PNHP

Health providers, advocates criticize Institute of Medicine on insurance recommendations

Health providers, advocates criticize Institute of Medicine on insurance recommendations

By Chelsea Conaboy, Globe Staff
Boston Globe, White Coat Notes, Dec. 1, 2011

More than 2,400 health care providers and advocates sent a letter to Secretary of Health and Human Services Kathleen Sebelius today objecting to recommendations made by a panel of the Institute of Medicine regarding what benefits must be covered in state health insurance marketplaces developed under the Affordable Care Act.

States are required by the federal law to create insurance exchanges for individuals and small businesses, similar to the one Massachusetts started in 2006.

The panel was charged with creating a framework for the essential health benefits that must be covered based on a “typical” plan available today. The critics objected to the group’s decision to start with a typical small business plan rather than a more comprehensive plan offered by larger employers.

Michael Chernew, a professor of health care policy at Harvard Medical School and a member of the institute’s panel, said the critique was “completely unfair.”

The authors said that “enshrining these skimpy plans as the new standard” will threaten the health of Americans and the country’s finances as people faced with high out-of-pocket costs forgo necessary care.

Here’s an excerpt from the letter, circulated by the Physicians for a National Health Program, with leadership from several Boston area physicians including Dr. Danny McCormick, an internist and assistant professor at Harvard Medical School and a former Institute of Medicine fellow:

The inadequate coverage the IOM recommends would shift costs from corporate and government payers onto families already burdened by illness. Yet this strategy will not lower costs. Delaying care often creates even higher costs. Steadily rising co-payments and deductibles over the past two decades have failed to stem skyrocketing medical inflation. And nations that assure comprehensive coverage – with out-of-pocket costs a fraction of those in the United States – have experienced both slower cost growth and greater health gains than our country. Our patients urgently need what people in these other nations already enjoy: universal and comprehensive coverage in a nonprofit system that prioritizes human need over corporate profit.

The authors went on to say they believed the panel that drafted that Institute of Medicine recommendations was “riddled with conflicts of interest” because it included executives from health insurers and consulting firms with ties to the health industry.

Chernew said the panel decided to base its recommendations on a typical small business plan because the exchanges primarily will be used by individuals and small businesses. However, he said, that choice won’t have a large impact on the plans.

The essential benefits covered under small and large business plans don’t differ dramatically, Chernew said. Where those plans do diverge is on the amount of costs left to the consumer. But, Chernew said, those coverage guidelines, already laid out under the Affordable Care Act, were not within the panel’s purview.

Chernew said he can understand why people might criticize the panel’s decision to include costs as a factor in the recommendations, but it was necessary.

“The entire system runs the risk of collapsing if it just becomes too expensive,” he said.

As for the charge of a conflict of interest, Chernew said, “I don’t find that particularly credible.”

Insurance executives could benefit more if the plans sold in the exchanges cost more, he said, because their profits under the federal law are calculated as a percentage of total costs.

Chelsea Conaboy can be reached at cconaboy@boston.com. Follow her on Twitter @cconaboy.

http://www.boston.com/Boston/whitecoatnotes/2011/12/health-providers-advocates-criticize-institute-medicine-insurance-recommendations/8JFeoXCdlykDFQ6hTisDrN/index.html

Letter to Sebelius criticizes IOM's 'essential benefits' recommendations

By Andis Robeznieks
Modern Healthcare, Dec. 1, 2011

More than 2,400 people have signed an open letter to HHS Secretary Kathleen Sebelius protesting the Institute of Medicine’s recommendations for defining “essential benefits,” which the signers said give more weight to “cost rather than medical need.”

The letter, signed mostly by doctors — including IOM members — and circulated by the Physicians for a National Health Program single-payer advocacy group, also stated that the IOM committee that drafted the report was “riddled with conflicts of interest” as several members had “amassed personal wealth” through association with insurance companies and other for-profit healthcare ventures.

In a statement released after the report was issued, America’s Health Insurance Plans President and CEO Karen Ignagni said that a recommendation to reflect the scope of benefits and design under a typical small employer was an “important step toward maintaining affordability.” But the PNHP saw praise by the insurance industry, which, according to the letter, has “sought to undermine real health reform at every turn,” as evidence of the report’s bias.

“Our patients urgently need what people in these other nations already enjoy: universal and comprehensive coverage in a nonprofit system that prioritizes human need over corporate profit,” the letter concluded.

Read more: Letter to Sebelius criticizes IOM’s ‘essential benefits’ recommendations – Healthcare business news and research | Modern Healthcare
http://www.modernhealthcare.com/article/20111201/NEWS/312019957#ixzz1fNqVOVeg?trk=tynt

Dr. John Geyman's new book on primary care: 'Breaking Point'

By Wendell Potter
Firedoglake, Nov. 27, 2011

Just last week, the 34-nation Organization for Economic Cooperation Development (OECD) released the results of its most recent study of the health care systems in the 40 counties considered to be “developed.” It came as no surprise to see that the U.S. health care system — if we can even call it a system — is still by far the most expensive on the planet.

We spend two-and-a-half times more on health care per person than the OECD average. The average expenditure per person in the U.S. is $7,960. The OECD average, by comparison, is just $3,233. Yet we rank 29th in the number of hospital beds per person and 29th in the average length of a stay in the hospital. We have high rates of avoidable hospital admissions for people with asthma, lung disease, diabetes, hypertension and other common illnesses, and we lag behind many other countries on other measures of quality and accessibility.

And when it comes to access to physicians, we’re considerably closer to the bottom than the top. We rank 26th in the number of physicians, especially primary care doctors, per 1,000 people.

All of the bad news for the U.S. in the OECD report is troubling if not shocking, but that last data point — that 25 countries have more physicians per capita than we do — even caught me by surprise.

But after reading Dr. John Geyman’s latest book, “Breaking Point—How the Primary Care Crisis Endangers the Lives of Americans,” I now understand why and how we have sunk so low. Not only does Geyman explain what has happened to our primary care infrastructure over the past several decades, he makes the most compelling case I’ve read anywhere about the urgency of rebuilding it. He also suggests ways we can do it.

If you’re not acquainted with Geyman, you should be. He is one of the wisest and most prolific writers about health care in America. “Breaking Point” is his 12th book and follows another must-read: “Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform.”

