PNHP

Medicare fee reduction for ASCs

Medicare fee reduction for ASCs

Doc group says new ASC rate would be 'death blow'

By Jennifer Lubell
Modern Physician
August 20, 2007

Ambulatory surgery centers (ASCs) are trying to figure out how they’ll cope with a new Medicare payment system that threatens to drastically reduce their reimbursement rates.

The CMS last month issued a series of regulations to revise the payment system for ASCs, setting a new compensation rate of 65% of what hospital outpatient departments get paid under Medicare. While some centers may seek to benefit under the rule, others–particularly single-specialty ASCs, whose payments are expected to drop dramatically–will be left with some tough decisions on whether to keep their Medicare patient base or to close their doors altogether.

The new payment rate was included in the annual proposed rulemaking for the hospital outpatient prospective payment system, or OPPS, whose final rulemaking is usually issued in November and goes into effect the following calendar year.

The CMS’ procedures bring the total number of covered surgical procedures under the revised payment system to about 3,300. The agency stipulates that ASCs will get paid for any procedure that is determined by the CMS not to pose a safety risk to Medicare beneficiaries, and will not require an overnight stay.

“The system we are announcing today will promote the goals of quality and efficiency in care furnished to people with Medicare in ambulatory surgery centers,” said Leslie Norwalk, who resigned last month as the CMS’ acting administrator, in a written statement. The revised system will also take a “major step forward” toward eliminating financial incentives for choosing one care setting over another, she said.

(David Johnson, M.D., president of the American College of Gastroenterology) and others in the industry dispute that fact. If anything, the rule “will force Medicare patients to migrate back into the more expensive hospital outpatient setting, ultimately costing the federal government more,” he says.

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20070820/MODERNPHYSICIAN/308200004/-1/newsletter06

Comment:

By Don McCanne, MD

Why should Medicare pay higher prices for procedures done in a hospital outpatient setting than it does for procedures done in an efficient, free-standing ambulatory surgery center (ASC)? This is our tax money. Shouldn’t we be receiving a better value?

It is important to understand that the extra payment to hospitals is not wasted. That extra buffer helps to fund charity care, money-losing services such as emergency centers, and other essential hospital services that may not be directly reimbursed. The hospital balance sheet does require the input from profit centers to balance the losses that are inevitable in other services. Hospitals cannot remain solvent if they allow profitable services to be outsourced while continuing to provide only services that result in losses. Thus the taxpayers are receiving value for the Medicare fees being paid to hospitals for ambulatory services.

What about the fees paid to ASCs? Although they are already lower than the fees paid to hospitals, they are much higher than their actual costs since the ASCs do not have to pay for all of the ancillary services and money-losing services that hospitals must provide. Also, since ASCs do not provide charity services, they don’t have to make up those losses with higher fees. CMS has determined, through the outpatient prospective payment system (OPPS), that profits are excessive, and that they can and should be reduced. Thus the lower fees will provide greater taxpayer value.

In a way, this is poetic justice. The ASCs were established primarily to dramatically enhance the fees paid to procedure-oriented physicians. By building and owning these centers, the physicians would receive not only their high, procedure-oriented professional fees, but they would also share in the generous profits of the free-standing ASCs. The profits were further enhanced by cream-skimming the profitable patients and dumping the others on the hospitals. (The fees for each paying patient that displaces a charity patient primarily go directly to the profit line, because fixed costs remain the same.) Though the prices of the procedures have been lower, the total costs to the taxpayer actually have been higher than they should have been because we still had to support the losses in our hospitals. It was only appropriate that the OPPS be used to improve taxpayer value in purchasing these services.

A previous Quote of the Day message on the book, “Medicare Prospective Payment and the Shaping of U.S. Health Care,” by Rick Mayes, Ph.D. and Robert A. Berenson, M.D., explained how Medicare is far more effective than the private insurance industry in setting fees that are based on legitimate costs and fair profits. The experience with ASCs provides us with yet one more example of why we should replace our fragmented, dysfunctional system of financing health care with a single public system that serves all of us well – the patients (affordable access), the providers (fair profits), and the taxpayers (value purchasing).

Canada's public health care system holds answers to surgery wait times

Canadian Centre for Policy Alternatives and the BC Health Coalition.
Press Release

(Ottawa) Surgical waitlists can be dramatically cut if governments develop a strategy to scale up innovations already underway in the public health care system, says a new study released today.

Why Wait? Public Solutions to Cure Surgical Waitlists looks at groundbreaking projects in BC, Alberta, Saskatchewan and Ontario that have significantly reduced wait times for procedures such as hip and knee replacements, cataract surgery and others.

The Saskatchewan Surgical Care Network, Canada’s first province-wide surgical patient registry, has used pro-active strategies to reduce wait times. “Accurate data is essential for creating management strategies and targeting resources for achieving long term success in wait list management,” says network Chair, Dr. Rob Weiler. The network doesn’t just report waitlists–regional health authorities are expected to actively manage them in partnership with surgeons.

The study also examines Alberta’s Hip and Knee Replacement Project and Ontario’s Wait Time Strategy, both successful initiatives. Five projects in British Columbia are profiled, including the Joint Replacement Access Clinic (JRAC) at Lions Gate Hospital in North Vancouver, where waits for the first surgical consult have dropped from almost a year to between two and four weeks. Without any additional resources, the project implemented common waitlits and a one-stop booking service that streamlines all aspects of patient screening and care before, during and after surgery.

The projects point to two key reforms needed in the surgical system:

* Team-based care in specialized clinics: Surgeons moved from working mainly on their own to working in teams in specialized clinics. The shift to team-based care means patients are better prepared for surgeries, operations are less likely to be cancelled, operating rooms function more efficiently and hospital stays are shorter. These projects also make greater use of nurses and other health care workers at every stage of the process.

* Pro-active waitlist management: Shifting responsibility for managing waitlists from individual surgeons to health authorities means patients can access the first available surgeon. Health authorities in turn can make sure efficiencies and best practices from individual hospitals are applied across the system.

“Canadians don’t need superficial wait time guarantees,” says study co-author Dr. Michael Rachlis. “We need a strategy that helps provinces implement the kinds of public sector innovations featured in this study. The federal government’s wait time guarantee fails to provide that leadership, and leaves the door open to private delivery.”

“Solving the waitlists problem will require some major cultural shifts in how our surgical system functions,” says co-author Marcy Cohen. “We need more collaboration, not a competitive private model that will siphon precious health care professionals out of the public system.”

“There’s this myth out there that only the private sector can innovate, but this study shows that is false,” says Rachlis.

-30-

Why Wait? Public Solutions to Cure Surgical Waitlists was released today by the Canadian Centre for Policy Alternatives and the BC Health Coalition.

To arrange an interview, call Terra Poirier, 604-801-5121 x229 or Shannon Daub, 604-801-5121 x226 (cell 604-836-9372).

For BC Health Coalition interviews only, call Leslie Dickout at 604-681-7945.

