PNHP

Rescuing Primary Care, Part 1

Rescuing Primary Care, Part 1

Summary: In the first of two posts, we discuss a blog on how primary care is being acquired and distorted by huge corporations seeking massive profits by exploiting CMS value-based care, specifically capitation. The excerpt, a bit more than usual, is worth a read. Next time we’ll examine a proposal for making primary care a publicly-financed common good.

Explaining Corporate America’s Aggressive Investment In Primary Care, Health Affairs Forefront, April 5, 2023, by Paul A. Branstad & Claude R. Maechling

Not that long ago, primary care practices sold for hundreds of dollars per patient, depending on how “fat” their files were and what proportion were economically undesirable Medicare patients. 


Now, suddenly, the likes of Amazon, CVS Health, Walgreens, Walmart, UnitedHeath, and Humana are vying to acquire and build primary care practices targeted at serving the US’s seniors. 
  and the competition has driven prices north of $50,000 per patient. When the US finally grasps what is going on, how this competition was triggered in the first place, and what the long-term consequences will be, none of us will like it. 


Too late will we realize we have lost our last best chance to reinvent a health care system centered around the large-scale provision of high-quality primary care—even though this is what value-based contracts started out trying to do. The problem lies not with the Centers for Medicare and Medicaid Services’ (CMS’s) intentions, but with how the game they have structured plays out. 


The root cause of the $50 billion investment frenzy is the financial opportunity created by CMS’s commitment to convert all Medicare beneficiaries to accountable care relationships with value-based payment models. 
 [this] is just table stakes to vie for the $1 trillion prize that McKinsey and Company estimates will be claimed by the winners among the consumer oligopolists competing for the prize. 


CMS seems to lack the foresight to anticipate how market forces will adapt and respond to its policies, so it is not able to foresee unintended consequences of its reimbursement and insurance practices. 
 CMS’s tortuous primary care reimbursement practices have been more than 30 years in the making and have led directly to the erosion of the central role that primary care physicians could and should play. 


Our conclusion is: CMS’s commitment to value-based contracting is simply the next stage of its long-standing, philosophical aversion to fee-for-service reimbursement. This aversion is reflected in the increasing justification and reporting requirements imposed on primary care physicians, requirements that represent an affront to their integrity and challenge their medical judgment. The resulting suppression of practice revenue and increased administrative burden have pushed many previously independent primary care physicians past their breaking point and into the arms of hospital-based health systems.

It is not mere coincidence that, over the past decade, the percentage of primary care physicians employed by a hospital-based health system or corporate entity has increased from 36 percent to 74 percent, while MA coverage of Medicare beneficiaries increased from 27 percent to nearly 50 percent.

The issue is not about who owns primary care practices but about how the proliferation of value-based contracts in Medicare is leading to a profound change in the historic physician-patient relationship. The health systems and corporations that own primary care practices often find it most efficient to organize care delivery around CMS’s process-of-care measures to maximize their reimbursement opportunity. So physicians who, heretofore, practiced patient-centered medicine that earned trust by focusing on personalized diagnostic and treatment services, are now obliged to align with these same quality protocols. They are being told how to drive from the passenger’s seat, while the patient is moved to the back.

The economic heart of value-based contracts is negotiation over capitation, in which aspiring MA plans bid to manage all care for a group of patients, according to prescribed CMS protocols, for a fixed price per patient. 


The [price] benchmark is subject to 
 adjustments. First, the benchmark can be increased by 5 percent, a “quality” bonus, if the MA plan earns a four on CMS’s star rating performance measurement system. The system is based on 46 measures of access, process, patient experience, and clinical quality and is indexed such that, last year, 90 percent of MA enrollees were in plans rated four stars or higher.

Second, the benchmark is adjusted in subsequent years for the risk score of the enrolled population. 
 [I]ntensive coding efforts translate into higher risk scores when the plan comes up for annual renewal.

[Discussion of risk selection, which lowers costs in Medicare Advantage and assures that individuals remaining in traditional Medicare – which determines payment benchmarks – will be increasingly expensive over time.]