As you can tell by the title of that book, Geyman is not a big fan of the Affordable Care Act, a.k.a. “Obamacare.” While he notes that the reform law will expand access over the next several years, “it will not make a dent in the primary care crisis.”

In fact, he goes on, “the 32 million Americans who gain some kind of insurance coverage between now and 2019 will find it more difficult than ever to find a primary care physician. Insurance without a physician — how much of a gain is that?”

A former Republican country doctor, Geyman writes that when he graduated from medical school in 1960, there already was a growing shortage of general practitioners, but not nearly as severe as today. In 1960, 18 percent of U.S. doctors were in general practice. By 2000, the number had fallen to 12 percent, and it continues to spiral downward because of the many disincentives in the U.S. for medical students to go into primary care.

Those disincentives have led to primary care physicians becoming an endangered species.

“Specialization, subspecialization and sub-subspecialization are increasingly taking over the physician workforce,” he writes. “The reasons for these changes have much to do with money and the business of medicine. The decline in generalist medicine and primary care is inexorable with present policies in health care, and present trends signal a disaster unfolding.”

That disaster is indeed unfolding, although you’d hardly know it from the politicians and pundits who are more interested in ideology and the gamesmanship of reform than truly addressing the problems with workable solutions. And while the far-reaching reforms that are needed have so far been beyond the ability of lawmakers to enact—also having to do with money and the business of medicine—the disaster that is unfolding is increasingly being felt by American families.

Because of increases in population and the dwindling supply of general practitioners, more and more Americans are unable to find a personal primary care physician for themselves or their family. As a result, Geyman writes, their care has become increasingly expensive and fragmented.

Why does primary care matter? Geyman lists several reasons. Patients with regular access to primary care doctors receive more preventive services, and they have fewer preventable emergency room visits and hospital admissions. Because they get to know their patients well over time, primary care doctors order fewer tests than specialists, and they help protect their patients from inappropriate, unnecessary and expensive over-utilization of specialist services.

Having primary care leads to earlier diagnosis and treatment of illnesses, enhancing quality and outcomes of care. Primary care doctors are also ideally suited to coordinate care for patients who need multiple specialists. And studies have shown that patients with an ongoing relationship with a primary care doctor are more compliant with treatment.

Geyman believes, and I agree, that primary care must be at the heart of a transformed U.S. health care system — and it ultimately will be transformed because the status quo is not sustainable. And, like me, he is an optimist — transformation not only is possible, it is inevitable.

Toward the end of “Breaking Point,” Geyman provides us with “ten lessons for primary care and health policy” that every reform advocate and every lawmaker truly interested in reform should read. Only someone with Geyman’s knowledge as a physician in private practice for decades and a renowned scholar of health care systems around the world could develop what essentially is a roadmap out of our unfolding disaster.

The last of those ten lessons is especially important for advocates who were disheartened and disillusioned when Congress passed the Affordable Care Act because of its shortcomings and the fact that it gives the insurance industry a renewed lease on life. Lesson #10: “The fight for sustainable and accountable health care can be a long one, but it can be won in the end by those prepared to keep at it.”

“Breaking Point” is worth reading not only to get a better understanding of the value of primary care but also Geyman’s wise counsel, reality-based optimism and challenge for us to stay in the fight and never give up. “We can all make a difference if we choose to do so,” he concludes. “Let’s go for it!”

Indeed. It’s time for all of us to rally, especially with the fate of the Senate and White House at stake.

http://fdlbooksalon.com/2011/11/27/fdl-book-salon-welcomes-john-geyman/

The PROMETHEUS Bundled Payment Experiment

The PROMETHEUS Bundled Payment Experiment: Slow Start Shows Problems In Implementing New Payment Models

By Peter S. Hussey, M. Susan Ridgely and Meredith B. Rosenthal
Health Affairs, November 2011

As mandated by the Affordable Care Act of 2010, the Centers for Medicare and Medicaid Services recently announced a national Medicare bundled payment initiative. There is strong support for bundled payment on conceptual grounds. However, there is only limited empirical evidence to support the use of bundled payment, and concerns have been raised about the feasibility of its implementation.

This paper presents findings from an evaluation of the initial “road test” of PROMETHEUS Payment. PROMETHEUS (an acronym for Provider Payment Reform for Outcomes, Margins, Evidence, Transparency, Hassle Reduction, Excellence, Understandability, and Sustainability) is a bundled payment model managed and implemented by the Health Care Incentives Improvement Institute, a nonprofit organization.

After three years of implementing systems and processes to support a bundled payment model, pilot participants have yet to make bundled payments or execute new payment contracts.

PROMETHEUS was designed to pay for all of the care required to treat a defined clinical episode, particularly those services recommended by clinical guidelines or experts. The multiple services that are anticipated to be required under a particular episode of care are referred to as “bundles.”

PROMETHEUS has defined twenty-one bundles that include chronic medical conditions such as diabetes, acute medical conditions such as acute myocardial infarction, and procedures such as hip replacement.

Our data collection occurred over the years 2009–11.

Progress of the pilots

As of May 2011, none of the pilot sites had achieved the goal of using PROMETHEUS as a payment method or had executed bundled payment contracts between payers and providers. The participants expressed disappointment at the slow progress, which for some lagged months or years behind their planned milestones.

Bundled payment is complex and must build on existing complex health care systems. As implemented, PROMETHEUS builds on fee-for-service claims infrastructure and thus adds to the complexity of existing payment systems. Services that are part of a clinical episode, and thus subject to bundled payment, are identified using the information about the patient’s diagnoses and services that providers report on fee-for-service insurance claims. The same information is also used to classify each service as either typical care or a potentially avoidable complication.

The decision rules that determine whether specific services are part of a bundle and, if so, whether they constitute typical care or potentially avoidable complications are complex and depend on the quality of the information that providers include on claims, which are not designed with the needs of a bundled payment system in mind.

Identifying bundles during claims processing is important not only so that payments can be processed appropriately by insurers, but also so that providers can rapidly receive information on their patients who had initiated clinical episodes subject to bundled payment. No site succeeded in modifying its claims processing methods to identify bundled services using the PROMETHEUS Engine or an alternative.

