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“Paying for value” could mean the end of small family practices

“Paying for value” could mean the end of small family practices

A Boehner-Pelosi prescription for Medicare doc fixes

By Jennifer Haberkorn and David Rogers
Politico, March 15, 2015

In a rare display of bipartisanship, House leaders are actively pursuing a deal to permanently change the way Medicare pays doctors and to extend a children’s health program for two years.

While details are still being ironed out, the basic contours are clear: The plan would permanently eliminate the Sustainable Growth Rate, the outdated formula that calls for frequent and deep cuts to Medicare providers, and replace it with a new payment system. This is a priority for both parties to end the need for frequent “doc fixes.”

The replacement policy agreed to by the House Energy and Commerce and Ways and Means committees and the Senate Finance Committee would move away from volume-based payments, in which physicians are paid based on the number of tests or procedures ordered, into a value-based system. That would reward them with higher payments when they meet performance thresholds on improved care and quality.

This new system would set up a series of quality measures that physicians will have to meet and would incentivize care coordination, particularly for patients with chronic care needs in which multiple doctors are involved.

The replacement policy is widely supported by medical organizations. But some critics argue the bill is too vague and that its reporting requirements could be ruinous to small practices.

“Aspirationally, it is correct, but we don’t know enough about how to measure value,” said Robert Berenson, the former vice chairman of the Medicare Payment Advisory Commission. “This could mean the end of small general practices for all practical purposes.”

http://www.politico.com/story/2015/03/medicare-doctors-john-boehner-nancy-pelosi-116097.html

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Comment:

By Don McCanne, MD

The rhetoric sounds great. We are moving away from paying for the volume of health care provided, and we are going to pay for value instead.

In reality, volume will always be an important factor in determining health care costs. Maybe there are marginal expenses that can be reduced, but most services are clinically appropriate and do have relatively fixed costs involved. Reducing volume has really been code language for using various schemes such as accountable care organizations and bundling of payments to reduce prices. These schemes have an almost negligible impact on reducing volume.

What is this increased value that the industry envisions? Usually they are referring to quality measures. Yet those measurements are very primitive. As Robert Berenson says, “we don’t know enough about how to measure value.” Yet reducing payments for volume and giving rewards for Mickey Mouse quality scores increases administrative complexity – increasing busy work without increasing value.

Do we really want to do this? Again, quoting Robert Berenson, “This could mean the end of small general practices for all practical purposes.” My personal primary care physician is a solo practitioner. I should have to give him up simply because some policy people believe that we should continue down this path when there is very little support that these measures will either reduce costs or increase quality?

What the policy people do know is that an improved Medicare that covered everyone for the same amount that we are spending today is the most effective way to improve value. We should go where the action is. Once there, we can tweak the system for quality and volume.

Feds Knew About Medicare Advantage Overcharges Years Ago

By Fred Schulte
NPR, March 13, 2015

Federal health officials were advised in 2009 that a formula used to pay private Medicare plans triggered widespread billing errors and overcharges that have since wasted billions of tax dollars, newly released government records show.

Privately run Medicare Advantage plans offer an alternative to standard Medicare, which pays doctors for each service they render. Under Medicare Advantage, the federal government pays the private health plans a set monthly fee for each patient based on a formula known as a risk score, which is supposed to measure the state of their health. Sicker patients merit higher rates than those in good health.

Health insurer Humana Inc. disclosed that its Medicare Advantage plans are being looked at by the feds.

The program is a good fit for many seniors. Some 16 million people have signed up — about a third of people eligible for Medicare — and more are expected to follow. Supporters argue that Medicare Advantage improves care while costing members less out of pocket than standard Medicare. The Medicare Advantage industry is lobbying hard to block budget cuts sought by the Obama administration.

Medicare Advantage plans are “clearly an important force to be reckoned with when it comes to making public policy,” said Dr. Robert Berenson, a former government health official, who is now at the Urban Institute.

But overspending tied to rising risk scores has cost taxpayers billions of dollars in recent years, as the Center for Public Integrity reported in a series of articles published last year. And concerns that some health plans overstate how sick their patients are date back years, according to records recently released to the Center for Public Integrity under the Freedom of Information Act.

The documents include an unpublished study commissioned by the agency that runs Medicare and the Centers for Medicare and Medicaid Services, and dated Sept. 29, 2009; the study tracked growth in risk scores starting in 2004, the year after Congress created the billing tool.

The study found that risk scores for Medicare Advantage enrollees grew twice as fast between 2004 and 2008 as they would have had the same person remained in standard Medicare. The study said it was “extremely unlikely” that people who enrolled in the plans actually got sicker and noted that coding inflation “results in inappropriate payment levels.”

The lead author was Richard Kronick, then a researcher at the University of California, San Diego. Kronick now heads the federal Agency for Healthcare Research and Quality, a research arm of the Department of Health and Human Services. He had no comment. Other authors listed included three CMS employees.

A CMS spokesman said on Thursday that the agency sought to publish the findings on a government run research site, but was told it needed to be “substantially shortened” to be considered. “Given competing workload demands we were not able to revise and resubmit the article,” the official said in a statement.

The study cited diabetes as an example of the billing problem.

The private Medicare Advantage health plans reported rates of diabetes with medical complications more than twice as often as for people in standard Medicare. “It seems extremely unlikely that the actual distribution of diabetics changed substantially in MA plans … and almost surely reflects MA efforts to more fully document members’ diagnoses,” the study said.