What will be the consequences for Americans?

[C]onsolidation will raise the cost of care without any improvement in care capacity or quality
.

Researchers estimate that Medicare Advantage will cost CMS $75 billion more in each of the coming years 
 less than 2 percent of national health expenditures 
 But it becomes far more significant when we think of it in terms of primary care. The US spends about $100 billion on primary care physician consultations 
 the money wasted on VBC overpayments could be put to very productive use remedying primary care underinvestment.

Spent correctly, this $75 billion could make a huge contribution to solving the biggest health care problem we have in this country—a lack of primary care to address the high burden of chronic disease. Reinvesting the funds could create comprehensive, relationship-based, personalized care overseen and coordinated by trusted, in-charge primary care physicians who have the time to make full use of their clinical reasoning 


Tragically, conversion to VBC plans will also undermine efforts to address the social determinants of health for disadvantaged communities. When we sacrifice higher-quality, relationship-based primary care medicine, we also sacrifice the opportunity for a physician to understand each patient’s biography, or lived experience, which arguably contributes as much to their ill-health as their biology or genetics.

Comment:

By Jim Kahn, M.D., M.P.H.

This article ably reviews how CMS’ extreme focus on value-based care undermines rather than strengthens primary care. My only addition is to highlight that ACO REACH, in traditional Medicare, is headed down the same path, as we’ve previously discussed in HJM.

Key points:

  • CMS capitation rules, most visibly in Medicare Advantage, offer corporations – especially those owning primary care practices – massive profit opportunities.
  • As a result the value and price of primary care practices has shot up more than 100-fold.
  • Profit tactics include risk selection (finding and keeping less expensive enrollees), exaggerated diagnostic coding, and maintaining process-of-care quality scores. Corporate maneuvers to manipulate these mechanisms outflank CMS technical and political abilities to oversee them.
  • A long-standing aversion to fee-for-service payment leads to onerous requirements imposed on primary care doctors, driving them to sell to and work for corporations.
  • Corporate tactics to maximize profits often conflict with and displace comprehensive, high quality primary care.
  • Physicians become cogs in this machine, their pursuit of quality primary care shunted aside. Patients must follow along. The physician-patient relationship is undermined.
  • $75 billion dollars per year in overpayments, largely directed to profits, could save primary care.
  • The opportunity to address patient-specific social determinants of health – critical to pursuing equity – is squeezed out.

Next time – a proposal for doctors and allies to join in a social movement to make primary care a publicly-financed common good.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Medicare for All Explained Podcast: Episode 96

Why Does the Government Keep Letting Medicare Advantage Plan Companies Off the Hook

April 15, 2023

Podcast host Joe Sparks marvels at the way policymakers bend over backwards to support Medicare Advantage, despite well-documented patterns of wrongdoing on the part of companies participating in the program.

“Medicare Advantage companies don’t need the money,” he says, in reference to planned increases in their reimbursement rates. “They are doing quite well.”

Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Medicare for All Is the Timely Solution for Texas Health Care

With the recent expiration of pandemic-era health insurance requirements, millions of Texans may lose their Medicaid coverage over the coming months. It doesn’t have to be that way.

By Yosha Singh, M.P.H. and Rohit Prasad
The Austin (Texas) Chronicle, April 14, 2023

Nearly 1 in 10 Texans may lose their health insurance over the coming months. Women and children will be hit hardest.

It’s clear, we need Texas to expand Medicaid now. In addition, we need to restructure our national health insurance system.

Doctors know firsthand the benefits of consistent health insurance. Dr. Lauren Thaxton, an OB-GYN in Austin, says, “Stable insurance coverage throughout a person’s life can increase health and wellness and allow issues to be addressed before they become critical.”

Texas already ranks last in the nation in health care affordability. The U.S. overall has the highest rate of women dying in childbirth among developed nations. So, as state officials decide whether 2.7 million Texans can keep their Medicaid over the coming months, these statistics may get worse. It is time for Texans to demand a solution.

