PNHP

Solution to health care is Medicare for all

Solution to health care is Medicare for all

By Jack Bernard
Las Cruces (N.M.) News, May 2, 2018

In 2017 op-eds, I described the mess that Congress made of health reform. They were taking a flawed program, Obamacare, and modifying it to be much worse via Trumpcare…which I believe Donald Trump still has never given up on enacting; he is just waiting until the opportunity arises.

In the meantime, he and Alex Azar, his new DHHS secretary, will do everything that they can administratively to undermine the ACA. In 2017 there were fewer people covered by insurance than in 2016 due to Trump’s policies.

Many conservative politicians state incorrectly that we have the “best” health care in the world. But, our mortality-morbidity rates are higher than other developed nations. Reports by the respected Commonwealth Fund consistently rate us last or next to last on health-care quality, access and cost criteria.

Plus, our costs are escalating, via higher premiums and deductibles. In 1980, healthcare was 9 percent of GNP. It is more than double that now, taking money that could be used for other vital areas.

So, where should we go with Medicare, Medicaid and the ACA (Obamacare)?

The GOP House of Representatives has a radical health-care agenda, devised by and expressed repeatedly by departing Speaker Ryan and Tom Price, former House member and x-secretary of DHHS. Both Price and Ryan are motivated solely by federal budget concerns versus quality or financial access.

Former Rep. Mick Mulvaney, now the head of OMB, shares this lack of concern over the impact of policy changes on real people. Mulvaney, a Tea Party darling, founded the right-wing House Freedom Caucus which advocated a shutdown of our government rather than budgetary compromise.

The Ryan-Price strategy of Medicare and Medicaid abandonment is not supported by the majority of Americans in either party, as various surveys show. It is abandonment when you privatize Medicare via vouchers, destroying senior finances, and cut funding for Medicaid via state block grants, thus denying care to our poorest citizens.

The bill that Price originally proposed as a replacement for the ACA cut financial support for millions (85 percent of Health Exchange enrollees) who are now receiving a high level of governmental assistance in order to purchase insurance. The average cost of a family’s health-care insurance policy is over $18,000 annually. How many lower-income families can afford to purchase health-care insurance with a stipend of only $3,000 as detailed in the original Price legislation?

So, if the radical privatization schemes and confusing, elusive block grants won’t work, what will?

The situation becomes clearer when we look at the health-care costs in other developed nations. At a per capita cost of over $9,000 in the USA, we run nearly three timesthe per capita cost in Italy, whose health system is rated second best in the world by WHO.

How do these other developed countries do it? The answer may surprise you: single payer (Medicare for All) or something like it (utility models) with more government involvement, not less.

Through cutting out marketing and overhead expenses, savings are achieved. Medicare has only a 2 percent overhead versus 12 percent for private insurance. And, centralized budgeting combined with leveraging of governmental purchasing power makes sure that costs are contained.

The primary impediment to Medicare for All, which has been proposed in bill form by Senator Bernie Sanders and co-sponsored by 16 senators, is clear: big business lobbying. Why?

Price escalation by Big Pharma would be severely limited under Medicare for all, as it is in other nations. Instead of spending money on health insurance corporate marketing and overhead expenses, money would go to direct patient care. Insurance and pharmaceutical companies would lose business. Their executives would not be getting those seven figure salaries. So, they buy influence.

This situation can only be corrected by you, the American taxpayer, by knowing the issues and voting.

Jack Bernard, the first director of health planning for Georgia, has been a senior executive with several national health care firms, working with New Mexico hospitals on cost containment.

https://www.lcsun-news.com…

Four million working-age people have lost insurance coverage since 2016

First Look at Health Insurance Coverage in 2018 Finds ACA Gains Beginning to Reverse

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

The marked gains in health insurance coverage made since the passage of the Affordable Care Act (ACA) in 2010 are beginning to reverse, according to new findings from the latest Commonwealth Fund ACA Tracking Survey. The coverage declines are likely the result of two major factors: 1) lack of federal legislative actions to improve specific weaknesses in the ACA and 2) actions by the current administration that have exacerbated those weaknesses. These include the administration’s deep cuts in advertising and outreach during the marketplace open-enrollment periods, a shorter open enrollment period, and other actions that collectively may have left people with a general sense of confusion about the status of the law. Signs point to further erosion of insurance coverage in 2019: the repeal of the individual mandate penalty included in the 2017 tax law, recent actions to increase the availability of insurance policies that don’t comply with ACA minimum benefit standards, and support for Medicaid work requirements.

Findings

* About 4 million working-age people have lost insurance coverage since 2016

* The uninsured rates among lower-income adults rose from 20.9 percent in 2016 to 25.7 percent in March 2018

* The uninsured rate among working-age adults increased to 15.5 percent

* The uninsured rate among adults in states that did not expand Medicaid rose to 21.9 percent

* The uninsured rate increased among adults age 35 and older

* The uninsured rate among adults who identify as Republicans is higher compared to 2016

* The uninsured rate remains highest in southern states

* Five percent of insured adults plan to drop insurance because of the individual mandate repeal

From the Policy Implications

In the absence of bipartisan support for federal action, legislative activity has shifted to the states.

More broadly, leaving policy innovation to states will ultimately lead to a patchwork quilt of coverage and access to health care across the country, a dynamic that will fuel inequity in overall health, productivity, and well-being. At some point, Congress will likely face pressure to step in to level the playing field.

http://www.commonwealthfund.org…

***

Comment:

By Don McCanne, M.D.

Although building on our current fragmented health care financing system is the most expensive model of reform, it was understood from the beginning that the Affordable Care Act would fall far short of our goals of universality, comprehensiveness, and affordability. If there is any surprise here, it is how quickly some of the gains could be reversed without the formality of enacting repeal and replace legislation. Not only is ACA a fundamentally flawed model, it is subject to damage through the political whims of ideologues.

Some of the proposed policy options to improve coverage include more advertising of exchange plans, reinsurance to reduce risk of insurer losses, more premium and cost sharing subsidies, and even a public option such as a Medicare buy-in. The problem is that these leave in place the high costs and administrative waste and other deficiencies that characterize our system while failing to protect against political chicanery.

If we had in place a well designed single payer national health program – an improved Medicare for all – everyone would have access to their choice of health care professionals and institutions, and care would be prepaid automatically  through progressive taxes and thus affordable for everyone. It would be the privilege once granted that became an irrevocable right, if there were any doubts before.

The Commonwealth Fund would have plenty of other features of our health care system to study, but no longer would they have to keep count of how many go without any health care coverage at all, or how many face financial hardship because they are underinsured. Everyone would be included and nobody would be deprived of care because it was not affordable. So the question is, why do we continue to tolerate the injustices of our highly dysfunctional financing system when we don’t have to?

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It Is Time to Liberate Hospitals from Profit-Centered Care

By Sidney M. Wolfe, M.D.1, Steffie Woolhandler, M.D., M.P.H.2,3, and David U. Himmelstein, M.D.2,3
Journal of General Internal Medicine, April 30, 2018

The way we pay hospitals is toxic. It rewards, indeed requires, bad behavior from hospital leaders and stifles the better angels of their nature.

In our market-driven payment system, hospitals’ success, and even survival, depends on generating profits. Even non-profit hospitals live or die based on profit margins (often labeled “surpluses” in non-profit facilities). Hospitals that lack profits (or the prospect of future profits that can entice lenders or investors) face a grim future. Unable to renovate or expand their original facilities, purchase new equipment, acquire other hospitals, or grow their provider networks, unprofitable hospitals often spiral downward. As one public hospital CEO admonished two of us, “no margin, no mission.”

