Summary: Dr. Glaucomflecken efficiently & amusingly skewers private equity. Plus a technical report …

How to Ace Your Private Equity Interview, 2-minute YouTube video, by Dr. Glaucomflecken

“Rapid maximal extraction of wealth by any means necessary.”

Comment:

By Jim Kahn, M.D., M.P.H.

Dr. Glaucomflecken, in his usual concise, elegant, and entertaining style, precisely captures how private equity ownership of provider practices threatens physician autonomy, evidence-based medicine, and patient welfare.

For those craving a more technical read today on the rapid expansion of private equity, market distortions, and higher costs, see a detailed report here.

http://healthjusticemonitor.org…

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Summary: The White House announced several actions to improve health care financial protections for consumers. Left in place is a fragmented and dysfunctional health insurance system which imposes massive burdens on consumers. Time for single payer!

President Biden Announces New Actions to Lower Health Care Costs and Protect Consumers from Scam Insurance Plans and Junk Fees, The White House, July 7, 2023

• The Biden-Harris Administration is cracking down on junk insurance. New proposed rules would close loopholes that the previous administration took advantage of that allow companies to offer misleading insurance products that can discriminate based on pre-existing conditions and trick consumers into buying products that provide little or no coverage when they need it most. These plans leave families surprised by thousands of dollars in medical expenses when they actually use health care services like a surgery. If finalized, the rule would limit so-called “short-term” plans to truly short time periods, close loopholes made worse by the previous administration, and establish a clear disclosure for consumers of the limits of these plans.

• The Administration is releasing important guidance on rules against surprise medical billing. Biden-Harris Administration rules are already preventing as many as 1 million surprise medical bills every month. New guidance will help stop providers from gaming the system by evading the surprise billing rules with creative contractual loopholes that still leave consumers with unexpected costs.

• The Administration is announcing new steps to protect consumers from unfair medical debt. For the first time in history, the Consumer Financial Protection Bureau, HHS, and Treasury are collaborating to explore whether health care provider and third-party efforts to encourage consumers to sign up for medical credit cards and loans are operating outside of existing consumer protections and breaking the law. Medical credit cards and loans often lead to higher costs without consumers fully understanding the risks.

• The Department of Health and Human Services is releasing a new report showing that nearly 19 million seniors and other Part D beneficiaries are projected to save $400 per year on prescription drugs when President Biden’s $2,000 out-of-pocket cap goes into effect. It’s also releasing state by state data that demonstrates how seniors across the country are helped by just one element of the President’s robust agenda to lower prescription drug prices.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

Everyone knows that we have very serious problems with our health care system. We spend the most per capita of any nation, yet leave millions without adequate health care coverage or with any health care coverage at all, resulting in rampant financial hardship and even personal bankruptcy. We know that we can readily fix this by enacting and implementing Medicare for All – a single payer, publicly financed and publicly administered health care financing system.

Yet what reform does the current administration in Washington offer us? They would “crack down” on short-term junk insurance, but nevertheless leave it in place. They would reduce gaming of surprise out-of-network billing, while leaving in place restrictive provider networks and uncovered services. They would rein in abusive medical credit practices, while leaving in place the massive deductibles and cost-sharing (and uninsurance) that result in nearly half of adults having medical debt and hundreds of thousands of bankruptcies annually. They would save Medicare beneficiaries a few hundred dollars in drug costs, while leaving in place lack of and incomplete drug coverage for tens of millions.

It’s time to stop “leaving in place” our fundamental health insurance problems. Medicare for All legislation is sitting in the House and the Senate waiting for action.

My gosh. Talk about insensitivity. Those horrible problems are staring us in the face, and they are merely going to spin their wheels in minor rule-making.

Let’s get real. Single payer! Now!

http://healthjusticemonitor.org…

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Summary: We all spend too much time as patients wrangling medical billing. Here’s one creative approach to accounting for that. Disappears with single payer, of course.

Billing the Hospital Billing Department, The New Yorker, July 3, 2023, by Kendra Allenby

Late-stage capitalism getting you down? Try this fun, D.I.Y. fix—sending your own personalized bill to the hospital billing department:

Dear billing department,

Below are the fees that you’ve incurred. Please pay the balance at your earliest convenience.

