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More about the crisis of lack of interoperability

More about the crisis of lack of interoperability

A private health care information technology system

By Don McCanne, M.D.
Physicians for a National Health Program, Quote of the Day, July 21, 2004

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The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care

By David J. Brailer, MD, PhD, National Coordinator for Health Information Technology
Health and Human Services, July 21, 2004

Health information technology provides a mechanism for refocusing care delivery around consumers without substantial regulation and industry upheaval. Information technology can result in better care (care that is higher in quality, safer, and more consumer responsive) and at the same time, more efficient (care that is appropriate, available, and less wasteful).

The private sector role

While the federal government plays an important role in HIT adoption, the effective use of, and value creation from, this technology lies predominantly with the private sector. The federal government will provide a vision and a strategic direction for a national interoperable health care system, but will rely on a competitive technology industry, privately operated support services, and shared investments in HIT adoption. The private sector must develop the market institutions to deliver the products and services that can transform the paper-based health care system into an electronic, consumer-centered, and quality-based system. The private sector can best ensure that HIT products are successfully implemented in ways that meet the varying needs of American health care across settings, cultures, and geographies. The private sector can also continue constant innovation in HIT and ensure that products are delivered on an affordable basis.

Federal and state governments have delegated most components of quality assurance to voluntary private organizations, including but not limited, to the JCAHO, NCQA, the National Quality Forum, residency review committees, and others. This will be true of quality and performance accountability in the future world of HIT. New market institutions need to be developed that can support clinician adoption of HIT, provide interoperability, and enhance the value realized by these investments. Close collaboration between public and private sectors can develop new methods for improving care without creating unnecessary regulation and minimizing reporting burdens on private industry.

Comment by Don McCanne, M.D. (7/21/04):

The private, competitive market has produced for us computers that are powerful yet inexpensive. Software that is used widely is quite inexpensive, and that in the public domain is essentially free after the initial development costs. With inexpensive computers and software developed in the public domain, the cost of an integrated health care IT (information technology) system should be quite modest. And the return in error reduction and administrative efficiency would far more than offset any real costs.

The Veterans Administration is far ahead of the rest of the nation in developing and utilizing an integrated IT system. And this has been developed in the public (government!) sector. Many other nations with universal health care systems have also introduced integrated IT systems primarily through the public sector.

What has the magic of the competitive marketplace produced in the way of an integrated IT system to this date? High costs, very poor penetration, and system failures! Competitive market theory dictates that we should be leading the world with a high quality health care IT system at a low cost. What went wrong?

First of all, a fragmented system of multiple private plans, public programs and uninsurance does not provide an infrastructure that is very conducive to an integrated IT system. A single payer system, or, at minimum, a highly regulated system of universal coverage through multiple plans, would provide a framework that would ensure adaptability of an integrated IT system. Of course, a single, publicly administered system would be much preferred for an integrated IT system.

But the greatest difficulty with private IT solutions lies in the very nature of these marketplace models. Their goals are, above all, to maximize profits and to maximize the market price of their shares. To achieve those goals, corporate behavior varies from that of a public entity that has a simpler goal of establishing an effective and efficient high quality system that serves the heath care system and its patients well. The public system does not have to be concerned about being a successful business enterprise, but the private model does.

What might the private sector do that doesn’t serve our interests well? They will produce products that command the highest prices that the market will bear. They will design the products to provide a continuing revenue stream. Once gaining a significant share of the market, they will design incompatibility with other systems in an attempt to garner the entire market. They will design obsolescence into their systems to ensure future markets for their new innovative products. They will partner with and perhaps acquire other related entities that can expand profit potentials through greater control of components of the health care system which their products can influence. Although these are good business practices, they are terrible policies for our health care system.

But without market incentives, wouldn’t innovation be suppressed? We have market innovations now, and they have not resulted in the IT developments that we desperately need. Public innovations have been effective in developing systems in other nations and in the VA that are already working. If private entrepreneurs can develop innovations that could benefit a public system, there is no reason that they couldn’t be sold to the government to place in the public domain. But they should be priced to reflect costs plus a fair one-time profit. We really don’t need more superfluous profit centers in our health care system.

The health information technology report released today should alarm us all. Although we all agree on the importance of an integrated IT system, the Bush administration is limiting the role of the government to being an enabler that encourages the private sector to develop a successful business model. Rather than higher quality at a lower cost, we’ll end up with mediocrity at a much higher cost, wasting even more of our health care dollars.

We desperately need strong leadership from our government in developing a health care IT system that will serve us all well. But based on the current leadership that has failed to address even the fundamental issue of adequate health care coverage for all, it is unlikely that we’ll see any enlightened leadership on this in the near future.

https://pnhp.org…

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Meeting Meaningful Use Criteria and Managing Patient Populations

By Philip A. Verhoef, M.D., Ph.D.
Annals of Internal Medicine, November 19, 2013

To the Editor:

I read with interest DesRoches and colleagues’ article on assessing physician use of EHRs and whether such use was meaningful, as outlined by the Centers for Medicare & Medicaid Services. The fundamental flaw in the authors’ research question (and in the Centers for Medicare & Medicaid Services’ misguided use of this metric) is that the meaningful use criteria pertain to patient care, but the commercially available EHRs are invariably designed to optimize billing and insurance reimbursement. Thus, the finding that fewer than 1 in 10 physicians reported being able to use their systems to meet meaningful use criteria is hardly surprising.

