PNHP

Singular solution

Singular solution

By Ana Malinow, M.D.
Pittsburgh Post-Gazette, Letters, May 4, 2014

Kudos to Bill Toland for his April 27 piece “How Did America End Up With This Health Care System?” To briefly summarize 100 years of our patchwork, dysfunctional health care system is almost as remarkable as finding a real solution for it. Mr. Toland gets all the particulars right, but the solution will not be found in the Affordable Care Act, no matter how long we wait for it to change.

As Americans gain more experience with the ACA, they will become disappointed when they realize that plans in the marketplace have low actuarial value and high deductibles. Narrow provider networks will prevent Americans from having choices in physicians and hospitals. Those previously satisfied with their employer-sponsored coverage will find they, too, have fewer options at greater cost. This incremental step will put billions in the pockets of insurance companies, entrenching them further in our system.

The solution today as in 1915, when the first national health insurance bill was introduced in Congress, is a health care system that is truly universal, affordable, accountable, accessible, sustainable and just.

Only with a single-payer system or improved and expanded Medicare for all will we ever have a health care system worth $2.8 trillion — something that cannot be said for what we have today or what we are getting under the ACA.

Dr. Ana Malinow resides in Shadyside.

Read more: http://www.post-gazette.com/opinion/letters/2014/05/04/Singular-solution/stories/201405040080#ixzz30lTqtxS7

Obamacare’s Empty Victory

By Margaret Flowers, M.D.
The Indypendent (Brooklyn, N.Y.), May 2, 2014

It feels truly Orwellian that progressives are applauding the forced purchase of private health insurance — one of the most hated industries in the United States — while the right is opposing a model that originated from their political leaders. The Affordable Care Act (ACA) is a step farther on the path to total privatization of our health care system, not towards the health care system that most Americans support: single payer Medicare for all.

In the months leading up to the March 31 deadline to obtain health insurance, ACA supporters united around their mission to enroll people. Volunteers knocked on doors and tabled in their communities. Celebrities and athletes tweeted and labor unions ran robocalls. The media buzzed with speculation about whether the ACA would succeed or fail. March 31 felt like election night. And after it was over, ACA supporters clapped each other on the back and celebrated.

Obamacare survived. But now that the law is implemented and the dust is settling, it’s time to question what this actually means for health care and what we should do now.

Before President Obama was elected in 2008, Drs. David Himmelstein and Steffie Woolhandler, two of the co-founders of Physicians for a National Health Program, raised a crucial question in their report, “Our Health Care System at the Crossroads: Single Payer or Market Reform?” They outlined the health care crisis and how past reforms were taking us toward increasingly “threadbare insurance coverage.” Knowing that health care reform would be front and center for the next few years, they argued that as a nation, we had a choice to make. We could stay on the same path toward a market-based health care system or take an evidence-based approach and create national single payer health insurance.

With the ACA, we have now passed that crossroads and are headed down the road to a completely market-based system of privatized health care. This is not something to celebrate. Dr. Adam Gaffney recently wrote an excellent history in Jacobin on the turn we have taken away from the concepts of universal health care and economic justice to a neoliberal model. We are inundated with market rhetoric telling us how wonderful it is to have the choice of shiny silver insurance in the brand new marketplace. Insurance plans are called products and we are consumers of them.

The problem with these public relations messages is that having health insurance doesn’t guarantee access to health care and health care doesn’t belong in the marketplace. As patients, we do not have a choice of whether or not to purchase health care when we need it. Delaying or avoiding necessary care can and does have serious consequences. And we can’t predict how much health care we will need or when we’ll need it. In a market-based system, profits are the bottom line and people receive only the amount of health care they can afford, not what they need.

The ACA is transferring hundreds of billions of public dollars to the private insurance industry to subsidize plans that leave people underinsured, unable to afford care and at risk of financial ruin if they have a serious accident or illness. And even at its best, tens of millions of people will remain without insurance.

Most of the 7.5 million people who purchased health insurance on the exchanges were already insured. More than 80 percent bought the lower-tier silver, bronze or catastrophic plans with the hope that they would not get sick. These plans have the lowest premiums but require that patients pay thousands of dollars out of pocket before insurance kicks in, and then pay 30 to 40 percent of the cost of covered care. The result is that underinsured people will continue to self-ration, delay or avoid care due to cost, as 80 million of us did in 2012.

The ACA includes regulations, but as usual the insurance industry has ways to work around them. Many insurers had caps on out-of-pocket costs waived. Insurers also found a way to “cherry pick” the healthiest customers by leaving cancer centers and major medical centers out of their networks. In fact, most of the new plans have narrow and ultra-narrow networks that shift more of the cost of care onto patients because care outside of insurance networks isn’t covered. And while insurance companies cannot drop individuals when they get sick, they can stop selling their plans in areas that don’t make a profit. Some are already doing this, which means the competition that was supposed to emerge did not. Instead, in 515 of the poorest counties in 15 states, only one insurance company is available on the health exchange. And greater consolidation of the health care system is underway through mergers and acquisitions.

Our public insurances, Medicaid and Medicare, are being increasingly taken over by private insurances in the form of Managed Care Organizations and Medicare Advantage. They compete for the healthiest patients and siphon more of the health dollars for profit, salaries and administration than public insurances. Top advisors to the White House expect our public plans to be rolled into the health exchanges in the near future with subsidies, a plan similar to Congressman Paul Ryan’s voucher proposal.

Nations that treat health care as a public good and not a commodity have universal coverage that costs less and produces better health outcomes. And in polls, some two thirds of Americans support single payer. Now our tasks is to shift the national debate away from how many people have insurance to what type of health care system we support. Efforts to do this are taking place at both state and national levels.

State efforts to educate and organize for universal health systems are using a human rights framework. This started with the Health Care is a Human Right campaign in Vermont that is working to create universal coverage, and similar organizing is happening in Maine, Pennsylvania and Maryland. An essential component of this organizing model is to develop leadership within communities that are uninsured or underinsured. States such as Washington, Oregon, Colorado and New Mexico also use human rights messaging in their campaigns.

