PNHP

Follow-Up Appointments Often Hard to Arrange

Follow-Up Appointments Often Hard to Arrange

Obtaining follow-up psychiatric care in the Boston area can be a serious challenge, even for patients with good private insurance.

By Mark Moran
Psychiatric News, September 16, 2011 (Volume 46 Number 18 Page 22)

A survey of mental health facilities in the Boston area by individuals posing as patients recently discharged from an emergency department with mental illness found a remarkably low rate of available follow-up appointments—a finding that may come as no surprise to psychiatrists in every area of the country.

The survey, published as a letter to the editor in the August Annals of Emergency Medicine, found that of 64 sites that were contacted, only eight offered appointments, and only four offered “patients” an appointment within a two-week period.

“Disappointing but not surprising” is how psychiatrist J. Wesley Boyd, M.D., Ph.D., the lead author of the letter, described the results in an interview with Psychiatric News. “What this speaks to in my mind is the under- or de-valuation of psychiatric care.”

He is with the Cambridge Health Alliance Department of Psychiatry and the Department of Psychiatry at Children’s Hospital Boston.

Two study personnel (including a psychiatry resident who was also a coauthor of the letter and a college student applying to medical school) posed as patients insured by the Blue Cross Blue Shield of Massachusetts Preferred Provider Organization, the largest insurer in Massachusetts. They called every in-network mental health facility within a 10-mile radius of downtown Boston, claiming to have been evaluated in an emergency department (ED) for depression and discharged with instructions to obtain a psychiatric appointment within two weeks.

According to Boyd, when necessary the “patients” left a message and made a second call attempt.

(“Facilities” contacted in the survey included mental health clinics, hospitals with psychiatric departments, and neighborhood clinics in the Boston area.)

Boyd explained that the survey was originally designed to be a comparison of private insurance and Medicaid, and because reimbursement is so low in the Massachusetts Medicaid plan that virtually no private practice psychiatrists participate, the survey was confined to facilities and did not include private-practice clinicians.

The phone calls were first made to the Blue Cross facilities, and the results were so poor that Boyd and his students did not proceed with calling the Medicaid facilities.

The principal reasons for failure to make an appointment were that calls were not returned or that the facility required patients to have an in-system primary care provider. Six sites stated that they needed more information before scheduling an appointment.

Assuming that the six sites would have offered timely appointments, Boyd estimated that the highest number of facilities that would have had appointments available within the two-week period for all 64 sites that were called was 10 (15.6 percent).

He also added that the requirement by facilities that patients have an in-system primary care provider is one that does not typically apply to any other medical service and constitutes what he called a form of “stealth rationing.”

“Psychiatry is underreimbursed and a money-losing specialty for hospitals, yet they have to offer psychiatric services,” he noted. “So how do you limit the [financial] pain? By limiting the access as much as possible. That doesn’t happen if people need cataract surgery or a hip replacement or an MRI.”

In the Annals letter, Boyd stated that a third of homeless individuals and more than half of all prison and jail inmates have mental illness and that the nation’s EDs have become “de facto psychiatric wards, with 79 percent of emergency physicians reporting that their hospitals board psychiatric patients for whom appropriate treatment resources could not be found, sometimes for days.”

In remarks to Psychiatric News, Boyd said an architect friend of his who designs hospitals has informed him that he now designs EDs to include space and beds for boarded psychiatric patients. “So we are now actually designing emergency departments with space and room for boarding patients who can’t get care,” he said.

The causes of this dearth of available follow-up care are multiple, but Boyd said a principal problem is the low reimbursement for psychiatric care. “We call for higher reimbursement,” he said. “That is more than an economic issue; it is a social and cultural and political issue. We are reimbursing poorly for services necessary to patients who can’t adequately advocate for themselves, something that speaks very poorly of our culture.”

“The Crisis in Mental Health Care: A Preliminary Study of Access to Psychiatric Care in Boston” is posted at http://www.annemergmed.com/article/S0196-0644(11)00346-5/fulltext

http://pn.psychiatryonline.org/content/46/18/22.1.full?sid=242cc82f-f769-4d32-b9e4-50f286f5df3e

Marmor, Mashaw, and Lakoff – the language of egalitarianism has been hijacked

How Do You Say ‘Economic Security’?

By Theodore R. Marmor and Jerry L. Mashaw
The New York Times, September 23, 2011

In the face of nothing but bad economic news, Americans often take heart in remembering that we have been here before — during the Great Depression, when conditions were far worse than they are today — and we survived.

But there is a crucial difference between then and now: the words that our political leaders use to talk about our problems have changed. Where politicians once drew on a morally resonant language of people, family and shared social concern, they now deploy the cold technical idiom of budgetary accounting.

This is more than a superficial difference in rhetoric. It threatens to deprive us of the intellectual resources needed to address today’s problems.

In 1934, the government was us. We had shared circumstances, shared risks and shared obligations. Today the government is the other — not an institution for the achievement of our common goals, but an alien presence that stands between us and the realization of individual ambitions. Programs of social insurance have become “entitlements,” a word apparently meant to signify not a collectively provided and cherished basis for family-income security, but a sinister threat to our national well-being.

Over the last 50 years we seem to have lost the words — and with them the ideas — to frame our situation appropriately.

Can we talk about this? Maybe not.

(Theodore R. Marmor is a professor emeritus of public policy, and Jerry L. Mashaw is a professor of law, both at Yale.)

http://www.nytimes.com/2011/09/24/opinion/how-do-you-say-economic-security.html

And…

The Use of 9/11 to Consolidate Conservative Power: Intimidation via Framing

By George Lakoff
Huff Post Politics, September 10, 2011

From 9/11 on, the American people have been subject to conservative intimidation by framing. I’ve now written five books explaining how framing works in the brain and what citizens could do about it — Moral Politics, Don’t Think of an Elephant, Whose Freedom?, Thinking Points, and The Political Mind. The books were based on results from the cognitive and brain sciences on how reason about social and political issues really works — primarily in terms of morally-based frames, metaphors, and narratives, and only secondarily, if at all, in terms of policy, facts, and logic.

