By William E. Bruhn, BS; Lainie Rutkow, JD, PhD, MPH; Peiqi Wang, MD, MPH; Stephen E. Tinker, BS; Christine Fahim, PhD; Heidi N. Overton, MD; Martin A. Makary, MD, MPH
JAMA, June 25, 2019

An estimated 20% of US consumers had medical debt in collections in 2014. Medical debt has been increasing with direct patient billing, rising insurance deductibles, and more out-of-network care being delivered, even at in-network facilities. Bills sent directly to patients may use the undiscounted price of a hospital’s services and can result in financial hardship and avoidance of future medical care. Hospitals need to be paid for care delivered, but some bills are unpaid. Hospitals may negotiate, reduce, or write off payments. Some have begun adopting a range of aggressive strategies for collecting unpaid bills, including suing patients and garnishing their wages or bank savings. We examined garnishment legal actions among Virginia hospitals.

From the Discussion

Thirty-six percent of Virginia hospitals garnished wages in 2017, with a small number of hospitals accounting for most cases. Some characteristics suggest that hospitals with greater financial need (nonprofit, lower annual gross revenue) may be pursuing debt collection to the final stage of garnishment.

https://jamanetwork.com…

The Nonprofit Hospital That Makes Millions, Owns a Collection Agency and Relentlessly Sues the Poor

By Wendi C. Thomas
ProPublica, June 27, 2019

From 2014 through 2018, Methodist Le Bonheur Healthcare filed more than 8,300 lawsuits, according to an MLK50-ProPublica analysis of Shelby County General Sessions Court records.

Other hospitals in Memphis and around the country also sue patients. According to a study published Tuesday in the Journal of the American Medical Association, researchers found more than 20,000 debt lawsuits filed by Virginia hospitals in 2017.

Its handling of poor patients begins with a financial assistance policy that, unlike many of its peers around the country, all but ignores patients with any form of health insurance, no matter their out-of-pocket costs. If they are unable to afford their bills, patients then face what experts say is rare: A licensed collection agency owned by the hospital.

Lawsuits follow. Finally, after the hospital wins a judgment, it repeatedly tries to garnish patients’ wages, which it does in a far higher share of cases than other nonprofit hospitals in Memphis.

Its own employees are no exception. Since 2014, Methodist has sued dozens of its workers for unpaid medical bills, including a hospital housekeeper sued in 2017 for more than $23,000. That year, she told the court, she made $16,000. She’s in a court-ordered payment plan, but in the case of more than 70 other employees, Methodist has garnished the wages it pays them to recoup its medical charges.

Debt That Will Follow Her to the Grave

Judge Betty Thomas Moore called Carrie Barrett’s name again.

Barrett stood, and (hospital attorney Dewun) Settle asked the judge to set her payments at $100 a month.

The judge agreed, denying Barrett’s motion to pay $40 per month.

Months later, Barrett was still bothered by the outcome.

“If you know I can’t pay $40, why you think I can pay $100?” Barrett said.

Between February and May, Barrett managed to make her payments on time, by shorting other bills and relying on payday loans. But this month, she missed her payment due date.

If Methodist doesn’t add any interest to Barrett’s debt and she pays as ordered, she will pay it off in 330 months.

She will be 90 years old.

Not long after her day in court, Barrett filed her 2018 taxes.

She made $13,800.

“It’s in the hands of God now,” she said. “There’s only so much I can do.”

https://www.propublica.org…

When Hospitals Sue For Unpaid Bills, It Can Be ‘Ruinous’ For Patients

By Selena Simmons-Duffin
NPR, June 25, 2019

(Daisha) Smith is unflinching when she talks about Mary Washington and what happened to her after she went to the hospital in 2017.

At the time she didn’t have insurance. She was working part time at Walmart for $11 an hour. She doesn’t want to give the details about why she ended up at the hospital. “I was not myself,” she says. “So I walked myself into Mary Washington to get help — to get myself on track.” She says she was admitted for two weeks.

The hospital sued her for $12,287.68. She had a default judgement against her and did not realize she had been sued until she saw her paycheck mysteriously disappearing.

“When I looked at my pay stub, I’m like, ‘Why do I only have like $600-something in my account?’ ” She noticed “garnish” written on the bottom of her pay stub. “So I called my company and asked them, ‘Who’s garnishing my check?’ ” They told her it was Mary Washington.

With the garnishment, her take-home pay for a month of work comes to about $1,400. Her rent is $1,055. “I literally have no food in my house because they’re garnishing my check,” she says.

https://www.npr.org…

Comment:

By Don McCanne, M.D.

Even with insurance, our current health care financing system does not prevent medical debt for millions of workers and their families. For far too many, essential expenses such as housing, food, and transportation exceeds their incomes. What does adding to this the stresses of wage garnishment and taking out usurious loans from payday lenders do? Who benefits when the hole is only dug deeper?

Under a single payer Medicare for All program that eliminates premiums and cost sharing, no medical debt accrues since the health care system is prepaid through equitable taxes. Taxes should not create the same kind of financial burden since progressive taxes are based on the ability to pay.

