By Michael K. Gusmano, Miriam Laugesen, Victor G. Rodwin, and Lawrence D. Brown
Health Affairs, November 2020

Abstract

Although the US has the highest health care prices in the world, the specific mechanisms commonly used by other countries to set and update prices are often overlooked, with a tendency to favor strategies such as reducing the use of fee-for-service reimbursement. Comparing policies in three high-income countries (France, Germany, and Japan), we describe how payers and physicians engage in structured fee negotiations and standardize prices in systems where fee-for-service is the main model of outpatient physician reimbursement. The parties involved, the frequency of fee schedule updates, and the scope of the negotiations vary, but all three countries attempt to balance the interests of payers with those of physician associations. Instead of looking for policy importation, this analysis demonstrates the benefits of structuring negotiations and standardizing fee-for-service payments independent of any specific reform proposal, such as single-payer reform and public insurance buy-ins.

From the Introduction

The rising costs of US health care make affordability—for consumers, employers, and governments—an elusive goal. Studies show that these expenditures are higher in the US than other countries not because the volume of service is higher but because prices are higher. One reason for the higher prices in the US is that private insurers typically do not have sufficient market leverage to control them, and there are dramatic price variations in the private market. Medicare has done better at controlling prices than private insurers have, but Medicare is limited by Congress in the degree to which it can negotiate prices.

In most countries with universal health insurance, physicians are paid on a fee-for-service basis, yet prices there are lower than in the US. As Miriam Laugesen and Sherry Glied explain, “Higher fees, rather than higher practice costs, volumes, or tuition expenses, are the main driver of higher US spending.”

Representatives of systems with universal health insurance explain that their health systems reflect an enduring commitment to solidarity. Their position reflects the insistence that health care is a human right and a continuing affirmation of redistribution and reciprocity as a central element of social justice.

In this article we explore how three countries—France, Germany, and Japan—appear to achieve economic sustainability in a fee-for-service system. We then identify the institutional processes that influence the prices of physician services in universal health insurance systems. These countries have all attempted to contain rising health care costs by negotiating prices with physician associations and adapting fee-for-service to the evolution of health care provision.

In the US, in contrast, insurance regulation is less developed and has suffered from a lack of national uniformity. Because there is no universal health insurance, public programs including Medicare and Medicaid address the gaps in coverage.

Summary of the approaches

The three countries we examined all negotiate fees in the context of expenditure constraints, but they have contrasting institutional processes to address health care prices and volumes. France has negotiated prices aggressively but has few controls over the volume of care. Germany controls service volume indirectly by imposing budget caps on sickness funds and physician associations and putting them in charge of enforcing volume controls.

Japan’s approach is more centralized, with a complex set of conditions that govern how and where health care services can be provided. These conditions are specified in the same document that lists the negotiated fees for each service. The aim is to constrain volume by limiting the volume of services billable for each item and by limiting the number and types of hospitals, clinics, and physicians that are allowed to provide particular services.

Although France and Germany hold physician fees at lower levels than in the US, both countries pay specialists more than primary care physicians. These fee schedules reflect a bias for more technical or procedural services over services such as office visits in primary care. In contrast, Japan, uniquely, pays private office–based generalist physicians, represented by the Japan Medical Association, more than academic hospital–based specialists.

From the Discussion

The health systems we studied focus on controlling prices in the context of fee-for-service medical practice and national expenditure constraints that do not result in withholding health care from the population. The use of fee-for-service physician payment does create problems, but marking fee-for-service as the major cause of high health care spending in the US is problematic, especially as countries with lower prices and expenditures use fee-for-service systems. France, Germany, and Japan limit the incomes of physicians by standardizing and adjusting the fees they are paid while using a variety of approaches to limit the volume of services provided.

The diversity of payment arrangements in the US acts as a constraint on unified approaches while also creating growing pressure to change and standardize fees. Although some Democratic leaders in Congress emphasize the buying power and leverage of a single-payer health care system to contain prices, extending Medicare to all legal residents would introduce challenges in negotiating prices with hospitals, pharmaceutical manufacturers, and physicians within the context of US institutions. Perhaps the most important implication of our study is that regardless of whether either fundamental changes such as Medicare for All or incremental expansion of the Affordable Care Act are proposed, both would oblige policy makers to think hard about how to set prices and oversee service volume.

Although France, Germany, and Japan vary in their approaches to regulating prices and service volume, all three rely on centralized fee negotiations. This general approach is evident in some Democratic health reform proposals, some of which have proposed empowering the secretary of health and human services to create a national fee schedule for payers and providers within a public option or Medicare for All design.

The experiences of these countries suggest that changes in physician reimbursement policy need not presuppose widespread changes to coverage and vice versa. Both become more interdependent when governments are committed to providing universal and affordable health insurance coverage. Health care pricing is an important pillar supporting and upholding universal coverage. Even without universal coverage, the US can and should regulate how much discretion providers of health care services have in setting their own prices. Standardization of prices can reduce treatment and administrative costs alike.

Americans should work within their institutional framework to allow for greater standardization of prices based on negotiation. Such an approach would be a shift away from the current system, in which payment negotiations lack transparency. The absence of arrangements similar to those in the three countries we have studied leaves payers fragmented and gives providers too much control over their own prices.

The purpose of international comparisons for policy learning is not to transplant or import foreign systems into domestic institutions. The US lacks a solidaristic vision—the population is distributed across separately regulated private insurance plans, and programs designed for different groups remove a shared identification, balkanizing the system of health care. Our approach to understanding physician payment policy across nations acknowledges the absence of solidarity in the United States. Price negotiations must reflect the history and distinct characteristics of each country.

