PNHP

David Baltimore on national health insurance

David Baltimore on national health insurance

Science For Life: A Conversation With Nobel Laureate David Baltimore By Barbara J. Culliton
Health Affairs
May 16, 2006

(David Baltimore is the new president of the American Association for the Advancement of Science, soon-to-retire president of the California Institute of Technology, former president of Rockefeller University, and founding head of the Whitehead Institute at the Massachusetts Institute of Technology.
Baltimore shared the Nobel Prize in Medicine in 1975.)

Barbara Culliton: One of the questions is this: If the economists, the health policy people, and the health services research people could talk to the scientists, might we devise entirely new ways of approaching projects and problems?

David Baltimore: We might. It’s worth trying. Let me comment on one place where I think this is critical. We talk about universally available health insurance that would not depend on a person’s particular history but would provide health care coverage for everyone-the arguments that are made about this are arguments about availability, about cost. There’s another argument, which overwhelms all of those; it has to do with what the genomics revolution will produce in the future. The genomics revolution that we’re just living through is making it clear that we are all genetically hamstrung in one way or another. And the only way to treat people who have genetic diseases, and we all do, is to think about universal coverage. We can’t hold individuals responsible for their genetics. We must insure them nationally.
If we do hold people responsible for their individual genetics, then we will have a completely unacceptable level of discrimination. It’s inevitable, because insurance companies will say, I need to know your genetic constitution before I insure you. And they’re right.

Culliton: That is what the insurance industry does.

Baltimore: That’s what they’re about. That’s what they’re trying to do. That’s what they’ve always tried to do. And now we’ve given them this very powerful tool that could enable them to really discriminate. I think the implications of that powerful tool are that there should no longer be an insurance system that holds people responsible for inherited diseases, whether they be so-called Mendelian diseases, such as sickle cell or cystic fibrosis or Tay-Sachs, or complex diseases, such as cancer or heart disease.

Culliton: So that means you’d go to universal health insurance?

Baltimore: Absolutely, I think that it does.

http://content.healthaffairs.org/cgi/content/full/hlthaff.25.w235v1/DC1

Comment:

By Don McCanne, M.D.

“We must insure (everyone) nationally.”

Tinkering incrementalists, listen up!

A Pennsylvania state senator proposes universal coverage for state residents.

Healthy Choice
Philadelphia Weekly
(May 17-23)
by Jesse Smith

Last month Massachusetts garnered national attention for legislation heralded as an answer to the state’s-and possibly the nation’s-problem of health coverage gaps. Requiring that all residents have health insurance, the state will subsidize coverage for the poor but will force others to purchase theirs through private insurers.

In Pennsylvania, legislators led by state Sen. Jim Ferlo and healthcare advocates are working on their own plan for universal coverage, one that would take private insurers out of the mix entirely.

“We needed a model bill out there for public debate,” Ferlo says. “Change isn’t going to happen in a vacuum. This is our plan, and now the legislature, governor and candidates can react to it.”

Now in the Public Health and Welfare Committee, Senate Bill 1085-the Balanced and Comprehensive Healthcare Reform Act-proposes the establishment of a state-run healthcare trust as a means of repairing a system Ferlo describes as a “sick patient in need of radical surgery.”

Funded by a 10 percent payroll tax on employers, a 3 percent individual wellness tax on personal income and federal money, the program would cover most medical services (with the exception of cosmetic procedures) and make no exclusions of preexisting conditions. Unlike most traditional insurance plans, the proposed system would cover those services without a beneficiary co-pay or deductible.

The program’s reach would extend beyond universal coverage in a state with an uninsured population of approximately 1.5 million. It would establish a malpractice payout program that essentially eliminates the notoriously high premiums providers currently pay. It would provide transitional employment assistance to workers affected by the shift from private insurers. And in an attempt to strengthen the state’s volunteer emergency responder network, it would offer those volunteers a $1,000 annual tax rebate.

The single-payer Medicare-like plan would exempt employees with collective bargaining agreement benefits equal to or greater than those of the state plan, but would automatically enroll all other Pennsylvanians, including out-of-state students, the homeless and migrant agricultural workers.

Under Ferlo’s proposal, private insurers would operate in Pennsylvania only to serve collective bargaining units and individuals seeking coverage for those treatments (mainly cosmetic) not covered by the state plan.

His attempt to drop private insurers from the healthcare equation is in stark contrast to the high-profile Massachusetts plan, a program the senator describes as “a marketing scheme” and “fraudulent” for its connection to the profit-driven sector.

That industry views the situation differently. Sam Marshall, president and CEO of the Insurance Federation of Pennsylvania Inc., agrees the cost of healthcare is a “real problem,” but says eliminating private insurers isn’t the solution. Marshall says instead, increasing their presence will drive down the cost of coverage by creating more competition, a scenario he believes is achievable through a prohibition of non-competition clauses among current insurers.

Marshall says the presence of cost-conscious private insurers also encourages more efficient innovation and keeps costs low, something he doubts the government can do. “Is it realistic to think a government spending $600 on toilet seats is going to deliver cheaper healthcare coverage?” he asks.

