By Patrice A. Harris, M.D., M.A.
President, American Medical Association
AMA, May 29, 2020

“In the grip of a global pandemic that has already killed more than 100,000 Americans, severing ties with the World Health Organization (WHO) serves no logical purpose and makes finding a way out of this public health crisis dramatically more challenging. This senseless action will have significant, harmful repercussions now and far beyond this perilous moment, particularly as the WHO is leading worldwide vaccine development and drug trials to combat the pandemic. COVID-19 affects us all and does not respect borders; defeating it requires the entire world working together. In the strongest terms possible, the American Medical Association urges the president to reverse course and not abandon our country’s leadership position in the global fight against COVID-19.”

https://www.ama-assn.org…

---

Comment:

By Don McCanne, M.D.

President Trump’s effort to sever ties with the World Health Organization during this horrendous pandemic seems like it screams out for nonviolent resistance. Can’t we get anything right?

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Stacey McMorrow, Lisa Dubay, Genevieve M. Kenney, Emily M. Johnston, and Clara Alvarez Caraveo
Urban Institute, May 28, 2020

Abstract

Alarming increases in US maternal mortality have generated national attention, a search for policy solutions to promote maternal health, and an increased recognition of how important the postpartum period is for mothers’ and infants’ health and well-being. Without access to consistent, comprehensive health insurance coverage, many new mothers can face extreme challenges obtaining the care they need to support their and their infants’ health. This analysis uses 2015–18 data from the National Health Interview Survey (NHIS) to document access and affordability challenges facing uninsured new mothers and 2015–17 data from the Pregnancy Risk Assessment and Monitoring System (PRAMS), a state-specific surveillance system of pregnancies resulting in a live birth, to describe the health status of women who lost Medicaid coverage following their pregnancies. Together, our analysis provides new evidence on the access and affordability barriers that could be reduced and the health problems that could be treated if these uninsured new mothers were to gain coverage through a postpartum Medicaid extension or broader Medicaid expansion.

From the Discussion

Despite documented increases in insurance coverage for new mothers under the ACA, more than 1 in 10 new mothers remained uninsured from 2015 to 2018, and over half of those women were Hispanic and nearly two-thirds lived in the South. About 1 in 5 uninsured new moms reported at least one unmet need for medical care because of cost, and over half were very worried about paying their medical bills, emphasizing that health care affordability is a problem for many new mothers. Moreover, about half of all uninsured new mothers reported that losing Medicaid or other coverage after pregnancy was the reason they were uninsured. Thus, it appears many new mothers could benefit from the financial protection that insurance can provide and would likely benefit from the extensions of postpartum Medicaid coverage that have been proposed at both the federal and state levels.

Even if a permanent postpartum extension were adopted, however, not all uninsured new mothers would qualify. Access to postpartum coverage under current rules depends critically on state-specific eligibility criteria for pregnancy-related Medicaid coverage, based both on income and immigration status and on which women actually enroll in Medicaid during their pregnancies. These same factors will determine who is eligible for the maintenance-of-effort provisions under the Families First Coronavirus Response Act and state-specific implementation of the provisions may vary. Moreover, the economic downturn may extend well beyond the public health emergency, leaving many new mothers at higher risk of being uninsured when the maintenance-of-effort provision expires or if they lose other coverage sources because of rising unemployment. Without additional federal or state action to expand access to affordable coverage options, many new mothers may remain uninsured both during and after the public health crisis.

Our findings suggest that if new mothers were to gain coverage through an extension of postpartum Medicaid eligibility, they could experience reduced affordability problems and an improved ability to manage chronic conditions during that critical period after giving birth. However, longer-term solutions to addressing the maternal morbidity and mortality crisis would involve achieving continuous coverage and care throughout a woman’s reproductive years. A more comprehensive Medicaid expansion, for example, would allow more low-income women to identify and manage their chronic conditions, plan and support wanted pregnancies, and maintain good health to support ongoing maternal and child well-being.

https://www.urban.org…

---

Comment:

By Don McCanne, M.D.

“And poor people who are uninsured? They can always get Medicaid.”

No. There are a great many reasons why uninsured, low-income individuals may not be able to enroll in Medicaid, ranging from qualifications based on their own personal situations to public policies that vary by the state in which they reside. This Urban Institute study shows that even those who may have been enrolled in Medicaid during a pregnancy can lose that coverage in their postpartum period. That certainly indicates a serious policy deficiency.