Cross-national comparisons, however, offer perspective on the challenges that Americans confront and the ways in which experience abroad might be adapted to the specificities of other national institutions. The ways and means by which France, Germany, and Japan are “getting the price right” should not be ignored by US policy makers concerned with universal health insurance or with the incremental extension of affordable health insurance coverage.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Health care spending is highest in the United States, and a major reason for this is our very high prices. The private insurance industry in the United States has not been particularly effective in controlling prices, and our government has largely limited its control of prices to public programs such as Medicare and Medicaid, though, even there, the government has refused to control Medicare drug prices. The authors use the examples of the universal programs in France, Germany and Japan to show how governments can get the price right.

The authors contend that we do not have to enact a Medicare for All system to control prices. But when you look at our fragmented health care financing system and the free rein that the private sector is allowed – especially the private insurers – it does not take too much imagination to see that trying to implement fee controls across the entire system would be much like herding cats. The fact that the crisis has been with us for many decades without any real progress being made in price controls, outside of Medicare and Medicaid, demonstrates that these cats are not very herdable.

Essentially all other nations have been effective in controlling spending through control of prices, and we could be too, but it sure would be a lot easier if we had a well designed, single payer, improved Medicare for All. That way we would be standardizing prices in a system based on solidarity.

Why solidarity? The current political turmoil should provide us with enough evidence that we sure could use an infusion of a whole lot more solidarity. Just our lack of solidarity in managing the COVID-19 pandemic is causing suffering, economic hardship, and loss of lives, simply because we have prioritized political squabbles over solidarity. Let’s give solidarity a try – for our health.

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Healio, November 10, 2020

POINT by Benjamin Sommers, M.D., Ph.D.

Yes.

A public option can improve health care affordability with continued private insurance and better access to quality providers, but only if the design is set up in a way that provides more financial protection upfront. You could also push private insurers to do this, but a public option is a better vehicle to make sure the cost-sharing terms are affordable for patients.

Many individuals who are currently insured in the marketplace have high deductibles — up to several thousand dollars in some cases. This leaves many people paying out of pocket for their care unless they get critically sick.

If the public option aggressively negotiates payment rates to providers, it will bring down the overall costs, as is the case with Medicare and Medicaid. There is a trade-off because it could possibly limit the number of providers but, on the other hand, it would save the whole system money.

There are a lot of varieties of public options. The one from the Biden campaign is for patients not in Medicaid expansion states. This would help patients who are too rich for Medicaid but too poor for the marketplace. Those people — and there are a lot of them — have fallen through the cracks.

This could also help patients in places where there is limited competition, which leads to higher premiums. Creating more competition brings down the costs.

However, there isn’t a magic number when, once hit, suddenly everyone is able to afford care and be covered. Every step taken squeezes people out. The only way to get everyone insured is through a single-payer system but, even then, it has to be more generous than the current Medicare plan. That being said, there doesn’t seem to be the political will or leverage to implement that.

The Medicare component of the public option is popular, but it also has substantial cost-sharing; about 20% in most cases. That’s why there are supplemental plans.

The U.S. Congress — Democrats and Republicans alike — gives away benefits with a value that substantially exceeds what the users pay. Each beneficiary on average receives $310,000 more in benefits than they pay. The unpaid bills — $37 trillion at last count — have been kicked down the road to future generations in the form of bigger federal deficits. The Galen Institute reports that Medicare’s annual deficits are responsible for one-third of U.S. federal debt.

Yet, Medicare’s enormous scale confers genuine administrative and purchasing efficiencies. Medicare spends up to seven times less than private insurers on administrative costs. It also pays hospitals 40% less and providers 2 to 3.5 times less than private insurers pay for the same services. Some contend that providers merely shift Medicare and Medicaid’s unpaid charges to private insurers, but that charge has been refuted. Rather, it is plausible that these payments appropriately help to squeeze out the one-third of health care expenditures that many experts view as sheer waste.

Americans generally like both private insurance and Medicare but universally hate their costs. “Medicare for All” eliminates private insurers and increases taxpayers’ burden. The public option keeps private insurers and controls health care costs.

Benjamin Sommers, MD, PhD, is the Huntley Quelch professor of health care economics at Harvard University T.H. Chan School of Public Health.

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COUNTER by David Himmelstein, M.D.

No.

A public option insurer that doesn’t try to dodge unprofitable enrollees like traditional Medicare does would be saddled with more than its share of sick, expensive patients and would become a de facto high-cost, high-risk pool. Although a public option really can’t achieve universal coverage, a single-payer system, usually referred to as Medicare for All, can.

CMS’s decades-long efforts to level the playing field have not worked against private insurers, which breaks their promises of fair competition. Insurance companies have also used their political muscle to sustain and increase their competitive advantage over traditional Medicare. The result is that a public plan and the taxpayers absorb the losses while private insurers skim off profits. This imbalance is so big that private plans can outcompete a public plan despite squandering vast sums on overhead costs, CEO salaries and shareholder profits.

The bottom line is that a public option is a more expensive way to do this than a single-payer system.

Private insurers currently take in $252 billion more than they pay out per year, which is equivalent to 12% of their premiums. A single-payer system with overhead costs comparable to Medicare’s could save about $220 billion of that money. A public option would save far less, or possibly nothing, if much of the new public coverage is channeled through Medicare Advantage plans, whose overhead, at 13.7%, is even higher than the average commercial insurer.

A single-payer system would put private insurance companies out of business. Drug companies and medical suppliers would also stand to lose billions because they would face a buyer that could actually drive down costs.

The excess overhead inherent to multipayer systems imposes a hidden surcharge on the fees that doctors and hospitals must charge all patients — not just those covered by private insurance. All told, a public option reform would sacrifice about $350 billion annually of single payer’s potential savings on providers’ overhead costs, over and above the $220 billion in savings it could sacrifice annually on insurers’ overhead.

Finally, a public option would undermine the rational health planning that is key to the long-term savings under single payer. Each dollar that a hospital invests in new buildings or equipment increases its operating costs by 20 to 25 cents in every subsequent year. At present, hospitals that garner profits have the capital to expand money-making services and buy high-tech gadgets, whether they’re needed or not, while neglecting vital but unprofitable services.

