PNHP

The ills of money-driven medicine

The ills of money-driven medicine

By Philip Caper, M.D.
Bangor Daily News (Maine), May 17, 2012

A couple of weeks ago, nine medical specialty societies released a list of 45 medical tests and procedures they believed are significantly overused. On the heels of this announcement was a conference on “Avoiding Avoidable Care” attended by about 150 experts, mostly physicians. I attended.

We spent two days discussing the reasons for and ethics of unnecessary medical care in the U.S. Instead of blaming others (such as patients or malpractice lawyers), the doctors at this conference mostly agreed that “If you’re looking for an explanation for medical care overuse — too many tests, procedures and prescriptions — follow the money.”

The amount of overuse was estimated to be around 30 percent of all medical care. We spend $2.7 trillion annually on medical care in the U.S. Thirty percent of a big number is still a big number, about $800 billion in this case. In our industrialized health care system, moving “product” is important, whether or not it is really necessary.

The World Health Organization reported earlier this month that the U.S. ranks poorly in our rate of premature births. Our rate of prematurity has risen around 30 percent since 1981. We are now on a par with Turkey, Kenya, Thailand and Honduras at about 12 percent. Canada, Australia and Europe all fare significantly better with rates around 7 percent.

The high U.S. rate is attributed to a variety of factors. Lack of prenatal care tied to poor health insurance coverage is prominent among them. Many of these premature births could be prevented, and have been in many other countries, through better primary care and inexpensive public health measures. Many in Congress are now trying to eliminate such programs — to save money.

The BDN recently reported that 750 people showed up last month in Machias for free dental care offered by volunteers. The lack of dental care in rural Washington County was attributed largely to economic barriers made worse by poor economic times, such as lack of dental insurance, and to diets filled with cheap “soda, sweets and junk food.”

But don’t worry, your health care dollars are at work in other ways. Documents released earlier this month by the Minnesota attorney general detailed the increasingly desperate tactics employed by hospitals as unpaid debts mount. They are attempting to collect money owed by patients seeking emergency care, sometimes by threatening denial of services. Accretive Health, the company employed by the hospitals to collect the bills, reported a $29.2 million profit last year. Accretive Health saw its stock decline 19 percent after the papers were released.

The real tragedy in these stories is that the dysfunction in each is mostly avoidable. They are all the result of applying the principles of business and the techniques of industrialization to health care, where they don’t belong.

During the past several decades, clinical decision-making, from lab tests to pharmaceutical prescribing to procedures (including some highly invasive ones), have become subject to “market forces.” Most Maine doctors are now employed by large corporations that hold them to “productivity (profit) targets,” achieved mainly by ordering tests and procedures, in order to meet “business objectives.”

The result has been an explosion of health care services and costs for those who can pay. We as a nation now spend twice as much as other countries that provide health care for all their people, and with better results, at about half the cost.

Ballooning health care costs are crowding out public health and prevention measures, education, infrastructure and public safety. They have contributed in a major way to job-lock, stagnation of wages and declining health insurance protection (think MaineCare) for all but the most well-off.

While the federal health reform law was a remarkable political accomplishment and makes some important but limited progress, it will fall far short of getting the job done.

Real reform has to occur in three phases. First, replace our employment-based, for-profit health insurance system with a single nonprofit, publicly financed system — everyone in, nobody out. Second, remove economic incentives from clinical decision-making. Third, establish firm and effective budgetary limits on all aspects of health care that apply fairly to everybody. Finally, return the culture of health care to one of maintaining health and healing illness, and away from money-driven medicine.

Given the gridlock in Congress, I don’t expect to see such changes coming from Washington. But we in Maine can do it ourselves. All it takes is the will.

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/2012/05/17/health/the-ills-of-money-driven-medicine/

GAO on the Small Employer Health Insurance Tax Credit

Small Employer Health Tax Credit: Factors Contributing to Low Use and Complexity

GAO (Government Accountability Office)
May 14, 2012
Fewer small employers claimed the Small Employer Health Insurance Tax Credit in tax year 2010 than were estimated to be eligible. While 170,300 small employers claimed it, estimates of the eligible pool by government agencies and small business advocacy groups ranged from 1.4 million to 4 million. The cost of credits claimed was $468 million. Most claims were limited to partial rather than full percentage credits (35 percent for small businesses) because of the average wage or full-time equivalent (FTE) requirements. 28,100 employers claimed the full credit percentage. In addition, 30 percent of claims had the base premium limited by the state premium average.
One factor limiting the credit’s use is that most very small employers, 83 percent by one estimate, do not offer health insurance. According to employer representatives, tax preparers, and insurance brokers that GAO met with, the credit was not large enough to incentivize employers to begin offering insurance. Complex rules on FTEs and average wages also limited use. In addition, tax preparer groups GAO met with generally said the time needed to calculate the credit deterred claims. Options to address these factors, such as expanded eligibility requirements, have trade-offs, including less precise targeting of employers and higher costs to the Federal government.
http://www.gao.gov/assets/600/590832.pdf

One of the benefits of the Affordable Care Act is the tax credits offered to small businesses to help them obtain health insurance coverage for their employees. This evaluation by the GAO shows that, in 2010, 83 percent of small businesses eligible for the full credit did not even offer health insurance.
According to the report, “small employers do not likely view the credit as a big enough incentive to begin offering health insurance and to make a credit claim, according to employer representatives, tax preparers, and insurance brokers we met with.”
Though the complexity of the rules and the modest amount of the credits are cited as causes for the low participation rates, the fundamental flaw is that this program was designed to comply with our fragmented, dysfunctional system of financing health care – a model that will always fall short of reform goals.
Instead of trying to patch our fragmented program of private plans and pubic programs, we need to replace it with a single payer national health program – an improved Medicare for all.