The authors suggest that the incremental reform of expanding coverage during the postpartum period can close the gap for some of them, though there will always be others who remain uninsured for various reasons.

The authors then make what at first glance seems to be an excellent suggestion of providing Medicaid coverage throughout a woman’s reproductive years. But what happens when that woman moves to a different state with different rules, or her income no longer falls within the qualifying level, or she has stuttering coverage through her spouse’s employer-sponsored plan(s), or qualifications change based on Medicaid waivers or budgetary constraints, or whatever? Also, why cover her only through her reproductive years and not in childhood and beyond menopause? And why not automatically cover the infant produced by that pregnancy? And what about other women not eligible for the Medicaid program? And, while we’re at it, what about everyone else throughout their entire lives?

Incremental reforms such as expanding postpartum coverage fail to correct the gross fundamental defects in our health care financing system such as the lack of universality, the profound, expensive administrative excesses, the lack of affordability for far too many individuals and families, and the profound inequities that should not exist in the most expensive system in the world. Most of the proposed incremental reforms add to the administrative complexity and costs while falling far short of the essential goals of universality, comprehensiveness, high quality, effectiveness, efficiency, equity, and affordability.

Instead of tinkering with postpartum coverage of Medicaid patients, the Urban Institute should look at their own study of single payer Medicare for All, correct its deficiencies (we’ll help them), and then advocate for its adoption since it would truly ensure health care for all of us, with postpartum care automatically included.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Arundhati Roy
Financial Times, April 3, 2020

But unlike the flow of capital, this virus seeks proliferation, not profit, and has, therefore, inadvertently, to some extent, reversed the direction of the flow. It has mocked immigration controls, biometrics, digital surveillance and every other kind of data analytics, and struck hardest — thus far — in the richest, most powerful nations of the world, bringing the engine of capitalism to a juddering halt. Temporarily perhaps, but at least long enough for us to examine its parts, make an assessment and decide whether we want to help fix it, or look for a better engine.

The mandarins who are managing this pandemic are fond of speaking of war. They don’t even use war as a metaphor, they use it literally. But if it really were a war, then who would be better prepared than the US? If it were not masks and gloves that its frontline soldiers needed, but guns, smart bombs, bunker busters, submarines, fighter jets and nuclear bombs, would there be a shortage?

---

Finally, on March 19, the Indian prime minister addressed the nation. He hadn’t done much homework. He borrowed the playbook from France and Italy. He told us of the need for “social distancing” (easy to understand for a society so steeped in the practice of caste) and called for a day of “people’s curfew” on March 22. He said nothing about what his government was going to do in the crisis, but he asked people to come out on their balconies, and ring bells and bang their pots and pans to salute health workers.

On March 24, at 8pm, Modi appeared on TV again to announce that, from midnight onwards, all of India would be under lockdown. Markets would be closed. All transport, public as well as private, would be disallowed.

He said he was taking this decision not just as a prime minister, but as our family elder. Who else can decide, without consulting the state governments that would have to deal with the fallout of this decision, that a nation of 1.38bn people should be locked down with zero preparation and with four hours’ notice? His methods definitely give the impression that India’s prime minister thinks of citizens as a hostile force that needs to be ambushed, taken by surprise, but never trusted.

Locked down we were. Many health professionals and epidemiologists have applauded this move. Perhaps they are right in theory. But surely none of them can support the calamitous lack of planning or preparedness that turned the world’s biggest, most punitive lockdown into the exact opposite of what it was meant to achieve.

---

What is this thing that has happened to us? It’s a virus, yes. In and of itself it holds no moral brief. But it is definitely more than a virus. Some believe it’s God’s way of bringing us to our senses. Others that it’s a Chinese conspiracy to take over the world.

Whatever it is, coronavirus has made the mighty kneel and brought the world to a halt like nothing else could. Our minds are still racing back and forth, longing for a return to “normality”, trying to stitch our future to our past and refusing to acknowledge the rupture. But the rupture exists. And in the midst of this terrible despair, it offers us a chance to rethink the doomsday machine we have built for ourselves. Nothing could be worse than a return to normality.

Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next.