Phone calls pre-procedure: To make double, extra sure that the procedure is going to be fully covered by insurance. (Am assured that it will be.) An hour and a half at $300 per hour: $450

Initial phone call post-procedure: Asking why this huge bill showed up after I made double, extra sure that the entire procedure would be covered by insurance. Forty-five minutes at $400 per hour: $300

Follow-up phone call: To find out that the incorrect code was used in billing the procedure. Forty-five minutes at $400 per hour: $300

Misc. phone calls (three): To get the code changed to the correct code. Two hours and fifteen minutes at $400 per hour: $900

One more phone call: To get assurance and e-mail confirmation that the code has been changed and that I will not receive additional bills in the mail. Thirty minutes at $400 per hour: $200

Mug: Smashed when the third bill arrived in the mail. One mug at $47 per mug: $47

Fee for sterile disposal: Of mug. One mug at $347 per mug: $347

Fee for lost sleep: Over the huge bill that should have been entirely covered by insurance. A hundred and thirty-two hours over six months at $300 per hour: $39,600

Therapy to treat anxiety: Resulting from a six-month protracted follow-up on a bill that I never should have received in the first place, plus anxiety spikes upon repeatedly seeing additional bills in the mailbox. Twenty-four sessions at $200 per session: $4800

Tylenol. Couldn’t hurt: One pill at $300 per pill: $300

TOTAL COST: $47,244

My dog has negotiated your rate so that you are only responsible for a percentage of the total cost. If you choose not to go with my dog’s negotiated rate, you may be responsible for the total cost of the fees.

ADJUSTMENTS (as negotiated by dog): -$10,014

CURRENT BALANCE DUE: $37,230

Congratulations, you saved $10,014!

Comment:

By Jim Kahn, M.D., M.P.H.

Exactly right, sadly. Excellent dose of humor for a vexing situation.

We’ve all experienced this (I know I have … e.g., hours of calls regarding vaccination for foreign travel, and many letters and calls and emails to get reimbursed for an urgent care visit, and … and …).

HJM discussed research on this issue in late 2021.

http://healthjusticemonitor.org…

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Summary: Democracy and health intersect and interact. Threats to one are threats to both. On this July 4th, let’s recognize these links, and redouble efforts to strengthen democracy by strengthening our health system … with single payer. Health care for all, not for the few who stand to profit the most.

Threats to Democracy Are Threats to Health, MedPage Today, June 29, 2023, by Lawrence O. Gostin and Sarah Wetter

The U.S. is facing dual crises: a crisis of health and a crisis of democracy. Our nation has been getting sicker. We’re facing the greatest decreases in life expectancy in over a century — with causes extending beyond COVID-19 to include rising drug overdoses, injuries, heart and liver diseases, and suicide. Maternal mortality, often considered a test of a society’s commitment to health and equality, has risen sharply. On all of these measures of health and equity, we are falling behind most all of our peer nations.

Our democracy, too, is unwell, with few guardrails on campaign financing, allowing wealthy individual and corporate donors to have outsized influence on policy and gerrymandering, making political representation simply unrepresentative of the populace.

The health of our nation is inextricably linked to the health of our democracy. Our laws directly affect whether someone has access to health services (e.g., abortion or transgender care) and safe environments (e.g., workplace safety or gun control). In theory, democracy is all about the public’s health, safety, and welfare. Political leaders should have no greater calling. Free and fair elections enable voters to elect leaders who fight to fulfill their health needs; political leaders are incentivized to pay attention to voters’ wellbeing, and are held accountable.

Yet, unlimited and dark money has shifted politicians’ attention away from constituents’ health and toward the interests of big donors. Gerrymandering pushes representation toward the extremes, enabling super-majorities in state legislatures that can pass measures harmful to health (e.g., targeting transgender individuals, forgoing Medicaid expansion, banning abortion, encouraging fossil fuels). And voting rights restrictions often fall on the most vulnerable: the poor and racial minorities. When the voting rights of society’s most vulnerable citizens are curtailed, it makes it all too easy for politicians to ignore them.

