PNHP

qotd weekend special: The Super Bowl and a Crystal Stair

qotd weekend special: The Super Bowl and a Crystal Stair

Well here we are. Super Bowl weekend! Hurrah! What could be more American than this? Billions of dollars and the nation’s full attention directed to a couple dozen men playing a game. And this is no sandlot game. No. This is our nation at its finest – honoring in unparalleled splendor those great Americans who prevail and are declared winners of this historic rough-and-tumble fracas. And what more could our nation be than about winners?

Let me digress for a moment. I have a little story to tell.

I was still in practice during the Clinton effort to reform health care. Although practicing in an affluent community, I was experiencing great frustrations in trying to obtain specialized health care services for not only our indigent patients, but also for our insured patients who were facing increasing managed-care barriers to care.

Previously, in 1989, a life-changing event had occurred for me. It was simply that I read an article in The New England Journal of Medicine titled “A National Health Program for the United States,” written by a team led by David Himmelstein and Steffie Woolhandler, representing a group called Physicians for a National Health Program. I was stoked! I joined PNHP.

Then Bill Clinton was elected, and the nation was ready for a national health program. As masters of health policy science, PNHP was there and ready to help guide the process. But President Clinton decided that they would follow the path of political expediency and build reform based on the existing private insurers/managed care entities. Thus, in a political maneuver, to be repeated years later, PNHP was denied a seat at the table.

I watched the process closely. I listened as the opposition proposed a model almost identical to that of the Patient Protection and Affordable Care Act. I saw the effort go down in flames. I decided that we couldn’t just walk away.

I felt then that a pure single payer program, as much as I wanted it, could never pass. But I thought that there was enough agreement on fundamental principles that almost everyone would be able to support some model of social insurance, if we just had the right one. So I crafted a model. It was brilliant – just the right balance to achieve our goals while pleasing everyone.

I sent it in to PNHP. The task of reviewing it was handed to PNHP’s new president, Claudia Fegan. It required more postage to return it to me, because it was newly laden with red ink.

My lesson? I was passionate about reforming our system so that everyone would have the health care that they need, but I knew nothing about health policy science. I am forever indebted to Claudia for showing me the light, and resetting my course in my advocacy for reform. The principle she taught me is that you change policy recommendations only when policy science has demonstrated that there are better policies available. You do not ever change policy recommendations simply to conform to politics.

Claudia has continued to be a great inspiration to me. And that brings us to a crystal stair. On this glittering Super Bowl weekend, we should take a look at that crystal stair. You will understand what I mean when you read the Claudia’s remarks that she delivered to the Louisville, Kentucky Urban League on January 15, 2011. After reading her comments maybe we can think about what it really takes to make winners in America.

Cladia Fegan’s remarks to the Louisville Urban League:
http://www.spiritualprogressives.org/article.php/2011020212215961

Half of

Issues In Health Reform: How Changes In Eligibility May Move Millions Back And Forth Between Medicaid And Insurance Exchanges

By Benjamin D. Sommers and Sara Rosenbaum
Health Affairs
February 2011

The Affordable Care Act will extend health insurance coverage by both expanding Medicaid eligibility and offering premium subsidies for the purchase of private health insurance through state health insurance exchanges. But by definition, eligibility for these programs is sensitive to income and can change over time with fluctuating income and changes in family composition. The law specifies no minimum enrollment period, and subsidy levels will also change as income rises and falls. Using national survey data, we estimate that within six months, more than 35 percent of all adults with family incomes below 200 percent of the federal poverty level will experience a shift in eligibility from Medicaid to an insurance exchange, or the reverse; within a year, 50 percent, or 28 million, will.

Income fluctuation raises issues for all subsidy-eligible individuals or families up to 400 percent of the federal poverty level, which includes those whose incomes place them squarely within the exchange system. For those purchasing coverage with subsidies through exchanges, income changes may trigger the obligation to repay some or all subsidies received; the amounts subject to repayment were significantly increased recently by Congress. But income fluctuations pose a particular challenge for individuals and families who cross the Medicaid-exchange divide, because this change may trigger a shift between plans and provider networks. In short, for this group, income fluctuation carries both financial and health care consequences.

Our multivariate analyses show that income fluctuations were common even among adults initially with incomes below the poverty level. This is particularly troubling because many of these people will often have incomes low enough to exempt them from the federal insurance mandate, which means that fatigue with frequent coverage changes may lead them to simply stop signing up for insurance over time. This is a problem on two fronts. First, it is uninsured low-income adults who have the most to gain from health reform. Second, this group includes millions of healthy adults whose participation in the exchanges is crucial to robust risk pools. We found that income changes were more common among adults who were younger, more educated, and white—characteristics that correlate with a lower burden of illness. Indeed, these results are consistent with previous findings on changes in Medicaid coverage among adults.

http://content.healthaffairs.org/content/30/2/228.abstract

Comment: 

By Don McCanne, MD

We have previously made the point that fluctuations in eligibility for Medicaid and for the income-related subsidies in the exchange plans create instability in coverage. Impaired outcomes occur because of gaps in coverage, and disruptions in provider networks. This new study puts a number on the degree of instability. Within one year, over 50 percent of adults with a family income under 200 percent of the federal poverty level (FPL) will experience a shift in eligibility from Medicaid to an insurance exchange, or vice versa.