We can choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks and dead ideas, our dead rivers and smoky skies behind us. Or we can walk through lightly, with little luggage, ready to imagine another world. And ready to fight for it.

https://www.ft.com…

---

Comment:

By Don McCanne, M.D.

Financial Times has made the full article available for free at the link above. It is quite provocative. In this difficult time of the pandemic and associated financial crisis, provocation seems to be right in order.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Gemma Hughes, Sara E. Shaw, Trisha Greenhalgh
The Milbank Quarterly, May 20, 2020

Abstract

Context: Integrated care is a broad concept, used to describe a connected set of clinical, organizational, and policy changes aimed at improving service efficiency, patient experience, and outcomes. Despite examples of successful integrated care systems, evidence for consistent and reproducible benefits remains elusive. We sought to inform policy and practice by conducting a systematic hermeneutic review of literature covering integrated care strategies and concepts.

Methods: We used an emergent search strategy to identify 71 sources that considered what integrated care means and/or tested models of integrated care. Our analysis entailed (1) comparison of strategies and concepts of integrated care, (2) tracing common story lines across multiple sources, (3) developing a taxonomy of literature, and (4) generating a novel interpretation of the heterogeneous strategies and concepts of integrated care.

Findings: We identified four perspectives on integrated care: patients’ perspectives, organizational strategies and policies, conceptual models, and theoretical and critical analysis. We subdivided the strategies into four framings of how integrated care manifests and is understood to effect change. Common across empirical and conceptual work was a concern with unity in the face of fragmentation as well as the development and application of similar methods to achieve this unity. However, integrated care programs did not necessarily lead to the changes intended in experiences and outcomes. We attribute this gap between expectations and results, in part, to significant misalignment between the aspiration for unity underpinning conceptual models on the one hand and the multiplicity of practical application of strategies to integrate care on the other.

Conclusions: Those looking for universal answers to narrow questions about whether integrated care “works” are likely to remain disappointed. Models of integrated care need to be valued for their heuristic rather than predictive powers, and integration understood as emerging from particular as well as common contexts.

From the Introduction

A guiding principle for system redesign is integrated care. Integrated care refers to both the methods that might be used to organize, fund, and deliver health and related services and the interrelated goals of better outcomes, experiences, and use of resources. Integrated care has been studied in various ways—for example, as an organizational and social process, as an indicator of health system effectiveness, and for its effects, such as economic impact. The result is a heterogeneous body of literature with the term used by different authors to mean different things. Most espouse “patient‐centered” goals and values. Few dispute the principle of integration. (Who would want care that is not integrated?)

To date, consistent benefits from integrated care programs have proved elusive. Despite evidence of some aspects of improvement in certain settings for certain people, expectations that integrated care programs will improve outcomes and reduce health service utilization are often disappointed.

From the Discussion

The search for integrated care is a search for unity. This applies both to efforts to integrate patient care, services, and organizations and to scholarly work to create unified conceptual models. However, we found two key tensions across the literature that undermine the idea of integrated care as a unified concept. First, we found that “integrated care” was not one empirical phenomenon; rather, it covered a multiplicity of objects, strategies, and aims. Practical efforts to integrate care were concerned with creating unity of a great variety of objects: patient care and experience, multidisciplinary and interorganizational working, and health care systems. “Integrated care” included overlapping, interrelated, and, at times, conflicting strategies and experiences. Moreover, integration was pursued for a variety of ends (eg, to both improve patient experience and to reduce hospital admissions) and meant different things to different people. Patients, service providers, and policymakers had different ideas about, and different experiences of, integrated care.

Second, we found that conceptual models of integrated care assumed alignment of patient and system perspectives and of multiple strategies into a coherent, decontextualized whole. However, the range of framings provided by scholars bringing social theory and critical analysis to the study of integrated care undermines the normative, and often deterministic, frameworks provided by unified models.

Integrated care programs are contextually shaped but have common logics. Normative models of integrated care can therefore be of heuristic value (for example, in accounting for features of successful programs), but they will inherently fall short of accounting for the intricacies of different contexts and processes. The range of theoretical framings found in this review used to analyze integrated care preclude the creation of a single explanatory model. Integrated care can more usefully be studied and understood as comprising an emergent set of practices intrinsically shaped by contextual factors than as an intervention that will achieve a predetermined set of outcomes.

https://onlinelibrary.wiley.com…

---

Comment:

By Don McCanne, M.D.

