By Elizabeth Warren
Medium, November 15. 2019

Every serious proposal for Medicare for All contemplates a significant transition period. Today, I’m announcing my plan to expand public health care coverage, reduce costs, and improve the quality of care for every family in America. My plan will be completed in my first term. It includes dramatic actions to lower drug prices, a Medicare for All option available to everyone that is more generous than any plan proposed by any other presidential candidate, critical health system reforms to save money and save lives, and a full transition to Medicare for All.

(Most of the report describes transitional steps including strengthening the Affordable Care Act, Medicare and Medicaid, and establishing a “true Medicare for All option.”)

Completing the Transition to Medicare For All

By pursuing these changes, we will provide every person in America with the option of choosing public coverage that matches the full benefits of Medicare for All. Given the quality of the public alternatives, millions are likely to move out of private insurance as quickly as possible.

No later than my third year in office, at which point the number of individuals voluntarily remaining in private insurance would likely be quite low, I will fight to pass legislation to complete the transition to the Medicare for All system defined by the Medicare for All Act by the end of my first term in office.

Moving to this system would mean integrating everyone into a unified system with zero premiums, copays, and deductibles. Senator Sanders’s Medicare for All Act allows for supplemental private insurance to cover services that are not duplicative of the coverage in Medicare for All; for unions that seek specialized wraparound coverage and individuals with specialized needs, a private market could still exist. In addition, we can allow private employer coverage that reflects the outcome of a collective bargaining agreement to be grandfathered into the new system to ensure that these workers receive the full benefit of their bargain before moving to the new system. But the point of Medicare for All is to cut out the middleman.

I believe the next president must do everything she can within one presidential term to complete the transition to Medicare for All. My plan will reduce the financial and political power of the insurance companies — as well as their ability to frighten the American people — by implementing reforms immediately and demonstrating at each phase that true Medicare for All coverage is better than their private options. I believe this approach gives us our best chance to succeed.

Why do we need to transition to Medicare for All if a robust Medicare for All option is available to everyone? The answer is simple and blunt: cost and outcomes. Today, up to 30% of current health spending is driven by the costs of filling out different insurance forms and following different claims processes and fighting with insurance companies over what is and is not covered. I have demonstrated how a full Medicare for All system can use its leverage to wring trillions of dollars in waste out of our system while delivering smarter care — and I’ve made clear exactly how I would do it. The experience of other countries shows that this system is the cheapest and most efficient way to deliver high-quality health care. As long as duplicative private coverage exists, we will limit our ability to make health care delivery more effective and affordable — and the ability of private middlemen to abuse patients will remain.

This final legislation will put a choice before Congress — maintain a two-tiered system where private insurers can continue to profit from being the middlemen between patients and doctors, getting rich by denying care — or give everybody Medicare for All to capture the full value of trillions of dollars in savings in health care spending. I believe that the American people will demand Congress make the right choice.

https://medium.com…

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Comment:

By Don McCanne, M.D.

As promised, Elizabeth Warren is proposing dramatic transitional steps in improving our health care financing system, ending in the third year with a full transformation into a bona fide single-payer improved Medicare for All program. The sketchy details of the transformation are spelled out in her article, but much more important is that the end goal of a single payer model of Medicare for All is not compromised. It really can be achieved.

PNHP does not endorse any political candidate for public office.

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By Paige Minemyer
FierceHealthcare, November 13, 2019

Blues plans are launching a high-performance network nationwide.

The Blue Cross Blue Shield Association (BCBSA) revealed this week that its member plans would offer Blue HPN beginning in January 2021. The network will be available in 55 markets across the U.S.

Jennifer Atkins, vice president of network solutions at BCBSA, told FierceHealthcare that the goal in launching the network was to build on the plans’ existing value-based and patient-centered models.

There was strong interest in the individual markets for such a network, she said. About 70% of members in BCBSA plans are enrolled in a value-based contract.

