PNHP

The Cost-Effectiveness of Medicare for All

The Cost-Effectiveness of Medicare for All

A health consultant says the free market has failed to rein in medical costs.

By Ken Lefkowitz
New York Times, Letters, August 16, 2019

To the Editor:

Re: “The Tough Calls on ‘Medicare for All’” (The Upshot, Aug. 13):

The discussions about choice and competition, as well as cost, ignore some critical information and perspectives.

American health care is financed through a free market that has proved ineffective in controlling costs because it requires transparency so consumers can compare prices. But the dizzying complexity of both medical care and insurance plan design precludes the consumer from making informed choices. Primary care physicians strongly influence choice, and insurance company provider networks limit choice even further.

Also, single-payer universal health care, or Medicare for all, is quite cost-effective. It has proved to be less costly in other countries. It will wring out the duplicative and wasteful administrative costs of the free marketplace and provide powerful national negotiating leverage to stabilize medical provider and pharmacy costs.

A University of Massachusetts study demonstrated that Medicare for all can cover all citizens, including today’s uninsured, eliminating deductibles and co-pays, and still save an estimated $600 billion.

Even those who receive health care through their unions or companies should welcome such a plan, since premiums, deductibles and co-pays have been rising at a rapid rate in their plans.

The writer, a consultant, has designed and managed health care plans for major companies.

https://www.nytimes.com…

Medicare for All Explained Podcast: Episode 18

Interview with Kristy Fogle

August 15, 2019

Emergency medicine physician assistant and Maryland Progressive Healthcare Coalition founder Kristy Fogle discusses her recent organizing work and reminds listeners that all private health insurance plans pale in comparison to improved Medicare for All. Hosted by Joseph Sparks. Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

JG Kahn & E Marseille: Fears and facts of Medicare for All

Medicare for all: fears and facts

By Drs. James G. Kahn and Elliot Marseille
The Hill, August 14, 2019

Each candidate has their own way to fix what ails health insurance. Everyone claimed “Medicare” at the heart of their strategy. Sen. Bernie Sanders (D-Vt.) and Sen. Elizabeth Warren (D-Mass.) urged sweeping reform, while former Vice President Joe Biden and others advocated tinkering at the margins, stoking fear of big change.

What does it all mean?

After the first Democratic debate, we wrote a Cheat Sheet to clarify key concepts, and reviewed the minimal role of private insurance under “Medicare for all.” This time, we’re tackling people’s fears about reform and comparing the proposed plans.

Let’s start with three fears raised in the debate:

Should I be afraid of losing my insurance? Yes — under the current system. Unless you’re on Medicare, your health insurance is not guaranteed. Your employer can cancel the plan you like, forcing you to find a new doctor.

You may change jobs, or be laid off and lose your insurance. The premium may rise so much that you can no longer afford it. Coverage that’s guaranteed wherever (or whether) you work requires insurance that covers people based on U.S. residency rather than employment, like Rep. Pramila Jayapal’s (D-Wash.) Medicare for All Act of 2019.

Should I worry that taxes will go up? With Medicare for all, taxes will replace rising premiums, copays and deductibles.

These taxes will be progressive. The more you earn, the higher rate you pay. That’s fairer than charging for health insurance based on age, without regard to income, like now. The Affordable Care Act provides premium subsidies for some poorer people, but not for all and requires high deductibles and copays. For most people, the new taxes for health care will be less than what they currently pay in premiums and out-of-pocket costs. Low and middle-income families will save money. High-income families will pay more.

Should I fear losing choice of doctor? Sadly, we already have. Unless you’re on traditional Medicare, you can’t choose any doctor or hospital you like (except if you pay the costs yourself). Some presidential candidates say the choice worth making is between health insurers. Isn’t it more important to choose the doctor and hospital that provides your care, as permitted under Medicare for all?

Now, let’s compare the candidates’ plans. There are three approaches (see side-by-side table):

Medicare for all (single payer) provides coverage for life, regardless of health, wealth, or work status. Everyone has a comprehensive benefit package, accepted by all doctors. A public agency directly pays doctors and hospitals’ negotiated rates. Medicare for all combines superb coverage with lower costs. How? By simplifying every aspect of insurance, from enrollment to coverage to billing.

This results in massive administrative savings ($400-500 billion per year) and lower drug prices. How we pay for health care would also change. Taxes would rise, especially on the wealthy, but premiums and out-of-pocket costs would disappear. Most importantly, health care would cost our society less — 5 to 8 percent less in most studies, while covering everyone.

Public Option (or Medicare expansion) means we keep the current super-complex mix of private and public plans, while letting some people buy into Medicare. This protects private insurance companies, and so keeps the bad stuff — restricted doctor networks, deductibles and copays, and administrative bloat.

Medicare Advantage for all Sen. Kamala Harris (D-Calif.) recently proposed an approach based on Medicare Advantage, the HMO part of Medicare. This assures a large role for private insurers. Thus, it has most of the same drawbacks as the Medicare public option, with few savings opportunities. It would leave private insurers and all their unnecessary expenses burdening Americans for another decade.

Is Medicare for All “fairytale economics,” as former Rep. John Delaney said? It’s a system widely used in other countries — and works incredibly well. The real fairy tale is that we can still afford insurance middlemen taking a cut out of our health-care budget.

