PNHP

People worry most about unexpected medical bills

pnhpf3a

People worry most about unexpected medical bills

Surprise medical bills could be a powerful campaign issue

By Drew Altman
Axios, September 24, 2018

As the chart shows, unexpected medical bills are the number one health cost problem people worry about, ahead of all the cost issues that get more attention, including deductibles, drug costs, and premiums. They’re even a bigger concern than other family expenses, such as paying the rent, mortgage, or utilities.

* Surprise medical bills also affect a lot of people. In a recent Kaiser Family Foundation tracking poll, four in ten adults (39 percent) say they had a surprise bill from a doctor, hospital or lab in the past year.

* 10 percent report that an unexpected bill was from an out-of-network provider.

* Almost 18 percent of inpatient admissions result in non-network claims for patients with large employer coverage.

Percent who are very or somewhat worried about being able to afford…

67% – Unexpected medical bills

53% – Health insurance deductible

46% – Gasoline or transport costs

45% – Prescription drugs

43% – Monthly utilities

42% – Monthly health insurance premium

41% – Rent or mortgage

37% – Food

The bottom line: Unlike consumers, experts do not generally put surprise bills at the top of their list of the problems in the health system. But people talk about their unexpected bills a lot, and with a sense of outrage.

https://www.axios.com…

Discussion draft of “Protecting Patients from Surprise Medical Bills Act”:
https://www.scribd.com…

***

Comment:

By Don McCanne, M.D.

According to this survey, unexpected medical bills such as the surprise bills from out-of-network providers are the number one health cost problem that people worry about. Even if insured, an individual may be exposed to large medical bills that were not expected.

Currently under discussion is proposed federal legislation that would limit the patients’ exposure to these unexpected bills but would shift at least some of the extra charges to the insurer. Not only would those costs be transferred to the insured through higher premiums, but we should also ask if it is fair to pay physicians who agree to becoming a network provider less than is paid to those physicians who refuse to cooperate. Although opinions on that would certainly vary, we can say that such a payment scheme is, at least, inequitable.

The fundamental problem is more than the fact that insurers deliberately limit the breadth of their provider networks; it is that private insurers include a multitude of design features to enhance their business model for the benefit of their investors.

Under a well designed, single payer, improved Medicare for all there would be no surprise medical bills, nor would there be any of the other injustices that a market model would inflict upon their enrollees. Plus everyone would be included and it would be affordable for all. We spend a lot of time talking about the injustices of our fragmented, dysfunctional system such as these surprise bills, but it is the last point – affordable care for everyone – that should be the driving force behind health care reform.

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

Our current medical system is failing

By H. Dixon Turner, M.D.
Portsmouth (N.H.) Herald, September 24, 2018

To the Editor:

I have been involved in providing primary care medical care for 44-plus years. Unfortunately, I now on a daily basis encounter many ways that our current medical system is failing. The costs of medical insurance, medications and many aspects of care are outrageously expensive and many patients do not even have access to basic care.

A case in point is the cost of epinephrine. I regularly order epinephrine ampules for the emergency cart in my office. Not too long ago I could get 25 ampules for around $25. When I ordered ampules about 18 months ago the cost for 25 ampules had risen to $62.50 or $2.50 per ampule. When I ordered the same ampules 2 weeks ago the cost had risen to $23-$25 per ampule!! That represents a 10 fold increase in cost in 1 ½ years. This is outrageous and quite frankly immoral. Unfortunately under our current medical care system such arbitrary price increases are allowed and are not regulated.

President Trump’s and the Republicans’ efforts to dismantle the Affordable Care Act will further fragment our medical care system, lead to more people not having access to care and will greatly increase the cost of medical care for all of us. These efforts — in the name of allowing “free choice” — only lead to increased profits for insurance and pharmaceutical companies.

Currently in the USA 17 percent of our GPA is spent on medical care, which does not cover all of our citizens. Compared to other developed countries, we have the worst medical outcomes even though those countries’ expenditures are as little as half as much as ours.

We must move toward a single payer or regulated payers’ system where reasonable limits are set on the cost of medications and medical care and in which all people are included and have access to medical care.

http://www.seacoastonline.com…

For profit hospitals have higher readmission rates

Proprietary management and higher readmission rates: A correlation

By Manish Mittal, Chih-Hsiung E. Wang, Abigail H. Goben, Andrew D. Boyd
PLOS ONE, Abstract, September 18, 2018

Introduction

Reducing preventable readmissions among Medicare beneficiaries is an effective way to not only reduce the exorbitantly rising cost in healthcare but also as a measure to improve the quality of patient care. Many of the previous efforts in reducing readmission rate of patients have not been very successful because of ill-defined quality measures, improper data collection methods and lack of effective strategies based on data driven solutions.

