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Harvard Medical School researchers find limited access to pediatric mental health care in five major U.S. cities

Harvard Medical School researchers find limited access to pediatric mental health care in five major U.S. cities

Simulated patient study points to long wait times, bias against Medicaid patients and misinformation by private insurers

FOR IMMEDIATE RELEASE, May 10, 2017
Contact: Clare Fauke, communications specialist, PNHP, 312-782-6006 or clare@pnhp.org
J.Wesley Boyd, M.D., Cambridge Health Alliance, 617-833-1840 or jwboyd@cha.harvard.edu

A new study published in the International Journal of Health Services  found that access to outpatient mental health care for children—whether with a child psychiatrist or a pediatrician—is very limited, even for those with private insurance or the ability to pay out of pocket for care. Almost one-fifth of children and adolescents in the United States suffer from a serious mental disorder, but fewer than half of those needing care receive treatment. Researchers found several roadblocks to obtaining timely care, including longer wait times for psychiatric appointments versus pediatric appointments, a lack of providers accepting Medicaid patients and incorrect contact information provided by the insurer.

The study attempted to replicate the experience of a parent trying to obtain needed psychiatric care for a child. Using the Blue Cross Blue Shield (BCBS) online database of in-network providers, the authors called child psychiatrists and pediatricians in the Boston, Seattle, Minneapolis, Chapel Hill, and Houston metropolitan areas. Researchers called the offices of 601 pediatricians and 312 child psychiatrists claiming to be the parent of a 12-year-old child with depression seeking the earliest possible appointment. The authors altered their proposed method of payment, randomly stating either that they 1) carried BCBS PPO insurance, 2) carried Medicaid, or 3) were willing to pay out of pocket for care.

The roadblocks to care include the following:

  • Longer wait times for psychiatry appointments: Pediatricians were twice as likely to see new patients and to see them sooner than child psychiatrists. Appointments were obtained with 40% of pediatricians but only 17% of child psychiatrists; the mean wait time for psychiatry appointments was 30 days longer than for pediatrics. Research has shown that long wait times for mental health appointments can negatively impact a person’s engagement in care.
  • Limited access for children on Medicaid: Callers were less likely to obtain appointments for children on Medicaid (22%) than for those with private insurance (37%) or the ability to pay out-of-pocket (37%). Measures to increase physicians acceptance of public insurance, such as higher physician reimbursement and decreased administrative paperwork, may help improve access for patients with Medicaid.
  • Incorrect contact information listed by insurer: One of the most common barriers to making appointments was incorrect or outdated provider information listed on the BCBS site, suggesting that insurance companies may not be vigilant about maintaining accurate databases. “Given how difficult it can be for parents to obtain needed mental health care for their children, insurance companies need to ensure that their provider lists contain accurate information and are as user-friendly as possible,” said lead author Shireen Cama, M.D., a child psychiatry fellow at Cambridge Health Alliance and Harvard Medical School.

Analysis: Private insurers lack incentive for improving access to care

Senior author J. Wesley Boyd, M.D., Ph.D., an attending psychiatrist at Cambridge Health Alliance and faculty member in psychiatry and in the Center for Bioethics at Harvard Medical School, observed that under America’s fragmented, for-profit health insurance system, private insurers do not have an incentive to ensure better access to care. “We found that rosters of health professionals provided by insurance companies often include providers who have either left a practice location, are no longer accepting new patients, or simply aren’t listed with a correct phone number,” said Dr. Boyd. “Insurance companies profit when their enrollees are unable to access care, and patients suffer as a result. We need to take the profit motive out of health care and adopt a single payer, Medicare for all system that guarantees care for patients, not profits for insurers.”

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“Availability of outpatient mental health care by pediatricians and child psychiatrists in five U.S. cities,” Shireen Cama, M.D., Monica Malowney, M.P.H., Anna Jo Bodurtha Smith, M.D., M.P.H., Margaret Spottswood, M.D., M.P.H., Elisa Cheng, M.D., Louis Ostrowsky, M.D., Jose Rengifo, M.D., J. Wesley Boyd, M.D., Ph.D. International Journal of Health Services, May 9, 2017. A copy of the full study is available to media professionals upon request from Clare Fauke, clare@pnhp.org or 312-782-6006.

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and educational organization of more than 21,000 doctors who support a single-payer national health program. PNHP had no role in funding or otherwise supporting the studies or commentary described above.

True fix to health care system won’t come with private insurance companies

By Mark Hickling
The Vashon-Maury Island (Wash.) Beachcomber, May 10, 2017

Public roads. Public libraries. Public street lighting. Public schools. Publicly funded fire departments and police departments. Publicly funded military. These are things that We The People have established to ensure our safety and survival in this difficult world.

But there’s one item missing, one item included in the public contract of every other advanced nation: publicly funded universal health insurance.

As a nation, our unique failure to publicly fund health insurance places the well-being of We The People in the hands of profit-making private insurance companies driven, each year, to continually grow profits by raising premiums while further cutting operational costs — restricting access to health care through complex contractual means and ever-tightening networks.

The ACA, for all of its goodness, failed to address this dynamic. Instead it emboldened and empowered private insurers, handing over public money to boost their bottom lines.