* Editorial: Public Solutions Could be Undermined by Private Interests
* Press Release: Innovative surgical projects show how waitlists can be solved: Submission to BC ‘conversation on health’

Download the Report/Study:

* Why Wait? Public Solutions to Cure Surgical Waitlists – PDF File, 747 Kb
* SUMMARY: Why Wait? Public Solutions to Cure Surgical Waitlists – PDF File, 569 Kb

Insurance doesn't make you feel secure

By Rose Ann DeMoro
South Florida Sun-Sentinel
August 12, 2007

News that some doctors in South Florida will now be charging patients annual “administrative fees” like credit card companies or banks is a sober reminder of how out of control our increasingly dysfunctional healthcare system has become, and in need of genuine, comprehensive reform.

On the same day the South Florida Sun-Sentinel reported the latest trend of doctors’ fees — on top of the other out-of-pocket charges for co-pays and deductibles — a Wall Street Journal/NBC News poll August 2 found that “costs of health care” is the top economic concern for Americans. Those findings echoed what has become a steady drumbeat this year. What is now evident is the problem is no longer just the 45 million Americans without health coverage, but increasingly the health insecurity for those already insured.

In January, a vice president of the Kaiser Family Foundation testified to the House Ways and Means Committee that one in six adults who are privately insured have “substantial problems paying their medical bills.”

In February, the journal /Health Affairs /projected out-of-pocket costs for consumers would jump 76 percent within the next decade.

In March, the journal of the American Academy of Pediatrics noted that families with high deductible health plans are far more likely to put off needed care due to the cost.

In April, Harvard researchers found that higher healthcare costs place a particularly harsh burden on women who typically have greater medical needs than men.

In July, a Rand study in the /Journal of the American Medical Association /reported that for each 10 percent hike in out-of-pocket costs, patients stop buying up to 6 percent of needed prescription drugs.

Some doctors may well feel squeezed by a health care industry where higher revenues and increased market share seem to be the new Hippocratic oath. But every additional tax and fee only exacerbates the crisis for patients and families.

And public anger is increasing at those who are profiting off their pain and health insecurity. The /Journal//NBC poll on Americans’ views on the economy also asked respondents to rate their confidence in 16 varied institutions. The bottom rung was firmly held by health insurance companies.

Those polled may not know the numbers, but they would probably not be surprised to learn that insurance industry profits jumped from $20.8 billion in 2002 to $57.5 billion in 2006. In the same period, drug company profits went from $64.4 billion to $94.8 billion, according to a June report by the Institute for Health and Socio-Economic Policy, the research arm of the California Nurses Association/National Nurses Organizing Committee.

Americans have had enough. Several recent polls have documented that two-thirds believe the government should guarantee healthcare for everyone, even if it means an increase in taxes.

There is one reform that accomplishes that goal — HR 676 in Congress, a single-payer system in the form of an expanded and enhanced Medicare for all. It would cover everyone with comprehensive benefits, choice of physician and hospitals, and end the thousand daily cuts of co-pays, deductibles, and new administrative fees. Perhaps best of all, it gets the insurance companies out of the way.

The public is ready. Now we just need our legislators and presidential candidates to follow.

Rose Ann DeMoro is executive director of the California Nurses Association/National Nurses Organizing Committee, www.calnurses.org.

In search of vision on health care

Presidential candidates talk about it, but their plans fall short.

Editorial
Des Moines Register
August 19, 2007

“Millions of our citizens do not now have a full measure of opportunity to achieve and to enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection.”

Who spoke those words?

A. Hillary Clinton, at the Iowa State Fair.

B. Mitt Romney, in a town-hall meeting.

C. President Harry Truman, in a 1945 speech to Congress proposing a national health-care system, and President Lyndon Johnson, who quoted Truman when he signed Medicare and Medicaid into law in 1965.

Those words sound like statements made by today’s candidates, but if you chose C, you get an A in health-care history.

Unfortunately, the words of Truman are as true today as they were 62 years ago. An estimated 47 million Americans are uninsured and don’t have the opportunity to enjoy good health. They aren’t protected against the financial disaster an illness can bring. This country is facing a health-care crisis. In poll after poll, Americans list health care as the most important domestic issue.

What’s needed: a president with the vision and passion to reform this country’s health-care system the way Johnson and Congress eventually did.

It’s up to Iowans – who are in the unique position of being visited by droves of presidential candidates – to demand that kind of vision and passion from our visitors.

It’s time for this country to do something historic. The creation of Medicare and Medicaid were historic. Poor and elderly Americans needed health care. Congress responded.

Now it’s time for Congress to respond again by creating a system that provides basic coverage to all Americans at an affordable cost. This editorial page has long argued that the best option would be to finance the system through tax dollars, similar to the popular Medicare program for seniors. Under so-called “single-payer” systems, the government is the payer for services delivered by private-sector hospitals, doctors and clinics. Patients would still choose their own doctors.

Such a system would dramatically cut red tape and administrative costs. Medicare’s administrative costs run less than 5 percent, compared to double-digit administrative costs in the private sector.

It’s up to the next president to lead Congress down the road to an affordable health-care system that covers everyone. All of the candidates spend time on the stump criticizing the current system. And several have rolled out reform plans. Unfortunately – with a few exceptions – the plans are tepid or misguided or half-baked. They’re too safe. They lack vision.

Some plans wouldn’t really cover everyone. Others are vague about the price tag or include no realistic mechanisms to control costs. Most gloss over the tough questions about what a “basic” plan would really cover.

Maybe they fear offending the insurance industry and powerful special interests that make campaign contributions. Or they’re afraid a plan will be labeled “socialized medicine.” Or they push ideas such as “electronic medical records” – which amount to tinkering with the system.

What they should be pushing is vision – the vision of doing what’s right.

Leaving millions of Americans without health insurance isn’t right. Forcing people into bankruptcy because they’re sick isn’t right. Living in a country that offers great medical advances and life-saving treatments but to only some of the people isn’t right.

Twentieth-century American history is littered with failed health-care reform plans. The next president must have a clear vision for doing right by Americans on health care – and the passionate persistence to see a reform plan enacted.

Standing up for what’s right starts on the campaign trail.

Single-pay system would slash costs

By CINDY PURVIS
GoErie.com
August 10, 2007

In 2004, General Motors announced that liabilities for employee health care topped $60 billion. In November 2005, GM laid off 30,000 employees. In January 2006, Ford cut 25,000 jobs. In February, Chrysler announced that it faces $21.1 billion in future retiree health-care liabilities. The majority of the obligation is not funded.

The fortunate employees of companies that have made health care part of a benefits package are seeing an ever-decreasing benefit. Small businesses find it impossible to afford health-care benefits for their employees, and many can’t afford to purchase health-care insurance for themselves.

Our entire country is walking around in fear of getting sick; in fear of the annual increase in health insurance; in fear of changing jobs; in fear of being denied coverage because of a pre-existing condition.

In Pennsylvania, some very brave people have come out to confront our collective fear.

