By Roosa Tikkanen and Robin Osborn
The Commonwealth Fund, July 11, 2019

As recent congressional hearings on Medicare for All proposals have illustrated, members of Congress and presidential candidates are looking outside the United States to find ways to achieve universal coverage. Some have suggested that other countries are able to provide universal coverage because they “ration” care — a term rife with negative connotations. This post examines the extent to which health care is rationed in Germany, the Netherlands, Sweden, Switzerland, and the United Kingdom — as compared to the U.S.

Examples of health care rationing tend to focus on long wait times for procedures —such as hip replacements, or MRIs — or limited access to the newest drugs. This happens in some (but not all) countries and can be a challenge for policymakers. But there are other ways in which health systems engage in rationing, by restricting access to insurance, through insurance benefit design, or by imposing high patient cost-sharing. While other countries may ration because of national budget constraints and supply-side factors, the United States’ lack of access to comprehensive insurance and affordable care represent a de facto form of rationing that leads people to delay getting care or going without it entirely.

Getting in the Door

In the five European countries we examined, all residents are entitled to health care through the national system. These range from tax-funded systems in Sweden or the U.K. to private insurance-based systems in Germany, the Netherlands, and Switzerland. In the latter, governments regulate premiums to be affordable and provide income-related subsidies to low-income families, which include 27 percent of Swiss and 30 percent of Dutch residents. Governments also mandate generous benefit packages that typically guarantee a minimum set of services: primary, specialty, and hospital care; prescription drugs; mental health; maternity; and palliative care.

In comparison, there are 30.4 million uninsured people in the U.S. Not having affordable, comprehensive insurance coverage often means that sick Americans do not even get in the door to see a doctor. For those who do have coverage, new rules that allow states to circumvent the Affordable Care Act’s mandated essential health benefits may mean skimpy coverage for some.

Waiting to Be Seen

Patients in some countries face longer wait times for specialty care than in the U.S., where only 25 percent of Americans need to wait longer than one month for a specialist appointment. Patients in Germany and Switzerland get in just as fast (27% and 26%, respectively) as their U.S. counterparts, but those in Sweden and the U.K. do not (45% and 43%, respectively). Similarly, very few U.S., Dutch, and Swiss patients (4% to 7%) who need elective surgery face wait times longer than four months, while 12 percent of Swedish and British patients do. It should be noted that in Sweden and the U.K., where wait times for specialty care are longer, people can buy supplemental insurance to gain quicker access to private specialists.

While Americans overall enjoy shorter wait times for specialty care, wait times for same- or next-day appointments when sick are around average compared to other countries. U.S. adults are among the most frequent users of emergency departments. Nearly half who do report doing so because they couldn’t get an appointment with their regular doctor.

Weighing Health Against Your Wallet

In a recent Commonwealth Fund survey, fewer than one of 10 patients in the U.K., Germany, the Netherlands, or Sweden reported skipping needed care or treatments because of cost. This contrasts sharply with the U.S., where one of three Americans reported the same. This is partly because of the rise in high deductibles, unpredictable and opaque copayments, and higher health care prices in the U.S. than in other countries. An estimated 44 million Americans who have insurance are effectively underinsured because their out-of-pocket costs and deductibles are very high relative to their incomes.

Other countries are more protective. In the U.K., Germany, and the Netherlands, patients have no out-of-pocket costs when they visit a primary care doctor, and Brits never pay for hospital care. In Germany, out-of-pocket costs are capped at 2 percent of annual household income and 1 percent for chronically ill people. In Sweden, out-of-pocket costs for physician visits and drugs are capped at $370 annually. No one in these five countries declares bankruptcy because of medical debt.

Paying for Value

A commitment to providing universal coverage means that other countries have to make hard choices to ensure that each health care dollar is spent effectively.

Countries aim to give patients access to the most clinically meaningful and cost-effective drugs. In the U.K., only drugs that are deemed cost-effective are covered, while in Germany, manufacturers have to demonstrate that their new drug adds clinical benefit to negotiate a higher price than other existing drugs. This doesn’t mean that new technologies aren’t available; in fact, 79 percent of new cancer drugs are approved for routine use in the U.K.

These kind of controls, coupled with fixed copayments and annual caps on patient drug spending, translate into better access. While nearly one of five U.S. adults skip doses or do not fill a prescription because of costs, just 2 percent to 9 percent of patients do so in the other countries discussed here.

Conclusion

It would be a missed opportunity for America to ignore lessons about universal coverage from other countries out of a fear that they ration health care more than we do. In reality, more people in the U.S. forgo needed health care because access to care is rationed through lack of access to adequate insurance or unaffordable services and treatments.

https://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

Opponents of single payer frequently claim that if we enact Medicare for All we will have rationing of health care like they have in Canada and the European nations. They then usually provide a selected statistic from a selected country (often Canada or the United Kingdom) that shows a delay (queue) for some service (such as cataract removal), or a product (often a drug) that may be in short supply. This Commonwealth Fund report provides a proper perspective by comparing the United States with five European nations – Germany, the Netherlands, Sweden, Switzerland, and the United Kingdom.

Supply side controls sometime result in prolonged queues for services such as elective joint replacement. Some nations do better than others in providing stewardship of their system capacities and application of queue management. Excessive queues are not an inevitability though they can occur even in nations with very high spending, as we sometimes see in the United States. But the United States is unique in that millions of individuals are not allowed a place in the queue.