The Republican House has now slapped We The People in the face, reminding us that profit making is a heartless business — a business that does not care about our health or financial survival — a business that should not stand between our loved ones and life-saving care.

We The People demand a fair and cost-efficient system, one that does not burden us (or our employers) with the incredible costs and inefficiencies of our current, outdated system.

It is time for us to join every other advanced nation in the world by switching to publicly funded health insurance: Medicare For All — America’s original, publicly funded single-payer insurer for more than 50 years, available now only to people 65 and older.

Improved Medicare For All. Let’s make this happen. Learn more about this at PNHP.org: Physicians for a National Health Program.

http://www.vashonbeachcomber.com…

Healthy Indiana patients are being dumped into lower-tier plan

More than half of Indiana’s alternative Medicaid recipients didn’t make payment required for top service

By Maureen Groppe
IndyStar, May 8, 2017

More than half the low-income people who qualified for Indiana’s alternative Medicaid program failed to make a monthly payment required for the top tier of service — a key feature of the program Vice President Mike Pence insisted on as a condition to expanding the health care program when he was Indiana’s governor.

That’s according to a new evaluation of the Healthy Indiana Plan, a program designed by Indiana health care consultant Seema Verma, who — as the new administrator for the Centers for Medicare and Medicaid Services — can now grant other states permission to impose similar monthly fees.

Opponents say the department of Health and Human Services should not allow other states to do this, because this study and other research has shown requiring poor people to pay is a barrier to care.

Verma, along with HHS Secretary Tom Price, already have told states they want to be as permissive as possible.

Of the 590,315 Hoosiers determined eligible for Medicaid during the 22 months after Indiana expanded eligibility, 55 percent either never made the first payment or missed one while on the program.

Nearly nine in 10 ended up in the lower-tier plan as a result, according to an evaluation done for the state and submitted to the federal government.

“The evaluation makes clear that Healthy Indiana’s complicated use of premium payments is not working,” said Joan Alker, executive director of Georgetown University’s Center for Children and Families. “More than half of the enrollees have missed a payment at some point, and as a result are bouncing around in and out of coverage sources or no coverage at all. These are very poor people for whom premiums are a hardship.”

Pence insisted on including monthly payments as a condition for expanding Medicaid through the Affordable Care Act. He argued the payments promote personal responsibility and better decision making by patients who have “skin in the game.”

It’s a sentiment shared by Verma. “The Healthy Indiana Plan is about empowering individuals to take ownership for their health,” Verma said during her confirmation hearing.

The insurance companies which offer the Medicaid plans say Indiana’s payment requirements and two-tiered system is more costly to administer.

http://www.indystar.com…

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Comment:

By Don McCanne, M.D.

Although we’ve covered this topic before, this report provides new evidence that the Healthy Indiana Plan is providing a disservice to eligible Medicaid beneficiaries by shifting most of them into the lower-tier plan where they lose dental and vision benefits, have more limited drug coverage, and are exposed to copayments. Since most of these individuals have no discretionary income, many do without these important services. This is the opposite of what a program designed to provide low-income individuals with affordable access to health care should be doing.

One of the major problems with our health care financing system is that we pay hundreds of billions of dollars for outrageous administrative waste. Now the insurers report that the Healthy Indiana Plan is even more costly to administer than traditional Medicaid. Just exactly what we need – more administrative waste!

Recently-appointed CMS Administrator Seema Verma worked with then Governor Mike Pence to establish this ideologically-driven but cruel policy, and now she wants to work with HHS Secretary Tom Price to expand this concept to other states. Enough! We do not need more inefficiency and impaired access to care. We need a single payer national health program – an improved Medicare for all so that all of us can have the care that we need, when we need it.

Free market is a disaster for sick Americans

By Phil Kadner
Chicago Sun-Times, May 9, 2017

Will someone please tell me what evidence exists that a free market benefits consumers in this country when it comes to health insurance? Would anyone even argue that market demand ought to determine how much a person pays when it comes to saving the life of a baby?

The average working stiff has little choice when it comes to health insurance. If you are lucky enough to have an employer who provides insurance as a benefit, that’s what you’re stuck with because going into the free market (before Obamacare) meant you were going to have to pay a king’s ransom on private insurance premiums.

Millions of Americans, of course, had no health insurance prior to Obamacare.

That’s because many of them had pre-existing conditions, which included cancer, diabetes, mental health problems, heart conditions, kidney disease and many more.

Obamacare, for the first time, required that insurance companies cover people with pre-existing conditions. That is a government regulation that offends many conservative Republicans because it interferes with the free market.

Most Americans, however, realize that given the freedom to deny coverage to sick people, insurance companies would do exactly that.

If you’re in business to make a profit, you do not want to cover people who are going to cost your company a lot of money. You would prefer to customers who are young and healthy. These are people considered low-risk individuals who still pay pretty stiff premiums to protect themselves against that day they get a serious illness, or suffer a terrible injury.

That’s how the free market health insurance system works if left alone by the government. That’s how it worked for decades before Obamacare.

I would also point out that even low-risk people with insurance were sometimes told their illness did not qualify for medical coverage, or that the treatment recommended by their doctors was considered experimental so would not be covered.

