PNHP

Destroying England's National Health Service (as we know it)

Destroying England's National Health Service (as we know it)

How the Health and Social Care Bill 2011 would end entitlement to comprehensive health care in England

By Allyson M Pollock, David Price, Peter Roderick, Tim Treuherz, David McCoy, Martin McKee, Lucy Reynolds
The Lancet, January 26, 2012

(Excerpts)

The National Health Service (NHS) in England has been a leading international model of tax-financed, universal health care. Legal analysis shows that the Health and Social Care Bill currently making its way through the UK Parliament would abolish that model and pave the way for the introduction of a US-style health system by eroding entitlement to equality of health-care provision. The Bill severs the duty of the Secretary of State for Health to secure comprehensive health care throughout England and introduces competitive markets and structures consistent with greater inequality of provision, mixed funding, and widespread provision by private health corporations. The Bill has had a turbulent passage. Unusually, the legislative process was suspended for more than 2 months in 2011 because of the weight of public concern. It was recommitted to Parliament largely unaltered after a “listening exercise”. These and more recent amendments to the Bill do not sufficiently address major concerns that continue to be raised by Peers and a Constitution Committee of the House of Lords, where the Bill now faces one of its last parliamentary hurdles before becoming law.

Fundamental to the Bill are provisions that transform a mandatory system into a discretionary one with structures that permit the introduction of charging for services that are currently free under the NHS, as well as a system in which much delivery would be privatised. Under the current statutory framework the Government has a legal duty to secure comprehensive health care, whereas, under the new system, substantial discretionary powers will instead be extended to commissioners and providers of care. These measures will increase inequalities of provision.

The whole system has been publicly administered and funded on the basis of contiguous geographical areas by bodies, now called primary care trusts (PCTs), that act on behalf of the Secretary of State and have responsibility for the health-care needs of everyone in their area.

The Bill creates two new bodies with responsibility for managing care: an NHS Commissioning Board and Clinical Commissioning Groups (CCGs), the number of which remain unclear. PCTs will be abolished and not replaced.

Clause 12 of the Health and Social Care Bill repeals the Secretary of State’s “duty to provide” specific services. Instead, a “duty to arrange” provision is imposed on each of the many CCGs that will also have transferred to them the power to determine what care is necessary to meet all reasonable requirements. However, CCGs will not have the duty to promote a comprehensive free health service.

As well as transferring powers from the Secretary of State to other bodies, the Bill leaves each CCG free to choose the patients for whom they have responsibility. Unlike PCTs, CCGs will not be responsible for all residents within contiguous geographical areas. CCGs select patients, initially assembling their patient populations on the basis of general practitioners’ (GPs) lists; they will not have to cover everyone in a geographical area but only “persons for whom it [the CCG] has responsibility”. Nor will they be required to arrange for the provision of all the services that are currently part of the comprehensive health system.

These changes will have substantial legal consequences. First, the duty to provide a national health service throughout England would be lost if the Bill became law. It would be replaced by a duty on an unknown number of CCGs, not GPs, to arrange provision as they see fit for various sections of the population for which they are separately responsible. Second, CCGs would not be bound by the “duty to continue to promote a comprehensive free health service” when exercising their functions. Under present law, according to a judgment of the Court of Appeal, the Secretary of State “has the duty to continue to promote a comprehensive free health service and he must never, in making a decision [about services provided], disregard that duty”. Third, the Secretary of State’s accountability to Parliament for the provision of services to patients in the new NHS will be diminished.

The Government has not disclosed the radical nature of this reform.

In the USA, opposition to health reforms under both the Clinton and Obama administrations is articulated as erosion of personal freedom by increasing government powers. Conversely, pro-market reforms of universal health systems in Europe are often justified on the grounds that they increase personal freedom by transferring powers from government to non-governmental or commercial bodies and by increasing choice. Citizens’ rights in democracies are underpinned not just by limitations on government powers but also by legal duties imposed on governments, such as those that guarantee citizens access to health care. The Bill would withdraw this legal underpinning. As the Bill enters its final critical stages it is crucial that Peers observe three red lines for the NHS (below) and are fully aware of the key parts of the legislation that would abolish core NHS functions, if they are to safeguard the NHS for future generations.

****

Red lines to protect the NHS

# The Secretary of State must have the duty to secure provision of comprehensive and equitable health care for the whole of the population of England, taking action whenever there are problems.

# CCGs (Clinical Commissioning Groups), operating on behalf of the Secretary of State, must make sure that comprehensive and equitable health care is available for everyone and be responsible for all residents living in single geographically defined areas that are contiguous, without being able to pick and choose patients.

# Nothing must be done that undermines the ability of the Secretary of State to fulfil the duty to secure provision of comprehensive and equitable health care, by bringing more of the NHS within the scope of EU competition law so that, in particular:

* There must be no increase in the commercial contracting of health services;
* The current authorisation system for central regulation of Foundation Trusts must be retained;
* Statutory functions of CCGs must be carried out by NHS staff, with CCG finances being used solely for the benefit of patients;
* Statutory and enforceable codes of conduct must be laid down for all NHS bodies, underpinned by sanctions that are rigorously policed;
* Information about commercial contracting, including the planning, procurement, financing, and monitoring, must be available as a matter of course.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60119-6/fulltext (The Lancet is offering access to this important article for free, but they do require registration.)

Comment:

By Don McCanne, MD

The Conservative government of David Cameron is about to destroy England’s National Health Service, as we know it. While we are struggling in our attempt to ensure health care for everyone (and are still not receiving it under the Affordable Care Act), the British government is severing its responsibility to secure comprehensive health care throughout England.

Health care justice is an international cause. We should partner with our colleagues in England to support their cause in this moment of crisis, as they later partner with us to see that health care justice becomes a reality in the United States… and throughout the world.

