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Bernie Sanders introduces S. 1782, The American Health Security Act of 2013

Bernie Sanders introduces S. 1782, The American Health Security Act of 2013

S. 1782, The American Health Security Act of 2013

Senator Bernie Sanders
Introduced in the Senate, December 9, 2013 Summary of S. 1782, The American Health Security Act of 2013 The American Health Security Act of 2013 (S. 1782) provides every American with affordable and comprehensive health care services through the establishment of a national American Health Security Program (the Program) that requires each participating state to set up and administer a state single payer health program.  The Program provides universal health care coverage for the comprehensive services required under S. 1782 and incorporates Medicare, Medicaid, the Children’s Health Insurance Program, the Federal Employees Health Benefits Program and TRICARE (the Department of Defense health care program), but maintains health care programs under the Veterans Affairs Administration.  Private health insurance sold by for-profit companies could only exist to provide supplemental coverage.
 
The cornerstones of the Program will be fixed, annual, and global budgets, public accountability, measures of quality based on outcomes data designed by providers and patients, a national data-collection system with uniform reporting by all providers, and a progressive financing system.  It will provide universal coverage, benefits emphasizing primary and preventive care, and free choice of providers.  Inpatient services, long term care, a broad range of services for mental illness and substance abuse, and care coordination services will also be covered. A seven-member national board (the Board) appointed by the President will establish a national health budget specifying the total federal and state expenditures to be made for covered health care services. The Board will work together with similar boards in each of the fifty states and the District of Columbia to administer the Program. A Quality Council will develop and disseminate practice guidelines based on outcomes research and will profile health care professionals’ patterns of practice to identify outliers.  It will also develop standards of quality, performance measures, and medical review criteria and develop minimum competence criteria. A new Office of Primary Care and Prevention Research will be created within the Office of the Director of the National Institutes of Health (NIH). The Program is designed to provide patient-centered care supported through adequate reimbursement for professionals, a wealth of evidence-based information, peer support, and financial incentives for better patient outcomes.  The Program seeks to ensure medical decisions are made by patients and their health care providers. The Program amends the tax code to create the American Health Security Trust Fund and appropriates to the Fund specified tax revenues, current health program receipts, and tax credits and subsidies under the Affordable Care Act.  While the final structure of the financing component is still under consideration and is subject to change, the tax revenues in the draft include a new health care income tax, an employer payroll tax, a surcharge on high income individuals, and a tax on securities transactions. The federal government would collect and distribute all funds to the states for the operation of the state programs to pay for the covered services. Budget increases would be limited to the rate of growth of the gross domestic product.  Each state’s budget for administrative expenses would be capped at three percent. Each state would have the choice to administer its own program or have the federal Board administer it.  The state program could negotiate with providers and consult with its advisory boards to allocate funds.  The state program could also contract with private companies to provide administrative functions, as Medicare currently does through its administrative regions.  State programs could negotiate with providers to pay outpatient facilities and individual practitioners on a capitated, salaried, or other prospective basis or on a fee-for service basis according to a rate schedule.  Rates would be designed to incentivize primary and preventive care while maintaining a global budget, bringing provider, patients, and all stakeholders to the table to best determine value and reimbursement. Finally, the Program also relieves businesses from the heavy administrative burdens of providing health care coverage, puts all businesses on an even playing field in terms of healthcare coverage, and increases the competitiveness of American companies in the global marketplace.  Every other industrialized nation has been able to use the power of a public authority to provide universal health care.  The American Health Security Act of 2013 seeks to do just that for all Americans and their businesses. S. 1782, The American Health Security Act of 2013 (189 pages): http://www.sanders.senate.gov/download/american-health-security-act-of-2013?inline=file

Comment:

By Don McCanne, M.D. Introduction of another single payer bill – S. 1782, The American Health Security Act of 2013 – is very timely. Here’s why. Implementation of the Affordable Care Act is proceeding, and a handful of citizens are pleased to finally gain entrance to an insurance market that they’ve been locked out of. Nevertheless, dissatisfaction is widespread because of a mandate to purchase insurance products that are expensive, that leaves individuals exposed to excessive out-of-pocket costs should they need health care, and that reduces health care choices by reducing the number of providers allowed in the insurance networks. Those with employer-sponsored plans are beginning to see the same changes that reduce both financial security and choices of physicians and hospitals. People are not happy. The rocky rollout of the exchanges created more smoke than fire, but it did cause people to think more about whether Obamacare is a wise solution to the problems with our health care financing system. On the left, there is a loud and clear call to move forward with enactment of a single payer system – an improved Medicare for all. On the right, there is a loud clamor that Obamacare is so bad that we might end up with a single payer system. By some on the right, that’s posed as a threat, but by others it seems to be a dispirited acknowledgement that Obamacare is so bad, and the proposed Republican reforms are so ineffective, that people will demand a system that works – single payer. Because increased awareness of the flaws in Obamacare, and because of the intensification of the national dialogue on single payer, along with the recent endorsement of respected thought leaders, now is the perfect time to introduce a new single payer bill. Sen. Bernie Sanders has introduced S. 1782 in the Senate, and Rep. Jim McDermott is sponsoring the sister bill in the House. Some might be concerned that introduction of another single payer bill into Congress when we already have Rep. John Conyers’ single payer bill – H.R. 676 – could muddle the politics by diverting attention of potential supporters to the two bills, with a contest to decide which is the better legislation. There are differences in the bills, but it is crucial to understand that they are simply two expressions of the one single payer concept. The differences that we should be discussing in public are not the differences in these two bills, but rather the differences between an effective and efficient single payer model that achieves our goals, and our current highly inefficient, dysfunctional multi-payer model that falls far so short – the flawed model that Obamacare perpetuates. When it becomes time to move the legislation forward, the details can be worked out. Proven single payer policies would be inviolate, but the markup would be direct ed more to crafting appropriate legislative language rather than to sabotaging beneficial single payer principles. While there is a lot of noise and dissatisfaction, now is the time to push the single payer message. When we have people like Colin Powell, John Podesta, Steven Nissen and Donald Berwick willing to speak up, then we know it’s time for us to get to work.

