PNHP

Universal Free Insurance? Yes! Stripped Down? No!

Universal Free Insurance? Yes! Stripped Down? No!

Summary: The new book “We’ve Got You Covered” offers a laudable prescription for the US: universal free insurance for primary, specialty, and hospital care. However, its vision for basic (“bare bones”) coverage unnecessarily undermines the potential for high quality care for all.

We’ve Got You Covered: Rebooting American Health Care, Portfolio, 2023, by Liran Einav and Amy Finkelstein

How can we fix the US health-care system?

Requiring coverage did not get us to universal coverage. We must therefore provide it. Automatically. Only then will we achieve universal coverage. This is why basic coverage must be taxpayer financed. Charging premiums for basic coverage is at odds with providing that coverage automatically.

Any medical care that is included in basic coverage must be completely free to the patient. If not, the lesson is clear: we’ll end up back in the same mess of trying – and not fully succeeding – to come to the aid of patients who cannot afford the required payments for that basic coverage. We’ve described what basic coverage must do – it must be provided automatically, with no patient payments for covered services.

Basic coverage must systematically cover all essential medical care for the critically ill. For all conditions. Basic coverage must also include primary and preventive care for patients who are not yet critically ill.

The big picture is clear. Basic coverage should include primary and preventive care, specialist, outpatient, emergency room, and hospital care. Once we go beyond that high-level description, there will inevitably be a multitude of gray areas. There are many aspects of medical care that can be excluded from basic coverage while still fulfilling our social contract: infertility treatment, dental care, vision care, physiotherapy, various forms of long-term care, and the list goes on and on. These are hard choices, But they are just that – choices.

For the thirty million Americans without formal insurance, basic coverage would be an improvement. It would provide reliable coverage of major medical needs without any costs to the patient – or attempts to collect costs from them. For the seventy million low-income Americans with Medicaid, basic coverage would be similar to the coverage they already have.

For the remaining two-thirds of Americans, basic coverage would likely be worse on many – although not all – dimensions. We suspect that many of them would purchase supplementary insurance. This includes the one hundred fifty million Americans who have private health insurance and the sixty-five million elderly and disabled Americans with Medicare. For them, basic coverage would mean longer wait times, for example – along the lines of what those covered by Medicaid or the Veterans Affairs experience – and less well-apportioned waiting areas and hospital rooms.

The coverage we do have is a universal mess. The only option is to tear down the current “system” and rebuild it from the ground up.

Comment:

By Don McCanne, M.D.

In their book, “We’ve Got You Covered,” Liran Einav and Amy Finkelstein have provided a very valuable contribution to the dialogue on healthcare reform in the United States. They have described many of the defects in our very expensive yet highly dysfunctional financing system that result in financial hardship for so many while leaving tens of millions without adequate coverage for care.

In their proposal for reform, they do advocate for a few policies that would be essential in a system of healthcare justice for all. They would include absolutely everyone automatically without the necessity of requiring an insurance premium but rather funding the covered system with a progressive income tax. They would eliminate deductibles and co-payments to make healthcare free on access. They would include primary and preventive care for everyone.

In their policy proposals, they do make one profoundly deficient recommendation. They would propose a basic set of benefits for everyone that would be similar to the current coverage under Medicaid, but, for two-thirds of Americans, coverage would be worse than people now receive under private insurance or Medicare. Basically this would be much worse than the proposed single payer Medicare for All model because it would be Medicaid for All (though the authors reject this label because individuals could purchase upgrades in coverage).

What would be wrong with this? Their intent is to make healthcare affordable for everyone by eliminating premiums, deductibles, and copayments, yet most individuals would be faced with the potential for large out-of-pocket costs unless they did buy a major upgrade in coverage, but then they would have to pay for that. This means that the private insurance industry would continue in its role of diverting billions of our healthcare dollars to its own pecuniary interests with the inevitable high costs and consequent impaired outcomes that we are seeing today.

Also, the healthcare delivery system would likely continue to try to avoid providing care to the sector that was structured like the underfunded Medicaid beneficiaries, and would cater to the more affluent sector that was insured with these supplementary plans, creating a two-tiered or multi-tiered delivery system: basement ward with budget drugs for the basic plan and penthouse medical suite with the million dollar miracle drugs for the affluent. Besides, how many physicians would decline to see patients covered only by the basic plan, accepting only patients with comprehensive supplemental coverage, just as they now decline Medicaid patients?

I’d like to go back a few decades and give a different definition of what basic care is. My brother, Monte, and I practiced primary care in South Orange County. (In 1995, the Los Angeles Times published a human interest story on our practice.) We saw routine illnesses, minor trauma, employment physicals, family planning, uncomplicated obstetrics, and other routine problems you would expect, referring more serious problems to the specialists, or to specialized centers. We were paid by private insurance, Medicaid, Medicare, cash, and often not at all, but we basically just provided care as it was needed, even to the undocumented, largely ignoring the payment side of the practice. Primary care with interaction with the rest of the healthcare delivery system is what I would suggest is basic care and is what should be covered by a single payer Medicare for All system. This approach really worked well for our patients. Rather than being care that is stripped down, like the authors suggest, it is just reasonable routine care that we should be giving, rejecting extravagances such as the building of luxurious penthouse medical suites, or the production of new drugs designed to sell for a million dollars.

