PNHP

We still know little about accountable care

We still know little about accountable care

Moving Forward With Accountable Care Organizations

By Carrie H. Colla, PhD; Elliott S. Fisher, MD, MPH
JAMA Internal Medicine, February 13, 2017

During the past 4 years, we have made great strides in advancing our understanding of the changes that hospitals and physician groups implement in response to changes in payment and how providers perform under alternative payment models. Accountable care organization contracts, one type of alternative payment model, hold groups of health care professionals responsible for the cost and quality of care delivered to patients. Accountable care organization programs attract a diverse array of providers with differing legal and governance structures, varied contracts, and mixed capabilities that span service dimensions. These capabilities may include care management personnel and programs, adoption of advanced analytics (eg, to estimate the risk of hospitalization), or support for shared decision making. On average, ACO patients are spending modestly less on health care services and are associated with improved patient satisfaction and other patient-reported measures, with gains often concentrated in high-need, high-cost populations. Previous exposure to risk-bearing contracts, greater numbers of dually eligible or disabled patients, and higher initial financial benchmarks have been associated with greater savings. At the same time, these results mask variation in performance, with some ACOs saving while others spend over their benchmark following ACO formation. In addition, these modest savings have come at a net cost to the Medicare program (both program costs and shared savings rewards) and, although some quality measures have improved, many have not.

The research presented in this issue of JAMA Internal Medicine provides insights from 3 different ACO payment models: the Medicare Shared Savings Program (MSSP), Colorado’s Accountable Care Collaborative, and Oregon’s Coordinated Care Organizations. All 3 programs show some degree of success, although the results continue to be modest in magnitude.

These findings are relevant to 3 major considerations facing policymakers: (1) concerns about the harms of consolidation, (2) the amount of risk bearing needed to produce changes in behavior, and (3) how to manage potential conflicts between alternative payment models.

Consolidation between clinical providers, such as purchase of physician groups by hospital systems, and striking the proper balance between facilitating clinical integration and limiting market power is a major concern. Many believe that continued survival of independent practices is critical, yet economic incentives favor consolidation due to higher reimbursement for the same service in a hospital-based office compared with a physician office. Hospital-physician group consolidation can also raise prices in less-competitive commercial markets through increased bargaining power vis-à-vis insurers.

Accountable care organizations are defined by their accountability for the cost and quality of care, but the degree of accountability for spending varies dramatically across contracts. The amount of financial risk bearing necessary to achieve behavior change is an important area of inquiry, in part because so little is known. The incentives in most existing alternative payment models, including ACOs, are commonly considered insufficient to result in behavior change.

A third issue concerns potential conflicts between Medicare alternative payment models and the poorly understood interplay of incentives across these reforms. Currently, hospitals retain savings within inpatient-initiated bundles for patients attributed to an MSSP ACO. Although incentivizing value within a bundle, bundled payment models do not eliminate the incentive to provide more bundles. As the Centers for Medicare & Medicaid Services expands alternative payment models, it is possible that bundled payment programs will undermine overall savings.

In summary, we still have much to learn. Accountable care organizations have been established across diverse market settings, using a multitude of organizational structures and approaches to governance and operations, and this heterogeneity is reflected in the heterogeneity of their performance. The 2 articles published in this issue add to a growing body of evidence on overall performance, several dimensions of quality, and spending. Nevertheless, we know little about the effects of ACOs on patients’ health and quality of life. Perhaps most important for ACO leaders and the long-term success of these programs, we know little about the key ACO capabilities that are important to ensuring their success in different organizational or market contexts. Although the Centers for Medicare & Medicaid Services has conducted rigorous evaluations of the Pioneer program, generalizable findings tailored to organizational contexts are few. A long-term commitment to alternative payment model evaluation is necessary to ensure effective, sustainable payment and delivery system reform.

http://jamanetwork.com…

***

Comment:

By Don McCanne, M.D.

This lesson on accountable care, from the Dartmouth Institute, shows us that we still have much to learn. The respected authors state that a long-term commitment to alternative payment model evaluation is necessary. In the meantime, “we know little about the key ACO capabilities that are important to ensuring their success in different organizational or market contexts.”

We actually do have quite a bit of information, and it is unimpressive. What we cannot do is to allow a protracted course of many years or decades of studying accountable care to distract us from the urgent need to make changes that will ensure that everyone has affordable access to health care while dramatically reducing the profound administrative waste in our system.

The Affordable Care Act made some improvements, but not nearly enough as witnessed by the tens of millions uninsured and underinsured, by the failure to make health care affordable for too many of us, and by the perpetuation of the costly administrative excesses.

The next phase of reform being undertaken by our current Congress seems to be pending enactment of policies that would make markets work better for insurers but at a cost of leaving patients exposed to excessive out-of-pocket spending. They do not seem to be even pretending that accountability in shifting from volume to value is anything more than rhetoric (and the studies to date suggest this is true).

First things first. Let’s do what really works – enact a single payer national health program, an improved Medicare for all. It is a far better infrastructure to tease out data that might be used to actually improve quality while containing costs. But let’s not stall any longer on enacting the fundamental reform that we really need to make health care affordable for all of us.

A Political Opening for Universal Health Care?

