PNHP

Congressman Ryan drags "premium support" out of the health policy trash heap

Congressman Ryan drags "premium support" out of the health policy trash heap

The Path to Prosperity

Fiscal Year 2012 Budget Resolution
Chairman Paul Ryan of Wisconsin
House Committee on the Budget

Premium support ā€“ a better way to deliver secure beneļ¬ts

Starting in 2022, new Medicare beneļ¬ciaries will be enrolled in the same kind of health care program that members of Congress enjoy. Future Medicare recipients will be able to choose from a list of guaranteed coverage options, and they will be given the ability to choose a plan that works best for them. This is not a voucher program, but rather a premium-support model. A Medicare premium-support payment would be paid, by Medicare, to the plan chosen by the beneļ¬ciary, subsidizing its cost.

The premium-support model would operate similar to the way the Medicare prescription-drug beneļ¬t program works today. The Medicare premium-support payment would be adjusted so that wealthier beneļ¬ciaries would receive a lower subsidy, the sick would receive a higher payment if their conditions worsened, and lower-income seniors would receive additional assistance to cover out-of-pocket costs.

This approach to strengthen the Medicare program ensures security and affordability for seniors now and into the future. First, it ensures security by setting up a tightly regulated exchange for Medicare plans. Health plans that choose to participate in the Medicare exchange must agree to offer insurance to all Medicare beneļ¬ciaries, to avoid cherry-picking and ensure that Medicareā€™s sickest and highest-cost beneļ¬ciaries receive coverage.

While there would be no disruptions in the current Medicare fee-for-service program for those currently enrolled or becoming eligible in the next ten years, all seniors would have the choice to opt into the new Medicare program once it begins in 2022. No senior would be forced to stay in the old program. This budget gives seniors the freedom to choose a plan that works best for them and guarantees health security throughout their retirement years.

http://budget.house.gov/UploadedFiles/PathToProsperityFY2012.pdf

Comment: 

By Don McCanne, MD

Under Republican control, the House Budget Committee proposes phasing out the traditional Medicare program and replacing it with an insurance exchange offering a variety of private plans with the government’s role limited to offering a premium support (same mechanism as a voucher) to apply toward the purchase of a plan. This converts Medicare from a defined benefit (specified benefits are covered) to a defined contribution (the premium support being a specified dollar amount contributed toward the purchase of a private plan).

This proposal treats the budget as the patient, curing the budget problems with the trade off of further burdening the Medicare beneficiaries who are already paying too much out of pocket. It shifts future increases in health care costs from the government to the beneficiaries. It is much easier for Congress to control federal spending by limiting the value of the premium support rather than trying to reduce the benefit package.

The proposal would adjust the premium support for those with greater health care needs, but that is very difficult to do in a timely manner in that an adjustment next year doesn’t help to relieve this year’s increased costs. Also risk adjusting is very difficult in that it requires having a precise assessment of each individual’s health status and anticipated needs. It is a profound change from the current Medicare program in which equitable funding through the tax system is divorced from the uniform benefit package which everyone shares.

The proposal also would reduce premium support for wealthier Medicare beneficiaries, requiring them to pay more for exchange plans. Actually this principle of progressive financing already exists. Although the current standard premium for Medicare Part B is $96.40 for most individuals ($115.40 for new beneficiaries), it is indexed to income. Those with an income of $214,000 pay $438.20 (including an added Part D premium only for higher-income individuals).

Although progressive financing is an equitable concept, it belongs over on the tax revenue side for funding of the entire Medicare risk pool. By having it as a progressive premium on the benefit side, it fractures solidarity by creating a desire for the wealthy to obtain their own coverage and care independently of Medicare, since they are paying higher premiums anyway. Once they are on their own, they would look upon Medicare as a welfare program, not unlike Medicaid except with much fewer benefits, and chronic underfunding would be inevitable.

The debate that we should be having is over an improved Medicare for everyone. The sad state of politics today is certainly exemplified by the fact that those supporting the transfer of wealth from the masses to our plutocracy have been able to reframe the debate as a need to save our federal budget by cutting back on our social programs, especially Medicare and Medicaid (while reducing the tax rate on the wealthy from 35% down to 25%). What ever happened to common decency?

HHS/CMS proposed rule for accountable care organizations

Department of Health and Human Services
Centers for Medicare and Medicaid Services

For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services proposes to amend 42 CFR Chapter IV by adding part 425 to read as follows:

SUBCHAPTER B–MEDICARE PROGRAM

PART 425–MEDICARE SHARED SAVINGS PROGRAM

Subpart A–General Provisions

Ā§425.2 Basis and scope.

(a) Basis. This part implements section 1899 of the Act by establishing a shared savings program that promotes accountability for a patient population, coordinates items and services under parts A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient services. Under this program, groups of providers of services and suppliers meeting criteria specified by the Secretary may work to together to manage and coordinate care for Medicare fee-for-service beneficiaries through an accountable care organization (ACO). ACOs that meet quality performance standards established by the Secretary are eligible to receive payments for shared savings. During years in which the ACO is participating in a two-sided model, the ACO may be required to share losses.

(b) Scope. This part sets forth the following:
(1) The eligibility requirements for an ACO to participate in the Medicare Shared Savings Program (Shared Savings Program).
(2) Program requirements, including quality and other reporting requirements.
(3) The method for assigning Medicare fee-for-service beneficiaries to ACOs.
(4) Payment criteria and methodologies (one-sided model and two-sided model).
(5) Compliance monitoring and sanctions for noncompliance.
(6) Reconsideration of adverse determinations.

Proposed rule (429 pages):
http://www.ofr.gov/OFRUpload/OFRData/2011-07880_PI.pdf

Comment: 

By Don McCanne, MD

Accountable care organization (ACO) is a concept that grew out of concerns over excessive levels of spending for health care that is often only mediocre. It was thought that health care professionals and facilities could organize themselves into integrated organizations through which they would become accountable for both the cost and the quality of health care.

The Affordable Care Act established the Medicare Shared Savings Program which would use ACOs to achieve savings in the Medicare fee-for-service program, and the savings would be split between the ACOs and the government. The proposed rule for ACOs has now been released. I’ll try to reduce the 429 pages down into a few salient comments.

