PNHP

The public judges health care by the ‘medical bill score’

The public judges health care by the ‘medical bill score’

The medical bill score: How the public judges health care

By Drew Altman
Axios, October 3, 2017

We track a lot of numbers in health care: how much we spend on health as a share of our economy; the number of uninsured; and the share of the federal budget allocated to health programs. What we don’t track — and a number the Congressional Budget Office cannot score — is the statistic that means the most to the American people: the share of the public having problems paying their health care bills.

Percent saying they have taken action in order to pay medical bills:

72% – Put off vacations, household purchases

70% – Cut back on food, clothing, basic items

59% – Used up all or most of savings

41% – Taken an extra job or worked more hours

37% – Borrowed money from friends or family

34% – Increased credit card debt

26% – Taken money out of long-term savings

17% – Changed your living situation

15% – Taken out another type of loan

13% – Borrowed from a payday lender

12% – Sought aid of a charity or non-profit

02% – Taken out another mortgage

15% – Made other significant changes

The bottom line:

The “medical bills score” is the single most important measure of how we are doing in health care from the public’s perspective. And ultimately, if Congress ever passes a new health care bill, it is how the public will evaluate that plan — from Graham-Cassidy to Medicare for All and everything in between.

The numbers that matter:

As we found in a Kaiser Family Foundation poll in February:

* 31% of Americans age 18-64 report they or a family member face problems paying their health care bills.

* But that number shoots up to 57% for people who are sick.

It makes sense that people who use more care have more health care bills, but it also reveals how poorly our system performs from a consumer perspective when people who need care the most are protected the least by insurance coverage.

The impact:

Not surprisingly, the uninsured (41%) are more likely to have problems paying medical bills. But this is not a problem limited to the uninsured: 30% of the insured – think voters — have problems with medical bills.

The back story:

The share of the public reporting problems paying their medical bills has not moved much in recent years. The Affordable Care Act has extended coverage and better financial protection to tens of millions, but it doesn’t have much of an impact on affordability beyond people covered by the Medicaid expansion and the marketplaces.

In the far larger employer-based health insurance sector, deductibles and other forms of cost sharing have been growing about five times faster than wages, and deductibles have been growing especially sharply for people who work for smaller employers.

What to watch:

Health care is a pocketbook issue for most of the public and the American people have their own scoring system. They may give this or that mostly partisan response about a health reform idea on a poll, but until they see how they’ll get help paying their health care bills, they will ultimately be disappointed by every health reform plan.

https://www.axios.com…

***

Comment:

By Don McCanne, M.D.

“Yes, but how will health care reform affect me?” For most people that means, how much will I have to pay for my insurance, and how much will I have to pay out of pocket for my health care?

Except for low-income individuals with heavily subsidized insurance, members of the work force are paying too much for their insurance, either directly or through forgone wages, and they are paying too much when they need to access health care, especially through high deductibles.

Under the Physicians’ Proposal – a single payer model advocated for by Physicians for a National Health Program – insurance premiums would be eliminated and replaced by equitable funding  of a universal risk pool that would be affordable for each of us, and deductibles and other cost sharing would be eliminated for all essential health care services since other, more patient-friendly methods of cost containment would allow the removal of financial barriers to care.

As Drew Altman states, “until they see how they’ll get help paying their health care bills, they will ultimately be disappointed by every health reform plan.” The obvious lesson is that we need to show the public how a single payer, improved Medicare for all program will give them the “medical bill score” they have been looking for, and thus end the scourge of medical debt.

A Physicians’ Proposal for Single-Payer Health Care Reform:
https://pnhp.org/nhi

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

Multispecialty consolidation drives prices up

NBER Working Paper 23871: Does Multispecialty Practice Enhance Physician Market Power?

By Laurence C. Baker, M. Kate Bundorf, and Daniel P. Kessler
National Bureau of Economic Research, September 2017

Abstract

In markets for health services, vertical integration – common ownership of producers of complementary services – may have both pro- and anti-competitive effects. Despite this, no empirical research has examined the consequences of multispecialty physician practice – a common and increasing form of vertical integration – for physician prices. We use data on 40 million commercially insured individuals from the Health Care Cost Institute to construct indices of the price of a standard office visit to general-practice and specialist physicians for the years 2008-2012. We match this to measures of the characteristics of physician practices and physician markets based on Medicare Part B claims, aggregating physicians into practices based on their receipt of payments under a common Taxpayer Identification Number. Holding fixed the degree of competition in their own specialty, we find that generalist physicians charge higher prices when they are integrated with specialist physicians, and that the effect of integration is larger in uncompetitive specialist markets. We find the same thing in the reciprocal setting – specialist prices are higher when they are integrated with generalists, and the effect is stronger in uncompetitive generalist markets. Our results suggest that multispecialty practice has anticompetitive effects.

http://www.nber.org…

***

Comment:

By Don McCanne, M.D.

Advocates of consolidation in health care tell us that both horizontal and vertical integration improve efficiency and improve the services delivered, thus improving quality and reducing costs. The secret, they say, is to allow the markets to work. But what does this study tell us?

Integration of generalist and multispecialty practices drives up prices of both the generalists and the specialists, which the authors attribute to the anticompetitive nature of multispecialty practices.

Of significance is that this study did not use Medicare data but rather used data from the Health Care Cost Institute which compiles data on commercially insured individuals – the private sector. This study shows, once again, that the U.S. system is unique in relying heavily on the medical-industrial complex, and we are paying dearly for that.

