PNHP

Robert Reich: Aftershock

Robert Reich: Aftershock

Aftershock

By Robert B. Reich
Published 2010 by Alfred A. Knopf

Introduction

In September 2009… Treasury Secretary Tim Geithner, assessing what had happened to the United States in the years leading up to the Great Recession, repeated the conventional view that “for too long, Americans were buying too much and saving too little.”

The problem was not that Americans spent beyond their means but that their means had not kept up with what the larger economy could and should have been able to provide them.

Part I – The Broken Bargain
Chapter 2 – Parallels

Economists Emmanuel Saez and Thomas Piketty have examined tax records extending back to 1913. They discovered an interesting pattern. The share of total income going to the richest 1 percent of Americans peaked in both 1928 and in 2007, at over 23 percent.

Between the two peaks is a long, deep valley. After 1928, the share of national income going to the top 1 percent steadily declined… to 9 to 11 percent in the 1950s and 1960s, finally reaching the valley floor of 8 to 9 percent in the 1970s. After this, the share going to the richest 1 percent began to climb again… reaching its next peak of more than 23 percent in 2007.

Part III – The Bargain Restored
Chapter 1 – What Should Be Done: A New Deal for the Middle Class

Medicare for all. The passage of health care legislation in 2010 represents only the first step toward reform. The next stage should be Medicare for all. The most efficient way to provide all Americans with high-quality health care is to allow everyone to sign up for Medicare and to subsidize the costs for middle-class and lower-income families.

http://www.randomhouse.com/catalog/display.pperl/9780307592811.html

Emmanuel Saez – Striking it Richer: The Evolution of Top Incomes in the United States
http://elsa.berkeley.edu/~saez/saez-UStopincomes-2008.pdf

Comment: 

By Don McCanne, MD

The landmark study by Emmanuel Saez and Thomas Piketty has been cited by many in helping to explain what went wrong with our economy. The productivity gains of American workers were not shared with the workers but were transferred to the wealthiest Americans. Robert Reich explains that the economy falters when the masses to not have the funds to purchase the products and services made possible by their own productivity.

What should be done is intuitive. In restoring the bargain by creating a New Deal for the middle class, one of the most obvious and effective measures would be to establish a Medicare program for everyone and fund it publicly through progressive tax policies.

So simple and so right. Yes, Reich is right.

Robert Reich: Aftershock

Aftershock

By Robert B. Reich
Published 2010 by Alfred A. Knopf

Introduction

In September 2009… Treasury Secretary Tim Geithner, assessing what had happened to the United States in the years leading up to the Great Recession, repeated the conventional view that “for too long, Americans were buying too much and saving too little.”

The problem was not that Americans spent beyond their means but that their means had not kept up with what the larger economy could and should have been able to provide them.

Part I – The Broken Bargain
Chapter 2 – Parallels

Economists Emmanuel Saez and Thomas Piketty have examined tax records extending back to 1913. They discovered an interesting pattern. The share of total income going to the richest 1 percent of Americans peaked in both 1928 and in 2007, at over 23 percent.

Between the two peaks is a long, deep valley. After 1928, the share of national income going to the top 1 percent steadily declined… to 9 to 11 percent in the 1950s and 1960s, finally reaching the valley floor of 8 to 9 percent in the 1970s. After this, the share going to the richest 1 percent began to climb again… reaching its next peak of more than 23 percent in 2007.

Part III – The Bargain Restored
Chapter 1 – What Should Be Done: A New Deal for the Middle Class

Medicare for all. The passage of health care legislation in 2010 represents only the first step toward reform. The next stage should be Medicare for all. The most efficient way to provide all Americans with high-quality health care is to allow everyone to sign up for Medicare and to subsidize the costs for middle-class and lower-income families.

http://www.randomhouse.com/catalog/display.pperl/9780307592811.html

Emmanuel Saez – Striking it Richer: The Evolution of Top Incomes in the United States
http://elsa.berkeley.edu/~saez/saez-UStopincomes-2008.pdf

The landmark study by Emmanuel Saez and Thomas Piketty has been cited by many in helping to explain what went wrong with our economy. The productivity gains of American workers were not shared with the workers but were transferred to the wealthiest Americans. Robert Reich explains that the economy falters when the masses to not have the funds to purchase the products and services made possible by their own productivity.

What should be done is intuitive. In restoring the bargain by creating a New Deal for the middle class, one of the most obvious and effective measures would be to establish a Medicare program for everyone and fund it publicly through progressive tax policies.

So simple and so right. Yes, Reich is right.