Executing contracts is difficult because of the number and complexity of considerations involved, including the market power – or lack thereof – of individual payers and providers in their own health care markets.

Shared savings has turned out to be more difficult to implement than expected. Interviewees at two sites reported that neither payers nor providers were eager to set aside funds from which to make the bonus payments. In addition, some payers did not accept the idea that they should share any savings.

All three sites are using electronic health records as a crucial component of their strategies for care redesign. However, the sites have found that their record systems lack key capabilities that would enable more effective care redesign.

Providers in all three sites have begun planning and implementing care delivery before payment methods actually change. However, they recognize that without new payment incentives in place, these efforts will be limited because they may decrease provider revenues.

We found that the PROMETHEUS road test encountered major challenges, and none of the pilot sites had made bundled payments as of May 2011. The pilot has taken longer than expected to implement primarily because of the complexity of the model and the fact that it builds on existing complex health care systems. Despite efforts by the institute and the pilot sites, some of the most prominent issues that have been raised with respect to bundled payment remained obstacles to implementation.

The debate we observed about how payers and providers should share risk around episodes of care mirrors the current debate about the final form of accountable care organization risk-sharing regulations.

http://content.healthaffairs.org/content/30/11/2116.abstract

Comment: 

By Don McCanne, MD

The PROMETHEUS Bundled Payment Experiment held the promise of improving the quality of care while controlling costs simply by bundling together services of multiple health care providers into a single package covering a specific acute or chronic disorder. After three years of implementation, the payers and providers have not been able to make bundled payments or execute new payment contracts. The experiment is an abject failure.

The authors of this report suggest that the experiment has been of value because the participants have learned lessons, and they understand the complex obstacles to implementation, even if they were unable to surmount them. They conclude, “Payment and delivery reform models may yet yield desired improvements in health care quality and spending, but notable gains may not come quickly or easily.”

It is so clear that the health reform efforts to date have been a fiasco, and yet what do we do? We diddle around playing the PROMETHEUS board game, trying to get past “Go” so we can collect $200, but without going to jail (though perhaps some players should).

It is long past time to get serious about reform. We have more than enough money to finance a premier health care delivery system for everyone. We simply need to start spending our health care dollars more wisely, by enacting a financing system that places patients first – a single payer national health program (Improved Medicare for All).

The PROMETHEUS Bundled Payment Experiment

The PROMETHEUS Bundled Payment Experiment: Slow Start Shows Problems In Implementing New Payment Models

By Peter S. Hussey, M. Susan Ridgely and Meredith B. Rosenthal
Health Affairs, November 2011

As mandated by the Affordable Care Act of 2010, the Centers for Medicare and Medicaid Services recently announced a national Medicare bundled payment initiative. There is strong support for bundled payment on conceptual grounds. However, there is only limited empirical evidence to support the use of bundled payment, and concerns have been raised about the feasibility of its implementation.

This paper presents findings from an evaluation of the initial “road test” of PROMETHEUS Payment. PROMETHEUS (an acronym for Provider Payment Reform for Outcomes, Margins, Evidence, Transparency, Hassle Reduction, Excellence, Understandability, and Sustainability) is a bundled payment model managed and implemented by the Health Care Incentives Improvement Institute, a nonprofit organization.

After three years of implementing systems and processes to support a bundled payment model, pilot participants have yet to make bundled payments or execute new payment contracts.

PROMETHEUS was designed to pay for all of the care required to treat a defined clinical episode, particularly those services recommended by clinical guidelines or experts. The multiple services that are anticipated to be required under a particular episode of care are referred to as “bundles.”

PROMETHEUS has defined twenty-one bundles that include chronic medical conditions such as diabetes, acute medical conditions such as acute myocardial infarction, and procedures such as hip replacement.

Our data collection occurred over the years 2009–11.

Progress of the pilots

As of May 2011, none of the pilot sites had achieved the goal of using PROMETHEUS as a payment method or had executed bundled payment contracts between payers and providers. The participants expressed disappointment at the slow progress, which for some lagged months or years behind their planned milestones.

Bundled payment is complex and must build on existing complex health care systems. As implemented, PROMETHEUS builds on fee-for-service claims infrastructure and thus adds to the complexity of existing payment systems. Services that are part of a clinical episode, and thus subject to bundled payment, are identified using the information about the patient’s diagnoses and services that providers report on fee-for-service insurance claims. The same information is also used to classify each service as either typical care or a potentially avoidable complication.

The decision rules that determine whether specific services are part of a bundle and, if so, whether they constitute typical care or potentially avoidable complications are complex and depend on the quality of the information that providers include on claims, which are not designed with the needs of a bundled payment system in mind.

Identifying bundles during claims processing is important not only so that payments can be processed appropriately by insurers, but also so that providers can rapidly receive information on their patients who had initiated clinical episodes subject to bundled payment. No site succeeded in modifying its claims processing methods to identify bundled services using the PROMETHEUS Engine or an alternative.

Executing contracts is difficult because of the number and complexity of considerations involved, including the market power – or lack thereof – of individual payers and providers in their own health care markets.

Shared savings has turned out to be more difficult to implement than expected. Interviewees at two sites reported that neither payers nor providers were eager to set aside funds from which to make the bonus payments. In addition, some payers did not accept the idea that they should share any savings.

All three sites are using electronic health records as a crucial component of their strategies for care redesign. However, the sites have found that their record systems lack key capabilities that would enable more effective care redesign.

Providers in all three sites have begun planning and implementing care delivery before payment methods actually change. However, they recognize that without new payment incentives in place, these efforts will be limited because they may decrease provider revenues.

We found that the PROMETHEUS road test encountered major challenges, and none of the pilot sites had made bundled payments as of May 2011. The pilot has taken longer than expected to implement primarily because of the complexity of the model and the fact that it builds on existing complex health care systems. Despite efforts by the institute and the pilot sites, some of the most prominent issues that have been raised with respect to bundled payment remained obstacles to implementation.

The debate we observed about how payers and providers should share risk around episodes of care mirrors the current debate about the final form of accountable care organization risk-sharing regulations.

http://content.healthaffairs.org/content/30/11/2116.abstract

The PROMETHEUS Bundled Payment Experiment held the promise of improving the quality of care while controlling costs simply by bundling together services of multiple health care providers into a single package covering a specific acute or chronic disorder. After three years of implementation, the payers and providers have not been able to make bundled payments or execute new payment contracts. The experiment is an abject failure.

