PNHP

The Democrats’ market-friendly health care alternative

The Democrats’ market-friendly health care alternative

The Democrats’ Market-Friendly Health-Care Alternative

By Ezekiel J. Emanuel, Neera Tanden and Donald Berwick
The Wall Street Journal, September 24, 2012

Conservative and liberal health-policy experts agree that the key to sustainable cost control lies in encouraging physicians and hospitals to focus on quality rather than quantity, and value rather than volume.

According to a study published in August in the New England Journal of Medicine, over the past decade per-person costs in Medicare have increased less than those of private insurance, and are projected to be 1.2 percentage points lower than those of private insurance per year over the next decade.

Why should anyone believe that the Affordable Care Act and our new proposals will actually control costs? After all, skeptics argue, Medicare costs have increased inexorably despite myriad policies designed to control them. But we propose a break from the past, which has largely relied on the government’s setting of payments. Our alternative is to allow the market to set many prices for medical goods and then to change payment and reimbursement methods so that physicians and hospitals have the incentive to keep patients healthy. This is neither government nor insurer rationing. It is a market-friendly approach that empowers health providers to re-engineer how they care for patients.

http://online.wsj.com/article/SB10000872396390444017504577645193107383610.html?mod=googlenews_wsj

And…

Health Care Cost and Utilization Report:  2011

Health Care Cost Institute (HCCI)
September 2012

For 2011, HCCI found increases in prices were the primary cause of increased health care spending for the privately insured younger than 65 and covered by ESI (employer-sponsored insurance).

The rate of price growth for all major services outpaced changes in utilization. The primary cause of increased prices was growth in unit prices.

http://www.healthcostinstitute.org/files/HCCI_HCCUR2011.pdf

Comment: 

By Don McCanne, MD

The authors of this Wall Street Journal opinion article have participated in the development and implementation of the Democrats’ Affordable Care Act. Increases in prices continue to be a primary cause of increases in health care spending, so what do these authors recommend? “Our alternative is to allow the market to set many prices for medical goods and then to change payment and reimbursement methods so that physicians and hospitals have the incentive to keep patients healthy.”

Health care prices remain a problem. The health care market, such as it is, always has set prices high and will continue to do so. Utilization is not excessive. It is comparable to other nations with far lower total spending. Incentives designed to reduce utilization risk impairing access to appropriate care, thereby impairing quality.

It is futile to continue to pretend that market approaches within our highly dysfunctional financing system – that perpetuated by the Affordable Care Act – will ever bring us quality health care at a reasonable cost. Allowing the market to set prices is utter nonsense. Our own public stewards, working with the health care delivery system, can price our health care services and products properly, providing that they are allowed to function as a single payer monopsony (not to mention all of the other benefits of single payer financing).

We don’t need more market-friendly Democrats. We need patient-friendly politicians, though they are a rare sighting these days.

True democracy demands a healthy electorate

By Dr. Sara Stalman
Kennebec Journal, Sept. 25, 2012

To write about health care and politics is to write about the sacred and the profane.

Our word “health” has the same etymological root as our words “whole” and “holy.”

It reflects ancient awareness that we are designed and guided by sacred forces that, although beyond human comprehension, we know to be greater than ourselves and to be good. “Health” has “the sacred” at its very root.

“Politics,” on the other hand, refers to activities related to governance. Our political realities foster the greatest disparity of wealth between rich and poor that our country has ever known.

One in five Mainers do not seek medical care because they cannot afford it. Many have health insurance but, with high monthly payments and high deductibles, they see doctors only in emergencies.

At the same time, Maine is hemorrhaging health care dollars to out-of-state insurance profiteers. In 2002, 38 to 50 cents of every dollar spent on health insurance left Maine never to return. It’s only gotten worse.

Working people pay for everybody’s health care. That’s the reality.

In a single-payer health insurance system, that money would go into a single pot that would pay all health care costs directly. There would be minimal overhead, no insurance company profiteers and direct purchase of medications for the cheapest negotiated price.

Our veterans receive health care through a single-payer system. Minus the prescription-drug nonsense, Medicare, too, is a single-payer system.

In 2001, Maine was the first state to be standing within a hair’s breadth of legislatively passing a single-payer health insurance system.

By a vote of 76-54, “single-payer” passed with strong bipartisan support in the House. With the Senate set to vote in favor along party lines (18-16), then-Gov. Angus King vowed to veto the bill.

The final Senate vote of 15-17 precluded the governor’s veto, but in no way changed his position.

The tremendous economic impact a single-payer health insurance system would have for Maine can be seen in the results of a feasibility study funded in 2002. Maine is a small state with an aging population and high incidence of chronic disease.