The commercial EHR has resulted in more money in the pockets of physicians who use it, although it has failed to facilitate meaningful use or show overall cost-savings. Further, one need only look at the U.S. Department of Veterans Affairs Veterans Health Information Systems and Technology Architecture (VistA) Computerized Patient Record System as an example of an EHR that was designed to optimize patient care and has successfully achieved meaningful use. The West Virginia Department of Health implemented a statewide modified VistA system for one tenth the cost of the introduction of the Epic system (Epic Systems, Verona, Wisconsin) at West Virginia University.

The VistA system within the U.S. Department of Veterans Affairs allows easy exchange of information with physicians around the country because all of the hospital inpatient and outpatient sites are linked. Both Veterans Affairs and non–Veterans Affairs hospitals using the VistA system are among the few in the nation that achieve measurable meaningful use according to the Healthcare Information and Management Systems Society. Finally, the VistA system has won repeated accolades over the past 2 decades for its ease of use and for improving efficiency and optimizing prescription accuracy.

Why, then, would a physician or health system implement anything other than the VistA EHR if they seek to use an EHR in a meaningful way, as the Centers for Medicare & Medicaid Services mandates? Stated differently, and in parallel with our current health financing crisis, why do we pay so much more for a privately delivered product that is so much less effective than one developed with taxpayer dollars?

https://www.ncbi.nlm.nih.gov…

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National Coordinator Rucker Urges CMIOs to Participate in Helping to Improve Interoperability, Usability

By Mark Hagland
Healthcare Informatics, March 5, 2018

Moving forward towards greater interoperability and usability will take time and effort, (National Coordinator Donald) Rucker said, but he said he remained convinced that much will change in the coming years, some of it stimulated by the federal government, but a great bulk of it stimulated by consumer empowerment and the mechanisms of the free market.

https://www.healthcare-informatics.com…

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Comment:

By Don McCanne, M.D.

Yesterday’s message discussed the failure of our conservative government stewards, past and present, to move forward with an effective plan that would establish much needed interoperability of the health care IT system throughout the nation. More needs to be said now because the current path will have serious negative consequences for decades to come for our health care delivery system and its patients. And ultimately health care should be all about the patients.

It was mentioned that David Brailer, the first National Coordinator for Health Information Technology, had decided that the system, including interoperability, should be developed in the private sector. In a Quote of the Day message published in 2004 (above), he said that the federal government “will rely on a competitive technology industry, privately operated support services” in the creation of “a national interoperable health care system.”

Rather than repeating here, please read my comment from 7/21/04 (above). The state of the art at that time was the VA’s VistA system. It was owned by us, the people of the United States, and was a far better system at a small fraction of the cost of the systems being privately developed. Most important, the VistA system was designed to benefit patients, whereas the private systems were designed to fulfill entrepreneurial dreams of control and wealth.

A decade later, Philip Verhoef, in the Annals of Internal Medicine, describes the consequences of the decision to place control of electronic health records in the hands of the private sector. As he says, “why do we pay so much more for a privately delivered product that is so much less effective than one developed with taxpayer dollars?” And now, over four years later, the politicians still have learned nothing. (Philip Verhoef is a board member of Physicians for a National Health Program – an organization with a mission dedicated to patients.)

The current National Coordinator for Health Information Technology, Donald Rucker, at a meeting this week said that moving forward towards greater interoperability and usability will be stimulated by consumer empowerment and the mechanisms of the free market. VistA certainly is not a free market creation. Even the Internet was a government creation.

Perhaps the most arrogant comment this week was by the White House’s Jared Kushner who gleefully took credit for the “huge win” in bringing in the private IT vendor Cerner to displace the VistA system at the time that the VistA system was successfully undergoing an upgrade. The “win” is that the VA will copy the Cerner system currently being implemented for the active duty military – a process that has been described as “We took a broken system and just broke it completely.” That’s okay as long as it’s the private sector that gets to break it.

There are some things that the government does better than the private sector, like health IT. The issue is not public versus private, both have a role. The issue is that you do not elect/appoint as your government stewards people who do not believe in government, especially those individuals who support policies that take very good care of the wealthy while leaving the rest of us flat.

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Our incompetent stewards for health IT interoperability

‘We took a broken system and just broke it completely’

By Arthur Allen
POLITICO, March 8, 2018

President Donald Trump last year hailed a multibillion-dollar initiative to create a seamless digital health system for active duty military and the VA that he said would deliver “faster, better, and far better quality care.”

But the military’s $4.3 billion Cerner medical record system has utterly failed to achieve those goals at the first hospitals that went online. Instead, technical glitches and poor training have caused dangerous errors and reduced the number of patients who can be treated, according to interviews with more than 25 military and Veterans Affairs health IT specialists and doctors, including six who work at the four Pacific Northwest military medical facilities that rolled out the software over the past year.

Prescription requests came out wrong at the pharmacy. Physician referrals failed to go through to specialists. Physicians were unsure how to do basic things such as request lab reports. Doctors complained it could take 10 minutes to get into the system, which then frequently kicked them out.

“We took a broken system and just broke it completely,” said one doctor, who like most of those interviewed requested anonymity because they lacked military authorization to speak about the project.

These and other problems, particularly concerns about the VA’s ability to share records with civilian health systems, contributed to VA Secretary David Shulkin’s decision in December to delay signing a $10 billion contract to install Cerner at the VA.

Despite the startup issues, which have been glossed over in public discussion of the project, the White House continues to make the overhaul of the military and VA medical records a centerpiece of its government reform efforts.

“This was a huge win for our service,” Jared Kushner told a health IT conference in Las Vegas on Tuesday, referring to Shulkin’s decision last spring to use Cerner following consultations with Kushner’s office. “The president wants to make interoperable health records available for all Americans.”