But since the 2008 election, conservative intimidation of the electorate via framing has come back big time, with no adequate Democratic defense against it. With a Democratic president in office, Democrats, both citizens and office-holders, turned their attention to policy and logical, fact-based arguments for the policies. In response to the president’s health care policies, conservatives attacked on the moral front, choosing two moral values from their value system: freedom (“government takeover”) and life (“death panels”). Knowing well that morality trumps lists of policy details, lists of facts, and logic, conservatives won that framing encounter, and have kept winning. Why? Because people, using their real reason, normally think unconsciously in terms of morally based systems of frames, metaphors, and narratives.

Since the 2008 election, America has returned to post-9/11 conservative intimidation by framing. The intimidation does not use violence. It uses media. When conservatives, using their moral system, are able to frame the main values that define public discourse, the media follows suit, because that is how “mainstream” public discourse has been defined. The media, encountering more conservative language, picks up on that language and uses it. Since conservative language evokes conservative frames and values, which are carried with it, the media (liberal or not) winds up helping conservatives. Even arguing against conservatives, liberal pundits in the media first quote what they say. Liberals in the media help the conservatives by quoting their language, even to argue against it.

In the post-2008 return to 9/11 style intimidation by framing, conservatives have been winning. They have protected banks from financial regulation, health insurance companies from government insurance, and corporations from serious environmental regulation. They have successfully attacked the very idea of the public — public education, employees, unions, parks, housing, and safety nets.

Here’s how public intimidation by framing works.

The mechanism of intimidation is framing, not just the use of words or slogans, but rather the changing of what voters take as right as a matter of principle. Framing is much more than mere language or messaging. A frame is a conceptual structure used to think with. Frames come in hierarchies. At the top of the hierarchies are moral frames. All politics is moral. Politicians support policies because they are right, not wrong. The problem is that there is more than one conception of what is moral. Moreover, voters tend to vote their morality, since it is what defines their identity. Poor conservatives vote against their material interests, but for their moral identity.

All language activates frames in the brain. Conservative language activates conservative frames, which activate conservative moral worldviews in the brains of those who hear the language. The more those frames are activated, the stronger the conservative moral views get in people’s brains.

When Democrats are intimidated into using conservative language, they help conservatives, even if they are arguing against them. Here’s why. The main voters you want to affect are the bi-conceptuals, those who are conservative on some issues and progressive on others; that is, those who have both conservative and progressive moral worldviews, but on different issues. They are sometimes misnamed as “the center,” “independents,” or “moderates.” But they do not have any single overriding worldview. Instead they have two. Given the way brains work, the activation of one worldview will inhibit the other worldview. The more one is activated, the stronger it gets and the weaker the opposite one gets. The worldview that is most activated by the public discourse they hear will most likely govern how they will vote. What activates one worldview versus another? Framing. Conservative language activates conservative frames, which activate conservative worldviews. If Democrats use conservative language, even to argue against it, they are just helping conservatives.

To a large extent, Democrats don’t understand this. They think that language is neutral and that reason works by logic. If you just tell people the facts and reason logically, everyone should be convinced. But they aren’t, because language works by framing and by brain mechanisms. Framing is just the normal way people think and talk. Conservatives tend to understand this. They avoid using liberal language. They frame issues very carefully to fit their goals. Democrats need to do the same — avoid using conservative frames and instead frame the issues with their own values.

The conservative consolidation of power violates this most basic of democratic principles. It replaces social and personal responsibility with personal responsibility alone. It approves of the government over our lives by corporations for their own profit, and hence sees government by, of and for the people as immoral and to be eliminated.

The good news is that it doesn’t have to be that way. It is possible for Democrats to learn how frames, narratives, and brains really work. It is possible to take moral stands, with all policies backed up by a single moral vision. It is possible to awaken and strengthen the progressive worldview already present in swing voters who are partly progressive a
s partly conservative (called “independents,” “moderates,” and “the center”). It is possible for Democrats to say what they believe and win, without giving in to intimidation tactics.

http://www.huffingtonpost.com/george-lakoff/the-use-of-911-to-consoli_b_955954.html

Comment:

By Don McCanne, MD

Words. Language. Framing. Egalitarianism? How do you frame that? Is that an American concept? Is that a defining value of democracy? Do our citizens believe that we should strive to ensure that all people have equal rights and opportunities? Or is this a left-wing conspiracy that deprives people of the realization of their individual ambitions? Is it then really just about freedom?

Whatever label you use, the right has gained control of the framing, and framing controls cognitive function. Cognition does not require logic. Those who have been watching the Republican debates have been able to witness cognitive activity that is almost totally devoid of logic, yet the candidates have been well versed on framing. It is the moral worldview of freedom from government that prevails, while dismissing the logic of the great benefits that we receive as a people joining together to establish and operate our own government. This worldview allows them to dismiss the obvious logic of an improved Medicare program that would cover everyone.

We do need to recapture the framing from the conservative ideologues who would destroy as much government functioning as they can. Why they would is beyond the capacity of many of us to understand, but then we are looking for logic where it may not exist.

Do we need to reframe the problems and their potential solutions from a liberal, progressive, Democratic, politically polarized position? Or can we use framing with which the great majority of us can identify? Would framing supporting economic security for everyone work? That’s a moral worldview that is also logical.

Can we talk about this?

Marmor, Mashaw, and Lakoff – the language of egalitarianism has been hijacked

How Do You Say ‘Economic Security’?

By Theodore R. Marmor and Jerry L. Mashaw
The New York Times, September 23, 2011

In the face of nothing but bad economic news, Americans often take heart in remembering that we have been here before — during the Great Depression, when conditions were far worse than they are today — and we survived.