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Colin Powell pitches single-payer health care in U.S.

By Alex Lazar
ABC News, Dec. 9, 2013 Former Secretary of State Colin Powell has waded into the health care debate with a broad endorsement of the kind of universal health plan found in Europe, Canada and South Korea. “I am not an expert in health care, or Obamacare, or the Affordable Care Act, or however you choose to describe it, but I do know this: I have benefited from that kind of universal health care in my 55 years of public life,” Powell said, according to the Puget Sound Business Journal, last week at an annual “survivors celebration breakfast” in Seattle for those who, like Powell, have battled prostate cancer.  “And I don’t see why we can’t do what Europe is doing, what Canada is doing, what Korea is doing, what all these other places are doing.” Europe, Canada and Korea all have a “single-payer” system, in which the government pays for the costs of health care. Some Democrats who strongly advocated for, and failed to get, a single-payer system in the 2010 Affordable Care Act, still believe the current law doesn’t go far enough to reform the US health system. A retired four-star general and former chairman of the Joint Chiefs of Staff, Powell told the audience about a woman named Anne, who as his firewood supplier, faced a healthcare scare of her own.  Anne asked Powell to help pay for her healthcare bills, as her insurance didn’t cover an MRI she needed as a prerequisite to being treated for a growth in her brain.  In addition, Powell’s wife Alma recently suffered from three aneurysms and an artery blockage.  ”After these two events, of Alma and Anne, I’ve been thinking, why is it like this?” said Powell. “We are a wealthy enough country with the capacity to make sure that every one of our fellow citizens has access to quality health care,” Powell.  “(Let’s show) the rest of the world what our democratic system is all about and how we take care of all of our citizens.” Powell, who has taken heat from Republicans for twice endorsing President Obama’s election and reelection bids, said he hopes universal healthcare can one day become a reality in the U.S.  ”I think universal health care is one of the things we should really be focused on, and I hope that will happen,” said Powell.  ”Whether it’s Obamacare, or son of Obamacare, I don’t care.  As long as we get it done.” http://abcnews.go.com/blogs/politics/2013/12/colin-powell-pitches-universal-healthcare-in-us/

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Single Payer Is Getting a Second Life as Obamacare Frustration Peaks

Could anger at the Obamacare rollout make Americans more receptive to a kind of Medicare-for-all system? That’s what activists are hoping—and they’re plotting a state-by-state fight.

By David Freedlander
The Daily Beast, December 10, 2013

As the rollout of Obamacare clunks forward, activists who opposed the law from the beginning say it is time to seize the moment, to tear down the current health-care edifice and start anew, especially now as frustration with the law’s implementation is reaching a peak.

These are not Tea Party activists but advocates for a single-payer health-care system who say some of the problems with the launch of the Affordable Care Act—in addition to built-in problems with the law itself—have made the American public more receptive than ever to a Medicare-for-all kind of coverage system.

On Monday, Sen. Bernie Sanders (I-VT) introduced the American Health Security Act, which would require each state to set up a single-payer health-care system and would undo the exchanges that have plagued Obamacare. Meanwhile, various state-led efforts are under way that advocates hope will sweep the country statehouse by statehouse, as soon as lawmakers see the advantage of a single-payer system. In Vermont, for example, lawmakers have set aside the financing and are already preparing to adopt a single-payer system when the federal government permits it, which according to provisions of the Affordable Care Act will be in 2015. In Massachusetts, Don Berwick, a former top Obama administration health official, is basing his campaign for governor on bringing a single-payer system to the commonwealth. And advocates in New York, Maryland, Oregon, and around the country say they see new energy around their cause.

“As the president fully understands, the rollout has been a disaster, the website has been a disaster,” said Sanders in an interview moments after his bill was introduced in the Senate. “But the truth is, even if all of those problems were corrected tomorrow and if the Affordable Care Act did all that it was supposed to do, it would be only a modest step forward to dealing with the dysfunction of the American health-care system. When you have a lot of complications, it is an opportunity for insurance companies and drug companies and medical equipment suppliers to make billions and billions of profits rather than to see our money go into health care and making people well.”

Democrats conceded that Republican efforts to sabotage Obamacare with endless lawsuits and by declining to set up state-run exchanges have damaged the law’s popularity, but they say the confusion will lead the public inevitably to conclude that a simple single-payer system, one that avoids malfunctioning websites and complicated gold/silver/bronze options, is preferable. Advocates pointed enthusiastically to a tweet last month from John Podesta, the former Clinton White House chief of staff who isjoining President Obama to help with health care—“Just applied online for Medicare. Took 5 minutes. Single payer anyone?”—calling it proof that wild-eyed radicals are not the only ones supporting single payer. The notion is gradually becoming more mainstream among the Democratic establishment, advocates said.

“I think the thing that is most interesting about government is that populism gets its biggest support not from Democrats but from what Republicans do,” said former Pennsylvania governor Ed Rendell, who stressed that he did not count himself among the populist members of the Democratic Party. “They torpedo the Affordable Care Act, and I believe we will now have single payer in this country within the next 15 years.”

