PNHP

Report: Private Insurers Cost Medicare Billions In Excess Payments

Report: Private Insurers Cost Medicare Billions In Excess Payments

By Rachel Zimmerman
CommonHealth blog, WBUR (Boston NPR), Oct. 11, 2012

The doctors over at Physicians for a National Health Program, advocates of a single-payer system, sure are prolific researchers, and here’s the headline from their latest report: Private insurers have cost Medicare $282.6 billion in excess payments since 1985.

From the group’s news release:

Researchers say privately run Medicare Advantage plans have undermined traditional Medicare’s fiscal health and taken a heavy toll on taxpayers, seniors and the U.S. economy

In the first study of its kind, a group of health policy experts has determined the amount of money that Medicare has overpaid private insurance companies under the Medicare Advantage program and its predecessors over the past 27 years and come up with a startling figure: $282.6 billion in excess payments, most of them over the past eight years.

That’s wasted money that should have been spent on improving patient care, shoring up Medicare’s trust fund or reducing the federal deficit, the researchers say.

The findings appear in a paper by Drs. Ida Hellander, Steffie Woolhandler and David Himmelstein titled “Medicare overpayments to private plans, 1985-2012” which they say is forthcoming in the International Journal of Health Services.

(Hellander is policy director at Physicians for a National Health Program, a nonprofit research and advocacy group. Woolhandler and Himmelstein are professors at the City University of New York School of Public Health, visiting professors at Harvard Medical School and co-founders of PNHP.)

The work is timely because national proposals, notably from vice presidential candidate Paul Ryan (set to debate vice president Joe Biden tonight) rely on great expansions of private Medicare plans.

Here are more of the group’s findings on private Medicare plans, known as Medicare Advantage plans:

The authors find that private insurers have exploited loopholes to garner overpayments above and beyond what it costs them to care for their enrollees. For instance, Medicare gives private insurers a full premium for each enrollee, even for those who get most of their care for free at the Veterans Health Administration.

In addition, through heavy lobbying, the insurance industry induced Congress and the Bush administration to add bonus payments to Medicare Advantage premiums beginning in 2003.

Finally, private plans cherry-pick by enrolling seniors whose care will cost far less than the premiums, guaranteeing large profits. Although private plans must accept all seniors who choose to enroll, they cherry-picked by selectively recruiting the healthiest seniors through advertising, office location, etc., and induced sicker ones to disenroll by making expensive care inconvenient.

After Medicare began risk adjusting the premium payment for each patient’s diagnoses in 2004, the plans began cherry-picking in a new way. They recruited otherwise healthy seniors with very mild (and inexpensive) cases of sometimes serious conditions – automatically triggering higher premiums from the risk-adjustment scheme, but escaping payments for expensive care. For instance, many seniors have very mild cases of arthritis, heart failure and bronchitis that require little or no treatment.

The full report includes further details on these and other schemes that private insurers have used to increase their Medicare payments.

“We’ve long known that Medicare has been paying private insurers more than if their enrollees had stayed in traditional free-for-service Medicare, but no one has assessed the full extent of these overpayments,” said Dr. Ida Hellander, lead author of the study. “Nor has anyone systematically examined the many ways that private insurers have gamed the system to maximize their bottom line at taxpayers’ expense.”

“In 2012 alone, private insurers are being overpaid $34.1 billion, or $2,526 per Medicare Advantage enrollee,” Hellander said.

Co-author Dr. Steffie Woolhandler said: “It’s clear that having Medicare Advantage programs compete with Medicare doesn’t save us money. In fact the opposite is the case. The private plans only add waste, and the aggregate waste is staggering – enough to be a significant drag on the economy.

“Unfortunately, recent legislative and technical attempts to reduce Medicare’s overpayments to these insurance firms have had little or no impact,” she said.

“It’s time we look to proven, cost-effective ways of providing high-quality care to Medicare’s beneficiaries and to the entire population,” Woolhandler said. “That means taking a fresh look at the single-payer model of reform.”

Blogger, CommonHealth Rachel Zimmerman worked as a staff reporter for The Wall Street Journal for 10 years, most recently covering health and medicine out of the paper’s Boston bureau. Rachel has also written for The New York Times and the (now-defunct) Seattle Post-Intelligencer, among other publications. Rachel co-wrote a book about birth, published by Bantam/Random House, and spent 2008 as a Knight Science Journalism Fellow at MIT.

http://commonhealth.wbur.org/2012/10/private-insurers-cost-medicare-billions

Important! Medicare Advantage rip-off now quantified

Medicare Overpayments to Private Plans, 1985-2012: Shifting seniors to private plans has already cost Medicare $282.6 billion

By Ida Hellander, M.D., Steffie Woolhandler, M.D., M.P.H., David U. Himmelstein, M.D.
International Journal of Health Services (Forthcoming), October 2012

Abstract

Previous research has documented Medicare overpayments to the private Medicare Advantage (MA) plans (also known as Medicare Part C or Medicare HMOs) that compete with traditional fee-for-service Medicare. This research has assessed individual categories of overpayment for a single year, or at most a few years. However, no previous study has calculated the total Medicare overpayments to private plans since the inception of the Medicare program.

There are five ways in which private insurers systematically garner excess Medicare Advantage payments from the Medicare program.

Prior to 2004, the selective enrollment of healthier seniors by private plans – what we call “old cherry-picking” – was the major source of excess payments. We conservatively estimate that this old cherry-picking has added $41 billion to Medicare’s costs since 1985. Medicare adopted a new risk-adjustment scheme in 2004 based on 70 medical diagnoses (“hierarchical condition categories”), but this scheme has not curbed, and may have increased, private plans’ ability to game Medicare’s payment system, albeit with a new strategy: now, plans seek to selectively enroll patients who have mild versions of the medical conditions that determine payment. This “new cherry-picking” has added $122.5 billion to Medicare’s costs since 2004.

Congress mandated increased payment to private plans in the 2003 Medicare Modernization Act, adding $84.4 billion to the cost of Medicare through 2012.

The Affordable Care Act (ACA) mandated a drop in these overpayments, but a new demonstration project on quality will offset one-third of the reductions called for by the ACA through 2014.

Another major way that private plans are overpaid is by enrolling persons who are eligible for Veterans Health Administration (VA) benefits. The VA has provided $34.8 billion in care to MA enrollees since 1985.

In total, we find that Medicare has overpaid private insurers by $282.6 billion, or 24.4 percent of all MA payments, since 1985. In 2012 alone, we find that MA plans are being overpaid by $34.1 billion, or 6.2 percent of total Medicare spending.