Private insurers blame health care prices

Health Care Cost and Utilization Report: 2010

Health Care Cost Institute
May 2012

The Health Care Cost Institute (HCCI) was created in September 2011 to provide comprehensive data on health care costs and promote independent, nonpartisan research and analysis on the causes of the rise in U.S. health spending.

HCCI’s research activities are based on de-identified data voluntarily provided by Aetna, Humana, Kaiser Permanente, and UnitedHealthcare, four of the nation’s largest insurers.

The 2010 HCCI Health Care Cost and Utilization Report is the first report of its kind to track changes in expenditures and utilization of health care services by those younger than 65 covered by employer sponsored, private health insurance (ESI).

$4,255 –
Average annual per capita health care spending for beneficiaries younger than 65 and covered by employer-sponsored group insurance in 2010.

1.6% & 3.3% –
The consumer price index (CPI-U), a measure of price inflation, and the growth rate of average per capita spending on group ESI beneficiaries younger than 65 (2009-2010). Per capita spending outpaced overall price inflation in 2010.

2.6% & 7.1% –
Growth rate of estimated per capita health care spending by insurers and beneficiaries, respectively, between 2009 and 2010.

Summary of the Executive Summary

We find continued growth in per capita and estimated aggregate health care spending in this population, although that growth is less than 4 percent. This is consistent with the Centers for Medicare & Medicaid Services’ findings regarding national health expenditures. Patients’ out-of-pocket share of prices paid went up, although the cost-sharing rate on a per capita basis (including beneficiaries who did not use services) did not change much. Prices increased across all categories of service, with outpatient services experiencing the fastest growth. Unlike other recent reports on health care spending, we find that the increased spending is mostly due to unit price increases rather than changes in the quantity or intensity of services.

http://www.healthcostinstitute.org/files/HCCI_HCCUR2010.pdf

And…

S&P Healthcare Economic Indices

March 2012 Update

7.84% – S&P Healthcare Economic Commercial Index
2.41% – S&P Healthcare Economic Medicare Index

http://www.standardandpoors.com/indices/sp-healthcare-economic-indices/en/us/?indexId=sp-healthcare-economic-indices

Comment:

By Don McCanne, MD

Until now, much of our information on health care costs has been obtained from government sources – especially Medicare and Census data. The Health Care Cost Institute is an effort on the part of the private insurance industry to share their data in an effort to improve research and analysis on the causes of the rise in U.S. health care spending.

Cooperating in this effort are Aetna, Humana, Kaiser Permanente, and UnitedHealthcare. Conspicuously absent are Cigna, and especially WellPoint.

Many reasons are given for our very high health care costs, but this study adds to the evidence that price increases are the most important factor (except, of course, for the administrative waste that is usually ignored in studies like this). The excess increase in prices is a particularly relevant observation since this study was limited to individuals under 65 with employer-sponsored, private health insurance.

This report establishes beyond any doubt that the nation’s largest private insurers have been ineffective in controlling health care prices (not to mention generating more administrative waste). In spite of the contracts that the private insurers have with health care providers, health care price increases continue to greatly exceed the rate of inflation. Also, the most recent S&P Healthcare Indices confirm, once again, that our government Medicare program has been far more effective in controlling per capita health care costs than have the private commercial insurers.

All other nations control health care prices. Medicare controls health care prices. Only our private insurers have been incompetent in slowing price escalation. This is yet more evidence that private insurer intermediaries functioning relatively autonomously in the health care marketplace are ineffective in bringing us better pricing of health care products and services. This is a job for government, not the marketplace.

We are often accused of being unfairly critical of the private insurers since it is not their fault that health care prices are so high. Do we really care whether or not it is their fault? Prices are high, and they haven’t helped. They are a profoundly expensive administrative industry. We should continue to waste our vast sums on their ineffective model of price containment?

Look at the growth rates of per capita health spending that they report in this study of their own industry. The spending by the insurers increased at a rate of 2.6%, a feat that they were able to accomplish partly by increasing beneficiaries costs by 7.1%! Is that the kind of assistance that we need from this industry?

It’s time to throw them out of the Temple (a biblical proxy for all religious and secular moralists).

The smug 800-pound gorilla

By Toni Vafi
St. Louis Post-Dispatch, May 20, 2012

Regarding “Single-payer is the key” (May 16): From the inequities and insufficiencies in care to medical bankruptcies, Dr. Ed Weisbart reminds us of the millions of Americans suffering and dying for lack of health care. Those of us using this system are reminded of our own precarious position each time we seek medical care. It seems strange that our lawmakers and politicians fail to see the difficulties described in this Dr. Weisbart’s commentary and experienced by all of us.

