PNHP

Medi-Cal violates civil rights

Medi-Cal violates civil rights

California talks big on health, but so few docs take Medi-Cal that it violates civil rights

By Bill Lann Lee
The Sacramento Bee, August 9, 2017

California draws praise for leading the country in many ways, but our state is faltering badly in an area that is vital to millions: healthcare for our most vulnerable residents.

Fully one-third of our population, including seniors, people with disabilities and children, depend on Medi-Cal, the Medicaid health insurance program for low-income Californians. While there is wide coverage, Medi-Cal recipients have worse access to healthcare than Medicaid recipients in almost every other state, judged by the percentage of physicians who accept Medicaid patients.

This means suffering for people who have health coverage but, in fact, can’t get care. Too often, Medi-Cal patients are told no doctors will treat them, must endure long delays in scheduling appointments, and are forced to travel long distances for care. Poor, disproportionately Latino Medi-Cal patients often are unable to access care they would receive if covered by other health insurance.

Our state’s payments are so low that they deter many providers from treating more than a few, if any, Medi-Cal patients, with physicians saying that Medi-Cal payments are far below their costs of providing care, whether in fee-for-service or managed care.

This not only endangers the health of millions of Californians, but as our state officials should know, it violates health and civil rights laws.

Why?

Today, Latinos are more than half of all Medi-Cal enrollees statewide. As Latino enrollment in the program surged, Medi-Cal’s relative reimbursement rates plummeted.

In 2000, Medi-Cal rates were about two-thirds of Medicare’s, but they have fallen to about half what Medicare pays. Meanwhile, the number of Latinos in Medi-Cal climbed from 2.3 million in 2000 to 7.2 million in 2016. California’s politicians cannot blame financial shortfall; this alarming trend of disinvestment continued whether the state budget was tight or flush.

Civil rights and healthcare laws require that Medi-Cal recipients have access to healthcare equal to people with other insurance, such as Medicare and employer-sponsored insurance. Our state health officials have been so resistant to improving this situation that my organization, the Civil Rights Education and Enforcement Center, joined the Mexican American Legal Defense and Educational Fund to challenge this inequality.

Making sure that Medi-Cal provides the access to health care for those it covers is simple justice.

Bill Lann Lee, former Assistant Attorney General for Civil Rights with the U.S. Department of Justice, is senior counsel at the Civil Rights Education and Enforcement Center.

http://www.sacbee.com…

Los Angeles Times editorial: Does state funding for Medi-Cal discriminate against the Latinos it serves?
http://www.latimes.com…

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Comment:

By Don McCanne, M.D.

Many proclaim that the greatest success of the Affordable Care Act was the 30 percent increase in Medicaid enrollment – now 74 million individuals. But Medicaid is a chronically underfunded welfare program, critically so in states like California.

One-third of Californians are enrolled in Medi-Cal (California’s Medicaid), and over half – 7.2 million – are Latinos. Access is impaired because of a lack of willing providers due to payments that are well below the costs of providing health care. Unequal access to care violates the civil rights of the Latinos enrolled in this program. More broadly, it establishes the principle that lower income individuals on Medicaid are not entitled to the same level of access to care as those with higher incomes covered by more traditional health insurance.

A single payer system would be much more egalitarian, ensuring as much as possible that care would be there for anyone who needs it.

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Medicare for All Should Be a Litmus Test

Don’t believe the critics. Medicare for All is the most realistic way to win universal, equitable health care.

By Adam Gaffney, M.D.
Jacobin, August 10, 2017

Fresh off a victory against Trumpcare, health care activists are now looking hopefully towards the future. Already there has been significant progress: within the Democratic Party “Medicare for All” has now achieved a level of support and enthusiasm unprecedented in recent memory.

Yet even as a broad spectrum of progressives coalesces around the cause, others are warning that we should be pressing on the brakes, not the throttle. Joshua Holland penned a piece in the Nation making this case just last week, and Paul Krugman made many similar points in his New York Times column on Monday.

Both argue that single payer should not be a “litmus test” for progressive candidates. They’re sorely mistaken.

Let’s begin with Holland’s arguments as to why Medicare for All may not be the best solution to our health care woes. Holland opens by asserting that while advocates want to use Medicare as the model for single payer universal health care, “Medicare isn’t a single-payer system in the sense that people usually think of it.” After all, he correctly notes, Medicare is partially privatized (via Medicare Advantage plans run by private insurers, as well as in the privatized design of its drug benefit). In addition, because Medicare imposes out-of-pocket expenses on enrollees (for example, co-payments and deductibles) and fails to cover some services, many enrollees purchase supplementary coverage (“Medigap” plans).

“The array of options,” Holland writes, “can be bewildering — it’s a far cry from the simplicity that single-payer systems promise.”

Indeed it is! Which is precisely why prominent single-payer proposals discard these flawed elements. Medicare Advantage primarily functions as a siphon from the public purse to insurance company coffers, and Medicare’s out-of-pocket payments squeeze many seniors. Both are unnecessary. Both should be nixed.

There seems to be some confusion here between what we might call “Currently Existing Medicare for All,” which basically nobody is proposing, and what advocates mean when they speak of “Medicare for All.” But there shouldn’t be: you don’t have to read Conyers’s bill to know that its title is not the “Medicare-for-All Act,” but rather the “Expanded and Improved Medicare-for-All Act.” Holland clearly understands this (he mentions later in his piece that Conyers’s legislation lacks cost-sharing and includes comprehensive benefits), but for the most part he fails to incorporate it into his analysis, leading him to erroneous conclusions.

Consider, for instance, a second point that Holland and Krugman raise: the disruptive impact that single payer could have for those who are already insured through their employer. Krugman believes that problems might arise when the “156 million people who currently get insurance through their employers, and are largely satisfied with their coverage,” switch to single payer. Holland is even more fretful about the political impact of such “loss aversion,” arguing that the portion of the population that enjoys decent employer-sponsored plans may not be thrilled at the idea of being shepherded into Medicare.

“Many employer-provided policies cover more than Medicare does,” he notes, “so a lot of people would objectively lose out in the deal.”

But would they? Again: all major single-payer proposals go beyond Medicare, eliminating cost-sharing and covering a more comprehensive array of health care benefits.

What differentiates the small-bore approaches that Holland and Krugman support from the deeper reform that single-payer advocates propose is that the latter is designed to improve health care for everybody, not just to make sure the uninsured get some form of coverage. After all, despite the talk about people wanting to keep their good employer-sponsored plans, in 2016 29 percent of covered workers had a high-deductible health plan (up from 4 percent in 2006), while the dollar value of workers’ deductibles has shot up by 300 percent since 2006.

Workers also often face copayments and coinsurance (a percent of the cost of the health care service paid out of pocket) for doctors’ visits, hospitalizations, tests, and drugs. And such payments are generally much higher under the non-group private plans purchased on or off the Obamacare exchanges. Many also have to deal with shifting — and often narrow — networks of doctors and hospitals, to the great detriment of doctor-patient relationships and continuity of care, not to mention choice and equal access.

In short, Holland’s point about “loss aversion” misses the mark by a mile: who would resent exchanging a limited network, high-deductible private insurance plan for a public plan that provided first-dollar comprehensive coverage without networks, and which could never be taken away?