The authors noted that “a number of companies have successfully marketed services to help MA plans increase their risk scores.” They also said that the problem was worsening over time.

The study said that a number of large Medicare health plans, which were not named, raised risk scores far above their peers. But the agency chose not to ferret out the worst offenders and discipline them. Instead CMS cut rates industrywide in 2010 by 3.41 percent to offset the jump in risk scores.

Berenson, of the Urban Institute, said cutting rates across the board was a kind of “rough justice.”

“It seems to me that they need to identify the plans that are bending the rules,” Berenson said. “It’s not so easy to focus in on plans that are overly aggressive [in billing],” he said.

Medicare Advantage plans are currently mounting an aggressive lobbying effort to stave off proposed new federal budget cuts. Fifty-three senators signed a recent letter opposing the cuts. The Coalition for Medicare Choices, run by the health insurance industry, even rolled out a “Medicare Advantage”-themed food truck that parceled out free cookies and coffee near the U.S. Capitol. Utah Sen. Orrin Hatch was among those who stopped by.

Separately, an advocacy group called the Better Medicare Alliance on March 10 unveiled a pair of advertisements arguing any cuts would cause seniors to pay more for their medical care.

Clare Krusing, a spokeswoman for America’s Health Insurance Plans, said in a statement:

“Seniors enrolled in Medicare Advantage have already faced year-over-year cuts to the coverage they rely on. Now, CMS is proposing another cut at a time when beneficiaries, policymakers, providers are all calling for stability in the program. Preventing any further cuts to Medicare Advantage will ensure seniors can continue to rely on this critical lifeline.”

Though Medicare Advantage has built formidable support in Congress, the risk-based payment system has critics in other areas of government.

Earlier this week, the Government Accountability Office, the audit arm of Congress, cited more than $12 billion in improper payments to Medicare Advantage plans among a total of nearly $60 billion in misspent Medicare funds for 2014. A broader GAO audit of how well federal officials have monitored the industry to curb overbilling is underway; it’s due to be released later this year.

The industry has a good track record when it comes to building the political support to silence its critics. For instance, an ad campaign run by the industry in 2013 turned a proposed 2 percent cut in rates into a 3 percent rate hike. In backing down, CMS officials said the revised rates would give patients “more value in the care they receive and greater protections against increasing costs.”

President Obama’s proposed 2016 budget seeks more than $36 billion in Medicare Advantage cuts over the next decade, mainly by taking aim at risk scoring.

A final decision on the payment rates for 2016 is due in April.

This piece comes from the Center for Public Integrity, a nonpartisan, nonprofit investigative news organization. For more, follow the center on Twitter @Publici, or sign up for its newsletter.

http://www.npr.org/blogs/health/2015/03/13/392755143/feds-knew-about-medicare-advantage-overcharges-years-ago

Report: Medical loss ratio has no impact on private insurers’ overhead

Plans met MLR limit before Affordable Care Act was in place

By Dori Zweig
Fierce Health Payer, March 16, 2015

The Affordable Care Act seemingly has had little or no impact on health insurers’ overhead, according to a new report from the International Journal of Health Services.

The report’s authors examined medical loss ratios (MLRs) using the pre-2011 definition set by the Department of Health and Human Services: Total premium income divided by total medical payments. The authors analyzed this data for risk-bearing plans for every insurer listed in the Fortune 500 for three years prior to and after implementation of the MLR rule in 2012. The rule requires an MLR of at least 80 percent in the individual and small-group markets and 85 percent in the large-group market.

Here’s what the authors found:

The average MLR of the nine Fortune 500 insurers assessed did not change before and after the new regulation: 83.04 percent for 2009-2010 and 83.05 percent for 2011-2013. (Cigna was excluded from the study due to changes in accounting practices that made an accurate assessment impossible.)

MLRs dropped at three of the four largest insurers. UnitedHealth’s MLR from 2008-2010 was 81.6 and fell to 80.9 percent for 2011-2013. Humana’s was 83.4 percent and dropped to 83.2 percent, while Aetna’s was 83.0 percent and fell to 81.6 percent.

Centene experienced the most significant increase in MLR. From 2008-2010, the average was 83.3 percent; it rose to 88.5 percent for 2011-2013.

“Although overhead was reduced at some insurers, with one exception these reductions were within the range of year-to-year fluctuations commonly seen in the past,” the authors pointed out. Additionally, these results are consistent with trends in the National Health Expenditure Accounts, which found medical spending decreased slightly as a proportion of private insurance premiums two years into ACA implementation. Finally, the report concluded that overhead at private insurers remains six times as high as traditional Medicare overhead.

As of late, insurers have pushed for change to MLR requirements, FierceHealthPayer previously reported. The industry wants payments to brokers and agents excluded from administrative costs, claiming that their inclusion in MLR calculations hurts insurers’ bottom lines and drives up premiums.

For more – here’s the report.

http://www.fiercehealthpayer.com/story/report-medical-loss-ratio-has-no-impact-private-insurers-overhead/2015-03-16

Medicare works; open it to everyone

By Larry Donohue, M.D.
The Daily Herald (Everett, Wash.), March 15, 2015

Is our social contract obsolete, only a fond memory of a simpler time? Some, perhaps many, on the political right who embrace a libertarian view hold that their successes are self-made and so should be yours.

As conservatives legislatively seek its repeal and the U.S. Supreme Court again reviews the constitutionality of the Affordable Care Act, or Obamacare, it is possible that we could return to the shame that in this affluent country so many of our citizens could again be without affordable access to even basic health care.

