PNHP

'Obamacare won't solve the problems'

'Obamacare won't solve the problems'

By Robert Speer
Chico (Calif.) News and Review, March 17, 2011

To understand why the Patient Protection and Affordable Care Act has fallen short of what President Obama envisioned for health-care reform, consider the story of Billy Tauzin, as told by Dr. Jeff Lobosky.

Lobosky, a Chico neurosurgeon and the author of a new book, The Doctor Won’t See You Now: The Failure of American Health Care and a Prescription for the Cure, was one of four health-care professionals who participated in a forum titled “Health Care Reform: Mission Accomplished?” last Wednesday (March 9) at the Enloe Conference Center.

The others were Mike Wiltermood, CEO of Enloe Medical Center; Dr. Henry Abrons, board president of the California Chapter of Physicians for a National Health Program; and Dr. Richard Thorp, a Paradise internist and former president of the Butte-Glenn Medical Association.

Tauzin, Lobosky related, was a Democratic congressman from Louisiana who, after the Republican takeover of Congress in 1994, switched parties. As chairman of the committee that oversees the drug industry, in 2005 Tauzin played a central role in creating President Bush’s Medicare Prescription Drug Bill, or Medicare Part D, which included a provision that Medicare could not use its massive buying power to negotiate drug prices—a prohibition worth many billions to the pharmaceutical industry.

Two months later, Tauzin resigned and took a job, at a salary of $2 million, as chief lobbyist for PhRMA, a powerful drug industry trade group. In that role, in 2009, he cut a backroom deal with the Obama administration during health-care-reform negotiations that traded industry support for the bill and $80 billion in other savings in return for keeping the ban on negotiating drug prices.

But, as Lobosky said, Obama had campaigned on a health-care-reform platform that included ending the ban on Medicare drug-price negotiations, among other worthy goals, such as a public option to compete with private insurers. No sooner did he try to implement these goals, however, than the “special interests raised their ugly heads” and screamed about “socialized medicine.”

To get a bill through, Obama was forced to abandon an open process and start making backroom deals, including the one he cut with Tauzin.

A major problem with the bill, Lobosky said, is that, while it will expand access to Medicaid, it will decrease access to care. That’s because it will pay for that expansion by reducing Medicaid and Medicare reimbursements to providers. In turn, fewer doctors will accept Medicaid and Medicare patients. As many Medicaid patients already know, having insurance means nothing if they don’t have access to care.

Abrons, a pulmonologist and clinical-care doctor by training, sought to refocus the discussion. Before we talk about services and costs, he said, we need to talk about morality and what kind of society we want to be.

Do we hold the free-market view that each individual is responsible for his or her own health care, or do we recognize—as all other advanced nations do—that health care is a right, not a product?

The market view of health care ignores a fundamental aspect of the transaction: The buyer doesn’t have a choice. A sick person can’t just walk away.

The current system is money-driven, he said, but most providers are primarily service-driven. They went into medicine because they care. Only a single-payer system—essentially an expansion and upgrading of Medicare—has the simplicity of design that would free them from the stranglehold of the money-driven system.

Obama’s Affordable Care Act is an improvement, Abrons said, but it “will achieve only mediocre, expensive health care for some.” About 25 million people will remain uninsured; it will foster under-insurance; fail to provide financial security; have high deductibles; and continue the burdensome administrative waste and paperwork that now costs about $400 billion a year.

And the requirement that people buy insurance, he said, “is a mandate to purchase a defective corporate product.”

From his perspective as a hospital CEO, Wiltermood doesn’t have high hopes for the Affordable Care Act. It’s “just rearranging the chairs on the Titanic,” he said.

His biggest concern is that it will reduce reimbursement rates. “As payments become squeezed, it drives the best and the brightest from health care.”

It also forces hospitals to charge private insurers more—“cost shifting,” it’s called—leading insurance premiums to go up.

Nor is Wiltermood optimistic about single-payer. His experience with Medicare is that lawmakers are constantly rewriting the codes, and “now we have thousands and thousands of codes.” Every time a new code is written, he said, a “cottage industry of former Medicare employees springs up to teach hospitals how to deal with the change.”

Americans now pay 18 percent of their gross domestic product to health care, twice as much as any other country, “and that’s wrong,” Wiltermood said. “We have to do something.”

But he offered no direction, other than to say that “We have to work together locally.” With state budget cuts and the downturn in the economy, the hospital’s charity care has gone from an average of $10 million per year to nearly $20 million, and bad debt has risen, too. “The next four years are going to be tough. … We need the community’s support.”

Thorp devoted most of his talk to showing charts and graphs that illustrated the country’s finances from a business perspective. His goal was to illustrate something he said at the beginning of his talk: “It concerns me when they talk about Medicare-for-everyone when the Medicare program is going broke.”

Sure enough, the charts showed that we’re spending more on Medicare than we’re taking in from Medicare taxes, an unsustainable situation.

“We’re going to have difficult decisions to make,” Thorp said. “As a society we can’t afford to give everyone everything.”

He stopped short of endorsing any particular approach to solving the problem, though he did say, during the question-and-answer period, that he would like to see all insurance providers become nonprofits.

Responding to a question about single-payer, Abrons stressed that it wouldn’t cost more than the present system and could cost less. “We don’t have all the answers, but we have learned a lot from other countries. … Right now it’s a game of ‘get the money any way you can.’ ”

http://www.newsreview.com/chico/content?oid=1940233

Heading North To Rally In Single-Payer-Land

By Carey Goldberg
WBUR, Boston NPR, March 17, 2011

There’s a new cause that calls for getting on the bus. Next Saturday morning, (3/26), dozens of Boston-area medical students and others heading into health care careers plan to board buses for Montpelier, to rally at the State House in support of the single-payer system that Vermont leaders aim to create.

“We’re going up there trying to hammer home the message that as students and other health professionals from out of state, we want to see Vermont lead the way, and be able to point to Vermont as an alternative,” said Sim Kimmel, a third-year Harvard medical student and one of the buses’ organizers. “Some people have gone as far as saying that if Vermont were to have a single-payer system, they would pledge to move there.”

Click here for information on the rally, which is slated to include Sen. Bernie Sanders and Governor Peter Shumlin (who was on Radio Boston last week explaining the state’s plans.) Here, students explain why the rally is important to them.

Sim says the Boston contingent hopes to gather about 100 students for the 8 a.m. buses from Back Bay and Harvard Square, and they’ll be joined by colleagues from around the Northeast at the rally.

“It’s quite clear from the experience in Boston and in Massachusetts and around the country that we’re not organizing health care in a reasonable or rational way,” he said.

But, I asked, wouldn’t a single-payer system — the government-controlled type used in Canada or England — mean that as a future doctor, he’d earn less money?

“That’s not exactly clear, but even if it meant that, I would still support it,” Sim said. “Physicians spend so much time fighting with insurance companies and filling out paperwork, and so much of the cost of health care is lost in administrative waste. Having a single-payer system would essentially reduce that work so I could spend time doing what I actually want to be doing, which is seeing patients.”

For anyone tempted to dismiss the bus-riders as idealistic youth, it’s worth noting that support for a single-payer system among American physicians is surprisingly strong, surveys have found. The rally is being organized by Physicians for a National Health Program and the American Medical Students Association.

What is Universal Healthcare?

By Annie Brown
EDGE (Boston), March 18, 2011

Patients, doctors and health insurance companies are engaged in a historic debate surrounding the future of healthcare in America. Most of the discussions surrounding healthcare are led by politicians who either celebrate President Obama’s Patient Protection and Affordable Care Act (2010) as a necessary first step towards equal access or view it as a direct assault on constitutional rights.

However, there are millions of patients and physicians who aren’t pleased with either party’s response to the healthcare crisis.

Dr. Susan Miller, a family physician and Virginia’s representative for Physicians for a National Health Program, is one of these individuals.

Dr. Miller’s perspective on the healthcare issue is informed by extensive experience as a physician, a small business owner, and an individual who has witnessed first-hand the inequality and inefficiency of modern American healthcare. She, like many Americans, is frustrated with the rhetoric politicians are using to describe the current state of healthcare to their constituents.