State health reform faces significant barriers because federal legislation is needed to allow the creation of a state single payer system. However, state campaigns are essential because they push state health policy to be the strongest it can be and build an informed and organized grassroots movement that can also push for solutions at the national level.

Legislation for single payer health systems exists in Congress. In the House, Congressman John Conyers (D-MI) has introduced HR 676, “The Expanded and Improved Medicare for All Act,” in every session since 2003. So far it has 56 co-sponsors. In late 2013, Senator Bernie Sanders (I-VT) introduced SB 1782, “The American Health Security Act,” in the Senate. National organizations are working together to encourage more members to sponsor them and a national lobby day is happening in Washington, D.C., on May 22.

On a personal level, I have chosen to be a conscientious objector to the ACA. I cannot in good conscience give my support to the very industry I am trying to eliminate. Being a conscientious objector is a decision that people have to make for themselves. So far nearly 500 people have joined me by signing a petition at PopularResistance.org.

Some people speculate that the ACA will bring us to single payer some day because it will fail. This will only happen if we fight for it. Every day that we delay, people suffer and die in this country unnecessarily. Neil H. Buchanan says it best, “The ACA is as good as it gets, when it comes to basing a health care system on private insurance, and it is simply not good enough. Even as the ACA takes effect, therefore, we need to start planning to make it disappear.”

Margaret Flowers is a pediatrician and co-chair of the Maryland chapter of Physicians for a National Health Plan. She serves on the board of Healthcare-Now and of the Maryland Health Care is a Human Right campaign. She is also an editor at popularresistance.org.

http://www.indypendent.org/2014/05/02/obamacare%E2%80%99s-empty-victory

Is The Commonwealth Fund serious about searching for disruptive breakthroughs?

Searching for the Next Breakthrough in Health Care

By Anne-Marie J. Audet, M.D, M.Sc., S.M.
The Commonwealth Fund, May 5, 2014

It is well documented that health care in the United States is not just expensive; it’s world-class expensive, and unsustainably so. And although many would like to believe that all that spending buys us the safest, most effective care to be found anywhere on the planet, it is equally well documented that our health care system, on many levels, doesn’t measure up on a global scale. We’re simply not getting what we pay for.

Clearly, it’s going to take more than minor tweaks or adjustments to change our course. It’s going to take a real breakthrough.

What do we mean by a breakthrough? Though incremental change is valuable, and The Commonwealth Fund pursues this in many of its other programs, that’s not what we’re looking for here. We mean an idea, a paradigm, a strategy that positively and profoundly disrupts the status quo.

The Commonwealth Fund’s new Breakthrough Health Care Opportunities program aims to discover and vet transformative ideas that have the potential to expand access to care, dramatically simplify the delivery of care, decrease costs, and improve health outcomes.

We’ve set the bar high. Here are our working criteria for a breakthrough:

  • How much does it disrupt the status quo? We’re looking for major disruption—a whole new approach that represents a break with what we do now.
  • How big a difference will it make? Broad societal impact is the goal, with large numbers of people benefiting nationwide. To gauge impact, we’re using a 20/20 rule for screening breakthroughs: the potential must be at least a 20 percent improvement in health care quality and/or a 20 percent reduction in costs nationally.
  • How quickly can it become a reality? The timeframe we envision is up to 10 years to achieve impact.

Our work in exploring breakthrough opportunities is just beginning. We will seek ideas from a broad network of colleagues, and communicating what we find along the way. Please share your thoughts with us here or Tweet them with the hashtag #hcbreakthrus.

http://www.commonwealthfund.org/Blog/2014/May/Searching-for-the-Next-Breakthrough-in-Health-Care.aspx

Breakthrough Health Care Opportunities: http://www.commonwealthfund.org/Program-Areas/Breakthrough-Health-Care-Opportunities.aspx

Comment:

By Don McCanne, MD

The Commonwealth Fund’s new Breakthrough Health Care Opportunities program is looking for “major disruption – a whole new approach that represents a break with what we do now.” They aim to “discover and vet transformative ideas that have the potential to expand access to care, dramatically simplify the delivery of care, decrease costs, and improve health outcomes.”

Uh, there is a great idea already out there that would seem to be just what they are looking for – a well designed single payer system. It is highly unlikely that anyone will come up with any other idea that does not yet exist which is a truly disruptive, transformative breakthrough that will achieve their goals. It is much more likely that proposals will be for incremental tweaks or adjustments which they say they are not looking for.

But are they serious? As one example of “the scale and ambition we believe are needed to achieve dramatic improvements in U.S. health care” they suggest “the massive and widespread implementation of financial risk-sharing arrangements to encourage more careful allocation of resources and create incentives to keep patients healthy.” Yikes! We already have introduced that with accountable care organizations and their predecessors, and the results to date indicate that improvements are negligible or worse. A special form of risk sharing – requiring patients to pay more of the costs of the care they obtain – might slow spending very modestly but at a cost of increasing financial hardship and impairing health care access.

Although single payer is not a new concept, it would certainly be a beneficial, disruptive breakthrough for the United States. It will be interesting to see if they are really serious about considering all ideas, or if this will be yet another ABSP proposal. (ABSP – Anything But Single Payer).

Getting serious about single payer

Getting serious about a single payer system 

By James F. Burdick
The Baltimore Sun, May 1, 2014

A single payer system — where the government pays for health costs — is now recognized by many in the U.S. as the best solution for our health care problems. It was taken “off the table” in 2009 by Sen. Max Baucus, A Montana Democrat who reportedly received more money from the pharmaceutical and health insurance industries than any other Congressman. But now the flood of single payer advocacy cannot be turned off by vested business interests. It is time to progress from the stereotype of single payer to having a serious discussion about it.

Ironically, even after its recent success in covering millions more Americans, the problems with the Affordable Care Act serve to illuminate the advantages of single payer. The public, although confused by the divisive rhetoric around health care reform, is coming to realize that the complexity of the law and the pursuit of insurance company profits are major problems for the ACA. Back in 2009, a majority of Americans favored a single payer-like system. The country may now lose patience with the protracted process of ACA implementation, with Republicans yapping at its heels, until 2020 when the final provision closing the Medicare prescription drug doughnut hole fully kicks in.