* The ACO would be composed of professionals arranged in networks or in group practices, and may partner with or be employed by hospitals.

* The ACO is accountable for the quality, cost, and overall care of the Medicare fee-for-service (FFS) beneficiaries assigned to it.

* The ACO shall include primary care ACO professionals that are sufficient for the Medicare FFS beneficiaries assigned to the ACO (minimum 5000 beneficiaries).

* The ACO shall have in place a leadership and management structure that includes clinical and administrative systems.

* The ACO shall define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies.

* A benchmark will be established based on recent spending in the fee-for-service Medicare program.

* If spending for patients assigned to the ACO falls below the benchmark, the ACO will be rewarded with a portion of the amount saved, and the government keeps the rest.

* If spending for patients assigned to the ACO is more than the benchmark, then the ACO must pay a penalty of a portion of the excess (with a maximum two-year exemption for ACOs participating as a “one-sided” model with lower rewards but no penalty).

* The ACO must meet detailed quality requirements to qualify for the shared savings, but also may be terminated for failure to meet minimum standards.

* Patients will have free choice of any physician at all times, but will be assigned to an ACO based on plurality use of primary care services, for the purpose of assigning accountability for savings and quality. The ACO, which theoretically controls cost and quality for the patient assigned to it and will be rewarded or punished for the results, will have no control of the cost and quality of care delivered outside of the ACO.

* And over 400 pages of etc., etc.

Under the proposed rules, ACOs are not simple organizations formed on just a handshake. They require a formal legal structure with management, a specified governance board, a medical director, a quality assurance program, and more. They must implement evidence-based clinical guidelines.  The required documentation of quality is particularly onerous. They must have an infrastructure, such as information technology, to collect and evaluate data, and provide feedback. They must comply with extensive legal, business, and clinical documentation requirements. Since ACOs often involve consolidation within the health care delivery system, they must coordinate with antitrust agencies.

Obviously, considerable time, effort and expense is involved, so the reward must be worthwhile. And what is that reward? If they can improve their productivity while meeting quality standards, the financial benefit accrues to the government, but the reward is that the government lets them have a fraction of their productivity gains, providing that they are compliant with the complex set of rules. Since it’s almost impossible to continue to improve productivity in health care year after year, the reward would dry up soon.

With the trend of increasing frequency and intensity of services, there is a risk that the ACO may exceed the benchmark and have to pay back to the government a portion of the higher spending as a penalty.

What would happen if a group of professionals who were considering forming an ACO decided not to? First, they wouldn’t have all of the extra expenses and effort that establishing an ACO would require. They certainly would not have an incentive to reduce Medicare’s spending (i.e., reduce their income) since they would keep all revenues and not have to share them with the government. And if their spending for Medicare exceeded the benchmark? They would still keep it all, and wouldn’t have to pay a penalty.

Since most people with any business sense would never participate in such a scheme, why is it that there seems to be such a rush to form ACOs? In my opinion, they are not looking for the Medicare fee-for-service business. They are forming commercial ACOs in the private sector, looking for the private insurance business that will expand greatly in the new insurance exchanges. They are taking advantage of the prevailing attitude that we must back off on enforcing antitrust regulations in order to provide flexibility for the ACOs. They are consolidating to gain greater market control. Many are using “accountable care organization” as a deceptive label for expanded managed care oligopolies and monopolies.

The notion of accountable care organization was originated as a well meaning, altruistic, aspirational concept by individuals who really care about the health care that all of us receive. To be successful in improving quality and reducing costs the concept would have to be dependent on patients and health care professionals and administrators who were determined to do the right thing regardless of pecuniary or other self-interests. Yet health care, as the business that it is – like it or not – cannot afford to embrace altruism, for it would fail in its business responsibilities to maximize market
opportunities.

Does it have to be this way? Do we really need to depend upon private stewards devoted to the amoral business ethic to administer the financing of health care? Well, when you think about it, a single payer system is an automated system of financing health care that does not depend on the altruism of its players. That’s because the single payer model is structured as an altruistic, aspirational system that, quite automatically, actually does, in itself, improve quality and control costs. It just works.

Canadian health care system leaves us envious

By WILLIAM G. SESLER
Erie (Penn.) Times-News, April 3, 2011

While doing some research on health-care reform, I came across an interesting story.

In 2004, the Canadian Broadcasting Co. conducted polls for Canadians to nominate their choice for the man or woman whom they felt was the best Canadian in history. The person who won was Tommy Douglas.

I had heard of famous Canadians like Alexander Graham Bell, Wayne Gretzky and Dr. Frederick Banting (the inventor of insulin), but I had no idea who Tommy Douglas was.

It turns out that Douglas was the leader of the New Democratic Party, and he is considered the founder of the Canadian Healthcare System. He was (horrors!) a socialist and the seventh premier of Saskatchewan from 1944 to 1961. He led the first socialist government in North America and introduced public health care in Canada.

This tells me that Canadians must think a lot of their health-care system. America and Canada had similar health-care systems before Canada went to a single-payer system in the 1970s. Today, the United States spends much more money on health care than Canada, on both a per-capita basis and as a percentage of the GDP.

In 2006, per-capita spending on health care in Canada was U.S. $3,678; in the U.S. $6,714. The U.S. spent 15.3 percent on health care in that year; Canada spent 10 percent. Life expectancy is longer in Canada (80.34 years), compared to 78.6 years in the U.S. But to be fair, there is debate about the underlying causes of these differences.

An economic overview of America’s health-care system shows that about 42 million people are not covered at all. Many health-care plans place rigid limitations on which doctors and hospitals people can use; administrative costs are approaching 25 percent of the health-care dollar; managed care is generally structured so that some physicians have incentives to cut costs and gain revenue by withholding care; and many Americans live in fear of losing whatever care they have.

The current system is based on the power of the insurance industry to stifle any challenges from real alternatives.

In contrast, the single-payer system, which Canada has used for the last 25 years, has drastically simplified its administrative costs. One report indicates it takes more people to administer Blue Cross/Blue Shield of Massachusetts than it does to administer the entire health-care system in Canada.

