PNHP

Why don’t Americans live longer?

Why don’t Americans live longer?

Why Don’t Americans Live Longer?

By David Leonhardt
The New York Times
January 25, 2011

The National Academy of Sciences has just released a fascinating report on life expectancy in rich countries around the world. The researchers who wrote the report — public-health experts, demographers, economists and others, from around the world — have tried to figure out why Americans don’t live as long as people in many other countries.

From a summary of the report:

“Over the last 25 years, life expectancy at age 50 in the U.S. has been rising, but at a slower pace than in many other high-income countries, such as Japan and Australia. This difference is particularly notable given that the U.S. spends more on health care than any other nation….

“Three to five decades ago, smoking was much more widespread in the U.S. than in Europe or Japan, and the health consequences are still playing out in today’s mortality rates, the report says. Smoking appears to be responsible for a good deal of the differences in life expectancy, especially for women….

“Obesity’s contribution to lagging life expectancies in the U.S. also appears to be significant, the report says. While there is still uncertainty in the literature about the magnitude of the relationship between obesity and mortality, it may account for a fifth to a third of the shortfall in longevity in the U.S. compared to other nations, the report says….

“Lack of universal access to health care in the U.S. also has increased mortality and reduced life expectancy, the report says, though this is a less significant factor for those over age 65 because of Medicare access….”

And from the report itself:

“With respect to income inequality, it is widely believed that such inequalities are higher in the United States than in other high-income countries, in part because the United States does less to redistribute wealth among its citizens…. Poverty rates also appear to be higher in the United States than in most of the other countries….

“This combination of factors could result in higher mortality rates among people in the lower socioeconomic brackets in the United States than in other countries, pulling down U.S. life expectancy levels in general…. In particular, there is a clear pattern among U.S. white males that fits the hypothesis….On the other hand, the pattern for U.S. women is somewhat different: mortality rates are higher than in most Northern and Western European countries among those who are highly educated as well as among the least educated….

“It is difficult to draw a precise conclusion as to the size of the role of inequality in relative levels and trends in U.S. mortality above age 50.”

This country has made a lot of progress against smoking. Obesity remains a major problem, though there are some signs it’s leveling off. And as the report notes, the link between obesity and mortality isn’t yet clear. Inequality’s role also seems unclear.

So beyond reducing smoking further, the single best strategy for extending American lives would appear to be extending universal health-insurance coverage below the age of 65.

http://economix.blogs.nytimes.com/2011/01/25/why-dont-americans-live-longer/

National Research Council of the National Academies:
“Explaining Divergent Levels of Longevity in High-Income Countries”
http://www.nap.edu/catalog.php?record_id=13089

We frequently look at the lower life expectancy in the United States, in comparison to other wealthy nations, as a sign of the relatively poor performance of the U.S. health care system. We conclude that we would benefit if we established a reasonably comprehensive national health program that included everyone. Opponents contend that our system is outstanding and that reform is not necessary; individuals need only to take better care of themselves.

This new report by the National Research Council does not provide all of the answers, but it does provide very useful information. Two detrimental factors in which individuals do play some role are smoking and obesity.

On smoking, there is good news. Our high incidence of deaths from lung cancer and chronic pulmonary disease are related to the very high rates of smoking from a few decades ago. In the recent couple of decades, smoking cessation programs have been very successful, so much so that we can predict a significant increase in life expectancy as the non-smoking generation ages. Score one for those who blame individuals for our higher death rates, but also score ten for those who support the multitude of public health programs that have been so effective in reducing smoking behavior.

Obesity is a more difficult problem. Certainly a sedentary life style and poor eating habits contribute, so individuals can bear some blame, but other complex factors play even more important roles. Genetic factors, which are very important, we have no control over. Computers, televisions, work-at-home arrangements all reduce physical exertion. Community design and transportation have reduced self-propelled locomotion (i.e., walking). The food industry has not been particularly helpful, marketing excesses of nutritionally unbalanced foods, though there are signs that an awareness has set in and that product selection should improve. It’s easy to say that everyone should exercise more and eat less, but it is going to require intensive public policy and public health measures – more intensive than with the smoking cessation programs – to alter the obesity-inducing milieu.

Socioeconomic inequality in the United States certainly plays a role in our shorter life expectancy statistics. Considerable heated debate takes place over whether that is a cause or a symptom of factors leading to premature deaths. That debate is misdirected since socioeconomic inequality is deplorable for far more reasons than just our health outcomes. We do need national policies to raise the lot of those who are falling hopelessly behind. Although there is much to do, we can begin by reversing the income transfer that has been taking place from the productive workforce (hard-earned income) to the very wealthy (largely unearned income). Simple progressive tax policies can ensure that everyone has a living income, without impacting in the least the life styles of the wealthy.

You really need to read the 200 page report to understand what is known and what is not known about why we have lower life expectancies than should be expected for a wealthy nation. Regardless of those who would distract us by blaming personal failure for increased mortality, one conclusion of the report really stands out:

“The lack of universal access to health care in the United States undoubtedly increases mortality and reduces life expectancy. It is a smaller factor above age 65 than at younger ages because of Medicare.”

We know how to fix that.

'How everybody exists' in D.C. doesn’t have to be

By Wendell Potter
The Huffington Post, Jan. 25, 2011

If you want to know how things really get done in Washington — or don’t get done, depending on the desires of America’s corporate executives — all you have to do is read a couple of paragraphs in a Jan. 23 Philadelphia Inquirer story.

Reporter Joe DiStefano quotes a vice president at APCO Worldwide — one of DC’s most powerful and influential PR firms — in response to questions about my book, “Deadly Spin.” Throughout the book I disclose the previously secretive work APCO did for the health insurance industry to manipulate public opinion on health care reform, in part by trying to scare people away from a movie, Michael Moore’s 2007 documentary “Sicko.”

The surprising gem in the Inquirer piece was that APCO VP Bill Pierce essentially agreed with me. He acknowledged that interest-funded pressure groups “are all over the place” in Washington. “That’s how everybody exists here,” Pierce said.

He’s right. That is indeed how the influence peddlers and spinmeisters exist (although a much more accurate word is thrive) in Washington.

Credit Where Credit is Due

Here’s the context. Pierce — an old (and probably now former) friend from my nearly two decades inside the insurance industry — was quoted by DiStefano as saying that I erred when I wrote that APCO set up and operated a fake grassroots front group, Health Care America, to discredit Moore and his movie because insurance company executives were terrified that “Sicko” would convince even more Americans that the government should play a much greater role in the U.S. health care system.

The trend was already going against the industry: In the spring of 2007, a few weeks before Sicko’s U.S. premier, the insurance industry’s pollsters told the executives that for the first time ever, more than half of all Americans were so disillusioned with the way private insurers controlled the health care system that they wanted more government involvement.

My error, according to Pierce, is not in pointing out that APCO was doing the dirty work of the industry through its phony front group — but that I failed to acknowledge the role that other big special interests played in funding Health Care America, as well. (Pierce was listed on the now-defunct group’s press releases as Health Care America’s media contact. If you called the number on the press release for Pierce, you would have reached him at his desk at APCO.)

DiStefano is at least the second reporter to hear Pierce complain that I did the public a disservice by not giving sufficient credit to other big special interests who paid APCO to create and run Health Care America. In November of last year he told PR industry watchdog Jack O’Dwyer the same thing.