But Dr. Adam Tsai, a University of Pennsylvania researcher and member of the Pennsylvania Health Care Solutions Coalition-an advocacy group that helped draft the bill-says private insurers’ obligation to both their investors and customers creates a “built-in conflict of interest.” Profit, marketing and overhead costs, fueled by what Tsai sees as an administrative bureaucracy that seeks to deny claims, raise healthcare costs far above what they would be under a single-payer system, he says.

These costs account for 16.7 percent of claims costs for private insurers, as opposed to approximately 5.2 percent for Medicare, according to a report released earlier this year by the Council for Affordable Health Insurance, an association of carriers that advocates for marketplace solutions.

Tsai emphasizes the proposed system isn’t a publicly funded/publicly delivered socialized system, but rather a publicly funded/privately delivered system of social insurance that allows consumers to still choose providers while ensuring that quality isn’t compromised.

That doesn’t mean such a radical plan’s time has arrived just yet. Tsai is skeptical of the bill’s chances for passage, but he believes the attempt is a necessary first step. “It may not be viable in election year, but I think states in general are ripe for trying this sort of reform,” he says. “If we don’t try, we’ve already lost.”

Dartmouth Atlas – Major overhaul of health care required

The Dartmouth Atlas of Health Care
In the News
May 16, 2006

New Study Shows Need for a Major Overhaul of How United States Manages Chronic Illness

Staggering variations in how hospitals care for chronically ill elderly patients indicate serious problems with quality of care and point toward unnecessary spending by Medicare. Lower utilization of acute care hospitals and physician visits could actually lead to better results for patients and prolong the solvency of the Medicare program, according to a new study by the Center for the Evaluative Clinical Sciences (CECS) at Dartmouth Medical School.

Three issues drive the differences in the cost and quality of care, according to principal investigator John E. Wennberg, M.D., M.P.H.

“Variation is the result of an unmanaged supply of resources, limited evidence about what kind of care really contributes to the health and longevity of the chronically ill, and falsely optimistic assumptions about the benefits of more aggressive treatment of people who are severely ill with medical conditions that must be managed but can’t be cured,” said Wennberg.

The Dartmouth Atlas Project studied the records of 4.7 million Medicare enrollees who died from 2000 to 2003 and had at least one of 12 chronic illnesses. The study demonstrates that even within this limited patient population, Medicare could have realized substantial savings – $40 billion or nearly one third of what it spent for their care over the four years – if all U.S. hospitals practiced at the high-quality/low-cost standard set by the Salt Lake City region.

The new research is based on Medicare claims data for more than 4,300 hospitals in 306 regions, released today in a new database available at www.dartmouthatlas.org.

“The problem of overuse of acute care hospitals and medical specialists in the management of chronic illness is rapidly getting worse,” said Wennberg.

He points to finding that the resources per capita allocated to managing chronic illness during the last two years of life are increasing steadily each year. For example, the nation’s health care providers were using 13.6 percent more ICU beds in 2003 than they did in 2000. Physician labor used to manage chronic illness also increased substantially: 13.4 percent for medical specialists and 7.7 percent for primary physicians. The acceleration was greatest in regions that were already using the most care, so the gap between high and low rate regions grew greater over the four years.

Both doctors and patients generally believe that more services – that is, using every available resource such as specialists, hospital and ICU beds, diagnostic tests and imaging etc. – produces better outcomes.

Based on this assumption, the supply of resources – not the incidence of illness – drives utilization of the services. In effect, the supply of hospital beds, ICU beds, and specialty physicians creates its own demand, so areas with more resources per capita have higher costs per capita.

“This report should end the ‘more is better’ myth in health care,” said Donald M. Berwick, M.D., M.P.P., president and CEO of the Institute for Healthcare Improvement (IHI) and a leading national authority on health care quality and improvement issues. “The nation can do a lot to improve the quality and lower the cost of health care once providers, policymakers, payers and the public share an understanding that ‘more care’ is not by any means always ‘better care,’ and that new technologies and hospital stays can sometime harm more than they help.”

Press release:
http://www.dartmouthatlas.org/press/2006_atlas_press_release.shtm

>From the Executive Summary

The reallocation of resources from the acute care sector to create a population-based, community-wide integrated system for managing severe chronic illness is today only a thought experiment. It should become a national goal. Realizing the savings that better organized care can bring requires building community-wide systems of coordinated care. In most communities, such systems do not now exist. The benchmarks from efficient practice indicate that Medicare already invests more than enough money to build and maintain such a system. The problem is that the resources are now largely locked in by Medicare’s reimbursement policy. To meet their payrolls and amortize their debts, acute care hospitals are dependent on utilization; reduced utilization results in loss of income. In many regions the reduction in utilization required to meet efficiency benchmarks would have serious – indeed, devastating – consequences for acute care hospitals. Finding a solution will require payers, particularly Medicare, to develop new methods of financing care that provides a fiscal “safe landing” for hospitals and retained savings for use in building community-based systems for managing severe chronic illness. It will also require accountability for system integration. With proper reform of financial models, large group practice and integrated care systems should be able to provide this accountability for the populations they serve in regions where such practices exist.

Through economic incentives, existing large group practices might be persuaded to accept responsibility for organizing such care in regions where it does not now exist. Traditionally, hospitals have served as the focus for coordinating community resources. They are the only locus of organized care available throughout the United States; perhaps acute care hospitals could take on the mission of integrating providers into community-based systems for managing chronic illness.