Opponents to single payer certainly have reasons to believe the momentum is on their side. Further meddling with the American health-care system, after not just the botched rollout of the Affordable Care Act but also the grueling five-year fight to get there, seems unlikely. But proponents of single payer pointed to polls that show a majority of Americans want some version of Medicare for all. It is up to Democratic pols to show leadership on the issue and risk defying the powerful health-care industry, advocates said.

“It is not possible to put together a good program unless you antagonize the powers that be,” said Dr. David Himmelstein, one of the leaders of Physicians for a National Health Program. The White House, he added, “largely played an inside-the-Beltway game in passing Obamacare. They refused to rally the American people for something truly radical which every poll shows that the American people really want.”

Sanders joked that he expected to have his bill passed by chambers of Congress and ready for President Obama’s signature by the time he returns from Nelson Mandela’s funeral in South Africa, but few proponents see much hope of gaining traction for single-payer health care in a Congress that has struggled to pass a routine budget.

Instead they are turning to a legislature-by-legislature fight in statehouses across the country. Advocates in New York and California said they were counting on labor unions’ opposition to the Affordable Care Act—some labor leaders have feared that their members may pay higher premiums under the law and have pushed for exemptions. In Vermont, a single-payer bill passed in 2011, and Dr. Deb Richter, the president of Vermont Health Care for All, said that if anything, the passage of Obamcare slowed the group’s work there.

“We had all the momentum going on the single-payer side, and it was really slowed by the Affordable Care Act,” she said. A state measure similar to Obamacare faltered, she added, because it lacked the appropriate enforcement mechanisms. Now, with the law set to take effect in 2015, advocates are working to calm fears among Vermonters who have been scared off by talk of “socialized medicine.”

“We have all of the right ingredients, but there is a lot of room for mischief. You can confuse people, freak them about rationing and all of that stuff,” said Richter. She said she thought Obamacare’s failure to deal with the spiraling cost of health care would lead more and more people to see the logic of single payer.

“I think that eventually most states will recognize this,” she said. “We keep talking about how the health-care system is unsustainable. We haven’t reached that point yet, but when health care starts eating up 25 percent of GDP and you have hospitals failing, they will look for guaranteed financing, and the only way you get there is through a single-payer system. It is not a matter of if but of when.”

http://www.thedailybeast.com/articles/2013/12/10/single-payer-is-getting-a-second-life-as-obamacare-frustration-peaks.html

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MedPAC conflicted between fiscal neutrality and paying private programs more

Public Meeting of the Medicare Payment Advisory Commission (Medpac)

November 7, 2013 From the transcript:
 
MR. [GLENN] HACKBARTH [CHAIR, MEDICARE PAYMENT ADVISORY COMMISSION]: Okay. It is time to begin….
 
Our first topic today is synchronizing Medicare policy across the options that Medicare beneficiaries will face in the future….[Medpac staff] Julie [Lee] is going to lead the way on this topic. Julie, it is all yours.
 
DR. LEE: Good morning. In recent months, the Commission has been thinking about the relationship between … ACOs, Medicare Advantage plans, and traditional fee-for-service….
 
In the past, the Commission has expressed a general desire to “move away from fee-for-service.” In today’s presentation, we want to clarify what you mean by “moving away” and by “synchronizing” Medicare policy across delivery systems…. [pp 3-4]
 
The title of this presentation says, “Synchronizing Medicare policy across delivery systems,” but we haven’t defined what we mean by “synchronizing.” Does it mean payment neutrality across delivery systems? In other words, would Medicare pay the same amount for the same beneficiary whether she gets her Medicare through fee-for-service, ACO, or MA? …. Alternatively, if not neutrality, does synchronizing mean moving toward one system over another? For instance, would Medicare policy create incentives to move away from traditional fee-for-service? If so, what would that entail? ….[pp 13-14]
 
DR. [MICHAEL] CHERNEW [VICE CHAIR]: My view is that we have to start with fiscal neutrality…. [p 62]
 
DR. CHERNEW: I’ve heard … broad consensus [from other commission members] around the notion of some type of fiscal neutrality…. [p 72]
 
[MEDPAC STAFF] MS. [KATELYN] SMALLEY: … CMS reported [ACO Pioneer] program savings of about 0.5 percent…. The ACOs we spoke with confirmed that the cost of running the ACO was about one to two percent….[p 164]
 
MR. HACKBARTH: If your ultimate goal is to try to move everybody
or a high percentage of care delivery into this new [ACO] model,
then I think … you’ve got to have a clear, explicit strategy for how you’re going to make fee-for-service increasingly uncomfortable. [p 222]
 
http://www.medpac.gov/transcripts/11_13_transcript.pdf

Comment:

By Kip Sullivan The Medicare Payment Advisory Commission (Medpac) has set an impossible task for itself. Even though the traditional fee-for-service (FFS) Medicare program is indisputably less expensive than the Medicare Advantage (MA) program and probably less expensive than the new ACO pilot programs, the commission wants to move doctors and patients out of the FFS program and into the MA and ACO programs while still maintaining “fiscal neutrality,” that is, while paying the same amount per beneficiary regardless of whether the beneficiary is enrolled in the FFS, MA, or ACO program.
 
Medpac has been weaving the intellectual trap it now finds itself in for many years. On the one hand, Medpac has been urging Congress for decades to honor the rule of fiscal neutrality in deciding how much to pay MA plans vis a vis the FFS program and, specifically, to stop paying MA plans more per beneficiary than it pays for FFS beneficiaries. As the excerpts above indicate, there appears to be a consensus among commission members to make fiscal neutrality a fundamental criterion in deciding how much to pay ACOs as well.
 