If we could get past polarized political positions, there is no question that Obamacare can be and indeed needs to be improved. Legislative compromises left Obamacare less than it could be. Quality improvement opportunities include:

First, the costs of health care are not optimally curtailed.

There is no question that we should pay for quality of care not quantity of care, as we have traditionally done, easy in concept but more difficult in operation.

The low hanging fruit of cost containment is the administrative costs of our commercial insurers. There is up to 20 percent of the premium dollar going for advertising, high executive salaries and other items that don’t contribute to improving health care. But this low hanging fruit is not as easy to harvest as it might be.

Bloomberg Business stated it clearly.

“But the thing that few people talk about, and that no serious policy proposal attempts to fix — the arrangement that accounts for much of the difference between health spending in the U.S. and other places — is the enormous administrative overhead costs that come from lodging health-care reimbursement in the hands of insurance companies that have no incentive to perform their role efficiently as payment intermediaries.”

Second, commercial health insurance rules and regulations introduce expensive-to-administer complexity, not value. Each health insurance plan contractually assembles its own networks of providers, benefits and rules. It need not contract with providers that it judges expensive, despite the providers expertise. An example is Seattle Children’s Hospital, a locally cherished and nationally respected health care facility. Several insurers are reported to have not contracted with Children’s, citing cost. Their insureds are denied access to these renowned physicians. With pressure from the Office of the Insurance Commissioner, more insurers are now including Seattle Children’s Hospital in their networks, but with each contract year the problem can return.

A University of Washington Medical School Professor opined that one of the problems of our health care system is that strategy decisions are now being crafted by masters of business administration rather than by health care professionals. The bottom line trumps the common good.

A second example, arguably the premier cancer research and treatment center in the country, The Seattle Cancer Care Alliance (The Fred Hutchinson Cancer Research Center, University of Washington Medicine and Seattle Children’s Hospital) and the largest provider of commercial health insurance in the state, Regence BlueShield, covering some 1.1 million people, have failed to reach contractual agreement, thus denying these 1.1 million fellow Washingtonians affordable access to world-class cancer experts.

A diagnosis of cancer is enough of a psychological assault without adding the additional burden of having to choose between paying for locally available, internationally recognized cutting edge care and risking personal bankruptcy or choosing to forgo potentially life saving state-of-the-art care.

Both of these quality improvement opportunities can be addressed by adopting a “Medicare for all” program to administer health care payment.

The Medicare program is efficient and popular with users. In the heat of argument a few years ago, an impassioned speaker said “Keep your government hands off my Medicare!” Go figure!

The major obstacle to accomplishing these quality improvements is the untoward influence of health care industry lobbyists. More than 2,400 individuals are registered as lobbyists for the health care sector. The National Journal’s “Influence Alley” reported that health insurance lobbyists funneled $102.4 million to the Chamber of Commerce during the health care reform debate. Health care industry lobbyists regularly spend $500 million each year influencing Congress.

If the only dialogue is between the lobbyists and politicians, affordable, efficient, quality health care for all will not happen. It is up to us to get involved and make our voices heard. The wisdom of the people can figure it out.

Larry Donohue has worked as a physician with the U.S. Army, UW and Harborview medical centers and a small group practice, served on the governing board of Swedish Medical Center and was an ombudsman and associate medical director for Regence BlueShield. He lives in Seattle. He is also a cancer patient.

http://www.heraldnet.com/article/20150315/OPINION03/150319541

Patients lack enough assets to pay insurance cost sharing

Consumer Assets and Patient Cost Sharing

By Gary Claxton, Matthew Rae, and Nirmita Panchal
Kaiser Family Foundation,  March 11, 2015

While concerns about cost sharing are not new, the recent coverage expansions under the ACA put a new focus on what it means for coverage to be affordable. The goal of the law was to cover more of the uninsured, many of whom have limited means. The law requires most people to have health insurance, if they can afford to pay the premium, or to pay a penalty. The issue for some families, however, is that the policies with affordable premiums may have cost sharing requirements that would be difficult for them to meet when they access services. Many of the policies in the state and federal marketplaces have significant cost sharing, as do many policies provided to people at work. The ACA provides cost-sharing assistance to some, primarily to those with incomes below 200 percent of poverty purchasing through a state or the federal marketplace. Others potentially face much higher out-of-pocket expenses.

Deductibles

Overall, three in five (63%) households have enough liquid financial assets to meet the lower deductible amounts ($1,200 single/$2,400 family) while one-half (51%) can meet the higher deductible amounts ($2,500 single/$5,000 family). These percentages are similar for single-member and multi-member households, but vary significantly by family income. Only 32% of households with incomes between 100% and 250% of poverty can meet the lower deductible amounts, while one-in-five can meet the higher deductible amounts. In contrast, 88% of households with incomes over 400% of poverty can meet the lower deductible amounts and three-in-four (79%) can meet the higher amounts.

Out-of-Pocket Limits

Out-of-pocket limits are higher than deductibles and meeting them is more difficult for many families. Forty-eight percent of households have enough liquid financial assets to meet the lower out-of-pocket limits ($3,000 single/$6,000 family) and 37% can meet the higher limits ($6,000 single/$12,000 family). The percentages are quite low for households with incomes between 100% and 250% of poverty, with 18% having enough liquid financial assets to meet the lower out-of-pocket limits and 11% being able to meet the higher limits. Among households with incomes over 400% of poverty, 75% have enough liquid financial assets to meet the lower out-of-pocket limits while just 62% can meet the higher limits.

