PNHP

Effective Single Payer Advocacy

Powerful coalitions forming against single payer Medicare for All

Doctor, hospital groups organize to oppose single-payer in California

By Angela Hart
The Sacramento Bee, August 28, 2018

A group of influential, deep-pocketed business and health care organizations that have long helped shape the legislative agenda in California have joined forces to oppose any future effort to craft a universal, single-payer health care system for the nation’s largest state.

The main focus of the coalition, called “Californians against the costly disruption of our health care,” is to kill any single-payer health care bill in the state Legislature, said Ned Wigglesworth, a political strategist for the coalition.

“As long as proponents plan to bring this back time and again, we think it’s important to have a strong, unified presence to oppose it,” Wigglesworth said, referring to Senate Bill 562, the 2017 single-payer bill pushed by the California Nurses Association that was shelved last year by Assembly Speaker Anthony Rendon.

The anti-single payer coalition includes powerful groups representing the interests in Sacramento of doctors, hospitals, insurers and businesses. Instead of single-payer, the coalition is expected to press for alternatives, which could include several legislative proposals on health care that failed this year and some under discussion, including expanding state insurance subsidies, allowing undocumented adults to sign up for Medi-Cal and creating a state-based individual mandate for everyone to have coverage.

“I think you’re going to hear our messaging loud and clear,” said Charles Bacchi, president and CEO of the California Association of Health Plans. “It’s going to be really focused around how expensive (single-payer) would be for California to do, and how disruptive it would be for people who currently receive health care coverage.

https://www.sacbee.com…

Partnership for America’s Health Care Future:
https://americashealthcarefuture.org

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Comment:

By Don McCanne, M.D.

The coalition, “Californians against the costly disruption of our health care,” is basically a group of vested interests and their agents, with power and money, that intends to wipe out the single payer movement in California. A national coalition, “Partnership for America’s Health Care Future,” has even more power and more money and intends to snuff out the single payer Medicare for All movement throughout the United States.

The good news is that this shows that the Medicare for All movement is viewed as a very real threat to the sponsoring organizations, which shows how effective the single payer advocates have been to date. The bad news is that power and money can extinguish our flame.

What can we do? We may not have the money but we can harness the power of the people by continuing to do what we have been doing to bring the single payer Medicare for All movement to the forefront, but we need to do a lot more of it. Education, coalitions, grassroots efforts, community organizing, creating a presence everywhere using the spoken and written word, networking with our families, friends, associates, religious and civic institutions, and more. We need to be there and do it, and bring others with us.

These coalitions that intend to defeat single payer will try to present a positive front by offering expanded programs under our existing dysfunctional and fragmented system, but that will only perpetuate the waste and inequities, thus perpetuating the health care injustices that permeate our system, not to mention that such an approach is uniquely by far the most expensive model of health care reform the world has ever known. This can only perpetuate and compound the problem of lack of affordability of health care that is tormenting us in the United States.

Our message resonates much better: include everyone for life, providing free choice of physicians, hospitals and other health services and products, simplify the financing system to reduce the profound administrative waste unique to the United States, establish fair prices that are adequate to support the system while preventing gouging, and fund the entire system equitably such that each person pays his or her fair share based on ability. Thus our simple message is that all of us receive the health care we need, and none of us suffers financial hardship as a result.

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Anthem refuses to cooperate with a federal false claims investigation

Feds want to force Anthem to comply with Medicare billing investigation

By Shelby Livingston
Modern Healthcare, August 21, 2018

Health insurer Anthem has refused to comply with the U.S. Justice Department’s investigation into its Medicare Advantage billing practices, according to federal court documents filed Tuesday.

So the Justice Department this week asked the U.S. District Court for the Southern District of New York to force Anthem to comply with a civil investigative demand issued in March to provide testimony about its chart review and risk-adjustment program for its Medicare Advantage plans.

The Justice Department initially demanded the testimony by April 13 but said Anthem has yet to provide a witness to testify. The court on Monday ordered Anthem to explain why it should not be forced to provide testimony. Anthem has until Sept. 4 to respond.