Drug prices? Most other nations use government oversight to demand that drugs be cost effective, but not the Unites States, not to mention that we allow exorbitant pharmaceutical firm profits plus middleman gouging such as through pharmacy benefit managers.

Access to acute and primary care services tends to be quite adequate in all nations, except the United States. So what is going on?

In this report, these authors state, “In reality, more people in the U.S. forgo needed health care because access to care is rationed through lack of access to adequate insurance or unaffordable services and treatments.” That is, as has been stated many times before, we ration based on the ability to pay. In spite of per capita spending at twice the average of other nations, this rationing based on our flawed health care financing system has resulted in relatively poor outcomes on average compared to other higher performance nations. Of course, those poor outcomes are much more prevalent amongst the uninsured and underinsured – health financing deficiencies that are almost nonexistent in other nations.

We are spending more than enough to eliminate rationing in the United States, except for legitimate scarcity such as organs for transplant. But to do that we need to change the way we collect and allocate our health care funds. That is precisely what the single payer model of Medicare for All is designed to do. Merely adding a Medicare public option will not fix our financing system.

So when are at a meeting and you hear that Medicare for All will bring rationing to the United States, use your bullhorn to let the speaker know that single payer will virtually eliminate our highly prevalent form of rationing – rationing by ability to pay. If they try to pull you out of the meeting, flip your bullhorn over to a colleague – and keep passing it to other colleagues until we are absolutely certain that they got the message.

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By Frederick J. Zimmerman, PhD, Nathaniel W. Anderson, BA, of the Jonathan and Karin Fielding School of Public Health, Department of Health Policy & Management, University of California, Los Angeles
JAMA Network Open, June 28, 2019

Abstract

Importance: Health equity is an often-cited goal of public health, included among the 4 overarching goals of the Department of Health and Human Services’ Healthy People 2020. Yet it is difficult to find summary assessments of national progress toward this goal.

Objectives: To identify variation in several measures of health equity from 1993 to 2017 in the United States and to test whether there are significant time trends.

Design, Setting, and Participants: Survey study using 25 years of data, from January 1, 1993, to December 31, 2017, from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System to assess trends in health equity and health justice by race/ethnicity, sex, and income in 3 categories by year.

Main Outcomes and Measures: Health equity was assessed separately for each of 2 health constructs: healthy days—the average of physical and mental healthy days over the previous 30 days—and general health in 5 categories, rescaled to approximate a continuous variable. For each health construct, average health was calculated along with 4 measures of health equity: disparities across 3 income groups; black-white disparities; health justice—a measure of the correlation of health outcomes with income, race/ethnicity and sex; and a summary health equity metric.

Results: Among the 5 456 006 respondents, the mean (SD) age was 44.5 (12.7) years; 3 178 688 (58.3%) were female; 4 163 945 (76.3%) were non-Latinx white; 474 855 (8.7%) were non-Latinx black; 419 542 (7.7%) were Latinx; and 397 664 (7.3%) were of other race/ethnicity. The final sample included 5 456 006 respondents for self-reported health and 5 349 527 respondents for healthy days. During the 25-year period, the black-white gap showed significant improvement (year coefficient: healthy days, 0.021; 97.5% CI, 0.012 to 0.029; P < .001; self-reported health, 0.030; 97.5% CI, 0.025 to 0.035; P < .001). The health equity metric for self-reported health showed no significant trend. For healthy days, the Health Equity Metric declined over time (year coefficient: healthy days, −0.025; 97.5% CI, −0.033 to −0.017; P < .001). Health justice declined over time (year coefficient: healthy days, −0.045; 97.5% CI, −0.053 to −0.038; P < .001; self-reported health, −0.035; 97.5% CI, −0.046 to−0.023; P < .001), and income disparities worsened (year coefficient: healthy days, −0.060; 97.5% CI, −0.076 to −0.044; P < .001; self-reported health, −0.029; 97.5% CI, −0.046 to −0.012; P < .001).

Conclusions and Relevance: Results of this analysis suggest that there has been a clear lack of progress on health equity during the past 25 years in the United States. Achieving widely shared goals of improving health equity will require greater effort from public health policy makers, along with their partners in medicine and the sectors that contribute to the social determinants of health.

From the Discussion

The results of this study show a worrisome lack of progress on health equity during the past 25 years in the United States. Although there are some differences across conceptualizations of health equity, and small differences across the 2 concepts of overall health, the overall pattern is one of stagnation mixed with unambiguous decline.

Conclusions

Improving health equity often figures as an important goal for communities, thought leaders, and policy makers in public health. Yet, this analysis suggests that across the past 25 years, the promise of improving health equity has not been met. Greater or different efforts than those tried in the past will have to be mustered if health equity is to improve. Performance tracking of health equity may help to keep policy makers accountable to making the necessary changes.

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

The authors conclude that the overall pattern of health equity during the past 25 years in the United States is one of “stagnation mixed with unambiguous decline.”

Shocking! Shocking! Absolutely shocking!

How can anyone call this a great nation when we tolerate such injustices?

Progress will not come from the private sector. There is an urgent need for the enactment and implementation of new public policies if we ever hope to reverse these injustices.

Although there is much to be done, we have before us legislation that would would take a giant step forward in improving health equity, and that is the Medicare for All Act of 2019 in the House (Jayapal) and in the Senate (Sanders). The features of this single payer model of health care would dramatically advance health equity because it would automatically include absolutely everyone in a system financed equitably through progressive taxes.

Yet the House is bogged down in protecting the private insurance industry instead – a source of much of the inequity in health care – and the Senate is going to do all they can to prevent the government from becoming involved.

