the compromise was to give all Americans the option of buying into a “Medicare-like plan” that competed with private insurers. Who could be against freedom of choice? Fully 70 percent of Americans polled supported the idea. Open to all Americans, such a plan would have the scale and authority to negotiate low prices with drug companies and other providers, and force private insurers to provide better service at lower costs. But private insurers and Big Pharma wouldn’t hear of it, and Republicans and “centrists” thought it would end up too much like what they have up in Canada.

So the compromise was to give the public option only to Americans who wouldn’t be covered either by their employers or by Medicaid. And give them coverage pegged to Medicare rates. But private insurers and … you know the rest.

So the compromise that ended up in the House bill is to have a mere public option, open only to the 6 million Americans not otherwise covered. The Congressional Budget Office warns this shrunken public option will have no real bargaining leverage and would attract mainly people who need lots of medical care to begin with. So it will actually cost more than it saves.

But even the House’s shrunken and costly little public option is too much for private insurers, Big Pharma, Republicans and “centrists” in the Senate. So Harry Reid has proposed an even tinier public option, which states can decide not to offer their citizens. According to the CBO, it would attract no more than 4 million Americans.

It’s a token public option, an ersatz public option, a fleeting gesture toward the idea of a public option, so small and desiccated as to be barely worth mentioning except for the fact that it still (gasp) contains the word “public.”

And yet Joe Lieberman and Ben Nelson mumble darkly that they may not even vote to allow debate on the floor of the Senate about the bill if it contains this paltry public option. And Republicans predict a “holy war.”

But what more can possibly be compromised? Take away the word “public”? Make it available to only 12 people?

Our private, for-profit health insurance system, designed to fatten the profits of private health insurers and Big Pharma, is about to be turned over to … our private, for-profit healthcare system. Except that now private health insurers and Big Pharma will be getting some 30 million additional customers, paid for by the rest of us.

Upbeat policy wonks and political spinners who tend to see only portions of cups that are full will point out some good things: no preexisting conditions, insurance exchanges, 30 million more Americans covered. But in reality, the cup is 90 percent empty. Most of us will remain stuck with little or no choice — dependent on private insurers who care only about the bottom line, who deny our claims, who charge us more and more for co-payments and deductibles, who bury us in forms, who don’t take our calls.

I’m still not giving up. I want every senator who’s not in the pocket of the private insurers or Big Pharma to introduce and vote for a “Ted Kennedy Medicare for All” amendment to whatever bill Reid takes to the floor. And if this fails, a “Ted Kennedy Real Public Option for All” amendment. Let every Senate Democrat who doesn’t have the guts to vote for either of them be known and counted.

Talking points on HR 3962 with some comparisons to the Senate (Reid) bill in bold and Obama’s proposal in blue.

Charts comparing the three plans from The New York Times and The Chicago Tribune are below.

By Ida Hellander, MD
Updated on February 24, 2010

Overall –

  • The House bill is completely inadequate in expanding coverage and controlling costs.  It is essentially an insurance industry bailout. Most provisions to expand coverage don’t even go into effect until 2013 (2014 in the Senate), after which it still leaves at least 17 million Americans uninsured. The Senate bill would have even less impact, leaving at least 24 million Americans uninsured.  Similarly, Obama’s proposal would delay coverage expansions until 2014, and even then would leave at least 24 million Americans with no coverage and tens of millions more underinsured.
  • It forgoes over $400 billion annually in potential savings on overhead and bureaucracy in the health system – enough to cover all 47 million uninsured – by retaining profit-driven private health insurers instead of replacing them with a streamlined, more efficient, Medicare for All system.
  • It makes private health insurance mandatory for middle-income working people, forcing them to buy a defective product.  It will become a federal crime to be uninsured, with a penalty of 2.5 percent of income, starting in 2013. The fines in the Senate bill are lower, starting at $95 a year in 2014 and rising to $750 by 2019.  Obama proposes that fines for failure to buy private coverage rise from $95 or 1 percent of income (whichever is greater) in 2014 to $695 to 2.5 percent of income in 2016.  Thereafter, they would rise with inflation. Families with incomes under $18,700 are exempt from the requirement to purchase coverage, as are those who would face premiums higher than 8 percent of income.
  • Families of very modest means, at 200-400 percent of poverty, will be required to spend an unaffordable 8-12 percent of their incomes (8-9.5 percent under Obama’s proposal) on insurance premiums if they don’t have employer-sponsored coverage.  Additionally, the basic benefits are very skimpy and the cost-sharing requirements are high, meaning that families of very modest means could spend 20 percent or more of their incomes on premiums and cost-sharing before receiving any benefits. In the Senate, the lowest-cost plan would only cover 60 percent of health care costs. 
  • A Medicaid expansion (to families with incomes under 133 percent of poverty) will cover more low-income Americans, but coverage gains – both in Medicaid and for people receiving tax assistance to buy coverage – will be short-lived because the cost is unsustainable as we’ve seen in several states that have attempted reform in recent years.
  • The insurance industry hijacked the process:  Private insurers get millions of mandatory new customers and $605 billion in taxpayer subsidies.  This will have the effect of making the health insurance lobby even more powerful, and more able to hijack political processes in the future. The Senate bill provides $447 billion in taxpayer subsidies to insurers.  Obama’s plan provides somewhat more than the Senate bill for subsidies.
  • To pay for subsidies to insurers, the bill cuts payments to safety net hospitals that serve a large number of low-income patients.  The Senate bill cuts payments to safety-net hospitals by $43 billion.
  • We will have a nation of underinsured families and businesses who will be paying money they can hardly afford for health plans that will never meet their needs.  Globally, the U.S. economy will continue to be at a competitive disadvantage.
  • People in other developed nations all use some form of non-profit national health insurance to get better care for less money.  Their average per capita cost of healthcare is about half what it is in the United States, yet people in Canada and western Europe live about two years longer and have lower infant mortality. As with our traditional Medicare program, they have completely free choice of doctor and hospital. We need to start from scratch with a Medicare-for-all, single-payer approach.