Methods

In this study, we analyzed the readmission data of patients for six major diseases including acute myocardial infarction (AMI), heart failure (HF), coronary artery bypass graft (CABG), pneumonia (PN), chronic obstructive pulmonary disease (COPD), and total hip arthroplasty and/or total knee arthroplasty (THA/TKA) from the Center for Medicare and Medicaid Readmissions Reduction Program (HRRP) program for the period 2012–2015 in context with the ownership structure of the hospitals.

Results

Our analysis demonstrates that the readmission rates of patients were statistically higher in proprietary (for profit) hospitals compared to the government and non-profit hospitals which was independent of their geographical distribution across all six major diseases.

Conclusion

This finding we believe has strong implications for policy makers to mitigate any potential risks in the quality of patient care arising from unintended revenue pressure in healthcare institutions.

From the Discussion

The policy makers need to carefully evaluate and design healthcare policies that mitigate potential risks associated with unintended revenue pressure in harming patients.

https://journals.plos.org…

***

Comment:

By Don McCanne, M.D.

Is the primary mission of the health care organization to serve the needs of patients, or is it to make a buck? It makes a difference. This study shows that readmission rates were higher in proprietary (for profit) hospitals than in non-profit hospitals.

This fundamental difference in hospitals that must cater to passive investors is one reason why the single payer, improved Medicare for all model as supported by Physicians for a National Health Program would covert for profit entities to non-profit. Unfortunately, this important policy recommendation is being left out of many of today’s discussions on health care reform.

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

There is just no denying that Medicare for all is the right solution

By Olveen Carrasquillo, M.D., M.P.H.
Miami Herald, September 21, 2018

Keep the government away from Medicare.

Seriously?

Herman Cain, former CEO of the National Restaurant Association and a former presidential candidate, ludicrously argues that single-payer healthcare would be a death sentence for seniors in his Sept. 19 op-ed in the Miami Herald.

He seems unaware seniors are already insured through single-payer health insurance — it’s called Medicare.

He cites anecdotes from other countries, yet all academic studies show such nations have better access and quality healthcare. They also have better health outcomes at much lower costs.

In our public hospital, we are confronted daily with the suffering that results from having so many with poor access to health care.

In our offices, we waste way too much time fighting private insurance companies that arbitrarily deny tests, procedures and medications to our patients.

Skyrocketing insulin prices force many with diabetes to ration or not take their lifesaving medications.

It is easy to dismiss rhetoric from someone whose political ads highlighted the virtues of smoking.

But Cain is correct that Obamacare was problematic. It provided many with expensive private insurance with limited benefits. Wisely, Obama has seen the error of his ways and now advocates for an improved Medicare for All.

Medicare is the right solution for our seniors and now needs to be extended to everyone else!

Dr. Carrasquillo is professor of medicine and public health, and chief, division of General Internal Medicine at the University of Miami, Miller School of Medicine.

https://www.miamiherald.com…

Kentucky’s Medicaid expansion is cost-effective and saves lives

By Barbara Casper, M.D.
Louisville Courier-Journal, September 20, 2018

I am a physician who has spent my entire 32-year career caring for uninsured and underinsured patients – 20 of those in Kentucky. I have written editorials in the past supporting the ACA as well as the Medicaid expansion and I feel that I need to respond to an editorial published in this paper written by Jordan Harris.

First of all, Mr. Harris points out in his editorial that 1.4 million of our neighbors are poor enough to qualify for Medicaid. That is simply stunning – it means that 1.4 million people are living below 127 percent of the poverty level inner state. As someone who cares for many of these patients, I can tell you that the idea that these folks are taking advantage of the system is simply untrue. Are there a few “able-bodied” people who have chosen not to work and therefore qualify for Medicaid? Yes there are. However, the vast majority of our patients work in jobs that do not provide employer-based insurance, have disabilities that have taken them out of the workforce or are caring for aging parents and children. In addition more and more of my patients are caring for their grandchildren as the children’s parents are suffering in the current opioid use crisis.

Secondly we cannot afford to let these folks lose their insurance. The cost of medical care does continue to increase but taking insurance away from patients will not decrease that cost, but will shift it. Patients will continue to get sick. We have to make a decision as a society whether we are OK with patients dying because they cannot afford lifesaving treatment or if we are willing to absorb that cost. It is also much more cost-effective to treat illnesses earlier rather than when the disease has progressed. Let me give you a real-life example.

A 50-year-old man has a screening colonoscopy as recommended for his age. A 1 cm polyp is found in his rectal area and is removed and has no evidence of cancer. Because he had a polyp, he has a repeat colonoscopy every five years for the next 10 years and thankfully has no further polyps. The cost of the initial colonoscopy with biopsy is $2,145 and the subsequent colonoscopies are $1,905 each for a total cost over 10 years of $5,955.

By contrast his brother does not have insurance and cannot afford to pay for a screening colonoscopy. Five years later he develops rectal cancer requiring a resection and a colostomy. He also undergoes chemotherapy and radiation treatment. The cost of the colon resection alone can be up to $38,000. The cost of chemotherapy and radiation treatment will be equally if not more expensive. I am not an accountant but it seems much more cost-effective to allow people to have recommended treatments and preventive care. This does not even take into account the pain and suffering for our patient now with a colostomy.