The article discusses some of the implications of this, including problems with shifting eligibility levels for exchange subsidies for those with incomes over 200 percent of the FPL. Though eligible for one program or another, many individuals will have incomes that exempt them from the mandate to purchase insurance, and, assuredly, the healthier ones who are needed to round out the risk pools will go without coverage as a result of fatigue over multiple ejections by one program or another.

The authors offer policy options that might reduce this instability in coverage, but these options can never eliminate it. Our fragmented financing system of various private and public programs will never ensure that everyone is covered at all times, and it will continue to waste funds on administrative excesses such as trying to keep up with eligibility shifts due to income fluctuations.

A policy option that would work, not mentioned by the authors, would be to dump our dysfunctional multi-payer system and enact an improved Medicare that includes everyone. The problem of fluctuating incomes is greatly simplified because it impacts only the contribution through the tax system, without moving the individual in or out of Medicare.

Half of

Issues In Health Reform: How Changes In Eligibility May Move Millions Back And Forth Between Medicaid And Insurance Exchanges

By Benjamin D. Sommers and Sara Rosenbaum
Health Affairs
February 2011

The Affordable Care Act will extend health insurance coverage by both expanding Medicaid eligibility and offering premium subsidies for the purchase of private health insurance through state health insurance exchanges. But by definition, eligibility for these programs is sensitive to income and can change over time with fluctuating income and changes in family composition. The law specifies no minimum enrollment period, and subsidy levels will also change as income rises and falls. Using national survey data, we estimate that within six months, more than 35 percent of all adults with family incomes below 200 percent of the federal poverty level will experience a shift in eligibility from Medicaid to an insurance exchange, or the reverse; within a year, 50 percent, or 28 million, will.

Income fluctuation raises issues for all subsidy-eligible individuals or families up to 400 percent of the federal poverty level, which includes those whose incomes place them squarely within the exchange system. For those purchasing coverage with subsidies through exchanges, income changes may trigger the obligation to repay some or all subsidies received; the amounts subject to repayment were significantly increased recently by Congress. But income fluctuations pose a particular challenge for individuals and families who cross the Medicaid-exchange divide, because this change may trigger a shift between plans and provider networks. In short, for this group, income fluctuation carries both financial and health care consequences.

Our multivariate analyses show that income fluctuations were common even among adults initially with incomes below the poverty level. This is particularly troubling because many of these people will often have incomes low enough to exempt them from the federal insurance mandate, which means that fatigue with frequent coverage changes may lead them to simply stop signing up for insurance over time. This is a problem on two fronts. First, it is uninsured low-income adults who have the most to gain from health reform. Second, this group includes millions of healthy adults whose participation in the exchanges is crucial to robust risk pools. We found that income changes were more common among adults who were younger, more educated, and white—characteristics that correlate with a lower burden of illness. Indeed, these results are consistent with previous findings on changes in Medicaid coverage among adults.

http://content.healthaffairs.org/content/30/2/228.abstract

We have previously made the point that fluctuations in eligibility for Medicaid and for the income-related subsidies in the exchange plans create instability in coverage. Impaired outcomes occur because of gaps in coverage, and disruptions in provider networks. This new study puts a number on the degree of instability. Within one year, over 50 percent of adults with a family income under 200 percent of the federal poverty level (FPL) will experience a shift in eligibility from Medicaid to an insurance exchange, or vice versa.

The article discusses some of the implications of this, including problems with shifting eligibility levels for exchange subsidies for those with incomes over 200 percent of the FPL. Though eligible for one program or another, many individuals will have incomes that exempt them from the mandate to purchase insurance, and, assuredly, the healthier ones who are needed to round out the risk pools will go without coverage as a result of fatigue over multiple ejections by one program or another.

The authors offer policy options that might reduce this instability in coverage, but these options can never eliminate it. Our fragmented financing system of various private and public programs will never ensure that everyone is covered at all times, and it will continue to waste funds on administrative excesses such as trying to keep up with eligibility shifts due to income fluctuations.

A policy option that would work, not mentioned by the authors, would be to dump our dysfunctional multi-payer system and enact an improved Medicare that includes everyone. The problem of fluctuating incomes is greatly simplified because it impacts only the contribution through the tax system, without moving the individual in or out of Medicare.

Will ACOs be used to further privatize Medicare?

Berwick Indicates CMS Still Plans To Mix Private Payers, Medicare In ACO Demo

By John Wilkerson
Inside Health Reform
February 3, 2011

CMS Administrator Donald Berwick indicated on Feb. 1 that CMS still plans to use a demonstration to let accountable care organizations include Medicare beneficiaries and patients with private insurance. Specifically, he said the CMS innovation center will make room for the “vanguards” of accountable care organizations so CMS can test ACO models that go beyond what is called for under the ACO program.