On private insurers

  • Private health insurance is an overpriced, defective product, and this bill won’t change that. The majority of Americans who face medical bankruptcy start their illness with private health insurance, but are bankrupted anyway by gaps in coverage, like co-payments, deductibles and uncovered services.
  • Individuals and families with incomes up to 400 percent of poverty ($73,240 for a family of 3) are eligible for skimpy subsidies to buy coverage through a new “insurance exchange.”  Families of very modest means (200-400 percent of poverty) are still responsible for paying an unaffordable 8-12 percent of their income (8-9.5 percent under Obama’s proposal) towards health insurance premiums.
  • Obama’s proposal would create a new “Health Insurance Rate Authority” under HHS with the power to block an insurance company’s premium increases in states where they are not already regulated. Insurance commissioners in 27 states already have the power to regulate premium hikes, but have been ineffective in controlling health care costs.
  • The bill bans denials of coverage based on pre-existing conditions (starting in 2013)(2014 in Obama’s proposal) and recissions (retro-active cancellation of coverage) immediately.  But insurers are still allowed to deny claims, and two industry whistleblowers (Dr. Linda Peeno and Wendell Potter) have testified before Congress that the industry is now so sophisticated in its ability to deny claims, control care, and cherry-pick that these protections are essentially worthless.
  • Similarly, caps on out-of-pocket expenses (at $5,000 for individuals and $10,000 for families) don’t prevent medical bankruptcy because they don’t include expenses for uncovered services.  Obama’s proposal doesn’t cap out-of-pocket expenses, but it does raise the share of benefits covered by insurance for the lowest-income families (under $33,000) from 70 percent to 94 percent.  However, families could still face bankruptcy from uncovered services, out-of-network care, etc.
  • Insurers are supposed to spend 85 percent of premiums on care, but experience from Minnesota shows that insurers are able to circumvent this rule easily by categorizing administrative expenses as “clinical” or “quality improvement.”
  • Obama’s plan assesses a $67 billion fee on insurers over 10 years, starting in 2014.

On Medicaid and community health center expansion

  • The bill expands Medicaid after 2013 to additional low-income Americans (up to 150 percent of poverty), which is good, but you don’t need this bill to expand Medicaid.  Also, rising costs, and a lack of funds for Me
    dicaid at the state level, will quickly erode any gains in coverage.  The Senate bill only expands Medicaid to up to 133 percent of poverty.  The CBO estimates that states will need to contribute $34 billion (House bill) 2010-2019 to fund the expansion.  Obama’s proposal expands Medicaid up to 133 percent of poverty starting in 2014 and pays at least 90 percent of costs for newly eligible individuals through 2020.
  • The bill increases funding (by $11 billion) for community health centers, which again, is good, but this could be done independently.
  • The House bill eliminates the Children’s Health Insurance Program in 2014, routing the beneficiaries into Medicaid (under 150 percent of poverty) or into the purchase of private coverage), adding hassle and possibly disrupting care arrangements for these children.  Obama’s proposal would maintain CHIP until 2019, but only authorizes funding through 2016.
  • As a welfare program, representing a population without an audible political voice, Medicaid is chronically underfunded.
  • Inadequate reimbursement rates due to inadequate funds results in a lack of willing providers. Too many physicians are not willing to accept the losses under this program. This lack of providers impairs access to care.
  • Many states are struggling with budgets burdened by massive Medicaid spending. Although this expansion would use federal funds initially, some of the financing burden would be shifted to the states even though they do not have the budget flexibility of the federal government.
  • On paper, Medicaid looks like a great program. It provides a generous benefit package for lower-income individuals who cannot afford to purchase private health plans. In reality, most Medicaid patients do not have the same access to essential specialized services that wealthier privately insured individuals do, and access to even basic services is often compromised.
  • Expanding the Medicaid program further locks in a tiered health care system, effectively providing less for the least amongst us. In health care, that’s simply not acceptable.

On the public option

  • The public plan option is a sham. According to the Congressional Budget Office, the premiums will actually be higher than premiums in the private sector, and fewer than 2 percent of Americans (6 million people) will enroll.
  • Payment rates would not be tied to Medicare.  Instead, the government has to negotiate payment rates with providers.
  • So the public plan option will be an expensive, tax-funded subsidy to private health insurance, because the public plan option will take the sickest patients off their hands. It won’t expand coverage or decrease costs. Obama’s proposal has no public option.

On the employer-mandate

  • Starting in 2013, employers with payrolls over $500,000 are required to provide coverage and pay a share of the premiums (72.5 % for individual, 65% for family coverage) or pay an 8 percent payroll tax.  The Senate bill places the burden on individuals, not employers, to obtain coverage.  Employers would only pay a $750 penalty per worker for employees who sought subsidized coverage.  Under Obama’s proposal, employers with more than 50 workers would pay a penalty if any of their workers obtained subsidized coverage.  The penalty would be larger than in the Senate bill, $2,000 for each worker in the company minus the first 30 workers.  Since employer-sponsored coverage is costly ($4,824 for individual and $13,375 for family coverage in 2009), it would still be cheaper for employers to pay the fine than provide coverage. 
  • Employers with fewer than 25 workers and average wages under $50,000 would be eligible for tax credits to help them provide coverage to their workers.  Obama’s proposal provides $40 billion for tax credits for business.
  • Employers are not required to meet benefit standards until 2018, but even then are only required to help fund the “lowest cost plan” that meets the “essential benefits package,” and so may offer very skimpy coverage.   The “basic plan” on the insurance exchange, for example, is only required to cover 70 percent of benefit costs (60 percent of benefit costs in the Senate).   As there are no cost controls, coverage will deteriorate further, leading to a rise in underinsurance nationwide.
  • Millions of working Americans will continue to lack coverage.  In Hawaii, which has had an employer mandate since the 1970’s, many employers circumvent the requirement by hiring part-time employees or using consultants.  Also, small businesses are not required to provide coverage (but receive a paltry tax credit for two years if they do).