You might wonder what happened to our practice. Employer sponsored plans converted to managed care and were not interested in including solo practitioners like my brother and me in their panels. MediCal, a very large part of our practice, was privatized and our patients were sent to contracting groups, including our fairly large obstetrical (midwifery) practice. Eventually, Medicare privatization, especially Medicare Advantage plans, also excluded our practice from their panels, though that was about the time we retired. Based on this, I would say that we do not want to look for the insurance industry to provide us with coverage for basic care, as I have defined it.

We just need to reinforce the delivery system, staff it, provide the care that people need, and use public funding to finance the system. We are spending enough now to do that. Truly comprehensive basic care for everyone! Medicare for All!

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Functioning Democracy: A Prerequisite for Single Payer

Comment:

By Jim Kahn, M.D., M.P.H.

On Tuesday, a Washington DC grand jury handed down four indictments of former President Donald J. Trump for his efforts to overturn the results of the 2020 election. This reflects the investigation led by special prosecutor Jack Smith, guided by the Congressional Jan. 6 hearings. It is a historic moment – holding to account a US president whose conspiratorial actions threatened a pillar of democracy: that the vote should determine the election outcome.

In my view, it is far more than symbolic. Many voters in the general presidential election will be swayed by the evidence of Trump’s malfeasance presented at trial, and by convictions. This will shift votes to the Democratic candidate, likely Joe Biden. Thus, the pursuit of justice may be a deciding factor for who is the next president, and by extension the country’s future.

The implications for single payer are also vast. A Trump presidency would be a large step toward fascism, with dire consequences for progressive political action. Our political challenges in achieving single payer are well-acknowledged. Indeed, many Democratic leaders oppose single payer. But at least in a functioning democracy we have the freedom to work toward change, to translate broad popular support for public funding of universal insurance into legislative action. And thus to transform our health system.

As discussed previously in HJM, I believe that single payer is fundamentally democracy-enhancing. It fosters our highest democratic values– e.g., health, freedom, equality, and community. Our fragmented and profit-oriented system, on the other hand, deepens inequality and causes countless unnecessary deaths.

What a great day indeed when the tenets of democracy are enhanced, increasing the likelihood that the single payer movement can in the future return the favor. It’s the perfect healthy feedback loop.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

The problem with upcoding under Medicare Advantage

By Julie Pease, M.D.
Portland (Maine) Press Herald, Letters, August 1, 2023

On July 30, 1965, President Johnson signed Medicare into law, allowing millions of seniors to access health care. On the occasion of Medicare’s 58th birthday, Medicare is under threat. Efforts to privatize Medicare are eroding this landmark program, allowing the greed of a few to threaten the well-being of us all.

The Medicare Advantage program is diverting billions of dollars a year to corporate profiteering. Through the process of “upcoding” (making patients look sicker than they actually are), insurance corporations have been overpaid by taxpayers to the tune of tens of billions of dollars.

Here’s how “upcoding” happens: I am 66 years old, in good health. I am enrolled in a Medicare Advantage plan. I am getting several calls each month from the insurance company, urging me to take advantage of a “free” health screening. The purpose of this home health visit is not to provide health care. Rather, its purpose is to “upcode”: to add irrelevant diagnoses to my medical history just to increase the insurance company’s payout.

President Biden has taken some steps to try to rein in the practice of upcoding, but he can do more. Therefore, on the occasion of Medicare’s 58th birthday, I am encouraging President Biden to take executive action to prohibit upcoding, and to stop overpayments to Medicare Advantage. The tax dollars saved can be used to improve traditional Medicare – eliminating deductibles and expanding coverage to include dental, vision and hearing – so that we have the freedom to just choose Medicare, not a privatized plan.

https://pressherald.com…

Dr. George Bohmfalk responds to single-payer criticism

By George Bohmfalk, M.D.
California Association of Neurological Surgeons, Newsletter, August 2023

Letter to the Editor:

Reading Dr. DiGiorgio’s essays on single-payer healthcare in the previous two issues, I am pleased that he agrees that universal coverage is a worthy goal and that the current system is not praiseworthy. And I’m happy that he knows a prominent spine surgeon who favors a single-payer system. Those are great beginnings!

As a retired (Texas) community neurosurgeon with many patients who struggled to obtain or pay for needed care, I realized many years ago that we desperately need a better system. Over the past several years, I’ve become convinced that the only viable option is single-payer healthcare. We don’t need universal Medicare, as it’s currently designed, for many reasons. The solution is improved Medicare for All, as described in bills currently before Congress (H.R.3421 and S.1655).

Dr. DiGiorgio criticizes the proposal for a state-level single-payer system in California; I agree with many of his points. While states can be the laboratories for many ideas, there are many practical reasons why single-payer systems are likely to fail in individual states. As more and more Americans cannot access or pay for needed healthcare, the issue is approaching a national crisis. Only a national solution will suffice.