The authors state, “Greater or different efforts than those tried in the past will have to be mustered if health equity is to improve.” Let’s start with enacting single payer improved Medicare for all. If our politicians won’t do that, then we should replace them. Or shall we just abandon our claim of being a great nation?

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By Michael D. Frakes, Jonathan Gruber, and Anupam Jena
National Bureau of Economic Research, July 2019

Abstract

Stemming from the belief that the key barrier to achieving high-quality and low-cost health care is the deficiency of information and medical knowledge among patients, an enormous number of health policies are focused on patient education. In this paper, we attempt to place an upper bound on the improvements to health care quality that may emanate from such information campaigns. To do so, we compare the care received by a group of patients that should have the best possible information on health care service efficacy — i.e., physicians as patients — with a comparable group of non-physician patients, taking various steps to account for unobservable differences between the two groups. Our results suggest that physicians do only slightly better in adhering to both low- and high-value care guidelines than non-physicians – but not by much and not always.

Introduction

There is widespread belief in health care that the deficiency in information and medical knowledge among consumers is the key barrier to achieving high-quality health outcomes and lower costs of care. An enormous number of health policies follow from this assumption, including efforts to educate patients about health, both at a population level through large-scale public health campaigns (e.g., campaigns to encourage exercise and healthier diets) and at an individual level through provider-led patient education (e.g., education of patients about the inappropriateness of antibiotics for the common cold, the importance of vaccination, etc.), decision-making support, and so on. In addition to information-based policies intended to improve health, other important demand-side approaches intended to improve the efficiency of health care (e.g., high-deductible health plans) focus on increasing direct consumer engagement in the purchase of health care, relying heavily on the notion that informing patients about the costs and benefits of health care services can steer patients towards higher-quality, more efficient care.

The widely prevailing view that information scarcity is a key obstacle to achieving high quality health outcomes raises the basic question: is it simply inadequate medical knowledge and information among patients that has limited the utility of various demand-side approaches to health improvement? If so, it remains possible that improvements could be made along both cost and quality lines should policymakers and providers encourage even greater levels of information disclosure to patients, a point not only stressed by patient-centered health care enthusiasts promoting shared decision-making models, but also intrinsic to the many public health efforts that aim to use patient education as a primary way to improve health. In this paper, we attempt to shed light on whether eliminating the scarcity of information in medical knowledge – an extreme form of information disclosure – could plausibly lead to the delivery and receipt of higher value patient care.

A natural way to explore the importance of scarcity of medical knowledge and information is to look at the care received by a group of patients that should have the best possible information on health care service efficacy: physicians. The decisions of physicians about which type of health care to receive would likely place an upper bound on how well non-physicians could do in selecting their health care treatments if fully informed about the costs and benefits of different types of health care interventions. With the exception of Johnson and Rehavi (2016), who focused on a single health care service – cesarean sections – there is no work which has been able to study the role of physicians as patients.

We are able to address this shortfall by using a source of data previously unexploited in economics research: data on physicians in the Military Health System (MHS). The MHS provides health insurance for all active duty military, their dependents, and retirees. Care is provided both directly on military bases and purchased from an off-base network of contracted providers. The MHS is one of the largest sources of health care spending in the U.S., with spending of over $50 billion per year. We have gathered data on the complete claims records for all MHS enrollees over a ten-year period. Importantly, this includes the claims data for MHS physicians when they are treated as patients themselves (drawing from records of over nearly 35,000 military physicians). The ability to observe physicians as patients provides us with a unique and powerful opportunity to answer the question: do especially well informed patients elect to receive higher value medical services?

For these purposes, we evaluate the quality of health care services received by physicians and non-physicians, focusing on a set of services for which objective, evidence-based standards exist. In particular, we assess whether physicians receive more services deemed “high value” by the relevant medical literature and fewer services deemed “low-value,” in each case relative to the less-informed comparison group of similar non-physician patients. An example of low value care is a chest x-ray before eye surgery, a very low risk procedure for which pre-operative diagnostic testing is not recommended. An example of high value care would be statin therapy for patients with cardiovascular disease. If deficiency of medical knowledge and information is an important reason why demand-side interventions to improve patient health have met with limited success, we should expect that physicians as patients would exhibit markedly higher levels of adherence to high-value health care services and lower levels of low-value care compared to otherwise similar non-physician patients.

Our results suggest that physicians do only slightly better than non-physicians – but not by much and not always. Across most of our low-value settings, physicians receive less low-value care than do non-physicians, but the differences are modest, and generally amount to less than one-fifth of the gap between what is received by non-physicians and recommended guidelines. The results are slightly more mixed in the case of the high-value care analysis, with some evidence suggesting that physicians appear to receive high-value care at roughly the same rate received by non-physicians and some evidence suggesting that physicians do slightly better than non-physicians. These results provide a rough boundary on the extent to which additional information disclosure (beyond prevailing levels) can be expected to improve the delivery of health care in the U.S. Relatedly, these findings suggest that, despite the threat to the optimality of the health care system posed by information asymmetries between physicians and patients (Arrow 1963), most of the explanation behind the over- and under-utilization of low- and high-value services likely arises from factors other than informational deficiencies of patients.

Moreover, in the case of low-value care—where we do find modest physician effects — we attempt to shed light on the mechanisms underlying any information channel. We do not find consistent evidence to suggest that the observed average physician effects arise from the patient’s choice of a low-intensity physician or from a reduced scope for physician induced demand. Given these findings, it is likely that some of the modest physician effects we estimate arise simply from informed patients making higher quality choices at the moment of the care decision itself.