The Justice Department asked for Anthem’s testimony as part of an investigation into whether Anthem unlawfully obtained hundreds of millions of dollars in Medicare Advantage risk-adjustment payments in violation of the False Claims Act by submitting inaccurate patient diagnosis codes to the CMS.

The feds also want to know if Anthem deliberately disregarded its duty to ensure the diagnosis codes submitted were valid, and asked for testimony about the processes and people Anthem relied on to verify diagnosis codes obtained by providers and through a retrospective chart review.

An Anthem spokeswoman declined to comment.

http://www.modernhealthcare.com…

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Comment:

By Don McCanne, M.D.

Anthem has an opportunity to demonstrate to the Justice Department that they have not been cheating the taxpayers out of hundreds of millions of dollars by upcoding diagnoses of their Medicare Advantage patients, thus qualifying for higher risk adjusted payments based on the fact that their codes indicate that the patients have more costly disorders than they actually have.

If Anthem is innocent, then why does it take the order of a federal court to produce the evidence that would clear them, after failing to comply with an earlier demand? Maybe they are just trying to work the float on the heavy penalties that they know they will eventually have to pay (investing money for their own profit – money that belongs to the taxpayers). Hey, the insurers keep showing us that do know how make a buck off of us, even in a bad situation. And we want to keep them in charge?

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

There are many advantages to single-payer health care

By Ann Troy, M.D., F.A.A.P.
Marin (Calif.) Independent Journal, August 27, 2018

I am a physician and I advocate a single-payer system or Medicare for all.

Under a single-payer system we would be healthier. It is well known that people without insurance or with high deductibles wait longer to seek medical care; thus, their illnesses and problems become more deep-rooted and more difficult to treat. They suffer more from injuries, disabilities and ill-health, resulting in decreased productivity and poorer quality of life. Sometimes they die because they put off getting care.

Under a single-payer system, people would have a wider choice of doctors and would not have to change their doctors every time they change jobs or their employer finds a cheaper health plan. Continuity of care would improve and problems would be treated earlier (when easier and less expensive to treat). More people would receive vaccines and preventive care. Public health would improve and social problems associated with untreated mental illness and addiction would decrease.

The U.S. ranks at or near the bottom of the developed world on every measure of health. According to the World Health Organization, we are No. 37 on overall measures of health. Shameful for such a rich country that spends so much on health care!

A single-payer system would benefit us economically. U.S. companies are at a disadvantage compared with companies in other developed countries which are not saddled with the high cost of providing health care for their employees. Smaller companies can’t compete for the best employees because they can’t afford to provide health insurance. Unhappiness over health benefits is the leading cause of labor unrest.

Some employees commit workers’ comp fraud to gain access to care. People stay in jobs they hate because they need health insurance, rather than going back to school or creating new ventures. Families struggle to pay astronomical health insurance premiums than pay for care until they’ve met their deductibles. Half of all bankruptcies in the U.S. (approximately 1 million a year) are due to medical debt. All of this would change with a single-payer system.

Finally, there are the legal and moral arguments. Health care is considered a human right in every other developed nation. By not providing Medicare to all Americans, the government is not providing equal protection under the law: those with Medicare have more protection against the devastating effects of illness and injury, get more help overcoming or living with disabilities, and are protected against financial ruin.

People say that single-payer would cost too much. Not true.

We could provide health care for all our citizens for no more than we are currently spending on our very dysfunctional, fragmented and unfair system.

How is this possible? Currently almost half of every health care dollar is spent on something other than health care: profit for insurance companies; multi-million-dollar salaries for their CEOs; money spent on advertising, processing (and rejecting) claims; and creating mountains of paperwork and endless hassles for doctors and patients.

Then there is the money we have to spend dealing with the insurance industry: billing, authorizations, etc. Dealing with insurance companies is so cumbersome that we have created intermediary entities (such as IPAs) to deal with them. It is estimated that American hospitals spend about 25 percent of their budget on administration, most of it insurance generated! Layers and layers of costly administration would disappear under a single-payer system.

We do not need more studies to prove this. Other developed nations provide health care for all of their citizens for an average of half of what we spend per capita and an average of 10 percent of their GDP (versus our 19 percent).