The 30-page H.R. 676, the single payer bill of Rep. John Conyers Jr., a Michigan Democrat, shows how simple it is to cover everyone. It provides savings through quality care — including protection from harmful overuse and efficient, timely management of chronic disease — as well as savings through national monopsony buying power and freedom from insurance business profits.

Most politicians and health policy experts with national reputations remain silent. Some may have too great a stake in the ACA to join in the single payer adventure right away. But the country did just pass this valuable law. Even recognizing the tight political maneuvering required, this attests that the political potential for major change to our health care system is there. Luminaries who have asserted the wisdom of single payer include political commentator Bill Maher, former U.S. Secretary of State Colin Powell, Nobel-prize winning economist Paul Krugman, Sen. Bernie Sanders of the Vermont Progressive Party and former U.S. Labor Secretary Robert Reich. With even conservative columnist Ross Douthat alluding to the unspeakable in the April 5th New York Times “(ahem, single payer)” and a number of states trying to establish it on their own, supporting single payer nationally no longer appears out of reach.

The paper by Drs. Ray Drasga and Lawrence Einhorn, both of Indiana, in the Journal of Oncology Practice from January showing how their cancer patients would benefit from single payer is a beacon for all of medicine. Other prominent doctors recently supporting it include Dr. Nancy Snyderman of NBC and Dr. James Mitchiner of The American College of Emergency Physicians. The Physicians for a National Health Program promoting single payer is now 19,000 members strong. American nurses strongly support single payer.

Soon candidates who wish to be seen as working for all Americans will support single payer, or they will have some explaining to do.

Dr. James Burdick is Professor of Surgery at Johns Hopkins University School of Medicine.

http://www.baltimoresun.com/news/opinion/oped/bs-ed-single-payer-20140501,0,2307598.story

Comment:

By Don McCanne, MD

As the serious deficiencies of the Affordable Care Act become ever more obvious, people will be looking for solutions to our health care crisis that will actually work. As they begin to better understand the single payer model, the groundswell of support will drive the reform process. By then, the “economic elite” will no longer be able to stop us.

Legal challenge threatens Canada’s medicare

No evidence that for-profit health care results in better outcomes

By Monika Dutt and Rachel Tutte
Vancouver Sun, May 1, 2014

We are just four short months away from an unprecedented legal challenge to Canadian public health care that will put the fundamental Canadian principle of care based on need, not ability to pay, on trial.

The legal case is being driven by Dr. Brian Day, owner of the Vancouver-based for-profit Cambie Surgery Centre, infamous for unlawfully billing patients for health care services.

Dr. Day hopes to strike down the rules that prevent a U.S.-style system in Canada, where some people get to pay privately to jump the queue. His claim is that B.C.’s Medicare rules violate the Canadian Charter of Rights and Freedoms.

It is hard to overstate the significance of this challenge. If Dr. Day wins, the public system that Canadians rely on — and overwhelmingly support — will be dismantled across the country. We will be left with a system that looks very much like that of the United States — physicians will be permitted to charge patients any amount they like for services, and the rich elite will get care faster than the rest of us.

Evidence shows that the kind of system Dr. Day is seeking via the courts would result in longer wait times and poorer health outcomes for Canadians.

An abundance of evidence shows that for-profit hospitals reduce access to care for everyone but the wealthy elite. Studies in Canada, Europe, and the UK show that patients who can’t pay, and whose doctors work in both public and private systems, have the longest waits. Australian research shows that private for-profit clinics drain the limited supply of doctors and other health professionals from the rest of the health care system, lengthening waiting times for all but those who can afford expensive private insurance.

This bears emphasizing: A second, for-profit tier does not relieve pressure on the public system; instead, evidence shows wait times actually increase.

Similarly, there is no evidence that private for-profit care results in better outcomes — not anywhere in the world.

There is no doubt we are in need of improvements to our system. Those improvements need to reflect the Canadian values of equity and cost-effectiveness. We need to scale up evidence-based innovations that have been proven to reduce wait times and improve health outcomes. Across Canada, there are dozens of innovative projects improving access, quality, and cost-effectiveness while protecting equitable access to care. For example, the Alberta Bone and Joint Institute reduced wait times from 11 months to nine weeks for hip and knee surgery.

Dr. Day’s true motives are clear. A provincial audit of Day’s Cambie Surgery Centre and the associated Specialist Referral Clinic found that patients were unlawfully extra-billed $491,654 in just 30 days. In one case, a Cambie patient was billed $7,215.00 for services that would only have cost $1,288.04 in the B.C. health care system. Auditors also found over $66,000 in overlapping claims — evidence that suggests double dipping for the same services.

Charging patients nearly six times the actual cost of a procedure is not about human rights, and it’s not about system improvement. It’s about profit.

For the good of all Canadians, let’s hope this dangerous legal challenge is struck down and we can get on with the work of improving a system that cares for all of us.

Dr. Monika Dutt, chair of Canadian Doctors for Medicare, is a Medical Officer of Health, Cape Breton District and Family Physician. Rachel Tutte is co-chair of the BC Health Coalition and a physiotherapist.

http://www.vancouversun.com/news/Legal+challenge+threatens+medicare/9797988/story.html#ixzz39X4LRPiy

Getting serious about single payer

Getting serious about a single payer system

By James F. Burdick
The Baltimore Sun, May 1, 2014

A single payer system — where the government pays for health costs — is now recognized by many in the U.S. as the best solution for our health care problems. It was taken “off the table” in 2009 by Sen. Max Baucus, A Montana Democrat who reportedly received more money from the pharmaceutical and health insurance industries than any other Congressman. But now the flood of single payer advocacy cannot be turned off by vested business interests. It is time to progress from the stereotype of single payer to having a serious discussion about it.

Ironically, even after its recent success in covering millions more Americans, the problems with the Affordable Care Act serve to illuminate the advantages of single payer. The public, although confused by the divisive rhetoric around health care reform, is coming to realize that the complexity of the law and the pursuit of insurance company profits are major problems for the ACA. Back in 2009, a majority of Americans favored a single payer-like system. The country may now lose patience with the protracted process of ACA implementation, with Republicans yapping at its heels, until 2020 when the final provision closing the Medicare prescription drug doughnut hole fully kicks in.

