PNHP

Dartmouth devises ACO concept, but then abandons its own

Dartmouth devises ACO concept, but then abandons its own

Dropout by Dartmouth Raises Questions on Health Law Cost-Savings Effort

By Robert Pear
The New York Times, September 10, 2016

In its quest to remake the nation’s health care system, the Obama administration has urged doctors and hospitals to band together to improve care and cut costs, using a model devised by researchers at Dartmouth College.

But Dartmouth itself, facing mounting financial losses in the federal program, has dropped out, raising questions about the future of the new entities known as accountable care organizations, created under the Affordable Care Act.

The entities are in the vanguard of efforts under the health law to move Medicare away from a disjointed fee-for-service system to a new model that rewards doctors who collaborate and coordinate care.

“There’s little in the way of analysis or data about how A.C.O.s did in 2015,” said Dr. Ashish K. Jha, a professor at the Harvard School of Public Health. “The results have not been a home run.”

In addition, he said, “there is little reason to think that A.C.O.s will bend the cost curve in a meaningful way” unless they bear more financial risk, sharing losses as well as savings with the government.

An evaluation for the federal government found that Dartmouth’s accountable care organization had reduced Medicare spending on hospital stays, medical procedures, imaging and tests. And it achieved goals for the quality of care. But it was still subject to financial penalties because it did not meet money-saving benchmarks set by federal officials.

“We were cutting costs and saving money and then paying a penalty on top of that,” said Dr. Robert A. Greene, an executive vice president of the Dartmouth-Hitchcock health system. “We would have loved to stay in the federal program, but it was just not sustainable.”

Dr. Elliott S. Fisher, the director of the Dartmouth Institute for Health Policy and Clinical Practice, said: “It’s hard to achieve savings if, like Dartmouth, you are a low-cost provider to begin with. I helped design the model of accountable care organizations. So it’s sad that we could not make it work here.”

Dartmouth-Hitchcock is the main teaching hospital for Dartmouth’s medical school, of which the Dartmouth Institute is part.

http://www.nytimes.com/2016/09/11/us/politics/dropout-by-dartmouth-raises-questions-on-health-law-cost-savings-effort.html

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Creating Accountable Care Organizations: The Extended Hospital Medical Staff

By Elliott S. Fisher, Douglas O. Staiger, Julie P.W. Bynum and Daniel J. Gottlieb
Health Affairs, January 2007 (online December 2006)

Abstract

Many current policies and approaches to performance measurement and payment reform focus on individual providers; they risk reinforcing the fragmented care and lack of coordination experienced by patients with serious illness. In this paper we show that Medicare beneficiaries receive most of their care from relatively coherent local delivery systems comprising physicians and the hospitals where they work or admit their patients. Efforts to create accountable care organizations at this level — the extended hospital medical staff — deserve consideration as a potential means of improving the quality and lowering the cost of care.

http://content.healthaffairs.org/content/26/1/w44.abstract

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How does the Affordable Care Act define ACOs?

Comment by Don McCanne, M.D.
Quote of the Day, October 28, 2010

Excerpt

So how do ACOs achieve higher quality and lower cost?

The ACOs are not rewarded monetarily for meeting the quality standards. Their motivation to comply is to avoid being suspended from the program.

Costs are reduced by the shared savings program. A benchmark is established for each ACO “using the most recent available 3 years of per-beneficiary expenditures for parts A and B services for Medicare fee-for-service beneficiaries assigned to the ACO.” If the ACO can provide care for costs below the benchmark, the ACO then shares those savings with HHS. The benchmark is reset at the beginning of each 3 year agreement.

If the costs are above the benchmark, then the fees are still paid as usual, with no adjustments.

Think about this. The incentives continue to promote greater volume. There is no penalty for running the charges up. Is the reward for reducing the volume and intensity of services enough? Since fixed costs for the ACO are relatively unchanged, the reductions in marginal overhead expenses due to reduced volume must be greater than the amount of savings that HHS shares with the ACO in order to come out ahead. Since this is the opposite of “making it up in volume,” it is more likely that net income will be reduced. Further, since the benchmarks are reset every 3 years based on lower utilization, it is very unlikely that that the ACO could continue to ratchet down services to qualify for shared savings.

(A later iteration included penalties for failure to meet savings targets.)

https://www.pnhp.org/news/2010/october/how-does-the-affordable-care-act-define-acos

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Elliott Fisher questions whether ACOs will work

Comment by Don McCanne, M.D.
Quote of the Day, March 28, 2011

Excerpt

Accountable care organizations (ACOs) began as an abstract concept of integrating health care providers into a not-yet-defined entity that would be rewarded for improving quality and reducing costs. Without knowing what they were, Congress included them in the Affordable Care Act (ACA). Dartmouth’s Elliott Fisher, who was one of the first to promote the concept, now says that “there are some really important questions about whether this will work.”

https://www.pnhp.org/news/2011/march/elliott-fisher-questions-whether-acos-will-work

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Comment:

By Don McCanne, M.D.