This trend in consolidation has been increasing, and yet where is the government when we need it? Does Medicare do any better? Well, yes. Prices are lower under Medicare than under the private insurance plans, except for the private Medicare Advantage plans (though more is paid to the insurers for administration and profits).

What would happen under an Improved Medicare for All program? Prices would be negotiated to cover legitimate costs and fair margins. That might mean that some Medicare fees would be adjusted upward, especially for primary care, but the chicanery of the private insurers in partnership with their contracted providers would no longer be a factor since they would be replaced by the single payer system.

No doubt progressive members of the policy community will say, “There goes PNHP again with their pipe dreams about single payer nirvana.” But other wealthy nations cover everyone at an average of half of our per capita costs, precisely because they rely on greater government oversight. “Only in America” do we put up with this – American exceptionalism that bites us.

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

Single-payer in Penn. and beyond

Panel featuring Dr. William Davidson

WITF, Smart Talk, October 2, 2017

The Senate’s third attempt to repeal and replace the Affordable Care Act, or Obamacare, failed last week before the vote made it to the floor. It was the third attempt since the inauguration of Donald Trump, who campaigned with the promise to overturn the ACA, saying on many occasions the plan “…is unaffordable and it’s a disaster.”

Earlier in September, Vermont Senator Bernie Sanders proposed a “Medicare-for-all” bill that, according to Sanders’ own website, would “…create a federally administered single-payer health care program.” The plan would cover all aspects of healthcare; preventative and emergency care, primary, specialized, vision, dental, mental – everything for everyone. People could choose any doctor and prescriptions would be covered.

Supporters of universal single-payer healthcare are thrilled that the bill brings the topic to the national narrative, though it has little chance of passing the Republican-controlled congress. Critics contend that further government involvement in the healthcare process would only take choices away from consumers and cost would skyrocket.

On the Monday edition of Smart Talk, we will spend the hour discussing the merits and drawbacks of a single-payer healthcare system.  Pennsylvania State Representative Pamela DeLissio (D – 194th) will discuss her proposal – the Pennsylvania Health Care Plan – a single payer plan administered by the state.

We’ll also speak with Dr. William Davidson, a cardiologist who has served Central Pennsylvania for 30 years and is a member of Physicians for a National Health Program, an organization of doctors advocating for a universal single-payer system.

We’ll also speak with critics of the single-payer concept; Vince Phillips is a retired lobbyist who advocated for the Pennsylvania Association of Health Underwriters and Eric Beittel, a financial planner and the former President of the Board of the Central Pennsylvania Association of Health Underwriters. We’ll also hear from Elizabeth Stelle, the Director of Policy Analysis for the Commonwealth Foundation.

http://www.witf.org…

The policy community’s approach to narrow networks

A better approach to regulating provider network adequacy

By Mark Hall and Paul B. Ginsburg
USC-Brookings Schaeffer Initiative for Health Policy, September 14, 2017

Health care reforms, including those put in place by the Affordable Care Act, are making insurers more competitive. However, in their effort to lower costs, health insurers more often are selling health plans that cover fewer hospitals, and many fewer physicians.

This narrowing of provider networks is a sign that market reforms may be improving consumer value,  but network narrowing also raises a number of concerns. For example, a narrow network may have insufficient capacity to serve the number of people enrolled, or the providers may be too geographically dispersed to be reasonably accessible.

Rules dictating the adequacy of care in these networks have been in place for several decades, but state and federal regulators have begun to assess whether these rules are suited for the modern conditions.

In “A better approach to regulating provider network adequacy,” Mark Hall and Paul B. Ginsburg argue that the current set of regulations are not sufficient to ensure network adequacy without placing undue constraints on market innovation. Instead, the authors argue that a more layered approach is needed, including a form of patient-specific [or case-specific] dispute resolution.

This layered approach to network adequacy consists of the following recommended eight elements:

1. A general qualitative standard for network adequacy is needed

2. Insurers should provide reasonably up-to-date and user-friendly network directories, and network size should be more clearly labeled for consumers.

3. Some basic baseline quantitative standards should be considered that are fairly easy to administer, such as a minimally acceptable number of higher-volume providers in the major areas of primary care and specialty practice, and at least one such provider within a defined distance of most of the plan’s enrolled population.

4. Quantitative standards should be presumptive, but not conclusive.

5. If quantitative standards are adopted, consideration should be given to maximum wait times (rather than simply number and distribution of providers).

6. Regardless of the substantive adequacy standards in place, a backstop dispute resolution process is also needed to protect patients who might face inadequate access due to a restricted network.

7. Patients should be held financially harmless when a reviewer determines there are grounds to receive care out of network.

8. If network adequacy requirements might add substantially to the cost of insurance, then states should consider creating an additional dispute resolution process focused on financial implications.

The authors conclude that a robust dispute resolution process can ease the administrative burden of overseeing network adequacy. “Nevertheless, well-designed regulation of network adequacy is not easy to achieve. Because no single regulatory approach is likely to be sufficient, we need to think more in terms of a layered approach – one that thoughtfully melds together different dimensions and techniques of oversight.”

https://www.brookings.edu…

Full report:
https://www.brookings.edu…

***

Comment:

By Don McCanne, M.D.

