By James C. Mitchiner, MD, MPH, American College of Emergency Physicians
ACEP News, August 7, 2012

“You can always trust the Americans to do the right thing, once they’ve tried everything else.”

Winston Churchill’s iconic remark, reportedly issued at the dawn of America’s entry into World War II, is equally applicable to the present American health care debate and the crisis that spawned it. Regardless of whether you are elated or disappointed with June’s historic Supreme Court decision upholding the constitutionality of the Affordable Care Act, it is certainly no panacea for the problems facing U.S. health care. Even with the law intact, and despite its best intentions, it will still leave some 25 million uninsured, underinsure millions more, expand the corporatization of health care, and do little to control the escalating costs of care over the long term. So it’s clear we need to do the right thing: the creation of a national, universal, publicly funded health care system, free of the corrupting power of profit-oriented health insurance, and at the same time capable of passing constitutional muster. In short, the right thing is an expanded and improved Medicare-for-All program, otherwise known as single-payer.

Don’t be so shocked. For the last 30 years, we have tried all the alternatives, and none of them have worked. We have experimented with HMOs, PPOs, high-deductible health plans, health savings accounts, pay-for-performance, capitation, and disease management. These ideas have been promoted in various iterations, often with great fanfare, by public and private payers alike, yet none of them have shown long-term success at bending the cost curve. And the promise of the latest reforms du jour, such as Accountable Care Organizations and Patient-Centered Medical Homes, is speculative at best. American health care is unique among the world’s democracies in that it was never planned in terms of enabling legislation or explicit constitutional authority. As others have stated, our employer-based insurance system, which now covers about 160 million Americans, was an accident of history. Its lineage can be traced to FDR’s wage and price control policies during World War II, where employers were permitted to offer workers health insurance in lieu of higher wages as a job inducement. This benefit has evolved piecemeal into the Rube Goldberg complexity that is contemporary employer-sponsored health insurance, with some 1,200 private plans each doing the same things – medical underwriting, coordination of benefits, claims adjudication and denial, marketing, public relations, lobbying, litigating, and paying shareholder dividends and inflated CEO salaries while forcing individuals to pay a higher share of premiums, increased deductibles, expanded copays, or a combination of all three. Taken as a whole, private insurers’ activities are duplicative, inefficient, wasteful of scarce health care resources, conducive of job lock, and completely misdirected in supporting the 21st-century health care agenda that America needs and deserves.

The objective of the ACA’s individual mandate was to remedy a flaw in the market for health insurance: the expectation by the uninsured that the costs of their inevitable illnesses would be benignly transferred to those fortunate to have coverage. If you believe that guaranteed issue and community-rating requires 100% participation in the health insurance market to sustain financial viability, clearly the most efficient mechanism to achieve this is not through an individual mandate, in which the heavy hand of government coerces people to do what they otherwise would not. If the federal government has a professed welfare interest in controlling health care costs, it can – and should – accomplish that goal through a more economically efficient single-payer mechanism.

Given that the primary business objective of a for-profit insurer is to make a profit, the fundamental question we should be asking is this: What is the marginal value of private health insurance? That is, what advantage vis-à-vis a single-payer model like Medicare does our system of private, profit-oriented health insurance convey to patients, providers, and employers? What exactly do private insurers do, above and beyond what Medicare does, that is deserving of their inflated premiums? To my knowledge, there is no evidence that commercial insurance provides easier access or less hassle-free care, is more cost effective, produces care of higher quality, or has better consumer satisfaction ratings than Medicare (if anyone has evidence to the contrary, from the peer-reviewed health policy literature, please advise). And according to a recent poll, most Americans prefer to keep Medicare as it is, rather than switching to a premium-support financing mechanism as advocated by Rep. Paul Ryan (R-Wis.). Whatever bad things you can say about our government, at least the Feds are not required to make a profit but are required to answer to all taxpayers, rather than private shareholders who are concerned only with the bottom line.

Under a single-payer system, every American would receive a basic package that would include inpatient and outpatient care, primary care and specialty physician services, emergency care, preventive and restorative care, mental health and substance abuse services, dental care, prescription drugs, home health care, and long-term care. Doctors and other providers would be paid based on a fee-for-service schedule, as negotiated with state governments, with funding coming from progressive payroll taxes paid by both individuals and employers. Quality would be monitored and publicly reported, with financial incentives awarded to providers who followed clinical guidelines endorsed by their medical specialty societies. All services provided would be publicly accountable. Medical decision making at the bedside would be left to the physician.

Conceptually, single-payer is imbued with many myths and misconceptions.

Myth #1: Single-Payer Is One-Size-Fits-All

The No. 1 myth – the alpha myth – is that single-payer represents a choiceless, one-size-fits-all, government-run health care monopsony. This is a blatant falsehood. Single-payer is simply a more efficient and more equitable way of financing health care – and nothing more. By consolidating the administrative functions of insurance, it eliminates bureaucratic duplication and reduces administrative waste, saving time and money for employers, providers, state governments, and consumers alike. It would remove the profit motive from financing care, but not from delivering it. Single-payer would efficiently provide for all Americans – regardless of age, health condition, income, or employment status – universal health care that is portable, affordable, equitable, nonterminating, publicly accountable, and funded through progressive taxation, which for the average family would imply a small additional payroll tax that is much less than its current outlay for insurance premiums. A single-payer system would not supplant the private practice of medicine; you could go to a primary care doctor, specialist, hospital, pharmacist, and lab of your choice.