Employers are taking a more “activist” role in healthcare, and part of that effort includes greater uptake of options such as direct contracting and high-performance networks to drive lower costs without pushing additional cost sharing for employees.

Atkins said that existing value-based contracts deliver an average of 10% in total cost savings and that the BCBSA members expect a high-performance network to grow that number further. With 74 million members in its base, Atkins said the Blues plans believe they can reach the “critical mass” necessary to gather quality providers.

In developing the networks, the plans will take a “best of local” approach that allows each plan to meet the needs of its markets under a shared set of standards. Quality metrics focus on offering the appropriate care, promoting adherence and boosting outcomes, and Blue HPN allows for individual plans to build in their own metrics to fit regional needs.

A key concern in a narrow-network plan is that members may not have a full grasp of what’s covered, which could put them at greater risk of unexpected medical bills that they cannot afford.

“We have been working hard to ensure that when we’re communicating to employees though employer that picked the high-performance network so that they can be confident that they’re receiving the best care at best price,” Atkins said.

https://www.fiercehealthcare.com…

Blue High Performance Network:
https://www.bcbs.com…

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Comment:

By Don McCanne, M.D.

One problem with employer-sponsored plans today is that cost sharing, especially high-deductibles, has been pushed to the limit. By making patients pay more out of pocket at the time of service, health care has been made less affordable and patients may forgo beneficial health care services because of these out-of-pocket costs. Employers have been recognizing these adverse consequences and thus are looking for alternative means of controlling health care spending.

Instead of pushing cost sharing even higher, BlueCross BlueShield Association is embarking on an ambitious national plan to establish a narrow “high-performance” network in selected markets nationally. Although they are marketing these networks to employers as being high performance, to achieve cost savings they actually are contracting for lower rates by promising health care providers greater exclusivity, thus reducing competition for those in the networks by keeping the provider networks narrow.

This is typical of the highly undesirable tradeoffs that are inevitable in a market of private health plans. In this case, patients lose their choices of physicians and hospitals in exchange for avoiding further increases in their out-of-pocket spending. But they may also be exposed to surprise medical bills because of care unavoidably provided out of network.

Contrast this with a well designed, single payer model of Medicare for All. Patients have free choice of their health care professionals and institutions, while financial barriers to accessing health care are removed. Of course there are endless other benefits such as guaranteed coverage for everyone for life, efficiencies through reduction in administrative waste, public administration of pricing, and care finally becomes affordable for each individual by the use of equitable (progressive) tax policies to fund the universal risk pool.

Blue Cross and Blue Shield plans are not inherently evil; it is our public officials who are evil when they insist that we continue with the fragmented, dysfunctional system of private and public plans when they have before them a model that would work well for everyone and they continue to reject its enactment and implementation, when their obligation is to inform the public on the moral imperative of single payer Medicare for All – a public that is much more influenced by sound bites than by policy science (what’s that?).

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By Dan Witters
Gallup, November 12, 2019

Highlights

• 34 million adults know someone who died after not getting treatment
• 58 million adults report inability to pay for needed drugs in past year
• Little progress seen by Trump administration in limiting rising drug costs

More than 13% of American adults — or about 34 million people — report knowing of at least one friend or family member in the past five years who died after not receiving needed medical treatment because they were unable to pay for it, based on a new study by Gallup and West Health. Nonwhites, those in lower-income households, those younger than 45, and political independents and Democrats are all more likely to know someone who has died under these circumstances.

These results are not meant to quantify the number of people who have died after not being able to pay for medical treatment, including prescription drugs, but rather the number of people who report knowledge of a death under such circumstances. In all, the Centers for Disease Control and Prevention estimate that about 2.8 million persons died in 2017 in the U.S. across all causes.