On the other hand, over the last decade Medpac has taken the position that Medicare’s FFS program encourages unnecessary services and must either be shrunk (“moved away from”) or transformed from a “volume-based” program to a “value-based” program by somehow subjecting doctors to the managed care methods – the financial incentives, report cards and third-party oversight – used by MA insurers and ACOs.
 
The statements by commissioners Chernew and Hackbarth, quoted above, capture the tension created by Medpac’s conflicting goals. Dr. Chernew notes a consensus among commission members that Medicare should not pay more per beneficiary to the ACO program than it pays to the FFS program, but Mr. Hackbarth, a former HMO executive, argues that unless Medpac is prepared to recommend making doctors in the FFS program “uncomfortable,” that is, make them suffer financially for staying in the FFS program, doctors won’t migrate into ACOs.
 
To sum up Medpac’s dilemma: They want to “move away from the FFS program” and “toward” the ACO and MA programs, and they know they can’t do that unless they starve the FFS program and fatten the ACO and MA programs, but they don’t want to starve FFS and fatten the ACO and MA programs because that would violate fiscal neutrality.
 
To those who are unfamiliar with the groupthink that currently dominates the debate about the American health care crisis, this dilemma seems unnecessary, even nonsensical. It would seem that Medpac has it backwards – that Medpac should support “moving away from the MA and ACO programs” and “toward” the FFS program unless and until the MA and ACO programs can demonstrate they cost no more than the FFS program. If Medpac were to adopt this goal, it could also honor the fiscal neutrality rule. That is, Medpac could simply recommend fiscal neutrality and know that fiscal neutrality would bankrupt all or most MA insurers, and would probably bankrupt all or most ACOs, and thereby “move Medicare toward” the FFS program.
 
But Medpac gives no sign of taking that position despite decades of evidence indicating MA insurers are less efficient than FFS providers, and a small but growing body of evidence that ACOs are also less efficient than FFS providers. As the excerpt above indicates, Katelyn Smalley, a member of the Medpac staff, reported to the commission that the latest results from the Pioneer ACO program indicate ACOs raise rather than lower health care spending. Ms. Smalley said CMS reported last summer that the 32 ACOs participating in the Pioneer ACO pilot cut total spending by Medicare by half a percent but expenditures by the ACOs rose by one to two percent. Neither Ms. Smalley nor any commission member pointed out the obvious: While Medicare may have saved a half percent, the health care system as a whole suffered an increase in total spending on the order of half to one-and-a-half percent.
 
Medpac appears to suffer from a split personality. One personality has the integrity to follow the evidence wherever it leads. It is this personality which constantly calls on Congress to stop overpaying MA plans. But Medpac’s other personality suffers from two delusions that afflict much of the US health policy establishment: (1)the delusion that volume, not price and the administrative waste which contributes to high prices, is the main cause of the US health care crisis; and (2) the delusion that the managed care tools pioneered by HMOs will someday demonstrate their ability to reduce volume and thereby lower medical costs more than the managed care tools themselves cost.
 
Medpac is an influential voice in the US health policy wars. We must hope that Medpac will soon recognize that the evidence does not support an endless experiment with managed care and that what America really needs is to move Medicare “toward” a true single-payer system, not just for the elderly and the disabled but for all Americans.

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Colin Powell calls for a universal, single payer system

Gen. Colin Powell calls for universal health care in the U.S.

By Valerie Bauman
Puget Sound Business Journal, December 5, 2013 Former Secretary of State and longtime Republican Colin Powell is calling for a universal health care solution in the U.S. “We are a wealthy enough country with the capacity to make sure that every one of our fellow citizens has access to quality health care,” he said Thursday at a Seattle fundraiser for prostate cancer. “(Let’s show) the rest of the world what our democratic system is all about and how we take care of all of our citizens.” The retired four-star general, a prostate cancer survivor, spoke at the Prostate Cancer Survivors Celebration Breakfast, organized by UW Medicine and the Fred Hutchinson Cancer Research Center. Powell took the opportunity to share some of his own experiences and to publicly call for a health care solution similar to those in Canada, Japan and other countries that have a universal, single-payer system. “I am not an expert in health care, or Obamacare, or the Affordable Care Act, or however you choose to describe it, but I do know this: I have benefited from that kind of universal health care in my 55 years of public life,” Powell said. “And I don’t see why we can’t do what Europe is doing, what Canada is doing, what Korea is doing, what all these other places are doing.” http://www.bizjournals.com/seattle/blog/health-care-inc/2013/12/colin-powell-calls-for-universal.html?page=all

Comment:

By Don McCanne, M.D. Colin Powell’s is a very welcome voice in the groundswell of support for single payer. As people better understand single payer, that support will grow until we reach a threshold where even Congress will join in.

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Cleveland Clinic’s Steven Nissen supports single payer

10 Questions: Steven Nissen, MD

By Todd Neale
MedPage Today, December 5, 2013 What’s the biggest barrier to practicing medicine today? That’s just the first of 10 questions the MedPage Today staff is asking leading clinicians and researchers to get their personal views on their chosen profession. In this series we share their uncensored responses. Here, answers from Steven Nissen, MD, of the Cleveland Clinic. There, Nissen is chair of the Robert and Suzanne Tomsich Department of Cardiovascular Medicine. A past president of the American College of Cardiology and former chair of the FDA’s Cardiovascular Renal Drugs Advisory Committee, he has had a leading role in highlighting potential risks associated with certain drugs, including rofecoxib (Vioxx) and rosiglitazone (Avandia). In 2007, Nissen was included on Time Magazine’s list of “100 men and women whose power, talent, or moral example is transforming the world.” 1. What’s the biggest barrier to your practicing medicine today? The lack of a single-payer system. We waste enormous amounts of time and energy dealing with insurance companies, whose major goal is figuring out how not to cover patients. http://www.medpagetoday.com/PracticeManagement/PracticeManagement/43257

Comment:

By Don McCanne, M.D. A couple hundred thousand physicians are closet single payer supporters. If only we could get more of them to out themselves, as Cleveland Clinic’s Steven Nissen has done here, maybe the public would understand that we really could have an improved Medicare for everyone since so many doctors agree.