But there is a crucial difference between then and now: the words that our political leaders use to talk about our problems have changed. Where politicians once drew on a morally resonant language of people, family and shared social concern, they now deploy the cold technical idiom of budgetary accounting.

This is more than a superficial difference in rhetoric. It threatens to deprive us of the intellectual resources needed to address today’s problems.

In 1934, the government was us. We had shared circumstances, shared risks and shared obligations. Today the government is the other — not an institution for the achievement of our common goals, but an alien presence that stands between us and the realization of individual ambitions. Programs of social insurance have become “entitlements,” a word apparently meant to signify not a collectively provided and cherished basis for family-income security, but a sinister threat to our national well-being.

Over the last 50 years we seem to have lost the words — and with them the ideas — to frame our situation appropriately.

Can we talk about this? Maybe not.

(Theodore R. Marmor is a professor emeritus of public policy, and Jerry L. Mashaw is a professor of law, both at Yale.)

http://www.nytimes.com/2011/09/24/opinion/how-do-you-say-economic-security.html

And…

The Use of 9/11 to Consolidate Conservative Power: Intimidation via Framing

By George Lakoff
Huff Post Politics, September 10, 2011

From 9/11 on, the American people have been subject to conservative intimidation by framing. I’ve now written five books explaining how framing works in the brain and what citizens could do about it — Moral Politics, Don’t Think of an Elephant, Whose Freedom?, Thinking Points, and The Political Mind. The books were based on results from the cognitive and brain sciences on how reason about social and political issues really works — primarily in terms of morally-based frames, metaphors, and narratives, and only secondarily, if at all, in terms of policy, facts, and logic.

But since the 2008 election, conservative intimidation of the electorate via framing has come back big time, with no adequate Democratic defense against it. With a Democratic president in office, Democrats, both citizens and office-holders, turned their attention to policy and logical, fact-based arguments for the policies. In response to the president’s health care policies, conservatives attacked on the moral front, choosing two moral values from their value system: freedom (“government takeover”) and life (“death panels”). Knowing well that morality trumps lists of policy details, lists of facts, and logic, conservatives won that framing encounter, and have kept winning. Why? Because people, using their real reason, normally think unconsciously in terms of morally based systems of frames, metaphors, and narratives.

Since the 2008 election, America has returned to post-9/11 conservative intimidation by framing. The intimidation does not use violence. It uses media. When conservatives, using their moral system, are able to frame the main values that define public discourse, the media follows suit, because that is how “mainstream” public discourse has been defined. The media, encountering more conservative language, picks up on that language and uses it. Since conservative language evokes conservative frames and values, which are carried with it, the media (liberal or not) winds up helping conservatives. Even arguing against conservatives, liberal pundits in the media first quote what they say. Liberals in the media help the conservatives by quoting their language, even to argue against it.

In the post-2008 return to 9/11 style intimidation by framing, conservatives have been winning. They have protected banks from financial regulation, health insurance companies from government insurance, and corporations from serious environmental regulation. They have successfully attacked the very idea of the public — public education, employees, unions, parks, housing, and safety nets.

Here’s how public intimidation by framing works.

The mechanism of intimidation is framing, not just the use of words or slogans, but rather the changing of what voters take as right as a matter of principle. Framing is much more than mere language or messaging. A frame is a conceptual structure used to think with. Frames come in hierarchies. At the top of the hierarchies are moral frames. All politics is moral. Politicians support policies because they are right, not wrong. The problem is that there is more than one conception of what is moral. Moreover, voters tend to vote their morality, since it is what defines their identity. Poor conservatives vote against their material interests, but for their moral identity.

All language activates frames in the brain. Conservative language activates conservative frames, which activate conservative moral worldviews in the brains of those who hear the language. The more those frames are activated, the stronger the conservative moral views get in people’s brains.

When Democrats are intimidated into using conservative language, they help conservatives, even if they are arguing against them. Here’s why. The main voters you want to affect are the bi-conceptuals, those who are conservative on some issues and progressive on others; that is, those who have both conservative and progressive moral worldviews, but on different issues. They are sometimes misnamed as “the center,” “independents,” or “moderates.” But they do not have any single overriding worldview. Instead they have two. Given the way brains work, the activation of one worldview will inhibit the other worldview. The more one is activated, the stronger it gets and the weaker the opposite one gets. The worldview that is most activated by the public discourse they hear will most likely govern how they will vote. What activates one worldview versus another? Framing. Conservative language activates conservative frames, which activate conservative worldviews. If Democrats use conservative language, even to argue against it, they are just helping conservatives.

To a large extent, Democrats don’t understand this. They think that language is neutral and that reason works by logic. If you just tell people the facts and reason logically, everyone should be convinced. But they aren’t, because language works by framing and by brain mechanisms. Framing is just the normal way people think and talk. Conservatives tend to understand this. They avoid using liberal language. They frame issues very carefully to fit their goals. Democrats need to do the same — avoid using conservative frames and instead frame the issues with their own values.

The conservative consolidation of power violates this most basic of democratic principles. It replaces social and personal responsibility with personal responsibility alone. It approves of the government over our lives by corporations for their own profit, and hence sees government by, of and for the people as immoral and to be eliminated.

The good news is that it doesn’t have to be that way. It is possible for Democrats to learn how frames, narratives, and brains really work. It is possible to take moral stands, with all policies backed up by a single moral vision. It is possible to awaken and strengthen the progressive worldview already present in swing voters who are partly progressive as partly conservative (called “independents,” “moderates,” and “the center”). It is possible for Democrats to say what they believe and win, without giving in to intimidation tactics.

http://www.huffingtonpost.com/george-lakoff/the-use-of-911-to-consoli_b_955954.html

Words. Language. Framing. Egalitarianism? How do you frame that? Is that an American concept? Is that a defining value of democracy? Do our citizens believe that we should strive to ensure that all people have equal rights and opportunities? Or is this a left-wing conspiracy that deprives people of the realization of their individual ambitions? Is it then really just about freedom?