Dovetailing with these results is a rising percentage of adults who report not having had enough money in the past 12 months to “pay for needed medicine or drugs that a doctor prescribed” to them. This percentage has increased significantly, from 18.9% in January 2019 to 22.9% in September. In all, the 22.9% represents about 58 million adults who experienced “medication insecurity,” defined as the inability to pay for prescribed medication at least one time in the past 12 months. The increase reflects a marked rise among women of over five percentage points to 27.5%, widening the gender gap to over nine points when compared with the 18.1% rate for men.

Bottom Line

The substantial number of Americans who know someone who has died after not receiving treatment because of their inability to pay for it, coupled with the rise in the percentage who have not had enough money to pay for their prescriptions, underscores the urgency of the U.S. healthcare cost crisis. These realities starkly highlight the significant practical implications of drug prices on U.S. residents, as well as the effects of healthcare policy action — or inaction.

Only 7% of U.S. adults report that the Trump administration has accomplished “a great deal” on the issue, and voters are clearly expecting more from their elected officials than what has been accomplished in the past three years.

https://news.gallup.com…

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Comment:

By Don McCanne, M.D.

People are dying because of their inability to pay for health care. Although there is a lot of political noise on the subject, the inertia is overwhelming. It’s not that we do not understand the policy solutions that would make health care affordable for everyone, we do. A single payer model of Medicare for All would work just fine. Rather it’s that we are allowing the political noise to drown out the pleas for help. Are we just going to walk away?

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By Navindra Persaud, MD; Michael Bedard, MD; Andrew S. Boozary, MD; et al
JAMA Internal Medicine, October 7, 2019

Abstract

Importance: Nonadherence to treatment with medicines is common globally, even for life-saving treatments. Cost is one important barrier to access, and only some jurisdictions provide medicines at no charge to patients.

Objective: To determine whether providing essential medicines at no charge to outpatients who reported not being able to afford medicines improves adherence.

Design, Setting, and Participants: A multicenter, unblinded, parallel, 2-group, superiority, outcomes assessor–blinded, individually randomized clinical trial conducted at 9 primary care sites in Ontario, Canada, enrolled 786 patients between June 1, 2016, and April 28, 2017, who reported cost-related nonadherence. Follow-up occurred at 12 months. The primary analysis was performed using an intention-to-treat principle.

Interventions: Patients were randomly allocated to receive free medicines on a list of essential medicines in addition to otherwise usual care (n = 395) or usual medicine access and usual care (n = 391).

Main Outcomes and Measures: The primary outcome was adherence to treatment with all medicines that were appropriately prescribed for 1 year. Secondary outcomes were hemoglobin A1c level, blood pressure, and low-density lipoprotein cholesterol levels 1 year after randomization in participants taking corresponding medicines.

Results: Among the 786 participants analyzed (439 women and 347 men; mean [SD] age, 51.7 [14.3] years), 764 completed the trial. Adherence to treatment with all medicines was higher in those randomized to receive free distribution (151 of 395 [38.2%]) compared with usual access (104 of 391 [26.6%]; difference, 11.6%; 95% CI, 4.9%-18.4%). Control of type 1 and 2 diabetes was not significantly improved by free distribution (hemoglobin A1c, −0.38%; 95% CI, −0.76% to 0.00%), systolic blood pressure was reduced (−7.2 mm Hg; 95% CI, −11.7 to −2.8 mm Hg), and low-density lipoprotein cholesterol levels were not affected (−2.3 mg/dL; 95% CI, −14.7 to 10.0 mg/dL).

Conclusions and Relevance: The distribution of essential medicines at no charge for 1 year increased adherence to treatment with medicines and improved some, but not other, disease-specific surrogate health outcomes. These findings could help inform changes to medicine access policies such as publicly funding essential medicines.

Trial Registration: ClinicalTrials.gov identifier: NCT02744963

From the Discussion

In our multicenter randomized trial, distributing a comprehensive set of essential medicines at no charge improved adherence. Free distribution also lowered systolic blood pressure and there was a suggestion of better diabetes control, although results did not reach statistical significance. There was no effect on low-density lipoprotein cholesterol levels. There was no increase in potentially inappropriate prescribing and there was no substantial difference in serious adverse events. Participants receiving free medicine distribution were more likely to report being able to make ends meet; the hypothesis that medicine access allows people to afford other necessities can be tested in future studies.