On the insurance exchange and tax subsidies

  • The bill creates a national insurance exchange (in Obama’s proposal, the “exchange” is state-based), a marketplace where individuals and small business would go (after 2013, 2014 in the Senate bill and Obama’s plan) to buy insurance. If you have subsidized coverage, you would have to buy your insurance through the exchange. Like the “Connector” in Massachusetts, the exchange will add another layer of bureaucracy to the health system, and an additional 4 percent overhead to every health plan.  Under Obama’s proposal, there is no national exchange.  Instead, each state would operate its own insurance exchange, increasing bureaucracy and reducing the potential for spreading risk and moderating costs even farther.
  • Subsidies for low-income people to purchase coverage will be hopelessly complex, requiring verification of income, citizenship, employer size, etc.
  • Millions will have their subsidies change as they change or lose jobs.  Imagine finding a job, losing your insurance subsidy, then being laid off your job and applying for a subsidy all within a year.  How would this work?

On evidence that this bill won’t reduce the number of uninsured or control costs

  • The coverage gains from the bill won’t last.  What’s happened in the past when bills like this have passed in the states is that they run out of money very quickly, healthcare is simply unaffordable, and then you start to see the coverage expansions cut back. The subsidies shrink, the Medicaid shrinks, and then you’re back at square one, where you’ve spent a lot of money and not made any progress. And we’ve seen this over and over in the United States—in Massachusetts in 1988, in Oregon in 1992, in Washington 1993—passed bills virtually identical to what’s being passed in the House right now, and there was no durable improvement in the number of uninsured in those states. Healthcare was not affordable ten years after those bills were passed.
  • The Massachusetts plan is the model for this bill. Massachusetts expanded Medicaid (which again, is good, but you
    don’t need this bill to expand Medicaid) and passed an individual mandate that makes it illegal to refuse to purchase private health insurance. The fine is up to $1,068.  The plan has been very expensive.  The state has opted to pay for that by taking money from safety net clinics and hospitals, so that safety net providers that care for immigrants, the mentally ill, people with substance abuse, that provide primary care, they’ve seen their funds shrunken, so that money could be handed over to purchase insurance policies.
  • Insurance commissioners in 27 states already have the power to regulate premium hikes, but have been ineffective in controlling health care costs.

On the anti-abortion provisions

  • The bill applies restrictions to policies sold through the insurance exchange to undermine women’s rights.  It creates an insurance exchange, a marketplace where you would go to buy your insurance. If you have subsidized coverage, you would have to buy your insurance through the exchange.  And any insurance plan purchased through the exchange would have to exclude coverage of abortion. So, for the first time, Congress has stepped in and said that even with your own money, with private money, it’s illegal for insurance to cover abortion. It’s a tremendous step backwards for women’s rights.
  • Under Obama’s plan, the existing ban on using federal money for abortions would apply.  Thus, as in the Senate bill, people buying subsidized coverage through the exchanges would likely have to make two separate monthly premium payments:  one for all coverage except abortion and one for abortion coverage.

On prescription drug costs

  • It fails to lower drug costs for the majority of Americans and those unable to afford expense medications.  Drugmakers have raised wholesale prices on brand name drugs by 9 percent this year alone in anticipation of reform.
  • Biotech firms receive a windfall 12 year patent on new drugs.
  • A very small share of the population, Medicare recipients who are in the doughnut hole, will receive a discount on brand-name medications.
  • The doughnut hole is reduced in size until it is eliminated in 2019 in the House, but not the Senate, version.  Obama’s plan would eliminate the doughnut hole in 2020 and would give a $250 rebate to beneficiaries who reach the doughnut hole in 2010. 
  • Obama’s plan would prohibit “pay for delay” practices that drug companies use to keep generics off the market.
  • Obama’s plan would assess $33 billion fee on the pharmaceutical industry over 10 years, starting in 2011.  The medical device industry would be subject to an excise tax starting in 2013 and yielding $20 billion.
  • Overall, the pharmaceutical industry is thrilled with the bill, and Wall Street has rewarded them by driving up the value of their stocks.

On undocumented immigrants

  • Requires verification of citizenship to apply for subsidies for the purchase of insurance.  Thus, the bill mandates that immigrants buy insurance, but leaves it unaffordable for them.
  • The Senate bill is even more onerous, prohibiting undocumented immigrants from using their own money to purchase health insurance through the insurance exchange.  Obama’s proposal also prohibits undocumented immigrants from buying coverage through the exchanges, even if they pay the full cost without federal subsidies.

Medicare Advantage Plans

  • The bill phases out overpayments to Medicare Advantage plans. The Senate calls for a bidding process that will save $118 billion. The House bill also requires them to spend at least 85 percent of premiums on care, but as shown in states like Minnesota, insurers can easily circumvent this rule.  Obama’s plan calls for a bidding model for Medicare Advantage plans similar to that in the Senate, but phases in the changes over time, saving less.

Community Living Assistance Services and Supports

  • The bill calls for the establishment of a “voluntary federal program for long-term care insurance” that would pay a cash benefit to help fund home-based services.
  • The CBO estimates that the revenues in the Senate version of this new program would exceed premiums by $72 billion in its first years of operation, and these revenues could be used to fund the bill.  In other words, $72 billion of the funding for taxpayer subsidies of private insurers would come from raiding a new federal long-term care insurance plan. 
  • This is just one example of how completely inadequate the bill is at addressing the real crisis in access to health care, including access to long-term care services.