The smug 800-pound gorilla — the health insurance industry — sitting in the center of the room gobbles up about 30 cents of each health care dollar. While it provides nothing in actual health care, it spends a lot time searching patient histories for policy loopholes that enable it to deny care. This is known as “obligation to stockholders,” my friend. Politicians smoothly refer to our health system as “the best in the world” but blandly ignore the gleeful gorilla victoriously surveying the scenes of destruction.

Isn’t it time for policymakers to grasp the cruelty of the present health care reimbursement system and transform it so that needed health care can come before obligation to stockholders? Isn’t it time for politicians to realize that the electorate no longer believes their commentary on our health care system? Isn’t it time for us to pay more attention to the Dr. Weisbarts of the world? I believe it is.

Toni Vafi resides in Webster Groves, Mo.

http://www.stltoday.com/news/opinion/mailbag/letters-to-the-editor-may/article_175005f0-1d18-5a5c-aba8-36034ebd5c60.html#ixzz1vW8D6Ftt

Patients go bankrupt as medical costs soar

By Colorado Public News and Erika Gonzalez
KUNC Colorado Public News (NPR), May 21, 2012

In 2008, Kimberly Fague was diagnosed with organ failure. Plagued by nausea, she lost a third of her body weight. She suffered from confusion and constant fatigue. Her liver and surrounding organs swelled to the point that she developed a hernia.

Her illness also took a financial toll. Too sick to work, Fague was forced to retire from her position at the Federal Bureau of Prisons after 18 years with the agency. And despite having government health insurance, she was forced to file for bankruptcy in 2010, after racking up $15,000 in medical debt.

“The bulk of it was for hospital stays, but there were also out-of-pocket expenses for procedures, outpatient surgeries, medications. It was very difficult,” said the Denver resident.

Two years later, Fague is still struggling to pay off medical bills. Disabled and still a few months away from qualifying for Medicare, Fague says many of her debts are in collections.

“The whole situation is not easy,” Fague said. “The phone calls start at 8 a.m. and they never stop.”

Some policy experts say Fague’s story is far from unique. Harvard University researchers and medical doctors David Himmelstein and Steffie Woolhandler found that medical problems contributed to more than 60 percent of all bankruptcies in 2007.

Another analysis, performed by Northwestern University’s Kellogg School of Management, puts the figure much lower, at 17 percent. The U.S. Department of Justice also examined 5,203 bankruptcy cases filed between 2000 and 2002 and found that of those reporting medical debts, those debts accounted for 13 percent of total unsecured debt.

While the contrasting data shows that it’s difficult to determine exactly how many Americans fall into bankruptcy because of mounting medical expenses, it’s clear that consumers are drowning in medical debt.

A 2007 survey by the Commonwealth Fund, a private foundation that supports independent research on healthcare issues, found that 41 percent of working-age Americans – 72 million people – have medical bill problems or are paying off medical debt. That figure is up from 34 percent in 2005. If the number of elderly adults who are dealing with the same issues are included, the total rises to 79 million.

“We do hear from a number of consumers here who have struggled with that issue,” said Serena Woods, director of strategic engagement for the Colorado Consumer Health Initiative.

CCHI does not track statistics on how many bankruptcies in Colorado stem from medical debt. State agencies also don’t have any figures on how large the problem might be on a statewide level.

But the feedback that CCHI received from consumers facing big medical bills led the organization to successfully push for a law this year limiting hospital charges to low-income uninsured patients and requires hospitals to offer a payment plan to eligible patients.

“Uninsured patients don’t have negotiating power like insured people do, so their starting price is often higher,” said Woods.

The Commonwealth Fund reports that problems with medical bills are most prevalent among uninsured adults. Of adults ages 19 to 64 who were uninsured, 60 percent said they had medical problems or accrued medical debt in 2010. That compares to 51 percent in 2005.

While some expect health care reform to improve the situation, Harvard’s Woolhandler says that the coverage mandated under the Affordable Care Act is too skimpy to provide adequate protection in the event of a major illness.

“Many people will go from being completely uninsured to being woefully underinsured and being underinsured still leaves you vulnerable to bankruptcy,” said Woolhandler.

She notes that more than three-quarters of the filers in her study were insured at the start of the bankrupting illness and most were solidly middle class – homeowners with college degrees. Still, out-of-pocket expenses for high co-payments and deductibles put them over the edge.

Fague knows that scenario too well.  She faced co-payments of as much as $300 for some medications, and spent $600 alone on gas driving to medical appointments. While the caps proposed in the bill wouldn’t apply to Fague because she has insurance, she testified in favor of the measure, hoping to gain better transparency in the billing process.

“The information about (payment programs) is not there, whether for the destitute or someone who has insurance,” she said.

Woolhandler contends that a single-payer system with full coverage is the best weapon to prevent more medical-related bankruptcies. A single-payer system is one in which a single entity – usually a government or quasi-governmental agency – funds the delivery of health care.

“Only single-payer, nonprofit national health insurance can give families the comprehensive coverage they need to be protected from medical bankruptcy,” said Woolhandler, co-founder of Physicians for a National Health Program, an organization comprised of 18,000 health care providers who support single-payer national health insurance.

