PNHP

Dr. Andy Coates: Health care is a social responsibility

Dr. Andy Coates: Health care is a social responsibility

The following is an excerpt from an unofficial transcript of a Jan. 28 telephone interview with Dr. Andrew Coates, president of PNHP and internist in Albany, N.Y., conducted by Dr. Margaret Flowers and Kevin Zeese on their radio show “Clearing the FOG” on We Act Radio, 1480 AM, in Washington, D.C. The program is also streamed at WeActRadio.com. The text below has been slightly edited for clarity.

Dr. Margaret Flowers: Our next guest is Dr. Andy Coates, president of Physicians for a National Health Program. He was recently featured in an article in the Buffalo News in an article titled “Doctor sees shift to single-payer health care.” Good morning, Andy.

Dr. Andrew Coates: Thank you for having me.

Dr. Flowers: In the Buffalo News article you talk about a person who left the hospital early despite having a serious problem. Can you talk about the concept of self-rationing that exists in the United States?

Dr. Coates: We have an incursion, first of all, of high-deductible private health insurance plans. People will pay $1,000, $2,000 even $5,000 out of pocket before their insurance kicks in. And if you think about the median income being in the $40,000 per year range for the average household, you can see the problem.

And then if you think about poor households – like here in New York state, where the middle of the bottom half is somewhere around $14,000 per household, a shockingly low number – the problem is extreme. In upstate New York cities such as Buffalo and Schenectady, we have a third or more – huge numbers – of children living in poverty.

So in view of out-of-pocket costs for health care going up and up and up, all the time now when we discharge people from the hospital we have to think about exactly how much the prescription is going to cost. It could easily be more than a week’s wages just for an antibiotic prescription, for example. And we have chronically ill people who we know are on six, eight medications.

All of those out-of-pocket costs discourage people from getting care. And there are studies to prove it. The randomized control trial that is famous was the RAND study of co-pays, which showed people avoid necessary care when they have to make out-of-pocket payments. But there are oodles of other studies that show co-pays, deductibles, coinsurance – all those things are impediments to care.

As I was thinking about today’s show, I looked at Franklin D. Roosevelt’s second inaugural address, and I just wanted to share with you these five lines or so.

“Here is the challenge to our democracy: In this nation I see tens of millions of its citizens — a substantial part of its whole population — who at this very moment are denied the greater part of what the very lowest standards of today call the necessities of life.        
“I see millions of families trying to live on incomes so meager that the pall of family disaster hangs over them day by day.
“I see millions whose daily lives in city and on farms continue under conditions labeled indecent by a so-called polite society half a century ago.
“I see millions denied education, recreation, and the opportunity to better their lot and the lot of their children. …
“I see one-third of a nation ill-housed, ill-clad, ill-nourished.”

This was in 1937. If you think about the pressure that came to bear on that White House and the frank recognition of poverty in these words, it’s a striking contrast to what we have today.

Kevin Zeese: We still have all those same problems. …

Dr. Coates: Absolutely.

Kevin Zeese: Talk a little about medical bankruptcy.

Dr. Coates: In the United States the leading cause of bankruptcy is medical debt, and of those who are bankrupted by medical debt in our society, the big majority have health insurance of some type when illness comes and ends up bankrupting them.

So health insurance does not protect – the way health insurance works in the U.S. today, it does not protect us from the devastating costs of serious illness. This problem continues at the end of life, where patients have bankrupting illnesses that lead them into long-term care under Medicaid.

Many people, out of self-sacrifice, lose their jobs taking care of loved ones – providing bodily care or getting them to appointments. The jobs that working people have don’t have lots of time off or sick leave. The Family Medical Leave Act gets you a pass from the boss, you get to keep your job perhaps, but you don’t have a paycheck, so people lose their homes because their parents are sick. It’s very, very devastating.

And these are the kind of tragedies taking place in our country. Everyone has a family member or an acquaintance who they know rather well who has faced one of these devastating consequences of illness. Yet even though that happens, it remains somehow a private tragedy.

Sometimes people even see it as something shameful, a personal failing. And of course it shouldn’t be viewed that way. It’s a social responsibility, dealing with these kinds of devastating illnesses, because it could happen to any one of us. So it’s in each of our interests to advocate for everyone being able get the best cancer care without going bankrupt, for example.

Dr. Flowers: Right, so let’s talk about Medicare. The dominant conversation out there right now is that we have to cut Medicare.

Kevin Zeese: Or worse, to privatize it.

Dr. Flowers: Yes, it’s horrendous what the Business Roundtable and others are promoting. So, Andy, can you talk about what’s not being talked about enough – about Medicare for all, about the fact that we actually have a solution that would bring us out of these crises – the health care crisis and the economic crisis?

Dr. Coates: It’s definitely an irony that in the United States there are models of care and paying for care that actually work rather well.

Medicare is coming up on its 50th anniversary. It’s perhaps the most popular program of all time in our country. That said, it’s not perfect. Medicare is far from adequate. It could definitely be improved upon and expanded. There are many things Medicare doesn’t pay for. People still face staggering costs. Dental care is left out of the coverage, for example.

But nonetheless, Medicare works, and it has worked well in terms of its cost savings. A big portion of the money goes to the care of human beings – only about 3 percent goes to administrative expense, compared to about 20 percent in the private health insurance industry.

People have come to completely count on Medicare. Upon retirement, it’s there. It’s a lifesaver for the elderly and it’s also there for the disabled. So Medicare has worked very well, and therefore saying that it’s failing and needs to be privatized is quite silly. It’s amazing where the discourse on this matter is at in the mainstream media.

Kevin Zeese: How would Medicare for all affect the deficit?

Dr. Coates: Well, certainly health care spending is gobbling up a huge portion of the economy. What would it mean to the government if all health care spending were redirected to a publicly financed system? There would arguably be enormous savings from the elimination of lots and lots of waste. That would mean real health systems planning, which would in turn mean establishing clinics and hospitals in places that need them – an expansion of infrastructure.

