PNHP

Slavitt says insurers didn’t charge enough

Slavitt says insurers didn’t charge enough

Regulators approve higher health premiums to strengthen Obamacare insurers

By Jacquie Lee and Jayne O’Donnell
USA TODAY, October 19, 2016

State insurance regulators across the country have approved health care premium increases higher than those requested by insurers, despite a national effort to keep rates for policies sold on Affordable Care Act exchanges from skyrocketing, a USA TODAY analysis shows.

This year may be the last for dramatic premium increases as insurers now understand their new markets better, say some supporters of the law, including the head of the Centers for Medicare and Medicaid Services (CMS).

“The business was underpriced in many markets in the first couple years,” says Andy Slavitt, CMS’ acting administrator. “In retrospect, life would have been a lot better and easier if things had started 10% higher, the rate increases had been higher and it had been just a smooth steady climb.”

“Nobody really knew what it would cost to insure sick people,” Slavitt said. “I don’t know how (anyone) could have known.”

http://www.usatoday.com…

***

Comment:

By Don McCanne, M.D.

Interesting. When the nation is upset about the very high increases in the insurance premiums for plans offered on the insurance exchanges, CMS acting administrator Andy Slavitt says that the insurers should have started with higher premiums, and the annual premium increases should have been greater.

Slavitt says that nobody could have known what it would cost to insure sick people, and, by implication, certainly not even the insurers.

But we, as a nation, are paying an extra half trillion dollars in administrative expenses to maintain our fragmented multi-payer system just to keep the private insurers in control of a major portion of our health care dollars. And their actuaries cannot even figure out how much money they need? Isn’t that fundamental to their business model?

Do we really want to keep on doing this? Or do we want to fill in our gaps in health care with that half trillion dollars? It doesn’t seem to be that difficult of a decision.

Slavitt says insurers didn’t charge enough

Regulators approve higher health premiums to strengthen Obamacare insurers

By Jacquie Lee and Jayne O’Donnell
USA TODAY, October 19, 2016

State insurance regulators across the country have approved health care premium increases higher than those requested by insurers, despite a national effort to keep rates for policies sold on Affordable Care Act exchanges from skyrocketing, a USA TODAY analysis shows.

This year may be the last for dramatic premium increases as insurers now understand their new markets better, say some supporters of the law, including the head of the Centers for Medicare and Medicaid Services (CMS).

“The business was underpriced in many markets in the first couple years,” says Andy Slavitt, CMS’ acting administrator. “In retrospect, life would have been a lot better and easier if things had started 10% higher, the rate increases had been higher and it had been just a smooth steady climb.”

“Nobody really knew what it would cost to insure sick people,” Slavitt said. “I don’t know how (anyone) could have known.”

http://www.usatoday.com…

***

Comment:

By Don McCanne, M.D.

Interesting. When the nation is upset about the very high increases in the insurance premiums for plans offered on the insurance exchanges, CMS acting administrator Andy Slavitt says that the insurers should have started with higher premiums, and the annual premium increases should have been greater.

Slavitt says that nobody could have known what it would cost to insure sick people, and, by implication, certainly not even the insurers.

But we, as a nation, are paying an extra half trillion dollars in administrative expenses to maintain our fragmented multi-payer system just to keep the private insurers in control of a major portion of our health care dollars. And their actuaries cannot even figure out how much money they need? Isn’t that fundamental to their business model?

Do we really want to keep on doing this? Or do we want to fill in our gaps in health care with that half trillion dollars? It doesn’t seem to be that difficult of a decision.

Kip Sullivan on the final MACRA rule

The Final Rule

By Kip Sullivan, JD
The Health Care Blog, October 19, 2016

I have read a substantial portion of CMS’s final rule, published last Friday. It is clear to me CMS intends to implement its original rule with only minor changes. I predict the implementation process will be a nightmare.

The most fundamental problem with the rule is its insane complexity. The complexity is a function of both the complexity of medicine and the impossibility of what Congress has asked CMS to do – to measure the cost and quality of physician services at both the individual and group level and to punish and reward doctors based on inaccurate scores, and to oversee the creation of vaguely defined and unproven entities like ACOs and “medical homes” which will also dish out penalties and rewards based on inaccurate data.

Implementing such a monstrously complex law, or even portions of it, would be very difficult even for an agency run by clear thinkers. But CMS is not run by clear thinkers. It is run by people who think like employees of advertising agencies. They think their job is to persuade their listeners that their product is wonderful. They think they are supposed to exaggerate what MACRA will do, and to deny or obfuscate MACRA’s obvious defects.

CMS committed both types of errors – exaggeration and denial – in its first rule, and it committed identical errors in the final rule. At this point I think it’s reasonable to predict that CMS won’t admit either type of error until long after implementation has begun and reality has repeatedly smashed its staff over the head. Of course, by then much time and money will have been wasted, and many patients may have been harmed as well.

I’ll devote the rest of this essay to examining the worst examples of both types of errors – hyping that which should not be hyped, and overlooking that which should not be overlooked. I will close with a comment on how similar MACRA and the Affordable Care Act are. Both laws are already in trouble because they rely on the same bankrupt theory of cost-containment. Their troubles have only just begun.

Republicans and Democrats share the blame for the MACRA mess

In this post I have aimed my criticism at CMS for approaching MACRA with the mindset of a PR agent. CMS deserves harsh criticism because they are not being forthright, and in some cases they have been downright dishonest. [1] CMS’s unwillingness to tell the truth about MACRA does not bode well for its implementation and the ensuing public debate.

But the ultimate blame for MACRA’s nightmarish complexity falls on Congress. Democrats and Republicans voted overwhelmingly for MACRA. How quickly we resolve the mess created by MACRA will depend ultimately on how quickly leaders of both parties understand MACRA’s defects. If both parties engage in some honest introspection, they will at some point realize both parties have subscribed to the same bankrupt theory of cost containment.

http://thehealthcareblog.com…

***

Comment:

By Don McCanne, M.D.

