PNHP

Insurer executive rolls her eyes over hokey ACOs

Insurer executive rolls her eyes over hokey ACOs

Doctors, hospitals and insurers team up

By Bernard J. Wolfson
Orange County Register, May 1, 2014

In an office building across the street from St. Joseph Hospital in Orange, midlevel managers from Blue Shield of California gathered around a conference table last week with representatives of St. Joseph Heritage Healthcare. The setting was unremarkable, but the conversation that took place was part of an increasingly common collaboration between a larger insurer and one of its key medical providers.

Christy Mokrohisky perked up when Nancy England, a senior pharmacist at Blue Shield of California, proposed a pilot program in which pharmacists would be parachuted into the clinics and physician offices of St. Joseph Heritage Healthcare to manage the prescriptions of sick patients for doctors who are too busy to do it.

For Mokrohisky, who oversees St. Joseph’s performance improvement efforts, the idea spoke directly to one of her driving ambitions: to keep chronically ill patients out of the hospital and away from the emergency room.

“We all know that issues around medication are the number one or close to the number one reason for trips to the ER or admissions to the hospital,” said Mokrohisky, giving voice to the consensus around the table.

The weekly meeting is only one manifestation of the huge upgrade in communication and information sharing between the two groups that has resulted from a 2-year-old alliance known, in the techno-jargon of the industry, as an accountable care organization, or ACO.

The main goal of the ACO is to improve the quality of patient care and save money through closer attention to patients’ needs, monitoring of their compliance with doctors’ orders and avoidance of unnecessary treatments.

Early signs indicate the Blue Shield-St. Joseph ACO is paying dividends. In its first year, it produced a sharp reduction in patient admissions, length of hospital stays, emergency room visits, outpatient surgeries and readmissions, according to in-house data from the insurance company. The group saved a total of $11.5 million, some of which the parties divvied up.

The financial windfall aside, people in both organizations say this kind of ongoing collaboration between an insurance company and a large medical group – virtually unheard of a few years ago – has changed the way they do business with each other.

“It sounds kind of hokey, and sometimes when I say it out loud I have to roll my eyes at myself, but it has created something I have never seen,” says Kristen Miranda, who oversees Blue Shield’s 15 ACOs statewide. “It absolutely has changed the way we interact with these providers and the way they interact with each other. We all now see ourselves as coming together to look at this population as if we are on the same side instead of just battling it out at the negotiating table every year.”

Blue Shield views the kind of orchestrated care it is offering through its ACOs as a competitive wedge against Kaiser Permanente, a health care giant in California that has a built-in advantage because its doctors, hospitals and insurance are integrated.

Some industry observers say ACOs are little more than traditional HMOs in new clothing.

(Glenn Melnick, a health economist at USC) worries that the ability of ACOs to save health care dollars may be time-limited.

“At some point, you are going to reduce inpatient days and other measures as low as they can possibly go,” he says. “Then the question becomes whether these ACOs will be able to generate additional savings from other areas that might be more difficult.”

http://www.ocregister.com/articles/blue-612097-shield-care.html

****

Comment:

By Don McCanne, MD

So now with ACOs, insurers and providers are “coming together to look at this population as if we are on the same side instead of just battling it out at the negotiating table every year.” They are sharing a “financial windfall” by having accomplished “a sharp reduction in patient admissions, length of hospital stays, emergency room visits, outpatient surgeries and readmissions, according to in-house data from the insurance company.” The insurers and providers have conspired to split the gains from not providing care. No wonder the person overseeing Blue Shield’s 15 ACOs has to “roll my eyes” since it seems so “hokey.”

No more hokey. Let’s have a financing system geared to patients, not to insurers – a single payer national health program.

Insurer executive rolls her eyes over hokey ACOs

Doctors, hospitals and insurers team up

By Bernard J. Wolfson
Orange County Register, May 1, 2014

In an office building across the street from St. Joseph Hospital in Orange, midlevel managers from Blue Shield of California gathered around a conference table last week with representatives of St. Joseph Heritage Healthcare. The setting was unremarkable, but the conversation that took place was part of an increasingly common collaboration between a larger insurer and one of its key medical providers.

Christy Mokrohisky perked up when Nancy England, a senior pharmacist at Blue Shield of California, proposed a pilot program in which pharmacists would be parachuted into the clinics and physician offices of St. Joseph Heritage Healthcare to manage the prescriptions of sick patients for doctors who are too busy to do it.

For Mokrohisky, who oversees St. Joseph’s performance improvement efforts, the idea spoke directly to one of her driving ambitions: to keep chronically ill patients out of the hospital and away from the emergency room.

“We all know that issues around medication are the number one or close to the number one reason for trips to the ER or admissions to the hospital,” said Mokrohisky, giving voice to the consensus around the table.

The weekly meeting is only one manifestation of the huge upgrade in communication and information sharing between the two groups that has resulted from a 2-year-old alliance known, in the techno-jargon of the industry, as an accountable care organization, or ACO.

The main goal of the ACO is to improve the quality of patient care and save money through closer attention to patients’ needs, monitoring of their compliance with doctors’ orders and avoidance of unnecessary treatments.

Early signs indicate the Blue Shield-St. Joseph ACO is paying dividends. In its first year, it produced a sharp reduction in patient admissions, length of hospital stays, emergency room visits, outpatient surgeries and readmissions, according to in-house data from the insurance company. The group saved a total of $11.5 million, some of which the parties divvied up.