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December reverie

By Andrew Coates, M.D., F.A.C.P.
WAMC Northeast Public Radio, Dec. 6, 2013
 
December arrives under honking geese. As the last dying leaves find their way to the ground, frost tints the mornings, snow flurries lick the landscape, and Orion rises before bedtime. Holiday gatherings have begun. Time away from work and school might not allow us a whole day for reflection. But we might each find at least a moment of reverie or pause.
 
Philosophers have long explained that the world endures through a great process of dying and becoming, in the sense that everything, everyone, its at once itself and also not itself, in flux, a developing whole made up of opposites. In the words of the ancient Greek philosopher, Heraclitus: “you cannot step twice into the same stream.” Although we recognize the truth of it when we hear this ancient observation, we seldom take, or can seldom find, time to see the world in this way.
 
In our frenetic, pressurized social world, we cope with so many arrangements not of our making or choosing, each complete with a corporate logo and expected brand loyalty. It often seems that an expanding tangle of obligations simply fill our days. Time to step back and think about our lives runs in a trickle.
 
Plus, it seems strange to say “you cannot drive twice upon the same highway.” But a glimpse of ourselves as at once our old self and also the person we are becoming, changing in a changing world, even on our familiar daily commute, might be the beginning of wisdom, if we aim to develop ourselves as human beings. But when we’re a few minutes late to work, driving in traffic that is building to a clog on Albany’s 787, it seems impossible that we might think “Where are we heading?” in a metaphysical or world-historical way.
 
Addled by the need to change lanes, or to plan to get gasoline, or snow tires, one doesn’t take time to reflect, for example, that the Livingston Avenue railroad bridge is still in use since the post-Civil War days of Radical Republicanism, while the very highway on which we’re rolling has already require restoration from dangerous decay, since the days when Reagan was in the White House. Or that the waves just rippling an otherwise placid Hudson River announce the turning tide of the Atlantic Ocean – the very tranquil waters that told Henry Hudson’s crew that they had discovered a great estuary, not the northwest passage.
 
Several years back, at this time of year, I practiced medicine in Shiprock, in the Navajo Nation. We moved as a family, children and all, to New Mexico. We cherish the brief acquaintance we had with Diné culture, in which we learned to respect the breathtaking Navajo landscape as the hallowed grounds of epic human struggle. The biting winds of winter’s eve still breathe life into those experiences. It was a powerful journey, one that brought us outside of ourselves and drew us together.
 
While evidence of indigenous human life has been almost entirely erased from our landscape here in upstate New York, the patterns of human settlement, farming, production, and commerce established during the first centuries of colonization by Europeans etch the landscape still. Yet the past recedes so quickly. For example among our new generations very few have a connection the old ways of farm life, hand tools and homespun, in the insightful ways that earlier generations, grandchildren of immigrants and slaves, once knew.
 
As the cold rises from the earth and pale grays and tans emerge to soften the woods and fields before the snowfall, like the generations before us, we should take time to reflect on our species in the larger arc of history – and also the immediate social predicaments that ensnare us personally. The effort to consider what it is that might make life more worthy of the people we love prove surprisingly powerful – for each of us and for all of us.
 
I have glimpsed the capacity each of have to change ourselves. Among the many indelible experiences brought to my life by the privilege of being a physician, attending the death of patients has taught me about people. In the face of the death of a family member, friend or even a stranger, people rise to the occasion. With death an irrevocable change occurs – and human beings reach inside, summon appropriate emotion, muster personal courage, as well as community resources of human solidarity – and then they transcend.
 
A time is coming when we will find that we simply must move forward to transcend our present social and environmental predicaments – personally and also as species. For today, a moment of personal reflection can help us meet that coming challenge.
 
Dr. Andrew Coates practices internal medicine in Upstate New York. He is president of Physicians for a National Health Program.
 
You can listen to Dr. Coates’ radio broadcast here: http://wamc.org/post/andrew-coates-time-reflect

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Medicare system for all best health care option

By Marc Lavietes, M.D.
Asbury Park (N.J.) Press, Dec. 5, 2013 Frustration with the rollout of The Affordable Care Act is understandable. We should remember that similar problems and criticisms were rampant when the Medicare program was initiated. In fact, conflict over the proper role of government in health care reflects the classic American debate regarding the role of government per se. This Jeffersonian-Hamiltonian debate is named after the most prominent proponents of either side. Despite the dire warnings, Medicare has been successful. Most important, readers should note these basic truths. Fifty million Americans have no health insurance. Fifty million more have grossly inadequate insurance. Only the wealthiest of Americans can survive the economic hardship accompanying a profound illness. Even in Massachusetts with an “Obamacare-like” health care system already in place, severe illness remains the major cause of personal bankruptcy. Maintaining our current health care delivery system, as suggested by some letter writers, best serves only those few Americans who profit from it. All other industrial countries provide better health care to their citizens at substantially lower costs. This truth is often dismissed by our mainstream media under the pretext of “socialized medicine.” While the outcome of the current battles over health care is unclear, it seems likely that those more progressive states having formed their own marketplaces will provide improved care to their citizens, albeit without cost savings. By contrast, the quality of health care in the remaining states will deteriorate. In the final analysis an improved “Medicare for all” system is the best answer. Dr. Marc H. Lavietes resides in Bradley Beach, N.J. http://www.app.com/article/20131205/NJOPINION02/312050027/Medicare-system-for-all-best-health-care-option?nclick_check=1

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10 Questions: Steven Nissen, M.D.