Before Canada implemented its national health-care program, their health costs were the same portion of their economy as in the U.S. After they implemented their program, their costs stabilized at 9 percent, while U.S. costs have increased to 15.3 percent of our GDP.

Canada has a much higher percentage of general practitioners and fewer specialists. Canadian doctors make about one-third less than American doctors, and yet their satisfaction level is high because they have more time to practice medicine because paperwork is minimized.

Since there is single-payer there, it is easier to set up and adhere to budgetary limits. Effective planning eliminates duplication of facilities and expensive technology. In the U.S., competition has led to greater redundancies in expensive equipment such as CT scans; doctor groups and hospitals buy high-technology equipment and then compete for selling these services.

Both the Congressional Budget Office and the General Accounting Office said that if we were to implement a health-care system similar to the Canadian one, we could extend coverage to all Americans while saving billions of dollars annually.

Way back during the health-care debate in 1993, there were 89 co-sponsors of the single-payer system, and yet, it was not given serious consideration. The principal reason for this was the well-funded health-insurance industry with its effective lobbying forces in Congress.

Right now, Vermont is studying a Canadian-style, single-payer health system, a proposal of which was presented to the Vermont Legislature on Jan. 19. It will be very interesting to see what happens in that state.

WILLIAM G. SESLER, an Erie lawyer, is a former state senator.

http://www.goerie.com/apps/pbcs.dll/article?AID=/20110404/OPINION08/304049989/-1/opinion

HHS/CMS proposed rule for accountable care organizations

Department of Health and Human Services
Centers for Medicare and Medicaid Services

For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services proposes to amend 42 CFR Chapter IV by adding part 425 to read as follows:

SUBCHAPTER B–MEDICARE PROGRAM

PART 425–MEDICARE SHARED SAVINGS PROGRAM

Subpart A–General Provisions

Ā§425.2 Basis and scope.

(a) Basis. This part implements section 1899 of the Act by establishing a shared savings program that promotes accountability for a patient population, coordinates items and services under parts A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient services. Under this program, groups of providers of services and suppliers meeting criteria specified by the Secretary may work to together to manage and coordinate care for Medicare fee-for-service beneficiaries through an accountable care organization (ACO). ACOs that meet quality performance standards established by the Secretary are eligible to receive payments for shared savings. During years in which the ACO is participating in a two-sided model, the ACO may be required to share losses.

(b) Scope. This part sets forth the following:
(1) The eligibility requirements for an ACO to participate in the Medicare Shared Savings Program (Shared Savings Program).
(2) Program requirements, including quality and other reporting requirements.
(3) The method for assigning Medicare fee-for-service beneficiaries to ACOs.
(4) Payment criteria and methodologies (one-sided model and two-sided model).
(5) Compliance monitoring and sanctions for noncompliance.
(6) Reconsideration of adverse determinations.

Proposed rule (429 pages):
http://www.ofr.gov/OFRUpload/OFRData/2011-07880_PI.pdf

Accountable care organization (ACO) is a concept that grew out of concerns over excessive levels of spending for health care that is often only mediocre. It was thought that health care professionals and facilities could organize themselves into integrated organizations through which they would become accountable for both the cost and the quality of health care.

The Affordable Care Act established the Medicare Shared Savings Program which would use ACOs to achieve savings in the Medicare fee-for-service program, and the savings would be split between the ACOs and the government. The proposed rule for ACOs has now been released. I’ll try to reduce the 429 pages down into a few salient comments.

* The ACO would be composed of professionals arranged in networks or in group practices, and may partner with or be employed by hospitals.

* The ACO is accountable for the quality, cost, and overall care of the Medicare fee-for-service (FFS) beneficiaries assigned to it.

* The ACO shall include primary care ACO professionals that are sufficient for the Medicare FFS beneficiaries assigned to the ACO (minimum 5000 beneficiaries).

* The ACO shall have in place a leadership and management structure that includes clinical and administrative systems.

* The ACO shall define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies.

* A benchmark will be established based on recent spending in the fee-for-service Medicare program.

* If spending for patients assigned to the ACO falls below the benchmark, the ACO will be rewarded with a portion of the amount saved, and the government keeps the rest.

* If spending for patients assigned to the ACO is more than the benchmark, then the ACO must pay a penalty of a portion of the excess (with a maximum two-year exemption for ACOs participating as a “one-sided” model with lower rewards but no penalty).

* The ACO must meet detailed quality requirements to qualify for the shared savings, but also may be terminated for failure to meet minimum standards.

* Patients will have free choice of any physician at all times, but will be assigned to an ACO based on plurality use of primary care services, for the purpose of assigning accountability for savings and quality. The ACO, which theoretically controls cost and quality for the patient assigned to it and will be rewarded or punished for the results, will have no control of the cost and quality of care delivered outside of the ACO.

* And over 400 pages of etc., etc.

Under the proposed rules, ACOs are not simple organizations formed on just a handshake. They require a formal legal structure with management, a specified governance board, a medical director, a quality assurance program, and more. They must implement evidence-based clinical guidelines.Ā  The required documentation of quality is particularly onerous. They must have an infrastructure, such as information technology, to collect and evaluate data, and provide feedback. They must comply with extensive legal, business, and clinical documentation requirements. Since ACOs often involve consolidation within the health care delivery system, they must coordinate with antitrust agencies.

Obviously, considerable time, effort and expense is involved, so the reward must be worthwhile. And what is that reward? If they can improve their productivity while meeting quality standards, the financial benefit accrues to the government, but the reward is that the government lets them have a fraction of their productivity gains, providing that they are compliant with the complex set of rules. Since it’s almost impossible to continue to improve productivity in health care year after year, the reward would dry up soon.

With the trend of increasing frequency and intensity of services, there is a risk that the ACO may exceed the benchmark and have to pay back to the government a portion of the higher spending as a penalty.

What would happen if a group of professionals who were considering forming an ACO decided not to? First, they wouldn’t have all of the extra expenses and effort that establishing an ACO would require. They certainly would not have an incentive to reduce Medicare’s spending (i.e., reduce their income) since they would keep all revenues and not have to share them with the government. And if their spending for Medicare exceeded the benchmark? They would still keep it all, and wouldn’t have to pay a penalty.