The financial windfall aside, people in both organizations say this kind of ongoing collaboration between an insurance company and a large medical group – virtually unheard of a few years ago – has changed the way they do business with each other.

“It sounds kind of hokey, and sometimes when I say it out loud I have to roll my eyes at myself, but it has created something I have never seen,” says Kristen Miranda, who oversees Blue Shield’s 15 ACOs statewide. “It absolutely has changed the way we interact with these providers and the way they interact with each other. We all now see ourselves as coming together to look at this population as if we are on the same side instead of just battling it out at the negotiating table every year.”

Blue Shield views the kind of orchestrated care it is offering through its ACOs as a competitive wedge against Kaiser Permanente, a health care giant in California that has a built-in advantage because its doctors, hospitals and insurance are integrated.

Some industry observers say ACOs are little more than traditional HMOs in new clothing.

(Glenn Melnick, a health economist at USC) worries that the ability of ACOs to save health care dollars may be time-limited.

“At some point, you are going to reduce inpatient days and other measures as low as they can possibly go,” he says. “Then the question becomes whether these ACOs will be able to generate additional savings from other areas that might be more difficult.”

http://www.ocregister.com/articles/blue-612097-shield-care.html

So now with ACOs, insurers and providers are “coming together to look at this population as if we are on the same side instead of just battling it out at the negotiating table every year.” They are sharing a “financial windfall” by having accomplished “a sharp reduction in patient admissions, length of hospital stays, emergency room visits, outpatient surgeries and readmissions, according to in-house data from the insurance company.” The insurers and providers have conspired to split the gains from not providing care. No wonder the person overseeing Blue Shield’s 15 ACOs has to “roll my eyes” since it seems so “hokey.”

No more hokey. Let’s have a financing system geared to patients, not to insurers – a single payer national health program.

Center for Public Integrity on the Medicare Advantage Money Grab

The Medicare Advantage Money Grab

The Center for Public Integrity, June 4, 2014

Why Medicare Advantage costs taxpayers billions more than it should

By Fred Schulte, David Donald and Erin Durkin

(Medicare Advantage) plans have sharply driven up costs in many parts of the United States — larding on tens of billions of dollars in overcharges and other suspect billings based in part on inflated assessments of how sick patients are, an investigation by the Center for Public Integrity has found.

Dominated by private insurers, Medicare Advantage now covers nearly 16 million Americans at a cost expected to top $150 billion this year. Many seniors choose the managed-care Medicare Advantage option instead of the traditional government-run Medicare program because it fills gaps in coverage, can cost less in out-of-pocket expenses and offers extra benefits, such as dental and eye care.

But billions of tax dollars are misspent every year through billing errors linked to a payment tool called a “risk score,” which is supposed to pay Medicare Advantage plans higher rates for sicker patients and less for those in good health.

Government officials have struggled for years to halt health plans from running up patient risk scores and, in many cases, wresting higher Medicare payments than they deserve, records show.

The Center’s findings are based on an analysis of Medicare Advantage enrollment data from 2007 through 2011, as well as thousands of pages of government audits, research papers and other documents.

Federal officials who run the Medicare program repeatedly refused to be interviewed or answer written questions.

Key findings:

  • Federal officials have made billions in “improper” payments to Medicare Advantage plans traced to risk score errors.
  • Medicare Advantage risk scores rose much faster than the national average in hundreds of counties nationwide between 2007 and 2011. That rise in risk scores cost taxpayers more than $36 billion; critics attribute that more to aggressive billing than sicker patients.
  • Though federal health officials have recently disclosed some Medicare billing data, key financial records of Medicare Advantage plans have been kept under wraps.
  • The failure to crack down on health plans that overbill doesn’t bode well for the Affordable Care Act, which relies on a similar risk scoring system.

Thomas Scully, who helped get the program running under President George W. Bush, said rates were generous in hopes of enticing insurers to expand their Medicare business and not shy away from people in poor health.

“We very intentionally tried to overpay them a little bit,” said Scully, now a Washington lobbyist with numerous health care industry clients.

http://www.publicintegrity.org/2014/06/04/14840/why-medicare-advantage-costs-taxpayers-billions-more-it-should

“The Medicare Advantage Money Grab”: http://www.publicintegrity.org/health/medicare/medicare-advantage-money-grab

****

Comment:

By Don McCanne, MD

Medicare Advantage is a program in which our government has conspired with insurers to privatize Medicare, even though it costs far more when private insurers are inserted as intermediaries than it does when Medicare is administered as a public program. This report from The Center for Public Integrity is just the latest that has exposed this outrageous use of our tax funds.

The program was set up to deliberately overpay the plans so that they could offer additional benefits that would entice Medicare beneficiaries into the private plans (see Scully’s comment above). Recognizing these overpayments, Congress included in the Affordable Care Act gradual reductions. Not to be outdone, the insurance industry has conspired with the Obama administration and has enlisted individual members of Congress to fight these reductions. In response, the Obama administration has used dishonest budgetary manipulations to offset a portion of the reductions for 2013, 2014 and 2015.

Even more outrageous is that the private insurance industry has used “innovations” to selectively enroll healthier beneficiaries, yet used “touch of illness” serious diagnostic codes to game risk adjustment, which has rewarded the insurers handsomely for claiming that their beneficiaries were much sicker than they really were. According to this report, federal Medicare officials refused to answer questions about these perverse practices.

The insurance industry has been very successful in framing this as “cutting payments for Medicare,” while mobilizing citizens to demand that these cuts be prevented. The cuts are not in Medicare, but they are a reduction of overpayments to private insurers. Yes, those who sign up with the private plans often have lower out-of-pocket costs, but the rest of us are paying for that through higher taxes and through our Part B Medicare premiums that are partially transferred to the private insurers.