As Kip Sullivan explains, MACRA is bringing us considerable administrative complexity and grief without evidence that it will achieve its goal of containing costs while improving quality. You may want to use the link above to read the rest of his article, including the footnote on CMS not being forthright.

Although MACRA did have strong bipartisan support in Congress, that support was not based on the merits of MIPS (merit-based incentive payment system) and APMs (alternative payment models including ACOs). Rather the support was based on bringing an end to the flawed SGR Medicare payment system that had plagued Congress for a couple of decades. MIPS and APMs were included as a seemingly benign replacement for SGR (sustainable growth rate). It was not benign, as some of us protested, but we were ignored largely for political reasons, as described by Kip Sullivan.

Besides being a flawed model of cost containment, MACRA will absorb much of the energy in health care reform, delaying for perhaps decades a serious consideration of a model of reform that has already been proven to contain costs while improving access and quality and ensuring universality – a single payer national health program. What a shame.

GAO: Misalignment of health care quality measures

By United States Government Accountability Office
Report to Congressional Committees, October 2016

Health Care Quality

HHS Should Set Priorities and Comprehensively Plan Its Efforts to Better Align Health Quality Measures

What GAO Found

While the full extent of misalignment among health care quality measures is unknown, it can have adverse effects on providers and efforts to improve quality of care. Misalignment occurs when health care payers require providers to report on measures that focus on different quality issues or define the measures using different specifications. GAO identified three studies that provided some information on the extent of misalignment. For the most part, these studies examined the number of measures that were used in common, among a narrow selection of public and private payers, and found that with few exceptions, only a small proportion of measures were commonly used by these payers. The Department of Health and Human Services’ (HHS) Centers for Medicare & Medicaid Services (CMS) agrees that misalignment exists, and some experts note that it adds to providers’ administrative burden and often results in quality information that is not comparable.

Factors Driving Misalignment of Health Care Quality Measures

*  Dispersed decision-making:  Among public and private payers and other stakeholders, each entity independently decides which quality measures it will use and which specifications should apply to those measures.

*  Variation in data collection and reporting systems:  Payers may choose different measures, or leave details about measure specifications up to providers in order to accommodate differences in data that providers collect and the systems they use to collect these data.

*  Few meaningful measures:  Although hundreds of quality measures have been developed, relatively few are measures that payers, providers, and other stakeholders agree to adopt, because few are viewed as leading to meaningful improvements in quality.

Conclusions

The use of health care quality measures is central to HHS’s and other payers’ efforts to improve health care quality. While quality measures can encourage improvements in care, they can also be burdensome to providers when the measures are misaligned and providers have to report different quality measures to different health care payers. Such misalignment has the potential to affect the success of HHS’s efforts to pay providers based on the quality of care they provide. HHS has acknowledged the need to substantially improve quality measurement for physicians and other providers, and has a stated goal of improving alignment between federal and private payers.

Although HHS has initiated a range of different efforts to reduce misalignment, we identified two deficiencies in these efforts. First, HHS has not prioritized the development of electronic quality measures with standardized data elements for the core sets of aligned measures. CMS and private payers have prioritized certain quality measures to be used in common so alignment is improved, but HHS has not focused resources on developing electronic quality measures for these quality measures. As providers increasingly use EHRs, HHS has the opportunity to pursue its stated objective to develop electronic quality measures that would allow physicians to collect automatically much of the clinical information needed for these measures as part of their normal clinical workflow, with a consequent decrease in the administrative burden faced by physicians.

Second, CMS has not comprehensively planned its measure development efforts to ensure the development of new, more meaningful quality measures targeted to reduce misalignment, which could jeopardize CMS’s efforts to achieve that goal. Some experts we interviewed told us that the paucity of meaningful measures makes it difficult for payers and providers to agree on aligned measures. In contrast, developing new, more meaningful measures to replace older, less meaningful ones could help to promote further agreement on aligned measures and gain broader support from physicians. However, CMS’s plans do not indicate how its efforts will target new measures that will lead to greater alignment, rather than simply adding to the array of available quality measures that has led to misalignment in the past.

http://www.gao.gov…

***

Comment:

By Don McCanne, M.D.

The mantra today is to pay for quality instead of quantity, and the government and private sector are rapidly moving ahead with administratively burdensome programs to implement this vision. But they left out a step. As this GAO report reveals, they have not developed a program that can adequately measure quality.

Measuring minutia that does not represent even one percent of health care – measures that also are misaligned between the various stakeholders – can hardly give a fair assessment of the quality of health care services delivered. Plans to add more measurements of minutia certainly will not help much.

Yet these almost worthless measurements are adding to the administrative burdens and costs of our health care system while intensifying physician burnout. Further, they are being used to assess financial penalties against the providers, and to shame providers through public reporting of quality ratings. Talk about depressing.

If we want real quality in health care, we need to do it through structural reform. We need to quit listening to Orszag, Emanuel, McClellan, and the others who support simple sound bites rather than effective policy on improving quality. Instead we should move forward with the model presented in a JAMA article over two decades ago: “A Better-Quality Alternative: Single-Payer National Health System Reform” by Gordon Schiff and his working group colleagues. The link:

https://www.pnhp.org…

Prop 61 – California’s Fight Against Outrageous Drug Prices

By Paul Y. Song, M.D.
The Huffington Post, Oct. 14, 2016

In the run up to the Affordable Care Act, the pharmaceutical industry’s annual lobbying efforts steadily increased to a peak of $273 million in 2009. Along with private negotiations between then Pharmaceutical Industry President Billy Tauzin and the White House, the ACA was written without any consideration towards making prescription medications more affordable.