In this issue of JGIM, Ly and Cutler1 demonstrate one noxious side effect of making profitability the arbiter of hospital success. Their analysis of changes in hospital profit margins between 2003 and 2013 indicates that hospitals won the profit game by boosting prices, not by improving efficiency, or through exemplary community service (e.g., by increasing their care for Medicaid patients). The losers cared for a disproportionate share of publicly insured patients (and presumably the uninsured, although Ly could not assess that) or had the bad luck to be located in rural America. Public hospitals lagged, while not-for-profits grew their profits even faster than for-profits. (Although not discernible from Ly’s analysis, MedPAC data indicates that investor-owned hospitals had much higher profit margins at baseline and retain a big profit lead.2) Chaining up was a winning strategy, presumably because it increased hospitals’  leverage in negotiations with insurers, allowing them to command higher prices.

Ly’s conclusion that upcoding did not drive profitability gains will surprise many clinicians whose hospital managers obsess about capturing every billable diagnosis. While the study found a positive relationship between growth in a hospital’s casemix index (CMI) and growth in its profit margin, this finding was not statistically significant. Unfortunately, this analysis was underpowered because it used all-payer CMI data, which was available for only a subsample of 587 hospitals in eight states. Nationwide, increases in the Medicare CMI (available for almost all hospitals) strongly predict total margin growth (Dickman S, Woolhandler S, Himmelstein DU. Unpublished analysis of Medicare Cost Report and Medicare casemix data, 1998–2016). It seems likely that upcoding is an important profit-driver.

Hospitals did not always have to turn a profit in order to survive. In our past (and today in Canada, much of Europe, and our VA system), funds for capital investments came from government grants or charitable donations.

During the first three decades of the twentieth century, private donors funded almost all US hospital construction.3 The federal government stepped in to provide capital funds to non-profit hospitals during the Great Depression, and its Hill-Burton program was the major funder of hospital construction in the post-war period. The seed of profit-based capital funding was planted by the hospital industry-controlled Blue Cross plans of that era, which paid hospitals a per diem rate that covered operating costs (including interest on loans, i.e., payment for existing capital investments), plus depreciation and a capital add-on to provide hospitals with reserves for future capital investment.4 But even as late as 1965 (when Congress passed Medicare and Medicaid), hospitals’ reserves together with their long-term borrowing accounted for only 31.9% of hospital construction funds.5

Two developments in the mid-1960s accelerated the shift from grant-based to profit margin-based funding for not-for-profit hospital capital. First, a 1963 IRS ruling triggered states to start offering tax-exempt bond funding for hospital construction, allowing hospitals to obtain loans with minimal down payments, and pay them off with future profits. Second, Medicare adopted Blue Cross’ capital payment model (with an extra profit allowance for investor-owned facilities). For hospitals with a good payer mix, this assured a flow of public dollars to build up reserves for future investments, and to pay off bondholders and investors. By the 1970s, 70% of construction was debt-funded, with much of the rest covered by hospitals’ reserves.6

Before the mid 1960s, explicit (if often flawed) public decision-making guided the allocation of government funding for hospital construction. Thereafter, the flow of taxpayer dollars surged but public control of decision-making shriveled. Profitability determined which hospitals could afford new projects, and private boards and executives decided how to deploy those funds.
 
Medicare’s (and private insurers’) capital payment policies have undergone many twists and turns over the past half century. But the link between profitability and ability to expand and modernize has been a constant. In effect, all non-federal hospitals have been forced to become quasi-commercial enterprises, and to think of themselves in business rather than social terms.4 As profitability became mandatory for hospital survival, the distinction between for-profit and non-profit hospitals began to erode—although even decades later, for-profits continued to deliver inferior quality care at higher prices.7,8

The price-boosting that Ly identifies as a key profit-driver (among non-profit as well as investor-owned hospitals) is just one of the ill-effects of making profit margin the mission. Hospitals’ manipulations of their payer and service mixes, the efforts squandered on financial gaming, and the ethical compromises that have become commonplace in the healthcare milieu are also, like price gauging, antithetical to the public’s interests.

Hospitals’ efforts to avoid money-losing patients, effectively excluding many of those most in need, have become so routine that many of us have become inured to this disgrace. New York City’s private academic medical centers exclude almost all uninsured persons and maintain separate clinic systems for patients with Medicaid, leading to the de facto racial as well as socioeconomic segregation of care,9 a situation that is not unique to New York. The CEO of the Mayo Clinic—which generated an operating surplus of $707 million last year, while investing $714 million in new capital projects—instructed employees to “prioritize” patients with private insurance over those with Medicaid, and even Medicare.10,11

The profit imperative, even among non-profit hospitals, similarly distorts the mix of services that hospitals choose to offer or promote. Money-losing services like mental health and primary care are accorded second-class status, in contrast to the opulent resources devoted to elective cardiac and orthopedic interventions, even those of dubious value.

Selectively recruiting profitable patients and excluding the unprofitably ill require considerable bureaucratic effort and expense. But that is just the beginning. Much more is spent to maximize billings and collect payment. At one non-profit Utah hospital system, 2,300 employees, 6% of all employees, work on claims processing and bill collections.12 Meanwhile, the patient chart has morphed from a clinical diary for facilitating care into a billing document driven by commercial imperatives, padded with redundant (and even misleading) material. Physicians now spend half their time on electronic documentation and other clerical/administrative tasks.13 Overall, the average US hospital now devotes more than one quarter of its budget to administration, a share that is continuing to increase, and is already twice that in Canada (or Scotland).14

Why is hospital administration so much leaner in Canada? Although physician payment in Canada’s single-payer system looks a lot like US Medicare’s, its hospital payment strategy is dramatically different, more akin to the way we fund the VA. Canadian provinces (and Scotland) pay hospitals’ global operating budgets, with separate government grants for capital costs. Even countries like France, Switzerland, and Germany which have more complex universal social insurance schemes, fund much of new hospital investments through government grants rather than hospitals’ profits. This dampens US-style entrepreneurial incentives, leading to lower bureaucratic costs, less price-inflating gaming, and greater healthcare equity.

Profit-seeking does not just undermine efficiency and equity, it also fosters corruption. For-profit hospital firms have been most frequently implicated in the most egregious incidents, paying billions to settle fraud and abuse claims. But the faltering moral compass of non-profit and even public hospital leaders has an even greater impact because they control 80% of community hospitals, and almost all academic medical centers. Massachusetts General Hospital received $123 million in royalties and licenses over a four-year period,15 mostly from orthopedic device-makers whose high prices are borne largely by Medicare. In 2013, 73 leaders of academic medical centers also sat on the boards of 85 publicly traded healthcare firms, receiving median compensation of $209,000 per directorship, and, in addition, held 5,493,946 shares of stock in those firms.16 It takes extraordinary ethical gymnastics to justify such dual commitments.

Ly implies that a crackdown on hospital prices would lead to salutary change, goading hospitals to seek profit through efficiency. But controlling prices without eliminating profits could amplify current profit-inflating misbehaviors, e.g., prioritizing the care of privately insured patients. As long as profit-centered care remains the key to hospital survival, patient-centered and community-centered care will suffer.

