PNHP

When will the lights go out on fee-for-service?

When will the lights go out on fee-for-service?

By Robert B. Doherty, ACP’s Senior VP in Washington, DC
From the July/August ACP Internist

Physicians have been paid according to the number of visits or procedures they bill for a very long time, almost half a century for Medicare. Fee-for-service might have made sense originally, when everything was done on an episodic, acute care basis, but medicine has changed, and the payment system needs to change with it.

Today, we know that the best thing for the patient is to help prevent illnesses or complications that require more invasive tests or surgical procedures or hospital admissions.

Good medical care requires coordination among teams of health professionals and family caregivers, not just the interaction between the individual doctor and patient. Some of the most valuable things doctors do happen outside of the office visit, such as making arrangements over the phone with other clinicians or family caregivers. And the cognitive services provided by primary care physicians are at least as valuable to patients as doing a procedure, and outcomes and quality matter more to patients than how many procedures their doctor orders.

Yet doctors and patients are stuck with an out-of-date system that fails to pay for the things that we now know are essential to good medical care. Is it any wonder, then, that we get what we do pay for: rushed, inefficient, high-volume, invasive, and fragmented care that undervalues primary and preventive care, and is highly dissatisfying to doctors and their patients alike?

Despite all the flaws with fee-for-service, the medical profession has steadfastly clung to it. Year after year, physician membership organizations have devoted most of their attention to trying to change it at the margins: getting new CPT codes adopted, persuading Medicare to increase the relative value units, and of course, fighting the perennial battle to halt cuts to the sustainable growth rate (SGR) formula. Despite physicians’ concerns about the current system, they have been skeptical about proposals to replace it. There is increasing evidence, though, that fee-for-service, like a play gone stale that has been on Broadway way too long, is about to end its half-century run.

“Unless we begin the process of developing a long-term solution, we will once again be faced with the unwanted choice of extending a fundamentally broken payment system or jeopardizing access to care for Medicare beneficiaries,” wrote Rep. Henry A. Waxman, ranking Democrat on the House Energy and Commerce Committee, in a March 28 letter to ACP and about 50 other physician membership organizations. “We cannot let either happen.”

The letter went on to request that the physician organizations provide the committee with specific ideas “on how to reform the physician payment system and move to a system that reduces spending, pays providers fairly, and pays for services according to their value to the beneficiary.”

The idea of paying for services according to their value to the beneficiary would be a fundamental departure from the current Medicare system. Fee-for-service is agnostic about value to the patient, because it only concerns itself with the number of procedures and visits generated, and the work and costs involved in delivering the services (the relative values), not how valuable they are to the patient. By comparison, value-based payments would mean paying physicians, at least in part, for achieving measurable improvements in the outcomes and efficiency of care provided.

Most proposals for value-based payments also change the unit of payment from a procedure code to a bundle of services, discreet episodes of care, or risk-adjusted payments per patient per month (capitation), with the opportunity to earn more or less depending on how well the physician or health care organization delivers care effectively and efficiently. Some proposals would maintain an element of fee-for-service with value-based payments layered on top.

Not only Congress has decided that the current payment system should be on its way out. ACP, the American Medical Association, the American College of Surgeons, the American Academy of Family Physicians, and the American Osteopathic Association responded to the Energy and Commerce Committee’s request by offering proposals to transition to new models aligned with value.

Although the details of their proposals varied, all called for a period of at least five years of stable payments with the annual updates guaranteed by statute instead of being set by the SGR. During this time, a variety of alternatives would be pilot-tested on a voluntary basis. Physicians who agreed to participate in the pilots could earn more for achieving better outcomes. Then, after the five-year period of stability and innovation, the models that were most effective in the pilots would be broadly adopted by Medicare. Physicians then would be given a clear timetable, another four or five years, to transition to the new models so that by the end of the decade, most practices would be paid, at least in part, on value to patients, not volume of services.

ACP recognizes that there will be many challenges in transitioning to new value-based payments, but the alternative is trying to defend a broken payment system that does not meet the needs of patients, the people who pay the bills (taxpayers and employers), and physicians themselves.

Copyright © 2011 by the American College of Physicians

http://www.acpinternist.org/archives/2011/07/washington.htm

Mark Weisbrot: U.S. health care problems are rooted in the private sector

Problems of U.S. Health Care Are Rooted in the Private Sector, Despite Right-Wing Claims

By Mark Weisbrot
McClatchy-Tribune Information Services, July 20, 2011

Right-wingers, insurance companies, and other opponents of health care reform in the United States are always looking for ways to blame the government for the failures of our health care system. But the simple truth is that they have it backwards: our problems with health care are firmly rooted in the private sector. That is why the average high-income country – where government is vastly more involved in health care – spends half as much per person on health care as we do, and has better health outcomes.