At the start of the pandemic, the national government – under both Presidents Trump and Biden – saw the value of health insurance. They required states to keep people enrolled in Medicaid until the end of the pandemic. This meant millions of Texans who otherwise may have lost their insurance stayed insured.

Continued coverage had the biggest effect on Texas women. Before the pandemic, almost 90% of pregnant Texans with public insurance lost coverage in the year after birth. For the past three years, though, all these women stayed covered. They were able to keep seeing their doctors and manage their health after having a baby. Pregnancy takes a toll. Stable insurance meant that Texas women were able to manage complications and recover from their pregnancy.

Texas is now reevaluating all Medicaid recipients because the federal rule keeping people on Medicaid expired at the end of March. As the rule goes, the dependable insurance that Texans have come to know may go with it. As health care providers, we worry about what this means for our patients.

There is one solution we could start with: expanding Medicaid. The state can change its requirements, bring more people onto Medicaid, and get more federal funding in the process. This would stop the bleeding short-term and keep the gains we made in the past three years. But, this would not solve the root problem.

If the cost of the U.S. health system were its own country, it would be the third-most expensive country in the whole world, just behind the United States and China. Yet, we have the highest rates of infant, mother, and avoidable death in the developed world. Why? According to experts, the reason is simple: prices. In the U.S. we simply, and unfortunately, just pay more – without any added benefit.

More insurers leads to more spending. At the University of Toronto hospital in Canada, there are 1,272 patients beds and seven billing clerks total. At the Duke Medical Center in the U.S., there are 957 patient beds and a whopping 1,600 billing clerks. Nearly double the number of patients. These examples span the country.

A national single-payer system would keep everyone insured, reduce costs, and leave money for patient care.

Naysayers commonly cite cost as a reason not to change our system. But as it stands now, we are paying more to achieve less. The U.S. Congressional Budget Office confirmed single-payer would give everyone insurance, eliminate co-pays and deductibles, and save $450 billion annually. Our current spending helps neither patients nor doctors. It helps insurance companies. Insurance CEOs have tripled their personal profits in the past decade.

The time to act is now. In Texas, and in the short-term, we must contact our state representatives to support House Bill 204 and Senate Bill 71. We must expand Medicaid. But, if we’re to be serious about improving the worst health system in the developed world in the long run, we must enact Medicare for All. The livelihood of women and children, and wallets of U.S. taxpayers, depend on it.

Yosha Singh and Rohit Prasad are members of the national single-payer health care advocacy organization Physicians for a National Health Program.

https://www.austinchronicle.com…

A conversation with doctors who support universal health care

Interview with Drs. Susan Rogers and Eric Reinhart

By Rose Aguilar and Bee Soll
KALW Public Media, Your Call, April 12, 2023

On this edition of Your Call, we speak with two doctors who are calling for universal health care. The United States is the only large, high-income nation that does not provide universal coverage to its citizens.

We’ll also discuss the high costs of relying on a for-profit system, the end of expanded COVID benefits, Republican controlled states that still refuse to expand Medicaid, the epidemic of gun violence in the U.S., and the health care worker crisis.

Thousands of doctors have left the workforce, leaving many hospitals and clinics struggling. One in five doctors says they plan to leave their practice in the coming years, according to studies published in JAMA.

What will it take to make universal health care and a robust social safety net a priority?

Dr. Susan Rogers is the immediate past president of Physicians for a National Health Program and assistant professor of medicine at Rush University.

Dr. Eric Reinhart is a political anthropologist of public health and law, psychoanalyst, and physician at Northwestern University.

full interview:
https://www.kalw.org…

2024 Payment Increase & Other Problems with Medicare Advantage

Summary: CMS just finalized the 2024 payment rule for Medicare Advantage, weakening the draft rule. There remain massive overpayments and widespread barriers to care. These fundamental problems are inevitable with reliance on private insurer intermediaries.