Miller believes that politicians are manipulating this debate to support personal goals. In the process, they are also distracting Americans from the facts and making the road to universal healthcare longer and more complicated than it should be. Rhetorical speeches don’t effectively explain healthcare legislation and rarely present possible solutions. It is my hope that this article will fill in the blanks left by politicians.

Miller has practiced family medicine for over 25 years. In the process she has participated in many aspects of the medical profession from safety-net clinics, to running her own private practice in the Richmond suburbs and, for the past five years, working with people from the inner city of Richmond. “I understand what it means to be a small business…I also understand the needs of [insured] middle-class patients and I know the problems of people who don’t have insurance.”

During our interview, I asked Miller to explain her perspective on American healthcare and why she supports a single-payer plan. I also spoke with her about resistance to The Patient Protection and Affordable Care Act (PPACA) in her home state of Virginia and the possibility of universal healthcare in states like Vermont. The intention of this article is to explore solutions beyond rhetoric and move towards a healthcare system that provides affordable and quality care to all Americans.

Improved Medicare for All

Miller supports the idea of “improved Medicare for all,” also known as a single-payer plan because she entered the field of medicine to help people. She continues, “I was into medicine and politics from the very beginning. I have been a single-payer supporter since I was first involved in medicine because I believe that healthcare is a human right.”

As the Virginia representative for Physicians for a National Health Program (PNHP), Miller educates others about a single-payer plan that could solve America’s healthcare crisis. PNHP is a single-issue organization that supports a universal, comprehensive single-payer national health program and has been advocating for healthcare reform since 1987.

The organization has over 18,000 members and chapters across the United States. Miller explains the concept of a single-payer plan as “taxpayers pool together money to fund a national health plan. With a single-payer system, insurance is nationalized, but healthcare is delivered by private practices.”

This plan would essentially be an improved and expanded Medicare system. Medicare for all means that ideally everyone born in the U.S. would be given a health insurance card or number when they are born or, for immigrants, when they gain citizenship. A quote used often by PNHP is, “Everybody in. Nobody out.”

Since the passage of PPACA, PNHP continues to lobby state and federal legislators to consider a single-payer national health program as a cost-effective and health beneficial program. However, PNHP lobbyists are going up against health insurance companies who, according to a 2010 article in the Huffington Post, supplied an average of eight healthcare lobbyists per every one member of Congress in 2009.

In 2010, Aetna spent $4,845,894 on lobbying expenditures, while Blue Cross/Blue Shield contributed $916,719 to political campaigns. The majority of Blue Cross/Blue Shield’s contributions supported Democratic candidates.

Health reform is a hot topic in Washington because it is an issue that affects all Americans and reform of the healthcare system is much needed.

In September of 2010, approximately 50.7 million people did not have health insurance. As a reformative bill, the 2010 PPACA aims to reduce this number and provide health coverage to over 30 million currently uninsured Americans “by expanding Medicaid and providing federal subsidies to help lower and middle-income Americans buy private coverage,” according to a recent article in the New York Times.

The law also forces health insurance companies to stop practices that prevent people from purchasing insurance. However, this most recent attempt at healthcare reform disappointed single-payer supporters. The PPACA “was health insurance reformed.”

“Single-payer supporters never even got to the table … Obama made a pragmatic political decision. Obama was a single-payer supporter before he ran for office … he abandoned that because he would have been labeled a socialist,” Miller explains.

As Miller sees it, Obama’s plan “cut back on some of the excesses, where these companies were denying people care and refusing to cover people if they had a preexisting illness. However, it is not healthcare reform.”

Although the final version of the bill did expand Medicare and provides more Americans with coverage, it bolsters the problematic private insurance industry and leaves 23 million Americans still uninsured by 2019, according to a recent Congressional Budget Office estimate

Deconstructing Healthcare Rhetoric

Despite the amount of conservative compromise that shaped the bill as it passed through both houses of congress, politicians are still debating the role of government in medicine. Many prominent political leaders have publically stated that one of their primary goals this year is to repeal Obama’s healthcare legislation on the basis that government should be separate from medicine.

Since the PPACA was passed, the Republican Party has turned to misleading rhetoric as they work to have the bill repealed. Although Republicans do support national healthcare plans, such as veteran’s insurance and Medicare, much of the party’s rhetoric attacks the PPACA as well as a single-payer system for being socialist and anti-business.

Miller explains that Obama’s bill is far from socialist. She says the act is “merely insurance reform, built on the privately owned profit making health insurance industry.” Although the solution of a single-payer plan, or Medicare for all, eliminates the need for private health insurance providers, it does not deserve the term socialist.

The single-payer system would not be socialized medicine, it would be social insurance, says Miller, “this means that society pools the risk, so that the people who are really ill get treatment…In this system healthcare is still delivered privately by your local doctor.”

Miller clarified that the only socialized healthcare we have in this country is insurance provided by the VA [the U.S. Department of Veterans Affairs], because it is supported by taxpayers as well as delivered by the government. Unlike in the single-payer system, healthcare provided though the VA is funded and delivered by the government.

Miller defends nationalized insurance against anti-business rhetoric by emphasizing the bur
den that providing insurance places on employers. “You would think people who support businesses should support a single-payer healthcare system. … Why is Toyota the best car company in the world? Because our companies in Detroit have to take $15,000 from the sale of each vehicle to pay for employee health benefits.” In a single-payer system, citizens would no longer have to rely on their employer to provide healthcare.

Today the United States remains the only industrialized country without a national health insurance plan. Medicare and Medicaid are the closest the country has ever come to a national health insurance program, but neither of these government programs were ever expanded to cover all Americans.

Understanding Cuccinelli’s Arguments

Some of the most intense arguments over government’s role in healthcare have occurred in Miller’s home state of Virginia.

On March 2, Attorney General Ken Cuccinelli stood before the House Judiciary Committee and explained his concerns about the PPACA. “The litigation is not so much about healthcare as it is about liberty,” Cuccinelli says. He took this same argument to Virginia Courts.

In the lawsuit, The Commonwealth of Virginia vs. Kathleen Sebelius, the Attorney General argues the federal law is unconstitutional due to the bill’s individual mandates provision, which requires that all Americans must purchase healthcare by 2014, or face a federal penalty. Kathleen Sebelius, Secretary of the U.S. Department of Health and Human Services, is defending her motion to dismiss Cuccinelli’s claim against individual mandates. Cuccinelli is acting as Plaintiff and representative of the Eastern District of Virginia.

“In this case, I agree with Cuccinelli. When else have we required Americans to buy a defective product?” Miller explains, “Individual mandates where the only way that the health insurance companies would agree to certain regulations, such as not eliminating people who had preexisting conditions.” With individual mandates, health insurance companies can maintain profits and also (using the money paid by insured customers) pay for more American’s healthcare.

In December, Virginia federal district judge Henry E. Hudson agreed with Cuccinelli’s argument stating, “The law’s central requirement that most Americans obtain health insurance exceeds the regulatory authority granted to Congress under the Commerce Clause of the Constitution.”

In his final ruling, Hudson ruled in favor of Cuccinelli, rejecting the federal government’s motion to dismiss the Commonwealth’s lawsuit and thereby allowing Cuccinelli to continue his efforts to have the PPACA repealed. A Circuit Court of Appeals in Richmond is scheduled to hear the government’s appeal this spring, unless the U.S. Supreme Court decides to take on the case first. If the Supreme Court rules that individual mandates are unconstitutional, the entire PPACA would be repealed since the mandates are a requirement of the law.

While the individual mandate clause may be the central focus of the healthcare debate in Virginia, Miller suspects that Cuccinelli’s argument against this one provision is representative of a broader conservative stance.

“The argument in this country is whether healthcare is a human right or if healthcare is a profit center,” says Miller, “Republicans want to make people cost sensitive so people won’t go to the doctors all the time…by making costs transparent and asking patients to be responsible when they choose providers. But the problem with this is that when someone needs their appendix out, they can’t shop around.”

In many ways, the competitive nature of capitalism doesn’t benefit patients. Miller elaborated on this point by citing several studies, including a Harvard study that showed for-profit dialysis centers to have higher death rates than nonprofit centers, as well her own experience as a doctor.

“Just before speaking with you,” Miller said after a brief pause in our interview, “I had a patient on the phone. I could tell that she was wheezing. I told her she should go to the emergency room, but she says she couldn’t afford the co-pay…We need to remove barriers to care.”