No law of nature requires that hospitals make profits in order to thrive. What is needed is a single-payer reform that:

  • Pays hospital lump-sum operating budgets, like those for schools, fire houses, or VA hospitals;
  • Claws back any money they do not spend on care; and
  • Allocates truly needed capital funding through a region-wide accountable government grant program that directs investments to the highest priority, community responsive projects.

https://link.springer.com…

References

1. Ly DP, Cutler DM. Factors of U.S. hospitals associated with improved profit margins: An observational study. JGIM 2018; DOI: https://doi.org…

2. MedPAC. Report to the Congress: Medicare payment policy. Medicare Payment Advisory Commission, Washington: March 15, 2017. Available at: http://www.medpac.gov… (access 2/17/2018).

3. Stevens R. In sickness and in wealth: American hospitals in the twentieth century. New York: Basic Books, 1989.

4. Brown JB with Thomas SR and members of the Harvard University Health Capital Project. Health capital financing. Ann Arbor, MI: Health Administration Press, 1988.

5. Stambaugh JL. A study of the sources of capital funds for hospital construction in the United States. Inquiry June, 1967;14:3–22.

6. Wilson G, Sheps CG, Oliver TR. Effects of hospital revenue bonds on hospital planning and operations. N Engl J Med 1982;307:1426–1430.

7. Devereaux, PJ, Choi PTL, Lacchetti C, et al. A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals. Can Med Assoc J 2002;166:1399–1406.

8. Devereaux PJ, Heels-Ansdell D, Lacchetti C, et al. Payments for care at private for-profit and private not-for-profit hospitals: a systematic review and meta-analysis. CMAJ. 2004;170(12):1817–1824.

9. Tikkanen RS, Woolhandler S, Himmelstein DU, Kressin NR, Hanchate A, Lin MY, McCormick D, Lasser KE. Hospital payer and racial/ethnic mix at private academic medical centers in Boston and New York City. International Journal of Health Services. 2017; 47(3):460–476.

10. Kacik A. Mayo Clinic CEO Noseworthy to retire. Modern Healthcare February 26, 2018:6.

11. Olson J. Mayo to give preference to privately insured patients over Medicaid patients: Pushback on Medicaid, Medicare part of a trend. Star Tribune March 15, 2017. Available at: http://www.startribune.com… (accessed March 4, 2018)

12. Kacik A. Intermountain joins outsourcing trend for revenue-cycle management. Modern Healthcare January 29, 2018:8.

13. Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders L, Westbrook J, Tutty M, Blike G. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Annals of internal medicine. 2016;165(11):753–60.

14. Himmelstein DU, Jun M, Busse R, Chevreul K, Geissler A, Jeurissen P, Thomson S, Vinet M-A, Woolhandler S. A Comparison Of Hospital Administrative Costs In Eight Nations: US Costs Exceed All Others By Far. Health Aff. September 2014;33:1586–1594.

15. https://openpaymentsdata.cms.gov… (accessed March 6, 2018).

16. Anderson TS, Good CB, Gellad WF. Prevalence and compensation of academic leaders, professors, and trustees on publicly traded US healthcare company boards of directors: cross sectional study. BMJ 2015:351:h4826.

Author credentials: 1. Public Citizen Health Research Group, Washington, DC, USA; 2. City University of New York at Hunter College, New York, NY, USA; 3. Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA

Corresponding Author: David U. Himmelstein, M.D.; City University of New York at Hunter College, New York, NY, USA (e-mail: dhimmels@hunter.cuny.edu).

Compliance with Ethical Standards:

Conflict of Interest: No conflicts of interest to report.

We all need health care for royalty, though not necessarily with the posh suite

The Royal Baby Is Lucky He Wasn’t Born in America

By Laurie Garrett
FP, April 24, 2018

On April 23, the Duchess of Cambridge gave birth to her third child in a posh London maternity center called the Lindo Wing inside St. Mary’s Hospital, where a small army of attendants looked after her and Prince William for 24 hours in a secluded, luxurious room at a cost of $8,900, according to the Economist.

Most Western Europeans and Canadians, of course, don’t deliver babies in the Lindo Wing. Otherwise, however, their treatment and outcomes are pretty much consistent with the royal couple’s. Parents pay nothing for their maternity care and delivery, with low risks of maternal and infant mortality.

The average American woman gives birth in a noisy hospital with few frills or amenities and for an average cost of $12,290. Everything is quite average, in terms of quality and aesthetics in the birthing environment, except, on a worldwide scale, the costs. Should she require a cesarean section (an average of $16,907) or any emergency services, her bill could swiftly soar above $30,000. Have premature triplets and costs top $870,000.

According to the National Academy of Medicine, the United States lags far behind the rest of the OECD for a long list of health problems, including maternal and infant mortality. In the OECD, only Turkey and Mexico had higher infant mortality rates than Mississippi, and the state with the best infant mortality in the United States — New Hampshire — would still rank way down at 28 in OECD stature.

One study found that Americans used health care services at about the same rate as Europeans — perhaps even less — yet paid nearly twice as much for just about everything.

Today, tens of thousands of Americans are crowdfunding their health care, searching for help to offset the costs that their insurance companies refuse to cover. It has come to this. America is a nation of beggars, forced to seek the pity of strangers who may, in turn, choose who shall live based on charity and who shall die for lack of financial support. A blonde 2-year-old girl in a ballerina tutu may garner more such kindness than a black 10-year-old boy in a Black Panther suit, who in turn gleans greater compassion from the online masses than a 50-year-old gunshot victim or an elderly Latina dying from diabetes. It’s like a macabre version of the 1950s TV show Queen for a Day, in which needy women pleaded for a fridge, dishwasher, new flatware, or a smart set of work clothes and an “applause-o-meter” was used to measure studio audience choices.

In a sensible health care system, there are no applause-o-meters; insurance actually covers patients’ costs; drugs and medicines are purchased in volume to bring down those prices; and life expectancy is independent of personal income.

https://foreignpolicy.com…

***

Comment:

By Don McCanne, M.D.

Fortunately most Americans are not dependent on crowdfunding or on Queen for a Day applause-o-meters to pay for health care, but in some ways these are symbolic of the humiliating dysfunctions inherent in our health care financing system. We should be ashamed that we spend twice the average of other nations on health care and yet leave tens of millions to suffer from financial hardship when they need health care, while not getting the results that we should be.

We already are spending enough money to provide health care for everyone, but we need to spend it more wisely. Through a well designed single-payer, improved Medicare for all, cost-sharing financial barriers could be essentially eliminated for everyone as they are in many other nations that spend much less.

Should we reprise the applause-o-meter to award that cute 2-year-old blond in a ballerina tutu the title of Princess for a Day in order to help pay at least some of the costs of her cancer care? Then what about the elderly Latina with late stage diabetes whose applause meter score did not qualify her as Queen for a Day, and who also failed to gain sympathy on a crowdfunding webpage?

This is America. We can do far better than that.

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Improved and expanded Medicare for all: The single-payer option we need

Improved and expanded Medicare for all: The single-payer option we need

By Judith L. Albert, M.D. and Ana Malinow, M.D.
Allegheny County Medical Society Bulletin, April 2018

Dr. Fredric Jarrett’s article in the February Bulletin, “Single-payer health care: Not an option,” offers an opportunity to correct many misperceptions about what the “single-payer option” is and to present instead, the case in favor of “expanded and improved Medicare for all.” 1 Dr. Jarrett initially suggests that proponents of single payer extol the virtues of the Canadian and British systems, a statement that is misleading since these two systems are quite different. While Canada does have coverage for all residents, it is administered at the provincial and federal levels. Health care providers are largely private. In the United Kingdom, a national health service exists, such that providers and hospitals are run by the government, and the government also pays for health care for most residents. There is, however, another option in the United Kingdom that allows wealthier individuals to obtain care outside the national health system, a factor that complicates and dilutes the potential for cost containment and equal access, and disqualifies the U.K. system as a model for a national health program in the United States.