Myth #2: Canadian Health Care Would Be Bad for America

Americans love to repeat anecdotes about the supposedly lousy medical care our northern neighbors receive from their single-payer system, by demoralized and overworked doctors who work at ill-equipped hospitals with out-of-date technology. This is rubbish. Do Canadians often wait for weeks to see a specialist? Yes. Do Americans also wait? Yes. There is no evidence that Canadians are dropping dead in the streets while waiting for their emergency bypasses or appendectomies, nor is there any evidence that Canadian physicians are emigrating to the U.S. or other countries en masse. Further, there is no evidence that the quality o
f care in Canada, across the board, is inferior to that practiced in the U.S. Despite comparable rates of smoking and alcoholism, Canadians on average live longer than Americans by more than 2 years, and their infant mortality rate is less than ours. Finally, consider this: Canadians spend much less than we do for health care, both in per-capita dollars and as a percent of GDP, so I have no doubt that if we were to adopt a Canadian-style system and fund it to the tune of $2.6 trillion annually, we would not have 9-month waits for MRIs, even if every one of them was clinically indicated.

Myth #3: Market-Based Medicine Trumps Single-Payer

Some argue that our private, market-based system is fundamentally sound, that it should be freed of government regulation and tweaked to promote greater competition based on price, and thus choice of health insurance plans. Really? Does anyone seriously believe that purchasing health care services is fundamentally no different from buying a new car or a flat-screen TV? (If so, I suggest he or she take a course in health economics.) And would anyone seriously believe that Americans want a choice of health insurance, when what they really desire is a choice of doctors and hospitals? What could be more American, more consumer-friendly, and more constitutional than the ability to choose your health care provider based on whatever criteria you deem important? So why not cut out the middleman and let doctors, hospitals, and other providers compete on such things as quality, service, reputation, convenience, and other personal preferences, rather than having private insurers make these choices for us?

Just consider what “The Market” has done for health care in the last 30 years: a steady increase in the number of uninsured; a decrease in the choice of providers; diversion of resources into more profitable hospitals and services; consolidation of HMOs into health care oligopolies; underfunding of less profitable endeavors, such as public health, trauma centers, and mental health services; unaffordable prescription drugs; dissatisfied patients; frustrated physicians; and of course, an inexorably increasing trajectory of health care costs.

Myth #4: Single-Payer Would Stop Medical Innovation

To my knowledge, there is no correlation between innovation and a country’s method of health care financing. Many technologies and medical advances we now take for granted originated in nations with national health insurance, for example, CT scans and MRIs (Great Britain), laparoscopic cholecystectomy (Canada), percutaneous coronary angioplasty (Germany), and H. pylori treatment (Australia). The largest single source of funding for medical research in the U.S. is a government agency – the National Institutes of Health – which provided almost $31 billion in funding for medical research in fiscal year 2012. And in terms of per-capita drug R&D costs, the U.S. lags behind Britain and Sweden.

Myth #5: Single-Payer Is Impossible to Enact Politically

Perhaps this is true – for now. But if social change depended solely on what was politically pragmatic, women would not have achieved the right to vote in 1920, civil rights legislation would not have been enacted in 1964, and Medicare would have failed in 1965. We should always be careful to distinguish between what’s desirable and what’s doable. The fact that tort reform is certainly desirable, but not politically doable at the present time, has not stopped ACEP from investing significant time and financial resources to advocate for change. Public opinion polls have consistently shown that the level of public support for single-payer is 60% plus. A survey of physicians published 4 years ago showed that single-payer garnered 59% support among the 2,193 physicians polled (support among emergency physicians was even higher, at 69%). Despite this, there is no question that moving to a single-payer system will face enormous obstacles. What is needed, as columnist David Lazarus of the Los Angeles Times pointed out, is a “massive infusion of political courage and the willingness to forsake political purity.”

Myth #6: We Can’t Afford Single-Payer

Given our current system, perhaps the better statement would be “we can’t afford not to have single-payer.” The most recent financial projections portend no overall decrease in the cost trajectory for health care over the next 8 years, even if the ACA remains intact. Under a single-payer model, a modest increase in taxes would be overshadowed by savings from elimination of insurance premiums, offsets from economies of scale, decreased out-of-pocket payments, and the disappearance of cost-shifting. The annual savings from transforming to a single-payer system are estimated to be $400 billion. If you look at the cost curves for U.S. and Canadian health care, they were identical until the mid-1970s, when Canada’s health system was fully implemented. From then on, the curves diverged, with America’s climbing much faster than Canada’s. When Taiwan converted to single-payer in 1995, the costs went up in the first year, as expected, and then leveled off to a reasonable increase of about 3% per year.

What Does This Mean for Emergency Medicine?

Well, consider the ED as a de facto single-payer environment. Patients come to us by choice without needing to first check with their health plan (assuming they have one) to see if their ED visit is covered. We see them without asking them to pay in advance for their ED services, and their care is not predicated on their job, income, or insurance coverage. As emergency physicians, we have more autonomy than our primary care colleagues in terms of making diagnostic and therapeutic decisions without the nonsense of “pre-authorization” or other interference from an insurer who is interested only in the bottom line. While it’s nice to be able to make medical decisions without checking on insurance status, it would be even nicer if we actually got paid for every ED patient treated. Private insurance companies simply have no incentive – in fact, it’s not at all consistent with their business model – to pay for EMTALA-mandated services provided by out-of-network emergency physicians.

Looking again to Medicare as a single-payer model, consider how we emergency physicians interact with Medicare vs. private insurers. In 29 years of practice, I have never had to seek permission from a CMS official to admit a fee-for-service Medicare patient, have never had a consultant refuse a referral for a Medicare beneficiary, and have never had a pharmacist call me to say the prescription for my Medicare patient was not covered by the formulary. This is not true for some of my patients in managed care plans, including those who were sick enough to be admitted but had to be transferred because my hospital (which the patients self-selected) did not participate in their plan.