Whatever label you use, the right has gained control of the framing, and framing controls cognitive function. Cognition does not require logic. Those who have been watching the Republican debates have been able to witness cognitive activity that is almost totally devoid of logic, yet the candidates have been well versed on framing. It is the moral worldview of freedom from government that prevails, while dismissing the logic of the great benefits that we receive as a people joining together to establish and operate our own government. This worldview allows them to dismiss the obvious logic of an improved Medicare program that would cover everyone.

We do need to recapture the framing from the conservative ideologues who would destroy as much government functioning as they can. Why they would is beyond the capacity of many of us to understand, but then we are looking for logic where it may not exist.

Do we need to reframe the problems and their potential solutions from a liberal, progressive, Democratic, politically polarized position? Or can we use framing with which the great majority of us can identify? Would framing supporting economic security for everyone work? That’s a moral worldview that is also logical.

Can we talk about this?

U.S. still the worst on amenable mortality

Variations in Amenable Mortality — Trends in 16 High-Income Nations

By Ellen Nolte, Ph.D., and Martin McKee, M.D., D.Sc.
The Commonwealth Fund, September 23, 2011

Synopsis

The rate of “mortality amenable to health care” — that is, deaths that are considered preventable with timely and effective health care — declined for people under age 75 across 16 high-income nations between 1997–1998 and 2006–2007. While all countries showed improvement, the United States improved the least.

Key Findings

In 2006–2007, amenable mortality accounted for 24 percent of deaths under age 75 in the 16 countries studied.

The highest levels were in the United States, with 95.5 deaths per 100,000 people.

Addressing the Problem

Although amenable mortality fell consistently in all countries, the scale and pace of improvement varied. The United States’s poor performance and relatively slow improvement compared with other nations may be attributable to “the lack of universal coverage and high costs of care,” the authors conclude.

http://www.commonwealthfund.org/Publications/In-the-Literature/2011/Sep/Variations-in-Amenable-Mortality.aspx?omnicid=20

Comment: 

By Don McCanne, MD

So, the United States has “the best health care system in the world,” except for all the others. Our amenable mortality – deaths that are preventable with timely and effective health care – is the worst amongst the 16 high-income nations studied.

The authors suggest that our poor result may be attributable to the lack of universal coverage and the high costs of care. Unfortunately the Affordable Care Act (ACA) will provide neither universal coverage nor adequate measures to control health care spending.

The policy community certainly understands that we could cover everyone and control excessive spending by enacting a single payer national health program – an improved Medicare for all. So why have they disappeared behind closed doors to work on ACA – a model that won’t get us there?

Please, policy wonks, come out of the closet!

U.S. still the worst on amenable mortality

Variations in Amenable Mortality — Trends in 16 High-Income Nations

By Ellen Nolte, Ph.D., and Martin McKee, M.D., D.Sc.
The Commonwealth Fund, September 23, 2011

Synopsis

The rate of “mortality amenable to health care” — that is, deaths that are considered preventable with timely and effective health care — declined for people under age 75 across 16 high-income nations between 1997–1998 and 2006–2007. While all countries showed improvement, the United States improved the least.

Key Findings

In 2006–2007, amenable mortality accounted for 24 percent of deaths under age 75 in the 16 countries studied.

The highest levels were in the United States, with 95.5 deaths per 100,000 people.

Addressing the Problem

Although amenable mortality fell consistently in all countries, the scale and pace of improvement varied. The United States’s poor performance and relatively slow improvement compared with other nations may be attributable to “the lack of universal coverage and high costs of care,” the authors conclude.

http://www.commonwealthfund.org/Publications/In-the-Literature/2011/Sep/Variations-in-Amenable-Mortality.aspx?omnicid=20

So, the United States has “the best health care system in the world,” except for all the others. Our amenable mortality – deaths that are preventable with timely and effective health care – is the worst amongst the 16 high-income nations studied.

The authors suggest that our poor result may be attributable to the lack of universal coverage and the high costs of care. Unfortunately the Affordable Care Act (ACA) will provide neither universal coverage nor adequate measures to control health care spending.

The policy community certainly understands that we could cover everyone and control excessive spending by enacting a single payer national health program – an improved Medicare for all. So why have they disappeared behind closed doors to work on ACA – a model that won’t get us there?

Please, policy wonks, come out of the closet!

Medical students weigh in on health care reform

Oregon Health & Science University Medical School News, Sept. 22, 2011

PORTLAND, Ore. — Allen Andrews, MS3, and Richard Bruno, MS3, recently contributed to a paper on health care reform titled, “Healthcare Reform and the Next Generation: United States Medical Student Attitudes toward the Patient Protection and Affordable Care Act.” The paper was published in the online journal PLOS One. The senior author of the paper was Paul Gorman, M.D., M.P.H., associate professor, Department of Medical Informatics & Clinical Epidemiology.

More than a year and a half after the passage of the Patient Protection and Affordable Care Act (PPACA), physician and public opinion have been very well documented; however, those who will be most affected by health care reform, namely physicians-in-training, have yet to be heard.

“Fundamentally, the purpose of our research was to shed some light on what future physicians thought of both the passage of PPACA and whether our current health care system needs to be reformed,” said Allen Andrews, MS3.

Over 1,200 medical students from 10 U.S. medical schools were surveyed between October and December 2010 to determine their attitudes toward reform and specifically the PPACA.

“This is the first of three national surveys of medical students aimed at investigating their attitudes toward the underserved, health reform, and advocacy work — all pointing to a need for medical school curricula changes to support stronger health policy and advocacy training,” said Richard Bruno, MS3, and class president.

Overwhelmingly, the study showed that a remarkable 95 percent of medical students believe the current health care system needs to be changed. Possibly even more surprising was the fact that 80 percent believe that PPACA’s reforms did not go far enough.