Our bad habits? Or our health care system?

What Changes In Survival Rates Tell Us About US Health Care

By Peter A. Muennig and Sherry A. Glied
Health Affairs
October 7, 2010

Many advocates of US health reform point to the nation’s relatively low life-expectancy rankings as evidence that the health care system is performing poorly. Others say that poor US health outcomes are largely due not to health care but to high rates of smoking, obesity, traffic fatalities, and homicides. We used cross-national data on the fifteen-year survival of men and women over three decades to examine the validity of these arguments. We found that the risk profiles of Americans generally improved relative to those for citizens of many other nations, but Americans’ relative fifteen-year survival has nevertheless been declining. For example, by 2005, fifteen-year survival rates for forty-five-year-old US white women were lower than in twelve comparison countries with populations of at least seven million and per capita gross domestic product (GDP) of at least 60 percent of US per capita GDP in 1975. The findings undercut critics who might argue that the US health care system is not in need of major changes.

We speculate that the nature of our health care system — specifically, its reliance on unregulated fee-for-service and specialty care — may explain both the increased spending and the relative deterioration in survival that we observed. If so, meaningful reform may not only save money over the long term, it may also save lives.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2010.0073v1

Comment: 

By Don McCanne, MD

This study provides credible evidence that lower life expectancy in the United States, when compared to twelve other nations, is not due to smoking, obesity, traffic accidents nor homicides. Thus this study can be used to refute those who contend that we have the greatest health care system on earth, but it is the bad habits of those unworthy of health care that result in our lower life-expectancy ratings.

The authors speculate, “It is possible that rising US health spending is itself responsible for the observed relative decline in survival.” Specifically they suggest that “reliance on unregulated fee-for-service and specialty care may explain both the increased spending and the relative deterioration in survival.” They seem to dismiss the lack of health insurance as not having been found to have “substantial impacts,” though there is “uncertainty on this point.”

This opinion meshes well with a prevalent view expounded during the reform process that our costs are high because of an excess of health services that often impair outcomes. With almost no substantial evidence, the Dartmouth variations often were blamed for impaired outcomes, while largely ignoring a plethora of data that show that insufficient care, especially related to being uninsured or under-insured, greatly impairs outcomes.

One of the authors of this study, Sherry Glied, is taking this spending-causes-decline-in-survival theory with her to the Department of Health and Human Services where she is assistant secretary for planning and evaluation. These “neo-theorists” preach that we can improve quality and decrease spending through economic tools such as accountable care organizations and bundling of services. Come on.

It’s time to bring in the old school European-style theorists who have already shown that universal social insurance programs with well established primary care infrastructures do control costs and improve outcomes. Many Europeans engage in the same bad habits as found here in the United States, yet none of them are unworthy of health care.

Our bad habits? Or our health care system?

What Changes In Survival Rates Tell Us About US Health Care

By Peter A. Muennig and Sherry A. Glied
Health Affairs
October 7, 2010

Many advocates of US health reform point to the nation’s relatively low life-expectancy rankings as evidence that the health care system is performing poorly. Others say that poor US health outcomes are largely due not to health care but to high rates of smoking, obesity, traffic fatalities, and homicides. We used cross-national data on the fifteen-year survival of men and women over three decades to examine the validity of these arguments. We found that the risk profiles of Americans generally improved relative to those for citizens of many other nations, but Americans’ relative fifteen-year survival has nevertheless been declining. For example, by 2005, fifteen-year survival rates for forty-five-year-old US white women were lower than in twelve comparison countries with populations of at least seven million and per capita gross domestic product (GDP) of at least 60 percent of US per capita GDP in 1975. The findings undercut critics who might argue that the US health care system is not in need of major changes.

We speculate that the nature of our health care system — specifically, its reliance on unregulated fee-for-service and specialty care — may explain both the increased spending and the relative deterioration in survival that we observed. If so, meaningful reform may not only save money over the long term, it may also save lives.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2010.0073v1

This study provides credible evidence that lower life expectancy in the United States, when compared to twelve other nations, is not due to smoking, obesity, traffic accidents nor homicides. Thus this study can be used to refute those who contend that we have the greatest health care system on earth, but it is the bad habits of those unworthy of health care that result in our lower life-expectancy ratings.

The authors speculate, “It is possible that rising US health spending is itself responsible for the observed relative decline in survival.” Specifically they suggest that “reliance on unregulated fee-for-service and specialty care may explain both the increased spending and the relative deterioration in survival.” They seem to dismiss the lack of health insurance as not having been found to have “substantial impacts,” though there is “uncertainty on this point.”

