PNHP

David Cameron's adviser says health reform is a chance to make big profits

David Cameron's adviser says health reform is a chance to make big profits

Kitchen cabinet aide says charging improves service and NHS should be shown 'no mercy' in drive for reform

By Daniel Boffey and Toby Helm
The Guardian, Saturday 14 May 2011

A senior adviser to David Cameron says the NHS could be improved by charging patients and will be transformed into a “state insurance provider, not a state deliverer” of care.

Mark Britnell, who was appointed to a “kitchen cabinet” advising the prime minister on reforming the NHS, told a conference of executives from the private sector that future reforms would show “no mercy” to the NHS and offer a “big opportunity” to the for-profit sector.

The revelations come on the eve of an important speech by the prime minister on the future of the NHS, during which he is expected to try to allay widespread fears that the reforms proposed in health secretary Andrew Lansley’s health and social care bill would lead to privatisation.

It has been suggested that Cameron may even announce an extension to the “pause” in the progress of the bill until after the party conference season, amid growing tensions on the issue within the coalition government.

Nick Clegg, has insisted that the Liberal Democrats will not support any reforms that allow the “profit motive to drive a coach and horses through the NHS”. Backbench Tory MPs, however, have called for the government to stick to the reforms and open the provision of services to the private sector. Britnell’s comments will inevitably raise the temperature of the debate.

Britnell, a former director of commissioning for the NHS, who is now head of health at the accountancy giant KPMG, was invited to join a group of senior health policy experts, described by the respected Health Service Journal as a “kitchen cabinet”, in Downing Street earlier this month. The group, which includes former NHS executives and the former Department of Health permanent secretary Lord Crisp, was assembled by Cameron’s new special adviser on health, Paul Bate.

In unguarded comments at a conference in New York organised by the private equity company Apax, Britnell claimed that the next two years in the UK would provide a “big opportunity” for the for-profit sector, and that the NHS would ultimately end up as a financier of care similar to an insurance company rather than a provider of hospitals and staff.

According to a glossy brochure summarising the conference held last October, Britnell told his audience: “GPs will have to aggregate purchasing power and there will be a big opportunity for those companies that can facilitate this process … In future, the NHS will be a state insurance provider, not a state deliverer.” He added: “The NHS will be shown no mercy and the best time to take advantage of this will be in the next couple of years.”

Writing in the Health Service Journal, Britnell also suggested that the NHS would be better served by breaking with the mantra that all services should be free at the point of delivery by allowing co-payment, where patients share the costs of care and drugs.

“It appears that countries that have a mixed blend of public and private provision, co-payment and social insurance are possibly more capable of providing resilient healthcare systems.”

The shadow health secretary, John Healey, said: “This revelation comes direct from Cameron’s inner circle and gives the game away on the government’s NHS plans. It confirms the Tories’ true purpose is to set up a free-market NHS and open up all parts of the health service to private companies.”

In a move that will pile more pressure on Lansley, the Department of Health last week released the latest Mori poll on satisfaction levels with the NHS. It shows that 66% of people questioned believed the NHS was the best health service in the world, while 37% of the public expected services to deteriorate following the reforms. However, nearly three-quarters said that they knew “not very much” or “nothing at all” about changes that the government plans to make.

Sir Michael Scholar, chairman of the UK Statistics Authority, demanded a rethink of the halt on funding for the General Lifestyle Survey, which is run by the Office for National Statistics. Scholar said: “If government is planning a major reform of the NHS, people will want to know if it is worse afterwards or not. These statistics are very important in reaching a rational view.”

Labour sources said that the only explanation for the cuts in funding was that the government expected a hostile reaction to the reforms that do proceed and ministers were “planning how best to keep that from view”.

Downing Street tried to distance itself from Britnell. A No 10 spokesman said: “We will never privatise the NHS. We remain committed to the principle of an NHS funded from general taxation and based on need not ability to pay. Mark Britnell is not the prime minister’s health adviser. We are listening to the views of experts, patients and staff on how to improve our plans to strengthen the NHS.”

http://www.guardian.co.uk/politics/2011/may/14/david-cameron-adviser-health-reform

ACOs, ACA, and integrated health systems

Letter to Donald Berwick, M.D., Administrator, CMS

American Medical Group Association
May 11, 2011

Re: Medicare Shared Savings Program:  Accountable Care Organizations

We write today, however, to express our serious concerns over the direction of the Proposed Rule. On its face, it is overly prescriptive, operationally burdensome, and the incentives are too difficult to achieve to make this voluntary program attractive. As you know, most policy experts believe multi-specialty medical groups are best poised to become ACOs in the short term. However, in a survey of AMGA members, 93 percent said they would not enroll as an ACO under the current regulatory framework.  
 
Our membership’s concerns were many and focused on issues such as the risk sharing requirement, static risk adjustment, retrospective attribution, quality measurement requirements, the Minimum Savings requirements and others. Without substantial changes in the Final Rule, we fear that very few providers will enroll as ACOs and that CMS and the provider community will miss the best opportunity to inject value and accountability into the delivery system. 

http://thehill.com/images/stories/blogs/healthwatch/amga.pdf

And…

Letter to Donald Berwick, M.D., Administrator, CMS

Billings Clinic
The Everett Clinic
Park Nicollet
Geisinger Clinic
Dartmouth-Hitchcock Health
Univ. of Michigan Med. School
Marshfield Clinic
St. John’s Clinic
Novant Medical Group
Middlesex Health System

May 12, 2011

On behalf of the multi-specialty groups participating in the Physician Group Practice (PGP) Demonstration Program, we are writing to you today regarding Section 3022 of the Affordable Care Act’s notice of proposed rule-making (NPRM) for the Medicare Shared Savings Program/Accountable Care Organizations (ACOs).

However, as presently proposed, we ALL have serious reservations about the economics and the complexity of the Medicare Shared Savings Program/ACO NPRM. All of our organizations are planning to individually respond with our own respective concerns, but broadly, the “Shared Savings” model/NPRM has the following aspects that are problematic: 
 
* There is downside risk during the initial 3-year term, unlike the recently concluded PGP Demonstration project. Such downside risk is compounded by significant investment cost on the part of the ACO.
* Savings are measured net of 2% threshold for the one-sided risk model. Additionally, the Minimum Savings Rate (MSR) is set at high levels for ACOs with lower enrollment. 
* Limits placed on accounting for beneficiary acuity level that is documented and appropriate will dilute true savings realized by the ACO, and is a disincentive for management of patients with complex care needs.  
* There are a large number of quality measures, especially new quality metrics in several domains, that go into effect starting year one. As an example, on average, it costs about $30,000 just to program a single new quality metric. This NPRM has more than 60 new ones, which equates to nearly $2,000,000 for each organization. The excellent results produced by the PGP demonstration are evidence of the benefits of a careful expansion of quality measures.
* Retrospective attribution places limits on the ACO’s ability to bend the cost curve. It impedes optimal patient engagement, timely program planning and course correction, and compounds underlying issues of claims lag and financial settlement. 
* The logistics associated with Medicare beneficiaries’ opt-out of the ACO program is simply not practical. We believe this would lead to beneficiary and physician confusion on the terms of engagement.