Summary of commendable features – some may not make it into final bill

  • Medicaid expansion (delayed until 2013, 2014 in Obama plan) to 150 percent of poverty (House) and 133 percent of poverty (Senate and Obama).  Obama’s plan would also increase funding for community health centers by $11 billion over ten years and increase funding for other community programs like home visiting programs.
  • Increased funding for primary care health professional education
  • Phasing out of doughnut hole in Medicare prescription drug plan by 2019 and Medicare Advantage plan overpayments. Restores government discounts on purchase of drugs for low-income seniors.  Allows government to negotiate drug prices with pharmaceutical companies.
  • Eliminating pre-existing conditions (2013, 2014 in Obama plan) and recissions (2010)
  • Ban on annual and lifetime limits; cap out-of-pocket costs at $5,000 for an individual and $10,000 for a family.  Obama’s plan would reduce cost-sharing in plans purchased on the exchange by families with incomes under $55,000; plans for this income group would cover between 94 and 73 percent of health care costs, up from 70 percent for families earning $55,000 to $88,000 and 60 percent for higher-income families.
  • Extending health benefit tax benefits available to married couples to domestic partners
  • Extending parental coverage to children aged 26-27.  Obama’s plan would cover adult dependents up to age 26.
  • Progressive tax on the wealthy for funding instead of taxing health plans that are comprehensive (so-called “Cadillac” plans). In contrast, the Senate places a 40 percent tax on health plans with premiums over $8,500 for an individual and $23,000 for family, attacking comprehensive coverage of older, sicker workers.  Obama’s proposal uses similarly reg
    ressive financing, with some minor modifications (e.g. the excise tax is delayed until 2018, and applies to policies over $10,200 for individual and $27,500 for family coverage).       
  • The Senate also raises the Medicare payroll tax to 1.95 percent on wages over $200,000 for individuals, jeopardizing solidarity for the Medicare program.  Similarly, the Obama proposal raises the Medicare payroll tax to 2.35 percent and imposes an additional 2.9 percent tax on unearned income for individuals earning over $200,000 and couples earning over $250,000.   
  • Immediate creation of a temporary high-risk insurance pool for people who’ve been denied coverage because of a pre-existing condition, with $5 billion in funding.  Eliminated in 2013, when the regulations on insurers go into effect.

From the New York Times

From The Chicago Tribune (click to enlarge)

Health IT savings projections are baseless

Hospital Computing and the Costs and Quality of Care: A National Study

By David U. Himmelstein, MD, Adam Wright, PhD, Steffie Woolhandler, MD, MPH
The American Journal of Medicine
November 20, 2009

BACKGROUND

Many believe that computerization will improve health care quality, reduce costs, and increase administrative efficiency. However, no previous studies have examined computerization’s cost and quality impacts at a diverse national sample of hospitals.

DISCUSSION

We used a variety of analytic strategies to search for evidence that computerization might be cost-saving. In cross-sectional analyses, we examined whether more computerized hospitals had lower costs or more efficient administration in any of the 5 years. We also looked for lagged effects, that is, whether cost-savings might emerge after the implementation of computerized systems. We looked for subgroups of computer applications, as well as individual applications, that might result in savings. None of these hypotheses were borne out. Even the select group of hospitals at the cutting edge of computerization showed neither cost nor efficiency advantages. Our longitudinal analysis suggests that computerization may actually increase administrative costs, at least in the near term.

The modest quality advantages associated with computerization are difficult to interpret. The quality scores reflect processes of care rather than outcomes; more information technology may merely improve scores without actually improving care, for example, by facilitating documentation of allowable exceptions.

Why has information technology failed to decrease administrative or total costs? Three interpretations of our findings seem plausible. First, perhaps computerization cannot decrease costs because savings are offset by the expense of purchasing and maintaining the computer system itself. Although information technology has improved efficiency in some industries (eg, telecommunications ), it has actually increased costs in others, such as retail banking.

Second, computerization may eventually yield cost and efficiency gains, but only at a more advanced stage than achieved by even the 100 “Most Wired” hospitals.

Finally, we believe that the computer’s potential to improve efficiency is unrealized because the commercial marketplace does not favor optimal products. Coding and other reimbursement-driven documentation might take precedence over efficiency and the encouragement of clinical parsimony. The largest computer success story has occurred at Veterans Administration hospitals where global budgets obviate the need for most billing and internal cost accounting, and minimize commercial pressures.

CONCLUSIONS

Whatever the explanation, as currently implemented, health information technology has a modest impact on process measures of quality, but no impact on administrative efficiency or overall costs. Predictions of cost-savings and efficiency improvements from the widespread adoption of computers are premature at best.

http://www.amjmed.com/home

PNHP press release:
https://pnhp.org/news/2009/november/projections-of-savings-from-health-it-are-baseless-harvard-researchers-say

VA’s VistA:
http://www.innovations.va.gov/

Comment:

By Don McCanne, MD

As currently implemented, health information technology (HIT) has no significant impact on administrative efficiency or overall costs, even in the “100 Most Wired” hospitals. Members of Congress should quit pretending that expanding HIT will produce savings that will help pay for the increased spending called for in their legislation.

This should not be interpreted as a blanket condemnation of HIT. The system used by the Veterans Administration hospitals has improved quality, though their system was designed specifically to enhance patient care. Profitable, proprietary, commercial HIT systems are usually designed to improve billing and cost accounting (and to make money for the vendors), whereas patient care information management in these proprietary systems is designed to mesh with these business functions that are given a higher priority.