Since we are paying for it, we should be receiving in the traditional Medicare program the same benefits of reduced out-of-pocket expenses. Let the people enrolled in Medicare Advantage keep the same level of benefits, but increase the benefits in the traditional Medicare program to the same level, then fire the private insurers that have been responsible for most of the cost overruns in the Medicare Advantage program.

The politicians seem to agree that we should be spending these excess funds on Medicare, so let’s be fair and spend them equitably on an improved Medicare, but not on insurer profits and waste. While we’re at it, let’s make that an improved Medicare for all.

Lack of funding is the real VA scandal

By Suzanne Gordon
Beyond Chron (San Francisco), June 3, 2014

As the firestorm about wait times at VA facilities continues, political representatives from both parties insist that waits must be eliminated for veterans seeking care. Now that Republicans have succeeded in forcing the resignation of Secretary of the Department of Veterans Affairs, Eric Shinseki, who resigned last week – the new focus is on seeking partial privatization of the system by allowing veterans to get care from private sector doctors – care that would be paid for by the government program. None of the current calls to action, however – whether they include criminal prosecutions of those responsible for secret waiting lists, or channeling vets into the private sector – will fix the wait times at the VA that keep vets from getting needed care.

There are two primary reasons for the problem of wait times. One has to do with Congress’ consistent failure to provide adequate funding so that the VA could hire more staff to care for an increasing number of veterans who live longer with complex service and age related health problems. The other – which may be the biggest and hardest to solve problem of them all – has to do with the US healthcare system’s persistent refusal to provide the number of physicians who deliver primary care services in this country.

Let’s look at the issue of funding. Over the course of the past ten years or more, the VA has been taxed with a population of veterans who have very particular problems. Many of those who survived the Vietnam and first Iraq war are often poor, sometimes homeless, have serious mental health problems and more than the usual share of age related health problems.

Added to this group are veterans who made it through the recent wars in Iraq and Afghanistan. They have survived long enough to be VA patients but with serious and equally special health problems. A not atypical VA patient might have a traumatic brain injury (TBI), plus an amputation, on top of Post Traumatic Stress disorder, combined with the normal problems of people who live longer in advanced industrialized societies – heart disease, diabetes, obesity, cancer, or asthma.

In spite of this increasing load of combat and age related problems, Congress has refused to allocate more funding to the VA.

In February of 2014, Independent Senator Bernie Sanders of Vermont proposed a bill that would have allocated $21 billion that would have improved access to healthcare, education, and other services for US veterans. Republicans – the same ones railing against Shinseki in particular and the VA in general – blocked killed that bill. Here is one typical comment that illustrates the tenor of the debate about adequately funding veterans’ care. “I don’t think our veterans want their program to be enhanced if every penny of the money to enhance those programs is added to the debt of the United States of America,” said Senator Jeff Sessions, (R-Alabama). If you go to this website you’ll hear even more: http://www.sanders.senate.gov/newsroom/video-audio/flashback-republicans-block-va-health-care-funds

The same politicians who killed Sanders’ bill are trying to find out what and who is at the bottom of the VA wait list crisis. It is clearly in their interests to ignore any serious discussion of how precisely the VA supposed to care for all the veterans who depend on its services with the limited resources it has been allocated – resources which Republicans staunchly refuse to increase.

This, in turn, leads to the broader and far more stubborn problem of the persistent shortage of primary care providers in the US.

Consider the preliminary report just issued by the VA’s inspector general. It documents that many of the veterans on waiting lists – secret or otherwise – are those seeking a first appointment in the VA system. The VA has set an ambitious policy of seeing such patients within 14 days of receiving a call for a non-urgent appointment. It considers longer waits of 30 days or more unacceptable. But fulfilling this goal is a mission impossible in a country whose medical education and training system (over which the VA has no control) consistently fails to produce enough primary care providers to care for the needs of an aging population suffering from an increasing number of chronic conditions.

Unlike other healthcare systems in other industrialized countries, students graduating from US medical schools and choosing their area of practice overwhelmingly eschew primary care and are increasingly going into highly paid specialties like gastroenterology, radiology, or orthopedics. Only about 20% of current medical school graduates are entering primary care.(Nursing schools are trying to produce more Nurse Practitioners (NPs) to deal with the crisis in primary care, but have been consistently attacked by MDs who insist that NPs are not well enough educated to provide even routine primary care.)

Even if the VA received the funding it would need to hire more physicians and nurse practitioners, where would they find them? They are simply not there to be hired. Not now and not next year or the next. It takes an average of seven to 12 years to produce a Nurse Practitioner, or Primary Care Physician.

If the US healthcare system suddenly figured out that it needed to produce 30% more primary care physicians than it has (bringing the ratio of primary care physicians to specialists at 50/50, which is what most other industrialized nations achieve), the US healthcare system would have to adjust its skewed incentives and begin producing more primary care providers next year in order to produce enough to care for patients in 2021 or 2026. (This would involve a whole series of reforms that Congress is loath to consider – including making medical and other health professional education free so that people do not incur the kind of huge debts when leaving school that push them in the direction of lucrative specialization among many other things).

Since these kinds of reforms are not even on the radar, the system-wide shortage of primary care providers also makes another “fix” Republicans have proposed almost laughable. Republicans who have long wanted to privatize the VA see a way to begin that process by pushing for creeping privatization. They want the government to allow vets to see physicians in the private sector and pay the freight.