Destroying England’s National Health Service (as we know it)

How the Health and Social Care Bill 2011 would end entitlement to comprehensive health care in England

By Allyson M Pollock, David Price, Peter Roderick, Tim Treuherz, David McCoy, Martin McKee, Lucy Reynolds
The Lancet, January 26, 2012

(Excerpts)

The National Health Service (NHS) in England has been a leading international model of tax-financed, universal health care. Legal analysis shows that the Health and Social Care Bill currently making its way through the UK Parliament would abolish that model and pave the way for the introduction of a US-style health system by eroding entitlement to equality of health-care provision. The Bill severs the duty of the Secretary of State for Health to secure comprehensive health care throughout England and introduces competitive markets and structures consistent with greater inequality of provision, mixed funding, and widespread provision by private health corporations. The Bill has had a turbulent passage. Unusually, the legislative process was suspended for more than 2 months in 2011 because of the weight of public concern. It was recommitted to Parliament largely unaltered after a “listening exercise”. These and more recent amendments to the Bill do not sufficiently address major concerns that continue to be raised by Peers and a Constitution Committee of the House of Lords, where the Bill now faces one of its last parliamentary hurdles before becoming law.

Fundamental to the Bill are provisions that transform a mandatory system into a discretionary one with structures that permit the introduction of charging for services that are currently free under the NHS, as well as a system in which much delivery would be privatised. Under the current statutory framework the Government has a legal duty to secure comprehensive health care, whereas, under the new system, substantial discretionary powers will instead be extended to commissioners and providers of care. These measures will increase inequalities of provision.

The whole system has been publicly administered and funded on the basis of contiguous geographical areas by bodies, now called primary care trusts (PCTs), that act on behalf of the Secretary of State and have responsibility for the health-care needs of everyone in their area.

The Bill creates two new bodies with responsibility for managing care: an NHS Commissioning Board and Clinical Commissioning Groups (CCGs), the number of which remain unclear. PCTs will be abolished and not replaced.

Clause 12 of the Health and Social Care Bill repeals the Secretary of State’s “duty to provide” specific services. Instead, a “duty to arrange” provision is imposed on each of the many CCGs that will also have transferred to them the power to determine what care is necessary to meet all reasonable requirements. However, CCGs will not have the duty to promote a comprehensive free health service.

As well as transferring powers from the Secretary of State to other bodies, the Bill leaves each CCG free to choose the patients for whom they have responsibility. Unlike PCTs, CCGs will not be responsible for all residents within contiguous geographical areas. CCGs select patients, initially assembling their patient populations on the basis of general practitioners’ (GPs) lists; they will not have to cover everyone in a geographical area but only “persons for whom it [the CCG] has responsibility”. Nor will they be required to arrange for the provision of all the services that are currently part of the comprehensive health system.

These changes will have substantial legal consequences. First, the duty to provide a national health service throughout England would be lost if the Bill became law. It would be replaced by a duty on an unknown number of CCGs, not GPs, to arrange provision as they see fit for various sections of the population for which they are separately responsible. Second, CCGs would not be bound by the “duty to continue to promote a comprehensive free health service” when exercising their functions. Under present law, according to a judgment of the Court of Appeal, the Secretary of State “has the duty to continue to promote a comprehensive free health service and he must never, in making a decision [about services provided], disregard that duty”. Third, the Secretary of State’s accountability to Parliament for the provision of services to patients in the new NHS will be diminished.

The Government has not disclosed the radical nature of this reform.

In the USA, opposition to health reforms under both the Clinton and Obama administrations is articulated as erosion of personal freedom by increasing government powers. Conversely, pro-market reforms of universal health systems in Europe are often justified on the grounds that they increase personal freedom by transferring powers from government to non-governmental or commercial bodies and by increasing choice. Citizens’ rights in democracies are underpinned not just by limitations on government powers but also by legal duties imposed on governments, such as those that guarantee citizens access to health care. The Bill would withdraw this legal underpinning. As the Bill enters its final critical stages it is crucial that Peers observe three red lines for the NHS (below) and are fully aware of the key parts of the legislation that would abolish core NHS functions, if they are to safeguard the NHS for future generations.

****

Red lines to protect the NHS

# The Secretary of State must have the duty to secure provision of comprehensive and equitable health care for the whole of the population of England, taking action whenever there are problems.

# CCGs (Clinical Commissioning Groups), operating on behalf of the Secretary of State, must make sure that comprehensive and equitable health care is available for everyone and be responsible for all residents living in single geographically defined areas that are contiguous, without being able to pick and choose patients.

# Nothing must be done that undermines the ability of the Secretary of State to fulfil the duty to secure provision of comprehensive and equitable health care, by bringing more of the NHS within the scope of EU competition law so that, in particular:

* There must be no increase in the commercial contracting of health services;
* The current authorisation system for central regulation of Foundation Trusts must be retained;
* Statutory functions of CCGs must be carried out by NHS staff, with CCG finances being used solely for the benefit of patients;
* Statutory and enforceable codes of conduct must be laid down for all NHS bodies, underpinned by sanctions that are rigorously policed;
* Information about commercial contracting, including the planning, procurement, financing, and monitoring, must be available as a matter of course.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60119-6/fulltext (The Lancet is offering access to this important article for free, but they do require registration.)

Comment:

By Don McCanne, MD

The Conservative government of David Cameron is about to destroy England’s National Health Service, as we know it. While we are struggling in our attempt to ensure health care for everyone (and are still not receiving it under the Affordable Care Act), the British government is severing its responsibility to secure comprehensive health care throughout England.

Health care justice is an international cause. We should partner with our colleagues in England to support their cause in this moment of crisis, as they later partner with us to see that health care justice becomes a reality in the United States… and throughout the world.