Even so, a single-payer health care pot composed of just 4 percent of Maine working people’s income and 7 percent of business payroll could pay for everyone’s health care (individual choice of doctor, preventive care, medical and surgical care, eye and dental care, prescription drugs and home care) — and save $350 million in the first year alone.

Minimal co-pays assessed on a sliding scale were required, but the maximum individual expense would be $1,000 per year, with no family paying more than $2,000. (With single-payer health insurance, businesses, of course, would no longer have to pay the health care costs of workers compensation insurance.)

With Maine’s population of 1.35 million, $350 million would mean that, for each of us, $260 unavailable now would be in the local economy — buying food, clothing, text books, whatever. Money would be changing hands, improving our quality of life and increasing our local tax base.

Moreover, local school budgets would no longer be burdened with the costs of employee health benefits.

Demonstrating we could afford a single-payer health insurance system (and could pass legislation to create that system) put Maine in the sights of those interests still working to undermine health care reform.

In 2002, the National Heritage Foundation arrived in the guise of the Maine Heritage Policy Center. Pouring money from around the country into our state, those interests continue to dominate Maine electoral politics — underwriting, for example, the candidacy of now-Gov. Paul LePage.

In writing the Declaration of Independence, our Founding Fathers asserted that government should recognize “Life, Liberty and the Pursuit of Happiness” as inalienable (sacred) rights of humankind.

Our democracy was the first modern government based on that principle.

Because powers of wealth and economic violence have threatened its founding principle since our country began, our American democracy (honored worldwide by men and women trusting that principle) remains a work in progress. Today, that threat can be seen at its most dangerous in the political battle over health care reform.

True democracy demands a healthy electorate. It demands an electorate able to experience the sacred, trust the sacred, and act on that trust.

Those opposing quality health care and a single-payer insurance system typically are accused of acting from profit motive alone. More profoundly, opposition to health care reform is opposition to true democracy: Democracy of the people, by the people, and for the people. All the people.

Dr. Sara Stalman of Brooklin has practiced neuropsychiatry for 18 years. Her clinical research investigating the relationship between early childhood experience and adult chronic depressive disorders is available from her website: bornforjoy.com.

http://www.kjonline.com/opinion/columnists/true-democracy-demands-a-healthy-electorate_2012-09-24.html

Music and health care

By Anne Scheetz, M.D.
Chicago Tribune, Letters, Sept. 24, 2012

Chicago Symphony Orchestra musicians are on strike because the CSO Association and the Orchestra Members Committee cannot agree on how to share the cost of health insurance premiums — only the latest of many labor disputes around escalating health care costs. Meanwhile, in 2009, the top executives of the nation’s five largest health insurance companies received $200 million in total compensation; Edward Hanway, CEO of Cigna, retired with a $73 million bonus; UnitedHealth Group earned $3.82 billion in net income, and its CEO reportedly earned more than $8 million. 

The CSO brings pleasure to millions, insurance companies deny claims and we see who is rewarded.

It doesn’t have to be this way.

If we get rid of health insurance companies with their bloated bureaucracies for marketing, underwriting and claims denial, as well as their profits and outrageous executive compensation, and instead enroll every person in the country in expanded and improved Medicare for all (also called single payer), we can cut our health care administrative costs in half. The $400 billion in savings generated is enough to pay for all necessary health care for everyone. We can have music and health care.

Anne Scheetz, M.D., resides in Chicago.

http://www.chicagotribune.com/news/opinion/letters/chi-music-and-healthcare-20120924,0,6378965.story

The Democrats' market-friendly health care alternative

The Democrats’ Market-Friendly Health-Care Alternative

By Ezekiel J. Emanuel, Neera Tanden and Donald Berwick
The Wall Street Journal, September 24, 2012
Conservative and liberal health-policy experts agree that the key to sustainable cost control lies in encouraging physicians and hospitals to focus on quality rather than quantity, and value rather than volume.
According to a study published in August in the New England Journal of Medicine, over the past decade per-person costs in Medicare have increased less than those of private insurance, and are projected to be 1.2 percentage points lower than those of private insurance per year over the next decade.
Why should anyone believe that the Affordable Care Act and our new proposals will actually control costs? After all, skeptics argue, Medicare costs have increased inexorably despite myriad policies designed to control them. But we propose a break from the past, which has largely relied on the government’s setting of payments. Our alternative is to allow the market to set many prices for medical goods and then to change payment and reimbursement methods so that physicians and hospitals have the incentive to keep patients healthy. This is neither government nor insurer rationing. It is a market-friendly approach that empowers health providers to re-engineer how they care for patients.
http://online.wsj.com/article/SB10000872396390444017504577645193107383610.html?mod=googlenews_wsj