As currently proposed, ACOs have a greater potential for incurring losses under either track, than for generating savings. This risk-reward imbalance makes it difficult, if not impossible, for internal decision-makers to accept the financial design.

http://thehill.com/images/stories/blogs/healthwatch/unhappyacos.pdf

And…

ACO start-up costs higher than estimated, AHA study says

By Rich Daly
ModernHealthcare.com, May 14, 2011

Accountable care organizations will likely face start-up and first-year costs six to 14 times higher than HHS has estimated, according to a study released by the American Hospital Association.

The study, which was based on an analysis of previous research, concluded that the various elements required to successfully manage the care of a specific population will cost between $11.6 million and $26.1 million—depending on the size of the hospital or hospital system involved in the ACO—and far more than the $1.8 million estimated by the CMS in its proposed rule.

The cost findings are based on 23 different capabilities that ACOs will need to develop across four categories: network development and management; care coordination, quality improvement and utilization management; clinical information systems; and data analytics.

http://www.modernhealthcare.com/article/20110514/NEWS/305149999/

Comment: 

By Don McCanne, MD

The accountable care organizations (ACOs) called for in the Accountable Care Act (ACA) don’t seem to be getting off to a good start. Most medical groups do not intend to participate, the hospitals have found that they are too expensive, and the distinguished participants in the Group Practice Demonstration Program all have serious reservations about the proposed rules for ACOs under the ACA. What is going on here?

The goal seems to be to establish integrated health care delivery systems with varying design characteristics based on local needs and logistical considerations. Size and complexity would vary greatly. Such systems should provide a primary care base for entry into the system and for coordination of services. Specialty care should be integrated within the system, providing appropriate access and interaction with primary care. Information technology systems should enable access to clinical records while providing tools that reduce error and duplication of services, while assisting with clinical decisions. Basically, we want health care professionals and hospitals working together to provide more efficient, higher quality care for everyone.

That is the concept behind ACOs. Integrated systems would be rewarded based on quality and efficiency (i.e., lower costs). Because of political considerations, Congress decided that they should apply the ACO concept exclusively to Medicare, while letting the private insurers supervise their own quality and cost programs.

The simplistic solution was to establish the Medicare Shared Savings Program. Reduced costs would be built in by rewarding the ACO systems with a portion of the funds that they saved, and ensuring quality by making the rewards dependent on meeting certain quality measures. The problem with this became evident when it came time to write the rules. Not only were the systems required to enable this very expensive, the rules would create what bureaucracies are so adept at creating – a bureaucratic quagmire. The letter from the participants in the Group Practice Demonstration Program list some of these aspects that proved to be problematic.

Bundling of payments has been another approach, but only certain clinical presentations conform well to bundling. So it would not be an answer to the majority of clinical problems. Also bundling removes risk from the common financing pool and splits it up amongst the provid
ers of health care. Luck or lack thereof plays too great of a role to ask the providers to place bets on it merely by agreeing to accept patients with conditions subject to bundling.

Much of the difficulty has stemmed from the new, widely touted principle that we should no longer pay for volume but instead we should pay for quality and efficiency, but both quality and efficiency have proven to be very difficult to define. The default has been a few parameters of each which in no way can represent the broader spectrum of quality and efficiency.

Health care is a lot of work. No matter what else, the delivery system will have to be paid primarily on volume, but we need to get the volume right. Much attention has been paid to excess volume being driven by the rewards of fee-for-service care. In fact, the largest volume increase has been in imaging services, yet most physicians who order the procedures are not compensated for these services. The Dartmouth variations do remain of concern and further attention in defining these is certainly warranted.

The greater problem with volume has been demonstrated to be underutilization of services. According to a RAND study, most patients receive only about half of the care that they should have. The emphasis on reducing the volume of care has been somewhat misguided since there is a greater need to increase the volume, though we need to get the pricing right when we do that. The SGR dilemma must be addressed, but the basis for it will not go away.

The bottom line? Integrated health systems that are designed for optimal patient service are an admirable goal, but integrated health systems designed predominantly as a business model are not. ACOs designed to comply with the Medicare Shared Savings Program are an abstract concept that will never fly, as today’s quotes indicate. On the other hand, ACOs designed as a business model – the so-called commercial ACOs – are just another label for the intrusive managed care organizations that most of us have been trying to get away from.

The goals of higher quality at reasonable costs would best be achieved by humanitarian integrated health systems financed not by a dysfunctional, fragmented system of private and public plans, but rather by a publicly-financed and publicly-administered universal risk pool – an improved Medicare for everyone.

The ACO misstep is more of a problem of well intentioned but misdirected policy application. The now-tarnished ACO label should be dropped as we move forward with mutual efforts to improve the quality and efficiency of our health care delivery system so it works well for all of us.

Vermont approves universal health program

The measure adopted by the Legislature and supported by the governor would establish a single-payer-type plan, although some private insurers would stay.

By Doug Trapp
Amednews, May 16, 2011

Vermont Gov. Peter Shumlin has pledged to sign a bill that paves the way for the state to launch a health system approaching a single-payer model later in the decade and to create a state health insurance exchange within the next several years.

The measure creates a powerful five-member Green Mountain Care Board, members of which will determine the benefits and craft a funding plan for Green Mountain Care, a state universal health plan. The board would have wide authority over state health spending and health system reform. The bill requires the governor to nominate Green Mountain board members by Oct. 1 and the Vermont Senate to confirm them.

The measure will set up a health insurance exchange in which Vermonters will shop for private health plans and enroll in public coverage. The exchange is to begin enrolling residents in November 2013 and be fully operational by January 2014. The bill calls for at least two private health insurance plans to participate in the exchange.

The Democratic-controlled Vermont Legislature approved the bill along party lines, with the state Senate voting 21-9 to pass it on May 3 and the House adopting it on May 5 with a 94-49 vote. Shumlin scheduled a bill-signing ceremony for May 26.

