Summary: In Part 1, we discussed how primary care is being acquired and distorted by huge corporations pursuing massive profits. Today, we present a competing vision: a broad social movement to reclaim primary care as a “common good” focused on public benefit.

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Forging a Social Movement to Dismantle Entrenched Power and Liberate Primary Care as a Common Good, Annals Of Family Medicine, March/April 2023, by Kevin Grumbach

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Abstract

The state of family medicine and primary care in the United States is precarious, afflicted by chronic underinvestment. Family physicians and their allies should not expect different policy outcomes without adopting a different theory of change and tactical approach to reform. I argue: (1) high-quality primary care is a common good, as asserted by the National Academies of Sciences, Engineering, and Medicine; (2) a market-based health system captured by extractive capitalism is inimical to primary care as a common good; (3) professionalism has both aided and constrained family physicians as agents of change for primary care as a common good; and, (4) to actualize primary care as a common good, family physicians must embrace “counterculture professionalism” to join with patients, primary care workers, and other allies in a social movement demanding fundamental restructuring of the health system and democratization of health that takes power back from interests profiting from the status quo and reorients the system to one grounded in healing relationships in primary care. This restructuring should take the form of a publicly financed system of universal coverage for direct primary care, with a minimum of 10% of total US health spending allocated to Primary Care for All.

Over past decades, several waves of health reform and advocacy efforts offered hope of revitalizing the specialty of family medicine and the primary care sector: the rise of managed care in the 1990s; the Joint Principles of the Patient- Centered Medical Home in 2007; enactment of the Patient Protection and Affordable Care Act in 2010; the launching of Family Medicine for America’s Health in 2013. Yet the reality on the ground has not fundamentally improved for family physicians and others working in primary care, or for patients struggling to obtain high-quality primary care. Between 2005-2015, the number of primary care physicians per capita in the United States declined, primary care visits per capita decreased, and waiting times for new primary care appointments lengthened. The earnings gap between primary care physicians and physicians in other specialties widened and burnout remains high. Most tellingly, only about 5% of national health expenditures in the United States are spent on primary care—one-half or less than the proportion spent in Canada and Europe. …

A Social Movement for Primary Care as a Common Good

To actualize primary care as a common good, family physicians must embrace what I call “counterculture professionalism” to join with patients, community members, primary care workers, and other allies to build a broad-based social movement demanding a fundamental restructuring of the health system and democratization of health that takes power back from interests profiting from the status quo and reorients the system to one grounded in healing relationships in primary care. A social movement must have clarity about what it wants to achieve, and how to achieve it. …

By social movement, I mean a coming together of people and organizations united by a sense of common purpose counter to the dominant power. The consequential issues of our times—climate change, systemic racism, inequality of wealth, gun violence, reproductive rights, among others—are all contests for the common good. Progress requires an activated citizenry working in solidarity to challenge profits, power, and privilege that harm collective well-being. High quality primary care for all is not simply a parochial interest for family medicine. In the US context, it is a radical proposition that calls for family physicians to find common cause with others who share this goal.

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Comment:

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

Kevin Grumbach (a colleague at UCSF) is a long-time leader in the single payer movement and in family medicine. He is thoroughly frustrated by the failure of typical policy tools – laws and high-profile reports – to mitigate the declining role of primary care in US health care. Our population suffers as a result.

Addressing family medicine doctors, Kevin proposes a broad-based social movement to reclaim primary care. His call to action is stirring. Kevin is realistic about the challenges facing social change, given powerful entrenched opponents. Yet he sees a movement as the only chance to revive primary care, given the futility of traditional policy levers.

Should the single payer movement endorse “primary care for all”, leaving specialist and hospital care for the time being in the hands of existing insurers and providers? Kevin proposes that a “successful PC4All program might prompt the nation to consider not only primary care, but all health care, to be a common good, and to join other countries with advanced capitalist economies in implementing a comprehensive, tax-financed universal health care program.”

Is “primary care for all” a stepping-stone for “health care for all”?

Maybe the more circumscribed revolution has a greater chance of success, demonstrating the value of a public approach to health care financing, and building the large and strong coalition needed for comprehensive health system transformation.

Lots to contemplate here.

http://healthjusticemonitor.org…

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Summary: Check out this terrific online conference.