Is it too drastic? During the Great Depression, we launched America’s biggest social insurance program: Social Security. It’s a great example of how the government can protect us against economic risk and improve our lives. Medicare for all is a grand solution in a grand American tradition. This kind of health-care reform is not only possible, it’s essential.

James G. Kahn, M.D., is an emeritus professor of health policy at the University of California San Francisco. Dr. Elliot Marseille, DrPH, is CEO of Health Strategies International.

https://thehill.com…

Comment:

By Don McCanne, M.D.

Many of the conversations taking place today on Medicare for All are strong on opinion and weak on facts. When we get the facts straight it becomes obvious that the single payer model of Medicare for All is an imperative.

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

Why doesn’t the United States have universal health care? The answer has everything to do with race.

By Jeneen Interlandi
New York Times, August 14, 2019

The smallpox virus hopscotched across the post-Civil War South, invading the makeshift camps where many thousands of newly freed African-Americans had taken refuge but leaving surrounding white communities comparatively unscathed. This pattern of affliction was no mystery: In the late 1860s, doctors had yet to discover viruses, but they knew that poor nutrition made people more susceptible to illness and that poor sanitation contributed to the spread of disease. They also knew that quarantine and vaccination could stop an outbreak in its tracks; they had used those very tools to prevent a smallpox outbreak from ravaging the Union Army.

Smallpox was not the only health disparity facing the newly emancipated, who at the close of the Civil War faced a considerably higher mortality rate than that of whites. Despite their urgent pleas for assistance, white leaders were deeply ambivalent about intervening. They worried about black epidemics spilling into their own communities and wanted the formerly enslaved to be healthy enough to return to plantation work. But they also feared that free and healthy African-Americans would upend the racial hierarchy, the historian Jim Downs writes in his 2012 book, “Sick From Freedom.”

Federal policy, he notes, reflected white ambivalence at every turn. Congress established the medical division of the Freedmen’s Bureau — the nation’s first federal health care program — to address the health crisis, but officials deployed just 120 or so doctors across the war-torn South, then ignored those doctors’ pleas for personnel and equipment. They erected more than 40 hospitals but prematurely shuttered most of them.

White legislators argued that free assistance of any kind would breed dependence and that when it came to black infirmity, hard labor was a better salve than white medicine. As the death toll rose, they developed a new theory: Blacks were so ill suited to freedom that the entire race was going extinct. “No charitable black scheme can wash out the color of the Negro, change his inferior nature or save him from his inevitable fate,” an Ohio congressman said.

One of the most eloquent rejoinders to the theory of black extinction came from Rebecca Lee Crumpler, the nation’s first black female doctor. Crumpler was born free and trained and practiced in Boston. At the close of the war, she joined the Freedmen’s Bureau and worked in the freed people’s communities of Virginia. In 1883, she published one of the first treatises on the burden of disease in black communities. “They seem to forget there is a cause for every ailment,” she wrote. “And that it may be in their power to remove it.”

In the decades following Reconstruction, the former slave states came to wield enormous congressional power through a voting bloc that was uniformly segregationist and overwhelmingly Democratic. That bloc preserved the nation’s racial stratification by securing local control of federal programs under a mantra of “states’ rights” and, in some cases, by adding qualifications directly to federal laws with discriminatory intent.

As the Columbia University historian Ira Katznelson and others have documented, it was largely at the behest of Southern Democrats that farm and domestic workers — more than half the nation’s black work force at the time — were excluded from New Deal policies, including the Social Security and Wagner Acts of 1935 (the Wagner Act ensured the right of workers to collective bargaining), and the Fair Labor Standards Act of 1938, which set a minimum wage and established the eight-hour workday. The same voting bloc ensured states controlled crucial programs like Aid to Dependent Children and the 1944 Servicemen’s Readjustment Act, better known as the G.I. Bill, allowing state leaders to effectively exclude black people.

In 1945, when President Truman called on Congress to expand the nation’s hospital system as part of a larger health care plan, Southern Democrats obtained key concessions that shaped the American medical landscape for decades to come. The Hill-Burton Act provided federal grants for hospital construction to communities in need, giving funding priority to rural areas (many of them in the South). But it also ensured that states controlled the disbursement of funds and could segregate resulting facilities.

Professional societies like the American Medical Association barred black doctors; medical schools excluded black students, and most hospitals and health clinics segregated black patients. Federal health care policy was designed, both implicitly and explicitly, to exclude black Americans. As a result, they faced an array of inequities — including statistically shorter, sicker lives than their white counterparts. What’s more, access to good medical care was predicated on a system of employer-based insurance that was inherently difficult for black Americans to get. “They were denied most of the jobs that offered coverage,” says David Barton Smith, an emeritus historian of health care policy at Temple University. “And even when some of them got health insurance, as the Pullman porters did, they couldn’t make use of white facilities.”

In the shadows of this exclusion, black communities created their own health systems. Lay black women began a national community health care movement that included fund-raising for black health facilities; campaigns to educate black communities about nutrition, sanitation and disease prevention; and programs like National Negro Health Week that drew national attention to racial health disparities. Black doctors and nurses — most of them trained at one of two black medical colleges, Meharry and Howard — established their own professional organizations and began a concerted war against medical apartheid. By the 1950s, they were pushing for a federal health care system for all citizens.