Space does not allow me to address every issue that concerns Dr. DiGiorgio, but I’ll touch on a few:

  • Like most critics of single-payer healthcare, he worries that we can’t afford it. In fact, we’re already paying more than a comprehensive, universal system would cost. The silver bullet is that around 34% of every healthcare dollar goes to administrative overhead resulting from our hundreds of insurance companies and thousands of plans. Beyond the multi-million dollar incomes of insurance execs, we waste billions on preauthorizations, denials, appeals, and other paper shuffling that do not exist in countries with rational systems. While there’s little chance of our ever-matching Taiwan’s 1.6% overhead, we should be able to halve ours with single-payer, saving enough to cover everyone comprehensively. We can easily afford this.
  • While several countries he mentions have multi-payer systems with private and competitive insurance companies, those companies are not-for-profit and highly regulated. They must provide identical coverage, similar to our for-profit “Medigap” supplemental policies. The overhead in these systems is several percent higher than in single-payer systems because of this multi-payer administrative duplication, advertising, and other expenses. Adopting such a system seems to have no advantage, only higher costs.
  • Using the Medicare framework as a basis for single-payer reimbursements does not mean that the dollar amounts would be what they currently are, only that this functional framework is the logical existing system to use rather than creating one from scratch. No one has suggested using current Medicare rates, which everyone understands are artificially low as private payers subsidize them. It’s disingenuous to assume that rates would be set so low as to cause needed physicians to close their practices. While it is likely that specialist incomes may decrease slightly, it’s reliably certain that primary care incomes will increase, as that’s the greatest national need. Specialists need not worry about being able to support their families, even with modest income reductions. The general public is not likely to be very sympathetic to complaints from neurosurgeons who earn over $900,000 annually. I imagine we could all scrape by on just a bit less in exchange for providing healthcare to everyone.
  • Regarding wait times and rationing, Dr. DiGiorgio’s mention of Canadians coming to the U.S. for healthcare ignores the hundreds of thousands of Americans who travel to other  countries for less expensive and often higher-quality care. We cruelly ration healthcare now based on the ability to pay, with endless wait times and hundreds of thousands of families filing for bankruptcy each year, mostly due to medical expenses, most of whom have some insurance. Wait times and rationing are functions of how well a system is funded. As the wealthiest nation on earth, the U.S. has enough capacity to fund our system to avoid such rationing.
  • Finally, Dr. DiGiorgio worries about who will make the rules in a single-payer system. Does he not worry about who makes the inconsistent rules now – faceless, unaccountable clerks in multiple for-profit insurance companies? A great book, Deadly Spin, gives a chilling look inside Cigna and other insurers’ operations. Single-payer rules will be made by panels of physicians, including surgical specialists, not faceless government bureaucrats. His charming notion that decisions would be best made between a physician and a patient toting a bag of money ignores so much. Namely, the powerful incentive for proceduralists to recommend procedures and that very few patients have a bag of money to offer. Policies and guidelines must be set, and panels of accountable medical experts are preferable to heavy-handed, unaccountable, profit-driven insurance company employees.

I recently heard a young physician say, “I went into medicine to help patients, not drive them into bankruptcy.” That’s what we too often do today in our dysfunctional system. I encourage you to learn more about single-payer than you can through short essays and invite you, once informed, to criticize single-payer proposals. The very readable book Medicare for All: A Citizen’s Guide is a great start. Upon being enlightened, I hope you’ll join me and thousands of other physicians in advocating for Medicare for All by joining PNHP (Physicians for a National Health Program).

Dr. George Bohmfalk is the chair of Health Care Justice — NC, the Charlotte, N.C. chapter of Physicians for a National Health Program.

https://cans1.org…

Round-up, Pause for Reflection, & Makeover

Greetings HJM readers – I’m using a different format today.

#1 – Round-up. Plenty of recent news items exemplify the usual rocky functioning of US health care. Here’s a sampling:

Medicaid: Eligibility assessment post-COVID proceeds apace, with 4 million disenrolled so far, widely variable by state (Texas is highest). CMS has asked some states to pause due to problems with the eligibility redetermination. One company is profits very well with this process. Meantime, the DHHS Inspector General found that prior authorization denial rates are especially high in Medicaid, which is 70% under managed care. So, in summary, it’s harder to stay on Medicaid and on Medicaid harder to get care, and private companies profit in the process.

Medicare: Risk selection of healthier individuals (within diagnosis) by Medicare Advantage plans yields 11% lower medical costs than enrollees in traditional fee-for-service Medicare. Higher diagnostic coding intensity adds 6%. The total cost difference of 17% represents $70 billion per year, or $1500 per MA enrollee. Another estimate comes in at 20%. And artificial intelligence (AI) is being misused to arbitrarily limit care. Meantime, drug companies are suing to stop price negotiations in the Inflation Reduction act. Who profits? MA plans and Pharma, of course.

