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As ER visits climb, hospitals react

The Philadelphia Inquirer
March 16, 2001
by Stacey Burling

“Some experts say the emergency room is being transformed from a last recourse in desperate moments to a place where people can get all sorts of care at all hours.”

“Rather than fighting the trend, some hospitals are accommodating the increased traffic by adding physicians’ assistants and nurse practitioners to ER staffs and offering ‘fast track’ care.”

Ted Christopher, ER director at Thomas Jefferson University Hospital:
“I think emergency medicine is probably misnamed. It should probably be named 24-hour-access care.”

Uwe Reinhardt, Princeton University health economist:
“Using the emergency room for routine procedures is actually quite efficient.”

Michael Carius, president-elect of the American College of Emergency Physicians:
“You can either try to change demand, or you can try to meet demand.”

Comment: There is a great need for night and weekend clinical services. The emergency rooms are filling this role by default. Emergency room costs are high, in part because of the numbers of uninsured that resort to this source of care. Shunting the non-life threatening cases to more efficient care within the same facility improves the utilization of resources. In addition, if we were to adopt universal health insurance, we would end the cost-shifting that makes emergency services outrageously expensive for the rest of us.

Insuring the uninsurable: The sick are losing a safety net against financial ruin

The Sacramento Bee
March 11, 2001
Editorial

“Every citizen who can’t get health insurance is a black mark against a society that claims to be civilized. But those whose plight ought to cause the biggest pangs of conscience are the medically uninsurable: men and women who are willing to pay for individual health insurance but who are denied individual coverage by insurance carriers because of pre-existing medical conditions.”

“A health insurance system worthy of the name ought to have mechanisms to make sure that even people with pre-existing conditions can get covered. A universal system, in which all citizens were required to participate, could do that, making everybody broadly and progressively share the higher costs of covering the sick.”

“In a state as rich as California, it’s a disgrace that more and more people with chronic illnesses face financial ruin because they are turned away for health insurance.”

Comment: Let’s hope that our “biggest pangs of conscience” for the “medically uninsurable” do not deter us from seeking a solution that will include coverage for the “financially uninsurable” who should be generating equally big “pangs.” Only by including everyone can a society erase all of its black marks.

Editorial debate: Rising Medical Costs

USA Today
March 14, 2001

View of USA Today: Better planning is needed to avoid pitfalls of last revolution.
Opposing view: Rather than shift rising costs to patients, cut out HMO middlemen.

USA Today:
“And employers who think defined-contribution health plans are the way to go will have to provide solid answers – before jumping at what appears to be a quick solution to the current cash crunch. The last thing the nation needs is another health-care revolution that fails to perform as promised.”

Ida Hellander, M.D., Executive Director of Physicians for a National Health Program:
“Upping costs for families and the sick would cause millions of casualties. National health insurance would cause just two: HMOs and obscene drug-company profits.”

USA Today opinion:
http://usatoday.com/news/comment/2001-03-14-nceditf.htm

Other opinion:
http://usatoday.com/news/comment/2001-03-14-ncoppf.htm

USA Today by Ida Hellander and Don McCanne

Upping patients’ share of premiums and medical bills won’t slow skyrocketing health-care costs. But it will penalize the sick and keep millions away from life-saving care.

Americans already pay more out-of-pocket for health care than patients in any other country. Yet we have the world’s highest health-care costs. We’re not getting much for our money: A recent World Health Organization study ranked the USA a dismal 37th in the quality of our health system. Meanwhile, 43 million Americans are uninsured; a recession would push that number to 60 million.

The last time premiums were rising in the double digits, policymakers herded workers en masse into skimpy HMOs. A decade later, studies show that HMOs didn’t save us a dime; they just diverted money from patient care to bureaucrats and investors. It’s now clear that the slowdown in premium increases in the mid-1990s came from a downturn in the insurance-underwriting cycle, not from HMO bean counters.

Meanwhile, HMOs sucked billions out of Medicare, then dropped seniors once the profits dried up. Rather than admit their world-class incompetence, the policymakers who pushed HMOs now want to shift the blame, and more of the health-cost burden, to working families and sick people.

What happens when you raise co-pays and force people into skimpier plans? Sick people don’t go to the doctor, and many skip essential medications. Some make it through on their own: The cough turns out to be a cold, not lung cancer; the stomachache is food poisoning, not appendicitis. But some don’t. Already, emergency-room doctors report seeing more patients who wait until their illness has advanced to stages previously seen only in the Third World.