But Kushner’s comments gave the impression the military had already created an electronic record system, and was just waiting for the VA to connect to it. In fact, the military’s MHS Genesis project, which started rolling out in February 2017, is still in the early stages, with completion scheduled for 2022.

And the tough experiences described by doctors and others suggest a thorny path ahead.

Efficiency promises notwithstanding, the new system has resulted in significant slowdowns so far, said physicians at the two hospitals that went live with MHS Genesis in September and October, respectively. At Bremerton, the system is so cumbersome and confusing that doctors who saw 18 to 20 patients a day now see 12 or 14, they said.

Shulkin’s decision to delay the contract won widespread praise, but critics bemoan his decision last year to shutter an internal program to modernize the VA’s existing digital record system, known as VistA. Many health IT experts left the agency after cancellation of the program, which involved hundreds of staff and contractors.

“We’re doing a once-in-a-lifetime replacement of an … [existing electronic health record system] that’s pretty functional — some of our physicians like it better than Epic or Cerner,” said a recently retired VA official. “Why replace it with something that’s basically the same?”

https://www.politico.com…

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ONC chief Donald Rucker lays out his agency’s very full plate

By Mike Miliard
Healthcare IT News, March 7, 2018

In an evening session at HIMSS18 on Tuesday, National Coordinator for Health IT Donald Rucker, MD, sat down for a candid talk about an array of issues related to federal healthcare policy.

On what makes interoperability so hard for healthcare:

What makes it hard is that you have to solve for multiple things at once. We have to solve simultaneously for just the physical wiring, the interoperability stack. We have to solve for the simple syntactic standards of data transmission. We have to come to some consensus for semantic interoperability: what was the meaning of what was transmitted. And then finally, we have to deal with the business case. And the business cases are hard to deal with because some of these cases are virtual things in the future, involving competitors, and business models that don’t exist at the present. And if that weren’t enough, we have to do it with privacy and security. That’s what makes it hard.

http://www.healthcareitnews.com…

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Comment:

By Don McCanne, M.D.

If we were to fulfill the dream of having immediate Internet access to any prior medical records throughout the nation, it was important that IT systems be interoperable. However, when David Brailer was appointed George W. Bush’s first IT guru, he insisted that the systems be developed in the private sector, rejecting a proven system that we, the taxpayers, already owned – the VA’s VistA system.

It was clear at the time that the private vendors did not want interoperability with any other systems than their own. Each wanted to become the dominant system, Microsoft-style, so that new purchasers of health IT systems would have to go with the dominant vendor to ensure interoperability. As it turns out, there are too many systems, and they are not interoperable. But the Trump administration is now claiming that they will bring interoperability to us, but through the private sector.

So what does the current IT guru, Donald Rucker, have to say about interoperability? He says, “we have to deal with the business case, and the business cases are hard to deal with because some of these cases are virtual things in the future, involving competitors, and business models that don’t exist at the present.” The business case.

In a speech at the same IT conference in Las Vegas this week, Jared Kushner is taking credit for the “huge win” for bringing in the private vendor Cerner to replace the VistA system, saying, “The president wants to make interoperable health records available for all Americans.” Well the interoperability is intended to be between the military’s health IT system and the VA system. He seems to assume that the military system being designed by Cerner is a given, but this report indicates that it has been a disaster and it has hardly even gotten off the ground. And that is going to be duplicated for the VA?

It’s too bad because the VistA system was undergoing modernization when the new administration shut the process down (and lost hundreds of highly competent staff and contractors).

Insisting on private sector solutions for interoperability has been a disaster, just as the private sector has been a disaster in financing of our health care system when a public single payer system would be vastly superior. Is Trump going to put Jared in charge of further privatizing our health care financing? Can hardly wait.

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

How to lower the cost of prescription drugs

By Leslie Hartley Gise, M.D.
The Maui (Hawaii) News, Letters, March 8, 2018

The high cost of prescription drugs is a common complaint and was in this newspaper in the Feb. 9 editorial, “Out-of-control health system.” The solution is simple. We have already done it. If our Congress would vote to allow Medicare to bargain with drug companies, like the VA already does, prices would drop significantly.

Drug companies were not penalized by the Affordable Care Act. Their profits and stock prices are soaring. Drug companies claim they need high costs to do research, but the vast majority of drug research is done by the government and at universities. Drug companies take over in the later stages when a drug is ready for testing on people. They focus on drugs that folks need to take for life and drugs that are still on patent. And they market aggressively.

They patent profitable “me too” drugs which are no better than the ones we already have. Their high costs are related to marketing, profits and administration. Drug companies spend enormous amount of money on lobbying and contribute massively to our legislators and to our FDA. We need to elect legislators who care about us and are not beholden to the pharmaceutical industry.

http://www.mauinews.com…

Worker health coverage needs rethinking

The recent contract negotiations between union workers and Hannaford provides an opportunity to examine the health care model.

By Daniel Bryant, M.D.
The Portland (Maine) Press Herald, Letters, March 8, 2018

Employment-based health insurance, now covering 56 percent of the nonelderly population, was introduced during World War II to help employers avoid wage controls. The issue of health care coverage in the recent contract negotiations between United Food and Commercial Workers Local 1445 and the company that operates the South Portland Hannaford distribution center provides an opportunity to examine that persisting model. When we do, several problems leap out.

• Employers are saddled with the unpredictable cost and hassle of insuring workers, while remaining vulnerable, as in the Hannaford case, to the threat of strikes. (A 2003 strike over health care benefits in Southern California cost three grocery chains over $2 billion.)

“In most labor negotiations during the past 30 years, more time and effort has probably been spent on the health care plans provided by labor agreements than on any other contract provisions, including pensions,” attorney Arthur Smith Jr. wrote in HR Magazine in 2013.