The winner in the fight between keeping Obamacare and rolling it back might be something else entirely

By Vann R. Newkirk II
The Atlantic, Feb. 14, 2017

The Senate confirmed Tom Price as secretary of health and human services at 2 a.m. on Friday. After a contentious confirmation process, the Trump administration and the Republican-controlled Congress had finally installed one of the leading generals in its war on Obamacare in the department that oversees its programs. Price is a titan in the GOP camp that wants to repeal the health law, and is perhaps one of the few Republican lawmakers with both the vision and the experience needed to begin the daunting task.  

But the battlefield under Price’s feet has shifted substantially in the past few weeks. Republicans have splintered, the timeline for repeal has dragged on and on, alternative plans have propagated in the fertile soil of disunion, and some have lost their resolve. And in the turmoil over the fate of Obamacare, the idea of universal health care has emerged as a third way among voters in both parties. The health system the mainstream GOP opposes most is now one some of its voters support—potentially making Price’s task of replacing Obamacare all the more complicated.   

The political appeal of a single-payer, universal health-care system is perhaps best outlined by Jessi Bohon, a high-school teacher who attended a raucous and often angry town hall with Republican Representative Diane Black in Murfreesboro, Tennessee, last week:

Bohon was able to ask Black a question, and she began with a defense of Obamacare. “As a Christian, my whole philosophy in life is pull up the unfortunate,” she said, referencing the law’s individual mandate and how requiring healthy Americans to purchase insurance lowers costs for the sick. But Bohon went a step further in her support of expanding coverage and her criticisms of the private insurers who’ve complicated the law: “Why don’t we expand Medicaid, and have everybody have insurance?” she asked.

It’s possible that Bohon’s question was simply an attempt to ask Black to implement policies that already exist in the Affordable Care Act. States have the option to expand Medicaid to more low-income adults under Obamacare, though Tennessee, among others, has chosen not to accept federal funds to do it. But her query and criticisms of market-based plans raise a broader question: Why rely on private insurers at all?

Senator Bernie Sanders had also made the case for government-run health care in a CNN debate on Obamacare just the night before. Although he was ostensibly brought on to defend the law against interlocutor Senator Ted Cruz’s criticisms, Sanders used his platform to argue for Medicare for all. His strategy was not to forcefully defend the law against critiques from Cruz, CNN, and the audience; rather, he often agreed with Cruz that those critiques were valid. But his solution undercut Cruz’s message of limited government. Why continue a system that relies on premiums at all, Sanders asked—and why continue to enrich insurers that simply cannot be relied upon to act in patients’ best interests?

Although Bohon—a self-identified Hillary Clinton voter—and Sanders certainly represent liberal sensibilities, several polls show that universal coverage is gaining traction among Democratic and Republican voters. A January Pew Research Center survey showed that 60 percent of Americans believe that government “should be responsible for ensuring health-care coverage for all Americans”—the highest mark in nearly a decade—though they are divided on whether government should be the sole provider of insurance. The recent increases nationally in support for universal coverage are mostly attributable to low-income Republicans. Over half of all Republicans surveyed who have family incomes of less than $30,000 agreed with the idea. Twenty-eight percent of all people polled in a recent Gallup survey expressed support for a single-payer system run by the government.

To be sure, the conclusions that can be gleaned from the polling here are a bit murky. Last year, my colleague Olga Khazan explored how support for a single-payer, Medicare-like plan decreases dramatically when such a plan would necessitate tax increases, which it almost certainly would. Also, a Kaiser Family Foundation survey from February 2016 showed that the label matters as well. Over 70 percent of Americans support Sanders’s “Medicare for all” plan. But they weren’t as enthusiastic about “universal health care” or “single-payer” health care. Although there are some real potential differences in these concepts that voters might be responding to—the term “universal health care” doesn’t specify financing or delivery, and “single-payer” doesn’t specify how the scheme is actually administered—the KFF poll potentially illustrates that there are barriers to understanding whether the public actually wants and understands a universal health-care system.

Still, the upswing in support for the government provision of health care among low-income Republicans provides a real opportunity for politicians in both parties. Trump himself once promised to implement “insurance for everybody.” Though it’s easy to view that one-time vow as fluff or a misunderstanding of his own party line, it could be a lifeline for Republicans facing revolts back home in poor districts where constituents are fearful of losing their insurance coverage. An Obamacare replacement with an expanded public-insurance system would follow through on promises to repeal the ACA. And it could also replace an unstable and weakening exchange system—dominated by reviled insurance companies—with Medicare or state-branded Medicaid programs like Kentucky’s Kynect, which tend to be widely trusted.

That route might be too far-fetched or expensive for Republicans to pursue en masse. Although their current repeal plan might bend Republican rules on passing legislation that increases the deficit, demolishing or controlling health-care markets and extending tax-funded insurance would be outright heresy against the party line. The resistance to such an idea in the health-care industry, and among its lobbyists, might threaten Republicans in Congress who rebel, thereby reinforcing the market-based status quo.

But it’s not too far-fetched for Democrats, who could, by embracing universal coverage, force Republicans to at least consider altering the party line. Democrats don’t face the same political risks with health care as Republicans do, not only because universal health care exists within liberal theory of government, but because a Republican-dominated Congress effectively renders many of their platforms, votes, and draft bills symbolic. The same dynamic in reverse created the anti-Obamacare fervor among congressional Republicans in the first place, and has been one of the largest factors in the GOP’s electoral strength since 2010.