Executive Summary:
http://www.dartmouthatlas.org/atlases/2006_Atlas_Exec_Summary.pdf

The full report (121 pages);
http://www.dartmouthatlas.org/atlases/2006_Chronic_Care_Atlas.pdf

Comment:

By Don McCanne, M.D.

Can you imagine the private insurance industry leading the process to reform the management of chronic illness? Our fragmented model of competing payers is not capable of promoting system integration. Not even Medicare has the clout to reorganize the health care delivery system.

If we had a single, publicly-administered national health insurance program, a Medicare-for-All, then we would be in a position to allocate our health care spending in a manner that would integrate our entire health care delivery system. If that would result in a savings for Medicare alone of $40 billion over three years, just think of how much that would save for our entire health care system. And that doesn’t even include the other savings possible though a single payer system such as reduction of administrative waste and efficiencies through negotiated purchasing.

This report makes it clear that action is mandated. It is difficult to see where we could begin without the crucial first step of establishing a program of national health insurance.

Target targets employee health plans

Tough health care medicine for Target workers
By Chris Serres
Star Tribune
May 11, 2006

Stung by rising health costs, Target Corp. is now offering private health accounts funded in large part by individual employees. The Minneapolis-based retailer also is considering taking the unusual step of dropping its traditional health insurance coverage altogether for high-deductible plans coupled with private savings accounts.

One of Target’s two new alternatives is a high-deductible plan coupled with health savings accounts (HSAs), which let users set aside money in accounts to spend as they see fit on medical needs. Unspent money stays with the employee from year to year and job to job and grows tax-free.

The other option is a high-deductible plan coupled with health reimbursement accounts, which are similar to HSAs, except these accounts are funded by the employer and do not transfer if a worker changes employers. This plan has much higher premiums, but the deductibles are lower than in Target’s HSA.

(For the HSA option) Target annually will contribute $400 for individual employees and $800 for families. Monthly premiums will drop to as little as $20 for individuals with Target covering the rest of the insurance plan premiums.

But deductibles will be much higher than Target’s traditional plan: up to $5,000 for families, including Target’s contribution. So a Target worker who incurs a $5,000 medical bill but has only $1,000 socked away in a health savings account must pay the remaining $4,000. Target pays 80 percent of expenses beyond the deductible and all expenses once a maximum out-of pocket level is reached — up to $8,800 for families.

Documents provided by Target employees to the Star Tribune offer a rare, detailed window into how one company is trying to resolve the problem. In the documents, Target touts the changes as part of a broader effort to encourage employees to take increased responsibility for their health care spending, which the company believes will help reduce costs.

“Think of it like the retail business — when people are spending their own money, they want the best value at the best price,” says a guide given to employees.

http://www.startribune.com/535/story/427778.html

Comment:

By Don McCanne, M.D.

So Target wants its employees to “take increased responsibility for their health care spending.” How many Target employees do you suppose can afford to pay $4200 out-of-pocket after the $800 health savings account is depleted? Target is really asking them to take personal responsibility for the medical debt they accrue.

The decline in protection provided by private insurance plans is a one-way street. It will only get worse.

Health Care Spending and Use of Information Technology in OECD Countries

Commonwealth Fund – Publications – May 2006

U.S. health spending per capita significantly and consistently outpaces that of other industrialized nations. One proposal for lowering health spending and improving quality is the adoption of health information technology (HIT). Yet the United States lags behind other countries by as much as a dozen years in its efforts to implement HIT.

Heeding lessons from other countries’ experiences with HIT development could facilitate U.S. implementation, finds a new analysis supported by The Commonwealth Fund. In “Health Care Spending and Use of Information Technology in OECD Countries,” (Health Affairs, May/June 2006) the authors present U.S. spending and HIT initiatives within an international context. They also discuss the key issues surrounding HIT implementation: creating incentives, ensuring interoperability, and easing the public’s privacy concerns.

U.S. Health Spending Highest
The U.S. continues to have the highest per capita health care spending among industrialized countries, according to the most recent data from the Organization for Economic Cooperation and Development (OECD). In 2003, U.S. spending per capita ($5,635) was two-and-a-half times the comparable median for OECD countries ($2,280) It also represented a significantly greater percentage of gross domestic product (15% vs. 8%).

Higher prices, not higher utilization or resources, appears to be the main driver. More spending does not translate into more services. In 2003, the U.S. had fewer physicians, nurses, and hospital beds than the median OECD country. And while the U.S. adopts many clinical technologies earlier than other nations, ultimately it does not make them more widely available, nor does it always provide the most sophisticated procedures compared with other countries.

Savings Potential of HIT Investment
The health spending disparity could widen as other countries begin to reap savings from national HIT systems. Although no firm data exist to quantify potential savings, one estimate calculates the adoption of electronic health records could produce efficiency and safety savings of $142 billion in U.S. physician offices and $371 billion in U.S. hospitals over the next 15 years. Yet the long-term savings come with a hefty initial price tag. Establishing a national HIT network would cost the U.S. an estimated $156 billion over five years, with an additional $48 billion in operating costs.