Single-payer is the only remaining option to simultaneously and synergistically expand access, control costs, preserve choice, and reduce disparities. There is simply no other efficient and constitutionally safe way to do this. Any other proposals are nothing more than tinkering around the edges and based on blind faith that some kind of future financial salvation will somehow save us from the impending health care meltdown. A single-payer, improved Medicare-for-All program would overhaul our dysfunctional health care financing system so that it works best for patients – and for physicians.

Dr. Mitchiner is an emergency physician in Ann Arbor, Mich., a former president of the Washtenaw County (Mich.) Medical Society, and a member of Physicians for a National Health Program.

http://www.acepnews.com/index.php?id=495&cHash=071010&tx_ttnews[tt_news]=1564#

Comment:

By Don McCanne, MD

Single payer is not on the table in next week’s president
ial election. It should be. This article explains why.

Dr. Mitchiner’s explanation of single payer, addressed to his emergency medicine colleagues, is so clear, concise and compelling that it should be widely distributed so others can understand the imperative of a single payer system – an improved Medicare for all.

It should be downloaded from the ACEP link above, or from the PNHP link below. Both can be converted into printer friendly formats by clicking “Printer friendly” (ACEP) or “Print page” (PNHP). Then be sure that as many people as possible read it and then share it with others. And on the Internet, this needs to go viral!