Biden Just Took the First Step to Overhaul Medicare Advantage. Many More Must Be Taken, Common Dreams, April 7, 2023, by Diane Archer

The corporations that run Medicare Advantage plans are engaged in widespread waste, fraud and abuse, resulting in tens of billions of dollars of overpayments to them every year. The advocates and government agencies overseeing Medicare Advantage have spent nearly two decades reporting on this fraud and waste and urging Congress to overhaul the program. Few in Congress or the administration were listening. Now, the Biden administration is finally taking action, but it’s only a first step.

The Biden administration has just finalized a rule that begins to rein in these overpayments, at last putting a spotlight on an issue that Congress and the public have long overlooked. The new rule is a small step towards reining in some of the overpayments to the Medicare Advantage plans and protecting the integrity of the Medicare Trust Fund, though it is not nearly enough.

The insurance industry’s fierce opposition and the multi-million dollar fear campaign the health insurance corporations launched against the proposed rule was their admission that Medicare Advantage plans can’t provide coverage at a reasonable cost. Medicare Advantage only works for the insurers if they are wildly overpaid and profiting exorbitantly. It was their admission that they cannot do what they were created to do and are legally obligated to do. They cannot deliver Medicare coverage anywhere near as cost-effectively as traditional Medicare, let alone at lower cost, as they had promised.

The fight over small improvements to the flawed Medicare Advantage payment system reveals how challenging it is to fix Medicare Advantage and free it of the bad actors who are engaged in massive — sometimes fraudulent — overbilling of Medicare. Medicare Advantage is in need of a substantial overhaul, as the advocates, along with the Medicare Payment Advisory Commission, the Government Accountability Office and the Office of the Inspector General, have all been saying for years. 


The Biden administration also recently finalized another rule, aimed at addressing widespread and persistent inappropriate delays and denials of care in Medicare Advantage. Among other things, the rule attempts to streamline the Medicare Advantage prior authorization process. It spotlights and begins to address the serious risks some Medicare Advantage plans pose to the health and well-being of their enrollees — our nation’s sisters and brothers, parents and grandparents.

Though it goes further than any past rule in its attempt to protect Americans from the bad actor Medicare Advantage plans, it does not provide the public with important information as to which plans are the bad actors. Nor will it lead to the government’s cancellation of contracts with the worst-performing Medicare Advantage plans. Therefore, it will not keep the bad actor Medicare Advantage plans from continuing to inappropriately delay and deny critical care.

[HJM bolding]

Comment:

By Jim Kahn, M.D., M.P.H.

Lobbying elected representatives and public scare campaigns are high-yield investments for health insurers. Their profits these days derive mainly from serving as intermediaries for Medicare Advantage and other public insurance programs. They spend millions to safeguard billions in excess payments from CMS. The rate of return may exceed 100:1. The Biden administration is starting to address overpayment, but their effort is undercut by massive industry push-back.

The final rule spreads the modest and overdue proposed adjustments over three years. If you want a good technical summary, look at the fact sheet. The net result is a payment increase of 3.3% for 2024, as compared with 1% in the draft rule. How much is the difference? $10 billion. All into profits.

And that doesn’t begin to represent the scale of the overcharging documented by the Medical Payment Advisory Commission (MedPAC) and others. Up to $50 billion per year.

The insurers no doubt also hope that delay will further benefit them — a more sympathetic administration might abandon the out-year adjustments. They might also argue that other much-needed broader changes must wait until these three years of slow adjustment are done.

This is a rules-based approach. Very long and complicated rules attempt to rein in private sector entities which spend every working day scheming how to evade and game those rules, to shift more of the Medicare Trust Fund to shareholder profits.

Diane does an excellent job describing the sweep of problems plaguing Medicare Advantage. She rightly calls for a major overhaul.

What kind of major overhaul would really work? So complete we might not want to use the word “overhaul”. We need to abandon the financial intermediary structure, which guarantees bloated costs and aggressive limits on access to care, especially expensive care.

