Kaiser Daily Health Policy Report
Capitol Hill Watch
Apr 24, 2009

On Thursday, witnesses at a House Education and Labor Health, Employment, Labor and Pensions Subcommittee hearing discussed strategies to curb rising health care costs while extending health insurance to more U.S. residents, CQ HealthBeat reports. Health care reform approaches discussed at the hearing include a single-payer health care system; a “employee benefit cooperative” system in which small employers, employees and families band together to purchase coverage; a national health insurance exchange; Medicaid expansion; and changes to the current model of employer-based plans to make coverage more affordable.

David Himmelstein, a primary care physician and associate professor of medicine at Harvard University, advocated a single-payer system (Norman, CQ HealthBeat, 4/23). Himmelstein said that he thinks a health reform modeled after the 2006 Massachusetts health insurance law “will fail” because it is “economically not viable.” According to Himmelstein, the Massachusetts law has “no means of cost containment” because the state is “increasing coverage … by buying additional insurance from (private insurers) on top of already high costs” (Wayne, CQ Today, 4/23). He added, “While reforms that maintain a major role for private insurers may be politically attractive, they are economically and medically nonsensical.”

Subcommittee Chair Robert Andrews (D-N.J.) called the discussion a “dynamic interchange” and a starting point for addressing how to provide quality insurance to all U.S. residents. Rep. John Kline (R-Minn.) said, “There is obviously a great deal of disagreement and diversity here… we’ve got a long way to go here” (CQ HealthBeat, 4/23).

By INGRID PERITZ
Globe and Mail
April 23, 2009

MONTREAL — The patient sat in the clinic’s waiting room, apparently dead, yet even that wasn’t enough to get him medical attention.

In a scene that combined tragedy with Monty Python farce, a 77-year-old man in acute respiratory failure turned up at a private medical clinic in Montreal only to be told to wait his turn.

Jean-Jacques Sauvageau waited until his heart stopped and his dentures fell out onto the floor. Even then, the famous doctor who came to tend to him did a cursory exam and didn’t try to revive him, leaving him instead before the horrified eyes of fellow patients.

The events were depicted in a report issued yesterday by Quebec coroner Catherine Rudel-Tessier. And the doctor taken to task for his failure to try to resuscitate the patient is private-care crusader Jacques Chaoulli.

In 2005, he made history by persuading the Supreme Court to overturn Quebec’s ban on private health insurance.

In this case, Dr. Chaoulli was on duty at a private clinic last year when Mr. Sauvageau showed up. His face was bluish-purple and he had severe trouble breathing. Though the clinic advertised itself as providing emergency care, he was told to take a seat.

After about a half hour, the increasingly alarmed fellow patients could see Mr. Sauvageau was unconscious and alerted the receptionist. Dr. Chaoulli came out, did a cursory examination and concluded the patient was already dead.

He left him sitting in the chair, and told the nurse to phone 911 to report the death.

But the 911 operator pleaded with the nurse to try to revive Mr. Sauvageau. Dr. Chaoulli got on the phone and tried to argue the patient was dead; however, the 911 operator insisted.

Meanwhile, the other patients grew increasingly alarmed, seeing the apparently dead man, his mouth and eyes wide open. Sarah Twain-Lagarde, in the clinic with her feverish toddler, called 911 herself and tried to resuscitate Mr. Sauvageau, but nurses told her to stop.

Eventually, ambulance medics arrived and tried in vain to revive the patient.

An autopsy later revealed that Mr. Sauvageau died of a pulmonary embolism and would not have survived anyway. But the coroner said that Dr. Chaoulli had no way of knowing that, and should have tried to perform CPR.

“[Mr. Sauvageau] had been alive just a few minutes earlier. Suddenly, he loses consciousness and his pulse stops. You have to throw yourself on him and get everything going again, and that wasn’t done,” Ms. Rudel-Tessier said in an interview. “[Dr. Chaoulli] should have done so.”

The coroner urged Quebec’s College of Physicians to write guidelines so private health clinics provide a safe environment for patients. She also urged the college to probe the quality of medical care given to Mr. Sauvageau.

