PNHP

CMS advocates tough love for ACOs

CMS advocates tough love for ACOs

By Shannon Firth
MedPage Today, October 5, 2018

“Risk” and “predictability” were key themes in the discussion between accountable care organization (ACO) participants and Adam Boehler, the recently appointed director of the Center for Medicare and Medicaid Innovation (CMMI).

“There are a lot of folks that should take risk and there are a lot of folks that shouldn’t take risk,” Boehler said Thursday at the National Association of ACOs (NAACOS) conference here. “And I’m a big believer in being what you are.”

One group that probably shouldn’t take risk: single physician groups. “That’s silly,” he said. But for those providers and hospitals who are ready, it’s his responsibility and that of the Centers for Medicare & Medicaid Services (CMS) to create “practical and simple” policies to help participants succeed, Boehler said.

And for those who aren’t? “It’s also our job to say to folks, ‘If you’re not cutting it, get out of the way,’ because there are others that will come that will cut it … People will come in and take that risk and do something with it,” he said.

Boehler’s comments are in line with CMS’s more aggressive vision for ACOs to move towards risk.

Training Wheels Off

In August, CMS released a proposed rule for the Medicare Shared Savings ACO program which shortened the glide path for ACOs to stay in upside only models (those without any risk) for 2 years, down from an initial 6 years.

NAACOS president and CEO Clif Gaus, ScD, swiftly panned the idea of a shorter transition period, saying at the time that CMS was “pulling the rug” out from under the program.

In May, a NAACOS survey found that 71% of ACO participants would likely leave the Medicare Shared Savings Program (MSSP) rather than take on two-sided risk.

https://www.medpagetoday.com…

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NAACOS: Proposed rule changes to ACO program are ‘deal breakers’

By Tina Reed
Fierce Healthcare, October 5, 2018

Proposed changes to the federal accountable care organization (ACO) model—namely, a cut in the shared savings rate from 50% to 25%—would cut the knees out from under the program, board members of the National Association of ACOs said on Thursday.

Speaking with reporters at their annual conference in Washington, D.C., ACO leaders said they supported many of the proposed changes that the Centers for Medicare & Medicaid Services have brought forward regarding ACOs.

But proposed rules that would speed their path to risk and reduce the reward they would reap in return for any savings they realize are “deal breakers” for new entrants to the program, said Clif Gaus, NAACOS president and CEO.

“I don’t know any ACO that would roll the dice for 25%,” Gaus said. “You’ve got the carrot and the stick. And you just cut the carrot in half.” 

https://www.fiercehealthcare.com…

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Verma, Azar take aim at ‘Medicare for All’ proposals

By Paige Minemyer
Fierce Healthcare, October 5, 2018

Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma took another swipe at calls for a “Medicare for All” healthcare system this week, saying expanding those benefits to every American would “dilute” the program.

“Putting more people in the program is not going to solve the problem, and actually threatens the focus and security of the program for seniors,” Verma said.

When FierceHealthcare requested more details on how expanded enrollment would hurt seniors, CMS declined to provide specific data.

Department of Health and Human Services Secretary Alex Azar has also drawn a clear line in the sand on Medicare for All. In a speech last week, hosted by the Nashville Healthcare Council, Azar said that expanding the program to all Americans would eliminate their ability to make health choices for themselves.

“It’s simple math: Higher payments from commercial insurers help doctors take on seniors whose Medicare plans pay less,” Azar said. “It’s far from an ideal set-up, but a single government system would completely unravel it, without a theory for how seniors’ access would be protected.”

https://www.fiercehealthcare.com…

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Comment:

By Don McCanne, M.D.

At last week’s meeting of the National Association of ACOs (NAACOS) there was considerable interest in CMS’s proposed rule in which accountable care organizations (ACOs) would be forced into downside risk after only two years instead of the previous six allowed, and the share of any savings for the ACO would be reduced from 50 percent to 25 percent, with Medicare keeping 75 percent.

Of course no ACO wants downside risk but that is their stick that drives accountability for costs of health care. If forced into downside risk, the ACOs want time to adjust their operations to meet the required benchmarks, but that time would be cut short by the rule such that most ACOs would anticipate losses. The carrot for sharing in savings also is being reduced in half. An industry survey suggests that close to three-fourths of ACOs would leave the program rather than take on two-sided risk, and you can imagine that there will be a paucity of new entrants into the program, if any at all.

Although the rule is still only proposed, it is well on its way to being adopted since it has the strong support of CMS administrator Seema Verma and HHS Secretary Alex Azar. They are so determined that CMS’s Adam Boehler, director of the Center for Medicare and Medicaid Innovation (CMMI), says, “If you’re not cutting it, get out of the way.”

Oops, where did everyone go?

ACOs have fallen far short of expectations, and now they want to tighten the vise on providers. How could anyone with the least knowledge of health policy ever conceive that this model could succeed? If you consider the provider costs of participating in the program, it has already failed.

As regular readers know there is a proven model that would work for all of us, patients and providers alike – a well designed, single payer, improved Medicare for all. Yet last week both Verma and Azar again have attacked Medicare for all. Can we change their minds, or do we need to replace them?

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

Only in America: Nobel laureate sells his medal to pay medical bills

A Nobel Prize-winning physicist sold his medal for $765,000 to pay medical bills. Only in America.

By Sarah Kliff
Vox, October 4, 2018

Leon Lederman won a Nobel Prize in 1988 for his pioneering physics research.

But in 2015, the physicist, who passed away Wednesday, sold his Nobel Prize medal for $765,000 to pay his mounting medical bills. The University of Chicago professor began to suffer from memory loss in 2011, and died in an Idaho nursing home.

In a lot of ways Lederman’s story represents the best and worst of America. Lederman was born in the 1920s to a father who worked in a laundry facility. He went on to discover the Higgs boson subatomic particle, the so-called “God particle.”

But even an accomplished physicist and university professor isn’t immune from America’s sky-high health care prices.

https://www.vox.com…

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Leon Lederman, 96, Explorer (and Explainer) of the Subatomic World, Dies

By George Johnson
The New York Times, October 3, 2018

Leon Lederman, whose ingenious experiments with particle accelerators deepened science’s understanding of the subatomic world, died early Wednesday in Rexburg, Idaho. He was 96.