Undoubtedly, PPACA will have a significant impact on patients and providers alike, but it will be up to us along with the spirit of Hippocrates, as the next generation of physicians, to continue working to ensure all Americans have access to quality, affordable health care.

http://www.ohsu.edu/xd/education/schools/school-of-medicine/about/school-of-medicine-news/education-news/reform-students-92711.cfm

Ida Hellander blogs on Lessons from an English GP

Lessons from an English GP visiting Chicago

Posted by Ida Hellander MD
Physicians for a National Health Program
PNHP Blog, September 22, 2011

Dr. Clare Gerada, president of the Royal College of General Practitioners, visited Chicago recently on a study tour to see how a market-based system works for society’s most vulnerable first hand. I was fortunate to be able to accompany her on several of her stops.

https://pnhp.org/blog/2011/09/22/lessons-from-an-english-gp-visiting-chicago/

Comment: 

By Don McCanne, MD

Today’s message is a twofer. First is the great news that Ida Hellander will be a regular contributor to the PNHP blog. Second is that her blog today on lessons from an English GP is well worth reading, and to free up your time so you can read it, no complicated policy qotd message will be posted today.

Don't turn your back on Ryan's Medicare plan

Health insurers likely to push privatized Medicare for their own benefit

By Wendell Potter
iWatchNews, September 22, 2011

If you think Rep. Paul Ryan’s plan to privatize Medicare is dead, think again. After Ryan unveiled his plan earlier this year, there was such widespread criticism that it briefly became a political liability for the Republicans.

The GOP-controlled House of Representatives approved the plan, which would replace the existing Medicare program with vouchers that beneficiaries could use to buy coverage from private insurance. But Ryan’s blueprint never made it out of the Senate.  It’s not hard to figure out why; the vouchers would have required most Medicare recipients—many of them on fixed incomes— would be paying more out of their own pockets for coverage than in the existing program.

I wrote at the time that the Ryan plan had the strong support of private health insurers, who would like nothing more than to have the federal government hand the Medicare program over to them.  The program would represent a vast new revenue stream guaranteeing profits forever.

Last week, the insurance industry and its allies began what I predict will be a massive campaign to sell the public and policymakers on the idea of moving forward with the Ryan plan—albeit with a few tweaks to make it seem more consumer-friendly.

An outfit called the Healthcare Leadership Council (HLC) issued a press release with the headline: “Health Industry Leaders Recommend Over $410 Billion in Healthcare Savings to Congressional ‘Super Committee.’ ”

At the core the HLC’s scheme is what might be called Ryan-lite, but don’t be fooled: the plan would—to use a favorite industry term—take us down the “slippery slope” toward a complete corporate takeover of the Medicare program.  (Insurers and their allies for years have warned Americans that enacting sweeping health care reforms they don’t like would lead us down the slippery slope toward socialism.)

While Ryan’s plan would move all Medicare beneficiaries into a privatized system in one fell swoop, the HLC’s plan would do it more gradually. It would, in the words of the press release, “create a new ‘Medicare Exchange’ in which private plans would compete on the basis of cost, quality and value.”

Sounds great, doesn’t it? The HLC—which comprises the CEOs of the country’s biggest insurers, drug companies, hospital chains and medical device manufacturers and some powerful industry trade associations—knows from years of research that if you can work in the words “compete,” “quality,” and “value” into the same sentence, you will persuade people to believe what they are peddling is what you should obviously want to buy.

But buyer beware. Rest assured that the HLC is far more interested in the special interests of its member companies and organizations than in what is in your best interests. And the very existence of the HLC shows why it has been so difficult to get Congress to enact comprehensive health care reform. The executives who fund the HLC want first and foremost to preserve their profits and protect their incomes.

I know all this from personal experience from my days as an insurance industry executive, going back to the early days of the Clinton administration.

The HLC actually came into existence during the last part of the administration of the first Bush in the White House. The CEOs that formed the leadership council  were hoping a Republican president would help them eliminate some of the government regulations they didn’t like.

The HLC really came into its own, however, after Bill and Hillary Clinton unveiled their health care reform proposal in 1993. Just about every health care special interest didn’t like one thing or another about the Clinton plan, so they came together under the umbrella of the HLC to kill the whole initiative. I attended many HLC meetings in Washington during that time and came to see quickly just how influential this heavily bankrolled organization would be in doing exactly what the CEOs wanted.

As I wrote in my book, Deadly Spin , the HLC was behind a fear-mongering campaign against the Clinton plan that the individual companies it represented could not pull off on their own without appearing self-serving. The CEOs needed a front group to do it, and the HLC fit the bill.

The HLC office became a war room for the special interests. Over the subsequent months, the organization conducted a multi-pronged attack , including grassroots organizing, lobbying by corporate executives and PR events. It faxed statements  almost daily to Washington-based reporters and also to lawmakers,  and it ran ads raising the specter of health care rationing and warning of bureaucratic interference with patient rights if the Clinton plan were enacted.

It worked. Americans came to believe the HLC claims, and so did enough members of Congress that the Clinton plan died.

We can all now expect HLC to embark on the same kind of campaign to privatize Medicare and to get a few other things its members have long hoped for from Congress. One of the priorities is enacting tort reform at the federal level (a favorite of doctors’ groups as well as insurers). The HLC also wants Congress to raise the age of eligibility for Medicare benefits from 65 to 67.

To make its Medicare privatization proposal more palatable, the HLC would allow folks to continue enrolling in the traditional Medicare program. At least for a while. And the HLS calls for a more generous “inflation factor” for premium subsidies than Ryan proposed.