He had pledged to enact a single-payer health system during his Jan. 6 inaugural address. “Let Vermont be the first state in the nation to treat health care as a right and not a privilege.”

Reaction to the bill

Many health care stakeholders are taking a wait-and-see approach to Green Mountain Care, which might not be implemented fully until 2017 — or ever, if it is projected to cost as much or more than the state’s existing health system, said Vermont Rep. Mark Larson, the bill’s sponsor. But Larson is optimistic that the plan will produce the necessary savings to proceed.

The measure’s lack of specificity created anxiety among health insurers, businesses and others in the state, said Leigh Tofferi, director of government, public and community relations for Blue Cross Blue Shield of Vermont, the state’s largest health plan. The nonprofit insurer supports the state’s efforts on payment and delivery system reforms and the creation of the insurance exchange, which could produce savings for the system.

But the measure does not lay out the financing plan and minimum benefits for Green Mountain Care, nor does it establish what would happen to existing health insurance and coverage. Those decisions are up to the Green Mountain Care Board. “We will weigh in on those other issues as they become more specific next year and the year after,” Tofferi said.

The measure requires the Green Mountain plan to pay enough to attract and retain high-quality health care professionals, said Vermont Sen. Kevin Mullin, the lone Republican to vote for the bill. He offered this and other changes that made it into the final bill, including a mandate that the plan’s funding be sustainable. Tofferi credited Mullin with improving the bill’s specificity.

The Vermont Medical Society did not take a position on the bill and has no policy on single-payer health care, said VMS Executive Vice President Paul Harrington. He expects the Legislature to adopt legislation related to the health reform bill in each of the next several years.

Larson predicted a similar outcome. “There’s much more work to be done in moving forward with the plan than not,” he said.

Not quite single-payer

The measure requires the Green Mountain Care Board to examine and attempt to limit the growth of state health care spending, begin pilot payment reforms, and continue to implement a previously enacted patient-centered medical home program.

The board would implement Green Mountain Care. All Vermonters would be eligible for the plan, which would cover hospital services and prescription drugs.

But Green Mountain Care cannot launch until three conditions are met. The Vermont Legislature must approve a board-proposed three-year budget for the plan — one that costs less than the state’s existing health system. The board also must define the plan’s benefits. Finally, Vermont needs the U.S. Health and Human Services Dept.’s permission to use health insurance exchange subsidies in the federal health reform law to support Green Mountain Care beginning in 2017. Waivers would be required to incorporate Medicaid, Medicare and other federal health funds.

Despite Shumlin’s statements on his inaugural promise, the bill does not meet the strict definition of a single-payer plan, in which the government is the sole third-party payer for health care. “But it is as close as we can get at the state level,” said bill sponsor Larson.

The measure would allow private health plans to continue in the state indefinitely. “You give up a significant part of the administrative savings by doing that,” said David Himmelstein, MD, founder of Physicians for a National Health Program. The organization, based in Chicago, advocates for a single-payer health system.

A true single-payer plan should have separate operating and capital budgets, Dr. Himmelstein said. It should require a single insurance fund to pay all claims, he said.

Self-insured businesses such as IBM — the state’s largest employer — could continue to offer private health coverage to employees. But businesses likely will be required to contribute to Green Mountain Care’s funding, possibly through a payroll tax.

Although the bill goes further toward single-payer than all other states and the national health reform law, it won’t solve Vermont’s health care problems, Dr. Himmelstein said. “Maybe it lays the foundation.”

Larson said no one else proposed a bill that could deliver the quality improvements and savings possible through his measure.

Mullin, the Republican senator, said he doesn’t care if the state enacts a single-payer or a multipayer system, as long as it works. “If they can prove that single-payer is going to work, God bless them,” he said.

ADDITIONAL INFORMATION: Step 1 to single-payer

Vermont lawmakers OK’d a bill that would pave the way for a single-payer-type health care system in the state. The measure approved by the Legislature has three major parts:

* Green Mountain Care Board, a five-member panel appointed by the governor with Senate confirmation. The board would design the state’s universal coverage plan, develop state health care budgets, and carry out health cost containment and payment reform.

* The Vermont Health Benefit Exchange, a state marketplace for health insurance as called for under the national health system reform law. The exchange would start operating by 2014 and could become the main source of health coverage in Vermont by 2017.

* Green Mountain Care, the state’s universal coverage plan, which could launch by 2017. The state would need federal approval to use federal health funds to help finance the plan. The state is expected to adopt payroll or income taxes to help pay for the plan.

http://www.ama-assn.org/amednews/2011/05/16/gvsa0516.htm

ACOs, ACA, and integrated health systems

Letter to Donald Berwick, M.D., Administrator, CMS

American Medical Group Association
May 11, 2011

Re: Medicare Shared Savings Program:  Accountable Care Organizations

We write today, however, to express our serious concerns over the direction of the Proposed Rule. On its face, it is overly prescriptive, operationally burdensome, and the incentives are too difficult to achieve to make this voluntary program attractive. As you know, most policy experts believe multi-specialty medical groups are best poised to become ACOs in the short term. However, in a survey of AMGA members, 93 percent said they would not enroll as an ACO under the current regulatory framework.

Our membership’s concerns were many and focused on issues such as the risk sharing requirement, static risk adjustment, retrospective attribution, quality measurement requirements, the Minimum Savings requirements and others. Without substantial changes in the Final Rule, we fear that very few providers will enroll as ACOs and that CMS and the provider community will miss the best opportunity to inject value and accountability into the delivery system.

http://thehill.com/images/stories/blogs/healthwatch/amga.pdf

And…

Letter to Donald Berwick, M.D., Administrator, CMS

Billings Clinic
The Everett Clinic
Park Nicollet
Geisinger Clinic
Dartmouth-Hitchcock Health
Univ. of Michigan Med. School
Marshfield Clinic
St. John’s Clinic
Novant Medical Group
Middlesex Health System

May 12, 2011

On behalf of the multi-specialty groups participating in the Physician Group Practice (PGP) Demonstration Program, we are writing to you today regarding Section 3022 of the Affordable Care Act’s notice of proposed rule-making (NPRM) for the Medicare Shared Savings Program/Accountable Care Organizations (ACOs).