Sources say CMS had been planning to announce a demonstration program late last year to assign Medicare and possibly Medicaid beneficiaries to existing clinically integrated entities in the private insurance market. That announcement was delayed, they said, leaving them to wonder whether CMS had backed off the plan – but Berwick seemed to say at a Brookings Institution conference that the plan is still in the works.

CMS is talking to private payers about public-private partnerships and about how clinically integrated organizations can align what they are doing for patients with private insurance with the goals of ACOs, Berwick told reporters after his presentation. (The Federal Trade Commission has warned that broad-based ACOs involving private payers could raise antitrust concerns, but the FTC has been working out those matters with CMS.)

Berwick said the proposed rule on the ACO program should be published soon, but when asked by Inside Health Policy whether a demonstration would be announced before the proposed rule, Berwick said only that the innovation center would move “quickly” on ACO demonstrations. The health reform law created an ACO program, which is permanent and separate from the temporary demonstrations that the innovation center approves. However, CMS could approve ACO demonstrations that would later be wrapped into the ACO program, sources say.

http://www.ahiphiwire.org/FocusMed/News/Default.aspx?doc_id=749955

Brookings Institution Conference: ACHIEVING BETTER CARE AT LOWER COSTS
THROUGH ACCOUNTABLE CARE ORGANIZATIONS (transcript – 110 pages):
http://www.brookings.edu/~/media/Files/events/2011/0201_accountable_care/20110201_accountable_care.pdf

Comment: 

By Don McCanne, MD

This Brookings Institute conference on accountable care organizations (ACOs) provides important insights as to what we might be facing. These experts, including Donald Berwick, Elliott Fisher and Mark McClellan, provide abstractions as to policies that might achieve the quality and cost-containment goals of the ACOs that are mandated by the Patient Protection and Affordable Care Act (PPACA).

The Medicare Shared Savings Program will begin on January 1, 2012, less than one year from now. At that time, “groups of providers of services and suppliers meeting criteria specified by the Secretary may work together to manage and coordinate care for Medicare fee-for-service beneficiaries through an accountable care organization” (PPACA). Details as to the requirements can be found in Sec. 3022 and Sec. 10307 of PPACA.

If you read the transcript of the Brookings presentations of the experts and the panel discussions following, you should be concerned – very concerned. Within months, these somewhat nebulous abstractions are to be transformed into real life organizations of health professionals and facilities that supposedly will deliver higher quality care at a lower cost, while splitting the savings with the government.

Obviously, these ACOs will not spring up de novo; there isn’t enough time. We already know that the early demonstration projects are using existing entities that can best be categorized as managed care organizations. According to the report from Inside Health Reform, “CMS is talking to private payers about public-private partnerships and about how clinically integrated organizations can align what they are doing for patients with private insurance with the goals of ACOs, Berwick told reporters after his presentation.”

As recorded in the transcript of the Brookings conference, CMS Administrator Donald Berwick stated, “Now, I’m in a little bit of an awkward moment, aren’t I? The Notice of Proposed Rulemaking isn’t out yet. It will be out very soon, but I can’t tell you what’s in it yet because I guess I’m not supposed to, but you’ll see it soon. And then there’ll be a comment period, which I hope you’ll all take seriously.”

Be ready. When the Notice of Proposed Rulemaking is released for public comment, peruse it to determine if Medicare is going to be turned over to private insurer/managed care organizations in the name of higher quality and lower costs through accountable care organizations. We need to find out if this is merely new rhetoric that will mask the further privatization of Medicare, intended or not. If so, we cannot let it stand.

Beyond the flawed Obama health care reform

The time is always right to do what's right': Dr. King and health reform

The following remarks were delivered by Dr. Claudia Fegan, past president of Physicians for a National Health Program, to the Louisville (Ky.) Urban League on Jan. 15. 2011

By Claudia Fegan, M.D.

It is indeed an honor and a privilege for me to stand here today celebrating the life and work of Dr. Martin Luther King Jr.

Dr. Garrett Adams, who gave me such a kind introduction, recently learned that my father was the photographer who took the picture of Emmett Till’s body the night his mother requested the casket be opened so that the public could see what they had done to her baby. That photo became an icon of the civil rights movement.

I was only 7 years old the day my daddy stood behind Dr. King’s right shoulder and photographed the crowd that stood before him on the Washington Mall as he gave his “I Have a Dream” speech. My father, a steelworker, was also a documentary photographer. I brought one of his photographs of Dr. King at that historic rally with me today.

We learned much from Dr. King, even though he was taken from us too soon. He taught us that “the time is always right to do what’s right.”

As we stand here today, there are 50 million Americans who are uninsured. African Americans are represented disproportionately among the uninsured. I am referring to the fact that while we represent only 12 percent of the population, we are 20 percent of the uninsured. This is our issue.

As a result of not having insurance, we have decreased access to the preventive services that would allow us to live longer, healthier, richer lives. We pay a tremendous price for this.

Our infant mortality rate is about 2.5 times that of whites, our rates of death from heart disease and cancer are 1.5 times that of whites, our rate of death from diabetes is almost 2.5 times that of whites and our rate of death from HIV is 5 times that of whites. African American patients on dialysis are less likely to be referred for evaluation for kidney transplant and therefore, not surprisingly, we are far less likely to get a kidney transplant. This is our issue.