It is time that we catch up with the rest of the developed world and provide health care for all with a single-payer system.

Dr. Ann Troy is a pediatrician who has been in practice for 30 years.

http://www.marinij.com…

Medicare for all can control rising costs, improve health outcomes

By Phil Caper, M.D.
Bangor (Maine) Daily News, August 26, 2018

A recent Associated Press story describing a study of Sen. Bernie Sanders’ proposal for Medicare for all carried the alarming headline: “Medicare for all projected to cost $32.6 trillion over 10 years.” Pretty scary stuff.

But the study, as reported, was misleading. Let’s correct that.

It’s true that transformation from a complicated mixed public-private system of financing health care to one that treats medical care as a public good would move a great deal of money from private, for-profit budgets to public nonprofit budgets and would result in a significant increase in taxes. But there is a big savings to doing just that. We who buy medical goods and services — including patients, employers, those buying health insurance and taxpayers — will save.

Replacing insurance with taxes will eliminate the need for much of the administrative and other sources of waste in our health care system. In fact, the study found that Medicare for all would reduce overall health care spending in the U.S. by $2 trillion over 10 years, compared to our existing system.

This waste is incurred by patients, doctors, hospitals and insurance companies as they each try to navigate the health care maze in order to maximize their revenue, and employers, patients and employees as they struggle to pay for medical care. According to the Medicare Trustees Report for 2018, Medicare’s administrative costs accounted for just 1.14 percent of all spending. But private insurance companies struggle to keep administrative costs below 20 percent. Those administrative costs do not buy a single bandage or aspirin.

A 2012 National Academy of Medicine study of America’s $3 trillion health care system identified $750 billion of waste. “Excess administrative costs” account for $190 billion. Another $575 billion is wasted by “prices that are too high,” inefficiently delivered services, unnecessary services, missed prevention opportunities and fraud.

Many of these costs are directly attributable to the use of insurance to finance medical care. Insurance requires the slicing and dicing of the insured population into “risk pools” to facilitate the pricing of premiums in our fragmented health insurance system. Medical underwriting requires a great deal of intrusively detailed information about those covered and armies of actuaries. All of that would be unnecessary and would disappear in a fully tax-funded system, because all beneficiaries would be pooled into a single fund. Everybody would be covered for life.

Insurance underwriting is not the only way to finance medical care. Instead of segmenting risk into multiple pools, Medicare puts all beneficiaries into one risk pool and payment for health care is made out of a federally administered — and controllable — fund.

A more unified system would produce many other benefits. Everybody in, nobody out would greatly increase the popularity, and therefore political stability, of our health care system. That’s what our half century of experience with Medicare has demonstrated.

A single payer negotiating prices for medical services, devices and drugs would save billions. Insurance administrative costs would drop from more than 20 percent to between 1 to 2 percent. Unpopular restrictions of pre-existing conditions and other medical underwriting would be eliminated.

New tools would be created to control rising costs. No changing your health care as individual circumstances change. “Job lock,” when employees aren’t able to freely leave a job over fear of losing health insurance, would be eliminated, decreasing business costs and increasing opportunities for entrepreneurs.

In fact, with everyone in and nobody out and everyone contributing, we could create a central database that would make the detection and remediation of fraud, waste and abuse — rampant in our current system — much easier.

Out of the savings generated, we could provide real primary prevention of disease, and gradually expand coverage to dentistry, eye care, long–term care and other beneficial services that reduce the demand for more expensive medical care.

Supreme Court Justice Oliver Wendell Holmes once said, “Taxes are the price of civilization.” We fund many popular services through taxes, including police, fire fighters, the military, schools, libraries, courts, roads and environmental protection. All are essential to a civilized society.

In the rest of the developed world, health care costs less and delivers better results. As the study actually shows, health care for all is better for the community and the economy.

And after it’s in place, we will all be thankful and will all wonder why it took so long.

Dr. Phil Caper is an internist and founding board member of Maine AllCare.

https://bangordailynews.com…

The bull market is foretelling Medicare Advantage for All

An unlikely winner in the long-running bull market: Health insurers

By Bertha Coombs
CNBC, August 19, 2018

The bull market, which is about to become the longest running in recent history, has produced healthy returns for investors. The S&P 500 is up well over 300 percent over the last nine years, but health insurance stocks have logged even more impressive gains.