Many patients did not see improvements in surrogate outcomes despite free distribution of medicines, emphasizing that cost is only one of several contributors to nonadherence and that medicines are just one part of care.

The setting and design of the trial allows inferences about the causal effects of essential medicine access to be drawn because all participants had access to publicly funded health care services. The study population included people with a range of income levels and sources and different ethnicities who lived in urban and rural settings.

https://jamanetwork.com…

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Even a Modest Co-Payment Can Cause People to Skip Drug Doses

By Aaron E. Carroll
The New York Times, November 11, 2019

There’s a logic to out-of-pocket medical payments. They’re supposed to make patients think twice before spending money on unnecessary health care.

When it comes to drugs, however, they’re often preventing people from getting necessary care.

(Cites extensive studies confirming reduced compliance with patient cost sharing.)

Canada’s single-payer system is sometimes held up as the preferred “other” model to the American status quo. But its drug coverage isn’t so good compared with the rest of the world. Pharmaceutical coverage is not part of Canada’s Medicare system, and differs from province to province. Still, Canadians do better than Americans.

Insurance isn’t enough, it seems clear. In 2015, researchers published a study in the Journal of General Internal Medicine that looked at medication adherence and cost-saving strategies of those who have Medicare. About 40 percent of this population took actions to try to cut their costs.

Cost sharing is supposed to lower spending without sacrificing quality. It was not meant to prevent patients who need drugs from receiving them.

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NYT Reader Comment:

By Don McCanne, M.D.

Another recent study in Canada showed that patients receiving medications at no charge had significantly higher adherence to treatment (JAMA Internal Medicine, October 7, 2019).

A health care financing system should make it easier for patients to receive essential care they should have. Cost sharing is a barrier to care and should be eliminated. A well designed single payer model of Medicare for All would do just that.

https://www.nytimes.com…

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By Adam L. Logeman, MS, Oscar Ponce, MD, Neri Álvarez-Villalobos, MD, Victor M. Montori, MD, MSc
Mayo Clinic Proceedings, November 2019

The health care system in the United States is capable of both health care excellence and pricing people out of care. Key individuals can exert influence on public and private discourse, policies, and actions that are responsible for health care’s current state and envision a path forward. Since 2003, the periodical Modern Healthcare has published a yearly ranking of the 100 most influential people in US health care. The list is compiled with readership input and vetted by the periodical’s editorial board using proprietary criteria; the selection is also opaque as to what (ie, health care or clinical policy and the practice or the business of care) or who (ie, policymakers, employers, payers, clinicians, and patients) is subject to their influence. Because it receives wide reporting and limited critique, this list stands as a useful longitudinal account of who others perceive to be in a position to influence health care.

Using the published yearly list and the reported characteristics of the persons listed, we sought to determine the relative ranking over time, covering the period 2002 to 2018, of executives and administrators, academics and frontline advocates, and government officials.

There were 1700 persons named from 2002 to 2018, a minority of them women (range over the period, 17% to 28%). Most influencers are top executives from nonprofit health care provider organizations; their proportion has increased from 23% in 2002 to 72% in 2018, with an apparent substantial upward inflection in this trend since 2009. This predominance appears to be at the expense of academics, advocates, and government officials.

We found that the perceived influence over US health care of chief executives of health systems is increasing. To the extent that the ranking validly reflects influence, the sharp rise in the influence of chief executive officers at the expense of representatives of patients or health professionals may underscore the increasing industrialization of health care. It is not possible to find patients, patient advocates, clinicians, or clinician advocates at the top of this list. This trend placing health care influencers within C-suites, accountable to boards mostly comprising other corporate leaders, may explain the rise of business language and thinking—for example, high-value health care.