But patients who already have good private insurance have trouble scoring an appointment with a primary care physician. Which is why, as Philip Longman, who wrote a wonderful book about the VA called Best Care Anywhere,  points out in his great interview at Vox, wait times for an appointment in Los Angeles are on average up to 59 days and in Boston up to 63. Newspaper reports like that in the New York Times spotlight vets who have been able to get immediate appointments in the private sector. Well I congratulate them.

Most other people I know, even those with good health insurance have a pretty hard time finding a PCP whose practice is even open to new patients and have to wait a good long time for specialist care as well. How will the nation’s overtaxed primary care doctors suddenly be able to accommodate millions of vets when they can’t handle the patients they already have, plus the influx of patients who will now be insured thanks to the Affordable Care Act?

Critics of the VA are studiously avoiding dealing with the only system-fixes that will solve the problem of wait times at the VA and elsewhere. It’s time for them to stop ranting about accountability and to take some real action to encourage medical students to go into primary care and allow more nurse practitioners to deliver the care our population so desperately needs. And it’s overtime for them to fund the VA at the levels necessary to serve the needs of America’s vets.

http://www.beyondchron.org/news/index.php?itemid=12674#more

Center for Public Integrity on the Medicare Advantage Money Grab

The Medicare Advantage Money Grab

The Center for Public Integrity, June 4, 2014

Why Medicare Advantage costs taxpayers billions more than it should

By Fred Schulte, David Donald and Erin Durkin

(Medicare Advantage) plans have sharply driven up costs in many parts of the United States — larding on tens of billions of dollars in overcharges and other suspect billings based in part on inflated assessments of how sick patients are, an investigation by the Center for Public Integrity has found.

Dominated by private insurers, Medicare Advantage now covers nearly 16 million Americans at a cost expected to top $150 billion this year. Many seniors choose the managed-care Medicare Advantage option instead of the traditional government-run Medicare program because it fills gaps in coverage, can cost less in out-of-pocket expenses and offers extra benefits, such as dental and eye care.

But billions of tax dollars are misspent every year through billing errors linked to a payment tool called a “risk score,” which is supposed to pay Medicare Advantage plans higher rates for sicker patients and less for those in good health.

Government officials have struggled for years to halt health plans from running up patient risk scores and, in many cases, wresting higher Medicare payments than they deserve, records show.

The Center’s findings are based on an analysis of Medicare Advantage enrollment data from 2007 through 2011, as well as thousands of pages of government audits, research papers and other documents.

Federal officials who run the Medicare program repeatedly refused to be interviewed or answer written questions.

Key findings:

  • Federal officials have made billions in “improper” payments to Medicare Advantage plans traced to risk score errors.
  • Medicare Advantage risk scores rose much faster than the national average in hundreds of counties nationwide between 2007 and 2011. That rise in risk scores cost taxpayers more than $36 billion; critics attribute that more to aggressive billing than sicker patients.
  • Though federal health officials have recently disclosed some Medicare billing data, key financial records of Medicare Advantage plans have been kept under wraps.
  • The failure to crack down on health plans that overbill doesn’t bode well for the Affordable Care Act, which relies on a similar risk scoring system.

Thomas Scully, who helped get the program running under President George W. Bush, said rates were generous in hopes of enticing insurers to expand their Medicare business and not shy away from people in poor health.

“We very intentionally tried to overpay them a little bit,” said Scully, now a Washington lobbyist with numerous health care industry clients.

http://www.publicintegrity.org/2014/06/04/14840/why-medicare-advantage-c…

“The Medicare Advantage Money Grab”:http://www.publicintegrity.org/health/medicare/medicare-advantage-money-…

Medicare Advantage is a program in which our government has conspired with insurers to privatize Medicare, even though it costs far more when private insurers are inserted as intermediaries than it does when Medicare is administered as a public program. This report from The Center for Public Integrity is just the latest that has exposed this outrageous use of our tax funds.

The program was set up to deliberately overpay the plans so that they could offer additional benefits that would entice Medicare beneficiaries into the private plans (see Scully’s comment above). Recognizing these overpayments, Congress included in the Affordable Care Act gradual reductions. Not to be outdone, the insurance industry has conspired with the Obama administration and has enlisted individual members of Congress to fight these reductions. In response, the Obama administration has used dishonest budgetary manipulations to offset a portion of the reductions for 2013, 2014 and 2015.

Even more outrageous is that the private insurance industry has used “innovations” to selectively enroll healthier beneficiaries, yet used “touch of illness” serious diagnostic codes to game risk adjustment, which has rewarded the insurers handsomely for claiming that their beneficiaries were much sicker than they really were. According to this report, federal Medicare officials refused to answer questions about these perverse practices.

The insurance industry has been very successful in framing this as “cutting payments for Medicare,” while mobilizing citizens to demand that these cuts be prevented. The cuts are not in Medicare, but they are a reduction of overpayments to private insurers. Yes, those who sign up with the private plans often have lower out-of-pocket costs, but the rest of us are paying for that through higher taxes and through our Part B Medicare premiums that are partially transferred to the private insurers.

Since we are paying for it, we should be receiving in the traditional Medicare program the same benefits of reduced out-of-pocket expenses. Let the people enrolled in Medicare Advantage keep the same level of benefits, but increase the benefits in the traditional Medicare program to the same level, then fire the private insurers that have been responsible for most of the cost overruns in the Medicare Advantage program.