Early in his career Dr. Lederman and two colleagues demonstrated that there are at least two kinds of particles called neutrinos (there are now known to be three), a discovery that was honored in 1988 with a Nobel Prize in Physics. He went on to lead a team at the Fermi laboratory, in Batavia, Ill., that found the bottom quark, another fundamental constituent of matter.

He and his wife, Ellen, moved to their place in Idaho, in Driggs, just before his 90th birthday. Found to have dementia, he was advised by his doctors to live in peaceful surroundings. In 2015 the couple agreed to let an online auction company sell his Nobel Prize medal. The proceeds, $765,002 before taxes, were set aside for future medical expenses.

“There’s always a place at the edge of our knowledge, where what’s beyond is unimaginable, and that edge, of course, moves,” Dr. Lederman told The Times in 1998.

In the beginning were the laws of physics. But where did the laws come from? At that point, he said, “You’re stuck.”

“I usually say, ‘Go across the street to the theology school, and ask those guys, because I don’t know.’”

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Yes, only in America. Nobel laureate Leon Lederman sold his Nobel medal in order to help pay for his pending medical bills.

To learn more about this remarkable gentleman, the full New York Times obituary is well worth reading.

Then take time out for a contemplative interlude. We all know about the injustices of our health care financing system that negatively impact those of modest or meager means, but a Nobel laureate?

We can do better that that, to the benefit of everyone.

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

Ask physicians what they think about valued-based care

Regulatory Burden Survey

Medical Group Management Association, October 2018

The federal government has focused on decreasing the regulatory burden on medical group practices. MGMA has long been a champion for decreased regulatory burden and increased administrative simplification and standardization in order to achieve a more efficient and effective care delivery process for patients and providers.

This study is the second in a series to assess the burden level of regulatory processes for physician practices participating in Medicare programs.

The move toward value

How do you view the move to paying physicians based on value of care delivered rather than volume of services provided?

57% – Negative
38% – Positive
5% – No opinion

Has the move toward value-based payment (in Medicare/Medicaid) improved the quality of care for your patients?

76% – No
15% – Yes
9% – No opinion

Has the move toward value-base payment (in Medicare/Medicaid) increased the regulatory burden on your practice?

90% – Yes
6% – No
4% – No opinion

Overall, has the move toward paying physicians based on value been successful to date?

79% – No
8% – Yes
13% – No opinion

https://www.mgma.com…

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The Future of Healthcare: A National Survey of Physicians

The Doctors Company

The 2018 Future of Healthcare report, compiled from the observations of more than 3,400 doctors, has uncovered a complex picture of the attitudes of physicians nationwide toward the important issues facing the industry.

43% of Doctors Believe Value-Based Care Will Negatively Impact Physician-Patient Relationship (42% No impact; 15% Positive impact)

61% of Doctors Believe Value-Based Care Will Negatively Impact Their Practice

https://www.thedoctors.com/future

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Half A Decade In, Medicare Accountable Care Organizations Are Generating Net Savings

By William Bleser, David Muhlestein, Robert Saunders, Mark McClellan
Health Affairs Blog, September 21, 2018

Summing Up

The MSSP (Medicare Shared Savings Program) like overall health care reform remains work in progress, with performance trends continuing to show improvement. While some organizations have been participating for half of a decade, most MSSP participants are still just a few years into their care transformation journey. Quality scores are generally high, the program is achieving net savings, and cost reduction is improving. But the modest savings suggest that learning from MSSP experiences to date to modify it for the future – and reinforcing these changes with other accountable care reforms – could do more to bend the curve of future cost growth. The new MSSP proposed rule would shift many more ACOs toward downside risk. But if many organizations that could have achieved savings over time drop out, and if those payments represent a small minority of total payments, even heightened downside risk may be insufficient to drive more substantial change toward a value-based health care. We are still early in the journey, but with more experience and more participants, the opportunities for evidence-based payment reforms and for shared learning to accelerate progress are greater than ever.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

The future of health care financing is all about value-based care (VBC) – paying based on value rather than volume – or so you would believe based on the proclamations of politicians and the policy community and the dissemination of that concept through the academic literature and lay media.

We are already several years into the Medicare Shared Savings Program (MSSP) through VBC experimentation using accountable care organizations (ACOs) and other alternative payment models (APMs). Two important questions to ask now about VBC are 1) How is it doing so far, and 2) What do the physicians on the front line think about it?

There are thousands of articles on VBC, but the status to date could be summed up by the recent Health Affairs Blog by Mark McClellan and his colleagues. They state that quality scores are generally high, but they are relatively meaningless since they have been pared back to measuring small bits of minutiae that are easy to game. They state that the program is achieving modest savings, but that is only in Medicare spending and it is almost negligible. When including the provider costs of complying with the program (hardware and labor) which are not included in the estimates, VBC through ACOs in the MSSP (in the language of the policy community) is resulting in higher total costs – the exact opposite of what VBC is supposed to deliver. As with so many of the academic papers on the topic, McClellan and colleagues state, “We are still early in the journey, but with more experience and more participants…” Come on.

The experiment with VBC has failed, though many are not ready to admit it. But the concept of value-based care now has a life of its own. Of great concern is that members of Congress who support Medicare for All are moving forward with changing HR 676 – The Expanded and Improved Medicare for All Act –  modifying it to include supposedly modern concepts of value-based care. But when you ask them to define specifically what value-based care is, they may reply with the meme that we will no longer pay for volume (which is untrue since even the most basic care requires a certain volume that must be funded). When you ask them to clarify what that means as far as it relates to transformation of the health care delivery system, after stumbling around, they may come up with accountable care organizations. Ask them what that is and the better informed politicians might tell you that it is an organization that is accountable for quality and costs (how astute of them). Zero in on that and ask them to define precisely what that is structurally, beginning with it being an organization to which patients are assigned without their knowledge. Got them, because  they don’t know what an ACO is because a precise definition does not even exist (even though ACOs were also included in the Affordable Care Act). And yet the progressives want to change HR 676 to include VBC and ACOs within the legislation.