That is why even Medicare – which has to pay for health care services and drugs at costs inflated by our dysfunctional private health care sector – has still proven to be much more efficient than private insurance.

The most effective way to insure everyone and make our health care system affordable would have been to expand Medicare to everyone, while beginning the process of reducing costs through negotiation with, and restructuring incentives for, the private sector. The private insurance companies use up hundreds of billions annually on administrative costs, marketing, and other waste – which is what you would expect from companies who maximize profit by insuring the healthy and trying to avoid paying for the sick.

It remains to be seen whether the PPACA will be a step toward more comprehensive, effective reform that gives us Medicare for all. In the meantime, the right will try to blame the government and the legislation itself for rising health care costs and other failures of our health care system. But in fact these result from the legislation not having gone far enough to rein in the private sector.

(Mark Weisbrot is co-director of the Center for Economic and Policy Research, in Washington, D.C.)

http://www.cepr.net/index.php/op-eds-&-columns/op-eds-&-columns/problems-of-us-health-care-are-rooted-in-the-private-sector-despite-right-wing-claims

Comment: 

By Don McCanne, MD

When it seems that we are making so little progress on the reform front, it is reassuring to see that PNHP and our single payer colleagues are not alone in spreading the Medicare for all message.

Timely Treatment for Depression Hard to Get, Even for the Insured

By Maia Szalavitz
Time magazine, Healthland, July 21, 2011

Massachusetts requires health insurance for all, is second in the nation in the number of doctors per capita, and mandates equal coverage for mental and physical illnesses.  Yet when researchers there posed as well-insured patients seeking treatment for depression, only 6 percent of calls to mental health facilities resulted in an appointment within two weeks, according to a new study.

This was true even though the prospective “patients” claimed that they’d been told by an emergency room doctor to seek psychiatric care within that time period — so those who took the calls should have been alert to the possibility that the patients were suicidal or otherwise needed urgent care.

“What this study says is that even with what is basically the best private insurance available in this state and [probably] in many others as well, help is very difficult to find and may be impossible to find for many,” says Steffie Woolhandler, visiting professor of medicine at Harvard Medical School and an author of the study.

The research, which was published in the Annals of Emergency Medicine, found that nearly a quarter of the calls made were never returned—even after the “patient” called again to follow up.  Another 23 percent of providers turned people away if they were not already patients of a primary care physician associated with their institution. Only 12 percent of the facilities actually offered appointments to the patients.

“I think a lot of systems are trying to cut back on psychiatric care, but they don’t want to cut back to zero, so they restrict access to the handful of appointments that they have to people who are already part of their system,” says Woolhandler.

Since depression itself can make help-seeking difficult because it reduces motivation and makes people feel hopeless, even small barriers to care can have a huge impact. “How many seriously depressed people are going to persevere through all of this to get an appointment?” Woolhandler asks.

The research was prompted by concerns raised by psychiatric residents, who were interested in access to mental health care. They had the sense that when they sent people home from the emergency room, they weren’t actually getting the follow-up care that had been recommended.

So for the study, researchers posed as patients in exactly that situation, saying they had Blue Cross/Blue Shield insurance, which is held by about half of all Massachusetts citizens and is considered to provide excellent coverage. All of the facilities they called were listed as preferred providers of care for BC/BS members, yet only 12 percent offered appointments.

“Having to suffer longer with depression is very painful and to expose people unnecessarily to prolonged suffer is really not acceptable when we have the resources to help people with this problem,” says Woolhandler.

Since this study only looked at what is basically the best-case scenario in the state that has an insurance system similar to the one that will be rolled out nationwide under President Obama’s Patient Protection and Affordable Care Act, it suggests that simply providing insurance will not be enough to make mental health care appropriately accessible to patients in need. Truly effective mental health care requires both coverage and ability to get services.

http://healthland.time.com/2011/07/21/timely-treatment-for-depression-hard-to-get-even-for-the-insured/#ixzz1SqLvoxm9

Mark Weisbrot: U.S. health care problems are rooted in the private sector

Problems of U.S. Health Care Are Rooted in the Private Sector, Despite Right-Wing Claims

By Mark Weisbrot
McClatchy-Tribune Information Services, July 20, 2011

Right-wingers, insurance companies, and other opponents of health care reform in the United States are always looking for ways to blame the government for the failures of our health care system. But the simple truth is that they have it backwards: our problems with health care are firmly rooted in the private sector. That is why the average high-income country – where government is vastly more involved in health care – spends half as much per person on health care as we do, and has better health outcomes.