Insurance companies have their own panel of doctors and medical experts who make those decisions. Your doctor’s opinion does not override theirs. Of course, you could also file a lawsuit and spend years in court fighting their decision. That’s how the free market works.

Every other nation in the civilized world has single-payer national health insurance, which is similar to Medicare in the United States. Everyone is thrown together in one insurance pool.

Even President Donald Trump recently acknowledged that’s a better system, noting Australia’s health system is better than that of the United States.

Unlike the rest of the industrialized world, our government does nothing to control medical costs. Nor does it do anything to control prescription drug costs.

So in the free market that is the United States,  a drug company that owns the rights to EpiPens, life-saving injection devices commonly used to treat people suffering from severe allergic reactions, can increase the price of a two-injection packet to $600. The actually cost of the drug inside was valued at less than $20. The same injection pen drug duo sells for $290 in Canada.

From 2013 to 2015, the average cost of prescription drugs in the United States rose 25 percent.

Health insurance and drug companies, by the way, spend massive amounts of money on commercial advertising and political lobbying in the United States. That is the free market at work.

If you believe in health care that is more expensive, if you believe in insurance that covers fewer people, if you think it’s right to deny insurance to babies born with birth defects, then you are a true believer in the free market.

If not, join the fight for single-payer, universal health care.

http://chicago.suntimes.com…

The Republican Health Care Bill Is An American Tragedy

By Sandro Galea, M.D.
WBUR (Boston), May 9, 2017

Last Thursday, congressional Republicans voted to pass the American Health Care Act, the first step in fulfilling their pledge to “repeal and replace” former President Obama’s health care law, the Affordable Care Act. This comes after attempts to pass an earlier version of the Republican health care bill imploded about a month ago. If the new version of the bill becomes law, it stands to reshape both the landscape of American health and the health care industry — one-sixth of our economy.

While the full scope of the changes the GOP health care redux would bring are still uncertain — the bill was passed before the nonpartisan Congressional Budget Office had a chance to evaluate it — the replacement health care plan will likely challenge Medicaid expansion, open the door to denying coverage to people with pre-existing conditions, and ultimately cause millions of Americans to lose health coverage.

It is perhaps not surprising, then, that the bill is opposed by nearly all major medical and public health associations in the United States, including the American Medical Association, the American College of Cardiology, the American Public Health Association and the AARP. Their opposition is warranted. Replacing the Affordable Care Act with the House-approved Republican health care plan would be an American tragedy, a tremendous step backward that we should collectively reject.

Given that the Affordable Care Act debate has spanned almost a decade, and the broader debate over health care reform in America stretches back to the middle of the last century, it is easy to wonder: Why is this such a fraught issue in the United States? It seems to me that there are two fundamental reasons.

First, America has not yet decided, at the level of basic national values, why it is important to offer universal health coverage to its citizens. This may sound strange. After all, is not the desire to keep ourselves and our family healthy a sufficient reason to support legislation designed to do just that? Perhaps, to a limited extent, it is. But a national health care system is more than a series of measures that shield us from disease and heal us when we are afflicted. It is a statement. It says that we, as a country, have chosen to care for each other in times of need, not just because it is in our self-interest to do so, but because to do otherwise would be a betrayal of our core ideals as Americans. The American health care debate, for all its many iterations over the years, has never been presented to us in these terms — as an issue that is, before anything else, a moral one. Because the critical question of the law’s raison d’ĂŞtre has remained unresolved, the Affordable Care Act has been vulnerable to the kind of attacks and distortions we have seen leveled at it in recent years.

Second, American health care in its current form lacks a federal requirement providing for necessary health services — such as doctor and hospital visits — to be sustained through a single payer system, which would ensure that all receive coverage, regardless of the rules of a given local market. So far, we have seen no legislative push to create such a requirement, nor much political will to bring health care under the umbrella of a single authority, one that would be accountable for maintaining a universal coverage guarantee. The Affordable Care Act, as it stands, is more quilt than whole cloth — a patchwork of legislative deals struck between interest groups, overseen by a range of stakeholders. This is a far cry from where we need to be, if we are to have a durable, effective means of delivering health care in this country.

Each of these critiques speaks to what the Affordable Care Act truly requires: reform, and perhaps bolder re-imagination to tackle some of its foundational challenges. It does not, however, require hasty and reckless repeal. It requires careful improvement, carried out in good faith, with the intention of protecting health, not scoring political points.

This is not likely to happen until we decide that health care truly is a right of citizenship — an extension of national values — and resolve to create a secure legislative framework to safeguard that right, now and in the future. The GOP health care bill does nothing to advance this vision. Rather than giving us a bill that arises from a clear moral case for what health care in this country should be, the Republican Congress has produced what amounts to a moral catastrophe.

News that the Senate may rewrite the bill, possibly tempering some of its more draconian features, provides mild reassurance. Perhaps the wave of public support for the Affordable Care Act can indeed give rise to its improvement so that one day, affordable and universal health coverage will become a non-negotiable norm in America.

Dr. Sandro Galea is dean of the Boston University School of Public Health and an expert in social epidemiology, trauma, and the health of urban populations.

http://www.wbur.org…

Search for mental health care for children is often fruitless

By Liz Kowalczyk
Boston Globe, May 9, 2017

Harvard researchers posing as the parent of a depressed 12-year-old called hundreds of child psychiatrists and pediatricians looking for appointments, and discovered what many actual parents know through bitter experience: Most of the time the calls were fruitless.