By Todd Neal, Senior Staff Writer
MedPage Today, Dec. 5, 2013

What’s the biggest barrier to practicing medicine today? That’s just the first of 10 questions the MedPage Today staff is asking leading clinicians and researchers to get their personal views on their chosen profession. In this series we share their uncensored responses. Here, answers from Steven Nissen, MD, of the Cleveland Clinic.

There, Nissen is chair of the Robert and Suzanne Tomsich Department of Cardiovascular Medicine. A past president of the American College of Cardiology and former chair of the FDA’s Cardiovascular Renal Drugs Advisory Committee, he has had a leading role in highlighting potential risks associated with certain drugs, including rofecoxib (Vioxx) and rosiglitazone (Avandia). In 2007, Nissen was included on Time Magazine‘s list of “100 men and women whose power, talent, or moral example is transforming the world.”

1. What’s the biggest barrier to your practicing medicine today?

The lack of a single-payer system. We waste enormous amounts of time and energy dealing with insurance companies, whose major goal is figuring out how not to cover patients.

2. What is your most vivid memory involving a patient who could not afford to pay for healthcare (or meds or tests, etc.) and how did you respond?

There are too many to count. I remember a patient who could not afford clopidogrel (Plavix), so he split his pills to stretch the prescription, but subsequently had a catastrophic in-stent thrombosis leading to cardiogenic shock and eventually heart transplantation.

3. What do you most often wish you could say to patients, but don’t?

If you continue to smoke, I would prefer that you see another physician.

4. If you could change or eliminate something about the healthcare system, what would it be?

Fee-for-service medicine. It drives overutilization and leads to poor outcomes.

5. What is the most important piece of advice for med students or doctors just starting out today?

Consider a career in academic medicine. It provides greater diversity and satisfaction than limiting your career to clinical practice.

6. What is your “elevator” pitch to persuade someone to pursue a career in medicine?

I have never regretted my decision. The relationship to patients as well as science makes medicine a unique career choice.

7. What is the most rewarding aspect of being a doctor?

The appreciation we receive from patients and their families. It’s always very special.

8. What is the most memorable research published since you became a physician and why?

I actually think the CAST Trial was most memorable. It continues to resonate. Drugs that suppressed arrhythmias increased the rate of death. It began the ongoing movement away from surrogate endpoints.

9. Do you have a favorite hospital-based TV show?

I don’t watch TV (except the NewsHour on PBS). Television lowers your IQ substantially. There’s a dose-response curve. The more you watch, the more stupid you become.

10. What is your advice to other physicians on how to avoid burnout?

If you can, do what you really enjoy. Then work becomes a pleasure.

Todd Neal is senior staff writer at MedPage Today. http://www.medpagetoday.com/PracticeManagement/PracticeManagement/43257?isalert=1&uun=g441580d398R5538349u&utm_source=breaking-news&utm_medium=email&utm_campaign=breaking-news&xid=NL_breakingnews_2013-12-05

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Wall Street’s view of narrow networks