Holland doubles down on this point, however, and brings up a related concern. He suggests that because some doctors might not take part in the national health program, “we couldn’t even promise that if you like your physician you can keep seeing him or her.” Yet a single-payer system would be the only game in town: while a tiny percentage of physicians might cater to the rich with boutique concierge practices, we can safely predict that the vast majority of physicians would participate in the national health program.

Why? Well, consider that even today (when there are alternative forms of insurance), some 93 percent of primary care doctors who see adults accept Medicare — essentially the same percent as those who accept private insurance. This rate would presumably be even higher under Medicare for All. Canadian physicians, after all, do quite well under the country’s single-payer system. And to ensure the same held true in the US, we could subsidize the educational costs of health care workers who participate in the national health program, as the latest proposal from Physicians for a National Health Program recommends.

Holland is on firmer ground when he moves to the issue of overall health care spending. While single payer would produce administrative savings, he’s right to note that we can’t reverse history: implementing Medicare for All wouldn’t suddenly bring US health care expenditures in line with those of single-payer countries. But so what? It doesn’t need to.

International examples strongly indicate that, at the very least, single payer should be no more expensive (in terms of overall national health spending) than what we have today. And what single-payer advocates are really arguing is not that we will soon be spending the same percentage of GDP on health care as Canada, but rather that by eliminating the enormous waste of the extractive and useless private health insurance apparatus and slashing drug prices (among other efficiencies), we will generate the savings we need to create the system we want: one in which everybody has first dollar coverage and equitable health care access.

But might there be a third, less disruptive, alternative to the status quo and single payer?

On the one hand, many other systems don’t actually do the sorts of things that single-payer advocates are calling for in the US (this is Holland’s point); on the other, single payer is not the only international example worth considering (a point that both Holland and Krugman stress).

Holland, for instance, notes that US single-payer proposals go beyond Canadian Medicare, which doesn’t cover prescription drugs or dental and eye care, causing many to buy supplementary insurance plans. This is true, yet it only reinforces the argument for a better single-payer system here. Canadian Medicare should cover those things; the fact that it doesn’t is one flaw of that overall superior system. One study, for instance, found that among eleven high-income nations, Canada was surpassed only by the US in the proportion of residents aged fifty-five and over who didn’t take medications because of cost. Not surprisingly, progressives in Canada are pushing for universal drug coverage.

Pointing out other single-payer systems’ shortcomings, then, is hardly a knock against a proposal for a more comprehensive single-payer system here.

In other respects, however, it’s not clear that single-payer advocates are asking for much more. Holland asserts, for instance, that “no other health care system offers such expansive benefits” as Conyers’s Medicare-for-All bill, which eliminates out-of-pocket costs for all health care services. While it is true that most systems have some form of (rather limited) cost-sharing, this is both unnecessary, and not universally the case, as Holland seems to suggest. There are no co-payments (much less deductibles) for doctor visits or hospitalizations in Canada or the United Kingdom. And in Northern Ireland, Scotland, and Wales, prescription drugs are free for all.

The second and larger point that Krugman and Holland stress is that some European nations have more of a mixed private-public model, and thus that single payer is not the only option. “There are lots of ways to skin this cat,” Holland writes. But while it is true that every health system is something of a snowflake, the best European examples share some key similarities. What we call single payer is basically national health insurance, which despite some (mostly unnecessary) organizational heterogeneity and complexities is what basically exists in countries like Australia, Canada, and (for the most part) France. The United Kingdom also has a single-payer system, albeit coupled with a more socialized delivery system: nationalized hospitals.

Other nations admittedly have more complex systems. Making sense of the basic nature of Germany’s system, for instance, has been called something of a “puzzle,” yet its not-for-profit system of highly regulated statutory sickness funds — jointly run by labor and employers — barely resembles the Obamacare system, and might better be seen as a decentralized form of national health insurance.

Then there is the Dutch example, often cited by those who find the incremental road appealing. However, though it is true that in 2006 the Dutch transitioned toward a somewhat more market-oriented, Switzerland-like, “managed competition” model, its system remains tightly regulated well beyond the Obamacare system; more importantly, evidence suggests that the managed competition makeover wasn’t particularly helpful, and indeed may have had a dubious impact in terms of equity and efficiency. As Kieke Okma, Theodore Marmor, and Jonathan Oberlander concluded in the New England Journal of Medicine in 2011:

The Dutch experience provides a cautionary tale about the place of private insurance competition…The idea that the Dutch reforms provide a successful model for US Medicare to emulate is bizarre. The Dutch case in fact underscores the pitfalls of the casual use (and misuse) of international experience in US health care reform debates.

Two final, key points: first, it is not clear that transitioning to a more complicated public-private model that turns insurers into nonprofit, highly regulated funds will be more politically feasible in the US than going all the way to national health insurance. The industry will fight both to the death. And second, hybrid models — like those in the Netherlands and Switzerland — are less efficient than fully public ones. If first-dollar comprehensive universal health care under single-payer produces some new costs (and it will), achieving such a system would only be that much more expensive, and perhaps truly unaffordable, when implemented within the framework — and subordinated to the interests of — the bloated private insurance industry.

In reality, neither Holland nor Krugman are recommending we adopt the Dutch model. What is it, then, that the Medicare-for-All naysayers are actually promoting in place of single payer?

Krugman mentions that the public option should be strongly considered, but that otherwise progressives should basically abandon health care reform and move on to other things. Holland, for his part, more explicitly discusses an ambitious public-option-like program drawn from political scientist Jacob Hacker, which he calls “Medicare-for-All-Who-Need-It.” But here’s the thing about both: they would not, if achieved, deliver the benefits that Medicare-for-All proponents are fighting for.

This is not simply about different ways to skin a given cat, as Holland writes, but about which particular cat we intend to skin (with due apologies to cat lovers). Single-payer advocates’ aims are admittedly ambitious, yet also quite clear: we want to eliminate uninsurance and underinsurance, and create a right to equitable, comprehensive, first-dollar health care for everyone in the country, as soon as possible. And our proposals (e.g., the Conyers bill) would achieve those goals if implemented.

The more incremental reform proposals wouldn’t. As I’ve written recently, adding a public option to the Affordable Care Act’s marketplaces would — according to the Congressional Budget Office — fail to even reduce the number of uninsured. And the admittedly far more robust Medicare for Some that Holland seems to favor would — even if it nearly eliminated uninsurance (hardly a certainty) — fail to remedy the US health care system’s other fundamental flaws.

What would it do for the growing ranks of the underinsured, including workers with employer plans who are being squeezed by rising deductibles and soaring drug costs? What would it do for those insured under Medicare, who lack access to important services like dental care, or who face cost-sharing that takes a sledgehammer to their finances? What would it do for drug prices on the national level? And how would it create the system-wide savings needed to achieve the comprehensive, first-dollar system single-payer proponents are struggling for?

Critiques like Holland and Krugman’s therefore crumble at the most basic level. With Improved and Expanded Medicare for All, we are aiming to improve health care for all — which is precisely what makes our project so politically potent, and hence possible: it is a universal program that, by giving something to nearly everybody, is designed to bring together the admittedly enormous coalition required to win it.