They don’t seem to be listening to the people on the front line – the physicians who are providing so-called value-based care, often through ACOs. What do the physicians have to say?

* 79% do not believe that value-based care has been successful to date

* 90% state that value-based care has increased the regulatory burden on them

* 76% do not believe that value-based care has improved the quality of care

* 61% believe that value-based care negatively impacts their practices

The process of rewriting HR 676 has already begun. The politicians involved seem to think that they are improving this two-decades-old legislation by introducing modern concepts of value-based care. The concept may be an empty meme, but the application of the concept is already causing serious harm where it really counts – at the physician-patient interface. When we are aiming for patient care nirvana through a single payer, improved Medicare for all, we don’t want to damage or destroy it by injecting into it a major element of VBC hell. Let the politicians know.

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

Single-payer health care likely less disruptive, better for economy

By George Bohmfalk, M.D.
The Aspen (Colo.) Times, October 4, 2018
(Part 5 of 6. Read parts 1, 2, 3, 4 and 6.)

Many people fear that moving abruptly to a single-payer system, as in expanding and improving Medicare to cover everyone, would be disruptive and might wreck the economy. I believe that the only areas that may face any disruption would be the insurance and pharmaceutical industries.

There is much disruption now in our disorganized, inefficient health care system. We ration health care based on ability to pay, not health need. Millions of people face unaffordable medical, drug and insurance bills. Narrowing provider networks force many to change doctors and travel miles away from nearby hospitals to find one in their network.

Americans switch insurance companies on average 10 times during their working years. Each insurance company has its own bewildering set of plans, forms and rules. Medicare enrollees struggle with confusing and expensive Medigap policies. My brother recently had to pay thousands of dollars out-of-pocket for his heart bypass operation, because he had checked the wrong box while selecting his Medigap policy. Many people with employer-provided health insurance would like to change jobs or start their own business but don’t, for fear of losing their coverage.

The transition to a universal, single-payer system would not only be painless for nearly everyone, it also would be a tremendous relief. Suddenly, everyone would have full insurance coverage, with free choice of private doctors and hospitals, through a reliable and efficient agency with a 50-year operating record. No one would ever again have to worry about switching insurers or picking plans. The adoption of Medicare in the pre-internet 1960s was very smooth, as was Taiwan’s move to a Medicare-like system in 1995.

Contrary to concerns that such a move would expand government, the size of government might actually shrink, as several federal and state agencies would be folded into a universal Medicare unit. Medicaid, the Children’s Health Insurance Program and the medical component of all 50 state workmen’s compensation programs would be absorbed into a single health system. It’s likely that the Indian Health Service and Veterans Administration eventually would be incorporated. The administrative savings by having a single funding agency would far exceed the new costs of universal coverage.

When I hear people say they don’t want to give up their employer-provided insurance, I wonder why they would prefer it, with its limitations and rising cost sharing. Their employers would be freed from the burden of contentious labor negotiations, as well as the unpredictable expense and hassles of providing employee coverage. Wages would probably rise. Everyone would be better off.

The economy likely would improve. Despite paying new taxes to fund this, 95 percent of households should see their net incomes and spending power rise, as those taxes should be less than their current total health care spending. Pharmaceutical company profits would drop, but as lower drug prices are negotiated, purchasers would have more money in their pockets to stimulate the economy.

What about the economic effect of all those lost insurance jobs? It’s estimated that fewer than 2 million such jobs may be lost. While that may sound like a lot, it is close to how many workers are fired each month, with no provisions for job placement or retraining. In our national full-time workforce of some 150 million, this is a small number. Many of these workers could be employed by an expanded Medicare agency. And both of the single-payer bills before Congress (H.R. 676, S.1804) provide funds for job placement and retraining.

We are experiencing severe disruptions and threats to the economy under the present health care arrangement, and they are likely to get worse. Improved Medicare for All would be a great comfort to the millions with limited or no health insurance, to those locked into their jobs in order to maintain coverage and to employers who dread annual labor negotiations over health care. People currently working in insurance administrative positions would likely find more productive and rewarding work. Many nurses and doctors hired away from the bedside to work in managed care would return to their first love.

It’s time that we join the rest of the industrialized world in adopting a commonsense solution to our health care crisis.

Dr. George Bohmfalk practiced neurosurgery in Texas before retiring to spend half of each year in the Roaring Fork Valley. He is active in Physicians for a National Health Program, a physician-driven group advocating for a single-payer health care system.

https://www.aspentimes.com…

One-third of people in small-firm low-income families remain uninsured

Despite Coverage Gains, One-Third Of People In Small-Firm Low-Income Families Were Uninsured In 2014–15

By Patricia S. Keenan, Paul D. Jacobs, and G. Edward Miller
Health Affairs, October 2018

Abstract

Obtaining health insurance coverage has historically been challenging for workers at small firms and the self-employed. Using data from the Medical Expenditure Panel Survey, we found that the overall uninsurance rate for these workers and their families declined by 5 percentage points over the past decade, but one-third of those with lower incomes remained uninsured in 2014–15.

From the Introduction

Obtaining health insurance has been a long-standing challenge for many self-employed and small-firm workers. The nature of this challenge has evolved over the past decade, as the Great Recession reduced access to employer-sponsored insurance, and health insurance reforms under the Affordable Care Act (ACA) increased the availability of private and public coverage. While the decline in employer coverage offer rates in small firms is well established, less is known about how recent changes to that coverage, individual insurance, and Medicaid have affected how small-firm and self-employed workers and their families get coverage.

Using data from the Medical Expenditure Panel Survey–Household Component (MEPS-HC), we found that insurance coverage improved at all income levels over the ten-year period from 2004–05 to 2014–15 (we pooled data into two-year pairs to improve precision). Those with family incomes below 200 percent of the federal poverty level showed the largest gains (9.5 percentage points), but one-third remained uninsured in 2014–15.