However, as presently proposed, we ALL have serious reservations about the economics and the complexity of the Medicare Shared Savings Program/ACO NPRM. All of our organizations are planning to individually respond with our own respective concerns, but broadly, the “Shared Savings” model/NPRM has the following aspects that are problematic:

* There is downside risk during the initial 3-year term, unlike the recently concluded PGP Demonstration project. Such downside risk is compounded by significant investment cost on the part of the ACO.
* Savings are measured net of 2% threshold for the one-sided risk model. Additionally, the Minimum Savings Rate (MSR) is set at high levels for ACOs with lower enrollment.
* Limits placed on accounting for beneficiary acuity level that is documented and appropriate will dilute true savings realized by the ACO, and is a disincentive for management of patients with complex care needs.
* There are a large number of quality measures, especially new quality metrics in several domains, that go into effect starting year one. As an example, on average, it costs about $30,000 just to program a single new quality metric. This NPRM has more than 60 new ones, which equates to nearly $2,000,000 for each organization. The excellent results produced by the PGP demonstration are evidence of the benefits of a careful expansion of quality measures.
* Retrospective attribution places limits on the ACO’s ability to bend the cost curve. It impedes optimal patient engagement, timely program planning and course correction, and compounds underlying issues of claims lag and financial settlement.
* The logistics associated with Medicare beneficiaries’ opt-out of the ACO program is simply not practical. We believe this would lead to beneficiary and physician confusion on the terms of engagement.

As currently proposed, ACOs have a greater potential for incurring losses under either track, than for generating savings. This risk-reward imbalance makes it difficult, if not impossible, for internal decision-makers to accept the financial design.

http://thehill.com/images/stories/blogs/healthwatch/unhappyacos.pdf

And…

ACO start-up costs higher than estimated, AHA study says

By Rich Daly
ModernHealthcare.com, May 14, 2011

Accountable care organizations will likely face start-up and first-year costs six to 14 times higher than HHS has estimated, according to a study released by the American Hospital Association.

The study, which was based on an analysis of previous research, concluded that the various elements required to successfully manage the care of a specific population will cost between $11.6 million and $26.1 million—depending on the size of the hospital or hospital system involved in the ACO—and far more than the $1.8 million estimated by the CMS in its proposed rule.

The cost findings are based on 23 different capabilities that ACOs will need to develop across four categories: network development and management; care coordination, quality improvement and utilization management; clinical information systems; and data analytics.

http://www.modernhealthcare.com/article/20110514/NEWS/305149999/

The accountable care organizations (ACOs) called for in the Accountable Care Act (ACA) don’t seem to be getting off to a good start. Most medical groups do not intend to participate, the hospitals have found that they are too expensive, and the distinguished participants in the Group Practice Demonstration Program all have serious reservations about the proposed rules for ACOs under the ACA. What is going on here?

The goal seems to be to establish integrated health care delivery systems with varying design characteristics based on local needs and logistical considerations. Size and complexity would vary greatly. Such systems should provide a primary care base for entry into the system and for coordination of services. Specialty care should be integrated within the system, providing appropriate access and interaction with primary care. Information technology systems should enable access to clinical records while providing tools that reduce error and duplication of services, while assisting with clinical decisions. Basically, we want health care professionals and hospitals working together to provide more efficient, higher quality care for everyone.

That is the concept behind ACOs. Integrated systems would be rewarded based on quality and efficiency (i.e., lower costs). Because of political considerations, Congress decided that they should apply the ACO concept exclusively to Medicare, while letting the private insurers supervise their own quality and cost programs.

The simplistic solution was to establish the Medicare Shared Savings Program. Reduced costs would be built in by rewarding the ACO systems with a portion of the funds that they saved, and ensuring quality by making the rewards dependent on meeting certain quality measures. The problem with this became evident when it came time to write the rules. Not only were the systems required to enable this very expensive, the rules would create what bureaucracies are so adept at creating – a bureaucratic quagmire. The letter from the participants in the Group Practice Demonstration Program list some of these aspects that proved to be problematic.

Bundling of payments has been another approach, but only certain clinical presentations conform well to bundling. So it would not be an answer to the majority of clinical problems. Also bundling removes risk from the common financing pool and splits it up amongst the providers of health care. Luck or lack thereof plays too great of a role to ask the providers to place bets on it merely by agreeing to accept patients with conditions subject to bundling.

Much of the difficulty has stemmed from the new, widely touted principle that we should no longer pay for volume but instead we should pay for quality and efficiency, but both quality and efficiency have proven to be very difficult to define. The default has been a few parameters of each which in no way can represent the broader spectrum of quality and efficiency.

Health care is a lot of work. No matter what else, the delivery system will have to be paid primarily on volume, but we need to get the volume right. Much attention has been paid to excess volume being driven by the rewards of fee-for-service care. In fact, the largest volume increase has been in imaging services, yet most physicians who order the procedures are not compensated for these services. The Dartmouth variations do remain of concern and further attention in defining these is certainly warranted.

The greater problem with volume has been demonstrated to be underutilization of services. According to a RAND study, most patients receive only about half of the care that they should have. The emphasis on reducing the volume of care has been somewhat misguided since there is a greater need to increase the volume, though we need to get the pricing right when we do that. The SGR dilemma must be addressed, but the basis for it will not go away.

The bottom line? Integrated health systems that are designed for optimal patient service are an admirable goal, but integrated health systems designed predominantly as a business model are not. ACOs designed to comply with the Medicare Shared Savings Program are an abstract concept that will never fly, as today’s quotes indicate. On the other hand, ACOs designed as a business model – the so-called commercial ACOs – are just another label for the intrusive managed care organizations that most of us have been trying to get away from.

The goals of higher quality at reasonable costs would best be achieved by humanitarian integrated health systems financed not by a dysfunctional, fragmented system of private and public plans, but rather by a publicly-financed and publicly-administered universal risk pool – an improved Medicare for everyone.

The ACO misstep is more of a problem of well intentioned but misdirected policy application. The now-tarnished ACO label should be dropped as we move forward with mutual efforts to improve the quality and efficiency of our health care delivery system so it works well for all of us.

Vermont moves closer to becoming first US state to provide 'socialised medicine'

By Jeanne Lenzer
BMJ, May 10, 2011

Vermont is set to become the first US state to launch a single payer healthcare plan after a bill passed both houses of the state’s legislature.

The plan is expected to be signed by Governor Peter Shumlin, who in February originally proposed the idea that would abolish most insurance plans and would instead provide healthcare to all residents through public funding. In the United States this is known as a “single payer” scheme and is fiercely opposed by many conservative politicians as “socialised medicine.”

Some doctors in Vermont are unhappy about the proposed changes. In an online poll of roughly 600 doctors conducted by the state representative George Till, a doctor who specialises in obstetrics and gynaecology, 28 percent said that they will stop practising medicine in the state if the plan is enacted. However, the poll by Dr Till, who opposes the governor’s plan, has been criticised for not preventing multiple responses from the same person or responses from people who weren’t doctors.