The Future of Universal Healthcare

While PPACA is being resisted in some states, such as Virginia and Florida, other states are taking this as an opportunity to discover sustainable solutions to America’s healthcare problem. For states to implement their own version of “Obamacare” the law requires they obtain federal waivers that relieve them of particular requirements specified by the plan.

The waiver provision was included in the original bill to allow states to test alternative ways of making health care accessible to the millions of Americans who need it. Waivers were not supposed to be available to states until 2017, but recently Obama stated he would support an amendment that would grant early waivers so that new healthcare models could be implemented as soon as possible.

Vermont is one of the states requesting an early waiver. After Obama announced his support of the early waivers amendment, Vermont Democratic Senator, Patrick Leahy stated, “Vermont has already been working hard to improve the state’s system of health care, and passage of the delegation’s waiver bill will move our state one step closer to that goal.”

Miller is hopeful about the future of healthcare in America. “They are moving forward with single-payer program legislation in states like Vermont, Oregon and California,” she says with excitement, “once states begin using a single-payer system, we will have a national experiment. We will see which states have better healthcare.”

There is already a federal bill written that lays out the steps needed to implement a single-payer program. The Expanded and Improved Medicare for All Act (HR676) established “a unique American universal health insurance program with single payer financing.” The summary written by Representative John Conyers Jr. (D-MI) continues,

“The bill would create a publicly financed, privately delivered health care system that improves and expands the already existing Medicare program to all U.S. residents…The goal of the legislation is to ensure that all Americans will have access, guaranteed by law, to the highest quality and most cost effective health care services regardless of their employment, income or health care status.”

The bill failed to make it past committee, but was reintroduced on February 11 of this year as “The United States National Healthcare Act,” with 28 co-sponsors. “The bill gradually transitions the whole healthcare system from profit to not for profit,” says Miller.

According to the Healthcare-NOW website, the program established in HR676 “will cover all medically necessary services. … Patients have their choice of physicians, providers, hospitals, clinics, and practices. No co-pays or deductibles are permissible under this act.”

With so much resistance towards the idea of a single-payer program coming from both the moderate left and the right, there is little chance that this bill will pass through either house any time soon, even if it is a potential solution to America’s healthcare crisis. “Americans need improved Medicare for all.”

“Of course Medicare is not perfect,” she adds, “but it’s a great platform to start from.” Miller speaks openly about the single-payer option with her colleagues because she wants to separate the facts from the rhetoric politics have built up around them.

Justifiably, she worries when politicians complicate the issue of healthcare reform. Circular rhetorical arguments cause Americans to tune out, even though this debate and its outcome is critical to national prosperity and personal health.

1. http://www.huffingtonpost.com/2010/02/25/eight-health-care-lobbyis_n_477215.html

2. http://www.opensecrets.org/
industries/indus.php?ind=H03#lobtotals2

3. http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/health_insurance_and_managed_care/health_care_reform/index.html

4. http://www.cbo.gov/publications/collections/health.cfm4

5. http://www.wtop.com/?nid=120&sid=22744035

6. http://thomas.loc.gov/cgi-bin/query/F?c111:7:./temp/~c111xl6p71:e81188: Section 1311, b(1)

7. http://www.washingtonmonthly.com/archives/individual/2010_12/027059.php

8. http://www.forensic-psych.com/articles/artDialysis.php6

9. http://www.reformer.com/localnews/ci_175438787

10. https://pnhp.org/news/2011/february/summary-hr-676-the-expanded-improved-medicare-for-all-act

http://www.edgeboston.com/index.php?ch=health_fitness&sc=health&sc2=features&sc3=&id=117433

State-Based, Single-Payer Health Care — A Solution for the United States?

William C. Hsiao, Ph.D.
NEJM, March 16, 2011

The United States faces two major problems in the health care arena: the swelling ranks of the uninsured and soaring costs. The Patient Protection and Affordable Care Act (ACA) makes great strides in addressing the former problem but offers only modest pilot efforts to address the latter. Experience in countries such as Taiwan and Canada shows that single-payer health care systems can achieve universal coverage and control inflation of health care costs. Because of strong political opposition, however, the U.S. Congress never seriously considered a single-payer approach during the recent reform debate. Now Vermont, wishing to solve the intertwined problems of costs and access through systemic reform, is turning in that direction. Vermont Governor Peter Shumlin campaigned on a platform of single-payer health care, and Democratic legislative leaders are committed to this approach.

In Vermont, the status quo in health care has become untenable. Despite numerous reforms over the past 15 years, Vermont’s health care costs are escalating rapidly, straining the state budget, household incomes, and employers’ bottom lines. More than 7% of Vermonters are uninsured, and another 15% have inadequate insurance.

The Vermont Legislature passed Act 128 in May 2010 authorizing a study to find the most viable and practical systemic solutions to these problems.1 The goals are clear and ambitious: Vermont wants to achieve universal coverage, reduce the rate of cost increases, and create a primary care–focused, integrated delivery system. The question is how to achieve those goals. My team of health system analysts at the Harvard School of Public Health was commissioned by the Vermont Legislature to develop and evaluate three options for health system reform and determine which option would best achieve the stated goals.

We conducted extensive fiscal, legal, institutional, and stakeholder analyses in Vermont to gain an in-depth understanding of the hurdles confronting any such plan and to design ways of overcoming or navigating around them. Our findings presented a striking picture. Vermont faces a $150 million budget shortfall. Employers argue that health care costs jeopardize their businesses’ financial viability, while families struggle to pay out-of-pocket health care costs. Vermont businesses and workers are unwilling to spend more for health care.

On the other hand, Vermonters are also largely unwilling to reduce their level of benefits. Our analysis found that, on average, Vermonters have rich insurance benefits approaching the ACA’s “platinum” standard. Similarly, physicians and hospitals are unwilling to accept reductions in their net incomes.

Our analyses led us to adopt several design principles that shaped our recommended design. First, we wanted to design a system capable of achieving universal coverage and reducing the cost inflation rate. Any increases in spending to cover the uninsured and underinsured would have to come from savings generated by systemic reforms. Any financing mechanism should not increase the costs to the state, businesses, and households. Second, we aimed to maintain Vermonters’ current average benefits. Third, we sought to maximize federal revenues from all sources. Fourth, we would not reduce overall net income of physicians, hospitals, or other providers. Finally, we sought to eliminate the perverse incentives inherent in the fee-for-service system, through risk-adjusted capitation payment plus performance bonuses, to provide incentives for the formation of accountable care organizations and care integration.

We found that the system capable of producing the greatest potential savings and achieving universal coverage was a single-payer system — one insurance fund that covers everyone with a standard benefit package, paying uniform rates to all providers through a single payment mechanism and claims-processing system. Our analysis showed that Vermont could quickly save almost 8% in health care expenditures through administrative simplification and consolidation, plus another 5% by reducing fraud and abuse.

We recommended that the single payer be a public–private partnership. An independent board with representation from both the major health care payers (employers, the state, and workers) and the major beneficiaries and recipients of payment (providers and consumers) would negotiate updates to the benefit package and payment rates. We also proposed contracting out claims administration through a competitive bid to create incentives to develop more efficient systems.

This system reduces the rate of cost increases over time by insulating major decisions about health care spending from politics, as well as by paying providers through capitation rather than fee for service, promoting delivery-system integration, and reducing the practice of defensive medicine by implementing a no-fault medical malpractice system. All told, we estimated that Vermont could save 25% in health care expenditures over 10 years (estimated savings for the first 5 years are shown in the table).


Estimated Impact of the Recommended Single-Payer Plan for Vermont.