Other OECD countries have already begun making substantial investments in HIT, although the scope and type of systems vary widely. The Canadian government, for instance, originally provided $420 million in funding but now expects to spend $1.2 billion to implement its system. In 2002, the United Kingdom announced that its HIT system would cost $4.3 billion over three years, but later more than doubled its estimate and timeframe to $10.8 billion over 10 years. In Australia, more than $1.1 billion in HIT projects are in the works.

In the U.S., pending legislation would authorize a total of $280 million in the next two years, with unspecified funds through 2010. While not yet law, the legislation would also establish a cooperative to adopt standards and authorize grant programs to encourage HIT adoption.

Other Nations Have Head Start on HIT
It was not until April 2004 that the U.S. established the Office of the National Coordinator for Health Information Technology. Several OECD nations are many years ahead in their efforts. Germany, which in 1993 became the first country to begin investing in HIT, expects to complete this year a national network, including “smart card” technology. Canada, whose efforts date back to 1997, expects to have electronic health records for half the population by 2010. The United Kingdom’s program, the most expensive and comprehensive internationally, plans by 2014 to have incorporated an integrated care record service, electronic appointment and prescription transmission systems, and a national network for all providers. Meanwhile, Norway and Australia have at least a six-year jump on the U.S.

The U.S. could gain ground, the authors say, by avoiding the problems that have plagued other nations’ efforts. For example, lack of interoperability among various providers’ HIT systems has presented difficulties in many countries. In addition to creating standards to ensure interoperability, many governments have made public subsidies contingent upon interconnectivity.

To counter privacy concerns, each country engaged in HIT is developing standards that govern how patient data are collected, used, and disclosed. In Germany, for example, the collection of administrative data (e.g., copyament status) is required, but patients can decide how clinical information\such as diagnoses and drug usage\is used and disclosed.

Other countries also recognized early on the importance of involving physicians. England and Australia, for instance, identified early adopters and used them to convince their colleagues of the value of HIT. In the U.S., proposals suggest paying physicians for each EHR submission or incorporating HIT rewards into pay-for-performance systems.

Efforts to Implement Health Information Technology in Six Countries,
2003
U.S. Australia Canada

Germany

Norway

U.K.
Initial year of national IT
effort		 2006 2000 1997 1993 1997 2002
Expected year of complete
implementation		 2016 Undefined 50% by 2009 2006 2007 2014
Estimate of total investment (as of
2005)*		 $125M $97.9M $1.0B $1.8B $52M $11.5B
Total investment per capita (as of
2005)**		 $0.43 $4.93 $31.85 $21.20 $11.43 $192.79
*In U.S. dollars. Exchange
rates as of September 2005: $1 U.S. = $1.31 AUS; $1.19 CAN; $0.80 EURO;
$6.21 NOR; $0.54 U.K.
** In U.S. dollars. Per capita is based on 2003
population numbers from the Organization for Economic Cooperation and
Development (OECD).
Source: Adapted from G. F. Anderson et al, “Health
Care Spending and Use of Information Technology in OECD Countries,”
Health Affairs, May/June 2006
25(3):819–31.

Citation
G. F. Anderson, B. K. Frogner, R. A. Johns, U. E. Reinhardt, Health Care Spending and Use of Information Technology in OECD Countries, Health Affairs, May/June 2006 25(3):819-31

www.cmwf.org/publications/publications_show.htm?doc_id=372221

Single payer's bold move into the political arena

California Democratic Party
2006 Platform
Adopted At The Democratic Party State Convention, April 30, 2006

California should lead the nation in providing comprehensive quality health care to all our people by transitioning to a single-payer public health care system.

http://www.cadem.org/atf/cf/{BF9D7366-E5A7-41C3-8E3F-E06FB835FCCE}/2006_platform_final.pdf

Comment:

By Don McCanne, M.D.

When the largest political party in the largest state in the nation explicitly endorses single payer, political feasibility becomes ever more real.

Now that the business community is beginning to understand better the benefits of the single payer model, maybe there will be interest in placing it in the Republican platform as well. We don’t want to hold our breath yet, but…

Let’s keep working to be sure that the business community fully understands all options for reform. A model that finally truly contains costs while allowing the additional luxury of providing comprehensive coverage for everyone just might be what they are looking for. Let’s be sure that they know what single payer really does, and that it’s available now.

Answer to health care issue

By Dr. Susanne King
Berkshire Eagle
Wednesday, May 10

SMALL BUSINESSES are a mainstay of the Berkshires \ restaurants, stores, garages, contracting and landscaping businesses, and many more, including doctors’ offices. Small business owners are suffering under the weight of the costs of providing and administering health care insurance for themselves and their employees.

Last week I was talking about health care with the chef of one of my favorite restaurants in the Berkshires. He is unhappy about the new health care law passed last month in Massachusetts. He recognizes that the bill will do nothing to reduce his health care costs, but will add millions to the profits of the private insurance companies who helped to craft the bill. He asked about single-payer health care, which would remove the responsibility from businesses to provide health insurance for their employees.

Single-payer health care means that the government (a single payer) would administer the health care funds, rather than the numerous private insurance companies that now administer the funds and keep a significant percentage of the health care dollar for their profits.