The Constitution’s Preamble expresses public wellbeing as the quintessential aim of American governance: “We the People, in Order to form a more perfect Union” and to promote the “general Welfare” do “ordain and establish this Constitution.” The “General Welfare” clause expresses a constitutional value of health, peace, and safety. The Supreme Court was supposed to be the guardian of the common welfare. Yet, it has done the opposite. The justices have given rich donors a virtual free hand to give huge sums of money (often dark money); loosened anti-corruptions restrictions; and allowed extreme gerrymandering and voting rights restrictions. …

Medical organizations call voting rights a social determinant of health. The reasons abound: access to voting is consistently associated with better health. Women’s suffrage is associated with decreases in child mortality rates as high as 15%; the Voting Rights Act has been tied to reductions in economic inequality and increased health spending. Voting is linked to reduced risks of cancer death and improved mental health, while voting restrictions correlate with higher likelihood of lacking health insurance.

Comment:

By Jim Kahn, M.D., M.P.H.

On July 4th, we celebrate the founding of US democracy. The revolutionary events of nearly 250 years ago prompted the rise of democracy around the world. This celebration is appropriate, despite – and indeed because of — today’s challenges to democracy at home and abroad. Democracy is under assault, and needs defending.

As Gostin and Wetter persuasively note, the crisis in democracy is echoed by, and intertwined with, a crisis in health. The role of government in advancing the public welfare is undercut by increasing deference to the preferences of corporations and the wealthy. The examples they provide are apt.

But they don’t go far enough. The entire US health system is the antithesis of democracy. A few wealthy individuals and corporations rule the many, by imposing a fragmented insurance system and consolidating the ownership of services. Compromised access to medical care and elevated mortality are accepted as collateral damage from an illusory “free market” in health (which brings no efficiency or welfare maximization) and all-too-real immense financial gains for executives and shareholders. Other wealthy countries democratize health care – everyone has identical coverage, with excellent access to care, and the freedom to choose a provider. Money is saved in the process, and directed to other social needs.

Single payer would foster democracy, freedom, and the general welfare. Let’s issue a “Declaration of Health Care for All”, and revamp our health care into a democracy-conforming and democracy-fostering approach. We will celebrate this revolution for at least the next 250 years.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Summary: Eric Reinhart brilliantly issues a call for physicians – long a conservative force in health care – to expand their political horizon from their own recent labor awakening to join the progressive movement to transform our desperately ailing health system.

The Political Education of US Physicians, JAMA Network Open, June 27, 2023, by Eric Reinhart

Since the beginning of Ronald Reagan’s presidency, the proportion of workers in the United States who belong to a union has declined by approximately 50%, while income inequality has increased by approximately 20%. Today, just 10% of all US workers are employed in unionized positions. But following the recession that started in 2007 and 2008 and then the temporary resurgence of a social democracy during a pandemic that exposed neoliberal policy as a public health disaster, labor organizing against exploitation and public abandonment has been increasing. Amid growing concern about workforce attrition associated with the demoralization of nurses and physicians in a flailing medical industry shaped by profit rather than ethics, health care workers have become increasingly involved in this revival of labor politics.

A wave of nurses’ strikes and house staff unionization has put this ideological shift front and center in contemporary health care politics. There are now approximately 70 000 physician union members in the US, representing 7% of physicians—a nearly 30% increase relative to a decade ago. …

It is into this context that the analysis of housing affordability and housing-related benefits for house staff by Brewster et al interjects. Using data from the 2022 to 2023 academic year, Brewster et al found that compensation levels at 60% of 855 institutions administering residency programs imposed rent-burdened status on their resident physicians (ie, they required residents to devote >30% of monthly income to rent). Brewster et al also found that while inflation-adjusted rental prices increased by 18% between 2000 and 2022, inflation-adjusted first-year resident salaries decreased by 0.2% during that same period. Concluding with a call for more equitable compensation, Brewster et al note that resident labor unions have been associated with improved access to housing stipends.

This adds to what should be already clear rationale for physicians, nurses, and other health care workers to unionize to protect their own interests and to protect patient safety by improving working conditions. But there is another intertwined and more fundamental issue at stake: the political education of the most influential workers in what may be the most powerful industry in the US.