This opinion meshes well with a prevalent view expounded during the reform process that our costs are high because of an excess of health services that often impair outcomes. With almost no substantial evidence, the Dartmouth variations often were blamed for impaired outcomes, while largely ignoring a plethora of data that show that insufficient care, especially related to being uninsured or under-insured, greatly impairs outcomes.

One of the authors of this study, Sherry Glied, is taking this spending-causes-decline-in-survival theory with her to the Department of Health and Human Services where she is assistant secretary for planning and evaluation. These “neo-theorists” preach that we can improve quality and decrease spending through economic tools such as accountable care organizations and bundling of services. Come on.

It’s time to bring in the old school European-style theorists who have already shown that universal social insurance programs with well established primary care infrastructures do control costs and improve outcomes. Many Europeans engage in the same bad habits as found here in the United States, yet none of them are unworthy of health care.

Insurance is a strange model for health care

It's meant for life's uncertainties, but illness is actually a pretty sure thing.

By EDWARD P. EHLINGER, M.D.
Minneapolis Star Tribune, Oct. 5, 2010

For once I agree with Jason Lewis — sort of. Using an insurance model to cover preexisting health conditions doesn’t make any sense, as he says (“Government health care is on the way,” Oct. 1).

But I would take his notion a step further. Using an insurance model for basic and essential health care also doesn’t make any sense.

Insurance is a great mechanism that people can use to offset their risk of losing some material thing of great value like their house, boat, car or jewelry. It can also be used to protect a valuable personal occupational asset like a voice for an opera singer, a hand for a surgeon or a knee for a football player. And it can be useful in providing protection from a singular catastrophic event like a malpractice suit or the premature loss of life.

But for something that is predictable, ongoing, needed by everyone, or necessary for the welfare of our community, an insurance model makes absolutely no sense. That’s why we don’t use an insurance model to provide police or fire services or to provide an education to our children. For these we use the tax model. Basic essential health care should also be in this category.

We know that almost everyone will eventually need some health care and much of it will be ongoing. For a defined population, the health care needs are predictable, and we know that the health of individuals affects the overall welfare of our community. In addition, most believe that people should get treated for illnesses, diseases and injuries that might befall them and expect that everyone should have access to preventive services like prenatal care and immunizations that make our communities a healthier and better place.

Our insurance-based model doesn’t match our societal needs and expectations in many respects. It denies coverage to those who need care the most. Since health and income are related, it charges more for the people who can least afford it. It encourages a link with employment that has numerous negative side effects. By its reimbursement mechanism, our insurance-based health care system has also fostered maldistribution of resources between primary and specialty care.

The proof of the folly of using an insurance-based model for health care is that, while we have the most expensive health care system in the world, approximately one-third of Americans are uninsured or inadequately insured. The consequences of this are that health status indicators for the United States are far from the best.

Lewis suggests that “most (perhaps not all) existing conditions can find coverage already — for a price.” That is true, but a free-market approach puts care out of reach for many of those who need it the most. Historically, it was the failure of the free-market approach that prompted us to go to an employer-linked health insurance-based model in the first place.

When health care costs, access to care and health status concerns became a major issue in the 1940s, the United States had a chance to implement a more rational tax-based health care financing system. However, the country did not have the political will to implement such a system and opted for the insurance-based model we have today. In the 1960s, the failure of that system for the elderly prompted the passage of Medicare, which has dramatically improved both the physical and economic health of senior citizens.

Lewis also rails against an entitlement mentality. As members of a civilized society, there are lots of things we should feel entitled to — police and fire protection, clean air and water, a functional electrical grid, basic education, safe borders, stable currency, etc. It’s logical to me and to most Americans that access to basic and essential health services should also be one of those entitlements.

With the continued problems of our insurance-based model of health care financing, perhaps it’s time to implement an improved Medicare-for-all approach. Then preexisting conditions would not be only redundant, they would be irrelevant.

Edward P. Ehlinger is a Minneapolis physician.

http://www.startribune.com/opinion/commentary/104380093.html?elr=KArks7PYDiaK7DUdcOy_nc:DKUiD3aPc:_Yyc:aUU

Touring doctors make case for single-payer system

By Landon Hall
The Orange County Register, Oct. 2, 2010

IRVINE, Calif. – Bill Honigman, an emergency-room doctor at Kaiser Permanente in Anaheim and Irvine, says the only way to make real progress on a health care overhaul is to get rid of private insurance companies altogether.

“Ultimately,” he says, “we’re going to have to muscle them out of the system.”