Patients: Administrative barriers to getting care can be very dangerous and extraordinarily expensive. This brings to life the stats — individuals spend 8 hours per month coordinating health care, and one in four insured patients delay or forego care due to administrative hurdles. Medical debt and bankruptcy are pervasive.

Insurers: Profits galore, billions and billions. Definitively covered in Wendell Potter’s HEALTH CARE un-covered. Largely due to Medicare Advantage and Medicaid managed care (see above).

Hospitals: Dubious hospital billing practices are being challenged, as hospital profits grow. Meantime, many rural hospitals suffer existential threats from low private insurer payment rates.

There’s more … there’s always more; our fragmented and dysfunctional insurance approach can be counted on to generate stories of care denied coupled with profits maximized. But enough for today.

#2 – Pause for Reflection

Reading a terrific book, The Persuaders: At the Front Lines of the Fight for Hearts, Minds, and Democracy by Anand Giridharadas. For those committed to progressive policy change, it’s revelatory – laying out vividly what persuasive strategies work. I’m contemplating how the insights can bolster single payer advocacy.

I’m also busy this summer with family travel and cataract / glaucoma surgery (luckily, I have very good insurance, and terrific ophthalmologists).

So, HJM posts will slow.

#3 – Makeover

The HJM website will be reborn later this year in much grander fashion. It will still have all the blog posts, plus some from Don’s prior “quote of the day”, with an advanced search capacity. Plus a glossary and FAQs, as well as visuals and resources for activism. Some short videos too. Stay tuned. If you want to be a “beta tester”, let me know.

Hope you’re having a great summer. – JGK (Dr. Jim Kahn)

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Dr. Marvin Malek: Medicaid unwinding: a summer of insitutionalized cruelty

It’s absurd to punish people for returning to the workforce by providing them with that uniquely American version of health insurance: The kind that works well — unless you actually get sick.

By Marvin Malek, M.D.
VTDigger.com, July 13, 2023

Thanks to Dr. Jane Katz Field for pointing out some of the implications of the Medicaid “unwinding” precipitated by the end of the Covid-related public health emergency.

During the emergency, Medicaid programs around the country were prohibited from disenrolling anyone already in the Medicaid program. With the end of the public health emergency, Medicaid eligibility determinations have resumed, and millions of Americans — including thousands of Vermonters — will lose their coverage.

Dr. Katz Field points out that many individuals who lose coverage actually are eligible, but are unable to properly collect and file the information.

But that doesn’t apply to millions of others. These individuals have been able to increase their earnings, and if their incomes rose to 38% above the poverty level or more, the letter will arrive in the mail: “Your Medicaid coverage is terminated.”

The best option for these individuals is the Obamacare exchanges: For a couple earning $50,000 annually — hardly swimming in money — the average Obamacare policy’s premiums add up to $2,970 annually. That wouldn’t be so bad, but before their coverage kicks in, the deductible will average $3,200.

So, aside from some preventive care, you have to spend $6,170 before you can actually use the coverage. And if it turns out that you require a lot of care, you will face ongoing expenses until you’ve reached $18,200. It’s easy to see why so many people simply choose to take a chance and go without any coverage.

For generations, Americans have prided themselves on our work ethic. If that’s the case, then why are we punishing people who return to the workforce by taking away affordable health coverage?

The Medicaid unwinding is expensive: Tens of thousands of employees of state governments around the country will spend uncounted hours poring over applications, and making their declarations: You can remain in, you’re out, or bring in more info. The cost of this institutionalized cruelty will total several hundred millions of dollars nationally.

How about if we try something new and different in the U.S.? How about if we redeploy these government workers and have them say yes to everyone? Enroll every single American in an improved Medicare with minimal copays, and, once and for all, put an end to this organized cruelty that passes for a health care system?

It’s absurd to punish people for returning to the workforce by providing them with that uniquely American version of health insurance: The kind that works well — unless you actually get sick.

There has never been a reason why Americans wait until age 65 to enroll in Medicare. Let’s start enrolling all Americans at birth.

This commentary is by Dr. Marvin Malek, an internist and member of the executive committee of Vermont Physicians for a National Health Program.

https://vtdigger.org…

NY Times Tantalizingly Close On Health Care Financing Issues

Summary: This week, a profile of challenges facing the UK NHS and an op-ed proposing universal coverage in the US got so many issues right. But they critically missed on pivotal pillars of successful health care financing: adequate funding and comprehensiveness of coverage.

A National Treasure, Tarnished: Can Britain Fix Its Health Service?, New York Times, July 16, 2023, by Mark Landler

As it turns 75 this month, the N.H.S., a proud symbol of Britain’s welfare state, is in the deepest crisis of its history: flooded by aging, enfeebled patients; starved of investment in equipment and facilities; and understaffed by doctors and nurses, many of whom are so burned out that they are either joining strikes or leaving for jobs abroad. …

Health care spending rose by an average of less than 2 percent a year from 2010 to 2019, compared with 5.1 percent from 1998 to 2008. Britain spent less a year per person on health care than the wealthiest European Union countries during the decade of austerity, and now has fewer doctors and hospital beds per capita than its European neighbors. Its capital investment lagged the bloc’s average by $41 billion, according to the Health Foundation, which tracks the industry.