In 2012, 13.5 million Medicare beneficiaries are in private plans, 27 percent of total enrollment. Some proposals would push millions more beneficiaries into private plans (e.g. voucher-type Medicare reform).

Risk adjustment does not and cannot work in the setting of for-profit MA plans, which have a strong financial incentive, and the data and ingenuity, to game whatever payment system Medicare devises. It is time to end Medicare’s long experiment with privatization and look toward proven-effective methods for controlling costs and improving coverage.

PNHP press release (The full article can be accessed through a link provided in this press release):
https://pnhp.org/news/2012/october/private-insurers-have-cost-medicare-2826-billion-in-excess-payments-since-1985

Comment:

By Don McCanne, MD

Although we have known all along that the private Medicare Advantage plans have been ripping off the taxpayers, this study brings together the data that quantifies the extent to which the taxpayers have been cheated by the private insurance firms: $282.6 billion!

The full report provides the details. It should be downloaded and read in full, and then used in your activism. Use the link above to access the press release (which is also well worth reading), and then use the link in the press release to download the full report.

The reason that this is so important is that it reveals the dishonesty behind the efforts to privatize Medicare through “premium support” – code for vouchers. Telling us that private insurers could provide equivalent Medicare benefits at a lower cost was the first deception, now proven false by three decades of experience. Nevertheless, because of anti-government ideology, legislators moved forward with the Medicare Advantage plans, deliberately paying them extra in order to draw beneficiaries into their plans through extra funds for high-profile marketing while affording them the ability to offer attractive extra benefits.

Once enough beneficiaries are drawn into these private plans, legislators could then begin the gradual process of defunding the traditional Medicare program. The premium support vouchers would provide a means to that end. As access in the underfunded traditional program diminished due to a decline in willing providers, beneficiaries would be able to use their premium support to move into the “better” plans offered in the private sector.

The traditional program might survive as a vestigial Medicaid-like welfare program, but essentially all who could afford it would have moved into the private plans. The next step? Reduce the value of the premium support both through attrition and through more nudges and pushes that the politicians would claim are absolutely essential to help close the gaping deficit hole.

As many have figured out, a primary purpose of the tax cuts that the politicians are telling us are essential is to increase the deficit even more to force other cuts in spending – deficits that “cannot be made up by tax increases because those taxes would destroy the economy.” Closing the deficit with tax cuts is one of the biggest lies of this campaign. They want to increase the deficit to force upon us a government austerity program.

We desperately need single payer – an improved Medicare that covers everyone. A more urgent task for us to address immediately is to cut the overpayments in the Medicare Advantage plans before the politicians shove us into their fraudulent premium support scheme. Check Figure 1 in the full report that you are downloading.  When we had Medicare + Choice plans, the deception was exposed and you will see that the plans started dropping out. The rebound of the plans is directly attributable to the fraud exposed in this report – deliberate overpayment of the private Medicare Advantage plans.

People keep asking what they can do. This one’s easy. Start organizing protests against this outrageous scheme that has cheated us taxpayers out of so much. Begin now, or start planning for your own austerity program when premium support vouchers won’t buy you or your children the health care plan that you need. It’s your choice.

Vermont must tackle health care head on

By Walter Carpenter
Burlington Free Press, October 5th, 2012

I would like to endorse the Burlington Free Press’s endorsement of single-payer in Aki Soga’s editorial, “Give single-payer a try” (Sept. 28). As Mr. Soga suggested, Vermont has to move forward rather than backward and to finally come to grips with how health care is for us, the people, and not to benefit the profit margins of health insurance corporations, as it is now and which Sen. Brock’s plan would almost certainly enhance.

Opponents of single-payer like to bandy about all the choices that will supposedly be available under the umbrella of competition between health insurance companies. As the editorial correctly pointed out, though, if we continue to tie health insurance to employment, “individuals have no real choices about where to get their coverage regardless of how many insurance companies and plans might be available.” All but ignored by these opponents is how our choices are already restricted by so many elements that are largely beyond our control — employment, employment status, income levels or eligibility, insurance networks, price, and many more — that it cannot be recognizable as choice. The idea that competition will alleviate these current restrictions on choice (much of which it is institutes itself) is facetious. It never has before; it never will.

As Gov. Shumlin is doing with the Green Mountain Care Board, we need to take our health crisis head on and solve it before so many more have to get shut out of access or go without insurance.

Walter Carpenter resides in Montpelier, Vt.

http://www.burlingtonfreepress.com/article/20121007/OPINION03/310070012/1006/OPINION/Letters-editor?nclick_check=1

Important! Medicare Advantage rip-off now quantified

Medicare Overpayments to Private Plans, 1985-2012: Shifting seniors to private plans has already cost Medicare $282.6 billion

By Ida Hellander, M.D., Steffie Woolhandler, M.D., M.P.H., David U. Himmelstein, M.D.
International Journal of Health Services (Forthcoming), October 2012
Abstract
Previous research has documented Medicare overpayments to the private Medicare Advantage (MA) plans (also known as Medicare Part C or Medicare HMOs) that compete with traditional fee-for-service Medicare. This research has assessed individual categories of overpayment for a single year, or at most a few years. However, no previous study has calculated the total Medicare overpayments to private plans since the inception of the Medicare program.
There are five ways in which private insurers systematically garner excess Medicare Advantage payments from the Medicare program.
Prior to 2004, the selective enrollment of healthier seniors by private plans – what we call “old cherry-picking” – was the major source of excess payments. We conservatively estimate that this old cherry-picking has added $41 billion to Medicare’s costs since 1985. Medicare adopted a new risk-adjustment scheme in 2004 based on 70 medical diagnoses (“hierarchical condition categories”), but this scheme has not curbed, and may have increased, private plans’ ability to game Medicare’s payment system, albeit with a new strategy: now, plans seek to selectively enroll patients who have mild versions of the medical conditions that determine payment. This “new cherry-picking” has added $122.5 billion to Medicare’s costs since 2004.
Congress mandated increased payment to private plans in the 2003 Medicare Modernization Act, adding $84.4 billion to the cost of Medicare through 2012.
The Affordable Care Act (ACA) mandated a drop in these overpayments, but a new demonstration project on quality will offset one-third of the reductions called for by the ACA through 2014.
Another major way that private plans are overpaid is by enrolling persons who are eligible for Veterans Health Administration (VA) benefits. The VA has provided $34.8 billion in care to MA enrollees since 1985.
In total, we find that Medicare has overpaid private insurers by $282.6 billion, or 24.4 percent of all MA payments, since 1985. In 2012 alone, we find that MA plans are being overpaid by $34.1 billion, or 6.2 percent of total Medicare spending.
In 2012, 13.5 million Medicare beneficiaries are in private plans, 27 percent of total enrollment. Some proposals would push millions more beneficiaries into private plans (e.g. voucher-type Medicare reform).
Risk adjustment does not and cannot work in the setting of for-profit MA plans, which have a strong financial incentive, and the data and ingenuity, to game whatever payment system Medicare devises. It is time to end Medicare’s long experiment with privatization and look toward proven-effective methods for controlling costs and improving coverage.
PNHP press release (The full article can be accessed through a link provided in this press release):
https://pnhp.org/news/2012/october/private-insurers-have-cost-medicar…