Our findings suggest that patients and clinicians are neither defining what health care is nor deciding how it should evolve. Urgently, they must find and use their collective voices to turn away from industrial health care and move decidedly toward careful and kind patient care for all.

https://www.mayoclinicproceedings.org…

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To Control Costs Expand Managed Care and Managed Competition

By Alain Enthoven, PhD; Victor R. Fuchs, PhD; Stephen M. Shortell, PhD, MPH, MBA
JAMA, November 7, 2019

The US health care financing and delivery system serves the public poorly. It costs far more than in any other country, does not produce better health outcomes, and leaves millions uninsured.

Over the years, managed care, defined as patient-centered coordinated care provided under payment incentives that reward achieving cost and quality measures, and managed competition, a market designed to create incentives for managed care organizations (MCOs) to reduce cost and improve quality and patient satisfaction, have demonstrated a potential to control costs without any sacrifice of quality.

Managed care increases efficiency of care delivery within individual health plans. Managed competition creates a structure within which health care plans compete with one another. The 2 are complementary and synergistic, and have several advantages over reforms that require government-initiated transformation of all medical care. These models offer the possibility of controlling costs without government price controls.

Managed Care

Managed care, a concept that addresses both payment and delivery, has a long history, beginning with Kaiser Permanente in the 1940s and including passage of the Health Maintenance Organization Act of 1973 and current interest in risk bearing ACOs. Managed care, fully or partially implemented, is now a widespread form of health care in most parts of the country.

2019 data suggest that more physician organizations are owned or strongly affiliated with a specific hospital/health system, reducing to some extent the overlap of physician networks.

Managed Competition

The competitors are health care financing and delivery plans based on managed care or traditional open-ended fee-for-service systems.

For managed competition to succeed, it must lead to the transformation of US health care from traditional, open-ended, uncoordinated fee-for-service systems to efficient MCOs.

From the Conclusions

When an economic or health care crisis comes, cost control will have priority, but crisis solutions are rarely the wisest. Managed care and managed competition are not panaceas. As is true of all types of medical care interventions, clinical or organizational, not every individual attempt will succeed; however, managed care and managed competition have a good record of success in controlling costs and maintaining quality without resorting to price controls, the principal alternative.

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

The most influential people in U.S. health care? It’s not the patients. It’s not the clinicians. It is not the academics, advocates, nor government officials. According to the Modern Healthcare survey, it’s the top executives of health care provider organizations, or leaders of “industrial health care” (forget about “medical”).

And what about the managed care revolution that failed to adequately control high health care spending and left in place the health care injustices that are so prevalent today? The deafening echo perpetuated through recent decades is intensifying in its call for yet more managed care, now often labeled as ACOs or value-based care. And what do we hear from the health care academics? Net savings performance still varies widely and quality performance is still highly variable (Health Affairs Blog, October 25, 2019). It is not working.

And just to confirm that not much has changed, the Old Guard (Enthoven et al) tell us that we need to continue to expand this model to control costs in order to avoid government price controls. What? Costs have continued their upward spiral in the private commercial insurance market (in spite of transient brief slowing) yet have been much better controlled under the government-run Medicare program. Tens of millions remain uninsured and many more remain underinsured while patients are losing their choices of physicians and hospitals. Again, managed care is not serving us well.

The private sector is not going to voluntarily bring most people under the safe umbrella of health care. When the private industry has already tapped those backed by adequate resources, only government policies can pull the rest in. Only the government can ensure that absolutely everyone is included, that financial and other barriers to access are removed, that all essential services are covered, and that the system is affordable for each of us through a universal financing system funded through equitable taxes. None of these are functions of managed care.

We need to discharge the private managed care managers and replace the system with our own public stewards. As the authors of the Mayo Clinic Proceedings article state, “patients and clinicians must find and use their collective voices to turn away from industrial health care and move decidedly toward careful and kind patient care for all.”