On the contrary, the ACA continued to prohibit Medicare from negotiating drug prices and outlawed the importation of cheaper drugs from Canada or Europe. The pharmaceutical industry also received increased patent protections and as a result drug prices are escalating at a much faster clip today than ever before, becoming the fastest growing aspect of all medical costs.

Sadly, it is the American consumer who continues to pay the highest drug prices in the world.

As state governments from New York to Montana struggle to protect consumers from drug company price-gouging, California is taking a leadership role in these efforts with Proposition 61, the measure on the Nov. 8 ballot to put a cap on prescription drug prices, the leading cause of skyrocketing health care costs.

Seven states have passed laws to ease the burden of drug costs on their citizens by limiting the out-of-pocket payments of patients in private health plans.

Californians have explored reforms to control drug industry price-gouging as spending on prescription drugs has been increasing nationally at a rate twice as fast as overall health care spending.

But even the most temperate reforms have hit a wall of resistance from a drug industry hell-bent on protecting its profits. Look at what happened with Sen. Ed Hernandez’ bill, SB 1010. It simply called for greater transparency in drug pricing. It was gutted so badly by the drug industry’s allies and lobbyists that its author unceremoniously yanked it off the table.

It turns out that the pharmaceutical industry did not become one of the most powerful interests on Capitol Hill or in Sacramento with campaign contributions alone. For every $1 the industry spent on contributions during the last election cycle, $7 were spent on lobbying in 2014. Between 1998 and 2016, the pharmaceutical industry spent over $3.3 billion on lobbying. It is clear that they have a clear interest in maintaining the political status quo.

More ambitious still is Prop. 61, the California Drug Price Relief Act. It has made California ground zero in the fight to control drug prices with the industry planning to spend at least $100 million campaign to defeat Prop. 61 with a barrage of misinformation and fear-mongering.

Prop. 61 is endorsed by Democratic presidential candidate Bernie Sanders, former U.S. Secretary of Labor Robert Reich, the Rev. Al Sharpton and scores of progressive organizations, including the California Nurses Assn., AARP California, the Urban League, the Courage Campaign, and Physicians for a National Health Program CA.

If approved, Prop. 61 would require California state government — as the ultimate buyer of drugs used by approximately 5 million Medi-Cal (aka Medicaid) patients, current and retired state employees and prisoners — to pay no more for drugs than what the U.S. Department of Veterans Affairs (DVA) pays for the same drugs. Typically DVA pays 20-24 percent less than market rate for its drugs. Passage of the law would be – so to speak – a difficult pill for Big Pharma to swallow.

But, not to fear, these companies will continue to reap giant profits as Big Pharma relentlessly prioritizes its profits above all, and its greed will not be easily tamed or shamed. This was recently exemplified by the infamous likes of “Pharma Bro” CEO Martin Shkreli of Turing Laboratories and Heather Bresch, the CEO of Mylan, the EpiPen maker.

As an oncologist, I have personally seen the increased financial burden of out-of-pocket spending on my patients as overall spending on cancer drugs increased by 18 percent in 2015 to $39 billion alone, according to IMS Health, a consulting firm that collects data for the drug industry. And some critical cancer drugs cost 600 times more in the United States than in other industrialized nations.

The drug companies have threatened to make Californians miserable if Prop. 61 wins. If approved, the drug companies warn they will 1) initiate cost-shifting (charging other customers more to make up for the revenues lost in selling to California state government); 2) cut their R&D budgets to make ends meet and thus damage their ability to design a new generation of wonder drugs; and/or 3) boost the prices they charge the DVA to nullify the benefits of the California reform measure.

But California voters should not be intimidated by drug company bullying.

The fact is that when Kaiser which currently insures nearly 25 percent of all Californians uses its marketshare to negotiate drug discounts, it is considered good free market business savvy, but when either Medicare or the state of California attempts to do the same, it is considered government interference.

If there’s going to be price-shifting it will only happen because of drug company greed, not because of drug company need. Big Pharma is rolling in dough and are not going to collapse if some reasonable price controls are enacted in California.

The drug companies’ claim Prop. 61 will force them to slash their R&D budgets to make ends meet is also phony. In fact, drug companies spend less than two percent of their revenues to create new drugs and as much as 80 percent of the cost of basic drug research is taxpayer-funded anyway. Just recently, a new prostate cancer drug called Xtandi, which was discovered using taxpayer-funded grants, was sold by UCLA to big Pharma for over $1 Billion and already costs patients $129,000 a year.

Finally, Big Pharma’s veiled threats to hold veterans hostage to protect itself from Prop. 61 is morally revolting. And it’s an empty threat. Federal law is clear: the drug companies cannot arbitrarily raise the prices they charge DVA. But, in reality, the VA drug formulary is relatively limited and Medicaid-HMOs will not be excluded, so Prop 61 is really more of a small overall step to address our grossly broken system.

So, why are the drug companies so scared and desperate? They understand that the only prescription that can break the stronghold of their lobbying efforts is when citizens bypass their beholden legislators to pass an initiative. Thus they fear passage of Prop. 61 in California will spark a “prairie fire” of reform that will spread across the nation. We hope they are right.

Dr. Paul Y. Song is a physician, healthcare activist, and co-chair of the Campaign for a Healthy California.

http://www.huffingtonpost.com…

Prop 61 – California’s Fight Against Outrageous Drug Prices

By Paul Y. Song, M.D.
The Huffington Post, Oct. 14, 2016

In the run up to the Affordable Care Act, the pharmaceutical industry’s annual lobbying efforts steadily increased to a peak of $273 million in 2009. Along with private negotiations between then Pharmaceutical Industry President Billy Tauzin and the White House, the ACA was written without any consideration towards making prescription medications more affordable.