Destroying England's National Health Service (as we know it)

How the Health and Social Care Bill 2011 would end entitlement to comprehensive health care in England

By Allyson M Pollock, David Price, Peter Roderick, Tim Treuherz, David McCoy, Martin McKee, Lucy Reynolds
The Lancet, January 26, 2012
(Excerpts)
The National Health Service (NHS) in England has been a leading international model of tax-financed, universal health care. Legal analysis shows that the Health and Social Care Bill currently making its way through the UK Parliament would abolish that model and pave the way for the introduction of a US-style health system by eroding entitlement to equality of health-care provision. The Bill severs the duty of the Secretary of State for Health to secure comprehensive health care throughout England and introduces competitive markets and structures consistent with greater inequality of provision, mixed funding, and widespread provision by private health corporations. The Bill has had a turbulent passage. Unusually, the legislative process was suspended for more than 2 months in 2011 because of the weight of public concern. It was recommitted to Parliament largely unaltered after a “listening exercise”. These and more recent amendments to the Bill do not sufficiently address major concerns that continue to be raised by Peers and a Constitution Committee of the House of Lords, where the Bill now faces one of its last parliamentary hurdles before becoming law.
Fundamental to the Bill are provisions that transform a mandatory system into a discretionary one with structures that permit the introduction of charging for services that are currently free under the NHS, as well as a system in which much delivery would be privatised. Under the current statutory framework the Government has a legal duty to secure comprehensive health care, whereas, under the new system, substantial discretionary powers will instead be extended to commissioners and providers of care. These measures will increase inequalities of provision.
The whole system has been publicly administered and funded on the basis of contiguous geographical areas by bodies, now called primary care trusts (PCTs), that act on behalf of the Secretary of State and have responsibility for the health-care needs of everyone in their area.
The Bill creates two new bodies with responsibility for managing care: an NHS Commissioning Board and Clinical Commissioning Groups (CCGs), the number of which remain unclear. PCTs will be abolished and not replaced.
Clause 12 of the Health and Social Care Bill repeals the Secretary of State’s “duty to provide” specific services. Instead, a “duty to arrange” provision is imposed on each of the many CCGs that will also have transferred to them the power to determine what care is necessary to meet all reasonable requirements. However, CCGs will not have the duty to promote a comprehensive free health service.
As well as transferring powers from the Secretary of State to other bodies, the Bill leaves each CCG free to choose the patients for whom they have responsibility. Unlike PCTs, CCGs will not be responsible for all residents within contiguous geographical areas. CCGs select patients, initially assembling their patient populations on the basis of general practitioners’ (GPs) lists; they will not have to cover everyone in a geographical area but only “persons for whom it [the CCG] has responsibility”. Nor will they be required to arrange for the provision of all the services that are currently part of the comprehensive health system.
These changes will have substantial legal consequences. First, the duty to provide a national health service throughout England would be lost if the Bill became law. It would be replaced by a duty on an unknown number of CCGs, not GPs, to arrange provision as they see fit for various sections of the population for which they are separately responsible. Second, CCGs would not be bound by the “duty to continue to promote a comprehensive free health service” when exercising their functions. Under present law, according to a judgment of the Court of Appeal, the Secretary of State “has the duty to continue to promote a comprehensive free health service and he must never, in making a decision [about services provided], disregard that duty”. Third, the Secretary of State’s accountability to Parliament for the provision of services to patients in the new NHS will be diminished.
The Government has not disclosed the radical nature of this reform.
In the USA, opposition to health reforms under both the Clinton and Obama administrations is articulated as erosion of personal freedom by increasing government powers. Conversely, pro-market reforms of universal health systems in Europe are often justified on the grounds that they increase personal freedom by transferring powers from government to non-governmental or commercial bodies and by increasing choice. Citizens’ rights in democracies are underpinned not just by limitations on government powers but also by legal duties imposed on governments, such as those that guarantee citizens access to health care. The Bill would withdraw this legal underpinning. As the Bill enters its final critical stages it is crucial that Peers observe three red lines for the NHS (below) and are fully aware of the key parts of the legislation that would abolish core NHS functions, if they are to safeguard the NHS for future generations.
****
Red lines to protect the NHS
# The Secretary of State must have the duty to secure provision of comprehensive and equitable health care for the whole of the population of England, taking action whenever there are problems.
# CCGs (Clinical Commissioning Groups), operating on behalf of the Secretary of State, must make sure that comprehensive and equitable health care is available for everyone and be responsible for all residents living in single geographically defined areas that are contiguous, without being able to pick and choose patients.
# Nothing must be done that undermines the ability of the Secretary of State to fulfil the duty to secure provision of comprehensive and equitable health care, by bringing more of the NHS within the scope of EU competition law so that, in particular:
* There must be no increase in the commercial contracting of health services;
* The current authorisation system for central regulation of Foundation Trusts must be retained;
* Statutory functions of CCGs must be carried out by NHS staff, with CCG finances being used solely for the benefit of patients;
* Statutory and enforceable codes of conduct must be laid down for all NHS bodies, underpinned by sanctions that are rigorously policed;
* Information about commercial contracting, including the planning, procurement, financing, and monitoring, must be available as a matter of course.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60119-6/fulltext (The Lancet is offering access to this important article for free, but they do require registration.)

The Conservative government of David Cameron is about to destroy England’s National Health Service, as we know it. While we are struggling in our attempt to ensure health care for everyone (and are still not receiving it under the Affordable Care Act), the British government is severing its responsibility to secure comprehensive health care throughout England.
Health care justice is an international cause. We should partner with our colleagues in England to support their cause in this moment of crisis, as they later partner with us to see that health care justice becomes a reality in the United States… and throughout the world.

Ontario should move carefully on medicare reforms

By Thomas Walkom
The Guelph Mercury (Canada), Jan. 24, 2012

Don Drummond, the Ontario government’s adviser-on-everything, is still a few days away from officially revealing details of his proposed spending cutbacks. But critics are already weighing in.