Were they to take the plunge, Democratic candidates could run as challengers in upcoming elections on a third way of health reform: neither extending unpopular pieces of a program nor rolling back coverage, but giving everyone Medicare. And if the Democratic Party were to support universal health care, that might put pressure on Republicans, who wouldn’t want to lose voters who fear loss of coverage or doctors under a massive repeal.

Thus the precariousness of the Republicans’ position. With Price atop the national public-health system and already empowered by an executive order from the White House, Republicans in the executive branch and Congress have run out of excuses to do the job they came to do. But they face an ever-mobilizing opposition that extends across both parties, and immediate decisive action carries significant risks of causing a conflagration if people lose coverage. Paradoxically, delays give more time for the party to splinter and lose momentum, and for the idea of universal care to take root as a viable alternative as the stresses of an unfixed existing system mount. For at least some Republicans, that option might now be the most attractive now.

https://www.theatlantic.com…

Republicans are now supporting the private insurers in the exchanges

Republicans, Aiming to Kill Health Law, Also Work to Shore It Up

By Robert Pear
The New York Times, February 12, 2017

After denouncing the Affordable Care Act as an abomination for seven years, Republicans in Congress, working with the Trump administration, are urgently seeking ways to shore up health insurance marketplaces created by the law.

While President Trump said as a candidate that “Obamacare is certain to collapse of its own weight,” Republicans fear such an outcome because, now that the fate of the health law is in their hands, they could be blamed by consumers and Democrats.

The administration is poised to issue a proposed regulation to try to stabilize insurance markets, and House Republicans are drafting legislation with a similar purpose. The regulation and the bills are intended to hold down insurance premiums and to lure insurers back into the public marketplaces from which they have withdrawn in the past couple of years.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

There could not be better evidence that the Republicans never did have an effective plan to replace the Affordable Care Act than the fact that they are now advancing legislation to protect the private insurers in the ACA exchanges – reinforcing them rather than shutting them down.

So their strategy has changed from repeal and replace, and then to repeal and repair, and now simply to repair – repair that will protect the private insurers.

Many of the legislators are facing angry citizens at their town hall meetings who do not want to lose the health care benefits that they may have gained through ACA. That partially explains why they failed to deliver on their promise to “repeal Obamacare on day one.”

Many voters were supportive of repeal and replace, but the politicians and the voters had different objectives. The Republican politicians wanted to repeal the expansions of ACA and thereby reduce government spending on health care. Voters wanted changes (replacement) that would ensure that they could always receive health care that was affordable.

Considering this, it is understandable why the Republicans have not moved immediately forward with their replacement proposals. Reducing Medicaid funding through block grants would cause millions to lose their coverage. Switching Medicare to a voucher program would create greater financial burdens for Medicare beneficiaries. Changing market rules to promote bare-bones private plans is the Republican version of providing “access,” but that would make actual health care truly unaffordable for a majority of Americans with significant medical needs because the very high out-of-pocket expenses would be beyond the capabilities of most American family budgets.

The simmering anger is because ACA was inadequate for too many Americans, and it appears that the Republican “replace” proposals will leave millions worse off. The “replace” that people want is affordable health care, but not merely a continuation of the inadequate policies of the Affordable Care Act. What they really want, though some do not realize it, is an equitably funded, universal health insurance program – an improved Medicare for all. That would give all of us affordable access to health care, and not just access to nearly worthless private health plans.

Progressives will never give up dream of a healthcare system that is fair

By Linda DeFeo, M.D.
Cape Gazette (Lewes, Del.), Feb. 13, 2017

Mark Twain is quoted as saying “there are lies, damned lies and statistics,” although these days we could say there are facts and alternative facts.

As a retired emergency physician who worked in underserved city hospitals, I can say one of the points Mr. Beveridge makes is correct. When patients come to the ER we must by law see them without asking how they will pay. We do bill them later and, as he stated, we frequently do not get paid; how can someone pay a huge bill when they couldn’t afford health insurance to begin with? Having spent the last 20 years of my career in Maryland, I was sad that their all-payer system was not talked about more during the primaries (go to https://innovation.cms.gov/initiatives/Maryland-All-Payer-Model/ for more information).

He speaks of Sen. Sanders, and others’ idea of expanding to a Medicare for all system, slaps the dreaded socialized medicine label on it, and warns of the cost. Currently FICA withholding is 12.4 percent total split between employer/employee for Social Security and 2.9 percent total for Medicare. He then calculates that expanding Medicare would increase that deduction to 30 percent. I don’t know how he came up with that figure, or if it is correct, but let’s look at some of the factors he has not addressed.

The United States spends $9,403 per capita for healthcare compared to $5,292 for Canada and $817 for Cuba (http://data.worldbank.org/indicator). Are we getting our money’s worth? While we’re at it, can anyone explain how you take seniors, who we all agree are high resource consumers, from the Medicare system with a 4 percent overhead and put them into for-profit private insurance with a 12 percent overhead and save money? (Check out https://oig.hhs.gov/reports-and-publications/hcfac/index.asp for information about Medicare fraud.)

But I digress.