Just like that? It’s one reason Honigman and his colleagues, who call themselves the “Mad as Hell Doctors,” face an uphill struggle in their fight to get the United States, starting with California, to adopt a single-payer system that covers everyone, at government expense.

Honigman shared the stage Saturday night with three other doctors – two from Corvallis, Ore., and another from the Bay Area – who have been touring California for the past week and a half addressing crowds both big and small about the inefficiencies of the current system. They don’t think much of the Obama administration-backed bill that became law six months ago, saying it was written by and for insurance companies.

They see California as a battleground because a bill that would establish a single-payer system (SB840) has twice passed both houses of the Legislature, only to be vetoed by Gov. Schwarzenegger. Dr. Marc Sapir, a primary-care physician in Hayward, said the failure of a similar measure (SB810) to advance robbed the public of the opportunity to learn about single-payer.

Honigman said the vetoes showed that the governor is on the side of big business and not the people.

“But we will bring it to the next session,” he said, noting that Sen. Mark Leno, D-San Francisco, plans to reintroduce SB810.

More than 100 people, mostly older, sat in the pews of the politically active Irvine United Congregational Church to listen to the “mad” doctors — Honigman, Sapir, Paul Hochfeld and Mike Huntington of Corvallis, and church member Howard Emery of Yorba Linda – give a nearly two-hour presentation. It’s a complicated subject, they acknowledged.

“Our goal is to give you the intellectual tools and the courage and the commitment and the insight to talk to your friends and your neighbors, and your Fox News-watching uncle, sitting around the Thanksgiving dinner table,” Hochfield said.

Steve Bell, 61, of Laguna Niguel, brought his stepdaughter Lindsey Buss, 25, and her boyfriend to the town hall-style meeting to learn more about single payer.

“We didn’t get health reform, we got insurance reform,” Bell said. “Once the reform implodes, which I’m sure it will, then maybe we’ll get another look at single payer.”

Another person in the audience taking careful notes was Christina Avalos, a Democrat who is running against Rep. Ed Royce in the 40th District.

“We’re not informed enough, and that’s what events like this are about,” Avalos said. “I plan to disseminate this information at the federal level so we can make it a national priority.”

Huntington said that even if Attorney General Jerry Brown is elected as governor, there’s no guarantee he’d sign single payer into law if it were to pass the Legislature again.

“He has never committed that to anyone,” Huntington said. “So regardless of who gets elected, we feel that this has to be a movement that involves lots of groups. If he’s going to be brave enough to sign a single-payer bill, he has to feel that there’s lots of support behind him.”

Contact the writer: lhall@ocregister.com or 714-196-2221

http://www.ocregister.com/news/payer-269330-single-honigman.html

HHS rushes into reform… with expedited waivers!

Statement on the application of medical loss ratio standards to certain health plans under the Affordable Care Act

U.S. Department of Health & Human Services
September 30, 2010

Jay Angoff, director of the Office of Consumer Information and Insurance Oversight, within the U.S. Department of Health and Human Services (HHS) released the following statement today, regarding the application of medical loss ratio standards to certain health plans under the Affordable Care Act:

“As many employers and insurers consider health insurance options for 2011, one question that has been raised is the applicability of provisions of the Affordable Care Act to health plans and coverage with special circumstances. HHS remains committed to implementing the law in a way that minimizes disruption to coverage that is available today while also ensuring that consumers receive the benefits the Act provides.

“For example, pursuant to the Affordable Care Act and our regulations, HHS recently announced an expedited process for plans to apply for a waiver from the requirement in the Affordable Care Act establishing minimum annual limits where such limits would result in decreased access or increased premiums. HHS has approved dozens of these waiver requests, most often filed by so-called “mini-med” plans, and in doing so, has ensured the continuation of health coverage for workers and their families. Complete waiver applications were generally processed in 48 hours.

“More recently, the issue of the applicability of the medical loss ratio requirements to plans such as mini-med plans has come up. HHS has not yet issued regulations implementing the medical loss ratio requirements because the Affordable Care Act tasks the National Association of Insurance Commissioners (NAIC) with first making recommendations to the Secretary.