The 30-page H.R. 676, the single payer bill of Rep. John Conyers Jr., a Michigan Democrat, shows how simple it is to cover everyone. It provides savings through quality care — including protection from harmful overuse and efficient, timely management of chronic disease — as well as savings through national monopsony buying power and freedom from insurance business profits.

Most politicians and health policy experts with national reputations remain silent. Some may have too great a stake in the ACA to join in the single payer adventure right away. But the country did just pass this valuable law. Even recognizing the tight political maneuvering required, this attests that the political potential for major change to our health care system is there. Luminaries who have asserted the wisdom of single payer include political commentator Bill Maher, former U.S. Secretary of State Colin Powell, Nobel-prize winning economist Paul Krugman, Sen. Bernie Sanders of the Vermont Progressive Party and former U.S. Labor Secretary Robert Reich. With even conservative columnist Ross Douthat alluding to the unspeakable in the April 5th New York Times “(ahem, single payer)” and a number of states trying to establish it on their own, supporting single payer nationally no longer appears out of reach.

The paper by Drs. Ray Drasga and Lawrence Einhorn, both of Indiana, in the Journal of Oncology Practice from January showing how their cancer patients would benefit from single payer is a beacon for all of medicine. Other prominent doctors recently supporting it include Dr. Nancy Snyderman of NBC and Dr. James Mitchiner of The American College of Emergency Physicians. The Physicians for a National Health Program promoting single payer is now 19,000 members strong. American nurses strongly support single payer.

Soon candidates who wish to be seen as working for all Americans will support single payer, or they will have some explaining to do.

Dr. James Burdick is Professor of Surgery at Johns Hopkins University School of Medicine.

http://www.baltimoresun.com/news/opinion/oped/bs-ed-single-payer-2014050…

As the serious deficiencies of the Affordable Care Act become ever more obvious, people will be looking for solutions to our health care crisis that will actually work. As they begin to better understand the single payer model, the groundswell of support will drive the reform process. By then, the “economic elite” will no longer be able to stop us.

Medicine and Money

On Medicine and Money

By Eli Y. Adashi, MD, MS
JAMA Forum, April 30, 2014

As might have been anticipated, much of the media coverage of the release of the CMS data focused attention on health care professionals dubbed “Medicare millionaires” and their practice patterns. Tantalizing as such details might be, more profound issues were being sidestepped. In particular, little has been said with respect to the uncomfortable relationship between medicine and money.

This is an unfortunate state of affairs, because the ethical and moral challenges associated with the juxtaposition of medicine and money are highly deserving of our attention.

Many see the pairing of money and medicine as a nonissue, and instead view it as capitalism at its best, with medicine being just another market in which competition reigns supreme. For proponents of this point of view, health care professionals might be seen as operatives in a retail business, wherein the volume of sales (of health services) carries the day, creating a vibrant health care market that sparks the scientific innovations upon which we have all come to depend. They see the business model of medicine as no different than that of any other field of pursuit, naturally rooted in foundational libertarian principles. Viewed in this light, the intersection of medicine and money is as American as apple pie. Exemplified by the time-honored “private practice” of medicine, this all-out embrace of the business principles of a market economy remains undiminished—if increasingly untenable.

But there’s a potential flaw in this line of reasoning: the presumption of a fail-safe firewall between financial considerations and clinical decision making. Sadly, that may not always be the case.

Clearly, opinions vary widely as to the ethical and moral wisdom of mixing medicine with money. Some would favor a lightly regulated, self-policing field, wherein unfettered entrepreneurship and Medicare millionaires are bound to thrive. According to this outlook, infractions perpetrated by a select few do not warrant the imposition of blanket, heavy-handed oversight.

But those who consider medicine and money to constitute a volatile mix may express preference for another model, such as a national health care system buttressed by a single governmental payer, in which value rather than volume of services determine provider compensation. Under this system, Medicare millionaires are unlikely to flourish.

http://newsatjama.jama.com/2014/04/30/jama-forum-on-medicine-and-money/

****

Comment:

By Don McCanne, MD

Physician. Seeing that word, what comes into your mind? Do you think of a person who is dedicated to promotion of health and healing of the sick? Or do you think of an occupation that is as American as apple pie in its dedication to retail business within the entrepreneurial health care marketplace?

Medicine is different. Those favoring unfettered entrepreneurship with the chance to become a Medicare millionaire really do not belong in the field. Most physicians find the imposition of money considerations into the relationship between the physician and the patient to be a great nuisance, if not outright repulsive.

Dr. Adashi reminds us that there is another model that would be preferred by most physicians who would rather be healers than entrepreneurial businessmen. That preferred model is “a national health care system buttressed by a single governmental payer.”

Isn’t it time for us to change our model?

Medicine and Money

On Medicine and Money

By Eli Y. Adashi, MD, MS
JAMA Forum, April 30, 2014

As might have been anticipated, much of the media coverage of the release of the CMS data focused attention on health care professionals dubbed “Medicare millionaires” and their practice patterns. Tantalizing as such details might be, more profound issues were being sidestepped. In particular, little has been said with respect to the uncomfortable relationship between medicine and money.

This is an unfortunate state of affairs, because the ethical and moral challenges associated with the juxtaposition of medicine and money are highly deserving of our attention.

Many see the pairing of money and medicine as a nonissue, and instead view it as capitalism at its best, with medicine being just another market in which competition reigns supreme. For proponents of this point of view, health care professionals might be seen as operatives in a retail business, wherein the volume of sales (of health services) carries the day, creating a vibrant health care market that sparks the scientific innovations upon which we have all come to depend. They see the business model of medicine as no different than that of any other field of pursuit, naturally rooted in foundational libertarian principles. Viewed in this light, the intersection of medicine and money is as American as apple pie. Exemplified by the time-honored “private practice” of medicine, this all-out embrace of the business principles of a market economy remains undiminished—if increasingly untenable.

But there’s a potential flaw in this line of reasoning: the presumption of a fail-safe firewall between financial considerations and clinical decision making. Sadly, that may not always be the case.