I’m not sure what innovation people think is going to be stifled with a single-payer system. In fact, Medicare has been much more innovative than private insurers. Most scientific innovation has come from the NIH and other countries. The CT scan, for example, came from Great Britain. Most of the money drug companies and insurance make goes to their shareholders; an astonishingly low amount goes to innovation. We’d be much better taking the money from those profits and amping up funding to the NIH.

Because a public option would leave the current dysfunctional payment approach in place, it would sacrifice most of the savings available via single-payer reform. I’m not opposed to having a public option because it would give more people insurance, but I just think it’s a bad way to provide insurance in this country. The bottom line is that a public option would either cost much more or deliver much less than single payer.

David U. Himmelstein, MD, is a professor of health policy at City University of New York School of Public Health at Hunter College.

https://www.healio.com…

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Comment:

By Don McCanne, M.D.

This is one of those situations where it is better to answer the question they should have asked rather than the one that they actually asked.

A Medicare-like public option that benefits from government-administered pricing and that is subsidized by the government obviously would bring down costs for patients who are enrolled in the program when compared to private commercial plans that are not government subsidized. But what about all of the other patients who are not enrolled in the public option? Some have suggested that competition from a public option might cause private plans to reduce their premiums, but they would do so by reducing their own costs through benefit reductions, increases in patient cost-sharing, and perhaps moving to more restrictive provider panels, shifting more costs to the patients, so any net cost reduction would be negligible.

Compare adding a public option to our current expensive, administratively complex, highly dysfunctional health care financing system to replacing the system with a well designed single payer system – an improved Medicare for All. Not only would everyone be covered with a high-performance system, the average costs for patients, except for the very wealthy, would be less than the average costs we are paying now simply because the entire system would be funded through equitable, progressive taxes – that’s on top of the sharp reductions in profound administrative waste and the efficiency of public purchasing.

As David Himmelstein explains, the bottom line is that we would have a superior system that would be affordable for each of us if we enacted and implemented a single payer system. Even Benjamin Sommers says, “The only way to get everyone insured is through a single-payer system,” and “Medicare’s enormous scale confers genuine administrative and purchasing efficiencies.” It’s nice to see that these experts appear to agree even if the question superficially seemed to bring them to opposite yes or no conclusions.

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By Jacqueline Ellison, Paul Shafer, and Megan B. Cole
Health Affairs, November 2020

Abstract

With the rise in the share of privately insured patients covered by high-deductible health plans (HDHPs), understanding sociodemographic trends in the uptake of health savings accounts (HSAs) is increasingly important, as HSAs may help offset the higher up-front costs of care in HDHPs. We used nationally representative data from the National Health Interview Survey from the period 2007–18 to examine trends in HDHP enrollment and HSA participation among privately insured adults by income level and race/ethnicity. Our findings show a substantial increase in HDHP enrollment across all racial/ethnic and income groups from 2007 to 2018. However, Black, Hispanic, and low-income HDHP enrollees were significantly less likely than their White and higher-income counterparts to participate in HSAs, and these gaps increased over time. This means that the HDHP enrollees most likely to benefit from the potential financial protection of HSAs were the least likely to have them. If these trends persist, racial/ethnic and income-based disparities in cost-related barriers to care may widen.

From the Discussion

Increased HDHP enrollment across all income levels and racial/ethnic groups reflects the larger trend in employers’ HDHP plan offerings during the past decade, as employers have often shifted costs to workers and attempted to minimize premium growth by using high deductibles and offering less generous benefits. Although other studies have documented increasing rates of HDHP enrollment in aggregate, our findings show that these increases have occurred across all income and racial/ethnic groups over time. As these trends persist, low-income, Black, and Hispanic populations, who already experience financial and structural barriers to care, may disproportionately experience negative consequences of high cost sharing.

Lower HSA participation among low-income individuals and families may be a result of this population being less likely to have an employer that contributes funds annually to the HSA or because lower-income people have fewer resources to set aside for future health care expenses. Research has demonstrated that lower savings levels among Black and Hispanic workers are primarily a consequence of inequities in intergenerational wealth, education, and employment. Thus, our finding of lower HSA participation among Black and Hispanic HDHP enrollees is likely a result of the disproportionate structural burdens borne by these communities. Fewer opportunities and lower incomes, compounded by labor-market discrimination, contribute to the racial/ethnic wealth gap and subsequent ability to save, as well as to the likelihood of being in a job that contributes to an HSA. Thus, institutionalized racism, as opposed to individual choices or agency, is the likely driver of observed racial/ethnic disparities in HSA participation.

Lower HSA uptake among people earning below 200 percent of the federal poverty level ultimately means that the people most likely to benefit from HSAs are those least likely to have them. Research consistently demonstrates that even minor cost sharing can result in the delay or avoidance of essential care, adverse events, and emergency department visits among low-income and chronically ill patients.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

High-deductible health plans (HDHPs) are promoted as a means to make patients more prudent shoppers of health care by making them responsible for upfront costs. But it has been well documented that these out-of-pocket costs have caused patients to forgo beneficial health care that they should have. To counter this adverse consequence, health savings accounts (HSAs) have been promoted to cover the upfront expenses. The problem here is that too many people do not have HSAs, and, if they do, the accounts frequently remain unfunded.

This study confirms that increases in HDHP enrollment have occurred in all income and racial/ethnic groups, whereas “Black, Hispanic, and low-income HDHP enrollees were significantly less likely than their White and higher-income counterparts to participate in HSAs.”

The consequences are obvious. Since those who have the greatest need for HSAs are less likely to have them, it is more likely that they will be unable to afford essential upfront health care services and then suffer the adverse health and financial consequences as a result.

Thus this study confirms that HDHPs and HSAs are yet one more example of institutional racism since they have a disproportionate negative impact on Black, Hispanic, and low-income individuals.