He suggests that while healthcare services would be available to all, you might have to wait a little longer for certain kinds of specialists. Where is his evidence that this leads to poorer outcomes? Comparing infant and child mortality rates and life expectancy statistics (2014 data from WHO) you find that the first two measures are actually lower in both Cuba and Canada than the United States, and that longevity is very similar, with them living just a bit longer than us.

His next point is that doctors will be employees of the government. That may be true in Cuba, but not Canada. Go to the Library of Congress website (if it hasn’t been taken down this week) (http://www.loc.gov/law/help/medical-malpractice-liability/canada.php) for an overview of the Canadian system.

He also suggests that doctors will not go to medical school if they will only earn as much as a mechanic. I don’t know about him, but I value my mechanics very much and hope they are well paid, however, most of us don’t go to medical school to become wealthy. If, as in Canada and Cuba, the cost of schooling combined with a less litigious society were in place here, it wouldn’t cost as much for us to train or pay malpractice insurance (a whole separate article can be written about defensive medicine) so we wouldn’t need to make as much money.

His last comments seem to suggest that if we get rid of Obamacare we will somehow fix long ER waits. I have no idea how he thinks that will happen. Repealing the ACA will increase the number of uninsured patients who then have no option except the emergency room. Every time I hear someone say “the American people know how to spend their healthcare dollars” I cringe. How can they possibly know how to navigate a system so complex? When your child or loved one is ill, do you ask who can help me for the lowest cost, or who is the best choice to help me, damn the cost?

Mr. Beveridge, you are correct. We progressives will never give up our dream of a healthcare system that is fair, efficient and available to all Americans.

Dr. Linda DeFeo resides in Lewes.

http://www.capegazette.com…

Tom Price as HHS Secretary: A Disaster for U.S. Health Care

By Dr. Carol Paris
Common Dreams, Feb. 11, 2017

The Senate’s vote to confirm Rep. Tom Price, R-Ga., as secretary of health and human services, while widely expected, should set off national alarm bells.

Price’s congressional track record, combined with his extensive health-policy paper trail, have shown him to be unabashedly pro-big-business and contemptuous of human needs – particularly when it comes to women’s and poor people’s needs. But the damage he will be able to do as HHS secretary will go far beyond that.

His appointment to the helm of HHS means he is now poised to wreak havoc on our already dysfunctional health care system, jeopardizing the lives of additional millions of Americans who desperately require medical care but can’t afford to get it.

Consider Price’s hostility to traditional Medicare, one of our nation’s most beloved social insurance programs. Together with Speaker Paul Ryan, R-Wis., Price has pushed for “premium support,” i.e. vouchers, whereby seniors would exchange their guaranteed health coverage under traditional Medicare (which they’ve paid into throughout their working lives) for a lump sum of money to go out shopping for a health policy on the private insurance market.

Can you imagine the chaos such vouchers would create among millions of seniors and their families? How much more precarious their health care – even their survival – would become?

“Premium support” is an underhanded prescription for the dismantlement – the destruction – of traditional Medicare. It would be the beginning of the end. The implementation of such a scheme would sharply increase out-of-pocket costs of our nation’s seniors and severely disabled, some of the most vulnerable parts of our population, even as it would bolster the profits (and CEO salaries) at the private health insurance, Big Pharma, and financial services industries.

Or take Price’s views on Medicaid. Much like President Trump’s nominee to head the Centers for Medicare and Medicaid Services, Seem Verma, has done, Price would embrace the conversion of today’s Medicaid program into federal block grants to the states. These block grants would give state governments wide latitude on how to use the money, opening the door to greater patient cost sharing among the poor (introducing copays, deductibles, or work requirements), even as it would enhance the already egregious profiteering by parasitic private Medicaid managed care companies.

Family planning? Price has displayed unconcealed hostility to women’s reproductive health, and his new position will allow him to literally place the health of millions of women at risk. His extreme views include opposition to abortion under almost all circumstances, a preference for “religious freedom” over access to contraception, and an obsession with eliminating federal funding for Planned Parenthood.

According to this week’s Monmouth University poll, Americans’ top worry today is with their mounting health care costs, more so than their job security, taxes or other household bills. With Price at the helm of HHS, this worry will mushroom.

I could go on – his unbridled animus toward LGBTQ rights, his fascination with discredited policies such as high-deductible health plans and allowing private insurers to sell policies across state lines, the threat he poses to our safety-net hospitals, etc. – but you get the picture.

Make no mistake: if Price’s policies are carried out, he will make an already bad system much worse. Research shows that repealing the Affordable Care Act, a cause for which Price has been a primary standard-bearer in the House, would likely result in 43,000 excess, preventable deaths.

In short, Price’s confirmation vote on Friday was a body blow to our nation’s health and welfare.

This is precisely the wrong direction we should be taking in health care. Rather than augmenting the power and profits of the medical-industrial complex (which, by the way, Price has a distinct affinity for), and cutting back on our people’s access to health care, we should be expanding high-quality care to one and all.

What we need to do – now more than ever – is to replace our fragmented dysfunctional system of health care with a streamlined, single-payer, Medicare-for-All system. The savings we’d reap from eliminating the wasteful bureaucracy and paperwork generated by our current multi-payer system – savings now estimated to be $500 billion annually – would be sufficient to cover everyone in the United States and to eliminate all copays and deductibles.