The man responsible for designing Vermont’s plan, William Hsiao, professor of economics at the Harvard School of Public Health in Boston, told the BMJ that he and his colleagues evaluated healthcare schemes around the globe and found that “fee for service is the worst payment [mechanism] in the world, [as] it’s inflationary—and it’s the incentive structure embedded in our healthcare system.” Costs spiral out of control, he said, because doctors and hospitals are paid more for doing more.

An analysis by Dr Hsiao, published in the New England Journal of Medicine (2011;364:1188-1190; doi:10.1056/ NEJMp1100972), concluded that the new plan is necessary because one in five Vermont residents have either inadequate or no health insurance and rising healthcare costs threaten the solvency of small businesses and citizens.

Dr Hsiao told the BMJ, “The US is the only advanced nation other than South Africa that builds health insurance on a free market of multiple private insurers” and conditional on employment. “We need to decouple employment and health insurance,” he said. “If you live in Vermont, you will be eligible for health insurance.”

The Vermont plan, Dr Hsiao’s analysis shows, could lead to cost savings of 25 percent over 10 years. Savings would come from “administrative simplification,” introduction of a no-fault malpractice system, elimination of “perverse [financial] incentives,” and by “insulating major decisions about healthcare spending from politics.” This last reform is especially needed in the US, Dr Hsiao told the BMJ, because politicians, whose campaigns are often underwritten by large contributions from industry, often support schemes that increase profits for drug companies, hospitals, and specialist groups.

One example, he says, is the Medicare plan passed under the former president George W Bush that prohibits Medicare from competitive bidding on drugs.

As for fears that doctors will leave Vermont, Dr Hsiao told the Boston Globe that he doubts doctors will actually leave the state (7 Apr, “With health costs rising, Vermont moves toward a single-payer system,” www.boston.com/bostonglobe/editorial_ opinion/blogs/the_angle/2011/04/vermonts_single.html). If they do, he said, communities and medical centres will not have trouble recruiting replacements.

Dr Hsiao acknowledges that the legislation has been weakened from its original version, owing to “politics.” He told the BMJ that, among other changes, the legislature defeated the no-fault insurance plan, instead calling for “further study.”

Stephanie Woolhandler, professor of medicine at Harvard Medical School and co-founder of Physicians for a National Health Program, told the BMJ that the Vermont legislation “falls well short of the single payer reform needed to resolve the healthcare crisis,” in part because it allows a “continuing role for private insurance, negating many of the administrative savings attainable through a single payer reform.” The plan, she said, would “force many patients to face copayments that obstruct access to care,” and it allows the participation of “for-profit hospitals and other providers, which research has shown deliver inferior care at inflated prices.”

But despite its shortcomings, the plan “may be a useful step toward progressive health reform,” Dr Woolhandler said.

Cite this as: BMJ 2011;342:d2921

Single Payer in Vermont? Well, Not Exactly

By Roger Collier
Healthcare Finance News, May 16, 2011

In just a few days, Vermont’s Governor Peter Shumlin will sign into law what the media is calling “single payer health care reform.” But is it?

Vermont has certainly demonstrated more enthusiasm for a single payer approach than any other state. The Governor and key Democratic legislators have supported the concept, the state has a well-organized lobbying group in Vermont for Single Payer, and a state-funded study earlier this year estimated that a single payer approach could dramatically reduce health care costs. The major result has been passage in the past month by both of the state’s legislative chambers of the bill that Governor Shumlin indicates that he will sign.

So does this mean that Vermont is ready to upend its existing health care financing system and replace it with a French or British-style system? Not exactly.

The versions of the bill passed by Vermont’s House and Senate are each far, far more tentative than committed single payer advocates would wish, and have already been subject to scathing criticism by national single payer advocates. [PNHP note: The PNHP board’s April 7 statement on Vermont, hardly “scathing,” can be found here.] The bill provides for the creation of the legal framework of a public insurance program, to be called Green Mountain Care, but includes no funding mechanism, defines no benefit standards, is vague on the future roles of private insurers, and is silent on exactly how existing federal programs are to be incorporated.

What the bill does do is to establish the state exchange required by the Accountable Care Act, encourage experimental capitated payment structures, and create a Board for Green Mountain Care with responsibility for examining funding, benefit, and other issues, with recommendations to be submitted to the state legislature in 2013.

Even if the Board’s proposals are very strongly in favor of a single payer system, they will face some considerable obstacles to implementation.

Because the present bill’s approach to creation of a new system is to allow two years for development of recommendations, any implementing legislation will be delayed until 2013 at the earliest, giving opponents considerable time to organize and fund their fight. At the same time, whatever funding structure the Board recommends will inevitably result in some winners and some losers—who will almost certainly oppose the proposal—even if the net result is a gain for Vermont’s citizens.

While small businesses are expected to get coverage through the state’s planned exchange, and thus could be forced to participate in a future state-controlled single payer plan, larger employers present more of a problem. If a single payer plan could be shown to be less costly, such employers would presumably be willing to participate. If they are not persuaded of the merits of single payer, however, they could rely on ERISA law to keep their employees out of the new program.

The bigger obstacles, however, are likely to be at the federal level. The Accountable Care Act allows states to opt out of federal reform starting in 2017, but not before. (Although an earlier date has been proposed, it has limited support). The pooling of federal funds envisioned by Vermont’s single payer advocates would require negotiations with Medicare, Medicaid, TRICARE, and Public Health administrators, all in the face of opposition from lobbyists for insurers, providers, and businesses who fear the impacts of a single payer structure on their revenues and profits. And who would be willing to guess whether or not in 2013 the administration in Washington DC is favorable towards any kind of health care reform?

http://www.healthcarefinancenews.com/blog/single-payer-vermont-well-not-exactly

Not everyone buying into Vermont's single-payer plan

By Nancy Remsen
Burlington Free Press, May 16, 2011

MONTPELIER, Vt. — The headline “Green Mountain Dreams” over a David Weigel piece in the online news magazine Slate last week captured how many people view the health reform legislation that Gov. Peter Shumlin will sign into law May 26.

For advocates of a single-payer health care system, the bill the Legislature passed during the final days of the 2011 session is a dream come true. For the first time, policy-makers have put the state on a road leading toward a government-financed insurance program that would cover all Vermonters.

Supporters acknowledge much remains to be done before the dream can become reality. The bill poses dozens of questions that must be answered, lists a host of conditions that must be met and sets the likely start date far in the future — 2017, or 2014 if the federal government cooperates.