In 2005, health plans in Massachusetts reported large profits, posting increased profits from the previous year. United Health Group CEO William McGuire grabbed attention last month with his $1.6 billion (yes, billion) in unexercised stock options. Profit for the company in 2005 was $3.3 billion; United Health had retained 21.4 percent of premiums paid for its own use.

There is no accountability or oversight for the health insurance industry. A recent report from the American Medical Association (AMA) states that while health insurers “are posting record profits, premiums for consumers have increased without any increase in benefits. Instead consumers are paying more out-of-pocket for their health care, through increased deductibles, co-payments and co-insurance.” The AMA did a study which showed that because of mergers and the consolidation of health insurance markets, the health insurance industry is not a competitive industry. In 95 percent of the markets they surveyed, one insurer accounted for at least one-third of the market. This is not a free market.

If we had a single-payer health care system, small business owners would be off the hook. Health care funds would come from a modest payroll tax, and would be administered by the government, at either a state or a national level. It would be like improved Medicare for all. Medicare’s administrative costs are 3 percent: the current system of health insurance consumes 30 percent of the health care dollar.

There would be much more choice in such a system. Patients could chose their own doctors. Patients and doctors would make health care decisions, rather than non-clinical employees of the health insurance industry. And small business owners would be relieved of the financial and administrative burden of trying to provide health insurance for themselves and their employees.

Just imagine such a single-payer system. You go to the doctor, and the office secretary swipes your card \ no deductibles or co-payments. For the doctor, there would be no paperwork or three-month wait for reimbursement or denial of payment from the insurance company: with electronic funds, payment could be immediate. Instead of the headaches and frustrations of dealing with insurance companies, doctors could get back to the job they do best, taking care of their patients.

Small businesses could remain competitive, as they would not have to worry about the financial drain of providing health care insurance for their employees and themselves. And everyone would have much more comprehensive health care insurance, including medical, mental health, dental, prescription drug, and long term care coverage.

Single-payer legislation is the real health care reform that the Massachusetts Legislature should enact, to save the small and struggling businesses that make up the fabric of the communities in our state.

Robert Bazell on health care reform

Bubba blew it. But can U.S. health care be fixed?
Other government programs, healthier nations show it’s possible
By Robert Bazell, NBC News’ Chief Science and Health Correspondent
MSNBC
May 9, 2006

Back in 1992 when Clinton first won the presidency, American health care reform dominated the campaign. When Clinton took office, the Republicans were ready to compromise. Some moderate Republican senators even told me they were willing to discuss extending Medicare, which covers everyone 65 and over, to the entire population. Presto! We would have had universal health insurance.

But Clinton refused to accept it. Instead he allowed Hillary Clinton to set up one of the great farcical bureaucratic efforts of all time – her commission to reform health care.

Why repeat this history? Because health care reform will become a big deal again soon. Right now the Iraq war and gas prices are dominating the political discussion, but lack of affordable heath care impacts so many Americans that it must rise to the top of the agenda again.

Call me old-fashioned (or many other things), but I believe the government can do some things well, and financing health care is one them. That might be worth remembering if someone like Clinton has another shot at universal reform.

MSNBC online survey (not scientific):

Should universal health care coverage be a priority for the U.S. government?
(1446 responses)

80% – Yes. What could be more important than the health of its citizens?
12% – No. It costs too much and isn’t the government’s job.
7.5% – Unsure. It’s a grand idea, but seems like a pipe dream.

http://www.msnbc.msn.com/id/12703029/

Comment:

By Don McCanne, M.D.

When a highly credible representative of the mainstream media is willing to speak up in support of government financing of health care… well… we’re making real progress.

Editorial Independence and the Canadian Medical Association Journal

John Hoey, M.D.
NEJM
May 11, 2006

On February 20, after almost 10 years as editor-in-chief of the Canadian Medical Association Journal (CMAJ), I was fired without cause.

I packed up my few personal belongings and left the editorial offices for the last time. Anne Marie Todkill, the Journal’s senior deputy editor and a 12-year veteran, was fired the same day. Deputy editor Stephen Choi was named acting editor-in-chief. Steve, a former editorial fellow of the CMAJ, conditioned his acceptance of the position on adoption by the CMA of 10 principles of editorial independence that he laid out. The CMA refused to adopt the principles, and he resigned, as did the CMAJ’s current editorial fellow, Sally Murray. Other resignations followed: Anita Palepu and Claire Kendall, both associate editors of the CMAJ; Laura Eggertson, associate news editor; Nick Barrowman, a biostatistician; and most of the CMAJ’s editorial board.1

The CMA gave no reasons for the firings other than, initially, to “freshen” the CMAJ and, later, for “irreconcilable differences” (so far unspecified) between me and the CMA. The most striking irreconcilable difference was the censoring by the CMA of a report describing the difficulties Canadian women had in obtaining Plan B (a nonprescription drug) from pharmacists.1

This action by the CMA was a clear violation of the principle of editorial independence, as formulated by the World Association of Medical Editors and adapted integrally by the International Committee of Medical Journal Editors (ICMJE), of which the CMAJ is a founding member. As required by this statement of principle, I and my colleagues publicly described the transgression in a lead editorial.2

Clearly, our ability to edit the CMAJ had been severely and, as subsequent events revealed, fatally compromised.