Those with Medicaid would retain their (often) broad benefits, but would enjoy equity of access. They’d be able to go to the same doctors and hospitals as everybody else, and perhaps more importantly, not worry about losing coverage as soon as they receive a tiny raise. Those insured by their employers (or via the Obamacare exchanges) would see their deductibles melt away, their networks expand, and the fear of losing coverage disappear forever. Those with Medicare could stop using scant household funds to buy supplementary “Medigap” plans, and would have their teeth cared for. And none of us would need to worry about getting dropped from our health coverage — or facing a medical bill, much less a medical bankruptcy — until the end of our days.

Sound good? It would be. Seem bold? Absolutely, but other nations show that it’s possible. Should Medicare for All be a litmus test? Damn right.

Adam Gaffney is a physician whose work has appeared in Salon, Dissent, and In These Times. He blogs at theprogressivephysician.org.

https://jacobinmag.com…

Dr. Adam Gaffney on ‘The Take’

PNHP national board member Dr. Adam Gaffney appeared on “The Take With Sue O’Connell” on New England Cable News on August 10, 2017, to present the case for improved Medicare for all. He addressed common concerns about logistics and financing, and added that the effort to repeal and replace the ACA had galvanized the movement for single payer.

Staff burnout in federally qualified health centers

Federally Qualified Health Center Clinicians And Staff Increasingly Dissatisfied With Workplace Conditions

By Mark W. Friedberg, Rachel O. Reid, Justin W. Timbie, Claude Setodji, Aaron Kofner, Beverly Weidmer and Katherine Kahn (all from RAND)
Health Affairs, August 2017

Abstract

Better working conditions for clinicians and staff could help primary care practices implement delivery system innovations and help sustain the US primary care workforce. Using longitudinal surveys, we assessed the experience of clinicians and staff in 296 clinical sites that participated in the Centers for Medicare and Medicaid Services (CMS) Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration. Participating FQHCs were expected to achieve, within three years, patient-centered medical home recognition at level 3—the highest level possible. During 2013–14, clinicians and staff in these FQHCs reported statistically significant declines in multiple measures of professional satisfaction, work environment, and practice culture. There were no significant improvements on any surveyed measure. These findings suggest that working conditions in FQHCs have deteriorated recently. Whether findings would be similar in other primary care practices is unknown. Although we did not identify the causes of these declines, possible stressors include the adoption of health information technology, practice transformation, and increased demand for services.

From the Discussion

Our findings are consistent with reports of increasing burnout and declining professional satisfaction among physicians across the United States, not just in safety-net clinics. However, they differ with the only assessment of longitudinal changes in provider experience during a medical home initiative published to our knowledge, in which transformation within a single Group Health Cooperative site was associated with improvements in provider burnout between 2006 and 2008. This discrepancy might be explained by differences in time frame, type of clinic (FQHC versus integrated system), and intervention design (the Group Health pilot was motivated by and designed to mitigate provider burnout). Moreover, some FQHCs have high staff turnover, and most serve patients with complex medical, behavioral, and social needs—which can make practice transformation more difficult. The finding that top-of-license scores did not improve suggests that many FQHCs in our sample may have transformed only to a modest extent. Applying for and receiving medical home recognition could have been a higher priority than transformation. In addition, when safety-net clinics have insufficient staffing levels, this can increase the risk of burnout associated with quality improvement efforts.

Conclusion

Clinicians and other staff members working in a national sample of federally qualified health center sites reported declines over time in multiple measures of professional satisfaction, work environment, and practice culture. Our analysis could not identify the factors contributing to these declines. However, as additional health system changes accumulate under the Medicare Access and CHIP Reauthorization Act of 2016 and new legislative and regulatory activity, policy makers should consider further study of how these forces could affect primary care working conditions—especially in FQHCs and other safety-net clinics.

http://content.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Imagine the satisfaction it must bring to health care professionals to practice in an environment wherein you know that you are providing health care access to less fortunate individuals who might otherwise go without care. Furthermore, these Federally Qualified Health Centers were engaged in improving the delivery system in a manner that should increase satisfaction through attaining the highest status level of patient centered medical homes. Yet measures of professional satisfaction, work environment, and practice culture all declined in this study, resulting in provider burnout. What went wrong?

One observation might give us a clue. A similar prior effort to transform a Group Health Cooperative site into a medical home resulted in a decline in provider burnout. The authors report that “the Group Health pilot was motivated by and designed to mitigate provider burnout.” In contrast the various innovations taking place today are designed by bureaucrats and policy wonks largely based on widespread application of health policy theory flavored by ideology. They don’t get it.

Could single payer improve the situation? It could if the stewards were always keeping in mind what is best for the patient, and that includes ensuring the contentment of the health care workforce. A single payer system should automatically establish the presumption that this is all about improving the health of the patients and the community at large. It is not about providing a favorable business environment for the stakeholders even though that means perpetuating health care injustices such as lack of insurance, impaired access, financial hardship, health care inequity, and poorer health outcomes.

So one of the more important gifts of converting to a single payer system would be an improvement in attitude. We really need it.

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America’s Health Care System Kills People—But It Doesn’t Have to Be This Way

In Australia, vital services like cancer treatments are free; in the US, countless people struggle to even get screened. We spoke to cancer patients in both countries about the drastic difference single-payer health insurance can make.

By Gabby Bess
Broadly, August 9 2017

Linda Kimber is a 65-year-old retiree in Australia. When discussing how she was diagnosed with breast cancer last November, through a thick Australian accent, over the phone, Kimber is straightforward and direct. Frankly, she makes cancer sound like it’s not a big deal.

At least one part of her treatment definitely wasn’t: She didn’t have to worry about the cost of the surgery, rounds of radiotherapy, and subsequent follow-ups. Unlike in the US, where the stress of financial panic often compounds a health emergency, Australia’s universal Medicare system, which provides free health insurance for every citizen through a general tax and an additional levy on high-income earners, covered the bill.

Kimber says the care she received was stress-free as well. After she was diagnosed, she was given a list of doctors to choose from for her surgery, and it was scheduled for three weeks later at a public hospital. “Then they just told me a day for the operation and I came in on that day,” she said. “That was basically it. From there, it was all in their hands. I’ve had radiotherapy. I saw a medical oncologist, and the follow-up has been absolutely fantastic. They bent over backwards.”

Following her surgery, a nurse came to her house every day to check in on her draining tube. In addition, she says, the hospital gave her a large pink tote bag to carry around the instruments related to her drain tube care—and books to read while recovering. “It was wonderful,” she said.

Australia’s health care system is consistently ranked one of the best in the world and the best for positive health outcomes. Every Australian is covered by public insurance and the option also exists for people to buy additional private insurance. For regular doctor’s visits in the public system, Australians either pay nothing or a small copay over what Medicare reimburses. (It’s up to physicians to decide whether or not they charge a copay, and low-income citizens, citizens over 65, parents with a child under the age of six, and children under the age of 16 never pay a copay. Many doctors choose to waive the copay, or bulk bill, to attract patients and to make sure that money isn’t a barrier to access.) And after that, if your doctor refers you to a specialist or recommends surgery to manage a condition, all visits and treatments are free.