And…

Health Care Cost and Utilization Report:  2011

Health Care Cost Institute (HCCI)
September 2012
For 2011, HCCI found increases in prices were the primary cause of increased health care spending for the privately insured younger than 65 and covered by ESI (employer-sponsored insurance).
The rate of price growth for all major services outpaced changes in utilization. The primary cause of increased prices was growth in unit prices.
http://www.healthcostinstitute.org/files/HCCI_HCCUR2011.pdf

The authors of this Wall Street Journal opinion article have participated in the development and implementation of the Democrats’ Affordable Care Act. Increases in prices continue to be a primary cause of increases in health care spending, so what do these authors recommend? “Our alternative is to allow the market to set many prices for medical goods and then to change payment and reimbursement methods so that physicians and hospitals have the incentive to keep patients healthy.”
Health care prices remain a problem. The health care market, such as it is, always has set prices high and will continue to do so. Utilization is not excessive. It is comparable to other nations with far lower total spending. Incentives designed to reduce utilization risk impairing access to appropriate care, thereby impairing quality.
It is futile to continue to pretend that market approaches within our highly dysfunctional financing system – that perpetuated by the Affordable Care Act – will ever bring us quality health care at a reasonable cost. Allowing the market to set prices is utter nonsense. Our own public stewards, working with the health care delivery system, can price our health care services and products properly, providing that they are allowed to function as a single payer monopsony (not to mention all of the other benefits of single payer financing).
We don’t need more market-friendly Democrats. We need patient-friendly politicians, though they are a rare sighting these days.

So you want coverage as good as that of members of Congress?

Rep. Jesse Jackson, Jr. Forced To Sell Luxury Townhouse To Pay Medical Bills

Your Black World
September 20, 2012

In a statement released by Rep. Jesse Jackson, Jr.’s chief of staff, Rick Bryant, Rep. Jackson and his wife have made the decision to sell their townhouse in Washington D.C. to defray medical expenses Jackson has acquired for his depression and bipolar disorders. “Like millions of Americans, Congressman Jackson and Mrs. Jackson are grappling with soaring health care costs and are selling their residence to help defray costs of their obligations,” the statement read. “The congressman would like to personally thank everyone who has offered prayers on behalf of his family.” Jackson aides could not say how much, if any, of the expenses are covered under his health insurance plan.

http://www.yourblackworld.net/2012/09/black-news/rep-jesse-jackson-jr-forced-to-sell-luxury-townhouse-to-pay-medical-bills/

Comment:  

By Don McCanne, MD

Those who say repeatedly that everyone should have the same health care coverage as members of Congress should check with Rep. Jesse Jackson, Jr. He is losing his Washington, D.C. townhouse because of medical bills.

Other than the statement released by his chief of staff, we don’t know any of the details, and we shouldn’t since common decency dictates that we respect his privacy.

We could speculate on the great many potential factors that might be involved as to why a member of Congress faces a financial hardship due to medical bills, but we won’t, even though many come to mind. We’ll merely state that we need a health care financing system that removes financial barriers to care – for everyone. A properly designed single payer national health program would do that.

So you want coverage as good as that of members of Congress?

Rep. Jesse Jackson, Jr. Forced To Sell Luxury Townhouse To Pay Medical Bills

Your Black World
September 20, 2012
In a statement released by Rep. Jesse Jackson, Jr.’s chief of staff, Rick Bryant, Rep. Jackson and his wife have made the decision to sell their townhouse in Washington D.C. to defray medical expenses Jackson has acquired for his depression and bipolar disorders. “Like millions of Americans, Congressman Jackson and Mrs. Jackson are grappling with soaring health care costs and are selling their residence to help defray costs of their obligations,” the statement read. “The congressman would like to personally thank everyone who has offered prayers on behalf of his family.” Jackson aides could not say how much, if any, of the expenses are covered under his health insurance plan.
http://www.yourblackworld.net/2012/09/black-news/rep-jesse-jackson-jr-forced-to-sell-luxury-townhouse-to-pay-medical-bills/

Those who say repeatedly that everyone should have the same health care coverage as members of Congress should check with Rep. Jesse Jackson, Jr. He is losing his Washington, D.C. townhouse because of medical bills.
Other than the statement released by his chief of staff, we don’t know any of the details, and we shouldn’t since common decency dictates that we respect his privacy.
We could speculate on the great many potential factors that might be involved as to why a member of Congress faces a financial hardship due to medical bills, but we won’t, even though many come to mind. We’ll merely state that we need a health care financing system that removes financial barriers to care – for everyone. A properly designed single payer national health program would do that.

Medical group administrator urges Medicare for all, supports H.R. 676

Administrator of Clark & Daughtrey interprets health care reform issues

By Robin Williams Adams
The Ledger (Lakeland, Fla.), Sept. 22, 2012

LAKELAND, Fla. — Sticking with the status quo won’t solve the woes of the United States health care system, Adil Khan said Friday, but he’s not convinced the changes now being implemented will either.