“Independence,” like “freedom,” is a word etched deep in human history. Although both evoke and provoke human emotions and actions, the words themselves are intangible abstract nouns, like “love.” Our understanding of these words comes with experience \ through falling in love or, in contrast, by having our freedom and independence curtailed by opposition and resistance. In Virginia Woolf’s To the Lighthouse, Lily Briscoe (not commenting on editorial independence) notes, “All that in idea seemed simple became in practice immediately complex; as if the waves shape themselves symmetrically from the cliff top, but to the swimmer among them are divided by steep gulfs, and foaming crests. Still the risk must be run; the mark made.”3

Thus, it is highly probable that each editor of a journal and each publisher and owner will have different views of editorial independence. In fact, it may be necessary for them to have differences, else the concept of editorial independence remains an abstraction, empty of meaning.

My experience is limited to editing a general medical journal owned by a national medical association. Journals owned by commercial publishers (for example, the Lancet) and those owned by other types of associations, such as the Public Library of Science (PLoS) journals, swim, perhaps, in different seas. But a common element is that editors and publishers have different perspectives on journal ownership. Owners see their legal rights and responsibilities, their corporate objectives, whereas editors gaze on authors, peer reviewers, editorial boards, journalists, and above all, interested readers, both professionals and members of the broader public. For an editor, the journal is much more than legal ownership. As some of my former colleagues and I have said, a journal is fundamentally about ideas: “The dissemination of medical science is, or should be, ultimately a humanitarian project, and not merely the special preserve of professional associations.”4

Editors must understand this broader journal ownership and convert its traditions, hopes, and aspirations into an editorial direction by recruiting editorial staff and editorial boards with the talents needed to achieve their goals both in the long term and day to day. Failure by journal owners to understand this larger constituency forced the American Medical Association to establish an independent journal oversight committee for its journal, JAMA. In Canada, former members of the CMAJ editorial board and others recently announced that they will launch their own general medical journal as early as this fall.

Medicine can be defined narrowly or broadly. In 1855, Thomas Wakley, founder and editor of the Lancet, editorialized on the Dickensian factory owners who were polluting London and lobbying the government “for the conservation of their right to fatten upon the injury of their neighbours . . . reeking in putrid grease, redolent of stinking bones, fresh from seething heaps of stercoraceous deposits.”5 Wakley saw medicine broadly and wrote about it unflinchingly. Do we? Should we?

For journal owners and publishers, generally risk avoiders, such a wide compass may be perceived (wrongly, I believe) as of little interest to their dues-paying members and as potentially damaging to their political or economic priorities. Owners may wish to limit the scope of their journal, to restrict its editorial perspective to matters of bedside medicine and the narrower interests (as perceived by the usually nonphysician publishers) of their physician readership.

This is neither my vision nor that of the other editors who were fired or resigned from the CMAJ. For Foucault, medicine is a political act. The notion that politically sensitive topics can be expunged from a medical journal is folly. It is also irresponsible. Physicians and their patients must have faith that professional journals facilitate a discourse unencumbered by the economic and political interests of their owners.

“Still the risk must be run; the mark made.”3 This effort must be made by the editor-in-chief and the senior editorial staff on a daily basis. Editorial decisions cannot be discussed or even divulged to the publisher until the articles have been published. To do otherwise, to enter into an operational partnership of some sort with the publisher, is to gut the editorial independence of a journal. The ability of an editor to edit depends to an important degree on the editor’s own outlook and self-assurance (often mistakenly interpreted as arrogance). An eager propensity to poke a stick into something or somebody is also useful. It is a characteristic so widespread, at least among the editors I have known, members of the ICMJE and others, that it may be essential. But the defining characteristic of an editor is quixotic idealism, a characteristic that makes publishers nervous.

The interests of publishers and owners need to converge on the shared objective of maintaining a profitable operation. A journal editor will not last long if the journal does not break even. For the editors of the few journals that make money, the pressures to agree on budgets are similar, since owners want profits maintained or increased.

But once a budget is negotiated, how should the money be spent and the resources allocated? It is here that the objectives of owners (both economic and political) can influence broad editorial direction. Usually, journal budgets have been based on previous years, with slight increases or decreases based on the bottom line. Now, however, even at journals where relations between owners and editors have been tranquil, dramatically expanding online readerships and the growth of open-access journals are beginning to threaten that tranquility, altering the relationship between editorial content and financial success.

Readers of the CMAJ, before it went full-text and free online in mid-1999, were mainly Canadian physicians, members of the CMA, who received the print journal as a benefit of membership. Online readers now outnumber print readers by more than 6 to 1, and only about a third are residents of Canada \ ratios that are undoubtedly similar to those of other general medical journals. Contributing little or no revenue, online readers now contribute most of the CMAJ’s content (manuscripts and letters), interest, and general buzz.

Online readers are a puzzlement to traditional journal publishers, who tend to concentrate on print readers and their associated revenue streams, derived from classified and display advertising. Are what they are reading Canadian, British, and American medical journals, or are they global medical journals? As journal editors stroke eagerly into the more open seas of worldwide readership, will owners be able and willing to follow?

I hope they will. In a world where political correctness obfuscates and public discussions are managed by public-relations firms and paid experts, there is a desperate need in medicine for open, plain-spoken discourse. Without it, the current erosion of public trust in science and medicine will continue and will ultimately translate into poorer individual and population health.