Discussion

Many non-elderly, non-poor households lack the resources to meet the deductibles and out-of-pocket limits that they may encounter in the private insurance market. Many households have insufficient liquid financial assets to meet the specified cost sharing measures, and the situation for net financial assets is no better. Not surprisingly, the difficulties are greater in households with lower incomes and with someone who lacked health insurance.

While the ACA provides for reduced cost sharing for some people with incomes below 250% of poverty that purchase coverage in a state or the federal marketplace, there is no assistance with cost sharing for those with higher incomes or for those obtaining coverage through a job. Substantial shares of households with incomes between 250% and 400% of poverty would be unable to meet even the lower out-of-pocket limits with their current resources, and meaningful shares of households with incomes over 400% of poverty would have problems as well.

http://kff.org/health-costs/issue-brief/consumer-assets-and-patient-cost-sharing/

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Comment:

By Don McCanne, M.D.

This important study demonstrates one of the most serious deficiencies in our dysfunctional system of health care financing: the mismatch between the personal financial assets that most Americans have and the cost sharing in the form of deductibles and out-of-pocket limits required by their insurance plans. Far too many individuals, should they have significant medical needs, do not have adequate liquid assets to cover the level of cost sharing required by most plans today.

Look at the most favorable example above: 25% of higher-income families (families with incomes over 400% of poverty) do not have enough liquid financial assets to pay lower out-of-pocket limits of $3,000 single/$6,000 family. Worse, 38% of these higher-income families do not have enough liquid assets to pay higher out-of-pocket limits of $6,000 single/$12,000 family (the 2015 out-of-pocket limits for plans in the ACA exchanges are even higher: $6,600 individual/$13,200 family). Further, net financial assets are usually lower than liquid financial assets because of family debt; families are even more broke than their cash on hand would indicate.

Except for those with the very highest incomes, our current flawed system of financing health care through private plans creates financial hardship for far too many of us who require significant amounts of health care. Today’s private insurance products are inadequate.

What is the source of support for this deficient coverage? Private insurers want to maintain access to markets by keeping their premiums competitive. They do this partly by shifting costs to patients’ pockets. Neoliberal and conservative politicians want to keep spending on government premium subsidies to a minimum, so they support cost sharing policies that reduce premiums. Libertarian and conservative ideologues want to place health care consumers in charge of spending their own money. If they don’t have enough funds, well, that’s too bad. They should have had enough personal responsibility to establish their own health savings accounts and fully fund them before medical needs arose. Sure.

Private insurers we can certainly do without. But what about the ideologues? Is there no place in this country for egalitarianism and social solidarity? I cringe when I think about current trends advancing income and wealth inequality as the social fiber continues to shred.

We desperately need a single-payer, improved Medicare for all, with first dollar coverage. Let’s harness the forces of social solidarity so we can achieve that goal.

Report: State-Funded Health Care Would Save New York $45 Billion

By Derek Hawkins
Public News Service (New York), March 12, 2015

NEW YORK – New York could save $45 billion a year in health care costs if it adopted a so-called “single-payer” insurance program.

That’s according to a new report from the University of Massachusetts at Amherst, which looked at the economic impact of a bill in the state assembly that would cut out private insurance in favor of state-funded health care.

The bottom line is a prediction of lower health care costs for nearly all New York households. Assemblyman Richard Gottfried (D-Manhattan) introduced the bill, dubbed the New York Health Act.

“The numbers are terrific,” says Gottfried. “The net savings of $45 billion a year, $2,200 savings per capita in New York. I think having these numbers really changes the debate.”

Republican leaders and private groups like the Business Council of New York State are fighting the New York Health Act, saying market-based insurance is more reliable and Gottfried’s bill would result in unaffordable tax hikes.

Eliminating private health insurance would cause the state to shed some jobs in the industry, but according to the study, a state-funded system would make up for it, creating some 200,000 new positions. New York households that earn less than $75,000 a year would benefit most, the study found. Marva Wade, second vice president of New York State Nurses Association, supports the bill.

“The study reinforces that there are real reasons that are based in the science of economics that there should be health care for everyone,” she says.

Last year, Vermont came close to adopting a statewide single-payer system, but the governor scrapped the plan in December, saying it would cost too much to implement.

http://www.publicnewsservice.org/2015-03-12/health-issues/report-state-funded-health-care-would-save-new-york-45-billion/a45075-1

ACA has not reduced insurers’ administrative waste

The Affordable Care Act and Medical Loss Ratios: No Impact in First Three Years

By Benjamin Day, David U. Himmelstein, Michael Broder, and Steffie Woolhandler
International Journal of Health Services, Volume 45, Number 1

The Patient Protection and Affordable Care Act (ACA) set limits on insurers’ overhead, mandating a medical loss ratio (MLR) of at least 80 percent in the individual and small-group markets and 85 percent in the large-group market starting in 2011. In implementing the law, the Obama administration introduced new rules that changed (and inflated) how insurers calculate MLRs, distorting time trends. We used insurers’ filings with the U.S. Securities and Exchange Commission to calculate the largest insurers’ MLRs before and after the ACA regulations took effect, using a constant definition of MLR. MLRs averaged 83.04 percent in the three years before reform and 83.05 percent in the three years after reform. We conclude that the ACA had no impact on insurance industry overhead spending.

In sum, the ACA has not decreased private insurers’ overhead, which remains six-fold higher than traditional Medicare’s.