“Although the NAIC is close to completing its work, we understand that some employers must soon make decisions regarding coverage options for 2011. As such, we fully intend to exercise her discretion under the new law to address the special circumstances of mini-med plans in the medical loss ratio calculations.  According to the Affordable Care Act, medical loss ratio “methodologies shall be designed to take into account the special circumstance of smaller plans, different types of plans, and newer plans.”  We recognize that mini-med plans are often characterized by a relatively high expense structure relative to the lower premiums charged for these types of policies. We intend to address these and other special circumstances in forthcoming regulations.”

http://www.hhs.gov/news/press/2010pres/09/20100930c.html

Comment: 

By Don McCanne, MD

So the Patient Protection and Affordable Care Act (ACA) didn’t extend health care coverage to everyone and didn’t enact significant cost containment measures, but at least it did establish regulations that would end insurance abuses such as low annual dollar caps on coverage and administrative excesses that waste dollars that should be going to health care. Or did it?

Next year plans are required to provide a minimum of $750,000 in coverage, phasing to unlimited coverage in 2014. Also group plans are required to pay out at least 85 percent of premium revenues for health benefits (medical loss ratio). These regulatory changes are essential if health plans are going to benefit the insured, even though that would require plan redesign by employers such as McDonald’s and Jack in the Box that currently offer limited-benefit plans (mini-med plans) to their employees.

These plans offer as little as $2,000 a year in benefits. This could be perceived as a practical joke, but it certainly isn’t funny. This isn’t under-insurance; it’s virtually no insurance at all. Also, with so few benefits paid out, these plans cannot possibly meet the required medical loss ratios. Though ACA will not insure everyone and will not control costs, the new regulatory rules were supposed to bring an end to these abusive un-insurance programs.

Under ACA the Department of Health and Human Services (HHS) was given an expanded role in regulatory oversight, so what is their response to these plans? They have established an expedited process for these plans to be granted waivers exempting them from the new requirements!

What will happen in 2014? What changes will take place in the interim that will cause HHS to terminate the waiver program and require removal of dollar caps on coverage along with compliance with medical loss ratios? If the employers need the waivers now, they’ll certainly need them in 2014 when premiums are much higher because of the new regulatory requirements.

Is HHS really that sympathetic to employers while being so uncaring about the needs of their employees? I mean waivers… not just waivers… but expedited waivers! Just what was reform supposed to have accomplished?

As with so many of these daily messages, this would not even be a topic if Congress had enacted a single payer national health program – an improved Medicare for all.

HHS rushes into reform… with expedited waivers!

Statement on the application of medical loss ratio standards to certain health plans under the Affordable Care Act

U.S. Department of Health & Human Services
September 30, 2010

Jay Angoff, director of the Office of Consumer Information and Insurance Oversight, within the U.S. Department of Health and Human Services (HHS) released the following statement today, regarding the application of medical loss ratio standards to certain health plans under the Affordable Care Act:

“As many employers and insurers consider health insurance options for 2011, one question that has been raised is the applicability of provisions of the Affordable Care Act to health plans and coverage with special circumstances. HHS remains committed to implementing the law in a way that minimizes disruption to coverage that is available today while also ensuring that consumers receive the benefits the Act provides.

“For example, pursuant to the Affordable Care Act and our regulations, HHS recently announced an expedited process for plans to apply for a waiver from the requirement in the Affordable Care Act establishing minimum annual limits where such limits would result in decreased access or increased premiums. HHS has approved dozens of these waiver requests, most often filed by so-called “mini-med” plans, and in doing so, has ensured the continuation of health coverage for workers and their families. Complete waiver applications were generally processed in 48 hours.

“More recently, the issue of the applicability of the medical loss ratio requirements to plans such as mini-med plans has come up. HHS has not yet issued regulations implementing the medical loss ratio requirements because the Affordable Care Act tasks the National Association of Insurance Commissioners (NAIC) with first making recommendations to the Secretary.

“Although the NAIC is close to completing its work, we understand that some employers must soon make decisions regarding coverage options for 2011. As such, we fully intend to exercise her discretion under the new law to address the special circumstances of mini-med plans in the medical loss ratio calculations.  According to the Affordable Care Act, medical loss ratio “methodologies shall be designed to take into account the special circumstance of smaller plans, different types of plans, and newer plans.”  We recognize that mini-med plans are often characterized by a relatively high expense structure relative to the lower premiums charged for these types of policies. We intend to address these and other special circumstances in forthcoming regulations.”

http://www.hhs.gov/news/press/2010pres/09/20100930c.html

So the Patient Protection and Affordable Care Act (ACA) didn’t extend health care coverage to everyone and didn’t enact significant cost containment measures, but at least it did establish regulations that would end insurance abuses such as low annual dollar caps on coverage and administrative excesses that waste dollars that should be going to health care. Or did it?