• Workers can’t see what they’re paying for health insurance within overall labor costs, have no guarantee that their plan or network will remain the same and risk losing coverage if they leave for any reason (the average worker has 11.9 jobs from age 18 to age 50, according to the Bureau of Labor Statistics). An employer’s retention advantage can be an employee’s job lock.

• When commercial insurers insure employees, they are cherry-picking the healthiest demographic, leaving the poorest, sickest and oldest pool to be funded by increased taxes and cost-shifting. And sometimes blamed (“state patients”).

The possibility of another strike at a Hannaford distribution center may not be as newsworthy as assault weapons or Russian meddling, but it should serve to remind us, when we get back to the issue of health care reform, that we should not let outdated conventions and entrenched interests keep us from rethinking the relevance of today’s workplace to today’s health care.

https://www.pressherald.com…

Doctors welcome Rep. Keith Ellison as new lead sponsor of Medicare for all bill

Unlike incremental reforms, single-payer plan is the only way to achieve both universal coverage and cost control

FOR IMMEDIATE RELEASE, March 7, 2018
Contact: Clare Fauke, communications specialist, 312-782-6006, clare@pnhp.org

Physicians for a National health Program (PNHP), the leading national physicians group advocating for single payer health care reform, welcomed Rep. Keith Ellison (D-Minn.) as the new lead sponsor of H.R. 676, the Expanded and Improved Medicare for All Act. That single-payer bill was modeled after a proposal originally crafted by PNHP that appeared in the Journal of the American Medical Association. It would improve Medicare’s benefits to include all medically necessary care, eliminate copayments and deductibles, and expand Medicare to cover everyone living in the U.S.

Universal health coverage has seen a surge in public support; a recent poll showed 92 percent of U.S. adults (including 82 percent of Republicans) believe that all Americans should have the right to affordable health care. H.R. 676 now has a record 121 co-sponsors, representing 63 percent of all House Democrats. PNHP, a nonprofit research and education organization with more than 22,000 members, notes that H.R. 676 would be far preferable to incremental reforms that would offer less comprehensive coverage at higher costs. Single payer would save an estimated $617 billion annually by slashing the administrative waste of private insurance and the paperwork insurers impose on hospitals and doctors ($504 billion), and bargaining down drug prices ($113 billion). That would free up enough money for universal, first-dollar coverage without any net increase in U.S. health spending.

“Everyone from Jeff Bezos to Paul Ryan is pushing ideas for how to reinvent health care,” said Dr. Carol Paris, a Nashville-based psychiatrist and president of PNHP. “Lots of groups claim they have a plan that can get to ‘universal coverage,’ but only a single-payer bill like H.R. 676 can get the cost savings that make universal coverage both feasible and sustainable. We welcome Rep. Ellison as the new lead sponsor of H.R. 676 and will work with him to win even more support for Medicare for all.”

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization whose more than 22,000 members support single-payer national health insurance.

White House memo on ‘Obamacare Relief Provisions’

White House pitch to bolster Obamacare includes tough trade-offs for Democrats

By Paul Demko
POLITICO, March 6, 2018

The White House is seeking a package of conservative policy concessions — some of which are certain to antagonize Democrats — in return for backing a legislative package bolstering Obamacare markets, according to a document obtained by POLITICO.

The source of the document provided to POLITICO isn’t identified and it isn’t dated. The White House declined to comment on the document but didn’t question its authenticity. A spokesperson for HHS said the department does not comment on leaked documents.

Two health policy experts who have been in contact with White House officials indicated that the document is consistent with ideas the administration has discussed for creating more stability and flexibility in the insurance markets.

“It’s legit,” said one former White House policy official.

https://www.politico.com…

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Unmarked memo purportedly from the White House

Obamacare Relief Provisions Congress Should Pursue

Obamacare has led to skyrocketing premiums and declining choices for American families. Middle-class families, in particular, have seen their premiums and deductibles soar year after year as a result of the law. Although congressional efforts to provide taxpayer money to prop up the exchanges is understandable, any such efforts must also provide relief to middle-class families harmed by the law and protect life. In order to support such efforts, the administration believes these three policies to provide greater choice and control for middle-class families must be included:

* Increase consumer options of more affordable, flexible insurance coverage by clarifying that issuers selling short-term, limited-duration insurance may offer renewals of that coverage to individuals without those individuals going through health underwriting.

* Increase control for middle-class families over their healthcare dollars by expanding Americans’ access to health savings accounts (HSAs). This will enable middle-class families to save pre-tax dollars for their healthcare expenses and help put them back in control of their healthcare. This can be accomplished by raising HSA contribution limits and allowing HSAs to be integrated with a broader number of plans.

* Modify age-rating requirements to permit premium variation of up to 5:1 in the individual and small group markets.

In addition to these three policies, any efforts to provide taxpayer money to stabilize the exchanges must be properly designed so that public dollars do the most good and that ensures all federal dollars are life-protected. The president also supports congressional efforts to fund and life-protect Obamacare’s cost-sharing reduction (CSR) payments after 2018. This would lower premiums for those who purchase their coverage on the exchanges as well as decrease federal spending due to a reduction in the premium tax credit amounts.

https://www.politico.com…

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Comment:

By Don McCanne, M.D.

This brief memo from the White House seems to be authentic. It lists three policies that the administration says must be included as part of “Obamacare relief provisions” that Congress should pursue.