Eligibility for coverage in the system would be based solely on proof of Vermont residency, the same requirement currently used by Vermont Medicaid; this approach effectively divorces health benefits from employment. However, we proposed to finance the system through a payroll contribution on all Vermont wages, split between employer and employee, to preserve the federal tax treatment of health benefits — a tax expenditure worth $400 million to $500 million in Vermont. We recommended delaying the implementation of the single-payer system until after Vermont’s insurance exchange has been operating for a year, at which point the state will have a basis for arguing for a waiver from the ACA requirements and estimating the amount of a federal block grant it would receive before 2017, when current ACA law allows for waivers.1

We used two economic models to estimate the impact of the proposed system. We fed estimated savings and costs under the single-payer system into a MicroSimulation Model, developed by the Massachusetts Institute of Technology’s Jonathan Gruber, which simulated the likely responses to the ACA by employers and low-income workers and estimated the amount of state and federal spending under the law, as well as computing the payroll contribution rates necessary to finance our plan. We then fed those results into a macroeconomic model developed by Regional Economic Models to estimate the effects on jobs and the gross state product that would result from additional spending for health care when more people were covered and the increase in household income and consumption when insurance premiums decreased with a single-payer plan. The models predicted that, as compared with implementing the ACA, the single-payer system would result in lower spending by employers, the state, and households and in the creation of more jobs in Vermont. For example, without single-payer reforms, we predict that employers would pay 12% of their payrolls in health insurance premiums in the first year, with further increases to follow.

The governor has already introduced legislation establishing the first building blocks of a single-payer system: payment reform, the creation of the independent board, and the mandate to build Vermont’s health insurance exchange as a platform for a single-payer infrastructure. Legislation establishing universal coverage and its
financing will follow, when the state can obtain waivers from Medicare’s and Medicaid’s provider-payment rules and the ACA’s individual mandate and subsidy rules. Innovative state reforms are being encouraged, as illustrated by President Obama’s support for the Wyden–Brown bill,2 which would grant waivers from ACA requirements in 2014 if states can meet the ACA’s goals. The Vermont single-payer plan certainly can.

Perhaps we are at the dawn of systemic reform in U.S. health care. The Vermont single-payer plan will never be as efficient as Taiwan’s or Canada’s because it must work within the bounds of federal laws and programs and the realities of porous state borders. Nevertheless, it can produce substantial savings to fully fund universal coverage, reduce health care costs for most businesses and households over time, and reform a fragmented delivery system. Of course, someone will bear the burden — mostly the private insurance industry and high-wage businesses that don’t currently offer insurance. But if Vermont can navigate its political waters and successfully implement this plan, it will provide a model for other states and the country as a whole.

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

This article (10.1056/NEJMp1100972) was published on March 16, 2011, at NEJM.org.

Source Information

From the Department of Health Policy and Management, Harvard School of Public Health, Boston.

References

1. Act 128 Health System Reform Design Final Report. (http://www.leg.state.vt.us/jfo/healthcare/FINAL%20REPORT%20Hsiao%20Final%20Report%20-%2017%20February%202011_3.pdf.)

2. Stolberg SG, Sack K. Obama backs easing state health law mandates. New York Times. February 28, 2011.

A Medicare lesson for Dick Armey

Civil Action No. 08-1715 (RMC)

United States District Court for the District of Columbia

BRIAN HALL, et al. (including Richard Armey), Plaintiffs,
v.
KATHLEEN SEBELIUS, Secretary, Department of Health and Human Services, et al., Defendants.

Plaintiffs are retired Federal employees who have reached age 65 and have applied for, and are receiving, Social Security Retirement benefits. As a result, they are “entitled” to Medicare Part A, coverage. They do not, however, want Medicare coverage. And the only avenue provided to Plaintiffs to un-entitle themselves is to cease receiving Social Security Retirement benefits – and to repay all such benefits already received. Plaintiffs declaim that such a requirement is contrary to the Social Security Act, of which Medicare is a part. The Court concludes that Plaintiffs’ claims are without merit.

FACTS

Plaintiffs Brian Hall, John Kraus, and Richard Armey share the following characteristics:

• They are retired from Federal employment and have attained the age of 65.
• They applied for, and are receiving, Social Security Retirement benefits.
• They are entitled to benefits under Medicare Part A.
• They had previously been enrolled in health plans under the Federal Employees Health Benefit (FEHB) program and wish to continue that coverage in full.
• They do not want to be covered by Medicare Part A and want to disenroll from Medicare Part A.
• They want to continue receiving their monthly Social Security Retirement benefits.

These facts are all undisputed and, for purposes of resolving this dispute, are the only facts that pertain.

ANALYSIS (excerpts)

Every individual who –

(1) has attained age 65, and
(2)(A) is entitled to monthly insurance benefits under section [42 U.S.C. § 402] of this title . . .

shall be entitled to hospital insurance benefits under part A of title XVIII [of this chapter] for each month for which he meets the condition specified in paragraph (2) . . . .

42 U.S.C. § 426(a). What this means is that an individual who has applied for Social Security Retirement benefits and qualifies to receive such benefits, so that he is “entitled” to Social Security Retirement benefits, automatically becomes “entitled” to Medicare Part A upon his 65th birthday. The only way to avoid entitlement to Medicare Part A at age 65 is to forego the source of that entitlement, i.e. Social Security Retirement benefits. There are but two ways to forego Social Security Retirement benefits: (1) fail to apply even though qualified, see 42 U.S.C. § 402(a) (requiring the filing of an application); or (2) withdraw one’s application and repay all retirement benefits already received, see 20 C.F.R. § 404.640.

Social Security regulations provide a means of avoiding entitlement to monthly Social Security Retirement benefits and thereby also provide a means of avoiding entitlement to Medicare Part A benefits. An individual may withdraw an application for Social Security Retirement benefits after it has been filed by submitting a written request and either repaying “[a]ll benefits already paid” or upon the SSA being “satisfied that they will be repaid.” See 20 C.F.R. § 404.640.3 These regulations are of no assistance to Plaintiffs, however, since they want to avoid Medicare Part A and retain their Social Security Retirement benefits.

There is a “dis-enrollment” possibility, albeit very unattractive, that allows a 65 year-old beneficiary to make himself un-entitled for Medicare Part A by foregoing one of the essential requirements to become entitled to Medicare Part A – receipt of Social Security Retirement benefits.

That Medicare entitlement has very specific consequences for a retired Federal employee: If a Federal retiree who has attained age 65 is “not covered” by Medicare Part A, perhaps because he withdrew his application for Social Security Retirement benefits, his FEHB “plan, other than a prepayment plan described in” 5 U.S.C. § 8903(4), “may not provide benefits . . . to pay a charge imposed by any health care provider, for inpatient hospital services which are covered for purposes of benefit payments” by Medicare Part A, “to the extent that such charge exceeds applicable limitations on hospital charges established for Medicare purposes.” 5 U.S.C. § 8904(b)(1)(A). Thus, even if Plaintiffs were to forego and repay all Social Security Retirement benefits, their FEHB-paid benefits would be no more, and no less, than what Medicare Part A would provide.

Plaintiffs argue that “entitled” to Social Security Retirement benefits does not mean “required to accept” so that “entitled” to Medicare Part A benefits does not mean “required to accept.” While the Plaintiffs’ plain-English reading of the word “entitled” has its attractions, in context the Medicare “entitled” does not actually mean “capable of being rejected.” An individual is “entitled” to Social Security Retirement benefits only after he has worked the requisite quarters, attained age 62 (or more), and filed an application. See 42 U.S.C. § 402. There being no affirmative filing of an application necessary for a Medicare Part A entitlement, it is a different type of entitlement because of its automatic nature. The Medicare Part A entitlement is tied exclusively to the fulfilment of two requirements: (1) receiving Social Security Retirement benefits; and (2) being age 65 – the removal of either having the effect of disestablishing that entitlement.

CONCLUSION

Plaintiffs are trapped in a government program intended for their benefit. They disagree and wish to escape. The Court can find no loophole or requirement that the Secretary provide such a pathway. Defendants’ Motion for Summary Judgment [Dkt. # 42], which was previously denied without prejudice, is reconsidered and will be granted and Plaintiffs’ Motion for Summary Judgment [Dkt. # 51] will be denied. A memorializing Order accompanies this Memorandum Opinion.

Date: March 16, 2011

ROSEMARY M. COLLYER
United States District Judge

https://ecf.dcd.uscourts.gov/cgi-bin/show_public_doc?2008cv1715-54

Comment: 

By Don McCanne, MD

Although this looks like another cute trick that Dick Armey tried to pull off, it is much more serious than that. This is a another blatant effort to try to destroy Medicare as a social insurance program to which all people over 65 who are receiving Social Security benefits are entitled.