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The theme is “Everybody In: Racial Equity & Medicare for All.”

Lots of great speakers—knowledgeable activists.

Register here: https://medicareforall23.sched.com

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

Summary: In the first of two posts, we discuss a blog on how primary care is being acquired and distorted by huge corporations seeking massive profits by exploiting CMS value-based care, specifically capitation. The excerpt, a bit more than usual, is worth a read. Next time we’ll examine a proposal for making primary care a publicly-financed common good.

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Explaining Corporate America’s Aggressive Investment In Primary Care, Health Affairs Forefront, April 5, 2023, by Paul A. Branstad & Claude R. Maechling

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Not that long ago, primary care practices sold for hundreds of dollars per patient, depending on how “fat” their files were and what proportion were economically undesirable Medicare patients. …

Now, suddenly, the likes of Amazon, CVS Health, Walgreens, Walmart, UnitedHeath, and Humana are vying to acquire and build primary care practices targeted at serving the US’s seniors. …  and the competition has driven prices north of $50,000 per patient. When the US finally grasps what is going on, how this competition was triggered in the first place, and what the long-term consequences will be, none of us will like it. …

Too late will we realize we have lost our last best chance to reinvent a health care system centered around the large-scale provision of high-quality primary care—even though this is what value-based contracts started out trying to do. The problem lies not with the Centers for Medicare and Medicaid Services’ (CMS’s) intentions, but with how the game they have structured plays out. …

The root cause of the $50 billion investment frenzy is the financial opportunity created by CMS’s commitment to convert all Medicare beneficiaries to accountable care relationships with value-based payment models. … [this] is just table stakes to vie for the $1 trillion prize that McKinsey and Company estimates will be claimed by the winners among the consumer oligopolists competing for the prize. …

CMS seems to lack the foresight to anticipate how market forces will adapt and respond to its policies, so it is not able to foresee unintended consequences of its reimbursement and insurance practices. … CMS’s tortuous primary care reimbursement practices have been more than 30 years in the making and have led directly to the erosion of the central role that primary care physicians could and should play. …

Our conclusion is: CMS’s commitment to value-based contracting is simply the next stage of its long-standing, philosophical aversion to fee-for-service reimbursement. This aversion is reflected in the increasing justification and reporting requirements imposed on primary care physicians, requirements that represent an affront to their integrity and challenge their medical judgment. The resulting suppression of practice revenue and increased administrative burden have pushed many previously independent primary care physicians past their breaking point and into the arms of hospital-based health systems.

It is not mere coincidence that, over the past decade, the percentage of primary care physicians employed by a hospital-based health system or corporate entity has increased from 36 percent to 74 percent, while MA coverage of Medicare beneficiaries increased from 27 percent to nearly 50 percent.

The issue is not about who owns primary care practices but about how the proliferation of value-based contracts in Medicare is leading to a profound change in the historic physician-patient relationship. The health systems and corporations that own primary care practices often find it most efficient to organize care delivery around CMS’s process-of-care measures to maximize their reimbursement opportunity. So physicians who, heretofore, practiced patient-centered medicine that earned trust by focusing on personalized diagnostic and treatment services, are now obliged to align with these same quality protocols. They are being told how to drive from the passenger’s seat, while the patient is moved to the back.

The economic heart of value-based contracts is negotiation over capitation, in which aspiring MA plans bid to manage all care for a group of patients, according to prescribed CMS protocols, for a fixed price per patient. …

The [price] benchmark is subject to … adjustments. First, the benchmark can be increased by 5 percent, a “quality” bonus, if the MA plan earns a four on CMS’s star rating performance measurement system. The system is based on 46 measures of access, process, patient experience, and clinical quality and is indexed such that, last year, 90 percent of MA enrollees were in plans rated four stars or higher.

Second, the benchmark is adjusted in subsequent years for the risk score of the enrolled population. … [I]ntensive coding efforts translate into higher risk scores when the plan comes up for annual renewal.

[Discussion of risk selection, which lowers costs in Medicare Advantage and assures that individuals remaining in traditional Medicare – which determines payment benchmarks – will be increasingly expensive over time.]

What will be the consequences for Americans?

[C]onsolidation will raise the cost of care without any improvement in care capacity or quality….