We should really think about whether we want to continue to use our public funds to promote private, entrepreneurial HIT systems that have a business orientation, or if we should use those funds for further development of less expensive, open-source HIT systems designed specifically to enhance the quality of patient care, just as the VA health system has done. Their award-winning system, VistA, is available for use in the private sector (VA’s VistA – link above). Isn’t it more logical to look at a system that actually works, and one that that’s already paid for and that we own?

The following is from the PNHP release (link above):

Dr. Steffie Woolhandler, professor of medicine at Harvard and study co-author, said several factors may explain why health IT has failed to reduce administrative costs.

“Any savings may have been offset by the costs of purchasing and running new computer systems,” she said. “In addition, most software is designed around the accounting and billing needs of hospitals, not the clinical side.”

She noted that a computer success story in recent years has been at the Veterans Administration, where global budgets eliminate most billing and internal cost accounting, allowing physicians to focus instead on delivering care.

“The VA system now has our nation’s highest quality and patient approval ratings,” Woolhandler said. “Congress should take note: to get the most benefit from our health care dollars and from health IT, we should adopt a single-payer, Medicare-for-all program. Nothing short of that will allow us to reap the full potential of computerization or to provide comprehensive, quality and affordable care to all.”

Study: No Cost Savings With Electronic Medical Records

By SACHA PFEIFFER
WBUR Radio / NPR, Nov. 20, 2009

BOSTON — A new Harvard study finds that computerized medical records don’t save money or make hospitals more efficient, despite claims that health information technology could generate huge financial returns.

The study has major implications for national health reform. Congress is counting on savings from health I.T. to help fund the cost of revamping the health care system, and the Obama administration plans to use about $30 billion in federal stimulus money to spur the nationwide adoption of health I.T., such as electronic medical records.

But Harvard Medical School professor Steffie Woolhandler says an analysis of 4,000 hospitals nationwide found no cost benefit from computerization.

“If people think we’re going to pay for health reform off of savings on hospital computerization, they’re really sorely mistaken,” said Woolhandler, one of the study’s co-authors. “There are no savings we were able to find looking at five years of information.”

The researchers examined data from 2003 to 2007, including from hospitals on the “100 Most Wired List” compiled by Hospital and Health Networks magazine. They analyzed the data for evidence of increased quality, cost savings, or improvements in administrative efficiency.

Besides finding no indication that computerization lowers costs, the researchers found that some hospitals actually saw administrative costs rise after computerizing, probably due to the expense of buying and maintaining equipment and paying for technology staffs.

And those increased administrative expenses weren’t just one-time upfront costs of purchasing computer systems; those expenses remained elevated even several years after computerization had taken place.

In addition, the research showed that computerization hasn’t helped hospitals become more efficient, although it may have “modestly improved the quality of care for heart attacks,” according to the study.

One reason computerization may not be improving efficiency and quality of care: many medical software programs are designed primarily to help hospitals with their billing, accounting and registration needs, not their clinical work.

When hospital computer systems are designed with clinical care in mind, Woolhandler said, they can help prevent medication errors, flag a patient’s drug allergies, and ensure that prescriptions are written properly.

“I’m still a believer in computerization; I’m not a total Luddite,” Woolhandler said. “But I think computerization is very often done wrong. And, certainly from a cost perspective in the U.S., it’s done wrong more than it’s done correctly…so I think we need to be smarter about the way we computerize in this country.”

The study appears online in the American Journal of Medicine.

http://www.wbur.org/2009/11/20/medical-records

No hospital savings with electronic records: study

By Susan Heavey
Reuters, Fri Nov 20, 2009

WASHINGTON (Reuters) – New electronic record systems installed in thousands of U.S. hospitals have done little to rein in skyrocketing healthcare costs, Harvard University researchers said in a study released on Friday.

A review of roughly 4,000 hospitals from 2003 to 2007 found that while many had moved away from the paper files that still dominate the U.S. healthcare system, administrative costs actually rose, even among the most high-tech institutions.

Advocates of such technology have been pushing for greater use of computerized health records to prevent costly errors and allow greater coordination among caregivers and patients. But adoption has been slow, prompting Congress to offer $19 billion in incentives as part of an economic stimulus bill.

The results, published in The American Journal of Medicine, come as the Senate presses ahead with legislation to expand access to healthcare. While the bill does not provide funds to buy necessary equipment, it does aim to facilitate their use and boost standards.

President Barack Obama has pointed to greater utilization of e-health records to help generate savings at a time when the nation’s healthcare costs far outpace inflation.

But lead author Dr. David Himmelstein, an associate professor at Harvard Medical School, and his team found so far the savings are not there.

“Our study finds that hospital computerization hasn’t saved a dime, nor has it improved administrative efficiency,” said Himmelstein, who oversees clinical computing at Cambridge Hospital in Massachusetts. “Claims that health IT will slash costs and help pay for the reforms being debated in Congress are wishful thinking.”

The push for wider electronic medical records affects companies like Microsoft Corp and Google Inc to others such as McKesson Corp and Allscripts Misys Healthcare Solutions Inc.

National government standards for many health IT products are due next month. But even with the passage of the stimulus bill’s funds, many experts expect it to take years before most Americans have an electronic health record.

The researchers found administrative costs increased slightly from 24.4 percent in 2003 to 24.9 percent in 2007, with facilities that computerized the most quickly seeing the largest jump. Hospitals with the highest costs tended to be smaller, for-profit, non-teaching ones in cities, they added.

Computerized records have yet to prove more efficient “because the commercial marketplace does not favor optimal products,” creating programs to focus more on codes and billing than doctors’ needs and patient care, they said.

Electronic records did show some improvements in tracking the quality of care delivered in cases of heart attacks, but it was unclear if those measure actually translated into improvements in patients’ health, they said.