Worst-among-peer-nations life expectancy, alongside globally unparalleled health care spending and rapidly declining trust in medicine, public health, and government, make undeniable that the US is in need of a basic reorganization of its health systems. After allowing health care over the last half century to be dominated by private entities motivated by profit and enabled by depoliticized concepts of charity as substitutes for rights guaranteed by public systems, to achieve meaningful change will require a repoliticization of care. This must be linked with mass movements to demand public investment in universal health care and, even more importantly for public health, infrastructures for everyday nonmedical care that are essential for preventing disease and shrinking the currently elephantine footprint of reactive US medicine.

Comment:

By Ana Malinow, M.D.

In a fiery “Invited Commentary.” Eric Reinhart responded to a concurrent article on lopsided housing affordability and resident salaries in JAMA Network Open. Reinhart blasts medical training exploitation for its “high medical-education costs, undercompensation, excessive work hours, and an infantilizing hierarchical culture characterized by intensive personality policing under the veneer of racist, misogynistic, and classist professionalism norms and their self-defensive moralisms.”

Wow.

The effort Reinhart believes would best achieve the “political education of US physicians” is the unionization movement currently taking hold in many institutions training residents today. He rightly maintains that by unionizing, residents have a chance to better their own working conditions, with spillover effects into better patient care.

But the goal of unionizing residents goes further to open the eyes of future doctors, who for too long have been blind to the paradox that is their training and the health care system in which they work.

For the last 100 years, Reinhart rightly asserts, the medical education of doctors has been political, but not in the way that raises awareness, but one that is “overwhelmingly conservative, profoundly uncritical, and reflexively protective of an ethically bankrupt field that has spent a century building up a capitalist health care industry.” It has been an anti-solidarity education that lulls doctors with the expectation of lucrative salaries and social position into complicity, working silently and thus propping up a health care system that immorally puts profits over patients. US physicians “have been professionalized into a convenient political nihilism” instead of questioning the paradox under which they labor. They accept, buttress, and uplift the for-profit, market-driven, repulsive health capitalism we call the U.S. health care system.

“Medical trainees deserve an explicitly political education,” Reinhart concludes, that “must be linked with mass movements.” This call must be heeded now more than ever, as for-profit insurance companies, private equity, venture capitalists, and corporations such as Amazon and Best Buy devour what is left of our public programs (Medicare and Medicaid especially), hospice, emergency departments, independent physician practices, and community and rural hospitals. An Obama-era scheme called “value-based payment” (VBP) is spreading across our health care system like wildfire, buttressing the profit-takers and, like wildfires, leaving widespread destruction behind. With the collusion of the Centers for Medicare and Medicaid Services, VBP and its corporations will soon take over the last bastions of non-corporate care provision and truly public financing, traditional Medicare and the Veterans Health Administration.

Through unionization, physicians begin to understand that extending care beyond the clinic into the community “hinges on power and policy” and beyond that, leads to “political organizing and struggle.” As physicians, we must join and amplify grassroots organizations that are fighting to end privatization of our public programs through local organizing, mobilization, and direct action. This grows the mass movement we need to achieve national single payer and end the paradox we serve. It would be a profoundly valuable use of physicians’ high incomes and social standing.

Reinhart’s is an incisive, impressive, and important essay, which I implore every physician to read. It’s a critical piece of our medical education.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Summary: Surprise, surprise – our fragmented, profit-driven, gap-permeated health insurance “system” leads to terrible consumer experiences accessing health care. It’s time, finally, to adopt a simple, efficient and generous solution – single payer.

Survey of Consumer Experiences with Health Insurance, KFF, June 15, 2023, by Karen Pollitz, et al.