Although we have known all along that the private Medicare Advantage plans have been ripping off the taxpayers, this study brings together the data that quantifies the extent to which the taxpayers have been cheated by the private insurance firms: $282.6 billion!
The full report provides the details. It should be downloaded and read in full, and then used in your activism. Use the link above to access the press release (which is also well worth reading), and then use the link in the press release to download the full report.
The reason that this is so important is that it reveals the dishonesty behind the efforts to privatize Medicare through “premium support” – code for vouchers. Telling us that private insurers could provide equivalent Medicare benefits at a lower cost was the first deception, now proven false by three decades of experience. Nevertheless, because of anti-government ideology, legislators moved forward with the Medicare Advantage plans, deliberately paying them extra in order to draw beneficiaries into their plans through extra funds for high-profile marketing while affording them the ability to offer attractive extra benefits.
Once enough beneficiaries are drawn into these private plans, legislators could then begin the gradual process of defunding the traditional Medicare program. The premium support vouchers would provide a means to that end. As access in the underfunded traditional program diminished due to a decline in willing providers, beneficiaries would be able to use their premium support to move into the “better” plans offered in the private sector.
The traditional program might survive as a vestigial Medicaid-like welfare program, but essentially all who could afford it would have moved into the private plans. The next step? Reduce the value of the premium support both through attrition and through more nudges and pushes that the politicians would claim are absolutely essential to help close the gaping deficit hole.
As many have figured out, a primary purpose of the tax cuts that the politicians are telling us are essential is to increase the deficit even more to force other cuts in spending – deficits that “cannot be made up by tax increases because those taxes would destroy the economy.” Closing the deficit with tax cuts is one of the biggest lies of this campaign. They want to increase the deficit to force upon us a government austerity program.
We desperately need single payer – an improved Medicare that covers everyone. A more urgent task for us to address immediately is to cut the overpayments in the Medicare Advantage plans before the politicians shove us into their fraudulent premium support scheme. Check Figure 1 in the full report that you are downloading.  When we had Medicare + Choice plans, the deception was exposed and you will see that the plans started dropping out. The rebound of the plans is directly attributable to the fraud exposed in this report – deliberate overpayment of the private Medicare Advantage plans.
People keep asking what they can do. This one’s easy. Start organizing protests against this outrageous scheme that has cheated us taxpayers out of so much. Begin now, or start planning for your own austerity program when premium support vouchers won’t buy you or your children the health care plan that you need. It’s your choice.

Who will remain uninsured?

After Millions of Californians Gain Health Coverage Under the Affordable Care Act, Who Will Remain Uninsured?

By Laurel Lucia, Ken Jacobs, Miranda Dietz, Dave Graham-Squire, Nadereh Pourat, and Dylan H. Roby
UC Berkeley Labor Center, September 2012

The implementation of the Affordable Care Act (ACA) is predicted to expand coverage to millions of Californians by 2019. This increase in coverage will primarily result from the expansion of Medi-Cal and the availability of subsidized coverage in the California Health Benefit Exchange (Exchange). However, three to four million Californians could remain uninsured even after the law is fully implemented.

Many Californians will remain uninsured

* 3.1 to 4 million Californians are predicted to remain uninsured in 2019.

* Almost three-quarters of the remaining uninsured in California will be U.S. citizens or lawfully present immigrants.

* Half of all remaining uninsured, or two million Californians, will be eligible for Medi-Cal or Exchange subsidies but remain unenrolled under the base scenario. Barriers to enrollment could include lack of awareness about the programs, challenges in the enrollment process, or inability to afford subsidized coverage.

* 72 percent of remaining uninsured Californians will be exempt from paying tax penalties under the minimum coverage requirements of the ACA due to income, lack of an affordable offer of coverage or immigration status. Approximately three percent of all Californians will owe a tax penalty due to not obtaining minimum coverage.

* Nearly 40 percent of the remaining uninsured will lack an offer of affordable coverage with premiums costing eight percent of household income or less. Some uninsured Californians will be ineligible for subsidized coverage due to income or immigration status, while others will be eligible for subsidized plans in the Exchange with premiums that exceed the affordability standard.

* Some of the remaining uninsured will lack coverage for short time periods due to life transitions.

Some demographic groups will be more likely to remain uninsured

* Two-thirds (66%) of Californians remaining uninsured will be Latino, compared to a projected 45 percent of the non-elderly population in 2020.

* Nearly three out of five California adults who remain uninsured will be Limited English Proficient.

* 57 percent of Californians who remain uninsured will have household incomes at or below 200 percent of the Federal Poverty Level.

http://laborcenter.berkeley.edu/healthcare/aca_uninsured.shtml

Comment:

By Don McCanne, MD

The projected numbers and demographics of the uninsured after full implementation of the Affordable Care Act in California are shameful. Although there would be regional differences in demographics, the national numbers would be roughly tenfold. We can do far better by enacting an improved Medicare for all.

Who will remain uninsured?

After Millions of Californians Gain Health Coverage Under the Affordable Care Act, Who Will Remain Uninsured?