And shifting costs onto patients is totally unnecessary for cost containment. Most other wealthy nations ï¿½ Sweden, Norway, Denmark, France, Germany, Canada and Australia ï¿½ control costs without significant co-payments or deductibles, while allowing patients a free choice of doctors.

Their secret? National health insurance. You make a health-care budget for the country as a whole. You cut out the HMO middlemen and strictly limit health-care bureaucracy to 2%-3% of costs. (We squander 25% on paperwork.) You negotiate fees with doctors and hospitals, and bargain hard for the best prices from the giant multinational drug companies. The savings on bureaucracy and corporate profits would allow us to fully cover everyone for what we’re now spending.

Upping costs for families and the sick would cause millions of casualties. National health insurance would cause just two: HMOs and obscene drug-company profits.

Ida Hellander, M.D., is executive director, and Don McCanne, M.D., director of Physicians for a National Health Program

Another quote of Uwe Reinhardt from the February 27 conference on "Bipartisan Paths to Expand Health Coverage"

“And I said this is the only issue (covering the uninsured) I actually take seriously. All the rest of American health policy to me, as you well know, is a joke or a source of humor. This one really is not.”

“… health insurance gives you financial protection. It protects you bankruptcy of families in the United States… And one may well ask what kind of society is it where if a family member gets stricken with cancer, the family also goes bankrupt with all the stress and indignity of that. You cannot travel in France as an American and hold up your head, that we allow this sort of thing to happen. Someone has a child sick with cancer and the family goes broke. That is uncivilized in the eyes of Europeans and Canadians, and in the eyes of many Americans, most of us here included.”

The transcript of the conference is available at:
http://www.kaisernetwork.org/admin/healthcast/uploaded_files/kff022701a.pdf

Another quote of Uwe Reinhardt from the February 27 conference on “Bipartisan Paths to Expand Health Coverage”

The transcript of the conference is available at:
http://www.kaisernetwork.org/admin/healthcast/uploaded_files/kff022701a.pdf

The State of Health Insurance in California: Recent Trends, Future Prospects

UCLA Center for Health Policy Research
March 2001

by E. Richard Brown, PhD, Ninez Ponce, PhD, & Thomas Rice, PhD

“The state’s strong economic growth has enabled more families and individuals to obtain job-based insurance, resulting in a lower uninsured rate for the first time in several years. But the future prospects for this trend continuing seem uncertain at best. The economy
appears to be cooling, accelerated in California by the energy crisis – a trend that may be undermining the major factor in the state’s recently expanding coverage. And there is clear evidence that health insurance premiums are going to rise by double digits in 2001, making health insurance coverage less affordable at the very time when the labor
market is likely to slacken. When the economy does contract and health insurance costs rise, more Californians will almost certainly become uninsured.”

“In the longer run, California and the nation need to extend to all residents affordable coverage that provides good access to high quality health care that enhances people’s health. Although there are costs to ensuring that all residents have coverage, there are great costs associated with a large portion of our population remaining uninsured – lost earnings, lost school days, lost potential, and lost life.”

The full report is available at:
http://www.healthpolicy.ucla.edu/FullReport.html

Bipartisan Paths to Expand Health Coverage: Prospects for 2001 and Beyond

February 27, 2001
Washington, DC

Gail Wilensky:

“… it doesn’t ignore the fact that making people more cost conscious, which I think Congressman McCrery, you ought to make sure is in every paragraph that you talk about your healthcare plan; it’s a very important issue that will drive change.”

Uwe Reinhardt:

“Whenever I hear cost-consciousness as an economist I ask myself — I read yesterday in ‘The Wall Street Journal’ that Paul O’Neill’s income last year was $56 million the Treasury’s Secretary. Now I ask myself, how do I want him to be cost conscious about healthcare? How do I do
that when the guy’s annual income is $56 million; what am I gonna charge, am I gonna charge 20 million for the bypass? Because that’s roughly what it would be to put him on power with the waitress, so when you say you want to make people more cost conscious you really should
speak plain English. You want to ration by income class.”

“So when you talk about cost consciousness, you’re really saying the lower middle class should get less healthcare, and maybe they should, but say so.”