We’re Already Paying for Universal Health Care. Why Don’t We Have It?, New York Times, July 18, 2023, by Liran Einav and Amy Finkelstein

There is no shortage of proposals for health insurance reform, and they all miss the point. They invariably focus on the nearly 30 million Americans who lack insurance at any given time. But the coverage for the many more Americans who are fortunate enough to have insurance is deeply flawed.

Health insurance is supposed to provide financial protection against the medical costs of poor health. Yet many insured people still face the risk of enormous medical bills for their “covered” care. A team of researchers estimated that as of mid-2020, collections agencies held $140 billion in unpaid medical bills, reflecting care delivered before the Covid-19 pandemic. To put that number in perspective, that’s more than the amount held by collection agencies for all other consumer debt from nonmedical sources combined. As economists who study health insurance, what we found really shocking was our calculation that three-fifths of that debt was incurred by households with health insurance.

What’s more, in any given month, about 11 percent of Americans younger than 65 are uninsured. But more than twice that number — one in four — will be uninsured for at least some time over a two-year period. Many more face the constant danger of losing their coverage. Perversely, health insurance — the very purpose of which is to provide a measure of stability in an uncertain world — is itself highly uncertain. And while the Affordable Care Act substantially reduced the share of Americans who are uninsured at a given time, we found that it did little to reduce the risk of insurance loss among the currently insured.

It’s tempting to think that incremental reforms could address these problems. For example, extend coverage to those who lack formal insurance. Make sure all insurance plans meet some minimum standards. Change the laws so that people don’t face the risk of losing their health insurance coverage when they get sick, when they get well (yes, that can happen) or when they change jobs, give birth or move.

But those incremental reforms won’t work. Over a half-century of such well-intentioned, piecemeal policies has made clear that continuing this approach represents the triumph of hope over experience, to borrow a description of second marriages commonly attributed to Oscar Wilde. …

Coverage needs to be free at the point of care — no co-pays or deductibles — because leaving patients on the hook for large medical costs is contrary to the purpose of insurance. A natural rejoinder is to go for small co-pays — a $5 co-pay for prescription drugs or $20 for a doctor visit — so that patients make more judicious choices about when to see a health care professional. Economists have preached the virtues of this approach for generations.

But it turns out there’s an important practical wrinkle with asking patients to pay even a very small amount for some of their universally covered care: There will always be people who can’t manage even modest co-pays. …

Finally, coverage must be basic because we are bound by the social contract to provide essential medical care, not a high-end experience. Those who can afford and want to can purchase supplemental coverage in a well-functioning market.

Keeping universal coverage basic will keep the cost to the taxpayer down as well. It’s true that as a share of its economy, the United States spends about twice as much on health care as other high-income countries. But in most other wealthy countries, this care is primarily financed by taxes, whereas only about half of U.S. health care spending is financed by taxes. For those of you following the math, half of twice as much is … well, the same amount of taxpayer-financed spending on health care as a share of the economy. In other words, U.S. taxes are already paying for the cost of universal basic coverage. Americans are just not getting it. They could be.

We … were struck — and humbled — to realize that at a high level, the key elements of our proposal are ones that every high-income country (and all but a few Canadian provinces) has embraced: guaranteed basic coverage and the option for people to purchase upgrades.

Comment:

By Jim Kahn, M.D., M.P.H. and Don McCanne, M.D.

The profile of UK NHS challenges is vivid and compelling in portraying the financial and associated operational and clinical problems plaguing that system. And, buried deep into the article, they do mention, in passing, the reason: “Health care spending rose by an average of less than 2 percent a year from 2010 to 2019, compared with 5.1 percent from 1998 to 2008.”

Let’s be appropriately blunt about this: The Conservative Party (the Tories) are intentionally bleeding the system, since 2010 putting the NHS on austerity footing. See HJM discussion here. Privatization is driving up family financial burdens and increasing mortality.

Thus, the crisis is intentional, policy- and politics-driven. The good news is that there is a good chance that the Tories will pay a steep political price for this evisceration of the popular NHS.

Turning to the US: Wow, Einav and Finkelstein got so much right. The health insurance system is fundamentally broken, unfixable. We need free, universal coverage. Just what we in the single payer movement have been saying for decades. Just what all other wealthy nations do.

But wait, “basic”? What does that mean? The article doesn’t elaborate (their book, to be released later this month, lays out some principles if not a definitive definition …).

We don’t like the sound of it. If “basic” means “access to under-funded and over-stretched providers,” that’s a recipe for a two-tiered system with divergent political interests, like we have for schools. If basic means excluding a subset of medical services, what would we comfortably omit? Not a good solution.

On the other hand, if “basic” means “everything necessary for quality medical care, and no fluff” that could be fine. As long as “medical care” includes inpatient, outpatient, drugs, mental health, dental, vision, medical equipment … everything medically indicated. That’s what other countries do: supplemental insurance is typically just a few percent of total health spending, for example providing access to private hospitals or specialists in a system with excellent public care. Long-term care should be in the “basic” category too.