This was not a broad anti-government stance. Medicare was targeted specifically. In this civil action, the plaintiffs wanted to specify that they had the right to reject Part A of Medicare, but they weren’t rejecting government programs in general because, in the same civil action, they wanted to keep their Social Security benefits, and they wanted to keep their government-sponsored federal employee retirement health benefits program (as their primary coverage and not secondary to Medicare).

When Medicare was enacted, a decision was mode to be certain that absolutely everyone over 65 on Social Security would be enrolled in Part A – the hospital component. Enrollment would be totally automatic, so much so that an individual could refuse enrollment only by refusing Social Security benefits and refunding to the government any payments already made.

What Dick Armey was trying to do was to establish the principle that individuals could decline Medicare completely and choose a private option (though in this case his private option was a government-sponsored private plan). Thi
s would be another step beyond merely selecting a private Medicare Advantage plan, still subject to Medicare regulations. This would totally divorce private plans from Medicare. The intent of the conservatives all along has been to move Medicare patients into private plans and then destroy Medicare by drastically underfunding it (and “drowning it in a bathtub”).

One of the most fundamental principles of the single payer model is that absolutely everyone is automatically enrolled. Opting out is not an option for anyone. People would still have the freedom to not use the health care system, but they couldn’t opt out of enrollment any more than pacifists like me can opt out of paying for our wars.

The conservatives and libertarians oppose single payer, and they fear that Medicare will be improved and then provided to everyone, as a single payer system. They will not stop in their efforts to shred Medicare into tatters, and walk away with their affluent friends to obtain their boutique health care on their own, leaving the rest of us to fend for ourselves – as if “personal responsibility” could buy a ticket to health care.

Let’s fool them. Let’s fix Medicare and then enroll absolutely everyone – automatically!

A Medicare lesson for Dick Armey

Civil Action No. 08-1715 (RMC)

United States District Court for the District of Columbia

BRIAN HALL, et al. (including Richard Armey), Plaintiffs,
v.
KATHLEEN SEBELIUS, Secretary, Department of Health and Human Services, et al., Defendants.

Plaintiffs are retired Federal employees who have reached age 65 and have applied for, and are receiving, Social Security Retirement benefits. As a result, they are “entitled” to Medicare Part A, coverage. They do not, however, want Medicare coverage. And the only avenue provided to Plaintiffs to un-entitle themselves is to cease receiving Social Security Retirement benefits – and to repay all such benefits already received. Plaintiffs declaim that such a requirement is contrary to the Social Security Act, of which Medicare is a part. The Court concludes that Plaintiffs’ claims are without merit.

FACTS

Plaintiffs Brian Hall, John Kraus, and Richard Armey share the following characteristics:

• They are retired from Federal employment and have attained the age of 65.
• They applied for, and are receiving, Social Security Retirement benefits.
• They are entitled to benefits under Medicare Part A.
• They had previously been enrolled in health plans under the Federal Employees Health Benefit (FEHB) program and wish to continue that coverage in full.
• They do not want to be covered by Medicare Part A and want to disenroll from Medicare Part A.
• They want to continue receiving their monthly Social Security Retirement benefits.

These facts are all undisputed and, for purposes of resolving this dispute, are the only facts that pertain.

ANALYSIS (excerpts)

Every individual who –

(1) has attained age 65, and
(2)(A) is entitled to monthly insurance benefits under section [42 U.S.C. § 402] of this title . . .

shall be entitled to hospital insurance benefits under part A of title XVIII [of this chapter] for each month for which he meets the condition specified in paragraph (2) . . . .

42 U.S.C. § 426(a). What this means is that an individual who has applied for Social Security Retirement benefits and qualifies to receive such benefits, so that he is “entitled” to Social Security Retirement benefits, automatically becomes “entitled” to Medicare Part A upon his 65th birthday. The only way to avoid entitlement to Medicare Part A at age 65 is to forego the source of that entitlement, i.e. Social Security Retirement benefits. There are but two ways to forego Social Security Retirement benefits: (1) fail to apply even though qualified, see 42 U.S.C. § 402(a) (requiring the filing of an application); or (2) withdraw one’s application and repay all retirement benefits already received, see 20 C.F.R. § 404.640.

Social Security regulations provide a means of avoiding entitlement to monthly Social Security Retirement benefits and thereby also provide a means of avoiding entitlement to Medicare Part A benefits. An individual may withdraw an application for Social Security Retirement benefits after it has been filed by submitting a written request and either repaying “[a]ll benefits already paid” or upon the SSA being “satisfied that they will be repaid.” See 20 C.F.R. § 404.640.3 These regulations are of no assistance to Plaintiffs, however, since they want to avoid Medicare Part A and retain their Social Security Retirement benefits.

There is a “dis-enrollment” possibility, albeit very unattractive, that allows a 65 year-old beneficiary to make himself un-entitled for Medicare Part A by foregoing one of the essential requirements to become entitled to Medicare Part A – receipt of Social Security Retirement benefits.

That Medicare entitlement has very specific consequences for a retired Federal employee: If a Federal retiree who has attained age 65 is “not covered” by Medicare Part A, perhaps because he withdrew his application for Social Security Retirement benefits, his FEHB “plan, other than a prepayment plan described in” 5 U.S.C. § 8903(4), “may not provide benefits . . . to pay a charge imposed by any health care provider, for inpatient hospital services which are covered for purposes of benefit payments” by Medicare Part A, “to the extent that such charge exceeds applicable limitations on hospital charges established for Medicare purposes.” 5 U.S.C. § 8904(b)(1)(A). Thus, even if Plaintiffs were to forego and repay all Social Security Retirement benefits, their FEHB-paid benefits would be no more, and no less, than what Medicare Part A would provide.

Plaintiffs argue that “entitled” to Social Security Retirement benefits does not mean “required to accept” so that “entitled” to Medicare Part A benefits does not mean “required to accept.” While the Plaintiffs’ plain-English reading of the word “entitled” has its attractions, in context the Medicare “entitled” does not actually mean “capable of being rejected.” An individual is “entitled” to Social Security Retirement benefits only after he has worked the requisite quarters, attained age 62 (or more), and filed an application. See 42 U.S.C. § 402. There being no affirmative filing of an application necessary for a Medicare Part A entitlement, it is a different type of entitlement because of its automatic nature. The Medicare Part A entitlement is tied exclusively to the fulfilment of two requirements: (1) receiving Social Security Retirement benefits; and (2) being age 65 – the removal of either having the effect of disestablishing that entitlement.

CONCLUSION

Plaintiffs are trapped in a government program intended for their benefit. They disagree and wish to escape. The Court can find no loophole or requirement that the Secretary provide such a pathway. Defendants’ Motion for Summary Judgment [Dkt. # 42], which was previously denied without prejudice, is reconsidered and will be granted and Plaintiffs’ Motion for Summary Judgment [Dkt. # 51] will be denied. A memorializing Order accompanies this Memorandum Opinion.

Date: March 16, 2011

ROSEMARY M. COLLYER
United States District Judge

https://ecf.dcd.uscourts.gov/cgi-bin/show_public_doc?2008cv1715-54

Although this looks like another cute trick that Dick Armey tried to pull off, it is much more serious than that. This is a another blatant effort to try to destroy Medicare as a social insurance program to which all people over 65 who are receiving Social Security benefits are entitled.

This was not a broad anti-government stance. Medicare was targeted specifically. In this civil action, the plaintiffs wanted to specify that they had the right to reject Part A of Medicare, but they weren’t rejecting government programs in general because, in the same civil action, they wanted to keep their Social Security benefits, and they wanted to keep their government-sponsored federal employee retirement health benefits program (as their primary coverage and not secondary to Medicare).

When Medicare was enacted, a decision was mode to be certain that absolutely everyone over 65 on Social Security would be enrolled in Part A – the hospital component. Enrollment would be totally automatic, so much so that an individual could refuse enrollment only by refusing Social Security benefits and refunding to the government any payments already made.

What Dick Armey was trying to do was to establish the principle that individuals could decline Medicare completely and choose a private option (though in this case his private option was a government-sponsored private plan). This would be another step beyond merely selecting a private Medicare Advantage plan, still subject to Medicare regulations. This would totally divorce private plans from Medicare. The intent of the conservatives all along has been to move Medicare patients into private plans and then destroy Medicare by drastically underfunding it (and “drowning it in a bathtub”).