By Chris Doherty
Deseret News
Friday, April 24, 2009

Let me begin by stating that I believe that neither the Canadian nor the U.S. health-care system is perfect, and both could be improved. Some Canadians in need of elective procedures are said to have to wait to see a specialist for their medical conditions in Canada. I, personally, had an appointment last week with a specialist here whom I had been waiting 16 weeks to see, because he is one of a small group of providers “approved” by my insurance. Waits can occur on either side of the border.

But my wait had an end to it. Some 48 million people will have no end to medical problems they are experiencing. Imagine having a migraine that had no end to it or a painful urological condition that continued indefinitely. Imagine if you had a suspicious mole and no way to know if it was cancer or not. That is the state of 48 million Americans, through no fault of their own.

Granted, there may be some who just thought they would save a buck or two and made an unwise decision. Those who willingly run the unnecessary risk may pay, and pay dearly, for their mistake. The rest are a group of people who are excluded from health care in this country. They are those who have either been priced out of the private insurance market, or have pre-existing conditions. In America, you are safe, as long as your medical conditions don’t prevent you from working for an existing company with benefits, you don’t get laid off and you don’t want to start your own company. Then you will continue to be covered.

Otherwise, you may want to consider moving to Canada, where health care is not just offered to the healthy or wealthy. Unfortunately, however, you still run the risk of bankruptcy, since medical bills contribute to half of all personal bankruptcies in this country, and three-fourths of those bankrupted have health insurance at the time they get sick or injured.

Consider what two peer-reviewed medical journals have published on the subject. First, from the Journal of the American Medical Association, “Proposal of the Physicians Working Group for Single-Payer National Health Insurance,” where we are told that “the United States spends more than twice as much on health care as the average of other developed nations,” and “the United States alone treats health care as a commodity distributed according to the ability to pay rather than as a social service to be distributed according to medical need.” From the New England Journal of Medicine, “A large sum might be saved in the United States if administrative costs could be trimmed by implementing a Canadian-style health-care system.”

The Physicians Proposal, published in the Journal of the American Medical Association, is available at www.pnhp.org. It is a proposal put together by responsible physicians who advocate an expanded and improved version of traditional Medicare. According to the proposal, “the world’s richest health-care system is unable to ensure basics like prenatal care and immunizations, and we trail the developed world on such indicators as infant mortality and life expectancy.”

In life expectancy, we are 29th, right behind Bosnia. People largely misunderstand this statistic. They think that Americans may live a few years less than the rest of the developed world. That is not what this statistic represents, since once people in this country reach that magical age of 65, they are eligible for universal care, in the form of Medicare. What skews this statistic are the unnecessary deaths of Americans before 65. This is what causes the average life expectancy to drop.

Our country discovered much of the medical knowledge that the rest of the world enjoys. Why, then, are we exporting these discoveries and trailing the rest of the developed world?

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Chris Doherty, a multiple sclerosis patient, lives in Bountiful.

By Timothy Noah
Slate
Wednesday, April 22, 2009

On April 21, the Senate Finance Committee held the first of three planned hearings on health care reform. The focus was on improving the efficiency of health care “delivery systems”–i.e., hospitals and doctors. It’s an important issue, but not one that’s likely to be the primary focus of the health care reform bill, which will probably have more to do with reforming health insurance. For this reason, the hearing didn’t get much press coverage, and what few stories there were groped around for an angle. I groped a little myself before deciding not to write anything. A day later, though, I changed my mind and decided that the hearing had generated a kind of Zen-riddle news–not about the witnesses who appeared, but rather about a witness who, on reflection, seemed conspicuous for his absence.

The hearing was, I suspect, a sop to Sen. Charles Grassley, R-Iowa, the committee’s ranking member. Grassley spoke with greater urgency than Sen. Max Baucus D-Mont., the committee chairman, about reforming delivery systems. (Click here for Grassley’s opening statement and here for Baucus’.) “How do we make sure that we’re really tackling delivery reform?” Grassley asked. There was a lot of talk about the need to reform or eliminate the “fee-for-service” model, which pays doctors and hospitals based on the number of procedures performed rather than on outcomes; about the need to collect information on best practices and to alter treatments accordingly; and, especially, about the need to increase computerization of medical records (this last should be greatly accelerated by the stimulus bill’s allocation of $21 billion to hospitals and doctors for information technology).