That is why even Medicare – which has to pay for health care services and drugs at costs inflated by our dysfunctional private health care sector – has still proven to be much more efficient than private insurance.

The most effective way to insure everyone and make our health care system affordable would have been to expand Medicare to everyone, while beginning the process of reducing costs through negotiation with, and restructuring incentives for, the private sector. The private insurance companies use up hundreds of billions annually on administrative costs, marketing, and other waste – which is what you would expect from companies who maximize profit by insuring the healthy and trying to avoid paying for the sick.

It remains to be seen whether the PPACA will be a step toward more comprehensive, effective reform that gives us Medicare for all. In the meantime, the right will try to blame the government and the legislation itself for rising health care costs and other failures of our health care system. But in fact these result from the legislation not having gone far enough to rein in the private sector.

(Mark Weisbrot is co-director of the Center for Economic and Policy Research, in Washington, D.C.)

http://www.cepr.net/index.php/op-eds-&-columns/op-eds-&-columns/problems-of-us-health-care-are-rooted-in-the-private-sector-despite-right-wing-claims

When it seems that we are making so little progress on the reform front, it is reassuring to see that PNHP and our single payer colleagues are not alone in spreading the Medicare for all message.

Even good health insurance doesn't ensure access to doctors

By David W. Freeman
CBS News, July 21, 2011

Just because you have health insurance doesn’t mean you can get a doctor. That’s the apparent take-away message of a shocking new study showing that even in Massachusetts – a model for the federal health legislation that President Obama signed into law in 2010  – access to medical care is severely limited.

And that’s true even in emergencies – and even for people who have top-drawer insurance coverage.

For the study, Harvard researchers posed as patients insured by Blue Cross Blue Shield of Massachusetts, the state’s largest insurer. They called every mental health facility within a 10-mile radius of downtown Boston, saying they had been diagnosed with depression and needed to see a psychiatrist within two weeks.

What happened? Only eight of the 64 facilities (12.5 percent) listed as preferred providers offered an appointment, and only four (6.2 percent) offered an appointment within two weeks.

Perhaps most shocking – given the urgency of the requests for appointments – one in four calls to providers were never returned.

Study author Dr. J. Wesley Boyd, an attending psychiatrist at the Harvard-affiliated Cambridge Health Alliance, blamed health insurers for having highly restrictive provider networks and low reimbursement rates for psychiatric care. They’ve “created a situation where a patient with a potentially life-threatening disorder, such as the severe depression portrayed in our callers’ scenario, is essentially abandoned at a time of great need,” he said in a written statement.

In the continuing debate over health care insurance, “we tend to fixate on getting people insurance,” study author Dr. Rachel Nardin, chief of neurology at the alliance, told CBS News. “But the real question is, “What happens if I get sick? Can I get the care I need?”

http://www.cbsnews.com/8301-504763_162-20081423-10391704.html

Psychiatric Care Hard To Get, Even For The Insured, Study Finds

By Rachel Zimmerman
WBUR, CommonHealth blog, July 21, 2011

It turns out a good shrink (or just about any shrink) is hard to find, even in the medical mecca of greater Boston.

According to a new study by Harvard researchers, access to outpatient psychiatric care is extremely limited here, and it doesn’t make much difference if the patient has top-notch health insurance or is suffering from a dire mental illness. As part of this “simulated patient” study, published Thursday as a letter in the Annals of Emergency Medicine, researchers posed as severely depressed patients with excellent health insurance and tried to get an appointment for psychiatric care at a facility in downtown Boston. But of the 64 facilities they called, they were only able to get 8 appointments, and only 4 of those were within two weeks.

“The takeaway here is that having insurance is obviously important but it is not sufficient when it comes to access to psychiatric care,” says Dr. J. Wesley Boyd, an attending psychiatrist at the Harvard-affiliated Cambridge Health Alliance, and the study’s lead author. “What does it say when there’s a patient with a potentially life-threatening disorder, such as the severe depression portrayed in our callers’ scenario, who is is essentially abandoned at a time of great need?”