Yet most of the Democrats in the presidential debate last evening want to protect the private, employer-sponsored insurance system that covers about half the population. They seem to feign obliviousness to the consequences of such a financing system including potential exposure to wage garnishment and usurious payday loans. Not that the Republicans are any better since they keep promising a better system but than never deliver.

Single payer Medicare for All removes financial barriers to care. It’s that simple.

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

By Tara Bannow
Modern Healthcare, June 25, 2019

Patients’ out-of-pocket costs for inpatient services increased by 14% on average between 2017 and 2018, according to a new report from TransUnion Healthcare.

Revenue-cycle management provider TransUnion revealed its findings Tuesday during the Healthcare Financial Management Association’s annual conference in Orlando, Fla.

Last year, patients who received inpatient care saw the biggest hikes in their out-of-pocket costs. Patients’ deductibles and co-pays averaged $4,659 for an inpatient visit in 2018, compared with $4,086 in 2017.

Outpatient care saw a noteworthy uptick of its own. Patients’ out-of-pocket costs averaged $1,109 for an outpatient visit in 2018, up 12% compared with $990 in 2017.

Parallon, HCA Healthcare’s revenue-cycle subsidiary, has observed patients’ co-pays and deductibles increasing between 6% and 8% annually for at least seven years, said Eric Ward, Parallon’s CEO.

https://www.modernhealthcare.com…

Comment:

By Don McCanne, M.D.

According to this report, co-pays and deductibles have been increasing between 6% and 8% for at least seven years, and it is getting worse. Between 2017 and 2018, the increase in out-of-pocket costs was 14% on average.

Recent polls have shown that it is the costs of health care about which the public is most concerned, yet the insurance industry appears to be relatively insensitive to these issues. Also a recent poll showed that much of the public is not aware that the single payer model of Medicare for All would eliminate deductibles, coinsurance, and co-payments.

In advocating for single payer Medicare for All, it is important to deliver this point. There are no out-of-pocket expenses for accessing health care. The system is prepaid by fair taxes based ability to pay. Most individuals would be paying less than they do now, though much of what they are paying is hidden from them (forgone wage increases for employer contributions to plans, and general revenue taxes that pay for much of government-funded health care which is about 60% of all health care spending).

It is also important that they know that single payer uses tools to slow the rate of increases in health care costs, providing greater financial security for the future.

These out-of-pocket costs are highly visible to the patients. They need to understand that they would go away under single payer Medicare for All.

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

By Paige Minemyer
Fierce Healthcare, June 19, 2019

Cigna chief David Cordani said it’s time to pump the brakes on calls for a healthcare system overhaul like “Medicare for All.”

Cordani, speaking at the AHIP Institute & Expo Wednesday, said insurers should hear the underlying message from consumers that their care is often too costly. And while reform on the scale of transitioning to a single-payer system may not be necessary, consumers’ frustration with healthcare costs does speak to the need for real, substantial change, he said.

“There’s a real call from a societal standpoint for more value and more peace of mind to be delivered to individuals,” Cordani said.

Instead, Cordani said the solution is for insurers like Cigna to strengthen the public-private partnerships they operate today—Medicare Advantage and Medicaid managed care being the two prime examples—and pivot toward work that keeps people healthy in the first place.

https://www.fiercehealthcare.com…

Q&A: ‘We have had a maniacal focus on the patient’

Modern Healthcare, June 22, 2019

Dr. William Shrank had some big shoes to fill. In April he succeeded now-retired Dr. Roy Beveridge as chief medical officer at Humana. Shrank was previously CMO at UPMC. Shrank recently met with Modern Healthcare’s editorial board to discuss his goals at the large insurer.

MH: How will you apply some of what you learned at UPMC to your new role at Humana?

Shrank: We’re focused on the elderly population; we’re focused on Medicare Advantage. We have been putting a whole host of assets and tools together that we can wrap around and meet patients in the community.

MH: Recently it was reported that Humana CEO Bruce Broussard came out against proposals to adopt a Medicare for All type of proposal. What would you see as some of the drawbacks of such a plan?

Shrank: We should be really precise about some of the terms here. Everyone agrees that expanding healthcare coverage is a good thing. That’s not in question. The response was very specific about a very specific part of a proposal that said that there would be no private insurance, there would be no Medicare Advantage. We believe very firmly that Medicare Advantage is an important part of the solution set for our seniors for a variety of reasons. We know that Medicare Advantage allows us to offer a broader set of benefits that we know are not covered in traditional Medicare—vision, hearing aids, a variety of things that are not available in traditional Medicare.

We know that Medicare Advantage offers protection against financial catastrophe with maximum out-of-pocket costs. We know, most importantly, that Medicare Advantage is the most rapid way to transform healthcare to a value-based system.

https://www.modernhealthcare.com…

Former Aetna CEO Mark Bertolini on ‘Medicare for All’: No one can explain to me what it is

Medicare Supplement News, March 28, 2019

Squawk Box: How do you deal with things like Medicare for All?

Mark Bertolini: Well, let’s talk about Medicare for All. Medicare for All, single payer – great populist term to throw out to the public. What is it? Nobody can tell me… Tell me a country that has a program like that. Most people say Canada or the UK. Those are not Medicare for All or single payer systems. Those are socialized systems…

SB: Wouldn’t single payer here mean that it’s a public option and there aren’t private options any more?