Our paper proceeds as follows. Part II reviews the existing literature on the impacts of health care information initiatives and provides a conceptual overview behind our approach of observing physicians as patients as a means of exploring the bounds of the quality gains that may arise from greater information disclosure. Part III provides a background on the Military Health System and discusses our data and empirical methodology. Part IV presents the results of our analysis and Part V concludes.

Discussion and Conclusion

We attempted to explore the upper bounds of the gains that may ensue from consumer-driven health care approaches that draw upon greater information-disclosure to patients by exploring the care choices of physicians when acting as patients themselves relative to the clinical choices of non-physician patients. In an attempt to isolate the information-component to the differences between these two groups of patients, we took various approaches to ensure comparability between physician and non-physician groups. Our results consistently suggest that, at most, superior patient knowledge is associated with only modest improvements in the quality of care selected during medical encounters. Perhaps one interpretation of these findings is that patients remain generally deferential to the care recommendations of their treating physicians, even in the case of near fully-informed patients. This interpretation would be consistent with other recent findings in the health economics literature, including recent research by Chernew et al. (2018) showing that referring physicians are dramatically stronger determinants of where patients receive MRIs relative to patient cost-sharing factors. Should concerns over the quality of care received by patients remain—as is suggested by the large gaps demonstrated between prevailing rates of adherence to high- and low-value care guidelines and recommended rates of adherence — our results are informative on the limitations that may come with information-focused, demand-side solutions.

Despite our efforts to ensure comparability across our treatment and control groups, concerns may remain over the generalizability of our findings. In particular, among other external validity issues, some may be concerned that we tested for the impacts of information in an environment characterized by very low levels of cost-sharing. The influence of information, however, may interact with financial considerations of this nature. Consider, for instance, preoperative testing and assume, as is the case with the Military Health System beneficiaries, that copayments for these diagnostic procedures are negligible. Even though such tests may render insufficient benefits to justify their full social costs and even if patients are aware of this, informed patients may nonetheless undertake the tests anyway given the negligible financial implications. In contrast, informed patients may decide to forego these tests when cost-sharing is more substantial.

This consideration does not necessarily threaten the external validity of our low-value care findings—at least not overly so—in light of the fact that the costs to undergoing low-value care extend beyond just direct financial outlays. For instance, in the case of pre-operative testing by the patients in our sample, we demonstrate in the Online Appendix that much or most of these instances of pre-operative testing necessitate an entirely separate visit to a medical provider on a separate day, an outcome that likely imposes costs and inconveniences of another nature on the affected patient. Accordingly, if we still estimate modest physician effects in the face of low-value care decisions that carry potentially significant non-cost-sharing consequences, such modest findings may indeed generalize to populations facing higher levels of cost-sharing.

Further reinforcing this point, the costs associated with receiving low-value care may extend beyond cost-sharing dollars in light of the possibility of physical harms and discomfort associated with the care itself. This is very likely true with the case of cesarean delivery, especially considering the recovery period involved. These physical consequences are, of course, likely to be far less significant in the preoperative testing setting, especially in the case of blood draws.

Finally, it is important to note that this particular generalizability concern does not extend to the high-value care analysis. If anything, the fact that cost-sharing is lower in the MHS should only elevate the role of information in encouraging greater guideline adherence. In this light, our finding of little to no improvements in high-value-care adherence in fully-informed patients is likely to generalize to settings with higher levels of cost-sharing.

The entire 49-page paper can be downloaded for free at the following link:
https://www.nber.org…

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Doctors aren’t much better at picking the best medical treatments than laypersons

By Michael Hiltzik
Los Angeles Times, July 8, 2019

In recent years, the idea has spread that forcing consumers to pay more for healthcare — giving them “skin in the game” is the usual mantra — will prompt them to become more discerning medical shoppers.

The goal is to improve the efficiency of the healthcare system by saddling consumers with higher costs if they opt for less useful or more overpriced services. Experts have identified numerous flaws with this concept, as we’ll get to in a bit.

But a new paper by Michael D. Frakes of Duke, Jonathan Gruber of MIT and Anupam Jena of Harvard raises an important and oft-overlooked point: Even if consumers have better information about the efficacy of particular treatments, will they be any good at using that information?

The answer is: probably not.

The authors tested the theory behind “consumer-driven healthcare” by examining the behavior of the best-informed consumers of all: doctors. (Their sample of physicians as patients came from the massive Military Health Service.) What they found was that doctors are better at picking high-value treatments and avoiding low-value care — but “not by much and not always.”

The message is that “purely relying on consumer cost-sharing and high deductibles won’t get us to the best outcome,” Gruber says.

The authors’ examples of low-value care included caesarean sections, which are judged by experts to be vastly overused; and pre-operative diagnostic tests for low-risk surgeries, such as chest X-rays prescribed for patients undergoing eye operations. The high-value examples included comprehensive diabetes care, statin use for patients with cardiac risk, and child vaccinations.

“There really should be 100% consumption of high-value and 0% of low-value care,” Gruber told me. “On those benchmarks, doctors don’t do a whole lot better than non-doctors.”

The finding is important because it suggests there’s a limit on how much more efficient the healthcare system can become by making consumers better informed. If doctors, the best-informed medical consumers, can’t consistently be steered to the most cost-effective treatments, then obviously average consumers will do much worse.

“If our approach is just to get more information to patients,” Frakes says, “that may not give us a great deal of return.”