One of the most fundamental principles of the single payer model is that absolutely everyone is automatically enrolled. Opting out is not an option for anyone. People would still have the freedom to not use the health care system, but they couldn’t opt out of enrollment any more than pacifists like me can opt out of paying for our wars.

The conservatives and libertarians oppose single payer, and they fear that Medicare will be improved and then provided to everyone, as a single payer system. They will not stop in their efforts to shred Medicare into tatters, and walk away with their affluent friends to obtain their boutique health care on their own, leaving the rest of us to fend for ourselves – as if “personal responsibility” could buy a ticket to health care.

Let’s fool them. Let’s fix Medicare and then enroll absolutely everyone – automatically!

Why the Vermont student rally for single payer is important to me

I’m a fourth-year student preparing to start residency in Family Medicine. I chose medicine, and primary care in particular, to provide access to health care to the underserved. From all I have read and learned so far, it has become abundantly clear that a single-payer health care plan is the best way to address the horrifying inequities in health care in our country. Being in Massachusetts, I’ve seen firsthand how alternative solutions have fallen short. I’m so inspired by the hope that Vermont can lead the way in showing the country what single payer can do. It gives me hope for the future of health care reform.

— Anjana Sharma
Harvard Medical School 2011

As a University of Vermont College of Medicine student it is incredibly exciting to have students and practitioners come from around the country to support the health reform process that is currently happening in Montpelier. Many of us plan to practice in Vermont after our training is complete, and it is our great hope that every future patient will have the ability to afford quality health coverage for themselves and their families through a single payer system, while still allowing Vermont providers the means to care for their patients in a financially sustainable fashion. We appreciate all of the nationwide support that this rally is highlighting, and we look forward to the time spent together on March 26th!

— Larry Bodden
University of Vermont College of Medicine 2014

I’m a second-year medical student at Albany Medical College in New York and co-president of our PNHP chapter here. Last week I was reminded of why I am a single payer activist. I saw a 62-year-old patient at our downtown screening clinic that had stopped taking his hypertension medication three years ago. His blood pressure was so high we considered sending him to the emergency room. He was a cook in town, but couldn’t afford his medication. He was also a smoker, and his landlord had recently turned off his heat. Needless to say, winter in Albany gets quit frigid. We gave the gentleman a number to a full service free clinic in town, as well as information on free legal aid to pursue his negligent landlord. But I couldn’t help but feeling defeated. This patient needed more. Here was a person whose life would have directly benefited from regular and reliable medical attention and care — his blood pressure would be within a safe range, he would be receiving regular reminders by a physician about the importance of tobacco cessation, he would be connected with resources to improve his dangerous housing condition. It’s not easy to be a student activist, but it’s experiences like these that motivate me. I’m motivated to work for single payer because I know it will improve the lives of my patients and will enhance the effectiveness of, and therefore the pride I have for, our profession.

— Danielle Alexander
Albany (N.Y.) Medical College 2013

Health care should be a right and not based upon the ability to pay. Single payer will allow health care providers to care for all patients who require assistance for healing, regardless of health insurance plan or amount of coverage. Aspiring doctors should be able to practice medicine in an environment that encourages patient-physician relationships and focuses on well-being, rather than on reimbursement rates and profit.

— Kathleen Mahan
University of Minnesota Medical School 2013

I’m a fourth-year medical student at the Yale School of Medicine, and I entered the field of medicine so that I could help care for anyone who asked. I see that the cost of health insurance is crippling individuals, families, and businesses across the nation. Governor Shumlin of Vermont understands that single payer is the best solution for his state. I’ve been helping to organize the March 26 rally in Montpelier help make single payer a reality. Let’s hope that Vermont can lead the way for all 50 states!

— Carl Berdahl
Yale School of Medicine 2012

As a nurse practitioner working with Boston Health Care for the Homeless Program, I see firsthand the gaps that patient after patient fall through in our current medical system. My patients experience the greatest of life’s hardships every day. The least we can do is give them an equal chance at being healthy to have the strength to pull themselves up again. We need health care reform that is actually comprehensive and completely universal.

— Desiree Otenti
Boston University School of Public Health 2012

As a future physician, I want to participate in a rally that stands for the kind of health care system that I hope to be a practicing part of. As a student at the University of Vermont College of Medicine, I am honored that the state of Vermont is being used as an example of a health care system worth striving for in other states and, hopefully, around the nation. I believe that health care is a fundamental human right and I hope that the rally will spread awareness that physicians in training are hopeful for a system where the patient and physician are focused on one goal, rather than divided between barriers created by insurance companies. It is my hope that setting the example of a single-payer system in Vermont can demonstrate to the nation that comprehensive, quality and affordable care is possible and worth striving for. It is also my hope that policy makers can see that physicians should be involved in decisions about health care and health care policy and should be able to be more involved — since, after all, they are the ones committed to working for the system.

— Mariah H. Stump
University of Vermont College of Medicine 2012

“Miller, this place is killing me!”” That’s Murphy’s Law at P.S. 163, a struggling Bronx, New York, elementary school. Ms. Murphy, another faculty member at the school where I taught in 2006 and 2007, started saying that after we had been teaching there for eight months. Unfortunately, some places really can kill you, or at least contribute to an early death: I know that because I hope to devote my career as a physician to promoting the safety of public institutions like P.S. 163 through environmental epidemiology advocacy and research. There’s no reason why harmful environmental conditions should exist, no place in the America we like to think we know. We need to establish a fair and just American health care system. Vermonters: we’ve we’ve got you covered.

— Maureen Miller
New York University School of Medicine 2013

I feel that the knowledge and experiences that I will gain at the Vermont student rally will translate to a stronger and more robust coordination in Oregon’s fight for single-payer health care. This is the great social movement of my generation, and I want to be there on the front lines to help bring it to fruition in Vermont. I have talked with my wife and she has encouraged me to go. “This is your movement,” she says. I’m going.

— Richard Bruno
Oregon Health and Science University 2013

I am really excited to go to Vermont to show that my generation of doctors is not willing to let the American health care system fail our patients. Currently, the way we provide health care recapitulates and exacerbates the inequalities of our society. It was working at a free clinic at a homeless shelter that made me want to go to medical school. I saw how a doctor-patient interaction had the power to either support or undermine a patient’s sense of self-worth, and unfortunately how often the latter happens. When we continue to construct a health care system based on charity care or a two-tiered model, we send a message that not all Americans are equally deserving of medical care. And this will remain true no matter h
ow much I care for each individual patient unless we have systems-level reform. I’m going the rally in Vermont so that someday soon I won’t have to work in a medical system that keeps patients and our society sick.

— Kirsten Austad
Harvard Medical School 2013

I entered the field of medicine in order to serve those less empowered by circumstance and society, who often experience significant challenges to living healthfully and managing disease. Through my training in medicine and public health thus far, I have seen firsthand how much the current lack of a unified and equitable health care system is a stumbling block in doing the work I care about. This is why action to improve health care, through measures such as implementing a single-payer financing system, is important to me. I strongly believe that our best hope for true systematic health reform in the U.S. lies with individual states that can implement a single-payer financing mechanism along with other reforms to improve health care and control costs. If these leaders are successful, then other states, the broader public, and Washington will find the lure of a well-functioning health care system irresistible. My hope is that some day, everyone in this country will have access to health care and the resources necessary to maximize their health. Lead the way, Vermont!

— Jonathan Takahashi
Harvard Medical School 2012

It doesn’t take long in the hospital to see that the way we arrange health care and health care spending is irrational — it’s not good for patients and it’s not good for health care providers. As a third-year medical student in the Cambridge Integrated Clerkship at Cambridge Health Alliance, I’ve had the chance to see the health system from the patient’s perspective as I follow patients longitudinally through the year. Experiences with these patients have deepened my commitment to single payer. As I help with organizing this rally, I think about a patient I saw in my primary care clinic who came in with uncontrolled diabetes. This man has private insurance through the grocery store where he has worked for a decade — only his plan is full of holes. He reached his spending limit two weeks into his month and was left to pay out-of-pocket for his medications and diabetes supplies — items he simply couldn’t fit into his budget if he wanted to pay for his kid’s clothes or put food on the table. I asked him if he has been checking his sugars and he said, of course not, the strips are too costly. This is just one of many patients’ lives I’ve seen affected by our current system of insurance. These stories make me proud to be part of a movement to right health injustices and to humanize and reorganize our system in a way that makes it possible to get patients the care they need. We need to make single-payer health care a reality.