There were those in the 2009 health care debate who said, “Support the Affordable Care Act; it’s the only politically feasible plan; we’ll get to Medicare for All later.” But Congress passed the ACA, and six years later we’re still saddled with the most serious structural deficiencies of a private-health-insurance-based system, including 28 million uninsured. The ACA didn’t get us where we need to be.

Today, there are those who would say that all we should ask for is to retain the ACA. I’m sorry. As a physician, 28 million uninsured is unacceptable. Now is the time to go beyond the ACA, and to replace it with H.R. 676, the Expanded and Improved Medicare for All Act.

Unrealistic, you say? It’s remarkable what millions of people in motion – which is what it will take – can do. What’s truly unrealistic is thinking we can have truly universal care and control costs without a single-payer system.

We can’t afford to delay any longer. Too much is at stake. We have no time to lose.

Dr. Carol Paris is a psychiatrist and president of Physicians for a National Health Program. She was one of the “Baucus 8″ arrested with Dr. Margaret Flowers and others for protesting the absence of representation for single payer universal health care on the Baucus Senate Panel hearings.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License

http://www.commondreams.org…

GOP Docs Rise To Power As Congress Retools Health Care Law

By Phil Galewitz
NPR, Feb. 10, 2017

The confirmation of Tom Price, the orthopedic surgeon-turned-Georgia congressman, as secretary of Health and Human Services on Friday represents the latest victory in the ascendancy of a little-known but powerful group of conservative physicians in Congress — the GOP Doctors Caucus.

During the Obama administration, the caucus regularly sought to overturn the Affordable Care Act, and it’s now expected to play a major role determining the Trump administration’s plans for replacement.

Robert Doherty, a lobbyist for the American College of Physicians, the professional organization for internal medicine doctors, says the GOP Doctors Caucus has gained importance with Republicans’ rise to power. “As political circumstances have changed, they have grown more essential,” Doherty says.

“They will have considerable influence over the discussion on repeal and replace legislation,” he says.

Price’s supporters have touted his medical degree as an important credential for his new position, but Price and the caucus members are hardly representative of America’s physicians in 2017.

The “trust us, we’re doctors” refrain of the caucus obscures its conservative agenda, critics say.

“Their views are driven more by political affiliation,” says Mona Mangat, an allergist-immunologist and chair of Doctors for America, a 16,000-member organization that favors the current health law. “It doesn’t make me feel great. Doctors outside of Congress do not support their views.”

For example, while the American College of Obstetrics and Gynecology has worked to protect access to abortion, the three obstetrician-gynecologists in the 16-member House caucus are anti-abortion and oppose the ACA provision that provides prescription contraception without copays.

While a third of the U.S. medical profession is now female, 15 of the 16 members of the GOP caucus are male, and only eight of them are doctors.

The other eight members are from other health professions, including a registered nurse, a pharmacist and a dentist. The nurse, Rep. Diane Black of Tennessee, is the only woman.

On the Senate side, there are three physicians, all of them Republican and male: Sen. John Barrasso, an orthopedic surgeon from Wyoming; Sen. Bill Cassidy, a gastroenterologist from Louisiana; and Sen. Rand Paul, an ophthalmologist from Kentucky.

While 52 percent of American physicians today identify as Democrats, just two out of the 14 doctors in Congress are Democrats, Reps. Ami Bera and Raul Ruiz, both of California.1

About 55 percent of physicians say they voted for Hillary Clinton and only 26 percent voted for Donald Trump, according to a survey by Medscape in December.

Meanwhile, national surveys show doctors are almost evenly split on support for the health law, mirroring the general public. And a survey published in the New England Journal of Medicine in January found almost half of primary care doctors liked the law, while only 15 percent wanted it repealed.

Rep. Michael Burgess, R-Texas, a caucus member first elected in 2003, is one of the longest serving doctors in Congress. He says the anti-Obamacare Republican physicians do represent the views of the profession.

“Doctors tend to be fairly conservative and are fairly tight with their dollars, and that the vast proportion of doctors in Congress [are] Republican is not an accident,” he says.

Price’s ascendency is in some ways also a triumph for the American Medical Association, which has long sought to beef up its influence over national health policy. Less than 25 percent of practicing physicians are in the AMA, the organization says.

Price is an alumnus of a boot camp the AMA runs in Washington each winter for physicians contemplating a run for office. Price is one of four members of the caucus who went through the candidate school. In December, the AMA immediately endorsed the Price nomination, a move that led thousands of doctors who feared Price would overturn the health law to sign protest petitions.

Even without Price, Congress will have several GOP physicians in leadership spots in both the House and Senate.

Those include Rep. Phil Roe of Tennessee, the caucus co-chair, who also chairs the House Veterans Affairs Committee, and Burgess, who chairs the House Energy and Commerce subcommittee on health. Sen. Cassidy sits on both the Finance and the Health, Education, Labor and Pension Committees. Sen. Barrasso chairs the Senate Republican Policy Committee.

Roe acknowledges that his caucus will have newfound influence. Among his goals in molding an ACA replacement are to kill the requirement that most people buy health insurance (called the individual mandate) as well as to kill the requirement that 10 essential benefits, such as maternity and mental health care, must be in each health plan.

He says the caucus will probably not introduce its own bill, but rather evaluate and support other bills. The caucus could be a kingmaker in that role. “If we came out publicly and said we cannot support this bill, it fails,” Roe says.