These trends are particularly important given ongoing policy interest in improving coverage for small-firm and self-employed workers. Compared to large-firm workers, small-firm workers typically face more limited availability of employer-sponsored insurance and higher premiums because of higher administrative costs and a more limited ability to spread risk. Small-firm workers and the self-employed are less likely than workers in larger firms to have an employer coverage offer. They also generally earn less, which makes more of them eligible for Medicaid or the ACA’s Marketplace premium subsidies. Other ACA policies such as the Small Business Health Options Program and Small Business Health Care Tax Credits aimed to enhance coverage, but take-up has been limited. The 21st Century Cures Act of 2016 created an option for small firms to make tax-advantaged contributions to help subsidize individual-market coverage for their workers. The administration of President Donald Trump is implementing policies intended to make it easier for small businesses to buy group insurance coverage for workers through association health plans or contribute to the individual-market coverage that workers purchase.

Recent studies have analyzed changes in coverage for small-firm workers and the self-employed, but little is known about how coverage has changed for these workers and their families. By including family members, we account for the availability of employer coverage through a spouse. We also comprehensively describe the relationship between working in small firms and having insurance coverage for family members.

From the Discussion

Among the subgroups we examined, from 2010–11 to 2014–15 uninsurance rates fell the most among low-income families with small-firm or self-employed workers and in families with only small-firm workers, as Medicaid and other private insurance grew. Despite gains in coverage, these groups still had the highest uninsurance rates in 2014–15, with nearly one-third of people in low-income families uninsured.

A number of factors make small-firm and self-employed workers and their family members more likely to be uninsured than individuals in families with one or more large-firm workers. Compared to larger firms, small firms in the US face significant challenges in providing affordable insurance to their employees. Small firms also have low and declining employer coverage offer rates and provide less continuity of coverage than larger firms do. In addition, small firms are less likely to offer affordable dependent coverage, which may lead families to obtain coverage from multiple sources and could reduce uptake of coverage for children (as shown in studies of Medicaid).

Small-firm workers and their families with lower incomes were more likely to be uninsured and had the lowest employer coverage rates, which suggests that the high and increasing cost of such coverage is likely a major impediment to coverage for lower-income families.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

During the development of the Affordable Care Act (ACA), it was interesting to watch Congress patch together policies to try to fill the voids in health care coverage. Although each patch helped, the patchwork model of reform still inevitably left many holes in the system. This study shows that, for low-income individuals employed by small firms, one-third of family members remain uninsured – obviously an unacceptable deficiency in coverage.

For those who support building on the Affordable Care Act as a means to fill in the gaps in coverage, they are going to have to propose specific policies that will work. Expand Medicaid? The program has already been expanded under ACA, and so how are you going to change it to target these families? An employer mandate? That was rejected for small firms because of their very tight budgets. An individual mandate? These people have low incomes, so the subsidies would have to be even greater and how far would they extend into middle-income families that are also having difficulties with paying for health insurance? Depend on lower premiums through market competition of health plans? Get real.

Not only does the patchwork approach still leave too many holes in the system, it also leaves in place the existing health care financing infrastructure with its profound administrative waste, extreme fragmentation and inefficiency, and very high costs, while leaving in place inequities and deficiencies in coverage.

We seem to be having difficulty explaining to ACA supporters that building on ACA is not only the most expensive model of reform, but it is one of the least effective in that it leaves most of the flawed policies in place. Instead of increasing costs while falling far short, with what we’re already spending we could fill in all the voids while increasing efficiency and equity in the system simply by enacting and implementing a well designed, single payer, improved Medicare for all. That would take care of not only low-income families dependent on small-firm employment, but it would guarantee comprehensive, life-long coverage for everyone else as well.

Adding a public option to this mess would do very little to fill the voids and correct the deficiencies. That is why it is important to call people out who are using the “Medicare for All” label to refer to merely adding a public option or buy-in. We have to demand that the Medicare for All label refers only to the real thing – an improved and expanded Medicare that includes absolutely everyone and is affordable for all. The public option doesn’t even come close.

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Immigrants help pay for our health care

Immigrants Pay More In Private Insurance Premiums Than They Receive In Benefits

By Leah Zallman, Steffie Woolhandler, Sharon Touw, David U. Himmelstein, and Karen E. Finnegan
Health Affairs, October 2018

Abstract

As US policy makers tackle immigration reform, knowing whether immigrants are a burden on the nation’s health care system can inform the debate. Previous studies have indicated that immigrants contribute more to Medicare than they receive in benefits but have not examined whether the roughly 50 percent of immigrants with private coverage provide a similar subsidy or even drain health care resources. Using nationally representative data, we found that immigrants accounted for 12.6 percent of premiums paid to private insurers in 2014, but only 9.1 percent of insurer expenditures. Immigrants’ annual premiums exceeded their care expenditures by $1,123 per enrollee (for a total of $24.7 billion), which offsets a deficit of $163 per US-born enrollee. Their net subsidy persisted even after ten years of US residence. In 2008–14, the surplus premiums of immigrants totaled $174.4 billion. These findings suggest that policies curtailing immigration could reduce the numbers of “actuarially desirable” people with private insurance, thereby weakening the risk pool.

From the Discussion

Immigrants contributed far more in premiums for private coverage in 2014 than their insurers paid out for their care, with undocumented immigrants generating the largest per enrollee surplus. This net surplus offset a deficit incurred by US natives and exceeded total insurance industry profits by about $10 billion that year. Our 2014 findings were not anomalous: Immigrants made large net contributions in every year in the period 2008–14, with little change over time.

While immigrants’ premiums were similar to those for US natives, immigrants incurred much lower expenditures—a disparity that was present in analyses limited to working-age adults. Among immigrants, expenditures increased with duration of time in the US, a phenomenon documented previously. This may reflect worsening health habits related to acculturation, increased care-seeking behaviors, and increased educational standing with time in the US. However, because premium contributions also increased with time in the US, immigrants made a net contribution to private health insurance regardless of their length of residence in the US.

Our findings contradict assertions that people born in the US are systematically subsidizing the medical care of immigrants, particularly those who are undocumented. On the contrary, immigrants subsidize US natives in the private health insurance market, just as they are propping up the Medicare Trust Funds.