They have written a bill and found a group of braver Pennsylvania senators and representatives who have introduced the Family & Business Health Security Act.

This is SB300 in the Senate and HB1660 in the House.

It provides for total coverage for every Pennsylvanian and includes medical, dental, vision, mental health, prescription drugs and long-term care. There are never any co-pays, never any applications and never any denials.

It is funded by the cost-saving, single-payer system. No, this is not socialized medicine, though socialized medicine works well for Veterans Administration medical centers, which are owned by the federal government, and staffed by government employees.

The Family & Business Health Care Security Act is instead funded by a change in how we all pay for health care. Instead of purchasing health insurance, health care would be financed mainly through a new 10 percent employer payroll tax.

Most businesses would save money. Several examples that are near and dear to us taxpayers are our local taxing bodies.

With the cost of health-care coverage for the employees being reduced to just 10 percent of payroll, the city of Erie would save more than $5 million per year, the Erie County almost $5 million per year and the the Erie School District $9 million per year. It would save smaller school districts, such as Harbor Creek, almost $900,000, and Corry more than $1.3 million per year.

Instead of paying into a health-insurance plan or purchasing their own, Pennsylvanians would pay a 3 percent of earnings payroll tax. For a family making $50,000 per year, the cost would be $1,500. But remember: There is never a co-pay or a fee for prescriptions or out-of-pocket expenses.

These funds would go into a trust called the Pennsylvania Health Care Trust Fund.

All money collected and received by the plan are by law to be used exclusively to finance the plan. In other words, no other state agency or legislative body could dip into this fund for use in other areas. Pennsylvanians are assured that the funds are put into “a lock box” to be used only for health care.

This plan gives us the freedom to choose our own doctors, dentists, hospitals and any other decision affecting our health.

This plan eliminates the greed-ridden insurance system that chooses for us what care we are allowed to receive.

This system is of the people, by the people, for the people. We will no longer need to live in fear of getting sick or changing jobs or retiring.

This plan also eliminates the need for companies to pay retiree health-care benefits. Whatever Medicare does not cover would be automatically covered under this plan.

For more information, to read the entire bill or to get a petition to distribute to garner support from our area Pennsylvania legislators: www.healthcare4allpa.org.

CINDY PURVIS is an Erie resident. She is a member of Lake Erie Alliance for Democracy and co-chairwoman of HealthCare4All Pa, an organization focused on providing health care for every American.

World's Best Medical Care?

Editorial
New York Times
Published: August 12, 2007

Many Americans are under the delusion that we have “the best health care system in the world,” as President Bush sees it, or provide the “best medical care in the world,” as Rudolph Giuliani declared last week. That may be true at many top medical centers. But the disturbing truth is that this country lags well behind other advanced nations in delivering timely and effective care.

Michael Moore struck a nerve in his new documentary, “Sicko,” when he extolled the virtues of the government-run health care systems in France, England, Canada and even Cuba while deploring the failures of the largely private insurance system in this country. There is no question that Mr. Moore overstated his case by making foreign systems look almost flawless. But there is a growing body of evidence that, by an array of pertinent yardsticks, the United States is a laggard not a leader in providing good medical care.

Seven years ago, the World Health Organization made the first major effort to rank the health systems of 191 nations. France and Italy took the top two spots; the United States was a dismal 37th. More recently, the highly regarded Commonwealth Fund has pioneered in comparing the United States with other advanced nations through surveys of patients and doctors and analysis of other data. Its latest report, issued in May, ranked the United States last or next-to-last compared with five other nations — Australia, Canada, Germany, New Zealand and the United Kingdom — on most measures of performance, including quality of care and access to it. Other comparative studies also put the United States in a relatively bad light.

Insurance coverage. All other major industrialized nations provide universal health coverage, and most of them have comprehensive benefit packages with no cost-sharing by the patients. The United States, to its shame, has some 45 million people without health insurance and many more millions who have poor coverage. Although the president has blithely said that these people can always get treatment in an emergency room, many studies have shown that people without insurance postpone treatment until a minor illness becomes worse, harming their own health and imposing greater costs.

Access. Citizens abroad often face long waits before they can get to see a specialist or undergo elective surgery. Americans typically get prompter attention, although Germany does better. The real barriers here are the costs facing low-income people without insurance or with skimpy coverage. But even Americans with above-average incomes find it more difficult than their counterparts abroad to get care on nights or weekends without going to an emergency room, and many report having to wait six days or more for an appointment with their own doctors.

Fairness. The United States ranks dead last on almost all measures of equity because we have the greatest disparity in the quality of care given to richer and poorer citizens. Americans with below-average incomes are much less likely than their counterparts in other industrialized nations to see a doctor when sick, to fill prescriptions or to get needed tests and follow-up care.

Healthy lives. We have known for years that America has a high infant mortality rate, so it is no surprise that we rank last among 23 nations by that yardstick. But the problem is much broader. We rank near the bottom in healthy life expectancy at age 60, and 15th among 19 countries in deaths from a wide range of illnesses that would not have been fatal if treated with timely and effective care. The good news is that we have done a better job than other industrialized nations in reducing smoking. The bad news is that our obesity epidemic is the worst in the world.

Quality. In a comparison with five other countries, the Commonwealth Fund ranked the United States first in providing the “right care” for a given condition as defined by standard clinical guidelines and gave it especially high marks for preventive care, like Pap smears and mammograms to detect early-stage cancers, and blood tests and cholesterol checks for hypertensive patients. But we scored poorly in coordinating the care of chronically ill patients, in protecting the safety of patients, and in meeting their needs and preferences, which drove our overall quality rating down to last place. American doctors and hospitals kill patients through surgical and medical mistakes more often than their counterparts in other industrialized nations.

Life and death. In a comparison of five countries, the United States had the best survival rate for breast cancer, second best for cervical cancer and childhood leukemia, worst for kidney transplants, and almost-worst for liver transplants and colorectal cancer. In an eight-country comparison, the United States ranked last in years of potential life lost to circulatory diseases, respiratory diseases and diabetes and had the second highest death rate from bronchitis, asthma and emphysema. Although several factors can affect these results, it seems likely that the quality of care delivered was a significant contributor.

Patient satisfaction. Despite the declarations of their political leaders, many Americans hold surprisingly negative views of their health care system. Polls in Europe and North America seven to nine years ago found that only 40 percent of Americans were satisfied with the nation’s health care system, placing us 14th out of 17 countries. In recent Commonwealth Fund surveys of five countries, American attitudes stand out as the most negative, with a third of the adults surveyed calling for rebuilding the entire system, compared with only 13 percent who feel that way in Britain and 14 percent in Canada.

That may be because Americans face higher out-of-pocket costs than citizens elsewhere, are less apt to have a long-term doctor, less able to see a doctor on the same day when sick, and less apt to get their questions answered or receive clear instructions from a doctor. On the other hand, Gallup polls in recent years have shown that three-quarters of the respondents in the United States, in Canada and in Britain rate their personal care as excellent or good, so it could be hard to motivate these people for the wholesale change sought by the disaffected.