MB: So that’s the second question I ask. Who runs all of our public programs today… The private insurers… The health care insurance companies are the intermediaries for Medicare and Medicaid. We run it for the government. They give us the specs. We build it out…

SB: There’s a lot of things in Medicare, a lot of waste, a lot of fraud.

MB: There sure is in Medicare fee for service, not in Medicare Advantage which is what we run more tightly…

SB: Didn’t we try to drive a stake into Medicare Advantage?

MB: It’s too big to kill; it’s over 20 million lives… Back to the ACA, if we had allowed Medicaid expansion to happen and we would have means tested people down to age 50 for Medicare – Medicare Advantage – so 50 to 65, we would have covered more people than the ACA did at far less cost…

http://medsuppnews.com…

As Democrats Talk Single Payer, Private Medicare Advantage Soars

By Bruce Japsen
Forbes, February 3, 2019

Health insurers are reporting unprecedented growth in the number of seniors flocking to private Medicare Advantage plans amid talk of a single payer government-run approach that could uproot such coverage.

https://www.forbes.com…

How About Medicare Advantage for All?

By Froma Harrop
Real Clear Politics, September 13, 2018

Let’s be blunt. The government must limit its spending by fiat. Then we can let the market step in and sort out the details. Under Medicare Advantage for all, the insurers would become, in effect, regulated utilities.

https://www.realclearpolitics.com…

One Proven Way to Improve U.S. Health Care: Expand Medicare Advantage

By John S. Toussaint
Harvard Business Review, February 14, 2018

It’s time for a better idea that addresses both cost and quality. That better idea is expanding the successful Medicare Advantage program to both Medicaid and employer-covered populations.

https://hbr.org…

Comment:

By Don McCanne, M.D.

The single payer model of Medicare for All would eliminate private health insurance plans (except for supplemental plans for nonessential services), but nobody should expect the insurance industry to sit back and accept this fate. In fact, the private Medicare Advantage plans have already been very successful in displacing about 40 percent of the traditional Medicare program. It appears that they are ready to take advantage of the popularity of the Medicare for All concept by usurping it as an even better Medicare for All by offering competing private plans supposedly with higher quality and lower costs: Medicare Advantage for All.

As the private insurers continue to integrate themselves into the health care delivery system, it will be much more difficult to displace them with a single, publicly-administered Medicare for All insurance program. Two decades of delay have allowed them to become thoroughly entrenched in the Medicare and Medicaid programs. Experimenting with a public option model of Medicare for some will just give them that much more time to implement their irreversible innovations. How do you get rid of the large private insurers when they have become the health care delivery system?

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

By Paul Krugman
The New York Times, June 22, 2019

No doubt many wealthy backers of tax cuts for themselves and benefit cuts for others manage to convince themselves that this is in everyone’s interest. People are in general good at that sort of self-delusion. The fact remains that the wealthy, on average, push for policies that benefit themselves even when they often hurt the economy as a whole. And the sheer wealth of the wealthy is what empowers them to get a lot of what they want.

So what does this imply going forward? First, in the near term, both during the 2020 election and after, it’s going to be really important to ride herd on both centrist politicians and the media, and not let them pull another 2011, treating the policy preferences of the 0.1 percent as the Right Thing as opposed to, well, what a certain small class of people want. There’s a fairly long list of things progressives have recently advocated that the usual suspects will try to convince everyone are crazy ideas nobody serious would support, e.g.

• A 70 percent top tax rate
• A wealth tax on very large fortunes
• Universal child care
• Deficit-financed spending on infrastructure

You don’t have to support any or all of these policy ideas to recognize that they are anything but crazy. They are, in fact, backed by research from some of the world’s leading economic experts. Any journalist or centrist politician who treats them as self-evidently irresponsible is doing a 2011, internalizing the prejudices of the wealthy and treating them as if they were facts.

But while vigilance can mitigate the extent to which the wealthy get to define the policy agenda, in the end big money will find a way — unless there’s less big money to begin with. So reducing the extreme concentration of income and wealth isn’t just a desirable thing on social and economic grounds. It’s also a necessary step toward a healthier political system.

Reader Comment:

By Don McCanne, M.D.

Although there has been considerable support for the single payer model of Medicare for All, the prevailing rhetoric has now become “letting you keep the insurance you have,” and this bears directly on the wealth inequality issue.

The single payer model addresses wealth and income inequality by switching from a system heavily dependent on individual contributions (premiums, deductibles, and especially forgone wage increases) to a system that uses progressive taxes to fund the 18 percent of our economy that we’re devoting to health care. This is one of the most important tools available to us to reduce the inequities in income and wealth distribution.

Most of the politicians who claim they support Medicare for All actually support the perpetuation of our highly regressive method of funding health care through employer-sponsored plans – health care financing that is costing middle-income Americans a significantly larger percentage of their incomes than they would be paying under single payer, whereas the wealthy are paying a percentage that is not detectable to them, unless they study their accountants’ reports.

Only the genuine single payer Medicare for All proposal of Bernie Sanders and Pramila Jayapal would take a major step towards reducing income inequality. The other Medicare for Some proposals fall miserably short of this crucial goal.