Clearly, opinions vary widely as to the ethical and moral wisdom of mixing medicine with money. Some would favor a lightly regulated, self-policing field, wherein unfettered entrepreneurship and Medicare millionaires are bound to thrive. According to this outlook, infractions perpetrated by a select few do not warrant the imposition of blanket, heavy-handed oversight.

But those who consider medicine and money to constitute a volatile mix may express preference for another model, such as a national health care system buttressed by a single governmental payer, in which value rather than volume of services determine provider compensation. Under this system, Medicare millionaires are unlikely to flourish.

http://newsatjama.jama.com/2014/04/30/jama-forum-on-medicine-and-money/

Physician. Seeing that word, what comes into your mind? Do you think of a person who is dedicated to promotion of health and healing of the sick? Or do you think of an occupation that is as American as apple pie in its dedication to retail business within the entrepreneurial health care marketplace?

Medicine is different. Those favoring unfettered entrepreneurship with the chance to become a Medicare millionaire really do not belong in the field. Most physicians find the imposition of money considerations into the relationship between the physician and the patient to be a great nuisance, if not outright repulsive.

Dr. Adashi reminds us that there is another model that would be preferred by most physicians who would rather be healers than entrepreneurial businessmen. That preferred model is “a national health care system buttressed by a single governmental payer.”

Isn’t it time for us to change our model?

P4P harms poor patients

Health law’s pay policy is skewed, panel finds

By Robert Pear
The New York Times, April 28, 2014

Federal policies to reward high-quality health care are unfairly penalizing doctors and hospitals that treat large numbers of poor people, according to a new report commissioned by the Obama administration that recommends sweeping changes in payment policy.

Medicare and private insurers are increasingly paying health care providers according to their performance as measured by the quality of the care they provide. But, the draft report by an expert panel says, the measures of quality are fundamentally flawed because they do not recognize that it is often harder to achieve success when treating people who do not have much income or education.

Low-income people may be unable to afford needed medications or transportation to doctor’s offices and clinics, the panel said. If they have low levels of formal education or literacy, they may have difficulty understanding or following written instructions for home care and the use of medications. In addition, the clinics and hospitals they use may lack the resources and high tech equipment needed to diagnose and treat illnesses.

The panel found that existing payment policies unintentionally worsen disparities between rich and poor by shifting money away from doctors and hospitals that care for “disadvantaged patients.”

Measures of health care quality and performance — widely used by Medicare and private insurers in calculating financial rewards and penalties — should be adjusted for various “sociodemographic factors,” the expert panel said. The panel was created by the National Quality Forum, an influential nonprofit, nonpartisan organization that endorses health care standards.

….The Obama administration commissioned the study, but is not entirely comfortable with the recommendations, officials acknowledged. The existing policies of the National Quality Forum and the government say performance scores should generally not be adjusted or corrected to reflect differences in the income, race or socioeconomic status of patients.

…. “We do not want to hold hospitals to different standards of care simply because they treat a large number of low-socioeconomic-status patients,” said Dr. Kate Goodrich, the director of quality measurement programs at the federal Centers for Medicare and Medicaid Services. “Our position has always been not to risk-adjust for socioeconomic status within our measures because of concern about masking disparities, and potentially rewarding providers who provide a lower level of care for minorities or poor patients.”

Comment:

By Kip Sullivan

The notion that doctors and hospitals are screwing up and will behave if they are subjected to punishment and reward by third parties is not new. The Code of Hammurabi (1750 BC) subjected Mesopotamian doctors to a combination of reward (more shekels) and punishment (cutting off of doctors’ hands)  http://economix.blogs.nytimes.com/2013/04/26/hammurabis-code-and-u-s-health-care/.  But even Hammurabi didn’t recommend punishing the patients.

But that is effectively the position taken by the National Quality Forum (NQF), the Obama administration, and the numerous private-sector firms and groups that peddle pay-for-performance (P4P) as a solution to the health care crisis. By refusing to adjust scores on report cards to reflect patient socioeconomic status (SES), P4P proponents are guaranteeing that the P4P fad will punish clinics and hospitals that serve poorer patients.

It is widely known that report cards on clinics and hospitals that are used in P4P schemes are, with rare exceptions, poorly adjusted to reflect differences in patient health. It is also widely known that report cards are almost never adjusted for income, insurance status and other SES indicators. But what was not widely known until Monday’s report in the New York Times was that the NQF and the Obama administration have actually endorsed a policy of prohibiting the use of SES data to adjust scores on report cards.

Why would the NQF go to the trouble of explicitly outlawing the use of SES adjusters and thus draw attention to a serious defect in virtually all P4P schemes in use in America today?

As is always the case with managed care propositions, finding a well-documented argument for the NQF’s position is impossible. All we have is this tiny remark in footnote 15 in an NQF document:

“Risk models should not obscure disparities in care for populations by including factors that are associated with differences/inequalities in care, such as race, socioeconomic status, or gender (e.g., poorer treatment outcomes of African American men with prostate cancer or inequalities in treatment for CVD risk factors between men and women).” http://www.qualityforum.org/docs/measure_evaluation_criteria.aspx

Like most report-card proponents, the NQF gives at least lip service to the necessity of adjusting scores to reflect differences in patient health because (a) these differences affect quality measures and (b) they are beyond provider control. Why, then, wouldn’t the NQF treat SES factors the same way? Patients’ low income, their lack of health insurance, their illiteracy and other factors subsumed under the concept of low SES status affect the outcome of medical care, and they are all way beyond the control of providers.

The basic premise of the NQF and the Obama administration is that the only way for policy makers to know if medical care has worse outcomes in poor people is via report cards. This premise is so foolish its mere statement constitutes a rebuttal.

The NQF “argument” then goes on to claim that the benefits of revealing disparities in health care outcomes via report cards outweighs the damage done to providers who treat poor people and to poor people themselves. Or at least that’s what we have to imagine went through the minds of the folks at NQF. As I said, the proponents of this bizarre policy apparently did not feel compelled to leave a paper trail that would help the rest of us comprehend their thinking.