Australia also has free, national preventative programs, since it’s in everyone’s best interest to detect diseases early on, when they’re less expensive to treat. In Kimber’s case, BreastScreen Australia, which calls in women between the ages of 50 and 74 for a free mammogram every two years, was able to detect the tumor in her breast while it was small and before it could spread to other parts of her body and cause additional, more serious complications. “Her prognosis is good,” her general practitioner, Dr. Marie Shieh, told Broadly. In two weeks, Kimber has an appointment with her oncologist and an ultrasound, where she will find out if she is in remission.

When I asked Kimber if she would have wanted to go through cancer treatment in America, her answer was a resounding no. Who could blame her? In comparison, health care in the US is a gamble, and if you have cancer you might not also have health insurance.

Some people receive insurance through their employers, which might be comprehensive or skimpy, expensive or not. Others get it through the byzantine system of the Affordable Care Act exchanges, in which private insurers receive subsidies from the government in order to be able to eliminate preexisting conditions and keep costs down. People who fall below the poverty line and the elderly are insured through Medicaid and Medicare, respectively.

This patchwork of insurance schemes leaves holes everywhere. Without guaranteed, universal coverage, many Americans have to make dangerous calculations when they’re sick. Instead of being automatically provided with the care that they need, they have to ask: Should I see a doctor or save the money?

Those who argue that the US government should directly pay hospitals and doctors for everyone’s care are always met with the same rebuke: It’s simply impossible to move the country to such a system. But it’s really our current system, not single-payer health care, that should evoke incredulous reactions. Health care in the United States consistently ranks last among wealthy countries, despite being the most expensive by far.

Kimber says she doesn’t know how Americans get by without the health security she has. “I think [health care in the US] is horrendous, to be honest. I think it’s absolutely disgusting,” she said. “If it’s the middle of the night and you’ve got chest pain and something could be wrong with your heart, you wouldn’t want to be lying there thinking that you can’t afford to go to the hospital. How terrible is that?”

Dr. Shieh, now a general practitioner in Australia, used to be a family doctor in the US. Practicing medicine stateside, she saw firsthand how cruel our health care system is—and when she moved to Australia, she saw how much better it could be.

“When I was in the US, I knew there was a problem, but I didn’t know what the solution could be. I worked in places where patients couldn’t afford the medicines I had prescribed, where I would try to refer them to specialists and their insurance wouldn’t cover those referrals, where they wouldn’t come back to see me because it was too expensive,” she said. “Once I couldn’t order an electrocardiogram because it was too expensive for the patient. I just felt bad for people. I realized a lot of people just couldn’t afford health care.”

Ryan Wanninger, now 40, didn’t have insurance when he was diagnosed with cancer two years ago. As a self-employed IT technician and freelance music instructor in Boston, he made enough money to disqualify him from the state’s Medicaid program—MassHealth—and he didn’t receive employer-sponsored insurance. Some years his IT business would do better than others, so on the good years he signed up for a health insurance policy, and when money was tight he dropped his policy and went without it.

Then the 2008 financial crisis hit. “When the economy crashed I lost half of my clientele in one week. They all called me and canceled contracts, dropped services, maintenance, everything,” he said over the phone. “I had a couple big jobs that I had bid on—all of those were canceled. Every business was panicking when the economy tanked. That was horrendous.” For the next few years he steadily forwent insurance because he no longer had the money to spare as he was trying to build his client list back up.

In early 2014, a few months after the ACA exchanges were up and running in Massachusetts, Wanninger finally attempted to get insurance again now that he had the money. But the state’s ACA-compliant website was a complete failure. “Despite trying several times to use the website I was unsuccessful,” he said. “I spoke with personnel over the phone about this because the national deadline was quickly approaching. I was first told that all applicants were having similar problems and that nobody was successfully signing up for any plans.”

Wanninger says was told that because of the site’s technical issues, he would be able to sign up after the national deadline. But when he tried again to get insurance through the exchange he was denied. Two months later, while Wanninger was finishing up a job, he started to feel horribly sick.

“I got in my car and I looked in the rearview mirror, and I saw my eyes were yellow and my skin was yellow. I was jaundiced,” he explained. “I wasn’t even sure I could drive home that day because I felt like I was going to pass out. I had to call a friend to talk to me just to keep me awake, and I drove right down to the hospital.”

In the hospital parking lot, he called one of his guitar lesson clients, who happened to be a doctor there, for help because he had no health insurance or regular doctor. The doctor did blood work tests on Wanninger over several days and found large numbers of cancer antigen in his bloodstream. To find out exactly where the cancer was in his body, Wanninger needed a CT scan, but his lack of insurance became a problem.

“The CT scan was tricky,” he said. “The hospital didn’t want to allow me to have a CT scan—it was very expensive, a few thousand dollars, and I didn’t have insurance to cover it.”

Panicking and ill, he went to the counselor at the hospital to see what his financial aid options were. By some miracle, he says, he happened to be in luck: As Massachusetts’s state health care system struggled with the transition to comply with the ACA, the state government allowed anyone to sign up for Medicaid, even if they didn’t meet the income requirements.

The next morning he was able to meet with an oncologist, where he found out his prognosis was dire. He had a tumor on his colon, the original site of the cancer; a tumor on his liver, which had caused the jaundice; and tumors on his lungs. He was 24 hours from going into septic shock, his doctors informed him. If he hadn’t been able to get a CT scan when he did and go in for surgery, he would have died.

“I’m lucky in some respects, but health care shouldn’t rely on luck,” Wanninger said. He was able to stay on the state’s Medicaid program for seven months before the state finished the conversion to meet all the mandates of the ACA and they were able to review the cases of the applicants who had been covered by MassHealth during the transition period.

In other respects, however, he’s not so lucky. By the time the seven-month period ended, Wanninger’s condition worsened to the point where he had to stop working, so he qualified for Medicaid outright. When his cancer was detected it was already advanced; as of three months ago, the last treatment available to him stopped working.

Wanninger says the US health care system is to blame for his now-terminal status. “In retrospect, it was pretty clear that I had been neglecting myself and had been neglected by doctors, back when I had one, and the health system,” Wanninger said in a video he made about his health care struggles in support of single-payer health care. “My father died of the same colon cancer at the age of 37 back in 1986. No one told me that because of this I should have been having regular colonoscopy screenings every three to five years, starting in my twenties.” And in any case, he added in our interview, he didn’t have health insurance to cover a colonoscopy.

“Health care should be a right. People should be able to have basic scans, testing, and things that can catch major diseases before they become a problem,” Wanninger said. “My life will most likely be shortened because of this, and that’s not fair to me. This could have most likely been prevented. A colonoscopy would have found a small tumor and it could have been removed safely.”

Wanninger’s treatments have all been covered through Medicaid, but, as he puts it, he’s “lucky.” As he works through his bucket list items—a trip to Spain funded by money his friends pooled together, a solo guitar concert that he will be putting on, which his doctors will attend—and looks to experimental trials for a possible cure, he at least does not have to file for bankruptcy. He says that within the first month of his diagnosis, he racked up $60,000 worth of bills, which he would not have been able to pay. In total, he says he treatments have cost more than $1 million.

“It’s pretty obvious that the way our system is now doesn’t work. We have to do something better,” he said.