For example, we always talk about dignified home care for the elderly. However, one of the greatest hypocrisies in this society is that while th
ere is so much celebration of the Greatest Generation, the World War II generation – many of whom are in their senescence, some near death – they are not able to get dignified care in their homes because of reasons of cost.

So if a publicly financed Medicare program were improved and expanded to cover home care, that would be our way of showing respect for that generation that they deserve.

We could train and deploy, through a system of local planning, home-care teams that could keep people at home and dignified rather than losing their homes or going into a reverse mortgage or all these other horrible choices.

And what would that mean for the economy and the deficit? Well, I think it would be an incredible jobs program. I think that would go a long way toward reducing any kind of deficit.

Dr. Flowers: Thank you so much Andy for taking time out of your busy day to be with us.

Dr. Coates: Thank you for having me.

To listen to the full program (or to Dr. Coates’ segment, which begins at the 38-minute mark), visit:

http://clearingthefogradio.org/steven-hill-and-dr-andy-coates-on-deficit-dont-cut-social-security-and-medicare-expand-them/

What will replace SGR?

SGR Repeal Bill Favors Primary Care

By Robert Lowes
Medscape Medical News, February 6, 2013
Two members of Congress today reintroduced an ambitious bill that would repeal Medicare’s sustainable growth rate (SGR) formula for setting physician pay and gradually phase out fee-for-service (FFS) reimbursement.
One major difference this time around for the bipartisan bill, originally introduced in May 2012, is that its price tag appears considerably lower, making passage more likely.
When Reps. Allyson Schwartz (D-PA) and Joe Heck, MD (R-NV), proposed this legislation last year, the Congressional Budget Office (CBO) had estimated that repealing the SGR and merely freezing current Medicare rates for 10 years would cost roughly $320 billion.
Since then, the CBO has reduced that 10-year estimate on the basis of lower than projected Medicare spending on physician services for the past 3 years. In a budget forecast released yesterday, the agency put the cost of a 10-year rate freeze at $138 billion.
The immediate effect of the bill from Schwartz and Heck, titled the Medicare Physician Payment Innovation Act, would be to avert a Medicare pay cut of roughly 25% on January 1, 2014, that is mandated by the SGR formula. Instead, the bill maintains 2013 rates through the end of 2014.
After 2014, Medicare would begin to shift from FFS to a methodology that rewards physicians for the quality and efficiency of patient care. From 2015 through 2018, the rates for primary care, preventive, and care coordination services would increase annually by 2.5% for physicians for whom 60% of Medicare allowables fall into these categories. Medicare rates for all other physician services would rise annually by 0.5%.
Meanwhile, the bill calls on the Centers for Medicare & Medicaid Services (CMS) to step up its efforts to test and evaluate new models of delivering and paying for healthcare (experiments with medical homes, accountable care organizations, and bundled payments are already underway). By October 2017, CMS must give physicians its best menu of new models to choose from. Two menu options would allow some physicians unable to fully revolutionize to participate in a modified FFS scheme.
The year to transition from FFS to “high quality, high value care” will be 2019 under the legislation. Physicians will either operate in a new, CMS-approved delivery and payment model of their choosing or traditional FFS Medicare. The government would keep FFS rates in 2019 at 2018 levels.
After 2019, physicians still embracing traditional FFS Medicare would see their rates reduced until 2024, when they would be permanently frozen at 2023 levels. Physicians operating in the new models, in contrast, would have the opportunity to earn raises for high-quality, low-cost care.
http://www.medscape.com/viewarticle/778879
A summary of the MEDICARE PHYSICIAN PAYMENT INNOVATION ACT OF 2013 can be downloaded by clicking on the link at the bottom of Rep. Allyson Schwartz’s press release:
http://schwartz.house.gov/press-release/schwartz-and-heck-introduce-bipa…

The Medicare sustainable growth rate (SGR) formula seemed to be an equitable method of slowing the non-sustainable increases in Medicare spending. What happened?
Health care spending continued to increase at very high rates, and these increases were funded by private commercial insurance plans. The funds paid pumped up the supply side in health care while having very little ameliorating impact on the demand side. As our health care system continued to be richly funded (too richly, when compared to other wealthy nations), the Medicare SGR formula fell further behind each year in meeting this ever-increasing demand for more funds.
It soon became apparent that if the SGR rates were imposed, physicians would likely restrict their participation in the Medicare program, first by not accepting new patients, and eventually many of them would drop out of the program altogether. For that reason the SGR reductions were deferred most years, and now they have grown to a deficit of about 26 percent.
When physicians are already dissatisfied with Medicare payment rates (cumulative increases have been less than the medical inflation rate), a further abrupt reduction of 26 percent would surely cause many physicians to bail – either limiting their practices to privately insured patients, or retiring early if the reductions wipe out net income.
Members of Congress do support Medicare, even if some would want to shift costs from the federal budget to the beneficiaries themselves. They do understand that the guillotine effect of imposing these reductions would likely severely impair access for patients due to a lack of willing providers. They know that they have to do something.
In defining this problem, members off Congress think in terms of the federal budget. By postponing the reductions, the money has already been spent, yet it is carried on the books as a deficit. What can Congress do to remove this deficit from the budget without having to increase federal revenues?
Quite simply, they need to find other ways to reduce the projected increases in spending. If you download the summary of the Medicare Physician Payment Innovation Act of 2013 (link above), you will see some of the schemes proposed. Most are already familiar, though many are unproven, and some ideas are innovative. Regardless, they are all methods of slowing the growth in Medicare spending while doing very little that would control spending in the private sector. We will still be faced with the same problem that we have now under SGR. In comparison with private insurance payments, Medicare will continue to trail, and the physicians will grow evermore restless.
Rather than taking one program – Medicare – and trying to make it comply with budget austerity, we need to have a financing system in which the entire health care delivery system complies with a single, universal global budget – a single payer national health program. Yes, there would continue to be turf issues between the factions competing for the funds and the public stewards of the funds, but at least the distribution would be equitable and adequate, which was the intent of SGR in the first place.
There are those who contend that we could never adhere to a budget, that it is impossible to fund all of the care that we need if we are limited by a budget. We need only to look at other nations to see that they, with their publicly supervised global or quasi-global budgets, have been able to provide quality care for everyone at an average of half of what we are spending. We can do it, and with a very rich budget at that.