The Institute of Medicine in its 2004 study on “The Consequences of Uninsurance” estimated over 18,000 people a year die as a result of not having access to health insurance:

* Uninsured adults receive fewer and less timely preventive and screening services
* Uninsured cancer patients die sooner due to delayed diagnosis
* The uninsured receive less chronic illness care, poorer hospital care and are more likely to die in the hospital.
* The risk of premature death among uninsured Americans is 25 percent higher than among Americans with health insurance.

This is our reality, the reality of health care for African Americans in this country. We will never get more until we demand more. This is our issue.

Physicians for a National Health Program, PNHP, is an organization of 18,000 physicians. Since 1986 we have been trying to convince physicians, patients and politicians that if we tossed out the private insurance industry and made the government the single payer for health care in this country, we could provide coverage for everyone with same money we are using now to cover only two-thirds of the country poorly.

I have a patient who is 63 years old. Ms. Lenoir has worked all her life, she is active in her church, she cares for her elderly mother and together she and her husband have raised their children to be self-sufficient members of society. Ms. Lenoir does not have health insurance because her employer has never provided that benefit.

The problem is Ms. Lenoir needs a new hip. After more than 20 years of arthritis in her hip, the joint is destroyed. She has bone grinding on bone. No amount of anti-inflammatory medication will relieve her pain. I had to plead with her to consider taking a narcotic to relieve her pain so that maybe she could get a good night’s sleep.

I sent Ms. Lenoir to a pain specialist who injected the joint to provide her with temporary relief and who then called me and said, “This woman needs a new hip.” I told her, I know that, but have you got one you can give her? No one will pay for a hip for her until she turns 65 and Medicare will provide her with coverage.

I wish you could look into this woman’s eyes each time she comes to see me and feel her pain. Will the legislation passed last year provide her with a new hip before she turns 65 in 2013? No probably not. This is our issue.

In the book “The Heart of Power,” David Blumenthal chronicles the efforts of presidents from Franklin Roosevelt through George W. Bush to achieve access to health care for the American public. “Major health reform is virtually impossible: difficult to understand, swarming with interests, powered by money, and resonating with popular anxiety,” he writes.

The congressional veteran and co-chair of the 9/11 Commission, Lee Hamilton, said, “Health care is so difficult because Congress is an incremental body and health care is a non-incremental issue.”

What Barack Obama did with the passage of the Patient Protection and Affordable Care Act (ACA) was nothing short of miraculous, but it was not enough and it will not solve our problems.

Going forward there will not be a fair, open or honest discourse about this legislation. It is a fact that ACA will do nothing to control costs. That is the major flaw of the legislation.

Why are we still talking about single payer? Because single payer will address the issues of cost, access and quality.

Dr. King taught us being right is not enough. We have to win the hearts of the American public.

We didn’t lose the war to gain access to health care for all Americans. We got battered in an ugly skirmish, but we’re not done.

It is time to change our tactics. The opportunity for change is still ahead of us. More recent studies have taught us that actually 45,000 people die each year as a result of not having health insurance which means 180,000 more people will die before implementation of the majority of the ACA legislation. If everything goes exactly as planned, there will still be at least 23 million uninsured once all the changes have taken effect. This is our issue.

Camille Rucks was a security guard for a small company on the South Side of Chicago. In the spring of 2008 she developed breast cancer. She received outstanding care at the University of Chicago and did well. However, in November 2008, which we now know was the beginning of the recession, when her company began to struggle, she was laid off. She thought she was targeted because she had been out sick so much when she was receiving chemo, but it doesn’t matter.

In January 2009, when she had some blood-streaked sputum, her primary care physician (PCP) ordered a chest X-ray that showed a spot that raised the question of maybe her cancer had returned. Her oncologist told her she couldn’t see her because she was no longer insured. Her surgeon never returned her phone calls.

Her PCP called me because she was not able to get the necessary tests done for Camille because she was no longer insured. I told her PCP to have Camille come see me the next day.

I said, sure, of course, this is what we do; we’re the County Hospital. In less than a week she had a CT of her chest, and within two weeks she had been seen by pulmonary and oncology. She did have metastatic cancer and we took care of her. I wish I could tell you this story had a happy ending, but it doesn’t. Camille died last year, but she told me she had no regrets. We treated her with dignity and respect.

My question is this: Who doesn’t deserve dignity and respect? Why should you have to pass a wallet biopsy before a health care provider determines she can talk to you, order a test, figure out what is wrong or
decide how to treat you? This is our issue.

The Affordable Care Act has not made health care a right. Access to care is a profit center controlled by the insurance industry. We pay them to limit access to care. We spend more per capita on health care than any country in the world — more than $8,000 per person — and yet we are ranked only 36th in the world by the World Health Organization for the care we provide.