Elliott Fisher and his colleagues at the Dartmouth Institute are generally credited with introducing in 2006 the concept of the accountable care organization (ACO) – coordinated organizations of hospitals and their extended medical staffs that would improve quality and lower costs (HMO 2.0?). The concept was incorporated into the Affordable Care Act. But by 2011, we should have been concerned when Elliott Fisher said, “there are some really important questions about whether this will work.”

Many doubts have been expressed about this model, and after a decade of fooling around with it, the record can be summed up by Ashish Jha’s understatement, “The results have not been a home run.”

Well it did not work for Dartmouth-Hitchcock in spite of Elliott Fisher’s presence. They dropped out of the program a year ago (though Robert Pear’s article provides much needed transparency on the ACO concept). Fisher said that he helped design the model so it is sad that they couldn’t make it work there. He said that it was hard for Dartmouth-Hitchcock to achieve savings since they were already “a low cost provider.”

But it should not have been a surprise. In a Quote of the Day in 2010 (excerpt above) we explained why, in a “think about this” comment, that the basic concept was fundamentally flawed – the reward for participation being that you would have to give a major portion of your savings to Medicare instead of keeping them as profits (Medicare shared savings).

It’s too bad that Congress didn’t listen to those of us expressing concerns when they included the concept in the Affordable Care Act. Yet acting CMS administrator Andrew Slavitt is moving forward, saying that the current iteration is “like the iPhone 2.” If you read the thousands of pages of rules that CMS is generating, it is clear that this will be a godsend – for those profiting from administrative services, that is.

Abstractions of higher quality and lower costs sound great, but you need proven policy to carry them out. The single payer experiments have already been done, and they work! Even Gail Wilensky says, “Enough demonstrations, already.”

Stronger Rx than Obamacare needed to cover everyone and control costs: physician leader

Citing Census Bureau report that 29 million people were uninsured last year, and noting that rising deductibles and other out-of-pocket expenses are deterring millions of insured Americans from seeking needed care, Dr. Robert Zarr says moving to a single-payer, improved-Medicare-for-all program has never been more urgent

FOR IMMEDIATE RELEASE, Sept. 13, 2016
Contact: Mark Almberg, PNHP communications director, 312-782-6006, mark@pnhp.org

“The Census Bureau’s official estimate that 29 million Americans, including 3.7 million children, still lacked health insurance in 2015, five years after the passage of the Affordable Care Act, starkly illustrates how our inefficient, private-insurance-based system of financing care is fundamentally incapable of providing universal coverage,” said Dr. Robert Zarr, a Washington-based pediatrician who is president of Physicians for a National Health Program.

“The fact that 29 million people remain uninsured – a figure that won’t change much over the next decade, according to the Congressional Budget Office – is totally unacceptable to me as a physician,” he said. “Studies show that lack of insurance is linked to a higher mortality rate. Being uninsured is lethal, and currently leads to tens of thousands of deaths annually.”

Zarr noted that since the ACA’s passage the number of uninsured has fallen by about 41 percent – from about 49 million people in 2010 to 29 million in 2015, with the largest gains among the poor, near-poor, and minorities. He said such gains “can only be welcomed, since research shows that having some kind of coverage is better than none.”

But he said the Census Bureau report shows that new sign-ups dramatically slowed last year, with a decrease in the uninsured rate of only 1.3 percentage points from 2014. Zarr said other research shows that even if all the states that opted out of the ACA’s Medicaid expansion program were to opt in, the overall picture would largely remain the same.

“That tens of millions of people will remain uninsured under our current arrangements is perhaps the most compelling argument for why our nation needs to swiftly adopt a single-payer system, where everyone, without exception, would be covered and get first-dollar coverage for all medically necessary care,” he said. “But it’s by no means the only argument.”

Zarr pointed out that, once again, the Census Bureau report leaves unmentioned the declining quality of health insurance in the United States, or the “hollowing out” of already inadequate insurance, which takes the form of very high deductibles and copays, rising coinsurance rates, and narrow provider networks that restrict patients’ access to care.

“Too many people have skimpy policies that deter them from seeking care when they should get treatment, and that leave them unprotected against financial hardship when illness or injury strikes,” he said. “And their number is growing.”

He said that a 2014 study by the Commonwealth Fund shows that about 31 million people who have health insurance – nearly a quarter of all non-elderly adults – are “underinsured,” or have inadequate coverage based on their income. That’s nearly double the rate in 2003. Of these, 44 percent went without a doctor’s visit, medical test, or prescription due to cost, while 51 percent had problems paying off medical bills.