On the contrary, the ACA continued to prohibit Medicare from negotiating drug prices and outlawed the importation of cheaper drugs from Canada or Europe. The pharmaceutical industry also received increased patent protections and as a result drug prices are escalating at a much faster clip today than ever before, becoming the fastest growing aspect of all medical costs.

Sadly, it is the American consumer who continues to pay the highest drug prices in the world.

As state governments from New York to Montana struggle to protect consumers from drug company price-gouging, California is taking a leadership role in these efforts with Proposition 61, the measure on the Nov. 8 ballot to put a cap on prescription drug prices, the leading cause of skyrocketing health care costs.

Seven states have passed laws to ease the burden of drug costs on their citizens by limiting the out-of-pocket payments of patients in private health plans.

Californians have explored reforms to control drug industry price-gouging as spending on prescription drugs has been increasing nationally at a rate twice as fast as overall health care spending.

But even the most temperate reforms have hit a wall of resistance from a drug industry hell-bent on protecting its profits. Look at what happened with Sen. Ed Hernandez’ bill, SB 1010. It simply called for greater transparency in drug pricing. It was gutted so badly by the drug industry’s allies and lobbyists that its author unceremoniously yanked it off the table.

It turns out that the pharmaceutical industry did not become one of the most powerful interests on Capitol Hill or in Sacramento with campaign contributions alone. For every $1 the industry spent on contributions during the last election cycle, $7 were spent on lobbying in 2014. Between 1998 and 2016, the pharmaceutical industry spent over $3.3 billion on lobbying. It is clear that they have a clear interest in maintaining the political status quo.

More ambitious still is Prop. 61, the California Drug Price Relief Act. It has made California ground zero in the fight to control drug prices with the industry planning to spend at least $100 million campaign to defeat Prop. 61 with a barrage of misinformation and fear-mongering.

Prop. 61 is endorsed by Democratic presidential candidate Bernie Sanders, former U.S. Secretary of Labor Robert Reich, the Rev. Al Sharpton and scores of progressive organizations, including the California Nurses Assn., AARP California, the Urban League, the Courage Campaign, and Physicians for a National Health Program CA.

If approved, Prop. 61 would require California state government — as the ultimate buyer of drugs used by approximately 5 million Medi-Cal (aka Medicaid) patients, current and retired state employees and prisoners — to pay no more for drugs than what the U.S. Department of Veterans Affairs (DVA) pays for the same drugs. Typically DVA pays 20-24 percent less than market rate for its drugs. Passage of the law would be – so to speak – a difficult pill for Big Pharma to swallow.

But, not to fear, these companies will continue to reap giant profits as Big Pharma relentlessly prioritizes its profits above all, and its greed will not be easily tamed or shamed. This was recently exemplified by the infamous likes of “Pharma Bro” CEO Martin Shkreli of Turing Laboratories and Heather Bresch, the CEO of Mylan, the EpiPen maker.

As an oncologist, I have personally seen the increased financial burden of out-of-pocket spending on my patients as overall spending on cancer drugs increased by 18 percent in 2015 to $39 billion alone, according to IMS Health, a consulting firm that collects data for the drug industry. And some critical cancer drugs cost 600 times more in the United States than in other industrialized nations.

The drug companies have threatened to make Californians miserable if Prop. 61 wins. If approved, the drug companies warn they will 1) initiate cost-shifting (charging other customers more to make up for the revenues lost in selling to California state government); 2) cut their R&D budgets to make ends meet and thus damage their ability to design a new generation of wonder drugs; and/or 3) boost the prices they charge the DVA to nullify the benefits of the California reform measure.

But California voters should not be intimidated by drug company bullying.

The fact is that when Kaiser which currently insures nearly 25 percent of all Californians uses its marketshare to negotiate drug discounts, it is considered good free market business savvy, but when either Medicare or the state of California attempts to do the same, it is considered government interference.

If there’s going to be price-shifting it will only happen because of drug company greed, not because of drug company need. Big Pharma is rolling in dough and are not going to collapse if some reasonable price controls are enacted in California.

The drug companies’ claim Prop. 61 will force them to slash their R&D budgets to make ends meet is also phony. In fact, drug companies spend less than two percent of their revenues to create new drugs and as much as 80 percent of the cost of basic drug research is taxpayer-funded anyway. Just recently, a new prostate cancer drug called Xtandi, which was discovered using taxpayer-funded grants, was sold by UCLA to big Pharma for over $1 Billion and already costs patients $129,000 a year.

Finally, Big Pharma’s veiled threats to hold veterans hostage to protect itself from Prop. 61 is morally revolting. And it’s an empty threat. Federal law is clear: the drug companies cannot arbitrarily raise the prices they charge DVA. But, in reality, the VA drug formulary is relatively limited and Medicaid-HMOs will not be excluded, so Prop 61 is really more of a small overall step to address our grossly broken system.

So, why are the drug companies so scared and desperate? They understand that the only prescription that can break the stronghold of their lobbying efforts is when citizens bypass their beholden legislators to pass an initiative. Thus they fear passage of Prop. 61 in California will spark a “prairie fire” of reform that will spread across the nation. We hope they are right.

Dr. Paul Y. Song is a physician, healthcare activist, and co-chair of the Campaign for a Healthy California.

http://www.huffingtonpost.com…

Health professionals’ duty in responding to structural racism

Structural Racism and Supporting Black Lives — The Role of Health Professionals

By Rachel R. Hardeman, Ph.D., M.P.H., Eduardo M. Medina, M.D., M.P.H., and Katy B. Kozhimannil, Ph.D., M.P.A.
The New England Journal of Medicine, October 12, 2016

On July 7, 2016, in our Minneapolis community, Philando Castile was shot and killed by a police officer in the presence of his girlfriend and her 4-year-old daughter. Acknowledging the role of racism in Castile’s death, Minnesota Governor Mark Dayton asked rhetorically, “Would this have happened if those passengers [and] the driver were white? I don’t think it would have.”