The politicians seem to agree that we should be spending these excess funds on Medicare, so let’s be fair and spend them equitably on an improved Medicare, but not on insurer profits and waste. While we’re at it, let’s make that an improved Medicare for all.

Large variation in cost-sharing reductions in silver plans harms patients

Analysis of Benefit Design in Silver Plan Variations

By Kelly Brantly, Hillary Bray and Caroline Pearson
Avalere Health, June 2014

Both state-based and federally-facilitated exchanges offer financial assistance for low-income enrollees. The assistance takes two forms: advanced premium tax credits and cost-sharing reductions (CSRs). This report focuses on CSR plans, which are available to individuals and families earning between 100% of the federal poverty level (FPL) and 250% FPL.

CSR plans use federal subsidies to increase their actuarial value (AV) and lower cost-sharing for low-income exchange enrollees. Avalere Health conducted an analysis of the standard silver and CSR plans offered in the federally-facilitated exchange (FFE) that spans 34 states.

  • Cost-sharing reductions are more often applied across multiple types of benefits
  • in 94% and 87% AV plans compared to 73% AV plans. 
  • Many CSR plans have MOOP (maximum out-of-pocket) limits lower than the amount required by law. 
  • Almost all CSR plans feature lower deductibles than the standard silver plans, though wide variation remains.
  • Consistent with standard silver plans, copays for specialist visits are higher than those for primary care visits.
  • Low-income consumers may face very high coinsurance for drugs on tiers three and four, which is least likely to be reduced in CSR plans.

The large variation in co-payments, co-insurance, and deductibles required by CSR plans may not be clear to exchange enrollees with limited income.

Across all CSR plans, there is broad variation in how issuers reduce cost-sharing across benefit categories relative to the standard silver plans. Because issuers have a high level of flexibility in designing these CSR plans, cost-sharing amounts vary across services and in some cases mirror the cost-sharing in standard silver plans.

The large variation in how plans apply the cost-sharing reductions across covered benefits may not be clear to consumers while they are shopping and comparing plans.

Notably, consumers with the lowest income who qualify for the highest level of financial assistance (100% to 150% FPL) could encounter some 94% AV CSR plans with cost-sharing requirements for specific services that are identical to standard silver plans. Even for CSR plan cost-sharing that is reduced, out-of-pocket costs could still serve as a barrier to accessing care.

(This analysis was funded by PhRMA.)

At this link, click “Download PDF” for full report: http://avalerehealth.com/expertise/managed-care/insights/avalere-analysis-cost-sharing-reductions-unevenly-applied-across-services-i

****

Comment:

By Don McCanne, MD

This report provides a highly technical explanation of the great variation in cost-sharing provisions for lower-income individuals insured by the various silver plans in the exchanges. This is just another example of the unnecessary increase in administrative complexity brought to us by the Affordable Care Act.

What is particularly egregious is the intolerably high cost-sharing required of low-income individuals who need higher-tier drugs. High cost drugs, such as those used to treat hepatitis C or those that meet the expanded recommendations for HIV prophylaxis, will be unaffordable for individuals with low incomes, in spite of the cost-sharing reductions.

By making these drugs unaffordable, the insurers accomplish two ends: 1) the cost sharing is so high that many lower-income individuals will not fill their prescriptions, saving the insurers those costs, and 2) those with chronic hepatitis C, those at high risk of HIV exposure, or the many others who have  disorders requiring expensive tier 4 drugs will likely select other insurers once they realize that the drugs that they need will be unaffordable (favorable selection). These are some of the newer innovations that the insurers are using since they are now prohibited from using medical underwriting to deny insurance to individuals with greater anticipated health care costs.

More administrative complexity. More insurer chicanery. More inequity in the provision of health care. And this is because our politicians selected the most expensive model of health care reform – one that places insurers and pharmaceutical firms above patients. Many studies have shown that the most efficient and equitable model of comprehensive health care coverage – single payer – is also the least expensive of the comprehensive models of reform. Amongst other important measures, it would put pharmaceutical firms in their place, and it would dismiss the intrusive and wasteful insurers from the scene.

We can still do that.

Retired doctor reflects on his 90 years in new book

By Ross Forman
Windy City Times (Chicago), June 3, 2014

Quentin Young offers his take on a variety of topics, including people, politics and policies, in his new book: “Everybody In, Nobody Out: Memoirs of a Rebel Without a Pause.”

Young certainly speaks from experience. He celebrated his 90th birthday last September.

Born and raised in Chicago, and still calling the Hyde Park area home, Young is now in California, opting out of the Chicago cold and snow.

“I’ve lived a long life, so there’s a lot to tell. I like the book; it really tells the story of [my] 90 years,” Young said.

The book was published in late 2013.

Written in collaboration with Steve Fiffer, Young’s memoir offers a rare glimpse inside the mind of a fearless advocate for a single-payer health system, following his path through the civil-rights movement on through his stint as the head of Cook County Hospital.

Young retired in 1985.

“We’re in deep trouble in terms of health care, at least that’s my point of view,” said Young, who spent about 18 months writing the book that travels his 90 years. “I think the book does a pretty decent job of tracing the fight for national health insurance. We’re a country of 50 states, and there’s a different story in every state.

“The thing I like the most about the book is, the success of the senior component, Medicare. It’s been a dramatic economic change [over the years].”

In fact, Young added, “We’ve had a century of progress, and I’ve seen so many changes,” in the medical world.

The medical world of 2014 is seemingly at a paradox, trying to figure out what’s the best plan, he said. “Every polls seems to show that American people want to be covered against health-care costs. No one wants to go bankrupt because of a major illness,” he said.