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

Although this blog is devoted primarily to achieving health care equity through a single payer national health program, the profound income and wealth inequity in our nation is a parallel problem, but the great thing is that they can both be addressed simultaneously.

Although the politicians are once again touting employer-sponsored health insurance as the mainstay of health care financing (“you can keep the insurance you have” for half of the population), middle-income employees and their families are finding health care less affordable because they are footing the bill for their share of the 18 percent of our economy devoted to health care since they have to pay individually through premiums, deductibles, and especially through forgone wage increases.

This has been compounded during the last four decades by an economy that has left wages comparatively flat while gains of increased productivity have moved to the top of the income scale. Opponents of single payer Medicare for All claim that there is not enough money amongst the very rich to be able to make health care affordable for the rest of us. They also say that individuals could not afford the payroll taxes that would be required to pay for health care. This is nonsense, and here’s why.

The money is there, but a disproportionate amount is up at the top. This means that, if we want everyone to have health care, we have to shift from individual financing to a more progressive, equitable system of financing, and that means progressive taxes. Funding it all through payroll taxes leaves too great of a burden on workers, and it fails to correct the profound inequity of income and wealth. So the taxes need to be more progressive.

This is not the place to discuss specifics of the intricacies of tax policy, but suffice it to say that taxes are not only important as a revenue source to fund our essential government functions, tax policies also can go a long way toward correcting some of the economic injustices in our society. Thus we need to consider using potential tax sources such as higher progressive taxes on marginal income, wealth taxes including taxes on high net worth estates, appropriate taxes on pass-through income, Tobin taxes on equity transactions, and the $1.5 trillion in tax expenditures (reductions in federal income tax revenues through deductions, exclusions and other tax preferences – why should tax payers help pay for mortgages on million dollar homes when homelessness is rampant?). The money is there, and the amount that would be collected under a more progressive but equitable tax system would never impact the life styles of the wealthy.

Thus when we advocate for an affordable and equitable health care system – single payer Medicare for All – we will have the satisfaction of knowing that we would also be reducing (though not eliminating) the profound inequities in income and wealth. The rich will still be very, very rich, but all the rest of us will have health care.

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

By Philip Armour and Claire O’Hanlon
National Bureau of Economic Research, February 2019

Abstract

A substantial portion of the costs associated with, and the value to beneficiaries of, Social Security Disability Insurance is Medicare eligibility. However, the benefits of this eligibility can vary due to differences in state policies on supplemental Medicare coverage, also known as Medigap. Although Medigap policies are federally regulated to be issued to 65-and-over Medicare beneficiaries with specific restrictions over underwriting, these policies are left to states to regulate with regard to the under-65 SSDI population, generating substantial cross-state and temporal variation. This paper documents the variation in availability and generosity of under-65 Medigap eligibility for the SSDI population. Furthermore, it exploits this variation to provide initial estimates of how this eligibility affects the health status of non-Medicaid-eligible SSDI recipients. Our main finding is that requiring Medigap plans be offered for under-65 SSDI recipients substantially improves self-reported health of this population, with suggestive evidence that this improvement is stronger as underwriting restrictions increase and among SSDI beneficiaries with mental health conditions. The estimated effect is highly robust to alternative scaling or categorizations of self-reported health, choice of data set, inclusion of fixed effects, controls for local Medicare Advantage penetration, and falsification tests. This effect is nearly three times the size of the estimated increase in self-reported health in the Oregon Medicaid expansion.

From the Conclusion

Overall, the size and robustness of the estimated effect indicates that the SSDI Medicare population’s health is very sensitive to even supplemental coverage; that is, the policy variation in question is over the remaining 20% coinsurance and insurance products that limit this cost sharing. The size of the impact on changes in health indicates that state-level Medigap policy has not just a comparable, but a substantially larger effect on health for under-65 Medicare beneficiaries than Medicaid expansion on the marginal Oregon Medicaid entrant.

https://www.nber.org…

Comment:

By Don McCanne, M.D.

The conclusion of this study is quite intuitive. Individuals under 65 with long term disabilities who qualify for Medicare – people who could benefit from health care – have substantial improvement in their self-reported health (a valid indicator of health) when they receive additional coverage through a Medigap plan.

It is not unreasonable to conclude that those over 65 with disabling medical conditions would also benefit if Medigap benefits were added to the traditional Medicare program. Further, if we had a single payer Medicare for All program covering everyone, essentially everyone with significant medical needs would benefit. So why is Congress catering to the private Medicare Advantage plans by enabling them to offer more generous benefits, at taxpayer expense, while neglecting the traditional Medicare program?

Better benefits equate to not only better health outcomes but also greater financial security in the face of medical need. So why is there so much stubborn resistance to enacting and implementing single payer Medicare for All when it would greatly benefit those who need it now and those who may need it in the future?

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

By Benjamin D. Sommers, M.D., Ph.D., Anna L. Goldman, M.D., M.P.A., M.P.H., Robert J. Blendon, Sc.D., E. John Orav, Ph.D., and Arnold M. Epstein, M.D.
The New England Journal of Medicine, June 19, 2019

As of April 2019, nine states have received approval by means of a federal waiver to implement work requirements in Medicaid, and six have applications pending. According to the Centers for Medicare and Medicaid Services, work requirements — also known as community engagement requirements — may promote better health and help beneficiaries escape poverty. However, critics dispute these claims and warn that the policy could lead to large coverage losses.