In response, I wrote a blog post on Nov. 22 detailing the history and work of the front group. Here’s an excerpt:

O’Dwyer blogged last Tuesday that, ‘Just about every known evil practice that PR has ever engaged in is described in Deadly Spin.’ He noted that I had mentioned APCO — the second biggest firm in the O’Dwyer ranking, with $100.3 million in fees in 2009 — several times in the book. APCO and AHIP must be paying a media monitoring service to alert them immediately when I am mentioned in the media, as they did for Michael Moore and “Sicko” three years ago. Within hours, APCO Senior Vice President William Pierce sent O’Dwyer an email to challenge my credibility because of my failure to disclose Health Care America’s original incarnation. He’s right — partially. I should have pointed out in the book that APCO repurposed Health Care America for the insurance industry and other special interests who were concerned that “Sicko” might lead to reforms that would threaten their profits, too. I would have disclosed it if I had known about it. Unlike PR people who practice the dark arts of PR, I had no intention of misleading anyone.

Textbook Playbook

Had Pierce been more forthcoming, he might have shared with DiStefano the PR plan APCO prepared for America’s Health Insurance Plans (AHIP), the insurance industry’s big lobbying group, to discredit “Sicko” and set the stage for the industry’s campaign to shape health care reform legislation.

Since he didn’t, I will.

Here it is, courtesy of Bill Moyers, who disclosed  portions of the APCO/AHIP plan on the July 10, 2009, edition of Bill Moyers Journal, and posted it on his website. As you can see, the plan shows how APCO planned to use Health Care America and other organizations that APCO could press into service in the industry’s campaign against “Sicko.” If you’ve ever wanted to know how to create a PR plan to discredit an enemy and manipulate public opinion, you should take a look at this one. It’s a classic.

Back to Pierce’s comments to DiStefano. Here’s the full quote:

‘Pharma, hospitals, doctors backed Health Care America, not insurers,’ Pierce said. He doesn’t see why Potter thinks such groups are a threat to democracy: In Washington, interest-funded pressure groups ‘are all over the place,’ and many are backed by liberals. ‘That’s how everybody exists here.’

Pierce and I agree on this last point. Pierce admitted in a few words that one of the core truths of my book is indeed true: the near-total control exerted by corporate special interests over the democratic process in America is simply, and in the most literal way possible, business as usual.

The irony seems to be lost on Pierce, however. What’s the big deal, he asks?

Endangered Democracy

The big deal is that this dynamic threatens the very foundations of our democracy. It puts the interests of corporations, and the institutional shareholders that own them, above the interests of individual citizens — you and me. It concentrates power in the hands of a few “business leaders” rather than in the people who vote and the people those voters elect to represent them. It gives the loudest voice not to those with the best ideas but to those who can afford the most expensive lobbyists.

In the end, the true will of the people — such as the widely popular but still elusive policy of providing universal access to affordable, quality health care, as do the countries featured in “Sicko” — will continue to be thwarted until this is no longer “how everybody exists” in Washington.

http://www.huffingtonpost.com/wendell-potter/how-everybody-exists-does_b_813532.html

John Goodman: "real" insurance means sick pay more

The Case for Health Insurance

By John Goodman
John Goodman’s Health Policy Blog
January 26, 2011

I’m one of the very few health policy wonks you know (maybe the only one) who believes everyone should have access to health insurance the same way they currently have access to life, disability and homeowner’s insurance. In fact, I often refer to my blog as about the only health policy blog on the Internet that believes real health insurance is a legitimate business.

Wait a minute, Goodman. How can you say that? What about the Commonwealth Fund and Families USA? Don’t they believe everyone should have health insurance? What about everyone in Congress who supported ObamaCare? What about the president himself? Aren’t they all promoting the business of health insurance?

The short answer to all those questions is “no.” Real insurance involves a pooling of risks. The insurer must make sure each new entrant to the pool pays a premium that reflects the expected costs that entrant brings to the pool. Otherwise, the insurer won’t be able to pay claims. The business of insurance is the business of pricing and managing risk.

The organizations and people noted above don’t believe that “pricing and managing risk” is a legitimate activity. In fact, they went a long way toward completely outlawing the practice in the health reform bill. The only legitimate purpose of insurance, in their view, is to collect money and pay bills. For public insurance, this means collecting taxes and paying expenses. Their view of acceptable private insurance is to copy government insurance — a sort of private sector socialism.

Okay, Goodman, let’s accept that distinction for the moment. Doesn’t pricing risk mean charging me a premium that reflects my health status? The less healthy I am, the more I have to pay. Why should I want to buy insurance from a company that does that?

Because if your insurer doesn’t do that, a lot of bad things will happen.

Remember the phrase, “You’re in good hands with Allstate”? It was the voiceover at the scene of an auto accident where there has been catastrophic damage. The ad speaks volumes about what happens in real insurance markets. Basically, insurance is unimportant to you until things go very wrong. It’s at that point that you want good service.

Contrast Allstate’s ad with the kind of ads federal employees are subjected to during the fall open season for choosing a health insurance plan. What you never see in Washington are ads saying, “You are in good hands with [Aetna, Cigna, UnitedHealth, etc.] if you get [AIDS, cancer, heart disease, etc.].” Instead, the typical open season ad pictures young families with healthy children and no apparent health problems. The not-so-subtle message is: “You’ll be in good hands with us if you look like the people in these photos.”

Why is the health insurance market so different from auto insurance? Answer: health insurers are not allowed to charge federal employees premiums that reflect their health status.

Since the health overhaul legislation plans to make the federal employee health benefit system the model for health insurance exchanges nationwide, it’s instructive to stop and consider the incentives the health plans in these systems have. As explained in a previous analysis, if insurers have to take all applicants for the same premium, they will obviously try to attract the healthy (on whom they will make profits) and avoid the sick (on whom they will incur losses). After enrollment, their incentive is to overprovide to the healthy (to keep the ones they have and attract more of them) and to underprovide to the sick (to encourage them to leave and discourage enrollment by others just like them). If a TV ad could summarize how this health insurance market works, it would say, “You’re in good hands with us, unless you really need us — then we hope you will go somewhere else.”

And the reason this works is because people really can go somewhere else if they get sick — paying no extra premium.

So the incentives of the healthy employees are: Find plans that have lots of services for healthy people — knowing that if they get sick, they can always enroll in some other plan. The incentives for employees with a serious health problem (or more likely, a family member with a health problem) are to seek out plans that are the best at treating costly illness. But, as in a game of musical chairs, no insurer wants to be chosen.

In such a world, comparative effectiveness research, FDA rulings on drugs, end-of-life counseling and so many other controversial issues of late become very relevant. Insurance companies can’t just dump their sickest patients out on the street. They need cover. They need reasons not to pay for the latest cancer drug or the latest expensive test. Given the slightest encouragement, denial is in their self-interest.

Okay, Goodman. This is all very persuasive. But if my premium reflects my health status, what happens to people who are too poor or too sick to be able to afford those premiums? And what happens if a healthy person gets really sick (high medical costs) and wants to switch insurers?

These are good questions. I will answer them in a future Health Alert.

http://healthblog.ncpa.org/the-case-for-health-insurance/

Comments

By Don, McCanne, MD (Originally published here)

In pooling risk, the decision to assign premiums based on an individual’s risk is purely arbitrary, albeit it is convenient for those marketing the traditional business model of insurance – “real” health insurance, as John Goodman calls it.