Since most people with any business sense would never participate in such a scheme, why is it that there seems to be such a rush to form ACOs? In my opinion, they are not looking for the Medicare fee-for-service business. They are forming commercial ACOs in the private sector, looking for the private insurance business that will expand greatly in the new insurance exchanges. They are taking advantage of the prevailing attitude that we must back off on enforcing antitrust regulations in order to provide flexibility for the ACOs. They are consolidating to gain greater market control. Many are using “accountable care organization” as a deceptive label for expanded managed care oligopolies and monopolies.

The notion of accountable care organization was originated as a well meaning, altruistic, aspirational concept by individuals who really care about the health care that all of us receive. To be successful in improving quality and reducing costs the concept would have to be dependent on patients and health care professionals and administrators who were determined to do the right thing regardless of pecuniary or other self-interests. Yet health care, as the business that it is – like it or not – cannot afford to embrace altruism, for it would fail in its business responsibilities to maximize market opportunities.

Does it have to be this way? Do we really need to depend upon private stewards devoted to the amoral business ethic to administer the financing of health care? Well, when you think about it, a single payer system is an automated system of financing health care that does not depend on the altruism of its players. That’s because the single payer model is structured as an altruistic, aspirational system that, quite automatically, actually does, in itself, improve quality and control costs. It just works.

Wisconsin doctors' group: 'Save SeniorCare!'

Single-payer advocates call on U.S. health secretary to block changes that would hurt seniors

FOR IMMEDIATE RELEASE
April 1, 2011

Contact:
Melissa Stiles, M.D., wisconsin.pnhp@gmail.com
Laurel Mark, M.D., wisconsin.pnhp@gmail.com

This morning the Wisconsin chapter of Physicians for a National Health Program joined many other Wisconsin organizations in opposing changes to SeniorCare and called upon Kathleen Sebelius, U.S. secretary for health and human services, to block any federal waivers that would undermine the program. The groupā€™s statement follows:

Wisconsin has been a national leader in providing affordable prescription medications to our senior citizens at a lower cost and with better coverage than Medicare Part D.

SeniorCare was established in 2002 under Gov. Tommy Thompson and extended in 2007 and 2009 with bipartisan support from our congressional delegation. It is a very popular part of the Medicaid program, a joint federal and state program that requires federal approval for changes.

With an enrollment of 91,000 Wisconsin seniors, a $30 annual enrollment fee, co-payments ranging from $5 to $15, and no gaps in coverage, SeniorCare is a proven program that works. In addition to providing exceptional drug coverage, the program also saves taxpayers tens of millions of dollars by negotiating for discounts from drug companies.

Now this program is at risk. Gov. Scott Walkerā€™s proposed budget would change and effectively dismantle SeniorCare so that it would only fill in gaps in private insurance coverage, at a higher cost to seniors and with continued gaps in coverage. If this change is allowed to take place, many seniors will not be able to afford needed medications, leading to more illness, suffering and death.

SeniorCare is financially solvent. It currently runs a $20 million surplus and saved $50 million in drug costs in 2009 alone. There is no need to dismantle this program except for political ideology.

As physicians and health care professionals caring for Wisconsin seniors every day, we emphatically oppose changes to SeniorCare and call on Secretary of Health and Human Services Kathleen Sebelius to reject any plan that would weaken or dismantle the program. We applaud Sen. Herb Kohl for his leadership on this issue and thank all our elected officials who have supported SeniorCare in the past and present.

Until such time as our nation adopts a single-payer health plan that provides universal and comprehensive coverage to everyone, the 350 physician-members of PNHP Wisconsin stand together with Wisconsin seniors in supporting SeniorCare in its current form.

*****

Physicians for a National Health Program (www.pnhp.org) is an organization of 18,000 doctors who advocate for single-payer national health insurance, an improved Medicare for all. To speak with a physician near you, visit www.pnhp.org/stateactions, or call (312)782-6006.

'Health care is a civil rights issue': Black caucus leader

Congresswoman addresses ā€˜stubborn disparityā€™ in health care between whites and blacks

By Ginny Lee
Illinois Times (Springfield), March 31, 2011

ā€œHealth care is the civil rights issue of the 21st century,ā€ Donna Christensen, a member of Congress, stated Monday evening at the Southern Illinois University School of Medicine in Springfield. The congresswoman from the U.S. Virgin Islands spoke on ā€œEthics, Race and Classā€ to members of the medical community and others.
 
Christensen is a former practicing family physician and current vice chair of the Congressional Black Caucus. She reminded the audience that the U.S. is the only industrialized country in the world that does not provide health care for its citizens.
 
Though the Congressional Black Caucus has existed for 40 years, Christensen said, progress on issues has been minimal.
 
ā€œIn 2000, minorities received fewer tests and less sophisticated treatment for a panoply of ailments,ā€ Christensen said, ā€œincluding heart disease, cancer, diabetes and HIV/AIDS.ā€ African Americans have the highest death rate from breast cancer in this country, she said, and African Americans are 3 1/2 times more likely than white diabetics to have a lower limb amputation.
 
African Americans without health insurance have a 78 percent greater chance of dying than insured white Americans, Christensen said. ā€œIf you are poor and of color, there is a double whammy,ā€ she added.
 
Christensen noted the 1985 Heckler Report, which documented the continuing disparity in the deaths and illnesses experienced by blacks and other minority Americans. The report shows that the ā€œstubborn disparityā€ that civil rights pioneer W.E.B. Du Bois spoke of at the turn of the century persists today.
 
ā€œWe could have had a much better, stronger health care bill if it were based on ethics,ā€ Christensen said. ā€œWhat ethical standards leave 47 million people without health care? Without ethical implementation, the whole health care program will fail. It will take stronger intervention from the White House to maintain the health care bill.ā€
 
The National Institutes of Health in Atlanta has created the National Center on Minority Health and Health Disparities, Christensen said, but it is an organization in name only.
 