The authors of this report suggest that the experiment has been of value because the participants have learned lessons, and they understand the complex obstacles to implementation, even if they were unable to surmount them. They conclude, “Payment and delivery reform models may yet yield desired improvements in health care quality and spending, but notable gains may not come quickly or easily.”

It is so clear that the health reform efforts to date have been a fiasco, and yet what do we do? We diddle around playing the PROMETHEUS board game, trying to get past “Go” so we can collect $200, but without going to jail (though perhaps some players should).

It is long past time to get serious about reform. We have more than enough money to finance a premier health care delivery system for everyone. We simply need to start spending our health care dollars more wisely, by enacting a financing system that places patients first – a single payer national health program (Improved Medicare for All).

Does the U.S. Have the World's Best Health Care System?

By Wendell Potter
CommonDreams.org, Nov. 29, 2011

A little more than a year ago, on the day after the GOP regained control of the House of Representatives, Speaker-to-be John Boehner said one of the first orders of business after he took charge would be the repeal of health care reform.

“I believe that the health care bill that was enacted by the current Congress will kill jobs in America, ruin the best health care system in the world, and bankrupt our country,” Boehner said at a press conference. “That means we have to do everything we can to try to repeal this bill and replace it with common sense reforms to bring down the cost of health care.”

Boehner is not the first nor the only Republican to try to make us believe that the U.S. has the world’s best health care system and that we’re bound to lose that distinction because of Obamacare. I’ve heard GOP candidates for president say the same thing in recent months, charging that we need to get rid of a President who clearly is trying to fix something that doesn’t need fixing, something that isn’t broken in the first place.

Well, those guys need to get out more. Out of the country, in fact. They need to travel to at least one of the many countries that are doing a much better job of delivering high quality care at much lower costs than the good old USA.

If they’re not interested in a fact-finding mission abroad, then perhaps they might take a look at two recent reports before they make any other statements about the quality of American health care.

Last week, the 34-nation Organization for Economic Cooperation (OECD) released the results of its most recent study of the health care systems in its member countries, including the U.S., plus six others, for a total of 40. And those results are illuminating.

If Boehner and his fellow Republicans had characterized the U.S. system as the most expensive in the world, they would have been right on target. But they would have been way off base by calling it the best.

The OECD report is just the most recent evidence that Americans are not getting nearly as much bang for the health care buck as citizens of most other developed countries — and even some countries in the developing world.

The OECD found that the United States spends two-and-a-half times more on health care per person than the OECD average. The U.S. even spends more than twice as much as France, which many experts contend has one of the best health care systems on the planet.

The average expenditure per person in the U.S. is $7,960, a third more than in Norway, the second highest. The OECD average, by comparison, is just $3,233. (It is $3,873 in France.)

Here are some reasons why: Hospital spending is 60 percent higher than the average of five other relatively expensive countries (Switzerland, Canada, Germany, France and Japan); spending on pharmaceuticals and medical goods is much higher here than any of the other countries; and administrative costs are more than two-and-a-half times the average of the others.

It was not all bad news for us. We’re number one in the five-year breast cancer survival rate and number two (behind Japan) in the five-year colorectal cancer survival rate. We’re also number one in costly knee replacements and number two (again behind Japan) in the number of MRI units per million people.

But we rank 29th in the number of hospital beds per person and 29th in the average length of a stay in the hospital. And we have high rates of avoidable hospital admissions for people with asthma, lung disease, diabetes, hypertension and other common illnesses.

When it comes to access to physicians, we’re also near the bottom of the pack. We rank 26th in the number of physicians, especially primary care or family doctors, per 1,000 people.

In terms of life expectancy, we rank 28th, just behind Chile. The average age of death in the U.S. is 78.2, well below the average of 79.5 years in the other OCED countries.

The OECD study backs up the results of a report released by the Commonwealth Fund in October, which showed that the U.S. is actually losing ground to other countries in assuring that its citizens have equal access to affordable, efficient care.

The Commonwealth Fund “scorecard” found that the U.S. is failing to keep up with gains in health outcomes made by other nations. We now rank last out of 16 countries in the Commonwealth Fund study when it comes to deaths that could have been prevented by timely and effective medical care.

A big reason for the dismal results is the fact that more and more Americans are falling into the ranks of the uninsured and underinsured. As of last year, according to the Commonwealth Fund, 81 million adults in the U.S. — 44 percent of all adults under age 65 — were either uninsured or underinsured at some point during the year, up from 61 million as recently as 2003.

So the next time you hear a politician claim that the U.S. has the best health care system in the world, be aware that he or she is trying to get you to believe something that is demonstrably not true, undoubtedly for no reason other than to advance their political agenda. We deserve better — in both rhetoric and results.

Wendell Potter is former vice president of corporate communications at CIGNA, one of the United States’ largest health insurance companies. In June 2009, he testified against the HMO industry in the U.S. Senate as a whistleblower. He is now the Senior Fellow on Health Care for the Center for Media and Democracy in Madison, Wisconsin.

http://www.commondreams.org/view/2011/11/29-6

Vt. gets $18M for health exchange

By CHRIS GAROFOLO
Brattleboro Reformer, Wednesday, November 30, 2011

BRATTLEBORO — The U.S. Department of Health and Human Services announced on Tuesday Vermont will receive more than $18 million to fund the design and development of a larger health benefits exchange to serve as the foundation for the state’s future single-payer plan.

Thirteen states received grants to establish affordable insurance exchanges — a so-called one-stop online marketplace where consumers can choose a private health insurance plan fitting their individual insurance needs — to provide more flexibility and resources within the Affordable Care Act.

Overall, the federal $220 million in Affordable Insurance Exchange grants will help uninsured citizens buy private health insurance through online marketplaces.

“This is what we hoped for,” said State Rep. Mike Mrowicki, D-Putney, who was recently appointed to the Health Access Oversight Committee.

“It’s part of the plan that we’re hoping to take to the next step in creating our exchange and continuing along that path of being ready to, either 2014 or 2017, implement our new health care system,” he added. “I think it vindicates support for what we’re going here in Vermont and trying to help us move forward. I think it’s actually a great opportunity for Vermont because there are some states that are actually stepping back and that leaves more room for Vermont to be in the forefront of health care reform.”