Immigrants’ subsidies to private insurance and Medicare likely reflect their relative youth and good health, as well as the reluctance of many to seek care. Policies that curtail the flow of immigration to the US are likely to result in a declining number of such “actuarially desirable” persons, which could worsen the private insurance risk pool.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Immigrants who come to the United States to work are generally relatively young and healthy and thus have little need for health care services, yet they pay payroll taxes into the Medicare Trust Funds and thus are subsidizing health care for U.S. citizens on Medicare. This study adds to that by showing that immigrants, whether or not they are documented, pay more in health insurance premiums that they utilize in health care; thus they are also subsidizing U.S. citizens through the private health insurance market.

Currently the Trump administration is considering a proposed rule that would greatly expand the guidelines for “public charge” – immigrants who use  government services. If they are deemed a public charge, the rule would be used to reduce or revoke their immigration status, perhaps even deporting them from the country in spite of otherwise having complied with immigration requirements. Obviously this could have a deleterious impact on the health of the immigrants and their families, even if they are here legally.

Perhaps the fact that they pay more into Medicare and private health plans than they receive in health benefits should warrant a new concept – “public credit.” Public credit could include other factors such as, for example, the contribution of immigrants to our economy that is significantly greater than the very modest incomes that most of them receive. This and other studies suggest that the public credit would be much larger on the balance sheet than would be the public charge. Surely deportation is not a proper expression of gratitude for the debt that we owe most of them.

The proposed rule on public charge is about to be published in the Federal Register at which time a 60 day period for public comment will begin, after which the rule will be implemented. If we wish to continue to benefit from the contributions of our immigrants, we should consider requesting that a public credit be applied as an offset against the public charge (though that might be a concept that would clash with the ethnic animus of the nationalists in the Trump administration).

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

The case for improved Medicare for all

Interview with Dr. Elizabeth Rosenthal

America’s Work Force Radio, October 2, 2018

Today on the show we have two guests, Jason Perlman and Dr. Elizabeth Rosenthal. Jason Perlman is a political director with the Ohio AFL-CIO and Dr. Elizabeth Rosenthal is a dermatologist.

Dr. Rosenthal, who spent 38 years practicing dermatology, talks about health care and single payer health care. Dr. Rosenthal is the daughter of a doctor and the granddaughter of a doctor, so she knows all about how health care has changed over the years. She discusses expanding Medicare to all Americans by taking out the private parts, and keeping the public parts…and giving them to everybody; publicly funded, privately delivered.

Note: Dr. Rosenthal’s segment starts at the 37:45 mark.

full audio:
http://awfradio.com…

Medicaid managed care contracts with academic medical centers

Whipsawed: Low-Income Patients At UC Davis Losing Coverage Again

By Rob Waters
California Healthline, September 26, 2018

Whipsawed is not a medical condition, but it describes exactly how Lee Henderson feels about his on-again, off-again care at UC Davis Medical Center, a place he’s been visiting since he was a child.

For the second time in three years, Henderson is about to lose access to his primary care team at the Sacramento institution.

When Henderson had surgery there in 2015 to remove an adrenal gland that was severely elevating his blood pressure, he was covered by Health Net, the only Medi-Cal managed-care plan in Sacramento County whose members could go to UC Davis for primary care at the time.

But shortly after his surgery, Henderson learned that his insurer and the university were terminating their contract, forcing him and an estimated 3,700 other Health Net Medi-Cal members to leave UC Davis and find new primary care doctors.

Now, history is repeating itself. After briefly regaining access to UC Davis last year, when UnitedHealthcare entered the Sacramento Medi-Cal market and signed an agreement with the medical center, Henderson and 1,000 other patients are getting booted out again.

On July 25, those patients got a letter from UnitedHealth. “Dear member,” it began, “we’re writing to let you know that our Medi-Cal services in Sacramento County will be discontinued effective October 31, 2018.”

Medi-Cal, California’s version of the federal Medicaid program for low-income residents, serves 13.5 million people, about one-third of the state’s population. The vast majority of them — about 80 percent — are served by managed-care plans, in which the state pays insurers a fixed amount per enrollee to provide comprehensive care.

That contrasts with fee-for-service Medi-Cal, in which the state pays medical providers directly for services provided. Medi-Cal enrollees are generally required to sign up for managed care.

The exit of UnitedHealth from Sacramento County’s managed-care Medi-Cal program means that, once again, no Medi-Cal patients on managed-care plans in the county will be able to go to UC Davis for primary care.

At the core of the issue is money. UC Davis has complained for years about low Medi-Cal reimbursement rates. (UC Davis spokesman Charles) Casey said that in 2017 the health system absorbed more than $93 million in unreimbursed costs serving Medi-Cal patients.

(Senator Richard) Pan, who now chairs the Senate Health Committee, said the structure of Medi-Cal managed care in Sacramento, which gives enrollees the choice of multiple plans, was a lose-lose for UC Davis and UnitedHealth, because the sickest, most expensive patients wanted to be on a plan that gave them access to the medical center.

“You get all the sick people — asthma or cancer or sickle cell,” he said. “The Medi-Cal contract did not account for the fact that you have a sicker population.”

The sudden loss of access to the broad and highly skilled network of doctors at UC Davis is especially hard for patients with complex conditions, said Elaine Abelaye-Mateo, a community advocate with the Health Access Action Team of Sacramento Building Healthy Communities.

https://californiahealthline.org…

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Comment:

By Don McCanne, M.D.

Although the concept of a single payer, improved Medicare for all has become quite popular, many in the policy community and legislative bodies would prefer to continue with our existing health care financing system as modified by the Affordable Care Act (ACA). Even if it were tweaked to further expand coverage, today’s report demonstrates just one of a great multitude of examples as to why the current system is unsatisfactory.

Under ACA, more low-income Californians were enrolled in Medi-Cal (California’s Medicaid program) – a total of about 13.5 million (more than the entire population of each of 46 other states!) and 80 percent of them have been shoved into Medicaid managed care plans on the theory that it would be cheaper (by administrative fiat – California ranks 47th of all states for Medicaid payment rates) and that care would be better managed (highly disputed and likely untrue).