The only way taking Medicaid away from the patient is cost effective is if we allow them to die. People die from lack of insurance. Unfortunately, I have personally experienced situations where patients delay treatment due to concerns of cost and seek care when there is little we can offer. I hope we will not, as a society, get to the point that this is acceptable.

Which brings me to Mr. Harris’ second point. He posits that conservatives are uncomfortable with a “welfare” state. He cites studies which do not show cost-effectiveness of the expansion of Medicaid. I can provide equally compelling evidence from the literature that shows that since the implementation of the ACA and Medicaid expansion, there have been fewer ED visits, increased primary care visits and improved compliance with medications in Kentucky. My own experience corroborates this. It will take years to prove the benefits of management of chronic medical conditions such as diabetes and hypertension. However, I have witnessed improved BP and diabetes control in my patients who now have access to medications and other resources. As a physician I am confident we are making a difference.

I also believe it is time to have an honest discussion about the role of government in our lives. I find it interesting that conservatives decree government intervening when people need help with health care, housing, etc., but have no issue with telling me who I can love or what I can do with my body. It is true that the cost of health care has skyrocketed but taking insurance away from people will NOT change that cost. Please be clear that very few people could afford to pay for health care with the assistance of insurance, whether employer-based or Medicare or Medicaid. The absolute best solution would be to have a single payer system – Medicare for all. Until we, as a country, decide we need to provide essential medical care to all citizens, we cannot afford to dismantle the Medicaid expansion.

Dr. Barbara R. Casper is a professor at the University of Louisville School of Medicine.

https://www.courier-journal.com…

Middle Georgia medical crisis made worse by state- and national-level decisions

By Jack Bernard
The (Macon, Ga.) Telegraph, September 20, 2018

Georgians self-report poor/fair health at a much higher rate than Americans in general, 19 percent to 16 percent. Georgians are correct based on objective morbidity factors (University of Wisconsin “County Health Rankings and Roadmaps”) as shown below. Even more important to a Telegraph reader, Bibb County is significantly worse than the rest of the state, ranking 143 out of 159 counties on statistical health outcomes and 98 on general health factors.

A major reason for Georgia’s poor health status is that our rate of medically uninsured (younger than 65) is 16 percent, much higher than the national average of 11 percent. This dismal situation was caused by the failure of our state leaders to accept Medicaid expansion via the Affordable Care Act (Obamacare), although 90 percent of the cost of expansion is paid by the federal government. But, the long-term solution is Medicare expansion, not Medicaid.

I’ve pulled two indicators to illustrate how our state falls short: (a) Premature deaths for the U.S. as a whole are 6,600 per 100,000 versus 7,500 per 100,000 for Georgia. The low birth weight rate for the USA is 8 percent versus 10 percent for Georgia.

On the provider end, The Medical Center of Central Georgia and other hospitals that serve a disproportionate number of medically uninsured have high levels of bad debt, causing medical price increases for Bibb’s private pay patients. Also, due to indigent care, many of Georgia’s public hospitals are asking for increased subsidies paid for from local taxes.

The bottom line is that Georgia is a less healthy state, and Bibb is even more unhealthy. Clearly, providing health insurance to more Georgians will have a greater positive impact on Bibb citizens versus the state as a whole. And that is the reason that single payer (Medicare for All) should be supported by all Bibb taxpayers. But it is not because of deliberate misinformation, some of it by health professionals.

Medicare is one of the nation’s most efficient and popular programs, having an overhead of just 2 percent versus an average of 12 percent for private insurance. Few conservative Americans older than 65 believe that their Medicare represents socialism. All providers are private, as will be the case when it is finally expanded.

Countries with single payer and similar systems all provide universal care at a fraction of the cost here while covering everyone.

All have better healthcare outcomes. Some of this is undoubtedly due to a healthier lifestyle. But, I doubt that all my distant relatives in Naples and Paris turn down second helpings of food while bicycling to work daily.

It is a real pity that the word “socialism” scares politicians who would otherwise endorse Medicare for All. Trump repeatedly endorsed single payer until he became a politician.

Health coverage and cost are not problems that will resolve themselves via minor changes. Thirty million folks are still uninsured. Since my time as director of health planning for Georgia, national expenditures on health care as a percent of GDP has risen from 8 percent to over 18 percent. This situation has meant less money for infrastructure and education.

But, there is hope long term. The majority of Democrats now supports single payer. Someday, so will the GOP. If for no other reason than cost, change will inevitably come. At that point, hopefully health status for Bibb residents will improve.

Jack Bernard, the first director of health planning for Georgia, has been an executive with several national health care firms. A Republican, he’s a former chairman of the Jasper County Commission.

https://www.macon.com…

Follow the money to health care’s undo administrative costs

By George Bohmfalk, M.D.
The Aspen (Colo.) Times, September 20, 2018
(Part 3 of 6. Read parts 1, 2, 4, 5 and 6.)