That fight put the National Medical Association (the leading black medical society) into direct conflict with the A.M.A., which was opposed to any nationalized health plan. In the late 1930s and the 1940s, the group helped defeat two such proposals with a vitriolic campaign that informs present-day debates: They called the idea socialist and un-American and warned of government intervention in the doctor-patient relationship. The group used the same arguments in the mid-’60s, when proponents of national health insurance introduced Medicare. This time, the N.M.A. developed a countermessage: Health care was a basic human right.

Medicare and Medicaid were part of a broader plan that finally brought the legal segregation of hospitals to an end: The 1964 Civil Rights Act outlawed segregation for any entity receiving federal funds, and the new health care programs soon placed every hospital in the country in that category. But they still excluded millions of Americans. Those who did not fit into specific age, employment or income groups had little to no access to health care.

In 2010, the Affordable Care Act brought health insurance to nearly 20 million previously uninsured adults. The biggest beneficiaries of this boon were people of color, many of whom obtained coverage through the law’s Medicaid expansion. That coverage contributed to a measurable decrease in some racial health disparities, but the success was neither as enduring nor as widespread as it might have been. Several states, most of them in the former Confederacy, refused to participate in Medicaid expansion. And several are still trying to make access to the program contingent on onerous new work requirements. The results of both policies have been unequivocal. States that expanded Medicaid saw a drop in disease-related deaths, according to the National Bureau of Economic Research. But in Arkansas, the first state to implement work requirements, nearly 20,000 people were forced off the insurance plan.

One hundred and fifty years after the freed people of the South first petitioned the government for basic medical care, the United States remains the only high-income country in the world where such care is not guaranteed to every citizen. In the United States, racial health disparities have proved as foundational as democracy itself. “There has never been any period in American history where the health of blacks was equal to that of whites,” Evelynn Hammonds, a historian of science at Harvard University, says. “Disparity is built into the system.” Medicare, Medicaid and the Affordable Care Act have helped shrink those disparities. But no federal health policy yet has eradicated them.

Jeneen Interlandi is a member of The Times’s editorial board and a staff writer for the magazine.

https://www.nytimes.com…

Medicare ACO outcomes are indistinguishable from zero

Association Between Care Management and Outcomes Among Patients With Complex Needs in Medicare Accountable Care Organizations

By Mariétou H. Ouayogodé, PhD, Alexander J. Mainor, JD, MPH, Ellen Meara, PhD, Julie P. W. Bynum, MD, MPH, and Carrie H. Colla, PhD
JAMA Network Open, July 12, 2019

Abstract

Importance

People with complex needs account for a disproportionate amount of Medicare spending, partially because of fragmented care delivered across multiple practitioners and settings. Accountable care organization (ACO) contracts give practitioners incentives to improve care coordination to the extent that coordination initiatives reduce total spending or improve quality.

Objective

To assess the association between ACO-reported care management and coordination activities and quality, utilization, spending, and health care system interactions in older adults with complex needs.

Design, Setting, and Participants

In this cross-sectional study, survey information on care management and coordination processes from 244 Medicare Shared Savings Program ACOs in the 2017-2018 National Survey of ACOs (of 351 Medicare ACO respondents; response rate, 69%) conducted from July 20, 2017, to February 15, 2018, was linked to 2016 Medicare administrative claims data. Medicare beneficiaries 66 years or older who were defined as having complex needs because of frailty or 2 or more chronic conditions associated with high costs and clinical need were included.

Exposures

Beneficiary attribution to ACO reporting comprehensive (top tertile) care management and coordination activities.

Main Outcomes and Measures

All-cause prevention quality indicator admissions, 30-day all-cause readmissions, acute care and critical access hospital admissions, evaluation and management visits in ambulatory settings, inpatient days, emergency department visits, total spending, post–acute care spending, health care contact days, and continuity of care (from Medicare claims).

Results

Among 1 402 582 Medicare beneficiaries with complex conditions, the mean (SD) age was 78 (8.0) years and 55.1% were female. Compared with beneficiaries assigned to ACOs in the bottom tertile of care management and coordination activities, those assigned to ACOs in the top tertile had identical median prevention quality indicator admissions and 30-day all-cause readmissions (0 per beneficiary across all tertiles), hospitalization and emergency department visits (1.0 per beneficiary in bottom and top tertiles), evaluation and management visits in ambulatory settings (14.0 per beneficiary [interquartile range (IQR), 8.0-21.0] in both tertiles), longer median inpatient days (11.0 [IQR, 4.0-33.0] vs 10.0 [IQR, 4.0-32.0]), higher median annual spending ($14 350 [IQR, $4876-$36 119] vs $14 229 [IQR, $4805-$36 268]), lower median health care contact days (28.0 [IQR, 17.0-44.0] vs 29.0 [IQR, 18.0-45.0]), and lower continuity-of-care index (0.12 [IQR, 0.08-0.20] vs 0.13 [IQR, 0.08-0.21]). Accounting for within-patient correlation, quality, utilization, and spending outcomes among patients with complex needs attributed to ACOs were not statistically different comparing the top vs bottom tertile of care management and coordination activities.