The 13 witnesses were chosen for their expertise on these topics. Particular deference was granted to Glenn Steele, president and chief executive officer of Geisinger Health System, which employs about 800 doctors in rural Pennsylvania. Geisinger is seen as an innovator in streamlining health care. The company imposes a single charge for treating particular illnesses, integrating physician and hospital fees into what it terms a “warranty.” It has standardized treatments for the most common chronic diseases according to “consensus-based best practices,” and it invested early and aggressively in computerized patient records. Also present was Paul Diaz, president and chief executive officer of Kindred Healthcare, the largest provider of long-term health care in the country, who is a strong advocate for shifting more medical care into home settings. There were representatives from the American Hospital Association, the American College of Physicians, and (representing patients) the National Partnership for Women and Families. Mark McClellan, who ran the Medicare and Medicaid programs under President George W. Bush, was there. So was Glenn Hackbarth, chairman of the Medicare Payment Advisory Commission, an agency that advises Congress about the Medicare program.

Who wasn’t there? Eric Shinseki.

Shinseki was the Army chief of staff who effectively ended his career when, prior to the Iraq war, he testified before the Senate Armed Services Committee that the postwar occupation would require several hundred thousand troops. This estimate, which proved accurate, was deemed scandalously disloyal at the time by Defense Secretary Donald Rumsfeld and Deputy Defense Secretary Paul Wolfowitz, who were lowballing the official estimate at 100,000. What does all this have to do with health care reform? Absolutely nothing. But President Obama rewarded Shinseki’s truth-telling by appointing him secretary of veterans affairs, and the Senate confirmed him on Obama’s first day in office. If you still don’t know what this has to do with health care reform, then I urge you to read Best Care Anywhere, Phillip Longman’s indispensable 2007 account of how the Veterans Administration turned itself into the country’s pre-eminent health care delivery system. (Full disclosure: I wrote the book’s forward. I received no money for doing so, and will receive none if you purchase a copy.) Or you can read the 2005 Washington Monthly article on which the book was based or the column I wrote when Longman’s article first appeared, or The Next Progressive Era, a book Longman just published (with Ray Boshara) that includes a summary of the arguments put forth in Best Care Anywhere.

Phil and I have publicized this story repeatedly because no one else seems willing to–no one, that is, except for experts on medical economics, to whom the VA’s superiority to other health care delivery systems is boringly old news. The general public doesn’t know about it because nonexperts harbor a deep resistance to believing it. This stems in part from confusion over the well-publicized scandals involving Walter Reed Army Medical Center, which even many Washington policy jocks think (mistakenly) is part of the VA hospital system. (It isn’t. As the name implies, Walter Reed is run by the Army.) It also stems from a conviction that has seeped deep into the political culture that anything run by the federal government must be inferior to market-based alternatives. The Obama administration and Congress are utterly terrified that in crafting health care reform they will run afoul of this infantile prejudice. They will therefore move heaven and earth to avoid acknowledging the VA’s pioneering use of computerized medical records, its avoidance of the justly lamented fee-for-service model (VA physicians are salaried), and the efficiencies it realizes by treating patients over the long term. The implications of this success are too terrifyingly pinko. The VA is, after all, a system in which the role of insurer, physician, and hospital are all assumed by the U.S. government. The Bush administration did its patriotic best to diminish the VA’s record of success by withholding necessary funding and vastly expanding its use of private contractors, an experiment that, according to a recent article by Tara McKelvey in The Nation, is off to an unpromising start. But the VA’s own doctors and hospitals continue to provide a distressingly positive model for health care reform.

Baucus and his staff recently met privately with experts from the VA to learn about these achievements, but he isn’t about to put any of these folks in front of a TV camera. The rationale for excluding the VA from the hearing was that because it is run separately from the rest of the health care system, the VA probably won’t be affected by any delivery-system reforms Congress enacts. But that’s absurd. The hearing was an attempt to seek out models for reform. The VA hospitals represent the most successful large-scale reform in the delivery of health care that this country has seen in decades. But–shhhhh!–let’s keep that between you and me. I’ve probably said too much already.

By Jacob Goldstein
WSJ’s blog
April 20, 2009

How would you respond if a computer called you and asked the following question?

“Would you be willing to get involved to make your voice heard so that we can improve our nation’s health care system?”

If the computer was calling you on behalf of WellPoint, the big insurer that runs Blue Cross and Blue Shield programs in 14 states, would your answer be any different?