The S&P Managed Care sector, made up of the largest insurers, has gained more than 1,100 percent during the market’s bull run. That’s more than twice as much as the gains in the biotech sector.

Nine years later, two of the biggest health-care winners have seen large growth in part because of Obamacare.

The Medicaid boom

Medicaid expansion under the ACA has resulted in nearly 15 million people gaining coverage under the government health program for the poor and disabled. At the same time, over the last decade, states have increasingly turned to insurers to manage their Medicaid programs.

Medicaid insurer WellCare Health Plan’s shares have gained more than 4,000 percent since March 2009, and its annual revenues have nearly tripled from $6.9 billion to an estimated $18.7 billion this year.

Rival Centene’s shares have gained nearly 1,800 percent over the last nine years. Annual revenues have ballooned from $3.4 billion to an estimated $59.8 billion this year. Centene is up 42 percent year to date, trading near record highs.

At the same time that the Medicaid business has expanded, Medicare has seen big growth over the last decade as more baby boomers have aged into the government health plan for seniors.

For the major health insurers that has meant that their government business has grown faster than the commercial employer and individual insurance plan business. Government plans now account for more than 50 percent of the industry’s insurance revenues.

More diverse businesses

Government plans have been one of the growth drivers for the nation’s largest insurer, UnitedHealth Group, which is up 19 percent year to date, and has seen shares gain nearly 1400 percent over the last nine years.

United’s health plan membership has grown from 32 million to nearly 50 million over the last nine years; its Medicaid and Medicare membership has more than doubled, during the period.

But new business segments outside of health insurance have played a big role in growing the health-care giant’s annual revenues from $87 billion in 2009 to an estimated $225 billion this year. The health services and products under the Optum division have become a key driver of top-line growth.

United’s Optum unit now accounts for 20 percent of revenues, and includes data analytic services, pharmacy benefit management, physician practices and outpatient surgical centers.

Revenues from the services businesses are not subject to the ACA regulatory caps, which require insurers to spend at least 80 percent of premium revenues on medical care. That makes them more profitable.

United’s success has been part of the impetus behind the increasing number of vertical health insurer deals. More health plans have acquired health-care providers and services in order to have greater control over medical costs in their health plans.

Pharmacy benefit giant CVS Health’s $69 billion deal for Aetna and Cigna’s $54 billion deal to buy pharmacy benefit firm Express Scripts are both predicated on trying to driving cost efficiencies by having greater control over a wider range of members’ care.

Meantime, Democrats have revived the health reform debate over single-payer Medicare For All, nine years after investors were rattled by the prospect of single-payer health care under the ACA.

If either side gains traction, analysts say the major insurers have positioned themselves to adjust more readily to the shifting landscape over the last decade.

“Even if it’s Medicare for all, it would probably be Medicare Advantage for All,” with the government funding private Medicare plans, said Deep Banerjee, health-care credit analyst at Standard & Poor’s.

“Health care today is a public-private partnership … it’s very hard to see a system without a private player meaningfully involved,” he said.

https://www.cnbc.com…

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Comment:

By Don McCanne, M.D.

Since enactment and implementation of the Affordable Care Act (ACA) we have heard stories about how tough it has been for the insurance industry. Congress and both the Obama and Trump administrations have responded with measures to ensure the viability of this industry (in spite of blowhard repeal activity of the Republicans that had essentially no detrimental impact on the insurers – they just raised their premiums). You really need to read this very brief summary of the past nine years to understand what a godsend this has been for the health insurance industry.

Much of the clamor has been over the ACA exchange plans. Yet in the overall picture that has been a very small part of what has really happened in the past decade. In fact, it has been such a small part that some of the largest insurers have pared back their involvement in the exchanges since they have been an insignificant contributor to their business successes.

So what has been the source of their success? The two government programs, Medicare and Medicaid, and the expansion and diversification of their industry.