The GOP Doctors Caucus has played a prominent role in health matters before.

For example, in 2015, when former House Speaker John Boehner needed help to permanently repeal a Medicare payment formula that threatened physicians with double-digit annual fee cuts, he turned to the GOP Doctors Caucus. It got behind a system to pay doctors based on performance — the so-called “doc fix.”

“When the speaker had a unified doctors’ agreement in his coat pocket, he could go to Minority Leader Nancy Pelosi and show that, and that had a lot to do with how we got this passed,” Roe says.

But not all doctors are unified behind the caucus. Ruiz, one of the two physicians in the House who are Democrats, says he worries because few doctors in Congress are minorities or primary care doctors.

Ruiz, an emergency room physician who was elected in 2012, says he is wary about Price leading HHS because he is concerned Price’s policies would increase the number of Americans without insurance.

Indeed, many doctors feel the caucus’ proposals will not reflect their views — or medical wisdom.

“My general feeling whenever I see any of their names, is that of contempt,” says Don McCanne, a family medicine physician in California who is past president of the Physicians for a National Health Program. “The fact that they all signed on to repeal of ACA while supporting policies that would leave so many worse off demonstrated to me that they did not represent the traditional Hippocratic traditions which place the patient first.”

This story was produced through a collaboration between NPR and Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation. Follow Phil Galewitz on Twitter: @philgalewitz.

http://www.npr.org…

1. Doctors In The 115th Congress

House

Ralph Abraham, R-La., family doctor
Larry Bucshon, R-Ind., heart surgeon
Michael Burgess, R-Texas, ob-gyn
Scott DesJarlais, R-Tenn., family doctor
Neal Dunn R-Fla., urologist
Andy Harris R-Md., anesthesiologist
Roger Marshall, R-Kan., ob-gyn
Phil Roe, R-Tenn., retired ob-gyn
Ami Bera, D-Calif., internal medicine
Raul Ruiz, D-Calif., emergency medicine

Senate

Rand Paul, R-Ky., ophthalmologist
Bill Cassidy, R-La., gastroenterologist
John Barrasso, R-Wyo., orthopedic surgeon

Source: American Medical Association

Tom Price confirmed as HHS Secretary

How the GOP wants to fix health care

By Rep. Tom Price (Confirmed as HHS Secretary at 2:00 a.m. today)
Politico, July 30, 2009

I can attest that nothing has had a greater negative effect on the delivery of health care than the federal government’s intrusion into medicine through Medicare.

http://www.politico.com…

***

Comment:

By Don McCanne, M.D.

Man your stations.

Price’s confirmation is body blow to nation’s health: physician leader

FOR IMMEDIATE RELEASE, February 10, 2017
Contact: Mark Almberg, communications director, Physicians for a National Health Program, mark@pnhp.org, (312) 782-6006

Dr. Carol Paris of Nashville, Tenn., is president of Physicians for a National Health Program (www.pnhp.org). This morning, in response to the Senate’s vote to confirm Rep. Tom Price, R-Ga., as secretary of health and human services, Dr. Paris said the following:

“The Senate’s confirmation of Tom Price as health secretary is a body blow to the health and welfare of all Americans. According to this week’s Monmouth University poll, Americans’ top concern today is with their mounting health care costs, more so than their job security, taxes or other household bills. With Price at the helm of HHS, this concern is only going to escalate.

“Price’s vision for reforming U.S. health care would result in millions of Americans losing their existing health insurance coverage, and millions more having to make do with bare-bones policies that offer little to no meaningful protection. He can also be expected to push high-deductible health plans, which already result in millions of people forgoing needed care, and to undermine Medicare, the Medicaid program and safety-net hospitals.

“If Price’s policies come to pass, the free-market ideologues who supported them will no longer be able to hide behind false promises like ‘universal access.’ The results will be laid bare for everyone to see, and elected officials will have to answer to the poor, working-class, elderly, and chronically ill Americans who will suffer needlessly as a result. Studies show that about 43,000 people will die each year if such policies are implemented.

“Congress urgently needs to reverse course and embrace the obvious solution: an improved Medicare for all.”

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization of more than 20,000 doctors who support single-payer national health insurance. It was founded in 1986. For more on PNHP’s assessment of Tom Price, click here.

Health care is top concern of American families

3-in-10 struggling to maintain current financial situation

Monmouth University Polling Institute, February 7, 2017

Paying for health care has emerged as the top concern of American families, according to the latest national Monmouth University Poll. Two years ago this concern was clustered with job security and other household bills as causing the most anxiety for American households.

Currently, 1-in-4 Americans (25%) report that the cost of health care is the biggest concern facing their family right now. Two years ago, 15% reported this as their family’s primary concern. Anxiety about meeting health care costs now outpaces job and unemployment worries (14%) as well as concerns about paying everyday household bills (12%). Health care is the top concern of American families regardless of income level or partisan identity. A variety of other concerns register in the single digits, such as school costs (4%) and taxes (4%).

“The top three concerns were clustered together just two years ago. Now, health care has jumped to the top of the list as Americans grapple with balancing their household budgets,” said Patrick Murray, director of the independent Monmouth University Polling Institute in West Long Branch, New Jersey. “It’s also worth noting that issues that have been dominating the news, such as immigration and national security, rank very low on the list of items that keep Americans up at night.”