The ultimate pooling of risk would be one national pool that includes everyone. Yet average medical costs for a worker’s family of four is now over $18,000 (Milliman), when median household income is $50,000. A middle-income family can no longer afford an equally-allocated premium plus out-of-pocket costs for that risk pool, much less a premium that is adjusted upward for higher risk.

Many of of us who do believe that everyone should have access to health care free of significant financial barriers understand that the traditional concept of “real” insurance no longer works. If individuals with health problems are priced out of risk pools, then how can they possibly pay premiums for the pools that concentrate high-risk individuals? And don’t say that you merely have to set up state-run high-risk pools. Not only have they already been proven to be ineffective in seriously addressing this problem, they would still have to be funded by us anyway, through the tax system. If we moved most high-risk individuals into these pools, that would consume a major portion of our national health expenditures (i.e., much of the 20 percent of people who consume 80 percent of health care).

In fact, think of our largest risk pool – the collective pools of employer-sponsored plans. These are largely composed of the healthy workforce and their young healthy families (the 80 percent of people who use only 20 percent of health care). Yet these low-cost pools that benefit from favorable selection (opposite of adverse selection) are already straining the budgets of employers and their employees. Isn’t it kind of silly to pool together these massive numbers of healthy people, while leaving out most of those with greater needs, and pretend that somehow we have provided the nation with “real” insurance? That serves the insurance industry well, but not the people.

Since average-income individuals can no longer afford their equally-allocated portion of our national health expenditures, funding will have to be progressive, based on income. The least adminis
tratively complex and a less expensive method of doing that would be to establish a single risk pool, and fund it through progressive tax policies.

If our goal is seeing that everyone gets the care they need, then we really do need to discard the antiquated business model of “real insurance” and adopt a single payer system – an improved Medicare that covers everyone.

John Goodman: “real” insurance means sick pay more

The Case for Health Insurance

By John Goodman
John Goodman’s Health Policy Blog
January 26, 2011

I’m one of the very few health policy wonks you know (maybe the only one) who believes everyone should have access to health insurance the same way they currently have access to life, disability and homeowner’s insurance. In fact, I often refer to my blog as about the only health policy blog on the Internet that believes real health insurance is a legitimate business.

Wait a minute, Goodman. How can you say that? What about the Commonwealth Fund and Families USA? Don’t they believe everyone should have health insurance? What about everyone in Congress who supported ObamaCare? What about the president himself? Aren’t they all promoting the business of health insurance?

The short answer to all those questions is “no.” Real insurance involves a pooling of risks. The insurer must make sure each new entrant to the pool pays a premium that reflects the expected costs that entrant brings to the pool. Otherwise, the insurer won’t be able to pay claims. The business of insurance is the business of pricing and managing risk.

The organizations and people noted above don’t believe that “pricing and managing risk” is a legitimate activity. In fact, they went a long way toward completely outlawing the practice in the health reform bill. The only legitimate purpose of insurance, in their view, is to collect money and pay bills. For public insurance, this means collecting taxes and paying expenses. Their view of acceptable private insurance is to copy government insurance — a sort of private sector socialism.

Okay, Goodman, let’s accept that distinction for the moment. Doesn’t pricing risk mean charging me a premium that reflects my health status? The less healthy I am, the more I have to pay. Why should I want to buy insurance from a company that does that?

Because if your insurer doesn’t do that, a lot of bad things will happen.

Remember the phrase, “You’re in good hands with Allstate”? It was the voiceover at the scene of an auto accident where there has been catastrophic damage. The ad speaks volumes about what happens in real insurance markets. Basically, insurance is unimportant to you until things go very wrong. It’s at that point that you want good service.

Contrast Allstate’s ad with the kind of ads federal employees are subjected to during the fall open season for choosing a health insurance plan. What you never see in Washington are ads saying, “You are in good hands with [Aetna, Cigna, UnitedHealth, etc.] if you get [AIDS, cancer, heart disease, etc.].” Instead, the typical open season ad pictures young families with healthy children and no apparent health problems. The not-so-subtle message is: “You’ll be in good hands with us if you look like the people in these photos.”

Why is the health insurance market so different from auto insurance? Answer: health insurers are not allowed to charge federal employees premiums that reflect their health status.

Since the health overhaul legislation plans to make the federal employee health benefit system the model for health insurance exchanges nationwide, it’s instructive to stop and consider the incentives the health plans in these systems have. As explained in a previous analysis, if insurers have to take all applicants for the same premium, they will obviously try to attract the healthy (on whom they will make profits) and avoid the sick (on whom they will incur losses). After enrollment, their incentive is to overprovide to the healthy (to keep the ones they have and attract more of them) and to underprovide to the sick (to encourage them to leave and discourage enrollment by others just like them). If a TV ad could summarize how this health insurance market works, it would say, “You’re in good hands with us, unless you really need us — then we hope you will go somewhere else.”

And the reason this works is because people really can go somewhere else if they get sick — paying no extra premium.

So the incentives of the healthy employees are: Find plans that have lots of services for healthy people — knowing that if they get sick, they can always enroll in some other plan. The incentives for employees with a serious health problem (or more likely, a family member with a health problem) are to seek out plans that are the best at treating costly illness. But, as in a game of musical chairs, no insurer wants to be chosen.

In such a world, comparative effectiveness research, FDA rulings on drugs, end-of-life counseling and so many other controversial issues of late become very relevant. Insurance companies can’t just dump their sickest patients out on the street. They need cover. They need reasons not to pay for the latest cancer drug or the latest expensive test. Given the slightest encouragement, denial is in their self-interest.

Okay, Goodman. This is all very persuasive. But if my premium reflects my health status, what happens to people who are too poor or too sick to be able to afford those premiums? And what happens if a healthy person gets really sick (high medical costs) and wants to switch insurers?

These are good questions. I will answer them in a future Health Alert.

http://healthblog.ncpa.org/the-case-for-health-insurance/

In pooling risk, the decision to assign premiums based on an individual’s risk is purely arbitrary, albeit it is convenient for those marketing the traditional business model of insurance – “real” health insurance, as John Goodman calls it.

The ultimate pooling of risk would be one national pool that includes everyone. Yet average medical costs for a worker’s family of four is now over $18,000 (Milliman), when median household income is $50,000. A middle-income family can no longer afford an equally-allocated premium plus out-of-pocket costs for that risk pool, much less a premium that is adjusted upward for higher risk.

Many of of us who do believe that everyone should have access to health care free of significant financial barriers understand that the traditional concept of “real” insurance no longer works. If individuals with health problems are priced out of risk pools, then how can they possibly pay premiums for the pools that concentrate high-risk individuals? And don’t say that you merely have to set up state-run high-risk pools. Not only have they already been proven to be ineffective in seriously addressing this problem, they would still have to be funded by us anyway, through the tax system. If we moved most high-risk individuals into these pools, that would consume a major portion of our national health expenditures (i.e., much of the 20 percent of people who consume 80 percent of health care).

In fact, think of our largest risk pool – the collective pools of employer-sponsored plans. These are largely composed of the healthy workforce and their young healthy families (the 80 percent of people who use only 20 percent of health care). Yet these low-cost pools that benefit from favorable selection (opposite of adverse selection) are already straining the budgets of employers and their employees. Isn’t it kind of silly to pool together these massive numbers of healthy people, while leaving out most of those with greater needs, and pretend that somehow we have provided the nation with “real” insurance? That serves the insurance industry well, but not the people.