Key Findings:

• Most insured adults give their health insurance positive ratings, though people in poorer health tend to give lower ratings. … 84% of people who describe their physical health status as at least “good” rate insurance positively, compared to 68% of people in “fair” or “poor” health.
• Despite rating their insurance positively, most insured adults report experiencing problems using their health coverage; people in poorer health are more likely to report problems. A majority of insured adults (58%) say they have experienced a problem using their health insurance in the past 12 months – such as denied claims, provider network problems, and pre-authorization problems.
• Nearly half of insured adults who had insurance problems were unable to satisfactorily resolve them, with some reporting serious consequences.
• Among those with the greatest mental health needs, many adults across insurance types find their coverage lacking and report forgoing needed care. Among insured adults who report being in “fair” or “poor” mental health, four in ten (43%) say there was a time in the past year when they did not get mental health services or medication they thought they needed …
• Affordability of premiums and out-of-pocket costs are a concern, particularly for those with private health coverage, and for some, contributed to not getting care.
• Insured adults overwhelmingly support public policies to make insurance simpler to understand and to help them avoid or resolve insurance problems.

Adults with Medicare are the most positive in their overall ratings with nine in ten (91%) rating their coverage positively, including half who say it is “excellent.”

Marketplace enrollees, regardless of health status, are the most likely to rate their insurance negatively.

Over the years, Congress has enacted a number of measures to make health insurance more understandable and easier to navigate, and to hold health insurers and public programs accountable for the coverage they promise. Alone, these measures are unlikely to eliminate all the problems people encounter with health insurance, especially those related to affordability, but they may help to reduce somewhat the dizzying complexity of health insurance in the U.S. And they may inform oversight so that regulators can better monitor how well insurance works when people need to use it. At the same time, stronger oversight and accountability could entail more administrative costs – a trade-off we did not probe in this survey.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

This comprehensive survey should be read in its entirety to understand the startling inadequacy of US health insurance under our complex combination of public and private plans and no insurance at all. Despite its failings, it is the most expensive health system of all nations.

One of the major deficiencies in our system is the very high administrative costs which waste funds that could be filling the voids in care, so it is ironic that Congress responds to the recognized problems with even more administrative burdens. Which “may help to reduce somewhat the dizzying complexity of health insurance in the US” … wow, how low can we set expectations?

Viewing the report, much of the problem lies with the tools used by the private insurance industry, but when you think about that, it is not too difficult to understand why. Private insurance is designed primarily to make generous profit for the owners – the billionaire shareholders whose goal is further wealth accumulation. On the other hand, truly public insurance is owned by the people of the nation and is designed specifically to deliver health care to those who need it.

When you read the findings, it’s obvious that all we would have to do to correct the deficiencies is to make the entire insurance program public. The simplest, most efficient, most effective, and most equitable way would be to enact and implement a single payer (an improved Medicare for All) that includes everyone, a single payer that we, the people, own. The problems listed in the Key Findings above would melt away.

But this does mean that elected leaders would have to put in place policies that serve the people rather than the private insurers and their investors. This last point we must tackle seriously now. Really! Access to health care is at stake, as the report vividly describes.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Summary: The corporate takeover of medicine has forced doctors to deviate from their healing mission to attend to financial optimization for their employers. This is indeed a moral crisis. Harkening back to the huge benefit that Medicare offered seniors 57 years ago reminds us of the universal medical access and health focus we would achieve with Medicare for All.

A Moral Crisis of America’s Doctors, The New York Times, June 15, 2023, by Eyal Press

The corporatization of health care has changed the practice of medicine, causing many physicians to feel alienated from their work.

In July, 2018, psychiatrist Wendy Dean published an article with Simon G. Talbot, a plastic and reconstructive surgeon, that argued that many physicians were suffering from a condition known as moral injury. Doctors on the front line of America’s profit-driven health care system were susceptible to such wounds as the demands of administrators, hospital executives and insurers forced them to stray from the ethical principles that were supposed to govern their profession. The pull of these forces left many doctors anguished and distraught, caught between the Hippocratic oath and “the realities of making a profit from people at their sickest and most vulnerable.”

Throughout the medical system, the insistence on revenue and profits has accelerated. This can be seen in the shuttering of pediatric units at many hospitals and regional medical centers, in part because treating children is less lucrative than treating adults. It can be seen in emergency rooms that were understaffed because of budgetary constraints. And it can be seen in the push by multibillion-dollar companies like CVS and Walmart to buy or invest in primary-care practices, a rapidly consolidating field attractive to investors because many of the patients who seek such care are enrolled in the Medicare Advantage program, which pays out $400 billion to insurers annually. Over the past decade, meanwhile, private-equity investment in the health care industry has surged, a wave of acquisitions that has swept up physician practices, hospitals, outpatient clinics, home health agencies. The staffing in 30 percent of all emergency rooms is now overseen by private-equity-owned firms.