We think it will be impossible to define “basic” narrowly in a way that is medically sound and doesn’t lead to operational and political fractures. The good news is, we don’t need to be stingy. Analyses of single payer demonstrate that we can provide standardized, comprehensive coverage and still save money for the system and for households.

Our colleague Ed Weisbart put it very well: “Two-tiered systems become as underfunded as the UK’s National Health Service, and outcomes degrade. We’re either all in this together, as a society that looks out for each other, or it’s Game of Thrones for us all.”

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Medicare for All Explained Podcast: Episode 101

Drowning, Guns, Healthcare, and What People Say

July 15, 2023

Podcast host Joe Sparks laments our inaction when it comes to preventable death—whether it be from drowning, gun violence or lack of health coverage.

Some say we don’t have a national health plan in the U.S., but Sparks says we do. “Our national health plan is, Oh well, some people just die from lack of health care.”

Additional episodes will be uploaded monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Fee-for-Time Payment for Physicians

Summary: Current physician payment rules are complex, time-consuming, and unfair to primary care providers. Success of universal coverage with single payer will require a simpler and fairer approach. Fee-for-Time is such a proposal.

Optimizing physician payment for a single-payer healthcare system, International Journal of Social Determinants of Health and Health Services, May 24, 2023, by Stephen B. Kemble and James G. Kahn

For independent physicians, we recommend that a U.S. single-payer system return to fee-for-service payment, replacing RBRVS [Resource-Based Relative Value Scale] with a time- and training-based system designed to be as administratively simple, objective, fair, and incentive-neutral as possible.

This approach would improve on RBRVS in multiple ways. It would base the value of physician services on two straightforward factors: time to complete the procedure (i.e., effort) and years of training (i.e., investment for needed expertise). Physician cognitive and procedural activity would be valued equally, given equal training duration. Practice expenses would be measured and fully covered. Payment would be delinked from extensive documentation, easing EHR demands and ending gaming to maximize income. Physicians would be paid for all time spent on patient care, including documentation, coordination, alternative care delivery modes such as telephonic and telehealth care, and administration. Total physician work and training would determine physician personal income. The physician’s interest in a clinical focus and the system’s interest in efficiency would align to minimize administrative burdens.

A simple example illustrates how this system might work. Assume 2,400 work hours in a year. A doctor who works more hours would earn more, and part-time practitioners would earn less. Practice expenses would be reimbursed at cost, so the work component determines physician personal income. Assume collective negotiations arrive at a base rate for medical school plus internship of $80/hour, plus $25/hour per added year of required training for the next 2 years and $15/hour for subsequent years. That would yield the following personal annual incomes by specialty:

Example Scenario of Fee-for-Time Physician Payment

The complications and gaming now seen with RBRVS-based fee-for-service for providers paired with data demands of capitated fiscal intermediaries, or with capitation of providers, would disappear with the FFT proposal. There would be no disincentive to treat sicker people (no risk pool to game), no risk adjustment of capitation rates and therefore no up-coding, no incentive to deny care inappropriately, no complicated problems with attribution, and no problematic benchmarking methods. In other words, the gaming of payment now seen with all forms of capitation would no longer be motivated or possible.

Conclusion: We believe fee-for-service payment of independent physicians using the Fee-for-Time proposal would be substantially simpler, more objective, fairer, and less costly to administer than fee-for-service based on RBRVS and Evaluation/Management coding or “value-based” payment (notably capitation) with pay-for-performance and risk adjustment. A universal single-payer system that paid hospitals with global budgeting and physicians based on time and expertise, with standardized salaries for employed physicians and time-based payment for independent physicians, would likely achieve greater administrative savings and lower total cost than any proposal based on existing Medicare fee-setting policies or shifting insurance risk onto doctors and hospitals. U.S. healthcare might then achieve cost-effectiveness comparable to all other advanced countries.

Comment:

By Steve Kemble, M.D. and Jim Kahn, M.D., M.P.H.

Moral injury and burnout are now pervasive among U.S. physicians. Doctors are disenchanted with private practice due to the complexities and frustrations of medical billing and collections, compounded by the distractions and documentation demands of “value-based payment.” These administrative tasks frustrate a focus on clinical care. Further, inappropriate interference in physician-patient decision-making by insurance plans is now widespread, via care denials and unreasonable formulary restrictions and prior authorization policies. Physicians are rapidly losing professional autonomy and control over their time.

When private practice becomes untenable, physicians are driven to sell their practices to large corporations, often for-profit and investor-owned, or private equity. They stay on as clinicians, soon discovering that accountability is to shareholders and investors who expect return on investment, even at the expense of the best interests of patients and providers.

For all these reasons a single-payer healthcare system is increasingly attractive to physicians.

However, many remain skeptical because they fear that a publicly funded system would mean “Medicare-as-we-know-it for all,” with complex billing rules including value-based payment. RBRVS has been complex and subject to gaming, detracting from clinical focus. They need assurances about the implications of single payer for medical practice – confidence of adequate income and a focus on clinical care.