It was the existence of this strange policy that led to the convening of the expert panel described in the Times article. http://www.qualityforum.org/Risk_Adjustment_SES.aspx The panel rejected the NQF-administration rationale by huge margins. According to the panel’s report:

“There is a clear and expanding body of evidence to suggest that providers serving ‘low-socio-demographic’ populations and communities are more likely to be identified as ‘poor performers’ and either be less likely to receive financial rewards, or be more likely to face financial penalties, in pay-for-performance programs.”

“The net effect,” said the panel, “could worsen rather than ameliorate healthcare disparities.”  To avoid this outcome, said the panel, the NQF should “reconsider” its policy. If the NQF remains concerned that lawmakers may remain in the dark about disparities in health outcomes, it should seek evidence for such disparities through other, more traditional means. In the future, the panel concluded, “purchasers, policymakers and other users of performance measures should assess the potential impact on disadvantaged patient populations …. (p. 10)” before imposing P4P schemes.

How did it come to this? Why do our country’s top health policy makers have to be told to honor the fundamental principles of science and medicine, namely, make sure whatever you recommend is safe and effective before administering it?

There are some big obstacles to achieving universal coverage in the US under a single-payer system. None is more serious than the sloppiness of managed care think – the refusal of the health policy elite to honor the equivalent of evidence-based medicine and the equivalent of the Hippocratic Oath. It encourages lawmakers to buy cheap, snake oil health policy in place of real medicine. All of us who care about an efficient and humane health care system in the US must redouble our efforts to shine a light on the establishment’s cavalier attitude toward science and ethics in health policy.

The Canadian health care system I disparaged

Single-payer regime up north represents a better way

By Wendell Potter
The Center for Public Integrity, April 28, 2014

When I returned home after a two-week speaking tour of Canada and began catching up on news about Obamacare, I was angry and upset, and not just at politicians and special interests that benefit from deception-based PR tactics. I was — and still am — mostly angry and upset with myself. And I know I always will be.

Over the course of a two-decade career as a health insurance executive, I spent hours and hours implementing my industry’s ongoing propaganda campaign to mislead people about the Canadian health care system. We spread horror stories about “rationed care” and long waiting times for medically necessary care. Our anecdotes were not at all representative of most Canadians’ experiences, but we spent millions of dollars to persuade Americans that they were.

At every stop between Halifax and Vancouver this month, I explained how the United States had achieved the dubious distinction of having both the most expensive health care system on the planet and also one of the most inequitable. While Canadian lawmakers in the 1960s were implementing a partnership between the federal and provincial governments to create the country’s publicly funded universal health insurance system — known as Medicare — our lawmakers in Washington were establishing America’s own single-payer Medicare program, but only for folks 65 and older and some younger disabled people. Congress also created the federal and state-administered Medicaid program for the nation’s poor.

Ever since, most of the rest of us have had to deal with private insurance companies and pay whatever they felt like charging us for coverage. Canadians are also paying more for coverage these days because of medical inflation and an aging population, but not nearly as much more as we in the U.S. are paying. Just about everybody in every audience I stood before gasped when I told them that health insurance premiums in the U.S. increased 131 percent between 1999 and 2009 — the main reason why 50 million of us were uninsured at the end of the last decade — and that by 2013 the average employer-based family policy cost $16,351.

At one stop in Toronto, I was asked if there was anything about the U.S. system that Canadians should consider adopting. I was stumped. I noted that while we had some of the world’s best doctors and hospitals, they were in many cases off-limits to millions of Americans, many of whom were uninsured because of preexisting conditions that made them “uninsurable” in the eyes of private insurance companies.

Later, on reflection, I realized I should have mentioned some aspects of our Medicare system and our other single-payer program — the Veterans Health Administration — both of which consistently out-perform private insurers in customer satisfaction surveys.

The two aspects of our Medicare system worth emulating are: (1) the fact that it’s a federal arrangement, meaning that benefits and services do not vary from state to state, and (2) the prescription drug benefit (Medicare Part D) that Congress added a few years ago. The Canadian Medicare program is akin to our Medicaid program in that the provinces have broad latitude in administering benefits and services. As a consequence, Albertans’ experience with Medicare can be quite different from that of Newfoundlanders. And the Canadian Medicare program still does not cover medications. Canadians have to buy private insurance for their prescriptions. Consumer advocates there continue to push for the adoption of a nationwide drug benefit.

As for the Veterans Health Administration, which owns and operates its own hospitals, it not only gets higher customer-service scores than private hospitals, it is frequently cited for better health outcomes. For example, the RAND Corporation found in a 2004 study published in the Annals of Internal Medicine that the VHA outperformed all other sectors of the U.S. health care system in 294 measures of quality.

In other words, Canadians should consider making their system even more public than it is, rather than more private.

I usually began my remarks in Canada with an apology — for all the misinformation I helped spread in the U.S. about their system, which, by the way, continues to have overwhelming support. I didn’t encounter a single Canadian who didn’t talk about their Medicare program with pride.

Back in the states, among the distressing pieces I read was a New York Times story last Monday based on interviews with Americans who said they had decided to remain uninsured either because they couldn’t afford to pay the premiums or had just decided to gamble with their health and personal finances.

Those are decisions completely unknown and unnecessary in Canada, where the per capita spending on health care is far lower than it is here and where people live longer.

Former CIGNA executive-turned-whistleblower Wendell Potter writes about the health care industry and the ongoing battle for health reform.

http://www.publicintegrity.org/2014/04/28/14674/canadian-health-care-system-i-disparaged

P4P harms poor patients

Health law’s pay policy is skewed, panel finds

By Robert Pear
The New York Times, April 28, 2014

Federal policies to reward high-quality health care are unfairly penalizing doctors and hospitals that treat large numbers of poor people, according to a new report commissioned by the Obama administration that recommends sweeping changes in payment policy.

Medicare and private insurers are increasingly paying health care providers according to their performance as measured by the quality of the care they provide. But, the draft report by an expert panel says, the measures of quality are fundamentally flawed because they do not recognize that it is often harder to achieve success when treating people who do not have much income or education.

Low-income people may be unable to afford needed medications or transportation to doctor’s offices and clinics, the panel said. If they have low levels of formal education or literacy, they may have difficulty understanding or following written instructions for home care and the use of medications. In addition, the clinics and hospitals they use may lack the resources and high tech equipment needed to diagnose and treat illnesses.