This study isn’t the first to cast doubts on the theory that high deductibles and co-pays alone will lead consumers to make better and more cost-effective choices on healthcare. In 2015, a team from UC Berkeley and Harvard examined what happened when a large company shifted from an all-expenses-paid health plan to a high-deductible plan in a single year.

They found that total medical spending fell by as much as 13.8%, but that consumers cut spending on “potentially valuable care” such as preventive services as well as potentially wasteful care, such as X-rays and scans. They found “no evidence of consumers learning to price shop after two years in high-deductible coverage.” That confirmed a 1993 study by the Rand Corp. that also found that consumers reduced spending on good treatments and bad alike.

The latest study found that physician families did reduce their rate of C-sections, but only modestly and not enough to bring the rate into line with what medical experts say is proper. (Medical professionals say the rate, which is about 30%, should be only 10% to 15%.) Physician patients received unnecessary pre-surgical diagnostic tests nearly 20% of the time, less than non-physicians but still much too often.

That led the authors to conclude that “even the best informed patients do not make any less use of low-value health services.”

As for high-value care, physician patients failed to receive comprehensive diabetes care 30% of the time. There was virtually no difference between doctors and laypersons in receiving post-cardiac care, or in vaccinations for diphtheria/tetanus/pertussis and hepatitis. There were “small improvements” in compliance for child vaccinations for chicken pox, polio and measles/mumps/rubella.

The findings don’t show that there’s no place for deductibles and co-pays in the U.S. healthcare system. “There’s no step forward in healthcare that doesn’t have pros and cons,” Gruber says. “Absent any consumer cost-sharing, healthcare will be overused; the potential con is that people will forego both more valuable and less valuable care.”

That points to a more nuanced system of deductibles and charges, he says. Often this is termed “value-based healthcare,” in which flexible cost-sharing steers consumers to more effective care. That means lower co-pays for generic drugs, higher charges for unnecessary tests or higher-cost treatments not shown to have better results than lower-cost alternatives.

“The right answer for our system is not to tell patients they can’t have service X,” Gruber says, “but to say service X isn’t cost-effective — if you want it you have to pay for it. That’s controversial and hard, but the lesson from this paper is that we should bring expert analysis into cost sharing, rather than relying on consumers to figure it out.”

https://www.latimes.com…

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Comment:

By Don McCanne, M.D.

Please excuse the fact that today’s Quote of the Day selections are relatively long, but they are because it is imperative that we clearly understand the fundamental health policy implications that can be extrapolated from this NBER report.

For a few decades much attention has been directed to the concerns about the very high health care costs in the United States in a system that is delivering mediocrity. The debate has centered around whether public policies – the government – or consumer-directed health care – the market – can deliver greater value in health care – higher quality at lower costs.

This study is important because it places the provider of health care – the physician – in the role of the health care consumer – the patient. Nobel laureate Kenneth Arrow showed us long ago that information asymmetry – the fact that the health care provider has information that the health care consumer does not – is a major flaw in the theory that free markets are more effective in improving quality and reducing costs when it comes to health care. The fact is that free markets do not work effectively in health care.

Government regulation and public administration have been shown to be effective in improving value in health care, much to the chagrin of conservative/libertarian ideologues. To counter the perceived “government takeover” of health care there have been efforts to reinforce the effectiveness of markets, especially though consumer-directed health care policies that theoretically place the patient in charge.

One major effort has been to place more information in the hands of the patient to enable informed decisions to be made by the patient in the health care marketplace. This landmark NBER paper is important because it essentially eliminates information asymmetry as a significant factor by observing the behavior of the most informed of patients – physicians themselves – in the health care “marketplace.” They show that these highly informed health care shoppers – physicians – do not do much better than comparable uninformed laypersons. The minimal benefit, if any, is so small that we cannot rely on expanding available information for the patient-consumer to use the market more effectively to improve quality and reduce costs. This study shows that giving every single patient a medical school education would not have much of an impact.

Another effort to increase the effectiveness of health care shopping in the marketplace has been to increase price sensitivity of the patients. Supposedly, when all things are otherwise equal, the patient will go for lower prices. Here we run into real problems.

Health care has become too expensive. Patients need some form of health care coverage to prevent financial hardship. Insurance products have been designed to expose patients to costs through deductibles and other cost sharing. This really doesn’t have much impact on health care prices since the ultimate costs are not determined by the patient-consumer but rather by nontransparent business arrangements between the health care providers and the third party payers such as the private insurers. The patients may not even be aware of the actual prices unless they eventually see them in the insurers’ explanation of benefits.

So since the deductibles and other cost sharing arrangements do not have much influence actual prices, then what impact do they have? Deductibles do cause patients to forgo some recommended care. It is often glibly stated that, since both low-value care and high-value care are forgone because of cost sharing, it is a trade-off, as if that is perfectly acceptable. Well, it isn’t. Forgoing high-value care is always wrong and indicates that the health care financing system is not functioning properly. So what about low-value care? By definition, it is not care that is totally without value, so it is care that should be seriously considered in the management of the patient. It is only no-value care that should never be rendered. More about this in a moment.

The consumer-directed advocates have recommended health savings accounts to increase the shopping power of the patient-consumer. But they are a gimmick that unfairly provides regressive tax benefits to higher-income individuals. More important, families with inadequate disposable income cannot benefit from an empty health savings account. They are not a satisfactory solution to the financial barriers created by high deductibles.