Last year, the United States spent around $3.5 trillion on health care. As there are about 325 million of us, that comes to a bit over $10,000 per person.

Not only is that twice the per-person average that other industrialized countries spend, at around 18 percent it is also about twice the percentage of gross domestic product that those countries spend on health care. And they cover everyone.

According to data provided by the Organization for Economic Co-Operation and Development, a group of 36 countries working on economic and social issues, we are not getting our money’s worth.

We pay the world’s highest prescription drug prices. Our medical outcomes, such as maternal and infant mortality and our overall life expectancy, are worse than those of most other modern nations. Millions of Americans have no health care insurance, and millions more who have insurance either defer needed care or go bankrupt due to unaffordable deductibles and copayments. Where is all the money going, if not to good care?

Some experts point to our high prices as the culprit. They believe that price transparency and more competitive markets can solve our problems. Our prices are high, but there’s an even larger elephant in the room, gobbling up a ton of money. In fact, it consumes close to one-third of all health care spending. That unproductive and ravenous elephant is administrative overhead.

How did we come to spend around $1 trillion a year on health care administration? There are many reasons, but the main ones are for-profit private insurance companies and a bureaucratic industry called managed care.

The overheads of private insurance companies average around 20 percent. Until reigned in by provisions in the Affordable Care Act (aka Obamacare), many companies spent even more than that, on advertising, executive compensation, sales commissions, shareholder dividends, and routine claims processing, including denials and appeals. The overhead of Traditional Medicare is 2 percent to 3 percent, because all it does is process claims.

In the 1970s, as health care costs were rising everywhere, we in the United States tried to bring them under control through better management. We experimented with health maintenance organizations and hired physicians, nurses and case managers, to reduce hospital lengths of stay, deny treatments and otherwise micromanage health care. The result has been a slight improvement in some medical costs, but this has been accompanied by an enormous new managed care bureaucracy, spread among hospitals, physicians’ offices and insurance companies. The cost of all this bloated administration accounts for that trillion dollars.

About the same time that we went in that direction, Canada implemented its single-payer national health care system, with private doctors and hospitals. By eliminating around half of the administrative overhead of a complex, multi-payer, for-profit insurance system, their percentage of GDP spent on health care remained fairly flat, while ours has continued to escalate. Their health outcome results are better than ours, and everyone is covered.

Multiple academic studies agree that we could cut our health care administrative overhead by around half by moving to a single-payer system, saving as much as $500 billion each year. We could save $100 billion more by negotiating prescription drug prices. That total amount is many billions more than it would cost to provide full health care insurance to everyone, with no deductibles or copayments. That amount is more than enough to pay negotiated prices for prescription drugs, as well as dental, vision and hearing care. Billions now spent each year on paperwork could be redirected to actual care.

How do we move the money around? There will be taxes, as you have no doubt heard. What you may not have heard is that for 95 percent of households, those taxes will be less than what they currently pay in insurance premiums, deductibles, copayments, prescription drugs and other components of health care. The only ones expected to pay more are those with annual incomes around $400,000 and higher. For the 99 percent, you would pay less and get more.

The simplest route to this goal is to expand and improve Medicare, a proven and efficient single-payer system. There may be some tradeoffs, but the greatest result would be improvement in our nation’s health and the relief of much unnecessary physical and financial suffering.

Dr. George Bohmfalk practiced neurosurgery in Texas before retiring to spend half of each year in the Roaring Fork Valley. He is active in Physicians for a National Health Program, a physician-driven group advocating for a single-payer health care system.

https://www.aspentimes.com…

Opening the Pandora’s Box of commercial insurance data

Health Care Spending Under Employer-Sponsored Insurance: A 10-Year Retrospective

By Amanda Frost, Eric Barrette, Kevin Kennedy, and Niall Brennan
Health Affairs, September 19, 2018

Abstract

Using a national sample of health care claims data from the Health Care Cost Institute, we found that total spending per capita (not including premiums) on health services for enrollees in employer-sponsored insurance plans increased by 44 percent from 2007 through 2016 (average annual growth of 4.1 percent). Spending increased across all major categories of health services, although the increases were not uniform across years or categories. Growth rates for total per capita spending generally slowed after 2009 but increased between 2014 and 2016. Spending on outpatient services grew more quickly (average annual growth of 5.7 percent) compared to spending on the other types of services. However, the overall distribution of spending across categories remained largely unchanged. In the context of the dramatic economic and policy events that have taken place since 2007—including the Great Recession, the Affordable Care Act, and numerous medical innovations—this assessment of ten-year spending trends provides insights into how the largest insured population in the US contributes to health care spending growth.

https://www.healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

Previously much of our access to data on health care spending has been through government programs – Medicare and Medicaid. Data on commercial insurance spending, especially employer-sponsored plans, were hidden in a cloud of secrecy as proprietary information. Now a group of major insurers has made that information available though the Health Care Cost Institute. Having this information is helpful because it can reveal underlying health care spending trends in the very large sector of commercial insurance (covering 54 percent of Americans) that was not disturbed by the Affordable Care Act (ACA).