So what are some of the policy considerations under Medi-Cal? Perhaps above all, Medi-Cal is a welfare program and thus is chronically underfunded, failing to meet the financing requirements for the essential health care services required by the enrollees.

Investor-owned, for-profit Medicaid managed care organizations are required to make a profit for their investors, so when underfunded with a fixed capitation rate, they can profit only by decreasing care provided. As masters of innovation, there are many ways the private insurers can do that, but basically their measures impair access to health care services.

An important component of the health care delivery system is the academic medical center (AMC). Patients with more complex and long-term problems will often select plans that include an AMC in their provider networks, especially if they are already patients of that center. Adverse selection is inevitable since the plans that include AMCs will attract sicker, more expensive patients. When a Medicaid managed care program is already operating at a loss, adverse selection will increase their losses and thus force a decision to withdraw from the market. This is exactly what Health Net and then UnitedHealth did with their contracts with UC Davis Medical Center. With no UC Davis Medi-Cal contract for primary care, Medi-Cal managed care patients were left without a choice of a plan that included UC Davis. Besides, Sen. Richard Pan says, “Why is a public, state-owned university that’s running a health system not contracting with the state health plan?”

Suppose we had a single payer Medicare for all instead. First, we would not have a separate health care welfare program for low-income people without much of a political voice; we would have a single, comprehensive program for everyone. We would not have private, investor-owned, for profit corporations managing the health care funds in a manner that, by necessity (ask SEC), places investors above patients; we would have a single, publicly-funded and publicly-administered program instead. We would not have stewards trying to create barriers to health care to improve the bottom line; instead our public  stewards would be assisting patients in gaining access to the care they need. We would not have patients arbitrarily excluded from academic medical centers; instead the centers would be providing specialized services to patients equitably, based on priority. We would not have a financing system that frequently results in adverse selection with all of its consequences; risk would be borne by the public payer rather than the providers or patients. We would not have sectors of health care that were deliberately underfinanced, with its consequences as well; the national global budget for health care would be adequate to meet the needs of the nation. We would not have narrow provider networks that deliberately limit access and fragment care for strictly business purposes; patients would have their choice of health care professionals and institutions.

The academic medical center should be available to the entire community with appropriate referral made through the primary care infrastructure and the universal, integrated referral system. Under a well designed, single payer, improved Medicare for all, AMCs would be available to all, as appropriate.

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Immigrants paid $24.7 billion more into private insurance than was spent on their care: Harvard researchers

Study published today in Health Affairs finds that immigrants boost the profits of private insurers, heavily subsidize the benefits of U.S.-born enrollees

FOR IMMEDIATE RELEASE: October 1, 2018

Contacts: Leah Zallman, M.D., M.P.H., Institute for Community Health and Harvard Medical School, lzallman@icommunityhealth.org; Clare Fauke, PNHP communications specialist, clare@pnhp.org.

Immigrants pay billions more in private insurance premiums than insurers pay out for their care, according to a new study by researchers from Harvard Medical School and the City University of New York at Hunter College. The study, the first to look at immigrants’ role in financing private health insurance, found that immigrants paid $88.7 billion in private insurance premiums but used only $64.0 billion in insurer-paid health care, generating a surplus of $24.7 billion in 2014. Between 2008 and 2014, immigrants generated a cumulative surplus of $174.4 billion.

On a per-enrollee basis, the study found that immigrants provided an average premium-over-payout surplus of $1,123 each, while U.S.-born Americans incurred an average deficit of $163 each. Undocumented immigrants, who generally use little medical care, generated the largest surplus at $1,445 per enrollee. Previous research shows that insurance outlays for immigrants are low because they are relatively young and healthy, and often face linguistic and other barriers to care.

Researchers used data from the Medical Expenditure Panel Survey and the Census Bureau’s Current Population Survey to determine immigrants’ premium contributions to private insurance, including premiums that employers paid on their behalf (which economists consider part of employees’ earned compensation). Then they tabulated all payments that private insurers made to doctors, hospitals, and other providers for immigrants’ care to determine whether immigrants paid more or less into private insurance than they used.

The authors note that since undocumented immigrants or those residing legally in the U.S. for fewer than five years are not eligible for Medicaid and Medicare, private insurance is often immigrants’ only coverage option. Because immigrants are mostly working-age adults with high rates of labor force participation, many enroll in job-based coverage.

“Almost every day I see immigrant patients who avoid seeking the care they need to stay healthy,” said lead author Dr. Leah Zallman, director of research at the Institute for Community Health, physician at Cambridge Health Alliance, and assistant professor of medicine at Harvard Medical School. “Political leaders have created a climate of fear by blaming immigrants for driving up health care costs. However, this study and our prior research shows that by paying more into the system than they receive, immigrants actually subsidize both private insurance and Medicare for U.S.-born citizens.”

“Immigrants contribute tens of billions to our health economy, and account for 21% of all doctors in the U.S.,” said Dr. Steffie Woolhandler, professor of health policy at Hunter College, City University of New York, and lecturer in medicine at Harvard Medical School. “Reducing immigration could weaken both the private insurance risk pool and the Medicare Trust Fund, making insurance more expensive for everyone else.”

***

“Immigrants Pay More in Private Insurance Premiums Than They Receive in Benefits” Leah Zallman, M.D., M.P.H., Steffie Woolhandler, M.D., M.P.H., Sharon Touw, M.P.H., David Himmelstein, M.D., Karen Finnegan, P.h.D., Health Affairs, Oct. 1, 2018. DOI: 10.1377/hlthaff.2018.0309

A copy of the full study is available to media professionals upon request from Ms. Fauke.

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and educational organization of more than 22,000 doctors who support a single-payer national health program. PNHP had no role in funding or otherwise supporting the study above.