Oregon rally shows growing support for single payer

A house bill sponsored by Rep. Michael Dembrow, D-Portland, is not expected to pass, but advocates claim momentum

By Christopher David Gray
The Lund Report (Portland, Ore.), Feb. 5, 2013

SALEM, Ore. – Nearly a thousand people swarmed the front of the Oregon Capitol Building for the opening session Monday, demanding that Oregon become the second state to enact single-payer health care legislation, which would set up a government financing system to pay for and provide health care coverage and access for all Oregon residents.

Protesters at the Health Care for All Oregon rally hoisted signs, listened to speeches, heard woeful tales of the current health care system, and sang along to bluesman Norman Sylvester: “I don’t care what party you’re in, Democrat or Republican, we don’t need to fight, health care is a human right.”

“The brother said we don’t need a fight, but they’re going to fight us,” said Rep. Michael Dembrow, D-Portland, leading the crowd. Dembrow is the chief sponsor of the single-payer legislation, House Bill 1914. “We don’t necessarily need to fight back, we need to organize. Let’s go forward and organize this state, everybody in, nobody out.”

Dembrow said HB 1914 and companion legislation in the Senate already had 19 co-sponsors, all Democrats — eight more sponsors than its predecessor from the last session, HB 3510.

One of those new sponsors, Rep. Jennifer Williamson, D-Portland, said she supported the legislation because her sister was one of the thousands of Oregonians who each year file for bankruptcy under the weight of medical bills.

“I’ve been a legislator for three weeks now,” Williamson said. “The first bill I signed onto as chief legislator was a bill for universal health care.”

Dr. Paul Gorman, a member of Physicians for a National Health Program, said he ran a free clinic where a man came in complaining of pain in his abdomen. The man had no insurance and he put off seeing a doctor for a long time, allowing his pain to get worse and worse. “By the time he came to see us, his liver cancer was advanced, and he died.” Gorman said 500 Oregonians die each year because they don’t have insurance.

Health Care for All Oregon argued that while the Affordable Care Act signed into law by President Obama in 2010 does improve access for some people — expanding Medicaid and offering private health insurance subsidies to others — the single-payer advocates said the reforms were inadequate and would do little to rein in skyrocketing costs.

Single-payer health care would work similar to Medicare, with a single government fund paid for through taxes rather than paying premiums to several private companies.

HB 1914 isn’t expected to pass the Legislature or even come to the floor for a vote this session. But Dembrow expected to double the number of legislative sponsors and asked everyone in the crowd to lobby their representatives to support single-payer, hoping to find three more legislators by the end of the day.

The number of sponsors didn’t immediately grow to the goal of 22 legislators, but Marissa Johnson, an aide for Dembrow said they hoped to exceed that goal by the end of the week.

“We have interest from more than a handful of representatives and [Dembrow] will be following up with them today,” Johnson said.

Dembrow said at the rally he expected a million votes would be needed to pass a statewide measure while withstanding millions of dollars of negative advertising from groups like the for-profit private health insurance industry, which would be cut out of health care under the proposed system.

“The real work is not going to be done inside this building,” he said. “It’s going to be solved by a million people in Oregon, organized.”

“I think it’s going to take a lot of people stepping outside their comfort zones,” said Rio Davidson of Newport, who volunteered at the end of the rally handing out lists of legislators and asking people to contact their representatives. “Unfortunately, a lot of people who want single-payer are working low-wage jobs.”

Longtime advocate Betty Johnson said afterward that 60 organizations had been involved in the Health Care for All Oregon rally, and the group had recently hired a full-time field organizer. “Absolutely we are growing. We are organizing a number of chapters throughout the state,” she said.

Gov. John Kitzhaber has not shown support for single-payer, putting his energies instead into implementing a private health insurance exchange and transforming the health care delivery system through coordinated care organizations. Despite his position, Johnson said she hoped he would meet with single-payer advocates to discuss how it could work in tandem with the CCO model.

“He’s strengthening the delivery system,” Johnson said. “We really want to change the financing system. When we pass single-payer, the CCO system will work alongside it.”

Dembrow said there are restrictions in the federal Affordable Care Act that prevent states from passing single-payer laws without special permission before 2017. He lamented the added restriction, but said it also gave single-payer supporters three years to build support, get better organized, and develop a plan that would work for Oregon.

The state of Vermont enacted single-payer legislation in 2011 to cover all of its residents, but funding mechanisms are still being worked out and the state will also have to wait until 2017 to receive federal waivers.

Dembrow is introducing a second bill this session that would call on the Legislature to support a formal study of how single-payer would work in Oregon. Activists on Monday called on supporters to ask their legislators for public money, but Johnson said Dembrow believes the study could be paid for with private money.

http://www.thelundreport.org/resource/opening_day_crowd_shows_growing_support_for_single_payer

National Health Service Corps and primary care

National Health Service Corps expands the primary care workforce

U.S. Department of Health & Human Services, February 6, 2013

The National Health Service Corps awarded more than $10 million in funding for loan repayment to 87 medical students in 29 states, the District of Columbia and Puerto Rico, who will serve as primary care doctors and help strengthen the health care workforce, Department of Health and Human Services Secretary Kathleen Sebelius announced today.

Made possible by the Affordable Care Act, the National Health Service Corps’ Students to Service Loan Repayment Program provides financial support to fourth year primary care medical students in exchange for their service in the communities that need them most.