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By Michael Anne Kyle, Robert J. Blendon, John M. Benson, Melinda K. Abrams, and Eric C. Schneider
Health Affairs, November 2019

Abstract

In a national survey, seriously ill Medicare beneficiaries described financial hardships resulting from their illness—despite high beneficiary satisfaction with Medicare overall and the fact that many have supplemental insurance. About half reported a serious problem paying medical bills, with prescription drugs proving most onerous.

Conclusion

Medicare insurance is broadly popular, but seriously ill beneficiaries who most need financial protection report widespread problems affording care and financial instability.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Medicare should be especially advantageous for beneficiaries with serious illness, but about half reported a serious problem paying medical bills.

Although “Medicare for All” initially referred to the vastly superior single payer model of reform, the label has been corrupted. For some it refers to merely adding a Medicare-like public option to our dysfunctional system of health care financing. For others it means that your insurance through work will be taken away from you, and, to compound problems, your taxes will go up.

Regardless of labels, it is imperative that the public understands that the single payer model would provide affordable, comprehensive health care for absolutely everyone. No other model, whether or not labeled “Medicare for All,” comes close. That begins by understanding that we are not proposing to continue with the inadequate traditional Medicare program, but we would be replacing it with a vastly improved version, whether labeled “Single Payer Improved Medicare for All” or whatever.

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By John Furse
London Review of Books, November 7, 2019

The Americanisation of the NHS is not something waiting for us in a post-Brexit future. It is already in full swing. Since 2017 Integrated Care Systems (ICSs) have been taking over the purchasing as well as the provision of NHS services in England, deciding who gets which services, which are free and which – as with the dentist and prescriptions – we have to pay for. Known in the US as Accountable Care Organisations (ACOs), ICSs are partnerships between hospitals, clinicians and private sector providers designed – and incentivised – to limit and reduce public healthcare costs, and in particular to lessen the demand on hospitals. Health Maintenance Organisations (HMOs), the forerunners of ACOs, were pioneered by the US health insurance provider Kaiser Permanente in 1953. President Nixon’s adviser John Ehrlichman explained to his boss the basic concept before the passage of the 1973 HMO Act: ‘The less care they give them the more money they make.’ In May 2016 Jeremy Hunt, then health minister, admitted at a Commons Health Committee hearing that Kaiser was a model for his planned NHS reforms. When a trial of ACOs was announced in the UK in 2017, it caused an outcry from campaigners and NHS England quickly rebranded them ICSs. But the Kaiser model isn’t new to healthcare policy in the UK: it has been the inspiration for the long and discreet process of the dismantling and reformation of the NHS since the 1980s.

In his report to the Conservative Party’s Economic Reconstruction Group in 1977, Nicholas Ridley wrote that “denationalisation should not be attempted by frontal attack but by preparation for return to the private sector by stealth. We should first pass legislation to destroy the public sector monopolies. We might also need to take power to sell assets. Secondly, we should fragment the industries as far as possible and set up the units as separate profit centres.”

After coming to power two years later, Thatcher was able openly to denationalise many industries, but the NHS, with its huge number of staff and institutions, its largely effective and equitable provision of healthcare and its great popularity, was a far more difficult proposition. In 1986 hospital cleaning services were privatised. In 1988 Oliver Letwin and John Redwood published Britain’s Biggest Enterprise: Ideas for Radical Reform of the NHS, which proposed turning the NHS into an independent trust and advocated joint ventures with the private sector and the introduction of fees.

The first major legislative step was the creation of the internal market. Kenneth Clarke’s 1990 NHS and Community Care Act split the NHS into ‘service purchasers’ and ‘service providers’: hospitals and GPs would compete for custom and the successful parties would be rewarded with greater funding. The influence of the HMO model and of the Kaiser consultant Alain Enthoven was acknowledged in Parliament by the then Tory MP Quentin Davies. ‘The fund-holding practice concept owes something to the system of HMOs in the United States … Elements of the Bill reflect some of the thinking of Professor Enthoven in his famous report and reflect his concept of an internal market.’ Enthoven was seen as an expert on ‘unsustainable growth’ in health expenditure and in 1985 his report ‘Reflections on the Management of the National Health Service’ had advised the Thatcher administration that ‘in competition doctors impose on themselves controls they would never dream of accepting if the government tried to impose them.’ ‘The system needed to be reconfigured,’ he later explained, ‘in such a way as to give incentives to motivate the self-interest.’