Immigrants’ Health Premiums Far Exceed What Plans Pay For Their Care

By Carmen Heredia Rodriguez
Kaiser Health News, October 1, 2018

President Donald Trump has repeatedly condemned U.S. immigration policy, arguing that many immigrants pose a threat to the nation and drain U.S. resources. But a study released Monday about health insurance challenges the president’s portrayal.

The study in the journal Health Affairs found that immigrants covered by private health insurance and their employers contributed nearly $25 billion more in premiums in 2014 than was spent on their care. Those in the country without legal status contributed nearly $8 billion toward the surplus.

In contrast, U.S.-born enrollees spent nearly $25 billion more than they paid for in premiums.

These findings surface as the Trump administration’s immigration policies — including a plan to tie migrants’ efforts to get permission for permanent residency to their use of federal benefit programs — have come under scrutiny.

Earlier studies also found that immigrants contribute more to Medicare than they receive in benefits, but the authors of this study say it is the first to look at the effect in private insurance plans.

Leah Zallman, assistant professor of medicine at Harvard Medical School and lead author of the study, said her findings allude to the potentially negative consequences that tighter immigration policies could have on the health care industry.

“I think in today’s era … there’s so much concern about immigrants and immigration really sort of draining our resources in the U.S.,” Zallman said. “This really points to the critical role that immigrants have in actually subsidizing and maintaining our current systems.”

Researchers calculated the financial contributions and expenses of enrollees and their employers using two surveys created by the federal government. Plans sold on the federal health law’s insurance exchanges were not included because they “differ from other private insurance in important ways and are unavailable to undocumented people,” the study authors noted.

Anyone born outside of the United States was categorized as an immigrant. However, the surveys did not ask non-citizens with private coverage about their legal status. Researchers used national data on undocumented immigrants to estimate how many people in the study group illegally resided in the country.

In 2014, immigrants and their employers contributed $88.7 billion in private insurance premiums, but spent only $64 billion for care, according to the study’s findings. Of that group, undocumented immigrants alone paid more than $17 billion to private insurers but used only $9.4 billion.

Native-born consumers paid $616 billion in premiums and received nearly $641 billion in insurers’ payments for care. They also consistently outspent immigrants across all age groups. Among enrollees 65 and older, the U.S.-born made a net contribution of nearly $10,000 more toward their care than those born overseas, according to the study.

The researchers reported that, on average, individual immigrants paid $1,123 more for premiums in 2014 than they received in insurance-covered care. U.S. natives instead cost insurers $163 on average.

Leighton Ku, director of the Center for Health Policy Research at George Washington University who was not involved in the study, said several factors contribute to immigrants’ low health care expenses. The group tends to be healthier and younger when they arrive in the United States. Cultural and language differences also hinder them from accessing care.

The study noted that immigrants’ health care expenditures increased the longer they remained in the country. But it added that since their premiums also increased at the same time, they continued to make a net contribution to their private health plans.

The findings come about a week after the Department of Homeland Security proposed redefining how it would determine “public charge,” a term used to describe a person likely to become dependent on the government for assistance. The proposal would make it harder for immigrants to live and work permanently in the U.S. if they receive certain types of federal assistance, such as Medicaid, food stamps and housing subsidies.

Trump has vowed to be tough on immigration standards. During his campaign, he berated U.S. health expenditures on immigrants, arguing that the U.S. spent $11 billion for care to people who were in the country without authorization, the study’s authors note.

But they point out that earlier research shows that immigrants have low rates of health care use and spending, compared with native residents. Their payments to private plans and Medicare in essence prop up care for patients who are U.S.-born, the authors say.

A study Zallman published earlier showed unauthorized immigrants contributed $35.1 billion more to Medicare from 2000 to 2011 than they used in services.

Benedic Ippolito, an economist at the American Enterprise Institute, cautioned using the study’s findings to draw conclusions on a large scale about immigrants and their role in health insurance. An estimated 20 percent of immigrants — including nearly half of the undocumented population — are uninsured, according to the study. Ippolito said the cost of their uncompensated care affects whether immigrants’ financial contributions actually lead to surpluses for health care overall.

“I would be careful about how much I extrapolate these results to a) other parts of the health insurance market and b) even further to what this means for immigration policy,” Ippolito said. “This paper alone does not tell us everything we need to know.”

Ku echoed the uncertainty. He said he is not certain how the Trump administration’s latest actions will affect immigrants enrolled in private insurance. Having a private plan may suggest they are employed with a certain income stability. However, if enough immigrants leave the insurance market, he added, it may have the unintended consequence of making health plans more expensive for everyone else.

“That does have the following implication that to the extent that we do things to suppress immigrants or make it harder for them to purchase insurance then in that case we may do harm to the citizens,” he said.

https://khn.org…

Single-Payer Health Care: “The Next Logical Step”

By Chandak Ghosh, M.D., M.P.H.
EyeNet, Letters, October 2018

Reading “Single-Payer Health Care: Of Canada and California” (Current Perspective, August), I was struck by its alarmist tone.

Single-payer health care is suddenly looking attractive to Americans because of the failure of for-profit, private insurance-centered health care. Before the Affordable Care Act (ACA) was implemented in 2010, insurance prices were increasing exponentially; 15% (and quickly rising) of Americans were uninsured; medical bills caused most bankruptcies; quality remained the worst among comparable countries; and health care was reaching 20% of the federal budget and gross domestic product.1

With the ACA, we attempted a market-based approach. It stabilized prices, but its complexity and continued reliance on private insurance has doomed it. The Republican Party is dismantling ACA without any workable replacement.2

The type of single-payer gaining most support is an improved “Medicare for all.” Yes, taxes will go up, but Americans will no longer pay private insurance premiums, deductibles, co-pays, and co-insurance. Drug prices will fall.1 People will pay about one-third less for health care overall.1 Doctors and hospitals will enjoy a precipitous drop in administrative costs and malpractice insurance prices.2 Medical students will pay much less for schooling and avoid the crush of student loans. Best of all, every American will gain access to a higher quality of care, improving outcomes while decreasing costs.