By Laurel Lucia, Ken Jacobs, Miranda Dietz, Dave Graham-Squire, Nadereh Pourat, and Dylan H. Roby
UC Berkeley Labor Center, September 2012
The implementation of the Affordable Care Act (ACA) is predicted to expand coverage to millions of Californians by 2019. This increase in coverage will primarily result from the expansion of Medi-Cal and the availability of subsidized coverage in the California Health Benefit Exchange (Exchange). However, three to four million Californians could remain uninsured even after the law is fully implemented.
Many Californians will remain uninsured
* 3.1 to 4 million Californians are predicted to remain uninsured in 2019.
* Almost three-quarters of the remaining uninsured in California will be U.S. citizens or lawfully present immigrants.
* Half of all remaining uninsured, or two million Californians, will be eligible for Medi-Cal or Exchange subsidies but remain unenrolled under the base scenario. Barriers to enrollment could include lack of awareness about the programs, challenges in the enrollment process, or inability to afford subsidized coverage.
* 72 percent of remaining uninsured Californians will be exempt from paying tax penalties under the minimum coverage requirements of the ACA due to income, lack of an affordable offer of coverage or immigration status. Approximately three percent of all Californians will owe a tax penalty due to not obtaining minimum coverage.
* Nearly 40 percent of the remaining uninsured will lack an offer of affordable coverage with premiums costing eight percent of household income or less. Some uninsured Californians will be ineligible for subsidized coverage due to income or immigration status, while others will be eligible for subsidized plans in the Exchange with premiums that exceed the affordability standard.
* Some of the remaining uninsured will lack coverage for short time periods due to life transitions.
Some demographic groups will be more likely to remain uninsured
* Two-thirds (66%) of Californians remaining uninsured will be Latino, compared to a projected 45 percent of the non-elderly population in 2020.
* Nearly three out of five California adults who remain uninsured will be Limited English Proficient.
* 57 percent of Californians who remain uninsured will have household incomes at or below 200 percent of the Federal Poverty Level.
http://laborcenter.berkeley.edu/healthcare/aca_uninsured.shtml

The projected numbers and demographics of the uninsured after full implementation of the Affordable Care Act in California are shameful. Although there would be regional differences in demographics, the national numbers would be roughly tenfold. We can do far better by enacting an improved Medicare for all.

Supreme Court ruling on the ACA: Minnesotans react

By the editors
Minnesota Physician, September 2012

The Supreme Court’s ruling on the Patient Protection and Affordable Care Act (ACA) on June 28 will have major repercussions for patients and providers. Minnesota Physician asked representatives from Minnesota health care organizations to respond to this question:

“How will the Supreme Court’s ruling on the ACA affect your organization and its patients/constituents?”

[Excerpt]

Response by Physicians for a National Health Program:

ACA will not fix the health care crisis

The work of the Minnesota chapter of Physicians for a National Health Program (PNHP) will continue in earnest. While the ACA will be helpful for some patients who gain access to insurance coverage, the legislation will not fix the health care crisis facing our state and nation. Even with the ACA fully enacted, more than 200,000 Minnesotans will be left out of the system completely (uninsured) and thousands more will remain woefully underinsured. PNHP’s goal remains comprehensive health care for ALL Minnesotans, and the ACA will not get us there.

In Minnesota, we can and should hold ourselves to a higher standard. By enacting a single-payer, Medicare-for-all system, we can show the nation what happens when individuals flourish and fulfill their productive potential without fear of financial ruin should they become ill. By severing our unhealthy relationship with a private insurance industry that amasses great wealth at the expense of sick patients, we can save a tremendous amount of money and actually spend it on health care. The Lewin study (March 2012) showed us that the administrative simplicity of a single-payer system in Minnesota would lower health care spending while covering everyone with comprehensive care.

— Ann Settgast, M.D., and Elizabeth Frost, M.D., co-chairs, Minnesota Chapter, Physicians for a National Health Program

http://issuu.com/mppub/docs/mpsept12?mode=window&pageNumber=14

Universal health care and the Iron Triangle myth of U.S. policy makers

Donald Light on the Iron Triangle Myth

By Donald Light

Response to the October 4, 2012 Quote of the Day on the meme of access, cost and quality (https://pnhp.org/news/2012/october/aaron-carroll-repeats-meme-of-access-cost-and-quality):

In my comparative studies of universal health care systems, I find their cost/quality profiles vary quite a bit between each other, and over time for the following reasons. The more such systems pay by fee, the more providers drive up costs in the name of “quality” from which they profit, such as Germany from after World War II up to the 1980s. The Canadian system has been suffering from this seeming trade-off for decades. Access stays universal but there seems to be “an iron trade-off” between cost and quality, until systems start moving towards bundled payments and then population-based capitation or salary within a national health service and an ethos of shared responsibility to improve quality within a fixed budget. (Notice the so-called “iron triangle” has faded from view.)

Thus it’s holding costs constant while maintaining universal access that is key to improving quality, not only by eliminating care that is detrimental but also unnecessary or avoidable care, by rethinking clinical strategies. Ironically, some of the models of shared access and budgets increasing quality are in the United States. Few, if any national systems, can match the steady improvements in quality and value of Kaiser Permanente, Intermountain, Marshfield, or the reformed VHA (Veterans Health Administration). For example, the English NHS has been learning from them for years.

The transformation of the VHA from a single-payer, fee-based, poor-quality set of hospital-centered services, to a single-payer system based on area population budgets centered on primary care, with coordinated, community-based specialty back-up and hospitals as a last resort offers inspiring lessons. Quality improved and costs sharply dropped, so that 30 percent more veterans could be treated within the same, fixed budget.

Reforms in Germany in the 1990s through today have also improved quality while lowering relative costs and expanding access from about 94 percent to 99 percent. Germany’s multi-insurer base has been made single payer-like by the government creating a single channel where all insurers’ premiums are risk-adjusted so all insurers operate on the same risk-adjusted budgetary basis. The Dutch reforms since 2006 operate in a similar way, with some distinct differences.

In sum, I would say the key is not single-payer per se but population-based budgeting together with universal access, and a shared ethos to improve quality within budgetary frames that give the lie to the so-called iron triangle.

The Iron Triangle is an American myth for lazy and unobservant policy leaders.

Donald W. Light, Ph.D.
Professor, UMDNJ-SOM
Visiting Researcher, Center for Migration & Development, Princeton University
Resident Fellow, Edmond J. Safra Center for Ethics, Harvard University
Senior Fellow, Center for Bioethics, University of Pennsylvania

Comment:

By Don McCanne, MD

As Professor Light shows us, with controlled budgets you can still improve quality in a system that ensures appropriate access for everyone. Although he states that the key is not single payer per se, it is clear that the Iron Triangle (interdependency of cost, quality and access) still applies to our fragmented, dysfunctional financing system in the United States – a system that has only been perpetuated with the Affordable Care Act. However, social insurance programs, including single payer and health service models, have shown that the inevitability of the Iron Triangle is a myth. An improved Medicare for all would provide us with “population-based budgeting together with universal access, and a shared ethos to improve quality within budgetary frames.”