As the focus on revenue and the adoption of business metrics has grown more pervasive, young people embarking on careers in medicine are beginning to wonder if they are the beneficiaries of capitalism or just another exploited class. In 2021, the average medical student graduated with more than $200,000 in debt. In the past, one privilege conferred on physicians who made these sacrifices was the freedom to control their working conditions in independent practices. But today, 70 percent of doctors work as salaried employees of large hospital systems or corporate entities, taking orders from administrators and executives who do not always share their values or priorities.

Young doctors are noticing how the emphasis on the bottom line routinely puts them in moral binds, and they in particular are contemplating how to resist. “I think a lot of doctors are feeling like something is troubling them, something deep in their core that they committed themselves to,” Dean says. “Not only are clinicians feeling betrayed by their leadership, but when they allow these barriers to get in the way, they are a part of the betrayal. They’re the instruments of betrayal.”

Comment:

By Don McCanne, M.D.

Well, this is depressing. Read the full article if you’re in the mood to be in a funk. But does it really have to be this way? Do we have to put up with a health care financing system that is causing moral injury? I think that the clear answer is “no,” and I have proof.

My twin and I joined our father and brother in practice in 1966, a few months before Medicare was initiated. Just imagine what took place for our patients over 65. Suddenly essentially all financial barriers to care were removed for that patient population. We could get them all of the care that they needed. It didn’t take me long to figure out that we should expand Medicare to cover everyone, and I’ve been advocating for it ever since.

In the meantime, corporatization, such as with the Medicare Advantage plans and ACO REACH, has played havoc with the program, and CMS is continuing in that vein such as with the forthcoming 10 year “Making Primary Care” experimental program. But that does not mean that we cannot reverse these nefarious aberrations and reestablish Medicare as a traditional health care financing program like it was before, even better than other private and public insurance plans were before greed became the primary driving force.

Obviously we need reform. Absent politics, the easiest step to correct almost all of our deficiencies would be the enactment and implementation of a single payer financing system. It will be difficult to design the system to reduce the impact of corporatization so that the funds go to patient care rather than private investors. But it sure would be nice to have a health care financing system like it was for our senior patients in 1967. No longer would our young physicians feel like they are instruments of betrayal.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Summary: An excellent op-ed in the New York Times properly highlights lessons from other wealthy nations. Diving deeper into those examples reveals that single payer is the only plausible path to achieving efficient and equitable health care financing in the US.

I Studied Five Countries’ Health Care Systems. We Need to Get More Creative With Ours, New York Times, June 14, 2023, by Aaron E. Carroll

[H]ealth care reform doesn’t seem to be a top political issue in the United States right now. That’s a mistake. The American health care system is broken. We are one of the few developed countries that does not have universal coverage. We spend an extraordinary amount on health care, far more than anyone else. And our broad outcomes are middling at best.

When we do pay attention to this issue, our debates are profoundly unproductive. Discussions of reform here in the United States seem to focus on two options: Either we maintain the status quo of what we consider a private system or we move toward a single-payer system like Canada’s. That’s always been an odd choice to me because true single-payer systems like that one are relatively rare in the world, and Canada performs almost as poorly as we do in many international rankings. …

In the first half of the year, I was privileged to visit five other countries and learn about their health care systems. In February I traveled to Britain and France with Indiana University’s Kelley School of Business and, more recently, with the Commonwealth Fund and AcademyHealth to New Zealand, Australia and Singapore. …

America could learn a thing or two from these other countries. We could take inspiration from them and potentially improve access, quality and cost. However, it’s important to frame our examination correctly. Focusing on these countries’ differences misses the point. It’s what they have in common — and what we lack — that likely explains why they often achieve better outcomes than we do. …

Universal coverage matters. What doesn’t is how you provide that coverage, whether it’s a fully socialized National Health Service, modified single-payer schemes, regulated nonprofit insurance or private health savings accounts. All of the countries I visited have some sort of mechanism that provides everyone coverage in an easily explained and uniform way. That allows them to focus on other, more important aspects of health care.