Private insurance is just a middleman that moves money from the patient to the provider. Its real point is to make profits for shareholders, yet we are paying 30 cents of every health care dollar for administrative costs and insurance company profits, instead of improving health.1

The single-payer form of universal coverage will come to the United States, as it remains the cheapest way to cover everyone. We see it succeeding in nearly every developed country of the world, and in the United States as Medicare, the government’s most beloved program. Expanding Medicare to cover everyone is the next logical step.

https://www.aao.org…

References

1. Gaffney A. Journal of Policy Analysis and Management. 2018;37:188-195.

2. Woolhandler S, Himmelstein D. Ann Intern Med. 2017;166(8):587-588.

Doctor: National health care is a ‘moral imperative’

By Jenny Gray
Fulton (Mo.) Sun, September 30, 2018

This week, Dr. Robert Blake, emeritus professor of Family and Community Medicine at the University of Missouri, remembered a patient who died, but possibly could have lived a longer life.

“He was a farmer and had high blood pressure,” Blake said.

The farmer had an insurance policy with a high deductible, and because of that, couldn’t afford to do a lot.

“It was a huge barrier to him getting health care,” Blake said.

The doctor said he helped him as much as possible with cheaper medication and good advice, but if he’d had access to more expensive treatment, his story might have ended another way.

“He had a disabling stroke and died soon after,” he added of the patient.

Blake brought his understanding of challenges to health care in rural communities to a gathering Monday at KACO the Kitchen. This informal discussion was hosted by Callaway County Concerned Citizens, a local group that discusses issues in Callaway County.

“I’m old enough to remember the old hospital on Jefferson Street,” group leader Margot McMillen said.

That facilities lacked in technology, and so the Fulton community decided to build another.

“The community got together to buy land and build the hospital on Hospital Drive,” she said. “Nowadays, we don’t know what the future of that hospital will be.”

CCCC started meeting about a year and a half ago to look at issues including education, environment and health care. They’ve also discussed alternative energy, a community health ordinance to do with confined animal feeding operations and voter line redistricting.

“We meet on the fourth Monday of every month at KACO,” McMillen said.

In line with concerns about rising costs of health care and lack of access and affordability, CCCC members invited Blake to talk about a national health care system, including a Medicare-for-all option. For decades, he has been a member of a national organization, Physicians for a National Health Program, comprising health professionals and others who advocate for universal health care in the United States. Blake is also a member of the recently organized Columbia chapter of Physicians for a National Health Program (pnhp.org/states/missouri).

In 1971, Sen. Ed Kennedy began advocating for a national health care system in the United States. In 2009, before his death, he wrote in Newsweek magazine: “Every American should be able to get the same treatment that U.S. senators are entitled to. This is the cause of my life.”

Blake finds the state of health care in the U.S. in need of a major overhaul, he said.

He added that health is, “A state of complete physical, mental and social well-being — not just the absence of disease.”

Health is vital to quality of life, Blake said.

“Health enables you to do what you want to do,” he added.

Blake said and others back up the fact Americans spend more on health care per capita than any other country in the world.

“We spent $3.5 trillion on health care, and it’s 18 percent of the GDP (gross domestic product) of our economy. It costs about $10,000 per person — two times as much as any other country for an individual person,” he said.

That $3.5 trillion is about one-sixth of the U.S. economy. Despite the high price tag, the U.S. remains the only wealthy, developed nation without universal health coverage.

“We should have the best health care system in the world, but in fact, that’s far from the case,” Blake said.

“Look at the longevity rates, the mortality rates. We have shorter life spans and higher infant mortality,” than countries with universal health care, he said. “Women are more likely to die from pregnancy complications than women in 45 other countries.”

Blake cited one example of a common disease.

“People with cystic fibrosis in Canada live 10 years longer than in the United States,” he said. “It’s the same disease. It’s the same treatments.”

There are several different kinds of health care systems being managed around the world.

“Canada pays for insurance for everybody,” Blake said. “Taiwan and Australia and Sweden do it in somewhat different ways.”

The United Kingdom used the National Health Service, single-payer model, tax funded with most health care provided through public hospitals and clinic. In the U.S., the U.S. Department of Veterans Affairs operates similarly.

National Health Insurance is a model in which the government mandates everyone have health insurance delivered through a mix of public, nonprofit and for-profit providers.

The U.S. Medicare system is also a single-payer model where everyone is required to pay into a government insurance plan, which in turn pays doctors and hospitals. While Medicare serves citizens age 65 and older, some are calling for reformation including all citizens in this program.

Blake said, before the Affordable Care Act, 50 million Americans — 17 percent of the population — had no health insurance. Another 50 million were under-insured.

“They didn’t have what they needed,” he said. “And 44,000 Americans die every year because of the lack of health insurance. Imagine the reaction if 44,000 Americans were killed by terrorists. It would be a different reaction.”

When the ACA was enacted, the 17 percent dropped to 9 percent, but in states like Missouri that didn’t expand Medicaid programs to its residents, the number dropped to just 12 percent.

“I think there is a better solution,” Blake added. “We have the resources. We should be able to do this. Other countries are able to do this.”

Opening Medicare to everyone is a popular option, “And it’s also effective,” Blake said.

He said health improves for older Americans once they are eligible for Medicare.

“At age 65, the mortality in the United States begins to improve, and it’s progressive,” he added. “Medicare covers these people, and this is incredibly powerful evidence.”

Administrative costs for Medicare are 3 percent, with the rest of the money collected going to patient care. For Medicaid, it’s 5 percent. However, for insurance companies, it’s more like 20-30 percent. The ACA required 80-85 percent of funds raised go to patient care.

“It forced insurance companies to spend more on patients, and so they pulled out of the exchanges,” Blake added.

People with no insurance — often the poorest and most at risk — are charged the highest rates.

“With a single-payer system, you get rid of all that,” Blake said.

If all Americans are paying into that system, it will support a big pool of money for those who need it the most.

For Blake, it comes down to one thing.

“There’s the moral argument. Our fellow citizens deserve this,” he said. “Health care to me is a fundamental human right. We’re never going to provide a system that provides everybody with everything they want; we need professional to help them meet their needs. The number one reason we deserve this: To me, it’s a moral imperative.”

http://www.fultonsun.com…