The group phoned 913 doctors listed as network providers by Blue Cross Blue Shield organizations in Boston, Chapel Hill, N.C., Houston, Minneapolis, and Seattle. After two attempts, they were able to get an appointment with a pediatrician 40 percent of the time and with a psychiatrist a meager 17 percent, according to the study published Tuesday in the International Journal of Health Services.

The obstacles began with the insurers’ online provider directories, which they tout as a tool to help consumers find doctors. But when researchers called the offices listed, they were often told that the doctor had retired or moved, or that the phone number was simply wrong. Even when the listing was accurate, a longstanding shortage of child psychiatrists meant that many practices were not taking new patients or had long wait lists.

Cheryl Meas, the mother of a teenager in Lowell, can vouch for the study’s discouraging results. A year and a half ago, the clinic that had been treating her 15-year-old son for anxiety and a mood disorder for five years suddenly closed due to bankruptcy. There, he had seen a therapist and a nurse practitioner who, working with a psychiatrist, prescribed his medications.

After the clinic closed, her son’s pediatrician agreed to prescribe his medicines temporarily, but that grew into months. Meas repeatedly called Magellan Health, which handles mental health benefits for her employer. She told the company that she would take any doctor within an hour and 15 minute drive of her home. Each time Magellan gave her names of psychiatrists in the network who treat children. Each time, she struck out.

“They sent me a bunch of doctors who don’t even practice anymore,’’ Meas said. “We went through this for six months. We just went in circles.’’

She ultimately called more than 40 psychiatrists, including a few from the Yellow Pages, she said. Meanwhile, her son was taking a turn for the worse and his pediatrician was not sure how to adjust his medicine, Meas said. The Department of Mental Health eventually referred her to an agency in Lowell and, with help from an advocate, was able to persuade Magellan to pay for an out-of-network provider. The company said in a statement that it “strives to provide the most accurate and up-to-date information.’’

Meas was able to keep her son stable during this unsettled period, but that is not always the case, said Dr. J. Wesley Boyd, a study coauthor and a psychiatrist at Cambridge Health Alliance.

“In some cases, kids will hold on and be OK until they get to that first appointment,’’ he said. “In other cases, a crisis will arise in the meantime and they will end up in the emergency room.’’

School work and relationships with family and friends also can suffer during the delay, said Lisa Lambert, executive director of the Parent/Professional Advocacy League in Boston and Worcester. “Parents are often exhausted because they are trying to manage what is happening but they are not sure if they are doing the right thing,’’ she said.

In the study, Boyd, who is affiliated with Harvard Medical School, and his coauthors chose five cities in different regions that spanned the country. They made the calls in 2015, and included pediatricians because they provide a growing amount of mental health care amid the psychiatrist shortage. The callers asked for the first available appointment — but did not go through with making it.

They tracked the wait for an appointment in cases where a slot was available. It ranged from an average of 12 days in Chapel Hill to 30 days in Seattle — though the average wait time for a psychiatrist was far longer at 43 days. The overall average wait in the Boston area was 15 days.

Researchers also found that the chance of getting an appointment plummeted when they said the child was insured by Medicaid, the government program for the poor and disabled. When they told doctors’ offices they had private insurance or would pay out-of-pocket, they got an appointment 37 percent of the time. When they mentioned Medicaid, that dropped to 22 percent. Boyd said fewer doctors accept Medicaid, which tends to pay doctors lower rates.

Twenty-two percent of the pediatricians called and 26 percent of psychiatrists were not accepting new patients.

The shortage of child psychiatrists has been well documented. The American Academy of Child & Adolescent Psychiatry said there are about 8,000 child and adolescent psychiatrists in the United States but that about 30,000 are needed to treat children afflicted with mental illness; estimates are that about one in five children requires such treatment.

The group ranks Massachusetts as a state with a “high’’ but not “severe’’ shortage overall, with about 442 child psychiatrists. The gap, however, is considered severe on the North Shore, the South Shore, and in Hampden County.

The organization blames the shortage in part on the extensive training requirements. Residents must finish two additional years of training in treating children, after an initial three years in adult psychiatry, leaving them with huge debts. The academy is lobbying states to approve loan forgiveness programs.

Another obstacle researchers faced was inaccurate provider lists on the Blue Cross websites — a phenomenon Lambert refers to as ghost networks. In 24 percent of the calls made to child psychiatrists, the doctor no longer worked there, the receptionist had never heard of the doctor, or it was otherwise the wrong number.

“We recognize that this is a problem,’’ said Dr. Ken Duckworth, medical director of behavioral health at Blue Cross Blue Shield of Massachusetts. He said the insurer has begun sending quarterly reminders to all its doctors to update their contact information and work status.

Duckworth said Blue Cross provides financial support to the Massachusetts Child Psychiatry Access Project, a longstanding program that assists pediatricians treating patients with mental health diagnoses.

“We want people to get the help they need, and we want them to be seen,’’ he said.

But not all pediatricians are comfortable caring for these patients, even with extra help, especially given the increasing use of psychiatric drugs, leading to some children being on three or four medications at once.