“For example, today a 40-year-old man earning $25,000 who signed up for a silver plan on the exchange would be eligible for government subsidies, but would still be at risk for $5,000 in copayments and deductibles,” he said. “Or a family of four with an income of about $60,600 could face out-of-pocket costs for copayments and deductibles – after premium payments – as high as $13,700. And these numbers apply to ‘in network’ services only. Out-of-network costs can go much, much higher. Such financial barriers are untenable, economically and morally.”

“The problem has only gotten worse over the past several years,” Zarr said. “Last week the National Center for Health Statistics reported that the percentage of persons under age 65 with private insurance enrolled in a high-deductible health plan increased to 40 percent in the first quarter of 2016, up from 25.3 percent in 2010. This is an alarming proliferation of an insurance model that discourages care-seeking, a model that will lead to much suffering and in too many cases, early death.”

Zarr said the recent announcement by Aetna, UnitedHealth Group, and other insurers of their withdrawals ACA’s marketplaces in many U.S. counties because the enrollees there were unprofitably ill – even as the insurers’ overall profits and stock prices have soared to record highs – shows they cannot be relied upon to fulfill the basic function of protecting patients’ financial security in time of need.

“Whether it be the big private insurers’ increases in premiums, deductibles, and copays, or the skyrocketing costs of medications by Big Pharma – the recent EpiPen price hike is a glaring example, although dramatic increases in the costs of insulin and other life-saving medications have also occurred – it’s clear that our corporatized health industry is bent on maximizing their profits at the expense of our patients’ health,” he said.

“Only a nonprofit, single-payer health care program will cut out the huge bureaucratic waste in our system, freeing up the funds to provide everyone with quality coverage. And a single payer will give us the tools we need to rein in rising costs. That’s why I and thousands of other physicians earlier this year issued a statement calling for a single-payer system.

“Our patients and our economy can’t wait any longer for an effective remedy to our health care woes. The stakes are too high. We need to swiftly move beyond the ACA to a single-payer national health insurance program.”

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Historical state-by-state data on the uninsured from 2012-2015, compiled by PNHP staff from the Census Bureau’s newly published data, can be found here.

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.

Lower-income workers get less health care with HSA-eligible health plans

The Impact of an HSA-Eligible Health Plan on Health Care Services Use and Spending by Worker Income

By Paul Fronstin, Ph.D. and M. Christopher Roebuck, Ph.D.
Employee Benefit Research Institute, Issue Brief, August 2016

This study examines whether there is variation by worker income on how an HSA-eligible health plan affects health care services use and spending. Does the typically flat-dollar gap between a health plan’s deductible and the employer contribution to a health savings account (HSA) have a bigger impact on the use of health care services among lower- income workers than it does for higher-income workers?

The data for this study come from a large employer that offered an HSA-eligible health plan alongside a preferred provider organization (PPO), includes between 150,000 and 200,000 individuals, and covers health care services use and spending over the six-year period from 2009‒2014.

*  The HSA-eligible health plan was associated with a decline in (non-preventive) outpatient office visits for workers at all income levels, but the decline was over twice as large for workers and their dependents with incomes less than $50,000 as compared with those with incomes of at least $100,000. The decline in specialist visits accounted for most of the decline in outpatient office visits among the group of workers with less than $50,000 in income.

*  There was an across-the-board decline in prescription drug fills regardless of worker income.

*  The HSA-eligible health plan was associated with a reduction in various preventive services by worker income.

https://www.ebri.org/pdf/briefspdf/EBRI_IB_425.Aug16.HSAs.pdf

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Comment:

By Don McCanne, M.D.

Yes, this is yet another report that confirms that enrolling in HSA-eligible high-deductible health plans is associated with a decline in physician visits and in high-value preventive services. This negative impact occurs across all income levels but is twice as great amongst lower-income individuals than it is for those with higher incomes.

Yet we continue to see a significant increase in enrollment in high-deductible plans whether or not they are associated with a health savings account. Slowing health care spending by reducing the use of beneficial health care services is not the type of health care policy we should be supporting.

Our current policies are creating more financial barriers to care; they are reducing our choices in our health care professionals; they are increasing administrative waste, and they have have inflamed an epidemic of physician burnout. Yet we continue to let the medical-industrial wonks lead us down this path to the everlasting bonfire.

Hey, aren’t we wonks too? We know a far better path – one that leads to health care nirvana. Why aren’t we doing the leading?

Is it true that 85% do not have to worry about premium increases?