Despite the passage of the Affordable Care Act in 2010, 27 million people are still uninsured. Many people, like Wanninger, have been left out by the complicated scheme devised to make private insurance market tenable. People who are insured by the ACA have found that costs have been rising out of the realm of affordability because, as it turns out, giving sick people health care coverage isn’t profitable for insurance firms. Even more are underinsured, meaning they have insurance that doesn’t actually cover their health care costs.

Universal, single-payer insurance would entirely eliminate this dysfunction. And with the amount we spend on our piecemeal health care system—through premiums, Medicaid, Medicare, the ACA, and the VA—universal health care is not fiscally out of reach. Currently, the cost of managing chronic diseases accounts for 75 percent of the nation’s health spending, according to the CDC; giving everyone access to free, preventative services would cause this to go down.

Cutting out the middleman—insurance companies—would also drive down costs. “What single-payer proposes is actually very simple,” Dr. Carol Paris, the president of the advocacy group Physicians for a National Health Program, which has written a policy paper on what single-payer could look like in the US, told Broadly. “Take all of the money we’re currently spending in a very fragmented way on the financing of health care and create one risk pool. That’s the single payer. It’s really just a way of eliminating the administrative waste, and the profit of the health insurance industry that contributes nothing to the health of the American people.”

By doing this, Paris says, we would save about $500 billion a year. “That’s just by eliminating the bureaucratic waste and profit of the health insurance industry,” Paris adds. “Then if we also negotiated drug prices, which we would be in a much better position to do, as a single negotiator for every person in the country, we could save another hundred billion dollars a year.”

Paris says a single-payer system is “the only sensible way to manage the financing of health care.” There are certainly flaws with Australia’s health care system, as well as with the universal coverage schemes in other countries, “but it’s absolutely better than what we do in the United States,” she said. Ironically, a major problem with health care in New Zealand, where Paris has worked, and in Australia is that private insurers are allowed to exist alongside the public system. “But they don’t ration care based on your ability to pay for it. No one is turned away because they can’t afford care,” Paris explained.

Now that the Republican’s draconian efforts to repeal the ACA have been stalled, it’s time for the Democratic party to stand up for something more ambitious; the proposed “bipartisan reforms” to the Affordable Care Act are not enough. For most people who live with the burden of the US health care system, the need for single-payer is clear. There’s been growing support for single-payer over the last year, but Paris says we still have a long way to go to bring politicians on board with the idea.

“We are going to have to have a movement of movements. The American people are going to have to make it toxic for our members of Congress not to get on board with this,” she warned. “When they actually feel like their ability to get elected is weighing in the balance, they’re suddenly going to become outspoken advocates for a national health program, but they’re not going to do it until then.”

Wanninger says that if his story can help build that movement by changing even one person’s mind about single-payer, that would check off another item on his bucket list.

https://broadly.vice.com…

Single-payer health system can be had with U.S. ingenuity

By Carol A. Paris, M.D.
Alaska Dispatch News (Anchorage), August 9, 2017

In his column regarding a single payer health care system (ADN, Aug. 2), Charles Wohlforth rightly points out Americans currently spend more per person for health care than any other developed country. What do we get for our yearly $3.2 trillion? Compared to other industrialized nations, we rank 25th in preventable deaths, we leave 28 million uninsured, and our businesses are losing their competitive edge due to the cost of employee health insurance.

Attempts at incremental, market-based reforms have failed to return our nation to its position as a global leader in health care. But it is not beyond our grasp. A single-payer solution would save $500 billion annually by eliminating the “middle men,” the private insurance companies and their third-party administrator subsidiaries that siphon profits out of the system, but contribute nothing toward patient care.

Wohlforth notes investor-owned health care entities such as for-profit hospitals, surgery centers and nursing homes would be required to reorganize as nonprofit entities under a single-payer plan. But he is wrong to equate removal of the profit motive with “massive nationalization of private assets and individuals’ careers.” To be clear, the delivery of care would remain as it has always been: a mix of public (VA and IHS) and private care. Hospitals and doctors’ offices would be privately run. We simply need to eliminate the profit motive and conflicts of interest that drive up health care costs for everyone.

The Senate’s failure to repeal the Affordable Care Act has opened up a new national dialogue on the future of health care. While some may argue for more market-based tweaks to our health system, Wohlforth correctly points out in a previous column that “increased competition” can never work in rural states like Alaska because of its small population and isolation from larger markets.

We can either act boldly to achieve universal, high-quality health care at lower costs, or we can bow to Wohlforth’s assessment that it can’t be done. As for me, I’ll put my faith in American ingenuity and determination any day.

Dr. Carol Paris is a psychiatrist and president of Physicians for a National Health Program. She resides in Nashville.

https://www.adn.com…

Anthem issues policy threatening nonpayment for ’nonemergency’ ED visits

Anthem BlueCross BlueShield, May 11, 2017

Save the ER for emergencies — Or you’ll be responsible for the cost

Going to the emergency room or calling 9-1-1 is always the way to go when it’s an emergency. And we’ve got you covered for those situations.

But starting June 1, 2017, you’ll be responsible for ER costs when it’s NOT an emergency (this isn’t a change to your benefits plan).

http://mediad.publicbroadcasting.net…

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Physicians protest harmful Anthem emergency care coverage policy

By Andis Robeznieks
AMA Wire, August 7, 2017

A new policy by Anthem Blue Cross Blue Shield holds patients responsible for bills stemming from care delivered in emergency departments that is later deemed nonemergent.

The AMA has asked Anthem to immediately rescind the policy in states where it has been put into effect and halt implementation in all other states.

The AMA, the American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) also suggest that the new policy may violate the “prudent layperson standard” which has been codified into state and federal laws—including the Affordable Care Act (ACA). The standard defines an emergency medical condition as one that manifests itself “by acute symptoms of sufficient severity” that a prudent layperson could reasonably expect that the absence of immediate medical attention could place their health in serious jeopardy. Anthem’s retrospective review appears to be inconsistent with such a standard.

https://wire.ama-assn.org…

***

AMA Letter:

From: James L. Madera, MD, EVP and CEO, AMA
To: Joseph R. Swedish, Chairman, President and CEO, Anthem, Inc.

On behalf of the American Medical Association (AMA) and its physician and student members, I write to state our concerns with Anthem’s policy in several states to deny coverage of many emergency services when the diagnosis is retrospectively determined not to have required emergency care. We ask that Anthem rescind this policy in states where it has taken effect, and halt implementation in all other states.

Physicians know that patients and caregivers should never second guess their instincts that emergency care is needed, nor should they be expected to self-diagnose to determine whether, for example, chest pain is a heart attack or indigestion. But with this policy, Anthem is asking that patients act as highly trained diagnosticians, skills our members spent many years of their lives acquiring. Moreover, Anthem’s policy requires that they diagnose their acute symptoms at a critical and emotional moment, when time could be of the essence. The impact of this policy is that very ill and vulnerable patients will not seek needed emergency medical care while, bluntly, their conditions worsen or they die.

http://www.mag.org…

***

Comment:

By Don McCanne, M.D.

What a bizarre policy this is. Anthem assigns to the patient the responsibility for deciding if a medical situation is an emergency. Anthem then assumes for itself the responsibility of deciding only after the care has been given whether or not it was an emergency after all, even though the perspective of that judgment can be quite different after a problem is evaluated and managed. If Anthem unilaterally decides, only in retrospect, that the patient’s judgment that this was an emergency was in error, Anthem may refuse to fulfill its obligation to pay for the emergency department services.