Supporters of expanded and improved Medicare for all favor the following: “Universal coverage for all medically necessary care – health care that is publicly financed but largely privately delivered. Patients no longer face burdensome premiums, copays or deductibles, even as they gain free choice of physician and hospital. Doctors gain clinical autonomy and dramatically reduced paperwork.” 2 Any discussion of the “single-payer option” must use rigorous definitions to avoid confusion.

Dr. Jarrett voiced concerns about allowing the single payer to “make the rules” regarding medical necessity. We would argue that placing the decision-making for medical coverage with a public, single-payer option with public accountability will remove the profit motive for decision-making that exists in our current private insurance system. Do we really want health care decisions to be made by corporate insurance executives whose primary interest is their bottom line? Two current single-payer bills in the House (H.R. 676) 3 and Senate (S. 1804) 4 have explicit provisions that address accountability and transparency in the management of the health care program.

Dr. Jarrett goes on to acknowledge that the health care system in Canada enjoys near universal popularity among Canadians, due to the elimination of “medical bankruptcy,” a condition that is all too common here in the United States when lack of insurance coverage or under-insurance allows huge medical debt to accrue for individuals. 5 One of the advantages of the Canadian system is the ability of the health care program to negotiate with pharmaceutical companies on drug prices. Tremendous savings in health care expenditures would result from the ability of a U.S. national health program to negotiate drug prices and would eliminate at least one cause of medical bankruptcy. 6

Dr. Jarrett alludes to critical differences between the U.S. and Canadian health care infrastructure that make comparisons difficult, and clearly mandate that a single-payer system in the United States must be specific to the needs of our much larger population and complex medical systems. It is true that the United States is far better equipped to handle the need for necessary imaging when compared to Canada (we have three and a half times as many MRI and CT scanners). However, emergency imaging is always available in Canada without delay. While in the United States, we have the capacity, uninsured and underinsured individuals cannot afford CT or MRI scans. Millions of Americans are not even afforded the luxury of a place in line. 7

Dr. Jarrett cites the anecdotal increased mortality from abdominal aortic aneurysm due to patients waiting for approval in the United Kingdom. Compare that to the projected excess annual mortality of 36,000 Americans as a result of the 28 million people who are uninsured. 8 Lack of health insurance is bad for our health and results in increased mortality. The United States spends nearly twice as much for health care than other economically developed countries in the world, yet ranks last among 11 industrialized countries when it comes to quality, efficiency, access, equity and healthy lives. 9 Surely, with our massive healthcare resources, we can do better than this.

Finally, we would disagree that the nearest current prototype to single payer we have is Medicaid, because Medicaid is a means-tested program that varies by state. The current prototype for single payer is Medicare, which insures all adults 65 and older. While Medicaid does provide for the medical care of many non-elderly individuals, it is not universal coverage for that population in the way that Medicare is for the elderly. Dr. Jarrett neglected to mention House Bill H.R. 676, which currently has the support of 122 members of Congress. 10 The bill is 30 pages long and would create a publicly financed, privately delivered health care system that builds on the existing Medicare program. It would improve and expand Medicare to cover all U.S. residents. By replacing our nation’s fragmented patchwork of competing private insurance companies (with their wasteful administrative costs, profits and high executive salaries) with a nonprofit single-payer program, the nation would save more than $500 billion per year, 6 enough to guarantee comprehensive health care to all, with no co-pays or deductibles. Numerous surveys of physicians and health care consumers indicate a majority support the idea of expanding Medicare to provide health insurance to every American, including 59 percent of all physicians 11 and 60 percent of Americans. 12 There is even support for expanding Medicare from 40 percent of Trump voters! 12

As physicians, we have an obligation to advocate for all Americans and their health. As members of our professional organizations, we have a duty to seek evidence and report the facts. There is strong evidence that having health insurance fosters improved health and reduced mortality for all individuals. Our current system is giving us exactly what it was designed to do: increased profits for private insurance companies and the rationing of care based on the ability to pay. Improved and expanded Medicare for all: the single-payer option we need.
 
Dr. Albert is an obstetrician/gynecologist and reproductive endocrinologist who has been in practice in Pittsburgh since 1992. She and Dr. Malinow founded the Pittsburgh chapter of Physicians for a National Health Program with several other physicians in fall 2017.

Dr. Malinow is a general pediatrician in Pittsburgh. She is past president of Physicians for a National Health Program, an organization of more than 20,000 health care providers that support a single-payer, national health program.

The authors can be reached at bulletin@acms.org.

References

1. Jarrett F. Single-payer health care: Not an option. Allegheny County Medical Society, February 2018 Bulletin.

2. Physicians for a National Health Program, Single Payer FAQ, https://pnhp.org…

3. H.R. 676 Expanded and Improved Medicare for All Act, 115th Congress (2017-2018) https://www.congress.gov…

4. S. 1804 Medicare for All Act of 2017, 115th Congress (2017-2018) https://www.congress.gov…

5. Himmelstein DU, Thorne D, Warren E. Medical Bankruptcy in the US, 2007: Results of a National Study. The American Journal of Medicine. Vol 122, Issue 8, August 2009: 741-746. https://pnhp.org…

6. Woolhandler S, Himmelstein DU. Savings of $500 B/year. Woolhandler S and Himmelstein D. Single-Payer Reform: The Only Way to Fulfill the President’s Pledge of More Coverage, Better Benefits, and Lower Costs. Annals of Internal Medicine, April 18, 2017. http://annals.org…

7. Papanicolas I, Woskie LR, Jha AK. Health Care Spending in the United States and Other High-Income Countries. JAMA. 2018;319(10):1024-1039. https://jamanetwork.com…

8. Wilper, AP, et al. Health Insurance and Mortality in US Adults. American Journal of Public Health. 2009;99:2289-2295. https://pnhp.org…

9. The Commonwealth Fund. US Health System Ranks Last Among Eleven Countries on Measures of Access, Equity, Quality, Efficiency, and Healthy Lives. June 16, 2014. http://www.commonwealthfund.org…

10. H.R. 676 Expanded and Improved Medicare For All Act 115th Congress (2017-2018) Cosponsors https://www.congress.gov…

11. Carroll A, Ackerman R, Support for National Health Insurance Among American Physicians: Five Years Later. Annals of Internal Medicine April 1 2008. http://annals.org…

12. The Economist/YouGov Poll. April 2-4, 2017. https://d25d2506sfb94s.cloudfront.net…

https://www.acms.org…

Single-payer health insurance advocates launch chapter in Greenville

By Liv Osby
Greenville (S.C.) News, April 29, 2018

There was the uninsured truck driver in his 50s who skimped on his blood pressure medication because of the cost and wound up having a stroke.

And the housekeeper in her early 60s who couldn’t afford health insurance on her meager wages and had no way to pay for breast cancer treatment.

Over the years, there have been thousands of other patients like these, said Dr. David Keely, a family physician who spent his career caring for people who had trouble affording health care.

“I’ve seen it over and over,” he told The Greenville News. “Either their illness got worse because they were unable to afford their medication or they presented uninsured with hardly any money and had a medical condition that had to be treated.”

Now semi-retired from a community health clinic in rural Rock Hill, Keely is trying to make healthcare something that all Americans — poor, uninsured and underinsured included — can access by establishing a chapter of Physicians for a National Health Program in Greenville.