Use of information technology. Shockingly, despite our vaunted prowess in computers, software and the Internet, much of our health care system is still operating in the dark ages of paper records and handwritten scrawls. American primary care doctors lag years behind doctors in other advanced nations in adopting electronic medical records or prescribing medications electronically. This makes it harder to coordinate care, spot errors and adhere to standard clinical guidelines.

Top-of-the-line care. Despite our poor showing in many international comparisons, it is doubtful that many Americans, faced with a life-threatening illness, would rather be treated elsewhere. We tend to think that our very best medical centers are the best in the world. But whether this is a realistic assessment or merely a cultural preference for the home team is difficult to say. Only when better measures of clinical excellence are developed will discerning medical shoppers know for sure who is the best of the best.

With health care emerging as a major issue in the presidential campaign and in Congress, it will be important to get beyond empty boasts that this country has “the best health care system in the world” and turn instead to fixing its very real defects. The main goal should be to reduce the huge number of uninsured, who are a major reason for our poor standing globally. But there is also plenty of room to improve our coordination of care, our use of computerized records, communications between doctors and patients, and dozens of other factors that impair the quality of care. The world’s most powerful economy should be able to provide a health care system that really is the best.

Single-payer healthcare advocate Johnathon Ross M.D., M.P.H. takes a local look at the national HMO crisis

by Johnathon S. Ross, M.D.
Toledo City Paper
Published August 8th 2007

Johnathon Ross doesn’t see Michael Moore’s op-ed documentary “Sicko” as a film — it’s his life.

Ross has practiced and taught internal medicine at St. Vincent Mercy Medical Center for 27 years and every day witnesses the results of America’s crippled state of healthcare. Whether it’s trying to find ways to help uninsured patients get treatment or helping insured patients find care when their HMOs refuse to cover their medical expenses, Ross has his hands full.

And he’s mad as hell it got to this point.

Ross is one of many advocates of a nationally based single-payer health insurance system and is a member of the state council of the Single Payer Network of Ohio (spanohio.org). He is currently campaigning in support of House Bill 676 (co-sponsored by Dennis Kucinich, Marcy Kaptur and other Ohio House members) ensuring that all Americans have access to tax-paid national healthcare.

In a City Paper exclusive, Ross recounts some of the horrific experiences that Toledoans are forced to endure due to the current state of healthcare. In simple, direct language, Ross explains what national healthcare is, can be, and — more importantly — that it’s not akin to socialism.

Perhaps you have seen the billboards and the full-page ads. Perhaps you have asked yourself, as I have, why the health insurance companies, drug companies and health-care systems are allowed to waste so much money on advertising when ordinary people struggle to get the care that they need? Perhaps you have seen the movie “Sicko” and wonder if you could be the next insured person that the system will fail. I have come to believe that in healthcare, market forces are the disease for which they are supposed to be the cure. These “healthcare marketing wars” in Northwest Ohio and elsewhere in the country soak up billions and are symptoms of that disease.

Every day in the St. V’s clinic, I see a near miss. Every week I see a wounding. Every month or so I see a death due to a sickness care non-system that leaves 50,000 Lucas County citizens, more than a million Ohioans, more than 45 million Americans uninsured, and all of us unsure if healthcare will be there for us if we need it. The Institute of Medicine, our most prestigious health experts, estimates that more than 18,000 of our fellow citizens, our friends, neighbors and family, die every year from lack of health insurance alone, and nearly another 100,000 will die from medical errors. The system is broken and it needs to be fixed.

By the time you’ve read this article and have thought about it for just a few minutes, another fellow American will die from lack of health insurance. One person dies every half hour or so, day after day, year after year. While our elected representatives quibble, we sacrifice these people up to our stubborn market ideology.

A day in the life of a Toledo clinic

A recent Friday morning was a typical clinic session where I work. Here are a few stories from just that single morning. Imagine similar stories day after day for the past 27 years and you will understand why I am writing this article. I have changed the names for privacy but I did ask each patient if it was OK to tell their story and each agreed.

Tommy’s heart

Tommy is 41. He was making his first visit following bypass surgery after suffering a massive myocardial infarction (heart attack). Tommy can’t read or write very well. He was working a low-wage job that did not have insurance so he never saw a doctor. That doesn’t matter much now since he lost his job due to his illness. He became very depressed in the hospital and started on medication for his depression and for his heart. Fortunately, he was at the clinic with a family member who had paid more than $100 for medication to keep him alive until his appointment with us. Thanks to CareNet, a free-care program I helped to devise which helps some of the uninsured in Lucas County, he was able to see us in the clinic without charge. But there was little likelihood he would be able to pay for follow up with the heart specialists, let alone the bills they would soon be sending for his hospital care. One of our nurses spends hours every day trying to help people get “free” drugs from the pharmaceutical companies. She looked deflated when we gave her the long list of expensive medication he needed. The drugs may be “free,” but her salary is not.

Shelly’s stomach

Shelly works as a temp at another hospital. She doesn’t have any benefits or health insurance, even though she works full-time as a nurse’s aide. The irony of a healthcare worker who is not covered for healthcare is not lost on me, as I see lots of nurse’s aides who work in extended care facilities with no benefits. She was seen in the emergency room for severe stomach pain. She hasn’t seen the bill yet, but I suspect her stomach pain will get worse when she does. Her stomach still hurts and she had no money for the ulcer medicine they wrote. I search the free samples and manage to find about two weeks of medicine. I give her a follow-up appointment and hope for the best. Even if she was covered, it can take a month or more to get a gastroenterologist to see my patients at the hospital sponsored GI clinic, although with a personal call sometimes our generous gastroenterologists will let me jump the line for an urgent case.

Where’s Nolan’s Medicare?

A clerk tells me that Nolan is at the window and he is upset. He is out of pills and needs samples of medication for his blood pressure. He should be covered by Medicare as he is 68. He has a card, but the pharmacy says it is no good — he is not sure if it is no good for all or some of his medication. He just knows he is not supposed to miss his medicine. We have referred him several times to the Social Security office and they tell him he is covered by his card. There are 50 different plans, all with different formularies, and there is no time today to sort out (again) why his card is no good. I tell the nurse to give him samples and we will try to sort out what is wrong with his card later. The Medicare D program will continue to send money to the middlemen who will continue to not pay for Nolan’s medicine. Somewhere, the stockholders are smiling. Thank you, President Bush, for such a totally complex and confusing program.

Chris: Out of breath

Chris has asthma, low back pain and high blood pressure. She is doing OK with her current medication but isn’t sure if her re-application for Medicaid will go through in time to allow her to get the refills that she needs. She says that she might have to “spin down”. She’s not sure what this means, but I know. She works a little and may have made too much money this past month to qualify for help and might need to “spend down” not “spin down” to poverty or perhaps she will do both. In any case, she will be out of medicine in about 10 days. The last time she missed her asthma medicine she ended up in the ER with an asthma attack. I give her one of my last samples of an inhaler just in case, and hope I don’t need it for someone else with more immediate needs.