To test their hypothesis that the availability of psychiatric services has greatly diminished (due to a combination of paltry reimbursement rates and budget cutbacks) Boyd and his colleagues embarked on a stealth plan involving a little bit of dramatic play. A psychiatric resident, Andy Linsenmeyer, pretended to be a patient named Andrew Meyer suffering from severe depression and in need of psychiatric care.

Linsenmeyer and an undergraduate student researcher, both posing as patients, chose 64 medical centers listed on the Blue Cross Blue Shield of Massachusetts website all within a 10-mile radius of downtown Boston, and set out to call each one. (Blue Cross played no role in the study). This is what the “patient” said when he got someone on the phone: “I was seen in the emergency room last night for depression and discharged with instructions to get a followup psychiatric appointment in two weeks.” He said he was covered under a Blue Cross Preferred Provider Organization health plan.

Linsenmeyer, now a fourth year resident in the Harvard Longwood psychiatry program, didn’t do so well undercover as Andrew Meyer trying to get professional help.

Only 8 of the 64 medical facilities he and his student called offered appointments (12.5 percent); and only four of those offered an appointment within two weeks, researchers reported. Moreover, 15 providers (23 percent) never returned calls seeking an appointment, even after two detailed messages were left. Finally, 15 other providers (23 percent) flat out refused to offer an appointment due to requirements that all patients be enrolled with a primary care doctor affiliated with that particular psychiatric facility, researchers said.

Was anyone surprised by the results? Not really. “A big part of residency is trying to get care for people and I know how difficult it can be, so unfortunately, I wasn’t that surprised, ” Linsenmeyer said. “But I think the point here is that having health insurance does not equal access to care. Everyone here is like, ‘Oh, Massachusetts is so great because everyone has health insurance,’ but it’s really not great because people put up all these barriers to care, so it’s a little disingenuous. Everyone has health insurance but that doesn’t mean you can get care.”

The dearth of psychiatric care available in Massachusetts has larger national implications, the authors write:

“This result confirms our suspicion that even for patients with private insurance, mental health services in the Boston area are severely limited, which is in line with national data showing limited availability; for example, two thirds of primary care physicians report that they cannot obtain outpatient mental health services for patients who need them.

“Our inadequate mental health system has widespread social effects. A third of the homeless and more than half of all prison and jail inmates have mental illness. The nation’s EDs are de facto psychiatric wards, with 79% of emergency physicians reporting that their hospitals board psychiatric patients for whom appropriate treatment resources could not be found, sometimes for days.

“Although there are many contributors to the inadequacy of our mental health system, managed care has hit psychiatric services hard. Private insurers aggressively constrain patients’ access to services by stringently limiting provider networks.

“As our study shows, this is often covert; insurers provide lists of in-network providers, but most are unavailable. Reimbursements for psychiatric services are far lower than for other types of care, so institutions frequently restrict access as stringently as possible, often, as in our study, by requiring that a patient have an in-system primary care provider (even though the insurer requires no referral). Many private practitioners refuse to accept insurance payments altogether. Improved reimbursements for psychiatric care will be an important step in reducing the barriers to care experienced by patients with severe depression.”

The study was unfunded, Boyd said. However the group, Physicians for a National Health Program, an organization of physicians who advocate for single-payer national health insurance, helped publicize the research, as all of the authors are members of the group and two are co-founders.

Blue Cross Blue Shield was critical of the study, according to The Boston Globe:

“Blue Cross Blue Shield spokesman Jay McQuaide took issue with the study, describing the researchers as opponents of private insurers who were trying to extract higher reimbursement rates for themselves. McQuaide said the study was ‘an attempt to publicly pressure the state’s health plans, like Blue Cross, to pay these clinicians more money which, frankly, is disappointing.’ The authors dismissed that claim, saying that only two of the five authors are psychiatrists and the real goal of the study was to examine access to mental health care.”

http://commonhealth.wbur.org/2011/07/psychiatric-care-hard-to-get-even-for-the-insured-study-finds/

Mental care can be hard to find, even for insured

Survey shows many roadblocks to aid in Boston facilities

By Chelsea Conaboy
The Boston Globe, July 21, 2011

Massachusetts patients with top-flight medical insurance may still find it difficult to get the mental health services they need, according to research from Harvard doctors released today that provides fresh evidence of a crisis in psychiatric care.