Woolhandler points to Canada, where she says medical bankruptcies are rare because the majority of costs associated with treating medical illnesses are covered. Medicare recipients also struggle less with medical debt than their younger counterparts. Just 19 percent of adults over 65 reported any medical bill problems or debt, according to the Commonwealth Fund.

The Medical Bankruptcy Fairness Act of 2009, which stalled out in Congress a few years ago, presented another solution. The act would have provided special protections to debtors whose filings were caused by medical expenses.

For her part, Fague says she just wishes that the hospitals where she received treatment had been more flexible and willing to work with her, based on the costs involved in treating her illness. Despite the bankruptcy filing and tapping retirement savings to pay off medical bills, she still considers herself lucky.

“I am in a better situation than most out there because my insurance covers quite a bit,” Fague said. “Somebody without this good of a plan could be in debt easily three times the amount I am.”

http://www.kunc.org/post/patients-go-bankrupt-medical-costs-soar

WellPoint critic, 88, leads docs' crusade for Medicare for all

By Dan Carpenter
The Indianapolis Star, May 18, 2012

He was personal physician to the Rev. Martin Luther King Jr. and future President Barack Obama when they were in Chicago.

He fought to end racial segregation in that city’s hospitals in the 1950s and 1960s.

He ministered to civil rights marchers in the dangerous Deep South as head of an interracial doctors’ group, the Medical Committee for Human Rights, whose efforts paved the way to Medicare.

Quentin Young, M.D., has devoted his retirement, after 61 years of practice, to the fight for national health insurance — Medicare for all. On Wednesday, he stood in brilliant sunshine on Monument Circle facing the fortress of his greatest adversary.

“We’re for single payer. It just makes sense, economically, medically. And we’re optimistic,” the 88-year-old activist said as he waved toward the WellPoint headquarters. “But we’re really small compared to our opponent.”

That depends. The protest staged at WellPoint’s annual shareholders’ meeting by Hoosiers for a Commonsense Health Plan and the Chicago-based Physicians for a National Health Program was aimed at huge money, reaped in profits and spent on lobbying and campaigns against health care reform by the nation’s second-largest private insurer.

Yet the single-payer side can point to polls showing wide support by Americans in general and physicians in particular. Young and his fellow leaders, Drs. Robert Stone of Bloomington and Garrett Adams of Louisville, wore their examining coats to illustrate the point that doctors feel walled off from patients by insurance companies and are having Peter Finch “Network” moments.

Young, who is national coordinator of Physicians for a National Health Program, can remember when the profession was a lot more conservative than that. From his long perspective, popular sentiment will overcome concentrated power just as it did with race and gender equality.

Whether or not the Affordable Care Act passes its Supreme Court test, he and his compatriots said, America’s for-profit system, costliest in the world and less effective than dozens of others, is unsustainable. It leaves 50 million Americans uninsured, and the advocates say 50,000 of those die every year for lack of access.

“The corporate model seeks to maximize return on investment,” Young said. “This made America great, in many industries. You can’t apply it to health care. You make money on health care by getting rid of sick people.”

They won’t get rid of Quentin Young any time soon if his personal prognosis holds up. His parents each lived to be 98, and his quick smile and full head of gray hair bespeak a man who could pester WellPoint and Congress another decade and then some.

“I quit practice four years ago after 61 years and asked myself what was I going to do with the rest of my life,” he said. “I decided to work for national health care. I don’t know how useful I am, but I feel good about it.”

Carpenter is Star op-ed columnist.

Correction: Dr. Young’s partner in his Hyde Park practice, Dr. David Scheiner, was Obama’s personal physician.

http://www.indystar.com/article/20120520/OPINION05/205200301/

WellPoint critic, 88, leads docs’ crusade for Medicare for all

By Dan Carpenter
The Indianapolis Star, May 18, 2012

He was personal physician to the Rev. Martin Luther King Jr. and future President Barack Obama when they were in Chicago.

He fought to end racial segregation in that city’s hospitals in the 1950s and 1960s.

He ministered to civil rights marchers in the dangerous Deep South as head of an interracial doctors’ group, the Medical Committee for Human Rights, whose efforts paved the way to Medicare.

Quentin Young, M.D., has devoted his retirement, after 61 years of practice, to the fight for national health insurance — Medicare for all. On Wednesday, he stood in brilliant sunshine on Monument Circle facing the fortress of his greatest adversary.

“We’re for single payer. It just makes sense, economically, medically. And we’re optimistic,” the 88-year-old activist said as he waved toward the WellPoint headquarters. “But we’re really small compared to our opponent.”

That depends. The protest staged at WellPoint’s annual shareholders’ meeting by Hoosiers for a Commonsense Health Plan and the Chicago-based Physicians for a National Health Program was aimed at huge money, reaped in profits and spent on lobbying and campaigns against health care reform by the nation’s second-largest private insurer.

Yet the single-payer side can point to polls showing wide support by Americans in general and physicians in particular. Young and his fellow leaders, Drs. Robert Stone of Bloomington and Garrett Adams of Louisville, wore their examining coats to illustrate the point that doctors feel walled off from patients by insurance companies and are having Peter Finch “Network” moments.