The researchers analyzed data from the industry’s Healthcare Information and Management Systems Society, hospital reports on costs incurred through the Medicare insurance program for the elderly and the 2008 Dartmouth Health Atlas, which compiles government health data.

Their study was released by the nonprofit Physicians for a National Health Program, which backs a single-payer U.S. health insurance.

(Editing by Chris Wilson)

http://www.reuters.com/article/domesticNews/idUSTRE5AJ0MQ20091120

Breast cancer screening and the uninsured

The New York Times, Nov. 20, 2009

Your editorial on the U.S. Preventive Services Task Force recommendation against routine screening mammograms for healthy, low-risk women under the age of 50 takes a wise and balanced view. Nonetheless, this controversy has demonstrated a broad national consensus about the value of breast cancer screening. After practicing family medicine for nearly 30 years, I would observe that a critical aspect of this issue has been totally ignored: the deadly impact of lack of health insurance.

Uninsured women are much more likely to be diagnosed with advanced-stage breast cancer than their insured peers. This is well documented in a 2008 report by the American Cancer Society. In 2005 while 75 percent of women with insurance had had a mammogram in the past two years, only 33 percent of women uninsured greater than 12 months had this test. Just 8 percent of insured women aged 18-64 of all ethnic groups had Stage III or IV breast cancer at diagnosis, compared with 18 percent of uninsured women. All breast cancer patients with insurance had an 89 percent five-year survival compared with only 77 percent five-year survival for those who were uninsured.

Clearly lack of insurance coverage increases the likelihood that a condition like breast cancer will go undetected and, when found, be less responsive to treatment.

A new Harvard study in the American Journal of Public Health shows being uninsured increases a person’s risk of death by 40 percent. Furthermore, the American Cancer Society report “Spending to Survive” published in February of this year documented 25 representative cases of cancer patients who were fully insured yet had to limit or give up treatment or even declare bankruptcy because of insurance policy co-pays, deductibles or policy limits. I recently had a patient who refused a mammogram because she feared that if anything was found she would become uninsurable.

The current health reform bills in Congress are very complex. They seem to trying to impact some of these problems, but they leave many insurance company policies unmentioned and untouched such as time-consuming and resource-expensive prior authorization and payment procedures and increasingly high co-pays and deductibles for care, diagnostic tests and medications. At best they would limit middle-class family costs to 20 percent of income (!) and leave at least 17 million uninsured. In contrast, a single-payer, Medicare-for-all program would be vastly less complex and less expensive, be truly universal and save tens of thousands of lives annually.

Jeoffry B.Gordon, M.D., M.P.H.
San Diego, CA

http://community.nytimes.com/comments/www.nytimes.com/2009/11/20/opinion/20fri1.html?permid=7#comment7

Veterans Day

Editorial
Berkshire Eagle
Wednesday, Nov. 11

On Veterans Day, America honors those who fought in World War II, Korea, Vietnam, Iraq, Afghanistan and other war zones, as well as World War I, which is passing deeper into history and is represented by only one surviving American veteran. America should also take this opportunity to assess if current veterans are being well-treated by the nation they serve, which means sending them to fight only in justifiable wars and providing them whatever health care they require. In this area, we can and must do a lot better.

President Obama is pondering his options in Afghanistan, which former vice president Dick Cheney sees as dithering. If Mr. Cheney had spent more time dithering about Iraq, a needless misadventure that continues to claim American lives as it winds down, he perhaps, for one example of many, would not have had to admit that he was wrong to claim the insurgency there had been broken when it was ramping up. We prefer Mr. Obama’s cautious, considered approach, and his late night visit to Dover Air Force Base in Delaware to honor 18 veterans killed in action in Afghanistan shows he knows what it is at stake. There is no evidence that either Mr. Cheney or his pupil President Bush ever roused themselves from bed to make that same visit or saw troops as much more than cannon fodder and campaign props.

The U.S. must root out al-Qaida and its allies, but it cannot engage in nation-building — certainly not in a nation
that is one in name only, whose president is corrupt and whose populace is increasingly conflicted about the U.S. presence. While an escalation is out of the question, the administration cannot allow its enemies to survive and fester there either.

With health care reform dominating the news, a Harvard Medical School research team Tuesday released a timely and sobering report estimating that 2,266 U.S. military veterans under the age of 65 died last year because they lacked health insurance and had limited access to care. This is far more than the 155 troops killed last year in Afghanistan. Unhappily, the weak and watered down health care reform plans slogging through Congress won’t begin to address this shameful situation.

These numbers are of no concern to the aging reform protesters who bray about socialized medicine while benefiting from their own socialized medicine in the form of Medicare. But they should shame every American embarrassed that a wealthy nation leaves as many of its citizens without health insurance as we do. That so many veterans, many of whom return from foreign wars with mental scars as well as physical, are uninsured and receive little or no health care is a national disgrace.

Pittsfield honors its veterans today with a parade and ceremony at the World War I monument on South Street, which is undergoing a major restoration. As attendees admire this remarkable monument and honor our veterans, we hope they will keep in mind those veterans who deserve much more from their nation.

Projections of savings from health IT are baseless, Harvard researchers say

National survey of U.S. hospitals shows information technology has yielded neither administrative efficiencies nor cost savings

EMBARGOED until
Nov. 20, 2009, 12:01 a.m. EST

Contact:
David Himmelstein, M.D.
Steffie Woolhandler, M.D., M.P.H.
Mark Almberg, PNHP, (312) 782-6006, mark@pnhp.org

The increased computerization in U.S. hospitals hasn’t made them cheaper or more efficient, Harvard researchers say, although it may have modestly improved the quality of care for heart attacks.