Asked if he has any advice for parents trying to find a child psychiatrist, Boyd said “you just have to be dramatically persistent.’’

Meas is bracing for another frustrating search. Her son’s new psychiatrist told her last week that she is leaving the Lowell practice. If the organization can’t replace her, it will be up to Meas to find someone.

https://www.bostonglobe.com…

PNHP Note: To read our news release on the Harvard study cited above, click here. To read the full study in the International Journal of Health Services, click here.

With Obamacare under GOP attack, New York could fight back with a single-payer plan

New York may be the first states to escape the Trumpcare threat by offering a single-payer option to all residents

By Amanda Marcotte
Salon, May 9, 2017

Last week the House of Representatives passed a bill that would repeal the Affordable Care Act, cutting taxes by $1 trillion for the wealthiest Americans and potentially resulting in as many as 24 million people without health insurance by 2026. Senate Republicans are currently working on their own version of the bill, and while it’s expected to be less severe than the House plan, the end result will almost certainly be similar: tax cuts for the rich, with millions of people losing coverage.

Understandably, there’s panic across the country at the prospect of soaring premiums and loss of coverage. But while Democrats in Washington can do little to save health care when Republicans control both Congress and the White House, Democrats who hold power in state capitals can take steps to save local residents from disaster. State governments are free to offer their own health care plans — and one popular option being considered in many blue states is a single-payer, Canadian-style system, sometimes called “Medicare for all.”

New York is probably the state in the country that’s closest to creating a single-payer system, although it’s not alone. The New York Health Act, which would enroll every New Yorker in a state-run insurance program, has passed the New York State Assembly and is two votes short of being passed in the state’s Senate.

“It really does seem that the worse things get in D.C., the more pressure there is on Albany to protect New Yorkers from these terrible policies,” said Katie Robbins, the executive director of the New York metro chapter of Physicians for a National Health Program, in a phone conversation. “We’re seeing a tremendous surge in interest in what the New York Health Act would do for New Yorkers.”

The bill, introduced by Assemblyman Richard Gottfried who represents a district in midtown Manhattan, is ambitious but appealing.

“The bill would create a single-payer system in New York state that would provide universal, complete health coverage to every New Yorker without financial obstacles to care,” Gottfried explained over the phone. “No deductibles, no co-pays, no restricted provider network or out-of-network charges.” 

Also, he argued, it would be a lot fairer than the current private insurance system, which charges the same amount for a plan “whether you a multimillion-dollar CEO or the receptionist or the janitor.” Instead, the bill “would be funded through a broad-based, progressively graduated tax based on ability to pay,” by way of a combination of taxes on capital gains and payrolls.

The fact that this plan would be funded by raising taxes might make it sound like a nonstarter politically. But Gottfried argued that “almost all New Yorkers would pay less than they currently do” because they would be able to replace their current plans with this more affordable state-based plan. 

Gerald Friedman, an economics professor at the University of Massachusetts Amherst, agreed. In 2015 he wrote an analysis of the proposed bill and concluded that a single-payer system would save money across the board by reducing health care spending.

“One [advantage] is that a single-payer plan will allow providers to economize on the costs of handling the billing and insurance-related expenses,” Friedman argued. 

There are a lot of different numbers flying around in the world of health care policy analysis, but one thing is certain: Government-run single-payer systems, such as Medicare, spend less money on administrative costs than private insurance systems do. As Ezra Klein detailed in The Washington Post in 2009, 5 percent to 6 percent of Medicare spending goes toward things like billing and other administrative matters. In private insurance, it’s from 7 percent to 30 percent.

Doctors and hospitals spend a lot of money wrangling with insurance companies, Friedman said. By eliminating that aspect, a single-payer system would reduce the amount that hospitals and doctors have to charge.

Robbins of the New York physicians’ organization also pointed out it would reduce the amount of energy that doctors must expend on dealing with insurance companies. “It can be a real nightmare to deal with the paperwork that they require,” she said. And doctors “are really burning out on this system that is so dominated by private health insurance.”

The American Medical Association, however, officially opposes single-payer health care. Polling data on doctor opinion is sadly not very good on this subject, though a 2009 poll conducted by the Mount Sinai School of Medicine in New York found that 73 percent of doctors favored some sort of government-provided health insurance that patients could opt for.

One major political obstacle to the adoption of a single-payer plan is that the one state that has tried it, Vermont, watched the experiment go up in smoke. The governor concluded in 2014 that the state would have to raise taxes too much to pay for the program. It may well have ended up saving many Vermonters money, but concern was widespread that taxes would be too high for others.

Single-payer advocates, however, feel that New York might have better luck because since it is bigger and richer.

“We are a large state,” Gottfried said. “To the extent that there are benefits from economies of scale, we have that. We are also a state that has a tremendous concentration of wealth. While there are certainly a lot of poor people in New York, there are also a lot of wealthy people. So our ability to fund a program with a lighter burden on working people is partly because of the substantial number of upper-income New Yorkers.”

The sheer size of the state — with almost 20 million residents — would greatly increase the bargaining power of its single-payer system, Friedman argued. New York has more people than the Netherlands, which has an inexpensive universal system of coverage. Putting all New Yorkers on one system, Friedman argued, would give the government leverage over the health care system — and that leverage could be used to lower prices.