Young, who is national coordinator of Physicians for a National Health Program, can remember when the profession was a lot more conservative than that. From his long perspective, popular sentiment will overcome concentrated power just as it did with race and gender equality.

Whether or not the Affordable Care Act passes its Supreme Court test, he and his compatriots said, America’s for-profit system, costliest in the world and less effective than dozens of others, is unsustainable. It leaves 50 million Americans uninsured, and the advocates say 50,000 of those die every year for lack of access.

“The corporate model seeks to maximize return on investment,” Young said. “This made America great, in many industries. You can’t apply it to health care. You make money on health care by getting rid of sick people.”

They won’t get rid of Quentin Young any time soon if his personal prognosis holds up. His parents each lived to be 98, and his quick smile and full head of gray hair bespeak a man who could pester WellPoint and Congress another decade and then some.

“I quit practice four years ago after 61 years and asked myself what was I going to do with the rest of my life,” he said. “I decided to work for national health care. I don’t know how useful I am, but I feel good about it.”

Carpenter is Star op-ed columnist.

Correction: Dr. Young’s partner in his Hyde Park practice, Dr. David Scheiner, was Obama’s personal physician.

http://www.indystar.com/article/20120520/OPINION05/205200301/

Private insurers blame health care prices

Health Care Cost and Utilization Report: 2010

Health Care Cost Institute
May 2012
The Health Care Cost Institute (HCCI) was created in September 2011 to provide comprehensive data on health care costs and promote independent, nonpartisan research and analysis on the causes of the rise in U.S. health spending.
HCCI’s research activities are based on de-identified data voluntarily provided by Aetna, Humana, Kaiser Permanente, and UnitedHealthcare, four of the nation’s largest insurers.
The 2010 HCCI Health Care Cost and Utilization Report is the first report of its kind to track changes in expenditures and utilization of health care services by those younger than 65 covered by employer sponsored, private health insurance (ESI).
$4,255 –
Average annual per capita health care spending for beneficiaries younger than 65 and covered by employer-sponsored group insurance in 2010.
1.6% & 3.3% –
The consumer price index (CPI-U), a measure of price inflation, and the growth rate of average per capita spending on group ESI beneficiaries younger than 65 (2009-2010). Per capita spending outpaced overall price inflation in 2010.
2.6% & 7.1% –
Growth rate of estimated per capita health care spending by insurers and beneficiaries, respectively, between 2009 and 2010.
Summary of the Executive Summary
We find continued growth in per capita and estimated aggregate health care spending in this population, although that growth is less than 4 percent. This is consistent with the Centers for Medicare & Medicaid Services’ findings regarding national health expenditures. Patients’ out-of-pocket share of prices paid went up, although the cost-sharing rate on a per capita basis (including beneficiaries who did not use services) did not change much. Prices increased across all categories of service, with outpatient services experiencing the fastest growth. Unlike other recent reports on health care spending, we find that the increased spending is mostly due to unit price increases rather than changes in the quantity or intensity of services.
http://www.healthcostinstitute.org/files/HCCI_HCCUR2010.pdf

And…

S&P Healthcare Economic Indices

March 2012 Update
7.84% – S&P Healthcare Economic Commercial Index
2.41% – S&P Healthcare Economic Medicare Index
http://www.standardandpoors.com/indices/sp-healthcare-economic-indices/en/us/?indexId=sp-healthcare-economic-indices

Until now, much of our information on health care costs has been obtained from government sources – especially Medicare and Census data. The Health Care Cost Institute is an effort on the part of the private insurance industry to share their data in an effort to improve research and analysis on the causes of the rise in U.S. health care spending.
Cooperating in this effort are Aetna, Humana, Kaiser Permanente, and UnitedHealthcare. Conspicuously absent are Cigna, and especially WellPoint.
Many reasons are given for our very high health care costs, but this study adds to the evidence that price increases are the most important factor (except, of course, for the administrative waste that is usually ignored in studies like this). The excess increase in prices is a particularly relevant observation since this study was limited to individuals under 65 with employer-sponsored, private health insurance.
This report establishes beyond any doubt that the nation’s largest private insurers have been ineffective in controlling health care prices (not to mention generating more administrative waste). In spite of the contracts that the private insurers have with health care providers, health care price increases continue to greatly exceed the rate of inflation. Also, the most recent S&P Healthcare Indices confirm, once again, that our government Medicare program has been far more effective in controlling per capita health care costs than have the private commercial insurers.
All other nations control health care prices. Medicare controls health care prices. Only our private insurers have been incompetent in slowing price escalation. This is yet more evidence that private insurer intermediaries functioning relatively autonomously in the health care marketplace are ineffective in bringing us better pricing of health care products and services. This is a job for government, not the marketplace.
We are often accused of being unfairly critical of the private insurers since it is not their fault that health care prices are so high. Do we really care whether or not it is their fault? Prices are high, and they haven’t helped. They are a profoundly expensive administrative industry. We should continue to waste our vast sums on their ineffective model of price containment?
Look at the growth rates of per capita health spending that they report in this study of their own industry. The spending by the insurers increased at a rate of 2.6%, a feat that they were able to accomplish partly by increasing beneficiaries costs by 7.1%! Is that the kind of assistance that we need from this industry?
It’s time to throw them out of the Temple (a biblical proxy for all religious and secular moralists).