Khan, chief administrative officer of Clark & Daughtrey Medical Group in Lakeland, sees more promise in proposed legislation — languishing in Congress for years — that would expand Medicare to cover all ages. It’s H.R. 676, the National Health Insurance Act.

“This is not socialized medicine,” he told members of the Lakeland South Rotary Club at their noon meeting.

“We’re not talking about changing Medicare. It’s already there. We’re talking about expanding it.”

Socialized medicine, he said, would be if the government owned all or most hospitals and medical practices, a change neither the current legislation approved by Congress nor the Medicare expansion would make.

Medicare already is in place, serving almost 10 percent of the population, Khan pointed out, and its 3 percent overhead costs are much lower than those of commercial health insurance plans.

Hospitals and most doctors accept Medicare.

In contrast, Medicaid, which the current health care reform effort would expand, isn’t popular among doctors.

Most don’t accept it, Khan said, explaining that Medicaid “does not cover the cost of providing care.”

A shortage of doctors, particularly acute in Polk County, already makes it difficult for people on Medicaid to have much choice when getting medical care.

Khan spent a few minutes showcasing the expanding capacity of Clark & Daughtrey before getting straight to the heart of his message:

What’s wrong with the current system?

Will the Patient Protection and Affordable Care Act solve the current health care crisis?

If not, what could?

“Our system is on the verge of collapse,” said Khan, 44.

Eighteen percent of the gross national product went to health care last year, a percentage that’s expected to increase, he said. The cost in dollars was $2.6 trillion, almost half of it government funded.

“We are seeing a lot of hospitals changing their practices,” he said. “Some are having to close.”

And 33 percent of people in the U.S. say they’ve avoided getting needed health care because of the cost, he said, compared with 5 percent in the United Kingdom, 15 percent in Canada and 25 percent in Germany.

Many people who lack health insurance seek care at hospital emergency departments, which Khan said is less efficient and more costly than seeing a doctor.

The Patient Protection and Affordable Care Act, which several in the audience referred to as Obamacare, would close some gaps in getting care to the currently uninsured, Khan said.

Aspects he said he favors include letting children stay on their parents’ insurance plans until age 26 and not allowing pre-existing medical conditions to keep people from getting insurance coverage.

He considers the Medicaid-expansion it would use “very inefficient,” however, and said implementing all the changes would add additional bureaucracy.

If the alternative he prefers were adopted, Khan said, Medicare could cover the entire U.S. population for $2.2 trillion dollars, which is less than the $2.6 trillion spent on health care overall in 2011.

“It’s far from perfect,” he said of H.R. 676, “but it’s better than the health-care reform plan we have now.”

http://www.theledger.com/article/20120922/NEWS/120929771/1134?Title=Administrator-of-Clark-Daughtrey-Interprets-Health-Care-Reform-Issues-

Webster Physician Joins Health Care Debate

Dr. William Fogarty Jr. to present his views Sept. 20 at Ethical Society

By Don Corrigan
Webster-Kirkwood Times, September 14, 2012

Speeches on health care, its costs and its delivery found a place at both party conventions this 2012 election season. Dr. William Fogarty Jr. fears the fiery political oratory may be generating more heat than light.

Fogarty, who serves on the local leadership committee of Physicians for a National Health Program, finds all the political rhetoric exasperating. He will explain his organization’s take on the health care debate at the Ethical Society, 9001 Clayton Road, at 6:30 p.m., Thursday, Sept. 20.

“If logic dictated what we do in America – which it doesn’t – we would have Medicare for all,” said Fogarty, a resident of Webster Groves. “Medicare works well at a far lower cost than private insurance. It has high levels of patient satisfaction. 

“Talk to most doctors and you will find far more unhappiness with the insurance companies, than with the government’s Medicare,” Fogarty added. “Some $400 billion is now lost to administrative costs of health insurance companies annually. This could be saved to cover the 25 million who remain uncovered under the Affordable Care Act (ACA).”

The ACA, tagged by its critics as “Obamacare,” has inspired negative reactions and harsh political rhetoric. Fogarty said the reaction underscores his premise that America and its citizenry are illogical when it comes to a good health care system.

“All the polls show that Americans like a system where you cannot be cut off care for pre-existing conditions; where prescription costs are held down; where the young can stay on their parents’ policies until 26,” said Fogarty. “Then you ask them if they like the Affordable Care Act and they scream, ‘no.'”

Fogarty said it makes no sense, because all of the positive attributes for care are under ACA. Fogarty said he has no desire to be embroiled in politics and his wife tells him that after a solid practice in St. Louis medicine for more than three decades, he should keep a low profile.