Arthur’s hunt

Arthur, on the other hand, has insurance. He has Medicaid, our state-funded insurance for the poor. This is his third visit for a rash that won’t go away. I would make a referral but it seems there are no dermatologists in town who will take his Medicaid HMO. I try to make light of a bad situation and remark that his new private insurance card (they contract with Medicaid) is actually a hunting license — we get to go hunting for specialists who will accept his plan. We decide to continue our game of musical medicines to see if one will help. At least, he has coverage for his medicines. Welcome to the best healthcare system in the world.

Sharpen the focus

For patients, soaring health insurance premiums are the norm and uninsured Americans now exceed 45 million. Eighty percent of the uninsured are working people and their kids. They are not covered by their jobs or cannot afford to buy health insurance when faced with skyrocketing premiums or are refused coverage for pre-existing conditions. Managed care, with its restrictions and market competition, failed to cure rising costs or expand access, but it surely created hassles for doctors and patients. Those same self-interested insurers who brought us HMOs insist that financially squeezing patients using high deductibles will cure the cost crisis. In reality, high deductible health plans and health savings accounts are just another way that insurers and employers shift the cost burden onto employees, whose co-payments and deductibles soar while their coverage sinks. If doctors and patients have problems now with billing, collections, insurance hassles, and continuity of care, just wait until HSAs with Swiss cheese coverage become the norm. Unfortunately, market forces will not work. There will never be an effective market for healthcare services. Why?

Healthcare is not an ordinary product that people want. Rather, it is a necessity that they must have. The consumer’s not sovereign. The doctor, not the patient, orders the care. There’s no easy exit from the market for patients. Price does not matter. When critically (and expensively) ill, you buy or die. The most expensive healthcare is necessary not desired. Even the best physicians are unsure at times what tests or treatments will benefit a patient. Thus, the costs of patient care are often unpredictable. It is this uncertainty and unpredictability that creates the need for insurance in the first place. Asking patients to assume more responsibility for out-of-pocket costs will not work. Americans already pay the highest out-of-pocket healthcare costs in the Western world, and this has done little to control costs. Research shows that higher out-of-pocket payments will reduce the number of outpatient visits, but these payments fail to increase the appropriateness of the visits. Paying more does not create wiser consumers of healthcare. To understand the absurdity of using individual market forces to control healthcare costs, imagine open-heart surgery is on sale. Would you have two? The most expensive surgery or medical care is the least optional, predictable or negotiable. The sickest 10 percent of patients generate 73 percent of the healthcare bills at an average of about $39,000 per person yearly. They will save nothing in their HSAs. The market for medical services fails these tests of an effective market and will fail in the guise of HSAs. The insurance industry says that consumers need to have “more skin in the game”. They think it’s a game. We know who will get skinned.

Massachusetts is forcing uninsured working families to buy bare-bones coverage from private insurers who will keep a big chunk of the premiums for administrative costs and profits. This is hailed as reform but hardly seems wise, fair or efficient. It will leave these families vulnerable to large healthcare bills that are potentially financially fatal to working families, and there seems to be little effort to improve the quality of care under this so-called reform. It is a Marie Antoinette solution: “Let them buy high deductible health plans”! Many of these families cannot afford to keep food on the table and the lights on. A riddle: What is the difference between a mandatory premium payment and a tax? Answer: A mandatory premium allows insurers to keep a larger percentage of the money collected before healthcare is delivered (20 percent for private for profit insurers vs. 3 percent for Medicare).

If market forces cannot work, the proven alternative is a tax-financed universal health insurance system. It may seem counter-intuitive that a tax-financed universal health insurance program that covers everyone could be less expensive than a health system based on cutthroat competition between private insurance companies that leaves 45 million Americans uncovered. Yet, this has proven to be the case for every other industrial democracy. Recently, Taiwan made just such a switch and again proved it could be done. They covered everyone with little increase in cost. On the other hand, national health insurance, as proposed in HB 676 (co-sponsored by Congressmen John Conyers [D., Mich.] and Dennis Kucinich [D., Ohio]), would replace private premiums with fair payroll taxes. These funds, added to current public spending, would create a single insurance pool adequate to cover all Americans with no added spending. Here in Ohio, The Health Care for All Ohioans act could do the same thing for all Ohioans. Ohio could lead the way. How can this be true?

How it could work

In multipayer systems, complexity yields high administrative costs. Each insurer, hospital and doctor must keep track of a myriad of contracts, discount arrangements, benefit packages, formularies, limited referral networks, and insurance regulations designed to reduce utilization. Market solutions leave this insurance and billing bureaucracy in place and add the complexity of tracking 300 million individual insurance policies. The result can be predicted from Economics 101: One person’s income is another person’s cost. The growth of administrative personnel in healthcare has jumped more than 2500 percent in the past 30 years while the growth of doctors and nurses has grown about 150 percent. Healthcare has become a jobs program for an army of paper-pushers. Most of them are chasing the money to pay for care and, in our multipayer system, chasing money is complicated work.

The current system is failing most if not all of us. Americans and Ohioans need affordable, guaranteed, high-quality healthcare coverage that they cannot lose if they change or lose a job, whether they are rich or poor, whether they are healthy and want to stay that way or whether they are sick and want to get well. Single payer national health insurance or a similar state-based plan could accomplish the goals of guaranteed coverage, quality and cost control.

Doctors would get paid for every patient and malpractice and administrative costs would drop. They could maintain continuity of patient care. Patients would get needed care as ordered without a wallet biopsy. Outcomes and quality would improve. Emergency room overuse and abuse would diminish. Chronic disease management would improve. Multiple studies confirm that the administrative simplicity of a single universal insurance pool — like Medicare — yields hundreds of billions in savings that allow comprehensive coverage for all at current levels of spending. A tax-based public system is simple and efficient. There is simply less work to do. The data from a universal system can also be used to track and evaluate the appropriateness and the quality of care and offers the best opportunity to improve the quality of care.

Healthcare costs are hurting the competitiveness of our products in the world markets. American business and governmental employers are struggling with the burden of healthcare costs and, despite almost twenty years of experimentation with these different approaches to cost control, healthcare costs are growing at double the rate of the Gross Domestic Product. At the same time, the number of uninsured full-time workers has soared by tens of millions, as premiums have become more and more unaffordable. Several large industries are giving up responsibility for insuring their workers, creating insurance trusts that will be maintained by unions who — not surprisingly — support national health insurance. The largest U.S. employer, Wal-Mart, has come under severe criticism for its failure to cover its workers. They are targeted with state laws aimed at forcing them to insure their employees or pay special taxes to the state to help cover the uninsured. More business leaders are calling for a national solution. One can only speculate that it must be ideology alone that keeps many business leaders from supporting a national solution.