In June 2018, Arkansas became the first state to implement work requirements in Medicaid. Medicaid beneficiaries 30 to 49 years of age were notified by the state (by mail and informational fliers) that they were required to work 80 hours per month, participate in another qualifying community engagement activity such as job training or community service, or meet criteria for an exemption such as pregnancy or disability. Three months of noncompliance or nonsubmission of monthly online reports within a year led to removal from Medicaid. By December, nearly 17,000 adults were notified by mail that they had been removed from Medicaid. In March 2019, a federal judge halted the program owing to concerns about its effect on coverage. Although several analyses have predicted various results of Medicaid work requirements, data from independent assessments since the policy took effect have been limited. Our objective was to assess early changes in insurance coverage and employment after implementation of the work requirements in Arkansas.

From the Discussion

Using a timely survey involving low-income adults in Arkansas and three comparison states, we found that implementation of the first-ever work requirements in Medicaid in 2018 was associated with significant losses in health insurance coverage in the initial 6 months of the policy but no significant change in employment. Lack of awareness and confusion about the reporting requirements were common, which may explain why thousands of persons lost coverage even though more than 95% of the target population appeared to meet the requirements or qualify for an exemption.

Our results show that this loss of Medicaid coverage was accompanied by a significant increase in the percentage of adults who were uninsured, indicating that many persons who were removed from Medicaid did not obtain other coverage.

Although Medicaid has always struggled with high turnover owing in part to legally required annual eligibility redeterminations, our findings suggest that work requirements have substantially exacerbated administrative hurdles to maintaining coverage.

In conclusion, in its first 6 months, work requirements in Arkansas were associated with a significant loss of Medicaid coverage and rise in the percentage of uninsured persons. We found no significant changes in employment associated with the policy, and more than 95% of persons who were targeted by the policy already met the requirement or should have been exempt. Many Medicaid beneficiaries were unaware of the policy or were confused about how to report their status to the state, which suggests that bureaucratic obstacles played a large role in coverage losses under the policy.

https://www.nejm.org…

Comment:

By Don McCanne, M.D.

Should there ever be a circumstance in which individuals are deliberately deprived of appropriate health care? There are certainly financial barriers to care, but shouldn’t public policies be designed to remove those barriers? Yet several states are deliberately attempting to erect financial barriers to care for low-income individuals who fail to meet work or community service requirements for Medicaid.

Arkansas led the way and has shown us that Medicaid work requirements caused thousands to lose their Medicaid coverage as the number of adults who were uninsured increased. Further, there were no significant changes in employment suggesting that this policy did not achieve its intended goal. Also the program increases the administrative burden even though health care in the U.S. is already unique for its wasteful administrative excesses. Hopefully, we will not learn what the long-term results of this policy would be since it has been halted by a federal judge, though the Trump administration is appealing the decision.

What is most perplexing is that it seems that our public policies should be designed to enable everyone to receive appropriate health care when they need it, yet they are not. When our public stewards establish or perpetuate policies that impair access to care, then it seems that we should dismiss them and bring in people who actually do care about the health of the nation.

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

By Adam A. Markovitz, BS; John M. Hollingsworth, MD, MS; John Z. Ayanian, MD, MPP; Edward C. Norton, PhD; Phyllis L. Yan, MS; Andrew M. Ryan, PhD
Annals of Internal Medicine, June 18, 2019

Abstract

Background:
Accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) are associated with modest savings. However, prior research may overstate this effect if high-cost clinicians exit ACOs.

Objective:
To evaluate the effect of the MSSP on spending and quality while accounting for clinicians’ nonrandom exit.

Design:
Similar to prior MSSP analyses, this study compared MSSP ACO participants versus control beneficiaries using adjusted longitudinal models that accounted for secular trends, market factors, and beneficiary characteristics. To further account for selection effects, the share of nearby clinicians in the MSSP was used as an instrumental variable. Hip fracture served as a falsification outcome. The authors also tested for compositional changes among MSSP participants.

Setting:
Fee-for-service Medicare, 2008 through 2014.

Patients:
A 20% sample (97 204 192 beneficiary-quarters).

Measurements:
Total spending, 4 quality indicators, and hospitalization for hip fracture.

Results:
In adjusted longitudinal models, the MSSP was associated with spending reductions (change, −$118 [95% CI, −$151 to −$85] per beneficiary-quarter) and improvements in all 4 quality indicators. In instrumental variable models, the MSSP was not associated with spending (change, $5 [CI, −$51 to $62] per beneficiary-quarter) or quality. In falsification tests, the MSSP was associated with hip fracture in the adjusted model (−0.24 hospitalizations for hip fracture [CI, −0.32 to −0.16 hospitalizations] per 1000 beneficiary-quarters) but not in the instrumental variable model (0.05 hospitalizations [CI, −0.10 to 0.20 hospitalizations] per 1000 beneficiary-quarters). Compositional changes were driven by high-cost clinicians exiting ACOs: High-cost clinicians (99th percentile) had a 30.4% chance of exiting the MSSP, compared with a 13.8% chance among median-cost clinicians (50th percentile).