“The Affordable Care Act and Medical Loss Ratios: No Impact in First Three Years” http://org.salsalabs.com/o/307/images/JOH45_1_DayArticle(1).pdf

PNHP press release: “Health law hasn’t cut insurers’ rate of overhead spending: study” https://www.pnhp.org/news/2015/march/health-law-hasn’t-cut-insurers’-rate-of-overhead-spending-study

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Comment:

By Don McCanne, MD

All policy experts agree that the profound administrative waste that is unique to the U.S. health care system needs to be reduced. The architects of the Affordable Care Act (ACA) rejected the solution that would have worked – a single payer national health program – and instead included in their legislation a requirement that private insurers are allowed to keep, for their own administrative costs and profits, no more than 80 percent (individual and small group insurance markets) or 85 percent (large group markets) of the premiums collected. Insurers refer to this percentage that they have to spend on patient care as the medical loss ratio, i.e., paying for health care is a loss to them. We complained that this meager requirement would be ineffective in reducing administrative waste. This study confirms that the medical loss ratio has not changed after three years of implementation of ACA.

Of course, much of the administrative waste in our system is due to the additional administrative burden that the insurers have placed on the health care professionals and institutions. ACA reduced none of this yet added another layer by establishing the health insurance exchanges, or Health Insurance Marketplaces as the Obama administration calls them. Waste, waste, waste.

The percentage of administrative costs for our traditional Medicare program are only one-sixth that of the private insurers. Further, if Medicare were our only payer, the administrative burden placed on our health care delivery system would be only a fraction of what it now is. Obviously, a single-payer, improved Medicare that covers everyone is precisely what we need. Then we could spend that money on patients instead of paperwork.

Health law hasn’t cut insurers’ rate of overhead spending: study

Study finds Affordable Care Act’s requirement that health insurers spend at least 80-85 percent of premiums on actual medical care had no impact in the law’s first three years

FOR IMMEDIATE RELEASE
March 12, 2015

Contact:
Mark Almberg, PNHP communications director, 312-782-6006, mark@pnhp.org

Despite claims by the Obama administration that the Affordable Care Act will reduce health insurance companies’ spending on overhead, thereby channeling a greater share of consumers’ premium dollars into actual patient care, insurers’ financial filings show the law had no impact on the percentage of insurer expenditures on such things as administration, marketing and profits.

That’s the chief finding of a team of researchers, including two prominent physicians on the faculties of the City University of New York’s School of Public Health and Harvard Medical School, in an article published Wednesday in the peer-reviewed International Journal of Health Services.

Examining U.S. Securities and Exchange Commission filings of nine large insurers, and using a constant definition of what constitutes an insurer’s “medical loss ratio” or MLR – i.e. actual spending on payments to doctors, hospitals, pharmacies, etc. – the researchers found that the weighted average MLR in the three years after the new ACA regulations took effect (2011-2013) was 83.05 percent, compared to 83.04 percent in the three years prior to the reform.

The ACA sets limits on insurers’ overhead, mandating an MLR of at least 80 percent in small-group markets and 85 percent in the large group market. However, the Obama administration changed the traditional yardstick by which the MLR is measured.

The new way of calculating the MLR allows insurers to classify most expenditures on “quality improvement” initiatives and the updating of coding systems as medical expenditures, and allows them to subtract most taxes, regulatory fees and “community benefit” spending.

“Rather than go along with the administration’s moving of the goal posts to the apparent advantage of the insurers, we stuck with the traditional way financial analysts and insurance firms calculate MLR, namely, by dividing total medical payments by total premium income,” said Benjamin Day, the study’s lead author.

“What we found is that there’s been no significant change in the insurers’ MLR since the implementation of the new regulations.”

MLRs fell at four firms – UnitedHealth, Humana, Aetna and WellCare – and increased slightly at four others and markedly at one (Centene, a major managed Medicaid contractor).

Day continued: “Although the MLR requirements forced insurers to pay rebates of $1.1 billion in 2011 and $504 million in 2012 – payments that were touted by the Department of Health and Human Services as a major boon to consumers – these rebates constituted less than 0.1 percent of private insurance company revenues and appear to have had no overall impact on MLRs.”

Day, whose published research includes articles on labor history and health care reform, currently serves as executive director at Healthcare-NOW, a national coalition of groups advocating for a single-payer health care system.

Senior author Dr. Steffie Woolhandler, professor at the City University of New York’s School of Public Health at Hunter College and co-founder of Physicians for a National Health Program, said a number of factors might explain why the ACA hasn’t raised MLRs.

“Most plans already met the MLR requirement from 2007-2009, even without the MLR redefinition in the ACA,” Woolhandler said. “Moreover, self-insured employer plans, which accounted for 60 percent of all covered workers in 2011, were entirely exempt from the MLR requirement. In addition, a number of exemptions and adjustments were granted to a wide spectrum of plans and to several states, temporarily nullifying the new mandate.”

Woolhandler observed that traditional Medicare’s overhead is about 2 percent, i.e. 98 percent of Medicare’s spending goes toward medical care. “The ACA is too lenient on private insurers, sets too low a bar for their payments for actual care, and provides them with too many loopholes.

“The lesson is clear,” she said. “We need to adopt a publicly financed, improved Medicare for All.”

“The Affordable Care Act and Medical Loss Ratios: No Impact in First Three Years,” Benjamin Day, M.A., David U. Himmelstein, M.D., Michael Broder, B.A., Steffie Woolhandler, M.D., M.P.H. International Journal of Health Services, Vol. 45, No. 1 (January 2015).