Still one local supporter, Walter Carpenter of Montpelier, said the legislation means the state now stands “on the doorstep of history.”

Outside Vermont, single-payer advocates have a more tempered reaction.

“They have announced an intention more progressive than other states have done,” said Dr. David Himmelstein, a founder of Physicians for a National Health Program. “It could be important if they go ahead and do it, but they haven’t done anything that I can tell.”

Opponents see the legislation’s stated intention — to establish Green Mountain Care to provide health insurance to Vermonters — as either a pipe dream or a nightmare.

Rep. Patti Lewis, R-Berlin, explained some of her concerns after voting against the bill.

“I cannot support a bill of this magnitude, when there is no true answer to how much this plan will cost. Our state is simply too small to finance this plan,” she said. She added, “This is like taking a prototype plane for its first flight.”

Darcie Johnston, executive director of a newly organized group, Vermonters for Health Care Freedom, fears the worst.

“As much as the governor would like to portray this bill as harmless, it is anything but,” Johnston said. “This bill will put into motion a process that will kill job growth and drive some of our doctors out of state or out of business. It will also require the Legislature to come back next year and pass the largest tax increase in Vermont history to begin paying for it.”

Outside Vermont, Robert Zirkelbach, press secretary for America’s Health Insurance Plans, warned that Vermont’s legislation would take away the health insurance coverage that people like and rely upon, and “put Vermont taxpayers on the hook for the soaring cost of medical care.”

More than single-payer

Anya Rader Wallack, Gov. Shumlin’s special assistant for health reform, says the legislation is much more than a promise to explore consolidation of the state’s health insurance system.

For example, the bill responds to the federal mandate that states establish health benefit exchanges, or health insurance markets, by planning one for Vermont that would also simplify insurance purchases and claims processing.

“What makes Vermont stand out is it is taking the federal law and going a step further with it,” said Alan Weil, executive director of the National Academy of State Health Policy. “It is intriguing and exciting in the sense of seeing a state want to pursue its own approach within the national context.”

The legislation also tries to tackle the biggest problem in health care — its skyrocketing cost, Wallack said.

“In most states, the focus is on how to contain costs in the current budget year,” Wallack said. “We were able to pull together all the legislative leaders and the governor to look way out in the future.”

The bill creates a board charged with overseeing initiatives to control cost growth. Topping the list of initiatives the board must pursue: revamping the way doctors and hospitals are paid to move away from a system that encourages quantities of tests and procedures over efficiency and best practices.

Enrique Martinez-Vidal, vice president of AcademyHealth and director of its State Coverage Initiative, said many states are talking about provider payment reform, but few have laid the groundwork that Vermont has with its Blueprint for Health. Nor, he added, has any other state tried to “tackle that issue statewide.”

A lot of states will be watching Vermont’s payment reform efforts, Martinez-Vidal said.

“Vermont could be totally unsuccessful doing single-payer health care and be successful in payment reform, and that could be huge,” Martinez-Vidal said.

The third component of the legislation is the planning process it spells out to determine if and how the state could move to a more consolidated health coverage system.

“The fact that people were able to broadly agree that we need to go somewhere like single-payer is something to be proud of,” Wallack said. “There is a lot of work to do here. We know that.”

Himmelstein at Physicians for a National Health Program said he would have preferred legislation with more commitment to a single-payer system. Still, he added, “I’m not condemning what they did.”

“There are a lot of studies and reports, but that will provide a lot of information states will be interested in,” Martinez-Vidal said. “We applaud Vermont for taking the lead in that.”

In Vermont, supporters, critics and skeptics also wait anxiously for the reports that more than 50 people across state government have been charged with producing over the next one to two years.

Wendy Wilton, Rutland treasurer and former state senator, is among those eager for more details. Over several months, she gathered data to produce what she called her “back-of-the-envelope” analysis of the finances for Green Mountain Care.

She ended up with more questions than answers about the feasibility of a more consolidated insurance system, she said.

“Having done this process, I concluded the proposed system has the same damn problem as the current system — health care costs will increase faster than the economy grows.” she said.

“I know we need reform,” Wilton said, noting that health insurance represents one quarter of the payroll expense in Rutland where she is treasurer.

“This thing is monumental. It affects everyone. That is why it is so important to get this right,” Wilton said. “We have to have our eyes wide open going forward.”

http://www.burlingtonfreepress.com/article/20110516/NEWS03/110515016/Not-everyone-buying-into-Vermont-s-single-payer-plan

Funding for primary care panel blocked

Partisan fights in Congress stall panel on primary-health-care shortage

By Amy Goldstein
The Washington Post, May 13, 2011

When the government set out to help 32 million more Americans gain health insurance, Congress and the Obama administration acknowledged that steering more people into coverage had a dark underside: If it works, it will aggravate a shortage of family doctors, internists and other kinds of primary care.

So Page 519 of the sprawling 2010 law to overhaul the health-care system creates an influential commission to guide the country in matching the supply of health-care workers with the need. But in the eight months since its members were named, the commission has been unable to start any work.

The group cannot convene, converse or hire staff because $3 million that it needs for its initial year has been blocked by two partisan wars on Capitol Hill — strife over the federal budget and Republicans’ disdain for the health-care changes that Democrats muscled into law 14 months ago.

“We’ve been sort of hamstrung,” said Fitzhugh Mullan, a professor of medicine and health policy at George Washington University who is one of the 15 commission members appointed by the Government Accountability Office. The panel’s only activity so far, Mullan said, was a single conference call during which members were told they could not lobby members of Congress for funds or accept money to operate from foundations or anywhere else.

The National Health Care Workforce Commission is intended as an ongoing brain trust to focus new energy on solving an old problem that will become increasingly severe. The law says the new commission will analyze primary-care shortages and propose innovations for the government — and medical schools — to help produce the doctors and other health workers the nation needs.

Proponents of the workforce commission say they were surprised that Republicans have balked, because there has, in the past, been little ideological schism over the need to bolster the supply of primary care — doctors, nurses, physicians assistants and others.

http://www.washingtonpost.com/national/health/partisan-fights-in-congress-stall-panel-on-primary-health-care-shortage/2011/05/09/AFCKBW2G_story.html

Comment: 

By Don McCanne, MD

Republicans and Democrats agree with the health policy community that we desperately need to reinforce our primary care infrastructure. The National Health Care Workforce Commission that would propose innovations to help build primary care requires a mere $3 million to establish operations, but the Republicans have blocked this authorization. Do they expect us to simply rely on the private sector to meet this need? How is that working for us so far?