We could make progress in countering institutional racism by enacting and implementing a well designed, single payer, improved Medicare for All. Maybe we don’t have to call active opponents of Medicare for All racists, but we could let them know that their position does support institutional racism. Hopefully enough of them would be sensitive enough to that issue that they might take a more serious look at Medicare for All.

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The same cannot be said for those more centrist lawmakers who continue to defend the nation’s increasingly unpopular for-profit healthcare system.

By Jon Queally
Common Dreams, November 7, 2020

Highlighting an interesting—and to many, instructive—electoral trend that others have spotted in the days since 2020 voting ended earlier this week, Congresswoman Alexandria Ocasio-Cortez on Saturday—just as jubilation spread nationwide among Democrats and progressives upon news that Joe Biden will be the next U.S. President—pointed out that every single congressional member this year who ran for reelection while supporting Medicare for All won (or was on their way to winning) their respective race.

The tweet emerged as many across the corporate media landscape, including pundits and former high-level Democratic officials like Rahm Emanuel, unabashedly pushed a narrative that progressives calling for policies like a single-payer universal healthcare system or the Green New Deal are somehow a hindrance to electoral success. Ocasio-Cortez was not standing for it.

As Common Dreams reported Friday, while corporate-friendly Democrats have continued to go to bat for the for-profit healthcare system that lavishes billions of dollars each year on insurance companies, for-profit hospitals, and pharmaceutical giants, a new poll this week—put out by Fox News no less—shows that 72% of all U.S. voters would prefer a “government-run healthcare plan.” And the poll is far from an outlier, with numerous surveys in recent years showing this trend.

https://www.commondreams.org…

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Amid Tears and Anger, House Democrats Promise ‘Deep Dive’ on Election Losses

By Luke Broadwater and Nicholas Fandos
The New York Times, November 5, 2020

Representative James E. Clyburn of South Carolina, the third-ranking Democrat, said the party needed to overcome racial animus in the electorate, and had to shy away from certain far-left policies that alienate key segments of voters if Democrats wanted to win a pair of Senate seats currently in play in Georgia.

“Those two seats offer us the opportunity to change the dynamics in the Senate, but we are going to have to win those seats to do it,” he said. He cautioned against running on “Medicare for all or defunding police or socialized medicine,” adding that if Democrats pursued such policies, “we’re not going to win.”

https://www.nytimes.com…

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Alexandria Ocasio-Cortez on Biden’s Win, House Losses, and What’s Next for the Left

By Astead W. Herndon
The New York Times, November 7, 2020

We finally have a fuller understanding of the results. What’s your macro takeaway?

Well, I think the central one is that we aren’t in a free fall to hell anymore. But whether we’re going to pick ourselves up or not is the lingering question. We paused this precipitous descent. And the question is if and how we will build ourselves back up.
We know that race is a problem, and avoiding it is not going to solve any electoral issues. We have to actively disarm the potent influence of racism at the polls.

But we also learned that progressive policies do not hurt candidates. Every single candidate that co-sponsored Medicare for All in a swing district kept their seat. We also know that co-sponsoring the Green New Deal was not a sinker. Mike Levin was an original co-sponsor of the legislation, and he kept his seat.

To your first point, Democrats lost seats in an election where they were expected to gain them. Is that what you are ascribing to racism and white supremacy at the polls?

I think it’s going to be really important how the party deals with this internally, and whether the party is going to be honest about doing a real post-mortem and actually digging into why they lost. Because before we even had any data yet in a lot of these races, there was already finger-pointing that this was progressives’ fault and that this was the fault of the Movement for Black Lives.

I’ve already started looking into the actual functioning of these campaigns. And the thing is, I’ve been unseating Democrats for two years. I have been defeating D.C.C.C.-run campaigns for two years. That’s how I got to Congress. That’s how we elected Ayanna Pressley. That’s how Jamaal Bowman won. That’s how Cori Bush won. And so we know about extreme vulnerabilities in how Democrats run campaigns.

Is there anything from Tuesday that surprised you? Or made you rethink your previously held views?

The leadership and elements of the party — frankly, people in some of the most important decision-making positions in the party — are becoming so blinded to this anti-activist sentiment that they are blinding themselves to the very assets that they offer.

I’ve been trying to help. Before the election, I offered to help every single swing district Democrat with their operation. And every single one of them, but five, refused my help. And all five of the vulnerable or swing district people that I helped secure victory or are on a path to secure victory. And every single one that rejected my help is losing. And now they’re blaming us for their loss.

So I need my colleagues to understand that we are not the enemy. And that their base is not the enemy. That the Movement for Black Lives is not the enemy, that Medicare for all is not the enemy. This isn’t even just about winning an argument. It’s that if they keep going after the wrong thing, I mean, they’re just setting up their own obsolescence.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

A turning point in the nomination process for the Democratic Party was when the centrists decided to bump Bernie Sanders and align behind Joe Biden, claiming that leftist socialist concepts such as Medicare for All would result in defeat for the Democratic Party. Joe Biden reinforced this by emphatically denouncing the Medicare for All concept even though it was very popular amongst members of the Democratic Party. The surge to the right was so effective that the centrists managed to keep Medicare for All out of the Democratic Party platform.

The Democrats expected a blue tide which would expand their control of the House and take over control of the Senate. They got neither, though certainty of the control of the Senate will have to wait for the two runoff elections in Georgia, both highly likely to go to the Republicans.

It is ironic that the centrists are now blaming the progressives for this political failure, when it appears that the candidates supporting Medicare for All and other progressive issues prevailed, whereas the losses were amongst the candidates who refused to support Medicare for All.

I live in Orange County, California – a traditionally politically conservative county – home of the John Birch Society, the Nixon Western White House, and the Lincoln Club. For the last half century our Congressmen, all males, have been Republicans, until the 2018 midterm election. At that time, an environmental attorney, Mike Levin, ran for the seat. Health care remained a top concern that President Trump was not adequately addressing. Levin ran on progressive issues, strongly supporting Medicare for All and even including mention of Physicians for a National Health Program in his campaign literature. (He is a neighbor of mine, and I did support him in the campaign, but he was not influenced so much by me but rather by his own innate sense of health care justice.)