The largest expansion as a result of ACA has been in the Medicaid program, and that has coincided with a massive shift into the private Medicaid managed care programs. The behavior of the Medicaid managed care stocks has demonstrated what a phenomenal business success this has been (even if it appears that this success has been made possible by the implementation of their business model that simply prevents their Medicaid patients from receiving much of the care that they should have). Since the private Medicaid managers have been successful in barely providing health care to huge numbers of Medicaid beneficiaries at a very low cost to the government, it its likely that this program is locked in place for the indeterminate future. The political process will be very resistant to any proposals that would increase spending on poor people – the low-income population that qualifies for Medicaid.

The success of the private Medicare Advantage plans has not been due to ACA but rather due to other programs that were set up in an effort to privatize Medicare. Again, Congress and the Bush, Obama and Trump administrations have all nurtured this program by providing them with very generous funding (much due to administrative chicanery) while at the same time giving the insurers regulatory backup to pay for health care at rates considerably below the rates paid by standard commercial plans. With high volume, generous funding, and low costs, it is no wonder that these insurance companies have become darlings of Wall Street.

What should be very alarming to us is the success that these insurance companies have had in diversifying their businesses. They are no longer just the insurers and administrators, they have now become an integral part of the health care delivery system with their acquisition of physician practices, outpatient surgery centers, pharmacy benefit managers, data analytic services, and other vertical acquisitions. Profits from these expansions are not limited by the ACA regulatory caps, and if there is anything that the private insurers understand, that is how to make a buck.

So where is the money coming from that has created this phenomenal success for the private insurers? Well, a large amount is from the taxpayers through the Medicaid managed care and private Medicare Advantage plans – part of the silent costs of health care that the taxpayers do not realize they are already paying. Some is coming from a diversion of funds from the health care providers into the coffers of the insurers. Some is coming from the Wall Street customers who are paying excessive amounts for stock purchases plus the cost of churning in this protracted bull market. And some is from the excessive administrative services that the insurers keep selling us. You can probably think of more sources of their enrichment.

We’ve been saying for three decades that it is urgent that we change to a publicly funded and publicly administered, single payer, improved Medicare for All. Not only have we wasted funds on the excesses of our current dysfunctional system, but also far too many have gone without essential health services, and tens of millions have faced unnecessary financial hardship.

But what has snuck up on us is that the insurance industry has taken over. They have planted themselves in a position to capitalize on the Medicare for All movement. Medicare for All has now become the rallying cry for the Medicare public option. Just as the private Medicare Advantage plans are engulfing the traditional Medicare program, the insurance industry is positioned to be sure that the Medicare public option will be a Medicare Advantage public option, and they will do it with the support of our politicians, including many who profess to be progressive or liberal or whatever label assuages their guilt.

The latest Reuters/Ipsos poll shows that 70 percent of Americans support Medicare for All, including half of Republicans. But, with the complicity of the neoliberals, the industry has latched onto the Medicare for All rhetoric and will use it to expand their business successes.

What can we do? Well if the public is really serious about wanting affordable health care for all, it will require massive community action – education, grassroots, coalitions, voter engagement – now! Otherwise, sit back and watch them implement Medicare Advantage for All. It’s almost here.

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

Reuters/Ipsos poll: 70 percent support Medicare for All

Reuters/Ipsos, June and July 2018

Would you support or oppose the following?

A policy of Medicare for All? (When it comes to the U.S. healthcare system)

Democrat
84.5% – Support
10.7% – Oppose
4.8% – Don’t know

Republican
51.9% – Support
37.4% – Oppose
10.7% – Don’t know

Total
70.1% – Support
20.6% – Oppose
9.3% – Don’t know

https://www.reuters.com…

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Comment:

By Don McCanne, M.D.

In this new Reuters/Ipsos poll of 2,989 American adults, 70 percent support Medicare for all, and even a majority of Republicans – 52 percent – do so as well.

Don’t forget the Republicans in your advocacy work.

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

The Democrats’ Approaching Dilemma

What should they do about health reform?

By Caroline Poplin, M.D., J.D.
MedPage Today, August 23, 2018

If the Democrats begin to retake control of the federal government in November — for example, by flipping the House — they should start thinking about their next moves on health reform.