Think of various reasons that a decision could be made retrospectively that the visit was not an emergency. Consider those patients who are commonly blamed for wasting health care dollars by abusing the emergency department. Now back up and consider the reasons that the patients thought, before the visits, that they should go to the emergency department. Your ankle was only sprained and not fractured so it could have waited until your physician or nurse practitioner was available on Monday. You are from out of town and you found that your insulin wasn’t packed in your luggage and so your blood sugar is suddenly out of control. You feel very ill and there is an epidemic of a potentially lethal virus but it turns out that you just had a nonlethal respiratory virus, written off as a common cold, even though you really felt sick. You have a seizure disorder and are whisked away to the emergency department while still in a postictal state – the third time this happened. Although it is likely that Anthem would agree to pay for these visits, the threat of nonpayment might keep these people away in situations that might have turned out to be more serious.

Yet you hear all the time about how people are abusing the emergency department. Okay, so you hear about someone who wants a sports physical exam form filled out, but that person doesn’t make it past the triage desk. In my experiences with emergency departments, direct and indirect, I’ve decided that abuses severe enough to penalize a patient financially are so rare that they are basically a fiction that reform opponents keep propagating. Low acuity and low severity might be considered an issue, but that is still relative and not absolute, and the patient should not be penalized for having to make an uninformed decision. People do not go to emergency departments just for social visits.

Based on a “prudent layperson standard” then anyone that clears the triage desk should be assumed to be there legitimately. Under their nonpayment for non-emergency policy, either Anthem would be refusing to pay for legitimate services, or Anthem is making a major PR faux pas by issuing an unnecessary directive that will only make people angry. Either way, this is a terrible policy to establish. But what else do we expect from the private, for-profit insurance industry that places its own net profits over the health care of the patients?

I’ve decided after the fact that getting rid of the private insurers is a true emergency. Let’s do it.

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Paul Krugman loses his way on the incremental path to reform

What’s Next for Progressives?

By Paul Krugman
The New York Times, August 7, 2017

For now, at least, the attempt to repeal the Affordable Care Act appears dead. Sabotage by a spiteful Trump administration is still a risk, but there is — gasp! — a bipartisan push to limit the damage, with Democrats who want to preserve recent gains allying with Republicans who fear that the public will blame them for declining coverage and rising premiums.

This represents a huge victory for progressives, who did a startlingly good job of marshaling facts, mobilizing public opinion, and pressuring politicians to stand their ground. But where do they go from here? If Democrats regain control of Congress and the White House, what will they do with the opportunity?

What would I do instead? I’d enhance the A.C.A., not replace it, although I would strongly support reintroducing some form of public option — a way for people to buy into public insurance — that could eventually lead to single-payer.

Meanwhile, progressives should move beyond health care and focus on other holes in the U.S. safety net.

So if it were up to me, I’d talk about improving the A.C.A., not ripping it up and starting over, while opening up a new progressive front on child care.

I have nothing against single-payer; it’s what I’d support if we were starting fresh. But we aren’t: Getting there from here would be very hard, and might not accomplish much more than a more modest, incremental approach. Even idealists need to set priorities, and Medicare-for-all shouldn’t be at the top of the list.

***

NYT Reader Comment:

By Don McCanne, M.D.
San Juan Capistrano, CA

Improving ACA?

None of the incremental proposals would cover everyone.

None of the incremental proposals would remove financial barriers to care.

None of the incremental proposals would return choice of your physicians and hospitals.

None of the incremental proposals would recover the profound administrative waste in our health care financing system.

Single payer?

Everyone is covered for life.

Obtaining care does not create financial hardship.

Patients can choose their health care professionals and institutions.

The efficiency gains would be enough to pay for the gains in coverage.

We need to quit pretending that patching our fragmented, dysfunctional system is almost as good as single payer. It doesn’t come close.

https://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

Perhaps the greatest fraud in health policy today is being perpetrated by the politicians – Republicans who say health care will be more affordable and accessible by taking away coverage, and Democrats who say that incremental additions to the Affordable Care Act are almost as good as enacting single payer – an improved Medicare for all.

We will continue to spend over $3 trillion on health care. That is enough to pay for a system that would be superior to those of all other nations that spend on average half of what we do. Why should we accept less, far less, which is what we would be doing if we merely patched our system – the poorest performing financing system of all wealthy nations?

Once more. Incremental changes to ACA will not fix the fundamental flaws in our financing infrastructure that may leave people sick, broke, and even dead.

We cannot let Paul Krugman rest on his Nobel laureate status as he pontificates for “a more modest, incremental approach,” while acknowledging he would support single payer “if we were starting fresh.” Well, apparently a fresh start is precisely what we need.

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Now is the time for single-payer

By John Benziger, M.D.
Santa Fe New Mexican, August 5, 2017

Republicans vehemently opposed the Affordable Care Act, also known as Obamacare, for seven years while irresponsibly offering no alternative option of their own. The “plan” under the GOP’s effort to preserve the status quo seems to be “Don’t get sick!” What they really care about is giving more big tax breaks to the very rich and to big corporations.

Instead of trying to fix our broken system, GOP leaders were acting more like toddlers, mid-tantrum, smashing our health system into smaller and smaller pieces, threatening to push even more Americans — the most vulnerable among us — through the cracks. Recently, a few Senate Republicans stood up and acted like adults, putting (we hope) an end to this dangerous game (“GOP unsure what to do about health care,” July 29).

So today, we can breathe a quick sigh of relief and celebrate Medicare’s 52nd birthday. But we cannot celebrate a return to the status quo, to a system that rations health care based on income and allows thousands of Americans to die each year unnecessarily. We must fight even harder for a system we know can work — improved Medicare for all.

Every other advanced nation sees health care as a basic right and provides better quality care at half the cost. It’s time for the American system to deliver needed quality health care to everybody, protect people against huge medical care expenses and reverse the spiral of increasing costs.

A single-payer, “improved Medicare for all” could cut costs dramatically by streamlining health care paperwork and making health care affordable. Savings would be enough to provide coverage for everyone, without any additional spending. The concept is popular with the American people and enjoys the support of most doctors. The time has come!

Dr. John Benziger is a retired physician who grew up, went to college and studied medicine in New Mexico.

http://www.santafenewmexican.com…

The bipartisan compromise: cheap, worthless plans

Bipartisan moves to steady insurance market face same old conflicts over regulation

By Harris Meyer
Modern Healthcare, August 3, 2017

Democrats and a growing number of Republicans are eager to steady the struggling individual market covering nearly 20 million Americans to prevent an exodus of insurers and healthy customers.

Senate HELP Committee chairman Lamar Alexander (R-Tenn.), who has scheduled committee hearings early next month on how to stabilize the market, wants to go further. He has proposed expanding state innovation waivers to allow states to waive ACA insurance requirements such as minimum essential health benefits. A bipartisan group of 40 House lawmakers, calling themselves the Bipartisan Problem Solvers Caucus, has offered a similar proposal.

The GOP goal is to allow insurers to lure more healthy people into the market by offering lower-priced plans. “Any solution… should also include greater flexibility for states in approving health insurance policies,” Alexander said.