Why do private insurers establish narrow provider networks? They claim that they contract for higher quality at lower costs, but quality has nothing to do with it. They reduce costs by granting physicians and hospitals greater numbers of patients in return for contracted lower prices. They also lower costs by reducing patient access to care as a result of failure to use the full complement of heath care resources in the community. This not only allows insurers to offer more competitive premiums and thus greater insurance sales, but it also enhances profits and shareholder returns.

Narrow networks are a business tool of for-profit, private insurers. They are detrimental for patients because they lose access to their choices in their health care professionals and institutions. They are also detrimental to care provided by dedicated primary care physicians because they reduce access for their patients to specialists and their specialized services (often without the knowledge of patients when physicians remain silent on potential health care resources that are out-of-network).

Traditional Medicare does not use narrow networks. Medicare’s mission is to enable access to care for the beneficiaries, not to obstruct access to that care. Although entrepreneurial endeavors and public service health programs may superficially appear to have similar goals, their primary targets are quite different – investor returns versus optimal health care.

These differences have been widely recognized. So what should be done about this problem? To see what the policy community recommends, skim through the eight elements listed above. With a little thought, you can immediately recognize the problem, and that is that they have not acknowledged what the real problem is.

The elements listed would hardly tweak the current system, yet they are the type of approaches that are taken when you make the assumption that we are going to leave our health care system under the control of the medical-industrial complex. The real problem is the dysfunctional health care financing system that we continue to support.

If we were to change to a well designed, single payer national health program, the narrow provider networks would be eliminated because they counter the goals of a premier performing health care system. The sooner we do that, the better.

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

Atul Gawande: Is health care a right?

Is Health Care a Right?

By Atul Gawande
The New Yorker, October 2, 2017

Is health care a right? The United States remains the only developed country in the world unable to come to agreement on an answer. Earlier this year, I was visiting Athens, Ohio, the town in the Appalachian foothills where I grew up. The battle over whether to repeal, replace, or repair the Affordable Care Act raged then, as it continues to rage now. So I began asking people whether they thought that health care was a right.

***

“My personal opinion is that anytime the government steps in and says, ‘You must do this,’ it’s overstepping its boundaries,” Joe said. “A father, mother, two kids working their asses off—they’re making minimum wage and are barely getting by—I have no problem helping them. If I have someone who’s spent his whole life a drunk and a wastrel, no, I have no desire to help. That’s just the basics.”

Such feelings are widely shared. They’re what brought the country within a single vote of repealing major parts of President Obama’s expansion of health-care coverage. Some people see rights as protections provided by government. But others, like the Duttons, see rights as protections from government.

***

People don’t think about their water, Tim said, but we can’t live without it. It is not a luxury; it’s a necessity of human existence. An essential function of government, therefore, is to insure that people have clean water. And that’s the way he sees health care. Joe wanted government to step back; Tim wanted government to step up. The divide seemed unbridgeable. Yet the concerns that came with each viewpoint were understandable, and I wondered if there were places where those concerns might come together.

***

Monna considered herself a conservative. The notion of health care as a right struck her as another way of undermining work and responsibility: “Would I love to have health insurance provided to me and be able to stay home?” Of course, she said. “But I guess I’m going to be honest and tell you that I’m old school, and I’m not really good at accepting anything I don’t work for.”

She could quit her job and get Medicaid free, she pointed out, just as some of her neighbors had. “They have a card that comes in the mail, and they get everything they need!” she said. “Where does it end? I mean, how much responsibility do tax-paying people like me have? How much is too much?” She went on, “I understand that there’s going to be a percentage of the population that we are going to have to provide for.” When she was a young mother with two children and no home, she’d had to fall back on welfare and Medicaid for three months. Her stepson, Eric, had been on Medicaid and Social Security Disability Insurance before he died. Her eighty-three-year-old mother, who has dementia and requires twenty-four-hour care, was also on Medicaid. “If you’re disabled, if you’re mentally ill, fine, I get it,” Monna said. “But I know so many folks on Medicaid that just don’t work. They’re lazy.” Like the Duttons, she felt that those people didn’t deserve what they were getting.

But then we talked about Medicare, which provided much of her husband’s health care and would one day provide hers. That was different, Monna told me. Liberals often say that conservative voters who oppose government-guaranteed health care and yet support Medicare are either hypocrites or dunces. But Monna, like almost everyone I spoke to, understood perfectly well what Medicare was and was glad to have it. I asked her what made it different.

“We all pay in for that,” she pointed out, “and we all benefit.” That made all the difference in the world. From the moment we earn an income, we all contribute to Medicare, and, in return, when we reach sixty-five we can all count on it, regardless of our circumstances. There is genuine reciprocity. You don’t know whether you’ll need more health care than you pay for or less. Her husband thus far has needed much less than he’s paid for. Others need more. But we all get the same deal, and, she felt, that’s what makes it O.K.

“I believe one hundred per cent that Medicare needs to exist the way it does,” she said. This was how almost everyone I spoke to saw it. To them, Medicare was less about a universal right than about a universal agreement on how much we give and how much we get.

Understanding this seems key to breaking the current political impasse. The deal we each get on health care has a profound impact on our lives—on our savings, on our well-being, on our life expectancy. In the American health-care system, however, different people get astonishingly different deals. That disparity is having a corrosive effect on how we view our country, our government, and one another.