There is considerable talk today about value-based health care. It is often suggested that the patient should pay more for low-value care, but less or nothing at all for high-value care. Obviously this is an attempt to counter the negative impact of high deductibles. So let’s look at this.

A high performance health care system should be designed to enable people to get the care they should have. Thus high-value care should have no financial barriers, thus no deductibles or other coast airing. Care that is of no value should never be offered and thus no payments should ever be made for it. Regarding the more difficult problem of low-value care, which may be entirely appropriate, some would suggest that patients should pay larger amounts out-of-pocket for lower-value care. But rather than the patients making those decisions based on the amount of out-of-pocket spending, the providers are in a better position to decide the value based on cost effectiveness. (Conservatives often say that cost effectiveness should never enter into the decision, but they are wrong. You cannot give the health care delivery system a blank check, where anything goes.) Regardless of high-value, low-value, or no-value, if pricing decisions were left to patients, they would price high-value and low-value care too low and no-value care too high. If pricing decisions were left to providers, everything would be (and already is) priced too high.

The beauty of a well designed single payer financing system is that it uses very effective tools to get pricing right (global budgets, negotiated rates, bulk purchasing, etc.). Today’s lesson is that if physicians are not much better health care shoppers than anyone else then it is time to dump the consumer-driven market ideology and move forward with a proven method of financing health care equitably so that we all receive the care we should have: single payer improved Medicare for all.

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

By Ed Weisbart, M.D.
St. Louis Post-Dispatch, July 4, 2019

Shhh! Don’t tell the insurance companies (it’s a secret).

That’s the logic of the presidential candidates who are pushing a “public option,” also known as Medicare for Those Who Want It. They claim that adding a Medicare-like option onto the health insurance marketplace is an easier political lift than real Medicare for All, and that such an option would thrive in the free market and open the door for Medicare for All. Then the insurance industry would admit defeat and quietly ride off into the sunset, finally achieving what should have been done in the first place.

The fact that the insurance industry is lobbying hard for this circuitous incremental approach should tell you all you need to know.

Sadly, many of us don’t understand the choice we’re being offered. That helps them sell the idea that having more options is always better. It’s true that we need free choice of doctors and hospitals, but insurance should disappear into the background. That’s what would happen with Medicare for All; that’s not what would happen with a public option, and the difference is all-important.

We could spend the next few years passing a public option and then wait several more years to see how it works. Ten years later, we would still be playing catch-up with the rest of the industrialized world, where health care costs half of what it does here in America and yet produces dramatically better results.

Why isn’t a public option good enough?

First, it’s missing nearly all the savings of a single-payer system. Health care insurance companies operate at 15% to 20% overhead; Medicare’s overhead is 2%. We will never reach Medicare’s efficiency by keeping today’s complex insurance industry in the mix. Never. Plus, the insurance companies’ inefficiency — as high as it is — is dwarfed by the untold time and money patients, doctors and hospitals waste in dealing with those companies.

American hospitals employ one insurance-related clerk for every bed they operate. We physicians often spend half of our workday fighting insurance company barriers. We’re heartsick over seeing patients skip dosages or decline essential testing because they can’t afford them.

None of this waste disappears by adding one more insurance “option.” A public option would do nearly nothing to bring down the cost of health care.

Second, a public option would be funded by premiums and co-pays. It would essentially be another regressive tax, least affordable to those in the greatest need. Only the sickest of today’s uninsured would join, driving public-option prices up higher and becoming a “high-risk pool.” Insurance depends on a mostly healthy pool of patients to balance the sickest. Whenever you turn that on its head, it goes down in flames.

Last, a “public option” does nothing to help those who now have insurance. Millions would still have sky-high deductibles. They would still be constrained by networks that tell them which doctors and hospitals to use. They would still be forced to be on constant guard for surprise medical bills and charges, even when they go to in-network hospitals. Millions still would not have access to dentistry, eyeglasses and hearing aids.

Each of these problems would be resolved by simply passing the real Medicare for All bills, H.R. 1384 and Senate Bill 1129, featuring tax-funded comprehensive benefits with no premiums, no copays, no surprise bills and your choice of doctors and hospitals.

Both bills empower Medicare to negotiate drug prices for us. Most of the public-option bills do not.

Both Medicare for All bills would stabilize hospital finances by making sure every patient had insurance and reducing administrative burdens.

Both bills allow every American their choice of physician and hospital, without fearing that a change of jobs would mean changing insurance and searching for a new doctor.

Some worry that the adversaries of Medicare for All are too powerful. In other words, they want us to believe we can sneak our way there through a public option, as if the insurance industry will never see it coming.

The next time you hear a politician say they support Medicare for All, and that the best way to get there is through a public option, raise some of these challenges. Don’t let them derail the best solution; too many lives are at stake.

Dr. Ed Weisbart is a family physician and chair of the Missouri chapter of Physicians for a National Health Program.

https://www.stltoday.com…

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Comment:

By Don McCanne, M.D.

Do those supporting the diversion of plans to enact a single payer model of Medicare for All to enacting instead a “public option” – a Medicare for some – understand the terrible consequences of perpetuating our current inequitable, dysfunctional system that Ed Weisbart explains so well in this op-ed? Or do they just not care? Ask them. We need to know whether or not they really do believe in health care justice for all.