Limitation:
The study used an observational design and administrative data.

Conclusion:
After adjustment for clinicians’ nonrandom exit, the MSSP was not associated with improvements in spending or quality. Selection effects — including exit of high-cost clinicians — may drive estimates of savings in the MSSP.

Primary Funding Source:
Horowitz Foundation for Social Policy, Agency for Healthcare Research and Quality, and National Institute on Aging.

https://annals.org…

Spending Reductions in the Medicare Shared Savings Program: Selection or Savings?

By J. Michael McWilliams, MD, PhD, Alan M. Zaslavsky, PhD, Bruce E. Landon, MD, MBA, and Michael E. Chernew, PhD
The Incidental Economist, June 17, 2019

Prior studies suggest that accountable care organizations (ACOs) in the MSSP have achieved modest, growing savings. In a recent study in Annals of Internal Medicine, Markovitz et al. conclude that savings from the MSSP are illusory, an artifact of risk selection behaviors by ACOs such as “pruning” primary care physicians (PCPs) with high-cost patients. Their conclusions appear to contradict previous findings that characteristics of ACO patients changed minimally over time relative to local control groups.

Conclusion

Monitoring ACOs will be essential, particularly as incentives for selection are strengthened as regional spending rates become increasingly important in determining benchmarks. Although there has likely been some gaming, the evidence to date — including the study by Markovitz et al. — provides no clear evidence of a costly problem and suggests that ACOs have achieved very small, but real, savings. Causal inference is hard but necessary to inform policy. When conclusions differ, opportunities arise to understand methodological differences and to clarify their implications for policy.

https://theincidentaleconomist.com…

Comment:

By Don McCanne, M.D.

This important study in the highly reputable Annals of Internal Medicine concludes that accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) did not show any improvement in spending or quality when adjustments were made for selection effects, especially the non-random exit of high-cost clinicians (“I’m worth the extra money, and if you’re gonna cut my fees, I’m outta here.”)

The conclusions were immediately challenged by others in the policy community who have previously published studies indicating that “ACOs have achieved very small, but real, savings,” albeit admitting that “there has likely been some gaming.” And the savings were, indeed, very small. Others have suggested that the very small savings did not take into consideration the significant increase in provider administrative costs for technological equipment and personnel to run the ACOs, and certainly did not consider other unintended consequences such as the tragic increase in physician burnout.

Another problem with the infatuation for ACOs is that politicians and the policy community are insisting that we continue with this experiment in spite of the disappointing results to date. That simply postpones the adoption of truly effective policies, such as those in a single payer Medicare for All program, that would actually improve quality while greatly reducing administrative waste. The tragedy is that this also perpetuates uninsurance, underinsurance, and personal financial hardship from medical bills.

People are suffering and dying while the policy community continues to diddle with ACOs and other injudicious policy inventions. Enough! It’s long past time to reduce suffering and save lives! Single Payer Medicare for All!

(Yes, I’m angry, but even more I’m terribly anguished over the health care injustices that we continue to tolerate through our collective inaction.)

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

By Ashley Kirzinger, Cailey Muñana, Lunna Lopes, Liz Hamel, and Mollyann Brodie
Kaiser Family Foundation, June 18, 2019

The most recent KFF Health Tracking Poll finds majorities across partisans think taxes for most people would increase under a national health plan, sometimes called Medicare-for-all (78 percent), and about half (53 percent) think private health insurance companies would no longer be the primary way Americans would get health coverage under such a plan. However, when it comes to other key changes that the leading Medicare-for-all bills introduced by Sen. Bernie Sanders and Rep. Pramila Jayapal would bring, large shares are unaware of how the current health care system may be affected. For example, majorities say people would continue to pay deductibles and co-pays (69 percent) and continue to pay premiums (54 percent) under a Medicare-for-all plan. Likewise, majorities say people with employer-sponsored or self-purchased insurance would be able to keep their plans (55 percent each) under a Medicare-for-all plan.

Though lowering costs and increasing access emerge as the top issues that Democrats and Democratic-leaning independents want to hear presidential candidates talk about, there are some notable differences between liberals and moderates. One-fourth of liberal Democrats and Democratic-leaning independents (23 percent) offer implementing a single-payer or Medicare-for-all system when asked what health care issue they want to hear the candidates discuss, making it among the top health care issues offered by this group along with increasing access (27 percent) and lowering the amount people pay for health care (24 percent). Among moderate Democrats and Democratic-leaning independents, more than three times as many offer lowering the amount people pay for health care (34 percent) than implementing a Medicare-for-all system (9 percent).

A National Health Plan or Medicare-for-all

Eight in ten (78 percent) think that under a national health plan, sometimes called Medicare-for-all, taxes for most people would increase. Majorities of Democrats (71 percent), independents (80 percent), and Republicans (85 percent) say that taxes for most Americans would increase under a national health plan.

In addition, about half of Americans (53 percent) – including half of Democrats and independents (52 percent each) and most Republicans (57 percent) – think that under a national health plan, private health insurances would no longer be the primary way Americans would get health coverage. Still, a substantial four in ten of the public believe that under such a plan, private health insurance companies would still be the primary source of coverage for most Americans and an additional seven percent say they do not know what would happen under a national health plan.