Under the ACA, everyone will be required to carry or purchase private insurance. For those who can’t afford it, we’re requiring states to either cover them under Medicaid or to provide supplements so they can purchase private insurance. This is an industry that has a history of profiteering by retroactively denying coverage to people with illnesses. So now we’re requiring everyone to buy coverage, and yes, we have told the insurance companies they can’t deny coverage to those with illnesses.

My question is why can’t we just pay for the care without having to go through the insurance industry? They are not to be trusted. Ask the state of Massachusetts how it has worked out for them with mandating insurance coverage and paying for those who can’t afford it. The cost of premiums has gone up so high so fast in the first year the governor met with the major companies to request they hold off on their premium increases because the costs had exceeded three times the original projections. The state now teeters on insolvency. This is our issue.

We spend enough money on health care in this country. We just let too many people who aren’t involved in providing care take profit from it.

This is about justice. Health care should be a right to which everyone is entitled. Remember we live in the wealthiest country in the world. We spend more on health care than any other country. It is time we got our money’s worth. It is time we got the health care we deserve, not the care the insurance industry is willing to let us have. It is time we made health care a right and not a privilege.

We have to speak up. We have to speak loudly. We have to make our voices heard.

The Affordable Care Act is an opportunity: It is not going to work!

We have to remind the people — there is still a simpler, easier solution. People want to know, they have questions. They will ask, is this the answer? Will this work? Will this solve the problem?

Multinational Big Pharma charges the American public the highest pharmaceutical prices in the world, while it sells the very same drugs all over the world at prices one-half, one-third or even one-tenth of the price they charge in the United States. They do this because in the rest of the industrialized world, there is legislation that limits profits for medications, while the U.S. allows these companies to charge whatever the market will bear. The Affordable Care Act does not address this issue. This is our issue.

Dr. King said, “When people get caught up with that which is right and they are willing to sacrifice for it, there is no stopping point short of victory.” The Affordable Care Act was /not/ victory. We now have a House of Representatives that thinks the American public will be appeased by political theater instead of substance. They had planned to spent time reading the Constitution omitting the parts about Blacks being only three-fifths of a person, or the prohibition of alcohol; revisionist history at best, trying not to acknowledge the Constitution has been changed repeatedly throughout history.

They had planned to spend time voting to repeal the law when they knew it was an empty gesture. The shootings in Arizona at least gave them pause for that.

What the American public wants is not so different from what African Americans want and deserve. We want guaranteed access to care, freedom of choice of provider, quality health care and two words you don’t hear in association with health care very much anymore: trust and respect.

We know it can be done because every other industrialized country in the world has figured how to do this. Most of them spend less than half what we do and they have better outcomes with more satisfaction.

It is not so complicated what we want: we want a health care system that takes everybody in and leaves nobody out. It is only the phony solutions they are attempting to confuse us with, that are complicated, just so we don’t notice they fail to expand coverage to those who need it and deserve it. That’s why this will be the civil rights struggle of the 21st century, and /this is our issue.

I understand people are reluctant to criticize the ACA because our president is under assault from the right and he needs our support. I think Dr. King would tell us it is important to tell the truth. “The time is always right to do what’s right.”

When I think about this struggle I think about a poem my father taught me as a child. It was written by Langston Hughes and is called “Mother to Son.”

*Mother to Son*

Well, son, I’ll tell you:
Life for me ain’t been no crystal stair.
It’s had tacks in it,
And splinters,
And boards torn up,
And places with no carpet on the floor —
Bare.
But all the time
I’se been a-climbin’ on,
And reachin’ landin’s,
And turnin’ corners,
And sometimes goin’ in the dark
Where there ain’t been no light.
So, boy, don’t you turn back.
Don’t you set down on the steps.
‘Cause you finds it’s kinder hard.
Don’t you fall now  —
For I’se still goin’, honey,
I’se still climbin’,
And life for me ain’t been no crystal stair.

The issue of guaranteeing access to care for everyone is an issue of social justice. Battles for social justice are never over, because there will always be reactionary forces waiting in the wings to turn back the clock. There are no easy solutions. We have to be willing to fight for what we believe in and keep fighting.

The night before he was assassinated Martin Luther King said: “Let us stand with greater determination. And let us move in these powerful days, these days of challenge to make America what it ought to be. We have an opportunity to make America a better nation.”

I hope you will join me in saying what we expect from any health care program any politician will offer us:

Everybody in, Nobody out!
Everybody in, Nobody out!
Everybody in, Nobody out!

Thank you.

http://www.spiritualprogressives.org/article.php/2011020212215961

Will ACOs be used to further privatize Medicare?

Berwick Indicates CMS Still Plans To Mix Private Payers, Medicare In ACO Demo

By John Wilkerson
Inside Health Reform
February 3, 2011

CMS Administrator Donald Berwick indicated on Feb. 1 that CMS still plans to use a demonstration to let accountable care organizations include Medicare beneficiaries and patients with private insurance. Specifically, he said the CMS innovation center will make room for the “vanguards” of accountable care organizations so CMS can test ACO models that go beyond what is called for under the ACO program.