Once in Congress, Levin became an original co-sponsor of Pramila Jayapal’s Medicare for All Act of 2019 – H.R. 1384. When he ran for re-election this year he still quietly supported Medicare for All, but his health care emphasis has been to support expanding access on an urgent basis because of COVID-19, by strengthening the Affordable Care Act. He also supports other progressive causes such as eliminating the nuclear waste at our decommissioned San Onofre Nuclear Plans, and, importantly, supporting the large number of veterans who live here near Camp Pendleton. So he did continue to support Medicare for All, and he was re-elected.

I should mention another Democratic congressman, Harley Rouda, who was also elected in the Orange County Democratic sweep in 2018. Once in Congress, he declined to cosponsor Jayapal’s Medicare for All bill. He lost his current bid for re-election to a controversial Republican who, as a member of the Orange County Board of Supervisors, opposed requiring face masks during the pandemic, amongst other controversial positions.

Conor Lamb, a moderate from Pennsylvania, said that people are not clamoring for single payer health insurance nor the Green New Deal, but he was re-elected by a very narrow margin (51 to 49), so he seems to be an exception in this election by having survived in spite of his failure to support Medicare for All.

Also of interest is that Democrat Donna Shalala, a former HHS Secretary, was also opposed to Medicare for All, and she lost her bid for re-election to the House.

The centrists have it wrong. Instead of blaming the progressives for disappointing results in the election, they should be joining the progressives and enlightened conservatives in support of single payer, improved Medicare for All. The election is over. They should get to work.

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By Rupinder K. Legha, David R. Williams, Lonnie Snowden, and Jeanne Miranda
Health Affairs Blog, November 4, 2020

The coronavirus pandemic has exposed the racist structures, policies, and ideologies that are killing Black lives with impunity. Then on May 25th, 2020, a police officer charged with protecting the community instead exerted the weight of his knee and the force of his power to end George Floyd’s life, a painful visual depiction of racism that most were unable to deny. Health care workers have joined worldwide protests against the pandemic of American racism; but we, too, must ask how we can get our knees off Black people’s necks.

Racism and anti-Blackness in our country’s structures and medical systems can be seen as clearly as the footage of Mr. Floyd’s life being taken. They warrant immediate reform. Drawing upon Ibram Kendi’s scholarship, we propose an anti-racist approach to medical care that emphasizes recognizing racism’s historical roots, identifying racism within ourselves and our medical systems, and then dismantling it with the ultimate goal of challenging enduring racial health disparities.

An Anti-Racist Approach to Clinical Care: Five Core Components

• Learn the legacy of racism in American medicine to avoid perpetuating it.
• Admit to being racist to become anti-racist.
• Slow down: Pause to heighten racial consciousness and prepare for challenging racism.
• Identify and oppose racism at the individual, institutional, and policy level.
• Our hospitals and health care institutions must become involved in human capital and economic development in local communities. Health systems often serve as anchors in communities and should, therefore, take an active part in building health equity.

(Each of these components is discussed in the article.)

Conclusion

An anti-racist approach to medical care cannot overcome the structural racism embedded within our country nor rectify centuries of oppression and injustice. Nor does it address the racism and racist abuse experienced by Black medical students, residents, and attending physicians. Despite its shortcomings, however, an anti-racist approach empowers health care providers to immediately challenge the racism and anti-Blackness that ended George Floyd’s life. By admitting to being racist in order to become anti-racist, we can redirect the weight of our authority to get off Black people’s necks and to protect them instead. We encourage similar approaches focused on other racial, sexual, and gender minority communities, too.

Rupinder Legha, MD, is an assistant clinical professor in the Department of Psychiatry and Biobehavioral Sciences at the University of California, Los Angeles.

David R. Williams, PhD, MPH, is the Florence Sprague Norman and Laura Smart Norman Professor of Public Health and chair of the Department of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health. He is also a professor of African and African American studies and sociology at Harvard University.

Lonnie R. Snowden, PhD, is a professor of health policy and management at the University of California, Berkeley School of Public Health.

Jeanne Miranda, PhD, is a professor in the Department of Psychiatry and Biobehavioral Sciences at the University of California, Los Angeles.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Enough stress lately? We need to refresh our thinking.

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

The New York Times, November 5, 2020

https://www.nytimes.com…

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Learning From November 3: A Wake-Up Call for Public Health

By Sandro Galea, M.D., M.P.H., Dr.P.H.
Milbank Quarterly, November 4, 2020

This was supposed to be an election about health. For the first three years of his presidency, Donald Trump presided over what appeared to be a robust economy, which he made the foundation of his re-election campaign. Polls last year suggested economic gains that could place Trump in a favorable position for re-election. Then, in 2020, there came a novel coronavirus, which became known as COVID-19. As of now, more than nine million Americans have been infected with COVID-19, and over 233,000 have died, a story that rightly has dominated the national conversation.

In response to this crisis, the president acted in direct opposition to public health and medical advice, sometimes seeming to reject the very existence of COVID-19, and making this outlook central to his re-election platform. This seemed at dramatic odds with how the country felt about COVID-19. Polls suggest that Americans consider COVID-19 to be an important threat—in June, 66% of Americans said they were worried about exposure to the disease. This concern is, of course, consistent with reality, with hundreds of thousands of Americans dying and many more becoming infected with the virus.

This set the stage for an election that seemed to be entirely about health. This dramatic health concern dominated public attention like no other in 100 years, and the election featured two candidates, one of whom—Vice President Biden— contended that he would follow the advice of public health experts in order to control the pandemic, while the other—President Trump— suggested little concern about COVID-19, an attitude in direct opposition to what the general population seemed to think about the pandemic.