Conclusions and Relevance

The ACO self-reports of care management and coordination capacity were not associated with differences in spending or measured outcomes for patients with complex needs. Future efforts to care for patients with complex needs should assess whether strategies found to be effective in other settings are being used, and if so, why they fail to meet expectations.

From the Discussion

To measure whether ACO efforts to manage and coordinate care are associated with health care utilization and spending outcomes in groups likely to benefit from such services, we used data from the NSACO to form a care management and coordination index that plausibly targets older patients with complex health needs. We found wide variation in reported care management and coordination activities across MSSP participants. For example, when index scores were ranked by the level of care management activity reported, we observed large differences in the use of evidence-based approaches to care transitions for hospitalized patients. In multivariate analyses of patient-level measures for 244 ACO respondents, we found that high levels of care management and coordination intensity were not associated with significant differences in hospitalizations, inpatient days, E&M visits in ambulatory settings, spending, and health care system contact days despite large samples of beneficiaries in each group of ACOs.

Although our study is not definitive and includes several limitations, our estimates on various outcomes are indistinguishable from zero, indicating a call to invest in these areas with caution and to track local results in careful evaluations. Our results suggest that organizations should consider the effectiveness of investing heavily in care coordination activities that are difficult to implement.

https://www.ncbi.nlm.nih.gov…

Comment:

By Don McCanne, M.D.

Regarding this study of outcomes among patients with complex needs in Medicare accountable care organizations, these authors report, “our estimates on various outcomes are indistinguishable from zero.” If there were any merit to ACOs, it should certainly show up in patients with complex needs.

As with many other studies that are reporting negligible results in their evaluations of accountable care organizations, these authors also recommend, “As ACOs focus on expanding care coordination and management efforts, it is important to continually evaluate the effectiveness of those programs for different patient populations.” More study of the same unsuccessful, mindless policy options?

There are endless conferences, seminars, and journal articles on accountable care organizations, all for naught. Yet where are the conferences on the single payer model of Medicare for All? These other conferences are a distraction from what we need to be doing – moving forward with enacting and implementing a model that would be truly effective, efficient, equitable, and affordable for all; Single Payer Medicare for All. Accountable care organizations are a dead end.

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

Medicare for all: fears and facts

By James G. Kahn, M.D. and Elliot Marseille, Dr.P.H.
The Hill, August 14, 2019

Each candidate has their own way to fix what ails health insurance. Everyone claimed “Medicare” at the heart of their strategy. Sen. Bernie Sanders (D-Vt.) and Sen. Elizabeth Warren (D-Mass.) urged sweeping reform, while former Vice President Joe Biden and others advocated tinkering at the margins, stoking fear of big change.

What does it all mean?

After the first Democratic debate, we wrote a Cheat Sheet to clarify key concepts, and reviewed the minimal role of private insurance under “Medicare for all.” This time, we’re tackling people’s fears about reform and comparing the proposed plans.

Let’s start with three fears raised in the debate:

Should I be afraid of losing my insurance? Yes — under the current system. Unless you’re on Medicare, your health insurance is not guaranteed. Your employer can cancel the plan you like, forcing you to find a new doctor.

You may change jobs, or be laid off and lose your insurance. The premium may rise so much that you can no longer afford it. Coverage that’s guaranteed wherever (or whether) you work requires insurance that covers people based on U.S. residency rather than employment, like Rep. Pramila Jayapal’s (D-Wash.) Medicare for All Act of 2019.

Should I worry that taxes will go up? With Medicare for all, taxes will replace rising premiums, copays and deductibles.

These taxes will be progressive. The more you earn, the higher rate you pay. That’s fairer than charging for health insurance based on age, without regard to income, like now. The Affordable Care Act provides premium subsidies for some poorer people, but not for all and requires high deductibles and copays. For most people, the new taxes for health care will be less than what they currently pay in premiums and out-of-pocket costs. Low and middle-income families will save money. High-income families will pay more.

Should I fear losing choice of doctor? Sadly, we already have. Unless you’re on traditional Medicare, you can’t choose any doctor or hospital you like (except if you pay the costs yourself). Some presidential candidates say the choice worth making is between health insurers. Isn’t it more important to choose the doctor and hospital that provides your care, as permitted under Medicare for all?

Now, let’s compare the candidates’ plans. There are three approaches (see side-by-side table):

Medicare for all (single payer) provides coverage for life, regardless of health, wealth, or work status. Everyone has a comprehensive benefit package, accepted by all doctors. A public agency directly pays doctors and hospitals’ negotiated rates. Medicare for all combines superb coverage with lower costs. How? By simplifying every aspect of insurance, from enrollment to coverage to billing.

This results in massive administrative savings ($400-500 billion per year) and lower drug prices. How we pay for health care would also change. Taxes would rise, especially on the wealthy, but premiums and out-of-pocket costs would disappear. Most importantly, health care would cost our society less — 5 to 8 percent less in most studies, while covering everyone.

Public Option (or Medicare expansion) means we keep the current super-complex mix of private and public plans, while letting some people buy into Medicare. This protects private insurance companies, and so keeps the bad stuff — restricted doctor networks, deductibles and copays, and administrative bloat.

Medicare Advantage for all: Sen. Kamala Harris (D-Calif.) recently proposed an approach based on Medicare Advantage, the HMO part of Medicare. This assures a large role for private insurers. Thus, it has most of the same drawbacks as the Medicare public option, with few savings opportunities. It would leave private insurers and all their unnecessary expenses burdening Americans for another decade.