Next year plans are required to provide a minimum of $750,000 in coverage, phasing to unlimited coverage in 2014. Also group plans are required to pay out at least 85 percent of premium revenues for health benefits (medical loss ratio). These regulatory changes are essential if health plans are going to benefit the insured, even though that would require plan redesign by employers such as McDonald’s and Jack in the Box that currently offer limited-benefit plans (mini-med plans) to their employees.

These plans offer as little as $2,000 a year in benefits. This could be perceived as a practical joke, but it certainly isn’t funny. This isn’t under-insurance; it’s virtually no insurance at all. Also, with so few benefits paid out, these plans cannot possibly meet the required medical loss ratios. Though ACA will not insure everyone and will not control costs, the new regulatory rules were supposed to bring an end to these abusive un-insurance programs.

Under ACA the Department of Health and Human Services (HHS) was given an expanded role in regulatory oversight, so what is their response to these plans? They have established an expedited process for these plans to be granted waivers exempting them from the new requirements!

What will happen in 2014? What changes will take place in the interim that will cause HHS to terminate the waiver program and require removal of dollar caps on coverage along with compliance with medical loss ratios? If the employers need the waivers now, they’ll certainly need them in 2014 when premiums are much higher because of the new regulatory requirements.

Is HHS really that sympathetic to employers while being so uncaring about the needs of their employees? I mean waivers… not just waivers… but expedited waivers! Just what was reform supposed to have accomplished?

As with so many of these daily messages, this would not even be a topic if Congress had enacted a single payer national health program – an improved Medicare for all.

Who will design and operate the accountable care organizations?

Health Care Providers, Insurers: Accountable Care Organizations Bring Legal Worries

By Jenny Gold and Phil Galewitz
Kaiser Health News
October 5, 2010

Doctors and hospitals eager to pursue a new model of health care being promoted by the Obama administration are raising concerns that they could run afoul of antitrust and anti-fraud laws, while insurers are warning that the new arrangements could lead to higher prices for medical care.

A key part of the health overhaul law encourages the development of “accountable care organizations” that would allow doctors to team up with each other and hospitals in new ways to provide medical services. Health care providers want to make sure their ACOs won’t be accused of stifling competition or trying to fix prices when they bargain with insurance companies. Insurers, meanwhile, are expressing concern that providers could use the leverage of ACOs to demand higher prices.

Whether ACOs – which are just a concept for now – can be made to work could determine whether the health care law ultimately succeeds in lowering costs and improving care for consumers.

The federal health program for the elderly and disabled is due to start trying out ACOs in 2012, and some providers are scrambling to figure out how to apply the idea to privately insured patients as well. The antitrust rules mostly concern the  private insurance market; in Medicare, the government sets the payment rates.

But America’s Health Insurance Plans, the insurers’ trade group, warned government officials against being too accommodating. It said in a recent letter  that ACOs won’t help consumers “if they are mere vehicles for price fixing or aggregating market power, and the antitrust agencies must continue their efforts in this area, using enforcement, guidance, and other tools.”

Cory Capps, an economist at Bates White Economic Consulting, said, “We could end up in the worst world,” one in which the delivery of care isn’t made more efficient but providers accumulate “greater pricing power.”

Susan DeSanti, director of policy planning at the FTC, said that the agency is working with CMS on the issues, and that guidance on ACOs will be issued to reduce uncertainty. “The antitrust laws are actually consistent with the goals of ACOs,” she said. “The antitrust laws encourage collaborations when they are going to produce good things for consumers, like improved health care, and the only caveat is that the creation of market power shouldn’t go along with that. But antitrust is not a barrier here.”

Humana Medical Director Dr. Tom James said the insurer wants to show that “health plans have a role with ACOs,” adding that it’s important that ACOs be seen as more than cost-cutters. “If not done right, it could give the whole movement a bad name,” he said. “We learned that with HMOs in the 1990s.”

http://www.kaiserhealthnews.org/Stories/2010/October/05/accountable-care-organizations.aspx

Comment: 

By Don McCanne, MD

The Patient Protection and Affordable Care Act (ACA) promises us greater affordability through the establishment of accountable care organizations (ACOs). By adopting an as-yet-to-be-defined team approach to health care, the organizations purportedly would improve quality while controlling costs, theoretically by eliminating the excess services demonstrated by the Dartmouth Atlas (even though our much greater problem is under-utilization as demonstrated by Commonwealth, RAND, and others).