Sources say CMS had been planning to announce a demonstration program late last year to assign Medicare and possibly Medicaid beneficiaries to existing clinically integrated entities in the private insurance market. That announcement was delayed, they said, leaving them to wonder whether CMS had backed off the plan – but Berwick seemed to say at a Brookings Institution conference that the plan is still in the works.

CMS is talking to private payers about public-private partnerships and about how clinically integrated organizations can align what they are doing for patients with private insurance with the goals of ACOs, Berwick told reporters after his presentation. (The Federal Trade Commission has warned that broad-based ACOs involving private payers could raise antitrust concerns, but the FTC has been working out those matters with CMS.)

Berwick said the proposed rule on the ACO program should be published soon, but when asked by Inside Health Policy whether a demonstration would be announced before the proposed rule, Berwick said only that the innovation center would move “quickly” on ACO demonstrations. The health reform law created an ACO program, which is permanent and separate from the temporary demonstrations that the innovation center approves. However, CMS could approve ACO demonstrations that would later be wrapped into the ACO program, sources say.

http://www.ahiphiwire.org/FocusMed/News/Default.aspx?doc_id=749955

Brookings Institution Conference: ACHIEVING BETTER CARE AT LOWER COSTS
THROUGH ACCOUNTABLE CARE ORGANIZATIONS (transcript – 110 pages):
http://www.brookings.edu/~/media/Files/events/2011/0201_accountable_care/20110201_accountable_care.pdf

This Brookings Institute conference on accountable care organizations (ACOs) provides important insights as to what we might be facing. These experts, including Donald Berwick, Elliott Fisher and Mark McClellan, provide abstractions as to policies that might achieve the quality and cost-containment goals of the ACOs that are mandated by the Patient Protection and Affordable Care Act (PPACA).

The Medicare Shared Savings Program will begin on January 1, 2012, less than one year from now. At that time, “groups of providers of services and suppliers meeting criteria specified by the Secretary may work together to manage and coordinate care for Medicare fee-for-service beneficiaries through an accountable care organization” (PPACA). Details as to the requirements can be found in Sec. 3022 and Sec. 10307 of PPACA.

If you read the transcript of the Brookings presentations of the experts and the panel discussions following, you should be concerned – very concerned. Within months, these somewhat nebulous abstractions are to be transformed into real life organizations of health professionals and facilities that supposedly will deliver higher quality care at a lower cost, while splitting the savings with the government.

Obviously, these ACOs will not spring up de novo; there isn’t enough time. We already know that the early demonstration projects are using existing entities that can best be categorized as managed care organizations. According to the report from Inside Health Reform, “CMS is talking to private payers about public-private partnerships and about how clinically integrated organizations can align what they are doing for patients with private insurance with the goals of ACOs, Berwick told reporters after his presentation.”

As recorded in the transcript of the Brookings conference, CMS Administrator Donald Berwick stated, “Now, I’m in a little bit of an awkward moment, aren’t I? The Notice of Proposed Rulemaking isn’t out yet. It will be out very soon, but I can’t tell you what’s in it yet because I guess I’m not supposed to, but you’ll see it soon. And then there’ll be a comment period, which I hope you’ll all take seriously.”

Be ready. When the Notice of Proposed Rulemaking is released for public comment, peruse it to determine if Medicare is going to be turned over to private insurer/managed care organizations in the name of higher quality and lower costs through accountable care organizations. We need to find out if this is merely new rhetoric that will mask the further privatization of Medicare, intended or not. If so, we cannot let it stand.

Senate Judiciary testimony of Prof. Charles Fried on single payer

Hearing on the Constitutionality of the Affordable Care Act

Senate Judiciary Committee
February 2, 2011

Testimony of Charles Fried, Beneficial Professor of Law, Harvard Law School, and Former U.S. Solicitor General, Reagan Administration, 1985-1989

As I recall, the great debate in the Senate was between this device (the individual mandate) and something called the government option. And the government option was described as being something akin to socialism, and I think there’s a bit of a point to that. But what is striking, Senator, is that I don’t think anybody in the world could argue that the government option, or indeed a single payer federal alternative, would have been unconstitutional. It would have been deplorable. It would have been regrettable. It would have been Western if not Eastern European, but it would not have been unconstitutional. And it’s odd that this (the individual mandate), which is an attempt to keep it in the private market, is now being attacked.

(96 minutes into the video)
http://judiciary.senate.gov/hearings/hearing.cfm?id=4964

Comment: 

By Don McCanne, MD

Harvard Professor Charles Fried may not like single payer, but he emphatically agrees that single payer is constitutional. This is something we can do if the people of this nation demonstrate their desire to have it.

Senate Judiciary testimony of Prof. Charles Fried on single payer

Hearing on the Constitutionality of the Affordable Care Act

Senate Judiciary Committee
February 2, 2011

Testimony of Charles Fried, Beneficial Professor of Law, Harvard Law School, and Former U.S. Solicitor General, Reagan Administration, 1985-1989

As I recall, the great debate in the Senate was between this device (the individual mandate) and something called the government option. And the government option was described as being something akin to socialism, and I think there’s a bit of a point to that. But what is striking, Senator, is that I don’t think anybody in the world could argue that the government option, or indeed a single payer federal alternative, would have been unconstitutional. It would have been deplorable. It would have been regrettable. It would have been Western if not Eastern European, but it would not have been unconstitutional. And it’s odd that this (the individual mandate), which is an attempt to keep it in the private market, is now being attacked.