Since average-income individuals can no longer afford their equally-allocated portion of our national health expenditures, funding will have to be progressive, based on income. The least administratively complex and a less expensive method of doing that would be to establish a single risk pool, and fund it through progressive tax policies.

If our goal is seeing that everyone gets the care they need, then we really do need to discard the antiquated business model of “real insurance” and adopt a single payer system – an improved Medicare that covers everyone.

(Comment originally published here)

Merger of Harvard Pilgrim Health Care and Tufts Health Plan

2 big health plans may merge

By Robert Weisman and Kay Lazar
The Boston Globe
January 25, 2011

Harvard Pilgrim Health Care and Tufts Health Plan are close to signing a memorandum of understanding that would combine their operations in four New England states and make them a stronger competitor to the market leader, Blue Cross Blue Shield of Massachusetts, in their home state. (Update: the memorandum of understanding was signed today.)

Consumer advocates said it is unclear how the insurers’ subscribers might be affected by the union, which would leave Massachusetts with only two major health companies.

“There has been tremendous value in having three strong locally based health plans in terms of choices for consumers,” said Nancy C. Turnbull, associate dean at the Harvard School of Public Health and a former deputy insurance commissioner. “But on the other hand, this could create a consolidated plan that could create a stronger competitor to Blue Cross and it could create a plan that has stronger leverage than either of them individually in negotiating with providers.”

Partly in reaction to the pressure to switch from fee-for-service to global payments, several Massachusetts hospitals have combined operations, while others say they are seeking buyers.

http://www.boston.com/business/healthcare/articles/2011/01/25/tufts_harvard_pilgrim_explore_merger/?page=full

Comment: 

By Don McCanne, MD

Choice. Wasn’t that the clarion call during the campaign for health care reform? We could have our choice of keeping the health plan we have, or choosing from a market of plans in the health insurance exchanges. Since Massachusetts had a head start in establishing the model of reform selected for the nation, let’s see what choice has meant to them.

Has health plan competition in the marketplace kept Massachusetts’ health care costs under control? No. They have the highest health care costs in the nation, and costs continue to rise.

Well that didn’t work. So now Massachusetts has begun the process of reducing the competition to two major health plans. That creates an oligopoly, which suppresses competition. Out with the market theory that competition reduces prices. In with the market theory that concentration provides the health plans with leverage to extract greater price concessions from the providers of health care. Of course, choice is a casualty of concentrated markets.

How do the providers fight back? Hospitals are already merging, in an effort to establish market dominance. Physicians are evaluating the concept of accountable care organizations (ACOs) as called for in the Patient Protection and Affordable care Act. Although the intent of the law is that ACOs would control costs (after all, they’re supposed to be accountable), physicians and their health provider partners will certainly use them to leverage their end of price negotiations (i.e., fight for higher prices, not lower).

Fundamental to competition is that when you have winners, you must have losers. That might be appropriate in sporting events, but it is an ethical breach to establish a health care financing system that automatically moves a significant portion of our health care providers into the column of losers. We need a financing system that makes patients winners by providing them access to a health care delivery system that strives for optimal care through cooperation, rather than competition.

That is partly what a single payer system is all about. Using global budgeting and negotiation, the public administrator works with the providers – all providers – to pay legitimate costs and provide fair margins.

Under such a system, competition becomes moot. Eliminating private health plans obviously eliminates health plan competition. If consolidation of health providers improves efficiency, quality and access, then there is no reason to be concerned about a lack of competition there either. Even without consolidation, appropriately compensated providers still can fully engage themselves in serving their patients, unencumbered with the distraction of having to compete.

Merger of Harvard Pilgrim Health Care and Tufts Health Plan

2 big health plans may merge

By Robert Weisman and Kay Lazar
The Boston Globe
January 25, 2011

Harvard Pilgrim Health Care and Tufts Health Plan are close to signing a memorandum of understanding that would combine their operations in four New England states and make them a stronger competitor to the market leader, Blue Cross Blue Shield of Massachusetts, in their home state. (Update: the memorandum of understanding was signed today.)

Consumer advocates said it is unclear how the insurers’ subscribers might be affected by the union, which would leave Massachusetts with only two major health companies.

“There has been tremendous value in having three strong locally based health plans in terms of choices for consumers,” said Nancy C. Turnbull, associate dean at the Harvard School of Public Health and a former deputy insurance commissioner. “But on the other hand, this could create a consolidated plan that could create a stronger competitor to Blue Cross and it could create a plan that has stronger leverage than either of them individually in negotiating with providers.”

Partly in reaction to the pressure to switch from fee-for-service to global payments, several Massachusetts hospitals have combined operations, while others say they are seeking buyers.

http://www.boston.com/business/healthcare/articles/2011/01/25/tufts_harvard_pilgrim_explore_merger/?page=full

Choice. Wasn’t that the clarion call during the campaign for health care reform? We could have our choice of keeping the health plan we have, or choosing from a market of plans in the health insurance exchanges. Since Massachusetts had a head start in establishing the model of reform selected for the nation, let’s see what choice has meant to them.

Has health plan competition in the marketplace kept Massachusetts’ health care costs under control? No. They have the highest health care costs in the nation, and costs continue to rise.

Well that didn’t work. So now Massachusetts has begun the process of reducing the competition to two major health plans. That creates an oligopoly, which suppresses competition. Out with the market theory that competition reduces prices. In with the market theory that concentration provides the health plans with leverage to extract greater price concessions from the providers of health care. Of course, choice is a casualty of concentrated markets.

How do the providers fight back? Hospitals are already merging, in an effort to establish market dominance. Physicians are evaluating the concept of accountable care organizations (ACOs) as called for in the Patient Protection and Affordable care Act. Although the intent of the law is that ACOs would control costs (after all, they’re supposed to be accountable), physicians and their health provider partners will certainly use them to leverage their end of price negotiations (i.e., fight for higher prices, not lower).

Fundamental to competition is that when you have winners, you must have losers. That might be appropriate in sporting events, but it is an ethical breach to establish a health care financing system that automatically moves a significant portion of our health care providers into the column of losers. We need a financing system that makes patients winners by providing them access to a health care delivery system that strives for optimal care through cooperation, rather than competition.

That is partly what a single payer system is all about. Using global budgeting and negotiation, the public administrator works with the providers – all providers – to pay legitimate costs and provide fair margins.

Under such a system, competition becomes moot. Eliminating private health plans obviously eliminates health plan competition. If consolidation of health providers improves efficiency, quality and access, then there is no reason to be concerned about a lack of competition there either. Even without consolidation, appropriately compensated providers still can fully engage themselves in serving their patients, unencumbered with the distraction of having to compete.

Funding for health care law next big battle

By Robert Reich
San Francisco Chronicle
Sunday, January 23, 2011

Forget the symbolic vote to repeal health care. Republicans don’t have the votes to override President Obama’s sure veto.

The real move happens later, when Republicans try to cut the money needed to implement the law’s requirement that all Americans buy health insurance.

On its face, it’s a smart tactic. The individual mandate is the linchpin of the heath care law because it spreads the risks. Without the participation of younger or healthier people, private insurers won’t be able to take on older or sicker customers with pre-existing medical conditions, or maintain coverage indefinitely for people who become seriously ill. The result would be to unravel the health care law, which presumably is what many Republicans seek.