“It’s hard not to get political with this,” said Fogarty. “The Democrats have done a poor job promoting ACA and health care for all. Republicans have just been disingenuous. There is no doubt they are in the back pocket of the health insurance industry.

“I see ACA as a step on the way to Medicare for all,” said Fogarty. “ACA is not my first choice, but progress is slow and it’s a first step. The irony (of GOP opposition) is that ACA has two key Republican ideas: an insurance mandate that everyone must pay; and, a health insurance company policy exchange for many participants to choose from.”

Against “Obamacare” 

Once the ACA was passed in March 2010, the outcry against it was swift. That summer, citizens voiced their objections, often noisily, at candidate forums in the lead up to the midterm elections.

“I went to one of the forums at a school in South County and was shocked to see all these seniors yelling about keeping government hands off their Medicare,” Fogarty recalled. “I wanted to tell them that Medicare is by the government, but I was afraid I would get hurt.”

Republicans in the 2010 state legislature put “Obamacare” on the state ballot for August. Missourians then rejected it resoundingly in the non-binding referendum on Aug. 3. State Rep. Mike Leara, R-Sunset Hills, voted to put the ACA on the ballot and campaigned against it. 

“I am against the government having anything to do with our health care,” Leara told the Times. “People who pay for their health care should not be forced into a system resulting in rationing 10 years from now. The majority of people are covered now, and they like what they have.”

Sen. Jane Cunningham, R-Chesterfield, a primary sponsor of the referendum bill, said state voters wanted to nullify the ACA as unconstitutional, because it would fine them for not purchasing medical insurance coverage or for not participating in the federal plan.

In contrast, state Rep. Jeanne Kirkton, D-Webster Groves, said the referendum was a “symbolic political ploy.” She said the ACA, with its mandate to buy health insurance, was constitutional. On June 28 of this year, Kirkton was vindicated when the U.S. Supreme Court ruled ACA as constitutional.

Nevertheless, Missouri legislators continue to try to block ACA’s implementation in Missouri. They support another ballot measure to affirm “freedom and Missouri’s sovereignty” and to try to stop Gov. Jay Nixon from cooperating with setting up ACA in the state.

Battling Continues 

Cunningham and many outstate Republicans continue to battle for “nullification of Obamacare.” Some Democrats argue that failure to implement an approved federal program, which has been declared as constitutional, amounts to secession.

“I am a reluctant advocate for affordable care and for Medicare for all,” said Fogarty. “I’m reluctant because I dislike politics. I dislike all the political money being poured into this. I dislike all the legislative and industry obstacles being thrown up against health care for people.

“Missouri has already lost millions of ACA money meant to update and streamline our computerized medical records system,” said the Webster Groves physician, who was educated at St. Louis University School of Medicine. “Missouri is losing out and it’s all because politicians want something to beat up Obama with.”

Fogarty, who has been serving as a volunteer physician at two indigent clinics since retiring, said he can point to numerous studies that point to the benefits of health care reform for America.

“There’s a very good study of the U.S. health care system as compared to a dozen other developed countries,” said Fogarty. “Whether it’s the Danes or the French, they all have better patient satisfaction, better outcomes, better economics.

“But you try to point this out and you are accused of foisting European socialism on America,” said Fogarty. “All this hysteria over our American exceptionalism – we always do it better, except we don’t. And Medicare for all would not be socialism. Doctors would still have private practices.”

Several other study guides that Fogarty cites to support his views on health care are from the American College of Physicians, American Association of Retired Persons and Consumer Reports. For information on his Sept. 20 presentation go to: www.mosp.us/events.htm.

Read more: http://new.websterkirkwoodtimes.com/Articles-Features-i-2012-09-14-182677.114137-Webster-Physician-Joins-Health-Care-Debate.html#ixzz27P15fwWx

Anthem Blue Cross learns how to control costs

Cedars-Sinai and UCLA cut from Los Angeles health plan

By Chad Terhune
Los Angeles Times, September 21, 2012

Two of the most prestigious names in Southern California healthcare — Cedars-Sinai and UCLA — are getting shut out of a major insurance plan for being too expensive.

In a bold cost-cutting move, Anthem Blue Cross has eliminated doctors affiliated with the hospitals from a health plan offered to about 60,000 employees and dependents at the cash-strapped city of Los Angeles.

The city opted for Anthem’s plan because it will save $7.6 million in annual premiums next year by excluding physicians from the two institutions known for tending to the Southland’s rich and famous.

“Purchasers are sending a signal that certain prices are just unaffordable,” said David Lansky, chief executive of the Pacific Business Group on Health, which represents large companies such as Walt Disney Co. “We want great teaching and medical research institutions to survive. Whether that should happen by charging everyone in society a higher rate for routine services is more debatable.”