Alexander also wants to let everyone buy very high-deductible catastrophic plans, erasing the ACA’s age cap of 30. That could conceivably win support from some Senate Democrats who offered a bill in 2014 to let insurers sell cheaper “copper” plans, with a lower actuarial value than bronze plans. It raises big concerns, however, among insurance leaders and experts who say consumers can’t afford the deductibles and cost sharing under current plans.

Alexander also might try to revive a bill he introduced with his Tennessee GOP Senate colleague Bob Corker earlier this year to help consumers in counties where no exchange plans are being offered. The bill would let them use ACA premium tax credits buy plans sold outside the exchanges, including plans that do not comply with ACA coverage rules.

The Bipartisan Problem Solvers Caucus seeks changes in Section 1332 (which lets HHS grant states waivers to establish their own, customized coverage systems) to make it easier for states to win approval for setting up their own systems and to give them more leeway. House lawmakers also want to make it easier for states to enter into compacts that allow insurers to sell health plans across state lines in participating states.

ACA supporters and insurers say they’re potentially open to making 1332 waivers easier to get and more attractive to states, but only within limits. “My sense is there’s a willingness to expand state flexibility on 1332 waivers, it’s got a lot of potential,” said (Tom Daschle, the former Democratic Senate Majority Leader who’s now a healthcare lobbyist at Baker Donelson), who issued joint recommendations on that issue with former Republican House Speaker Newt Gingrich in late 2015.

Despite the looming policy clashes, some observers see a narrow window for a compromise deal on a market stabilization bill, especially since some Democrats in the past have signaled openness to letting insurers sell cheaper, skinnier plans.

http://www.modernhealthcare.com…

***

Comment:

By Don McCanne, M.D.

One of the great faults of the Affordable Care Act is that it was designed to make plans cheaper (lower premiums) by reducing the actuarial value of the plans (the percent of health care costs that the plans would cover) by requiring higher out-of-pocket costs, especially high deductibles. Although federal subsidies have softened the burden, cost sharing has made health care much less affordable, especially for middle-income Americans. Now Congress wants to make this problem even worse.

In the name of bipartisanship, Congress would supposedly save the individual health insurance market by making plans more affordable. They would do this by allowing an even lower actuarial value – higher deductibles – thus shifting more of the costs to individuals who actually need health care. They would also allow a reduction in the benefits covered, perhaps eliminating obstetrical care, mental health services, drug dependency programs, and preventive health services. Increasing out-of-pocket costs and stripping out benefits from the plans is the exact opposite of what most Americans want.

Of course, this would not salvage the individual market. If the premiums were low enough, healthier individuals might buy these cheap plans. Given a choice, many of the healthy would not buy the more expensive, more comprehensive plans. It is the individuals with significant health problems that would buy the higher actuarial value plans. Concentrating high cost individuals in these plans would cause the premiums to skyrocket, making them unaffordable for most, and the market would collapse in a “death spiral.” In the meantime, those buying the cheap plans who then develop significant medical problems would find that they are insolvent or bankrupt because of the unaffordable cost sharing. So the market for cheap plans wouldn’t work ether.

Yes, many people are unhappy with the high premiums that they are paying and want something done about it, but, no, they do not want their plans replaced with skimpy, almost worthless coverage that potentially leaves them exposed to insurmountable debt.

What do Americans want? They want to have the health care that they need, when they need it, without having to negotiate significant financial barriers to that care. In other words, they want a single payer national health program. Numerous polls have shown that they are beginning to grasp that concept.

Congress is going home for the summer recess. Republicans will face angry voters who feel that they have been betrayed by the failure of the Republicans to deliver on their false promises for a better health care system. The Democrats will mount their white horses to spread the message that they are ready to work with the Republicans to make health insurance more affordable. Neither camp will be honest with the voters and let them know what the low actuarial plans they have in mind really are, and how little health care the plans will actually cover.

What is our task? Members of Congress returning to their home districts must hear from us, their constituents – in the loudest, most unequivocal terms possible – how we reject the fraud of cheap health insurance, and that we demand the proven model of single payer national health insurance – an improved Medicare for all.

Get out your bullhorns!

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The rhetoric of payer-provider relationships, but where’s the patient?

Health reform driving payer-provider partnerships

By Les Masterson
Healthcare Dive, August 2, 2017

Payers and providers have for decades stayed in their silos, leading to a more fractured and adversarial healthcare system. That relationship, however, is starting to soften for many in the industry. Payer-provider partnerships put the two groups on the same team in hopes of reducing costs and improving care and outcomes through sharing data and better communication.

A major driver of these partnerships is the move away from fee-for-service payments and toward valued-based payments and population health management.

The payer-provider partnerships popping up across healthcare vary in type, size, location and model. There are 50/50 joint ventures with co-branding, and less intensive partnerships like accountable care organizations (ACO), patient-centered medical homes (PCMH), pay for performance and bundled payments.

The first step in these partnerships is building trust between payers and providers.

Another key is communication. (Chuck Lehn, president of Banner Health Network) acknowledged that communicating across systems and platforms between two organizations and healthcare providers requires time, attention and resources.

Caring for the whole patient works best when payers and providers share data, so there is improved care management, better interventions and better analytics around population health.

The two sides can go much deeper into care for patients by going beyond claims. In partnerships, payers shouldn’t have to wait for claims to see how their members are doing and doctors shouldn’t have to hope that their patients tell them when they have received care elsewhere.

In addition to regular back and forth, payers and providers need regular meetings, whether monthly or quarterly, that focus on strategic issues about the partnership, said (James Leatherwood, marketing communications manager at Availity).

One barrier that still needs resolution in partnerships is moving providers away from phone communication.

Leatherwood said a more efficient way is a queue system. In this system, a provider could check the status of all claims and get alerts when they need to provide more information. The system would allow providers to look in one queue, update the claims information and then move on with their day. Payers would have their own queue and would get alerts when providers have questions. This would reduce phone calls and create immediacy.

Leatherwood said the healthcare system is stuck in a “chart chase” between providers and payers, and moving to an automated queue system would be a gamechanger.

“I think in the near-term what we’re going to see is larger healthcare providers are going to be more strategic, working directly with payers. The health plans are going to be more interested not just in working with the staff level, but executive levels,” said Leatherwood.

The third part of a successful partnership is aligning incentives that focus on keeping people healthy and creating a positive healthcare experience, said (Thomas Robinson, partner at Oliver Wyman).

Partnerships must provide patients the right incentives, integration, investment, insight and innovation to work with the plan to deliver improvements across cost, quality, outcomes and experience, said Robinson.

“The point of these partnerships is to create something new, rather than just building the same old offerings with a narrow network. Successful partnerships will take the opportunity to innovate around the product and experience now that the incentives, insight, investment and integration are all for it,” said Robinson.

Aetna and Banner Health agreed on the partnership in October 2016 and have been laying out the groundwork before its launch this month in Maricopa and Pinal counties in Arizona. The two companies hope to expand the program statewide ultimately.

To prepare for the partnership, Tom Grote, who became CEO of Banner/Aetna joint venture in May, told Healthcare Dive that Banner Health and Aetna have developed joint operating committees, including marketing/sales and population health, that include members from both organizations.