The findings, published in today’s [Friday’s] online edition of The American Journal of Medicine, contradict claims by President Obama and many lawmakers that health information technology (health IT), including electronic medical records, will save billions and help make reform affordable.

“Our study finds that hospital computerization hasn’t saved a dime, nor has it improved administrative efficiency,” said lead author Dr. David Himmelstein, associate professor at Harvard Medical School and former director of clinical computing at Cambridge Hospital in Massachusetts. “Claims that health IT will slash costs and help pay for the reforms being debated in Congress are wishful thinking.”

The study uses data from the most extensive survey ever undertaken of hospital computerization. Data from approximately 4,000 hospitals for the years 2003 to 2007, including those on a list of the “100 Most Wired,” were analyzed for evidence of increased quality, cost savings or improvements in administrative efficiency.

The data came from the authoritative Healthcare Information and Management Systems Society (HIMSS) Analytics annual survey of hospital computerization; Medicare Cost Reports that virtually all hospitals submit annually to the Centers for Medicare and Medicaid Services (CMS); and the 2008 Dartmouth Health Atlas, which compiles CMS data on costs and quality of care.

Although the researchers found that U.S. hospitals increased their computerization between 2003 and 2007, they found no indication that health IT lowered costs or streamlined administration, even in the “most wired” institutions. While U.S. hospital administrative costs increased slightly, from 24.4 percent in 2003 to 24.9 percent in 2007, hospitals that computerized most rapidly actually had the largest increases in administrative costs. (By way of comparison, older studies have estimated administrative costs in Canadian hospitals at 12.9 percent).

The study found no evidence of lagged effects, e.g. lower costs in 2007 resulting from information technology introduced in 2003.

Modest quality gains were noted in the treatment of heart attacks (acute myocardial infarction) in more-computerized hospitals, but even these small improvements may merely represent better documentation rather than actual gains to patients.

Himmelstein said a report from the Congressional Budget Office in 2008 signed by Peter Orszag, now Obama’s budget director, expressed skepticism about claims by the RAND Corp. and others that health IT could generate $80 billion annually in savings.

“Part of the CBO’s skepticism was based on the limited information available to the RAND study and similar studies,” Himmelstein said. “But this new, detailed, national survey of diverse hospitals shows such doubts are well-founded. Information technology can’t rescue us from our national health care crisis.”

Dr. Steffie Woolhandler, professor of medicine at Harvard and study co-author, said several factors may explain why health IT has failed to reduce administrative costs.

“Any savings may have been offset by the costs of purchasing and running new computer systems,” she said. “In addition, most software is designed around the accounting and billing needs of hospitals, not the clinical side.”

She noted that a computer success story in recent years has been at the Veterans Administration, where global budgets eliminate most billing and internal cost accounting, allowing physicians to focus instead on delivering care.

“The VA system now has our nation’s highest quality and patient approval ratings,” Woolhandler said. “Congress should take note: to get the most benefit from our health care dollars and from health IT, we should adopt a single-payer, Medicare-for-all program. Nothing short of that will allow us to reap the full potential of computerization or to provide comprehensive, quality and affordable care to all.”

******
“Hospital computing and the costs and quality of care: a national study,” David U. Himmelstein, M.D., Adam Wright, Ph.D., and Steffie Woolhandler, M.D., M.P.H., The American Journal of Medicine, Nov. 20, 2009 (online).

Physicians for a National Health Program (www.pnhp.org) is an organization of 17,000 doctors who advocate for single-payer national health insurance. To contact a physician-spokesperson near you, visit www.pnhp.org/stateactions or call (312) 782-6006.

Weighing the Evidence for Single-Payer

By Ann Settgast, M.D., and Elizabeth Frost, M.D.
Minnesota Medicine, Nov. 2009

As physicians, we are troubled by the direction of federal health care reform. Whether via a public health insurance option or an insurance mandate, the proposals on the table build on the structure of our broken system—the most costly, fragmented, and bureaucratic in the world.

President Barack Obama acknowledged in his national address this summer that a single-payer system is the only way to cover all Americans. We agree, and we encourage him to re-embrace this solution to the health care crisis.

Conventional wisdom leads us to believe there are only two culprits responsible for skyrocketing health care costs—doctors and patients. Doctors order too many unnecessary tests, and patients demand too much care. We acknowledge that overtreatment of patients guided by improper incentives must be addressed. The issue of patients overusing care also must be confronted. However, the problem of overuse is minuscule compared with the consequences of underuse. In its most extreme form, underuse of health care contributes to more than 45,000 deaths in the United States annually, as revealed in a study by Wilper et al. in the American Journal of Public Health. But blaming doctors and blaming patients ignores the elephant in the room: private insurance.

Our unique multipayer financing structure based on private health insurance produces enormous waste. Of every health care dollar spent in the United States, 31 cents is spent on administration (more than double that of other industrialized nations). So we are wary of proposals that seek to simply expand private insurance and in so doing provide a bailout for this industry. Such expansion may decrease our embarrassing numbers of uninsured, but it will not solve our problems. Private insurance has been likened to an umbrella that melts in the rain. Consider the disturbing fact that 62 percent of all personal bankruptcies are related to medical bills. More astonishing is the fact that 77 percent of Americans who go bankrupt because of medical bills had insurance when they became ill. Because it is a business, private insurance has, at its core, the bottom line. The only way to succeed is to selectively recruit healthy patients or to deny coverage to patients when they become sick. As professionals who strive to make sick people well, we find this model for our system illogical and fatally flawed.

Elimination of U.S.-style private insurance has been a prerequisite to achieving universal health care coverage in every other industrialized nation. We ask, “What if the rest of the world is right?” Only under single-payer can we eliminate the administrative costs associated with billing hundreds of payers and the sizeable overhead of the private insurance industry. These overhead dollars are spent marketing, underwriting, lobbying, and fighting claims—none of which makes our patients healthier. Elimination of this administrative waste would save more than $400 billion annually.