“Implementation of the narrow network was a difficult choice, but one made necessary by the city’s fiscal constraints,” a city spokesman said. Los Angeles is expected to be the biggest employer to offer Anthem’s Select plan.

Officials at Cedars-Sinai and UCLA criticized the rationale for the move, saying the increased costs are tied to their world-class medical research and cutting-edge treatments in areas such as cancer or organ transplants that benefit the entire community.

Thomas Priselac, chief executive of Cedars-Sinai Medical Center, said these exclusions offer a “false economy” because they don’t reduce costs in the healthcare system overall.

“It just pushes the cost onto those who continue getting care at those facilities,” Priselac said. “Secondly, it doesn’t recognize the reason why places like Cedars and UCLA are more expensive than the typical community hospital.”

For its part, UCLA said its hospitals treat a large number of patients in Medi-Cal, the government program for the poor and disabled.

“Other providers don’t have to deal with the expenses UCLA has to deal with,” said Santiago Muñoz, chief strategy officer for the UCLA Health System.

Anthem isn’t alone in pursuing this strategy. Many insurers are aggressively pitching these sharply limited networks, which offer fewer choices and lower-priced doctors and hospitals, as a cost-cutting tool at a time when U.S. health insurance premiums have climbed three times as fast as inflation and wages over the last decade.

Industry giant WellPoint Inc., which owns Anthem Blue Cross in California, offers plans that include as few as 30% of the company’s full list of providers.

http://www.latimes.com/business/la-fi-hospital-costs-20120921,0,4069159,full.story

Comment:  

By Don McCanne, MD

The explosion in limited-network private insurance plans is taking choice away from more and more patients. The business tools that  private insurers use to control costs are very different from the patient-service tools of a single payer national health program. Not only do the private insurers’ tools restrict patients’ care, but they are also quite ineffective in controlling overall spending, as is demonstrated by the fact that our health care costs are about twice the average of other nations.

Under a single payer system, all legitimate costs are paid by the government and are not linked to specific health plans assigned to different individuals – a very inefficient and fragmented method of financing health care. Using the example of UCLA, there would be no tiers of private coverage and no problem with an underfunded Medicaid program. The hospital costs would be globally budgeted, just as are police and fire departments. Separate, extraordinary costs of research functions would be funded through our National Institutes of Health. Education grants can be provided through the global budgeting process since house staff members are, from a financing perspective, really just low-paid hospital employees.

We need to get WellPoint/Anthem Blue Cross and their ilk out of our health care and out of our lives. Let’s improve our own Medicare program and then provide it for everyone.

Anthem Blue Cross learns how to control costs

Cedars-Sinai and UCLA cut from Los Angeles health plan

By Chad Terhune
Los Angeles Times, September 21, 2012
Two of the most prestigious names in Southern California healthcare — Cedars-Sinai and UCLA — are getting shut out of a major insurance plan for being too expensive.
In a bold cost-cutting move, Anthem Blue Cross has eliminated doctors affiliated with the hospitals from a health plan offered to about 60,000 employees and dependents at the cash-strapped city of Los Angeles.
The city opted for Anthem’s plan because it will save $7.6 million in annual premiums next year by excluding physicians from the two institutions known for tending to the Southland’s rich and famous.
“Purchasers are sending a signal that certain prices are just unaffordable,” said David Lansky, chief executive of the Pacific Business Group on Health, which represents large companies such as Walt Disney Co. “We want great teaching and medical research institutions to survive. Whether that should happen by charging everyone in society a higher rate for routine services is more debatable.”
“Implementation of the narrow network was a difficult choice, but one made necessary by the city’s fiscal constraints,” a city spokesman said. Los Angeles is expected to be the biggest employer to offer Anthem’s Select plan.
Officials at Cedars-Sinai and UCLA criticized the rationale for the move, saying the increased costs are tied to their world-class medical research and cutting-edge treatments in areas such as cancer or organ transplants that benefit the entire community.
Thomas Priselac, chief executive of Cedars-Sinai Medical Center, said these exclusions offer a “false economy” because they don’t reduce costs in the healthcare system overall.
“It just pushes the cost onto those who continue getting care at those facilities,” Priselac said. “Secondly, it doesn’t recognize the reason why places like Cedars and UCLA are more expensive than the typical community hospital.”
For its part, UCLA said its hospitals treat a large number of patients in Medi-Cal, the government program for the poor and disabled.
“Other providers don’t have to deal with the expenses UCLA has to deal with,” said Santiago Muñoz, chief strategy officer for the UCLA Health System.
Anthem isn’t alone in pursuing this strategy. Many insurers are aggressively pitching these sharply limited networks, which offer fewer choices and lower-priced doctors and hospitals, as a cost-cutting tool at a time when U.S. health insurance premiums have climbed three times as fast as inflation and wages over the last decade.
Industry giant WellPoint Inc., which owns Anthem Blue Cross in California, offers plans that include as few as 30% of the company’s full list of providers.
http://www.latimes.com/business/la-fi-hospital-costs-20120921,0,4069159,full.story