Options for Bringing Down the Cost of Health Care

Letters, The New York Times, May 15, 2011

In “The Missing Fifth” (column, May 10), David Brooks says there are two basic ways to control health care costs: top-down government regulation (President Obama) and shifting costs to beneficiaries (Representative Paul D. Ryan). Neither approach alone or when combined is likely to work because neither improves health care or deals with the real drivers of medical inflation.

Fee-for-service payment, a fragmented and disorganized medical care system focused on providers’ income, and an investor-owned private insurance industry all contribute to rising costs. Fraudulent billing, duplicated and unnecessary services, and a large but unknown amount of defensive medicine compound the problem. These factors could be controlled in a public single-payer system that paid private not-for-profit organized groups of salaried physicians on a capitated basis to deliver quality care.

Difficult as such reform might be to achieve, there is hope in the fact that we are already spending enough to pay all the costs of a greatly improved system. Our problem is primarily political, and it should not take many more years for the general realization that major reform is not just the best, but the only, way to control costs.

ARNOLD S. RELMAN
Cambridge, Mass., May 10, 2011

The writer is professor emeritus of medicine and social medicine at Harvard Medical School and former editor in chief of The New England Journal of Medicine.

Private health insurance industry has failed patients

By Dr. Howard Green
Palm Beach Post, Sunday, May 15, 2011

All of the well-publicized political health care programs have one thing in common: They all seek to steer larger portions of Medicare and Medicaid through private insurance corporations. They differ only in their degrees of rationing, with President Obama’s plan restricting rationing for profit and Rep. Paul Ryan’s mandate allowing the most rationing by the health insurance industry.

What Republicans and Democrats fail to disclose is that for more than 40 years the middle man of American health care – the private insurance industry – has failed in almost every capitalistic, economic and medical measure to deliver for the American patient.

Unlike auto insurance, private medical insurance has failed to accept and spread risk, thereby preventing the delivery of quality, affordable health care .

All the private health insurers have failed to prevent personal bankruptcies due to medical illness. The administrative bureaucracy of private health insurers removes $500 billion a year from health care. Managed health care brokered by private insurance companies has failed to improve medical outcomes and lower morbidity (sickness) and mortality (death rates) for all Americans regardless of income, sex or location.

The private health insurance industry has needed massive taxpayer subsidies. It would not be profitable without a federal exemption from antitrust laws combined with a federal ban on collective bargaining by physicians. The private insurance companies would not be able to ration health care for profit without a federal law protecting the companies from malpractice lawsuits.

For over four decades private health insurance companies have decreased reimbursements to individual doctors, hospitals and therapists for care, while failing to lower the cost of care for insured citizens and business.

For 40 years, the private insurance industry has refused to invest in the development of integrated medical records and billing systems to prevent fraud and track outcomes and improve quality of care. Within the health insurance industry there is a failure to compete based on medical, surgical or preventative outcomes (the only product of health care). In addition, the health insurance industry has failed to operate profitably without massive diagnostic, treatment and reimbursement rationing of patient care by non-physician actuaries and insurance bureaucrats.

Private health insurance companies have failed to deliver to Americans low-cost medicines and drugs via competitive capitalistic bidding, even with massive federal Part D subsidies. With no real interest in our future health, the private health insurance industry has failed to contribute to meaningful medical or clinical research.

Health insurance companies can only claim success in diverting hundreds of billions of dollars of public and private money from health care providers and patients to profits and payoffs for their bondholders, shareholders, executives and political patrons.

If any other American industry failed to competitively and profitably provide a quality product for all Americans for 40 years, it would either be outsourced to an emerging nation, or shut down.

Health insurance companies ensure neither quality affordable health care nor quality insurance for most Americans. With no real product to sell, the private health insurance industry would fail to exist without hundreds of millions of dollars in direct and indirect payments to the elected officials in the Congress, state legislatures and the administration.

After 40 years of market and medical failure, America needs to cut out the middle man and move to single-payer national health insurance for all Americans with private doctors, hospitals, clinics, therapists and drug companies competing based on the quality of medical, surgical and preventive outcomes.

Dr. Howard Green is managing partner of Dermatology Associates of the Palm Beaches and director of the Dermatology Division at St. Mary’s Medical Center in West Palm Beach.

http://www.palmbeachpost.com/opinion/commentary/private-health-insurance-industry-has-failed-patients-1477361.html

'What Matters Is What Works': The State and the National Health Service in Scotland and Wales

By Colin Leys

As expert commentators have amply shown, the Coalition’s plan to privatise the National Health Service (NHS) lacks any basis in evidence – no surprise there. What is less well recognised, and so far amazingly unmentioned in the debate – is that powerful evidence against privatization exists on our own doorstep – namely, the fact that in Scotland and Wales the NHS is working well as a publicly provided and managed system, based on planning and democratic accountability.

Marketization was tried, especially in Scotland, and rejected. The purchaser-provider split, which is at the root of the marketization project, was introduced but then abandoned in both countries, and neither Foundation Trusts nor payment by results were introduced in either of them. Private finance initiative (PFI) was used in Scotland under the first Labour government in Holyrood, and one private treatment centre for NHS patients was opened, but the Scottish National Party (SNP) has since scrapped the use of PFI and taken the treatment centre into public ownership. Wales has used neither PFI nor private treatment centres. The NHS in both countries is once again planned and managed through a mix of democratically accountable central and local structures, as it was in England before the 1990s.[1]

Democratic and Accountable Planning

But this doesn’t mean that the NHS in Scotland and Wales has reverted to the past. On the contrary, in both countries the NHS has been modernizing, but under the influence of very different drivers from those being promoted in England. Instead of fragmenting the NHS and opening it to commercial competition, Scotland and Wales have opted for democratic and accountable planning. There, the drivers of change are: a) the input of medical specialists and GPs (rather than businessmen) on the Area and Local Health Boards where key policies are developed; b) the input on the Boards of community health and social care/social work staff, crucial for integrating primary and secondary care efficiently; and c) in Scotland, input from members of the local community, elected to the Boards on a trial basis since 2009.

The restoration of full political responsibility for health services has led to further democratizing or redistributive measures, including the abolition of prescription charges, and the abolition of charges for personal care in Scotland, and their radical reduction in Wales. Equally significant, and contrary to the claims of marketizers in England, health services in Scotland and Wales have steadily improved, on various measures, including waiting times. Scotland’s have been among the shortest in the UK.