The Vermont Agency of Human Services will use the funds to design a Health Benefits Exchange to work with consumers and other interested parties to continue insurance market reforms and develop new information technology systems.

Funding will also pay for a number of staff positions to ensure exchange implementation activities and coordination work moving forward.

According to Vermont’s Director of Health Care Reform Robin Lunge, the state intends to continue moving forward in the design of a benefits exchange to provide a platform for the evolution of the envisioned single-payer health care system.

“We’re very excited to get the federal funding that we were looking forward to. We’re continuing in the next steps for designing the health benefits exchange,” Lunge said. “We see the federal health benefit exchange as the way to create the foundation for the single-payer system. So we get the federal support to create state-of-the-art information technology systems (for example) and to help us design the next step in health benefits through the exchange.”

Gov. Peter Shumlin, a first-term Democrat, said the federal grant is a critical step toward overhauling the health care system within Vermont.

“This was great news from Washington because the $18 million federal grant will enable us to create an easy-to-use web-based system to help people find health care benefits, plan for affordable benefit packages for Vermonters, and more,” Shumlin said. “This grant will move us further along the path toward a single-payer health care system in Vermont that controls skyrocketing costs threatening Vermont families and businesses.”

The Shumlin administration said Vermont’s health benefit exchange will vastly simplify the insurance purchasing and enrollment programs beginning as soon as 2014. The state plans to convert the exchange by 2017 to a public, single-payer health care model.

For Vermont lawmakers, the arrival of the federal money is perfect timing. The state is in the process of designing a single-payer, publicly-financed system that will provide insurance to all Vermonters.

The Legislature passed the reform measure this spring, which set up a five-member Green Mountain Care Board to design a cost containment system and how the state will deliver the services.

Critics have questioned how Vermont’s government can afford such a program and fear businesses may flee the state, leaving future economic growth in jeopardy. Nevertheless, advocates for the groundbreaking legislation say this federal boost helps keep Vermont on the right track.

Said Lunge: “In terms of moving toward single-payer, I think what most people should keep in mind is that we see single-payer as an opportunity.”

Lawmakers against the health care reforms question having federal money establish a benefits exchange in Vermont that will be replaced by a single-payer system within the next four to six years.

The federal health and human services department reported more than half of the states are now creating marketplaces to help millions purchase insurance.

“We are committed to giving states the flexibility to implement the Affordable Care Act in the way that works for them,” HHS Secretary Kathleen Sebelius said in a statement. “And exchanges will give consumers more choices and make it easy to compare and shop for insurance plans.”

Establishing an insurance exchange is the first step for state residents to receive federal tax credits and premium subsidies for meaningful health insurance under the federal law. But the program can also manage an insurance exchange eventually to help administer a single-payer system.

U.S. Sen. Patrick Leahy, D-Vt., said in a release the state has proven itself as a national leader on health insurance policy and practice.

“These funds will allow our state to develop a health insurance marketplace that in the short term will help Vermonters choose affordable health insurance, and that in the long term will be a stepping stone to the state’s goal of universal health coverage,” he said. “Today’s difficult economy means fewer Americans have access to health insurance or have the ability to pay for health care. This award will help Vermont move closer to the goal of insurance access for every Vermonter and to address the problem of rising health costs.”

Of the 13 states awarded grants on Tuesday, 12 are receiving Level One status to provide one year of funding to those already making progress using their exchange planning grant. The thirteenth state, Rhode Island, is receiving the first-in-the-nation Level Two grant to offer multi-year funding for states further along in its planning.

Chris Garofolo can be reached at cgarofolo@reformer.com or 802-254-2311 ext. 275.

http://www.reformer.com/ci_19437115

Does ACA's "Basic Health Program" stabilize coverage?

Balancing Coverage Affordability and Continuity under a Basic Health Program Option

By John A. Graves, Ph.D., Rick Curtis, M.P.P., and Jonathan Gruber, Ph.D.
The New England Journal of Medicine, November 30, 2011

According to the Congressional Budget Office, the Affordable Care Act (ACA) will bring health insurance coverage to an estimated 32 million currently uninsured people. It does so through various mechanisms, including an expansion of Medicaid to Americans with incomes up to 138% of the federal poverty level (133% plus a 5% “income disregard”), premium and cost-sharing subsidies for coverage purchased through a new insurance exchange, small-employer tax credits, and an individual mandate to obtain health insurance.

The ACA’s incremental approach to near-universal coverage has raised concerns that changes in income, employment, and family composition will shift people into and out of different coverage arrangements over time – a phenomenon referred to as “churning.” Avoiding disruptions in coverage is an important goal because it can reduce unnecessary administrative costs and improve health plans’ incentives to invest in achieving longer-term health outcomes. Continuity of coverage can also help maintain clinician–patient relationships, especially in places where there are substantial differences between the clinicians participating in Medicaid and those participating only in private plans.

To address concerns about churning, some states are considering adopting a Basic Health Program (BHP) – an ACA-created option modeled after Washington State’s Basic Health Plan. Under this option, a state would receive an annual lump-sum payment equal to 95% of the projected cost of the subsidies for coverage through an insurance exchange for households with incomes between 139 and 200% of the federal poverty level. The state would then assume responsibility for financing a BHP for adults in that income range that met or exceeded the generosity and scope of benefits available in the exchange. A number of states are considering this option, including California, where BHP legislation has already passed the senate and final consideration is planned for 2012.

The eligibility range for a BHP is narrow – and there’s no guarantee that there will be continuity of access for people moving from Medicaid to a BHP, or vice versa. A BHP could theoretically extend access to the same plans and providers as Medicaid does, but in practice, states may find that providers willing to accept reimbursement that is often below their costs for their most indigent patients will be unable or unwilling to do so for an additional population. Moreover, introducing a BHP may create a new point of disruption: although patients might retain their coverage when moving above or below 138% of the poverty level ($30,843 for a family of four in 2011), they would be more likely to have coverage disruptions when moving above or below 200% of the poverty level ($44,700 for a family of four). Such disruptions could occur if the mainstream plans and providers used by people with incomes above 200% of the poverty level do not participate in the BHP. Finally, introducing a BHP would reduce the subsidized population in the insurance exchange by about half, which could compromise its efficiency and market role and reduce the proportion of uninsured people who gain access to mainstream coverage.