Perhaps the most alarming must-include policy is making short-term, limited-duration junk insurance renewable without further health underwriting. Since these policies will be almost worthless as far as the benefits they will provide, they will have low premiums and thus be affordable for those who otherwise could not pay for ACA-compliant plans. They may become popular with the perception that these plans would be better than nothing at all, though that is questionable. And making them renewable means that they are no longer limited-duration plans, and thus may become the standard for those who are not eligible for subsidized plans. An increase in personal bankruptcies for those with greater health care needs would be inevitable.

Another must-include policy is expanding “access” to health savings accounts (HSAs), enabling families to “save” pre-tax dollars for their health care expenses. The main difference between an HSA and any other savings account is the tax benefit which is highly regressive since it provides a tax expenditure that is proportional to income. Those who pay no taxes receive no benefit whereas the wealthy receive the most. Also most families with only modest incomes are not able to fund their HSAs. Having access to an empty HSA is of no value. So HSAs really do work for the healthy and wealthy, but not for many of the rest of us who don’t have the funds in the first place.

The third must-include policy is to jack up premiums for older individuals in the individual and small group markets. This may provide some premium relief for the young invincibles, but many older individuals not yet eligible for Medicare will find it very difficult if not impossible to pay premiums that are five times what younger individuals would be paying. This defeats the fundamental insurance function of arranging a transfer from the younger and healthier to the older and more infirm.

One other item in this memo is the recommendation to fund ACA cost-sharing reduction (CSR) payments after 2018. This is not as altruistic as it seems. The CSR payments would reduce the costs to the insurers, allowing them to reduce the premiums thus reducing premium subsidies that the government would be paying. That would help to reduce the federal budget deficit – an important PR move in an election year and the primary reason for this recommendation. But wouldn’t the CSR payments offset that reduction? Simple. Though it is not stated in this particular memo, they have decided to move the CSR payments off-budget, just like they pay for wars.

And about the code language of “life-protected” federal dollars…

Again, the most important item in this memo is that they want to make cheap junk insurance the new standard in the private insurance market – by making it renewable. That would destroy the private insurance markets without providing any other option. The pain inflicted might increase support for a single payer Medicare for all program, but tolerating that much physical and financial suffering is a terrible way to drive the political agenda that we need. Let’s just go to single payer now before more harm is done.

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

The West Virginia teachers’ strike is over. But the fight for healthcare isn’t.

The strike was largely about healthcare benefits, which the deal for the most part skirted

By Adam Gaffney, M.D.
The Guardian, March 7, 2018

A wildcat teachers’ strike that roiled West Virginia for nine long days ended on Tuesday, after the state government passed a 5% pay hike. For a state that doesn’t even allow state employees to engage in collective bargaining, this amounts to a historic victory. Yet much remains undone.

The strike was largely about healthcare benefits, which the deal mostly skirted. Even worse, the educators’ hard-won raise could come at the expense of other important state programs – potentially Medicaid, although this remains uncertain. Such an outcome only reaffirms a lesson made explicit throughout labor history: universal healthcare programs, rather than private benefits won through collective bargaining, must be a priority for organized labor.

Between rising healthcare costs on one hand and public austerity on the other, West Virginia’s teachers’ health insurance plans had grown gradually worse in recent years, reflecting the situation throughout much of the country. As one teacher told the Los Angeles Times, pay was “not what kept us out. It’s the insurance. That’s the big deal.”

A glance at the 64-page “Shopper’s Guide” teachers were forced to navigate illustrates just how hellish their options had become: in addition to rising monthly premiums, plan holders faced onerous deductibles, copays, and coinsurance for everything from prescription drugs to childbirth.

Most notoriously, they also faced coerced use of a patronizing app called Go365, a so-called “workplace wellness program.” “They implemented Go365,” one teacher told the New York Times “which is an app that I’m supposed to download on my phone, to track my steps, to earn points through this app. If I don’t earn enough points, and if I choose not to use the app, then I’m penalized…”

Such programs are being pushed on to workers everywhere. They were encouraged by the Affordable Care Act despite paltry evidence that they save money, much less improve health (although they may serve to push costs on to sicker workers). Workers, meanwhile, understandably find reporting their personal health information to their boss (much less being penalized for their cholesterol or BMI) paternalistic and Orwellian.

Go365 caused an uproar, and its penalties were dropped in January, while premium and deductible hikes have been deferred for now. However, the strike deal otherwise left healthcare untouched, apart from creating a taskforce to find solutions for the problem of rising costs. We can assume that its proposed solutions will be insufficient, at least in the long run: as long as health coverage remains a privatized benefit and not a public good, American workers’ healthcare will periodically return to the chopping block.

This is evident from Appalachia’s own long history of strikes over healthcare. In 1946, a strike by the United Mine Workers (UMW) ended with a famous agreement that brought its members comprehensive healthcare, paid for by a tax on coal.

The striking teachers have drawn inspiration from these “mine wars,” even brandishing the red bandannas said to have been worn by rifle-toting coalminers during the 1921 Battle of Blair Mountain, which pitched them against a powerful private militia in an epic gunfight over union rights.

Yet the teachers’ strike is connected to that bloody history in a more complex sense as well. As labor historian Alan Derickson has written, the UMW’s 1946 historic healthcare victory “gave other unions hope for gains in health benefits through collective bargaining,” but it also took the UMW away from the national health insurance cause.

Other big unions followed, such that by the late 50s, labor “had abandoned the goal of protection for the entire population.” The teachers’ inadequate healthcare coverage today, in other words, is in part the consequence of labor’s turn away from universal healthcare in history.

Unions, of course, must win benefits and protections for their workers in the short term. But the teachers – and organized labor as a whole – will have to go beyond what the miners long ago accomplished to make the rights of all workers secure, for a privatized welfare state cannot take the place of a public program of universal healthcare. That struggle remains ahead.