The panel found that existing payment policies unintentionally worsen disparities between rich and poor by shifting money away from doctors and hospitals that care for “disadvantaged patients.”

Measures of health care quality and performance — widely used by Medicare and private insurers in calculating financial rewards and penalties — should be adjusted for various “sociodemographic factors,” the expert panel said. The panel was created by the National Quality Forum, an influential nonprofit, nonpartisan organization that endorses health care standards.

….The Obama administration commissioned the study, but is not entirely comfortable with the recommendations, officials acknowledged. The existing policies of the National Quality Forum and the government say performance scores should generally not be adjusted or corrected to reflect differences in the income, race or socioeconomic status of patients.

…. “We do not want to hold hospitals to different standards of care simply because they treat a large number of low-socioeconomic-status patients,” said Dr. Kate Goodrich, the director of quality measurement programs at the federal Centers for Medicare and Medicaid Services. “Our position has always been not to risk-adjust for socioeconomic status within our measures because of concern about masking disparities, and potentially rewarding providers who provide a lower level of care for minorities or poor patients.”

http://www.nytimes.com/2014/04/28/us/politics/health-laws-pay-policy-is-…

The notion that doctors and hospitals are screwing up and will behave if they are subjected to punishment and reward by third parties is not new. The Code of Hammurabi (1750 BC) subjected Mesopotamian doctors to a combination of reward (more shekels) and punishment (cutting off of doctors’ hands)  http://economix.blogs.nytimes.com/2013/04/26/hammurabis-code-and-u-s-health-care/.  But even Hammurabi didn’t recommend punishing the patients.

But that is effectively the position taken by the National Quality Forum (NQF), the Obama administration, and the numerous private-sector firms and groups that peddle pay-for-performance (P4P) as a solution to the health care crisis. By refusing to adjust scores on report cards to reflect patient socioeconomic status (SES), P4P proponents are guaranteeing that the P4P fad will punish clinics and hospitals that serve poorer patients.

It is widely known that report cards on clinics and hospitals that are used in P4P schemes are, with rare exceptions, poorly adjusted to reflect differences in patient health. It is also widely known that report cards are almost never adjusted for income, insurance status and other SES indicators. But what was not widely known until Monday’s report in the New York Times was that the NQF and the Obama administration have actually endorsed a policy of prohibiting the use of SES data to adjust scores on report cards.

Why would the NQF go to the trouble of explicitly outlawing the use of SES adjusters and thus draw attention to a serious defect in virtually all P4P schemes in use in America today?

As is always the case with managed care propositions, finding a well-documented argument for the NQF’s position is impossible. All we have is this tiny remark in footnote 15 in an NQF document:

“Risk models should not obscure disparities in care for populations by including factors that are associated with differences/inequalities in care, such as race, socioeconomic status, or gender (e.g., poorer treatment outcomes of African American men with prostate cancer or inequalities in treatment for CVD risk factors between men and women).”http://www.qualityforum.org/docs/measure_evaluation_criteria.aspx

Like most report-card proponents, the NQF gives at least lip service to the necessity of adjusting scores to reflect differences in patient health because (a) these differences affect quality measures and (b) they are beyond provider control. Why, then, wouldn’t the NQF treat SES factors the same way? Patients’ low income, their lack of health insurance, their illiteracy and other factors subsumed under the concept of low SES status affect the outcome of medical care, and they are all way beyond the control of providers.

The basic premise of the NQF and the Obama administration is that the only way for policy makers to know if medical care has worse outcomes in poor people is via report cards. This premise is so foolish its mere statement constitutes a rebuttal.

The NQF “argument” then goes on to claim that the benefits of revealing disparities in health care outcomes via report cards outweighs the damage done to providers who treat poor people and to poor people themselves. Or at least that’s what we have to imagine went through the minds of the folks at NQF. As I said, the proponents of this bizarre policy apparently did not feel compelled to leave a paper trail that would help the rest of us comprehend their thinking.

It was the existence of this strange policy that led to the convening of the expert panel described in the Times article. http://www.qualityforum.org/Risk_Adjustment_SES.aspxThe panel rejected the NQF-administration rationale by huge margins. According to the panel’s report:

“There is a clear and expanding body of evidence to suggest that providers serving ‘low-socio-demographic’ populations and communities are more likely to be identified as ‘poor performers’ and either be less likely to receive financial rewards, or be more likely to face financial penalties, in pay-for-performance programs.”

“The net effect,” said the panel, “could worsen rather than ameliorate healthcare disparities.”  To avoid this outcome, said the panel, the NQF should “reconsider” its policy. If the NQF remains concerned that lawmakers may remain in the dark about disparities in health outcomes, it should seek evidence for such disparities through other, more traditional means. In the future, the panel concluded, “purchasers, policymakers and other users of performance measures should assess the potential impact on disadvantaged patient populations …. (p. 10)” before imposing P4P schemes.

How did it come to this? Why do our country’s top health policy makers have to be told to honor the fundamental principles of science and medicine, namely, make sure whatever you recommend is safe and effective before administering it?

There are some big obstacles to achieving universal coverage in the US under a single-payer system. None is more serious than the sloppiness of managed care think – the refusal of the health policy elite to honor the equivalent of evidence-based medicine and the equivalent of the Hippocratic Oath. It encourages lawmakers to buy cheap, snake oil health policy in place of real medicine. All of us who care about an efficient and humane health care system in the US must redouble our efforts to shine a light on the establishment’s cavalier attitude toward science and ethics in health policy.

Ezekiel Emanuel: “Reinventing American Health Care”

Reinventing American Health Care: How the Affordable Care Act Will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System

By Ezekiel J. Emanuel
PublicAffairs

There are 4 things the average physician can do. One is to begin the process of transformation to more efficient practice, knowing that payment changes that move away from fee for service are inevitably coming.

Second, part of this transformation means that physicians will need to change their business model to increasing efficiency in their delivery of the services.

Third, physicians should engage insurers to try to modify contracts so that they have a financial reward for being more efficient.