As a result of historic investments in the Affordable Care Act and the Recovery Act, the numbers of National Health Service Corps clinicians are at all-time highs. The number of providers serving in the Corps has nearly tripled since 2008. Today nearly 10,000 National Health Service Corps providers are providing primary care to approximately 10.4 million people at nearly 14,000 health care sites in urban, rural, and frontier areas.

http://www.hhs.gov/news/press/2013pres/02/20130206a.html

And…

NHSC Clinician Retention

National Health Service Corps

In addition to the recruitment of providers, the NHSC also works to retain primary care providers in underserved areas after their service commitment is completed to further leverage the Federal investment and to build more integrated and sustainable systems of care.

Short- and Long-Term Retention Rates

A 2012 retention assessment survey found that 82 percent of NHSC clinicians who completed their service commitment in the Corps continued to practice in underserved communities in the short-term, defined as up to one year after their service completion. Fifty-five percent of National Health Service Corps clinicians continue to practice in underserved areas 10 years after completing their service commitment.

Short-term retention increased by 28 percent when compared to the 2000 survey’s rate of 64 percent. The 2012 long-term retention (10 years after service completion) of NHSC clinicians in underserved areas is 55 percent, a 6 percent increase when compared to the 2000 rate of 52 percent. Long-term retention rates are higher for those who serve in rural as opposed to urban communities.

Retention: Primary Medical Care Providers
 
Physicians who completed their NHSC commitment more than 10 years ago had the highest retention rates as compared with physician assistants (PAs), nurse practitioners (NPs), and certified nurse midwives (CNMs). Ten years after their service commitment was completed, the retention rate for physicians was 60 percent. For nurse practitioners and certified nurse midwives, it was 59 percent; and for physician assistants it was 42 percent.

http://nhsc.hrsa.gov/currentmembers/membersites/retainproviders/retentionbrief.pdf

And…

About the NHSC

National Health Service Corps

NHSC-approved sites are health care facilities that provide outpatient, ambulatory, primary health services in Health Professional Shortage Areas (HPSAs), which are communities with limited access to care. Sites (with the exception of Federally Qualified Health Centers and Indian Health Service sites) must apply to become an NHSC site.  Once approved, NHSC sites gain access to desperately-needed primary care providers. NHSC providers often continue to work at their sites after they complete their NHSC service commitments.

Strengthening and growing our primary care workforce is critical to keeping this nation healthy. As more Americans gain access to health care, it is critical there are qualified health care providers to serve them. The NHSC, through its providers and sites, plays an important role in helping to address the country’s primary care shortage.

http://nhsc.hrsa.gov/corpsexperience/aboutus/index.html

Comment:

By Don McCanne, M.D.

As we assess the severe deficiencies in our primary care infrastructure, it is important to recognize the phenomenal contribution of our National Health Service Corps in helping to meet the primary care needs in rural and urban Health Professional Shortage Areas.

Today’s HHS release reporting that 87 more medical students have been granted funds for student loan repayment in exchange for service in the NHSC, is great news as far as it goes, but it seems that an average of fewer than two per state is hardly a modest advance.

At a time when the politicos in Washington are talking about spending cuts, it seems that we should be reassessing programs such as this one. We should be spending more money on this important reinforcement of primary care.

Even if we had an improved Medicare for all, this program would be invaluable in helping to correct some of the structural problems within the health care delivery system. In fact, it would be great if it evolved into a program that would provide better access to ever more of us. Backing into a national health service would not be all that bad of an idea.

National Health Service Corps and primary care

National Health Service Corps expands the primary care workforce

U.S. Department of Health & Human Services, February 6, 2013
The National Health Service Corps awarded more than $10 million in funding for loan repayment to 87 medical students in 29 states, the District of Columbia and Puerto Rico, who will serve as primary care doctors and help strengthen the health care workforce, Department of Health and Human Services Secretary Kathleen Sebelius announced today.
Made possible by the Affordable Care Act, the National Health Service Corps’ Students to Service Loan Repayment Program provides financial support to fourth year primary care medical students in exchange for their service in the communities that need them most.
As a result of historic investments in the Affordable Care Act and the Recovery Act, the numbers of National Health Service Corps clinicians are at all-time highs. The number of providers serving in the Corps has nearly tripled since 2008. Today nearly 10,000 National Health Service Corps providers are providing primary care to approximately 10.4 million people at nearly 14,000 health care sites in urban, rural, and frontier areas.
http://www.hhs.gov/news/press/2013pres/02/20130206a.html
And…

NHSC Clinician Retention

National Health Service Corps
In addition to the recruitment of providers, the NHSC also works to retain primary care providers in underserved areas after their service commitment is completed to further leverage the Federal investment and to build more integrated and sustainable systems of care.
Short- and Long-Term Retention Rates
A 2012 retention assessment survey found that 82 percent of NHSC clinicians who completed their service commitment in the Corps continued to practice in underserved communities in the short-term, defined as up to one year after their service completion. Fifty-five percent of National Health Service Corps clinicians continue to practice in underserved areas 10 years after completing their service commitment.
Short-term retention increased by 28 percent when compared to the 2000 survey’s rate of 64 percent. The 2012 long-term retention (10 years after service completion) of NHSC clinicians in underserved areas is 55 percent, a 6 percent increase when compared to the 2000 rate of 52 percent. Long-term retention rates are higher for those who serve in rural as opposed to urban communities.
Retention: Primary Medical Care Providers
Physicians who completed their NHSC commitment more than 10 years ago had the highest retention rates as compared with physician assistants (PAs), nurse practitioners (NPs), and certified nurse midwives (CNMs). Ten years after their service commitment was completed, the retention rate for physicians was 60 percent. For nurse practitioners and certified nurse midwives, it was 59 percent; and for physician assistants it was 42 percent.
http://nhsc.hrsa.gov/currentmembers/membersites/retainproviders/retentio…
And…