Conversations with … Quentin Young, MD

By George Lundberg, M.D.
MedPage Today

Transcript:

GEORGE LUNDBERG, M.D.: Hello, and welcome. I’m Dr. George Lundberg, editor-at-large for MedPage Today, and we are in Chicago taking an opportunity to have a conversation with a famous name: Dr. Quentin Young. Dr. Young, thank you so much for being with us.

QUENTIN YOUNG, M.D.: It’s a pleasure.

LUNDBERG: Dr. Young has been a practicing internist at Hyde Park for many decades. At one time, he was chairman of the Department of Medicine at the Cook County Hospital.

YOUNG: Yes.

LUNDBERG: I believe he’s been an AMA member since 1952.

YOUNG: Exactly.

LUNDBERG: Something like that. In other words, he was once the president of the American Public Health Association. But for the past couple of decades, or maybe 25 years, he’s been best identified as a physician leader for the United States on trying to get basic health care for all Americans, preferably through a single payer type system. His organization is called Physicians for National Health Policy.

YOUNG: Well, that’s a very generous introduction. It’s actually National Health Program, but the “P” is …

LUNDBERG: National Health Program, all right. Say it right.

YOUNG: Physicians for a National Health Program.

LUNDBERG: There you go.

YOUNG: And what’s interesting in my professional lifetime and yours, physicians have become, in this issue, much more liberal. They used to think of the government as the really huge enemy. Now they’ve found something worse than government: Corporations.

LUNDBERG: But why hasn’t the single payer movement, which I have always opposed the name — I think it should be “main payer.”

YOUNG: Okay.

LUNDBERG: Rather than “single,” because Americans hate monopoly.

YOUNG: Yes.

LUNDBERG: They want to have an escape valve of some sort.

YOUNG: Yes.

LUNDBERG: But anyway, despite the fact that Medicare gets very high ratings from patients and many doctors now, and the surveys of physicians …

YOUNG: Yes.

LUNDBERG: …are moving more and more towards the idea of a single payer. But it doesn’t have traction with the government or with the Congress. What’s wrong?

YOUNG: Well, as the power of corporate sector, 20 years at the most, there was no organized corporate medical delivery system, but this was a huge profit center, and for the last 20 years, we’ve seen the disappearance of private practice. And, yes, my colleagues in the medical profession, conservative as they are, have finally found something they hate worse than government, and it is the corporations. They lose the autonomy, which is really, as you well know, really central to the whole medical care transactions.

LUNDBERG: So physicians in America, many of them are unhappy.

YOUNG: To say the least. And while their income isn’t that bad, and we have to be honest about that, their autonomy is. And the domination of the system in the best sense, where doctors made the decisions in collaboration with their patients, that’s almost all gone. And another decade and we’ll have a corporate system with huge salaries and rewards at the top, and people, ordinary doctors and people at the bottom will have a hard time getting decent care.

LUNDBERG: But are you suggesting that in a Medicare-for-all type approach, physicians would have more autonomy?

YOUNG: I think so. It’s not guaranteed. We physicians will always have to assert our autonomy. But that’s what good medical systems are, based on doctors’ capacity to take the facts, interview the patient, and come up with the best answer. It’s a real paradox. Patients really like the medical profession, they trust their doctors, and yet doctors have lost a huge amount of their autonomy; they really don’t have control of the system. And that’s one of the items that we think is going to make national health insurance possible.

LUNDBERG: Well, when we’re having this conversation, we’re all waiting for the Supreme Court to issue its determination.

YOUNG: That’s right.

LUNDBERG: About the constitutionality, or the political acceptability, in some ways, of the Affordable Care Act. We don’t know how it’s going to shake out. What do you think?

YOUNG: Well, for the first time in my life, I think I don’t have the answer. There are two possibilities, they’re quite opposite, and either one could happen. I think the Supreme Court is divided four and four, liberal/conservative, and with Justice Kennedy having the swing vote. And from the preliminary interviews where he heard the arguments on both sides, he seemed like he was inclined toward outlawing the present bill, and I’m no legal expert obviously, but I think he may be right. And as soon as you take the Affordable Care Act off the table because you deem it unconstitutional, you have only two alternatives at marketplace, which is a fiasco, and also single-payer, or, as you would have it, Medicare-for-all.

LUNDBERG: So you would see an overturn of the Affordable Care Act as an opportunity for your movement.

YOUNG: Well, we certainly don’t vie for it, and we don’t have near the political power that would make it happen, but the answer is Yes. I think as soon as they rule, if they rule it unconstitutional, then they have to have an answer. You know very well, you’ve probably said many times, we spent twice as much per capita for our health care with 50 million people out of the loop; that’s ridiculous. And the health care economy is threatening the larger economies, coming to 18 percent of the gross domestic product, and I think we have to fix it fast or our nationhood supremacy is going to go in decline. I really feel that way.

LUNDBERG: I believe almost everybody now agrees with that point of view. I’ve been talking about the excess costs of medical and health care for 25 years probably, but it just keeps going up. But now I believe most people agree with the notion that it’s too expensive. If the court were to say only the …

YOUNG: Mandate.

LUNDBERG: … individual mandate was unconstitutional, the rest went forward, would this be an opportunity to put the public option back on the table?

YOUNG: I think so. There are different states approaching this; some are well along the way. Vermont comes to mind, Hawaii, California, for that matter. But on the other hand, there are many states that are in the clutches of very conservative forces, and in my mind, in the clutches of the corporate sector, and it’s really an abomination. As you know, I’ve been a doctor for some 60 years and enjoyed the entire run, but they’re making it very hard for patients to get the benefits of modern medical science, and the public is learning about it. I think they’re discouraged that they get sick and … actual finding themselves in a dreadful circumstance with bankruptcy as an alternative.

LUNDBERG: Right. I think one of the good things about the Affordable Care Act and all the discussions about it is that a great number of the public have learned a lot more about the system — its faults, its frailties, its difficulties — from the education of the discussion of this, even though the discussion about it has been largely partisan and sometimes filled with faulty information. Nonetheless, there’s been a lot of education about it.

YOUNG: Well, certainly, and it’s born out of necessity. People need health care at one point or another.

LUNDBERG: Of course.