In the decade that included the Great Recession and the enactment and implementation of ACA, there was an initial slowing in the rate of health care spending increases. The ACA enthusiasts were quite willing to take credit for that slowing, though there was not much evidence that the specific polices contained in ACA could be credited for it. It seemed much more likely that the slowing in health care spending growth was merely a manifestation of the global slowing of the economy during the recession.

In the latter part of the decade studied, health care spending growth increased again. Although ACA is still in force, this increase further suggests that the previous slowing was due to the recession and not due to any magical policies contained in ACA. In fact, many other studies have demonstrated disappointing results in the ACA measures that were supposedly designed to contain spending.

The significance of this is that it is wrong to continue to support ACA based on the concept that we merely need to give it more time to work, maybe while adding a public option – an option that would not change in any fundamental way the huge, highly dysfunctional, fragmented infrastructure of our health care financing system. It is wrong to reject a proven model that would be effective in reducing the rate of spending increases to sustainable levels – a single payer national health program.

Now that we have opened the Pandora’s Box of private commercial insurance data, we have confirmed that private insurance is not capable of containing the excessive growth in health care spending. So let’s move forward with establishing our own public program that would work – a single payer improved Medicare for all.

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

What do Americans want done about our high prescription drug prices?

High Prices, Broken Promises

NORC at the University of Chicago, September 13, 2018

Three-quarters of Americans consider the cost of prescription drugs in the United States to be “unreasonable,” and despite promises from the President and members of Congress to rein in prices, few approve of either’s handling of the issue, according to a new national poll from the West Health Institute, a nonpartisan, nonprofit healthcare research organization, and conducted by NORC at the University of Chicago.

The survey found the high cost of healthcare is a top public policy issue for Americans. When presented with a list of six issues, 78 percent said addressing healthcare costs was their highest priority, similar to the number who say the same about jobs and the economy (76 percent), and ranking higher than national security (71 percent), the environment (63 percent), immigration (51 percent), or trade (38 percent).

High prescription drug prices are a particular worry for most Americans. Sixty-five percent said they are extremely or very concerned about the issue. Another 88 percent said lowering medication costs should be a top priority for candidates running for Congress.

From the Survey:

To reduce the cost of prescription drugs, should…?

82% – Medicare be allowed to directly negotiate with drug companies to get lower prices on prescription drugs

82% – More lower-cost generic prescription drugs be allowed to compete with the equivalent high-cost brand name prescription drugs

80% – Drug companies be required to release information to the public on how they set their prices

65% – Americans be allowed to buy prescription drugs from Canada

52% – Prescription drug advertisements be eliminated

31% – Drug companies be required to set the price for a drug based on how well it works

Press release:
http://www.norc.org…

Full issue brief and results:
http://www.norc.org…

Topline:
http://www.norc.org…

***

Comment:

By Don McCanne, M.D.

Not only do Americans object to the high prices of prescription drugs, they also feel that the President and members of Congress have failed us in not doing more about it.

When offered a list of various options on what we can do, to no surprise at the top was that Medicare should be allowed to negotiate for lower drug prices (along with more generic drug competition and more transparency in the setting of drug prices). Again, Americans support a major government role in drug pricing.

With the current popularity of Medicare for All it would have been interesting to see how strong the support would have been for including drugs as a benefit of an improved Medicare that covered everyone, but they didn’t ask that. Regardless, if we already had in place a comprehensive, single payer, improved Medicare for all that included a drug benefit, there is no question that it would be extremely popular.

We hear the opponents of reform talk about how bad the systems in Canada and Great Britain are, yet we hear from their people that they would never consider transforming their systems into one like ours. Since the majority of our politicians continue to fail us, it seems that we should replace them with leaders who can hear our message.

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

Value-based care would improve under single payer

Payers and Providers Remain Far Apart

By Leemore Dafny, Ph.D. and Namita Seth Mohta, M.D.
NEJM Catalyst, March 2018

Health care stakeholders are not aligned in important goals and in large part are not working together to achieve value-based care, according to the NEJM Catalyst Insights Council. They are waiting on government regulators to change the payment model – including, possibly, single-payer health care.

More than half (58%) of Insights Council survey respondents indicate that their individual organizations are not aligned in working toward achieving value-based care. A higher percentage of clinicians (63%) than clinical leaders (53%) think that payers and providers at their organization are not aligned. At the health care industry level overall, the outlook is even bleaker, with 77% reporting a lack of alignment.

Unlike many industries where the private sector typically takes the lead in driving change, our survey confirms other research that in health care, government payers set the blueprint for private payers to piggyback on. Respondents rate regulatory payment model changes (such as from Centers for Medicare & Medicaid Services) as the most influential among drivers to improve payer-provider collaboration.