A Conservative Convert To Socialized Medicine by David Burgess

http://www.iht.com/articles/12871.html
http://www.commondreams.org/views01/0309-03.htm

PARIS – What’s the old joke? A conservative is a liberal who has just been mugged? Well, I am a conservative who has just been “mugged” by the socialized French health system, and, to my astonishment, I’m a believer. I have lived in France for nearly 19 years. Until about two years ago I was very cross about the amount I had to pay in taxes and in “social charges,” which finance the medical system, in which a pauper gets about the same medical care as a millionaire.

Let me take you quickly through my experience of being gravely ill in France.

For 20 years or so I had been a gobbler of antacids in one form or another, and in October 1998 I began to have trouble swallowing. I assumed it was an ulcer and took the appropriate medicine, but it didn’t go away. At the end of the year I was referred to a doctor who performed an endoscopy, in which, under anesthetic, a tube is inserted in the throat, allowing the doctor to have a look around and do a biopsy. He found that I had a malignant tumor at the base of my esophagus, where it meets the stomach, that had virtually closed the passage.

The doctor lost no time. He called my local hospital, which fortunately was one of the four in the Paris area that could do the operation that I needed, and reserved me a bed for the next day.

At the hospital, within an hour or two of my arrival, my surgeon, who has the title of professor, as he is head of the department of digestive surgery, paid me a visit. He outlined the operation I would have, and, in answer to my question, said the mortality rate for the kind of cancer that I had was about 85 percent within the first three years. But, he said, “Don’t worry, we’re going to beat it.”

Foolishly, I suppose, I believed him. Now, more than two years later, I still do; he has lots of charisma.

After my operation, which lasted more than 10 hours, I was in the hospital another three weeks, then home, where a nurse came by each day to give me the shots I needed, check and dress my surgical wounds and make sure that I wasn’t losing weight. Then back to the hospital for three days of chemotherapy every three weeks – four treatments in all.

I was operated on in mid-January 1999, went back to work part-time in mid-May, and returned to work full-time in September. (For those of you who are less than enthusiastic at the prospect of going to work in the morning, there is nothing like a serious illness to adjust your outlook.) Why does socialized medicine seem to work in some places and be a disaster elsewhere? Anyone who reads the British press is assaulted daily with tales of how cancer patients have to wait months for an appointment with an oncologist, or a candidate for a hip or knee replacement has to wait years. In France, such delays can be measured in days or, at most, weeks.

Why the difference? Take a deep breath. These are the numbers, provided by the French and British health ministries and translated into dollars (bear in mind that Britain and France have roughly the same populations). French total expenditure on health in 1999 was $109.5 billion. In Britain it was about $78.02 billion. Per capita, it was $1,800 in France and $1,312 in Britain. As a percentage of the gross domestic product, it was 8.5 percent in France and 5.9 percent in Britain.

I should mention that I am not yet out of the woods. My markers, blood tests that indicate the presence of cancer, started to rise last summer, and since the end of September I have again been in chemotherapy. The markers have dropped consistently, showing that the therapy is working. The treatment is debilitating. I expect to resume work part-time from April or May until the summer vacation, and full-time thereafter.

Last summer, I asked a friend of mine, a dean at a medical school in New England, what the cost of my care would have been in the United States. “About $700,000,” she said. I haven’t seen a bill. Well, that is not quite true. I got a bill for 43 francs (about $6.50). I’m not sure what it was for, but I paid it.

I no longer complain about my taxes.

Employers Say They Lack Data on Quality of Health Care

The Washington Post
March 8, 2001
by Bill Brubaker

Susan Pisano, a vice-president of the American Association of Health Plans:

“There is quite a lot of information that is available about the performance of America’s health plans.”

Comment: Unfortunately, most of the information currently available about the quality of health plans is of almost no value.

The majority of health plans are network model plans which contract with the health care providers at large. When quality parameters of different plans are measured, the same overlapping group of providers is being measured. When the same physician is being evaluated by each of the many plans with which he or she contracts, differences in sampling results have virtually no meaning.

The quality measurements designed by the health plan industry are usually designed to produce positive marketing messages. Patient satisfaction surveys are subject to the bias that, “Managed care is terrible overall, but I am very satisfied with my doctor and my health plan.”

Measurements of rates of favorable interventions, such as percentages of pap smears or retinal examinations in diabetics, have demonstrated that integrated staff model plans can improve the levels of these parameters
when compared to the loosely structured and overlapping network models. A deficiency of this approach is that providers are aware of the relatively few parameters that will be measured. The quality improvement programs are then often directed primarily to these very limited areas.