The full text of the article is available at the links above or from Mark Almberg at mark@pnhp.org.

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The International Journal of Health Services (joh.sagepub.com) contains articles on health and social policy, political economy and sociology, history and philosophy, ethics and law in the areas of health and health care.

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization of more than 19,000 doctors who support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.

Doctor points to insurance for woes

Chicago’s Orris speaks to area health consortium

By Rick Miller
Olean (N.Y.) Times Herald, March 6, 2015

OLEAN — The U.S. health care system is more costly and less effective than many other developed nations, a Chicago physician told members of the Cattaraugus County Healthy Liveable Communities Consortium on Thursday.

Dr. Peter Orris, a professor at Rush University and Northwestern University’s School of Medicine specializing in occupational and environmental medicine, told the audience at Bethany Lutheran Church that many health care shortcomings in the U.S. are the result of insurance companies.

Believing that a quasi-market approach to health care was the best way to go, the Affordable Care Act, or Obamacare, relies on for-profit insurance companies.

“Many of us have been critical of that for some time,” Orris told about 50 members of the Health Liveable Communities Consortium. “There is a disconnect between the cost of disease and the profits of providers and hospitals.”

A lack of controls and a lack of balance drives up costs. Health costs in the United States are about $9,160 per person per year, Orris said. That’s $3,000 above the cost of other developed countries, and often the results are not as good, he claimed.

Health insurance adds 30 percent to the costs of health care, Orris said.

Today’s market-defined health care is a far cry from the black bag and home visits by a doctor up until the early 1900s, Orris said.

“Most decisions are being made 500 or 1,000 miles away” nowadays, he added.

Insurance companies, he said, “make their money by holding on to your money.

“Every day they don’t have to pay a reimbursement to a hospital is money in their pockets,” he explained. “They get to hold the money for another couple of weeks.”

Hospitals have learned to increase their revenue by accurate billing and maximizing revenues, according to Orris. Money is being put aside instead of going into health care.

“There is a built-in overhead in the system,” he said. Orris expressed concern that despite higher health care spending, the United States had higher infant and maternal mortality than many countries.

The availability of medical health insurance under the Affordable Care Act should help the formerly uninsured and underinsured who might otherwise delay medical diagnosis and treatment.

However, Orris warned of high‑deductible health plans that could have the same effect on beneficiaries, who could delay treatment due to costs. With high-deductible policies, “most everything” comes out patients’ pockets, Orris said. People can delay treatment if they can’t afford it, he added.

The Affordable Care Act is providing health coverage for millions of families who did not have health insurance previously.

“It left the fox sitting at the henhouse,” Orris said.

In Canada, where there is national health insurance and a single-payer system, health care costs are 11 percent of the economy, while in the U.S. the amount is 18 percent.

Because of the quasi‑market approach of the Affordable Care Act, leaders “are unable to move ahead with logical changes in the health care system,” Orris said. What is needed to change the health care system locally is for patient organizations and organizations representing doctors and hospitals to get together and demand changes from insurance companies, according to Orris. One of the ways the Affordable Care Act is seeking change is by tying hospital reimbursement to scores from patient discharge surveys.

“Those answers, for the first time, will be affecting rates of reimbursement,” Orris said.

Orris was introduced to the group by Dr. Kevin Watkins, Cattaraugus County public health director, who knew him when he still lived and worked in Chicago.

The Cattaraugus County Healthy Liveable Communities Consortium, which meets four times year, was created to help county residents lead healthier lives by making good life choices.

In another development, John Eberth of Southern Tier Health Care Systems said the group is offering training for first responders and friends and family members of heroin addicts in the use of Narcan, which blocks opiate receptors in the brain and is used to help someone recover from a heroin overdose.

“Narcan saves lives,” Eberth told the group. The heroin antidote was recently used to save a local 13‑year‑old, he said.

Police officers, firefighters and family members of heroin users who want training in administering the drug can contact Southern Tier Health Care Services in Olean.

Contact reporter Rick Miller at rmiller@oleantimesherald.com. 

http://www.oleantimesherald.com/

The ‘Un’-Affordable Care Act is a weak start

By David E. Drake, D.O.
The Des Moines Register, March 10, 2015

Potential 2016 presidential candidate Sen. Bernie Sanders has stated: “There is one major country on Earth that does not guarantee health care as a right for all. There is one major country on Earth that spends twice as much per capita on health care as almost any other. There is one major country on Earth where private insurance companies and drug companies earn huge profits. Guess which country.”

As a physician in private practice I abhor each coming new year. This is the time when health care practices have to deal with patients with new insurance policies and former policies with stringent regulations. This year, more than any previous time, I’m noticing more and more folks who have high deductibles — allowed up to $6,600 with the Affordable Care Act (Obamacare). And for some folks that means they can’t see me or they have to greatly limit the number of times they can receive services from me.

In some cases I have to refer middle-class folks with these high deductibles to places with sliding scales, places I used to refer indigent folks with no insurance. Not seeking or delaying care can lead to delayed diagnoses and possible tragic consequences. And as Michael Moore has pointed out, now it’s the middle class who are hit with being under- or poorly-insured while more indigent folks now have an expansion of Medicaid. The confusing mix of deductibles, co-pays, co-insurance and limitations on what services can be provided are now daily frustrations with our lack of guaranteed health care for all.