Who will be making the decisions on the structure and then the operations of these teams? Will it be altruistic members of the medical, hospital, and policy communities? Very unlikely, based on the history of the HMOs. Although the original HMOs were designed with the intent of providing optimal patient care (through a team approach!), the enabling legislation that brought a surge in managed care also brought out the entrepreneurial minds that replaced health care altruism with a business ethic of health care.

There is absolutely no doubt that the same will occur now, and actually has already begun. The entrepreneurs will be in control before the altruists can develop a process to fulfill the vision for a health care utopia. Although the teams will be designed along business lines, purportedly to control costs, the motivation of those in control will be to make money. Even if the teams are not owned by passive investors, the physicians and hospital administrators will still be manipulating the structure and operations to serve their own interests first.

The vision of various teams competing with each other by offering higher quality and lower costs is a fantasy. These teams will use their oligopolistic and monopolistic powers to drive costs up. Markets do work very well for those who are able to pervert them. Just look at the perversions of the private insurance industry that has helped to orchestrate the most expensive health system in the world, while squandering the opportunities to bring some measure of quality to our system.

Congress and the Obama administration have brought us ACOs, and you would think that they would feel some obligation as government stewards to provide guidance and oversight. But what has been their response? Susan DeSanti of the Federal Trade Commission said that “the antitrust laws encourage collaborations,” and that “antitrust is not a barrier here.”

As Cory Capps of Bates White Economic Consulting stated, “We could end up in the worst world,” one in which the delivery of care isn’t made more efficient but providers accumulate “greater pricing power.”

The tragedy is that all of the attention that has been diverted to these ill-defined and perversely-incentivized ACOs has distracted our nation’s policy makers from seriously considering reform that actually would achieve our goal of quality, affordable care for everyone – an improved Medicare for all. Focus, folks.

Doctors push for single-payer at workers' rally

By Julian Pecquet
The Hill, Oct. 1, 2010

[PNHP note: This article in The Hill, published on the eve of the Oct. 2 “One Nation” march in Washington, was one of several news reports about the participation of single-payer, Medicare-for-all advocates in the gathering of 175,000 at the Lincoln Memorial. Early on Saturday morning, Mara Liasson on NPR mentioned that doctors were marching “and they want single payer,” and later that day The Associated Press noted, “There were people with union T-shirts and others participants who carried banners advocating expanding Medicare for all Americans.”]

Physicians who want a single-payer government health plan will be marching at Saturday’s “One Nation Working Together” rally in Washington, D.C. While the main focus of the march will be on jobs and the economy, part of the rally’s theme — “demanding the change we voted for” — relates to dissatisfaction with the health care reform law, according to Physicians for a National Health Program.
 
The group’s 18,000 members don’t believe the new health care reform law will put an end to rising health care costs, but rather it will make things worse by entrenching the role of private insurance companies.
 
“Reforming our health care system is unfinished business,” PNHP President Oliver Fein said in a statement. Physicians will be marching “to say we need a massive movement to press forward to the only rational remedy for our nation’s health care crisis: single-payer Medicare for all.”
 
http://thehill.com/blogs/healthwatch/health-reform-implementation/122093-doctors-to-push-for-single-payer-at-workers-rally

Doctors push for single-payer at workers’ rally

By Julian Pecquet
The Hill, Oct. 1, 2010

[PNHP note: This article in The Hill, published on the eve of the Oct. 2 “One Nation” march in Washington, was one of several news reports about the participation of single-payer, Medicare-for-all advocates in the gathering of 175,000 at the Lincoln Memorial. Early on Saturday morning, Mara Liasson on NPR mentioned that doctors were marching “and they want single payer,” and later that day The Associated Press noted, “There were people with union T-shirts and others participants who carried banners advocating expanding Medicare for all Americans.”]

Physicians who want a single-payer government health plan will be marching at Saturday’s “One Nation Working Together” rally in Washington, D.C. While the main focus of the march will be on jobs and the economy, part of the rally’s theme — “demanding the change we voted for” — relates to dissatisfaction with the health care reform law, according to Physicians for a National Health Program.
 
The group’s 18,000 members don’t believe the new health care reform law will put an end to rising health care costs, but rather it will make things worse by entrenching the role of private insurance companies.
 
“Reforming our health care system is unfinished business,” PNHP President Oliver Fein said in a statement. Physicians will be marching “to say we need a massive movement to press forward to the only rational remedy for our nation’s health care crisis: single-payer Medicare for all.”
 
http://thehill.com/blogs/healthwatch/health-reform-implementation/122093-doctors-to-push-for-single-payer-at-workers-rally

Who will design and operate the accountable care organizations?