Christensen, who has served in Congress for 14 years, called for ethics, race and class to be at the forefront of health care in this country. A single-payer plan, or Medicare for All, will be introduced in Congress again, she said. She quoted Martin Luther King Jr., who said, ā€œOf all forms of discrimination and inequalities, injustice in health care is the most shocking and inhumane.ā€
 
Jane Treadwell, university librarian at the University of Illinois Springfield, is credited for inviting Christensen to speak in Springfield. ā€œSome of us (in the group Friends of Brookens Library) were reading The Immortal Life of Henrietta Lacks,ā€ Treadwell said. Treadwell knew of Congresswoman Christensenā€™s commitment to minority health care, and with the large medical community in Springfield, she suggested her as a speaker.
 
Henrietta Lacks was a mother of five in Baltimore who died at age 30 in 1951 from an aggressive cancer. Doctors saved some of her tissue to use for research without telling her family. Years later when family members learned what had happened, they felt deceived by the medical community. Author Rebecca Skloot researched the history of Henriettaā€™s cells for 10 years before publishing her book.
 
http://www.illinoistimes.com/Springfield/article-8504-lshealth-care-is-a-civil-rights-issuers.html

N.H. mental health cuts will hurt people, families

Letters
Seacoastonline.com, March 30, 2011

The cuts in mental health services proposed in the New Hampshire Legislature will have a devastating effect on people with mental illness, their families and all who care about them. Seacoast Mental Health Center stands to have its budget cut by $1.9 million (out of $9.3 million) and will be forced to stop serving more than 1,000 people who have no where else to turn. The cuts will weaken the infrastructure, impair emergency care, interfere with treatment of current clients, delay or eliminate treatment with new clients and make it much harder to retain personnel. As a psychiatrist who has worked in the public mental health system for more than 30 years, I see first-hand the consequences of indifference to the poor, sick and vulnerable. These cuts will result in an increase in despair and suicides, hospitalizations, increased numbers of people being unable to work due to their symptoms, and more people getting unnecessarily entwined in the (much more costly) legal system.

These huge cuts are part of a national effort to roll back protections for our citizens and preserve more money for the wealthy. Their strategy is to pick away at the weakest among us, step by step, and hope that the rest of us won’t fight back. We see it in Congress, who gave tax cuts to the wealthy in order to get true tax relief and job promotions for the working class. We see it when leaders in Congress try to cut Social Security and Medicare. We see it in Wisconsin, Ohio, Indiana, Maine and New Hampshire, where collective bargaining rights are being attacked. We see it in Maine, where Gov. Paul LePage wants to cut taxes for the wealthiest 10 percent and pay public employees less.

And we see it in New Hampshire House, where Martin Harty stated, “I wish we had a Siberia so we could ship them all off to freeze to death and die and clean up the population.” While Harty only said it, the people who support these cuts will be taking a step in his direction. They’ll say it’s not, that these cuts are necessary for “shared sacrifice.” They think like Martin Harty; they are just better at hiding it.

In 1980, Ronald Reagan asked people, “Are you better off now than you were four years ago?,” replacing Kennedy’s admonition to “ask not what your country can do for you, ask what you can do for your country.” Selfishness became our core value, and taxes came to be the ultimate evil. Since Reagan uttered those words, 94 percent of the new wealth created in this country went to the top 20 percent of the wealthy. Forty-two percent went to the top 1 percent. The ratio of pay for CEOs of major corporations to the average worker went from 42:1 in 1980 to 344:1 in 2007. Chief executive officers’ pay at these corporations increased by 300 percent during this time span, while the average worker gained only 3.4 percent (adjusted for inflation).

The people at the top of the economic ladder seem to believe that they should benefit from the U.S. system of free enterprise and that they owe nothing to anyone else who helps make that system work. But where would rich people be without soldiers to fight the wars, without police to protect them from crime, without firefighters to save them in the middle of the night, without workers to perform the physical tasks that their fortunes are made from, without people who build and maintain the roads that their products travel on and without nurses when they get sick?

Don’t people deserve a decent wage, health care and a good education? There is no God-given right to selfish behavior and there is nothing in the U.S. Constitution that prevents us from determining how the fruits of our incredible country and amazing political system will be shared. Our well-being is what we decide together as a nation. Right now, the forces of selfishness have the upper hand. It doesn’t have to be this way.

On a national level, eliminating the Bush tax cuts for people who make over $250,000 a year and shifting our health care system away from one that is profit-driven toward a model centered on health (e.g. Medicare-for-all) would improve our health and pocketbook. Here in New Hampshire, we weathered the recent economic downturn better than many places. Slight adjustments to our current tax structure could easily pay for the cuts some say are “necessary.”

Today in New Hampshire, it’s the mentally ill, their families and those who care about them who are under attack. But if we let them get away with it this time, we’ll see that this is just a start.

There are many things you can do to help, but they will win if you do nothing! Come to the Rally for New Hampshire at the State Capitol building in Concord from noon to 1 p.m. Thursday, March 31. Write your senator and representatives. Make your voice heard ā€” that New Hampshire should support all its citizens!

Ted Drummond, MD
Associate medical director
Seacoast Mental Health Center

Solution to a Busted VEBA: Single Payer Health Care, HR 676

By Kay Tillow
FireDogLake, April 1, 2010

Detroit Diesel has been around since April 1937, a few months after the Flint sit down strike that won union recognition. 

This year, 1,100 retired auto workers at Detroit Diesel suffered a giant cut in company provision of health benefits because their Voluntary Employees Benefits Association, VEBA, went belly up.  Workers who retired between 1993 and 2004 will have to pick up an increasing share of the premiums that were once fully covered by the company.  Some retirees will have to pay as much as $4,000 per year, or even higher, just to keep their health coverage.

VEBAs are spreading.  Many companies seek to shift their liability for future health costs to the workers or the union through establishment of a VEBA.

So how do unions and workers, who are in danger of losing health benefits for which they worked for decades, fight back?  Educate and organize for national single payer health care, HR 676, an improved Medicare for all.  Build a movement that demands it.  Spread the word.  March for it. 