The mandate is also the least popular aspect of the law. According to a December 9-12 ABC News/Washington Post survey, 60 percent of the public opposes it. While most want to prevent insurers from dropping coverage when customers become seriously ill, they don’t like the idea of the government requiring them to buy coverage. The mandate not only offends libertarian sensibilities, but it also worries some moderates and liberals who fear private insurers will charge too much because of insufficient competition in the industry.

And the mandate is most vulnerable to legal challenge. In the first major ruling on the new law, announced Dec. 13, Judge Henry E. Hudson of the federal district court in Richmond, Va., struck it down, calling the mandate an “unbridled exercise of federal police powers” and an overreach of the Constitution’s Commerce Clause. The U.S. government is appealing that decision.

There’s a lesson for Democrats in all this.

The federal government wouldn’t be nearly as vulnerable to these political and legal obstacles had the health care law been built upon the framework of Social Security or Medicare – public insurance financed by payroll taxes.

Not only are these programs enormously popular (“Don’t take away my Medicare!” was a rallying cry among some conservative populists during the debates over the health care law), but they also rest on a more widely accepted relationship between the individual, the government and the market.

Americans are accustomed to paying for public insurance through their payroll taxes. Such payments aren’t viewed as federal mandates that encroach upon individual freedoms, or as payoffs to private companies likely to make even more money from mandatory purchases of their products, but as well-deserved entitlements.

Indeed, the biggest problem with Social Security and Medicare is they’re so popular that politicians have had a hard time trimming their benefits to match payroll-tax revenues.

For 60 years, the battle over health care reform has been waged over these two ways of spreading costs and risks: either through payroll taxes and public insurance, or mandated purchases from private insurers.

For most of those six decades, Democrats advocated the former. Harry Truman’s initial plan for adding health insurance to Social Security was defeated, but Lyndon Johnson’s Medicare succeeded. Apart from George W. Bush’s drug benefit, which was also based on this Democratic framework, Republicans have been on the side of mandated purchases from private insurers.

In 1974, Richard Nixon’s proposed Comprehensive Health Insurance Plan would have required private employers to provide their employees with comprehensive health insurance coverage purchased from private insurers. (An employer mandate is tantamount to an individual mandate in that employees are forced to pay it indirectly, via lower wages.) Sen. Edward Kennedy simultaneously proposed universal coverage financed through Social Security taxes, essentially copying Medicare. Neither plan succeeded, but Nixon’s framework redefined the idea of national health insurance from then onward.

Obama and a majority of Democrats in the last Congress opted for the Republican model even though many Democrats preferred a single-payer system – Medicare for all – or at the very least a public option. Most polls showed that the public favored such an option. But the White House hoped for Republican support and wanted to ward off opposition from health insurers and pharmaceutical companies by promising them some 30 million additional customers.

The current Republican attack on mandatory coverage shows that Democrats who wanted a single-payer system should have stuck to their guns.

Perhaps they’ll have another chance. If the Republican attack is successful, single-payer will be the only alternative. And it’s the system Americans seem to prefer – payroll taxes and public insurance.

© Robert Reich

Robert Reich, former U.S. secretary of labor, is professor of public policy at UC Berkeley and the author of the new book “Aftershock: The Next Economy and America’s Future.” He blogs at www.robertreich.org.

Read more: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2011/01/22/INQ81HANI5.DTL#ixzz1C3tyGAoF

Physicians for a National Health Program Tour Oregon to Promote Single Payer Health Care, February 2011

The Oregon Chapter of Physicians for a National Health Program (PNHP) and Mad As Hell Doctors (MAHD) will follow up on their landmark 2009 national tour and 2010 California tours with spirited rallies in Linn and Lincoln Counties during February. Their program will feature music by bluegrass singer and composer Bob Wickline of Fox Island, Washington; documentary videos by Paul Hochfeld M.D.; testimony by physicians and nurses; and “Mad As Heck Minutes” by audience members on camera and on screen.

 The doctors and nurses will start in Albany on Sunday, February 13, 6:30-8 p.m. at the Two Rivers Market, then go to Eugene for a parade starting at 5 p.m. and rally at 6 p.m. (place tba), hit the beach at Florence on Tuesday, Feb. 15, 6-8 p.m. at the Siuslaw Public Library, then Newport on Wednesday, Feb. 16, 7-9 p.m., at the Newport Visual Arts Center 2nd floor conference room, 777 NW Beach Drive (across from the Nye Beach Turnaround). Then it’s on to Lincoln City on Thursday, Feb. 17, 6:30 p.m., at the Lincoln City Cultural Center.2150 NE Oar Place.

 PNHP is a group of physicians, nurses, ancillary health providers, and other concerned citizens advocating for an improved and expanded Medicare program to provide financially sustainable universal health coverage for all Americans. In September 2009, PNHP doctors traveled 6,000 miles through America’s heartland from Portland, OR to Washington, D.C., stopping at over 40 venues in 22 states. After appearances on the Ed Schultz Show (MSNBC), Keith Olberman (MSNBC), Democracy Now! and interviews on dozens of other media outlets, the group is continuing its unique approach and activist flair to advocate for Single Risk Pool, Improved Medicare-for-all. 

 PNHP contends that the Patient Protection and Affordable Care Act (P-PACA) does too little to protect the health and livelihood of patients and their families. P-PACA serves to further entrench the current medical-industrial complex with an unsustainable cost spiral within our health care system.PNHP further contends that, while the Oregon Health Policy Board, a result of House Bill 2009, has proposed critical improvements in Oregon’s health care system, these improvements will be achievable only under a Single Risk Pool, Improved Medicare-for-all plan.

 PNHP is hitting the road again over the next several months to carry its message throughout Oregon. More information is available at www.pnhp.org/states/oregon and www.madashelldoctors.com. 

You can also interact with 11,000 friends on www.facebook.com/MadDrs.  

Mike Huntington, Physicians for a National Health Program, (541) 745-5635, mchuntington@comcast.net

Single-payer advances from Vermont to California to D.C.

January 24, 2011

Dear PNHP colleagues and friends,

The movement for fundamental health reform is making important advances “on the ground” in Vermont and elsewhere. Here’s a roundup of recent developments.

1. Vermont – draft report on single payer released, doctors speak out

2. H.R. 676 national single-payer bill reintroduced

3. California – medical students lobby for single payer

4. “Deadly Spin” author, former Cigna executive, on book tour

5. Kentucky honors MLK with single-payer forum

1. Harvard economist and architect of Taiwan’s single-payer health care system, William Hsiao, Ph.D., testified before the Vermont Legislature last week in support of a single-payer-like system. Hsiao was commissioned by the Legislature to design three options for health care reform for Vermont. Read the comments of Dr. Don McCanne, PNHP’s senior health policy fellow, on Hsiao’s report here.

Vermont’s congressional delegation (Senators Bernie Sanders and Patrick Leahy, along with Rep. Peter Welch) announced plans to introduce federal legislation that would allow Vermont to get waivers from the new federal health law and implement a single-payer health reform as soon as 2014. Vermont’s new governor, Peter Shumlin, also reiterated his strong support for a single-payer system.