https://pnhp.org/news/2012/november/its-time-for-single-payer

It’s Time for Single-Payer

By James C. Mitchiner, MD, MPH, American College of Emergency Physicians
ACEP News, August 7, 2012
“You can always trust the Americans to do the right thing, once they’ve tried everything else.”
Winston Churchill’s iconic remark, reportedly issued at the dawn of America’s entry into World War II, is equally applicable to the present American health care debate and the crisis that spawned it. Regardless of whether you are elated or disappointed with June’s historic Supreme Court decision upholding the constitutionality of the Affordable Care Act, it is certainly no panacea for the problems facing U.S. health care. Even with the law intact, and despite its best intentions, it will still leave some 25 million uninsured, underinsure millions more, expand the corporatization of health care, and do little to control the escalating costs of care over the long term. So it’s clear we need to do the right thing: the creation of a national, universal, publicly funded health care system, free of the corrupting power of profit-oriented health insurance, and at the same time capable of passing constitutional muster. In short, the right thing is an expanded and improved Medicare-for-All program, otherwise known as single-payer.
Don’t be so shocked. For the last 30 years, we have tried all the alternatives, and none of them have worked. We have experimented with HMOs, PPOs, high-deductible health plans, health savings accounts, pay-for-performance, capitation, and disease management. These ideas have been promoted in various iterations, often with great fanfare, by public and private payers alike, yet none of them have shown long-term success at bending the cost curve. And the promise of the latest reforms du jour, such as Accountable Care Organizations and Patient-Centered Medical Homes, is speculative at best. American health care is unique among the world’s democracies in that it was never planned in terms of enabling legislation or explicit constitutional authority. As others have stated, our employer-based insurance system, which now covers about 160 million Americans, was an accident of history. Its lineage can be traced to FDR’s wage and price control policies during World War II, where employers were permitted to offer workers health insurance in lieu of higher wages as a job inducement. This benefit has evolved piecemeal into the Rube Goldberg complexity that is contemporary employer-sponsored health insurance, with some 1,200 private plans each doing the same things – medical underwriting, coordination of benefits, claims adjudication and denial, marketing, public relations, lobbying, litigating, and paying shareholder dividends and inflated CEO salaries while forcing individuals to pay a higher share of premiums, increased deductibles, expanded copays, or a combination of all three. Taken as a whole, private insurers’ activities are duplicative, inefficient, wasteful of scarce health care resources, conducive of job lock, and completely misdirected in supporting the 21st-century health care agenda that America needs and deserves.
The objective of the ACA’s individual mandate was to remedy a flaw in the market for health insurance: the expectation by the uninsured that the costs of their inevitable illnesses would be benignly transferred to those fortunate to have coverage. If you believe that guaranteed issue and community-rating requires 100% participation in the health insurance market to sustain financial viability, clearly the most efficient mechanism to achieve this is not through an individual mandate, in which the heavy hand of government coerces people to do what they otherwise would not. If the federal government has a professed welfare interest in controlling health care costs, it can – and should – accomplish that goal through a more economically efficient single-payer mechanism.
Given that the primary business objective of a for-profit insurer is to make a profit, the fundamental question we should be asking is this: What is the marginal value of private health insurance? That is, what advantage vis-à-vis a single-payer model like Medicare does our system of private, profit-oriented health insurance convey to patients, providers, and employers? What exactly do private insurers do, above and beyond what Medicare does, that is deserving of their inflated premiums? To my knowledge, there is no evidence that commercial insurance provides easier access or less hassle-free care, is more cost effective, produces care of higher quality, or has better consumer satisfaction ratings than Medicare (if anyone has evidence to the contrary, from the peer-reviewed health policy literature, please advise). And according to a recent poll, most Americans prefer to keep Medicare as it is, rather than switching to a premium-support financing mechanism as advocated by Rep. Paul Ryan (R-Wis.). Whatever bad things you can say about our government, at least the Feds are not required to make a profit but are required to answer to all taxpayers, rather than private shareholders who are concerned only with the bottom line.
Under a single-payer system, every American would receive a basic package that would include inpatient and outpatient care, primary care and specialty physician services, emergency care, preventive and restorative care, mental health and substance abuse services, dental care, prescription drugs, home health care, and long-term care. Doctors and other providers would be paid based on a fee-for-service schedule, as negotiated with state governments, with funding coming from progressive payroll taxes paid by both individuals and employers. Quality would be monitored and publicly reported, with financial incentives awarded to providers who followed clinical guidelines endorsed by their medical specialty societies. All services provided would be publicly accountable. Medical decision making at the bedside would be left to the physician.
Conceptually, single-payer is imbued with many myths and misconceptions.
Myth #1: Single-Payer Is One-Size-Fits-All
The No. 1 myth – the alpha myth – is that single-payer represents a choiceless, one-size-fits-all, government-run health care monopsony. This is a blatant falsehood. Single-payer is simply a more efficient and more equitable way of financing health care – and nothing more. By consolidating the administrative functions of insurance, it eliminates bureaucratic duplication and reduces administrative waste, saving time and money for employers, providers, state governments, and consumers alike. It would remove the profit motive from financing care, but not from delivering it. Single-payer would efficiently provide for all Americans – regardless of age, health condition, income, or employment status – universal health care that is portable, affordable, equitable, nonterminating, publicly accountable, and funded through progressive taxation, which for the average family would imply a small additional payroll tax that is much less than its current outlay for insurance premiums. A single-payer system would not supplant the private practice of medicine; you could go to a primary care doctor, specialist, hospital, pharmacist, and lab of your choice.
Myth #2: Canadian Health Care Would Be Bad for America
Americans love to repeat anecdotes about the supposedly lousy medical care our northern neighbors receive from their single-payer system, by demoralized and overworked doctors who work at ill-equipped hospitals with out-of-date technology. This is rubbish. Do Canadians often wait for weeks to see a specialist? Yes. Do Americans also wait? Yes. There is no evidence that Canadians are dropping dead in the streets while waiting for their emergency bypasses or appendectomies, nor is there any evidence that Canadian physicians are emigrating to the U.S. or other countries en masse. Further, there is no evidence that the quality of care in Canada, across the board, is inferior to that practiced in the U.S. Despite comparable rates of smoking and alcoholism, Canadians on average live longer than Americans by more than 2 years, and their infant mortality rate is less than ours. Finally, consider this: Canadians spend much less than we do for health care, both in per-capita dollars and as a percent of GDP, so I have no doubt that if we were to adopt a Canadian-style system and fund it to the tune of $2.6 trillion annually, we would not have 9-month waits for MRIs, even if every one of them was clinically indicated.
Myth #3: Market-Based Medicine Trumps Single-Payer
Some argue that our private, market-based system is fundamentally sound, that it should be freed of government regulation and tweaked to promote greater competition based on price, and thus choice of health insurance plans. Really? Does anyone seriously believe that purchasing health care services is fundamentally no different from buying a new car or a flat-screen TV? (If so, I suggest he or she take a course in health economics.) And would anyone seriously believe that Americans want a choice of health insurance, when what they really desire is a choice of doctors and hospitals? What could be more American, more consumer-friendly, and more constitutional than the ability to choose your health care provider based on whatever criteria you deem important? So why not cut out the middleman and let doctors, hospitals, and other providers compete on such things as quality, service, reputation, convenience, and other personal preferences, rather than having private insurers make these choices for us?
Just consider what “The Market” has done for health care in the last 30 years: a steady increase in the number of uninsured; a decrease in the choice of providers; diversion of resources into more profitable hospitals and services; consolidation of HMOs into health care oligopolies; underfunding of less profitable endeavors, such as public health, trauma centers, and mental health services; unaffordable prescription drugs; dissatisfied patients; frustrated physicians; and of course, an inexorably increasing trajectory of health care costs.
Myth #4: Single-Payer Would Stop Medical Innovation
To my knowledge, there is no correlation between innovation and a country’s method of health care financing. Many technologies and medical advances we now take for granted originated in nations with national health insurance, for example, CT scans and MRIs (Great Britain), laparoscopic cholecystectomy (Canada), percutaneous coronary angioplasty (Germany), and H. pylori treatment (Australia). The largest single source of funding for medical research in the U.S. is a government agency – the National Institutes of Health – which provided almost $31 billion in funding for medical research in fiscal year 2012. And in terms of per-capita drug R&D costs, the U.S. lags behind Britain and Sweden.
Myth #5: Single-Payer Is Impossible to Enact Politically
Perhaps this is true – for now. But if social change depended solely on what was politically pragmatic, women would not have achieved the right to vote in 1920, civil rights legislation would not have been enacted in 1964, and Medicare would have failed in 1965. We should always be careful to distinguish between what’s desirable and what’s doable. The fact that tort reform is certainly desirable, but not politically doable at the present time, has not stopped ACEP from investing significant time and financial resources to advocate for change. Public opinion polls have consistently shown that the level of public support for single-payer is 60% plus. A survey of physicians published 4 years ago showed that single-payer garnered 59% support among the 2,193 physicians polled (support among emergency physicians was even higher, at 69%). Despite this, there is no question that moving to a single-payer system will face enormous obstacles. What is needed, as columnist David Lazarus of the Los Angeles Times pointed out, is a “massive infusion of political courage and the willingness to forsake political purity.”
Myth #6: We Can’t Afford Single-Payer
Given our current system, perhaps the better statement would be “we can’t afford not to have single-payer.” The most recent financial projections portend no overall decrease in the cost trajectory for health care over the next 8 years, even if the ACA remains intact. Under a single-payer model, a modest increase in taxes would be overshadowed by savings from elimination of insurance premiums, offsets from economies of scale, decreased out-of-pocket payments, and the disappearance of cost-shifting. The annual savings from transforming to a single-payer system are estimated to be $400 billion. If you look at the cost curves for U.S. and Canadian health care, they were identical until the mid-1970s, when Canada’s health system was fully implemented. From then on, the curves diverged, with America’s climbing much faster than Canada’s. When Taiwan converted to single-payer in 1995, the costs went up in the first year, as expected, and then leveled off to a reasonable increase of about 3% per year.
What Does This Mean for Emergency Medicine?
Well, consider the ED as a de facto single-payer environment. Patients come to us by choice without needing to first check with their health plan (assuming they have one) to see if their ED visit is covered. We see them without asking them to pay in advance for their ED services, and their care is not predicated on their job, income, or insurance coverage. As emergency physicians, we have more autonomy than our primary care colleagues in terms of making diagnostic and therapeutic decisions without the nonsense of “pre-authorization” or other interference from an insurer who is interested only in the bottom line. While it’s nice to be able to make medical decisions without checking on insurance status, it would be even nicer if we actually got paid for every ED patient treated. Private insurance companies simply have no incentive – in fact, it’s not at all consistent with their business model – to pay for EMTALA-mandated services provided by out-of-network emergency physicians.
Looking again to Medicare as a single-payer model, consider how we emergency physicians interact with Medicare vs. private insurers. In 29 years of practice, I have never had to seek permission from a CMS official to admit a fee-for-service Medicare patient, have never had a consultant refuse a referral for a Medicare beneficiary, and have never had a pharmacist call me to say the prescription for my Medicare patient was not covered by the formulary. This is not true for some of my patients in managed care plans, including those who were sick enough to be admitted but had to be transferred because my hospital (which the patients self-selected) did not participate in their plan.
Single-payer is the only remaining option to simultaneously and synergistically expand access, control costs, preserve choice, and reduce disparities. There is simply no other efficient and constitutionally safe way to do this. Any other proposals are nothing more than tinkering around the edges and based on blind faith that some kind of future financial salvation will somehow save us from the impending health care meltdown. A single-payer, improved Medicare-for-All program would overhaul our dysfunctional health care financing system so that it works best for patients – and for physicians.