Dr. Adam Gaffney is an instructor in medicine at Harvard Medical School and a pulmonary and critical care doctor at the Cambridge Health Alliance. He is secretary and president-elect of the advocacy organization Physicians for a National Health Program.

https://www.theguardian.com…

CMS may be moving forward with Medicare vouchers

GOP’s proposed Medicare voucher program would lead to demise of the system

By Max Richtman
The Hill, March 5, 2018

A request for public comment from the Centers for Medicare and Medicaid Services (CMS) has caught the eye of a group of Democratic Senators, alarmed about its implications for the future of Medicare.

In February, 15 Senators sent a letter to CMS Administrator Seema Verma expressing concern over a Fall, 2017 Request for Information (RFI) regarding a “new direction” for Medicare’s Innovation Center — and the agency’s subsequent failure to make public the more than 1,000 comments it received.

At the heart of the Senator’s concerns is ambiguous language in the RFI that suggests a shift toward converting Medicare into a voucher program, which would, “fundamentally restructure the guaranteed benefit traditional Medicare provides to older adults and people with disabilities.” 

The Senator’s concerns are well-founded, since Republicans in Congress (most prominently, Speaker Paul Ryan) have long-dreamed of privatizing Medicare by turning it into a voucher system — something that we and other senior organizations adamantly oppose.

Under the GOP’s voucher system, private plans could tailor their benefits to attract the youngest and healthiest seniors, leaving traditional Medicare with older and sicker beneficiaries.

Their higher health care costs would lead to higher premiums that seniors would be unable or unwilling to pay, resulting in a death spiral for traditional Medicare. 

This latest action is part of an ideological tilt to the right by CMS under Verma’s leadership — with subversion of traditional Medicare as one of the apparent aims.

The agency has demonstrated a bias toward private Medicare Advantage plans over traditional Medicare.

In the case of the implicit shift toward privatizing Medicare, the 15 Senators suggest that CMS may be breaking the law.

“We believe you are violating statutory requirements to safeguard older adults and people with disabilities from paying onerous out-of-pocket costs and going without needed health care,” says their letter to Verma.

Max Richtman is president and CEO of the National Committee to Preserve Social Security and Medicare.

http://thehill.com…

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Centers for Medicare & Medicaid Services: Innovation Center New Direction

Through this informal Request for Information (RFI) the CMS Innovation Center (Innovation Center) is seeking your feedback on a new direction to promote patient-centered care and test market-driven reforms that empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, reduce costs, and improve outcomes.

II. Provisions of this RFI

B. Potential Models

2. Consumer-Directed Care & Market-Based Innovation Models

CMS believes beneficiaries should be empowered as consumers to drive change in the health system through their choices. Consumer-directed care models could empower Medicare, Medicaid, and CHIP beneficiaries to make choices from among competitors in a market-driven healthcare system. To better inform consumers about the cost and quality implications of different choices, CMS may develop models to facilitate and encourage price and quality transparency, including the compilation, analysis, and release of cost data and quality metrics that inform beneficiaries about their choices. CMS will consider new options for beneficiaries to promote consumerism and transparency. For example, beneficiaries could choose to participate in arrangements that would allow them to keep some of the savings when they choose a lower-cost option, or that incentivize them to achieve better health. Models that we are considering testing include allowing Medicare beneficiaries to contract directly with healthcare providers, having providers propose prices to inform beneficiary choices and transparency, offering bundled payments for full episodes of care with groups of providers bidding on the payment amount, and launching preferred provider networks.

5. Medicare Advantage (MA) Innovation Models

CMS wants to work with Medicare Advantage (MA) plans to drive innovation, better quality and outcomes, and lower costs. CMS seeks to provide MA plans the flexibility to innovate and achieve better outcomes. CMS is currently implementing an MA plan model, the Medicare Advantage Value-Based Insurance Design (VBID) model, that provides benefit design flexibility to incentivize beneficiaries to choose high-value services; but this model could be modified to provide more flexibility to MA plans and potentially add additional states. More generally, CMS is interested in more models in the MA plan space and regulatory flexibility as necessary for purposes of testing such models. CMS is potentially interested in a demonstration in Medicare Advantage that incentivizes MA plans to compete for beneficiaries, including those beneficiaries currently in Medicare fee-for-service (FFS), based on quality and cost in a transparent manner. CMS is also interested in what additional flexibilities are needed regarding supplemental benefits that could be included to increase choice, improve care quality, and reduce cost. Additionally, CMS seeks comments on what options might exist beyond FFS and MA for paying for care delivery that incorporate price sensitivity and a consumer driven or directed focus and might be tested as alternatives to FFS and MA.

https://innovation.cms.gov…

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Letter to Ms. Seema Verma, Administrator, CMS

United States Senate, February 22, 2018

Excerpts:

We are writing to express our continued opposition to the concepts unveiled and the process used in a Request for Information (RFI) regarding “a new direction” for Center for Medicare and Medicaid Innovation (Innovation Center). …we continue to urge you to provide clarity on the specific model types under consideration.

In the RFI, CMS appeared to seek input on a possible model to restructure Medicare through a premium support or voucher program. We interpreted the RFI to mean that CMS is considering models that would fundamentally restructure the guaranteed benefit traditional Medicare provides to older adults and people with disabilities. Other Members of Congress, select journalists as well as patient and consumer advocates have expressed a similar interpretation and voiced concerns about the Innovation Center’s intentions.

While we understand that the RFI does not explicitly mention the terms ‘premium support’ or ‘voucher,’ the ambiguity of the proposal allows for a variety of interpretations… Absent further clarification, we do not believe Members of Congress, diverse stakeholders in the health community, and the public were provided a sufficient opportunity to comment on the model concepts outlined in the RFI.