Chief among these are the health care unions, who suspect from Drummond’s musings that the former bank economist will propose sweeping measures designed to make Ontario’s non-profit hospitals operate more like profit-maximizing private corporations.

The unions obviously have a monetary interest in this. Private corporations are under tremendous shareholder pressure to reduce costs by whatever means — including the contracting out of good jobs to cheaper, non-union shops.

But the Ontario Council of Hospital Unions, which bargains for 30,000 hospital, long-term care and ambulance workers, also argues that the kinds of free-market measures Drummond has been hinting at won’t save money for taxpayers.

The union analysis rests to a large extent on research done in the U.S. and Britain, where private corporations are far more involved in the delivery of publicly funded health services than in Canada.

So this week I called one of those experts, physician and public health professor Steffie Woolhandler, to see what she had to say.

Woolhandler, a former Harvard professor who now teaches at the City University of New York, has spent some time researching U.S. Medicare — a program that covers only those 65 and over.

Like Canada’s much more comprehensive health-care system, U.S. Medicare is publicly funded. Government pays not the whole tab, but most of it.

However, private, profit-making corporations play a far bigger role in delivering these publicly-funded health services than they do here.

Here’s what Woolhandler says research by her and others has shown.

First, for-profit hospitals don’t provide higher quality care. In fact, research shows that patients do marginally worse in the average U.S. private hospital.

In for-profit dialysis clinics, one investigation found that patients were 21 per cent more likely to die.

Second, and perhaps more important to Ontario Premier Dalton McGuinty, market reforms to U.S. Medicare haven’t saved money. Perversely, they have cost taxpayers more.

Eight separate empirical studies compared for-profit to non-profit hospitals, Woolhandler says. All showed that for-profit hospitals cost the government treasury more — by about 18 per cent.

“The evidence of higher cost is simply irrefutable,” she says.

Why would this be? Woolhandler’s explanation is that, in the realm of health care, for-profit institutions have an overwhelming incentive to game the system in order to squeeze as much as possible from their public paymaster.

In some cases, they encourage the use of unnecessary tests or services operated by their own subsidiaries. In others, they “upcode” the patients — present them as sicker than they are in order to reap higher payments.

Then there is so-called cherry picking. For-profit hospitals prefer to avoid seriously ill patients since these cost more to treat. Even hospices for the terminally ill are affected. Research shows that many try to fill their beds with dying heart patients in order to avoid end-of-life cancer victims, who require more costly treatment.

From time to time, the U.S. government tries to close these Medicare loopholes. But, says Woolhandler, the corporations just find new ways to game the system. (She refers to a 2011 study by the National Bureau of Economic Research that makes just that point.)

The lesson for McGuinty? Governments interested in reducing health care costs shouldn’t rely on free-market reforms to do the trick. Health care isn’t a commodity like, say, soap where the normal laws of supply and demand operate.

It is a human necessity where one side — the provider — has all the information and power, while the other — the patient — is far too often acting out of desperation.

Thomas Walkom is a columnist with Record News Services and national affairs columnist for the Toronto Star.

http://www.guelphmercury.com/opinion/columns/article/660049–ontario-should-move-carefully-on-medicare-reforms

Wyden-Ryan plan won't improve health care system

By Chris Goeser, M.D., and Samuel Metz, M.D.
Statesman Journal (Salem, Ore.), Jan. 24, 2012

“Health care is a human right” is what the people of Vermont told their legislators and governor, a view shared by the majority of Americans according to the 2009 Kaiser Health Tracking Poll.

On May 26, 2011, Vermont Gov. Peter Shumlin signed our country’s first statewide publicly financed health care law providing universal health care to all Vermonters. We should have a similar law in Oregon.

On Dec. 15, 2011, Sen. Ron Wyden, D-Ore., and Rep. Paul Ryan, R-Wis., co-authored “Guaranteed Choices to Strengthen Medicare and Health Security for All: Bipartisan Options for the Future.” It seems Sen. Wyden wants to further entrench private health insurance for those employed, and to let private plans compete with Medicare.

This is not in the best interest of Oregonians. What they propose is the not so new idea of “defined contribution” health care plans. Simply put, these are vouchers. Employers provide a fixed sum to employees who then purchase whatever insurance they can afford. Because employer contributions stay fixed while health care costs increase, basic benefits quickly become unaffordable.

Without reform, American businesses can survive only by shifting escalating health care costs to someone else. A “defined contribution” plan allows just that — it moves increasing costs away from businesses and onto employees. These plans do nothing, of course, for those without benefits or without a job.

No successful health care system uses “defined contribution” plans (or vouchers of any kind, for that matter). Nor do they discourage patients from seeking care with high co-pays and deductibles. In fact, we are the only industrialized country to do so.

Consequently, our health costs are double the amount of an average industrialized country, our public health is near the bottom of the industrialized world and the social consequences are devastating; no other industrialized country allows citizens to lose limbs, homes or lives if they get a treatable disease.

Health care financing in successful systems has three common properties:

1. Every citizen maintains health care access no matter how sick, poor, old or unemployed they become.

2. There are no financial impediments to receiving health care.

3. Financing is provided by publicly accountable, transparent, not-for-profit agencies.

“Defined contribution” plans have none of these properties. For the record, financing with all three properties but using one publicly accountable, transparent, not-for-profit agency is called “single-payer” health care. All of America’s successful health care systems (e.g., Veterans Affairs medical centers and multi-employer health care plans) use single-payer financing.

The most significant bipartisan agreement that Sen. Wyden and Rep. Ryan could make is to recognize that health care is not a privilege but a human right. Instead, their plan continues employer-based private insurance to finance health care, which will accelerate the destruction of American’s families, America’s health and America’s future as a civilized nation.

The Wyden-Ryan proposal is misleading and distracts from the best solution. Instead of “defined contribution” plans, let’s define for Sen. Wyden what this country needs to save health care: single-payer, universal coverage. “Everybody in, nobody out.”