Dr. Mitchiner is an emergency physician in Ann Arbor, Mich., a former president of the Washtenaw County (Mich.) Medical Society, and a member of Physicians for a National Health Program.
http://www.acepnews.com/index.php?id=495&cHash=071010&tx_ttnews[tt_news]=1564#

Single payer is not on the table in next week’s presidential election. It should be. This article explains why.
Dr. Mitchiner’s explanation of single payer, addressed to his emergency medicine colleagues, is so clear, concise and compelling that it should be widely distributed so others can understand the imperative of a single payer system – an improved Medicare for all.
It should be downloaded from the ACEP link above, or from the PNHP link below. Both can be converted into printer friendly formats by clicking “Printer friendly” (ACEP) or “Print page” (PNHP). Then be sure that as many people as possible read it and then share it with others. And on the Internet, this needs to go viral!
https://pnhp.org/news/2012/november/its-time-for-single-payer

By Katherine Baicker, Ph.D., and Helen Levy, Ph.D.
The New England Journal of Medicine, October 31, 2012

Medicare is an insurance program. The reason we have health insurance at all is not that health care is expensive, but rather that there is great uncertainty about who will need very expensive and potentially lifesaving care and when they will need it. Medicare should give beneficiaries not just access to medical care, but also protection from the risk of catastrophic spending. At the same time, Medicare — like any good insurance — should not cover so much care so generously that beneficiaries end up consuming too much care of questionable value and driving up costs for everyone. Thus, setting cost sharing for Medicare beneficiaries is a balancing act: too little cost sharing means patients have no incentive to spend Medicare dollars wisely; too much means Medicare fails to perform its insurance function.

How well does Medicare do at this balancing act? Not very. Medicare by itself offers only limited protection against economic ruin. The basic benefit lacks a cap on out-of-pocket spending, so beneficiaries are exposed to the risk of open-ended cost sharing that can generate substantial financial strain (or deplete assets for surviving spouses). Moreover, the odds of facing a catastrophic expense mount over time.

Beneficiaries without any supplemental coverage thus do not have enough insurance and face too much risk. This risk is one reason that 90% of beneficiaries obtain some other type of insurance (e.g., retiree health benefits, Medigap, Medicare Advantage, or Medicaid). But beneficiaries with generous supplemental coverage probably have too much insurance. “Too much insurance” may seem like a nonsensical concept, but there is ample evidence that when copayments are lower, patients consume more care, much of which is of questionable benefit to health. The systemwide effects are considerable: the increasing prevalence of health insurance in the United States is estimated to be responsible for about half the increase in per capita health care spending between 1950 and 1990. Having little or no cost sharing may lead enrollees to consume low-value care and drive up the cost of Medicare for everyone.

Nonpartisan and bipartisan groups such as the Congressional Budget Office, the National Commission on Fiscal Responsibility and Reform (also known as the Bowles–Simpson Commission), and the Medicare Payment Advisory Commission have advanced proposals that would address the imbalance in risk facing beneficiaries in the current Medicare program. Although these groups do not propose exactly the same fixes, some of the basic ideas are the same: First, put a cap on the out-of-pocket spending that beneficiaries are responsible for — as most private plans already do — so that those with no other coverage are protected from catastrophic costs. Second, restrict “first-dollar coverage” (coverage with no cost sharing by beneficiaries) in Medicare supplemental insurance, either by banning it or by imposing a surcharge on plans that provide it.