— Simeon Kimmel
MD/PhD in Anthropology, Harvard Medical School 2016

Lowering mortality by adding more diagnoses (a game)

Geographic Variation in Diagnosis Frequency and Risk of Death Among Medicare Beneficiaries

By H. Gilbert Welch, MD, MPH, Sandra M. Sharp, SM, Dan J. Gottlieb, MS, Jonathan S. Skinner, PhD, John E. Wennberg, MD, MPH
JAMA
March 16, 2011

Context: Because diagnosis is typically thought of as purely a patient attribute, it is considered a critical factor in risk-adjustment policies designed to reward efficient and high-quality care.

Objective: To determine the association between frequency of diagnoses for chronic conditions in geographic areas and case-fatality rate among Medicare beneficiaries.

Design, Setting, and Participants:  Cross-sectional analysis of the mean number of 9 serious chronic conditions (cancer, chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure, peripheral artery disease, severe liver disease, diabetes with end-organ disease, chronic renal failure, and dementia) diagnosed in 306 hospital referral regions (HRRs) in the United States; HRRs were divided into quintiles of diagnosis frequency. Participants were 5 153 877 fee-for-service Medicare beneficiaries in 2007.

Main Outcome Measures:  Age/sex/race–adjusted case-fatality rates.

Results: Diagnosis frequency ranged across HRRs from 0.58 chronic conditions in Grand Junction, Colorado, to 1.23 in Miami, Florida (mean, 0.90 [95% confidence interval {CI}, 0.89-0.91]; median, 0.87 [interquartile range, 0.80-0.96]). The number of conditions diagnosed was related to risk of death: among patients diagnosed with 0, 1, 2, and 3 conditions the case-fatality rate was 16, 45, 93, and 154 per 1000, respectively. As regional diagnosis frequency increased, however, the case fatality associated with a chronic condition became progressively less. Among patients diagnosed with 1 condition, the case-fatality rate decreased in a stepwise fashion across quintiles of diagnosis frequency, from 51 per 1000 in the lowest quintile to 38 per 1000 in the highest quintile (relative rate, 0.74 [95% CI, 0.72-0.76]). For patients diagnosed with 3 conditions, the corresponding case-fatality rates were 168 and 137 per 1000 (relative rate, 0.81 [95% CI, 0.79-0.84]).

Conclusion: Among fee-for-service Medicare beneficiaries, there is an inverse relationship between the regional frequency of diagnoses and the case-fatality rate for chronic conditions.

http://jama.ama-assn.org/content/305/11/1113.abstract

Comment: 

By Don McCanne, MD

This study from the Dartmouth Institute confirms the intuitive observation that the number of diagnoses of serious chronic conditions in Medicare beneficiaries has a positive correlation with case-fatality rates. The greater number of serious problems a person has, the greater the risk of death. But observation of the regional distribution of these serious diagnoses provides troubling results.

In this study, hospital referral regions varied in the average number of diagnoses per patient of these serious chronic conditions. There is an inverse relationship between the regional frequency of diagnoses and the case-fatality rate. As an example, if you had multiple serious diagnoses, your chances of dying are less if your diagnoses were made in a region where more people have a greater number of diagnoses than if the same diagnoses were made in a region where not as many people received multiple diagnoses.

The authors discuss possible explanations, but I’ll go out on a limb, and a very solid one at that, and give my opinion.  Assigning a greater number of serious diagnoses to a patient permits greater remuneration from upcoding, and it provides rewards for favorable quality and outcomes results since the patient is not as ill as the list of diagnoses would otherwise imply.

It is very difficult to differentiate a list of well documented diagnoses from an embellished list that may include some poorly substantiated notations in the record allegedly supporting the diagnoses. It would be very difficult to ferret out the claims that do not warrant additional consideration based on complexity or quality outcomes.

Reform was supposed to bring us higher quality at a lower cost, but it appears that continued gaming of the system will bring us higher costs with spurious results on quality and outcome assessments.

Much more work needs to be done before we could rely on these observations to improve quality and reduce costs. In the meantime, we could certainly tackle the issue of costs head on by the well proven method of enacting a single payer national health program. Quality and efficiency will be a continual work in progress.

Lowering mortality by adding more diagnoses (a game)

Geographic Variation in Diagnosis Frequency and Risk of Death Among Medicare Beneficiaries

By H. Gilbert Welch, MD, MPH, Sandra M. Sharp, SM, Dan J. Gottlieb, MS, Jonathan S. Skinner, PhD, John E. Wennberg, MD, MPH
JAMA
March 16, 2011

Context: Because diagnosis is typically thought of as purely a patient attribute, it is considered a critical factor in risk-adjustment policies designed to reward efficient and high-quality care.

Objective: To determine the association between frequency of diagnoses for chronic conditions in geographic areas and case-fatality rate among Medicare beneficiaries.

Design, Setting, and Participants: Cross-sectional analysis of the mean number of 9 serious chronic conditions (cancer, chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure, peripheral artery disease, severe liver disease, diabetes with end-organ disease, chronic renal failure, and dementia) diagnosed in 306 hospital referral regions (HRRs) in the United States; HRRs were divided into quintiles of diagnosis frequency. Participants were 5 153 877 fee-for-service Medicare beneficiaries in 2007.

Main Outcome Measures: Age/sex/race–adjusted case-fatality rates.

Results: Diagnosis frequency ranged across HRRs from 0.58 chronic conditions in Grand Junction, Colorado, to 1.23 in Miami, Florida (mean, 0.90 [95% confidence interval {CI}, 0.89-0.91]; median, 0.87 [interquartile range, 0.80-0.96]). The number of conditions diagnosed was related to risk of death: among patients diagnosed with 0, 1, 2, and 3 conditions the case-fatality rate was 16, 45, 93, and 154 per 1000, respectively. As regional diagnosis frequency increased, however, the case fatality associated with a chronic condition became progressively less. Among patients diagnosed with 1 condition, the case-fatality rate decreased in a stepwise fashion across quintiles of diagnosis frequency, from 51 per 1000 in the lowest quintile to 38 per 1000 in the highest quintile (relative rate, 0.74 [95% CI, 0.72-0.76]). For patients diagnosed with 3 conditions, the corresponding case-fatality rates were 168 and 137 per 1000 (relative rate, 0.81 [95% CI, 0.79-0.84]).

Conclusion: Among fee-for-service Medicare beneficiaries, there is an inverse relationship between the regional frequency of diagnoses and the case-fatality rate for chronic conditions.

http://jama.ama-assn.org/content/305/11/1113.abstract

This study from the Dartmouth Institute confirms the intuitive observation that the number of diagnoses of serious chronic conditions in Medicare beneficiaries has a positive correlation with case-fatality rates. The greater number of serious problems a person has, the greater the risk of death. But observation of the regional distribution of these serious diagnoses provides troubling results.

In this study, hospital referral regions varied in the average number of diagnoses per patient of these serious chronic conditions. There is an inverse relationship between the regional frequency of diagnoses and the case-fatality rate. As an example, if you had multiple serious diagnoses, your chances of dying are less if your diagnoses were made in a region where more people have a greater number of diagnoses than if the same diagnoses were made in a region where not as many people received multiple diagnoses.

The authors discuss possible explanations, but I’ll go out on a limb, and a very solid one at that, and give my opinion.  Assigning a greater number of serious diagnoses to a patient permits greater remuneration from upcoding, and it provides rewards for favorable quality and outcomes results since the patient is not as ill as the list of diagnoses would otherwise imply.

It is very difficult to differentiate a list of well documented diagnoses from an embellished list that may include some poorly substantiated notations in the record allegedly supporting the diagnoses. It would be very difficult to ferret out the claims that do not warrant additional consideration based on complexity or quality outcomes.

Reform was supposed to bring us higher quality at a lower cost, but it appears that continued gaming of the system will bring us higher costs with spurious results on quality and outcome assessments.