Is Medicare for All “fairytale economics,” as former Rep. John Delaney said? It’s a system widely used in other countries — and works incredibly well. The real fairy tale is that we can still afford insurance middlemen taking a cut out of our health-care budget.

Is it too drastic? During the Great Depression, we launched America’s biggest social insurance program: Social Security. It’s a great example of how the government can protect us against economic risk and improve our lives. Medicare for all is a grand solution in a grand American tradition. This kind of health-care reform is not only possible, it’s essential.

James G. Kahn, M.D., is an emeritus professor of health policy at the University of California San Francisco. Elliot Marseille, Dr.P.H., is CEO of Health Strategies International.

https://thehill.com…

Two med students make case for single-payer health care

By Scott Swartz and Bradley Heinz
San Francisco Chronicle, August 14, 2019

The most difficult part of our first year of medical school wasn’t memorizing anatomy or mastering the patient interview, but seeing firsthand how broken our current health care system is. We pay twice as much as other wealthy nations for health care, but receive some of the worst outcomes.

Many factors contribute to this dysfunction, and one looms large: a medical system dominated by for-profit private insurers. We hear about physicians spending countless hours battling insurance companies instead of actually providing care. It’s disheartening to envision ourselves practicing in a system in which, yearly, thousands die for not having insurance, and hundreds of thousands more face medical bankruptcy.

Thankfully, there is hope for a better future, which we can understand by looking to America’s past.

Last month we celebrated Medicare’s birthday. Medicare is a popular and efficient program that provides high-quality, life-saving care to over 55 million Americans. Fifty-four years ago, President Lyndon B. Johnson signed this program into law, one that critics then called “un-American” and written by “followers of the Moscow party line.”

The question of health care reform has dominated the Democratic presidential candidate debate stage. One proposal, Medicare For All, would expand and improve our existing Medicare system, guaranteeing quality health care as a right to all Americans. Critics of this single-payer system, most of whom receive payouts from private insurance lobbyists, echo Johnson’s critics from half a century ago. Some spread fear, invoking the specter of “socialism,” arguing it’s too drastic, and would spell certain defeat for Democrats.

Others simply preach moderation, supporting breezily named “glide paths” to universal coverage by offering a public option (“Medicare For All Who Want It”) or building upon the Affordable Care Act. Though steps in the right direction, these plans fail for the very reason they’re meant to appeal to voters: They leave our current broken system in place. A health care system dominated by private insurers is one focused on profit achieved by increasing prices and denying care to patients. Merely adding a public option or ACA expansion to this already fragmented system misses the promise of $300 billion of annual administrative savings achieved by transitioning from a patchwork of insurers to one single payer (UMass Amherst, 2018), and does little to curtail unusable high-deductible plans. Medicare For All seizes the opportunity to save 95% of Americans money while providing lifelong coverage.

The prospect of practicing medicine under a single-payer system like Medicare For All gives us hope for our future. We pursued careers in medicine to care for patients, not to fight insurance companies or to fear bankrupting those we treat. We never want to hear of patients rationing medications or spending precious minutes during an emergency to figure out whether the hospital down the street is in network.

We want to practice in a system in which every American is guaranteed comprehensive care, where everything from checkups to dental appointments, hospital stays to eye exams, is covered by one card in each person’s pocket. A system in which every health care provider is in network. A system in which all out-of-pocket expenses — premiums, copays, deductibles — would disappear.

The solution for frustrated patients and for wary physicians-to-be is Medicare For All. We implore politicians to listen to voters, 70% of whom support such a plan (Reuters-Ipsos), and find the courage to continue Johnson’s legacy by fighting for the health care we deserve.

Scott Swartz and Bradley Heinz are second-year medical students at the UCSF/UC Berkeley Joint Medical Program and members of Students for a National Health Program.

https://www.sfchronicle.com…

Out-of-network surprise billing quantified

Assessment of Out-of-Network Billing for Privately Insured Patients Receiving Care in In-Network Hospitals

By Eric C. Sun, MD, PhD; Michelle M. Mello, JD, PhD; Jasmin Moshfegh, MA, MSc; Laurence C. Baker, PhD
JAMA Internal Medicine, August 12, 2019

Abstract

Importance: Although surprise medical bills are receiving considerable attention from lawmakers and the news media, to date there has been little systematic study of the incidence and financial consequences of out-of-network billing.

Objective: To examine out-of-network billing among privately insured patients with an inpatient admission or emergency department (ED) visit at in-network hospitals.

Design, Setting, and Participants: A retrospective analysis using data from the Clinformatics Data Mart database (Optum), which includes health insurance claims for individuals from all 50 US states receiving private health insurance from a large commercial insurer was conducted of all inpatient admissions (n = 5 457 981) and ED visits (n = 13 579 006) at in-network hospitals between January 1, 2010, and December 31, 2016. Data were collected and analyzed in March 2019.

Exposures: Receipt of a bill for care from at least 1 out-of-network physician or medical transport service associated with patient admission or ED visit.

Main Outcomes and Measures: The incidence of out-of-network billing and the potential amount of patients’ financial liability associated with out-of-network bills from the admission or visit.