***

Arnold, with his code of self-reliance, had eliminated nearly all sources of insecurity from his life. But here was one that was beyond his control. “The biggest worry I have would be some sort of health-care need,” he said. A serious medical issue would cost him his income. As an independent contractor, he isn’t eligible for unemployment benefits. And, having passed the age of fifty, he was just waiting for some health problem to happen.

So did he feel that he had a right to health care? No. “I never thought about it as a matter of rights,” he said. “A lot of these things we think are rights, we actually end up paying for.” He thinks that the left typically plays down the reality of the costs, which drives him crazy. But the right typically plays down the reality of the needs, which drives him crazy, too.

In his view, everyone has certain needs that neither self-reliance nor the free market can meet. He can fix his house, but he needs the help of others if it catches fire. He can keep his car running, but he needs the help of others to pave and maintain the roads. And, whatever he does to look after himself, he will eventually need the help of others for his medical care.

“I think the goal should be security,” he said of health care. “Not just financial security but mental security—knowing that, no matter how bad things get, this shouldn’t be what you worry about. We don’t worry about the Fire Department, or the police. We don’t worry about the roads we travel on. And it’s not, like, ‘Here’s the traffic lane for the ones who did well and saved money, and you poor people, you have to drive over here.’ ” He went on, “Somebody I know said to me, ‘If we give everybody health care, it’ll be abused.’ I told her that’s a risk we take. The roads are abused. A lot of things are abused. It’s part of the deal.”

As he saw it, government existed to provide basic services like trash pickup, a sewer system, roadways, police and fire protection, schools, and health care. Do people have a right to trash pickup? It seemed odd to say so, and largely irrelevant. The key point was that these necessities can be provided only through collective effort and shared costs. When people get very different deals on these things, the pact breaks down. And that’s what has happened with American health care.

***

We relied on government to establish a system of compulsory public education, infrastructure for everything from running water to the electric grid, and old-age pensions, along with tax systems to pay for it all. As in other countries, these programs were designed to be universal. For the most part, we didn’t divide families between those who qualified and those who didn’t, between participants and patrons. This inclusiveness is likely a major reason that these policies have garnered such enduring support.

Health care has been the cavernous exception.

***

To win passage, the A.C.A. postponed reckoning with our generations-old error of yoking health care to our jobs—an error that has made it disastrously difficult to discipline costs and insure quality, while severing care from our foundational agreement that, when it comes to the most basic needs and burdens of life and liberty, all lives have equal worth. The prospects and costs for health care in America still vary wildly, and incomprehensibly, according to your job, your state, your age, your income, your marital status, your gender, and your medical history, not to mention your ability to read fine print.

Few want the system we have, but many fear losing what we’ve got. And we disagree profoundly about where we want to go. Do we want a single, nationwide payer of care (Medicare for all), each state to have its own payer of care (Medicaid for all), a nationwide marketplace where we all choose among a selection of health plans (Healthcare.gov for all), or personal accounts that we can use to pay directly for health care (Health Savings Accounts for all)?

***

What we agree on, broadly, is that the rules should apply to everyone. But we’ve yet to put this moral principle into practice.

***

Two sets of values are in tension. We want to reward work, ingenuity, self-reliance. And we want to protect the weak and the vulnerable—not least because, over time, we all become the weak and vulnerable, unable to get by without the help of others. Finding the balance is not a matter of achieving policy perfection; whatever program we devise, some people will put in more and some will take out more. Progress ultimately depends on whether we can build and sustain the belief that collective action genuinely results in collective benefit. No policy will be possible otherwise.

https://www.newyorker.com…

***

Comment:

By Don McCanne, M.D.

Years ago, here in conservative Orange County, I learned not to ask audiences whether they believed health care is a right. The “tis so,” “tis not” that followed was not productive. Nevertheless, the question frequently came up during Q&A, with the same result.

Atul Gawande’s long article is interesting because conservatives he interviewed used different framing to express the concept that people should have health care when they need it, without deeming it to be a right. Health care should be a basic service like trash pickup, water, a sewer system, roadways, police and fire protection, and schools. We don’t speak of a right to trash pickup, and we don’t need to anger others by getting into a cat fight over a “right” to health care.

It is no wonder that we are beginning to see conservatives supporting single payer, not as a right but as a necessity.

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

Our family, friends and communities deserve Medicare for all

By Peter Mahr, M.D.
The Oregonian (Portland, Ore.), September 27, 2017

As a family physician, I was trained to guide patients through difficult times with clinical expertise and emotional support. But I am finding it increasingly difficult to provide this care.

One of my patients without insurance received a $100,000 hospital bill after a heart attack and newly diagnosed congestive heart failure. She has declined all recommended follow up tests, specialist care and cardiac rehabilitation due to the cost. I had a young patient in his 20s who developed worrisome neurological symptoms that warranted tests to rule out a stroke. But he declined hospital admission as his insurance required a $3,000 copay. A father had a bicycle accident requiring life-saving emergency care for a broken pelvis and fractured arm. The emotional toll from his accident was compounded by the shock of a $5,000 deductible bill, and the stress of the resulting collections agency calls and threat of home foreclosure.

Patients’ financial stress has become a routine part of our medical practices. Although we stand by our patients during daunting medical challenges, we were never taught to protect them from bankruptcy when they seek the care they need. These are stories of a broken health care system. They reveal a dark side of medicine we were not trained for and did not choose to participate in.