YOUNG: When they’re born or when they’re late in life. But the system is not working; it’s not responsive. I’ve been in practi
ce since World War II, and I saw it, in my eyes, how the confidence and attraction of the health care service — what we doctors gave — slowly went away and became a medical anomaly and became very, very hard for people to get decent care.

And as the triumphs of medicine work against it, people are living longer, meaning they have more years to be ill.

So we have a very crucial fight. And I’m active in the Physicians for a National Program, as you’ve pointed out, and this is my valedictory. I’m pretty old, and I had to have some way, at the end of my life, and I’ve chose national health insurance. It’s going to be hard, because the opponents are extremely wealthy, extremely capable of resisting real reform, but I think it’s the only solution. And I don’t mean for the health system; for the economy. We can’t tolerate the kind of exorbitant costs associated with the present system.

And we think, and we feel it, that the public doctors on one hand and the general public as patients on the other have come to believe that the only way to get out of this mess is to join the rest of the world, and that’s worth noting. All of the other countries that resemble us, you know, that have an industrialized and capitalist kind of system, have all chosen to have a national health service, and they all do better. They have longer life expectancies. They have freedom from diseases that are preventable. It’s just something we shouldn’t put up with.

LUNDBERG: Right. Well, thank you very much, Dr. Quentin Young, for being with us today. Thank you for your lifetime of dedicated service to individual patients and trying to make things better for all people in the United States. We’ll all see what happens and look forward to further reactions.

YOUNG: Exactly.

LUNDBERG: Thank you for being with us. I’m Dr. George Lundberg, at large for MedPage Today.

Dr. George Lundberg is editor-at-large at MedPage Today.

http://www.medpagetoday.com/PublicHealthPolicy/GeneralProfessionalIssues/35173

Post-election deficit deal threatens Medicare and Social Security

The solution is Improved Medicare for All

By Kay Tillow
Firedoglake, Oct. 6, 2012

After the November election, there will be a major effort in Congress to pass a budget deal that will make cuts in Social Security, raise the Medicare and Social Security eligibility age, and perhaps more – unless we act to stop it with a solution that is close at hand.

There is agreement from the Wall Street Journal’s David Wessel to liberal economists Dean Baker and Paul Krugman that the pressure will be on to reach a Simpson/Bowles type of compromise. Such a bipartisan plan would damage our most cherished programs and excuse the dastardly deed by asserting that the cuts are small and necessary because of the deficit.

Those who relentlessly scream at us and finance ads to persuade us that the deficit threatens our grandchildren are obscuring the truth. The fact is that the transfer of wealth from public funds and the rest of us to the super rich is the real crisis. But those who have gorged themselves on this massive transfer of wealth also seek to undermine the Medicare and Social Security which are our grandchildren’s heritage from generations of struggles for a better life.

The projected cuts are not minor but very harmful. Even a small decrease in the Social Security Cost-of-Living Adjustment would deliver an ever increasing downward push on benefits while corporations continue to threaten secure pensions by turning them into lump sums that will fade with the stock market.

Raising the Medicare age to 67 would be disastrous. There will be no affordable health insurance for those in their 60s. The Affordable Care Act allows private insurance companies to charge premiums three times higher based on age. Under popular pressure, there were regulations placed into the health care reform bill to stop insurance companies from charging higher premiums based on pre-existing conditions. But the companies were allowed to charge three times the premium based on age.

Because of this allowed age discrimination, the Kaiser Foundation estimates that an individual of age 60 in 2014 with an annual income of $50,000 will pay a health insurance premium of over $10,000, or over 20 percent of income. That does not include out-of-pocket costs which can add up to an additional $6,000 annually. That brings the total to 32 percent of income — a bankrupting figure.

There is a solution that the single-payer movement must place on the nation’s table. Even Bill Clinton said that we could save $1 trillion a year if we adopted the health care system of any of the other developed countries in the world. No more stewing over the deficit!

An Expanded and Improved Medicare for All, H.R. 676, would save Medicare, end the uncontrolled, gargantuan rise in all health care costs, ease the deficit pressure, and actually bring universal health care to the nation.

This single-payer legislation, H.R. 676, introduced by Congressman John Conyers and co-sponsored by 76 representatives, would divert $400 billion annually from profits and waste generated by the private health insurance industry into care for all. Care would be expanded and costs bought under control through bulk purchasing, global budgeting, and the elimination of administrative expenses forced upon our system in the pursuit of profit.

Doctors would be freed from insurance industry interference with care. Patients would be freed to choose their physicians. Dental, eyeglasses, hearing aids, prescription drugs, long-term care, doctors, hospitals, home health, mental health — all medically necessary care would be included. Our health care costs would stop driving us over the cliff and level off just as Canada’s did when that country fully implemented their single-payer health care.

Co-pays and deductibles would be banned, ending today’s growing problem that health insurance policies are so miserly that even the insured forgo care because they can’t afford it.

Our country spends about twice per capita what other industrialized nations spend on health care, yet our health care system lags far behind at number 37 in the world.

So why are we even debating cuts to Medicare, Social Security and Medicaid when the solution is at hand that would bring us both better care and cost controls? H.R. 676, an improved Medicare for All, is sitting in the Congress, awaiting the rising of a movement that will insist upon its passage.

Kay Tillow is coordinator of the All Unions Committee for Single Payer Health Care, which builds union support for H.R. 676. She lives in Louisville, Ky., where she is also an activist with Kentuckians for Single Payer Health Care.

http://my.firedoglake.com/kaytillow/2012/10/06/post-election-deficit-deal-threatens-medicare-and-social-security/