About the NHSC

National Health Service Corps
NHSC-approved sites are health care facilities that provide outpatient, ambulatory, primary health services in Health Professional Shortage Areas (HPSAs), which are communities with limited access to care. Sites (with the exception of Federally Qualified Health Centers and Indian Health Service sites) must apply to become an NHSC site.  Once approved, NHSC sites gain access to desperately-needed primary care providers. NHSC providers often continue to work at their sites after they complete their NHSC service commitments.
Strengthening and growing our primary care workforce is critical to keeping this nation healthy. As more Americans gain access to health care, it is critical there are qualified health care providers to serve them. The NHSC, through its providers and sites, plays an important role in helping to address the country’s primary care shortage.
http://nhsc.hrsa.gov/corpsexperience/aboutus/index.html

As we assess the severe deficiencies in our primary care infrastructure, it is important to recognize the phenomenal contribution of our National Health Service Corps in helping to meet the primary care needs in rural and urban Health Professional Shortage Areas.
Today’s HHS release reporting that 87 more medical students have been granted funds for student loan repayment in exchange for service in the NHSC, is great news as far as it goes, but it seems that an average of fewer than two per state is hardly a modest advance.
At a time when the politicos in Washington are talking about spending cuts, it seems that we should be reassessing programs such as this one. We should be spending more money on this important reinforcement of primary care.
Even if we had an improved Medicare for all, this program would be invaluable in helping to correct some of the structural problems within the health care delivery system. In fact, it would be great if it evolved into a program that would provide better access to ever more of us. Backing into a national health service would not be all that bad of an idea.

Patients object to physicians' focusing on costs

Focus Groups Highlight That Many Patients Object To Clinicians’ Focusing On Costs

Roseanna Sommers, Susan Dorr Goold, Elizabeth A. McGlynn, Steven D. Pearson and Marion Danis
Health Affairs, February 2013

Abstract

Having patients weigh costs when making medical decisions has been proposed as a way to rein in health care spending. We convened twenty-two focus groups of people with insurance to examine their willingness to discuss health care costs with clinicians and consider costs when deciding among nearly comparable clinical options. We identified the following four barriers to patients’ taking cost into account: a preference for what they perceive as the best care, regardless of expense; inexperience with making trade-offs between health and money; a lack of interest in costs borne by insurers and society as a whole; and noncooperative behavior characteristic of a “commons dilemma,” in which people act in their own self-interest although they recognize that by doing so, they are depleting limited resources. Surmounting these barriers will require new research in patient education, comprehensive efforts to shift public attitudes about health care costs, and training to prepare clinicians to discuss costs with their patients.

From a discussion of Implications

The focus-group discussions revealed the following barriers to participants’ choosing less expensive care: the salience of unlikely but highly upsetting possibilities; a desire for zero risk, rather than for reasonable risk reduction; an assumption that price always signals quality; the misperception that health care sustainability can be achieved by eliminating wasteful spending alone, without needing to forgo some marginally beneficial care; and the belief that choosing more expensive care constitutes a kind of victory for patients over the insurance companies.

Conclusion

If patients and clinicians do not discuss and consider costs during the clinical encounter, the alternatives are problematic. Clinicians might make cost-conscious decisions—for example, judging when high-priced resources such as operating room times, hospital beds, imaging, and specialty referrals are warranted—without informing patients that cost considerations influenced their decisions. Evidence from other countries indicates that clinicians do occasionally limit the use of medical interventions on the basis of concerns about cost. Yet another alternative would be to make cost-conscious allocation decisions at the organizational level, with minimal clinician involvement.

Given the long-term projections about health care costs in the United States, it is inevitable that physicians will face increasing pressures to deliver cost-effective care to their patients. Doing so openly, in a way that allows patients an opportunity to hear the justification for cost-conscious decisions and to be active agents in thinking through treatment choices when feasible, is consistent with physicians’ ethical duties to be transparent with patients and to provide patient-centered care.

But this study’s findings suggest that for cost to be an explicitly recognized and discussed factor in clinical decisions, public attitudes about health care costs must first undergo a significant shift.

http://content.healthaffairs.org/content/32/2/338.abstract

Comment:

By Don McCanne, M.D.

Much attention is being directed today toward the very high costs that plague the U.S. health care system. That attention has not equated with effectiveness in controlling costs, as we witness continued increases in spending in spite of introduction of policies that may be well-meaning but not very effective, that may add to the administrative excesses of our system, and that sometimes are detrimental such as when we erect financial barriers to beneficial health care services.

Some of the emphasis has been directed toward increasing the engagement of the “medical consumer” in the decision process, often through the policies of consumer-directed health care. These policies are designed to make patients “better health care shoppers” by forcing them to recognize costs as they spend some of their own money on health care. The most common measure is to increase the deductibles and other forms of cost sharing that the patient must face when accessing care.

This important study used focus groups to determine the attitudes of potential patients toward injecting cost considerations into the delivery of health care. Patients don’t like it. They feel that they should receive the care that they should have without insurers or public programs making decisions on covering care based on cost considerations. Even if it is their own money, they do not want to compromise their care based on cost.

Other high-quality systems that are much less expensive than ours are able to provide care with first dollar coverage, eliminating the requirement that the patient be involved or even concerned about the costs of the care that they receive. We do not need to create an environment of distrust by the patient that would be engendered by thoughts of health care services being withheld for reasons of cost.

We can make far better clinical decisions based on studies generating guidelines such as those by the British National Institute for Health and Clinical Guidance (NICE). An example of how this works is in their guidance for “Cetuximab, bevacizumab and panitumumab for the treatment of metastatic colorectal cancer after first-line chemotherapy,” available at this link: http://guidance.nice.org.uk/TA242/Guidance/pdf/

If we replaced our fragmented, dysfunctional financing system with an efficient single payer system, and then applied rational decision making processes for diagnostic and therapeutic interventions, we would not have to have the patient involved in spending decisions. Those decisions could be made on a macro-system basis by better planning of system capacity and distribution, and then incorporating a greater element of evidence-based decision making.

We really don’t need angry, me-first patients provoked by having cost decisions forced upon them, particularly when the cost transparency demanded by the advocates of consumer-directed health care creates hostility towards health care professionals and third party payers whom they believe are withholding care that they should have, whether it is true or not.