The United States’ healthcare system is the most expensive in the world, yet 60 million of us remain uninsured or underinsured. Our administrative and drug costs dwarf other nations. Gallup reports that one-third of Americans delay or forgo care due to cost.  Despite spending twice as much per capita on healthcare, the US ranks 81st among 195 nations on mortality prevented by medical care – we’re tied with Estonia and one place above Lebanon.

Fortunately, there is light emerging from darkness. Sen. Bernie Sanders has introduced legislation that would enact a Medicare For All or “single payer” system in the U.S. All current health care financing — taxes, premiums, copayments and deductibles — would be placed into a single fund and pay for all medically necessary services. The vast majority of Americans would receive comprehensive medical coverage and pay less than they currently do. Each patient would have the freedom to go to any doctor or hospital. The dramatic reduction in administrative costs and the ability to negotiate drug prices will allow us to cover everyone and stabilize health care costs.

Single payer health insurance is what our family, friends, neighbors and communities deserve. We deserve continuous, affordable health insurance regardless of income, marital status, age or employment. We deserve to seek medical care when we are sick without fear of financial catastrophe. We deserve to choose our doctors or hospitals based on preference not on insurance networks. And we deserve the peace of mind that we will have access to health care when we need it.

I urge you to support Sen. Sanders’ Medicare For All Act of 2017. Oregon Sen. Jeff Merkely is a co-sponsor. Call Sen. Ron Wyden today and ask him to sign on as well.

Dr. Peter Mahr has practiced as a family physician in the metro area for 16 years and is president of the Portland chapter of Physicians for a National Health Program. He lives in Southeast Portland.

http://www.oregonlive.com…

CaPA’s Tarzynski sets record straight on single payer

Americans have been fighting over government's role in medical care for decades. That fight will continue.

By Steve Tarzynski
Los Angeles Times, September 27, 2017

From my decades of experience as a doctor, it seems to me that no market-driven healthcare system can simultaneously limit costs, guarantee universal coverage and deliver desired outcomes. Overwhelming evidence demonstrates that the best way to reduce costs and guarantee healthcare to everyone is to have the largest risk pool — that is, the entire nation. These facts compel the United States to move to a single-payer system guided by comparisons with other countries’ experiences and by our own American successes, such as Medicare and Medicaid.

The preamble of our Constitution states that government exists to provide “domestic tranquility” and “promote the general welfare,” which certainly suggests constitutional support for healthcare for all.

Steve Tarzynski is a physician and president of the California Physicians Alliance.

http://www.latimes.com…

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Comment:

By Don McCanne, M.D.

Because of an editorial glitch in a previous Los Angeles Times op-ed by Steve Tarzynski, there was some confusion over the relative positions of PNHP California and California Physicians Alliance on the goal of single payer. His followup message could not be more clear. We remain partners in the quest for health care justice for all. In fact, many of us, including me, belong to both organizations.

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

How Anthem and Medicare control MRI prices

Need An MRI? Anthem Directs Most Outpatients To Independent Centers

By Michelle Andrews
Kaiser Health News, September 26, 2017

Tightening the screws on pricey imaging exams, health insurer Anthem will no longer allow many patients to get MRIs or CT scans at hospital-owned, outpatient facilities, requiring them to use independent imaging centers instead.

Anthem says the change is aimed at providing high-quality, safe care while reducing medical costs.

But critics say that imposing a blanket rule that gives preference to freestanding imaging centers is at odds with promoting quality and will lead to fragmented care for patients.

Imaging tests are generally subject to preapproval by Anthem to confirm that they’re medically necessary. Under the new policy, AIM Specialty Health, an Anthem subsidiary, will also evaluate where they should be performed. Doctors who request non-emergency outpatient MRI or CT scans that can be done at an independent imaging center rather than one owned by the hospital will be given a list of centers eligible for patient referrals.

Hospital imaging is indeed pricier than imaging at freestanding centers. Average prices for MRI and CT scans ranged from 70 percent to 149 percent higher at hospitals, according to an analysis by the Healthcare Financial Management Association, a membership group for health care finance professionals.

But price isn’t the only important variable, and the perception that all imaging studies conducted by qualified providers generally yield comparable results is wrong, (said Leah Binder, president and CEO of the Leapfrog Group).

This is Anthem’s second coverage change this year attracting attention. Earlier, the company came under fire for a new policy under which it will no longer pay for emergency department visits that it determines after the fact weren’t emergencies. That decision raised concerns it could discourage people who might need emergency treatment from  seeking care.

Patient advocates and health care providers have also expressed concerns about the new imaging rule’s potential impact on patients.

Cancer patients who often are being treated at cancer centers within hospitals would feel the effect, noted Dr. J. Leonard Lichtenfeld, deputy chief medical officer for the American Cancer Society.

“They have to go to a new outpatient facility, get the film, get it read and transmitted back to the cancer center,” Lichtenfeld said. If, as often happens, the hospital and the imaging center’s computer systems don’t talk to each other, the patient may have to bring the results back to the doctor on a CD. “For that patient who’s in a lot of stress to begin with, it adds another level of stress,” he said.

Anthem isn’t the only insurer trying to find a way around hospitals’ steeper outpatient imaging costs, said Lea Halim, a senior consultant at the Advisory Board, a health care research and consulting company. The Medicare program is taking steps as well, although its approach doesn’t directly influence patient care in the same way.