Fee-for-Time payment (disclosure: we’re the authors) is a proposed answer to these questions. It greatly simplifies billing, fairly compensates physicians across specialty (notably, including primary care), and leaves providers the latitude to spend adequate time on patient care.

We encourage exploration of FFT, salary, and other simple, fair compensations systems under Medicare for All.

http://healthjusticemonitor.org…

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The Hazards of Private Equity

Summary: Dr. Glaucomflecken efficiently & amusingly skewers private equity. Plus a technical report …

How to Ace Your Private Equity Interview, 2-minute YouTube video, by Dr. Glaucomflecken

“Rapid maximal extraction of wealth by any means necessary.”

Comment:

By Jim Kahn, M.D., M.P.H.

Dr. Glaucomflecken, in his usual concise, elegant, and entertaining style, precisely captures how private equity ownership of provider practices threatens physician autonomy, evidence-based medicine, and patient welfare.

For those craving a more technical read today on the rapid expansion of private equity, market distortions, and higher costs, see a detailed report here.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Burnout is wearing doctors down. Could Medicare for All help?

By Brenda Gazzar
Code Wack Podcast, July 10, 2023

What are the most common concerns of doctors about Medicare for All? Would reforming America’s broken healthcare system improve – or worsen – doctors’ lives? How does the focus on corporate profits impact doctors’ experience? 

To find out, we spoke to Dr. David Leibowitz, hematologist-oncologist and past chair of Physicians for a National Health Program – California, a non-partisan voluntary organization that supports equitable access to high quality health care as a right to all people.

Transcript

Dispatcher: 911, what’s your emergency?

Caller: America’s healthcare system is broken and people are dying!

(ambulance siren)

Welcome to Code WACK!, where we shine a light on America’s callous healthcare system, how it hurts us and what we can do about it. I’m your host, Brenda Gazzar.

(music)

This time on Code WACK! What are doctors doing to reform America’s broken healthcare system? Why do some doctors support improved Medicare for All while others oppose it? To find out, we spoke to Dr. David Leibowitz, who conducted lab research for about 20 years before spending another 20 as a hematologist oncologist helping cancer patients. Now retired, Leibowitz fights for improved Medicare for All and is the past chairman of Physicians for a National Health Program-California, a nonpartisan voluntary organization that supports equitable access to high quality health care as a right to all people.

Welcome back to Code WACK!, Dr. Leibowitz.

Leibowitz: Thank you. It’s a pleasure to be here.

Q: As you know, in early 2022, Gov. Gavin Newsom’s Healthy California for All Commission made a strong case for a California Medicare-for-All program. What do you think are the biggest concerns some doctors have about adopting Medicare for All?

Leibowitz: So, I think as would be true for most people, physicians are concerned about their income and probably income and the freedom to practice the way they would like to practice and they’re worried that both of those would disappear. Part of this relates to the fact that more and more doctors are employed rather than independent, so that even now doctors’ freedom in terms of how they treat patients is not as great as it once was because companies that want to make money would like to have doctors practice in a way that is less expensive.

Then it, you know, in terms of income, since it would be a totally new system, people are worried that their income would be lower and part of that relates to the current reimbursement cuz our system is an enormous mess and reimbursement rates are different between private health insurance – employer-sponsored private health insurance, Medicare, and then Medicaid and Medicare and Medicaid have always reimbursed less than private insurance and Medicaid is quite low.

Medicare is kind of in between the two and the private insurers have been tending to try to lower their reimbursements towards Medicare, however that would turn out, that’s one of the things doctors worry about. Probably the best comparison we have would be Canada and in Canada, primary care physicians, that’s another problem we can talk about, but primary care physicians in Canada are actually paid a little bit more than what they’re paid in the United States and specialists are paid just a bit less, but still quite well. So we don’t really think that there’s going to be an enormous change in physician compensation. The importance of primary care physicians are that having enough primary care physicians to take care of everyone makes a lot of difference in terms of how much health care costs. Because if you have people kind of running willy-nilly to see specialists who are only looking at a small part of the individual and generally charge more, you end up with health care that’s not very well synchronized. It’s not cohesive. That’s what a primary care doctor can do, can make sure that the whole person is cared for in the appropriate way and so Canada has a much larger number of primary care doctors per person in the population and that’s actually true for all the other developed countries also and the improved Medicare for All programs usually include some way to encourage doctors to go into primary care.

Q: Got it. So what do physicians have to gain for having and supporting improved Medicare for All?

Leibowitz: Well, they would probably not burn out as much. Doctors today sometimes spend as much as three hours a day with paperwork documentation. There’s actually a very interesting slide I saw comparing how long…so most things now are in an electronic medical record and so they can figure out how long each doctor’s note is about a particular patient and if you compare the size of notes in the United States compared to other countries, it’s about four times as large. And that’s not because the care is four times as good, it’s because the whole set of regulations related to reimbursement has meant that doctors’ notes have become voluminous and contain a lot of information that actually can be quite distracting and make it make it difficult to find the little bits of information that you actually need to take care of someone.