As an editor, I worked with wonderful people at the CMAJ and around the world. I’ll miss it.

Source Information

Dr. Hoey, former editor-in-chief of the Canadian Medical Association
Journal, lives in Perth, Ontario, Canada.

References

1. Shuchman M, Redelmeier DA. Politics and independence — the
collapse of the Canadian Medical Association Journal. N Engl J Med
2006;354:1337-1339. [Full Text]
2. The editorial autonomy of CMAJ. CMAJ 2006;174:9-9. [Full Text]
3. Woolf V. To the lighthouse. New York: Harcourt, Brace & Company,
1929:235.
4. Hoey J, Caplan CE, Elmslie T, et al. Science, sex and semantics:
the firing of George Lundberg. CMAJ 1999;160:507-508. [Full Text]
5. Wakley T. Editorial. Lancet 1855;1:634-635. [CrossRef]

Why employer-sponsored coverage is unstable

Why Employer-Sponsored Insurance Coverage Changed, 1997-2003
By James D. Reschovsky, Bradley C. Strunk and Paul Ginsburg
Health Affairs
May/June 2006

Four and a half million Americans gained employer-sponsored health insurance coverage during 1997-2001, while nearly nine million lost coverage in the ensuing economic downturn (2001-2003), after population growth was accounted for. Macroeconomic trends affecting employment, job quality, and incomes drove most of the coverage changes, although key factors varied during the two periods. Take-up rates affected coverage, mostly reflecting the interaction of premium cost trends and labor-market tightness, but take-up also was influenced by the implementation of the State Children’s Health Insurance Program (SCHIP) during 1997-2001. Coverage among low-income people was most affected by economic conditions and premium costs.

http://content.healthaffairs.org/cgi/content/abstract/25/3/774

Comment:

By Don McCanne, M.D.

As if we didn’t have enough reasons to be concerned about using employer sponsorship as a basis for providing health insurance, this study clarifies several of the reasons behind one more important deficiency.
Employer sponsorship provides an unstable source of insurance coverage, in a large part due to factors beyond control of either the employer or the employee.

Once you are insured through an employer-sponsored plan, you have no assurance that you will remain covered until retirement, as this study and others demonstrate.

Once you are insured through an individual plan, you have no assurance that coverage will continue, especially since it has been shown that over two-thirds have left their plans by three years.

Once you are insured by Medicare after reaching age 65, you are assured that you will have coverage for the rest of your life. That’s stability.

We should all have a stable source of health care coverage, throughout life.

Only the government can make that possible.

How To Fix The System

By DONALD BERWICK
Time www.time.com web exclusive
Monday, Apr. 24, 2006

Donald Berwick is a Massachusetts pediatrician and president of the Institute for Healthcare Improvement.

Ask a doctor what’s wrong with America’s healthcare system, and be prepared to pull up a chair. You’ll hear a litany of complaints about Kafka-esque bureaucracies, litigious patients, unreasonable insurance companies, too few nurses, never enough time, too much testing and not enough talk. But complaining gets us nowhere–we need solutions. Here are my top seven reforms for health care.

1. Make Health Care in America a Human Right

The US spends almost twice as much in health care as the next most costly nation, and our system is not even close to the best on earth. The assertion that making health care a human right isn’t feasible — isn’t affordable — makes me mad. It’s just not true; in fact, we are the only developed Western country that fails to view health care as a human right. Leadership for change must come from the President and Congress. Without the promise of health care for all, we aren’t likely to muster the energy and political will we need to meet the needs of our entire population. We’ll limp along, instead, with defects in care and gaps in management that we have trained ourselves to regard as inevitable.

2. Pay for the Care of Populations, Not Events

Our current system of fragmented payment — for hospital stays, office visits, lab tests, drugs, and therapists — destroys the patterns of care that patients need, and leaves them confused and, too often, simply abandoned. Funding care for people over time, instead of for specific medical events, reduces the burden of illness by focusing on high quality preventive care. We need “managed care” as it was originally intended to be — the good kind, not the evil, mutant twin that just tried to cut costs, restrict choice, and limit available care. Correctly conceived, “managed care” addresses the real needs of patients over time and place, guiding them through the technological thicket of modern medicine, and making sure that they get exactly what they want and need, exactly when and how they want and need it.

3. Put the Patient in the Driver’s Seat

The more control patients have over their own care–the more they know, the more involved they are in the design of their care–the better. We haven’t even begun to plumb the real potential of patients who have been taught how to become their own physicians (to the extent that they want to). Despite the rhetoric, most people can’t even get access to their own medical records, and it’s often next to impossible to find data on how one’s own hospital or physician performs compared with others. Some people fear that, given choices, patients will not choose wisely or will demand too much. I doubt it–one study found that when patients actively shared in decisions about whether to have surgery, the rate of surgery fell 23% and satisfaction and outcomes both improved.

4. Computerize Medical Records, Once and for All

My pizza parlor is more thoroughly computerized than most of health care. It’s high time to put the paper medical record where it belongs — in the Smithsonian, next to the typewriter. Proper use of modern information systems for medical records will support much more integrated care, and will allow patients to feel better supported and remembered as they move from place to place and over time. Importantly, a computerized medical record [could] be, and should be, accessible to patients directly, and under their control.