Much more work needs to be done before we could rely on these observations to improve quality and reduce costs. In the meantime, we could certainly tackle the issue of costs head on by the well proven method of enacting a single payer national health program. Quality and efficiency will be a continual work in progress.

Vermonters urge lawmakers to pass single-payer health care

By Anne Galloway
VtDigger.com, March 15, 2011

What happened to Sabra Ewing, could have happened, as she put it, to anyone. She had a high deductible ($20,000) health insurance plan for her family. For years, doctors had told Ewing she was healthy, and she stopped going in for annual checkups to avoid the expense. Then one day she found a dark spot on the side of her heel. It took her three weeks to get an appointment with a dermatologist. By the time Ewing was diagnosed, she had stage three melanoma.

Ewing, of Vershire, said if she had kept up with regular checkups it’s likely the spot would have been detected early and her cancer would have been more readily curable. As it stands now, she said she is receiving treatment from top experts.

“I may not survive,” Ewing said. “I’m not thinking about cost containment. I’m thinking about my 19-month-old grandchild.

Cost containment has become one of Heather Lochlin’s main preoccupations – but not by choice. Lochlin, of Ludlow, who is insured by BlueCross BlueShield of Vermont through Catamount Health, says she has been denied coverage “every step of the way.” Though she has been fully insured throughout her illness, she said there has been “repeated systemic pressure” to limit her care through loopholes in the guidelines and vague information about coverage.

“Denials shouldn’t be based on cost-cutting,” Lochlin said. “The idea that any of us has insurance is a mirage.”

Lochlin and Ewing were two of the more than 70 Vermonters who spoke at a public hearing about H.202, the health care reform bill that would fundamentally alter the existing system, which is now based on a commercial insurance system and fee-for-service reimbursements to doctors and hospitals. Under H.202, the state would be the first in the nation to attempt a conversion to a single payer health care system in which state government would manage the provider payment system and essentially cut commercial insurers out of the loop. All Vermonters, regardless of pre-existing conditions or ability to pay would be covered under the plan.

Advocates for H.202 outnumbered opponents 4-to-1 in the virtual hearing via Vermont Interactive Television at 15 locations around the state. About 70 Vermonters spoke; many more watched the proceedings.

Lawmakers from the Senate and House health care committees attended most of the regional meetings. The hearing was held as a precursor to sure movement on H.202; the bill is slated to be voted out of committee this week.

In two-minute blocks of time, participants shared war stories about run-ins with the insurance industry, opined about the inefficiencies and “inhumanity” of the existing system or expressed reservations about the financial cost of a single payer health care plan.

Battle lines were drawn from the beginning: Advocates and citizens involved with the Vermont Workers’ Center’s Health Care is a Human Right campaign packed the Montpelier VIT site, wearing red T-shirts and the by-now familiar campaign buttons, which feature Rosie the Riveter. About 14 people in the anti-single payer camp spoke up.

The single-payer proponents sounded familiar themes: They called for equitable, universal coverage and an end to medical industry profits at the expense of human health.

A young woman named Rebecca from Johnson told the audience that her brother was in a bicycle accident last year in Winooski and injured both legs, knees and arms. He couldn’t move his legs at first, she said, but he refused to go to the hospital because he didn’t have health insurance. A year later, his pain hasn’t dissipated.

“Insurance companies must get out of the way,” Rebecca said. “People don’t need the middle man. If my brother had health insurance, he wouldn’t be feeling pain he’s feeling today. Make health care affordable to everyone so we can all get the health care we need.”

Many of the speakers talked about the rising cost of health care — even for people who have insurance. Several participants said they had gone without coverage at one point or another.

Detractors questioned the quality of a health care system that would be based on a uniform payment system. Several doctors expressed concern about the impact of low Medicaid reimbursements – should the administration of Peter Shumlin succeed in folding the Catamount Health Plan into the Vermont Health Access Plan.

Patricia Leahy Meriam said specialty doctors are afraid they will lose income if they stay in Vermont and they’re looking at “exit strategies.” She warned that special treatment of diseases will be harder to access in the new system because it will place too much emphasis on primary care physicians – at the expense of specialty docs.

Dianna Scholl, a hospital chaplain at Porter Medical Center in Middlebury, said health care workers are put in an immoral and unethical position because of the inequities of the system.

“The problem is the current system doesn’t cover everyone equally at a price we can afford,” Scholl said. “I have seen people with Cadillac insurance get the care they need. The private pay folks and (people with) limited insurance are not able to get care they need. It’s a very basic inequity that is hard to deal with.”

Scholl said she has seen insurance companies override physician’s treatment recommendations. “It was all about the money, it had nothing to do (with whether) we had the right equipment or drugs. It was just about the money. How can we provide compassionate care when we are sending people away or because people don’t have the deductibe or copays.”

http://vtdigger.org/2011/03/15/vermonters-urge-lawmakers-to-pass-single-payer-health-care/

Vermont forum leans toward single-payer health care

By NEAL P. GOSWAMI
Bennington Banner, March 14, 2011

BENNINGTON, Vt. — Dozens of Vermonters offered thoughts on health care reform in Vermont to members of the House and Senate Health Care Committees during a statewide interactive hearing Monday.

The meeting, held at 15 Vermont Interactive Television sites across the state, was largely dominated by supporters of a single-payer health care system that would provide coverage to all Vermonters. Many wore the customary red shirts of the Health Care is a Human Rights Campaign. Many people visible on the television screens held signs that read “Single-Payer NOW.”

In Bennington, Dr. Richard Dundas, a Bennington doctor who founded a free health care clinic, said the current system is broken and asked for a single-payer system.

“I wanted to implore the committee … to change our system because our current one is failing. I’ve been in practice for 30 years. It’s getting worse instead of better. We need universal health care,” Dundas said.

Dundas said a single-payer health care system would help lower costs for medical providers by, in part, eliminating private insurance companies.

“My concept of a single payer is that it has to seriously decrease the overhead that providers and hospitals … have to pay for overhead. This would include burdensome documentation that doctors are required to submit in order to get paid. It also includes severing our ties with the insurance industry,” he said.

Jane Norrie, who also testified in Bennington, said the current system requires tremendous paperwork and overhead. “I heartily agree with Dr. Dundas that we could save a huge amount of money just by not having to make reams of copies,” Norrie said.

Lawmakers are currently considering H.202, a plan submitted by the administration of Democratic Gov. Peter Shumlin. The legislation seeks to lay the groundwork for single-payer health care in Vermont.

It calls for a five-member board to help implement a system in which the state is the only health provider of health care coverage by 2014. Shumlin’s plan does not yet specify a funding mechanism, however. Nor does it provide information about benefits. That is expected to be included in a later phase, according to Shumlin. A payroll tax has been mentioned as a potential primary funding source, however.

Dr. William Hsiao, a Harvard professor and health care expert hired as a consultant by the state, delivered a report to state lawmakers earlier this year detailing where the state would see savings if it implements a single-payer plan. His report is expected to serve as the blueprint for a hybrid single-payer system run by the state but administered by a private insurance company.

With Democrats holding large majorities in both the House and Senate the plan is likely to move forward, despite GOP opposition. Not everyone was in favor of a single-payer system. “In Canada many have died because of their rationing,” said one man in Montpelier.

Others asked for more details on costs and what kind of benefits the plan would provide.

A woman testifying in Burlington decried “left-wing pressure groups” that she said were pushing a single-payer health care system. “These are groups that are loud, they’re outside funding groups using Vermont as a petrie dish,” she said. “Not only is government health care not wanted, there’s no money for it.”

But many of those that testified Monday said they are seeking the universal coverage a single-payer system would provide. Many shared stories of their own struggles with the current system.

A young woman in Brattleboro said her mother was recently laid off, causing a loss of health care covered. As a volunteer receiving a living stipend, the woman said she has only a supplemental plan, which does not cover necessary appointments for a medical condition. “Each appointment would cost me over $600, money I don’t have,” she said. The possibility of a life in pain scares me.”

Another woman in Springfield said she isn’t receiving the care her doctor wants to deliver because of interference from the insurance company. “Currently my care is being influenced by my insurance company. My doctor and I should make those decisions,” the woman said through tears.

The House Health Care Committee is scheduled to focus on H.202 this week and expected to advance it.

http://www.benningtonbanner.com/ci_17614241