All of this pointed to an election that would see the votes align with public perception of the virus, bringing Vice President Biden swiftly to power. That is not, of course, what has happened. While the election results remain uncertain, it is now clear that, regardless of who will eventually win, there was no dramatic sweep for Biden, and voters remain as evenly divided about the candidates as they were four years ago in the close race between Donald Trump and Hillary Clinton. This is the case despite the President’s apparent misalignment with the public’s attitude towards the pandemic.

So, what happened? What does this teach us? There is much, of course, that goes into the science of elections and voting, and one could focus much attention on the mechanics of voter influence, on efforts to suppress the vote, and on candidates’ efforts to persuade voters by making claims that may not hew exclusively to the truth. However, I would argue that this moment conveys two key insights, both of which are directly applicable to our understanding of health.

First, this moment teaches us humility in how we think about the importance of health. While the COVID-19 pandemic has been overwhelmingly an issue about health, and while it has captured public attention, with poll after poll showing that people care deeply about the pandemic, it is not at all clear that voters were willing to take the necessary steps to mitigate the virus. It is not at all clear that the steps involving widespread economic shutdown were palatable to the population despite its concern with the virus. This should be a critical wake-up call for those in public health. Simply speaking, health, on its own, was not enough to sway the election, and voters showed, decisively, that despite overwhelming concern about the pandemic, they were not willing to put aside everything else in the service of maintaining their health. This runs dramatically counter to public health thinking around the importance of the approaches necessary to contain the virus, which often involve substantial economic sacrifice, including lockdowns. This was seen, for example, in the recent John Snow Memorandum, which was drafted to repudiate the Great Barrington Declaration, the latter document suggesting a different approach to the pandemic that de-emphasized widespread lockdowns. Fundamentally, public health’s call in the past year has been premised on the notion that we should do nothing but ensure, to the best of our ability, that as few people as possible get the disease, and that anything falling short of this goal is unacceptable. The election shows us that message is not well received, and we have failed to articulate a message, through the political fog, that is well received and is responsive to what a large swath of the population wish for their health.

Second, I think this moment also teaches us about the deep divisions that characterize the country. I realize much has been written, and much more will be written, about how these divisions influence the electorate, and the implications of this for the election, in general, and for public health, in particular. I would argue that centrally, in the COVID-19 context, these divisions have widened the gap between those who are socioeconomically advantaged and those who are socioeconomically disadvantaged, with the former group largely advancing approaches to contain the pandemic that have disproportionately affected, and indeed harmed, the latter group. The economic challenge of COVID-19 has been deeply unequal, with job losses suffered by higher earning populations early in the pandemic largely returning, and lower earning workers remaining out of work. Simply put, those of us who are in a position of privilege have been perceived as proposing efforts to contain the virus that fundamentally affect and hurt those who are not in a position to make these recommendations or to implement these policies. This is, of course, a reflection of the undercurrents of socioeconomic division—which often overlap with racial/ethnic divides—that characterize the country. It is a stark reminder that there are socioeconomic divides in the country that are inextricable from the public perception of any public health decision or recommendation, even those that address the most consequential pandemic of this century.

In articulating these observations, I am simply trying to extract insight from this moment that is relevant to how we think about health. It seems that, at core, health is understood among the public to be a means to an end, not an end in itself. That end is being able to live a life as full and unencumbered as possible. Despite the public’s concern about sustaining the means to this end, the population is not overwhelmingly willing to sacrifice all aspects of their life at the behest of health. This seems particularly to be the case when the burden of sustaining these means falls disproportionately on a group that is not dictating the terms of what these measures must be.

I realize that there are many other complexities at work in this election, but I suggest that these points, in the light of this historic and perplexing day, are the most urgent takeaways of the moment. It seems fair to attribute agency to the voters who have, at this moment, spoken in a way that is different from how we in public health might have expected. It seems to me that it falls to us in public health to learn from what has happened, to think carefully about what the meaning of health is to a population, and to consider the role that socioeconomic and other divides play in shaping public attitudes. The issues raised by this election outcome suggest the need to redouble our effort to bridge the gaps between socioeconomic haves and have nots, and health haves and have nots, and to see health as a path toward doing so.

Sandro Galea, a physician, epidemiologist, and author, is dean and Robert A. Knox Professor at Boston University School of Public Health.

https://www.milbank.org…

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Comment:

By Don McCanne, M.D.

Sandro Galea is one of the great intellectuals in public health in the world today. With our worsening health care crisis due to the COVID-19 pandemic, and with the failure of the most important players in the pandemic – the people – to join together to ameliorate and eventually end this crisis, there is a compelling need to listen to the words of Professor Galea.

We are in the third and worst wave of this crisis. People are understandably very unhappy in being exposed to the potentially disastrous impacts on their health, not to mention the profoundly negative social and economic impact of the pandemic. Yet far too many have decided to abandon the best recommendations of our public health experts, and, instead, politicize it by following the bizarre lead of our president who has rejected health policy science in favor of… well, whatever it is that he is trying to do. It is no coincidence that the divide in our responses to the pandemic seems to match the political divide demonstrated by the election results this week.

But the concerns about the health of the nation are not evenly divided. When you find that you are in places where pandemic precautions are an imperative, the mask count is very high. Yet political functions led by our president have a very low mask count and exhibit entirely inadequate social distancing. Though most of us have at least some concern, it is difficult to know what percentage of our nation is willing to throw caution to the wind and ignore the best advice of our public health experts.

Some of us were actually naive enough to believe that the belligerent rejection of public health science by our president – a position that has contributed to the tragic trends noted in the pandemic curve above – would cause Americans to reject this callous carelessness by replacing our current president with someone who presumably would acknowledge the seriousness of the crisis and attempt to address it with essential government functions that are absolutely required to reduce the terribly tragic impact of the pandemic. Yet the nation remained split on what type of leadership we need in this time of crisis.