Health Care Providers, Insurers: Accountable Care Organizations Bring Legal Worries

By Jenny Gold and Phil Galewitz
Kaiser Health News
October 5, 2010

Doctors and hospitals eager to pursue a new model of health care being promoted by the Obama administration are raising concerns that they could run afoul of antitrust and anti-fraud laws, while insurers are warning that the new arrangements could lead to higher prices for medical care.

A key part of the health overhaul law encourages the development of “accountable care organizations” that would allow doctors to team up with each other and hospitals in new ways to provide medical services. Health care providers want to make sure their ACOs won’t be accused of stifling competition or trying to fix prices when they bargain with insurance companies. Insurers, meanwhile, are expressing concern that providers could use the leverage of ACOs to demand higher prices.

Whether ACOs – which are just a concept for now – can be made to work could determine whether the health care law ultimately succeeds in lowering costs and improving care for consumers.

The federal health program for the elderly and disabled is due to start trying out ACOs in 2012, and some providers are scrambling to figure out how to apply the idea to privately insured patients as well. The antitrust rules mostly concern the  private insurance market; in Medicare, the government sets the payment rates.

But America’s Health Insurance Plans, the insurers’ trade group, warned government officials against being too accommodating. It said in a recent letter  that ACOs won’t help consumers “if they are mere vehicles for price fixing or aggregating market power, and the antitrust agencies must continue their efforts in this area, using enforcement, guidance, and other tools.”

Cory Capps, an economist at Bates White Economic Consulting, said, “We could end up in the worst world,” one in which the delivery of care isn’t made more efficient but providers accumulate “greater pricing power.”

Susan DeSanti, director of policy planning at the FTC, said that the agency is working with CMS on the issues, and that guidance on ACOs will be issued to reduce uncertainty. “The antitrust laws are actually consistent with the goals of ACOs,” she said. “The antitrust laws encourage collaborations when they are going to produce good things for consumers, like improved health care, and the only caveat is that the creation of market power shouldn’t go along with that. But antitrust is not a barrier here.”

Humana Medical Director Dr. Tom James said the insurer wants to show that “health plans have a role with ACOs,” adding that it’s important that ACOs be seen as more than cost-cutters. “If not done right, it could give the whole movement a bad name,” he said. “We learned that with HMOs in the 1990s.”

http://www.kaiserhealthnews.org/Stories/2010/October/05/accountable-care-organizations.aspx

The Patient Protection and Affordable Care Act (ACA) promises us greater affordability through the establishment of accountable care organizations (ACOs). By adopting an as-yet-to-be-defined team approach to health care, the organizations purportedly would improve quality while controlling costs, theoretically by eliminating the excess services demonstrated by the Dartmouth Atlas (even though our much greater problem is under-utilization as demonstrated by Commonwealth, RAND, and others).

Who will be making the decisions on the structure and then the operations of these teams? Will it be altruistic members of the medical, hospital, and policy communities? Very unlikely, based on the history of the HMOs. Although the original HMOs were designed with the intent of providing optimal patient care (through a team approach!), the enabling legislation that brought a surge in managed care also brought out the entrepreneurial minds that replaced health care altruism with a business ethic of health care.

There is absolutely no doubt that the same will occur now, and actually has already begun. The entrepreneurs will be in control before the altruists can develop a process to fulfill the vision for a health care utopia. Although the teams will be designed along business lines, purportedly to control costs, the motivation of those in control will be to make money. Even if the teams are not owned by passive investors, the physicians and hospital administrators will still be manipulating the structure and operations to serve their own interests first.

The vision of various teams competing with each other by offering higher quality and lower costs is a fantasy. These teams will use their oligopolistic and monopolistic powers to drive costs up. Markets do work very well for those who are able to pervert them. Just look at the perversions of the private insurance industry that has helped to orchestrate the most expensive health system in the world, while squandering the opportunities to bring some measure of quality to our system.

Congress and the Obama administration have brought us ACOs, and you would think that they would feel some obligation as government stewards to provide guidance and oversight. But what has been their response? Susan DeSanti of the Federal Trade Commission said that “the antitrust laws encourage collaborations,” and that “antitrust is not a barrier here.”

As Cory Capps of Bates White Economic Consulting stated, “We could end up in the worst world,” one in which the delivery of care isn’t made more efficient but providers accumulate “greater pricing power.”

The tragedy is that all of the attention that has been diverted to these ill-defined and perversely-incentivized ACOs has distracted our nation’s policy makers from seriously considering reform that actually would achieve our goal of quality, affordable care for everyone – an improved Medicare for all. Focus, folks.