Chris Goeser, D.C., M.D., is a radiologist practicing in Salem, Silverton, Woodburn and Albany, and a member of both Physicians for a National Health Program and Mad As Hell Doctors. He can be reached at cdgoeser@diaradiology.org.Samuel Metz, M.D., is an anesthesiologist, member of Physicians for a National Health Program and founding member of Mad As Hell Doctors. He can be reached at SamuelMetz@SamuelMetz.com.

http://www.statesmanjournal.com/article/20120125/OPINION/201250381/Wyden-Ryan-plan-won-t-improve-health-care-system

Wyden-Ryan plan won’t improve health care system

By Chris Goeser, M.D., and Samuel Metz, M.D.
Statesman Journal (Salem, Ore.), Jan. 24, 2012

“Health care is a human right” is what the people of Vermont told their legislators and governor, a view shared by the majority of Americans according to the 2009 Kaiser Health Tracking Poll.

On May 26, 2011, Vermont Gov. Peter Shumlin signed our country’s first statewide publicly financed health care law providing universal health care to all Vermonters. We should have a similar law in Oregon.

On Dec. 15, 2011, Sen. Ron Wyden, D-Ore., and Rep. Paul Ryan, R-Wis., co-authored “Guaranteed Choices to Strengthen Medicare and Health Security for All: Bipartisan Options for the Future.” It seems Sen. Wyden wants to further entrench private health insurance for those employed, and to let private plans compete with Medicare.

This is not in the best interest of Oregonians. What they propose is the not so new idea of “defined contribution” health care plans. Simply put, these are vouchers. Employers provide a fixed sum to employees who then purchase whatever insurance they can afford. Because employer contributions stay fixed while health care costs increase, basic benefits quickly become unaffordable.

Without reform, American businesses can survive only by shifting escalating health care costs to someone else. A “defined contribution” plan allows just that — it moves increasing costs away from businesses and onto employees. These plans do nothing, of course, for those without benefits or without a job.

No successful health care system uses “defined contribution” plans (or vouchers of any kind, for that matter). Nor do they discourage patients from seeking care with high co-pays and deductibles. In fact, we are the only industrialized country to do so.

Consequently, our health costs are double the amount of an average industrialized country, our public health is near the bottom of the industrialized world and the social consequences are devastating; no other industrialized country allows citizens to lose limbs, homes or lives if they get a treatable disease.

Health care financing in successful systems has three common properties:

1. Every citizen maintains health care access no matter how sick, poor, old or unemployed they become.

2. There are no financial impediments to receiving health care.

3. Financing is provided by publicly accountable, transparent, not-for-profit agencies.

“Defined contribution” plans have none of these properties. For the record, financing with all three properties but using one publicly accountable, transparent, not-for-profit agency is called “single-payer” health care. All of America’s successful health care systems (e.g., Veterans Affairs medical centers and multi-employer health care plans) use single-payer financing.

The most significant bipartisan agreement that Sen. Wyden and Rep. Ryan could make is to recognize that health care is not a privilege but a human right. Instead, their plan continues employer-based private insurance to finance health care, which will accelerate the destruction of American’s families, America’s health and America’s future as a civilized nation.

The Wyden-Ryan proposal is misleading and distracts from the best solution. Instead of “defined contribution” plans, let’s define for Sen. Wyden what this country needs to save health care: single-payer, universal coverage. “Everybody in, nobody out.”

Chris Goeser, D.C., M.D., is a radiologist practicing in Salem, Silverton, Woodburn and Albany, and a member of both Physicians for a National Health Program and Mad As Hell Doctors. He can be reached at cdgoeser@diaradiology.org.Samuel Metz, M.D., is an anesthesiologist, member of Physicians for a National Health Program and founding member of Mad As Hell Doctors. He can be reached at SamuelMetz@SamuelMetz.com.

http://www.statesmanjournal.com/article/20120125/OPINION/201250381/Wyden-Ryan-plan-won-t-improve-health-care-system

Even With Insurance, Unemployed Have Worse Health Outcomes

Report finds that high co-pays, deductibles can still make medical care unaffordable

By Steven Reinberg, HealthDay Reporter
U.S. News and World Report, Jan. 24, 2012

People without jobs who have health insurance are less likely to get medical care or prescription drugs than people with jobs who have such coverage, U.S. health officials reported Tuesday.

During the depths of the recent recession, unemployment reached 9.6 percent, a level not seen since 1983. Because health insurance affects access to care and most people rely on getting insured through their employer, researchers wanted to look at the effect of unemployment and lower income on access to health care, according to the U.S. Centers for Disease Control and Prevention.

“Insurance without a job is a difficult position to be in,” said report author Anne Driscoll, a senior fellow at the CDC’s National Center for Health Statistics.

In the study, Driscoll and her colleague, Amy Bernstein, wanted to find out whether having private, public or no insurance mattered if you were employed or unemployed.

They found that private insurance, which experts think is the most comprehensive, was no guarantee of better health care.

“If you had private insurance but weren’t employed, you had worse mental health, worse physical health and were less likely to get prescriptions you needed or care that you needed than if you had a job,” Driscoll said.

Cost of care appears to be the overriding factor why having private insurance and no job was associated with lack of access to care, she said.

“Because you don’t have a job, deductibles and co-payments are the reasons you can’t use your insurance to the fullest. You’re better having insurance than no insurance, but it’s not a panacea. A job and insurance is the most advantageous category to be in, not just being insured,” Driscoll said.

For their study, the authors used data from the 2009 and 2010 U.S. National Health Interview Survey and compared the health insurance status, health and access to health care of employed and unemployed adults aged 18 to 64.