Our concern is compounded by the fact that the proposals under consideration may not allow for Medicare beneficiaries to maintain choice and that beneficiaries may not have the ability to opt out of Innovation Center models.

Additionally, we remain troubled by the Innovation Center’s plans to develop and implement the payment model described as “…allowing Medicare beneficiaries to contract directly with healthcare providers.” We believe you are violating statutory requirements to safeguard older adults and people with disabilities from paying onerous out-of-pocket costs and going without needed care.

Again, we urge you to publicly post RFI comments instead of obfuscating regular process in order to withhold unfavorable comments from public view or decide against responding to certain comments.

Signed, Senators Casey, Nelson, Brown, Whitehouse, Gillibrand, Market, Donnelly, Shaheen, Reed, Warren, Blumenthal, King, Cardin, Menendez, and Smith

https://www.aging.senate.gov…

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Comment:

By Don McCanne, M.D.

Without waiting for Congress to act, the Trump administration is moving forward with policies to shift government health programs to the private sector. The conservatives have long desired to privatize Medicare through premium support (vouchers), and it appears that they have devised a deceptive means of sneaking it in through this Request for Information. We need to watch this process closely, even though it is taking place behind closed doors, lest we find that it is published in the Federal Register and becomes the regulatory law of the land by administrative fiat.

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The Humans in Health Care—A Review of The American Mercy Tour

By Christopher C. Muth, M.D.
JAMA, March 6, 2018

Under the influence of partisan politics, health insurance and pharmaceutical companies, and hospital administrators, the US health care system often seems to function at odds with the interests of primary care physicians working within the system and the patients the system is supposedly designed to help.

Two plays, Mercy Killers and Side Effects, provide a much-needed reminder of the humanity of these individuals, arguably the most-crucial and least-powerful players in the drama of US health care.

Both plays are 1-act solo performances written and performed by the lively and dynamic Michael Milligan, a veteran actor and playwright who recently staged them back-to-back as The American Mercy Tour at the Greenhouse Theater Center in Chicago, Illinois, and who will tour them nationally in 2018.

full article:
https://jamanetwork.com…

Health Care for All worth a look

By James Fieseher, M.D.
Foster’s Daily Democrat (Dover, N.H.), March 6, 2018       

To the Editor:

Consider this: Suppose there was a way to cut all medical costs by 50 percent, improve the quality of health care you get when you do need to see a health appointment, decrease the number of sick days a person has over a lifetime and increase the average age of a person’s lifetime? At the same time, we could decrease or eliminate a significant portion of overhead for New Hampshire’s businesses?

Before you call the mental health specialists to have me hauled away (unlikely, considering the decreasing number of mental health specialists we have left in the state), there is actually a bill brought before the state Legislature that has the potential to do all of that. It is HB 1241 and it is a bill the would have the state “study the benefits and costs of a Health Care for All program in New Hampshire.”

The United States spends at least twice as much money per person on health care as people in other industrialized nations. It consumes over 18 percent of our GNP. Other countries get better health care and their citizen on average live longer than we do according to every independent international survey. Their health care is not linked to employers or businesses, so their businesses do not have to provide health care as part of their overhead costs, which make their products more competitive on the open market.

Our health care system is based upon socioeconomic status. If you have enough money and a job with the right employer, you get health care. Your employer picks you plan options and determines what percentage of your plan you must pay for. Your choice of doctor depends entirely upon the health plan your employer picked. You may or may not get a pay raise in your job from one year to the next, but if your health costs go up every year, you’re losing money in the long run. As I write this letter, the teachers in West Virginia are on a prolonged strike for just that very reason: their health care costs have risen far higher than their salaries can afford. If it can happen there, it can happen here as well.

A “Health Care for All” plan is not a new idea. It has been tried and tested many times over. All other industrialized nations have some version of this plan. Many are single-payer systems, but there are other versions that involve multiple payers that work as well. We even have two systems here in the United States that provide terrific health care at a much smaller cost: the V.A. health system and Medicare.

There is no perfect system and each system has its flaws. But the point is, all of them work better and cover more people than what we have now.

So why should you consider the pros and cons of a “Health Care for All” system? Because your state legislature will not. When presented with a chance to even consider a plan that would give every man, woman and child health care at a total cost much less than what we’re paying now, they said they wouldn’t even consider it. When presented with the possibility to lower the overhead of all New Hampshire businesses and making New Hampshire a more business friendly environment, they said it wasn’t even worth thinking about.

What is going on here?

Consider this: contact your state representative and tell them to vote no on the motion to “ITL” (Inexpedient To Legislate) HB 1241. We should consider new ways of making New Hampshire a business friendly state and lowering the cost while raising the quality of health care for all citizens.

http://www.fosters.com…

CMS fails to verify benefits of waivered Medicaid demonstration projects

As Trump Pushes Medicaid Testing, the Grading Falls Short

By Robert Pear
The New York Times, March 4, 2018

The Trump administration is hoping to transform Medicaid by allowing states to test work requirements, premiums and other conservative policies, but a new government report says federal and state officials do not properly evaluate whether such experiments improve patient care or reduce costs.

Evaluations “generally lacked rigor,” and the findings were often kept secret for years, so they were of little use to policymakers, the Government Accountability Office, a nonpartisan investigative arm of Congress, said in the report issued last month.

Under federal law, the secretary of health and human services can waive certain Medicaid requirements so states can use federal money for the program in ways that would not ordinarily be allowed — for example, to cover people and services that would not otherwise be covered.