But the United States can’t decide on a universal coverage scheme, and not only does it leave too many people uninsured and underinsured; it also distracts us from doing anything else. We have all types of coverage schemes, from Veterans Affairs to Medicare, the Obamacare exchanges and employer-based health insurance, and when put together, they don’t work well. They are all too complicated and too inefficient, and they fail to achieve the goal of universal coverage. Our complexity, and the administrative inefficiency that comes with it, is holding us back.

When I was younger, I was more of a single-payer advocate, until I realized how many systems perform better than Canada’s. More recently, I favored the tightly regulated, entirely private insurance system of Switzerland because it performs exceptionally well using a private scheme I thought would be more palatable to many Americans. Today, though, I really don’t care how we get to universal coverage.

If we could agree on a simpler scheme — any one of them — we could start to focus on what matters: the delivery of health services. …

What separates the countries I traveled to from the United States is that they largely depend on public delivery systems. Most people get their hospital care from a government-run facility. However, each country also has a private system that serves as a release valve. If people don’t like the public system, they can choose to pay more, either directly or indirectly, through voluntary private health insurance, to get care in a different system. …

In fact, explicit tiering is a feature, not a bug, of all of these other systems. Those who want more can get more, even in Singapore’s public system. But more isn’t better care; it’s more choice in terms of physicians, private rooms, fancier food and even air conditioning. (While many Americans see the latter as a necessity, most people in Singapore — where it’s much hotter — don’t agree.)

In the United States, on the other hand, most care is provided by private hospitals, either for-profit or nonprofit. Even nonprofit systems compete for revenue, and they do so by providing more amenity-laden care. This competition for more patient volume leads to higher prices, and while we don’t explicitly ration care, we do so indirectly by requiring deductibles and co-pays, forcing many to avoid care because of cost. …

I’m convinced that the ability to get good, if not great, care in facilities that aren’t competing with one another is the main way that other countries obtain great outcomes for much less money. It also allows for more regulation and control to keep a lid on prices.

I’m not arguing it would be easy to expand the number of public hospitals in the United States. It would be politically difficult to expand the government’s role in delivering health care, directly or indirectly. But allowing people to choose whether to accept cheaper care delivered by a public system or to pay more for care in a private system might make this much more palatable. By doing so, we could make sure that good care is available to all, even if better care is available to some.

Comment:

By Jim Kahn, M.D., M.P.H.

Dr. Carroll offers many cogent observations: the failure of our health system, the paramount importance of universal coverage, the valuable role of public providers, and the wisdom of investing in non-medical social welfare programs. He appropriately highlights admirable examples of universal coverage in other wealthy countries. I even accept his observation that the Canadian single payer system isn’t the most popular among single payer approaches.

What he fails to do is note the critical features of successful national insurance systems. Here they are:

1) Universal coverage with an identical broad benefit package. That is, everyone has the same excellent coverage, and the same payment rates. This is a far cry from universal coverage as defined in the US. It is essential for both equity and efficiency.

2) This universal coverage is provided by the government or not-for-profit insurers. Even in Switzerland and the Netherlands, cited as examples for feasibility of a private insurance model, these insurers provide standard comprehensive benefits without taking profit. He alludes to the not-for-profit highly regulated use of insurers. But he fails to point out that this model has nothing to do with how US private insurers operate.

3) Additional private insurance, such as for access to more providers or to cover cost-sharing, is a very small portion of total health spending, typically just a few percent. It’s the exception, not the system; the frill, not the core.

4) Cost-sharing is low, maximum hundreds of dollars instead of thousands or tens of thousands in the US. That’s critical for access to care, with nearly half of adults delaying or skipping care for financial reasons.

5) Providers deal with only one payer, instead of dozens here. This allows them to focus on clinical care instead of payment activities, which currently consume about 15% of US health care costs.

6) Drug prices and provider payment rates are regulated and negotiated centrally. This assures reasonable prices, not the outlandish levels so often seen in the US.