Disproportionate use of lethal force by law-enforcement officers against communities of color is not new, but now we increasingly have video evidence of the traumatizing and violent experiences of black Americans. Structural racism — a confluence of institutions, culture, history, ideology, and codified practices that generate and perpetuate inequity among racial and ethnic groups — is the common denominator of the violence that is cutting lives short in the United States.

The term “racism” is rarely used in the medical literature. Most physicians are not explicitly racist and are committed to treating all patients equally. However, they operate in an inherently racist system. Structural racism is insidious, and a large and growing body of literature documents disparate outcomes for different races despite the best efforts of individual health care professionals. If we aim to curtail systematic violence and premature death, clinicians and researchers will have to take an active role in addressing the root cause.

Structural racism, the systems-level factors related to, yet distinct from, interpersonal racism, leads to increased rates of premature death and reduced levels of overall health and well-being. Like other epidemics, structural racism is causing widespread suffering, not only for black people and other communities of color but for our society as a whole. It is a threat to the physical, emotional, and social well-being of every person in a society that allocates privilege on the basis of race. We believe that as clinicians and researchers, we wield power, privilege, and responsibility for dismantling structural racism — and we have a few recommendations for clinicians and researchers who wish to do so.

First, learn about, understand, and accept the United States’ racist roots.

Second, understand how racism has shaped our narrative about disparities.

Third, define and name racism.

Finally, to provide clinical care and conduct research that contributes to equity, we believe it’s crucial to “center at the margins” — that is, to shift our viewpoint from a majority group’s perspective to that of the marginalized group or groups.

Addressing violence against black communities can start with antiracist practices in clinical care and research. Do we have the courage and conviction to fight to ensure that black lives do indeed matter?

http://www.nejm.org…

***

Comment:

By Don McCanne, M.D.

The authors note that “most physicians are not explicitly racist and are committed to treating all patients equally,” but, importantly, “they operate in an inherently racist system.” Further, “structural racism is insidious, and a large and growing body of literature documents disparate outcomes for different races despite the best efforts of individual health care professionals.”

They state, “If we aim to curtail systematic violence and premature death, clinicians and researchers will have to take an active role in addressing the root cause.” They then offer some useful suggestions on how we might approach structural racism.

But we should go further. In an internal communication, David Himmelstein and Steffie Woolhandler suggest developing “a list of health financing demands related to fighting racism.”

One of the more obvious places to start would be the enactment of a single payer national health program in which financing of health facilities and health care would be equitable.

But reading the comments published by NEJM in response to this article suggest that we have more to do than simply address structural racism. One physician commented, “The NEJM, a formerly highly respected medical journal, has lowered itself to the level of  a political journal that supports people who advocate the murder of policemen… This journal is now a ‘throwaway’.”

Another commenter from Georgia wrote, “K-12 schools need to teach students how to comply with police orders.”

Sadly, the problems are deeper than just structural racism. That will make our task much more difficult. But as health professionals, it is imperative that we join in leading the way toward improving the health of the nation by implementing structural reform that would improve the health of each and everyone of us. These efforts should be disproportionately directed to the greatest problems until we can achieve a truly egalitarian equilibrium.

For more on this very important topic, see the article below:

***

Single-Payer Health Reform: A Step Toward Reducing Structural Racism in Health Care

By Dominic F. Caruso, MD/MPH Candidate, David U. Himmelstein, MD, and Steffie Woolhandler, MD
Harvard Public Health Review, July 20, 2015

https://www.pnhp.org…

Troubled workers’ comp system shows need for single-payer health care

By Johanna Ryan and Anne Scheetz
Fox Valley (Ill.) Labor News, Oct. 7, 2016

In Illinois and around the nation, big business has labeled workers’ compensation a system in crisis. Illinois Gov. Bruce Rauner has depicted it as a millstone around the necks of Illinois employers, who he claims are shelling out too much money to treat injuries that might not even be work-related. Rauner and other Republican governors have made “reforming” workers’ compensation a key part of their pro-business agenda.

However, any worker who has had to use the system lately knows the real “workers’ comp crisis” is too little health care, not too much. In Illinois, as in most states, your employer is required to carry standard workers’ comp insurance. But it’s private companies like Liberty Mutual, Travelers and AIG/Chartis that provide the coverage — and they would much rather pay lawyers to fight your claim than pay doctors to help you get well.

Under the system they’ve created, a worker hurt on the job is actually at higher risk of being denied medical care (or having their treatment cut short) than a worker who falls getting out of the bathtub at home.

We believe the best way to fight the growing attacks on workers’ compensation is to take private insurance companies out of the picture. A public, single-payer health care system, financed by taxes rather than insurance premiums, would accomplish these goals:

  • Eliminate delays and outright denial of care and the resulting long-term adverse effects on workers’ health;
  • Take medical decisions out of the hands of insurance companies and place them where they belong: in the hands of patients and their doctors; and
  • Make prevention the preferred approach to work-related health problems by strengthening our public health infrastructure.

This is the type of health care system workers in almost every other wealthy industrialized nation take for granted. Here in the USA, it has been endorsed by the United Mine Workers, National Nurses United, the Machinists’ Union, Amalgamated Transit Union and many others. Single-payer health care is a pro-active, rather than a reactive, approach to workers’ health. It is an ambitious program, but workers deserve no less.

To get medical care in a workers’ comp case, it’s not enough to show it’s necessary. You must also prove it’s related to a workplace injury. This can be especially hard for “wear-and-tear” injuries like carpal tunnel syndrome or tendonitis, but it can also affect the worker who falls off a ladder or is struck by a forklift.

Private insurers love to litigate these cases – they know it has a chilling effect on the next worker who thinks about filing a claim. So they’re happy to spend several thousand dollars to have you examined by an employer-friendly medical specialist who will declare your work injury was just a “minor strain,” and your current symptoms are due to chronic arthritis, an old football injury or some other cause. No PT for you, pal, and definitely no surgery.