In focus groups, many participants expressed skepticism about the idea that private insurance companies would cease to exist under a Medicare-for-all plan. Some thought these companies were just too powerful, and others thought they would continue to exist for people who want to buy extra coverage beyond what a national plan would offer.

When it comes to other potential impacts of a national health plan, many Americans say most aspects of the current health care system would remain unchanged. Majorities of Democrats, independents, and Republicans say people would continue to pay deductibles and co-pays when they use health care services (71 percent, 68 percent, and 68 percent, respectively). In addition, majorities of both Democrats and independents also believe people with employer-sponsored insurance would be able to keep their current coverage (68 percent and 53 percent), people who purchase their own plans would be able to keep their current coverage (65 percent and 55 percent), and individuals and employers would continue to pay health insurance premiums (61 percent and 53 percent). At least four in ten Republicans also say each of these things would happen under a national health plan. Small shares of the public overall say they don’t know whether each of these things would happen under such a plan (4 percent say they don’t know if people would continue to pay deductibles and co-pays, 7 percent say they don’t know for the other changes included).

https://www.kff.org…

Navigating the Medicare Debate

Navigator, June 17, 2019

The simple ideas of protecting and expanding Medicare are more popular than any branded program.

The most popular Medicare ideas among the public are also the simplest – the ideas of “protecting Medicare” and “expanding Medicare.” Both ideas are popular and have low negative ratings. “Medicare for All” as a brand shows promise, as it’s more popular than not (51% say it’s a good idea versus just 33% saying it’s a bad idea), though, as noted below, there is also clear confusion about the program. Proposals using more prescriptive language (e.g., “buy-in” or “single-payer”) score less positively, mostly due to a lack of knowledge as indicated by higher “don’t know” ratings.

Confusion: Medicare for… All who want it?

Only one in five Americans are very confident they know what “Medicare for All” would mean for our health care system (18% very confident) or their personal health care (20% very confident). When asked to characterize what “Medicare for All” means to them, respondents are divided: 40% think “Medicare for All” would eliminate the private insurance market and require everyone to switch to Medicare, while 60% think it would let anyone buy Medicare who wants to, while allowing others to stay on their private insurance. Perhaps most fascinating: Democrats are most likely to think “Medicare for All” is a “buy-in” program, while Republicans are much more likely to believe it will eliminate private insurance.

And those different interpretations of “Medicare for All” have dramatic consequences on the program’s support.

When respondents are asked whether they support “Medicare for All” – described as a buy-in program – 73% support it. However, when respondents are asked whether they would support “Medicare for All” – described as eliminating private health insurance – support drops significantly, with 47% saying they support it. This illustrates how support for Medicare for All is driven more by branding with the term “Medicare” than by specific knowledge of the program.

Concerns about Medicare for All center on costs.

Americans are most concerned that “Medicare for All” will raise taxes, cost too much, and increase the deficit. Given Americans’ top health care concern is cost, progressives should take serious note of and grapple with these cost concerns.

https://navigatorresearch.org…

Toplines:
https://navigatorresearch.org…

(Note that the KFF poll is designed to be neutral, whereas the Navigator poll is designed to inform the progressive community.)

Comment:

By Don McCanne, M.D.

Unfortunately, these polls demonstrate that Americans are not well informed on the single payer model of Medicare for All. There are two important factors that have contributed to the confusion: 1) Moderate Democrats who support adding a public option the current system under the Affordable Care Act have confused the public by using the label “Medicare for All” or variations of it when their proposals are actually only Medicare for some, and 2) the conservatives have been much more effective in disseminating negative messages about Medicare for All including threats of having their employer-sponsored plans taken away from them and having to pay egregiously high taxes.

Regarding the effectiveness of messaging, it is interesting that more Republicans believe that Medicare for All will eliminate private insurance (correct except for supplemental coverage of non-essential services), whereas more Democrats believe that Medicare for All is a buy-in (public option) preserving current private insurance (incorrect, except for the Medicare for some copycats) – Question 133X in the Navigator toplines.

Our message is quite straightforward, but it has not gained enough traction. We should probably specify Single Payer Medicare for All to distinguish it from the Medicare for Some models, and then keep the message simple:

Single Payer Medicare for All

• Universal (everyone in)
• Affordable (no medical bills; prepaid through equitable taxes)
• Comprehensive (including drug, dental, eye, hearing and long-term care)
• Free choice of doctors and hospitals (no insurer provider lists)
• Accessible (regional planning)
• Efficient (eliminate private insurance and administrative waste)
• Portable (care throughout the United States)
• Permanent (throughout life)

President Trump once again is promising us, within the next two months, “something terrific” to overhaul the nation’s health care system. Let’s see him match this list.

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

By Dr. Sanjeev K. Sriram
Common Dreams, June 12, 2019

When I talk to friends, family, and colleagues about Medicare for All, sometimes someone asks, “but don’t people like their insurance?” It’s not hard to see where they got that idea. America’s Health Insurance Plans (AHIP), the leading lobbyist for the for-profit insurance industry, says 71 percent of Americans “like” their private health insurance. It’s important to scrutinize the messenger and the message here. If McDonald’s told us that 71 percent of their customers said their food was healthy and nutritious, we’d be reasonably skeptical at the very least.