These waivers have been used for demonstration projects testing innovative ideas and involving millions of people and tens of billions of federal dollars. The Government Accountability Office said the number and scope of Medicaid waivers had grown in recent years, with demonstration projects now accounting for one-third of all federal Medicaid spending — and more than 75 percent in 10 states, including Texas.

The main purpose of the waivers, according to the report, is to test and evaluate new ways of providing coverage and care to people with modest incomes. But, it said, waivers have become a vehicle for wholesale changes in Medicaid, and neither federal nor state officials adequately assess the results. The evaluations have been plagued by “significant methodological weaknesses” and often leave critical questions unanswered, the report said.

The Trump administration has been flooded with requests from states seeking Medicaid waivers. They want to impose work requirements, charge premiums, suspend coverage for people who fail to pay premiums, and restrict eligibility or benefits in other ways. A few states would like to impose time limits on Medicaid coverage for some beneficiaries.

The Government Accountability Office found particular problems in the evaluation of a Medicaid waiver granted to Indiana. The state expanded Medicaid, as permitted under the Affordable Care Act, but obtained a federal waiver for policies emphasizing “personal responsibility,” including monthly premiums and incentives for healthy behavior.

The federal government wanted to know how Medicaid beneficiaries were affected by those changes, but it could not get the data it needed from the state, so its evaluation was severely limited, the Government Accountability Office said.

Conservatives see Indiana’s Medicaid program as a model, and other states are following suit. The architects of the Indiana plan include Vice President Mike Pence, who was the governor of Indiana from 2013 to January 2017, and Seema Verma, a consultant to the state who is now the administrator of the federal Centers for Medicare and Medicaid Services.

https://www.nytimes.com…

Government Accountability Office; Medicaid Demonstrations:
https://www.gao.gov…

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Success of Pence’s Medicaid expansion far from settled

By Virgil Dickson
Modern Healthcare, July 25, 2016

The success of the conservative approach to Medicaid devised by Indiana Gov. Mike Pence—Donald Trump’s pick for vice president—is a mixed bag so far, according to a report that offers fodder for both sides of the political spectrum.

A new analysis funded by the state shows both positive and concerning elements to Indiana’s alternative Medicaid expansion.

The report also comes as Indiana state officials continue to raise objections to the CMS performing its own analysis to see if Pence’s Medicaid expansion has been harmful to beneficiaries. Pence has argued there is no need for the agency to perform its own evaluation because the state already commissioned a report by the Lewin Group, an independent consultancy.

http://www.modernhealthcare.com…

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Trump approves Arkansas Medicaid work requirements

By Nathaniel Weixel
The Hill, March 5, 2018

Arkansas on Monday became the third state to get the Trump administration’s permission to impose work requirements on Medicaid beneficiaries.

The Centers for Medicare and Medicaid Services approved a Medicaid waiver that included a requirement for recipients to work, or participate in job training or job search activities for 80 hours a month.

State officials said they will begin implementing the work requirements June 1, making them the first state to do so. If a person fails to meet the requirements for three months, he or she will lose coverage for the rest of that calendar year.

http://thehill.com…

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Comment:

By Don McCanne, M.D.

Section 1115 Medicaid waivers allow states, with the approval of CMS, to establish demonstration projects that waive certain requirements of the Medicaid program as long as the objectives of the program are met. At the end of the waiver period, the results are to be formally evaluated. The GAO report shows us that these evaluations “lack rigor” and have not been released to provide important research results to the policy community.

Particularly important was the evaluation of the Indiana Medicaid waiver since it put into effect the conservative ideological preferences of Gov. Mike Pence (now vice-president) and Medicaid consultant Seema Verma (now CMS administrator). They contracted for a private study by the Lewin Group while fighting off a CMS evaluation. That is important because they both have touted the great advantages of their patient-empowerment Medicaid program when there is virtually no objective public data to show benefit – only the biased (and not all that impressive) report purchased from the Lewin Group.

Today, Arkansas followed Kentucky and Indiana to become the third state to be granted work requirements for Medicaid beneficiaries – a policy move based on conservative ideology rather than on patient benefit. We can anticipate a further expansion of anti-welfare warfare by the current administration.

When health care coverage is eventually expanded to cover everyone, it will be important to avoid segregating low-income individuals and families into an isolated welfare program. Such a program would always be vulnerable to attacks from anti-government political ideologues. Instead we need a universal egalitarian program that treats everyone fairly – a national single payer improved Medicare for all.

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

Americans already believe that everyone should have the right to affordable health care

Americans’ Views on Health Insurance at the End of a Turbulent Year

By Sara R. Collins, Munira Z. Gunja, Michelle M. Doty, Herman K. Bhupal
The Commonwealth Fund, March 1, 2018

The Commonwealth Fund Affordable Care Act Tracking Survey interviewed a random, nationally representative sample of 2,410 adults ages 19 to 64 between November 2 and December 27, 2017.

Do you think all Americans should have the right to affordable health care?

92% – Yes
7% – No
1% – Don’t know/Refused

Asked of the 8% who said no or don’t know/refused:

What if everyone had to contribute financially over their lifetime in order to have the right to affordable health care? Under those circumstances would you consider affordable health care to be a right?

29% – Yes
58% – No
13% – Don’t know/Refused

From the Policy Implications:

This survey’s finding that strong majorities of U.S. adults, regardless of party affiliation, believe that all Americans should have a right to affordable health care suggests there may be popular support for a discussion over our preferred path.

http://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

It has often been said that we cannot enact single payer Medicare for all until Americans agree that health care is a right. This survey shows that 94 percent of adults under 65 already agree that “all Americans should have the right to affordable health care.” Most of those over 65 already have it.

Let’s move on. We have work to do.

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