Critics of the New York Health Act, primarily conservative analyst Avik Roy of the Foundation for Research on Equal Opportunity, have argued that the tax increases necessary to fund a single-payer plan would run employers out of the state. Both Friedman and Gottfried argued the opposite, saying that a single-payer system would save employers money by ending their obligation to pay for employees’ health insurance.

“It will make New York an employment magnet,” Gottfried said, arguing “a level playing field” would be created for small businesses, which often struggle to attract the best workers as they can’t afford to provide the same level of benefits as larger companies do. 

“People who are looking to build a new business may flock to New York, and I hope they do,” he argued. 

The biggest obstacle to a single-payer system has always been political resistance more than economic fears. Voters tend to fear change, and shifting from an employer-based system to a government-run system scares people. Hostility toward “big government” has turned people away from the idea, even if they understand this will ultimately cost less money.

But the political calculus has changed dramatically in the past few months. Republicans in Congress continue to threaten to strip people of their health care protections (such as essential health benefits) or throw them off their insurance entirely.

In this environment of fear, the major advantage a single-payer system offers is the security. If New York can pull this off, it will be the one state in the country where voters feel that their health care is safe from market manipulations, job loss or the Republican determination to get rid of Obamacare at any cost. Voters in other states are bound to notice.

http://www.salon.com…

Charlie Munger supports single payer reform

Charlie Munger says single-payer healthcare is the solution

By Andy Serwer
Yahoo Finance, May 7, 2017

Charlie Munger says that single-payer healthcare is the answer to fix the nation’s healthcare system woes. A longstanding Republican, the Berkshire Hathaway vice-chairman acknowledges it is an unusual position for someone from his party to espouse.

“I’m not a normal Republican,” he said, noting that there’s “a lot wrong” with the system.

“Having a basic level of care for everybody with no insurance aspect as a right I think is a good idea” Munger said.

Munger, who Berkshire CEO Warren Buffett calls his partner, made the remarks in Omaha the day after Berkshire’s annual meeting. Munger said there’s good and bad parts of our healthcare system.

“At the top, it’s the best medical care in the world,” Munger said. He explained that if you have a difficult type of cancer or you’re in need acute care, you’re better off in the U.S. than anywhere else.

“That’s the good part,” he said. “The bad part is the Rube Goldberg system that arose by accident. There’s massive amounts of excess cost.”

“And of course the politicians on each side don’t want to figure this out, they just hate each other and scream at each other, so it’s a disgusting outcome. And of course the cost goes up three, four, five six percent a year!”

I asked Munger how to fix it.

“A benign despot would create a single payer system with people being able to opt out into private care that was a little faster or a little fancier like all of Europe and Canada,” he said.

I asked Munger if he was saying that a single-payer system is really the answer.

“Yes,” he said.

With an opt-out on the high end?

“Yes,” he said.

“I think you young people will live to see a healthcare system that looks a lot like Canada’s with a better private opt out system,” Munger said. “I won’t.” (Munger is 93.)

During the meeting, Warren Buffett called rising healthcare costs “a tapeworm,” eating away at American business. Munger agreed and added that U.S. manufacturers have a “huge competitive disadvantage caused by the health system” over say European counterparts since U.S. businesses have to pay for health care costs while European companies don’t.”

https://www.yahoo.com…

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Comment:

By Don McCanne, M.D.

When a prominent Republican Wall Street billionaire, Charlie Munger, endorses single payer, it is clear that the message is getting across.

Also, when his partner, Warren Buffet, says that U.S. manufacturers have a huge competitive disadvantage caused by the health system, then all of Wall Street and the business community at large should be listening as well and then taking action in support of single payer reform.

(One concern is that he calls for wealthier individuals being able to opt out into faster or fancier care, presumably creating a two-tiered system. Perhaps the wealthy should be allowed extras that should not be part of a publicly financed system, such as a hospital penthouse suite, but they should not automatically be granted a position at the front of a queue for essential services. In an equitable, egalitarian system we need them to advocate for policies that reduce excessive queues so that everyone, including themselves, has timely access to appropriate care. However this should not deter Munger from supporting single payer, since, as a billionaire, he will always have a place at the front of the queue, no matter the rules.)

Any Republicans listening?

By Richard Ellerbrake, M.H.A.
Belleville News-Democrat, May 8, 2017

“Expanded and Improved Medicare for All,” H.R. 676, added its 108th (as of May 4) co-sponsor. For the first time, a majority of House Democrats support single payer national health insurance.

Medicare is a very popular government program. The first Republican to co-sponsor the bill will go down in history as a states-person, not “just another politician.”

We talk a lot about “affordable care.” The United States spends nearly six times as much per capita on health care administration as the average developed country, with poorer outcomes. Private insurance administrative costs are about 17 percent, Medicare’s only 2 percent.

During 30 years as health system COO/CEO, I’ve heard people say, “Keep government out of my Medicare!” No, the health and safety of the people is a prime government concern, and Medicare promotes both at lower cost.

Improving Medicare and making it available to everyone would be a smart move. Any courageous Republican representative listening?

http://www.bnd.com…

Physicians shouldering more of patients’ cost sharing

As Patients Take On More Costs, Will Providers Shoulder The Burden?