With HR 676 what happens to locked out workers?  Health coverage continues.  To workers on strike?  Coverage continues.  To early retirees?  Coverage continues.  To laid off workers?  Coverage continues.   

ā€œOur struggle is not for more or better VEBAs.  That was the condition we faced in the last decade.  In this decade, we only have one choice, National Health Care (HR 676),ā€ says Al Gladyck of the UAW Local 7 Retirees Chapter and former Chief Steward at Chryslerā€™s Jefferson Assembly Plant.

ā€œHR 676 would make this situation a thing of the pastā€ Gladyck said, referring to the Detroit Diesel retireesā€™ loss.

Gladyck is one of the leaders of Retirees for Single Payer Health Care which meets regularly at UAW Local 22, 4300 Michigan Avenue in Detroit.  He has written three articles on Detroit Diesel, VEBAs, and the solution.  They are well worth reading.

Detroit Diesel:  The Death of a VEBA and the Cost to Retirees

Part I 

Part II

Part III

To find the ongoing activities of Retirees for Single Payer Health Care in Detroit, click here.

http://my.firedoglake.com/kaytillow/2011/03/30/solution-to-a-busted-veba-single-payer-health-care-hr-676/

Important RWJF report on cost-sharing

The Synthesis Project, Policy Brief No.20

Robert Wood Johnson Foundation
December 2010

Cost-sharing: Effects on spending and outcomes
By Sarah Goodell, M.A. and Katherine Swartz, Ph.D., based on a research synthesis by Swartz

This brief examines how cost-sharing affects the use of services, whether some patients are more sensitive to cost-sharing than others, and whether reduced use of services as a result of cost-sharing has an effect on health outcomes. All of these issues factor into whether and how cost-sharing could be used to reduce the rate of growth of health care spending.

Policy Implications

Recent studies of patient cost-sharing confirm the primary conclusion of the HIE ā€” demand for most health care services is price sensitive. When people have to pay more, they reduce their use of health care. The HIEā€™s exclusion of the elderly, the increase in the prevalence of chronic conditions, and changes to medical care and insurance design since the 1970s, however, make it important to re-examine the role of cost-sharing. Findings from more recent research highlight important implications for policy-makers, including:

*  Patient cost-sharing is not necessarily an effective mechanism for significantly slowing health care spending. Most people are healthy and cost-sharing would only modestly affect their health care spending. People who are very sick or who have serious chronic health conditions are typically deferring to their physicians rather than making choices about medical care based on cost-sharing. Moreover, by itself, cost-sharing is highly unlikely to slow the growth in spending unless the expected increases in the costs of appropriate care for the very sick also slow.

*  Cost-sharing is not well-targeted on low-value services. Patient cost-sharing generally has been organized in broad categories (e.g., outpatient care, inpatient care, emergency department care). These broad categorizations do not help people distinguish between essential and nonessential services. Comparative effectiveness research could help insurers and government programs better target cost-sharing to improve value.

*  Caution should be used when increasing cost-sharing for low-income populations or the chronically ill. Not only are low-income populations disproportionately affected by increased cost-sharing, but they also are more price sensitive than other income groups. Unless the cost-sharing increases are concentrated on services that are ineffective or unnecessary, low-income groups may avoid necessary medical care as a result. Increased cost-sharing for people with chronic conditions may result in higher expenditures for hospitalizations and other adverse outcomes if necessary care is reduced.

Policy Brief:
http://www.rwjf.org/files/research/121710.policysynthesis.costsharing.brief.pdf

Full Research Synthesis Report by Katherine Swartz, Ph.D. (40 pages):
http://www.rwjf.org/files/research/121710.policysynthesis.costsharing.rpt.pdf

Comment: 

By Don McCanne, MD

This is a very important report. Let me tell you why.

Conservatives have framed the problem of our very high health care costs as being due to a lack of sensitivity of health care prices by patient-consumers who are simply demanding too much care. This is been repeated so many times that moderates and liberals are now parroting the same message. They profess that patients must face large deductibles, co-payments and coinsurance if we are ever going to get our health care costs under control.

It is true that these forms of cost-sharing do reduce health care spending, but is the savings significant? And is there any downside, any unintended consequences, to applying these price sensitizers to health care shopping?

Too much care?

When is the last time that you went to your health care professional and demanded too much care? If it isn’t you who is guilty of this transgression, then who is? I didn’t see these people in my very busy practice. Sure, you can find a few anecdotes, but most people simply are not motivated to use their time and money to seek out care that they don’t need.

Reduction in spending

The healthier one-half of our population uses only three percent of health care. They may be price sensitive shoppers when they have significant cost-sharing, but even if they reduced spending by ten percent, the savings of three-tenths of one-percent would represent only a negligible decline in our national health expenditures.

Twenty percent of us use eighty percent of the nation’s health care. These are people with very significant problems who are preoccupied with accessing the health care that they need, and are no longer concerned about the deductibles that they’ve already gone through. Cost-sharing is not intended to apply to individuals with significant illnesses or injuries anyway. So cost-sharing has very little impact on eighty percent of our national health expenditures.

The remaining thirty percent of us use about sixteen percent of health care. Some of this is urgent care, over which we have little choice, so price shopping isn’t an issue. But suppose that we could actually reduce spending in this group by about ten percent; that would still be only about 1.6 percent of our national spending. Combined with the 0.3 percent above, that’s still under two percent.

If you read the report, you will find that it is common for people to make unwise decisions as to which care they decline because of the out-of-pocket costs involved. These studies show that the net costs are sometimes higher because forgoing treatment can result in a greater incidence of emergency department visits and hospitalizations, and can sometimes intensify their chronic problems, making them more expensive to manage. Much of the relatively paltry savings from creating price sensitivity is lost due to the offset of the higher costs of deferred medical management.

As this report states, “cost-sharing is highly unlikely to slow the growth in spending unless the expected increases in the costs of appropriate care for the very sick also slow.” We need to consider more effective options than cost-sharing if we want to tame health care costs.

Unintended consequences

Cost-sharing has been demonstrated to result in adverse outcomes in two particularly vulnerable groups: low-income individuals and families, and individuals with chronic disease.