Other significant efforts are being made to improve quality assessment, and we will have better measurements. However, there is a much greater need to design a system that will promote quality in the first place. Although we have had many technological advances, measurements have shown that they have not had much impact in improving outcomes, compared to their cost, primarily because our system has been incapable determining and promoting the optimum use of this technology. Standards of practice vary tremendously between communities and between individual practitioners. Integrated staff model organizations have demonstrated that better standards of practice can be recognized and encouraged, and
errors, such as incompatible medications, can be greatly reduced. In this modern age of information technology we now have the opportunity to integrate our entire health care system. Structural design is the key
to quality. With a rational system in place, quality assessment can be elevated to a more noble purpose, and that is to provide a basis for continuing improvement in our health care structure.

As long as we continue with our fragmented health care system, quality improvement will remain only a dream. Let’s defragment our system by starting with a foundation of a publicly administered, universal risk pool. We have the resources for high quality care for everyone. Let’s start using our resources wisely.

Those who know how government works will reject universal coverage

American Medical News
Published by the American Medical Association
March 12, 2001
Letters to the Editor

Daniel Joyce, M.D., Niles, Mich.:

“… when the government provides something like health insurance to everyone, people tend to look at it as their right to health insurance versus appreciating the wonderful gift that is being provided to them. I see this all the time in the government programs. The people who are provided these wonderful things are often very ungrateful. If charitable organizations provide the same assistance out of the generosity of their heart, people then realize that it isn’t their right and appreciate the kindness as it should be appreciated.”

Comment: The American Medical Association professes to serve the public interest in health care matters. Its leadership could do that now by instructing its members on the basic fundamentals of health policy. But before that is possible, the leaders themselves will have to take a crash course in health policy to learn why tax credits and medical
savings accounts, which they support, will never serve the public interest. If the AMA would shift to advocating for patients instead of physicians, the organization would find that they would be supporting a practice environment that is in the best interests of both patients and physicians.

Following are the comments of Tom Mainor, pastor of the Shady Grove Presbyterian Church in Memphis, TN. He has served the Presbyterian Church USA in health care ministries and has a very strong background in health policy.

Needed: clarification of the nature of single payer approaches

Don, et. al.

I am convinced that the frequent caricature of the single payer health care financing as “government-run medicine” needs to be challenged on every level. It side-tracks and mis-describes the effect of a single payer approach.

For example, single payer approaches can involve multiple not-for-profit payer sources, such as Medicare/Medicaid, Blue Cross/Blue Shield, Tenn Care, and such efforts as the Mayo Clinic, Kaiser Permanente, Seattle Puget Sound and other regional or national efforts.

Using a regional budgeting approach, e.g. looking at the kind of services delivered by local and regional hospitals, a budget providing full funding for hospitals, minus the costs normally associated with collection and financing, would provide first rate care for a predetermined population. The hospitals would know what they would receive, receive incremental payments monthly for providing services, and thus be able to better serve the populations they have already been serving. The savings in billing costs and administrative costs could be re-directed into preventive health strategies…

Getting too detailed, but, for example, our MED, the regional hospital here–which not only serves western Tennessee, but also eastern Arkansas, northern Mississippi, the boot heel of Missouri and western KY–is frequently required to take in patients from those other jurisdictions in spite of the knowledge that, say, Mississippi will not reimburse the MED, the University of Tennessee or Tenn Care for the care. Because we are on the Mississippi, I-40/I-55, as well as being a major distribution center, we also have persons being served who come from far away. With regional funding, based upon patient load and acuity, such hospitals could render far better services.

My contention is that we spend far too much for health care without organizing it in such a way as to make the dollars make sense, health-wise. Regional strategies, tied in with revitalized health departments, NIH, the Centers for Disease Control, etc, would be
health-and-cost-effective. With the increase in global warming, the diseases such as West Nile Virus and expanding areas of malaria, AIDS, Ebola and others are going to require a much more effectively integrated health system to do the job that public health did in the early 1900s, in addition to providing the sophisticated technologies at reasonable prices.

We need to realize public profits on drugs that we helped fund, and the pharmaceutical industries charge excessively for. Brazil is an example, currently. The issue is also raising its head in southern Africa and else where.