We need to jettison the insurers, and use a structure like traditional Medicare, with payments directly from the program to providers. For everyone. Single payer, Medicare for All.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Excess Deaths in US in 2021: COVID + 400,000

Summary: New research finds that in 2021 the US had nearly 900,000 excess deaths compared with wealthy European countries. About half were due to COVID and half due to other factors, including health care financing and delivery.

‘Excess’ Deaths Surging, but Why?, Medscape, March 29, 2023, by F. Perry Wilson

What do we mean when we say “excess mortality”? The central connotation of the idea is that there are simply some deaths that should not have occurred. 


That’s what this article does, calculating excess deaths in the United States by standardizing our mortality rates to the five largest Western European countries: the UK, France, Germany, Italy, and Spain. 


[page 2]

[E]ven before the pandemic, the United States had an excess mortality problem. This is not entirely a surprise; we’ve known that so-called “deaths of despair,” those due to alcohol abuse, drug overdoses, and suicide, are at an all-time high and tend to affect a “prime of life” population that would otherwise not be expected to die. In fact, fully 50% of the excess deaths in the United States occur in those between the ages of 15 and 64.

Excess deaths are also a concerning percentage of total deaths. In 2017, 17% of total deaths in the United States could be considered “excess.” In 2021, that number had doubled to 35%. Nearly 900,000 individuals in the United States died in 2021 who perhaps didn’t need to.

The obvious culprit to blame here is COVID, but COVID-associated excess only explains about 50% of the excess we see in 2021.

I’m sure some will take issue with the use of European numbers when applied to Americans. After all, Europe has, by and large, a robust public health service, socialized medicine, and healthcare that does not run the risk of bankrupting its citizens. How can we compare our outcomes to a place like that?

How indeed.

Dr. F. Perry Wilson is an associate professor of medicine and director of Yale’s Clinical and Translational Research Accelerator.

Comment:

By Don McCanne, M.D.

According to the data discussed here by Yale Professor Perry Wilson, in 2021 alone, not counting COVID deaths, about 400,000 people died who perhaps didn’t need to, deaths characterized as excess.

When compared with the five largest Western European countries, all of which have better outcomes, how indeed can we come to any other conclusion than that they have superior structural characteristics in their health systems? This includes robust public health services, socialized medicine, and healthcare financing systems that do not risk bankrupting their citizens.

Better care, for less money, that includes everyone. Sounds like something we could do – with expanded and improved, single payer, Medicare for All!

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Health Policy Presentations from Drs. Woolhandler & Himmelstein (April 2023)

PNHP co-founders Drs. Steffie Woolhandler and David Himmelstein developed a pair of slide sets (compact and large) on health policy issues relevant to single-payer reform (dated April 6, 2023).

[ Click HERE for an alternate visual presentation of the large slide set, developed by PNHP board secretary Dr. Ed Weisbart ]

Drs. Himmelstein and Woolhandler published these slides in their roles as Research Associates at Public Citizen’s Health Research Group; PDF and PowerPoint versions are available on the Public Citizen website.

An Immodest Proposal (for Excellent Financing of Our Health Care System)

Summary: A striking vision for how to pay for health care in our country.

An Immodest Proposal

(for Excellent Financing of Our Health Care System)

From: A humble health economist
To: The U.S. public

Dear kind family, friends, colleagues, neighbors, and fellow citizens:

The health and happiness of our population being of the utmost importance, I make bold to propose to you that we establish a system to pay for health care in the United States of America. The means to achieve this grand goal must include a health care financing system of a most refined and ingenious nature. I have contemplated how to accomplish this, and herewith share my conclusions, which I hope and trust you will find quite compelling.

First, we must commit great resources to this noble undertaking. I propose one in five dollars of all economic activity, though I would settle at the moment for just 17-18%. Our dear neighbors of the north country and friends in Europe are too stingy, dedicating only 8-12% to this august mission. We ought gladly proffer high recompense for our fine curative consultations, potions, and surgeries.