The explosion in limited-network private insurance plans is taking choice away from more and more patients. The business tools that  private insurers use to control costs are very different from the patient-service tools of a single payer national health program. Not only do the private insurers’ tools restrict patients’ care, but they are also quite ineffective in controlling overall spending, as is demonstrated by the fact that our health care costs are about twice the average of other nations.
Under a single payer system, all legitimate costs are paid by the government and are not linked to specific health plans assigned to different individuals – a very inefficient and fragmented method of financing health care. Using the example of UCLA, there would be no tiers of private coverage and no problem with an underfunded Medicaid program. The hospital costs would be globally budgeted, just as are police and fire departments. Separate, extraordinary costs of research functions would be funded through our National Institutes of Health. Education grants can be provided through the global budgeting process since house staff members are, from a financing perspective, really just low-paid hospital employees.
We need to get WellPoint/Anthem Blue Cross and their ilk out of our health care and out of our lives. Let’s improve our own Medicare program and then provide it for everyone.

Let the buyer beware in a free-market health care system

By Philip Caper, M.D.
Bangor Daily News, Sept. 20, 2012

For the past 30 years or so, a debate about the proper place for competition vs. regulation in our health care system has raged. That debate has now become a central theme in the 2012 presidential race. Democrats favor a regulated system while Republicans favor a more market-driven system, nationally and in Maine.

Americans have the most market-driven health care system in the world. We are now seeing the results. We have the world’s highest health care costs, the highest rates of un- and underinsurance, some of the poorest health outcomes, and an almost universal belief that our health care system is badly broken.

Having a choice of health care providers is very important, since trust is critical to healing. But full-blown market-based competition doesn’t work. It has been known for years that the more doctors and hospitals there are in a region, the higher the costs — a phenomenon known as “provider-induced demand.” The Institute of Medicine recently reported that our system wastes about $750 billion a year, more than 30 percent of our spending. Much is due to an oversupply of some services and technology.

Usually, I am a great fan of competitive markets — where the seller and the buyer each have the same information about prices, features and availability. When it comes to buying a car, washing machine, TV or computer, I go to Consumer Reports or other websites where I can get current and accurate information about the price, quality, availability, reliability and other characteristics of the product I’m interested in. I can also find the opinions of lots of other customers. Then I can decide, usually at my leisure, which features of those products are important to me, how much I want to spend, and when and whether to make my purchase.

Good information is the one indispensable ingredient of competitive markets.

None of this applies to the strange world of health care. I don’t know when I am going to have an injury or illness, what it will be, or what treatment will be recommended. There is vigorous disagreement among even the best-trained doctors about the most effective course of treatment for many conditions. Tests and procedures that have been standard for years can turn out to be more trouble than they are worth. Mammograms, prostate cancer tests and excessive imaging procedures for many patients are the latest examples.

The pricing of health care services is so complicated and irrational that it is impossible to determine in advance what the costs of treatment will be.

What about quality? Although there are efforts in Maine and elsewhere to measure and publish the quality of individual doctors and hospitals, they are very much in their infancy. During a recent personal encounter with the health care system, I found them to be of little use.

As far as shopping for health insurance (as opposed to health care), a recently issued report from Maine’s Consumers for Affordable Healthcare documents the early results of attempts by the Maine Legislature to increase “competition” in the health insurance market. Those results are just what I (and many other experts) predicted. If you’re young and healthy, your costs may go down a little. If you’re older and more likely to be ill, your costs will go up a lot. Instead of encouraging larger pools where risk can be broadly spread, the new pro-competition law goes in the opposite direction by enabling insurers to charge the most vulnerable even more.

Despite their claims to the contrary, insurance companies cannot effectively control health care costs. Price competition among them is really a race to the bottom resulting in skimpier policies with more policyholder costs that are not worth much when the time comes to use them. That’s why we’re seeing more and more bankruptcies due to medical costs filed by people who have health insurance.

Most of this is intuitive for many people. Nevertheless, the myth of the sanctity of free markets in health care keeps on chugging along, despite overwhelming evidence from around the world that they don’t work. That’s why I advocate for a health care system more like Medicare than a free market — sensibly regulated.

The next time somebody tells you we need more competition in health care, just remember that what you’re hearing is the sound of smoke being blown in order to create a smokescreen. What the free marketeers (mostly corporate health care providers who are benefiting from our current system) are really saying is, “Give us your money, and leave us alone.”