Young attended Northwestern University Medical School in the 1940s and interned at Cook County Hospital, where he also did his residency. He was a founder and served as national chairman of the Medical Committee for Human Rights, which was formed in 1964 to provide medical care for civil rights workers, community activists, and summer volunteers working in Mississippi.

He also was noted for providing emergency medical care to protesters at the 1968 Democratic National Convention in Chicago.

He retired from private practice in 2008.

Then, in 2009, Young was appointed by Illinois Governor Pat Quinn to Chair the Illinois Health Facilities Planning Board.

Young said he still remains active in medical world, particularly on the economics of health care.

So where do you see health care in the future?

“It’s a question of whether we will have a single-payer system, or we’ll have a chopped up system with all different kinds of various benefits, depending on where you work, or whether you work, and how old you are. People don’t like that uncertainty.

“I’m hopeful, before I leave this world, that I’ll see national health insurance.”

Young tagged it as a 50-50 odds that a national health insurance program will materialize.

“I think the next five years will tell the story,” he said.

When asked about the early days of the HIV era, of about 33 years ago, Young said, “That’s a very delicate subject; it was a very important time. In the … early 1980s, that was a time when so many people would get [diagnosed] and then die within three or four years, or sooner. It was a horrible death. Eventually, people were able to live with HIV, if they took the proper medication.”

Young treated HIV/AIDS patients, and prominently promoted prevention, most notably through safe sex.

http://www.windycitymediagroup.com/lgbt/Retired-doctor-reflects-on-his-90-years-in-new-book/47674.html

Privatization won’t fix the VA

By Suzanne Gordon
The Boston Globe, May 27, 2014

First it was Social Security, then Medicare and Medicaid, and then the public health care option under Obamacare. Now, in the wake of recent allegations that veterans hospitals put patients on secret wait lists, Republicans are calling for the privatization of the Veterans Health Administration, the nation’s largest public health care system which provides cost-effective and high quality care to 6.2 million veterans.

It is of course unacceptable if patients suffered as a result of any delays. But regardless of what went wrong at any VA facility, turning veterans over to private sector insurers and for-profit hospitals is not the solution.

With its salaried staff of nearly 280,000, the VA has long been a model for health care delivery. The VA’s 152 hospitals, 900 clinics, 300 mental health centers, and other facilities — many located in rural areas that the private sector ignores — care for more than 230,000 people a day. In a recent survey of veterans for the American Customer Satisfaction Index, patients rated the system’s services as equal to or better than private sector health care facilities.

One reason is the VA’s systematic efforts to improve quality care and patient safety. The VA computerized medical records long before private hospitals. The VA conducts widespread training on inter-professional communication and teamwork that decreases patient deaths and injuries due to the kind of medical mistakes and problems that kill over 400,000 patients a year. In 2007, the VA launched a successful initiative to dramatically reduce the dangers of one the deadliest hospital superbugs — methicillin-resistant Staphylococcus aureus.

The VA has singular expertise in the treatment of post-traumatic stress disorder. Many injured soldiers have returned from Iraq and Afghanistan with what is known as poly-trauma — PTSD plus traumatic brain injury and limb amputations. Few primary care physicians — or even specialists — have much experience treating such cases in the private sector. In fact, without the VA, vets would have trouble getting any primary care services given the serious shortage of primary care providers in this country.

Because the VA is a public entity, its facilities actually display greater accountability — and more transparency to patients and their families — than private health care systems. When veterans have a VA-related beef — or in-house whistle-blowers a tale to tell — they are quick to notify their elected representatives. Such complaints regularly trigger individual constituent service queries from members of Congress or, as is the case today, oversight hearings by House and Senate committees. (Good luck triggering a similar rapid response to patient or staff complaints in the private sector.)

The US Inspector General now has a task force probing the VA in Phoenix, which is accused of hiding long delays before veterans could see doctors. As Senator Bernie Sanders of Vermont, chairman of the Senate Veterans’ Affairs Committee, said, “It’s imperative that we uncover the problems that exist and address them boldly.” What’s already known is that the VA system in Phoenix cares for 80,000 vets, many of them older and with serious, chronic health conditions. If some waited too long to be seen, maybe it’s time for Congress and the White House to figure out how to free up funds to care for veterans who are living longer with more complex conditions.

Doing this would be far better for them and the nation than privatizing a system that is, in fact, a model for broader health care reform.

Suzanne Gordon’s latest book is “Beyond the Checklist: What Else Health Care Has to Learn from Aviation Teamwork and Safety.”

http://www.bostonglobe.com/opinion/2014/05/27/privatization-won-fix/OyQgH0er1VXFNfkQTy01tI/story.html

Large variation in cost-sharing reductions in silver plans harms patients

Analysis of Benefit Design in Silver Plan Variations

By Kelly Brantly, Hillary Bray and Caroline Pearson
Avalere Health, June 2014

Both state-based and federally-facilitated exchanges offer financial assistance for low-income enrollees. The assistance takes two forms: advanced premium tax credits and cost-sharing reductions (CSRs). This report focuses on CSR plans, which are available to individuals and families earning between 100% of the federal poverty level (FPL) and 250% FPL.

CSR plans use federal subsidies to increase their actuarial value (AV) and lower cost-sharing for low-income exchange enrollees. Avalere Health conducted an analysis of the standard silver and CSR plans offered in the federally-facilitated exchange (FFE) that spans 34 states.