Single-Payer Health Care Would Have a Positive Effect on Value-Based Care

Would the ability to provide value-based care get better, worse, or stay the same under single-payer health care?

61% – Better
22% – Worse
16% – Stay the same

Single-payer health care would have a strongly positive impact on the ability to provide value-based care, say Insights Council respondents. This reaction is consistent across all three audience segments of executives, clinical leaders, and clinicians. In verbatim responses, many respondents single out single-payer as the systemic change that would most improve payer-provider collaboration. These results continue the trend that NEJM Catalyst has observed among Insights Council members holding a positive view of single-payer health care.

https://cdn2.hubspot.net…

***

Comment:

By Don McCanne, M.D.

In the quest to change from volume to value in health care financing, gimmicky models such as accountable care organizations are being implemented, but the lack of alignment between payers and providers has not achieved the goal of value-based care. This survey of clinicians, clinical leaders and executives reveals that they believe that a single payer approach would have “a strongly positive impact on the ability to provide value-based care.”

Rather than continuing on the path to nowhere laid down by the politicians, bureaucrats, and policy community, doesn’t it seem logical that we should look at the model that those in the trenches – the clinicians, clinical leaders and executives – believe would actually work? Rather than having the payers attempting to align the providers, we should be having the providers who understand the delivery of health care give guidance to the design of the financing system. It becomes ever more evident to those providing the care that instead of a fragmented, dysfunctional market of private payers we should have a single, efficient public payer if we want to inject greater value into our health care system.

It would be infinitely better for the providers to give guidance to the design of the financing system to make it work optimally for patients than it would be to continue to allow the payers to try to design the health care delivery system. That’s how we have ended up with MACRA, MIPS, APMs, ACOs and other screwball ideas. Let’s work on improving the clinics and hospitals instead – under a single payer system. That’s where the value is.

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

I just want my blood pressure pills, dammit! (and why it should matter to others)

By Don McCanne, M.D.
September 17, 2018

In the big picture of health care in America, the following anecdote is quite trivial, but, as I’ll explain, the implications are of great consequence.

Through the years my wife and I have had great care coordinated by our highly competent primary care physician. He retired recently and his practice was taken over by another physician. I needed a refill on my two blood pressure medications, but rather than interacting with the physician, I was now interacting with OptumCare Medical Group, a subsidiary of UnitedHealth. (You’ve no doubt read about insurers consolidating with physician groups – it’s very real.) Although we have avoided the private Medicare Advantage plans, I found by perusing OptumCare’s website that, without my knowledge, I was assigned to their Medicare Pioneer ACO.

The trivial complaint of mine is that I had to have numerous contacts through an always-busy telephone system and a non-responsive contact point on their website which resulted in many days of effort just trying to get my two basic blood pressure medications refilled. Several errors were made and, in fact, they never were correct even after repeated attempts. The prescriptions had the names of two different nurse practitioners on them, and finally one had the name of my new primary care physician after I was finally able to see him. Part of these glitches were due to the fact that they were transitioning to a computer system.

Not only were my prescriptions under the control of OptumCare, I was also covered by a Part D Medicare drug plan through Anthem Blue Cross. All I wanted was a 90 day supply of each pill with 3 refills, just as I had had under our previous physician. Well, somewhere between OptumCare and the Anthem drug plan, our independent pharmacist of many years was authorized to fill only a 30 day supply, but for only one of them since it was too early to fill the other one. This meant that I would have to come back every 15 days indefinitely to pick up only one prescription at a time. I checked the Anthem website and found that not only was my pharmacy not on the preferred list, it was no longer listed in the Anthem network at all (with a statement that pharmacies could be changed at any time without notice).

I discovered that I could receive 90 day supplies by mail through Anthem’s pharmacy benefit manager, but it seemed unfair to me that they should take over the bread and butter trade of easy long term prescriptions while leaving the local pharmacist with the need to carry a huge stock of a great variety of prescription items that are filled usually only once, creating an overhead headache without a volume offset.

I finally gave up. Since I still have my medical license, I ordered stock jars of 1000 pills each through a medical supplier so I wouldn’t be bothered with the hassle any more (a strategy not available to most people). Of course, that’s not covered by the Part D plan, but I had had enough. (I should mention that though it is unethical for a physician to prescribe for himself, these two medications were actually prescribed by my primary care physician and by my cardiologist.)

Yes, this is very trivial compared to some of the horrendous problems that others face in our health care system. But it is what this annoyance represents that is so objectionable. The system should work so that I can get my very common, tier one generic medications every three months with an effortless system of refilling them. Instead, my physician has been hijacked by one of the largest insurers in the nation, and my pharmacist has had barriers erected by another of the largest insurers, together making it much more difficult for me to obtain my straightforward maintenance medication. What value are these giant insurers adding that we should have to tolerate their inanity?