Results: Of 5 457 981 inpatient admissions and 13 579 006 ED admissions between 2010 and 2016, the percentage of ED visits with an out-of-network bill increased from 32.3% to 42.8% (P < .001) during the study period, and the mean (SD) potential financial responsibility for these bills increased from $220 ($420) to $628 ($865) (P < .001; all dollar values in 2018 US$). Similarly, the percentage of inpatient admissions with an out-of-network bill increased from 26.3% to 42.0% (P < .001), and the mean (SD) potential financial responsibility increased from $804 ($2456) to $2040 ($4967) (P < .001).

Conclusions and Relevance: Out-of-network billing appears to have become common for privately insured patients even when they seek treatment at in-network hospitals. The mean amounts billed appear to be sufficiently large that they may create financial strain for a substantial proportion of patients.

From the Discussion

In a national sample of US patients with private health insurance, the incidence of out-of-network billing at in-network hospitals substantially increased between 2010 and 2016, from 32.3% to 42.8% of ED visits and from 26.3% to 42.0% of inpatient admissions. Moreover, the potential financial consequences of out-of-network billing in both settings nearly doubled during this period, and the top 10% of patients faced liabilities of more than $1000 for ED visits and more than $3000 for inpatient care. Sensitivity analyses suggested a lower incidence of unanticipated out-of-network billing for elective inpatient admissions, but showed a similar increase during the study period, with potential financial liabilities for patients that were similar to those in the main analysis. Overall, our findings suggest a growing risk to patients of incurring burdensome unexpected out-of-network bills.

https://jamanetwork.com…

Comment:

By Don McCanne, M.D.

Provider networks are a tool designed by the private insurance industry to give them control over how much will be paid for health care services covered by their plans. From the patient’s perspective, a benefit of contracted networks is that the insurers can use their negotiating clout to slow the increase in premiums charged for their plans. For that the patient has the tradeoff of limiting their selection of physicians and hospitals to those on the approved provider list, or else lose the protection of fee controls negotiated by the insurers.

In an emergency situation it is inevitable that many patients will receive services from physicians who are out of network. Patients then are subject to “surprise bills” – balance billing for charges in excess of the insurers’ negotiated fees. Besides facing the possibility of receiving care from out-of-network providers in the emergency departments or when admitted for in-patient services, most emergency medical transportation is also out-of-network. This study shows that a very large percentage of patients who thought that they were well covered by their insurance plans were exposed to sometimes staggering fees for out-of-network care, creating financial hardships for many.

Imagine what would happen under a well designed single payer model of Medicare for All. There would be no segregated networks since all physicians and hospitals would be essentially “in-network.” There would be no payments for deductibles, copayments nor coinsurance. The patient would receive whatever care they needed in the emergency department or as an inpatient, and then go home after the care is rendered. There would be no surprise bills nor any other bills.

Why are there providers who are not included in the networks? In some cases it could be that they could not negotiate fees with the insurers that would be acceptable to them. But more often it is inherent in the nature of the provider network tool. Providers who agree to lower rates have the advantage of a certain amount of exclusivity – being guaranteed a larger patient population to draw from, draining patents from out-of-network providers.

In actuality, the private insurers’ payments are usually significantly higher than Medicare payments, which is then reflected in higher insurance premiums that the patient pays. So the model is not nearly as successful as they would like you to believe. Yet the Medicare model of publicly administered pricing is much more successful in containing costs.

Right now there is a debate taking place as to how patients potentially facing surprise out-of-network bills might be provided some relief. One option would be to limit surprise bills to a percentage of Medicare fees, perhaps 125 percent. But why should a physician who has not signed a contract be required to accept the conditions of the contract anyway yet without the benefit of being included on the insurers list of approved physicians? If everyone is going to have to comply with a given set of rates, then wouldn’t it be far more logical to set those rates fairly for everyone under a single payer Medicare for All program?

Another suggestion would be to establish arbitration for fee disputes, but you could imagine the additional administrative burden that this would pile on top of the existing heap of profound administrative excesses.

So not only would single payer Medicare for All be a far better fix for surprise out-of-network bills, it would fix all of the other problems with our health care financing system as well. So instead of just tweaking surprise bills, let’s go ahead and actually enact and implement a model that would be effective, efficient, equitable and affordable for everyone – single payer Medicare for All.

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People care about coverage, not private plans

Undermining Right-Wing Attack, Poll Shows Most Americans With Employer-Provided Insurance Support Moving to Medicare for All

By Jake Johnson
Common Dreams, August 9, 2019

A Business Insider poll published Thursday found that most Americans with employer-sponsored health coverage support switching over to Medicare for All, undermining the right-wing narrative that the U.S. public is wedded to private insurance plans.

The survey showed that 59 percent of respondents who have employer-provided insurance “said they would support switching their employer-based health insurance to a government plan under Medicare for All” as long as quality of coverage would remain the same or improve.

The poll also found that Americans on government-run healthcare plans such as Medicare and Medicaid are more satisfied with their coverage than those on employer-sponsored plans, which have soared in cost over the past two decades.

According to Business Insider, 57 percent of respondents on government plans said they “love” their coverage. Just 41 percent of those with employer-provided plans said the same.

https://www.commondreams.org…

Business Insider:
https://www.businessinsider.com…

Comment:

By Don McCanne, M.D.