19. Turning to issues closer to home, what is the biggest concern facing your family right now? [LIST WAS NOT READ]

25% – Health care costs

14% – Job security, unemployment

12% – Everyday bills, groceries, etc.

4% – College tuition, school costs

4% – Taxes

3% – Housing, mortgage, rent

3% – Social Security, seniors

3% – Family illness, health

3% – The economy

3% – Safety, crime

3% – Immigration

3% – Civil rights

2% – Retirement saving

2% – Terrorism, national security

1% – Quality of government

1% – Education policy

1% – Trump as president

1% – Climate change, environment

2% – Other

10% – Don’t know/No answer

https://www.monmouth.edu…

***

Comment:

By Don McCanne, M.D.

Without being given a list of choices, when asked “what is the biggest concern facing your family right now,” the most common response was “health care costs” (25%). That places this concern well in front of job security (14%) and household bills (12%) with which it was tied two years ago. Although the improvement in the economy has reduced other concerns, health care has become the top concern of American families.

Although the Affordable Care Act did bring improvements, concerns have not been allayed. As the Republicans fumble around with their rhetoric of “replace,” “repair,” and “access,” it becomes ever more clear that they do not have a program that will reduce the health cost burden on most American families. In fact, many of the policies they support will increase the financial burden on individuals and families.

House Speaker Paul Ryan says that they will have a proposal in place by the end of next month. We know that the policies under consideration will not provide individuals with relief from the high costs of health care.

Since health costs are the number one concern of Americans, it is imperative that we intensify our message that the current financing system, even with the Republican tweaks, will leave the public vulnerable to high health care costs. But we have an answer! A well designed single payer national health program – an improved Medicare for all – will ensure that everyone has access to all essential health care services without being burdened by unaffordable premiums or out-of-pocket costs.

For those who would benefit from an elevator speech:  We can pay for it by reducing the profound administrative waste of our fragmented, multi-payer system (the waste of private insurers and the burden they place on the system); we can each afford it by funding the system through equitable tax policies (contributing based on ability to pay), and we can eliminate the perversities of high deductibles and narrow provider networks, eliminating surprise bills while giving us free choices of our health care professionals and hospitals.

Let’s get the word out ASAP. Congress is getting ready to move!

Few poor or minority patients in New York City’s academic hospitals

By Lisa Rapaport
Reuters, Feb. 9, 2017

(Reuters Health) – Black patients are half as likely as white patients to get care at academic medical centers in New York City even after accounting for differences in health insurance, a recent study suggests.

Compared to privately insured patients, people with coverage through Medicaid, the government health program for the poor, are three times less likely to receive treatment at these elite New York hospitals, the study also found. Uninsured patients are five times less likely to get care at academic hospitals.

“Academic medical centers are generally better able to provide highly specialized care for patients with complex or rare illnesses,” said lead study author Roosa Sofia Tikkanen, a researcher at the University of Massachusetts Medical School in Worcester who completed the work while at City University of New York School of Public Health at Hunter College.

“Most experts believe unequal access to high-quality health care contributes to disparities in health outcomes,” Tikkanen added by email. “In New York City, life expectancy can differ by up to 10 years between two neighborhoods that are located just six subway stops apart.”

About 18 percent of patients at academic medical centers are black, compared with almost one-third at other hospitals in the city, the analysis of discharge data from 2009 and 2014 found.

At the same time, 22 percent of patients were insured by Medicaid at academic hospitals, compared with 42 percent at other hospitals in the city. And only 1 percent of academic hospital patients were uninsured, compared with 4 percent elsewhere.

While Medicaid and uninsured patients accounted for nearly half of all patients at non-academic hospitals in the city, they made up less than one-quarter of inpatients at academic medical centers. At one-third of academic hospitals, less than 10 percent of patients had Medicaid or were uninsured.

To see how race, ethnicity and payer status affect the likelihood of being treated at an academic medical center, researchers analyzed data on adults discharged from hospitals in New York City in 2009 and 2014, and they also looked at similar data for Boston hospitals in 2009.

In Boston, uninsured and Medicaid patients were just as likely to be treated at academic medical centers as at other hospitals. And racial and ethnic minorities were slightly overrepresented at academic hospitals.

It’s possible some of the differences between the two cities might be explained by the extensive public hospital network in New York, the authors note in the International Journal of Health Services.

All of the academic medical centers in Boston and New York are nonprofit hospitals, however, and enjoy tax exemptions worth tens of millions of dollars, the researchers point out. In exchange, they are expected to provide community benefits, including caring for Medicaid and uninsured patients.

One limitation of the study is that researchers didn’t account for patients’ diagnoses or severity of illnesses, which could influence which hospital they went to for care, the authors add. The analysis of two cities also might not reflect what happens in other communities.

The study also didn’t examine the role of residential segregation or neighborhood poverty on use of academic medical centers, noted Asal Mohamadi Johnson, a public health researcher at Stetson University in Florida who wasn’t involved in the study.

“The issue of equity and fairness is at stake here,” Johnson said by email. “Academic medical centers should be held to higher levels of ethical standards in providing care for low income and minority patients.”

When there are disparities in patients’ access to care, academic medical centers may not offer the best possible education to new doctors, Johnson added.