Business owners should realize that the healthcare system provides the maintenance on their work force just as other experts provide maintenance on their expensive and complex industrial and business machinery. It makes good sense to get the most comprehensive maintenance system for the best price. More for the same money, value, is what a tax-financed universal health insurance system can provide. Those businesses avoiding the cost of insuring their employees are still the recipients of cost shifting. This occurs through higher taxes to fund indigent care and higher prices paid when doing business with companies who continue to insure their employees and pass along the healthcare costs shifted to them in the price of their products. Counter-intuitive or not, even conservative businessmen should support a single-payer universal health insurance solution. Financially, they already are.
Join the movement

The necessary economic conditions for an efficient competitive market for health services do not exist. Evidence from the current competition between insurers shows it is likely that market forces will aggravate the dual problems of high cost and poor access. A tax-financed universal health insurance offers the best alternative and is consistent with both progressive and conservative principles for reform.

The enactment of tax-financed universal health insurance at the national level will most likely require successful enactment at the state level. A significant mass movement for sweeping health reform will be needed and will require substantial leadership from the provider community to overcome the concentrated insurance and business interests likely to oppose reform. The opponents of reform will try to scare us off again.

“I am Oz the great and terrible — Pay no attention to that man behind the curtain! Taxes bad! Government bad! Socialized medicine bad!”

I, for one, will not listen to that humbug any more. Taxes are an efficient way to collect the money. The government is our own. It is not socialized medicine, this is social insurance just like Social Security, and Medicare. These programs work, and what would our seniors do without it?

A single-payer tax-financed universal health insurance, an improved and expanded Medicare program as that proposed in HR 676 or the HCFAO act will cover all of us comprehensively at no added cost. It’s good for business and our health. Single-payer national health insurance is conservative of the basic structure of the American healthcare system and in that it changes mainly the financing, easing our efforts to improve quality. It is conservative of individual freedom and responsibility in that it allows free choice of provider and eliminates financial barriers to preventive and chronic disease care. Single-payer national health insurance would cover everyone, save lives, save money, and it is the right thing to do. Join the movement and let’s roll.

Johnathon S. Ross M.D., M.P.H. Past President, Physicians for a National Health Program (pnhp.org). Member of the State Council, Single Payer Action Network of Ohio (spanohio.org).

Need for more doctors part of solution

By Robert Gumbiner
South Florida Sun-Sentinel
August 15, 2007

Michael Moore’s film, Sicko, begins to expose the problem — the lack of available health care insurance in the U.S. — but does he go far enough? The number of people in the U.S. who lack health insurance is part of the problem. This number includes people who have no health insurance, people who are under insured and people who may be covered but don’t have access to health care because of the lack of available health care providers or providers who refuse to cooperate with government plans such as Medicare or Medicaid.

The real problem is the impending lack of available physicians as physicians retire and are not replaced. What good is being able to pay for health care if you can’t find anybody to provide that care?

Doctors seem to be limiting their practices or retiring as fast as new doctors are produced. Then there’s the bigger problem of doctors moving to sub-specialties and super specialties. As medicine becomes more complicated, we will lose available doctors in the future. Doctors are becoming hospitalists, procedurists, super specialists, oncologists who only treat one type of cancer, dermatologists who only inject Botox, or opthomologists who specialize in one part of the eye, i.e. glaucoma. The list goes on.

What facts did Moore’s film miss? How about the fact that the Cuban system works well because they produce four times the doctors they need. Or how the British system is struggling because they are running out of British doctors and importing heavily from third world countries.

Sicko missed that we are already paying enough to supply health care to everybody in the U.S. If we would remove insurance companies from the mix, use the employer/employee contributions and government support and revise the system, national universal health care would be what we pay now.

Moore also had the opportunity to debunk the false allegation that people are resistant to a universal health system provided through a single payer, the federal government. Does Moore realize that we already have a single payer system and that it’s one of the biggest in the world, covering 47 million people? It’s called Medicare.

So, what can we do? Many solutions are simple and they have been implemented before. We need to produce more health care providers, particularly doctors, by paying for their schooling, tuition, books and paying them a salary to go to school. This was done in World War II on a large scale by the military. Doctors who are trained by the government can be assigned to places where doctors are needed and in necessary specialties. We need to move away from the laissez-faire attitude that doctors can go into any specialty they want, charge what they want, or live anywhere in the country, whether they are needed or not. If they are trained by the government then they will be obligated to serve the citizens. Today they are partially trained by the government (through state medical schools and federal grants) but without obligation.

The solutions come down to three key changes. One, educate doctors, nurses, dentists and other health care providers at government expense and pay them a salary while they are in training. Two, devise a system that changes the incentives of our current fee-for-every-service system. Three, reorganize the system and redistribute the available health care so everybody has access to health care providers.

If Sicko had gone a little further and dealt with the impending lack of providers as well as the fact that we already have a national universal health system, the film would have moved us further toward the solution to this country’s health care crisis.

Misguided proposals for two-tier health care

By Danielle Martin
The Toronto Star
August 15, 2007

What will the Canadian Medical Association do next?

Condemned by the public, editorial boards and politicians of all persuasions for its recent policy statement “Medicare Plus,” the CMA will have some explaining to do to its members — and to Canadians — at its annual meeting in Vancouver next week, Aug. 19 to 22.

Few Canadians would disagree with CMA president Colin McMillan’s speech releasing the recommendations in “Medicare Plus” calling for more doctors, nurses and other health professionals; for a broader spectrum of standards and a publicly funded guarantee to protect us against unreasonable wait times; and for the expansion of medicare to cover services like expensive drugs and long-term care.

These proposals recognize that our publicly funded system needs reforming to meet the needs of our aging population, the massive growth in pharmaceuticals and the shift away from a hospital and physician-centric model of health care.

However, conspicuously absent from McMillan’s remarks — and from the CMA’s Ipsos Reid poll on Canadians’ attitudes towards “Medicare Plus” — was the proposal that doctors be permitted to work in both public and private systems (dual practice) and that patients be allowed to buy private insurance for some publicly funded services covered by medicare.

It’s as if the CMA were embarrassed about this aspect of its policy and decided not to highlight it in public statements and surveys. And embarrassed it should be. There is a compelling body of evidence against parallel private insurance in the Canadian context. There is also an inherent conflict of interest for physicians working in dual practice since, as the public would understandably perceive, these physicians could have an interest in promoting longer wait times in the public system to increase use of the more lucrative private system.

This very evidence was reviewed in the CMA’s own 2006 discussion paper “It’s About Access!,” which found that the introduction of parallel private insurance:

* would not improve access to publicly insured services.

* would not lower costs or improve quality of care.

* could increase wait times for those who are not privately insured.

* could exacerbate human resource shortages in the public system.

Indeed, the CMA’s 2006 findings are in keeping with the recommendations of the Romanow Commission and the Kirby Senate Report against parallel private insurance, and with the experience of those few Western countries where it is actually permitted. Despite the repeated claims of incoming CMA president Brian Day, these countries do not include France and Germany. However, they do include the U.K., Australia and New Zealand, where experience has shown that parallel private insurance and dual practice reduces cost efficiency and increases wait times for patients in the public system. There is every reason to believe that this would also happen in Canada, particularly given our acute shortage of health professionals (which the CMA prominently and appropriately decries in “Medicare Plus”).