People on Medicare are more supportive of their coverage than are people on employer-sponsored plans. Although some polls have shown that support for Medicare for All declines when respondents are told that they would lose their choice of private plans, this poll confirms that the majority would be fine with Medicare for All as long as the coverage is the same or better.

The single payer model of Medicare for All, as in the Sanders and Jayapal bills, would, in fact, provide significantly better coverage (more benefits, choice of providers, and no deductibles). If the pollsters really wanted the truth, rather than asking a followup question about losing choice of private plans, they should be asking about preference for better benefits under Medicare for All. It is disingenuous to say that people want to keep their employer-sponsored plans with fewer benefits and less stability of coverage when they could have more complete coverage under Medicare for All, guaranteed for life. But people do have to have a better understanding of the single payer model of Medicare for All. We still have more work to do.

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Timothy Faust: Health Justice Now – a must read

Health Justice Now: Single Payer and What Comes Next

By Timothy Faust

This can all feel like so much. It feels like so much to me! I sit to read or write and the waves batter me and my body feels like a towel, wet and crumpled on the floor; I fall inside myself and wish for some angelic comet to plunge into my house and gently, quietly lift us all from this national suffering. But I don’t think that’s fair of me to do. It’s not very kind to indulge in nihilism when other people have even more at stake. What do you do? How do you tilt against the grotesque squalor of the world?

My answer begins with single-payer. Single-payer won’t solve all of the problems we’ve talked about in the previous section of this book. It won’t even solve most of them: it won’t build the houses, it won’t feed the people, it won’t bring jobs or money back to rural areas. But that’s all right, in a sense— no program can, not all at once. What single-payer can do, I believe, is serve as a ladder we can climb, all together, into a better world. A properly designed single-payer program is one titanic step toward making people safe in their own homes, in their own bodies. It is a reprieve from our continual fucking-over by the structure and stricture of private insurance. And it is a method of finally demanding accountability from a state that permits (or even encourages) the sins that cause mass suffering—and the medical inequities they produce.

It’s not a hard sell. Single-payer isn’t that complicated (the real complicated shit is the various bureaucratic coping mechanisms invented to respond to the inadequacies of private insurance!) and most people like it already. More people will be drawn to it once they learn what it means and how it fits into the nooks and crannies of their lives. Most doctors and nurses like it, both because they’ve seen the devastating consequences of uninsurance among their patients and because they’d like to avoid the grating bureaucracy of trying to get paid by insurance companies.

The people who tend not to like single-payer are people who wouldn’t like anything that didn’t make them money: the insurance companies it would replace, plus the pharmaceutical, device, and hospital CEOs whose profits might be cut into by the rise of a larger, stronger, payer. Then there’s the powerful people who generally benefit from human suffering: the abusive boss who wants to make sure you can’t quit your job; the abusive husband who wants to make sure you can’t quit your relationship; the CEO who enjoys being able to cut benefits while knowing his workers can’t strike for fear of losing insurance; the lizardlike politicians who find it useful to first advance policies that let rich people plunder their districts, then blame poor people, people with disabilities, and people of color for the resulting scarcity.

These problems are not new in America. We’ve been suffering needlessly for generations. We continue this suffering because, at every conceivable opportunity, our politicians, our policy-makers, the CEOs who mine us for profit—have decided to pursue moderate, subdued, pragmatic, and useless policies. They have had every opportunity to help and have refused. They must be left behind. They’ve started coming out of the woodwork, and they’ll continue to do so for the next few years. They’ll have “responsible solutions” for “new American healthcare.” They’ll smile and go on TV and say they’re very concerned about all these problems whose structural causes they, personally, have benefited from. They will reach out to take our hands, tenderly and piously, and whisper, “This really is the best we can do right now,” as they jam them in the garbage disposal. So they’re out.

We will have to turn to each other.

This is all to say that the work of health justice is not siloed. Housing work, healthcare work, anti-carceral work, disability liberation—all share health equity in their articulations of a better world. This and only this, I think, can bring about single-payer, and, beyond it, health justice. We have seen that movements for universal healthcare that are led from the top down have not succeeded.

Yet through this massive mobilization—and only through this massive mobilization—this is a fight we will win. Single-payer is already a wildly popular idea among the people it affects. This is not a radical proposition. We are simply discussing a basic principle of fairness.

After all, we all come from nothing. We are all fashioned from a formless and shapeless place. We have been thrust through the maw and born into a world that is arbitrary and unequal in its allocation of suffering. And yet instead of affording each other the basic dignities of being human, we have developed this bizarre system of American health in which one’s suffering is one’s own responsibility, in which empathy is vestigial and unnecessary. We have atomized suffering and, in turn, assigned blame for suffering to the people who suffer it.

I have seen such naked suffering inflicted in my American name. I have seen neighborhoods ripped apart by the unrepentant, unyielding bloodlust of capitalism. I have seen families torn limb from limb in the service of extracting profit. I have seen the dehumanizing machine all at once and felt despair. For me it is heinous to feel complicit, through my simple existence in my only and horrible home, in the mass immiseration and annihilation of those against whom the whole rotten weight of the world is stacked.

This is intolerable to me. I hope it is to you, too. And so I hope you join me in saying: enough.