Researchers estimate that Medicare Advantage will cost CMS $75 billion more in each of the coming years … less than 2 percent of national health expenditures … But it becomes far more significant when we think of it in terms of primary care. The US spends about $100 billion on primary care physician consultations … the money wasted on VBC overpayments could be put to very productive use remedying primary care underinvestment.

Spent correctly, this $75 billion could make a huge contribution to solving the biggest health care problem we have in this country—a lack of primary care to address the high burden of chronic disease. Reinvesting the funds could create comprehensive, relationship-based, personalized care overseen and coordinated by trusted, in-charge primary care physicians who have the time to make full use of their clinical reasoning …

Tragically, conversion to VBC plans will also undermine efforts to address the social determinants of health for disadvantaged communities. When we sacrifice higher-quality, relationship-based primary care medicine, we also sacrifice the opportunity for a physician to understand each patient’s biography, or lived experience, which arguably contributes as much to their ill-health as their biology or genetics.

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Comment:

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

This article ably reviews how CMS’ extreme focus on value-based care undermines rather than strengthens primary care. My only addition is to highlight that ACO REACH, in traditional Medicare, is headed down the same path, as we’ve previously discussed in HJM.

Key points:

• CMS capitation rules, most visibly in Medicare Advantage, offer corporations – especially those owning primary care practices – massive profit opportunities.
• As a result the value and price of primary care practices has shot up more than 100-fold.
• Profit tactics include risk selection (finding and keeping less expensive enrollees), exaggerated diagnostic coding, and maintaining process-of-care quality scores. Corporate maneuvers to manipulate these mechanisms outflank CMS technical and political abilities to oversee them.
• A long-standing aversion to fee-for-service payment leads to onerous requirements imposed on primary care doctors, driving them to sell to and work for corporations.
• Corporate tactics to maximize profits often conflict with and displace comprehensive, high quality primary care.
• Physicians become cogs in this machine, their pursuit of quality primary care shunted aside. Patients must follow along. The physician-patient relationship is undermined.
• $75 billion dollars per year in overpayments, largely directed to profits, could save primary care.
• The opportunity to address patient-specific social determinants of health – critical to pursuing equity – is squeezed out.

Next time – a proposal for doctors and allies to join in a social movement to make primary care a publicly-financed common good.

http://healthjusticemonitor.org…

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Summary: CMS just finalized the 2024 payment rule for Medicare Advantage, weakening the draft rule. There remain massive overpayments and widespread barriers to care. These fundamental problems are inevitable with reliance on private insurer intermediaries.

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Biden Just Took the First Step to Overhaul Medicare Advantage. Many More Must Be Taken, Common Dreams, April 7, 2023, by Diane Archer

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The corporations that run Medicare Advantage plans are engaged in widespread waste, fraud and abuse, resulting in tens of billions of dollars of overpayments to them every year. The advocates and government agencies overseeing Medicare Advantage have spent nearly two decades reporting on this fraud and waste and urging Congress to overhaul the program. Few in Congress or the administration were listening. Now, the Biden administration is finally taking action, but it’s only a first step.

The Biden administration has just finalized a rule that begins to rein in these overpayments, at last putting a spotlight on an issue that Congress and the public have long overlooked. The new rule is a small step towards reining in some of the overpayments to the Medicare Advantage plans and protecting the integrity of the Medicare Trust Fund, though it is not nearly enough.

The insurance industry’s fierce opposition and the multi-million dollar fear campaign the health insurance corporations launched against the proposed rule was their admission that Medicare Advantage plans can’t provide coverage at a reasonable cost. Medicare Advantage only works for the insurers if they are wildly overpaid and profiting exorbitantly. It was their admission that they cannot do what they were created to do and are legally obligated to do. They cannot deliver Medicare coverage anywhere near as cost-effectively as traditional Medicare, let alone at lower cost, as they had promised.

The fight over small improvements to the flawed Medicare Advantage payment system reveals how challenging it is to fix Medicare Advantage and free it of the bad actors who are engaged in massive — sometimes fraudulent — overbilling of Medicare. Medicare Advantage is in need of a substantial overhaul, as the advocates, along with the Medicare Payment Advisory Commission, the Government Accountability Office and the Office of the Inspector General, have all been saying for years. …

The Biden administration also recently finalized another rule, aimed at addressing widespread and persistent inappropriate delays and denials of care in Medicare Advantage. Among other things, the rule attempts to streamline the Medicare Advantage prior authorization process. It spotlights and begins to address the serious risks some Medicare Advantage plans pose to the health and well-being of their enrollees — our nation’s sisters and brothers, parents and grandparents.