HSC’s 18th Annual Wall Street Comes to Washington Conference

Center for Studying Health System Change, November 21, 2013 From the conference transcript: Paul Ginsburg (President, Center for Studying Health System Change): Let me move on to network innovations. And one thing that came up a little bit in our first session was narrow- or limited-network products. And let me start by asking about how are plans building limited networks? I mean, in a sense, what are they looking for as far as which providers would they like to have? How sophisticated are they in assessing the value of different providers? Carl McDonald (Director and Senior Analyst, Citi Investment Services): I can go quick: Price. I’m done. Paul Ginsburg: Okay. Actually, how sophisticated is the price? Carl McDonald: Sorry? “How sophisticated…” Paul Ginsburg: How sophisticated is the price? Is it price per episode? Is it simply, you know, unit prices? Carl McDonald: Yes, I mean, generally it’s going to be the unit price, or price per episode. Matthew Borsch (Vice President, Goldman Sachs): Let me just offer one thing that’s happening. This is not quite to the tiered-network strategy, or narrow-network strategy, per se, but it’s topical right now in that you’ve seen some of the health plans in Medicare Advantage taking some pretty strong steps to narrow their networks. On the physician side, it’s been the most notable. In fact, there was a, there’s been some communication about that. There was a letter that was posted yesterday from the health insurance industry to CMS, stressing how important it was for the plans to be able to make these network exclusions. But obviously, for doctors who’ve been, you know, contracted in Medicare Advantage to suddenly be, to be terminated, where, in most cases, they continue to participate on the commercial side, has created some real blowback. Paul Ginsburg: I had noticed that, and was wondering, it sounded to me that this was different way that a plan pursues a more limited network. Matthew Borsch: It is. Paul Ginsburg: It seems as though, and I saw The Wall Street Journal article a week or two ago about United, and it almost seemed as though they were trying to get their star quality scores up by culling out the physicians who contribute to low scores. And is that what it’s about, Matt? Matthew Borsch: Well, the truth is we don’t really know. Paul Ginsburg: Yeah. Matthew Borsch: You know, that, that is, from our perspective, somewhat of a black box, in terms of the decision making there. There are multiple criteria. There’s how each physician group feeds into the star quality scores. There are utilization, efficiency metrics that they can run on a broad, you know, larger companies can run on a broad set of claims data. There’s also, frankly, the consideration of which Medicare Advantage members are assigned to those physician groups. And again, I’m not pointing to any one of these three as a factor but there you could possibly have some effort to change the risk distribution of the underlying membership. Sheryl Skolnick (Managing Director & Co-Head of Research, CRT Capital Group): So, just to put this in context, Medicare Advantage rates are coming down very significantly next year. They’re actually going down next year from United’s perspective, what? about 3 1/2 percent or so. And when your rates go down, some of your plans, and some of your providers in those plans will have to be terminated, because you need to essentially shrink to a profitable size, or a sustainable size. So that’s part of what you’re seeing, is instead of the proactive “We’re introducing a new benefit plan, we’re going to build a narrow network,” now you’re seeing the reactive effect of United’s always been a very inclusive and broad based network. They’ve had some issues of adverse publicity in St. Louis and some other places when they’ve tried to narrow the network based on quality. There is a lot less push back on that sort of thing now. But they’re getting some push back on this one because in Connecticut alone, for example, it’s 2,000 providers. That’s a lot in Connecticut. It’s not that big a state. So, what you’re seeing is, first, the unwinding. Second, I agree with you completely, I think it is absolutely a strategy to get their star scores up, because they’re a major embarrassment. And they’re clearly, from their last conference calls, a focus of the company strategy for Medicare Advantage for the next couple of years, is to get the star scores up. But I also, I agree with Matt, that there are many other factors at work, most notably that they need to get all of these markets that they’ve expanded rather broadly to get rid of the marginal plan, to get rid of the marginal provider and, in some cases, the high cost member. Robert Berenson (Institute Fellow, The Urban Institute): But I think it’s important to point to a major difference between the Medicare managed care situation and commercial, which is that in Medicare, out of network services are paid at Medicare rates, so that changes the whole leverage situation. And it’s the reason, I think, that hospitals basically are in network at Medicare rates, or near to Medicare rates, because they don’t have the leverage. Balance billing is a whole different situation. I’m actually surprised that MA plans weren’t more aggressive in the past, because they have the protection for the out of network care. And others, there won’t be such push back from the beneficiaries hit with the complete balance bill, if their physician is not in network, or something like that. Paul Ginsburg: So, getting into the employer based, the commercial space, you know, it looks like there’s been substantial growth in small group plans to have narrow networks. And, of course, so many of the products of the exchanges are narrow networks. And, any comments about that strategy, how it’s going, is there going to be, is there going to be push back by the public? Sheryl Skolnick: For a long time the hospitals were telling us that while Wall Street was busy talking about the narrowing of networks, they weren’t actually seeing it. It was only when the exchange contracts came up that, even in the beginning, there was some concern that some of the contracts that were being signed weren’t narrow-network contracts, in the very beginning of the contracting. Towards the end of the contracting for reform these are commercial, by the way, these are fundamentally commercial contracts. So, by the end of the contracting, though, almost all of the contracts being signed were for some sort of a narrowed network. So, I think there was a very quick evolution in the thought process of the plans in negotiating these things, where they very quickly realized: This is one of the very few levers we have, we better pull it. Paul Ginsburg: Yes. And, to what extent, as they form these networks, to what extent are the savings going to come from keeping high cost providers out, or getting discounts from providers? Sheryl Skolnick: Yes. Yes. Paul Ginsburg: Which is the dominant piece, or are they both very important. Sheryl Skolnick: Very important. Paul Ginsburg: Okay. That’s the answer. http://www.hschange.org/CONTENT/1396/?id_conf=32

Comment:

By Don McCanne, M.D. If insurers were marketing products designed primarily to get their clients the health care that they need, you would think that they would do their best to make sure that they cover essentially all of the physicians that their clients would select. But they don’t, and they are narrowing even further their lists of contracted providers. Why? Wall Street understands. It ’s not about quality or access. It’s about the money.

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More health care regulations mean more middlemen, fewer doctors

By Stephen B. Kemble, M.D.
Honolulu Star-Advertiser, Nov. 27, 2013 I attended the recent Hawaii 2013 Healthcare Summit, on how Hawaii is implementing the Affordable Care Act and transforming health care. The keynote address by Dr. Abraham Verghese was inspiring — all about the sanctity of the doctor-patient relationship and how health care should be focused on the living patient, not the “iPatient” in the computer.
 
In panel discussions, Hawaii’s health plans and hospitals told us how they will guide us away from fee-for-service payment that rewards volume of services to value-based payment systems that reward quality and care coordination. The goals are the “triple aims” of improved quality, improved population health, and improved value/reduced cost. However, dig deeper and the conference was full of contradictions and confusion.
 
Information presented included:
 
* Hawaii has a low rate of medical procedures compared to the rest of the country.
 
* We have the lowest per capita fee-for-service Medicare expenditures in the country.
 
* Thanks to relatively broad coverage under our Prepaid Health Care Act, Hawaii covers more of our population than any state besides Massachusetts — our benefits are already at the “gold” and “platinum” levels for Obamacare plans, better than any other state — yet we have the third lowest insurance premiums in the country, and all of this under a fee-for-service system.
 
* Hawaii has 20 percent fewer physicians than needed for our population and this is projected to get worse. Shortages are especially severe on the neighbor islands.
 
* Two-thirds of Hawaii psychiatrists no longer accept new Medicaid patients, many dropping out in the past four years, and our ER and hospital costs for mental illness have risen 30 percent in that time.
 