These proposals are controversial. Placing a cap on beneficiary cost sharing would increase program spending at a time when there is intense pressure to cut spending. Restricting first-dollar supplemental coverage would cut program spending but is politically unpopular because it requires lawmakers to tell most beneficiaries that they cannot have the insurance (often private insurance) they are used to having. Furthermore, crude cost sharing that ignores the differences in health benefits produced by different types of care could reduce consumption of highly effective care as much as it reduces consumption of low-value care, especially for low-income populations. Nonetheless, striking a better balance between spreading risk and promoting efficiency would make Medicare a better insurance program.

Medicare was always intended not just to increase access to care but to protect the elderly from financial ruin. As President Lyndon Johnson said when signing Medicare into law in 1965, “No longer will illness crush and destroy the savings that [older Americans] have so carefully put away over a lifetime so that they might enjoy dignity in their later years.”

http://www.nejm.org/doi/full/10.1056/NEJMp1210789?query=TOC#t=article

Comment:

By Don McCanne, MD

Although cost sharing is a topic that we have covered before, Katherine Baicker, coauthor of this NEJM article, is very influential in the policy arena, and the issue is sure to be addressed further as politicians look for cost savings in health care, especially as they seek bipartisan solutions to reduce government spending on the Medicare “entitlement.” Both Barack Obama and Mitt Romney have indicated that Medicare entitlement reform will be on the agenda regardless of who is elected as president.

So what is the purpose of a public insurance program such as Medicare? That’s easy. It is or should be designed to ensure that beneficiaries receive the health care that they need when they need it, without having to face a financial hardship. The most effective design to accomplish this would be to cover all necessary medical costs with no cost sharing whatsoever. Financial barriers to health care would be eliminated.

But some say that  the purpose of insurance is to protect against catastrophic losses only, and that it is not intended to protect against routine expenses. The problem with this definition is that far too many individuals do not have enough disposable income to pay those routine expenses, so high-deductible coverage often defeats the goals of ensuring access and preventing financial hardship in the face of medical need.

What about a lower deductible and other forms of cost sharing such as copayments and coinsurance? Same thing. There are still too many who do not have enough disposable income to pay their share plus their other bills.

Let’s go back to what the purpose of a public health insurance program should be. It should remove financial barriers to care. Does cost sharing enhance this function? No, just the opposite. Cost sharing deliberately introduces financial barriers to care. Why? As Baicker and Levy state in this article, “Medicare — like any good insurance — should not cover so much care so generously that beneficiaries end up consuming too much care of questionable value and driving up costs for everyone.” This disregards the fact that it is almost impossible for patients and even doctors to segregate out which care is “questionable.”

Thus the intent of cost sharing is to control spending, not to improve access nor to protect personal finances, both of which it can worsen. The question then arises, is there any better way of controlling spending, especially by methods that would be even more effective? Of course. Simplify administration, establish global budgets, use regional planning to budget capital improvements, reinforce the primary care infrastructure, and switch to administered pricing to ensure fairness. In other words, change to a single payer financing system. Other nations have proven that you do not need cost sharing to control spending.

Though Medicare pays only about half of health care costs on average for seniors, many soften the blow through the use supplemental plans such as Medigap, retiree health benefit programs, or Medicare Advantage. These authors and many others contend that patients must be exposed to first dollar coverage (remember: to control spending, not to improve access nor financial security), and this should be done by either banning supplemental coverage or by penalizing it with surcharges, presumably to be paid by the beneficiaries.

This concept is now so prevalent that we can fully anticipate that it will be part of the entitlement reform that our politicians are clamoring fo
r. Medicare coverage is already inadequate, and they want patients to have even greater exposure to health care costs. Instead, we need to eliminate deductibles and coinsurance from Medicare to ensure both access and financial security. Switching to a single payer improved Medicare that covers everyone is the Medicare entitlement reform that we really need, not just for our seniors but for the rest of us as well.

The Insurance Value of Medicare

By Katherine Baicker, Ph.D., and Helen Levy, Ph.D.
The New England Journal of Medicine, October 31, 2012
Medicare is an insurance program. The reason we have health insurance at all is not that health care is expensive, but rather that there is great uncertainty about who will need very expensive and potentially lifesaving care and when they will need it. Medicare should give beneficiaries not just access to medical care, but also protection from the risk of catastrophic spending. At the same time, Medicare — like any good insurance — should not cover so much care so generously that beneficiaries end up consuming too much care of questionable value and driving up costs for everyone. Thus, setting cost sharing for Medicare beneficiaries is a balancing act: too little cost sharing means patients have no incentive to spend Medicare dollars wisely; too much means Medicare fails to perform its insurance function.
How well does Medicare do at this balancing act? Not very. Medicare by itself offers only limited protection against economic ruin. The basic benefit lacks a cap on out-of-pocket spending, so beneficiaries are exposed to the risk of open-ended cost sharing that can generate substantial financial strain (or deplete assets for surviving spouses). Moreover, the odds of facing a catastrophic expense mount over time.
Beneficiaries without any supplemental coverage thus do not have enough insurance and face too much risk. This risk is one reason that 90% of beneficiaries obtain some other type of insurance (e.g., retiree health benefits, Medigap, Medicare Advantage, or Medicaid). But beneficiaries with generous supplemental coverage probably have too much insurance. “Too much insurance” may seem like a nonsensical concept, but there is ample evidence that when copayments are lower, patients consume more care, much of which is of questionable benefit to health. The systemwide effects are considerable: the increasing prevalence of health insurance in the United States is estimated to be responsible for about half the increase in per capita health care spending between 1950 and 1990. Having little or no cost sharing may lead enrollees to consume low-value care and drive up the cost of Medicare for everyone.
Nonpartisan and bipartisan groups such as the Congressional Budget Office, the National Commission on Fiscal Responsibility and Reform (also known as the Bowles–Simpson Commission), and the Medicare Payment Advisory Commission have advanced proposals that would address the imbalance in risk facing beneficiaries in the current Medicare program. Although these groups do not propose exactly the same fixes, some of the basic ideas are the same: First, put a cap on the out-of-pocket spending that beneficiaries are responsible for — as most private plans already do — so that those with no other coverage are protected from catastrophic costs. Second, restrict “first-dollar coverage” (coverage with no cost sharing by beneficiaries) in Medicare supplemental insurance, either by banning it or by imposing a surcharge on plans that provide it.
These proposals are controversial. Placing a cap on beneficiary cost sharing would increase program spending at a time when there is intense pressure to cut spending. Restricting first-dollar supplemental coverage would cut program spending but is politically unpopular because it requires lawmakers to tell most beneficiaries that they cannot have the insurance (often private insurance) they are used to having. Furthermore, crude cost sharing that ignores the differences in health benefits produced by different types of care could reduce consumption of highly effective care as much as it reduces consumption of low-value care, especially for low-income populations. Nonetheless, striking a better balance between spreading risk and promoting efficiency would make Medicare a better insurance program.
Medicare was always intended not just to increase access to care but to protect the elderly from financial ruin. As President Lyndon Johnson said when signing Medicare into law in 1965, “No longer will illness crush and destroy the savings that [older Americans] have so carefully put away over a lifetime so that they might enjoy dignity in their later years.”
http://www.nejm.org/doi/full/10.1056/NEJMp1210789?query=TOC#t=article