Rauner wants to make the standard for causation even higher, by requiring that an accident at work must be more than 50 percent responsible for an injury compared to all other causes. He also wants the records made by the treating physician — the one who actually knows the patient and who assessed the problem at the time of its occurrence — to count for less, and the opinions of those employer-friendly “independent medical examiners” to count for more.

Such changes taken together would gut workers’ compensation. Employers who are reckless with workers’ health will be even more confident they can get away with it. Workers’ risk of injury will increase, and their access to care and compensation will decrease.

In theory, workers’ comp expenses should give employers an incentive to make the workplace safer. It would be nice if that were the case. Unfortunately, it’s hard to find anyone in the field who believes it. Workers’ comp costs are much like the legal fines and penalties paid by drug companies — just a cost of doing business, which is never big enough to make them change their ways.

Employers are fond of moaning about the high cost of workers’ comp, and make a public scandal out of any individual case of cheating, real or alleged. But the real root of rising costs is litigation, not featherbedding or fraud. Private workers’ comp carriers have made Illinois a happy hunting ground for insurance defense lawyers, even as the number of workers’ comp claims in the past decade has shrunk by more than a third. The changes Rauner proposes would make this much worse.

Take the example of one injured worker we know: A woman who’s been waiting a year and a half for repair of her torn rotator cuff, precisely because of this type of dispute. She now has neck and back problems too, thanks to months of trying to use her trapezius muscles to compensate for her damaged shoulder. Ask any doctor: when she finally gets her surgery, the results will be worse than average on account of all that delay.

A single-payer health care system would cover the care she needed, with no questions asked. Her lawyers could concentrate on fighting to get her disability payments and an eventual cash settlement; we wouldn’t have to to fight over medical care. Our client could at least get her surgery and physical therapy, even if the workers’ comp carrier denied her weekly benefit checks. She could recover and be working a new job while she waited for her shoulder claim to settle.

Relying on workers’ comp claims filed by individuals (or their next of kin) to enforce respect for workplace safety just doesn’t make sense. Would we depend on lawsuits alone to keep poisoned or spoiled foods off the market? Workplace safety, just like food safety, is a public health issue. We need public enforcement bodies, with real power, and with real penalties for violations.

According to an AFL-CIO report, in 2015, Illinois only had enough Occupational Safety and Health Administration (OSHA) inspectors to inspect all job sites only once every 143 years. The average penalty for a fatality investigation, of which there were 56, was $8,553. This clearly falls short of what’s needed to enforce workplace safety standards and protect workers’ lives. (A few states, such as Washington, have public workers’ compensation insurance funds with some limited powers over workplace safety. Unions in Washington strongly support this system. When Liberty Mutual and other private insurers tried to enter the market a few years ago, labor fought the measure through a statewide referendum and won.)

Wouldn’t we all be better off under a single-payer system that guaranteed treatment for any illness or injury, without a legal battle over the cause? Such a system would not only be cheaper, but it would provide better care. There was a time when most specialists welcomed workers’ comp patients. However, given endless payment delays and litigation hassles, those days are fast becoming history.

Instead of seeing the best doctors, too many injured workers have to put up with pro-employer “occupational health” clinics, or third-rate providers who pad their bills with useless charges to compensate for long payment delays.

Imagine if everyone, from janitors to CEOs, carried the same health insurance card! You would choose your own doctors and other care providers. No specialist would turn you away because of the type of insurance you had. You and your doctor – not your employer’s workers’ comp carrier, or any other insurance company, would make decisions about tests, surgery, physical therapy, medical equipment, and other care.

All care would be paid for by progressive taxes, and free at the point of service. Hospitals would not shut down in low-income neighborhoods if the residents had the same high-quality insurance as everyone else. No one would lose their health insurance through leaving a job, going on strike, or for any other reason.

Also, injured workers could get immediate care without having to prove to anyone exactly where, when or how they got hurt.

Workers’ comp lawyers (and we’d still need them) could concentrate on fighting for compensation – and we wouldn’t see clients dropping their claims or settling for pennies because they were desperate for medical care.

A strong public health system, the foundation on which primary care and specialty care must rest in order to be effective, would make protection of workers’ health a high priority.

That’s what a single payer system could offer all of us, union or nonunion. It sounds like a better way to us.

Please sign up as a supporter, persuade your union to do the same, and make sure to get involved.
http://ilsinglepayer.org/

References:
1. Number of Illinois workers’ comp claims
2. Gov. Bruce Rauner’s turn-around agenda
3. Illinois occupational illness and injury statistics

Johanna Ryan is a workers’ comp paralegal and a member of the Illinois Single-Payer Coalition.

Anne Scheetz, MD, a member of Physicians for a National Health Program and a founding member of the Illinois Single-Payer Coalition, cared for many patients with work-related health problems before her retirement from clinical practice.

Originally published in the 9/15/16, 9/22/16, and 9/29/16 print issues of Fox Valley Labor News.

http://foxvalleylabornews.com…

CMS pilot program for judging breadth of narrow networks

How Narrow Is It? Gov’t Begins Test Of Comparison Tool For Health Plan Networks

By Michelle Andrews
Kaiser Health News, October 14, 2016

The incredible shrinking provider network is nothing new in marketplace plans. One way insurers have kept premiums in check on the individual market is by reducing the number of providers available in a plan’s network. Earlier this year, the federal government said that it would introduce a tool this fall to help consumers who are shopping on HealthCare.gov gauge how narrow a plan’s provider network is compared with others in the area.

But most consumers who want that information will have to wait at least another year. The Department of Health and Human Services recently announced that the pilot project to test the network breadth tool just got a little, well, narrower.