“The goal is to mount an awareness campaign about the inequities (of) our current system,” he said, “and try to get a grass roots movement to … make our health care system better with the ultimate goal of single-payer financed, privately delivered universal care.”

PNHP is a nationwide nonprofit made up of 20,000 physicians, medical students and health professionals who support single-payer national health insurance.

Also known as Medicare for All, it would operate the way Medicare insurance does now, paying for care by private providers. It would cover doctors, hospitals, mental health, dental and vision care, prescription drugs and more, according to the group, and be funded by the savings from replacing the current system.

Surveys show most Americans favor the idea of Medicare for All, including 75 percent of Democrats and 46 percent of Republicans, according to PNHP.

Affording health care

As the first physician in his family, Keely started a practice in Chester County to repay his obligation to the National Health Service Corps, which helped pay his tuition to medical school in return for practicing in a high-need area.

Seeing the hardships his patients endured, Keely attended a PNHP presentation where a speaker said that 45,000 people in the United States die every year because they lack access to affordable health care.

“It was the equivalent of a jetliner crashing every other day and nobody surviving,” he said. “I thought ‘That’s immoral.’ ”

So Keely helped launch a chapter of PNHP in the Palmetto State. Called Healthcare for All – South Carolina, it has branches in Charleston, Columbia and Florence.

And now a regional group is getting started in Greenville.

“There are many reasons why a single-payer system would be better for us,” said Greenville psychiatrist Dr. Patrick Mullen, who is among the supporters.

For example, he said, dealing with only one insurer instead of many would be less complicated and save money.

Desperate need

“One simpler system to deal with — and I don’t see how it could be any more complicated than it is,” he said. “And I can’t think of anything bad from the standpoint of the health of the population.”

One of the group’s first events in Greenville is a May 2 presentation by Dr. Ed Weisbart, assistant professor of clinical medicine at Washington University in St. Louis, Missouri, and chair of the Missouri chapter of PNHP.

A family physician who volunteers at safety net clinics, he’s also seen his share of patients in desperate need.

One 63-year-old woman supporting three grandchildren stopped taking her blood pressure medicine to make the rent so the family wouldn’t be homeless, he said.

Another patient with warning signs of a massive stroke couldn’t afford an expensive test and surgery, so she rolled the dice and waited until she was eligible for Medicare about six months later.

“That’s not what should happen,” Weisbart said. “If she had had this stroke, and then been disabled, it would have been even more expensive to take care of. It’s not even a good business strategy to have people make these trade-offs.”

Yet all over the country, Weisbart said, people are going bankrupt and losing their homes because of medical bills.

Four in 10 Americans are fearful of having to pay for a serious illness, according to PNHP. Even the insured have difficulties, said Weisbart, noting that he and his wife pay $2,000 a month in insurance premiums and have a deductible of $12,000.

‘Opened my eyes’

Michelle Hunt and her husband have three young daughters, and the 6-year-old has been battling severe asthma most of her life.

The doctor just prescribed a medicine that costs $245 a month in addition to her $115 rescue inhaler, Michelle Hunt said. But with insurance premiums of $550 a month, that was going to be hard for the Rock Hill couple.

“I reached out … to see if there were any other cheaper medications, but there weren’t,” she said. “We have found a coupon that will bring it down to about $200. So I guess we will have to cut back on other things.”

Among them is her own allergy medication, which costs about $50 a month, she said. They may also cut out cable TV and other things they can live without. Her mother has also offered to help with the costs of Emily’s medicine.

“This is something she has to have to breathe better,” said Hunt, 38, a risk management administrator for a telecommunications company.

“We’ve never had anything like this happen before,” she said. “But even with insurance, this really opened my eyes. We need something to help out with these costs.”

Covering everyone

Weisbart said insurance overhead makes up 15 to 20 percent of health care costs. In addition, he said, the average independent physician has $85,000 worth of staff that does nothing but deal with insurance.

“I see this as a problem that’s affecting Americans and I believe the most prudent way to solve it is to take Medicare, improve a few things, and provide it to everybody,” he said.

Most research shows that a single-payer option  – which is not socialized medicine but an insurance plan – would result in a dramatic savings or at least break even with everyone covered, including the 28.8 million Americans who are uninsured now, he said.

“Other countries with single-payer systems spend half of what we do,” he said, “and they live longer.”

Keely, who still spends about 20 hours a week as a volunteer physician, said he isn’t unrealistic about the headwinds the group faces, but adds that the current system is unsustainable.

“We don’t think we have our heads in the wrong place, but it’s certainly a marathon and not a sprint,” he said. “It’s heartening to be able to reach people and get them be able to say, ‘I just hadn’t thought about this and what you say makes sense.’

“That’s what keeps me going.”

https://www.greenvilleonline.com…

Angus Deaton: Self-assessment of well-being and policy ethics

NBER Working Paper No. 24369; What do Self-Reports of Wellbeing Say about Life-Cycle Theory and Policy?

By Angus Deaton
National Bureau of Economic Research, March 2018

Abstract

I respond to Atkinson’s plea to revive welfare economics, and to considering alternative ethical frameworks when making policy recommendations. I examine a measure of self-reported evaluative wellbeing, the Cantril Ladder (a tool for self-assessment of wellbeing with ladder steps numbered 0 to 10), and use data from Gallup to examine wellbeing over the life-cycle. I assess the validity of the measure, and show that it is hard to reconcile with familiar theories of intertemporal choice. I find a worldwide optimism about the future; in spite of repeated evidence to the contrary, people consistently but irrationally predict they will be better off five years from now. The gap between future and current wellbeing diminishes with age, and in rich countries, is negative among the elderly. I also use the measure to think about income transfers by age and sex. Policies that give priority those with low incomes favor the young and the old, while utilitarian policies favor the middle aged, and men over women.

Conclusions

This paper takes up Atkinson’s challenge to bring back welfare into economics, and to do so in a way that does not have to deny the findings of modern behavioral economics. It also thinks about how policy varies with different ethical assumptions. It uses Gallup’s data on the Cantril Ladder measure of life evaluation as a measure of (period) utility, and examines the implications for welfare variations by age. I find a midlife dip in wellbeing in rich countries, but less or no evidence of it elsewhere.

Overall, only some features of the ladder are consistent with life cycle theory if it is interpreted as a period, or age-specific wellbeing measure; it is much harder to interpret it as a lifetime measure. People’s expectations of the ladder five years ahead are grossly inconsistent with those reports being the mathematical expectations of future period utility; throughout the world, people are generally over-optimistic about the future, except for the elderly in rich countries, who are generally over-pessimistic about the future. These findings are of considerable interest, but cast doubt on the idea that people arrange their consumption and labor supply to maximize the expected integral of age-specific utilities, at least if utilities are well measured by the Cantril Ladder as recorded in Gallup’s surveys. This does not, by itself, invalidate the ladder itself as a measure of period age-specific wellbeing.

Finally, I illustrate what the ladder measure would imply for distributing income by age, and how the choice of the ladder versus income interacts with different ethical frameworks. In the United States, income prioritarians will tend to favor redistribution towards elderly or young adults, whose incomes or per capita incomes are lowest. By contrast, utilitarians will favor those for whom marginal utility is highest, which turns out to be those in midlife, and especially men over women, a prescription that would be enhanced by giving additional priority to those whose wellbeing is lowest, also those in midlife. Both approaches would favor men over women. I make no prescriptions here, but am concerned only to show the possibilities that arise from having a direct measure of wellbeing. I also am responding to Atkinson’s challenge by emphasizing and illustrating that policy prescriptions depend, not just on measurement, but on ethics, a point that is not always given the weight that it should be when economists discuss policy.