But make no mistake. What the CEOs really want is exactly what Ryan proposed. They are just putting different clothes and a few more accessories on to make it prettier. 

http://www.iwatchnews.org/2011/09/22/6694/analysis-dont-turn-your-back-ryans-medicare-plan/

Kentucky Presbyterian group urges scrutiny of big health insurers, with eye to possible divestment

By Johanna W.H.van Wijk-Bos

On Saturday, Sept. 17, 2011, the Mid-Kentucky Presbytery of the Presbyterian Church (USA) voted at its regular stated meeting, held in Glasgow, Ky., to send an overture to its 220th General Assembly. The overture requests of the General Assembly to instruct the committee on Mission Responsibility Through Investment (MRTI) to report on the corporate practices of Cigna, Aetna, Humana, WellPoint, and UnitedHealthcare insurance companies to the General Assembly Mission Council.

In addition, the overture asks the General Assembly Mission Council to act on this information and, as it deems appropriate, implement divestment procedures, as well as encourage individual Presbyterians and congregations to divest of holdings in the said companies; and, in view of the urgency of the ongoing health care crisis, to take action within six months of the adoption of the recommendation; and to report to the 221st General Assembly (2014) on divestment action.

The overture was authored primarily by the Rev. A. David Bos, who died early in February of 2011. It was then unanimously endorsed by the session of Central Presbyterian Church in Louisville, Ky., and brought before the Presbytery by the Church Administration committee with its endorsement. The overture was supported also by the session of Buechel Presbyterian Church.

Following supportive comments by the Rev. Mark Baridon, one of the ministers of Central Presbyterian Church, and the Rev. Dr. Johanna W.H.van Wijk-Bos of Louisville Presbyterian Seminary, widow of David Bos, one opposing statement, and supportive remarks from the Rev. Nancy Troy, of Briargate Presbyterian Church, the moderator put the question to the vote. The great majority of the Presbytery voted in favor.

After the vote took place, the Rev. Adam Fischer of Harvey Browne Presbyterian Church placed the name of Johanna Bos in nomination to serve as Overture Advocate at the meeting of the General Assembly. This motion was seconded and passed unanimously.

The Overture Advocate is charged with taking the overture to the meeting of the General Assembly of the Presbyterian Church (USA), to take place in early July 2012, in Pittsburgh, Pa., and presenting it to the appropriate committee, which will take it to the floor of the Assembly for a vote.

It is the hope of those who have advocated for this cause in our Presbytery that other Presbyteries of the Church will join Mid-Kentucky and pass the Overture, so the endorsement may come to the General Assembly from as large a number of Presbyteries as possible.

Johanna W.H.van Wijk-Bos is Teaching Elder member of the Mid-Kentucky Presbytery and Overture Advocate to the 220th General Assembly of the Presbyterian Church (USA) for the overture on practices of the health care industry in the U.S. and on divestment from holdings in said industry.

Cost still a barrier for the uninsured in Mass., study says

By Chelsea Conaboy
The Boston Globe, Sept. 21, 2011

A new study of Cambridge Health Alliance patients shows that many of the people who remain uninsured have jobs and don’t qualify for a state subsidy, but they cannot afford an insurance plan on their own or through their employers. For others, job loss and glitches in the enrollment process have caused them to lose coverage.

Dr. Rachel Nardin, a neurologist at Cambridge Health Alliance, said the study offers a reminder of the pitfalls of the Massachusetts system that could be inherited by the rest of the country as provisions of the federal Affordable Care Act, modeled after Massachusetts’s 2006 health law, take effect.

“When you have a system that tries to insure people through a patchwork of different mechanisms, it’s inherently unstable,’’ said Nardin, chairwoman of the Massachusetts chapter of Physicians for a National Health Program, which supports a single-payer health system. “You’re going to leave some people out.’’

The study, published online last week by the Journal of General Internal Medicine, surveyed 431 patients, ages 18 to 64, who visited a Cambridge Health Alliance emergency department from July 2009 to March 2010, and found 189 people who were uninsured.

About two-thirds of the uninsured were employed, and 49 percent said they were motivated by the 2006 law to buy insurance but could not find an affordable plan. One quarter of the uninsured who had jobs worked for a company that offered an insurance plan, which disqualified them from being eligible for state-subsidized coverage.

Though the majority of the uninsured had incomes low enough that they should have qualified for state-sponsored plans, about 30 percent reported not being able to afford coverage.

“For some working poor, even heavily subsidized insurance premiums may be unaffordable,’’ the authors said.

About 35 percent of the uninsured reported losing their insurance coverage, most because they lost a job or had their plans canceled because of lapsed paperwork or other reasons.

The state reports that 98 percent of Massachusetts residents are now enrolled in a plan, though some estimates put that figure closer to 95 percent or slightly lower.

“We have achieved the near-universal goals of the landmark 2006 legislation,’’ said Dick Powers, spokesman for the Massachusetts Health Connector, the agency that manages the marketplace for state-subsidized plans. “The majority of the few remaining uninsured are low-income people whom we’ll strive to help as we implement national reform and perfect the Massachusetts model.’’

Nardin said her group’s study points to how hard it is to reach the uninsured.

“Even with incredible hard work, in a state that started out with enormous resources, this is the best we have been able to do,’’ she said.

Short of implementing a national single-payer plan, Nardin said the state could look at making more people eligible for state-sponsored plans or reducing the paperwork that people must complete to remain enrolled in a plan once they qualify.

Powers said controls on eligibility are critical to the program’s integrity and taxpayer confidence.

http://www.boston.com/news/local/massachusetts/articles/2011/09/21/study_looks_at_who_remains_uninsured_in_mass/

Study looks at who remains uninsured in Massachusetts

By Chelsea Conaboy, Globe Staff
The Boston Globe, White Coat Notes blog, Sept. 19, 2011

Much of the discussion around the 2006 Massachusetts health law has focused on how far the state has come in providing coverage for the uninsured.

Dr. Rachel Nardin, a neurologist at Cambridge Health Alliance and chair of the Massachusetts chapter of Physicians for a National Health Program, said sometimes it is important to take a different look — to look at the glass as half empty and ask, why?