Hospitals and health plans were well represented on panels, but no practicing doctors. Doctors were shaking their heads as panelists told us that solo and small-group medical practices will soon become extinct, replaced by competing “accountable care organizations.” Every health plan and hospital now has multiple “partners” deploying computerized systems to enable them to better manage health care. Doctors are going to be rewarded for meeting quality metrics and punished with financial penalties if they fail to purchase computer systems that achieve “meaningful use,” or if they fail to meet quality metrics.
 
You would think from these presentations that the problem is doctors who don’t care about quality and just want to do more procedures and see more patients to make more money. The health insurance plans and hospitals are going to make sure doctors get paid for “quality,” not “volume.” However, there is no evidence for the alleged problem with excessive “volume” of services here, and if you look at the actual “quality” metrics, they are either very narrow, focusing on those limited aspects of health care that can be easily measured, or they are seriously flawed and don’t actually measure “quality.”
 
The managers and middlemen in health care are proliferating while our supply of doctors is dwindling. The evidence shows that doctors in Hawaii are not actually delivering much unnecessary care, but there are not enough of them and the ones we have are overworked and overburdened with administrative requirements. We are apparently pursuing Dr. Verghese’s “iPatients” at the expense of real patients.
 
Doctors agree that time spent on charting and administration is increasing, so they must work longer hours, spend less time with each patient, or see fewer patients. They are restricting their practices to fewer insurance plans to control administrative burdens, leaving more patients with inadequate access to care. Many are talking about early retirement or dropping participation with health insurance entirely, converting to “concierge” practices for those who can afford it. All of this is taking us in the opposite direction from the “triple aim” goals.
 
Most of our problems are problems with inadequate access to care, especially for those with Medicaid, not fee-for-service incentives or lack of concern for quality.
 
Hawaii’s experience with our Prepaid Health Care Act shows that broader coverage and improved access to care actually reduce health care costs. Let’s take this further and expand coverage to everyone, build our health care provider work force, simplify and streamline administration, pay doctors the same for everyone, and eliminate barriers to access care. Single payer, anyone?
 
Stephen B. Kemble, M.D., is a psychiatrist, an assistant professor at the John A. Burns School of Medicine and immediate past president of the Hawaii Medical Association.
 
http://www.staradvertiser.com/s?action=login&f=y&id=233570491

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Pritzker students explore single-payer health care at PNHP national conference

By Pamela Peters, MS1
Pritzker News, University of Chicago Pritzker School of Medicine, December 4, 2013 With the recent enactment of key portions of the Affordable Care Act, health care reform has increasingly become a hot-button issue. Six students from Pritzker explored the option of single-payer health care reform by attending the annual meeting for the advocacy group Physicians for a National Program (PNHP) on November 2, 2013 in Boston. PNHP is a non-profit research and education organization of 19,000 physicians, medical students, and health professionals based in Chicago with chapters in almost every state. The turnout at the meeting set a new record for the organization, with 404 registrants from 38 states. “The conference was a great opportunity to discuss the economic and medical realities of health care going forward under the ACA, as well as the role of physicians in pushing for change in how medical care is financed,” commented Brandon Berger, MS1. “To me, single payer is a solution to the prohibitive cost of health care, an opportunity to provide medical care in a way that doesn’t discriminate based on ability to pay, and a public health initiative of enormous potential impact.” At the meeting, Pritzker students had the opportunity to listen to presentations from a variety of speakers, such as Vermont Governor Peter Shumlin, who outlined progress and barriers in creating a single-payer health care system for his state. Dr. Marcia Angell, former editor of the New England Journal of Medicine, gave a talk entitled, “Patients and Profits,” and PNHP co-founders Dr. David Himmelstein and Dr. Steffie Woolhander updated attendees with the most recent statistics about the status of health care in America. Pritzker students also had the opportunity to attend many student-specific workshop sessions, where medical students from around the country shared inspiring stories of activism and counseled newcomers on how to become more involved in the single-payer movement. Pritzker’s very own Scott Goldberg, MS2, who is a student delegate on the PNHP national board of directors, led a session entitled “Heroism vs. Evil in Medicine: Transitioning from Sympathizer to Activist.” Scott also founded the University of Chicago student chapter of PNHP, and spent time working with PNHP California this past summer to advocate for movement towards a state-based, single-payer health care system there. “I have seen the medical student movement for single-payer grow significantly in just one year since the last PNHP annual meeting, commented Scott. “The 140 students in attendance were organized, inspired, and committed to fighting for truly universal health insurance. The Affordable Care Act has a few strengths, but it does not fundamentally reform our costly, inefficient, unjust health care system. It still treats health care as a commodity to be traded not a public good. While single-payer reform may seem inevitable to some, it will only occur through the tireless efforts of medical students, physicians, and health professionals. I was honored to lead a workshop that could offer students some tools and insights into making that leap from advocate to activist.” The conference included an additional day of Leadership Training for those who were new to single payer or wanted to learn how to better discuss it with others. The Leadership Training was held on November 1 and began with instruction on how to present the concept of single payer health care in a Grand Rounds format. Three Pritzker students (Brandon Berger, MS1; Rachel Stones, MS1; Pamela Peters, MS1) were able to attend this workshop through generous scholarships from either the Nicholas Skala Student Activist Scholarship fund or the Illinois Single Payer Coalition.

“It was refreshing to be around so many doctors and students who are passionate and actively working towards a more equitable health care system,” said Rachel. “I became much more informed about single-payer and I will definitely be continuing the learning process. I was also inspired by the things that medical students are doing and the activism they are involved with around the country.”

Whether new to activism or a health policy and advocacy veteran, all who attended the conference benefited greatly from the thought-provoking presentations and the equally stimulating dialogues that followed them. http://pritzker.uchicago.edu/about/news/PNHP-Conf.shtml

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