PNHP’s Dr. Deb Richter, a Vermont family physician who has spent more than two decades working for single payer, said “the stars are aligned” for fundamental health care reform in Vermont. “The broad outlines of Dr. Hsiao’s single-payer proposals are very promising,” she said. “They represent a major step in the right direction.” (Read the comments of Richter and other Vermont doctors about the excessive paperwork in practicing medicine here.)

ACTION:

If you haven’t already signed the physicians’ petition to the Vermont Legislature to enact single payer, please do so today.

Vermont physicians are gathering at the Statehouse this Thursday, Jan. 27, to make the case for single payer with state lawmakers. For more information, visit www.vermontforsinglepayer.org. Medical students are rallying in Vermont on March 26. Contact Jenny@pnhp.org for more information.

2. H.R. 676, the “Expanded and Improved Medicare for All Act,” will be reintroduced by Rep. John Conyers (D-Mich.) early this week.

ACTION:

PNHP activists are encouraged to speak with their congresspersons about becoming co-sponsors of this hallmark national single-payer legislation, H.R. 676. (Each congressional session requires fresh co-sponsorship. Sponsors in the last session are listed here.) The congressional switchboard number is (202) 224-3121.

3. In California, hundreds of medical students and other health professionals-in-training flooded the steps of the Capitol for Student Lobby Day, urging state lawmakers to support the state single-payer bill sponsored by Sen. Mark Leno, SB 810. Californians are continuing to press forward with their single-payer bill and are encouraged by the recent departure of Gov. Arnold Schwarzenegger, who twice vetoed the Legislature’s approval of the legislation.

4. “Deadly Spin” author and insurance industry whistle-blower Wendell Potter spoke at a very successful event hosted by PNHP’s Indiana chapter, Hoosiers for a Commonsense Health Care Plan. The event, featuring Potter and a showing of Michael Moore’s movie “Sicko,” drew over 415 people.

Potter is on a speaking tour on his book “Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans.” PNHP chapters in New York City, Tennessee and several other states have also hosted or helped build impressive turnouts for Potter’s events.

5. PNHP President Dr. Garrett Adams and Kentuckians for Single Payer Health Care observed Dr. Martin Luther King Jr.’s birthday with a forum on single payer at the Louisville Urban League. The forum featured former PNHP president Dr. Claudia Fegan (“Dr. King said the time is always right to do what’s right”), Mayor Greg Fischer, Rep. John Yarmuth, and the head of the Falls City Medical Society, Dr. Joyce Howell, among others. Dr. Fegan also spoke to enthusiastic audiences at the Presbyterian Theological Seminary, a physicians’ luncheon and a potluck for activists. See this article in the Louisville Courier-Journal and visit www.kyhealthcare.org for more details.

There’s much more that we could report, both from chapters and from tasks forces like our Divestment group, but for the moment we want to stress that PNHP is continuing to make progress – and that we rely on you and others like you for support. Everything we do hinges on your continuing support. If you haven’t made a tax-deductible donation to PNHP recently, please do so today.

Cordially,

Quentin Young Sig

Quentin Young, M.D.
National Coordinator

Mark Almberg Sig

Mark Almberg
Communications Director

Vermont doctors say patient needs are buried in paperwork

By Kevin O’Connor
Times Argus (Barre-Montpelier, Vt.), Jan. 23, 2011

RUTLAND — Middlebury’s Dr. Jack Mayer knows that most patients want health care reform to cut rising prices. But he, along with a growing group of Vermont medical providers, hopes to point a scalpel at piles of related paperwork.

Back in 1976 when Mayer opened his first pediatric office in the tiny northernmost town of Enosburg Falls, the Bronx native often bartered his services for eggs, firewood or knitted afghans.

In a larger community and practice 35 years later, Mayer now works with two fellow physicians, a nurse practitioner and two full-time billing clerks who process claims for more than 200 insurance plans.

“Every company has its own paperwork, payment schedules and policies about what it will cover,” says Mayer, who notes that such overhead eats upward of 30 percent of U.S. medical expenses. “The administrative costs of my practice are enormous and don’t go toward improving health or patient care.”

Mayer isn’t alone in his assessment. So many Vermont medical professionals have similar concerns, the Legislature — now contemplating several plans to change the state’s health care system — will hold a public hearing in Montpelier this week to receive their testimony.

“What I hear from all my colle
agues is, ‘For every hour I put into clinical care, I put another into paperwork,’” says Dr. Deborah Richter, a Cambridge physician. “They can’t give the care that patients need because of these obstacles.”

Richter is president of the Vermont Health Care for All campaign, which for almost a decade has pushed for what a state consultant proposed last week: a single-payer system to provide medical coverage to all residents.

Richter wasn’t sure if her peers would respond when the Legislature — welcoming public comment through Feb. 3 — invited them to speak Thursday from noon to 2 p.m. at the Statehouse. So far 50 colleagues have confirmed they’ll be there.

“These are busy doctors,” she says, “but they’re willing to talk.”

Nothing but billing

Take Dr. Adam Sorscher, an 18-year primary care physician who juggles work at Central Vermont Medical Center in Berlin, Dartmouth-Hitchcock Medical Center in Lebanon, N.H., (the New Hampshire hospital is Vermont’s second-largest health care provider) and the Good Neighbor Health Clinic in White River Junction. He finds problems wherever he goes.

“I see people at the clinic who have neglected preventive care because of the high cost,” Sorscher says, “and then we have to provide therapies that are more expensive and wouldn’t have been necessary if the health care system was better organized.”

Or consider Dr. William Eichner, an eye specialist who opened his Middlebury practice in 1976 and has added branches in Rutland and Ticonderoga, N.Y. To do so, he has increased his staff to 20 — three of whom focus solely on financial paperwork.

“They don’t greet patients, they don’t handle charts,” the ophthalmologist says. “They do nothing but handle billing and insurance claims.”

That frustrates more and more doctors. Richter points to a 2006 survey she sent to Vermont’s 840 primary care physicians. Of the 300 who responded, four out of five agreed with such statements as “Unnecessary paperwork increasingly is taking away more of my time from my patients” and “I don’t find the intrusion from outside managers and companies helpful.”

Providers say the resulting costs are pricing out more and more patients.

“I feel ashamed we’re the last developed country in the world not to have universal health care,” Eichner says. “I feel a moral imperative that everyone has access and that it be affordable.”

‘Have to kowtow’

Burlington’s Dr. Peggy Carey recalls when, lacking health insurance in her 20s, she was diagnosed with diabetes. Inspired by a nutrition course she took to deal with her diagnosis, she went to medical school and now works as a family doctor in a group practice.

“I wanted to change the system,” says the former English teacher turned 19-year physician.

Carey belongs to the doctor-led Vermont for Single Payer campaign and Physicians for a National Health Program. But she fights her biggest battles inside her practice.

“The majority of the paperwork that comes to me is not in reference to patient care,” she says, “but to what insurance plans allow or don’t allow.”

The problem isn’t limited to physical health. Psychiatrist Dr. Alice Silverman moved to St. Johnsbury two decades ago because the state’s rural Northeast Kingdom lacked enough mental health workers. Today she’s president of the Vermont Psychiatric Association — yet remains one of her region’s few resources.

“I’ve had a waiting list for years,” she says, “and there’s no one else I can refer to.”

Even so, insurance hurdles keep more people out of Silverman’s office.