When independently surveyed, only 16 percent of Americans trust the health insurance industry to put patients before profits. The only group we trust less is Big Pharma (only 9 percent believe these corporations prioritize patients). So how do we make sense of all this? Do people really “like” health insurance plans sold by such untrusted corporations?

As a physician who regularly haggles with insurance companies, I have many four-letter words for that industry. “Like” is not one of them. Similar to millions of Americans with private health insurance, I have paid absurd co-pays, premiums, and deductibles to different insurance companies over the course of my career. I am certain I have never “liked” private health insurance the way I like comic books or the way my wife likes spin classes. I begrudgingly tolerate private health insurance (for now). The same goes for my patients, colleagues, friends, and family. Out of fear of financial ruin, we have allowed ever-increasing portions of our paychecks to go to health insurance companies.

Four in ten Americans with employer-sponsored health insurance say their family is struggling to pay premiums, medical bills, or out-of-pocket medical costs. Half of us have a family member who is avoiding necessary medical care or prescriptions because of cost.

Of Americans reporting problems paying medical bills, 73 percent are cutting back on food, clothing, and other basic necessities. Over six in ten of these everyday Americans have already depleted what little savings they had. One in three GoFundMe crowdfunding pages is directed toward paying for health care. For millions of patients and families, private health insurance is a source of, not a savior from, financial hardship.

As a physician and public health policy adviser, I used to believe the insurance industry would become better partners in our health care through the very reasonable guidelines and expectations set by the Affordable Care Act. Over the last several years, I have lost faith and accepted the insurance corporations for what they are: machines of unappeasable greed, accountable only to shareholders, never my patients or other families. In 2018, as millions of Americans borrowed $88 billion to pay for health care, 62 CEOs of health care companies made a combined total of $1.1 billion in compensation. When it comes to our current health care system’s priorities, patients are no match for profits.

We do not have to live like this. Thousands of physicians, medical students, nurses, and our colleagues across health care (but sadly, not the American Medical Association) are joining the Medicare for All movement because we want our work to be about protecting people’s health, not destroying their wealth.

Dr. Sriram completed his medical degree and his pediatrics residency at UCLA, where he served as Chief Resident at the Department of Pediatrics. In June 2009, he earned his Master’s in Public Health after completing the Commonwealth Fund Mongan Fellowship in Minority Health Policy at the Harvard School of Public Health. He currently practices general pediatrics in southeast Washington, D.C.

https://www.commondreams.org…

Sanders on Medicare for All: ‘People don’t like insurance companies, they like their doctors’

By Zack Budryk
The Hill, June 16, 2019

Sen. Bernie Sanders (I-Vt.), a 2020 presidential candidate, defended one of his signature policy proposals, Medicare for All, on “Fox News Sunday.”

“Medicare itself is far, far more popular than our private insurance,” Sanders told Fox’s Chris Wallace. “People don’t like insurance companies, they like their doctors and they like their hospitals.”

https://thehill.com…

Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage

Kaiser Family Foundation, April 24, 2019

Would you favor or oppose a national Medicare-for-all plan if you heard that it would do each of the following?

Percent opposed

• 58% – Eliminate private insurance companies
• 27% – Guarantee health insurance as a right for all Americans

How important is it that a national plan….?

Percent stating very or somewhat important

• 98% – Covers all Americans
• 97% – Simplifies the health care system
• 89% – Eliminates monthly premiums
• 88% – Eliminates out-of-pocket costs like co-pays and deductibles
• 83% – Shifts what people pay for health care to taxes
• 67% – Eliminates private health insurance companies

https://www.kff.org…

Comment:

By Don McCanne, M.D.

One of the most common reasons given for rejecting single payer Medicare for All is that individuals would lose their choice of continuing with the health plan they receive through their work. In fact, without supporting evidence, it is frequently claimed that people want to keep the plans they have rather than being forced into a one-size-fits-all program in which government bureaucrats dictate your care. Of course, the one size that is all inclusive is the size that most of us would prefer, and Medicare bureaucrats do not intervene in the physician-patient relationship.

Some polling has suggested that support for Medicare for All diminishes when told that private insurance would be eliminated. The KFF poll cited indicates that 58 percent would be opposed to elimination of private plans. The problem is that not enough information has been provided. When asked about a series of features of a national plan, two-thirds believe that it is important that the national plan would eliminate private health insurance companies. Other features strongly supported include universality, simplification of the system, eliminating monthly premiums, eliminating copays and deductibles, and shifting the financing to the tax system. When individuals know more about the details of single payer Medicare for All, they become even more supportive.

The point is that people do want to have their choice of physicians and hospitals, as they would under Medicare for all, but those choices are limited by the provider networks established by private insurers. They do like their doctors and hospitals that they have personally chosen, but they don’t “like” their insurers to which they are often assigned by default, especially when the insurers fail to protect them against financial hardship.

So do not let opponents of single payer infer that individuals like private plans better than Medicare for All when they haven’t been given the facts. The list in the KFF poll of what people think is important is a good place to start when describing what people really do like in health care financing.

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