In recent years, hospitals have been snapping up independent physician practices, outpatient imaging and testing facilities and then charging Medicare higher hospital outpatient fees for their services. In a bid to equalize payments, in January the Medicare program reduced by 50 percent the amount it pays some hospital-owned outpatient facilities, including imaging centers, that are located away from a hospital’s campus. A further reduction is proposed for 2018.

“So Medicare is doing something that’s in a way very similar to what Anthem’s doing,” Halim said.

http://khn.org…

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CMS Finalizes Hospital Outpatient Prospective Payment System Changes to Better Support Hospitals and Physicians and Improve Patient Care

CMS.gov, November 1, 2016

Focusing Payments on Patients Rather than Setting

CMS is finalizing policies to implement section 603 of the Bipartisan Budget Act of 2015, which requires that certain items and services furnished by certain off-campus hospital outpatient departments will no longer be paid under the OPPS beginning January 1, 2017. Currently, Medicare pays for the same services at a higher rate if those services are provided in a hospital outpatient department rather than a physician’s office. This payment differential has provided an incentive for hospitals to acquire physician offices in order to receive the higher rates. This acquisition trend and difference in payment has been highlighted as a long-standing issue of concern by Congress, the Medicare Payment Advisory Commission, and the Department of Health and Human Services Office of Inspector General. This difference in payment also increases costs for the Medicare program and raises the cost-sharing liability for beneficiaries.

This final rule with comment period describes which off-campus hospital outpatient departments are subject to this requirement and which items and services are “excepted” from application of these payment changes and will continue to be paid under the OPPS.

CMS is issuing an interim final rule with comment period (IFC) in conjunction with this final rule with comment period to establish new payment rates under the Medicare Physician Fee Schedule (MPFS) for the items and services provided by certain off-campus provider-based departments for CY 2017.

These new interim final rates being adopted in the IFC will permit hospitals to be paid for the furnishing of items and services that may no longer be paid under the OPPS, and we believe will reduce incentives for hospitals to acquire independent physician practices and convert the same service into more highly paid OPPS services.

https://www.cms.gov…

***

Comment:

By Don McCanne, M.D.

Prices charged for MRI scans in hospitals and outpatient departments are higher than those charged in freestanding facilities. Both Medicare and the private, for-profit insurer Anthem are taking measures to correct this imbalance. Health care consultant Lee Halim says that “Medicare is doing something that’s in a way very similar to what Anthem’s doing.” But are they really similar?

The problem to be addressed is that the prices are too high. What is not a problem is the location of the facility. Hospital and outpatient facilities are located conveniently, enabling them to provide services integrated with the mothership.

Obtaining MRI scans in unrelated freestanding facilities can be disruptive. Imagine a patient receiving outpatient care in a cancer center having to go across town to obtain an MRI from a radiologist that is not part of the integrated team. Imagine the confusion as to the precise imagining features desired, the transfer of the images to incompatible equipment, and the communication difficulties between the patient’s cancer team and an outsider. Yet this is Anthem’s solution to obtaining lower prices.

What does Medicare do? It does not change the location, but rather it uses administered pricing to reduce the costs to appropriate levels. As the Medicare release states, they are “focusing payments on patients rather than setting.”

Medicare made these patient-friendly changes almost a year ago, and now Anthem is following through in the most patient-unfriendly manner – disrupting health care to save a buck.

There really is a difference in the patient service culture of our Medicare program and the strict business ethic of the for-profit insurers, not to mention that Medicare is providing us with a better deal anyway.

Medicare still doesn’t have everything quite right, and that is why we need an improved Medicare. But then we’ll have a program that will be nearly ideal for all of us, and one that we can afford.

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Why I’m the last happy doctor

By Marsha Fretwell, M.D.
The Charlotte Observer, September 26, 2017

When I retired at 70 years old as a practicing geriatrician in Wilmington and said farewell to my medical colleagues, I slowly began to realize that I might be “The Last Happy Doctor” in town. Why is this and how did it happen? First, let me lay out some of the realities of practicing medicine today.

The surgeon general has declared that, second only to opioid addiction, “burned out” physicians is our most critical issue in health care. In a recent survey of N.C. physicians, the most prominent reason given for their “burnout” was erosion of clinical authority and the requirement of excessive insurance paperwork in order to get paid. Only 11 percent of physicians felt they had the time they needed to provide the highest standards of care. In the next one to three years, 44 percent plan to cut back on direct delivery of care, retire, or seek work in non-clinical jobs.

So, how did I end up as the “Last Happy Doctor”? It was a series of responses I made as the insurance industry began to reshape health care as a for-profit efficiency driven business. The first choice was to resist reducing the time spent with my patients. When I refused to schedule less than one half hour per patient, it became obvious that I would need to start and manage my own practice. Because of my choice to focus primarily on caring for older patients, my revenue stream was approximately 96 percent Medicare funded. Unaware, I had wandered into a “Medicare for All” financed healthcare practice.

Knowing that all my patients had coverage was a great relief to me and my office staff. That allowed us to focus on truly caring for and about them. Having a predictable reimbursement allowed me to create a budget. The greatest bonus was the lower overhead. Because my practice did not need to spend hours on the phone with agents of the for-profit insurance companies, I could hire fewer staff. Additionally, not only was I making clinical decisions based on patients’ needs, I got to decide on clinician-friendly computer software for data collection. This reduced the other major reason physicians are “burned out” and leaving practice: spending excessive time using computer software that does not actually serve any meaningful purpose for clinical care.