They will have plenty of time for contemplation: President Trump and his minions will, if anything, redouble their attack on the Affordable Care Act (ACA) for the next 2 years, and the Senate (unless also flipped) will do what it can to help. Even if they regain control, all House Democrats can do, especially if the Senate doesn’t flip, is block bad bills from getting to President Trump’s desk. There is no compromise with this man.

The Choice

But in 2020 (hopefully) the Democrats will be at a fork in the road, and they will need to answer an important question: Should they restore and improve whatever survives of the ACA, based on 10 years of real-world experience, or should they respond to rising calls for “Medicare for All,” for part or all of the under-65 population?

Now is the time to start thinking.

The debate to date is not evenly balanced. As you would expect, supporting the ACA are the large (and growing) industries that benefit — for-profit insurance companies, large for-profit hospital chains, pharmaceutical manufacturers, and so forth. (Indeed, the ACA was designed precisely to garner their support, or at least buy their silence.) In addition, though, over the last 30 years, an extensive and powerful “policy” community of academics, consultants, economists, and highly regarded think tanks (likely some with industry funding) have developed an elaborate intellectual infrastructure to support market-based commercial healthcare.

On the “Medicare for All” side, we have Physicians for a National Health Program (that should tell you something); Gerald Friedman, PhD, an economist at UMass Amherst; and recently, some advocacy organizations. No leading think tanks that I am aware of.

Since Democrats now have a choice, perhaps instead of starting from where we have been — the same thinking that led to the ACA — perhaps we should start with where we want to arrive.

We should have two principal goals. First, everyone needs to get the care they need at a price they can afford — that is to say, the objective is care, not coverage. Second, we need to get the total cost of the system down. That hasn’t happened despite strenuous efforts on many sides, possibly because the policy community has been ignoring some important costs as it bears down on what we pay clinicians (of which, full disclosure, I am one).

Important Cost #1: The Sickest Patients

One of the best opportunities to reduce cost — often overlooked in this context — is the sick patient. In general, 5% of a population is responsible for 50% of its total health care cost. Treating these patients, who have multiple problems including depression, functional and cognitive impairment, as well as, often, limited social support or financial resources, is expensive, yes. But secondary and tertiary prevention, close follow-up, and improving patients’ social determinants of health saves the system money — mostly by keeping these patients out of emergency rooms, hospitals, in-patient rehabilitation, and nursing homes — and improves patients’ quality of life.

Commercial health insurers and risk-bearing accountable care organizations (ACOs) want no part of the sickest patients — the way to make money is to insure and/or care for the healthy. Low cost, excellent outcomes, and numerous healthy patients mean high profits. Insurers and ACOs also seek reinsurance from the federal government, the states, high risk pools and other programs to which to transfer the costly 5%. These maneuvers allow insurers to keep their profits and socialize the losses.

Important Cost #2: Administrative Costs

The good news is, from 1990 to 2012, the U.S. healthcare workforce grew by 75%. The bad news? Ninety-five percent of that growth was in administrative staff, not physicians. By 2012, there were 16 non-doctors for every doctor. Worse, only six of the 16 were involved in patient care.

So how much value do the 10 non-clinicians contribute to patient care?

Drs. Jiwani, Himmelstein, Woolhandler, and Kahn extensively analyzed the data for 2012 and determined that expenses related to billing and insurance in our multi-payer system totaled almost 18% of U.S. healthcare expenditures that year, far more than in any other OECD country. In 2014, in The New York Times, Elisabeth Rosenthal estimated administrative costs at 20% to 30% of the total.

Today, the ratio of administrators to clinicians is probably higher, and accounts for a larger percentage of U.S. healthcare costs. Why?

First, as politicians and the policy community have pushed a market-based system, U.S. healthcare has become a very profitable business, with many participants answering to Wall Street. To stay in business, prosper and expand (those latter two are often linked), businesses need managers, and the above-mentioned consultants, to supervise marketing, identify profit and cost centers, and extract maximum productivity from the work force. Frequent negotiations between insurers and providers over prices also require businesspeople (and generate huge transaction costs).