As in the happiness literature in general, my findings are mixed; the Cantril Ladder is clearly useful, is not obviously inconsistent with standard notions of period utility, and allows us to say things about welfare and distribution that we could not say using standard revealed preference methods. It does not assume that people do not make mistakes. Reported expectations of future wellbeing are consistent with the widespread finding of optimism bias in psychology, but inconsistent with the rational expectations formulation that is standard in much of economics. Whether this is an advantage or a disadvantage will surely differ according to preference and disciplinary background.

http://www.nber.org…

***

Comment:

By Don McCanne, M.D.

Although this NBER working paper by Nobel laureate Angus Deaton is quite wonkish it is an interesting analysis of self-assessment of current and anticipated future well-being under variables of age, sex, wealth, and nationality. For a blog on single payer reform, this paper does have some application since perception of well-being might be an important attribute related to a nation’s health care system.

But that is not why this paper was selected for a Quote of the Day, rather one sentence extracted from the paper expresses a truth that is too often neglected in the policy community:

“I also am responding to Atkinson’s challenge by emphasizing and illustrating that policy prescriptions depend, not just on measurement, but on ethics, a point that is not always given the weight that it should be when economists discuss policy.”

We hear a lot of policy recommendations, but all too often it is difficult if not impossible to identify the ethical imperative. In contrast, the ethical imperative permeates the single payer model of reform.

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

The deficiencies of Trump’s short-term health insurance plans

Understanding Short-Term Limited Duration Health Insurance

By Karen Pollitz, Michelle Long, Ashley Semanskee, and Rabah Kamal
Kaiser Family Foundation, April 23, 2018

Late last year, Congress repealed the Affordable Care Act’s individual mandate penalty, the requirement that individuals have minimum essential health coverage or face a tax penalty.  Starting in 2019, the tax penalty will be reduced to $0.  It is possible this change could lead more consumers to consider purchasing short-term policies.  In addition, late last year, President Trump issued an executive order directing the Secretary of Health and Human Services to take steps to expand the availability of short-term health insurance policies, and a proposed regulation to increase the maximum coverage term under such policies was published in February.  This brief provides background information on short-term policies and how they differ from ACA-compliant health plans.

Background

As the name suggests, short-term health insurance policies are not renewable.  Whereas federal law since 1996 has required all other individual health insurance to be guaranteed renewable at the policyholder’s option, coverage under a short-term policy terminates at the end of the contract term.  To continue coverage beyond that date requires applying for a new policy.  As a result, an individual who buys a short-term policy and then becomes seriously ill will not be able to renew coverage when the policy ends.

The Affordable Care Act (ACA) exempted short-term policies from market rules that apply to most major medical health insurance policies sold to individuals in the non-group market: rules that prohibit medical underwriting, pre-existing condition exclusions, and lifetime and annual limits, and that require minimum coverage standards.  By contrast, short-term policies:

* are often medically underwritten – applicants with health conditions can be turned down or charged higher premiums, without limit, based on health status, gender, age, and other factors;

* exclude coverage for pre-existing conditions – policyholders who get sick may be investigated by the insurer to determine whether the newly-diagnosed condition could be considered pre-existing and so excluded from coverage;

* do not have to cover essential health benefits – typical short-term policies do not cover maternity care, prescription drugs, mental health care, preventive care, and other essential benefits, and may limit coverage in other ways;

* can impose lifetime and annual limits –  for example, many policies cap covered benefits at $2 million or less;

* are not subject to cost sharing limits – some short term policies, for example, may require cost sharing in excess of $20,000 per person per policy period, compared to the ACA-required annual cap on cost sharing of $7,350 in 2018; and

* are not subject to other ACA market requirements – such as rate review or minimum medical loss ratios; for example, while ACA-compliant non-group policies are required to pay out at least 80% of premium revenue for claims and related expenses, the average loss ratio for individual market short-term medical policies in 2016 was 67%; while for the top two insurers, who together sold 80% of all short-term policies in this market, the average loss ratio was 50%.

From the Discussion

Short-term health insurance policies offer lower monthly premiums compared to ACA-compliant plans because short-term policies offer less insurance protection.  Medically underwritten policies can only be purchased by people when they are healthy.  Individuals who buy short-term policies and then develop health conditions will lose coverage when the contract ends.  Short-term policies typically do not cover essential benefits, such as prescription drugs, and often apply dollar caps and higher deductibles on coverage that are no longer allowed under ACA-compliant individual market and group health plans.  As a result, people who buy short-term policies today in order to reduce their monthly premiums take a risk that, if they do need medical care, they could be left with uncovered bills and/or find themselves “uninsurable” under such plans in the future (though they would be able to buy ACA-compliant policies at the next open enrollment period).

To the extent that healthy individuals opt for cheaper short-term policies instead of ACA-compliant plans, such adverse selection contributes to instability in the reformed non-group market and raises the cost of coverage for people who have health conditions.  Income-related premium subsidies in the non-group market offset the cost differential, and so help correct for adverse selection to a significant extent.  Lower-income people would be protected by the premium subsidies, but middle-income people not eligible for subsidies who buy ACA-compliant plans would likely see premium increases.  So far, the individual mandate penalty also has helped offset the cost differential between short-term plans and ACA-compliant plans, though this will disappear starting in 2019.  The combined effect of repealing the individual mandate penalty and the administration’s efforts to promote the sale of short-term plans could result in fewer people signing up for ACA-compliant plans and higher premiums in the ACA-compliant individual market, potentially adversely affecting the stability of the ACA-compliant individual market.

https://www.kff.org…

***

Comment:

By Don McCanne, M.D.

President Trump has issued an executive order directing that steps be taken to expand the availability of short-term health insurance plans. Although there is a general recognition that these short-term plans are more limited than plans regulated by the Affordable Care Act, this policy brief from Kaiser Family Foundation explains just how severe the deficiencies in coverage are and the negative impact that they will likely have on more comprehensive plans that are compliant with the Affordable Care Act.

People will buy these plans because the premiums will be less, but most will suffer significant financial hardship should they be faced with severe acute or chronic conditions.

Why are President Trump, HHS Secretary Azar and CMS Administrator Verma not only supporting but actually encouraging these plans? Is there a rational reason, or do they share some form of psychopathology? Whatever it is, we need to fix the problem by enacting and implementing a single payer national health program – an improved Medicare for all – and do it as soon as possible.

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

Top Medical Schools Get Poor Marks for Racial Justice

A new report finds that ten leading medical schools come up short on promoting diversity, serving patients of color, and ensuring fair treatment of workers

FOR IMMEDIATE RELEASE, April 25, 2018

Contact: White Coats for Black Lives National Working Group
national@whitecoats4blacklives.org

White Coats for Black Lives, a national medical student and physician organization, has published its inaugural Racial Justice Report Card. The Report Card evaluates 10 leading U.S. medical schools on 15 metrics, assessing each school’s racial justice performance on curriculum and climate; student and faculty diversity; policing; racial integration of clinical care sites; treatment of workers; and research protocols. The 10 schools and affiliated teaching hospitals were chosen based on student interest and national prominence of the school as measured by NIH funding:

  • Harvard Medical School (Boston, Mass.)
  • Icahn School of Medicine at Mount Sinai (New York, NY)
  • Johns Hopkins University School of Medicine (Baltimore, Md.)
  • Perelman School of Medicine at the University of Pennsylvania (Philadelphia, Pa.)
  • Sidney Kimmel Medical College at Thomas Jefferson University (Philadelphia, Pa.)
  • University of California, San Francisco School of Medicine (San Francisco, Calif.)
  • University of Michigan Medical School (Ann Arbor, Mich.)
  • University of Pittsburgh School of Medicine (Pittsburgh, Pa.)
  • Washington University School of Medicine in St. Louis (St. Louis, Mo.)
  • Yale School of Medicine (New Haven, Conn.)