To investigate BHPs’ potential for reducing churning between Medicaid and an exchange by acting as a bridge between them, we used data from a dynamic income microsimulation model of the ACA. Since we follow an initially eligible cohort over a 2-year period, we can more easily model relative changes in churning in varied policy environments.

For our analysis, we used a national sample of adults 18 to 61 years of age who were initially uninsured or enrolled in nongroup coverage and who were eligible for subsidized coverage (had an income below 400% of the poverty level). We then simulated eligibility for Medicaid, a BHP, and an exchange in three policy environments: the baseline ACA structure, under which people with incomes up to 138% of the poverty level are eligible for Medicaid and those with higher incomes are eligible for the exchange; an integrated BHP, under which Medicaid and the BHP are run as a single program, with identical plans and providers; and three separate programs, with Medicaid, the BHP, and the exchange all operating independently, with different reimbursement rates, cost-sharing structures, and provider networks. Both Washington State’s original BHP and California’s pending BHP legislation would fit in the third category.

Our main findings are summarized in the Kaplan–Meier curves (see graph, available at link below), which show the overall proportion of subsidized adults who would remain continuously eligible for their initial program over a 24-month period.

As the graph shows, operating separate BHP, Medicaid, and exchange programs substantially increases churning. Under that policy, just 44% of adults remain eligible for their initial program after 1 year and less than one third remain so after 2 years; under the baseline ACA structure, the proportions are 63% and 49%, respectively. Given the dynamic nature of the wages and incomes of adults with moderate incomes, this finding is not entirely surprising: a separate BHP coverage category based on a narrow income range increases the likelihood of eligibility shifts between programs.

Perhaps more striking, however, is our finding that a BHP operating within Medicaid would result in slightly more eligibility losses than would the baseline ACA structure. Although we find that a BHP would reduce churning (i.e., increase retention) at the 138%-of-poverty threshold, there would be a more-than-offsetting increase in churning between the exchange and the Medicaid–BHP at 200% of the poverty level. The net result would be slightly more overall churning than with the baseline ACA structure. Moreover, these program-eligibility shifts would now happen around a “notch” created at 200% of the poverty level, where there are much larger implications for enrollees, in terms of premiums and cost sharing, of moving from Medicaid–BHP to private coverage. For example, a family moving from a Medicaid-like BHP program to the exchange tax-credit structure at 200% of the poverty level could suddenly see the value of its benefits fall by as much as 25% (depending on state decisions about patient cost sharing under the BHP). The ACA’s sliding-scale subsidies were designed to avoid such notches, which create major inequities between people with marginally different incomes and penalize them for additional work and earnings.

Ensuring access to stable and affordable coverage is an important ACA goal. Whether by design or through attrition of willing plans and providers, however, operating a BHP with provider networks different from those of both Medicaid and the exchange could further stratify the low-income and moderate-income population into three separate classes of coverage. As our modeling shows, such stratification would exacerbate the concerns about churning that BHPs were designed to address. Moreover, even a BHP integrated with Medicaid would slightly increase churning overall, with the increased churning around the 200%-of-poverty point more than offsetting the reduced churning around the 138%-of-poverty point. Although various policy considerations should enter into decisions about adopting a BHP, the need to achieve coverage and provider stability is an argument against doing so.

http://www.nejm.org/doi/full/10.1056/NEJMp1111863

Comment: 

By Don McCanne, MD

Section 1331 of the Patient Protection and Affordable Care Act (ACA) authorizes states to establish “basic health programs” to cover individuals with incomes between 133% and 200% of th
e federal poverty level, who are not otherwise eligible for Medicaid. The primary thrust of ACA is to cover many of the currently uninsured by expanding Medicaid and by establishing new state health exchanges offering private health plans. This NEJM article evaluates whether adding a third option – a basic health program – would improve stability and continuity of coverage for this low-income sector.

This is an important question since setting up an additional program adds considerable administrative costs and complexity to our health care financing system. The brief answer is “no.” After two years with three separate programs, less than one-third would still be in the programs in which they were originally enrolled.

Suppose the states decided against establishing basic health programs, what would happen under the baseline ACA structure with just Medicaid and the private exchange plans? Half of individuals would no longer be in their initial programs. This is only over a period of two years. Because of continual fluctuations in eligibility (changing income levels, etc.), stability over a decade or two would be virtually nonexistent.

This instability can be quite disruptive. Between Medicaid, basic health programs, and private exchange plans, there may be little or no overlap in provider networks. A change in coverage could also have a major impact on out-of-pocket expenses required of the insured individuals.

One intent of the basic health programs would be to save the government money by paying providers at levels close to those of Medicaid. Many physicians already reject Medicaid because of these low rates. Adding many more new patients to the Medicaid program, plus introducing an entirely new, under-funded, basic health program, would surely cause providers to flee both Medicaid and the basic health programs. The patients might have a basic health ticket, but nowhere to use it.

The entire ACA infrastructure is irreparably fragmented and dysfunctional. It needs to be replaced with… yes, an improved Medicare for all.

Teaneck, NJ, calls for immediate enactment of HR 676, national single payer health care

By Kay Tillow
All Unions Committee For Single Payer Health Care–HR 676, November 30, 2011

Paula Friedman, Chair of the Retiree Committee of the Bergen County Central Trades and Labor Council in New Jersey, reports that their latest victory is the successful passage of a resolution by the Township of Teaneck calling for the “immediate enactment” of HR 676, national single payer health care legislation introduced by Congressman John Conyers (D-MI).

The resolution notes that HR 676 “would assure universal coverage of all medically necessary services, contain costs by slashing bureaucracy, protect the doctor-patient relationship, (and) assure patients a completely free choice of doctors….”  Teaneck Council Member Elie Katz made the motion that was seconded by Council Member Monica Honis.  The vote was unanimous.

The HR 676 Resolution states that “the rising cost of insuring public employees can be reduced and best met not by limiting benefits but by providing benefits under a national, publicly-funded health insurance program…”  This is particularly important to New Jersey where the attacks on public employee benefits have been massive.