At a time when our neighbours to the south are absorbing the lessons of the Michael Moore film Sicko — including that health care should not be left to the profit motives of private insurers — the CMA should reject any regressive attempt to turn back the clock here in Canada. This is especially the case since, in comparison with the U.S., the evidence shows that Canada has as good or better health outcomes at significantly lower cost.

We all know medicare needs reform. Issues such as wait times, the rising cost of pharmaceuticals and our shortage of health-care professionals are real challenges that must be addressed. But nothing has happened to the health-care system in the last year to justify the CMA ignoring the findings of its own 2006 study. Rather, as McMillan himself acknowledged, “the fact of the matter is that governments ARE making progress” (his emphasis). As the Canadian Centre for Policy Alternatives has documented, across Canada there has been significant progress in reducing wait times through better management and team-based practice.

As CMA members and physicians, we need to ask our association why, if some physician resources are being underutilized, isn’t the CMA advocating for solutions that would increase patient care to all Canadians, on the basis of need, within the public system? Why is the CMA proposing dual practice and private insurance when this would pull nurses, technicians and other needed human resources out of the public system? Why is the CMA ignoring the evidence and separating itself from every other professional group on the issue of for-profit care?

During next week’s meeting, the CMA will have a chance to show a more constructive approach to health-care reform when delegates debate proposals on the expansion of homecare, pharmacare and environmental health — proposals that will help expand and modernize our publicly-funded health-care system to meet the needs of all Canadians, not just a wealthy few.

The misguided recommendations of “Medicare Plus” on private insurance and dual practice — which are not scheduled for debate — are best discarded like the bad medicine they are.

Danielle Martin is a family physician in Toronto and Chair of Canadian Doctors for Medicare.

Canada’s public health care system holds answers to surgery wait times

Canadian Centre for Policy Alternatives and the BC Health Coalition.
Press Release

(Ottawa) Surgical waitlists can be dramatically cut if governments develop a strategy to scale up innovations already underway in the public health care system, says a new study released today.

Why Wait? Public Solutions to Cure Surgical Waitlists looks at groundbreaking projects in BC, Alberta, Saskatchewan and Ontario that have significantly reduced wait times for procedures such as hip and knee replacements, cataract surgery and others.

The Saskatchewan Surgical Care Network, Canada’s first province-wide surgical patient registry, has used pro-active strategies to reduce wait times. “Accurate data is essential for creating management strategies and targeting resources for achieving long term success in wait list management,” says network Chair, Dr. Rob Weiler. The network doesn’t just report waitlists–regional health authorities are expected to actively manage them in partnership with surgeons.

The study also examines Alberta’s Hip and Knee Replacement Project and Ontario’s Wait Time Strategy, both successful initiatives. Five projects in British Columbia are profiled, including the Joint Replacement Access Clinic (JRAC) at Lions Gate Hospital in North Vancouver, where waits for the first surgical consult have dropped from almost a year to between two and four weeks. Without any additional resources, the project implemented common waitlits and a one-stop booking service that streamlines all aspects of patient screening and care before, during and after surgery.

The projects point to two key reforms needed in the surgical system:

* Team-based care in specialized clinics: Surgeons moved from working mainly on their own to working in teams in specialized clinics. The shift to team-based care means patients are better prepared for surgeries, operations are less likely to be cancelled, operating rooms function more efficiently and hospital stays are shorter. These projects also make greater use of nurses and other health care workers at every stage of the process.

* Pro-active waitlist management: Shifting responsibility for managing waitlists from individual surgeons to health authorities means patients can access the first available surgeon. Health authorities in turn can make sure efficiencies and best practices from individual hospitals are applied across the system.

“Canadians don’t need superficial wait time guarantees,” says study co-author Dr. Michael Rachlis. “We need a strategy that helps provinces implement the kinds of public sector innovations featured in this study. The federal government’s wait time guarantee fails to provide that leadership, and leaves the door open to private delivery.”

“Solving the waitlists problem will require some major cultural shifts in how our surgical system functions,” says co-author Marcy Cohen. “We need more collaboration, not a competitive private model that will siphon precious health care professionals out of the public system.”

“There’s this myth out there that only the private sector can innovate, but this study shows that is false,” says Rachlis.

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Why Wait? Public Solutions to Cure Surgical Waitlists was released today by the Canadian Centre for Policy Alternatives and the BC Health Coalition.

To arrange an interview, call Terra Poirier, 604-801-5121 x229 or Shannon Daub, 604-801-5121 x226 (cell 604-836-9372).

For BC Health Coalition interviews only, call Leslie Dickout at 604-681-7945.

* Editorial: Public Solutions Could be Undermined by Private Interests
* Press Release: Innovative surgical projects show how waitlists can be solved: Submission to BC ‘conversation on health’

Download the Report/Study:

* Why Wait? Public Solutions to Cure Surgical Waitlists – PDF File, 747 Kb
* SUMMARY: Why Wait? Public Solutions to Cure Surgical Waitlists – PDF File, 569 Kb

Insurance doesn’t make you feel secure

By Rose Ann DeMoro
South Florida Sun-Sentinel
August 12, 2007

News that some doctors in South Florida will now be charging patients annual “administrative fees” like credit card companies or banks is a sober reminder of how out of control our increasingly dysfunctional healthcare system has become, and in need of genuine, comprehensive reform.

On the same day the South Florida Sun-Sentinel reported the latest trend of doctors’ fees — on top of the other out-of-pocket charges for co-pays and deductibles — a Wall Street Journal/NBC News poll August 2 found that “costs of health care” is the top economic concern for Americans. Those findings echoed what has become a steady drumbeat this year. What is now evident is the problem is no longer just the 45 million Americans without health coverage, but increasingly the health insecurity for those already insured.

In January, a vice president of the Kaiser Family Foundation testified to the House Ways and Means Committee that one in six adults who are privately insured have “substantial problems paying their medical bills.”

In February, the journal /Health Affairs /projected out-of-pocket costs for consumers would jump 76 percent within the next decade.

In March, the journal of the American Academy of Pediatrics noted that families with high deductible health plans are far more likely to put off needed care due to the cost.

In April, Harvard researchers found that higher healthcare costs place a particularly harsh burden on women who typically have greater medical needs than men.

In July, a Rand study in the /Journal of the American Medical Association /reported that for each 10 percent hike in out-of-pocket costs, patients stop buying up to 6 percent of needed prescription drugs.

Some doctors may well feel squeezed by a health care industry where higher revenues and increased market share seem to be the new Hippocratic oath. But every additional tax and fee only exacerbates the crisis for patients and families.

And public anger is increasing at those who are profiting off their pain and health insecurity. The /Journal//NBC poll on Americans’ views on the economy also asked respondents to rate their confidence in 16 varied institutions. The bottom rung was firmly held by health insurance companies.