Although cost sharing is a topic that we have covered before, Katherine Baicker, coauthor of this NEJM article, is very influential in the policy arena, and the issue is sure to be addressed further as politicians look for cost savings in health care, especially as they seek bipartisan solutions to reduce government spending on the Medicare “entitlement.” Both Barack Obama and Mitt Romney have indicated that Medicare entitlement reform will be on the agenda regardless of who is elected as president.
So what is the purpose of a public insurance program such as Medicare? That’s easy. It is or should be designed to ensure that beneficiaries receive the health care that they need when they need it, without having to face a financial hardship. The most effective design to accomplish this would be to cover all necessary medical costs with no cost sharing whatsoever. Financial barriers to health care would be eliminated.
But some say that  the purpose of insurance is to protect against catastrophic losses only, and that it is not intended to protect against routine expenses. The problem with this definition is that far too many individuals do not have enough disposable income to pay those routine expenses, so high-deductible coverage often defeats the goals of ensuring access and preventing financial hardship in the face of medical need.
What about a lower deductible and other forms of cost sharing such as copayments and coinsurance? Same thing. There are still too many who do not have enough disposable income to pay their share plus their other bills.
Let’s go back to what the purpose of a public health insurance program should be. It should remove financial barriers to care. Does cost sharing enhance this function? No, just the opposite. Cost sharing deliberately introduces financial barriers to care. Why? As Baicker and Levy state in this article, “Medicare — like any good insurance — should not cover so much care so generously that beneficiaries end up consuming too much care of questionable value and driving up costs for everyone.” This disregards the fact that it is almost impossible for patients and even doctors to segregate out which care is “questionable.”
Thus the intent of cost sharing is to control spending, not to improve access nor to protect personal finances, both of which it can worsen. The question then arises, is there any better way of controlling spending, especially by methods that would be even more effective? Of course. Simplify administration, establish global budgets, use regional planning to budget capital improvements, reinforce the primary care infrastructure, and switch to administered pricing to ensure fairness. In other words, change to a single payer financing system. Other nations have proven that you do not need cost sharing to control spending.
Though Medicare pays only about half of health care costs on average for seniors, many soften the blow through the use supplemental plans such as Medigap, retiree health benefit programs, or Medicare Advantage. These authors and many others contend that patients must be exposed to first dollar coverage (remember: to control spending, not to improve access nor financial security), and this should be done by either banning supplemental coverage or by penalizing it with surcharges, presumably to be paid by the beneficiaries.
This concept is now so prevalent that we can fully anticipate that it will be part of the entitlement reform that our politicians are clamoring for. Medicare coverage is already inadequate, and they want patients to have even greater exposure to health care costs. Instead, we need to eliminate deductibles and coinsurance from Medicare to ensure both access and financial security. Switching to a single payer improved Medicare that covers everyone is the Medicare entitlement reform that we really need, not just for our seniors but for the rest of us as well.

By Nick Dorman
People.co.uk, October 28, 2012

Bosses at Britain’s first privately-run NHS hospital have asked for a bailout just six months after taking over.

In a major blow to Tory plans to privatise the health service further, contractor Circle racked up losses of £4.1million at Hinchingbrooke.

Now the firm, which is run by a former Goldman Sachs banker and has expressed an interest in running other hospitals, has been forced to ask the local NHS trust for a cash advance.

The hospital has fallen 19 places from the top of a Government league table of patient ­satisfaction since it was taken over by Circle.

Last night Unison health union said this raises big questions over Tory ­privatisation plans for the NHS.

Spokesman Anne Mitchell added: “This should force a rethink. Right from the start our view was a private company would not have the experience to run a large hospital like Hinch­-ingbrooke.

“They made many claims which they are now ­failing miserably to deliver.”

Shadow health minister Jamie Reed said: “Patients are paying the price for David Cameron’s eagerness to hand the NHS to private companies.”

http://www.people.co.uk/news/uk-world-news/2012/10/28/fury-as-first-privately-run-nhs-hospital-racks-up-4-1m-loss-102039-23936289/

And…

Hinchingbrooke losses double Circle Health estimate

BBC News, October 25, 2012

The first NHS hospital to be run by a private company has revealed losses in the firm’s first six months in charge were almost double those forecast.

Circle Health took over management of Hinchingbrooke Hospital in Cambridgeshire in February.