Highlights of the report include:

*  48 percent of unemployed adults had health insurance, compared with 81 percent of employed adults.
*  More of the unemployed had public insurance than those employed.
*  The unemployed had worse physical and mental health than the employed, whether they had insurance or not.
*  The insured unemployed were less likely to get medical care because of cost than the insured employed.
*  The insured unemployed were less likely to get prescription drugs because of cost than the insured employed.
*  The uninsured were less likely to get medical care and prescription drugs because of cost than people with public or private insurance, regardless of whether they had jobs or not.
*  The unemployed were more likely to be black, have less than a high school education and have an income below the poverty level.

Dr. Steffie Woolhandler, a visiting professor of medicine at Harvard Medical School and co-founder of Physicians for a National Health Program, doesn’t hold out hope that health care reform will make things better for the unemployed.

“During the recession, the use of health care plummeted. We had a 19.5 percent drop in primary care in the United States,” she said.

This study shows that even if people lost their jobs and held onto their insurance, they couldn’t afford to use health care, Woolhandler said.

“That’s a uniquely American issue because we have such high co-payments, deductibles and uncovered services that people can’t afford to use care,” she said.

Woolhandler noted that health care reform will help some people because the number of uninsured is expected to be cut by over half.

“While there will still be 23 million uninsured after health reform is fully implemented, it’s a whole lot less than it would be otherwise,” she said.

But, having health insurance will not mean that you can afford care if you lose your job, Woolhandler added.

“It will be a little worse after health reform, because the new policies that will be offered will be quite a bit skimpier than an employer policy is now. And there will be high co-pays, high deductibles. So even if you hang on to your insurance you likely won’t be able to afford care,” she said.

http://health.usnews.com/health-news/managing-your-healthcare/insurance/articles/2012/01/24/even-with-insurance-unemployed-have-worse-health-outcomes?page=2

"Global budgeting" for Children's Hospital Boston

Children’s, Blue Cross deal curbs payments

The Boston Globe
January 24, 2012

Children’s Hospital Boston has agreed to a three-year contract with Blue Cross Blue Shield of Massachusetts…

Perhaps most important, Children’s and its doctors groups will accept global payments for the first time, meaning they will be given a budget for patients’ care rather than billing for each visit and procedure.

“The contract is completely aligned with our aggressive and comprehensive efforts to take costs out of the system, while also improving quality,” said Children’s president Sandra Fenwick.

Until recently, it was thought unlikely that specialty providers such as Children’s, a 395-bed teaching hospital that is a national leader in pediatric research and training, would join the new global payment plans being offered by insurers.

Fenwick said the deal makes Children’s the first pediatric hospital in the nation to take global payments instead of traditional fee-for-service reimbursements. The contract also covers the Children’s Physicians Organization, made up of 959 specialists, and the Pediatric Physician Organization at Children’s, which includes 279 primary care doctors.

http://articles.boston.com/2012-01-24/business/30655411_1_pediatric-care-health-care-providers-specialty-hospitals

Comment: 

By Don McCanne, MD

Under a well designed single payer system, hospitals would be funded through global budgets, much like police and fire departments, libraries and other civic institutions. Single payer eliminates the need to provide complex, itemized billings for each and every patient to any of hundreds of third party payers. The hospitals are simply paid a global fee that covers all of their costs for the year. As Canada and other nations have shown, global budgeting dramatically reduces the high costs of the administrative excesses that U.S. hospitals face.

Blue Cross Blue Shield of Massachusetts has now negotiated the first contract with a pediatric hospital that they say uses global budgeting. So can we use this as an experiment to prove that global budgeting will work in the United States? Unfortunately, no.

This contract has almost nothing in common with global budgeting under a single payer system. A global budget limited to one insurer does not place the entire hospital under a single global budget. Far from it. They still have to interact with all other payers in our fragmented financing system. Further, the products and services provided to Blue Cross Blue Shield patients must be segregated and itemized separately to know the amount of the budget to be negotiated. The uncertainties on how to allocate various hospital costs also can result in inequities amongst the various payers, likely making Blue Cross Blue Shield a winner while other payers lose.

When we are told later on that we do not want hospitals globally budgeted under a single payer system because it did not work for Children’s Hospital Boston, be prepared to answer that this was not global budgeting. This was merely another individual contract between one hospital with its physicians’ organizations and one insurer, under a fragmented financing system in which it was impossible to achieve the efficiencies of globally budgeting of the hospital’s entire costs.

We can even invent a term based on what this process is. It is “segregated budgeting.” We can make that a pejorative term by demonstrating that it is merely another insurer gimmick in our dysfunctional system of financing health care. Let’s keep the definition of “global” clean, and not let the insurers steal it from us.

“Global budgeting” for Children’s Hospital Boston

Children’s, Blue Cross deal curbs payments

The Boston Globe
January 24, 2012

Children’s Hospital Boston has agreed to a three-year contract with Blue Cross Blue Shield of Massachusetts…

Perhaps most important, Children’s and its doctors groups will accept global payments for the first time, meaning they will be given a budget for patients’ care rather than billing for each visit and procedure.

“The contract is completely aligned with our aggressive and comprehensive efforts to take costs out of the system, while also improving quality,” said Children’s president Sandra Fenwick.

Until recently, it was thought unlikely that specialty providers such as Children’s, a 395-bed teaching hospital that is a national leader in pediatric research and training, would join the new global payment plans being offered by insurers.

Fenwick said the deal makes Children’s the first pediatric hospital in the nation to take global payments instead of traditional fee-for-service reimbursements. The contract also covers the Children’s Physicians Organization, made up of 959 specialists, and the Pediatric Physician Organization at Children’s, which includes 279 primary care doctors.

http://articles.boston.com/2012-01-24/business/30655411_1_pediatric-care-health-care-providers-specialty-hospitals

Comment: 

By Don McCanne, MD

Under a well designed single payer system, hospitals would be funded through global budgets, much like police and fire departments, libraries and other civic institutions. Single payer eliminates the need to provide complex, itemized billings for each and every patient to any of hundreds of third party payers. The hospitals are simply paid a global fee that covers all of their costs for the year. As Canada and other nations have shown, global budgeting dramatically reduces the high costs of the administrative excesses that U.S. hospitals face.