When it comes to competition and health care, let the buyer beware.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com.

http://bangordailynews.com/2012/09/20/health/let-the-buyer-beware-in-a-free-market-health-care-system/print/

Six million will face penalties under the Affordable Care Act

Payments of Penalties for Being Uninsured Under the Affordable Care Act

Congressional Budget Office
September 19, 2012

Beginning in 2014, the Affordable Care Act (comprising Public Law 111-148 and the health care provisions of P.L. 111-152) requires most legal residents of the United States to either obtain health insurance or pay a penalty tax. That penalty will be the greater of: a flat dollar amount per person that rises to $695 in 2016 and is indexed by inflation thereafter (the penalty for children will be half that amount and an overall cap will apply to family payments); or a percentage of the household’s income that rises to 2.5 percent for 2016 and subsequent years (also subject to a cap).

The Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) have estimated that about 30 million nonelderly residents will be uninsured in 2016, but the majority of them will not be subject to the penalty tax. Unauthorized immigrants, for example, who are prohibited from receiving almost all Medicaid benefits and all subsidies through the insurance exchanges, are exempted from the mandate to obtain health insurance. Others will be subject to the mandate but exempted from the penalty tax—for example, because they will have income low enough that they are not required to file an income tax return, because they are members of Indian tribes, or because the premium they would have to pay would exceed a specified share of their income (initially 8 percent in 2014 and indexed over time). CBO and JCT estimate that between 18 million and 19 million uninsured people in 2016 will qualify for one or more of those exemptions. Of the remaining 11 million to 12 million uninsured people, some individuals will be granted exemptions from the penalty because of hardship, and others will be exempted from the requirement on the basis of their religious beliefs.

After accounting for those who will not be subject to the penalty tax, CBO and JCT now estimate that about 6 million people will pay a penalty because they are uninsured in 2016 (a figure that includes uninsured dependents who have the penalty paid on their behalf) and that total collections will be about $7 billion in 2016 and average about $8 billion per year over the 2017–2022 period. Those estimates differ from projections that CBO and JCT made in April 2010: About two million more uninsured people are now projected to pay the penalty each year, and collections are now expected to be about $3 billion more per year.

Most of the increase—about 85 percent—in the number of people who are expected to pay the penalty tax stems from changes in CBO and JCT’s baseline projections since April 2010, including the effects of legislation enacted since that time, changes in the economic outlook (primarily a higher unemployment rate and lower wages and salaries), and other technical updates. A small share—about 15 percent—of the increase in the number of uninsured people expected to pay the penalty results from the recent Supreme Court decision. As a result of that decision, CBO and JCT now anticipate that some states will not expand their Medicaid programs at all or will not expand coverage to the full extent authorized by the ACA. Such state decisions are projected to increase the number of uninsured, a small percentage of whom will be subject to the penalty tax.

Among the uninsured individuals subject to the penalty tax, many are expected to voluntarily report on their tax returns that they are uninsured and pay the amount owed. However, other individuals will try to avoid payments. Therefore, the estimates presented here account for likely compliance rates, as well as the ability of the Internal Revenue Service (IRS) to administer and collect the penalty.

CBO and JCT have also updated their estimates of the distribution of those penalty tax payments by income category. Table 1 (in PDF available at link) shows how much of those payments are projected to be made by or on behalf of people who are uninsured in 2016 (which the IRS will collect in 2017) in each of several income categories, measured as percentages of the federal poverty level (FPL). In general, households with lower income will be subject to the flat dollar penalty (with adjustments to account for the lower penalty for children and an overall cap on family payments), and households with higher income will owe a percentage of their income. In 2016, households with income that exceeds 400 percent of the FPL are estimated to constitute about one-third of people paying penalties and to account for about two-thirds of the receipts from those penalties.

http://www.cbo.gov/publication/43628

Comment:

By Don McCanne, MD

When it was decided to use the purchase of private plans as the model for insuring everyone, it was clear that the law must include a requirement to purchase plans and that the threat of assessing a penalty would have to be included to ensure compliance, otherwise adverse selection would have driven insurance premiums up even higher than their current intolerable levels. It was also clear that this still wouldn’t ensure universality because of various exceptions and non-compliance.

We now have a reasonably reliable estimate from the Congressional Budget Office that tells us that 30 million people will remain uninsured and that 6 million of them will be assessed penalties. That is a terrible outcome when considering that a single payer system would have covered everyone automatically, obviating the need for penalties.

Some will note that the penalty is not as onerous as it might have been since two-thirds of the total amount will be paid by households with incomes over 400 percent of the federal poverty level. The fact that more lower income households will be exempt from the penalty is hardly a reason to celebrate when considering that the price they do pay is remaining uninsured.