The policy community and the medical-industrial complex seem to be fixated on business models of reform rather than patient service models. “Integrated care” seems to be a common theme of theirs, though this Milbank Quarterly report indicates that there is little agreement on precisely what integrated care means.

As the authors state, “Who would want care that is not integrated?” But Kaiser Permanente as an integrated delivery system is quite different from an accountable care organization to which patients do not even realize that they are nominally assigned. Hospitals purchasing physician practices is a different kind of integration than when large investor-owned insurers assume control of portions of the delivery system. Clinics coordinating with food, housing, and transportation services is another form of integration. Private Medicare Advantage plans integrated with contracted vendors is quite different from traditional Medicare that is integrated with almost the entire health care delivery system. And so on.

The greatest problem in health care today is that, in spite of spending $4 trillion, far too many are unable to access the care they need because of the financial barriers that result from the design of our health care financing system. The solution is simple. Fix the problems that are inherent in our existing Medicare program, expand it to include everyone, and fund it with equitable, progressive taxes that will make it affordable for each of us. If you want to call that an integrated financing system then go ahead, but do not let the business interests expand control through their integrated entities that are designed primarily for business success rather than for patient service.

The Milbank Quarterly article is an open access article. You may want to read the full article as it can assist you in rethinking integrated care. Let’s get it right for the patients, not the plutocrats.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Jesse Drucker, Jessica Silver-Greenberg and Sarah Kliff
The New York Times, May 25, 2020

A multibillion-dollar institution in the Seattle area invests in hedge funds, runs a pair of venture capital funds and works with elite private equity firms like the Carlyle Group.

But it is not just another deep-pocketed investor hunting for high returns. It is the Providence Health System, one of the country’s largest and richest hospital chains. It is sitting on nearly $12 billion in cash, which it invests, Wall Street-style, in a good year generating more than $1 billion in profits.

And this spring, Providence received at least $509 million in government funds, one of many wealthy beneficiaries of a federal program that is supposed to prevent health care providers from capsizing during the coronavirus pandemic.

So far, the riches are flowing in large part to hospitals that had already built up deep financial reserves to help them withstand an economic storm. Smaller, poorer hospitals are receiving tiny amounts of federal aid by comparison.

After the CARES Act was passed in March, hospital industry lobbyists reached out to senior Health and Human Services officials to discuss how the money would be distributed.

Representatives of the American Hospital Association, a lobbying group for the country’s largest hospitals, communicated with Alex M. Azar II, the department secretary, and Eric Hargan, the deputy secretary overseeing the funds, said Tom Nickels, a lobbyist for the group. Chip Kahn, president of the Federation of American Hospitals, which lobbies on behalf of for-profit hospitals, said he, too, had frequent discussions with the agency.

The department then devised formulas to quickly dispense tens of billions of dollars to thousands of hospitals — and those formulas favored large, wealthy institutions.

Hospitals that serve a greater proportion of wealthier, privately insured patients got twice as much relief as those focused on low-income patients with Medicaid or no coverage at all, according to a study this month by the Kaiser Family Foundation.

https://www.nytimes.com…

---

Distribution of CARES Act Funding Among Hospitals

By Karyn Schwartz
KFF, May 13, 2020

The Department of Health and Human Services (HHS) has now begun distributing $72.4 billion of the $175 billion allocated for grants to health care providers in the Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Paycheck Protection Program and Health Care Enhancement Act.

Our analysis shows that the size of the relief fund grants varies dramatically per hospital bed based on a hospital’s payor mix. Hospitals with the lowest share of private insurance revenue received less than half as much funding for each hospital bed compared to the hospitals with the greatest share of revenue from private insurance. These hospitals’ large share of private reimbursement may be due either to having more patients with private insurance or charging relatively high rates to private insurers or a combination of those two factors. All things being equal, hospitals with more market power can command higher reimbursement rates from private insurers and therefore received a larger share of the grant funds under the formula HHS used.

https://www.kff.org…

---

Comment:

By Don McCanne, M.D.

Compared to our highly dysfunctional, fragmented system of financing health care, heavily dependent on private health insurance, a single payer model of an improved Medicare program that covered everyone would be vastly superior, being much more efficient, effective, and equitable than our current system.