Managers do not come cheap: John Commins points out that in 2005, CEOs made three times as much as orthopedic surgeons (the physician heavy hitters); 10 years later, five times as much. Indeed, physician compensation represented only 8.6% of total healthcare expenditures in 2012. We know how orthopedic surgeons help patients — CEOs, not so much.

Second, hospitals, insurers, and health systems are consolidating ever more quickly, sometimes for survival, often for increased leverage with one another, and for increased profit. Consolidation of multiple hospitals or businesses requires additional administrators to manage the administrators of local systems. Or as Cathy Shoen, a senior expert at the Commonwealth Fund, put it,”[At] large hospitals there are senior V.P.s, V.P.s of this, that and the other.” Whether consolidation improves quality and reduces cost, it does move important decisions further and further from the bedside.

And finally, all these managers as well as the policy community and, alas, Congress, have an unshakable faith in the ability of health information technology to “transform” U.S. healthcare, reduce costs, and improve quality by collecting and analyzing vast amounts of data about everything.

Indeed, their faith was such that in 2009 Congress promulgated the so-called HITECH Act, “encouraging” all hospitals and doctors (first with carrots, then with sticks) who received payments from Medicare to buy electronic medical records systems so that they could send their outcomes data to CMS and other interested parties, who would presumably use them to improve care and reduce cost. Under the Medicare Access and CHIP Reauthorization Act (MACRA), passed in 2015, these required reports became even longer and more complicated.

It doesn’t appear that anyone has done a credible analysis of how much top-heavy management and its high-tech tools cost our system — my guess it’s become a significant percentage of the total. We need to reassess this before we design the system of the future. From my vantage point at the sharp end of the stick, expensive managers and HIT are not merely useless — they are counterproductive and wasteful.

And quality? At least one analyst crunched the numbers and concluded that “as countries spend a larger percentage of their healthcare dollars on administration (as opposed to public health, or providing patient care, for example), things get worse for patients and healthcare providers.”

What’s the Answer?

The cost of healthcare in the U.S. continues to rise in an unsustainable manner, particularly if we insist, as we should, that in a country as rich as this, everyone who needs medical care should get it. In 2009, the Democrats went with market based reform, based partly on what seemed politically most feasible. Truly. Not only did it undo them politically, but it did not save money. In 2020, with a little luck, they will get another chance.

The way to reduce costs, maintain quality, and cover all is to treat the sick, simplify, and decentralize, through Medicare for all. Providers must be non-profit. Now is the time to work out the details.

Dr. Caroline Poplin is an attorney and internist in Bethesda, Maryland. She is a former staff internist for the National Naval Medical Center, and currently practices medicine part-time at the Arlington Free Clinic in Virginia. She also consults for law firms on Medicare and Medicaid fraud.

https://www.medpagetoday.com…

Why Doctors Are Warming to Medicare for All

Burnout, cynicism, and endless insurance red tape. As America’s private health care system crumbles, doctors are waking up to the need for Medicare for All.

By Meagan Day
Jacobin, August 23, 2018

According to a poll earlier this year in the New England Journal of Medicine, a majority of American physicians say that single-payer is the best path forward. Doctors are not traditionally a progressive bunch — in the 1960s, the American Medical Association famously hired Ronald Reagan to attack Medicare as “socialized medicine.” So why might this be?

A new study exploring the phenomenon of physician burnout holds some clues. Researchers from University of California, Riverside School of Medicine found that under the current system, doctors are increasingly unhappy at work. They observed a sharp rise in physician burnout, which they define as “1) a feeling of a lack of accomplishment; 2) feelings of cynicism; and 3) a loss of zeal, zest, and enthusiasm for work.”

One of the reasons for this dissatisfaction is that, as researcher Kenneth A. Ballou pointed out, “the doctor-patient relationship has been morphed into an insurance company-client relationship that imposes limitations upon the treatment doctors can provide to the insurance company’s members.” In our current system, there are usually three parties involved in every medical decision: the doctor, the patient, and the insurer. The doctor and patient may agree on a course of treatment, but the insurer decides whether it will be covered. And since many Americans can’t afford ever-growing out-of-pocket medical costs, that often means that insurers have the final say in whether the treatment will be administered at all.