Researchers at Cambridge Health Alliance and Beth Israel Deaconess Medical Center called 64 mental health facilities within a 10-mile radius of downtown, posing as patients with Blue Cross Blue Shield insurance who were evaluated for depression at emergency departments and discharged with instructions to get a psychiatric appointment within two weeks.

Just four facilities could accommodate an appointment that soon, the researchers said. At four others, appointments were available – but more than two weeks later.

Fifteen facilities, about 23 percent, never returned the call, even after a second attempt. Another 23 percent told callers that patients had to have a primary care doctor within that facility’s system to be seen by a psychiatrist.

With those odds, “it’s quite unlikely that a severely depressed person could persevere’’ to get care, said Dr. Steffie Woolhandler, an author and former Cambridge Health Alliance primary care physician now at City University of New York.

The study was submitted to the Annals of Emergency Medicine but declined for publication on the grounds that it needs to be replicated on a larger level. Instead, the journal asked the authors to submit their results as a letter to the editor, scheduled to be published today.

The study grew out of concern from physician trainees in psychiatry that patients seen in the emergency department were unable to get follow-up care, Woolhandler said.

Dr. J. Wesley Boyd, a Cambridge Health Alliance psychiatrist, said he has seen mental health services squeezed in recent years by internal policies and shrinking reimbursements to physicians and clinics.

Cambridge Health Alliance is one of the largest in-patient mental health providers in the state but has scaled back services in recent years. Because of a reduction in state aid, Cambridge Health Alliance cut adult psychiatry beds about 39 percent, to 89. It also limited outpatient services to patients living within the hospital’s direct service area or those with a primary care doctor in the system.

The latter requirement, Boyd said, amounts to “a secretive way of rationing of care.’’ Hospital systems don’t put up such roadblocks for patients seeking high-paying imaging services or surgery, he said.

“Until psychiatry is better reimbursed, and this is not just an insurance issue, this is a social and cultural issue . . . there are going to be extreme limitations on services that are available to patients,’’ said Boyd, whose own private practice is at capacity, requiring him to turn away patients.

The state Legislature is considering a dramatic shift in the way hospitals and doctors are paid. Instead of receiving a payment for each service rendered, providers would receive a lump sum to cover all of a patient’s care. A leading consumer advocacy group, Health Care for All, said it believes the proposed payment system would encourage doctors to forge connections with patients before the onset of a major psychiatric episode, thus keeping people well and avoiding costs.

The Harvard study “reflects the kind of upside-down priorities of our health care payment system, where specialty care is very well remunerated and mental health is almost a stepchild of the health care system,’’ said Brian Rosman, research director of the consumer group.

Woolhandler, an advocate for a single-payer health system, said she worries that the proposed payment system may encourage hospitals to focus on healthy patients and avoid caring for people with high-cost mental illnesses.

Blue Cross Blue Shield spokesman Jay McQuaide took issue with the study, describing the researchers as opponents of private insurers who were trying to extract higher reimbursement rates for themselves.

McQuaide said the study was “an attempt to publicly pressure the state’s health plans, like Blue Cross, to pay these clinicians more money which, frankly, is disappointing.’’

The authors dismissed that claim, saying that only two of the five authors are psychiatrists and the real goal of the study was to examine access to mental health care.

McQuaide said that Blue Cross would be concerned if doctors in its network were turning away patients or, worse, not returning phone calls. Enrollees can call the customer service line listed on their insurance card if they are having trouble.

“We would find them an appointment,’’ he said.

http://www.boston.com/lifestyle/health/articles/2011/07/21/mental_health_care_can_be_hard_to_find_survey_says/

Grow economy by expanding Medicare

By Timothy Shaw
Letters, The Capital Times (Madison, Wis.), July 19, 2011

The Army taught us to follow our compasses instead of our native directional instincts. Former Labor Secretary Robert Reich explains that during the Depression, Utah businessman Marriner Eccles devised an economic compass to guide the nation out of economic catastrophe. Instinctively, conventional wisdom held that enriching the Wall Street/corporate class would eventually allow for economic growth. Hoover, then Roosevelt, followed this path only to find that the economy worsened.

Eccles theorized the problem wasn’t that the corporate class didn’t have enough capital, it was the workers did not have enough money to create the demand for America’s goods and services, and therefore job creation was stalled. Roosevelt eventually followed Eccles’ advice, expanded government spending, put money into the workers’ hands, created jobs, and the economy recovered.

During 1993-2000, Reich employed Eccles’ “compass.” By the time he left office, 23 million jobs had been created, the national debt was being paid down, and there was a budget surplus.