The reason that everyone should be concerned is that this takeover of health care is expanding rapidly, with no relief in sight. If it doesn’t work well for minor routine matters, how could it work well for the big stuff? A well designed, single payer improved Medicare for all program as is advocated by Physicians for a National Health Program would solve most of the problems with our highly dysfunctional health care financing system. Although there is widespread public support for such a model of reform, look very carefully at what is actually happening in the political arena.

Congress and the administration are continuing to expand the private Medicare Advantage and private Medicaid managed care models. They are continuing to push alternative payment models including accountable care organizations and other so called value-based proposals that involve intrusions by insurers and other managers. While using the Medicare for all rhetoric, they are quietly suppressing the bona fide single payer model while giving the business intermediaries an even greater role in (mis)managing our health care system.

HR 676, the Expanded and Improved Medicare for All Act contains many of the principles of a well designed single payer system. People are enthused to see the formation of a Medicare for All caucus in the House. There has also been considerable enthusiasm over the introduction in the Senate of Bernie Sanders’ bill, S 1804, as supposedly being a single payer Medicare for All bill in the Senate. However, to gain cosponsors, many compromises were made. Exemplifying them is the inclusion of the following:

“Sec. 611 (b) Application Of Current And Planned Payment Reforms.—Any payment reform activities or demonstrations planned or implemented with respect to such title XVIII as of the date of the enactment of this Act shall apply to benefits under this Act, including any reform activities or demonstrations planned or implemented under the provisions of, or amendments made by, the Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114–10) and the Patient Protection and Affordable Care Act (Public Law 111–148).”

This means that the payment models of ACA and MACRA with MIPS and APMs including ACOs would be perpetuated under S 1804. What is especially alarming is that members of the House Medicare for All caucus, instead of protecting and supporting the single payer features of HR 676 and encouraging the Senate to endorse the same, they want to change HR 676 to include the highly flawed features of S 1804. It appears that the intent of Congress is to perpetuate the entities that are creating many of the very problems that we are trying to solve with PNHP’s version of an improved Medicare for all. Leaving our dysfunctional system in place while merely adding a Medicare Advantage-style public option is no solution at all.

My wife and I have transferred our care to another excellent physician. We left OptumCare but are continuing with the traditional Medicare program with a Medigap supplement to protect us in the event of catastrophic events. We also are continuing with our Part D drug plan to protect us against the potential of those $100,000 drugs that are becoming so commonplace. But wouldn’t it be nice to have the Medigap benefits and the drug benefits rolled into the traditional Medicare program along with the other improvements that would be ideal in an improved Medicare for all? We’re not going to have that unless we start communicating more effectively with our members of Congress, even if it means using our boot.

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

Universal healthcare was unthinkable in America, but not any more

A single-payer healthcare system appears closer than ever but to make it a reality we must avoid the pitfalls of the past

By Adam Gaffney, M.D.
The Guardian, September 16, 2018

Barack Obama dropped a bombshell into the healthcare debate roiling the Democratic party last Friday. “Democrats aren’t just running on good old ideas like a higher minimum wage,” he said, “they’re running on good new ideas, like Medicare for All…” His endorsement made headlines, and for a good reason: until recently, real universal healthcare had long resided on the margins of the American political discourse. Obama’s announcement, then, was yet one more indication that this idea – also called single-payer healthcare – had migrated to the mainstream. The shift is an encouraging development for proponents, to be sure, but there is also cause for caution: as history shows, formidable political obstacles and pitfalls lie ahead.

It is difficult to overstate how far single-payer has recently moved. Consider, for a moment, where things stood after Democrats took the presidency and both houses of Congress in 2008. “The White House and Democratic leaders have made clear,” the Washington Post reported the following year, “there is no chance that Congress will adopt a single-payer approach…because it is too radical a change.” Single-payer supporters didn’t even have a seat at the table (and some were arrested when they showed up anyway).

Following the passage of the Affordable Care Act, however, several developments pushed single-payer to the fore. First, although Obamacare expanded coverage to some 20 million people – achieving much good – it raised hopes that universal healthcare would be achieved while failing to deliver it: some 29 million remain uninsured today, while many more face onerous deductibles, restrictive insurance networks, surprise bills, unaffordable medications, medical bankruptcies and disruptions in care with every change in insurance plan.

Next, there was the 2016 election of Donald Trump, which made it obvious that Republicans lacked even a semi-serious alternative. Congressman Paul Ryan’s long-awaited ACA repeal bill was mostly a mechanism to transfer healthcare dollars from the poor into the savings accounts of the rich, and it seemed to satisfy no one except for wealthy donors.

Finally, there was a marked progressive shift within the Democratic party, beginning with the 2015-16 presidential primary campaign. Former secretary of state Hillary Clinton opposed single-payer, saying it would “never, ever” happen, but it was central to the platform of Vermont senator Bernie Sanders. Sanders lost the primary, of course, but he advocated better ideas.

Obama’s endorsement of single-payer on Friday (despite having previously said something similar) is therefore tantamount to a major shift in the Overton window, reflecting years of activism by single-payer supporters as well as a historic intra-party shift.