  • Cost-sharing reductions are more often applied across multiple types of benefits
  • in 94% and 87% AV plans compared to 73% AV plans.
  • Many CSR plans have MOOP (maximum out-of-pocket) limits lower than the amount required by law.
  • Almost all CSR plans feature lower deductibles than the standard silver plans, though wide variation remains.
  • Consistent with standard silver plans, copays for specialist visits are higher than those for primary care visits.
  • Low-income consumers may face very high coinsurance for drugs on tiers three and four, which is least likely to be reduced in CSR plans.

The large variation in co-payments, co-insurance, and deductibles required by CSR plans may not be clear to exchange enrollees with limited income.

Across all CSR plans, there is broad variation in how issuers reduce cost-sharing across benefit categories relative to the standard silver plans. Because issuers have a high level of flexibility in designing these CSR plans, cost-sharing amounts vary across services and in some cases mirror the cost-sharing in standard silver plans.

The large variation in how plans apply the cost-sharing reductions across covered benefits may not be clear to consumers while they are shopping and comparing plans.

Notably, consumers with the lowest income who qualify for the highest level of financial assistance (100% to 150% FPL) could encounter some 94% AV CSR plans with cost-sharing requirements for specific services that are identical to standard silver plans. Even for CSR plan cost-sharing that is reduced, out-of-pocket costs could still serve as a barrier to accessing care.

(This analysis was funded by PhRMA.)

At this link, click “Download PDF” for full report:http://avalerehealth.com/expertise/managed-care/insights/avalere-analysi…

This report provides a highly technical explanation of the great variation in cost-sharing provisions for lower-income individuals insured by the various silver plans in the exchanges. This is just another example of the unnecessary increase in administrative complexity brought to us by the Affordable Care Act.

What is particularly egregious is the intolerably high cost-sharing required of low-income individuals who need higher-tier drugs. High cost drugs, such as those used to treat hepatitis C or those that meet the expanded recommendations for HIV prophylaxis, will be unaffordable for individuals with low incomes, in spite of the cost-sharing reductions.

By making these drugs unaffordable, the insurers accomplish two ends: 1) the cost sharing is so high that many lower-income individuals will not fill their prescriptions, saving the insurers those costs, and 2) those with chronic hepatitis C, those at high risk of HIV exposure, or the many others who have  disorders requiring expensive tier 4 drugs will likely select other insurers once they realize that the drugs that they need will be unaffordable (favorable selection). These are some of the newer innovations that the insurers are using since they are now prohibited from using medical underwriting to deny insurance to individuals with greater anticipated health care costs.

More administrative complexity. More insurer chicanery. More inequity in the provision of health care. And this is because our politicians selected the most expensive model of health care reform – one that places insurers and pharmaceutical firms above patients. Many studies have shown that the most efficient and equitable model of comprehensive health care coverage – single payer – is also the least expensive of the comprehensive models of reform. Amongst other important measures, it would put pharmaceutical firms in their place, and it would dismiss the intrusive and wasteful insurers from the scene.

We can still do that.

Selected letters on the VA scandal

The following four letters to the editor represent a sampling of opinion by single-payer advocates across the U.S. on the recently exposed wait-time problems in the Veterans Health Administration. For more on the current VA situation, see PNHP’s Articles of Interest and Dr. Don McCanne’s Quote of the Day.

The VA scandal, and the ones beyond

By Inge De Becker, M.D.
Star Tribune (Minneapolis), Letters, May 31, 2014

True, the VA has waiting lists, real and fake. We spend fortunes to send youngsters to war, yet underfund their care when they come home. They suffer for no good reason.

That is unacceptable.

Here’s what else is unacceptable. Even with the Affordable Care Act, 30 million U.S. people will remain uninsured. No one keeps their waiting lists, but each year tens of thousands will die because they lack adequate access to medical care. Nearly half of the states refuse to expand Medicaid, effectively condemning more than 7,000 uninsured each year to preventable deaths. Medical bills remain the leading cause of bankruptcy. We don’t have enough primary care physicians, both inside and outside the VA.

Even the best programs could be better, and doctoring waiting lists must stop, but patient surveys still make the VA the highest-rated health care program in the country. Let’s face it. The VA is a public, single-payer health care program. The day the United States and Minnesota choose an adequately funded, public single-payer system, everyone will have access to timely care, and everyone will be protected from financial disaster in time of illness.

Now that is acceptable.

Dr. Inge De Becker resides in St. Paul.

http://www.startribune.com/opinion/letters/261324261.html

*****

We need improved Medicare for all

By G. Richard Dundas, M.D.
Bennington (Vt.) Banner, Letters, June 4, 2014

We read in the Banner that as many as 40 veterans may have died in Phoenix because they could not get needed care at the VA hospital. This is truly outrageous (surely an overused adjective but probably better than disgraceful). We must do better for our veterans.

Here is another statistic that you may or may not want to know depending on your political mindset. It is estimated that in 2013 there were over 40,000 Americans (not a misprint) who died because they had no health insurance and could not access health care in a timely manner. This is similarly outrageous.

I long for the day when we Americans are smart enough to elect leaders who can translate outrage into action. The action that we need is improved Medicare for all. Everybody in, nobody out.

Dr. G. Richard Dundas resides in Bennington.

http://www.benningtonbanner.com/opinion/ci_25891663/letters-we-need-i

*****

Addressing the problems at the VA

By Philip R. Lee, M.D., and Philip Caper, M.D.
The New York Times, Letters, June 2, 2014

Part of the cause of the long waiting times in the V.A. system is surely a combination of the V.A.’s difficulties in recruiting doctors (especially primary care doctors) and the surge in demand in recent years due to our military interventions in Iraq and Afghanistan. Neither of these causes of the current backlog will be fixed quickly.