Second, let us rejoice in diversity. Every citizen shall have a different assortment of health benefits, for certainly these varied benefits shall align magnificently with future medical and financial needs, however unpredictably they shall manifest. Varied services allowed, disparate access to doctors, and a joyous plethora of cost-sharing arrangements, including impressively large deductibles and robust cost-sharing.

Third, let us elevate choice. Ours is a free country, so each citizen (and approved non-citizen resident) shall be permitted, nay obligated, to choose among insurance purveyors and health plans. Some say, “Pick your poison”, but I say, “Exercise your free market rights!” Alas, selection of physician may be ever so slightly restrained by the untrammeled and wondrous choice of a restricted provider network. Individuals will understand and accommodate if the most able medical practitioner for a worrisome affliction happens to labor external to the designated provider panel.

Fourth, let us further magnify the spectacular granularity of everyday tasks, because complexity is life. Let each insurance plan have different rules and procedures for securing payment for doctors and hospitals, so that the insurers may devote many fine US dollars to administration. Likewise, the providers shall dedicate one dollar in eight to billing paperwork. Long live and prosper the accounting room, and the myriad financial clicks of the electronic health record.

Fifth, admire the prospect of home foreclosures, a true blessing to ease the housing crisis, as medical bills further impoverish the poor. Manifold thanks for lack of insurance, and uncovered and out-of-network services; 40% in medical debt and 500,000 medical bankruptcies each annum is good fortune that we may all celebrate.

Sixth, savor the frustration and exhaustion of physicians straining for hours daily to digitally inscribe copious billing information, for the subsequent burnout thins their excess ranks.

Seventh, cheer delayed diagnosis and treatment as pandemics encroach, and too the chaotic data of fragmented billing systems which prevent us from worrying ourselves with nasty facts about disease spread.

Eighth, let us revel in the shorter life span offered by this financing system, for life is brutal (most especially when we cannot afford to consult a doctor to ease our pains). The sooner over the better.

Ninth, praise the myriad ways in which our system specially affects the lives of the impecunious and visibly different, with less and worse insurance, inferior quality of care and outcomes, and earlier release from life’s painful bonds.

Tenth, glory be to profits and spectacular CEO salaries, for these reflect the soul of the American experience. Insurers, drug companies, and hospital systems shall garner at least 10% of all revenue to enrich the worthy and kindly shareholders. CEOs of non-profit hospitals shall rightfully earn $10 million per annum in salary and other well-deserved recompense.

Finally, let us embrace un- and under-insurance, for they are the means that enable the flourishing of this fine and perfect system. Yes, spending more than any other nation, infinitely varied health care benefits, choice of health plan constrained to a narrow network, complexity in our daily lives, foreclosed homes, burned out doctors, pandemics ignored, brutish lives ended early, the downtrodden slighted, and, best of all, burgeoning profits for the few – all are thanks to the worthy sacrifices of the not really well-insured.

Respectfully submitted,

James G. Kahn, M.D. M.P.H.
(apologies to Jonathan Swift)

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Medicare for All Explained Podcast: Episode 95

Interview with Julie Baak

April 1, 2023

Rheumatology Practice Manager Julie Baak, of the Arthritis Center in Bridgeton, Mo., describes how commercial insurance companies bully independent medical practices by overwhelming them with denials, paperwork, and administrative minutiae.

“Offices don’t have the time, the energy, or the bench strength to tangle with these people,” she says, “so most of them are going to do what the insurance company wants.”

Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Dr. Susan Rogers on “Fixing the System”

PNHP immediate past president Dr. Susan Rogers was interviewed for “Fixing the System,” an examination of single-payer health care that was awarded third prize in the national C-SPAN StudentCam 2023 competition.

“Getting rid of private insurance companies would help a lot,” said Dr. Rogers while explaining the benefits of single payer. “What they’re doing is they’re shifting the cost to patients.”

“Fixing the System” was produced by Eastern Middle School (Silver Spring, Md.) students Adelaide Keller and Linnea Ericson.