A single-payer system of reimbursement for health care services has never seemed more in need, with 38 percent of Americans citing health care costs they pay out of pocket as a somewhat or significant level of stress, according to the physician website Doximity. 

Health care bills could go to one payer — an expansion and enhancement of Medicare — with a great reduction in administrative costs for paying the bills and for providers of health care and their offices. Single payer does not imply a system like the Veterans Administration, where all the providers are employees, but one that allows for private as well as employed practices.

Other Iowans join me in their support for moving the ACA past the private insurance companies as the regulating and paying source.

Maureen McCue, adjunct clinical professor at the University of Iowa, medical director of the Women’s Clinic, and Coordinator of the Iowa Chapter of Physicians for Social Responsibility, wrote me:

“Tinkering at the edges doing little to rein in the excesses of the profit-driven insurance system, pharmaceutical and biotech industries, and others. While allowing more citizens access to health insurance, the complexity of the new insurance mechanisms means accessing the health system itself has become ever more confusing and obtuse.”

Dr. McCue offers hope for a change. “It doesn’t have to be this way. There are tried and true solutions. The world’s healthiest populations pay far less for medical services.”

Douglas Steenblock is a physician from Marshalltown with extensive experience working in both the private and public sectors in his field of psychiatry. “It is unfortunate that Americans are so polarized when it comes to our medical system. Many people seem to think that any departure from our current profit-driven system represents ‘socialized medicine’ and that there is nothing in between the two extremes. I find it interesting that the ACA has been described as ‘government-run healthcare,’ when it is actually appears to be private healthcare run amok. The healthcare industry stands to profit handsomely from Obamacare, which explains why it was allowed to pass in the first place.”

Former state Rep. Ed Fallon wrote me: “While some aspects of the ACA move us forward toward a more fair and just health care system, the insurance industry remains the entrenched powerhouse that pulls the purse strings and calls the shots.”

Middle-class Iowans and Americans in general have much to gain from moving beyond the ACA. We will get to equitable health care for all in the U.S. It is simply the right thing to do.

Dr. David E. Drake is an adjunct clinical professor at Des Moines University and a relationship psychiatrist in private practice. Contact: drakeoffice@gmail.com

http://www.desmoinesregister.com/story/opinion/columnists/iowa-view/2015/03/11/un-affordable-care-act-weak-start/24745551/

Economic Analysis of the New York Health Act

Economic Analysis of the New York Health Act

By Gerald Friedman, PhD
March 6, 2015

This report analyzes the economic effects of the New York Health Act (the “Act”), which would establish a comprehensive, universal health insurance program for all New Yorkers.  The Act would replace the current multi-payer system of employer-based insurance, individually acquired insurance, and federally sponsored programs (e.g., Medicare and Medicaid) with a single billing pipeline funded by broad-based progressively graduated assessments collected by the State and based on income and ability to pay, thereby reducing administrative bloat and monopolistic pricing and dramatically reducing the cost of health care to New Yorkers even while extending and improving the provision of care.

The New York Health Act would finance medical care with substantial savings compared with the existing multi-payer system of public and private insurers.  By reducing administrative and other waste and eliminating health insurance company profits and excessive prices for drugs and medical devices, the New York Health Act would increase real disposable income for the vast majority of residents.  It would simultaneously increase employment by reducing the burden of health insurance on business.  Some of these savings would be used to extend coverage to the 7% of New York residents still without insurance under the Affordable Care Act; other savings would be reinvested in the health-care system to improve coverage for the growing number with inadequate coverage.  In addition to improving New Yorkers’ health by reducing barriers to access to health care, the Plan would eliminate the financial penalty associated with health problems.  It would also reduce economic inequality by replacing the current regressive system of health insurance finance with contributions proportional to income and ability to pay.

Conclusion: Better Health Care, Found Money, and Fairness

The New York Health Act would produce substantial health and economic gains for New York. The new system would create such large economies in the administration of health care that all of those currently uninsured could be given access to health care with money left over.  Furthermore, by financing health care with assessments based on ability to pay, the New York Health Act would produce large savings for the great majority of New York residents.  Finally, by reducing business costs, it would also lead to expansion in employment.

Professor Friedman is Chair of the University of Massachusetts at Amherst Economics Department. 

Economic Analysis – Gerald Friedman, PhD: http://www.dickgottfried.org/wp-content/uploads/2015/03/Friedman-Fiscal-Study-New-York-Health-Act-FINAL-3-10-15-925-AM.pdf

Bill A5062-2015,Gottfried/S5062-2015,Perkins – Provides for establishment of the New York Health plan
Sponsor – Richard Gottfried, Assembly/Bill Perkins, Senate: http://open.nysenate.gov/legislation/bill/A5062-2015

Press Release – Economic Study Shows Benefits of Universal Healthcare Bill – 3/10/15: http://www.dickgottfried.org/press-release-economic-study-shows-benefits-of-universal-healthcare-bill/

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Comment:

By Don McCanne, MD

The New York Health Act, introduced by New York Assembly Health Chair Richard Gottfried and in the Senate by Sen. Bill Perkins, and supported by the economic analysis of Prof. Gerald Friedman, is important because it demonstrates how much health care reform can be accomplished on a state level, especially when we have a Congress that is dominated by obstructionists.

Is this a single payer bill? The study refers to a “single billing pipeline.” Rather than being limited by labels, states wishing to go ahead with reform now and not wait for a receptive Congress should support any and all beneficial policy measures possible, including whatever can be accomplished with existing waivers and through negotiations with the U.S. Department of Health and Human Services.