“I may have someone who’s suicidal, but insurers say they have to see a provider in network, even when there is no one in network,” she says. “In psychiatry, people feel embarrassed enough — to have to call and get approval is a real obstacle. I spend 30 percent of my time trying to get care authorized.”

Burlington’s Dr. Joe Lasek, another psychiatrist, can relate. He works at the Howard Center, a private, nonprofit human service agency that takes care of his billing paperwork. But he still must tackle other insurance issues.

“If I try to get diagnostic tests or follow-up treatment for my patients, insurance companies can say no,” he says. “I have sick and sometimes suicidal patients who aren’t getting care.”

Such problems are keeping other professionals out of the business. Lasek’s wife has a medical degree.

“One of the main reasons she’s not practicing is these hassles,” her husband says. “I have other friends who are pulling back their hours or retraining in another field.”

Berlin’s Dr. Stuart Williams says a growing number of his colleagues support change. The 30-year practitioner is on the board of the Vermont Academy of Family Physicians, which found that a majority of members surveyed favor a single-payer system.

“It seems that physicians have capitulated responsibility to insurers,” Williams says. “We’ve become second tier when we recommend a procedure to a patient and have to kowtow to prior approval and paperwork to put that care in place.”

Different answers

Doctors may agree on the problem, but they aren’t united on the solution. While the Vermont Psychiatric Association has endorsed a single-payer plan, Williams — a member of the council of the Vermont Medical Society — says other medical specialists haven’t voiced a formal position.

Single-payer supporters believe state involvement will eliminate private insurers’ profit motives for questioning care. But they know that skeptics fear government interference.

“People worry that outsiders would be making decisions,” Sorscher says, “but important decisions already are being made by corporate entities.”

Proponents also point to the federal Medicare health insurance program, which, even with its own funding problems, estimates its overhead to be about 3 percent — a tenth of that of private insurers.

“It works for everyone over 65,” Eichner says. “Why not make it universal?”

Back in Middlebury, Mayer says physicians of all political opinions may complain about paperwork, but ultimately they’re most concerned about patients.

“If we as a nation take as a basic premise that health care should be a universal right of all citizens, equally, like Medicare, we will figure out an equitable way to pay for that,” he says. “My decision-making is impacted when I have to think about a person’s personal economics and how much some treatment will cost them. It’s just not fair for those financial considerations to get between me and the care my pediatric patients deserve.”

Global hospital payments by private insurers?

Blue Cross CEO says providers must control costs, or else

By Robert Weisman
The Boston Globe
January 23, 2011

The chief executive of Blue Cross Blue Shield of Massachusetts, the state’s largest health insurer, is calling on hospitals and doctors to step up efforts to contain health care costs, warning that those insisting on traditional fee-for-service contracts will face level or reduced payments from his company.

Andrew Dreyfus, who took the helm at Blue Cross Blue Shield in August, last week sent a letter to more than 400 leaders of hospitals and physicians practices, applying pressure on them to switch to a global payment plan.

Dreyfus’s letter acts as “both a threat and a promise,’’ said Stuart H. Altman, health policy professor at Brandeis University. “He’s saying to the hospitals, you can do better under global payments. But he’s also saying, if you don’t want to do it, if you’re more comfortable with the fee-for-service system, forget it, we’re going to come down on you.’’

http://www.boston.com/business/healthcare/articles/2011/01/23/blue_cross_ceo_says_providers_must_control_health_care_costs_or_else/

Comment: 

By Don McCanne, MD

One of the advantages of a single payer system, as envisioned by PNHP, is that hospitals can be placed on global budgets. They are paid periodically a flat budgeted amount based on legitimate operating expenses, just as other public service institutions, such as the fire department, are funded. This relieves the hospital of the high costs and administrative burden of itemizing a multitude of charges for each individual patient – not to mention that it does away with the $15 charge for a Tylenol or $35 charge for a Band-Aid.

Considering the efficiencies of global budgeting it might seem that the decision of Blue Cross Blue Shield of Massachusetts to switch to global payments for hospitals is a giant step toward single payer. It might seem that, but it isn’t.

Under a single payer system, all legitimate costs are budgeted (with separate budgeting of capital improvements), and payments made accordingly. With a global payment made by a single insurer in a multi-payer system, it is difficult to decide which costs should be allocated to that insurer. Furthermore, the insurer really doesn’t care.

A large insurer like Blue Cross Blue Shield will use its leverage to negotiate down its global payments in a secretive, proprietary process, while leveraging risk adjustment to its own advantage (“our privately insured patients are healthier than your sick Medicare patients”). Smaller insurers would be at a competitive disadvantage because of a lack of leverage and an excessive administrative burden per beneficiary. Public payers such as Medicare and Medicaid would continue to do what they already do, regardless of any agreements the hospitals work out with the private payers. Thus the inefficiencies, inequities, and administrative excesses of our current, fragmented, public and private financing system would be perpetuated.

We keep hearing that if we don’t do this, or if we don’t do that, we are going to have single payer. The problem is that if we do this, or do that, anything as long as it isn’t single payer, we’re only going to delay the inevitable. Wouldn’t it be much smarter to end the suffering and hardship now by enacting a single payer system, especially since it’s inevitable anyway?

Global hospital payments by private insurers?

Blue Cross CEO says providers must control costs, or else

By Robert Weisman
The Boston Globe
January 23, 2011

The chief executive of Blue Cross Blue Shield of Massachusetts, the state’s largest health insurer, is calling on hospitals and doctors to step up efforts to contain health care costs, warning that those insisting on traditional fee-for-service contracts will face level or reduced payments from his company.

Andrew Dreyfus, who took the helm at Blue Cross Blue Shield in August, last week sent a letter to more than 400 leaders of hospitals and physicians practices, applying pressure on them to switch to a global payment plan.

Dreyfus’s letter acts as “both a threat and a promise,’’ said Stuart H. Altman, health policy professor at Brandeis University. “He’s saying to the hospitals, you can do better under global payments. But he’s also saying, if you don’t want to do it, if you’re more comfortable with the fee-for-service system, forget it, we’re going to come down on you.’’

http://www.boston.com/business/healthcare/articles/2011/01/23/blue_cross_ceo_says_providers_must_control_health_care_costs_or_else/

One of the advantages of a single payer system, as envisioned by PNHP, is that hospitals can be placed on global budgets. They are paid periodically a flat budgeted amount based on legitimate operating expenses, just as other public service institutions, such as the fire department, are funded. This relieves the hospital of the high costs and administrative burden of itemizing a multitude of charges for each individual patient – not to mention that it does away with the $15 charge for a Tylenol or $35 charge for a Band-Aid.

Considering the efficiencies of global budgeting it might seem that the decision of Blue Cross Blue Shield of Massachusetts to switch to global payments for hospitals is a giant step toward single payer. It might seem that, but it isn’t.

Under a single payer system, all legitimate costs are budgeted (with separate budgeting of capital improvements), and payments made accordingly. With a global payment made by a single insurer in a multi-payer system, it is difficult to decide which costs should be allocated to that insurer. Furthermore, the insurer really doesn’t care.

A large insurer like Blue Cross Blue Shield will use its leverage to negotiate down its global payments in a secretive, proprietary process, while leveraging risk adjustment to its own advantage (“our privately insured patients are healthier than your sick Medicare patients”). Smaller insurers would be at a competitive disadvantage because of a lack of leverage and an excessive administrative burden per beneficiary. Public payers such as Medicare and Medicaid would continue to do what they already do, regardless of any agreements the hospitals work out with the private payers. Thus the inefficiencies, inequities, and administrative excesses of our current, fragmented, public and private financing system would be perpetuated.