(96 minutes into the video)
http://judiciary.senate.gov/hearings/hearing.cfm?id=4964

Harvard Professor Charles Fried may not like single payer, but he emphatically agrees that single payer is constitutional. This is something we can do if the people of this nation demonstrate their desire to have it.

Newsflash: Founders favored "government run health care"

By Greg Sargent
The Washington Post, Jan. 20, 2011

Forbes writer Rick Ungar is getting some attention for a piece arguing that history shows that John Adams supported a strong Federal role in health care. Ungar argues that Adams even championed an early measure utilizing the concept behind the individual mandate, which Tea Partyers say is unconstitutional.

I just ran this theory past a professor of history who specializes in the early republic, and he said there’s actually something to it. Short version: There’s no proof from the historical record that Adams would have backed the idea behind the individual mandate in particular. But it is fair to conclude, the professor says, that the founding generation supported the basic idea of government run health care, and the use of mandatory taxation to pay for it.

Here’s the background. Ungar points out that in July of 1798, Congress passed “An Act for the Relief of Sick and Disabled Seaman,” which was signed by President Adams. That law authorized the creation of a government operated system of marine hospitals and mandated that laboring merchant marine sailors pay a tax to support it.

Ungar argues that this blows away the argument made by many opponents of the individual mandate: That it’s unconstitutional to mandate that all citizens purchase health coverage, or that this violates the founding fathers’ view of the proper role of government.

Is this true? In some ways it is, according to Adam Rothman, an associated professor of history at Georgetown University. He argues that it’s a “bit of a leap” to compare the 1798 act directly to the individual mandate, because the act taxed sailors to pay for their health care, rather than “requiring that sailors purchase it.”

But Rothman says that it’s perfectly legit to see shades of today’s debate in that early initiative.

“It’s a good example that the post-revolutionary generation clearly thought that the national government had a role in subsidizing health care,” Rothman says. “That in itself is pretty remarkable and a strong refutation of the basic principles that some Tea Party types offer.”

“You could argue that it’s precedent for government run health care,” Rothman continues. “This defies a lot of stereotypes about limited government in the early republic.”

Also: Some have argued that the individual mandate is, in effect a tax, but one that cuts out the Federal government as middleman. In this reading, everyone will eventually participate in the health system anyway, and the mandate means the Federal government is merely directing people to buy insurance, rather than collecting a tax and using that money to purchase that same insurance for them.

We will never know whether the founding generation would have agreed with this concept or not. They didn’t agree on much even among themselves. But in Rothman’s view, they are already on record supporting government run health care, financed by mandatory taxation. So there!

http://voices.washingtonpost.com/plum-line/2011/01/founding_fathers_favored_gover.html

Anthem intercepting and redirecting imaging referrals

Need an MRI? Anthem might have a deal for you

By Shari Rudavsky
IndyStar.com
January 30, 2011

… an Anthem Blue Cross and Blue Shield pilot program made its debut in December. Under the program, an Anthem employee calls policyholders who have been approved for scans and lets them know whether a cheaper, high-quality option exists close to them. If the policyholder agrees, Anthem sets up the appointment.

Anthem officials say they designed the program to steer their patients toward higher-quality facilities that charge less. But some say more emphasis is being placed on costs and not on quality of care and consequences for the patient.

The program is currently limited to Central Indiana policyholders scheduled for imaging such as MRI and CT scans. Still, it could usher in a major change in health care in which insurers work directly with policyholders to keep costs low for a variety of medical services.

“This puts a lot more control in the hands of the individual consumer and allows the consumer to make a decision that is a good one,” said Susan Pisano, a spokeswoman for the Association of Health Insurance Plans. “I think you’re going to see this kind of program more and more in the short term.”

If the program proves successful, the company might explore the idea of similar programs for lab tests or colonoscopies.

http://www.indystar.com/article/20110131/BUSINESS/101310327

Comment: 

By Don McCanne, MD

WellPoint’s Anthem Blue Cross and Blue Shield subsidiaries have led the health insurance industry in innovation, but these innovations have been designed to improve their business model and profits, not to improve health care. Even though regulatory oversight of the insurers should increase as a result of enactment of the Patient Protection and Affordable Care Act, this new innovation of intercepting and redirecting patient referrals reveals that the private, for-profit insurance industry has every intention expanding the range of self-serving innovations that increase profits as long as the innovations fall below the threshold that would induce a patient backlash.

There are a great many reasons why a physician may select one imaging center over another for the patient’s procedure. The decision may be based on the quality of the equipment or the skills of the radiologist’s team. It may be based on prior positive or negative experiences with the centers. It may be based on integrated eHealth systems. It may be based on specific procedures not utilized in all centers. Regardless, these are clinical decisions that should be made by physicians who have their patients’ health care needs first and foremost in their minds.