In this analysis, Prof. Friedman estimates that through this legislation, New York can achieve the goals of universality, comprehensiveness, equity, free choice of providers, and removal of cost-sharing barriers to care, while achieving a net savings of $45 billion in the first year alone – funds that could be used for much better purposes than administrative waste.

For any given state, the economic advantage would depend on the specifics of the state legislation and might vary based on the economic assumptions used in the analysis. The important point is not the specific details of this particular analysis but rather that introducing as many single payer policies as possible does result in major improvements of the functioning of the financing infrastructure while significantly reducing the profound waste inherent in our current dysfunctional system.

Our primary goal remains to bring health care justice to everyone in the nation by enactment of a federal single payer system – an improved Medicare for all. In our state efforts we cannot set aside this goal since it is our prime goal. But Richard Gottfried and his colleagues have demonstrated the types of policies that we can apply on a state level as a transition until we can enact reform for the entire nation.

A Visit with our Neighbor to the North

By Richard Dillihunt, M.D.
Maine Medicine, July 2014

For decades, I have admired the Canadian health care system, first while at a remote Northern Quebec fishing camp. There, impromptu sick call was held for the Cree, local aboriginal people with rights to this remote land. Members of this tribe had various complaints that we treated with our medical chest. Despite the difference in language in the elderly, the shyness barriers were easily overcome. They seemed completely confident in our medical abilities.

We felt privileged as caregivers to be given such confidence and warm doctor-patient relationships came forth. Over the years we saw burns from campfire mishaps, an acute gallbladder, and a mangled hand injured beyond our medical capabilities. We made radio calls to regional flying services, and patients were fetched and flown to various medical centers. There were no lawyers or insurance companies involved. The only physical evidence of health care coverage was a small card that each patient guarded carefully. This card admitted them to their national health care system. It provided quality medical care covering all 35 million Canadians scattered across the second largest nation on earth.

The patient with the injured hand was emblematic of this system. A radio call summoned a floatplane, and the patient was loaded and lugged across and down the 150 km of the Peribonka River to the medical center in Chicoutimi. After treatment, he was returned by air. That little card had covered all medical care and transportation. Imagine what such a journey would cost us!

This system of universal health care came into being in 1946. It is attributed to a Canadian native son, Tommy Douglas. As premier of Saskatchewan, he established a universal single-payer health care for all of Canada. After his death he was voted “Greatest Canadian” by the Canadian Broadcast Corporation viewers.

Although medical service for the Cree and Inuit have been difficult for the Canadian government to perfect, they have enjoyed great success. Given the vast territory, the nation does well to spread its resources over ten million square km, much of it being a harsh environment.

The Canadian system deserves careful scrutiny by every American who has concerns regarding our badly broken health care system. Inspection of how the Canadians have successfully developed their universal single-payer form of health care uncovers features that the U.S. needs to seriously consider.

Just recently Danielle Martin, a brilliant young Canadian physician, called attention to the superior provisions of Canada’s public system in her testimony before Sen. Bernie Sanders’ committee in Washington. She showed that the Canadian system is based on need, not on the ability to pay. Her interaction with Sen. Burr (R-N.C.) went viral, generating over 700,000 views on YouTube across North America. Many major media outlets focused on her evidence-based, intelligent, and energetic defense of Canadian Medicare.

Canadians take great pride in their medicare-for-all system. They know that Canada’s life expectancy rates and maternal and infant mortality figures are superior to America’s, and their quality of care is equal to ours. They are aware that, traditionally, wait times have been a source of intense criticism of their system. They understand that this is largely overblown by stateside special interest groups whose propaganda has brainwashed America about horrendous waiting times for referrals and elective surgery. The facts show differently. Canada has addressed wait time issues with a Wait Time Alliance. Through this alliance there has been much improvement, and changes have been uncovered to correct this problem.

Two nations have developed, through different pathways, health care systems which are clinically similar and among the world’s best. When compared, Canada has taken the high ground, selecting a route featuring social justice and equality with a strong nationalism. Canadians are caring for one another. America’s profit-driven hard-nosed traditions and business practices have permeated the ways and means of the USA’s health care.

Lacking checks and balances, our system costs nearly twice that of Canada’s per capita, $8,233 vs $4,445 yearly. This accounts for 17.6 percent of America’s GDP while Canada’s health care expenditure is 11.4 percent of her GDP according to 2012 statistics. The most stunning statistic of all is this. Even with the ACA finally deployed, there are over 30 million uninsured American citizens, approximately equal to the entire population of Canada where everyone is covered by medicare, and a simple little card replaces by comparison a vast array of paperwork that chokes our system.

The Canadian system is remarkably popular in America. Maine must pay attention to this surge. Because of our unique geographical location, we are surrounded by Canadian relatives, friends, and neighbors. Canada can provide us with more than frigid winds. We need to lead the way in acknowledging a very attractive Canadian health care system.

Richard C. Dillihunt, M.D., of Portland is a retired surgeon.

Editor’s Note: The opinions expressed above are the opinion of MMA member and retired surgeon Dr. Dillihunt. MMA members with concurring or opposing opinions are welcome to share them with MMA for possible publication in future issues of Maine Medicine. Comments and articles (please keep your articles under 600 words) may be shared with Shirley Goggin at sgoggin@mainemed.com.

http://www.mainemed.com/sites/default/files/content/JulAugSep2014_FINAL.pdf