Blue Cross Blue Shield of Massachusetts has now negotiated the first contract with a pediatric hospital that they say uses global budgeting. So can we use this as an experiment to prove that global budgeting will work in the United States? Unfortunately, no.

This contract has almost nothing in common with global budgeting under a single payer system. A global budget limited to one insurer does not place the entire hospital under a single global budget. Far from it. They still have to interact with all other payers in our fragmented financing system. Further, the products and services provided to Blue Cross Blue Shield patients must be segregated and itemized separately to know the amount of the budget to be negotiated. The uncertainties on how to allocate various hospital costs also can result in inequities amongst the various payers, likely making Blue Cross Blue Shield a winner while other payers lose.

When we are told later on that we do not want hospitals globally budgeted under a single payer system because it did not work for Children’s Hospital Boston, be prepared to answer that this was not global budgeting. This was merely another individual contract between one hospital with its physicians’ organizations and one insurer, under a fragmented financing system in which it was impossible to achieve the efficiencies of globally budgeting of the hospital’s entire costs.

We can even invent a term based on what this process is. It is “segregated budgeting.” We can make that a pejorative term by demonstrating that it is merely another insurer gimmick in our dysfunctional system of financing health care. Let’s keep the definition of “global” clean, and not let the insurers steal it from us.

"Global budgeting" for Children's Hospital Boston

Children’s, Blue Cross deal curbs payments

The Boston Globe
January 24, 2012
Children’s Hospital Boston has agreed to a three-year contract with Blue Cross Blue Shield of Massachusetts…
Perhaps most important, Children’s and its doctors groups will accept global payments for the first time, meaning they will be given a budget for patients’ care rather than billing for each visit and procedure.
“The contract is completely aligned with our aggressive and comprehensive efforts to take costs out of the system, while also improving quality,” said Children’s president Sandra Fenwick.
Until recently, it was thought unlikely that specialty providers such as Children’s, a 395-bed teaching hospital that is a national leader in pediatric research and training, would join the new global payment plans being offered by insurers.
Fenwick said the deal makes Children’s the first pediatric hospital in the nation to take global payments instead of traditional fee-for-service reimbursements. The contract also covers the Children’s Physicians Organization, made up of 959 specialists, and the Pediatric Physician Organization at Children’s, which includes 279 primary care doctors.
http://articles.boston.com/2012-01-24/business/30655411_1_pediatric-care-health-care-providers-specialty-hospitals

Under a well designed single payer system, hospitals would be funded through global budgets, much like police and fire departments, libraries and other civic institutions. Single payer eliminates the need to provide complex, itemized billings for each and every patient to any of hundreds of third party payers. The hospitals are simply paid a global fee that covers all of their costs for the year. As Canada and other nations have shown, global budgeting dramatically reduces the high costs of the administrative excesses that U.S. hospitals face.
Blue Cross Blue Shield of Massachusetts has now negotiated the first contract with a pediatric hospital that they say uses global budgeting. So can we use this as an experiment to prove that global budgeting will work in the United States? Unfortunately, no.
This contract has almost nothing in common with global budgeting under a single payer system. A global budget limited to one insurer does not place the entire hospital under a single global budget. Far from it. They still have to interact with all other payers in our fragmented financing system. Further, the products and services provided to Blue Cross Blue Shield patients must be segregated and itemized separately to know the amount of the budget to be negotiated. The uncertainties on how to allocate various hospital costs also can result in inequities amongst the various payers, likely making Blue Cross Blue Shield a winner while other payers lose.
When we are told later on that we do not want hospitals globally budgeted under a single payer system because it did not work for Children’s Hospital Boston, be prepared to answer that this was not global budgeting. This was merely another individual contract between one hospital with its physicians’ organizations and one insurer, under a fragmented financing system in which it was impossible to achieve the efficiencies of globally budgeting of the hospital’s entire costs.
We can even invent a term based on what this process is. It is “segregated budgeting.” We can make that a pejorative term by demonstrating that it is merely another insurer gimmick in our dysfunctional system of financing health care. Let’s keep the definition of “global” clean, and not let the insurers steal it from us.

Principles for Cost-Effective, Sustainable Health Care Reform

By Stephen Kemble, M.D.

1.  Universality — single risk pool
2.  Standardized benefits, adequate for effective medically necessary care
3.  Minimize administration
4.  Promote professionalism in health care
5.  Quality improvement
6.  Ensure adequate professional workforce, especially for primary care
7.  Accountability must be to the health needs of the population
8.  Separate, sustainable funding for health care

1. Universality — single risk pool

Large health care savings become possible if competing plans are consolidated into a universal program with a single risk pool. This will eliminate insurance costs of underwriting, adverse selection, multiple private bureaucracies, brokers, lobbying, and marketing and advertising. Health plan incentives to avoid covering the sick and to “cherry pick” healthier subscribers and risk pools will be eliminated. There will be no pre-existing condition exclusions, cost-shifting, and disputes over who is responsible for paying for care. A broader risk pool will reduce per capita insurance reserve requirements. For businesses, a universal program will uncouple health insurance from employment status, and eliminate employer costs for health benefits administration. Patients will gain free choice of providers, with no restricted panels by plan. Everyone will have access to the same care, and the poor will no longer be relegated to an under-funded Medicaid program. The state will save the cost of eligibility determination for Medicaid. For care providers, there will be no uncompensated care. Universal coverage could remove health care costs from medical malpractice, worker’s compensation, and auto insurance, greatly reducing insurance costs, even without tort reform.