Universal health care and the Iron Triangle myth of U.S. policy makers

Donald Light on the Iron Triangle Myth

By Donald Light
Response to the October 4, 2012 Quote of the Day on the meme of access, cost and quality (https://pnhp.org/news/2012/october/aaron-carroll-repeats-meme-of-acce…):
In my comparative studies of universal health care systems, I find their cost/quality profiles vary quite a bit between each other, and over time for the following reasons. The more such systems pay by fee, the more providers drive up costs in the name of “quality” from which they profit, such as Germany from after World War II up to the 1980s. The Canadian system has been suffering from this seeming trade-off for decades. Access stays universal but there seems to be “an iron trade-off” between cost and quality, until systems start moving towards bundled payments and then population-based capitation or salary within a national health service and an ethos of shared responsibility to improve quality within a fixed budget. (Notice the so-called “iron triangle” has faded from view.)
Thus it’s holding costs constant while maintaining universal access that is key to improving quality, not only by eliminating care that is detrimental but also unnecessary or avoidable care, by rethinking clinical strategies. Ironically, some of the models of shared access and budgets increasing quality are in the United States. Few, if any national systems, can match the steady improvements in quality and value of Kaiser Permanente, Intermountain, Marshfield, or the reformed VHA (Veterans Health Administration). For example, the English NHS has been learning from them for years.
The transformation of the VHA from a single-payer, fee-based, poor-quality set of hospital-centered services, to a single-payer system based on area population budgets centered on primary care, with coordinated, community-based specialty back-up and hospitals as a last resort offers inspiring lessons. Quality improved and costs sharply dropped, so that 30 percent more veterans could be treated within the same, fixed budget.
Reforms in Germany in the 1990s through today have also improved quality while lowering relative costs and expanding access from about 94 percent to 99 percent. Germany’s multi-insurer base has been made single payer-like by the government creating a single channel where all insurers’ premiums are risk-adjusted so all insurers operate on the same risk-adjusted budgetary basis. The Dutch reforms since 2006 operate in a similar way, with some distinct differences.
In sum, I would say the key is not single-payer per se but population-based budgeting together with universal access, and a shared ethos to improve quality within budgetary frames that give the lie to the so-called iron triangle.
The Iron Triangle is an American myth for lazy and unobservant policy leaders.
Donald W. Light, Ph.D.
Professor, UMDNJ-SOM
Visiting Researcher, Center for Migration & Development, Princeton University
Resident Fellow, Edmond J. Safra Center for Ethics, Harvard University
Senior Fellow, Center for Bioethics, University of Pennsylvania

 
As Professor Light shows us, with controlled budgets you can still improve quality in a system that ensures appropriate access for everyone. Although he states that the key is not single payer per se, it is clear that the Iron Triangle (interdependency of cost, quality and access) still applies to our fragmented, dysfunctional financing system in the United States – a system that has only been perpetuated with the Affordable Care Act. However, social insurance programs, including single payer and health service models, have shown that the inevitability of the Iron Triangle is a myth. An improved Medicare for all would provide us with “population-based budgeting together with universal access, and a shared ethos to improve quality within budgetary frames.”

Health reform and professional ethics

By Stephen B. Kemble, M.D.

PNHP note: The following is the inaugural address that Dr. Kemble, president of the Hawaii Medical Association and single-payer advocate, delivered to the HMA at its annual Ola Pono Ike (“Health is Knowledge”) assembly on Oct. 6, 2012.

I have been thrust into HMA leadership based on my advocacy for universal health care. Although single-payer health care financing is not AMA policy, I want to thank all of you who have supported me in advocating for truly cost-effective, universal health care that puts the needs of our patients first, in keeping with the highest tradition of professional medical ethics. I also want to thank my family and friends for putting up with my obsessive preoccupation with health care reform over the past 5 years, and with all the time that has gone into what I refer to as “community service,” sometimes at the expense of time for family and for my psychiatric practice.

Much of the national discussion and policy initiatives on health care reform have been based on the assumption that runaway health care costs are due to “too much care,” either instigated by doctors due to fee-for-service incentives, or instigated by patients who want to “consume” too much care because it is covered by insurance. The assumption that we are delivering too much care is driving efforts to reform physician payment away from fee-for-service and towards pay-for-performance, pay-for-outcomes, bundled payments, capitation, and related schemes intended to counter the supposed incentive under fee-for-service to provide too much care. “Too much care” is also the rationale for increasing cost sharing for patients in the form of higher deductibles and co-payments. However, the beliefs that our health care cost problems are due to “the fee-for-service treadmill” and to patients demanding too much care are fundamental misdiagnoses of the problem. Inadequate access to necessary and appropriate care is a much bigger problem in the US than excessive care.1

If fee-for-service were a root cause of runaway health costs, then how are other countries that use fee-for-service payment of doctors able to cover everyone and spend 50-60% of what we do per capita on health care? These other countries include Canada, Australia, New Zealand, Taiwan, Japan, Germany, France, Switzerland, Israel, and many others. Much of the evidence for a large amount of unnecessary care in the US is based on studies of regional variation in Medicare spending2, but if this is due to fee-for-service, then how do we explain the fact that high and low spending regions use fee-for-service equally?

Although some “worried well” patients may be deterred from seeking unnecessary care by increased cost sharing, these patients account for only a tiny fraction of total health expenditures. For the seriously or chronically ill who account for 80-90% of health care spending, increased cost sharing deters necessary and beneficial care and has been shown in studies to increase total health care costs, especially for the poor and elderly who are the highest risk populations.3,4

So what is causing US health care to cost so much? There is plenty of evidence that administrative complexity is a large part of the problem.5,6 This is due to fragmentation of US health care and use of competing health plans to finance health care, whether private health insurance plans provided through employment, or privatized government-funded programs such as Medicaid managed care, Medicare Advantage, and Medicare Part D.

In my opinion, another major factor is the de-professionalization of doctors. There are two broad ethical paradigms in the world of economics: commercial ethics and “guardian” ethics. The commercial paradigm assumes a seller and buyer of goods or services, whose power and interests are balanced through the marketplace and the laws of supply and demand, with financial incentives as a primary motivator. Guardian ethics are applicable to socially necessary services that require specialized training and expertise not available or achievable by the general public, so that there is an inherent imbalance of power between the provider and recipient of services. Classic examples are the military, medicine, and other specialized professions. In these cases, the interests of the public are protected by a tradition of professionalism and concern for the welfare of the public, or patient, or client, which is held to be a higher ethical value than financial considerations.7

There has been a movement in this country for the past 50 years to de-professionalize medicine, with an underlying assumption that commercial ethics are the only valid and trustworthy ethics. This justifies increasing interference in health care decisions by hospitals, insurance plans, and government, and an over-reliance on financial incentives to “fix” problems in health care, and especially its high cost.

Medical students start their training with the Hippocratic oath and with an idealistic desire to help others. However, they are often burdened with exorbitant debt, and they discover that half their time is spent “treating the chart” so that the hospital or clinic where they are working can get paid. These problems are compounded by payment reform initiatives that rely on financial incentives, supposedly intended to “improve” care, such as diagnosis related groups (DRG’s), pay-for-performance, pay-for-outcomes, and denial of payment for adverse events. These strategies add administrative burdens and generally fail to account for the difficulties in accurately defining “quality” or “outcomes” due to the complexity of health care.