As physicians, we are obligated to use evidence-based medicine. The reform debate must be held to the same standard. Ample evidence, including studies by the Congressional Budget Office and the Government Accountability Office, shows single-payer can assure universal coverage while saving money. For those who say competition among insurers is needed to keep costs down, we say the experiment must end. It has been tried. It has failed. For those who ask whether something is better than nothing (ie, implementation of a public option), we again look at the evidence. A number of states have tried to patch their systems with piecemeal reforms over the past two decades. None has produced universal coverage while controlling costs.

For those who suggest we would lose choice under a single-payer system, we ask, choice of what? Choice of insurance plan—yes. Choice of doctor and hospital—no. A high-quality system is not one in which our patients choose their insurance plan but one in which they choose their doctor. Single-payer is the only reform option that actually expands choice. Bringing private insurance or a public option to more Americans retains limited provider networks and restricted choice.

For those who say single-payer is socialized medicine and worry that government bureaucrats will suddenly begin making health care decisions, they need to remember that single-payer is publicly financed but privately delivered. Medical decisions should be made by patients and doctors.

Given the magnitude of these difficult economic times, including a projected $1.8 trillion federal deficit for 2009 and rising unemployment, it is high time to reconsider the most fiscally conservative and financially sustainable option for reform—a single-payer system.

Ann Settgast and Elizabeth Frost are primary care physicians practicing in the Twin Cities. They co-chair the Minnesota chapter of Physicians for a National Health Program.

Mercer – Employers hold line on costs?

In a tough year, employers hold the line on health benefit cost increases

Mercer
November 18, 2009

* Employers hold cost growth to 5.5 percent in 2009, the lowest increase in a decade

* Growth in use of wellness or health management programs accelerates as large employers look to hold down cost without cost-shifting

* Small employers added consumer-directed health plans in 2009, helping to push up enrollment in these high-deductible plans to 9 percent of all covered employees

However, benefit cost growth outpaced inflation in 2009 by a widening margin.

The ongoing workforce health management (or “wellness”) movement gained considerable momentum in 2009, as offerings of virtually every type of health management program – from health risk assessments to disease management programs to behavior modification programs – rose significantly. While not conclusive, survey results suggest these programs are having an impact: Medical plan cost increases in 2009 were about two percentage points lower, on average, among employers with extensive health management programs than among those employers offering limited or no health management programs. And nearly three-fourths of employers that have measured the return on their investment in health management programs say they are satisfied with the year-over-year savings, lower utilization rates or improved health risks.  However, only about a third of all large employers have formally measured ROI.
 
“A lot more employers were willing to place their bet on health management in 2009,” said Linda Havlin, a worldwide partner and Mercer’s global health and benefits intellectual capital leader. “But they will want to see continual gains. Measuring health management ROI is inherently challenging and continues to evolve.”

Small employers held down cost increases by sharply raising deductibles for in-network PPO services. Consistent with past years, employers kept premium contributions relatively stable, choosing to keep the cost of coverage affordable while shifting the burden to those who use health services.

While growth in CDHP offerings in 2009 was evident only among small employers, the plans are still more common among larger employers: CDHPs are offered by 20 percent of employers with 500 or more employees, and 43 percent of those with 20,000 or more employees.

http://www.mercer.com/summary.htm?idContent=1364345

Comment:

By Don McCanne, MD

In their just released 2009 report on employer-sponsored health benefit programs Mercer seems to be celebrating the fact that this year employers have held the line on benefit cost increases. Is their optimism warranted?

Overall, the cost growth for 2009 is 5.5 percent, the lowest increase in a decade. However that increase outpaced inflation by a widening margin. The gap means that health care continues to consume an increasing percentage of wages, whether paid by the employee directly or through forgone wage increases.

Mercer cites two mechanisms for slowing cost increases: 1) small employers simply shifted more costs to the employees by raising deductibles, and 2) larger employers expanded their wellness and health management programs.

Since high deductible plans have lower premiums, small employers were able to avoid the full increases in health care costs, but their employees were further burdened by greater out-of-pocket expenses. Many large employers already offer high deductible plans and have been benefiting from this cost shift to the employee. Although Mercer frames this as being beneficial since it slows the increase in employers’ costs, it is detrimental for their employees since it expands the incidence of underinsurance.

Mercer suggests that wellness programs may have been the primary reason for the slowing of costs for large employers, but is that a valid conclusion? Most wellness interventions would demonstrate benefits in the out-lying years, but the early impact would be negligible on changing the need for health care services. Although many employers express satisfaction with these programs, most of them have not made any effort to measure the actual impact.

There is a far more logical explanation for the two percentage point advantage that they report in their health care costs. The health insurance underwriting cycle is a pattern of repeated larger gains and smaller gains that are due in part to periods of aggressive marketing by the insurers to gain greater market share. In those aggressive years, lower returns are the trade off. Once market share is established, premiums are pushed up to provide greater profit margins.

Insurers and plan administrators have found a new niche in wellness services. They are heavily marketing these products now and so are expected to be in the trough of the underwriting cycle. Once the market for these products stabilizes, we can expect the cycle to move into a peak, catching employers off guard when their health benefit program costs sharply increase in spite of having instituted these wellness programs. It is likely that the response of the employers will be to change their benefit designs which inevitably will result in even more underinsurance.

The point is that health care costs are continuing to increase at intolerable rates and that the purported slowing noted in this report is merely an artifact of the underwriting cycle combined with an expansion of underinsurance.

In an improved Medicare for all program underinsurance and underwriting cycles wouldn’t even exist, but Congress is insisting that we build on our current dysfunctional financing system, in spite of its perversities. How smart is that?