Patients object to physicians' focusing on costs

Focus Groups Highlight That Many Patients Object To Clinicians’ Focusing On Costs

Roseanna Sommers, Susan Dorr Goold, Elizabeth A. McGlynn, Steven D. Pearson and Marion Danis
Health Affairs, February 2013
Abstract
Having patients weigh costs when making medical decisions has been proposed as a way to rein in health care spending. We convened twenty-two focus groups of people with insurance to examine their willingness to discuss health care costs with clinicians and consider costs when deciding among nearly comparable clinical options. We identified the following four barriers to patients’ taking cost into account: a preference for what they perceive as the best care, regardless of expense; inexperience with making trade-offs between health and money; a lack of interest in costs borne by insurers and society as a whole; and noncooperative behavior characteristic of a “commons dilemma,” in which people act in their own self-interest although they recognize that by doing so, they are depleting limited resources. Surmounting these barriers will require new research in patient education, comprehensive efforts to shift public attitudes about health care costs, and training to prepare clinicians to discuss costs with their patients.
From a discussion of Implications
The focus-group discussions revealed the following barriers to participants’ choosing less expensive care: the salience of unlikely but highly upsetting possibilities; a desire for zero risk, rather than for reasonable risk reduction; an assumption that price always signals quality; the misperception that health care sustainability can be achieved by eliminating wasteful spending alone, without needing to forgo some marginally beneficial care; and the belief that choosing more expensive care constitutes a kind of victory for patients over the insurance companies.
Conclusion
If patients and clinicians do not discuss and consider costs during the clinical encounter, the alternatives are problematic. Clinicians might make cost-conscious decisions—for example, judging when high-priced resources such as operating room times, hospital beds, imaging, and specialty referrals are warranted—without informing patients that cost considerations influenced their decisions. Evidence from other countries indicates that clinicians do occasionally limit the use of medical interventions on the basis of concerns about cost. Yet another alternative would be to make cost-conscious allocation decisions at the organizational level, with minimal clinician involvement.
Given the long-term projections about health care costs in the United States, it is inevitable that physicians will face increasing pressures to deliver cost-effective care to their patients. Doing so openly, in a way that allows patients an opportunity to hear the justification for cost-conscious decisions and to be active agents in thinking through treatment choices when feasible, is consistent with physicians’ ethical duties to be transparent with patients and to provide patient-centered care.
But this study’s findings suggest that for cost to be an explicitly recognized and discussed factor in clinical decisions, public attitudes about health care costs must first undergo a significant shift.
http://content.healthaffairs.org/content/32/2/338.abstract

Much attention is being directed today toward the very high costs that plague the U.S. health care system. That attention has not equated with effectiveness in controlling costs, as we witness continued increases in spending in spite of introduction of policies that may be well-meaning but not very effective, that may add to the administrative excesses of our system, and that sometimes are detrimental such as when we erect financial barriers to beneficial health care services.
Some of the emphasis has been directed toward increasing the engagement of the “medical consumer” in the decision process, often through the policies of consumer-directed health care. These policies are designed to make patients “better health care shoppers” by forcing them to recognize costs as they spend some of their own money on health care. The most common measure is to increase the deductibles and other forms of cost sharing that the patient must face when accessing care.
This important study used focus groups to determine the attitudes of potential patients toward injecting cost considerations into the delivery of health care. Patients don’t like it. They feel that they should receive the care that they should have without insurers or public programs making decisions on covering care based on cost considerations. Even if it is their own money, they do not want to compromise their care based on cost.
Other high-quality systems that are much less expensive than ours are able to provide care with first dollar coverage, eliminating the requirement that the patient be involved or even concerned about the costs of the care that they receive. We do not need to create an environment of distrust by the patient that would be engendered by thoughts of health care services being withheld for reasons of cost.
We can make far better clinical decisions based on studies generating guidelines such as those by the British National Institute for Health and Clinical Guidance (NICE). An example of how this works is in their guidance for “Cetuximab, bevacizumab and panitumumab for the treatment of metastatic colorectal cancer after first-line chemotherapy,” available at this link: http://guidance.nice.org.uk/TA242/Guidance/pdf/
If we replaced our fragmented, dysfunctional financing system with an efficient single payer system, and then applied rational decision making processes for diagnostic and therapeutic interventions, we would not have to have the patient involved in spending decisions. Those decisions could be made on a macro-system basis by better planning of system capacity and distribution, and then incorporating a greater element of evidence-based decision making.
We really don’t need angry, me-first patients provoked by having cost decisions forced upon them, particularly when the cost transparency demanded by the advocates of consumer-directed health care creates hostility towards health care professionals and third party payers whom they believe are withholding care that they should have, whether it is true or not.

Hundreds rally in Oregon for single-payer health care

By Bennett Hall
Corvallis Gazette-Times, Feb. 4, 2013

SALEM, Ore. — Hundreds of people from all over Oregon rallied in Salem on the first day of the legislative session to call attention to what they claim is a broken health care system and call on lawmakers to enact reforms.

An estimated 1,000 protesters, many brandishing signs and wearing red “Health Care Is a Human Right” T-shirts, packed the Capitol steps to hear a dozen speakers tell horror stories of out-of-control medical costs and urge support for a single-payer health care bill.

Ten buses — including two from the mid-valley — delivered people from as far away as La Grande and Bandon, Ashland and Prineville for the lunchtime rally, organized by Health Care for All Oregon.

Rep. Michael Dembrow, D-Portland, got a hearty cheer as he took the stage to talk about his plans to reintroduce the Affordable Health Care for All Oregon Act, which foundered in the 2011 session.

This time, he said, the notion of a comprehensive taxpayer-supported health care system for all Oregonians has broader support, with 19 co-sponsors already on board, compared to 11 last time.

But he also predicted that a statewide ballot measure would ultimately be required to enact a single-payer system in Oregon. Using emotionally charged language, he exhorted the audience to work toward passing an initiative in the 2016 election.