Not in our name may this America persist. May we root ourselves not in fear but in love—love for those who suffer around us, as we, too, will one day suffer—and from that love, may we cultivate the fury by which this cruel machine can be destroyed.

My friends—single-payer is moral. Single-payer is necessary. Single-payer is achievable. Solidarity now, solidarity forever.

For an expanded version of these excerpts:
https://splinternews.com…

About the book, “Health Justice Now,” and how to purchase it:
https://healthjusticenow.com

Video: Tim Faust: Beyond Single Payer (45 minutes):
http://midwestsocialist.com…

Comment:

By Don McCanne, M.D.

Timothy Faust’s new book, “Health Justice Now,” provides an excellent description of the injustices inherent in our current health care system and the reforms that we can achieve with single payer as the springboard. But he doesn’t stop at single payer. He goes on to discuss the social and structural determinants of health as part of the broader overview of health justice.

Faust is very well versed in health policy, whereas his very different communication style you might find refreshing in comparison to the typically nerdy PowerPoint discussions that many of us at PNHP have been delivering. The video (link above) includes some topics covered in his book.

So which audiences might resonate with his style and rhetoric? Young adults, particularly with a sophomoric bent, might find that his approach clarifies some of the fundamental issues of health justice. Because of his smattering of profanity and the complexity of the topic, it would not be suitable for most young children, but, even there, it may give their parents some ideas with which they could communicate health justice concepts to their children and friends and especially nonbeliever friends. It might be very useful for those confused or misled by the prevailing rhetoric supporting expansion of the Affordable Care Act or supporting the option to continue with private insurance plans, with or without a public option – rhetoric that inappropriately rejects the model that really does work: the single payer version of Medicare for All. It might also be useful for audiences who are already sold on single payer in that it may add to their catalogue of sound bites and explanations of health policy concepts – concepts that some may otherwise find to be particularly mundane. Staid, conservative libertarians may find the rhetoric and references to socialism off-putting, but that is an audience that remains quite resistant to the single payer message anyway, though, who knows, maybe this could be a spark that awakens a sense of health justice that this group seems to lack. In sum, almost all audiences could benefit from his message, in spite of or because of his unique style and rhetoric.

I would emphatically recommend watching the 45 minute video (this weekend might be a good time) so that you have a better idea of his style and message. Then buy his book, and, above all, share it with others. We need to spread the word, and this can be an effective tool.

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Physicians and gun violence

GOP doctors dodge questions on gun violence

By Dan Diamond
POLITICO Pulse, August 8, 2019

What GOP doctors won’t say about gun violence — They won’t use the same language as the American Medical Association and other health groups, which have insisted that the nearly 40,000 annual deaths from gun violence should be treated as a “public health crisis,” according to a PULSE review.

— PULSE checked on all 16 physicians in Congress: Did they agree with medical associations that gun violence is a public health crisis? All three Democrats — Reps. Raul Ruiz (who specialized in emergency medicine), Ami Bera (general practice) and Kim Schrier (pediatrics) — have said yes, with staff referencing previous statements, like this tweet by Ruiz, where they called for treating gun violence like other public health problems.

“Every other major cause of death in the United States has the full weight of the Federal government backing research to solve it,” Schrier tweeted in June. “The same must go for the over 35,000 gun deaths every year, including many from suicide.”

— But all 13 Republican doctors either didn’t respond to PULSE’s questions or referenced previous statements on the link with mental illness. Many of those Republicans — Reps. Ralph Abraham and Scott DesJarlais (family medicine), Michael Burgess and Phil Roe (OB/GYN), Larry Bucshon (thoracic surgery), Neal Dunn (urology), Mark Green (emergency medicine), Andy Harris (anesthesiology), John Joyce (dermatology) and Roger Marshall (urology) and Sens. John Barrasso (orthopedic surgery), Bill Cassidy (gastroenterologist) and Rand Paul (ophthalmology) — previously have expressed skepticism of Democrats’ calls for gun control.

Surgeon General Jerome Adams didn’t respond to questions about whether he agreed that gun violence is a public health crisis. “HHS is deeply concerned about violence, including gun violence, that is rooted in mental illness, an area of significant focus to the Department in terms of both research and treatment,” Adams said in a statement. “One of our missions is to help Americans with mental illness find and obtain timely treatment.”

“PULSE CHECK”: Gun violence isn’t really a mental health problem — That’s according to Amy Barnhorst, a UC Davis psychiatrist who studies firearm violence, who said that’s misunderstanding the core issue and looking for retroactive red flags.

“I understand … why it’s easy for people to believe,” Barnhorst said on POLITICO’s podcast, but “just because somebody’s weird or they behave badly … that doesn’t mean they have a mental illness” like depression or schizophrenia or would have met the criteria for a diagnosis.

“It’s a convenient distractor from the other argument, which is that all of these guys do have one thing in common,” Barnhorst added. “And that thing 100 percent contributes to their being able to be a mass shooter, and that’s a gun.”

https://www.politico.com…

Comment:

By Don McCanne, M.D.

UC Davis psychiatrist Amy Barnhorst: “All of these guys do have one thing in common and that thing 100 percent contributes to their being able to be a mass shooter, and that’s a gun.”

It’s a public health issue. We must do better.

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