Smiley and West – "The Rich and the Rest of Us"

A Poverty Manifesto: The Rich and the Rest of Us

By Tavis Smiley and Cornel West

With history as our guide, we can chart the moment Americans got addicted to credit cards and the quest for the American Dream became a shopping-mall like adventure. Spending a cold night camped out in a parking lot to be the first in line when a store opens and getting trampled by a crowd competing  for “the sale of the day” doesn’t even seem to matter. But deep down we knew we’d never attain the lifestyles we saw on television. As brainwashed, robotic consumers armed with unending credit, we sought to transform our living-large fantasies into reality. Now, our supersized ambitions have been downsized.

The “new poor” find themselves standing shoulder to shoulder at the welfare office, food pantry, or thrift store with people they used to disregard. As the politicians they elected predict a doomed “entitlement nation” and boast of shredding the poor’s safety nets, the former middle class tries to reconcile these contradictions by clinging to the belief that this is a temporary destination, that somehow “they” are still better than “those people.”

How do we get folk to understand that there is no “they,” there is no “them”? Too many American are falling through gaping holes scissored out of America’s safety net. Income inequality is real. There is an institutionalized divide between the wealthy and the poor, so that what we now have are the rich and the rest of us.

*****

The new poverty numbers are forcing middle class families to rely on services that traditionally impoverished Americans have depended on for years.

According to the U.S. Department of Agriculture’s 2012 figures, over 46 million Americans (14 percent of the population) are now living on food stamps with the average recipient receiving $150 worth per month. Actually, “food stamps” have had a makeover in America. During the late 1990s, the government phased out the facsimile printed money for a specialized swipe-as-you-go debit-card system that can be processed for purchases in grocery stores and major retailers just like any other consumer.

For most of us, 46 million people poor enough to qualify for food-stamp debit cards is a depressing thought. But for banking and investment giant JPMorgan Chase, every time a new welfare debit card is issued, profits tick up a notch. The company is the largest, first, and only contracted processor of food-stamp benefit cards in America. In 2009, two years after the recession officially began, the company posted profits of $11.7 billion on revenues of $115.6 billion – a 109 percent jump and a 14 percent increase over the previous year. Christopher Paton, manager with JPMorgan’s public-sector benefit payments division, described how the welfare card division contributed to company profits:

“Right now, volumes have gone through the roof in the past couple of years. The good news, from JPMorgan’s perspective, is the infrastructure that we built has been able to cope with that increase in volume.”

*****

We recognize that the President’s health care reform bill will make health care more available to millions of Americans in 2014, but we are also cognizant of the aggressive efforts, particularly from the Right, to overturn the bill. Regardless of partisan political machinations, no American should die because they lack health insurance or access to quality health care. Medical insurance with the single-payer option should become a reality for all Americans, and we must invest in publicly funded community health centers and hospitals. Then the poor and uninsured will have other options than emergency rooms as their only source for primary care or early death.

http://www.hayhouse.com/details.php?id=6150

Comment:  

By Don McCanne, MD

Much has been written about the social justice topics addressed in this book by Tavis Smiley and Cornel West. “The Rich and the Rest of Us” is of particular value because it is written in a style that all of us, not just policy wonks, can easily understand and resonate with. It includes “The Poverty Manifesto” which hopefully will re-prioritize our thinking, moving us forward with an action plan to achieve social justice for all.

Single payer activists who are frustrated with the lack of progress in advancing a model of health care financing that is a moral imperative, will recognize a major hurdle touched upon in their book. There is no “they,” and there is no “them.” There’s only “us,” and that includes the 1 percent. We’re going to have to do this together.

Smiley and West – “The Rich and the Rest of Us”

A Poverty Manifesto: The Rich and the Rest of Us

By Tavis Smiley and Cornel West

With history as our guide, we can chart the moment Americans got addicted to credit cards and the quest for the American Dream became a shopping-mall like adventure. Spending a cold night camped out in a parking lot to be the first in line when a store opens and getting trampled by a crowd competing  for “the sale of the day” doesn’t even seem to matter. But deep down we knew we’d never attain the lifestyles we saw on television. As brainwashed, robotic consumers armed with unending credit, we sought to transform our living-large fantasies into reality. Now, our supersized ambitions have been downsized.

The “new poor” find themselves standing shoulder to shoulder at the welfare office, food pantry, or thrift store with people they used to disregard. As the politicians they elected predict a doomed “entitlement nation” and boast of shredding the poor’s safety nets, the former middle class tries to reconcile these contradictions by clinging to the belief that this is a temporary destination, that somehow “they” are still better than “those people.”

How do we get folk to understand that there is no “they,” there is no “them”? Too many American are falling through gaping holes scissored out of America’s safety net. Income inequality is real. There is an institutionalized divide between the wealthy and the poor, so that what we now have are the rich and the rest of us.

*****

The new poverty numbers are forcing middle class families to rely on services that traditionally impoverished Americans have depended on for years.