Applying the “Eccles/Reich compass” to health care, we should EXPAND Medicare, not cut it. American business cannot compete globally because of health care costs. A Green Bay small business owner pays $215,000 in health care insurance costs for 14 employees. A Medicare-for-all health system would collectively bargain to reduce medical costs per person, improve consumer confidence, increase workers’ buying power to create more jobs, and thus grow the economy.

The Army also taught us that the battle is won when ALL the soldiers cross the bridge together.

Timothy Shaw, M.D., resides in Fitchburg, Wis.

http://host.madison.com/ct/news/opinion/mailbag/article_31bc2f97-cf8d-5c03-a5ad-5b1c4e4953f7.html#ixzz1SZKpRj1J

Declines in preventable deaths linked to increases in public health spending

Evidence Links Increases In Public Health Spending To Declines In Preventable Deaths

By Glen P. Mays, and Sharla A. Smith
Health Affairs, July 21, 2011

Public health activities in the United States are supported through a patchwork of funding sources and financing arrangements that vary widely across states and communities and that are relatively unstable over time. These arrangements result in large geographic differences in spending for public health activities, even among communities with relatively similar population characteristics and health needs.

At the state level, per capita public health spending varied by a factor of more than thirty in 2010, ranging from a low of less than $4 in Nevada to a high of more than $171 in Hawaii. Local variation in public health spending was even larger, ranging from less than $1 per capita to more than $200 per capita in 2008.

Communities with larger increases in public health spending experienced larger reductions in mortality from leading preventable causes of death over a thirteen-year period. This relationship was consistent across several different mortality measures, and it persisted after accounting for differences in demographic and socioeconomic characteristics, medical resources, and unobserved community characteristics that jointly influence spending and health.

Although our study does not establish a definitive causal link between spending and mortality because of the observational research design we used, it nevertheless provides compelling evidence that differences in public health investments may contribute to differences in community health outcomes.

http://content.healthaffairs.org/content/early/2011/07/19/hlthaff.2011.0196.abstract

Comment: 

By Don McCanne, MD

This study is just a reminder that population health involves much more than just the interaction between patients and their health care professionals and institutions. The importance of the public role is undeniable. It’s too bad that our politicians don’t seem to understand that.

Even privately insured have hard time getting psychiatric care in Mass.: Harvard study

Difficulty in access to outpatient psychiatric care has national implications, researchers say

FOR IMMEDIATE RELEASE: July 21, 2011

Contact: Mark Almberg, communications director, (312) 782-6006, mark@pnhp.org

A new study by Harvard Medical School researchers published today in the Annals of Emergency Medicine finds that access to outpatient psychiatric care in the greater Boston area is severely limited, even for people with reputedly excellent private health insurance. Given that the federal health law is modeled after the Massachusetts health reform, the findings have national implications, researchers say.

Study personnel posed as patients insured by Blue Cross Blue Shield of Massachusetts PPO, the largest insurer in Massachusetts. They called every Blue Cross-contracted mental health facility within a 10-mile radius of downtown Boston, stating they had been evaluated in an emergency department for depression and discharged with instructions to obtain a psychiatric appointment within two weeks – i.e. they signaled they needed urgent care.

Only 8 of the 64 facilities (12.5 percent) listed by Blue Cross as preferred providers offered appointments; only 4 (6.2 percent) offered an appointment within two weeks. These findings indicate that even patients with top-drawer private insurance face grave difficulties in securing mental health services in the Boston area.

According to the study, 23 percent of phone calls seeking appointments were never returned, even after a second attempt. Another common reason appointments were unavailable was that 23 percent of psychiatric providers required that the patient already be enrolled with a primary care doctor affiliated with their psychiatric facility.

“People with mental health problems often can’t advocate for themselves – especially in a crisis,” said lead author Dr. J. Wesley Boyd, an attending psychiatrist at the Harvard-affiliated Cambridge Health Alliance. “Health insurers know this and yet, thanks to their restrictive provider networks and their low reimbursement rates for psychiatric services, they’ve created a situation where a patient with a potentially life-threatening disorder, such as the severe depression portrayed in our callers’ scenario, is essentially abandoned at a time of great need.”

“Despite having private coverage, our simulated patient faced daunting barriers when trying to access psychiatric care,” Boyd continued. “How likely is it that a real patient in the grip of severe depression would persevere through so many unsuccessful attempts?”