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By Leah Zallman, M.D., M.P.H.; Karen E. Finnegan, Ph.D.; David U. Himmelstein, M.D.; Sharon Touw, M.P.H.; Steffie Woolhandler, M.D., M.P.H.
JAMA Pediatrics, July 1, 2019

Abstract

Importance: In October 2018, the Trump administration published a proposed rule change that would increase the chance of an immigrant being deemed a “public charge” and thereby denied legal permanent residency or entry to the United States. The proposed changes are expected to cause many immigrant parents to disenroll their families from safety-net programs, in large part because of fear and confusion about the rule, even among families to whom the rule does not technically apply.

Objective: To simulate the potential harms of the rule change by estimating the number, medical conditions, and care needs of children who are at risk of losing their current benefits, including Medicaid and Children’s Health Insurance Program (CHIP) and Supplemental Nutrition Assistance Program (SNAP).

Design, Setting, and Participants: A cross-sectional study used nationally representative data from 4007 children 17 years of age or younger who participated in the 2015 Medical Expenditure Panel Survey to assess their potential risk of losing benefits because they live with a noncitizen adult. Statistical analysis was conducted from January 3 to April 8, 2019.

Main Outcomes and Measures: The number of children at risk of losing benefits; the number of children with medical need, defined as having a potentially serious medical diagnosis; being disabled (or functionally limited); or having received any specific treatment in the past year. The numbers of children who would be disenrolled under likely disenrollment scenarios drawn from research on immigrants before and after the 1996 welfare reform were estimated.

Results: A total of 8.3 million children who are currently enrolled in Medicaid and CHIP or receiving SNAP benefits are potentially at risk of disenrollment, of whom 5.5 million have specific medical needs, including 615 842 children with asthma, 53 728 children with epilepsy, 3658 children with cancer, and 583 700 children with disabilities or functional limitations. Nonetheless, among the population potentially at risk of disenrollment, medical need was less common than among other children receiving Medicaid and CHIP or SNAP (64.5%; 95% CI, 61.5%-67.4%; vs 76.0%; 95% CI, 73.9%-78.4%; P < .001). The proposed rule is likely to cause parents to disenroll between 0.8 million and 1.9 million children with specific medical needs from health and nutrition benefits.

Conclusions and Relevance: The proposed public charge rule would likely cause millions of children to lose health and nutrition benefits, including many with specific medical needs that, if left untreated, may contribute to child deaths and future disability.

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Conclusions

Most children who lose Medicaid and CHIP become uninsured. Without coverage, they are likely to forego or delay needed care, and some, such as children with epilepsy or asthma, as well as newborns who require immunizations, are likely to incur higher long-term health care costs. In addition, undertreatment of illness increases school absenteeism and parental work absence, which, in the case of asthma, led to a loss of parental productivity of $719.1 million in 1996 alone.

However, our main concerns are not economic but ethical. We believe that denial of needed health care and nutrition to anyone, but particularly to children, violates human rights. We call on the medical community to speak out against this unjust and unethical proposal to change the public charge rule.

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

As we struggle to teach the policymakers, the politicians, and our nation at large about the unequivocal practical and fiscal advantages of the single payer model of Medicare for All, we seem to assume that everyone would understand and support the ethics and moral imperative of this model. Sadly, the politicians currently in control apparently do not share this view of health care ethics as they intend to modify the “public charge” rule in a manner that would result in the disenrollment of millions of resident children from the Medicaid and CHIP programs, which will surely expose many of them to adverse health consequences.

Some would frame this as an immigration issue rather than a health care issue. There is no question but that we should have rational and humane immigration policies in place, but when our immigration policies create health problems, then we need to modify the policies. Health should never be a bargaining chip as we address other socioeconomic and political problems.

How often have you heard “zero tolerance” during discussions of immigration? Yet why do we not hear “zero tolerance” during discussions of reform models of health care financing? Except for the single payer model of Medicare for All, all other models would leave tens of millions without adequate coverage, access or affordability.

We need to sort out our values. Instead of using “public charge” as a hammer to deprive people of health care, we need to first make sure that everyone does have essential health care without having to suffer financial hardship. After we declare that as an inviolate right, we can work on our other issues, but we should never, ever consider trading away health care.

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By Khandelwal, Nita MD, MS; White, Lindsay PhD, MPH; Curtis, J. Randall MD, MPH; Coe, Norma B. PhD
Critical Care Medicine, June 2019

Abstract

Objectives: Use of intensive care is increasing in the United States and may be associated with high financial burden on patients and their families near the end of life. Our objective was to estimate out-of-pocket costs in the last year of life for individuals who required intensive care in the months prior to death and examine how these costs vary by insurance coverage.

Design: Observational cohort study using seven waves of post-death interview data (2002–2014).

Participants: Decedents (n = 2,909) who spent time in the ICU at some point between their last interview and death.

Interventions: None.

Measurements and Main Results: Two-part models were used to estimate out-of-pocket costs for direct medical care and health-related services by type of care and insurance coverage. Decedents with only traditional Medicare fee-for-service coverage have the highest out-of-pocket spending in the last year of life, estimated at $12,668 (95% CI, $9,744–15,592), second to only the uninsured. Medicare Advantage and private insurance provide slightly more comprehensive coverage. Individuals who spend-down to Medicaid coverage have 4× the out-of-pocket spending as those continuously on Medicaid.

Conclusions: Across all categories of insurance coverage, out-of-pocket spending in the last 12 months of life is high and represents a significant portion of assets for many patients requiring intensive care and their families. Medicare fee-for-service alone does not insulate individuals from the financial burden of high-intensity care, due to lack of an out-of-pocket maximum and a relatively high co-payment for hospitalizations. Medicaid plays an important role in the social safety net, providing the most complete hospital coverage of all the insurance groups, as well as significantly financing long-term care.

https://journals.lww.com…

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Comment:

By Don McCanne, M.D.