According to the U.S. Department of Agriculture’s 2012 figures, over 46 million Americans (14 percent of the population) are now living on food stamps with the average recipient receiving $150 worth per month. Actually, “food stamps” have had a makeover in America. During the late 1990s, the government phased out the facsimile printed money for a specialized swipe-as-you-go debit-card system that can be processed for purchases in grocery stores and major retailers just like any other consumer.

For most of us, 46 million people poor enough to qualify for food-stamp debit cards is a depressing thought. But for banking and investment giant JPMorgan Chase, every time a new welfare debit card is issued, profits tick up a notch. The company is the largest, first, and only contracted processor of food-stamp benefit cards in America. In 2009, two years after the recession officially began, the company posted profits of $11.7 billion on revenues of $115.6 billion – a 109 percent jump and a 14 percent increase over the previous year. Christopher Paton, manager with JPMorgan’s public-sector benefit payments division, described how the welfare card division contributed to company profits:

“Right now, volumes have gone through the roof in the past couple of years. The good news, from JPMorgan’s perspective, is the infrastructure that we built has been able to cope with that increase in volume.”

*****

We recognize that the President’s health care reform bill will make health care more available to millions of Americans in 2014, but we are also cognizant of the aggressive efforts, particularly from the Right, to overturn the bill. Regardless of partisan political machinations, no American should die because they lack health insurance or access to quality health care. Medical insurance with the single-payer option should become a reality for all Americans, and we must invest in publicly funded community health centers and hospitals. Then the poor and uninsured will have other options than emergency rooms as their only source for primary care or early death.

http://www.hayhouse.com/details.php?id=6150

Comment:  

By Don McCanne, MD

Much has been written about the social justice topics addressed in this book by Tavis Smiley and Cornel West. “The Rich and the Rest of Us” is of particular value because it is written in a style that all of us, not just policy wonks, can easily understand and resonate with. It includes “The Poverty Manifesto” which hopefully will re-prioritize our thinking, moving us forward with an action plan to achieve social justice for all.

Single payer activists who are frustrated with the lack of progress in advancing a model of health care financing that is a moral imperative, will recognize a major hurdle touched upon in their book. There is no “they,” and there is no “them.” There’s only “us,” and that includes the 1 percent. We’re going to have to do this together.

Smiley and West – "The Rich and the Rest of Us"

A Poverty Manifesto: The Rich and the Rest of Us

By Tavis Smiley and Cornel West
With history as our guide, we can chart the moment Americans got addicted to credit cards and the quest for the American Dream became a shopping-mall like adventure. Spending a cold night camped out in a parking lot to be the first in line when a store opens and getting trampled by a crowd competing  for “the sale of the day” doesn’t even seem to matter. But deep down we knew we’d never attain the lifestyles we saw on television. As brainwashed, robotic consumers armed with unending credit, we sought to transform our living-large fantasies into reality. Now, our supersized ambitions have been downsized.
The “new poor” find themselves standing shoulder to shoulder at the welfare office, food pantry, or thrift store with people they used to disregard. As the politicians they elected predict a doomed “entitlement nation” and boast of shredding the poor’s safety nets, the former middle class tries to reconcile these contradictions by clinging to the belief that this is a temporary destination, that somehow “they” are still better than “those people.”
How do we get folk to understand that there is no “they,” there is no “them”? Too many American are falling through gaping holes scissored out of America’s safety net. Income inequality is real. There is an institutionalized divide between the wealthy and the poor, so that what we now have are the rich and the rest of us.
*****
The new poverty numbers are forcing middle class families to rely on services that traditionally impoverished Americans have depended on for years.
According to the U.S. Department of Agriculture’s 2012 figures, over 46 million Americans (14 percent of the population) are now living on food stamps with the average recipient receiving $150 worth per month. Actually, “food stamps” have had a makeover in America. During the late 1990s, the government phased out the facsimile printed money for a specialized swipe-as-you-go debit-card system that can be processed for purchases in grocery stores and major retailers just like any other consumer.
For most of us, 46 million people poor enough to qualify for food-stamp debit cards is a depressing thought. But for banking and investment giant JPMorgan Chase, every time a new welfare debit card is issued, profits tick up a notch. The company is the largest, first, and only contracted processor of food-stamp benefit cards in America. In 2009, two years after the recession officially began, the company posted profits of $11.7 billion on revenues of $115.6 billion – a 109 percent jump and a 14 percent increase over the previous year. Christopher Paton, manager with JPMorgan’s public-sector benefit payments division, described how the welfare card division contributed to company profits:
“Right now, volumes have gone through the roof in the past couple of years. The good news, from JPMorgan’s perspective, is the infrastructure that we built has been able to cope with that increase in volume.”
*****
We recognize that the President’s health care reform bill will make health care more available to millions of Americans in 2014, but we are also cognizant of the aggressive efforts, particularly from the Right, to overturn the bill. Regardless of partisan political machinations, no American should die because they lack health insurance or access to quality health care. Medical insurance with the single-payer option should become a reality for all Americans, and we must invest in publicly funded community health centers and hospitals. Then the poor and uninsured will have other options than emergency rooms as their only source for primary care or early death.
http://www.hayhouse.com/details.php?id=6150

Much has been written about the social justice topics addressed in this book by Tavis Smiley and Cornel West. “The Rich and the Rest of Us” is of particular value because it is written in a style that all of us, not just policy wonks, can easily understand and resonate with. It includes “The Poverty Manifesto” which hopefully will re-prioritize our thinking, moving us forward with an action plan to achieve social justice for all.
Single payer activists who are frustrated with the lack of progress in advancing a model of health care financing that is a moral imperative, will recognize a major hurdle touched upon in their book. There is no “they,” and there is no “them.” There’s only “us,” and that includes the 1 percent. We’re going to have to do this together.