Those polled may not know the numbers, but they would probably not be surprised to learn that insurance industry profits jumped from $20.8 billion in 2002 to $57.5 billion in 2006. In the same period, drug company profits went from $64.4 billion to $94.8 billion, according to a June report by the Institute for Health and Socio-Economic Policy, the research arm of the California Nurses Association/National Nurses Organizing Committee.

Americans have had enough. Several recent polls have documented that two-thirds believe the government should guarantee healthcare for everyone, even if it means an increase in taxes.

There is one reform that accomplishes that goal — HR 676 in Congress, a single-payer system in the form of an expanded and enhanced Medicare for all. It would cover everyone with comprehensive benefits, choice of physician and hospitals, and end the thousand daily cuts of co-pays, deductibles, and new administrative fees. Perhaps best of all, it gets the insurance companies out of the way.

The public is ready. Now we just need our legislators and presidential candidates to follow.

Rose Ann DeMoro is executive director of the California Nurses Association/National Nurses Organizing Committee, www.calnurses.org.

World’s Best Medical Care?

Editorial
New York Times
Published: August 12, 2007

Many Americans are under the delusion that we have “the best health care system in the world,” as President Bush sees it, or provide the “best medical care in the world,” as Rudolph Giuliani declared last week. That may be true at many top medical centers. But the disturbing truth is that this country lags well behind other advanced nations in delivering timely and effective care.

Michael Moore struck a nerve in his new documentary, “Sicko,” when he extolled the virtues of the government-run health care systems in France, England, Canada and even Cuba while deploring the failures of the largely private insurance system in this country. There is no question that Mr. Moore overstated his case by making foreign systems look almost flawless. But there is a growing body of evidence that, by an array of pertinent yardsticks, the United States is a laggard not a leader in providing good medical care.

Seven years ago, the World Health Organization made the first major effort to rank the health systems of 191 nations. France and Italy took the top two spots; the United States was a dismal 37th. More recently, the highly regarded Commonwealth Fund has pioneered in comparing the United States with other advanced nations through surveys of patients and doctors and analysis of other data. Its latest report, issued in May, ranked the United States last or next-to-last compared with five other nations — Australia, Canada, Germany, New Zealand and the United Kingdom — on most measures of performance, including quality of care and access to it. Other comparative studies also put the United States in a relatively bad light.

Insurance coverage. All other major industrialized nations provide universal health coverage, and most of them have comprehensive benefit packages with no cost-sharing by the patients. The United States, to its shame, has some 45 million people without health insurance and many more millions who have poor coverage. Although the president has blithely said that these people can always get treatment in an emergency room, many studies have shown that people without insurance postpone treatment until a minor illness becomes worse, harming their own health and imposing greater costs.

Access. Citizens abroad often face long waits before they can get to see a specialist or undergo elective surgery. Americans typically get prompter attention, although Germany does better. The real barriers here are the costs facing low-income people without insurance or with skimpy coverage. But even Americans with above-average incomes find it more difficult than their counterparts abroad to get care on nights or weekends without going to an emergency room, and many report having to wait six days or more for an appointment with their own doctors.

Fairness. The United States ranks dead last on almost all measures of equity because we have the greatest disparity in the quality of care given to richer and poorer citizens. Americans with below-average incomes are much less likely than their counterparts in other industrialized nations to see a doctor when sick, to fill prescriptions or to get needed tests and follow-up care.

Healthy lives. We have known for years that America has a high infant mortality rate, so it is no surprise that we rank last among 23 nations by that yardstick. But the problem is much broader. We rank near the bottom in healthy life expectancy at age 60, and 15th among 19 countries in deaths from a wide range of illnesses that would not have been fatal if treated with timely and effective care. The good news is that we have done a better job than other industrialized nations in reducing smoking. The bad news is that our obesity epidemic is the worst in the world.

Quality. In a comparison with five other countries, the Commonwealth Fund ranked the United States first in providing the “right care” for a given condition as defined by standard clinical guidelines and gave it especially high marks for preventive care, like Pap smears and mammograms to detect early-stage cancers, and blood tests and cholesterol checks for hypertensive patients. But we scored poorly in coordinating the care of chronically ill patients, in protecting the safety of patients, and in meeting their needs and preferences, which drove our overall quality rating down to last place. American doctors and hospitals kill patients through surgical and medical mistakes more often than their counterparts in other industrialized nations.

Life and death. In a comparison of five countries, the United States had the best survival rate for breast cancer, second best for cervical cancer and childhood leukemia, worst for kidney transplants, and almost-worst for liver transplants and colorectal cancer. In an eight-country comparison, the United States ranked last in years of potential life lost to circulatory diseases, respiratory diseases and diabetes and had the second highest death rate from bronchitis, asthma and emphysema. Although several factors can affect these results, it seems likely that the quality of care delivered was a significant contributor.

Patient satisfaction. Despite the declarations of their political leaders, many Americans hold surprisingly negative views of their health care system. Polls in Europe and North America seven to nine years ago found that only 40 percent of Americans were satisfied with the nation’s health care system, placing us 14th out of 17 countries. In recent Commonwealth Fund surveys of five countries, American attitudes stand out as the most negative, with a third of the adults surveyed calling for rebuilding the entire system, compared with only 13 percent who feel that way in Britain and 14 percent in Canada.

That may be because Americans face higher out-of-pocket costs than citizens elsewhere, are less apt to have a long-term doctor, less able to see a doctor on the same day when sick, and less apt to get their questions answered or receive clear instructions from a doctor. On the other hand, Gallup polls in recent years have shown that three-quarters of the respondents in the United States, in Canada and in Britain rate their personal care as excellent or good, so it could be hard to motivate these people for the wholesale change sought by the disaffected.

Use of information technology. Shockingly, despite our vaunted prowess in computers, software and the Internet, much of our health care system is still operating in the dark ages of paper records and handwritten scrawls. American primary care doctors lag years behind doctors in other advanced nations in adopting electronic medical records or prescribing medications electronically. This makes it harder to coordinate care, spot errors and adhere to standard clinical guidelines.

Top-of-the-line care. Despite our poor showing in many international comparisons, it is doubtful that many Americans, faced with a life-threatening illness, would rather be treated elsewhere. We tend to think that our very best medical centers are the best in the world. But whether this is a realistic assessment or merely a cultural preference for the home team is difficult to say. Only when better measures of clinical excellence are developed will discerning medical shoppers know for sure who is the best of the best.

With health care emerging as a major issue in the presidential campaign and in Congress, it will be important to get beyond empty boasts that this country has “the best health care system in the world” and turn instead to fixing its very real defects. The main goal should be to reduce the huge number of uninsured, who are a major reason for our poor standing globally. But there is also plenty of room to improve our coordination of care, our use of computerized records, communications between doctors and patients, and dozens of other factors that impair the quality of care. The world’s most powerful economy should be able to provide a health care system that really is the best.