About this great health care financing system we have that several politicians want to protect, as this study shows, “Across all categories of insurance coverage, out-of-pocket spending in the last 12 months of life is high and represents a significant portion of assets for many patients requiring intensive care and their families.” In fact, many end up depleting their assets and go on Medicaid.

We must think that there is something good about having an estate at the end of life since we have public policies that prevent modest estates from being depleted through estate taxes. So why do we tolerate a health care financing system that wipes out assets of those unfortunate enough to require intensive care services in the last year of life?

We’ve long known that Medicare alone was inadequate, but this study shows that all categories of insurance coverage may be inadequate, though adding Medicaid to Medicare provides a safety net but only after the patient’s assets are depleted.

The single payer model of Medicare for All, by covering all essential services and by eliminating out-of-pocket spending, prevents compounding the end of life with financial hardship, not to mention protecting residual assets for the benefit of a surviving partner or progeny.

This may not represent the most pressing need for health care financing reform, but it does represent the fact that we seem to be more concerned about taking care of the insurance industry by continuing to tolerate the hundreds of billions of dollars in administrative waste while continuing to tolerate the patients’ financial hardships that the insurance industry is supposed to prevent.

A Medicare public option would not prevent this since the study shows, “Among insured decedents greater than or equal to 65, those with only Medicare FFS had the highest estimated OOP costs in the last year of life in every cost category except for prescription drugs.” Allowing people to buy into Medicare will not provide adequate protection.

And allowing people to keep their employer-sponsored insurance when 60 million people leave their jobs each year? Come on!

We want real reform that takes care of everyone in a system we can afford – single payer improved Medicare for all.

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

By Margot Sanger-Katz
The New York Times, July 3, 2019

The “Medicare for all” bill written by Senator Bernie Sanders would cover not just standard medical services, but also vision, dental and long-term care. It would offer more health benefits than the world’s leading universal health care systems.

But as some politicians who support the plan are quick to clarify when asked, that does not mean it would “abolish all private health insurance.”

The next thing they may say includes something about “a role” for private insurance or “supplemental coverage.”

The example of supplemental insurance Mr. Sanders typically mentions is coverage for cosmetic surgery.

To clarify: There is no private market for cosmetic surgery insurance.

“We are not aware of any,” said Adam Ross, a spokesman for the American Society of Plastic Surgeons, the leading professional group for plastic surgeons. “Not for cosmetic procedures.”

“No one would sell a cosmetic surgery plan, since the only ones buying it would be people expecting to need cosmetic surgery,” said Linda Blumberg, a fellow at the Urban Institute.

Mr. Sanders’s bill is so expansive that it’s actually quite hard to imagine many health care services that private insurance companies would be able to cover. While the bill doesn’t explicitly ban private insurance, it makes it unlawful to “sell health insurance coverage that duplicates the benefits under this act.”

“You have to really rack your brains to think of anything that would not be covered,” said Cynthia Cox, a vice president at the Kaiser Family Foundation, a health research group.

You might think that Democratic politicians who endorse the Sanders plan would embrace the bill’s comprehensiveness as a virtue. And, in some ways, they do. But some also appear nervous about saying that they will do away with an entire industry. Public opinion surveys suggest that voters are skeptical about plans that will take away their private coverage. Some co-sponsors of Mr. Sanders’s bill now say they are more comfortable with optional plans that would not bar duplicate coverage. Some others have embraced the “supplemental coverage” line.

“In order to create a role for private insurance in any of those ways, you need to weaken the main system,” said Adam Gaffney, the president of Physicians for a National Health Program, which supports a very broad single-payer plan along the lines of Mr. Sanders’s bill. He said the effective abolition of private insurance was a strength of the proposal, which doesn’t require insurance for financial or benefit gaps.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Why are so many politicians and others obsessed with protecting the private insurance industry when our goal is, or should be, to protect patients from financial hardship while ensuring access to appropriate health care? With high premiums, ever higher deductibles and other cost sharing, exposure to out-of-network medical bills, and exposure to costs of care not included as plan benefits, the private insurers fail to provide the financial protection that the single payer Medicare for All model is specifically designed to do.

Our current health care financing system is highly fragmented and extremely complex. That has not only caused it to be very expensive while falling short on efficiency and effectiveness, its complexity has also made it impossible to repair its inherent defects by merely adding to the system more complexity such as a public option which can only make modest adjustments in the numbers insured but not in the other flaws in the system.

Contrast that to a system that is specifically designed to include everyone, to provide all essential health care benefits, to eliminate financial barriers to care, and to make the system affordable to society as a whole by eliminating hundreds of billions of dollars in administrative waste. Protecting and perpetuating the private insurance industry by merely adding one more insurance option, even if public, to the current quagmire will only leave on place the current personal financial hardships and impaired access to care.

As PNHP president Adam Gaffney says, “In order to create a role for private insurance… you need to weaken the main system.” Flipping that statement to a positive, in order to strengthen the health care financing system, you need remove the role of private insurance. Abolition of private insurance is a strength of Medicare for All, not a weakness.

It is nonsense to suggest that we should open up other ways for the insurers to tap our health care dollars to benefit their own industry. They have been a very expensive monkey wrench thrust into our health care system. We need to pull the wrench out, repair the damage as we rebuild the machine, and then get on with providing comprehensive, high quality, affordable health care for everyone.

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