“Brothers and sisters,” Dembrow said, “the real work here is not going to be done inside this building. It’s going to be done outside this building, in all parts of Oregon, by all of you.”

Two of his co-sponsors, Reps. Jennifer Williamson of Portland and Dave Gomberg of Lincoln City, also spoke in support of the bill.

Monday’s rally had a festive air, with musicians performing protest songs, a 10-foot-tall puppet dubbed Big Nurse, and activists wearing open-backed hospital gowns that exposed padded foam derrierres to illustrate what private insurance just won’t cover.

The crowd, roughly six times the size of a similar gathering two years ago to support Dembrow’s previous single-payer bill, chanted and sang, cheered and shouted for a parade of speakers lamenting the ills of private heath insurance.

Wes Brain of Ashland recounted his daughter’s nine-year struggle with leukemia — and with a succession of insurance companies that didn’t want to pay for her care.

He recently marked the fourth anniversary of her death — and began his own battle against cancer. Unlike his daughter, Brain has no insurance.

“The bills are coming in,” he said, “and I just don’t have the money to pay them.”

The Rev. Joel Miller, pastor of the Unitarian Universalist Fellowship of Corvallis, spoke of his personal conversion from a free market capitalist whose parents ran a small business to a single payer advocate who sees how runaway health care costs are crippling the economy. Now that he’s an employer himself, he said, his eyes have been opened to the shortcomings of a system that ties health care access to employment.

“The system of coverage I’m working with is expensive, inefficient and flat-out immoral,” he said. “My employees live in terror of losing their health coverage. We all live in terror.”

Between speakers, event organizer Jess Hoffman of Health Care for All Oregon urged attendees to meet personally with their local legislators and lobby for single-payer health care.

“We really want to make sure we capture the energy of this moment today,” she said, “so we can use it for the rest of the movement.”

http://www.gazettetimes.com/news/local/hundreds-rally-for-single-payer-health-care/article_da39fec6-6f1e-11e2-bf35-001a4bcf887a.html?comment_form=true

CMS shows that the healthy go in and the sick come out of Medicare Advantage plans

Impact of Continued Biased Disenrollment from the Medicare Advantage Program to Fee-for-Service

By Gerald F. Riley
Centers for Medicare & Medicaid Services, Medicare & Medicaid Research Review , 2012: Volume 2, Number 4

Background: Medicare managed care enrollees who disenroll to fee-for-service (FFS) historically have worse health and higher costs than continuing enrollees and beneficiaries remaining in FFS.
 
Objective: To examine disenrollment patterns by analyzing Medicare payments following disenrollment from Medicare Advantage (MA) to FFS in 2007. Recent growth in the MA program, introduction of limits on timing of enrollment/disenrollment, and initiation of prescription drug benefits may have substantially changed the dynamics of disenrollment.

Conclusions: Despite substantial changes in policies and market characteristics of the Medicare managed care program, disenrollment to FFS continues to occur disproportionately among high-cost beneficiaries, raising concerns about care experiences among sicker enrollees and increased costs to Medicare.

Discussion

Despite substantial changes in policies and market characteristics of the Medicare managed care program, disenrollment to FFS continues to occur disproportionately among high-cost beneficiaries. Disenrollees had higher risk scores and incurred higher risk-adjusted payments than beneficiaries in FFS. Their high risk scores are in contrast to the risk scores of the general MA population, most of which is enrolled in plans with average risk scores similar to or less than local FFS experience (United States Government Accountability Office, 2010). Recent studies have also shown that MA plans continue to experience favorable selection through enrollment of low-cost beneficiaries (MedPAC, 2012; Riley, 2012). These research findings suggest a pattern of selective disenrollment whereby disenrollees are sicker and more expensive than the beneficiaries who remain enrolled in MA plans. This selective disenrollment potentially increases Medicare costs through the return of high-cost beneficiaries to the FFS sector, leaving behind a healthier and lower-cost population in the capitated MA sector.

The Affordable Care Act mandated changes to MA payment methods that will result in significant decreases in payment rates and bring them closer in line with plan costs. This may intensify pressure on plans to encourage selective disenrollment.

Disenrollees from PPOs and PFFS plans incurred lower payments post-disenrollment than disenrollees from HMOs and similar types of plans, and their average payments were closer to predicted levels. Possible explanations include a less chronically ill disenrollee population from PPO and PFFS plans, or less unmet demand for services when they transitioned to FFS. Less selective disenrollment from PPO and PFFS plans may be attributable to the more extensive network of providers available under these types of plans. Beneficiaries with chronic illnesses have a greater choice of physicians to manage their conditions and have more opportunities to switch providers if they become dissatisfied with their care. This expanded choice of providers may reduce the incentives for chronically ill enrollees to leave these types of plans.

http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MMRR/Downloads/MMRR2012_002_04_A08.pdf

Comment:

By Don McCanne, M.D.

Earlier studies of the Medicare + Choice plans and more recent studies of the successor Medicare Advantage plans have shown that, when it comes to managed care, the healthy go in and the sick come out. Taxpayers are paying more for the healthier, less-costly patients who are enrolled in the Medicare Advantage plans, and then pay more for the sicker patients who return to the traditional Medicare program (adverse selection). This CMS study adds to that evidence.

One interesting finding in this study is that those enrolled in PPO or FFS Medicare Advantage plans did not show as great post-enrollment cost increases. It is likely that the patients did not experience as much of a limitation in services in PPO plans, such as those offered by Blue Cross and Blue Shield, since their networks tend to include a much larger percentage of the physician population.

There are two important take-home points here. One is that we should stop wasting taxpayer funds on both the excesses of the Medicare Advantage plans, and the costly adverse selection burden that they place on the traditional Medicare program.

The other point is that we should reject the policies of the private insurance sector that is taking away our health care choices by establishing networks of health care providers. Our traditional Medicare program includes a choice of any provider, except for the rare physician who totally opts out of the Medicare program.