If Congress is serious about helping to alleviate the problem and showing our gratitude to and support for our veterans, it will expand Medicare coverage to include all veterans. If that is done, our veterans could choose between the V.A. system and any doctor who participates in Medicare.

Medicare is approaching its 50th anniversary as one of the most durable, successful and popular federal programs ever created. Do our veterans deserve any less?

Dr. Lee, a Korea veteran, was an assistant secretary for health in the Johnson and Clinton administrations. Dr. Caper was a senior health care adviser to Senator Edward M. Kennedy; he resides in Brooklin, Maine.

*****

Single-payer would fix health care

By Bob Fischer
Register Guard (Eugene, Ore.), Letters, June 2, 2014

In his May 24 letter Roger Russell said the serious problems at Veterans Affairs hospitals have to do with allegations of veterans waiting weeks or months to see a doctor, malpractice, fraud and even unnecessary deaths.

Those are symptoms of serious problems related to the VA’s size and financing. It’s too small to handle the enormous need, and it doesn’t receive the resources it needs to do the job.

Russell said having a single-payer system would mean the federal government would take over and control the nation’s health care system. That’s wrong, too, with the error due to confusing health care financing with health care delivery.

Single-payer is about financing health care. It’s like Medicare. Under a single-payer system, the government pays the bills and health care delivery is left in the hands of doctors, nurses and other health care professionals, a matter between patients and their doctors. Unlike private insurance companies, the government doesn’t intrude or interfere.

Single-payer means the for-profit insurance industry is taken out of the health care equation. Private insurance companies are the reason Americans pay twice as much for health care as people of other industrialized nations, and they’re the reason we get worse health care outcomes.

If we want to fix our health care system, single-payer is the only way to do it.

Bob Fischer resides in Bandon, Ore.

http://registerguard.com/rg/opinion/31640663-78/care-health-eugene-system-payer.html.csp

Physicians: Independent professional practitioners or employees controlled by health care’s big players?

By Edgar A. Lopez, M.D., F.A.C.S.
Louisville Medicine, Letters, June 2014 

In the New York Times issue of February 14, 2014, an article written by Elisabeth Rosenthal and titled, “Apprehensive, many doctors shift to jobs with salaries,” the following information caught my attention:

Today, accordingly to the AMA statistics, in the USA:

  • 60 percent of family doctors and pediatricians are employees 
  • 50 percent of general surgeons are employees
  • 25 percent of surgical specialists including ENT, ophthalmologists and others are employees

In 2007, 24 percent of cardiologists were employed; it jumped to 35 percent in 2012.

Local hospitals in the state of New Jersey bought, just recently, 22 private cardiology practices.

These statistics reflect the rapid demise of the concept of the private delivery of medical care that has fallen in this country into the tentacles of the private health insurance companies that continue to siphon off, in a macabre way, the tax money that is supposed to be used for health care. Instead the funding of private health care in the USA, the richest industrialized country in the world, is all about profiteering and the Wall Street dance of the stock market as it relates to escalating health care costs for everybody.

In the meantime, the Affordable Care Act has only brought more sophistication to the profiteering process of the private health insurance companies while still more than 45,000 citizens a year die because of lack of health insurance. Believe you me these victims are hard-working middle-class citizens; they are not the immigrants (documented or otherwise), they are not the veterans of war, they are not from the top 1 percent, they are not from below the poverty line, they are hard-working individuals, low-level executives and college graduates, adjunct professors, low-level employees of the same private health insurance companies, etc., who carry exorbitant deductibles in the newly baptized Platinum, Gold, Silver, Bronze plans that, in my opinion, rather than precious metals’ names, should be called “chatarra” (which in Spanish means: scrap metal).

The concept of incremental health care reform sponsored traditionally and continuously by serious institutions like the AMA and the American College of Surgeons is another clear manifestation of a non-viable, non-sustainable system for funding and delivery of health care. It just doesn’t work, and the price for the ones left behind the affordability wagon is: death, debt, despair and mental illness plaguing the streets.

When you have an acute catastrophic illness and you are, for whatever reason, underinsured or even worse uninsured (don’t know which one is worse) there is absolutely no time to wait for incremental shenanigans.

My dear colleagues, the only viable solution to save the private practice of medical care (funding and delivery) in this country, and at the same time serve Everybody In and Nobody Out, is a single-payer system based on the bill introduced in the U.S. Congress on repeated occasions through the years by Rep. John Conyers: H.R. 676. We can call it also: Improved-Expanded Medicare for All, from birth to death and without the participation of the private health insurance industry. That bill will save at least $400 billion a year, to begin with. H.R. 676 is properly explained on the Web. Just google H.R. 676 and read the bill. Everybody’s back is covered, including the low-level employees of the private health insurance companies.

I want to respectfully invite the current president of the GLMS [Greater Louisville Medical Society] and the president-elect to a public conversation including members of GLMS to discuss why H.R. 676 doesn’t have the support of certain medical organizations. It is not even discussed. You bring your team of experts and I will bring mine.

Logistics and details can be properly planned.

Dr. Edgar Lopez is a member of Physicians for a National Health Program (PNHP) and a founding member of the Kentucky chapter of PNHP.

https://www.glms.org/Content/User/Documents/Publications/LouisvilleMedicineJune2014.pdf