Letwin and Redwood’s ideas also had traction in Tony Blair’s 1997 National Health Service Act. Together, the 1990 and 1997 Acts turned NHS hospitals into trusts able to operate as commercial businesses. Many formed Private Finance Initiative partnerships to build and maintain hospitals – these deals, originally worth £11.4 billion, have lumbered the NHS with more than £80 billion of debt. Under New Labour a number of hospital trusts commissioned Kaiser and United Health, the largest US private health insurer, to run pilot programmes. ‘Consumer choice’ had been the mantra of the Thatcher era; under New Labour NHS patients became consumers and the goal ‘patient choice’.

These changes were minor compared to those introduced by the 2012 Health and Social Care Act (Letwin was by then a senior figure in Tory policy-making), which enabled hospital trusts to raise 49 per cent of their budgets from private patients and other sources, and to use NHS ‘brand loyalty’ to attract patients to their private services. In 2017 Swindon’s Great Western NHS Hospital advertised its private service saying: ‘Our patients benefit from a premium environment while having immediate access to specialist services often only available in large NHS hospitals.’

The Act gave more than 60 per cent of the NHS budget to local Clinical Commissioning Groups (CCGs), comprised of GPs and other clinicians, to be used to commission services from the private sector as well as from the NHS. Writing anonymously, one GP described the change as ‘how to get turkeys not only voting for Christmas but also plucking, basting and putting themselves in the oven’. Given their lack of business expertise, CCGs were provided with Commissioning Support Units run by private companies including KPMG, Price Waterhouse Cooper, McKinsey and Optum, the UK subsidiary of United Health. In practice, these companies now run the franchising of NHS services.

A key part of the 2012 Act, to which McKinsey was a significant contributor, was the abolition of the health minister’s responsibility for national healthcare provision. This was left to NHS England under its new director, Simon Stevens, a former health policy adviser to the Blair government appointed by David Cameron because ‘he knows more about NHS problems and market solutions than any man alive.’ In his previous role as a CEO of United Health, Stevens had led corporate opposition to the introduction of Obamacare. His ‘Five-Year Forward View’, launched in 2015, became the basis for NHS England’s Sustainability and Transformation Plans (STPs), drawn up with Optum and McKinsey. The STPs were supposed to create savings of almost £5 billion a year by 2020. As in the Kaiser model, costs are cut by reducing access to care. (Meanwhile, the revolving door continued to turn: senior government and NHS England figures who took prominent positions at Optum include Cameron’s health adviser Nick Seddon, NHS England’s commissioner David Sharp and its mental health director Martin McShane.)

The STPs divided England into 44 CCG-run ‘footprint’ areas, all of which were put under pressure to amalgamate hospitals and shrink specialist units. Hospital beds have been progressively cut: the UK’s bed-to-patient ratio is now one of the lowest in any developed country. Accident and emergency departments, which not only require expensive equipment and high numbers of staff but also take the brunt of social care failings, are in the process of being cut from 144 to about fifty. GP care is increasingly provided by ‘physician associates’, nurse practitioners and pharmacists, while patients are exhorted to use privately owned, profit-making online and app consultancies such as Doctaly, GP at Hand and myGP. Opening up new markets for US tech giants is a key factor in the reconfiguration of the NHS.