Senior author Dr. Rachel Nardin, chief of neurology at Cambridge Health Alliance, said: “The incentives of the current health insurance system are aligned against patients with mental illness. Insurers try to protect their bottom line by reimbursing poorly for psychiatric services and by constraining their in-network provider lists, both of which limit patients’ options so severely as to make services essentially unavailable.”

“Lack of adequate access to mental health care strains our entire health care system,” said Nardin. “Emergency departments are overwhelmed with boarding psychiatric patients for whom no other resources exist.”

“A good first step would be for insurance companies to immediately provide improved reimbursements for psychiatric care,” Nardin said. “A more fundamental solution, however, would be to remove private insurers from the picture altogether and to establish a single-payer national health insurance program – a program that would cover mental health services as part of its comprehensive benefits package.”

*********

“The crisis in mental health care: A preliminary study of access to psychiatric care in Boston,” J. Wesley Boyd, M.D., Ph.D.; Andrew Linsenmeyer, M.D.; Steffie Woolhandler, M.D., M.P.H.; David Himmelstein, M.D.; Rachel Nardin, M.D.  Annals of Emergency Medicine, July 21, 2011.

*********

Physicians for a National Health Program (www.pnhp.org) is an 18,000-member organization advocating a nonprofit, single-payer national health insurance program for the United States. PNHP had no role in funding the study mentioned above. To speak with a physician/spokesperson in your area, visit www.pnhp.org/stateactions or call (312) 782-6006.

Declines in preventable deaths linked to increases in public health spending

Evidence Links Increases In Public Health Spending To Declines In Preventable Deaths

By Glen P. Mays, and Sharla A. Smith
Health Affairs, July 21, 2011

Public health activities in the United States are supported through a patchwork of funding sources and financing arrangements that vary widely across states and communities and that are relatively unstable over time. These arrangements result in large geographic differences in spending for public health activities, even among communities with relatively similar population characteristics and health needs.

At the state level, per capita public health spending varied by a factor of more than thirty in 2010, ranging from a low of less than $4 in Nevada to a high of more than $171 in Hawaii. Local variation in public health spending was even larger, ranging from less than $1 per capita to more than $200 per capita in 2008.

Communities with larger increases in public health spending experienced larger reductions in mortality from leading preventable causes of death over a thirteen-year period. This relationship was consistent across several different mortality measures, and it persisted after accounting for differences in demographic and socioeconomic characteristics, medical resources, and unobserved community characteristics that jointly influence spending and health.

Although our study does not establish a definitive causal link between spending and mortality because of the observational research design we used, it nevertheless provides compelling evidence that differences in public health investments may contribute to differences in community health outcomes.

http://content.healthaffairs.org/content/early/2011/07/19/hlthaff.2011.0196.abstract

This study is just a reminder that population health involves much more than just the interaction between patients and their health care professionals and institutions. The importance of the public role is undeniable. It’s too bad that our politicians don’t seem to understand that.

Single Payer Ahead — Cost Control and the Evolving Vermont Model

By Anya Rader Wallack, Ph.D.
The New England Journal of Medicine, July 20, 2011

Governor Peter Shumlin of Vermont recently signed into law ambitious health care reform legislation that puts Vermont on course to implement a single-payer health care system. The law creates a Health Benefit Exchange, consistent with the federal Affordable Care Act, and anticipates using it as the administrative structure for a publicly funded program of health insurance coverage for all Vermonters. The Shumlin administration believes that a single-payer system offers the greatest promise for reducing administrative waste and hassle in our health care system, guaranteeing coverage to everyone in the state, and relieving employers of the increasingly crushing burden of health insurance costs.

Vermont’s plan would include many features common to single-payer systems around the world: a global budget for health care expenditures, guaranteed coverage that is not linked to employment, and a single system of provider payments and administrative rules. The health care delivery system would remain privately owned, however, and the state could contract with a private insurer to perform some functions required of the single payer. It is not yet clear how far the state can go toward establishing a complete single-payer system. Our administration is exploring the potential relationship between the single payer and federal programs such as Medicare and TriCare (the military’s health plan) and determining how self-insured employer plans will fit into the Vermont system. Other elements yet to be worked out include the specific sources of public financing and detailed specifications for covered benefits. We intend to develop these facets of the plan during the next 2 years and will request federal permission to have the single payer fully operational by 2017.