The introduction of widespread for-profit insurance financing of health care in the 1970s is a major factor in the demoralization of physicians. The percentage of the health care insurance market served by for-profits rose from 16 percent in 1981 to 65 percent in 1997. In the for-profit setting, physicians are required to care for patients under constant time pressure and with the knowledge that the cost of care may send their patients into bankruptcy. This model does not work in health care at the practitioner level because it requires reduction of human contact time. Without this human contact, a loss of satisfaction occurs for both the physicians and patients. Critical to the discussion is the significant lowering of survival rates and desired patient outcomes since 1950, all in the context of rapidly rising costs.

In a humane society, universal health care is a given, and those involved in health care optimally come with a calling. Helping individuals improve their health requires trusting relationships over time. Creating a “Medicare for All” financing system and removing for-profit insurers from the equation is an appropriate pathway to less expensive care, better health outcomes, happier patients and happier doctors. I know because I have been there.

Dr. Fretwell is retired from active practice in geriatric medicine. She is now activity working with Healthcare for All of Western North Carolina seeking fundamental change in the financing of health care.

http://www.charlotteobserver.com…

Bernie Sanders is right – why not Medicare for all?

Private doctors and hospitals would still provide care under Bernie Sanders' Medicare for All plan, offering better care at lower cost.

By James E. Dalen, M.D., M.P.H., Sc.D. (hon)
Arizona Republic, September 26, 2017

Bernie Sanders is introducing a bill that would ensure that all Americans have access to health care. It is called “Medicare for all.”

Is this a wild socialist scheme?

Nearly every industrialized nation (except the U.S.) provides universal access to health care. They spend less on health care than the U.S., and nearly all have better health care outcomes because they provide ongoing primary and preventive care to all their citizens.

There are two ways to ensure care

There are two ways that a nation may ensure health care for all its citizens. It may directly provide the health care by employing all physicians and health-care workers, and owning all hospitals and clinics. The cost of health care is paid by taxes.

This is the English system established as the National Health Service in 1948. This is socialized medicine. There may be rationing or significant waiting times for certain tests or procedures. Many Scandinavian countries also have this system. Socialized medicine works well for them, but it would never be accepted in the U.S.

The second way to provide universal care is mandatory national health insurance paid by a payroll tax shared by the employee and the employer. Health care is provided by the private sector: private physicians and private hospitals and clinics. The government does not provide the care.

This system has worked well in Germany, France and many other European countries for decades. There is no rationing of care and no long waits for care. Health-care costs are lower and the quality of care is equal to or exceeds the U.S’s.

Nations with universal health care have a single payer for health care: either the government itself or a national health insurance plan.

Sanders’ plan offers a single payer

In the U.S. we have multiple payers. Most Americans have employment based insurance. Employers contract with various insurance companies to pay the medical bills of their employees. Physicians and hospitals send their bills to hundreds of different insurance companies, each company has its own forms and fee schedules. It is a very complex and very expensive system.

The other major payors are Medicare and Medicaid. Again, they have different fees and different billing procedures.

Sanders proposes that all U.S. health-care bills would have a single payer: Medicare. Medicare would set fees and pay health providers in much the same way it currently pays for care to Medicare patients. Billing would be much simpler: a single billing form and a single fee schedule. The administrative costs of Medicare are about 2 percent, compared to about 17 percent for U.S. private insurance. Medicare as a single payer would decrease U.S. health-care costs by billions of dollars.

Many Americans will object to the Sanders plan because they believe that the government should not be involved in health care. Yet our government is already heavily involved in health care. More than half of U.S. health care – Medicare, Medicaid, military and VA care – is provided by or administered by federal or state governments.

Government is already involved in care

Many Americans oppose mandatory health insurance, yet we have had it for more than 50 years. Medicare is mandatory health insurance administered by the federal government.

Health care to Medicare patients is provided by private physicians and private hospitals and clinics; not the government as in England or Scandinavia. Patients have free choice of hospitals and physicians. All surveys have shown that quality of care is excellent and that seniors are pleased with their care. There is no rationing of care and no long waiting times for care.

Polls since 1945 have shown that most Americans favor national health insurance. A poll in 2007 showed that most U.S. physicians also favor national health insurance.

If we are looking for a way to provide comprehensive health care to all our citizens at less cost, it is in plain sight: Medicare for all.

Dr. James E. Dalen is dean emeritus at the University of Arizona Medical School and executive director of Weil Foundation in Tucson, which serves to advance integrated medicine.

http://www.azcentral.com…

USA TODAY: Obamacare or single payer?

Focus on Obamacare, not single-payer pipe dreams

By The Editorial Board
USA TODAY, September 25, 2017

Our view: Bernie Sanders’ Medicare for all is an unwieldy manifesto

Providing a Medicare-like public option alongside private insurers in ACA exchanges is another idea worth trying, particularly in any counties that go down to one or zero sellers. Allowing people 55 and older to buy into Medicare at the actual cost to government is another option.

But now, even with the Graham-Cassidy measure on life support, is the wrong time for Democrats to be focusing on Berniecare.

Reader Poll: What do you think of our view?

27% – Strongly agree

30% – Agree

6% – Don’t know

17% – Disagree

21% – Strongly disagree

(113 votes as of 2:20 PM Eastern)

https://www.usatoday.com…

***

Bernie Sanders: Time is ripe for Medicare for all

By Bernie Sanders
USA TODAY, September 25, 2017

Opposing view: Eliminate insurance industry profits and reduce waste

The truth is that the only reason we, among all major countries, do not have universal health care has everything to do with politics and greed.