Racism is a powerful force in American medicine, with consequences in population-level health outcomes (white Americans live, on average, 3.5 years longer than black Americans); health care delivery metrics (black patients with symptoms of heart attacks are less likely than white patients to undergo ECGs, chest X-rays, or oxygen saturation monitoring); and physician workforce statistics (black, Latinx, and Native American people represent 32% of the U.S. population, but only 8.9% of physicians).

Medical schools and affiliated hospitals are powerful institutions that receive massive amounts of public funding, provide care to millions of patients, and are often the largest employers in their regions. The Racial Justice Report Card encourages them to fight racism by directing their power and resources towards the needs of patients and health care workers of color through three principal goals:

  1. Articulate a vision of specific actions that medical schools and academic medical centers should take to promote racial justice.
  2. Increase transparency around current policies and practices of medical schools and academic medical centers.
  3. Support community-based organizing efforts that hold medical schools and academic medical centers accountable for promoting racial justice.

The Racial Justice Report Card was created by the medical student members of White Coats for Black Lives, with the collaboration of medical students at the graded schools. Schools received an advance copy of their report cards last week and were given the opportunity to correct any inaccuracies.

White Coats for Black Lives is a medical student-run organization working to safeguard the lives and well-being of patients through the elimination of racism.

Ipsos survey shows concern over paying for health care

Consumers for Quality Care, Ipsos Survey, March 13-25, 2018

From the executive summary

* Americans are acutely worried about paying for health care – even more than they worry about costs associated with retirement, college, housing, or child care.

* What people pay is the main pain point: Americans are more concerned about premiums, deductibles, and co-pays than they are about access to care or quality of care.

* When asked who is responsible for their out-of-pocket costs, Americans mostly blame insurance companies, pharmaceutical companies, and the federal government.

Q20: I am going to read you a series of statements. For each one, please tell me if it makes you more or less likely to support a candidate for Congress.

Would vote for candidates who support…

Health care companies disclosing costs
84% – Democrats
84% – Republicans
83% – Independents

Lowering out-of-pocket costs for Rx drugs
83% – Democrats
85% – Republicans
80% – Independents

Passing pharma discounts to customers
80% – Democrats
83% – Republicans
84% – Independents

Improving and funding Obamacare
77% – Democrats
15% – Republicans
52% – Independents

Repealing Obamacare
28% – Democrats
68% – Republicans
48% – Independents

Single-payer health care
59% – Democrats
44% – Republicans
53% – Independents

https://consumers4qualitycare.org…

***

Comment:

By Don McCanne, M.D.

This Ipsos survey confirms that Americans are still very much concerned about health care costs. What is perhaps of more interest here is what people think we should do about it.

There is still a sharp political divide on Obamacare with Republicans favoring repeal, Democrats favoring improving it, and Independents evenly divided. The divide seems to be based more on politics rather than policy.

The support for single payer seems to be about the same as other surveys have reported, though usually more Democrats than the 59% reported here are in support. Of note is that 44% of Republicans support single payer indicating that the single payer message should be targeted more broadly than just to progressives since there also is some significant support amongst conservatives for the concept.

What deserves special attention in this survey is the very strong support across the political spectrum for health care companies disclosing costs, lowering out-of-pocket costs for prescription drugs, and passing drug discounts on to patients. Although some might suggest that this indicates that Americans prefer incremental change, it more likely reflects the fact that it is easier to express support for one single beneficial policy issue at a time.

The nation needs to hear repeatedly just a couple of the specific policy issues that make single payer the moral imperative. We should work on that message, especially regarding affordability. For those whose attention we gain, we can elaborate on the full package.

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

Top US medical schools failing to reflect minorities, social justice group says

White Coats for Black Lives calls on elite schools to improve race bias shortcomings and help eliminate disparities in US healthcare

By Amanda Holpuch
The Guardian, April 25, 2018

Ten of the top US medical schools including Harvard and Yale do not have faculty and staff that reflect the country’s black, Native American and Latino population, according to a report by the social justice group White Coats for Black Lives (WC4BL).

The medical student-run group, which came together in response to the Black Lives Matter movement, on Wednesday published a 129-page report that grades medical schools on their work to combat racism.

The report, shared first with the Guardian, found that schools fell short of the activist group’s standards for 15 metrics, including providing robust anti-racism training and paying all workers a living wage for the local area.

Kathryn Himmelstein, one of nine people on White Coats for Black Lives’ national working group, told the Guardian they wanted to: “Turn a light on those 10 schools but also open up questions about what other academic medical centers do, and encourage folks at those places to inquire, to research, to question what their institutions could be doing better.”

For the inaugural report, WC4BL assessed:

  • Harvard Medical School in Boston
  • Icahn School of Medicine at Mount Sinai in New York
  • Johns Hopkins School of Medicine in Baltimore
  • Perelman School of Medicine at the University of Pennsylvania in Philadelphia
  • Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia
  • University of California in San Francisco
  • University of Michigan Medical School in Ann Arbor
  • University of Pittsburgh School of Medicine
  • Washington University School of Medicine in St Louis
  • Yale School of Medicine in New Haven

WC4BL selected the first 10 schools for its inaugural report because of their prominence and student interest in attending these schools and it plans to grade more schools in the future.

Of150 grades allotted across the 15 metrics for 10 universities, only eight were As, denoting the best record.

Johns Hopkins, UCSF, Thomas Jefferson, University of Pittsburgh and University of Pennsylvania said they embraced diversity and welcomed WC4BL’s report, but felt the analysis overlooked initiatives or had a questionable methodology.

Joseph Hill, senior vice president and chief diversity officer at Thomas Jefferson University’s Enterprise Office of Diversity, Inclusion and Community Engagement, said he was concerned information was missing from the report and highlighted that the school offered the only scholarship in the country for African-American males in medical school.

“We would welcome a discussion with our student members of White Coats for Black Lives about the many ways we are working to address these important issues,” Hill said.

Mary Masson, a University of Michigan medical spokesperson, said the school was looking forward to continued conversations with the group. “We were happy to provide additional details about our diversity, equity and inclusion efforts in several areas that were rated prior to receiving this information,” the statement said. “Together, we hope to continue elevating our shared values for the next generation of physicians, nurses, health professionals and scientists.”

Harvard, Mt Sinai, Washington University and Yale did not respond to requests for comment.

A call to colleges to fight US healthcare disparities

That race bias pervades medical institutions, research and care has been highlighted in studies showing black infants in the US are twice as likely to die as white infants, while black patients are less likely to be prescribed pain medicine. Black life expectancy is 3.6 years lower than white life expectancy in the US.

But only in recent decades has the impact of this bias been extensively researched.

With the report, WC4BL sought to use its power as a force within medical schools to outline how these elite institutions could leverage their power to help disadvantaged people and eliminate disparities in US healthcare.

Since December 2014, the group has led “die-in” protests at medical schools and Black Lives Matter demonstrations, including one held across the country last week in honor of unarmed black man Stephon Clark, who was killed by Sacramento police in March.