The question was part of an automated phone survey WellPoint conducted last week in what looks like a step into the national debate over health reform. The questions (online here) ask members how much they know about what’s happening with health reform and whether they want to learn more.

The company placed three million automated calls. Of those, 142,000 connected and 66,000 people told the computer on the other end of the line that they’d be interested in learning more, WellPoint spokeswoman Cheryl Leamon told the Health Blog.

Insurers sometimes enlist interested beneficiaries to help sway public opinion. “If there are members who are interested in supporting our position and being participants in the health care policy debate we want to make sure that they are able to participate,” Leamon said.

The health insurance industry’s main trade group, AHIP, has taken a few clear positions on health reform thus far — promising to insure all comers if there’s a mandate requiring everyone to buy insurance, and opposing a proposed public insurance plan that would compete with private plans.

Wellpoint’s Health Action Network scheme is at http://www.healthactionnetwork.com/keycontact.aspx

Letters
Berkshire Eagle
Tuesday, April 21

Dr. Susanne King (Eagle, op-ed, April 4) has again hit the nail on the head in asking citizens to support Sen. Bernie Sanders’ bill and Rep. John Conyer’s bill to truly reform health care by doing away with the current dysfunctional system of private health insurance plans and replacing it with an expanded and improved Medicare for All.

“The public plan option” now being discussed in Congress would not control costs as only 16 percent of the roughly $400 billion annually achieved by a single payer would be realized and would do nothing to streamline the administrative tasks (and costs) of hospitals, physicians’ offices, and nursing homes. They would still contend with multiple payers, and hence still need the complex cost tracking and billing apparatus that drives administrative costs.

In addition, a quarter century of experience with public/private competition in the Medicare program demonstrates that the private plans will not allow a level playing field. Despite strict regulation, private insurers have successfully cherry-picked healthier seniors and exploited regional health spending differences to their advantage. They have progressively undermined the public plan, which started as the single payer for seniors.

A public plan as one option will not lead toward single-payer, but toward the segregation of patients, with profitable ones in private plans and unprofitable ones in the public plan.

For these and other reasons, Berkshire Masscare and Physicians for a National Health Plan are asking people in the Berkshires to come out to support Single Payer Medicare for All during a nationally coordinated effort to achieve true equity in health care. There will be demonstrations in Wash D.C., major cities and elsewhere. Come to Park Square in Pittsfield on Friday from 5-6 p.m. to let the deciders know how you feel.

MICHAEL KAPLAN, M.D.
Lee

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http://www.berkshireeagle.com/ci_12189179

by Merton Bernstein
Health Affairs blog
April 22nd, 2009

Science does not permit ideology to foreclose inquiry; it requires facing facts and following where they and logic lead. Hence many cheered when President Barack Obama announced that science is back, that predisposition will no longer be permitted to trump reality. Everyone knew he was talking about stem cell research.

Who could have guessed that the Obama administration and key congressional players would exclude single-payer/Medicare-for-all programs from consideration even though that means ignoring the cost savings of hundreds of billions of dollars in private plans’ nonbenefit costs? Further, administration health experts advertise their focus on avoiding incentives for unnecessary treatment, but pay no mind to the expensive distortions that follow from physicians’ ownership interests in high-cost equipment and services. Odd that the scientific method does not apply to medical care where science should govern.

Snubbing And Chiding Single-Payer Advocates

Until the day before the Health Care Summit, no advocate of single-payer/Medicare-for-all had been invited to rub shoulders at the White House conference with the hordes of insurance and drug manufacturer officials and lobbyists, right-wing think-tank pundits, major employers and their organizations, and hospital executives — all deeply implicated in the design, execution, and defense of the current dysfunctional medical care insurance nonsystem — the supposed object of “reform.” An 11th hour invitation came only after a threatened demonstration by doctors, nurses, and medical students who back a single-payer proposal sponsored by 94 members of the U.S. House of Representatives. Even the legendarily unbiased Congressional Budget Office had shortly before issued two large studies of medical care, totaling about 400 pages, containing only a few cursory paragraphs about single payer/Medicare-for-all.