Private equity investors moving into dentistry

Dental Abuse Seen Driven by Private Equity Investments

By Sydney P. Freedberg
Bloomberg, May 16, 2012

Isaac Gagnon stepped off the school bus sobbing last October and opened his mouth to show his mother where it hurt. She saw steel crowns on two of the 4-year-old’s back teeth.

“The dentist man got me,” Gagnon remembers her son saying.

Isaac’s dentist was dispatched to his school by ReachOut Healthcare America, a dental management services company that’s in the portfolio of Morgan Stanley Private Equity, operates in 22 states and has dealt with 1.5 million patients. Management companies are at the center of a U.S. Senate inquiry, and audits, investigations and civil actions in six states over allegations of unnecessary procedures, low-quality treatment and the unlicensed practice of dentistry.

ReachOut is one of at least 25 dental management-services companies bought or backed by private-equity firms in the last decade. Dentists contract with the companies for marketing, scheduling, staff recruitment, supplies and other services. The companies account for about 12,000, or 8 percent, of U.S. dentists, according to Thomas A. Climo, a Las Vegas dental consultant.

Some of them have been riding a boom in Medicaid outlays on dentistry, which rose 63 percent to $7.4 billion between 2007 and 2010, outstripping the 4.9 percent growth in other dental spending. ReachOut and several of its private equity-backed rivals seek patients like Isaac Gagnon, who are covered by Medicaid, the federal-state insurance program for the poor and disabled.

On May 2, All Smiles Dental Center Inc., a management company owned by Chicago-based Valor Equity Partners, filed for bankruptcy protection. Its hand was forced in part by a Texas Medicaid action cutting off payment to some of its clinics because of allegedly “excessive” and “inappropriate” orthodontic care, according to an All Smiles executive’s affidavit included in the filing. All Smiles was part of a state audit in which 90 percent of Medicaid claims for orthodontic braces were found to be invalid because they weren’t medically needed, according to Christine Ellis, one of the auditors.

The All Smiles collapse followed another bankruptcy filing in February by Nashville-based Church Street Health Management LLC, which cited the costs of defending itself against lawsuits and investigations. Church Street is owned by Arcapita Inc., Carlyle Group LP (CG) and other private equity firms and affiliated with the Small Smiles network of dental clinics.

Dentistry is a fragmented, “cottage” industry ripe for management services, said Robert Fontana, chief executive officer of Aspen Dental Management, owned by Leonard Green & Partners, a Los Angeles private equity concern.

Management companies have “moved from being vendors of services,” such as patient billing, “into increasingly complex arrangements under which some — not all — have embedded themselves deeply into every aspect of the dental practice,” said Ken Burgess, an attorney for the North Carolina dental board.

http://www.bloomberg.com/news/2012-05-17/dental-abuse-seen-driven-by-private-equity-investments.html

Comment: 

By Don McCanne, MD

Although Isaac reported to his mother, “The dentist man got me,” we should be concerned not only about the fate of Isaac and patients like him, but also about the fate of professionalism in dentistry and the fate of our tax dollars in this government-financed Medicaid program, now that private equity firms are moving “into increasingly complex arrangements under which some have embedded themselves deeply into every aspect of the dental practice.”

This fairly long Bloomberg article (link above) provides many more details that should make us question the wisdom of passively allowing private equity firms to take control, when their mission is profit, and low-income children with dental problems are merely their means to profit.

Dentistry is not alone here. We are seeing a massive transfer of Medicaid patients, including dual-eligibles, from traditional fee-for-service physicians to managed care organizations. States are shifting from an emphasis on trying to obtain decent care for these low-income patients, to an emphasis on trying to control the Medicaid component of the state budgets.

The managed care organizations continue to promise higher quality at lower costs, though the historical record is certainly not particularly supportive of these alleged outcomes. Patient advocates have expressed concern about the disruption in care and questionable access to future care, especially for specialized services. State authorities seem to be ignoring access and quality issues and focusing on spending, as they move forward with a let’s-try-this-and-we’ll-see-if-it-works attitude, and if it doesn’t, at least we’ve saved money.

A well designed single payer system would eliminate Medicaid – an underfunded program tainted with a welfare mentality – and would include everyone in a comprehensive program which would cover all appropriate dental services.

Under such a program Isaac would not have had to suffer torture and indignity “while several adults held him on the dental table,” as he received an “excessive” number of x-rays and “unnecessary” root canals. He would have been treated like any other child would be in an uptown dental practice, even if in a downtown clinic.

We can do this.