The board reported that 46 nursing posts had been cut so far at the Huntingdon hospital under Circle’s management.

Karen Webb, regional director for the Royal College of Nursing (RCN) union, said: “The RCN doesn’t see how [quality care] can be achieved by removing nurses from the system.

http://www.bbc.co.uk/news/uk-england-cambridgeshire-20087078

And…

Ali Parsa: Government should not be running hospitals

By Andrew Cave
The Telegraph, August 4, 2012

“It’s all about bringing entrepreneurialism, ownership and a sense of engagement into health care,” says Parsa, pointing out that the company subsidiary delivering the health care is 49.9pc owned by hospital staff.

So, how big can Circle become? Parsa, who came to the UK by himself from Iran at the age of 16 a few years after the 1979 Islamic revolution and built up and sold a media promotions company before moving into investment banking with Credit Suisse, Merrill Lynch and Goldman Sachs, apparently sees no limit.

“I’m an entrepreneur with ambition,” he says. “And I didn’t come to run a small company in Circle. We came to create a very large organisation.

“On a 10 to 20-year view, I think the scale of private companies running NHS health care in Britain could be huge. I honestly cannot see why we should not be running many, many hospitals in the UK.

“And if we are doing a great job in the UK 10 or 20 years from now, there’s no reason why we should not be doing the same thing all over the world.”

http://www.telegraph.co.uk/finance/newsbysector/pharmaceuticalsandchemicals/9450088/Ali-Parsa-Government-should-not-be-running-hospitals.html

Comment:

By Don McCanne, MD:

Britain’s Conservative Prime Minister David Cameron has been eager to privatize their National Health Service. What a great start. Hinchingbrooke, now privately managed by former Goldman Sachs banker Ali Parsa, has racked up losses of £4.1 million and has plummeted on the Government’s new patient satisfaction league table. Apparently Cameron and his Conservatives are blind as to what has happened across the Atlantic.

Of significance is that the tendering process for this arrangement began under the Labour government. Just as the Democrats here have supported an expansion of privatization through private insurers and private managed care organizations, Labour seems to be complicit in Britain’s move toward privatization. Taking care of the one percenters seems to be an international phenomenon. Sad.

Fury as first privately run NHS hospital racks up £4.1m loss

By Nick Dorman
People.co.uk, October 28, 2012
Bosses at Britain’s first privately-run NHS hospital have asked for a bailout just six months after taking over.
In a major blow to Tory plans to privatise the health service further, contractor Circle racked up losses of £4.1million at Hinchingbrooke.
Now the firm, which is run by a former Goldman Sachs banker and has expressed an interest in running other hospitals, has been forced to ask the local NHS trust for a cash advance.
The hospital has fallen 19 places from the top of a Government league table of patient ­satisfaction since it was taken over by Circle.
Last night Unison health union said this raises big questions over Tory ­privatisation plans for the NHS.
Spokesman Anne Mitchell added: “This should force a rethink. Right from the start our view was a private company would not have the experience to run a large hospital like Hinch­-ingbrooke.
“They made many claims which they are now ­failing miserably to deliver.”
Shadow health minister Jamie Reed said: “Patients are paying the price for David Cameron’s eagerness to hand the NHS to private companies.”
http://www.people.co.uk/news/uk-world-news/2012/10/28/fury-as-first-priv…
And…

Hinchingbrooke losses double Circle Health estimate

BBC News, October 25, 2012
The first NHS hospital to be run by a private company has revealed losses in the firm’s first six months in charge were almost double those forecast.
Circle Health took over management of Hinchingbrooke Hospital in Cambridgeshire in February.
The board reported that 46 nursing posts had been cut so far at the Huntingdon hospital under Circle’s management.
Karen Webb, regional director for the Royal College of Nursing (RCN) union, said: “The RCN doesn’t see how [quality care] can be achieved by removing nurses from the system.
http://www.bbc.co.uk/news/uk-england-cambridgeshire-20087078
And…

Ali Parsa: Government should not be running hospitals

By Andrew Cave
The Telegraph, August 4, 2012
“It’s all about bringing entrepreneurialism, ownership and a sense of engagement into health care,” says Parsa, pointing out that the company subsidiary delivering the health care is 49.9pc owned by hospital staff.
So, how big can Circle become? Parsa, who came to the UK by himself from Iran at the age of 16 a few years after the 1979 Islamic revolution and built up and sold a media promotions company before moving into investment banking with Credit Suisse, Merrill Lynch and Goldman Sachs, apparently sees no limit.
“I’m an entrepreneur with ambition,” he says. “And I didn’t come to run a small company in Circle. We came to create a very large organisation.
“On a 10 to 20-year view, I think the scale of private companies running NHS health care in Britain could be huge. I honestly cannot see why we should not be running many, many hospitals in the UK.
“And if we are doing a great job in the UK 10 or 20 years from now, there’s no reason why we should not be doing the same thing all over the world.”
http://www.telegraph.co.uk/finance/newsbysector/pharmaceuticalsandchemic…

Britain’s Conservative Prime Minister David Cameron has been eager to privatize their National Health Service. What a great start. Hinchingbrooke, now privately managed by former Goldman Sachs banker Ali Parsa, has racked up losses of £4.1 million and has plummeted on the Government’s new patient satisfaction league table. Apparently Cameron and his Conservatives are blind as to what has happened across the Atlantic.
Of significance is that the tendering process for this arrangement began under the Labour government. Just as the Democrats here have supported an expansion of privatization through private insurers and private managed care organizations, Labour seems to be complicit in Britain’s move toward privatization. Taking care of the one percenters seems to be an international phenomenon. Sad.