She and others at the Harvard-affiliated health system published a study online with the Journal of General Internal Medicine last week looking at why people remain uninsured in Massachusetts despite a law mandating that most residents have health insurance.

The reasons won’t be surprising to people who have followed this issue closely: Many of the uninsured are working poor who don’t qualify for a state subsidy but can’t afford an insurance plan on their own or through their employers. For others, job loss and glitches in the enrollment process have caused them to lose coverage.

Nardin, who supports a single-payer health system, said the study offers a reminder of the pitfalls of the Massachusetts system that could be inherited by the rest of the country as provisions of the federal Affordable Care Act, modelled after Massachusetts’s health law, take effect.

“When you have a system that tries to insure people through a patchwork of different mechanisms, it’s inherently unstable,” she said. “You’re going to leave some people out.”

The study surveyed 431 patients, ages 18 to 64, who visited a Cambridge Health Alliance emergency department from July 2009 to March 2010, and found 189 people who were uninsured.

About two-thirds of the uninsured were employed, and 49 percent said they were motivated by the 2006 law to buy insurance but could not find an affordable plan. One quarter of the uninsured who had jobs worked for a company that offered an insurance plan, which disqualified them from being eligible for state-subsidized coverage.

Though the majority of the uninsured had incomes low enough that they should have qualified for state-sponsored plans, about 30 percent reported not being able to afford coverage.

“For some working poor, even heavily subsidized insurance premiums may be unaffordable,“ the authors said.

About 35 percent of the uninsured reported losing their insurance coverage, most because they lost a job or had their plans cancelled because of lapsed paperwork or other reasons.

The state reports that about 98 percent of Massachusetts residents are now enrolled in a plan, though some estimates put that figure closer to 95 percent or slightly lower.

“We have achieved the near-universal goals of the landmark 2006 legislation,” said Dick Powers, spokesman for the Massachusetts Health Connector, the agency that manages the marketplace for state-subsidized plans. “The majority of the few remaining uninsured are low-income people whom we’ll strive to help as we implement national reform and perfect the Massachusetts model.”

Nardin said her group’s study points to how hard it is to reach the uninsured.

“Even with incredible hard work, in a state that started out with enormous resources, this is the best we have been able to do,” she said.

Short of implementing a national single-payer plan, Nardin said the state could look at making more people eligible for state-sponsored plans or reducing the paperwork that people must complete to remain enrolled in a plan once they qualify.

Powers said controls on eligibility are critical to the program’s integrity and taxpayer confidence.

http://www.boston.com/Boston/whitecoatnotes/2011/09/study-looks-who-remains-uninsured-mass/M5HkClG4OiIeCwZ3MgY1nJ/index.html

The Nation: The Devilish Detail of Obama's Speech

By John Nichols
The Nation, September 20, 2011

President Obama has erected what is likely to be the left flank in the debates of the Congressional Joint Select Committee on Deficit Reduction—the so-called “super-committee” that will define so much of this fall’s fiscal and economic discourse.

That flank is sturdier than some of the president’s critics on the left might feared it might be. But the flank is weak, very weak, in at least one key area: the defense of Medicare and Medicaid.

So what’s the balance that progressives should strike with regard to the speech? Let’s consider:

President Obama wants wealthy Americans to pay a little bit more.

That’s good.

President Obama rejects House Budget Committee chair Paul Ryan’s schemes to turn Medicare and Medicaid into voucher programs that shift money away from carrying for the needy and toward the accounts of private insurers.

That’s good.

President Obama rejects, at least for the time being, the prospect of increasing the Medicare eligibility age that he put on the table several months ago.

That’s good.

But President Obama was still compromising with the Tea Party right when he delivered his remarks on Monday. Indeed, he proposed $580 billion in cuts to health and welfare programs, with $248 billion coming from Medicare and $72 billion from Medicaid.

That’s bad.

Very bad.

The president would have us believe that the cuts can be made by addressing “waste, fraud and abuse.” The reality is that cutting a quarter-trillion dollars from Medicare will undermine the quality of care for seniors and the disabled. The Alliance for Quality Nursing Home Care estimates that Obama’s approach would lead to $42 billion in cuts for post-acute care providers “placing patients, our workforce and local facilities at risk.”

The proposed cuts to Medicare and Medicaid will put new stress on the economy by making it harder to maintain hiring levels at the skilled nursing facilities that have been some of the real job creators in a period of layoffs and rising unemployment rates.

The proposed Medicare and Medicaid cuts place new stresses on working families, many of which are already struggling to care for elderly and disabled relatives.

And the proposed Medicare and Medicaid cuts will cause aging workers to think twice about retiring, thus reducing the number of openings for young workers.

Medicare and Medicaid are efficient programs. They are not perfect, but they have been pressured on “waste, fraud and abuse” issues for years; meaning that there is no chance that the cuts Obama proposes will be painless.

They will, in fact, be painful, for retired people and the disabled, for families, for workers and their unions, for communities and for the broader economy.

It is for this reason that FamiliesUSA, the progressive health policy group, is warning that proposed changes to Medicaid “shifts the burden to states and ultimately onto the shoulders of seniors, people with disabilities and low-income families who depend on the program as their lifeline.”

Congressional Progressive Caucus co-chairs Raul M. Grijalva, D-Arizona, and Keith Ellison, D-Minnesota, are similarly concerned. “While we support cutting waste, fraud and abuse, we reject any proposal that cuts benefits in Medicare or Medicaid,” they say. “We reject false Republican assertions that the solution to our deficit is deep cuts to programs that millions of Americans rely on, and we would hope President Obama would as well.”

Instead of talking about cuts in Medicare and Medicaid, Obama and the Democrats should be talking up the expansion of Medicaid so that it can serve as at the basis for a true national healthcare program.

America does not need less Medicare and less Medicaid.

America needs “Medicare for All,” along the lines proposed by the Healthcare-Now! movement.