By Michael Chernew and Jonathan Bush
Health Affairs Blog, May 4, 2017

Despite the uncertainty about the future of the Affordable Care Act (ACA) and any replacement, in the coming years, more Americans will almost surely find themselves in health plans with considerable patient cost sharing at the point of service (for example, high deductibles, copayments, or co-insurance). The trend toward more limited plans has been a reality for more than a decade. For example, the average deductible has grown from $818 in 2006 to $2,069 in 2015.

Moreover, Congress may try to reduce cost-sharing subsidies and encourage people to select more limited plans in other ways, such as increasing the attractiveness of health savings accounts. Cost sharing lowers premiums (an important goal for payers and policy makers) by lowering use and, to some extent, encouraging consumers to shop for lower-price care. It also shifts costs away from payers toward patients.

Public debate about more limited insurance plans has mostly focused on their impact on beneficiaries. Missing from the discussion has been an analysis of how these plans could affect providers.

Calculating The Provider Burden From Cost Sharing

Using medical claims data from athenahealth’s national network of 88,000 providers, we computed out-of-pocket obligations for commercially insured patients across all provider specialties, from 2012 through 2016. Our sample includes 125 million visits for ambulatory services (for example, office visits and ambulatory surgical procedures) by 18 million patients across 1,348 practices.

For each visit, we computed the required patient cost-sharing amount. We looked at those patient obligations across four broad categories, based on size of the patients’ out-of-pocket charge for the visit: small ($0-$35), medium ($35-$75), large ($75-$200), and very large (more than $200). We found that the average patient obligation per visit increased 20 percent between 2012 and 2016, with the overall distribution shifting from small to larger obligations.

Using the 2015 data, we then computed collection rates after 12 months for the different patient obligation size categories. For visits with small patient obligations, 93.8 percent of the balance was paid within a year. The rate drops to just 66.7 percent for visits with obligations above $200. For visits with the highest obligation, roughly 16 percent were written off as bad debt or abandoned, and about another 17 percent were sent to collection agencies.

Compounding this issue with larger patient balances is the opacity of obligation amounts at the time of service. While practices have visibility at the point of service into patient copayment amounts through eligibility data, the amount they can collect for patients with high-deductible health plans is unknown. Under current rules, they must bill the insurance carrier and wait for an explanation of benefits (often a two-week lag time) before billing the patient for his or her portion. Aside from this being an extremely complex and costly process, we know that collecting any amount becomes markedly more difficult once the patient leaves the office.

Implications

The tax on providers from increased patient cost sharing occurs against a backdrop of very slowly rising fees. The new physician payment system outlined in the Medicare Access and CHIP Reauthorization Act of 2015 calls for physician fees to rise by 0.5 percent (before accounting for inflation) through 2019 and then to be flat through 2024 and beyond. If general inflation rises by 2 percent through 2024, roughly as projected by the Federal Reserve, this represents an inflation-adjusted reduction in fees on average of more than 10 percent. While some physicians may fare well under the performance bonus system, fee increases for the high performers, beyond the exceptional performance bonus, will be funded by a reduction in fees for low-scoring physicians. The result for physicians could be a perfect storm of fee cuts and losses from writing off uncollected patient payments.

As in other markets, providers should have the price transparency and flexibility to offer discounts for time-of-service payments.

For physicians to weather the financial pressures coming, they will need to design and manage a “retail front end” for their practices, with the ability to offer “sales” to patients in return for speedy payment. They will also need to get sophisticated about accessing insurance companies online to assess what patients will owe before they leave the office. As important, physicians will need to find ways to manage their practice costs. Under existing fee-for-service payment models, however, any efficiency gains made by reducing wasteful care are captured by payers.

http://healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

The increasing prevalence and magnitude of cost sharing is not news. We have long recognized the burden this has placed on patients, not only the financial burden but also the decline in access to beneficial health care because of the lack of affordability due to higher out-of-pocket expenses. Today’s article adds the concern that the burden of cost sharing is being shifted onto physicians because of the difficulty that patients have in paying their cost-sharing obligations.

This is no small burden for physicians. Patient deductibles now average over $2000. It would not take very many delinquent accounts to significantly reduce the physicians’ take-home pay. Further, MACRA not only brought to physicians the burden of MIPS and APMs but it also scheduled flat fees in the future amounting to a ten percent inflation-adjusted reduction of fees. Further, the performance rewards will be financed by fee reduction penalties for those physicians who dedicate themselves to caring for the most needy since these patient populations result in empirically low “quality” scores.

Nobody expects the insurers or legislators to back off on the march toward more patient responsibility for paying medical bills. It will get worse, and, as these authors state, “a perfect storm of fee cuts and losses from writing off uncollected patient payments” will be brewing.

But what is the authors’ solution? Design and manage “a retail front end” – offer discounts, hold sales, reward speedy payments, develop more sophistication in accessing insurance companies to determine cost sharing requirements, and, of course, the inevitable recommendation that physicians are simply going to have to reduce their practice costs (where do you cut when you’re already down to the bone?).

Is this really the practice environment that patients want for their physicians (“… but today only, just for you, a deal you can’t refuse …”)? For that matter, do patients really want to exercise their consumer prowess by having the opportunity to pay upfront charges for their health care?