“Active participation of academic medical centers in caring for non-whites and the poor prepares a more qualified and culturally competent generation of physicians and health care providers who will have more familiarity with the unique circumstances and barriers confronting these patients,” Johnson said.

SOURCE: bit.ly/2kvPClc International Journal of Health Services, online February 2, 2017.

http://www.reuters.com…

Single-payer health system: the best solution

By Jessica Schorr Saxe, M.D.
Consumer Reports, Letters, March 2017

Re: “How to Get High-Quality, Low-Cost Healthcare,” January 2017:

Your entire article speaks to the need for a single-payer health system. All the problems you discuss would become obsolete. People would no longer avoid preventive and other necessary care due to anticipated expense. They would not need to invest time in comparison shopping, waste valuable time at doctor appointments discussing costs, schedule needed care around paying off deductibles, nor worry about in-network care (which can be difficult due to narrow, changing, or misleading networks). Other developed nations have some form of a single-payer system, which provides universal access, lower cost, better outcomes, and more choice than ours. Improving and expanding Medicare would mean that we could actually get health care instead of investing our personal (and collective) energy in strategizing about how to receive care.

Dr. Jessica Schorr Saxe is chair, Health Care Justice, Charlotte, N.C.

http://www.consumerreports.org…

Can high deductibles save money if the patient-consumer is informed?

I’ve put my family on a health insurance experiment. It’s been a challenge

By Ashish Jha
STAT, February 6, 2017

Enrollment in high-deductible health insurance plans has exploded over the past five years. I’m learning the hard way how these plans do — and do not — work.

About one-third of American workers covered by health insurance are now in high-deductible health plans, in which the policy holder pays a substantial portion of the cost of health care services out of pocket before insurance coverage kicks in. Many economists and health policy experts believe that these plans are a promising way to reduce health care spending.

So when a high-deductible plan became available through my employer, Harvard University, a couple years ago, I decided to enroll my family in it. If this is going to be a big national experiment, I thought that I, as a physician and a health policy scholar, ought to know what it’s like to live with this kind of health insurance. Debra, my wife, was not convinced.

My family is now in its second year under a high-deductible plan. That means we are responsible for paying the first $6,000 of our health expenses for the year, for everything from a doctor visit for a flu shot to surgery.

It has been an educational enterprise.

Our experiment is showing me again and again that it’s extremely hard to be a health care consumer in Massachusetts — just as I’m sure it is in other states. Want to know how much a particular type of health care costs, like a visit to a specialist or getting a minor surgery? Good luck figuring it out. My insurance company’s online tool was hard to use and, even as a physician, I could almost never guess what sets of services a visit to the doctor might generate.

The second lesson was that being a health care consumer is stressful, at least the way the system is currently set up. Here’s an example. Our son had surgery last year. We got a call saying it was time for his one-year follow-up. Deb stressed for nearly two months over whether or not to make the appointment. Of course she wants our son to get the care he needs, but did he truly need this follow-up? That’s both the promise and the peril of high-deductible plans — they are supposed to make you think twice about consuming health care.

She eventually went with our son for his one-year follow-up — they spent two minutes with the surgeon — and paid $465 for the visit. I’m not sure my son, or my spouse, felt any better afterward. There were many examples like this sprinkled throughout the year, but the most profound one was the one I experienced for myself.

I have supraventricular tachycardia, a common heart rhythm problem. When it hits, my heart races at about 180 beats per minute. It comes on a couple of times a year, lasts a few minutes, and usually isn’t a big deal. But one morning I woke up with my heart racing. After 30 minutes, I wondered if I should go to the emergency department, knowing that I’d probably get stuck with a multi-thousand-dollar bill. So I kept waiting. After an hour, during which my heart kept beating furiously, my chest started to hurt. I knew what that meant — I was at risk of having a heart attack.

Deb asked me what I would tell a patient in this situation. That was easy: I’d tell him or her to call 911. But I kept waiting. Finally, about 15 minutes later, the abnormal rhythm finally broke and I felt my heart calm down. I was lucky — I had rolled the dice and things had worked out.

If we continue with high-deductible health plans the way they exist today, more and more people will experience what my family did — the stress of having to make medical decisions with little information and few choices. At best, we’ll have a health care system that might save a little money — but at the risk of harming the health of our citizens.

Ashish Jha, MD, is an internist at the VA Boston Healthcare System, and a professor of health policy at the Harvard T.H. Chan School of Public Health.

https://www.statnews.com…

***

Comment:

By Don McCanne, M.D.

There are two potential adverse consequences of requiring high deductibles in health insurance plans. Developing a serious medical problem can expose the individual to financial hardship. Even more serious is that the potential for financial exposure can cause an individual to make a terribly consequential decision in electing to forgo medical care because of the deductible.

Some say that we merely need to provide the patients with adequate information and then patients can make their own informed decisions. That is a fundamental principle in consumer-driven health care. But the rhetoric does not match the real world.

In this instance, a noted physician and professor of health policy, Ashish Jha, made a decision to protect his personal finances even though that decision could have cost him his life! As an optimally informed patient-consumer, he made the wrong decision, even though fortunately he escaped the worst consequences.

Several other nations that cover everyone at a cost much lower than ours are able to provide care with first dollar coverage – no need to use high deductibles in a misguided effort to contain spending. Surely the United States could do the same.