Then, there is the fair return on investment on behalf of communities which have contributed the building of hospitals through a variety of means, including taxes. These are being bought up for a song by the health conglomerates to the detriment of many large and small community hospitals.

Health care is too important to the well-being of the nation to be left to the vagaries of the market place. It clearly does not increase services in places of greatest need. And the charges on advances in medical technology are outrageously high, and because of the paper trails created, there is rampant overcharging, duplication of charges and other waste.

I could go on. Sorry, didn’t mean to get wound up. But, clearly, there are many options out there beyond the current waste of precious lives and resources. Doctors ought to be able to treat patients according to medical standards, with hospital and peer review. Not second-guessed by someone at a health maintenance organization who gets rewarded for denial of care…

Thanks for the ventilation opportunity…

Tom Mainor

Subject: John Foster responds to John Gilman

Even the best and brightest don’t really get the skinny!

Spending more Federal dollars to “BUY SERVICES” simply invites drug companies and other vendors to get richer faster. Their prices will all go up.

But not in Medicare where the rules have evolved nicely over the many years, and cost increases have been moderate..

Only a single payer can control the cost of services, which is why, for example, Canadians get cheaper drugs.

Extending Medicare INCREMENTALLY would be a rational way towards a universal plan.

JOHN T. FOSTER(RETIRED ADMINISTRATOR)
Keene, NH

Subject: Susan Swan comments

Susan Swan, MSN, MPH, a Canadian, and currently a nurse practitioner in Atlanta, comments:

Re: Comments of Tom Mainor

In addition to Rev. Mainor’s comments I think it should be pointed out that the single payer system in Canada is not “government run”. Doctors are independent, fee for service practitioners. Hospitals are independently owned and operated – ie: we have Catholic hospitals, community hospitals, university hospitals etc. They are run by
voluntary boards of directors, not political appointee’s. Lastly, we have to ask the question “Why is the government inherently incompetent”? This “incompetence” arises from the nature of bureaucracy. Any large, multi-layered institution is going to be
inefficient, government or “private”. In fact, it is safe to say that most government bureaucracies pale in comparision to Blue Cross-Blue Choice’s or Kaiser Permanente’s of the world. The American myth that profit driven organizations are by nature well-oiled, finely tuned model’s of efficiency must be must be dispensed with. Every bit of evidence points to the contrary. Profits don’t influence efficiency and
have no place in healthcare.

Response of John Gilman, M.D., Health Policy Advisor to Senator Paul Wellstone:

“With this background, what are the current proposed solutions? Any form of universal, comprehensive reform is totally off the table.” — Don McCanne

Come on Don. Affordable universal health care may be off most of Washington’s radar screens, but not ours. Senator Wellstone, Congresswoman Tammy Baldwin, and Congressman David Obey (along with Reps. Conyers, Baca, Carson, and Filner) introduced the Health Security for All Americans Act last year and will reintroduce it again this Spring. This bill would assure that all Americans have affordable comprehensive health care within 5 years of its enactment. It is supported by APHA, Families USA, AMSA, and SEIU. No, it is not a national single payer bill; but it does set the national parameters that states must meet in terms of benefits, quality and affordability, and it provides matching federal funds (on average 70% federal, 30% state) to allow states to adopt the system of their choice, including single payer. This is a practical and principled approach that is capable of putting universal health care back on the table. It deserves attention
and support from anyone concerned about reaching universal coverage.

The Washington Post
March 6, 2001
“Bush Urges Congress to Revamp Medicare”

President George W. Bush:

“I believe the framework for a bipartisan consensus about how to make sure the Medicare system fulfills its promise is at hand, and we’ve got a lot of work to do.”

Comment: Medicare remains under intense attack. The Medicare “modernization” proposal of President Bush and the “bipartisan,” anti-government members of Congress is simply a proposal to shift more
of the costs of Medicare away from the tax system and onto the Medicare beneficiaries. The current out-of-pocket expenses already impair access to care for our moderately low income retired and disabled population, simply because of lack of affordability. The “premium support” or “competitive premium” proposal will compound this problem for these lower income individuals. We need to protect and improve Medicare. We should not support the “generosity” of our leaders who would like to use Medicare to provide additional grist for the middlemen vultures of the health plans. We need to remind our leaders that vultures don’t feed on
grist, they feed on carcasses.

Don McCanne
mccanne1@home.com

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