Though it goes further than any past rule in its attempt to protect Americans from the bad actor Medicare Advantage plans, it does not provide the public with important information as to which plans are the bad actors. Nor will it lead to the government’s cancellation of contracts with the worst-performing Medicare Advantage plans. Therefore, it will not keep the bad actor Medicare Advantage plans from continuing to inappropriately delay and deny critical care.

[HJM bolding]

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Comment:

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

Lobbying elected representatives and public scare campaigns are high-yield investments for health insurers. Their profits these days derive mainly from serving as intermediaries for Medicare Advantage and other public insurance programs. They spend millions to safeguard billions in excess payments from CMS. The rate of return may exceed 100:1. The Biden administration is starting to address overpayment, but their effort is undercut by massive industry push-back.

The final rule spreads the modest and overdue proposed adjustments over three years. If you want a good technical summary, look at the fact sheet. The net result is a payment increase of 3.3% for 2024, as compared with 1% in the draft rule. How much is the difference? $10 billion. All into profits.

And that doesn’t begin to represent the scale of the overcharging documented by the Medical Payment Advisory Commission (MedPAC) and others. Up to $50 billion per year.

The insurers no doubt also hope that delay will further benefit them — a more sympathetic administration might abandon the out-year adjustments. They might also argue that other much-needed broader changes must wait until these three years of slow adjustment are done.

This is a rules-based approach. Very long and complicated rules attempt to rein in private sector entities which spend every working day scheming how to evade and game those rules, to shift more of the Medicare Trust Fund to shareholder profits.

Diane does an excellent job describing the sweep of problems plaguing Medicare Advantage. She rightly calls for a major overhaul.

What kind of major overhaul would really work? So complete we might not want to use the word “overhaul”. We need to abandon the financial intermediary structure, which guarantees bloated costs and aggressive limits on access to care, especially expensive care.

We need to jettison the insurers, and use a structure like traditional Medicare, with payments directly from the program to providers. For everyone. Single payer, Medicare for All.

http://healthjusticemonitor.org…

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Summary: New research finds that in 2021 the US had nearly 900,000 excess deaths compared with wealthy European countries. About half were due to COVID and half due to other factors, including health care financing and delivery.

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‘Excess’ Deaths Surging, but Why?, Medscape, March 29, 2023, by F. Perry Wilson

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What do we mean when we say “excess mortality”? The central connotation of the idea is that there are simply some deaths that should not have occurred. …

That’s what this article does, calculating excess deaths in the United States by standardizing our mortality rates to the five largest Western European countries: the UK, France, Germany, Italy, and Spain. …

[page 2]

[E]ven before the pandemic, the United States had an excess mortality problem. This is not entirely a surprise; we’ve known that so-called “deaths of despair,” those due to alcohol abuse, drug overdoses, and suicide, are at an all-time high and tend to affect a “prime of life” population that would otherwise not be expected to die. In fact, fully 50% of the excess deaths in the United States occur in those between the ages of 15 and 64.

Excess deaths are also a concerning percentage of total deaths. In 2017, 17% of total deaths in the United States could be considered “excess.” In 2021, that number had doubled to 35%. Nearly 900,000 individuals in the United States died in 2021 who perhaps didn’t need to.

The obvious culprit to blame here is COVID, but COVID-associated excess only explains about 50% of the excess we see in 2021.

I’m sure some will take issue with the use of European numbers when applied to Americans. After all, Europe has, by and large, a robust public health service, socialized medicine, and healthcare that does not run the risk of bankrupting its citizens. How can we compare our outcomes to a place like that?

How indeed.

Dr. F. Perry Wilson is an associate professor of medicine and director of Yale’s Clinical and Translational Research Accelerator.

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Comment:

By Don McCanne, M.D.

According to the data discussed here by Yale Professor Perry Wilson, in 2021 alone, not counting COVID deaths, about 400,000 people died who perhaps didn’t need to, deaths characterized as excess.