Unfortunately, if doctors are stripped of their professional autonomy and treated as if financial considerations are paramount, they actually do start to abandon professional ethics for commercial ones. They start responding to financial considerations above patient needs; they select patients according to their insurance status; they try to avoid taking on sicker, more complex patients, and they look for ways to game the system or to make more money from things other than professional services. They begin to try to maximize income by any available means, helping drive the cost of health care higher. Sometimes this leads to outright fraud.

If these de-professionalizing forces are combined with fee-for-service, then we do indeed get unnecessary and inappropriate care. Insurance plans and government agencies then double down on monitoring documentation to look for fraud and abuse and try to develop financial incentives to deter unnecessary care. The result is a vicious cycle of escalating administrative burdens, declining access to care for patients who need it, and a demoralized physician work force8. This is exactly what we are now experiencing!

In the effort to slow the escalation in health care costs, whose ox will get gored? Will it be doctors and hospitals, in the form of rising administrative burdens and declining pay? Will it be patients, in the form of increased cost sharing, most of which is not affordable for those with significant health problems, and in declining access to needed care? Or will it be the insurance industry? Only one of these is not an integral part of health care, and the explosion in health care costs in the US is largely on their side of the ledger. However, the insurance industry does not want to be pushed out of health care and they have accumulated a lot of money to protect their interests, hence the focus on blaming doctors and patients for rising costs.

What are the solutions?
1.  Although health care does require some administrative functions, we need to minimize the role of competing insurance plans in managing delivery of care. This can be accomplished by developing a unified delivery system for a State or region in which all doctors and hospitals i
n a community participate, with standardized benefits and payment for providers, so that they are paid the same regardless of the source of funding for an individual patient. This is called an “all-payer” system, with a unified delivery system even if there are several sources of funding.
2.  We need public subsidies for medical education in exchange for practicing in underserved specialties and locations, as is being initiated here in Hawaii in the form of a new Hawaii State Loan Repayment program.
3.  We need to ensure the cost-effectiveness of care with physician-led quality improvement instead of insurance-driven managed care. Financial incentives such as pay-for-outcomes, bundled payments, and capitation of doctors ignore the complexities of health care and introduce perverse incentives to avoid treating sicker, more complex patients. They should have no place in quality improvement. A far better approach is William Demings’s Continuous Quality Improvement model, as has been demonstrated in auto manufacturing, airline safety, and in health care in some US communities, such as Intermountain Health Care in Utah, Rocky Mountain Health Plans in Western Colorado, and Community Care of North Carolina.9,10,11 With Continuous Quality Improvement all errors and quality problems are viewed as system problems, instead of looking for individuals to blame and punish. Everyone involved in health care is enlisted in sharing information and ideas to solve problems and improve delivery of care. Blaming individual doctors and hospitals, whether through individual sanctions or individualized performance and quality ratings tied to financial rewards and penalties, drives everyone into gaming documentation, and when there is an error, into silence and the arms of the attorneys, preventing effective improvement of care.
4.  We need to organize doctors for quality improvement. Physician-directed quality improvement requires organization, sharing of information necessary to improve quality, and a mechanism for shared savings from improving care. The alternative to organization of physicians is more managed care administered by insurance plans and government, and the continued de-professionalization of doctors.
5.  Quality improvement and efforts to make care more cost effective should not be based primarily on financial incentives, but must be rooted in professional ethics and in the goal of meeting the health care needs of both individual patients and population health.
6.  Instead of the complexities of the Resource Based Relative Value Scale and Evaluation and Management procedure codes, let’s simply pay doctors for their time, with a multiplier for training and practice costs.12 Separate quality incentives may be appropriate, but must be in proportion to those components of health care that can be accurately and meaningfully measured, and these are probably only about a quarter of health care due to its complexity. Specialties requiring more training and overhead would be paid at a higher hourly rate, but for each individual doctor this rate would be the same regardless of the activity or procedure being performed. Time for care coordination should be included in reimbursement. This would greatly reduce the complexities required by “pay-for-documentation” and it would allow documentation to be re-focused on patient care and quality improvement instead of reimbursement. If payment were task-neutral, then there would be no preferential incentive to do procedures instead of things like talking to patients and obtaining a good history and thorough physical exam. The primary incentive for physicians would then be to simply use their time and skills, to the best of their ability as professionals, to serve the health care needs of their patients.
7.  Above all, we need to place the best interests of our patients at the center of health care again.

Thank you.
 
REFERENCES:

1.  Elizabeth A. McGlynn et al., The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635-2645, 2641.
2.  Fisher ES, Bynum JP, Skinner JS. Slowing the Growth of Health Care Costs – Lessons From Regional Variation. N Engl J Med. 2009 Feb 26;360(9):849-52.
3.  M. Gregg Bloche. Consumer-Directed Health Care And The Disadvantaged. Health Affairs, 26, no.5 (2007):1315-1327
4.  Trivedi AN, Husein Moloo, Mor V. Increased Ambulatory Care Copayments and Hospitalizations among the Elderly. N Engl J Med. 2010;362:320-8.
5.  Blanchfield BB, Heffernan JL, Osgood B, Sheehan RR , Meyer GS.
Saving Billions Of Dollars−−And Physicians’ Time−−By Streamlining Billing Practices. Health Affairs 29,
No. 6 (2010): 1248–1254
6.  Morra D, Nicholson S, Levinson W, Gans DN, Hammons T, Casalino LP. US Physician Practices vs. Canadians: Spending Nearly Four Times as Much Money Interacting With Payers. Health Affairs 30 , No. 8 (2011): doi: 10.1377/hlthaff.2010.0893.
7.  Jacobs J. Systems of Survival: A Dialogue on the Moral Foundations of Commerce and Politics. New York: Random House; 1992
8.  Chen P. The Widespread Problem of Doctor Burnout. New York Times. Aug 23, 2012.
9.  James BC and Savitzdoi LA. How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts. Health Affairs 30, no. 6 (2011); DOI:10.1377/hlthaff.2011.0358
10.  Bodenheimer, T, West D. Low-Cost Lessons from Grand Junction, Colorado. N Eng J Med 2010; DOI:10.1056/NEJMp1008450.
11.  Community Care of North Carolina: Putting Health Reform Ideas into Practice in Medicaid. The Kaiser Family Foundation Publication #7899, May 2009. (http://www.kff.org/medicaid/7899.cfm)
12.  Wachtel TJ, Stein MD. Fee-for-Time System: A Conceptual Framework for an Incentive-Neutral Method of Physician Payment. JAMA 1993;270(10):1226-1229