Consumers can already check whether specific doctors or hospitals are included in a marketplace plan’s provider network on HealthCare.gov. But there’s currently no way to easily measure the breadth of a plan’s provider network. This can be an important factor for some consumers, especially given the growing number of plans with no out-of-network benefits.

The new tool will designate marketplace health plan networks as “basic,” “standard” or “broad” based on how they compare with other health plan networks in a county. The label will reflect the availability of three types of providers: primary care, pediatricians and hospitals.

Originally, network-breadth information was going to be available for the 35 states on HealthCare.gov, the federally facilitated marketplace. But in August HHS announced it would make the tool available in just six unnamed states.

In September, HHS said it would shrink the pilot still further, to four states — Maine, Ohio, Tennessee and Texas.

Although the tool will let people compare networks in their area, still, “it’s all relative,” (Georgetown Professor Sabrina) Corlette said. “If you’ve got a market where every single network is narrow, this network breadth rating is less useful.”

http://khn.org…

CMS update on the network breadth pilot program:
https://www.cms.gov…

***

Comment:

By Don McCanne, M.D.

One of the major concerns with the implementation of the Affordable Care Act is that many of the exchange plans have narrow to ultra-narrow provider networks. Since it is difficult to determine the breadth of providers included, CMS is providing a network rating system to provide more transparency, as if the problem of narrow networks wasn’t much more serious than simply lack of adequate information.

The fact that the pilot program was pared back suggests that this will not be a simple process. It will be difficult to match a fluctuating provider list with the medical needs of the plan enrollees. Further, since each enrollee has different medical needs, it will be even more difficult to be certain that the needs of each enrollee will be met, even if the enrollees’ preferences are ignored.

Although a recent report suggests that plans with narrow networks have premiums that are about 7 percent lower than plans with broad networks, once most insurers switch to narrow networks, that differential will go away.

But this is typical of CMS. When the problem is that insurers are limiting patients’ choices in their health care, CMS decides that the solution should be to merely tweak the system with more transparency while keeping it intact. The solution needed is to eliminate the restrictive provider list, allowing patient access to the entire health care delivery system.

Patients often choose their plans based primarily on the lowest premium prices. Secondarily they may sometimes check to be certain that their primary care physician is on the list, if they have one. But both of these are flawed policies. Choice of physicians and hospitals should be unlimited (except for providers expelled for reason). Also the entire health care system should be funded automatically through progressive taxes – a much more equitable system with much less wasteful administrative complexity than assigning varying individual premiums for a market of private plans.

Today CMS released the final rule on MIPS and APMs – a major administrative boondoggle if there ever was one. They just don’t get it. When we need real reform, they simply serve us more “garbage salad” (but not the one Trump serves).

PNHP note: Physicians for a National Health Program is a nonpartisan educational organization. It neither supports nor opposes any candidate for public office.

Cutting public employees’ health care is shortsighted

By Anne Scheetz, M.D.
The State Journal-Register, Oct. 12, 2016

Illinois Gov. Bruce Rauner and Chicago Mayor Rahm Emanuel may seem like political adversaries, but they’ve made common cause on at least one issue: public employees’ health insurance.

Unfortunately, they haven’t acted to relieve employees from rising premiums, sky-high deductibles, and unconscionable drug prices.

Instead they’ve sought to diminish workers’ benefits, furthering a trend that began in the private sector and that, unchecked, will end with health care being inaccessible to all but a privileged few.

Rauner wants to double state employees’ share of health care costs, which he calls unaffordable, shifting them from state government to individual workers and their families (who are taxpayers, by the way), ignoring the pain and financial hardship inflicted on people with serious medical needs.

Moreover, the governor’s “turnaround agenda” includes a proposal for changing state law to allow local government units to exclude public workers’ health benefits from collective bargaining entirely.

Given this stance, it is no surprise that Rauner used the Illinois budget impasse as an excuse to threaten to stop, and in some cases even to actually stop for a time, making health benefit payments for state workers, payments to managed-care plans, and payments of the state’s share of health insurance premiums.

Meanwhile, Chicago’s Rahm Emanuel crows that the city “stopped the rise in employee health care costs.” In reality, his administration didn’t eliminate those costs, but shifted them onto workers and retirees.

Emanuel’s plan, like Rauner’s, is divide and conquer: pit taxpayers against public employees, groups of workers against one another, unions against other unions, worker against worker within unions.

The mayor wants newly hired city employees to pay a larger portion of their health care costs than current employees. He wants to push most city retirees onto substandard Obamacare plans. And, he demands “cooperation” from unions as he seeks to degrade their members’ hard-earned health benefits.

In pushing these cuts, Rauner and Emanuel pose as defenders of the taxpayer. Nothing could be further from the truth. Their health policies are part of an agenda of austerity for ordinary people that allows for greater wealth accumulation for the tiny minority of people at the very top.

U.S. health care is too expensive. But the fault lies not with workers, public or private, but rather with our corporatized, for-profit health care system. Consider, for example, the private health insurance industry’s reluctance to pay medical claims (a profit enhancer), the wasteful bureaucracy this afflicts us with, and the profiteering of large pharmaceutical firms (think EpiPen).

While Rauner’s and Emanuel’s bipartisan assault on public employees’ health benefits should be rebuffed, that’s not enough.

To get at the root of the problem we must exclude private health insurance companies from health care, force drug companies to negotiate reasonable prices, and remove corporate profits from the health care equation.

The solution: a nonprofit single-payer health care system. Also known as Improved Medicare for All, such a publicly financed system would slash paperwork, negotiate fair prices for all goods and services, and institute evidence-based cost-control measures.

Studies show that the savings we’d reap from streamlined administration alone would be sufficient to provide everyone with high-quality coverage and eliminate all co-pays and deductibles. And health security would be assured for all workers, public and private.

Other countries do it. By working together, we can do it too.