In addition, the resolution states that “the complex bureaucracy arising from our fragmented, for-profit, multi-payer system of healthcare financing consumes approximately thirty percent (30%) of the United States health care spending while the single-payer Medicare system has administrative cost of less that 5%…” and that “managed care and other market-based reforms have failed to contain healthcare costs, which now threaten the international competitiveness of U. S. manufacturers…”

Friedman said that the Retiree Committee has been working to educate municipal governments in Bergen County and seeking their endorsement for HR 676,  also known as Expanded and Improved Medicare for All.  The committee is made up of representatives from the UAW, Teamsters, Sheetmetal Workers, AFT, Letter Carriers, CWA, and Lithographers, among others..

Friedman encourages unions, labor councils, and retiree councils across the country to endorse HR 676 and then pick up this campaign to win cities and states to also endorse.

The Teaneck Resolution is here:
http://unionsforsinglepayer.org/files/other_endorsers/Teaneck_NJ_Resolution.pdf

The list of union endorsers of HR 676 is here:
http://unionsforsinglepayer.org/union_endorsers

Sample union resolution for HR 676:
http://unionsforsinglepayer.org/files/union_endorsers/sample_resolution.doc

City Councils and State Legislatures endorsing HR 676:
http://unionsforsinglepayer.org/more

Protect the Sick: Health Insurance Reform in One Easy Lesson

By Deborah Stone
Journal of Law, Medicine & Ethics, 2008 Winter;36(4):652-9, 607

In most other nations, insurance for medical care is called sickness insurance, and it covers sick people. In the United States, we have “health insurance,” and its major carriers — commercial insurers, large employers, and increasingly government programs — strive to avoid sick people and cover only the healthy. This perverse logic at the heart of the American health insurance system is the key to reform debates.

Click to download and read the entire article.

More than 2,400 doctors, nurses and health advocates denounce Institute of Medicine’s health coverage recommendations

IOM panel ‘riddled with conflicts of interest’ in violation of agency’s own guidelines, signers of protest letter charge

FOR IMMEDIATE RELEASE
Dec. 1, 2011

Contact:
Steffie Woolhandler, M.D., M.P.H.
Oliver Fein, M.D.
Danny McCormick, M.D., M.P.H.
Mark Almberg, PNHP, (312) 782-6006, mark@pnhp.org

In a letter (appended below) sent to Secretary of Health and Human Services Kathleen Sebelius and posted on the Internet today, more than 2,400 physicians, nurses and other health advocates condemn the recommendations of an Institute of Medicine (IOM) committee regarding the “essential benefits” to be mandated under the 2010 federal health reform law.

The signers, most of whom are physicians, charge the committee’s recommendations amount to prescribing skimpy coverage that would “sacrifice many lives and cause much suffering,” and urge the Obama administration to reject them.

“The IOM panel endorsed insurance coverage similar to that offered by small employers rather than the more comprehensive coverage offered by large employers,” said Dr. Danny McCormick, an internist, assistant professor at Harvard Medical School and former IOM fellow who helped circulate the letter. “The recommendation was widely viewed as a victory for the health insurance industry, which has long opposed mandating comprehensive benefits.”

The panel also recommended that coverage under the new law be defined by a premium target – an approach often called “defined contribution” – rather than by a list of medically necessary benefits, McCormick said.

The protest letter accuses the IOM panel of being “riddled with conflicts of interest” and notes that many of the panel members have “amassed personal wealth through their involvement with health insurers and other for-profit health care firms” whose businesses would be affected by the panel’s recommendations.

The IOM committee’s members include Sam Ho, executive vice president of UnitedHealthcare; Leonard D. Schaeffer, director of the biotechnology company Amgen and former chairman and CEO of WellPoint (Schaeffer’s family foundation donated $2 million to the IOM in 2010); as well as executives from 3M Health Information Systems, a medical supplier, Milliman Inc., an actuarial consulting firm with close ties to the insurance industry, and The Blackstone Group, a private equity firm with major health care interests. The IOM’s full list of panel’s members, with a partial listing of their affiliations, is accessible here.

“Many committee members’ strong ties to the health industry violate the guidance offered in a 2009 report issued by the IOM which recommended that those with industry conflicts of interest should generally be excluded from such panels,” said Dr. Steffie Woolhandler, professor of public health at the City University of New York and visiting professor of medicine at Harvard Medical School, who served as an IOM fellow in 1990-1991. Woolhandler also circulated the letter.

The signers of the protest letter include several prestigious members of the IOM, as well as several former fellows. The letter was first circulated to colleagues by attendees at the IOM’s annual meeting near Washington in October. After learning of the letter, IOM officials instructed security officers to block its distribution at the meeting.

The letter was also circulated by Physicians for a National Health Program, which advocates for a single-payer health system, and by other health professional groups.

Besides being submitted to Secretary Sebelius and other administration officials, the letter has been accepted for publication in the International Journal of Health Services, Woolhandler said.

An Open Letter to Secretary Sebelius and President Obama regarding the Institute of Medicine’s recommendations on the Essential Benefits under the 2010 Health Reform Law

We protest the Institute of Medicine’s (IOM) recommendation that cost rather than medical need be the basis for defining the “essential benefits” that insurance policies must cover when the federal health reform law takes effect in 2014. If adopted by the Department of Health and Human Services, this recommendation will sacrifice many lives and cause much suffering. We call on Secretary Sebelius and President Obama to reject them.

The IOM proposal would base the required coverage on the benefits typical of plans currently offered by small businesses – enshrining these skimpy plans as the new standard. These bare-bones policies come with a long list of uncovered services and saddle enrollees with unaffordable co-payments and deductibles.

Already, millions of underinsured Americans forgo essential care: adults with heart attacks delay seeking emergency care1; children forgo needed primary and specialty care2; patients fail to fill prescriptions for lifesaving medications3; and serious illness often leads to financial catastrophe4.

The inadequate coverage the IOM recommends would shift costs from corporate and government payers onto families already burdened by illness. Yet this strategy will not lower costs. Delaying care often creates even higher costs. Steadily rising co-payments and deductibles over the past two decades have failed to stem skyrocketing medical inflation. And nations that assure comprehensive coverage – with out-of-pocket costs a fraction of those in the United States – have experienced both slower cost growth and greater health gains than our country.