So now that we have a catastrophic pandemic that mandates a response by government, how does our government that favors the private sector respond? Do they support expanding Medicare to fill in the deficiencies during this crisis? No. Instead they dispense the bulk of their grants to wealthy hospitals with more market power that receive much of their revenues from private insurers that pay much higher rates than the government programs. And financially precarious hospitals that receive much lower revenues because of their commitment to patients on government plans or who are uninsured, they are granted…a pittance.

If we believe that health care should be made affordable and accessible for everyone, the only way we can do that is by establishing a universal government program, ideally single payer Medicare for All. But in a representative democracy, that means that we, the people, must do our part in electing legislative and administrative stewards who are committed to such a program. Obviously over the last century we have failed to do so. Isn’t it about time we shaped up?

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Chris Girod, Paul Houchens, Dave Liner, Andrew Naugle, Doug Norris, Scott Weltz
Milliman Research Report, May 2020

Executive summary

In 2020, the cost of healthcare for a hypothetical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan is $28,653, according to the Milliman Medical Index (MMI).

Key findings of the 2020 MMI include:

Cost increases have continued to be mostly “moderate.” For an average person, healthcare cost grew by approximately 4.1% from 2019 to 2020. That rate is roughly consistent with rates over the past five years, and is definitely moderate relative to rates from 10 years ago, which were twice as high. Nevertheless, the cost increases continue to outpace gross domestic product (GDP) growth, which is roughly half the rate of healthcare cost growth. Recently, hospital costs have taken center stage, growing more quickly than costs for other services, climbing approximately 15% over the past three years, versus 10% for all other services combined.

COVID-19 will have big impacts on healthcare costs in 2020. That much is certain. However, the impacts will manifest as some very big cost increases (for direct COVID-19 care), and some very big cost decreases (for deferred and forgone services). On average, the net outcome is still highly uncertain. We know, for example, that COVID-19 testing and treatment costs are new in 2020. However, these amounts may be dwarfed by the spending reductions resulting from deferrals of care. At this time, there is tremendous uncertainty around the net effect on costs. Therefore, in this year’s MMI report we have not made explicit adjustments to our 2020 cost projections to reflect COVID-19 impacts.

For the first time, this year’s report looks at the effects of managed care on costs. Since its first edition in 2005, the MMI has focused on “what is”—namely, what employer-sponsored healthcare costs are on average nationwide. Very little time has been spent discussing “what could be”—what could healthcare costs be under an ideal system? Milliman’s research indicates that effective use of managed care principles could reduce overall healthcare costs for the MMI family by approximately 25%, which would lower the family’s annual costs from $28,653 to $21,490.

https://milliman-cdn.azureedge.net…

---

Comment:

By Don McCanne, M.D.

Just a reminder of what the Milliman Medical Index (MMI) is: It is the cost of health care for a hypothetical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan. For 2020 that cost is $28,653 per family.

Of great significance, the MMI continues to increase at twice the rate of the growth in our gross domestic product (GDP). Thus excessive health care cost growth has not been contained by the provisions of the Affordable Care Act, nor by the various other tools such as the Medicare Shared Savings Program (MSSP) and the alternative payment models (APMs) designed to replace volume with value, such as accountable care organizations (ACO), and merit-based incentive payment system (MIPS). Particularly disappointing have been the consumer-directed approaches of increasing deductibles and other cost sharing since not only have they failed to control costs but they have also created unnecessary financial hardship for far too many individuals and families who have greater health care requirements.

New in this year’s MMI report: Milliman estimates that managed care principles could be used to reduce health care costs by 25% – from annual family costs of $28,653 down to annual costs of $21,490. But other than stating the need for providers to have “skin in the game” though MSSP and APMs and other managed care, which have already been shown to be ineffective, they offer no objective support for arriving at a 25% savings. Managed care has already been proven to be a failed experiment.

It’s too bad that they avoided the topic of single payer Medicare for All. Although that model would not reduce total spending by 25%, it would greatly improve allocation of our health care funds such that health care would be accessible and affordable for all of us forever. Milliman should at least be interested in the fact that the single payer model bends the cost curve so that we would finally bring under control the most important finding in the MMI reports, and that is the excessive health care cost escalation that we could bring down to sustainable levels through enactment and implementation of single payer financing.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.