2. Standardized benefits, adequate for effective care

A universal program will require comprehensive benefits, adequate for all medically necessary care. Since those now covered under Medicaid will be included, co-pays and deductibles will have to be eliminated or so minimal that they could be waived for those who could not afford them. For the poor, there must be no financial barriers to seeking appropriate care. For those with moderate incomes, there will be no “under-insurance” or unaffordable costs for those with serious or disabling illness. Medical bankruptcy will be eliminated.

3. Minimize administration

With a universal program, billing and clams processing will be vastly simplified and standardized. Electronic health records and gathering of data for quality improvement will be standardized across all patients and providers. So will formulary and prior authorization policies for drugs. Incentives for cost-effectiveness should be at the point of service, between doctor and patient, minimizing central management of health care decisions by the program (managed care) with its high administrative costs. Global budgets for hospitals and integrated care systems will eliminate billing costs that can consume up to 20 percent of hospital budgets.

4. Promote professionalism in health care

In order to protect the public interest and safety, a universal health program must require maintenance of high standards for professional training. Professional scope of practice must be based on training, not lobbying. Physicians and other providers should be required to maintain membership in a professional organization, tied to licensure, to ensure that peer review and professional ethical standards are enforceable, and to promote continuing education. A universal program will also require organization of physicians and other professionals for negotiation of fees with the program, and for participation in quality improvement. The program should harness professionalism to keep health care equitable and cost-effective. The net income potential for professionals must be commensurate with the training and skills necessary for their scope of practice, and any reduction in professional pay must be tied to reduction in administrative burdens (cost, time, and hassles), reduced risk of lawsuits, and subsidies for training costs.

5. Quality Improvement

A system-wide quality improvement program with professional leadership should replace managed care administered by insurance companies. This program should follow William Deming’s Continuous Quality Improvement (CQI) model and focus on improving processes of care, rather than just HEDIS style quality measures. Unlike CQI, other strategies to reduce unnecessary and inappropriate care such as capitation, rating providers, pay-for-performance, and incentives based on outcomes are problematic because they create disincentives to treat difficult and complex patients.

6. Ensure adequate professional work force, especially for primary care

A universal program should improve payment for care coordination. Patients with significant chronic illnesses should be assigned to a “patient-centered medical home.” Primary care can also be encouraged with a state-level program similar to the National Health Service, with subsidies for medical education and training tied to commitment to practice in underserved areas and specialties.

7. Accountability must be to the health needs of the population

Health system policies, including fee structure, scope of practice issues, formularies, and covered benefits, must be set by a health authority that is accountable to the health needs of the community and insulated from special interests and lobbying. Funding for capital improvement in hospitals, nursing homes, diagnostic imaging centers, etc. should be determined by public health needs. Health care financing and institutions for delivery of care must both be not-for-profit. A universal health system will benefit from a continuous quality improvement program for administrative systems as well as for health care delivery, with robust feedback from providers and patients that can actually influence policies.

8. Separate, sustainable funding for health care

A universal health system must have its own separate funding stream, whether this is called a health tax or a premium. There must be no mixing of health care funding with general tax revenues. Funding must be responsive to actual costs of care and public health priorities.

Dr. Stephen Kemble is assistant professor of medicine at the University of Hawaii John A. Burns School of Medicine, and also in private practice as a general adult psychiatrist. He is a member of Physicians for a National Health Program. In September he was appointed by Hawaii’s Gov. Neil Abercrombie to the Hawaii Health Authority, charged with designing and then running a universal health care system for Hawaii.

This article originally appeared at OpEd News:
http://www.opednews.com/articles/Principles-for-Cost-Effect-by-Stephen-Kemble-111203-878.html

Ezekiel Emanuel wants liberals to worry about costs

What We Give Up for Health Care

By Ezekiel J. Emanuel
The New York Times, January 21, 2012

When it comes to health care, most liberals are committed above all to ensuring that every American has insurance. In their view, the greatest achievement of the health care reform act passed under President Obama is to finally erase the moral stain of the United States’ being the only major developed country without universal coverage. But we also hold the questionable distinction of having the world’s most expensive health care system — what about cost control? For many liberals, that just sounds like a cover for heartless conservatives who care only about cutting benefits and not about helping people in need.

But liberals are wrong to ignore costs. The more we spend on health care, the less we can spend on other things we value. If liberals care about middle-class salaries, public education and other state-funded services, then they need to care about controlling health care costs every bit as much as conservatives do.

During the campaign season and into 2013 — a vital year for health care legislation — liberals must make the issue of cost control their own.

(Ezekiel J. Emanuel is an oncologist, former White House adviser and a vice provost and professor at the University of Pennsylvania.)

http://opinionator.blogs.nytimes.com/2012/01/21/what-we-give-up-for-health-care/

Comment:

NYT Pick

Don McCanne
San Juan Capistrano, CA

Truly universal coverage and effective cost containment were the goals from the beginning, but Congress and the administration selected a model of reform that cannot possibly bring us either.

It is likely that tens of millions will remain uninsured because of affordability issues, and the measures supposedly designed to control costs will have very little impact. A new CBO report confirms that some of the mechanisms proposed have already been shown to be ineffective in pilot studies.

All other wealthy nations provide comprehensive services to everyone, and at prices that on average are half that of the United States. The other nations use similar technology, experience aging of their populations, and have similar rates of health care utilization, yet they are still able to contain their costs. The difference is that they have strong public oversight of their systems of social insurance or government health services.

Although single payer systems are well recognized for their savings through administrative efficiencies, they use many other tools to slow the increases in health care costs. These tools are not experimental, like those in the Affordable Care Act. They have already proven to be effective beyond any doubt in nations with such systems.

We can cover absolutely everyone, which should make the liberals happy, and we can do it while truly bringing our health care costs under control, and isn’t that what the conservatives want as well?

http://opinionator.blogs.nytimes.com/2012/01/21/what-we-give-up-for-health-care/?comments#permid=124