For greater economy and expanded choice, we should change to a program of an improved Medicare for everyone.

Redefining affordable

The future of health insurance premiums under the ACA

By Pippa Abston, M.D.
Pippa Abston’s blog, Feb. 2, 2013

In a move that goes beyond redefining the word “is,” the IRS has released its final rule on what will be considered “affordable” premiums for families. Although you will not be on the hook for a tax penalty if the premiums for your entire family exceed 8 percent of your income, an increasingly common problem, you will not be eligible to purchase a subsidized plan on the coming Exchanges as long as your individual premium for your employer plan is 9.5 percent or less of your household income.

Do you see where this is going? Let’s say your employer really doesn’t want to pay the wrist-slap penalty for failing to provide you with an “affordable” insurance option. So she finds a policy that costs exactly 9.5 percent of your total household income, which includes your spouse’s two part-time jobs. You have two children, and your spouse’s jobs don’t include benefits because they are part-time. Could a policy covering all four of you cost 38 percent of your income?

I used to have an option for individual or family coverage through my employer, but now there are premiums based on number of persons in my family. Even those of us with decent incomes are going to be hard-pressed to come up with that money, and remember — this is only the premium. It does not include the “cost-sharing” of co-pays, deductibles, and non-covered services.

For low-paying jobs, where it would be hard to find a policy that meets the criteria of essential health benefits for 9.5 percent of salary, look to insurers and the feds to get really creative finding loopholes. Less of your body might be essential than you now imagine. There are already waivers for so-called “mini-med” insurances until 2014. Do you really believe the waivers will disappear on schedule? I’m not holding my breath. Some sort of redefinition is probably already in the works.

If a state refuses to participate in the Medicaid expansion, your children might still be covered if you are under the poverty line. Children in families up to 300 percent of poverty are generally eligible for the SCHIP programs (ALLKids in Alabama). But what about you and your spouse? Oh, well, the IRS says. You don’t have to buy insurance — we won’t penalize you. You can “keep the coverage you have,” even if it is no coverage.

Can you hear me now? As long as private insurers are part of our health care system, our health is at risk. The insurers need to keep our care costs high, so they can rake in their allowed percentages, so there will be little effort to make serious improvements to health care that would keep us healthy at less cost — steps like eliminating subsidies for producers of toxic and obesity-promoting foods, getting corporate food out of the school lunch program, repairing the broken FDA, reducing our exposure to environmental poisons, or financing our public health system effectively.

Let’s get serious about health care reform — we need Medicare for All, now more than ever. Look at the estimates for taxpayer funding under this system, a pre-paid plan with no co-pays or deductibles. It’s affordable for ALL of us, no creative redefining needed. Medicare for All — everybody in, nobody out. Look for a chapter of PNHP (Physicians for a National Health Program), Healthcare-Now, or other single payer groups in your area, and find out what you can do to make it happen! If you are in North Alabama, we’ll be expecting you.

Pippa Abston M.D., Ph.D., F.A.A.P., is a general pediatrician who sees patients and teaches medical students and residents in Huntsville, Ala.

http://pippaabston.wordpress.com/2013/02/02/redefining-affordable-the-future-of-health-insurance-premiums-under-the-aca/

Americans deserve the kind of health care Sen. Kirk received

By Pamella Gronemeyer, M.D.
St. Louis Post-Dispatch, Letters, Feb. 2, 2013

We are all happy about and inspired by Sen. Mark Kirk’s recovery from the unexpected and catastrophic cerebrovascular accident that he suffered last year. His return to the Senate after a grueling year of intense and exhausting rehabilitation proves that we can fight back against medical problems if we have both the will and the access to quality care.

Sen. Kirk stated on his return that he will be “much more focused on Medicaid and what (his) fellow citizens face.” He learned how expensive health care is even though he is covered by the plan offered to Congress and acknowledges that he spent a large amount of his own resources in the process.

One has to ask what would have been the outcome if Sen. Kirk were employed by a more conventional employer rather than the American people. Would he have kept his job while being rehabilitated? Small businesses can’t afford sick leave or family leave. How much of his medical expenses would have been covered by current employer-sponsored health plans? Even though pre-existing conditions cannot prevent him from getting insurance, they can and do raise premiums. We are all seeing our health insurance plans having a larger deductible and greater co-pays.

We need to have quality health care for all Americans (just like the kind that Sen. Kirk received). If we look around the world, we spend more money per capita for health care in this country with poorer outcomes in life expectancy and infant mortality, to name a few. Many people receive their best quality care when they enter the Medicare system.

Sen. Kirk, we are asking you to support a Medicare for all/single-payer health care system that  will allow all Americans a chance to survive and thrive after a catastrophic medical event. Single-payer is really the only system that will allow us to control costs and make the United States join the other nations in the world where health care is considered a human right.

Dr. Pamella Gronemeyer resides in Glen Carbon, Ill.

http://www.stltoday.com/news/opinion/mailbag/letters-to-the-editor/americans-deserve-the-kind-of-health-care-sen-kirk-received/article_daea936a-783f-536b-ab0b-b40abf848ea8.html#.UQzv7jZyoTk.email

Holding our breath until 2017

By Vermont Health Care for All

The Shumlin administration presented a report on financing single payer to the legislature on January 24, 2013.  It once again demonstrates that we can have comprehensive health care coverage for every Vermonter and also achieve substantial savings when federal law allows us to implement a single payer system in 2017.

This is the latest in a long line of official reports that has come to the same conclusion.

Click here to see the key takeaway points from this report. (Click here to see Vermonters’ letters to the editor about this plan; please consider writing to your local papers.)

This report is just the start.  It shows us different sources of revenue for single payer, but it does not recommend a particular mix of taxes. (The legislature will not vote on a specific plan until 2015.) 

For decades, health insurance companies have told us they can fix our broken health care system. They had their chance—and they blew it! Vermont Health Care for All hopes to work with other individuals and groups to convene discussions in the months to come about the fairest way to finance a single payer system.  Stay tuned!