Dr. Anne Scheetz is a founding member of the Illinois Single-Payer Coalition and a leader of the Illinois chapter of Physicians for a National Health Program. She lives in Chicago.

http://www.sj-r.com…

UnitedHealth absconding with patients’ excessive drug co-payments

Customers sue UnitedHealth over prescription drug co-pay costs

By Brendan Pierson
Reuters, October 5, 2016

UnitedHealth Group Inc has been sued by three customers who accused the largest U.S. health insurer of charging co-payments for prescription drugs that were higher than their actual cost and pocketing the difference.

For example, the lawsuit claims, one class member paid a $50 co-payment for Sprintec, a contraceptive, while UnitedHealth paid the pharmacy only $11.65. The pharmacy was then required to hand the extra $38.85 over to UnitedHealth under its agreement with the insurer, the lawsuit said.

The lawsuit claims that such a co-payment “is not a ‘co-‘ payment for a prescription drug because the insurer is paying nothing,” but is instead “a hidden additional premium.”

The lawsuit says UnitedHealth has hidden this practice from its customers, forcing them to overpay for a wide variety of common, low-cost drugs.

The lawsuit claims UnitedHealth’s co-payments violate the Racketeer Influenced and Corrupt Organizations Act (RICO), a federal law used to target illegal conspiracies, and in some cases also violate a federal law governing employee benefit plans.

http://www.reuters.com…

***

Comment:

By Don McCanne, M.D.

Yesterday’s message described how insurers were using the deductibles to avoid paying anything for covered drugs while collecting a significant proportion of the patient’s payment for the prescription. Today’s shows how UnitedHealth is establishing co-payments much larger than the retail value of many of its authorized prescriptions, then requiring a kickback of the balance of the co-payment. In both instances, the insurer’s net payment for the prescriptions is zero whereas the patient is unknowingly making a generous payment to the insurer. The insurer is collecting additional patient funds in exchange for providing…nothing!

These two examples are not a mere coincidence. They are written into the contracts. They are proof of the ongoing conspiracy of the insurers to cheat their own clients – the patients.

A racketeering lawsuit has now been filed. But that is not enough. We need to expel these rip-off artists from our health care system. We need to replace these leeches with our own dedicated public stewards serving us in a financing system that works for patients instead: Single payer.

Insurers, not ColoradoCare, too big for our own good

By Virginia Gebhart
Daily Camera (Boulder, Colo.), Oct. 13, 2016

You’ve seen the countless ads on TV, sponsored by Coloradans for Coloradans. This is the opening line, “Sometimes too big can be bad.” I agree. I invite you to think about who is too big.

Is it ColoradoCare or is it an insurance company (Anthem, valued at $27 billion) and their pharmacy benefits manager (Express Scripts, valued at $59 billion) who continually, year after year, shift more and more costs to customers while making it harder every year to access care and prescription medication?

My son, Michael, is a liver transplant recipient. He takes anti-rejection medication that is expensive, about $600 per month, retail. Yes, it’s generic. He takes another anti-rejection medication that costs about $20 per month. Any pharmacy in the state of Colorado could fill these prescriptions with a few days’ notice. Yet Express Scripts declares that the expensive medication must be obtained from a specialty pharmacy in the state of Rhode Island. Their specialty seems to be the worst customer service in the history of the profession of pharmacy.

Michael has spent hours and hours and hours on the phone trying to understand and fulfill their requirements for a prior authorization for his anti-rejection medication that he has taken for nearly 10 years and will need to take for the rest of his life. Not surprisingly, it’s only the expensive medication that requires a prior authorization and procurement through a specialty pharmacy. His co-pays go up every year. Suddenly this year, he gets only a 30-day supply, so he pays the co-pays monthly, not every three months as in the past. Early this year, the co-pay was $80 per month for his expensive medication. Suddenly in August the co-pay became $500 per month. We don’t really know why and neither do the pharmacists at the specialty pharmacy. Michael got them to admit it was a mistake in August, but they charged the same $500 again in September. So apparently he’ll have to spend hours on the phone each month to get them to charge the correct co-pay.

Or not. Maybe he’ll just have to pay $500 each month going forward. He would have a rejection episode if he stopped taking his medication. At best, he’d land in the hospital, which would cost many thousands of dollars. At worst, he’d die. Who knows what he will have to pay next year? We know his insurance premiums will go up about 25 percent, but we don’t know what his deductible will be, nor his prescription co-pays.

Michael can’t understand why his insurance company makes it harder and harder each year to get his prescriptions filled. As a retired pharmacist, I understand very well. Insurance companies and pharmacy benefit managers have been shifting more and more costs to their customers for over 30 years. It gets worse and worse every year. I explained to Michael that there are two reasons for these immoral business practices which ought to be illegal. The first reason is that they know that as customers must pay more and more for their medications and the process for filling prescriptions in network (i.e. mail order) becomes more and more onerous, people will give up and just go to their neighborhood out-of-network pharmacy to fill prescriptions and pay full price out of pocket.

The second reason is that they are trying to drive him away. They hope he will get fed up with Anthem and search for a different insurance company, hoping for better coverage and service elsewhere. They don’t want him for a customer. However, Michael has learned that the pharmacy benefit managers like Express Scripts who command huge market share across the country are racing to the bottom together to provide the same inadequate coverage and terrible service to customers like Michael who have the bad manners to actually need health care and medication.

So you tell me, who is too big? Is it ColoradoCare, which will have the ability to shift away from perverse incentives that result in inadequate coverage and terrible service? Or is it Anthem (CEO compensation in 2015 was $13.6 million) and Express Scripts (CEO compensation in 2015 was $14.8 million)? Is it ColoradoCare that is too big, or is it Anthem, which has donated $1 million to defeating ColoradoCare?

Virginia Gebhart lives in unincorporated Boulder County.

http://www.dailycamera.com…