Now is the time to tell members of Congress that their job is to protect the American people, not the insurance companies and the drug companies. Now is the time for Medicare for all.

Reader Poll: What do you think of Sen. Sanders’ commentary?

69% – Strongly agree

11% – Agree

4% – Don’t know

4% – Disagree

12% – Strongly disagree

(745 votes as of 2:20 PM Eastern)

https://www.usatoday.com…

***

Comment:

By Don McCanne, M.D.

This poll is not scientific, but it is interesting. As of this posting, 80 percent agree with Bernie Sanders position on single payer, whereas 57 percent agree with the USA TODAY editorial board that we should focus on Medicare instead of single payer “pipe dreams.” But make of it what you will, as of the moment this is written, almost seven times as many readers elected to vote on Bernie’s Sanders’ commentary (745) as voted on the USA TODAY editorial (113). That netted 597 votes for Sanders’ position to 66 votes for The Editorial Board position.

There is certainly more passion behind the single payer movement than there is behind skipping single payer and focusing on Obamacare. Let’s turn that passion into action.

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

Five lessons from Canada on single-payer health care

By Colleen M. Flood and Allan Rock
Chicago Tribune, September 24, 2017

The United States is about to debate the merits of Bernie Sanders’ proposal for a single-payer health care system. While cost will be an issue, evidence shows that many countries provide access to quality care for all their citizens through a single-payer model while spending far less than the U.S. does now.

How can this be?

Single-payer systems are often promoted as a means to achieve social justice. But they are also more economically efficient than the private market alternative. Having one payer simplifies the administration of health care by avoiding multiple insurers processing claims.

Costly administration is one reason why the U.S. spends by far the greatest percentage of gross domestic product on health care in the Organization for Economic Co-operation and Development (while having the largest percentage of uninsured).

But not all single-payer models are created equal.

As Americans consider Sanders’ proposal, they should examine the successes and failures of single-payer systems elsewhere. Canada’s actual experience (and not the make-believe version portrayed by idealogues) might help Americans craft their own, better version.

We offer five lessons from Canada that Americans should take to heart.

• First and most important, a single-payer system does not and should not cover everything — just everybody. All health systems have their limits. But there must also be a process for deciding what services are insured. That list must change to keep pace with innovations and emerging needs.

Canada’s single-payer system is weak in this respect. It was created when health care meant doctors and hospitals, and so the Canada Health Act reflects that long-ago world.

The Sanders proposal is more modern, including long-term care [1], prescription drugs and other items important today (not covered in the Canadian model). But Sanders’ plan should include a fair process to periodically re-evaluate the services and treatments that are insured.

• Second, a single-payer system need not mean bleak government hospitals staffed by underpaid doctors. Single-payer can include a vibrant private sector both within and ancillary to the public plan.

Mythmaking aside, Canada’s system accommodates a major role for the private sector within the public system. Nothing in the Canadian model prohibits the private delivery of publicly paid services.

Indeed, most Canadian doctors are not salaried state employees but private contractors who are well remunerated — and who don’t have to manage multiple payers, chase accounts receivable and treat patients who can’t pay.

The private sector is also a complement to Canada’s public system, insuring services left out of the public plan. Some Canadians would prefer an even greater level of privately-insured care, which is an ongoing debate. Each single-payer system manages the public-private balance to best suit that country’s needs, values and priorities. Americans should consider how others have established that balance before determining their own.

• Third, single-payer need not mean reduced patient choice and increased wait times. Canadian patients can choose their own physicians and hospitals without the restrictions imposed by American “managed care.” While it is sadly true that Canada has struggled with wait times that are too long for some services, the problems derive not from the single-payer system itself but rather from issues of system management. The proof is found in many other single-payer systems that do not face the same issues.

Concerns with wait times should be addressed up-front in a U.S. single-payer plan, emulating successful models and setting maximum wait-times based on clinical evidence.

• Fourth, single-payer need not mean funding the system only from taxes. Canada’s experience is that tax funding alone can make the system vulnerable when economic downturns require steep government cuts. Wisely, the Sanders plan is in line with European models with a mix of funding sources, including premium payments by employers and employees together with some funding from tax revenues.

• Finally, the U.S. can learn from Canada’s vexed experience with federal-provincial negotiations about health care. If the federal government goes it alone in funding health care — as the Sanders plan seems to suggest — the difficult dynamic of federal-state negotiations will be avoided. But if the final plan involves federal grants to states, federal funding must have a guaranteed floor and be adjusted over time to fairly account for changing needs and technologies. There must also be a way to speedily resolve federal-state disputes when they arise.

As Canadians can attest, the single-payer health care model has enormous social and economic advantages. But its success in meeting the needs of a nation depends on its wise design and deployment. By considering the experience elsewhere, Americans have the historic opportunity to create a model that will be uniquely their own while capturing best practices everywhere.

Colleen M. Flood is associate vice president of research and director of the Centre for Health Law Policy and Ethics at the University of Ottawa. Allan Rock is president emeritus of the University of Ottawa and is a former Canadian minister of health.

PNHP Endnote:

1. In Sen. Sanders’ plan, long-term care would be administered by the states only for low-income individuals, similar to Medicaid today. PNHP believes long-term care should be provided to all as part of a national health plan.

http://www.chicagotribune.com…