When compared with the five largest Western European countries, all of which have better outcomes, how indeed can we come to any other conclusion than that they have superior structural characteristics in their health systems? This includes robust public health services, socialized medicine, and healthcare financing systems that do not risk bankrupting their citizens.

Better care, for less money, that includes everyone. Sounds like something we could do – with expanded and improved, single payer, Medicare for All!

http://healthjusticemonitor.org…

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Summary: A striking vision for how to pay for health care in our country.

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An Immodest Proposal

(for Excellent Financing of Our Health Care System)

From: A humble health economist
To: The U.S. public

Dear kind family, friends, colleagues, neighbors, and fellow citizens:

The health and happiness of our population being of the utmost importance, I make bold to propose to you that we establish a system to pay for health care in the United States of America. The means to achieve this grand goal must include a health care financing system of a most refined and ingenious nature. I have contemplated how to accomplish this, and herewith share my conclusions, which I hope and trust you will find quite compelling.

First, we must commit great resources to this noble undertaking. I propose one in five dollars of all economic activity, though I would settle at the moment for just 17-18%. Our dear neighbors of the north country and friends in Europe are too stingy, dedicating only 8-12% to this august mission. We ought gladly proffer high recompense for our fine curative consultations, potions, and surgeries.

Second, let us rejoice in diversity. Every citizen shall have a different assortment of health benefits, for certainly these varied benefits shall align magnificently with future medical and financial needs, however unpredictably they shall manifest. Varied services allowed, disparate access to doctors, and a joyous plethora of cost-sharing arrangements, including impressively large deductibles and robust cost-sharing.

Third, let us elevate choice. Ours is a free country, so each citizen (and approved non-citizen resident) shall be permitted, nay obligated, to choose among insurance purveyors and health plans. Some say, “Pick your poison”, but I say, “Exercise your free market rights!” Alas, selection of physician may be ever so slightly restrained by the untrammeled and wondrous choice of a restricted provider network. Individuals will understand and accommodate if the most able medical practitioner for a worrisome affliction happens to labor external to the designated provider panel.

Fourth, let us further magnify the spectacular granularity of everyday tasks, because complexity is life. Let each insurance plan have different rules and procedures for securing payment for doctors and hospitals, so that the insurers may devote many fine US dollars to administration. Likewise, the providers shall dedicate one dollar in eight to billing paperwork. Long live and prosper the accounting room, and the myriad financial clicks of the electronic health record.

Fifth, admire the prospect of home foreclosures, a true blessing to ease the housing crisis, as medical bills further impoverish the poor. Manifold thanks for lack of insurance, and uncovered and out-of-network services; 40% in medical debt and 500,000 medical bankruptcies each annum is good fortune that we may all celebrate.

Sixth, savor the frustration and exhaustion of physicians straining for hours daily to digitally inscribe copious billing information, for the subsequent burnout thins their excess ranks.

Seventh, cheer delayed diagnosis and treatment as pandemics encroach, and too the chaotic data of fragmented billing systems which prevent us from worrying ourselves with nasty facts about disease spread.

Eighth, let us revel in the shorter life span offered by this financing system, for life is brutal (most especially when we cannot afford to consult a doctor to ease our pains). The sooner over the better.

Ninth, praise the myriad ways in which our system specially affects the lives of the impecunious and visibly different, with less and worse insurance, inferior quality of care and outcomes, and earlier release from life’s painful bonds.

Tenth, glory be to profits and spectacular CEO salaries, for these reflect the soul of the American experience. Insurers, drug companies, and hospital systems shall garner at least 10% of all revenue to enrich the worthy and kindly shareholders. CEOs of non-profit hospitals shall rightfully earn $10 million per annum in salary and other well-deserved recompense.

Finally, let us embrace un- and under-insurance, for they are the means that enable the flourishing of this fine and perfect system. Yes, spending more than any other nation, infinitely varied health care benefits, choice of health plan constrained to a narrow network, complexity in our daily lives, foreclosed homes, burned out doctors, pandemics ignored, brutish lives ended early, the downtrodden slighted, and, best of all, burgeoning profits for the few – all are thanks to the worthy sacrifices of the not really well-insured.

Respectfully submitted,

James G. Kahn, M.D. M.P.H.
(apologies to Jonathan Swift)

http://healthjusticemonitor.org…

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