The contrast with England – where the NHS is now being driven into decline and, increasingly, into chaos, in the interest of privatization – is dramatic. If ‘what matters is what works,’ as Tony Blair liked to say (confident that the catch-phrase was enough to justify privatization), it is actually publicly-provided and democratically-managed health services that work, and the evidence for this is right here in the UK.

Lessons Learned

There is a wider lesson here for everyone concerned to defend the public sector. It shows the state working in its active role as the agent and shield of the majority. This needs emphasizing. After forty years of ideological onslaught the very idea of ‘the state’ is close to joining others, such as ‘collective’ (not to mention ‘socialist,’ and even ‘left’), in the depository of Unclean Concepts. ‘State bad, private good’ may be a crude slogan but it is the very real starting-point of many politicians and most media commentators and BBC interviewers today, from John Humphrys down.

‘State’ is so often coupled with ‘nanny,’ ‘bureaucratic,’ ‘inefficient,’ ‘wasteful’ or some other negative adjective, that this hardly raises an eyebrow. It is never called ‘rational,’ ‘efficient,’ or even ‘democratic’ – even though commentators and interviewers like to stress the accountability of government (state) to parliament (also part of the state, and always called democratic) when criticizing extra-parliamentary forms of political action.

Elements of the state that the corporate world likes and needs are usually treated as somehow not part of the state. The armed forces, the police, the judiciary, the monarchy and the Church of England are never described as part of the nanny state, or as being bureaucratic or inefficient. The nanny, inefficient, etc. state just means, in practice, those parts of the state which provide social and cultural services for everyone – schools, social services, and not least the NHS – and which the right doesn’t like.

The effect of this incessant drip of denigration is to narrow down our concept of the state to just these parts of it, and to make us at best indifferent toward them. We unconsciously absorb the idea that they are by nature bureaucratic, inefficient, monopolistic, etc. Every fault they exhibit tends to be accepted as evidence of an inherently defective institution. We stop seeing them as the historic collective achievements they are, as expressions of what a mature society can accomplish through collective effort, achievements we have a collective responsibility to protect and sustain. Above all we are conditioned to think that if they need improving, we ourselves can have no role to play in doing so – and that the only route to improvement is via privatization.

Yet the NHS in Scotland and Wales provides a dramatic contradiction of this whole way of thinking. The Scots and the Welsh have used their devolved powers to keep and develop the NHS as part of the state. This is partly a reflection of the stronger hold of solidaristic values in Scotland and Wales – including within the political class and the commentariat, and the medical professions. It is also due to the fact that the voting system in both countries helps the majority to get the policies they want.

It will be very interesting and important to follow what further improvements are achieved in Scotland and Wales – and how what counts as an ‘improvement’ is defined when it is patients’ needs, rather than business values, that are the measure of it. At the same time we should not expect improvements to run ahead of changes in other parts of the state in Scotland or Wales. The state was famously defined by the young Karl Marx as ‘the table of contents of civil society’: it registers the balance of social forces, and the level of democracy and solidarity and civic energy, that exist in the wider society. Without an expansion of the notion of democracy beyond the skin-deep variety, consisting merely of periodic heavily-managed elections, the progress made with the NHS in Scotland and Wales is bound to run up against limits set by the wider context.

Yet the progress already made could itself encourage experimentation in other fields, from education to central government. And it offers a badly-needed antidote to right-wing ‘Anglo-Saxon’ ideology. At the very least, the ‘Celtic’ NHS shows that the state can be a democratic, rational, progressive state – if we want it to be. •

Colin Leys is an honorary professor of politics at Goldsmiths College London, and former Professor of Politics at Queen’s University in Kingston, Canada.

Endnotes:

1. The situation in Northern Ireland is more mixed, but essentially close to the Scottish and Welsh pattern. Further details on the NHS in Scotland and Wales are given in The Plot Against the NHS by Colin Leys and Stewart Player, Merlin Press 2011, but comparative work on what is happening to the NHS in all three countries is urgently needed.

From bad to worse: Medicare proposal will surely lead to de facto 'death panels'

By Robert Kiefner
Concord (N.H.) Monitor, May 14, 2011

Say a patient comes to see us with poor appetite, low-grade temperature and progressive right lower quadrant pain, classic symptoms of appendicitis. The cure will be a date with a good local surgeon, during which he will bid farewell to his appendix and be home in a day or two to resume the joy of living. If the appendix is not removed, he will suffer a miserable death from rupture of the appendix and peritonitis.

Let’s imagine that, for political causes or for reasons of institutional greed, the patient cannot avail himself of the cure. The appendectomy cannot be done because he does not have access to the surgeon or he decided to tough it out because he cannot afford the deductible and co-pays if insured, or the stratospheric costs if uninsured.

I’d like to apply that scenario to our current health care system, where we are, collectively, that patient with health care needs, forced to make life and death decisions based on cost. The Affordable Care Act may improve access to private insurance for a relative few, but does nothing to rein in costs. Our premiums will continue to rise unchecked, mirrored by rising co-pays and deductibles which will price many folks out of even using their insurance.

Now the brilliant Rep. Paul Ryan, whose credentials consist of being a political science major in college, wants to take the most medically vulnerable Medicare population and toss them into the for-profit insurance world with a pittance in their pockets to pay for their care. His plan would surely lead us down the path of de facto “death panels” for the elderly, who would be unable to negotiate the insurance nightmare, let alone afford it.

To be certain, Medicare needs to undergo a major overhaul – but it must be more widely applied, not abandoned. The overhead involved in the redundant hierarchies of private insurers amounts to $400 billion per year, enough to cover all of the uninsured for basic health care needs. For some reason (let me see, maybe the campaign contributions, the umpteen lobbyists, profound ignorance, or perhaps just callous disregard for their constituents), our elected officials continue to support the hideously expensive, inefficient and dangerous network of private insurers in this country.

In comparison with other industrialized countries, we spend twice as much per capita on health care, yet we rank 37th in the world relative to standard measures of health. Health care should not be a partisan issue. We need to do better with an informed citizenry and legislators who are willing to turn away from corporate special interest groups and ignore mind numbingly stupid extremist constituents.

So, back to the bedside of our patient. The doctors and nurses making that decision to take out the appendix need to make the decision to save the patient without regard for anyone’s political or financial interests. And for the rest of us, the collective patient, we need to truly reform health care, break the cost curve, and support universal health coverage, a single payer system which places patients ahead of profits. It is the fiscally and morally responsible thing to do.

Robert Kiefner is a family physician in Concord.

http://www.concordmonitor.com/article/257041/from-bad-to-worse