(Physicians also may selectively refer to their own imaging centers – a conflict of interest that is another problem, though not covered in today’s message.)

When the insurer intercepts and redirects a referral, it is done to reduce the insurer’s costs. The insurer may claim that the intervention is to direct the patient to higher quality services, but the referring physician should be in a much better position to make that judgement. No, the decision is made on the basis of, “It’s the prices, stupid.”

The problem that the insurers are addressing is very real. Prices do vary tremendously, especially between facilities that are contracted with the insurer and those that are not. This raises the extremely important point that a health care financing system based on multiple private insurers acting independently cannot possibly bring us appropriate, reasonable pricing throughout the entire health care delivery system.

Of course, this is one of the more important advantages of a single payer system. Prices are not based on secret contracts and dysfunctional markets; instead they are based on negotiation with a public administrator, taking into consideration legitimate costs and fair profits. The interests of patients are served by preventing excessively high prices that waste taxpayer funds while providing adequate payment to ensure that the health care professions will remain attractive to well qualified individuals. The private insurance industry will never get this right.

Single-payer system would save money and lives

By Richard Weiskopf, M.D.
Letters, The Post-Standard (Syracuse, N.Y.), Jan. 23, 2011
 
With all the discussion about health care reform, including Rep. Ann Marie Buerkle’s (R-N.Y.) advocating repeal, I would like to cite three points researched and published (but not publicized enough) by Physicians for a National Health Program, which continues to advocate for national single-payer reform, and of which I am a member.
 
1. Administrative costs consume 31 percent of U.S. health spending, most of it unnecessary. The United States could save enough on administrative expenses (nearly $400 billion annually) with a single-payer system to cover all the uninsured.
 
2. Medical bills contribute to more than 60 percent of all bankruptcies. Three-fourths of those bankrupted had health insurance at the time they got sick.
 
3. Nearly 45,000 Americans die each year from lack of health insurance. The uninsured do not receive all the medical care they need – the live sicker and die younger. Those most in need of preventive services are least likely to receive them.

Anthem intercepting and redirecting imaging referrals

Need an MRI? Anthem might have a deal for you

By Shari Rudavsky
IndyStar.com
January 30, 2011

… an Anthem Blue Cross and Blue Shield pilot program made its debut in December. Under the program, an Anthem employee calls policyholders who have been approved for scans and lets them know whether a cheaper, high-quality option exists close to them. If the policyholder agrees, Anthem sets up the appointment.

Anthem officials say they designed the program to steer their patients toward higher-quality facilities that charge less. But some say more emphasis is being placed on costs and not on quality of care and consequences for the patient.

The program is currently limited to Central Indiana policyholders scheduled for imaging such as MRI and CT scans. Still, it could usher in a major change in health care in which insurers work directly with policyholders to keep costs low for a variety of medical services.

“This puts a lot more control in the hands of the individual consumer and allows the consumer to make a decision that is a good one,” said Susan Pisano, a spokeswoman for the Association of Health Insurance Plans. “I think you’re going to see this kind of program more and more in the short term.”

If the program proves successful, the company might explore the idea of similar programs for lab tests or colonoscopies.

http://www.indystar.com/article/20110131/BUSINESS/101310327

WellPoint’s Anthem Blue Cross and Blue Shield subsidiaries have led the health insurance industry in innovation, but these innovations have been designed to improve their business model and profits, not to improve health care. Even though regulatory oversight of the insurers should increase as a result of enactment of the Patient Protection and Affordable Care Act, this new innovation of intercepting and redirecting patient referrals reveals that the private, for-profit insurance industry has every intention expanding the range of self-serving innovations that increase profits as long as the innovations fall below the threshold that would induce a patient backlash.

There are a great many reasons why a physician may select one imaging center over another for the patient’s procedure. The decision may be based on the quality of the equipment or the skills of the radiologist’s team. It may be based on prior positive or negative experiences with the centers. It may be based on integrated eHealth systems. It may be based on specific procedures not utilized in all centers. Regardless, these are clinical decisions that should be made by physicians who have their patients’ health care needs first and foremost in their minds.

(Physicians also may selectively refer to their own imaging centers – a conflict of interest that is another problem, though not covered in today’s message.)

When the insurer intercepts and redirects a referral, it is done to reduce the insurer’s costs. The insurer may claim that the intervention is to direct the patient to higher quality services, but the referring physician should be in a much better position to make that judgement. No, the decision is made on the basis of, “It’s the prices, stupid.”

The problem that the insurers are addressing is very real. Prices do vary tremendously, especially between facilities that are contracted with the insurer and those that are not. This raises the extremely important point that a health care financing system based on multiple private insurers acting independently cannot possibly bring us appropriate, reasonable pricing throughout the entire health care delivery system.

Of course, this is one of the more important advantages of a single payer system. Prices are not based on secret contracts and dysfunctional markets; instead they are based on negotiation with a public administrator, taking into consideration legitimate costs and fair profits. The interests of patients are served by preventing excessively high prices that waste taxpayer funds while providing adequate payment to ensure that the health care professions will remain attractive to well qualified individuals. The private insurance industry will never get this right.