5. Use Modern Engineering Science to Make Health Care Safer and Smoother

The same sciences that allow airplanes to fly safely, that keep the lines moving at Disney World, and that continually reduce the costs and improve the reliability of computers and consumer goods, can help in health care too. To a large extent, health care systems were not designed with any scientific approaches in mind. Too often there are long waits, high levels of waste, frustration for patients and clinicians alike, and unsafe care. A bold effort to design health care scheduling systems, process flows, safety procedures, and even physical space will pay off in better, less expensive, safer experiences for patients and staff alike.

6. Re-Energize Primary Care and Nursing

Our current care system is hospital-centric and physician-centric. We cannot have excellent, coordinated, patient-centered, economical health care without a strong backbone of primary care, and without a vibrant, proud, and joyful nursing workforce. Yet fewer and fewer young people are choosing to go into primary care careers (instead, we are getting an oversupply in specialties like ophthalmology, radiology, anaesthesiology, and dermatology) and the average age of an American nurse is now over 47 years.

7. Give Up the “More Is Better” Myth

Good evidence now shows that the areas in the US with the highest rates of use of hospital beds, intensive care units, specialist consultations, and invasive testing don’t have the best quality of care and outcomes. In fact, they often have the worst. It would be a great advance in both quality and cost if somehow the American public came to understand that “more care” is not by any means always “better care,” and that new technologies and hospital stays can sometime harm more than they help. Patients need to ask more, “Are you sure I need that?” and to trust that, often, the best care is the most conservative care.

Proof that insurers selectively advertise to healthy

The Relationship Between Health Plan Advertising And Market Incentives:
Evidence Of Risk-Selective Behavior
Health Affairs
May/June 2006
By Ateev Mehrotra, Sonya Grier and R. Adams Dudley

Previous Medicare managed care efforts were undermined by risk selection or “cream skimming,” in which health plans selectively enrolled healthier patients and avoided sicker ones.

Most of the time, health plans are paid a fixed premium for each enrollee, regardless of the enrollee’s health status. In such a situation, patients with chronic illnesses are a potential financial liability, because they are more likely to incur high costs. Compared with reducing costs or improving quality, risk selection is a relatively easier mechanism for health plans to increase profits. A substantial body of research demonstrates that Medicare managed care enrollees are, on average, healthier than Medicare fee-for-service (FFS) enrollees. Provisions in MMA attempt to deter risk selection, but there is concern that these provisions are insufficient and that health plans will still have an incentive to engage in risk selection.

Some believe that health plans actively recruit healthier patients through advertising, but this has never been empirically demonstrated. Others believe that health plans deliberately structure their benefits so that sicker patients voluntarily leave the plan. However, since risk selection is seen even at the time of initial enrollment, pre-enrollment factors such as advertising probably contribute to it a great deal.

We found that the use of ads that are attractive to healthy patients increased nationally from the 1970s through the 1990s as HMOs became more common and gained market share. Furthermore, in 2000, the use of such ads was more common in markets with higher HMO market share than in those with lower market share.

These correlations suggest that as competition increases, health plans attempt to risk-select through advertising.

…health plans spent more than $70 million on newspaper advertising alone in 2000. The total advertising budget is much higher if all media types are included. Our findings imply that health plans are using that advertising to attract healthier patients. From a societal and clinical perspective, these resources are being misused.

http://content.healthaffairs.org/cgi/content/abstract/25/3/759

Comment:

By Don McCanne, M.D.

Advocates of free markets insist that competition between private health plans (e.g., Medicare Advantage) will always result in lower costs than is possible through a single public insurance program (e.g., traditional Medicare). All evidence to date indicates that this is simply not true. The government spends more per Medicare beneficiary in private plans than it does for Medicare beneficiaries, with equivalent health status, in the traditional public program.

One reason that private plans may spend more is the inclusion of pharmaceutical benefits. A much more important reason is the very high administrative costs plus profits that are not characteristic of the public Medicare program. The meme that markets always produce relatively lower prices through greater efficiency has been disproved when applied to health insurance.

Health insurance has a unique feature which allows the administrators to reduce prices without the necessity of increasing efficiency. That feature is risk pooling. If insurance administrators can keep higher risk individuals out of the pool that they are insuring, then costs per beneficiary can be reduced.

This study is important because it confirms, through objective evidence, what we’ve surmised all along. Private insurers are targeting their advertising to a healthy subset of the population.

Where do we draw the line? Is this merely smart business practice in the private market? Or is this a dishonest effort to shift a significant portion of the costs of health care to purchasers of other plans and to the taxpayers through public programs? Whether it’s labeled smart business or a method of cheating the rest of us, it’s clearly wrong!

Some contend that the answer is in risk adjustment, but prior efforts have been feeble or ineffective. Regardless, the success of the private insurance industry primarily has been due to the ability to keep patients with significant needs out of their risk pools. If we are ever successful in ending this perversity of risk pool manipulation, the private insurers will have to charge premiums that will price them out of competition with a publicly-administered program such as Medicare.

It is ironic that an equitable system would require private insurers to charge premiums that are so high that they would result in a death spiral, requiring them to withdraw from the market. But isn’t that the way markets are supposed to work?