Today, in primary contests across the country, progressive Medicare-for-All proponents are ousting more centrist and establishment candidates – Alexandria Ocasio-Cortez’s surprise primary win in New York’s 14th congressional district being the most popular example. At the same time, public support has soared: a recent Reuters poll found that 70.1% want Medicare for All, including 84.5% of Democrats. One might even argue that for people who want a job as a Democratic politician, in other words, supporting single-payer is nearly becoming a prerequisite.

None of this is to say, however, that enacting it legislatively – even with a new government in power – will be easy. We have, after all, been down this road before.

A concept older than Medicare

As some have noted, Obama wasn’t quite right to call Medicare for All a “new” idea: on the contrary, Medicare for All is a concept older than Medicare itself. Medicare came about after the defeat of single-payer – then called “national health insurance”– during the Truman administration. The campaign against it was led by the American Medical Association (AMA), which famously did it in with the help of a cutting-edge public relations firm that waged an unremitting campaign of cutthroat red baiting (drug firms also lent support).

But something similar is brewing today. As the Hill reported last month, a new anti-single-payer group has recently formed – drawing together the lobbying muscle of both insurance companies and big pharma – and it’s spoiling for a fight. Single-payer poses an existential threat to insurers, after all, and the industry’s coming PR blitz could make the famed “Harry and Louise” TV ad campaign of the 1990s – credited with helping sink Bill Clinton’s healthcare reform –look like an undergraduate’s mediocre final project for a marketing course.

This is a major obstacle, but a surmountable one: all great reforms in history, including Medicare itself, had to overcome powerful opponents. Yet a second potential pitfall lies ahead: despite all that has happened, politicians could still walk away from single-payer – probably by watering “improved Medicare for All” down into something unrecognizable. And again, something similar has happened before.

After the AMA’s defeat of national health insurance, its architects narrowed their proposal to cover just seniors; this became known as “Medicare.” However, the idea was that the Medicare approach could later be used to cover everyone. A push was made to realize this universal vision within a few years of the implementation of the program, and indeed, had things happened somewhat differently, some sort of national health insurance legislation could have been achieved in the 1970s.

Ultimately, however, the movement disintegrated – in large part the consequence of a historic rightward political turn that culminated in the election of Ronald Reagan. Fatefully, this was also the moment when the Democratic party abandoned national health insurance, instead embracing a private-insurance based alternative built on Richard Nixon’s reform proposal, which the ethically compromised Republican president had offered as a counter to single-payer.

Brick-by-brick, the campaign for national health insurance was rebuilt. In the late 1980s, for instance, the organization I serve – Physicians for a National Health Program – was formed, and its proposal for what was newly called “single-payer” became the blueprint for HR 676, the Improved and Expanded Medicare for All Act that was first introduced in Congress in 2003. That year, it had only 38 co-sponsors, but today HR 676 is supported by an unprecedented 123 lawmakers, or some two-thirds of the Democratic caucus. Meanwhile, Bernie Sanders’ companion bill in the Senate, the Medicare for All Act of 2017, has achieved 16 co-sponsors (his previous bills had zero).

The future of single-payer

The danger, however, is that even with the prospects of these bills on the rise, Democrats could turn away from the essence of the vision. Already, some are aiming to mutate Medicare for All into something vastly inferior – for instance, into an expansive “public option”-type program that would retain a major role for private insurers (e.g. the Center for American Progress’s confusingly labelled “Medicare Extra-for-All”). But to achieve real universal healthcare, Democrats can’t afford to repeat the mistakes of the past and flee to a private-insurance based reform a second time around. Medicare for All must remain what it is today – how it is detailed in a bill like HR 676 – if it is to mean anything at all: fully public national health insurance providing comprehensive, universal coverage to the entire nation.

Wilbur Cohen, a chief architect of both Truman-era national health insurance and Medicare, recognized this when he asserted that private insurance companies should have no role in a Medicare for All system, although it was not yet called that. “[O]nce the Federal Government decides that everybody is going to be insured,” he put it in 1977, “there is no need for a private insurance company to go out and sell coverage…using private insurance agencies to achieve the public responsibility seems to me to be wasteful and unnecessary, imposing an additional cost…without any essential advantage.”

His point is even more salient today: private insurance companies add only fragmentation and cost, something we can’t afford as we work to provide everyone in the nation with comprehensive first-dollar coverage.

For the first time in a generation, the realization of a right to healthcare – through implementation of a single-payer system – is on the horizon. But achieving it requires not repeating the mistakes of history. It means somehow countering a staggeringly rich corporate opposition while at the same time preserving the essence and the details of the vision – one which, by necessity, leaves no room for the waste and avarice of the private insurance industry. It is a formidable task, but one that has never seemed so winnable.

Dr. Adam Gaffney is an instructor in medicine at Harvard Medical School. He is secretary of the advocacy organization Physicians for a National Health Program.

https://www.theguardian.com…