We keep hearing that if we don’t do this, or if we don’t do that, we are going to have single payer. The problem is that if we do this, or do that, anything as long as it isn’t single payer, we’re only going to delay the inevitable. Wouldn’t it be much smarter to end the suffering and hardship now by enacting a single payer system, especially since it’s inevitable anyway?

Vermont doctors say patient needs are buried in paperwork

By Kevin O’Connor
Times Argus (Barre-Montpelier, Vt.), Jan. 23, 2011
 
RUTLAND — Middlebury’s Dr. Jack Mayer knows that most patients want health care reform to cut rising prices. But he, along with a growing group of Vermont medical providers, hopes to point a scalpel at piles of related paperwork.
 
Back in 1976 when Mayer opened his first pediatric office in the tiny northernmost town of Enosburg Falls, the Bronx native often bartered his services for eggs, firewood or knitted afghans.
 
In a larger community and practice 35 years later, Mayer now works with two fellow physicians, a nurse practitioner and two full-time billing clerks who process claims for more than 200 insurance plans.
 
“Every company has its own paperwork, payment schedules and policies about what it will cover,” says Mayer, who notes that such overhead eats upward of 30 percent of U.S. medical expenses. “The administrative costs of my practice are enormous and don’t go toward improving health or patient care.”
 
Mayer isn’t alone in his assessment. So many Vermont medical professionals have similar concerns, the Legislature — now contemplating several plans to change the state’s health care system — will hold a public hearing in Montpelier this week to receive their testimony.
 
“What I hear from all my colleagues is, ‘For every hour I put into clinical care, I put another into paperwork,’” says Dr. Deborah Richter, a Cambridge physician. “They can’t give the care that patients need because of these obstacles.”
 
Richter is president of the Vermont Health Care for All campaign, which for almost a decade has pushed for what a state consultant proposed last week: a single-payer system to provide medical coverage to all residents.
 
Richter wasn’t sure if her peers would respond when the Legislature — welcoming public comment through Feb. 3 — invited them to speak Thursday from noon to 2 p.m. at the Statehouse. So far 50 colleagues have confirmed they’ll be there.
 
“These are busy doctors,” she says, “but they’re willing to talk.”
 
Nothing but billing
 
Take Dr. Adam Sorscher, an 18-year primary care physician who juggles work at Central Vermont Medical Center in Berlin, Dartmouth-Hitchcock Medical Center in Lebanon, N.H., (the New Hampshire hospital is Vermont’s second-largest health care provider) and the Good Neighbor Health Clinic in White River Junction. He finds problems wherever he goes.
 
“I see people at the clinic who have neglected preventive care because of the high cost,” Sorscher says, “and then we have to provide therapies that are more expensive and wouldn’t have been necessary if the health care system was better organized.”
 
Or consider Dr. William Eichner, an eye specialist who opened his Middlebury practice in 1976 and has added branches in Rutland and Ticonderoga, N.Y. To do so, he has increased his staff to 20 — three of whom focus solely on financial paperwork.
 
“They don’t greet patients, they don’t handle charts,” the ophthalmologist says. “They do nothing but handle billing and insurance claims.”
 
That frustrates more and more doctors. Richter points to a 2006 survey she sent to Vermont’s 840 primary care physicians. Of the 300 who responded, four out of five agreed with such statements as “Unnecessary paperwork increasingly is taking away more of my time from my patients” and “I don’t find the intrusion from outside managers and companies helpful.”
 
Providers say the resulting costs are pricing out more and more patients.
 
“I feel ashamed we’re the last developed country in the world not to have universal health care,” Eichner says. “I feel a moral imperative that everyone has access and that it be affordable.”
 
‘Have to kowtow’
 
Burlington’s Dr. Peggy Carey recalls when, lacking health insurance in her 20s, she was diagnosed with diabetes. Inspired by a nutrition course she took to deal with her diagnosis, she went to medical school and now works as a family doctor in a group practice.
 
“I wanted to change the system,” says the former English teacher turned 19-year physician.
 
Carey belongs to the doctor-led Vermont for Single Payer campaign and Physicians for a National Health Program. But she fights her biggest battles inside her practice.
 
“The majority of the paperwork that comes to me is not in reference to patient care,” she says, “but to what insurance plans allow or don’t allow.”
 
The problem isn’t limited to physical health. Psychiatrist Dr. Alice Silverman moved to St. Johnsbury two decades ago because the state’s rural Northeast Kingdom lacked enough mental health workers. Today she’s president of the Vermont Psychiatric Association — yet remains one of her region’s few resources.
 
“I’ve had a waiting list for years,” she says, “and there’s no one else I can refer to.”
 
Even so, insurance hurdles keep more people out of Silverman’s office.
 
“I may have someone who’s suicidal, but insurers say they have to see a provider in network, even when there is no one in network,” she says. “In psychiatry, people feel embarrassed enough — to have to call and get approval is a real obstacle. I spend 30 percent of my time trying to get care authorized.”
 
Burlington’s Dr. Joe Lasek, another psychiatrist, can relate. He works at the Howard Center, a private, nonprofit human service agency that takes care of his billing paperwork. But he still must tackle other insurance issues.
 
“If I try to get diagnostic tests or follow-up treatment for my patients, insurance companies can say no,” he says. “I have sick and sometimes suicidal patients who aren’t getting care.”
 
Such problems are keeping other professionals out of the business. Lasek’s wife has a medical degree.
 
“One of the main reasons she’s not practicing is these hassles,” her husband says. “I have other friends who are pulling back their hours or retraining in another field.”
 
Berlin’s Dr. Stuart Williams says a growing number of his colleagues support change. The 30-year practitioner is on the board of the Vermont Academy of Family Physicians, which found that a majority of members surveyed favor a single-payer system.
 
“It seems that physicians have capitulated responsibility to insurers,” Williams says. “We’ve become second tier when we recommend a procedure to a patient and have to kowtow to prior approval and paperwork to put that care in place.”
 
Different answers
 
Doctors may agree on the problem, but they aren’t united on the solution. While the Vermont Psychiatric Association has endorsed a single-payer plan, Williams — a member of the council of the Vermont Medical Society — says other medical specialists haven’t voiced a formal position.
 
Single-payer supporters believe state involvement will eliminate private insurers’ profit motives for questioning care. But they know that skeptics fear government interference.
 
“People worry that outsiders would be making decisions,” Sorscher says, “but important decisions already are being made by corporate entities.”
 
Proponents also point to the federal Medicare health insurance program, which, even with its own funding problems, estimates its overhead to be about 3 percent — a tenth of that of private insurers.
 
“It works for everyone over 65,” Eichner says. “Why not make it universal?”
 
Back in Middl
ebury, Mayer says physicians of all political opinions may complain about paperwork, but ultimately they’re most concerned about patients.
 
“If we as a nation take as a basic premise that health care should be a universal right of all citizens, equally, like Medicare, we will figure out an equitable way to pay for that,” he says. “My decision-making is impacted when I have to think about a person’s personal economics and how much some treatment will cost them. It’s just not fair for those financial considerations to get between me and the care my pediatric patients deserve.”