Admittedly, Vermont is a small state (population about 625,000), but even on that scale, plans to launch a U.S. single-payer system seem noteworthy. Moreover, the single-payer provisions are not the only important components of our legislation; equally significant are the provisions for controlling health care costs. The governor has made clear that he will not pursue public financing for a single payer if Vermont hasn’t found a way to control cost growth — implementing true cost control, not just Medicaid fee cutting or cost shifting.

The law creates a new public board, the Green Mountain Care Board, that will be the locus of responsibility for cost control. The board can wield traditional tools such as fee-for-service rate setting, controls on the acquisition of technology, and reviews of both health insurers’ rates and hospitals’ budgets. However, the law also provides explicit direction to the board to create a global budget for health care spending and develop new payment models that create incentives for providers to stay within the budget. Like most states, we rely almost exclusively on a fee-for-service model to pay health care practitioners. This system creates a financial incentive to deliver more care and does not reimburse on the basis of quality, value, or health outcomes. The board is charged with implementing payment methods that encourage high quality and efficiency and provide the impetus for fundamental changes in the structure of the delivery system. It will apply these methods across all payers, private and public (we will seek permission from the federal government to include Medicare), and will monitor the effects of payment changes on both cost growth and quality indicators.

Achieving measurable cost control while tangibly improving the quality of care is certainly an audacious goal. But health care costs are eating up more and more of our economy even as the value of health insurance is eroding. Health care providers, particularly primary care providers and community hospitals, are financially stressed and drowning in red tape supposedly aimed at cost control. Vermont needs a framework within which providers have the right financial incentives, without all the wrong interference from insurers and government. Moreover, we must align incentives for payers, providers, and consumers so that the risks and rewards embedded in provider payment systems, benefit designs, and cost sharing all promote a higher-value health system and better health.

We have seen that changes in health care payment can drive more fundamental change. Since 2006, Vermont has been pursuing an ambitious project aimed at implementing the “advanced primary care medical home” model for care delivery. The state’s “Blueprint for Health” augments the capacity of physician practices with a community health team that helps manage patients’ care and connects them with social services. It also provides bonus payments, through all payers, whose amount is linked to performance on quality metrics. In January, the project will expand to include “anchor” specialists attached to advanced primary care medical homes, with bonus payments linked to both quality and total cost of care.

The next phase of our payment reforms will build on the Blueprint’s foundation of pay for performance and also move some groups of providers into budgeted or virtually budgeted arrangements. Such groups could include those capable of accepting a single, global payment for the complete care needs of a population, as well as looser affiliations of providers who will receive fee-for-service payments but face some combination of risk and reward if their total payments end up being above or below a targeted per capita level. The board will explore various models, as well as the use of bundled payments by all payers. The key to the board’s success will be focusing on implementing a narrow array of reforms that are predicted to have a high likelihood of success. The reforms must be readily understood by providers and create clear and strong incentives for re-engineering delivery systems and care patterns and making more efficient use of capital, technology, and human resources.

Our biggest challenge will be making the transition to a budgeted world. Much of Vermont’s existing regulation has been aimed at ensuring financial solvency for institutions, both hospitals and insurers. New payment models aimed at reducing waste and improving prevention and chronic care management necessarily shift resources out of the hospital. The Blueprint for Health already confirms this effect: as we have invested in and rewarded good primary care, hospital admissions and readmissions have been reduced. How do we continue this trend but assure Vermonters that they will have appropriate access to specialty and hospital services within their communities?

In addition to the direction and authority provided by the new law, Vermont has some other key ingredients for success in controlling health care costs. We believe we have a more efficient and collaborative health care system than most states. We have 14 community hospitals, all with fairly exclusive service territories. Competition for patients is not a major factor in how they do business. Our physicians did not come to the state to get rich. Our health care system is by no means bloated, and our providers want to do the right thing. We currently don’t reward them for doing the right thing. If we begin to reward them, and we clear away bureaucratic requirements, we believe we can achieve great things and provide an example to the country.

It is worth watching Vermont’s development of its single-payer system as a model for guaranteeing coverage for all citizens, reducing administrative waste, and simplifying insurance for both patients and providers. We can make health insurance simpler and easier for everyone and save money at the same time. But Vermont’s most meaningful work in the near term will be aimed at changing our health care payment and delivery systems. I am convinced that that’s where the real savings, and the sustainabili
ty, lie.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

Dr. Wallack is special assistant to the governor for health reform, Montpelier, VT.

This article (10.1056/NEJMp1104562) was published on July 20, 2011, at NEJM.org.