Sorry. This is not where we should be headed. We need to dump all this and move forward with first dollar coverage through a well-designed single payer national health program – an improved Medicare for all.

Donald Trump’s homicidal healthcare bill will kill some, and enrich others

Medicine saves lives, while stripping healthcare coverage to fund tax breaks for the rich takes lives. If this bill passes, legislators will have blood on their hands.

By Adam Gaffney, M.D.
The Guardian, May 5, 2017

Let us imagine that you would like to redistribute hundreds of billions of dollars from working class people to the rich, and wouldn’t hesitate to risk the lives of tens of thousands of people to do so. Well, as luck would have it, there is a bill—the “American Health Care Act” (AHCA)—that does precisely that.

On Thursday, it squeezed through the House of Representatives. Trumpcare – at least for the moment – has been triumphant.

Many of us thought – or hoped – that Paul Ryan’s bill was as good as dead on 24 March, when, in a pleasurable political moment (a rare event these days), he admitted he lacked the votes to push it through. But where there is a will to degrade the healthcare safety net, there is a way. And, to the House Republicans’ credit, they indeed found a way to ram this grotesquerie through.

To do so, the hard right had to compromise with the harder right, which made the current version of the AHCA fouler than the original.

The harder right found much to like about the original bill – like its historic gouging of Medicaid. The problem was that it left too much of the regulatory infrastructure of the Affordable Care Act (ACA) intact. Rules that insurers must cover 10 “essential health benefits” and cannot discriminate against those with pre-existing conditions? Eliminate those provisions, and let healthcare freedom reign.

The compromises worked. First, there was the MacArthur amendment, which permits states to redefine “essential health benefits” (this would allow insurers to exclude coverage of some types of healthcare, such as maternity care), or to allow insurers to charge people with pre-existing conditions higher premiums if they failed to maintain coverage.

As Timothy Jost noted on the Health Affairs blog, the latter provision “could effectively make coverage completely unaffordable to people with pre-existing conditions”, notwithstanding the clearly inadequate high-risk pools.

So far, so good.

However, in appeasing the harder right, the House leadership risked estranging the less hard right. But the latter proved to be a cheap date: they were bought off by the Upton amendment, added at the eleventh hour, which gave another $8bn to the fund theoretically designed to cover those left behind by the AHCA. Though this was a drop in the bucket relative to the size of the problem created by the AHCA, it brought just enough moderates back on board to secure a winning vote.

If the AHCA were signed into law by Trump – an unlikely but not impossible proposition given the headwinds it faces in the Senate – the negative impact on ordinary Americans would be enormous.

Given that the House GOP didn’t bother to wait for the Congressional Budget Office (CBO) score before voting, we don’t know just how bad it will be. But relying on the CBO’s initial estimates, we can say that the AHCA will, over a decade, reduce spending on Medicaid alone by more than $800bn.

Together with savings from having less adequate, skimpier insurance subsidies, these reductions will allow hundreds of billions of dollars to be channeled to the wealthy and corporations in the form of tax cuts.

By enriching the rich in this manner, the AHCA would leave an estimated 24 million more uninsured by 2028. Similar calculations have already been done, but it’s worth briefly revisiting the blood-arithmetic on this.

Colleagues of mine recently reported estimates, in the American Journal of Public Health, of how many newly insured people there would have to be to prevent one death per year. These estimates, which, being estimates, aren’t perfect, were based on five studies. The numbers ranged from 300 to 1,239 people.

If we were to pick a round number on the conservative end of that range – say 1,000 – we would estimate that stripping insurance from 24 million people would produce an estimated 24,000 additional deaths annually. That is 40% more than the sum total of all murders, estimated by the FBI at 14,429 for 2014 (using somewhat different numbers, Vox’s Julia Belluz makes this point and comes to the same figure).

Now, in all fairness to House Republicans, as a critical care physician, I too get blood on my hands when I go to work. The only difference is I can wash mine off.

Modern medicine saves lives, while stripping healthcare coverage from millions to fund tax breaks for millionaires takes lives. There’s no way around it, whatever some may tell themselves to help them sleep at night.

This, of course, raises an even larger issue, namely the injustices of the healthcare status quo, wherein 28 million remain uninsured and even more without adequate coverage – shortcomings that leave open the door to continued attack from the right.

This execrable, homicidal bill must obviously be stopped. But that’s not all we must do. The most enduring defense against the rightwing saboteurs is not continued championship of a flawed status quo, but instead the promise of a better tomorrow: healthcare for all, through a single-payer universal system. That alone will put an end to these deadly assaults on healthcare.

Adam Gaffney is an instructor in medicine at Harvard Medical School, a pulmonary and critical care doctor at the Cambridge Health Alliance, and a national board member of Physicians for a National Health Program. He blogs at theprogressivephysician.org.

https://www.theguardian.com…

Dr. Carol Paris on ‘The Real News’

PNHP president Dr. Carol Paris appeared on “The Real News” on May 5, 2017, to discuss the House of Representatives passing the American Health Care Act by the slimmest of margins. She said real reform, in the form of a single-payer national health program, would only come about as the result of a broad-based movement that pressured Congress to act.