Q: Wow. So if doctors would be spending less time on documentation and medical records, wouldn’t they be able to see more patients?

Leibowitz: Absolutely and that is kind of figured into most of the planning about single payer. I mean, most doctors like doing things with patients. If a doctor discovers that they don’t really like that, they will typically go into some aspect of medicine where they don’t really have much contact with patients but for most doctors doing things with patients is the fun part and so if they didn’t have to spend as much time with documentation and they didn’t have to worry as much about whether a particular treatment that they thought was indicated would actually be paid for, doctors would be much happier and actually the studies that have been done in California and also nationally show that more than 50%, often around 60-70% of doctors approve of a single-payer plan.

Q: How much did you say?

Leibowitz: 60% to 70%.

Oh wow. That’s more than I thought.

Leibowitz: Yes. It’s remarkable.

Q: For those doctors who do have concerns, what’s the best way to address them?

Leibowitz: Well, for the doctors themselves, I think the best way is to try to educate them and so Physicians for a National Health program is the largest doctors’ organization that supports single-payer health care and so part of its mission is really to try to convince doctors. We obviously like to convince everybody, but I guess we’ll try to influence doctors and then hopefully doctors will influence more people outside of the physician group.

You know, obviously the other large organized group of physicians would be the American Medical Association and they have really opposed any kind of national health program going back easily to President Truman and actually even Roosevelt thought about, but decided against trying to start a health program at the time he started Social Security cause it seemed like there was going to be too much opposition to it. And I mean the AMA was strongly against Medicare, but then as it turned out, Medicare boosted physician income quite a lot.

But you know, single payer is not a way to boost physician income. That’s not the main reason for thinking it’s a good thing. But we’d like the AMA to support it. They, I suppose, are worried again that income will go down. That’s been the main focus of the AMA in terms of things they do support or things they oppose, it’s mainly been related to how they think it will affect income.

Q: I guess my first question is how can they not support something that would save so many lives?

Leibowitz: Yes, that’s what I would ask also and I think some of the doctors in the AMA are starting to ask that same question and they are at least opposing single payer a little bit less strongly than they used to and in California, there is a group of doctors within Physicians for a National Health Program who are trying to set up a single-payer caucus within the California Medical Association.

Q: How interesting. So they’re trying to set it up, but it hasn’t been set up yet?

Leibowitz: No, no but they’re actually working quite actively on it now.

Q: So doctors who are in PNHP or Physicians for a National Health Program, can they also become a member of the AMA?

Leibowitz: Oh yes, absolutely.

Q: Okay, interesting. Are you currently practicing as a doctor?

Leibowitz: No, I retired about three years ago.

Q: What was the last place you worked?

Leibowitz: The Palo Alto Medical Clinic in Palo Alto. It’s part of the Palo Alto Medical Foundation.

Q: So what do you see as the biggest obstacles to winning single payer in America?

Leibowitz: The vested interests that have almost unlimited sums of money to fight against any change. The healthcare lobbying group overall, I think, is the largest single lobbying group in Washington DC and the insurance industry and the pharmaceutical industry are the two biggest opponents because they would stand to lose the most. The hospitals that have been consolidating into relatively larger organizations also tend to oppose single payer. It’s not clear that they really have as much at risk, but it would be something new and hospitals would be financed in a different way and so they’re certainly afraid of change, but the big opposition is from the insurers and the pharmaceutical companies who have a lot of money that they can donate to elected officials so it’s the old, old story really.

Q: Is that the main obstacle in California as well?

Leibowitz: Oh yes, absolutely – without any question.

Q: So what can be done about that, do you think?

Leibowitz: Well, campaign finance reform would be good, but that’s not very likely. There was an attempt to do that more than 20 years ago, and it didn’t last very long. So as long as companies can give enormous amounts of money to people running for office, it’s a tough problem. I mean, there are two ways to set up the system. You can do it by legislation, or in California in particular, you can have a voter-initiated proposition and initiative, which would set it up and either way is possible, even if legislation is passed, there will have to be a statewide vote afterward because the funding would require some changes in parts of the state constitution, which have resulted from initiatives in previous years.

Q: Got it. So what can we here in California do to help win single payer?

Leibowitz: Educate and inspire people – that’s really the best thing we’ve come up with and there are a number of different kinds of efforts that are going on. And if someone, if you’re in California, you can look at the PNHP website or you can look at the website. There’s a coalition of single-payer supporters – Healthy California Now – and if you start there, or if you start at the PNHP CA website, there’s information about a lot of different things you can do. In some of the states, there are actually pretty well developed single payer advocacy groups also. Certainly the state of Washington, Colorado, Maine, and New York all have pretty strong groups advocating for single payer. The state of Washington actually had a commission like the Healthy California for All Commission in California, and they actually reported a year or so ago so there is a large movement in the state of Washington so I think that that’s all we can do right now.

Thank you Dr. David Leibowitz.

Do you have a personal story you’d like to share about our wack healthcare system? Contact us through our website at heal-ca.org.

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Code WACK! is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country. I’m Brenda Gazzar.

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