“The creation of the Super Committee makes three of our country’s most vital safety net programs—Medicare, Medicaid, and Social Security—targets for cuts,” explains Healthcare-Now!” But these programs are not the problem, they are the solution. Our social insurance programs keep people healthy and out of poverty, which is particularly important during times like these when so many people are experiencing economic hardship. Medicare, Medicaid and Social Security should be strengthened, not cut. Medicare should be improved and extended to all.”

That’s right. By talking of cuts to Medicare and Medicaid, the president takes the debate in the wrong direction and, unfortunately, the “super committee” is likely to follow him there.

That does not mean that Healthcare-Now! and its allies in organized labor should back off and go silent. Quite the opposite. The great debates about austerity are yet to come. Ultimately, two sides will emerge as the murky middle (which the president tries, too frequently, to occupy) collapses. There will be those who are willing to cut Medicare, Medicaid and Social Security to balance budgets. And there will be those who recognize that cuts hurt rather than heal a broken economy.

Obama has moved toward the side of those who would ask the wealthy to pay their fair share in order to balance budgets. That is progress. But he needs to move further if he wants to catch up with economic reality and the aspirations of the American people.

http://www.npr.org/2011/09/20/140623784/the-nation-the-devilish-detail-of-obamas-speech

Examining the arguments for competitive pricing in Medicare

Competitive Pricing and the Challenge of Cost Control in Medicare

By Robert F. Coulam, Roger D. Feldman and Bryan E. Dowd
Journal of Health Politics, Policy and Law, August 2011

Abstract

The Medicare program faces a serious challenge: it must find ways to control costs but must do so through a system of congressional oversight that necessarily limits its choices. We look at one approach to prudent purchasing – competitive pricing – that Medicare has attempted many times and in various ways since the beginning of the program, and in all but one case unsuccessfully due to the politics of provider opposition working through Congress and the courts. We look at some related efforts to change Medicare pricing to explore when the program has been successful in making dramatic changes in how it pays for health care. A set of recommendations emerges for ways to respond to the impediments of law and politics that have obstructed change to more efficient payment methods. Except in unusual cases, competitive pricing threatens too many stakeholders in too many ways for key political actors to support it. But an unusual case may arise in the coming Medicare fiscal crisis related in part to the prices Medicare pays. At that point, competitive pricing may look less like a problem and more like a solution coming at a time when the system badly needs one.

What is to be done?

*  Recognize that competitive pricing is one part of fixing Medicare’s urgent fiscal problems

*  Consider ways to divide provider opposition or buy it off

*  Be aware that some bidding models might face fewer legal and political problems than others

*  Cultivate political leaders to support competitive bidding as policy

*  Compensate losers, at least through a transition period

*  Give beneficiaries and providers time to adjust

*  Strengthen the administrative and legal resources available to CMS in competitive bidding struggles

*  Revise the legal framework to narrow the grounds for challenges

*  Combine competitive pricing with mechanisms to increase quality

http://jhppl.dukejournals.org/content/36/4/649.abstract

Comment: 

By Don McCanne, MD

The authors of this article supporting competitive pricing for Medicare were funded by a grant from the American Enterprise Institute, an organization “committed to expanding liberty, increasing individual opportunity, and strengthening free enterprise.” It is interesting to read why they believe that previous efforts to introduce competitive pricing failed, but what is even more interesting is their list of proposals for action that might accomplish their elusive goal.

Medicare uses administrative pricing to determine payments. Prices are set by performing analytic calculations, using historical claims data. The goal of conservatives has been to use competitive pricing instead, a competitive bidding process to obtain the lowest prices. Although conservatives contend that competition will always provide the lowest prices, in fact, the top-down administered pricing by Medicare has been much more effective in controlling health care prices than has competition of private insurance plans in the private sector.

Regardless of the evidence, the conservatives have a ideological belief that competition must be more effective, and we can prove that by displacing administrative pricing with competitive pricing – showing that it really works. So let’s look at their proposals for introducing competition as a means of expanding liberty and strengthening free enterprise. In examining their proposals listed above, the concepts are the same, only the rhetoric is changed:

*  The first and most important point (according to the authors) is that we must accept without question the ideology of competition as the means to fix Medicare’s urgent fiscal problems, while implicitly totally rejecting government administrative pricing. The political process is to be driven by ideology rather than policy science.

*  Using the finest principles of market competition, we must use devious methods to divide the opposition of health care providers, or, failing that, simply buy them off. Just don’t call it a bribe since that term is offensive to free market purists.

*  Make sure the bidding models are rigged to circumvent legal and political barriers.

*  Cultivating political leaders to support competitive pricing is now much easier since the Supreme Court decided that the transfer of massive amounts of cash is a protected form of free speech.

*  Compensating losers through a transition period is a euphemism for the “so-sorry-but-that’s-the-way-competition-works” gratuitous comment to the losers who face financial ruin. Market purists would never give cash rewards to the competition that they just beat out.

*  Giving beneficiaries and providers time to adjust need not be a separate policy since it is automatic – the time between when they are informed that they lost their insurance or their provider contract and the date of the actual termination.

*  Strengthening the administrative and legal resources available to CMS in competitive bidding struggles is just what markets are all about – swindle the patients and providers by diverting more health care dollars to yet more administrative waste.

*  Revising the legal framework to narrow the grounds for challenges will be a cinch since they already have a Supreme Court that will protect their marketplace excesses.

*  Combining competitive pricing with mechanisms to increase quality – the old measuring-and-monitoring-quality trick wherein they pretend that it is the middleman insurer that creates quality rather than the dedicated health care professionals.

In reading this long article, I could understand why these AEI-funded authors were making excuses for the previous failed experiments in competitive pricing, but I have to admit that I was astonished when they gave us this list of reasons why we should never even remotely consider adopting competitive pricing in the Medicare program. That was very thoughtful of them.