The partnership looks to improve consumer experience by fully integrating providers, Aetna and administrative services, while eliminating redundancies in care and administrative problems. Aetna and Banner Health expect streamlining care and services will lead to savings for patients and employers.

(Brigitte Nettesheim, president of transformative markets for Aetna) said the partnerships are about “each side playing to its strengths, aligning incentives and driving scale.”

(Tom Leyden, director II of the Value Partnerships Program at BCBSM) said providers want to be active participants in system transformation.

“This requires ongoing support from the payer and demonstrated evidence of practice transformation and clinic results from the provider community,” said Leyden. “Administration of these programs is an integral aspect of measuring performance.”

Leyden said the payer strives to make the programs as manageable as possible because physicians need to perform many administrative tasks on an ongoing basis. BCBSM regularly solicits feedback from providers during quarterly meetings and phone calls, emails, webinars and in-person meetings on what’s working, what’s not and what needs to be changed.

“If we keep the customer — the end user — in mind and build partnerships with that as our North Star, we believe we will have a more successful, efficient and collaborative health system,” said Grote.

http://www.healthcaredive.com…

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Comment:

By Don McCanne, M.D.

Wow! These are the people who are in charge. They control the medical industrial complex. Based on this rhetoric they no longer have to be concerned about medical loss ratio minimums of 80 or 85 percent since their administrative functions have fused into health care delivery. That way they can best serve the “the customer — the end user.”

We need to throw these jerks out and establish a single payer national health program so that we can best serve, yes, the patient!

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Tom Price is taking care of physicians rather than patients

With Tom Price in charge, doctors are winning again in Washington

By Erin Mershon
STAT, August 1, 2017

As the Senate was barrelling toward one of its votes to repeal the Affordable Care Act earlier this summer, Tom Price was corralling a small group of doctors into a tiny, dimly lit conference room in a nondescript building in downtown Dallas.

It was, on its surface, another of the health secretary’s many meetings with “victims” of Obamacare — this time with some of the conservative physicians who felt the law was hurting their patients and their own bottom lines. An official readout from Price’s staff trumpeted the eight participating physicians as “witnesses” to Obamacare’s failings.

But that wasn’t Price’s only message to the doctors, according to two participants in the meeting. The health secretary also signaled he would protect the doctors from a raft of regulations that were put in motion by the Obama administration. And although Price, a former orthopedic surgeon, didn’t address specific regulations, he made clear he was listening to the physicians’ complaints about issues like Medicare payment rules and burdensome electronic health record requirements.

Quietly, away from the spotlight cast on his effort to dismantle Obamacare, Price has been rolling back regulations that have been criticized by his former physician colleagues. And, unlike with the ACA, he has been able to do so without the blessing of Congress.

He’s given an American Medical Association committee (RUC) even more power over how much the federal government pays for different medical services. He has pitched retroactively reversing certain Medicare rules to ensure some physicians no longer face penalties they would otherwise have had to pay. He has proposed using almost $1 billion in savings that would be achieved through cuts to certain hospital payments to boost spending on physicians.

And over and over again, he has delayed Obama-era regulations that would have penalized doctors who aren’t ready or able to move away from Medicare’s longstanding “fee-for-service” approach.

As the congressman for Georgia’s 6th District, Price made no secret of his strong relationship with doctors and their specialty societies. He fought for industry wish-list items like malpractice reform and a legislative change to let doctors charge Medicare patients higher prices.

Doctors rewarded him in turn. Health care providers and groups like the AMA and the American Academy of Orthopaedic Surgeons together donated nearly $500,000 to Price’s 2016 campaign and leadership committees, according to the Center for Responsive Politics’s OpenSecrets website.

In one of his first acts as secretary, Price took aim at a bipartisan 2015 law overhauling the way Medicare pays doctors. The law — referred to by its acronym, MACRA — gives bonuses to doctors who do an especially good job at certain activities like using electronic health records, coordinating care, or improving patient safety. Those who don’t get hit with penalties, which ramp up over time.

Price voted for the law in Congress, as did many of his Republican colleagues. The AMA and other physician groups supported it, largely because the package also eliminated a different payment program (SGR) that they had been fighting for nearly two decades.

“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” Seema Verma, the administrator of the Centers for Medicare and Medicaid, said in a statement unveiling the proposal. “That’s why we’re taking a hard look at reducing burdens.”

The agency wants “to be responsive to the concerns of the clinician community,” it wrote in the proposal.

The regulatory changes backed by Price are about more than avoiding penalties. He has promised that his administration, unlike the previous one, will accept the recommendations of an AMA committee (RUC) that lets physicians themselves decide how much Medicare should pay them for individual services.

The controversial and secretive committee lets doctors fight out among themselves whether to pay a certain specialty less or more, as procedures become less time-intensive or less expensive (or more so), despite what critics say is an obvious conflict of interest. The AMA and many specialty societies have defended the panel, saying doctors know best which services are most complicated.

CMS is proposing the values for individual services that generally reflect the expert recommendations from the [committee] without as many refinements as CMS has proposed in recent years,” the new administration said openly in a press release.

It’s a major concession to doctors and especially specialists, who perform more of the procedures that some primary care doctors have suggested are overvalued.

“The idea they would tell staff to just leave the [panel] alone is a concession to physicians, and in particular, physicians like orthopedists,” said Dr. Bob Berenson, an internist and a fellow at the Urban Institute, who has been critical of the committee. “The specialties that do procedures do very well with these misvalued codes, like orthopedists.”

HHS, moreover, may just be getting started in its work to improve Medicare for physicians. Attached to nearly everything the agency has released this year has been a very straightforward request to doctors, hospitals, and other health care stakeholders: Tell us what regulations you want us to nix.

https://www.statnews.com…

***

Comment:

By Don McCanne, M.D.

HHS Secretary Tom Price, an orthopedist and former Congressman from Georgia, has long supported measures that benefit physicians, often to the detriment of patients. His positions on MACRA and RUC exemplify this.

As a member of Congress, Price supported the Medicare Access and CHIP Reauthorization Act (MACRA) with its Merit-based Incentive Payment System (MIPS) and the Alternative Payment Model (APM). He did so in order to relieve physicians from having to comply with the Sustainable Growth Rate (SGR) which otherwise would have caused a reduction in physician payment rates. But, as we warned repeatedly, MACRA and its predecessors would create a major burden for physicians.

It is reassuring to see that Price and CMS administrator Seema Verma now recognize this burden and want to provide regulatory relief. The problem is that their concerns are directed towards physicians rather than patients. They support other policies that would reduce coverage and expose patients to greater health care costs. Even Verma’s physician husband refuses to accept Medicaid patients.

Price strongly supports the American Medical Association’s Specialty Society Relative Value Scale Update Committee (RUC). It provides advice to CMS on physician payment rates. It has long been criticized because of its bias toward procedures resulting in specialist rates that are much higher than rates for primary care. As an orthopedist, Tom Price fared very well under RUC. Again, Price is advocating for physicians when it is the patients that should be his primary concern.

What can we do? Let’s intensify our advocacy for a system that puts patients first – a single payer improved Medicare for all. We need to reach a threshold of support at which our nation’s leaders have no choice but to enact and implement a system that works best for all of us. Physicians and other health care professionals would do just fine under such a system.

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