Although Medicaid selectively covers the low-income sector with more generous benefits and usually without significant cost-sharing, as a chronically underfunded welfare program, access is often impaired because of a lack of willing providers. Also, as states struggle with their budgets, some are introducing more cost-sharing into their Medicaid programs in order to reduce spending.

For those with incomes just above the level at which they would qualify for Medicaid, the standard plan in the exchanges will have an actuarial value of only 70 percent, which can be achieved only by including cost-sharing in the plan design.

Creating financial barriers to care for this vulnerable sector clearly reduces their access to beneficial health care services – the opposite of what a well functioning health care system should be doing.

The same applies to the chronically ill. The health care financing system should be designed to help them get the care that they need. Cost-sharing does the opposite. Also it is in this sector that cost sharing has often been shown to result in the opposite of its intent. Instead of reducing health care spending, the financial barriers of cost sharing have often resulted
in higher costs because of more expensive emergency department and in-hospital care that must be rendered due to the financial barriers that result in inadequate chronic disease management.

Prevention of financial hardship

A prevalent concept is that the purpose of insurance is to protect against catastrophic loss, but individuals should be personally responsible for routine medical expenses. That has been repeated so often that it is widely accepted. Yet many studies have confirmed that so-called routine expenses can be very burdensome financially. When medical debt contributes to personal bankruptcy, the routine expenses of cost-sharing have defeated this purpose of preventing catastrophic loss since the necessity of filing bankruptcy is, in itself, catastrophic.

We need to abandon the glib definition of insurance as being only for the purpose of covering catastrophic loss, and replace it with the definition that a health care financing system is for the purpose of removing financial barriers to the care that a patient should have. Cost-sharing does the opposite by creating financial barriers that should be removed.

Solidarity

Another prevalent attitude is that the government should stay out of our lives, and we should each tend to our own needs. As an abstraction, that concept has a certain appeal, and, consequently, a wide following. But there are very few of us who are not offended when we hear real-life stories of people who suffer when they fail to receive the medical care that they should have. We are particularly offended when we hear that the individuals’ insurance failed them in their times of need.

Insurance should be designed to help people get the care they need. Yet, as we all know, it is frequently designed to reduce spending on health care for the business purposes of keeping insurance premiums competitive and enhancing profits. One of the most important tools used by the insurers is cost-sharing. At times it seems as if they are a business set up more for the purpose reducing health care spending than helping us get health care.

Traditional private insurance has represented a form of social solidarity in which we join together to pool our risks so that none of us would have to suffer financial hardship in the face of medical need. But the interests of private insurers are very different from the interests of patients. The tool of cost-sharing serves the interests of the private insurers very well, but it fractures the solidarity that was intended to bring those with needs the health care that they need.

Other nations have expressed solidarity in a more effective manner. The people join together, through their governments, to finance their universal pools to serve as a resource for funds to pay for health care that people need. Many of those nations have rejected the concept of cost-sharing because of its perversities. They provide first dollar coverage for health care.

Those nations that do eliminate the barriers of cost-sharing still provide comprehensive benefits for everyone at a cost much lower than what we spend here in the United States. That’s the kind of solidarity that we need and that we would have if people weren’t confused by prevailing misperceptions that our goal should be to stop people from demanding too much care, and that we can do that by assessing the penalties of cost-sharing on people who attempt to access the care that they need.

You should consider downloading the RWJF brief for future use. We need to change the national discourse from that of using the consumer-directed tools of cost-sharing – tools that save very little money and impair outcomes – that are being used to address the alleged but fictional excess patient demand for care. Instead we need to have a national dialogue on how we can improve access to the care that patients need, and do it in an affordable manner (i.e., single payer).

Important RWJF report on cost-sharing

The Synthesis Project, Policy Brief No.20

Robert Wood Johnson Foundation
December 2010

Cost-sharing: Effects on spending and outcomes
By Sarah Goodell, M.A. and Katherine Swartz, Ph.D., based on a research synthesis by Swartz

This brief examines how cost-sharing affects the use of services, whether some patients are more sensitive to cost-sharing than others, and whether reduced use of services as a result of cost-sharing has an effect on health outcomes. All of these issues factor into whether and how cost-sharing could be used to reduce the rate of growth of health care spending.

Policy Implications

Recent studies of patient cost-sharing confirm the primary conclusion of the HIE ā€” demand for most health care services is price sensitive. When people have to pay more, they reduce their use of health care. The HIEā€™s exclusion of the elderly, the increase in the prevalence of chronic conditions, and changes to medical care and insurance design since the 1970s, however, make it important to re-examine the role of cost-sharing. Findings from more recent research highlight important implications for policy-makers, including:

*Ā  Patient cost-sharing is not necessarily an effective mechanism for significantly slowing health care spending. Most people are healthy and cost-sharing would only modestly affect their health care spending. People who are very sick or who have serious chronic health conditions are typically deferring to their physicians rather than making choices about medical care based on cost-sharing. Moreover, by itself, cost-sharing is highly unlikely to slow the growth in spending unless the expected increases in the costs of appropriate care for the very sick also slow.

*Ā  Cost-sharing is not well-targeted on low-value services. Patient cost-sharing generally has been organized in broad categories (e.g., outpatient care, inpatient care, emergency department care). These broad categorizations do not help people distinguish between essential and nonessential services. Comparative effectiveness research could help insurers and government programs better target cost-sharing to improve value.

*Ā  Caution should be used when increasing cost-sharing for low-income populations or the chronically ill. Not only are low-income populations disproportionately affected by increased cost-sharing, but they also are more price sensitive than other income groups. Unless the cost-sharing increases are concentrated on services that are ineffective or unnecessary, low-income groups may avoid necessary medical care as a result. Increased cost-sharing for people with chronic conditions may result in higher expenditures for hospitalizations and other adverse outcomes if necessary care is reduced.

Policy Brief:
http://www.rwjf.org/files/research/121710.policysynthesis.costsharing.brief.pdf

Full Research Synthesis Report by Katherine Swartz, Ph.D. (40 pages):
http://www.rwjf.org/files/research/121710.policysynthesis.costsharing.rpt.pdf

This is a very important report. Let me tell you why.