The majority of Americans receive health coverage from a private insurance company. And while doctors and patients are both theoretically focused on patient health, the insurer is driven by an entirely different motivation: to maximize profit. Insurance companies are financially motivated to deny claims, and they do it all the time, even in life-or-death situations. One in four patients with a chronic or persistent illness or condition have had claims for medication, tests, or procedures denied by their insurer. In 70 percent of those cases, the condition was described as serious. Only 1 percent of patients said they trusted their health insurance provider’s judgment over their doctor’s or their own — and yet the buck stops with insurance companies.

When they deny claims, insurers give doctors and patients all kinds of excuses packaged in obscure industry terminology: formulary exclusion, prior authorization. But the simple fact is that patients aren’t getting the care they need — and doctors aren’t getting the opportunity to actually do their job. All too often, this is deadly for patients. For doctors, it’s depressing and demotivating. It hinders physicians’ ability to practice medicine, makes them feel powerless at work, and divests them of a feeling of personal accomplishment.

Another factor contributing to doctor burnout is depersonalization. Patients change doctors constantly under our current system. People switch jobs, or their employers switch insurers, and as a result patients are required to change networks and providers. Or people’s income fluctuates and they drift in and out of Medicaid eligibility, often going through periods where they aren’t insured at all. The ACA marketplaces are more or less designed to rupture relationships between doctors and patients, appealing to patients as consumers and communicating that if they shop around they can find a better plan, one that will finally meet all their needs — though it rarely does.

As a result of our jigsaw insurance network system, doctors and patients meeting for the first time can’t assume they’re embarking on a meaningful long-term relationship. “The doctor–patient relationship has sustained the happiness of both doctors and patients for generations,” write the UC Riverside researchers. “This centuries-old relationship has only recently been threatened by a de facto insurer–employer–provider relationship.” Seeing little purpose in getting to know patients intimately, doctors can become cynical. The lack of continuity leads to feelings of alienation and disinvestment for physicians who may have been attracted to the profession by the prospect of helping and healing people.

Finally, the study’s authors point to the proliferation of mandated use of Electronic Health Records (EHRs) as a cause of physician burnout. “No humanistic physician gets up with zeal in the morning, hopeful for a chance to have a meaningful relationship with Epic or MEDITECH,” they write. One time-motion study found that doctors spend twice as much time on EHR and desk work as on clinical face-time with patients. These medical records software programs are designed to facilitate documentation required for billing, more than for care itself. The upshot is that the clerical tasks associated with our byzantine insurance system take physicians away from the bedside and from practicing actual medicine.

This wouldn’t be the case if we had a simpler health care financing system — for instance if there were only one insurer, or single payer, for all patients. What makes the health system so complicated and time-consuming is that it’s carved up into private insurance networks, instead of a standardized system where a single public plan finances medical care for virtually everyone, as in dozens of other countries. Of course, the health insurance companies profit from this arrangement, and so does the rapidly growing health informatics sector intent on monetizing the management of our complex system. But there is no value for patients in private insurance — and, increasingly, doctors are finding that they too get the short end of the stick.

In a 2015 international survey of primary care doctors by the Commonwealth Fund, only 16 percent of US doctors said the US health care system “works pretty well and only minor changes are necessary,” while 14 percent said it “has so much wrong with it that we need to completely rebuild it” — versus 22 percent and 11 percent in the UK and 36 percent and 3 percent in Canada, both countries with single-payer systems.

Under a single-payer or Medicare for All system, there would be no private corporations with the motivation and the power to deny coverage just to improve their bottom line. In fact, since the government would be the sole financer of every individual’s care from cradle to grave, it would be incentivized to keep people healthy in ways that insurance companies — which play musical chairs with patients and ultimately hand them off to the government in old age — simply aren’t. Under a single-payer system, the insurer would want doctors to do their jobs and treat people, instead of thwarting them when financially convenient.

Moreover, under a single-payer system, nobody would change networks — because there wouldn’t be any networks. Doctors could build long-lasting, rewarding relationships with patients again. Between less time on billing paperwork, more continuity in care, and no private insurers prohibiting them from healing the sick, it’s really not so hard to see why physicians are warming to Medicare for All.

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