There are no simple answers, but everyone should try to understand Galea’s message. That is the first step we must take as we then come together to heal. It takes only a few to propagate the novel coronavirus. How are we going to bring them into our community tent designed for all if half of us support their ways through our political choices?

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By Joseph D. Bruch, B.A.; Alexander Borsa, B.A.; Zirui Song, M.D., Ph.D.; Sarah S. Richardson, Ph.D.
JAMA Internal Medicine, August 24, 2020

An influx of private equity involvement in women’s health care has garnered attention and scrutiny. Over the past decade, private equity firms have increasingly invested in or acquired hospitals, physician practices, laboratories, and biomedical device companies. Private equity firms use capital from corporations or wealthy individuals to invest in and acquire organizations and generally sell their holdings within 3 to 7 years. Proponents argue that they produce economic value by increasing operational efficiency while maintaining or improving the quality of care. Critics fear that the need to quickly achieve high returns on investments may conflict with the quality and safety of care or exacerbate health inequities.

We document formerly non–private equity women’s health care companies, including physician networks, practices, and fertility clinics, that gained a private equity affiliation between 2010 and 2019.

https://jamanetwork.com…

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Private Equity, Women’s Health, and the Corporate Transformation of American Medicine

By Lawrence P. Casalino, M.D., Ph.D.
JAMA Internal Medicine, August 24, 2020

In this issue of JAMA Internal Medicine, Bruch and colleagues inform us that during the past decade, private equity firms have acquired or invested in large numbers of obstetrician-gynecologist medical groups. Most of these acquisitions and investments occurred during the past 3 years.

The article by Bruch and colleagues adds another specialty to the list of physician specialty areas—notably dermatology and ophthalmology—for which recent articles have described private equity activity. We can anticipate that additional reports of growing private equity acquisitions in other specialties (eg, gastroenterology) will soon follow. Articles to date are similar in 3 ways. First, they report rapidly increasing private equity acquisitions in a given specialty. Second, they report a similar private equity modus operandi across specialties: acquire a relatively large platform practice (called target companies by Bruch and colleagues) in a given geographic area, then acquire smaller practices in that area and group them into the same organization as the platform practice; use debt to finance the acquisitions and assign that debt to the acquired practices; find ways to increase net revenue from the agglomerated practices; and sell the agglomerated practices within 3 to 5 years for considerably more than the price paid by the private equity company. Third, the articles, with 1 controversial exception, lack data on the performance—in quality and cost of care, or in physician or patient satisfaction, of private equity-owned practices.

In the absence of data, conceptual arguments can be made for and against private equity acquisition of medical practices. Private equity advocates argue that the firms bring much-needed capital that enables practices to invest in better information technology and to grow by adding physicians and/or acquiring practices. They argue that private equity firms bring management expertise to help with this growth, to make the business side of the practice operate more smoothly and relieve physicians of the burden of running the business, and to deal with regulatory demands and standardize patient safety processes. They also claim that private equity firms give physicians more autonomy than other potential purchasers of practices (notably, hospitals and health insurance companies), that they are better at managing practices than other purchasers, and that they make it possible for physicians to diversify their assets (by investing the money they are paid for their practice instead of having all of it tied up in the practice).

Opponents of private equity argue that the intense pressure on firms to generate returns for their investors (private equity firms generally project a return of 20% annually averaged across the 3 to 5 years before a practice is sold) is not compatible with putting patients’ interests first and not compatible with physician professionalism and its commitment to put patients’ interests first. They also argue that it is an intolerable burden for practices to pay off the loans that private equity firms used to acquire them and that private equity claims for skill in managing practices are exaggerated. Opponents do not necessarily see a benefit to practices merging or being acquired and point out that as a private equity firm acquires market share in a community, it may be able to demand higher payment rates from health insurers, which may be good for the physicians but not for their patients.

Attitudes toward private equity are likely shaped by attitudes toward physician professionalism and toward the corporate transformation of American medicine. This transformation has been occurring for decades and has been accelerating in recent years, as Bruch and colleagues point out. For better or for worse, the United States is moving from a system based on small, independent physician practices to physicians being employed by large corporations (including hospital systems, health insurers, and private equity firms), from small, independent community hospitals to multihospital systems (including hospitals owned by private equity firms), and from small, not-for-profit health insurers to a small number of very large national and regional insurers.

Conceptually, the advantages and disadvantages of corporate medical care parallel those described above for private equity. Corporate medical care lacks the human scale and flexibility of small physician practices and may lack the close, ongoing relationships among physicians, patients, and staff sometimes present in these practices.

Physicians in independent practices in the United States face a medical environment that is complex and rapidly changing with a high level of uncertainty about the future. Competition from hospital, private equity, and insurer-employed physicians is rapidly increasing, as are the pressures on practices from increased use of information technologies and increased rewards and penalties by health insurers and Medicare based on measures of physician performance. It is not surprising that many physicians are seeking shelter from the storm by selling their practices to corporate entities.

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

All around us we see private equity firms moving into health care. A recent Quote of the Day discussed private equity acquisition of hospitals. Today’s message discusses private equity acquisition of women’s health care practices as an example of the trend to cluster specific specialties into new corporate entities.

These equity firms may profess to infuse quality and efficiency into the systems they create, but their true objective is not altruism. Their interest is found in their label: equity, the more the better.

Their modus operandi: 1) acquire a relatively large platform practice in a given specialty, 2) then acquire smaller practices in the same geographic area and merge them into the platform practice, 3) use debt to finance the acquisitions and assign that debt to the acquired practices, 4) find ways to increase net revenue from the agglomerated practices, and 5) sell the agglomerated practices within 3 to 5 years for considerably more than the price paid by the private equity company. Conveniently, the debt is left with the practices they purchased, and the equity investors walk away with the money.