So … if the US is to learn from foreign experience, as it should, it’s not just about universal coverage. It’s about excellent identical insurance, with no profit motive, no or little cost-sharing for patients, simplicity for providers, and negotiated uniform prices. Our private insurers don’t and can’t align with these essential conditions. Ergo, single payer.

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Summary: CMS is proposing a 10-year comparison of primary care payment models (fee-for-service and capitation, with support for care delivery systems). At first glance, why not? On closer scrutiny, this is another delay for an experiment in our current flawed system that will yield limited and equivocal results. Let’s focus on real reform.

Making Care Primary (MCP) Model, Centers for Medicare & Medicaid Services, June 8, 2023

On June 8, 2023, the Centers for Medicare & Medicaid Services (CMS) announced a new voluntary primary care model – the Making Care Primary (MCP) Model – that will be tested in eight states. Launching July 1, 2024, the 10.5-year model will improve care management and care coordination, equip primary care clinicians with tools to form partnerships with health care specialists, and leverage community-based connections to address patients’ health needs as well as their health related social needs (HRSNs) such as housing and nutrition. CMS is working with State Medicaid Agencies in the eight states to engage in full care transformation across payers, with plans to engage private payers in the coming months.

To support team-based care, MCP will include prospective payments for primary care that will reduce organizations’ reliance on fee-for-service payments. Risk-adjusted enhanced services payments, which will also be paid prospectively and represent an additional investment in primary care, will allow participants to expand care management, screen for health-related social needs, and integrate with specialty care.

Track 1 – Building Infrastructure. Payment for primary care will remain fee-for-service (FFS), while CMS provides additional financial support to help participants develop care transformation infrastructure and build advanced care delivery capabilities. Participants can begin earning financial rewards for improving patient health outcomes in this track.

Track 2 – Implementing Advanced Primary Care. Payment for primary care will shift to a 50/50 blend of prospective, population-based payments and FFS payments. CMS will continue to provide additional financial support at a lower level than Track 1, as participants continue to build advanced care delivery capabilities. Participants will be able to earn increased financial rewards for improving patient health outcomes.

Track 3 – Payment for primary care will shift to fully prospective, population-based payment while CMS will continue to provide additional financial support, at a lower level than Track 2, to sustain care delivery activities while participants have the opportunity to earn greater financial rewards for improving patient health outcomes.

To be eligible to participate in MCP, an organization must be a legal entity formed under applicable state, federal, or Tribal law authorized to conduct business in each state in which it operates.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

At first glance, this may seem like a decent idea: explore different payment models for primary care within Medicaid and, if they agree, private insurers. Compare results over an extended period of time, between supplemented FFS, FFS-capitation, and fully capitated approaches.

But, then, it hits us: Here we go again! Ten more years of fiddling with a broken system, while avoiding real financing reform.

Of course, we need to ask, based on recent trends in Medicare and more broadly … who is going to own these “legal entities”? Private equity? The billionaires?

The hazards of capitation are clear: Increase the monthly payment level for providers who have better health outcomes, that is, healthy patients who may not need much care. And link these payments to diagnostic (up)coding via risk adjustment. The truly sickest and costliest patients can go elsewhere, to providers paid fee-for-service. Avoiding the chronically ill might not be the goal of the traditional health care providers with their Hippocratic traditions, but, under this CMS model, certainly it would be a primary goal of their entrepreneurial employers and their billionaire investors. That’s what we’ve seen in Medicare Advantage and in CMS ACOs.

If past experience informs, the benefits of new strategies will be modest and mixed, hard to interpret but with each slight drop in cost or isolated gain in outcomes lauded by CMS as major successes. Corporations will manipulate the evaluation findings to serve business purposes.

The unclear role of private payers is telling. What we need is primary care for all, not clunky semi-coordination of different payers in a hard-to-interpret demonstration project.

Real reform can’t be off the agenda for the next decade, while we wait for this and other tweaks to our broken system. This CMS proposal requires a response from us. We already have a great start: Medicare for All legislation in both the Senate and the House (Thank you Sanders, Jayapal, Dingell, and the many others). We need to go to the streets, not with guns, but with our placards and loud, passionate voices! And this time, let’s not just go home when the shouting is done. Let’s complete the job!

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Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.