Finally, these impending changes confront many physicians with the major existential question of whether to sell their practice to a hospital system or remain independent.

==

Six megatrends

* End of insurance companies as we know them

Insurance companies will either become purveyors of management analytics, and actuarial services, or integrated delivery systems actually employing (or contracting with) hospitals, physicians, and other providers to render patient care.

* VIP care for the chronically and mentally ill

Physicians and hospitals will focus on keeping patients with chronic illnesses healthy and out of the emergency room and hospital, thereby decreasing the frequency of avoidable complications and rate of hospitalization. Then they will begin routinely screening for depression and other mental health problems and develop standardized rapid interventions.

* The emergence of digital medicine and closure of hospitals

Over 1,000 acute-care hospitals will close. We will see a slew of new technologies for remote monitoring, testing, and treating patients in real time outside of the hospital and physicians’ offices.

* End of employer-sponsored health insurance

Fewer than 20% of workers in the private sector will receive traditional employer-sponsored health insurance.

* End of health care inflation

Health care inflation will be GDP+0%.

* Transformation of medical education

Medical education will be transformed in 4 fundamental ways: (1) three-year medical schools and shorter residencies; (2) half of medical school clinical training will be outside of hospitals; (3) integration of nurses, pharmacists, social workers with medical students in multi-professional team training; and (4) formal incorporation of population health and management skills in training.

==

Regardless of the short-term political costs, in the longer sweep of history, beginning in 2020 or so, the ACA will increasingly be seen as a world historical achievement, even more important for the United States than Social Security and Medicare had been. And Barack Obama will be viewed more like Harry Truman – judged with increasing respect over time.

http://www.publicaffairsbooks.com/book/hardcover/reinventing-american-health-care/9781610393454

Ezekiel J. Emanuel, speaking about his book, “Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System”

Politics and Prose, April 16, 2014

Q&A

At 39:30

Harvey Fernbach:  I’m a member of Physicians for a National Health Program. We believe in single payer simplicity, Medicare for all. As you know the president was for single payer, he said it, he’s for Medicare for all. Nancy Pelosi has come out for it. Harry Reid has. John Podesta when he signed up for Medicare said, “Hey, I signed up for Medicare in five minutes; how about single payer?” At a recent discussion at the Center for American Progress, Sen Daschle said very vigorously he was for single payer, if it was not for the politics. Do you have any philosophical problems with single payer, aside from the politics?

Ezekiel Emanuel:  Well, first of all, I think someone once said, “It’s not going to happen so I’m not wasting any time on it.” I think that was Jonathan Gruber, economist at MIT. It isn’t going to happen, so let’s just get clear. It ain’t gonna happen! We barely got the Affordable Care Act through. Single payer, zero chance! Okay, so let’s just be clear on that.

Dr. Fernbach:  No, I don’t think that’s clear. You can go twenty-five years back, and I’m not saying we’d do in six months, or by the end of this talk, but to say that sixty percent of the American people who are for it can’t have what they want…

Dr. Emanuel:  Let me repeat myself.

Dr. Fernbach:  Please.

Dr. Emanuel:  Certainly in my lifetime, not happening. Okay, so I’m not wasting any of my time on it. Okay? Let me just say philosophically I also do have some disagreements with it. Okay? It depends what you mean by “single payer.” You need.. you don’t want to have one system determining payments like Medicare does for 310 million people. I don’t think that’s an efficient system. There are many things Medicare does that aren’t efficient, that they can’t do, and they have to do slowly because they’re affecting so much of medical practice and so many people. Second, you do get a lot of political gridlock; a lot of what Medicare does is a response to political pressures rather than to top quality policy pressures or policy ideas. Second, you do want to have a lot of experimentation. We don’t know the best way to care for someone who’s got chronic conditions or mental illness. We just don’t. We need to experiment a lot, and I think if you have single payer it gets hard to experiment on those things. So, for those reasons, I’m not a wildly big advocate of it because I think it would slow down the ability to make changes. Having said that, you know, I also don’t think it’s politically gonna happen, so.. We couldn’t even, look, we couldn’t even get the public option. Okay? I mean… and we barely got this bill through! It has failed a hundred years worth! Okay?

http://www.politics-prose.com/video/reinventing-american-health-care

Comment:

By Don McCanne, MD

Ezekiel Emanuel’s “Reinventing American Health Care” is largely a history of reform efforts and a description of the enactment and early implementation of the Affordable Care Act. The last section is his view of the future of American health care – the source of the excerpts above.

Some of his suggestions are mere platitudes. Others are “it-sounds-like-a-good-idea” abstractions, but have little solid policy support as to how they would be accomplished. Other recommendations are basic functions physicians already provide. Several of his ideas have already been suggested by others and hold little promise of benefit, and still other ideas are simply sort of weird.

One example is he says that we should replace fee-for-service with bundled payments. Yet Medicare representatives objected for three reasons. There was too much uncertainty without extended testing; the computer infrastructure would have to be very complex to pay based on bundles; and the delivery system is not organized to handle bundles. Although Medicare was adamantly opposed, they were able to slip into ACA ten demonstration projects with the proviso that the administration could then mandate bundled payments throughout Medicare without the need to return to Congress.

In several interviews while promoting his book he has been asked if he sees the changes he predicts as steps toward single payer. He is quite emphatic in rejecting any such possibility. His response to Harvey Fernbach, transcribed above, is typical.

His opposition to single payer dates back to his previous efforts to sell the concept of vouchers for private insurance, paid for by a value-added tax, as the ideal model for reform – a proposal he shared with Victor Fuchs. Although he did not get that, tax credits for the purchase of individual “marketplace” plans seem to be close enough for him.

In his previous book, “Healthcare, Guaranteed,” he devotes an entire chapter to single payer. He concludes, “In their zeal, single-payer advocates seem to forget how American institutions and governmental agencies actually operate. They envision superbly efficient, incorruptible bureaucracies capable of rational policy choices. Unfortunately, American governmental agencies do not spontaneously operate this way.” Thus he dismisses single payer with the trite “incompetent government” meme.

The good news is that you do not have to put “Reinventing American Health Care” on your “must read” list, though some may find it of value as escape literature. But be forewarned that it is not humorous.