Himmelstein, a fourth-year medical student at the University of Pennsylvania’s Perelman School of Medicine, said WC4BL focused its first major report on medical schools because they are often the largest employers in their region, receive government funding for research and medical care and are gatekeepers to joining the medical profession. “Given they control so many resources and have this important social role, there was shockingly little accountability for how medical schools were or were not promoting social justice,” said Himmelstein.

In the report, each school was given a letter grade on 15 metrics, such as its policies toward immigrant patients. A is the best, B is middle and C is the worst.

The first metric assessed in the report is URM representation, the Association for American Medical Colleges term for the populations underrepresented in medicine.

Under the WC4BL criteria, schools receive an A if their student and faculty URM representation was proportionate to the US: at least 13% Black, 1% Native American and 17% Latinx – a gender-neutral term for people of Latin American descent. If a school met the minimum percentage for one of these groups, WC4BL gave it a B. If the school does not have a proportionate amount of any of these groups, WC4BL gave it a C – which is what all of the 10 schools were designated.

Colleges’ strongest at race discrimination reporting

On average, the 10 schools performed best in the area of discrimination reporting, with no school receiving a C because they all had racial discrimination policies. The University of Michigan, Washington University School of Medicine in St Louis and Yale School of Medicine were awarded As because they offer continued, documented support to people who make discrimination claims.

Grades were also handed out based on how the school recognizes people of color; how it involves community health leaders in the coursework; whether it calls race a social, not biological, construct; if it makes data about racial grade disparities public; what support is given to the URM population; if staff are compensated in line with the region’s minimum living wage; if it offers alternatives to police and security forces and what its standards are for how racial and ethnic minorities are incorporated into research.

WC4BL was inspired in part by the Black Panthers’ work to provide alternative healthcare for underrepresented communities.

“We hope there will be greater discussion both within the medical community as well as outside the medical community, about how are we leveraging the resources of academic medical centers to promote racial justice,” said Himmelstein.

WC4BL provided a copy of the report card to each university before the report’s release.

The group said that many of the schools provided additional information that was not previously publicly available to help build out the report, even if they disagreed with some of the assessments.

https://www.theguardian.com…

WARNING: CMS request for information (RFI) on direct primary care (DPC)

What is Direct Primary Care?

Direct Primary Care Coalition

Direct Primary Care (DPC) is an innovative alternative payment model improving access to high functioning healthcare with a simple, flat, affordable membership fee. No fee-for-service payments. No third party billing. The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider.

https://www.dpcare.org

***

Feedback on New Direction Request for Information (RFI) Released, CMS Innovation Center’s Market-Driven Reforms to Focus on Patient-Centered Care

CMS.gov, April 23, 2018

Today, the Centers for Medicare & Medicaid Services (CMS) announced that it has released the comments submitted by patients, clinicians, innovators, and others in response to the CMS Innovation Center’s New Direction Request for Information (RFI). Last fall, CMS released the RFI to collect ideas on a new direction for the agency’s Innovation Center 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. The Innovation Center is a central focus of the Administration’s efforts to accelerate the move from a healthcare system that pays for volume to one that pays for value and encourages provider innovation.

CMS is sharing the feedback received to promote transparency and facilitate further discussion of how to move the Innovation Center in a new direction.

Today, CMS is also taking a next step to develop a potential model in the area of direct provider contracting, informed in part by the RFI. A direct provider contract model would allow providers to take further accountability for the cost and quality of a designated population in order to drive better beneficiary outcomes. Such a model would have the potential to enhance the doctor-patient relationship by eliminating administrative burden for clinicians and providing increased flexibility to provide the high-quality care that is most appropriate for their patients, thus improving quality while reducing expenditures.

As part of its process to gain further insight from the public in this area and ask more focused questions, CMS is issuing a follow up RFI. The information being requested is detailed in nature and is intended to provide CMS the data needed to potentially design and release a model in this area. CMS is excited to continue to evaluate the concept of direct provider contracting and is also focusing its attention on other areas guided by input and feedback from the New Direction RFI as well as the public.

https://www.cms.gov…

***

Direct Provider Contracting Models – Request for Information

CMS.gov

The Centers for Medicare & Medicaid Services (CMS) is seeking broad input on direct provider contracting (DPC) between payers and primary care or multi-specialty groups to inform potential testing of a DPC model within the Medicare fee-for-service (FFS) program (Medicare Parts A and B), Medicare Advantage program (Medicare Part C), and Medicaid.

A DPC model would aim to enhance the beneficiary-physician relationship by providing a platform for physician group practices to provide flexible, accessible, and high quality care to beneficiaries that have actively chosen this type of care model.

The public is encouraged to provide feedback on their experiences with, and perspectives on, DPC and how CMS can use DPC models to reduce expenditures and preserve or enhance the quality of care for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries.

Please submit your comments to the CMS Innovation Center at DPC@cms.hhs.gov through 11:59pm EDT May 25, 2018.

https://innovation.cms.gov…

Request for Information on Direct Provider Contracting Models (9 pages):
https://innovation.cms.gov…

***

Comment:

By Don McCanne, M.D.

This CMS notice is important. CMS is requesting public input on factors that should be considered in including a direct primary care model (DPC) in traditional FFS Medicare, Medicare Advantage, Medicaid, and CHIP.

DPC is a model in which a retainer (membership fee) is paid by a patient to a primary care provider to cover all included primary care services. No insurer or third party payer is involved although it is usually recommended that the patient obtain catastrophic (high deductible) insurance for expensive, specialized care beyond what would be provided in a primary care practice.

From the physician’s perspective, DPC eliminates controls on fees, whether by a government program or commercial insurance. The physician does not contract with an insurer, does not bill an insurer, and does not accept any limitations demanded by an insurer. From the patient’s perspective, direct access to the primary care professional is supposedly much more readily available.

Keep in mind that today’s high deductible health plans are quite expensive; the premium added to a significant retainer fee would not be affordable for the majority. The RFI will be important for the government to design its portion of a retainer fee plus costs of catastrophic insurance that it will pay for with Medicare or with the other government programs.

Also note that the retainer is a form of capitation rather than fee-for-service. For individual physicians or small groups, capitation poses a risk should the practice attract a larger percentage of patients with chronic diseases.

In the request for information (RFI) on DPC, CMS states that the goal of DPC would be to reduce expenditures (presumably for the government) while maintaining quality. Since government programs already pay less than commercial insurance, the prospect of further reductions in payments (inadequate retainer fee) should raise alarms for health care professionals.

But what should be even more alarming is that CMS states that DPC incorporated into the public programs would eliminate the administrative burden and provide increased flexibility in the provision of care. Their RFI suggests that, under this model, a retainer could be provided in which the primary care professional will bear all upside and downside risk in an environment with greatly reduced regulatory oversight. In a program designed to reduce spending, you can be sure that patients with greater health care needs – downside risk – would be avoided, shifting those patients to what is left of the traditional, taxpayer-funded Medicare program. And reduced oversight? The temptation would be very great to market a comfy, patient-friendly practice environment while remaining silent on more costly primary care services that are not being provided.

This obviously represents an attempt of the administration to decrease the role of the government as a payer and a regulator. This program, driven by conservative ideology, poses a great hazard to our traditional government health programs, especially Medicare.

Everyone who cares should look at the nine page RFI (last link above) and consider submitting a response, or, even better, have your various professional or advocacy organizations submit a formal response. Deadline is May 28, 2018.

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