Conservatives have framed the problem of our very high health care costs as being due to a lack of sensitivity of health care prices by patient-consumers who are simply demanding too much care. This is been repeated so many times that moderates and liberals are now parroting the same message. They profess that patients must face large deductibles, co-payments and coinsurance if we are ever going to get our health care costs under control.

It is true that these forms of cost-sharing do reduce health care spending, but is the savings significant? And is there any downside, any unintended consequences, to applying these price sensitizers to health care shopping?

Too much care?

When is the last time that you went to your health care professional and demanded too much care? If it isn’t you who is guilty of this transgression, then who is? I didn’t see these people in my very busy practice. Sure, you can find a few anecdotes, but most people simply are not motivated to use their time and money to seek out care that they don’t need.

Reduction in spending

The healthier one-half of our population uses only three percent of health care. They may be price sensitive shoppers when they have significant cost-sharing, but even if they reduced spending by ten percent, the savings of three-tenths of one-percent would represent only a negligible decline in our national health expenditures.

Twenty percent of us use eighty percent of the nation’s health care. These are people with very significant problems who are preoccupied with accessing the health care that they need, and are no longer concerned about the deductibles that they’ve already gone through. Cost-sharing is not intended to apply to individuals with significant illnesses or injuries anyway. So cost-sharing has very little impact on eighty percent of our national health expenditures.

The remaining thirty percent of us use about sixteen percent of health care. Some of this is urgent care, over which we have little choice, so price shopping isn’t an issue. But suppose that we could actually reduce spending in this group by about ten percent; that would still be only about 1.6 percent of our national spending. Combined with the 0.3 percent above, that’s still under two percent.

If you read the report, you will find that it is common for people to make unwise decisions as to which care they decline because of the out-of-pocket costs involved. These studies show that the net costs are sometimes higher because forgoing treatment can result in a greater incidence of emergency department visits and hospitalizations, and can sometimes intensify their chronic problems, making them more expensive to manage. Much of the relatively paltry savings from creating price sensitivity is lost due to the offset of the higher costs of deferred medical management.

As this report states, “cost-sharing is highly unlikely to slow the growth in spending unless the expected increases in the costs of appropriate care for the very sick also slow.” We need to consider more effective options than cost-sharing if we want to tame health care costs.

Unintended consequences

Cost-sharing has been demonstrated to result in adverse outcomes in two particularly vulnerable groups: low-income individuals and families, and individuals with chronic disease.

Although Medicaid selectively covers the low-income sector with more generous benefits and usually without significant cost-sharing, as a chronically underfunded welfare program, access is often impaired because of a lack of willing providers. Also, as states struggle with their budgets, some are introducing more cost-sharing into their Medicaid programs in order to reduce spending.

For those with incomes just above the level at which they would qualify for Medicaid, the standard plan in the exchanges will have an actuarial value of only 70 percent, which can be achieved only by including cost-sharing in the plan design.

Creating financial barriers to care for this vulnerable sector clearly reduces their access to beneficial health care services – the opposite of what a well functioning health care system should be doing.

The same applies to the chronically ill. The health care financing system should be designed to help them get the care that they need. Cost-sharing does the opposite. Also it is in this sector that cost sharing has often been shown to result in the opposite of its intent. Instead of reducing health care spending, the financial barriers of cost sharing have often resulted in higher costs because of more expensive emergency department and in-hospital care that must be rendered due to the financial barriers that result in inadequate chronic disease management.

Prevention of financial hardship

A prevalent concept is that the purpose of insurance is to protect against catastrophic loss, but individuals should be personally responsible for routine medical expenses. That has been repeated so often that it is widely accepted. Yet many studies have confirmed that so-called routine expenses can be very burdensome financially. When medical debt contributes to personal bankruptcy, the routine expenses of cost-sharing have defeated this purpose of preventing catastrophic loss since the necessity of filing bankruptcy is, in itself, catastrophic.

We need to abandon the glib definition of insurance as being only for the purpose of covering catastrophic loss, and replace it with the definition that a health care financing system is for the purpose of removing financial barriers to the care that a patient should have. Cost-sharing does the opposite by creating financial barriers that should be removed.

Solidarity

Another prevalent attitude is that the government should stay out of our lives, and we should each tend to our own needs. As an abstraction, that concept has a certain appeal, and, consequently, a wide following. But there are very few of us who are not offended when we hear real-life stories of people who suffer when they fail to receive the medical care that they should have. We are particularly offended when we hear that the individuals’ insurance failed them in their times of need.

Insurance should be designed to help people get the care they need. Yet, as we all know, it is frequently designed to reduce spending on health care for the business purposes of keeping insurance premiums competitive and enhancing profits. One of the most important tools used by the insurers is cost-sharing. At times it seems as if they are a business set up more for the purpose reducing health care spending than helping us get health care.

Traditional private insurance has represented a form of social solidarity in which we join together to pool our risks so that none of us would have to suffer financial hardship in the face of medical need. But the interests of private insurers are very different from the interests of patients. The tool of cost-sharing serves the interests of the private insurers very well, but it fractures the solidarity that was intended to bring those with needs the health care that they need.

Other nations have expressed solidarity in a more effective manner. The people join together, through their governments, to finance their universal pools to serve as a resource for funds to pay for health care that people need. Many of those nations have rejected the concept of cost-sharing because of its perversities. They provide first dollar coverage for health care.

Those nations that do eliminate the barriers of cost-sharing still provide comprehensive benefits for everyone at a cost much lower than what we spend here in the United States. That’s the kind of solidarity that we need and that we would have if people weren’t confused by prevailing misperceptions that our goal should be to stop people from demanding too much care, and that we can do that by assessing the penalties of cost-sharing on people who attempt to access the care that they need.

You should consider downloading the RWJF brief for future use. We need to change the national discourse from that of using the consumer-directed tools of cost-sharing – tools that save very little money and impair outcomes – that are being used to address the alleged but fictional excess patient demand for care. Instead we need to have a national dialogue on how we can improve access to the care that patients need, and do it in an affordable manner (i.e., single payer).