Enforced centralisation has resulted in ‘hub’ hospitals and fewer, larger GP practices: at least a thousand have closed since 2014 and the number with more than twenty thousand patients has tripled. With funding incentives from NHS England, GPs are merging their practices into competing, largescale organisations with names like Primary Care Networks and Super-Practices, or becoming partners in commercially driven Multi-Speciality Community Provider centres. These reduced and restructured services are open to takeovers by private companies. NHS hospitals now lease space on their own premises to private companies. Guy’s Hospital, in the absence of the funding it needed to develop adequate cancer facilities, rented space to the Hospital Corporation of America for private cancer suites that were given access to the hospital’s facilities. The merging of public and private provision in the same space usefully blurs the distinction between them. And the rationing of non-urgent operations such as hip replacements and restrictions on follow-up therapies – as well as increased waiting times – encourage patients to seek private treatment.

A recent report by the Strategy Unit, an NHS consultancy, acknowledges that ICSs are designed to ‘moderate’ demand and reduce spending, while their partners keep the savings they make if they run below budget. It cautions that, as with ACOs, there is ‘only limited assurance that providers will not game the system and that quality will not suffer … large financial rewards may flow out of the NHS.’ At the 2012 World Economic Forum, Stevens (then working for United Health) led proposals to replace public healthcare systems around the world with accountable care systems. His collaborators included Medtronic, the world’s largest producer of medical devices (a US company based in Ireland for tax purposes), Qualcomm Life, which designs medical technology, and Kaiser. Since his arrival at NHS England, the influence of such companies has grown: IBM is now a lead supplier of IT; Optum runs GP referrals services and is in a partnership with the second largest GP federation, Modality. The UK’s largest GP network, the Practice Group, is owned by the American company Centene. Similar companies, such as the Priory Group, are major players in mental healthcare provision and are involved in mental health ICSs.

Private companies, with their increased overheads, higher rates of borrowing and shareholder dividends, are inherently more costly to the public than state-funded services. Less obvious are the high costs of management and administration involved in franchising and marketing services. In the US these are estimated to account for more than 30 per cent of the $3.6 trillion spent on healthcare. A 2010 report commissioned by the Department of Health estimated management and administration costs at 14 per cent of total NHS spending, more than twice the figure in 1990. Commercial confidentiality laws and opaque NHS accounting make the costs of privatisation hard to quantify but privatisation is probably adding at least £9 billion a year to the NHS budget.

Stevens was recently praised by politicians and the media when he called for the repeal of Section 75 of the 2012 Health and Social Care Act, which requires competitive market tendering for the provision of services – ostensibly a move away from privatisation. But the real reason lies in the small print. Section 75 subjects private contractors to the Competition and Markets Authority. Its repeal will deregulate the sector and make ICSs more attractive to companies. Andrew Taylor, the founding director of the Co-operation and Competition Panel for NHS Funded Services, told a Commons committee hearing in May: ‘I don’t think anyone’s realistically talking about removing the private sector from the NHS. What the proposals do in effect is deregulate NHS markets. They don’t actually remove markets from the NHS.’

The Ridley Report’s proposals for denationalisation are being hurried to fulfilment. NHS property and land assets worth £10 billion are being sold to private developers. The fragmentation of a once fully integrated service into competing and commercially-driven units is well advanced and has been accomplished without proper public scrutiny, knowledge, consent or appropriate Parliamentary legislation. Successive governments have been assisted by the failure of the media to recognise the overall shape of the project and sufficiently analyse the disparate changes. ICSs will be fully up and running throughout England within 18 months.

https://www.lrb.co.uk…

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Comment:

By Don McCanne, M.D.

This one you simply have to read. Only by doing so will you be able to understand why the change taking place in England’s NHS explains “how to get turkeys not only voting for Christmas but also plucking, basting and putting themselves in the oven.”

One snippet to pique your interest: When the UK introduced ACOs (US-style Accountable Care Organizations) the outcry caused NHS England to quickly rebrand them as ICSs (Integrated Care Systems). ICSs will be fully up and running throughout England within 18 months.

It’s turkey season. Big time!

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