The president opened and closed the one-day summit with his usual splendidly composed summary of hurdles to providing medical care to all and curbing costs. He had sharp words only for “bleeding-heart liberals,” chiding them for inattention to costs although they repeatedly stress the huge savings single-payer/Medicare-for-all could deliver. It is his experts who persistently ignore those cost savings while pursuing possibly desirable but unproven methods of reducing costs. So, for example, claims are made for vast savings by health information technology (IT), such as computerization of patient records, which might reduce medical errors if a uniform nationwide system becomes operational — years hence. Similarly, it is unproven that paying health care providers based on outcomes would be feasible; with hundreds of millions of billings, assessing the efficacy of each treatment seems impossible — and impossibly costly.

Savings From Medicare-For-All

Medicare-for-all would save hundreds of billions every year. Private insurers expend enormous sums for insurer commissions, advertising, Wall-Street-scale executive compensation, and profits. In contrast, Medicare spends little or nothing on these unnecessary, unproductive activities. Health care providers and private plans struggle with thousands of different billing schedules. As the New York Times reported: “The average provider — doctors or hospitals — has between 5 and 100 reimbursement rates for the same procedure. . . . A hospital chain may have 150 rates for the same procedure.”

In contrast, Medicare districts employ only one. That helps explain why Medicare’s nonbenefit expenditures require only 4 percent of benefit outlays while private plans expend far more — on the order of 20% for publicly traded companies and as much as 31% of premium for some. We are talking real money. A recent McKinsey Quarterly article found that medical care insurer billing consumes more than $300 billion a year, costing 15 percent or more of medical outlays. Medicare-for-all would make do on a sliver of that. (Harvard Medical School economist Rashi Fein tells the story of a former colleague working at a Montreal hospital, where three people processed bills there, primarily for traveling Americans. Later he worked at Chicago’s Michael Reese Hospital, where the billing facility, jammed with clerks at computers, stretched a football field’s length in two directions.)

Understand that Medicare uses private insurers to administer its program and pays private providers to deliver care; patients select their providers, a choice many private plans limit. Medicare confines its payments to a fee schedule it promulgates after receiving the advice of the Medical Payment Advisory Commission (MedPAC), which comprises a variety of practitioners and others. That price constraint reduces costs. But the big savings come from simplified billing/payment procedures.

In addition, Medicare delivers its benefits at lower cost than means-tested programs like Medicaid and the Children’s Health Insurance Program (CHIP). Absorbing all such programs (and there are many) into Medicare would save tens of billions more and speed up providing care.

Opponents dismiss Medicare-for-all as a “one-size-fits-all” formula. Well, who among us knows how to estimate when we or a family member will need medical care? Who among us can gauge when a heart attack may strike or a drunken driver will cross the median? In this world full of uncertainty, we all share the same need for assured medical care — that’s the size Medicare-for-all fits.

The Effects Of Conflicts Of Interest

Studies repeatedly show that medical care providers with ownership interests in labs and high-cost devices like computed tomography (CT) scan and magnetic resonance imaging (MRI) machines prescribe those services far more than those who do not own any. Medical societies should ban such conflicts of interest; if they don’t, Medicare, which attempts to curb them, should forbid them completely. That would save billions and confine providers to their proper role: treatment based on medical grounds uninfluenced by profit.

So why do the Obama medical care gurus, Senator Baucus and Senator Grassley, and the Congressional Budget Office exclude Medicare-for-all, although it would save far more than any rival plan? In large measure, that results from the propaganda war on single-payer. President Obama says that it would be impractical to try to substitute Medicare for “legacy” private plans because so many are “accustomed to” them. But “accustomed to” simply does not describe plans that are melting down, disappearing, and becoming constantly more unaffordable.

Further, Medicare does not charge higher rates for pre-existing conditions or for elderly and female patients as private plans do, thereby encouraging employers to discriminate in employment. Moreover, with everyone covered for all needed medical care, the greater part of malpractice compensation — medical repair — would be met without the delay and expenses of medical malpractice disputes and litigation.

Yet the Obama, Baucus, Grassley, CBO, and other playlists exclude consideration of Medicare-for-all. With rising discomfort with the price tag of recovery programs, those desiring comprehensive health care cannot afford to disregard a program with such enormous savings. If Medicare-for-all gets “on the table” before the Senate Finance and House Ways and Means committees, the CBO must report its vast savings and its greater efficiency and effectiveness compared with more expensive alternatives. Only by censorship — only by treating Medicare-for-all as nonexistent — can lesser alternatives be discussed with a straight face.

And censorship is not compatible with science.