Our patients urgently need what people in these other nations already enjoy: universal and comprehensive coverage in a nonprofit system that prioritizes human need over corporate profit.

The IOM committee was riddled with conflicts of interest, many members having amassed personal wealth through their involvement with health insurers and other for-profit health care firms. Its recommendations were lauded by insurance industry leaders who have sought to undermine real health reform at every turn. As the Lancet noted on its Dec. 5, 2009, cover: “Corporate influence renders the U.S. government incapable of making policy on the basis of evidence and the public interest.”5

Sadly, the committee’s damaging recommendations suggest that this corporate bug has also infected the IOM.

1. Smolderen KG, Spertus JA, Nallamothu BK et al. Health Care Insurance, Financial Concerns in Accessing Care, and Delays to Hospital Presentation in Acute Myocardial Infarction. JAMA 2010;303:1392-1400.

2. Kogan MD, Newacheck PW, Blumberg SJ et al. Underinsurance among Children in the United States. N Engl J Med 2010;363:841-51.

3. Doty MM, Edwards JE, Holmgren AL. Seeing Red: Americans Driven into Debt by Medical Bills. The Commonwealth Fund, August 2005.

4. Himmelstein DU, Thorne D, Warren E, Woolhandler S. Medical Bankruptcy in the United S
tates, 2007: Results of a National Study. Am J Med 2009;122:741-6.

5. Cover. The Lancet: Volume 374, Number 9705, 5 December 2009.

Physicians for a National Health Program (www.pnhp.org) is an organization of more than 18,000 doctors who support single-payer national health insurance. To speak with a physician/spokesperson in your area, visit www.pnhp.org/stateactions or call (312) 782-6006.

Don't Buy Insurers' Junk — Or Let Them Keep Selling It

By Wendell Potter
PRWatch, October 24, 2011 – 2:24pm

Members of Congress and the Obama administration have assured us that on January 1, 2014, junk health insurance plans — which offer only the illusion of adequate coverage to the millions of Americans enrolled in them — will become a thing of the past.

Among those who clearly don’t believe those plans are headed for extinction are the insurance companies that market these highly profitable plans, and the employers that buy them — primarily restaurant chains and retailers with high employee turnover.

If I were President Obama, I would send one of my aides to the Chicago suburbs later this week to see first-hand just how determined these companies are to continue selling these plans — which are euphemistically called “mini-med” and “limited-benefit policies” — long past 2014.

On Wednesday, the third annual Voluntary Benefits and Limited Medical Conference will open at the Marriott Renaissance Schaumburg Convention Center, not far from Chicago’s O’Hare Airport. In just three years, this conference has grown to be a very big, three-day extravaganza. According to the conference website, it will “bring together all the players in the industry, from employers and benefits managers, to insurance agents, consultants, brokers, insurance companies, TPAs (third-party administrators), and enrollment firms.”

All you have to do is spend a few minutes on the website to get an understanding of just how much money there is to be made selling inadequate coverage to naive consumers. You’ll see all the big names in the insurance world among the attendees and exhibitors, including the very biggest — Aetna, Blue Cross and Blue Shield, CIGNA, Humana and United — as well as dozens of restaurant and fast food chains and other employers of low-wage workers.

Maybe Obama himself should plan a trip to his hometown and crash the party. He would learn a lot more about the future of health care benefits as envisioned by the insurance industry and a big segment of corporate America than if he stayed in Washington.

Insurers’ Latest Scam: Fake Insurance

One of the reasons I left my job as an insurance industry executive is because I could not in good conscience continue promoting these plans, which all but guarantee that the people who enroll in them immediately join the fast-growing ranks of the underinsured.

Even calling them insurance is a stretch. Many of them have annual coverage caps of $2,000, meaning that after the insurer has paid $2,000 in claims, the policyholder is on the hook for all other medical expenses. And a lot of these policies provide no coverage whatsoever for a stay in the hospital. This is why consumer advocates refer to them as junk or fake insurance. People who enroll in them often have been sold a false sense of security, only to find out when it’s too late that they’ve been sending hard-earned money to insurance companies whose executives are laughing all the way to the bank while consumers are on their way to bankruptcy court.

One of the big for-profit insurers sponsoring this year’s conference markets a limited-benefit plan only to employers with inordinately high employee turnover. Not only are the benefits very limited, the underwriting criteria almost guarantee an impressive profit margin.

Under the plan, the average age of an employer’s workers cannot be higher than 40, and no more than 65 percent of employees can be female. (Insurers have long charged women more than men simply because of their internal plumbing.) To meet the insurer’s additional demands, employers must have a 70 percent or higher annual employee-turnover rate (that’s not a typo), which means that most employees won’t even stay on the job long enough to use their benefits. Employees also get no coverage for care related to any preexisting conditions they might need during their first six months of enrollment in the plan. And get this: Employees have to pay the entire premium. The insurer doesn’t even allow employers to subsidize their workers’ coverage. No wonder the big box retailers and restaurant chains love this junk. They list them among the employee benefits they supposedly offer but don’t have to part with a dime when a worker enrolls in one of the plans.

There are so many restrictions built into limited-benefit contracts that there is comparatively little risk to the companies that sell them, which is why the Obama administration is under intense pressure from insurers and their corporate customers to let them keep on selling them.

Will President Obama Force Americans to Buy Junk Insurance?

One of the provisions of the Affordable Care Act that is supposed to kill these plans off requires insurers to spend at least 80 percent of what they collect in premiums on their policyholders’ medical care. Insurers typically spend far less than that on medical care for people enrolled in limited-benefit plans. That’s why they are so profitable.

As I write this, the insurance industry and its corporate allies are lobbying the Obama administration to grant limited-benefit plans permanent waivers from that provision. If the White House caves in to their demands, millions of low-wage earners will be forced to buy junk coverage on January 1, 2014. That’s the date all of us will have to buy coverage from a private insurer if we’re not eligible for a public plan like Medicare or Medicaid. If you don’t want to be forced to buy junk, send the White House a message. Now.

http://www.prwatch.org/news/2011/10/11093/dont-buy-insurers-junk-or-let-them-keep-selling-it