How does this benefit the patients? How does this benefit the health care professionals? We know how it benefits the equity firm investors, but does anyone seriously contend that this is what health care should be about? But that’s what it has become.

We just had an election that shut down any further discussion of a health care financing system that would provide freedom to patients and their health care professionals to ensure that everyone would have the health care that they need in a system that would be affordable for each of us: single payer, improved Medicare for All. Instead, we are moving forward with a system that puts the squeeze on the people of our nation and the productive segment of society as we move most of the wealth to the top. For those who think that they are going to move to the top, they must realize that the people already there are not going to make room up there for the rest of us.

Maybe Medicare for All really is a better idea after all.

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By Adam Gaffney, M.D., M.P.H.; David Himmelstein, M.D.; Steffie Woolhandler, M.D., M.P.H.
Health Affairs Blog, October 29, 2020

Findings of increasing uninsurance after 2016 accord with results of other governmental and non-governmental surveys. Most likely more than 2 million individuals lost health coverage during the first three years of the Trump administration. A further, more substantial increase in 2020 seems almost certain to occur. Projections based on unemployment data during the pandemic suggest that 5 to 7 million additional Americans will join the ranks of the uninsured this year.

Based on the ACS coverage data, we estimate that between 3,399 and 10,147 excess deaths among non-elderly US adults may have occurred over the 2017-2019 time period due to coverage losses during these years. Using the NHIS figures for coverage losses yields a higher estimate (between 8,434 and 25,180 non-elderly adult deaths attributable to coverage losses), while the CPS figures yield an estimate of 3,528-10,532 excess deaths among non-elderly adults. These figures do not completely capture the population effects of coverage loss, as they exclude the excess deaths that would likely result from coverage losses among children. In 2020 and beyond, we can project even more loss of life if, as expected, millions more lose health coverage due to the economic downturn associated with the pandemic.

Declining insurance coverage during the Trump administration has hence come at a heavy cost in physical and mental health, financial security, and loss of life. However, larger policy changes may lie ahead that could have even greater health impacts. In November, the Supreme Court will hear arguments in the case California v. Texas. If, as the Trump administration has urged, it entirely overturns the Affordable Care Act, 19.9 million individuals could lose health coverage. Based on the same approach as outlined above, we estimate that this coverage loss would lead to 22,892 – 68,345 excess deaths among nonelderly adults annually. The life and health ramifications of this case — and of November’s election — are enormous.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

The negative life and health ramifications of the health policies supported by the current administration are enormous. It is hoped that today’s election will result in a shift to adopting policies that will have a positive impact on the life and health of the people of our nation. Regardless, after the election we will have to exercise people power no matter who wins.

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By James G. Kahn, M.D., M.P.H.
Emeritus Professor of Health Policy, University of California, San Francisco

Last week saw the passing of two amazing leaders in the pursuit of health care justice in the United States – one who operated at the highest political, policy, and academic levels, and one who worked tirelessly at the grassroots with the most vulnerable. Phil Lee and Don Bechler led and inspired us for decades in the ongoing struggle for a health system that benefits everyone. I had the distinct honor of knowing and working with both of them.

Philip R. Lee was 96, with a storied career spanning more than 50 years in government and academia. I met Phil in 1987 when he invited me to do an AIDS cost research project at the Institute for Health Policy Studies (now named for him) at UCSF. I extended my association with him in 1989 as a health policy fellow at IHPS. He was the ultimate networker, with a massive double Rolodex, when those were physical items. He knew everyone in health policy and often had hired and/or mentored them. He was the person in DC who, as Assistant Secretary for Health under LBJ, told U.S. hospitals: if you want Medicare money, no more racially segregated wards. After serving as UCSF Chancellor, he started IHPS as the first ever academic health policy unit in the U.S. He served another stint as Assistant Secretary for Health under Bill Clinton. He was and is a guiding light for many of us: with Phil, it was always about public service and improving health. He consistently projected his vision, his determination to achieve that vision, and his encyclopedic knowledge of people and ideas. He guided me in my fellowship days. One small memory comes to mind. I jotted on a piece of paper something like “Health services research is the study of how outcomes (mortality, cost, etc) in operating health systems vary according to location, type of provider, patient characteristics, etc.” Phil saw it, and said, that’s a great definition, where did you get it? “I made it up.” To this day, this approval from Phil is one of my proudest moments. I’m sure thousands will mourn his loss and recall his greatness. Millions benefited – and continue to benefit – from his leadership.

Don Bechler (73) followed a different and also awe-inspiring path. Don trained and worked as an airplane mechanic. He worked intensively in 1994 on the California Prop 186 single payer ballot initiative. In the late 1990s he was laid off from his airline job, and started full-time organizing around single payer, supported for living expenses by single payer colleagues. He had an unswerving devotion to work at the grassroots level with community members and groups, in mirror image to Phil’s hobnobbing with presidents and prominent academics. I wonder if they knew each other; I hope so. Don was a wonderful colleague in the single payer movement, appreciating the role of research like mine. I was always honored when Don called to request a talk about one economic issue or another. But for Don the core focus was people, the vulnerable and downtrodden, those who would be helped by truly universal health insurance. I remember when I saw him at a Bernie speech at Zellerbach Hall at UC Berkeley in 2016. We were chatting in line and I asked him, “So, realistically, is single payer happening?” – this question to a guy who lived each day as if it must. He became thoughtful, “There’s too much money vested in what we currently have.” Oddly, I wasn’t put off or disconcerted by that. I redoubled my efforts. Don was an inspiration: every day he worked for what was right and just, despite the odds. Don signed off of every email with “You are great! Don.” I try to pass that sentiment forward with my colleagues in the fight for health justice.

A Biden win in the election tomorrow saves democracy. It doesn’t solve health systems problems, but offers a platform for moving forward. Phil and Don will inspire us as we fight for that crucial next step.

More about them:
https://en.wikipedia.org…
https://healthpolicy.ucsf.edu…
https://www.legacy.com…

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