Steve Davis & Robert Laszewski confirm what I’ve been saying all along: Appx. 40% of ACA indy market is OFF EXCHANGE

By Charles Gaba
ACASignups.net, September 6, 2016

For 2 1/2 years, dating back to around February 2014, I’ve been trying to hammer home the importance of the OFF-exchange individual market. Time and time again I’ve been stunned at the seeming blind spot that people who should know better (such as Avik Roy) have regarding the millions of people who are enrolled in fully ACA-compliant policies, but are doing so directly through the carriers themselves. There are a few reasons why people buying individual/family policies would do this, but the most obvious one is simple: If you earn more than 400% of the Federal Poverty Level (around 97,000/year for a family of 4), there’s no reason to jump through the extra hoops of enrolling through HealthCare.Gov or the other various ACA exchanges…because you don’t qualify for federal financial assistance anyway. For whatever reason, however, numerous reporters, pundits and even the HHS Dept. itself keep acting as though this market doesn’t exist.

How many people are we talking about here? Well, back in 2014 I estimated that roughly 8 million people had signed up as of mid-April…almost exactly the same as the 8.02 million who selected QHPs on the ACA exchanges, or about 50% of the total. That 8 million included several million transitional and grandfathered policy enrollees, however, though I wasn’t sure what the breakout was.

By this year, the exchange-based number had grown to around 11.1 million as of March 2016, of course…but the off-exchange number has been tougher to estimate. I’ve generally estimated the total off-exchange indy market at around 8-9 million, with roughly 7-8 million of that consisting of people enrolling in ACA-compliant plans at full price, and another 1-2 million or so enrolled in ACA-noncompliant “grandfathered” or “transitional” policies.

This estimate has been strongly supported by Mark Farrah Associates, which pegs the total individual market in 2016 at around 20.5 million.

Well, today, Robert Laszewski stumbled upon an excellent piece of data diving by a reporter named Steve Davis, in which Davis dug up the broken-out enrollment numbers for a whole mess of Blue Cross carriers nationwide.

The overall picture is quite clear: Roughly 48% (2.3 million) of all individual policies sold by these carriers (Blue Cross only) are subsidized, while another 48% are ACA-compliant but unsubsidized (8% on exchange, 40% off exchange). The remaining 4% or so are grandfathered/transitional enrollees.

It’s important to note that in the states where there’s no Grandfathered/Transitional (GR/TR) numbers listed, some chunk of the “Off Exchange Unsubsidized” tally likely belongs in the GR/TR column. Even so, the above hard data is remarkably close to my own assumptions:

9.4 million on-exchange subsidized (47%)
+ 1.7 million on-exchange unsubsidized (8%)
+ 7.1 million off-exchange unsubsidized (ACA-compliant) (35%)
+ 2.0 million off-exchange unsubsidized (NON-ACA compliant) (10%)
= 20.2 million total

http://acasignups.net/16/09/08/steve-davis-robert-laszewski-confirm-what-ive-been-saying-all-along-appx-40-aca-indy-market

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Comment:

By Don McCanne, M.D.

More numbers. Moving directly to the point, HHS and others keep assuring us that the anticipated greater increase in ACA insurance premiums will not be a problem for the 85 percent of individuals who receive premium subsidies through the ACA exchanges. Well it is a problem not only for the 15 percent of individuals in the exchanges who do not receive subsidies but also for those who buy their individual plans outside of the exchanges.

Charles Gaba makes the point that the individual plans sold by the insurers both within and outside of the exchanges share a common risk pool.

So roughly 47 percent of plans sold by insurers servicing the exchanges are subsidized, but another 53 percent (10 percent of total are not ACA compliant) sold on and off the exchanges are not subsidized so the insured individual bears the full premium increase. So it is not 85 percent who do not have to worry, but rather it is closer to half of those with ACA compliant plans.

Middle-income individuals not only bear the brunt of the premium increases, but they also pay taxes that will be used to provide the subsidies for the higher premiums in the exchanges. This is one more example of why middle-income individuals have fared poorly under ACA.

Single payer would have been simpler, more equitable, and would have had better control of increases in health care spending that are contributing to higher premiums. We can still make the change.

Fewer are uninsured, but…

Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January–March 2016

By Robin A. Cohen, Ph.D.
Michael E. Martinez, M.P.H., M.H.S.A.
Emily P. Zammitti, M.P.H.
National Center for Health Statistics, September 2016

This report provides health insurance estimates from the first quarter of the 2016 National Health Interview Survey.

* In the first 3 months of 2016, 27.3 million (8.6%) persons of all ages were uninsured at the time of interview — 1.3 million fewer persons than in 2015 and 21.3 million fewer persons than in 2010.

* The percentage of persons under age 65 with private insurance enrolled in a high-deductible health plan (HDHP) increased, from 25.3% in 2010 and 36.7% in 2015 to 40.0% in the first 3 months of 2016.

* In the first 3 months of 2016, among adults aged 18–64, 11.9% were uninsured at the time of interview, 19.5% had public coverage, and 70.2% had private health insurance coverage.

* Among adults aged 18–64, the 12-month increase in the percentage with private coverage through the Health Insurance Marketplace or state-based exchanges — from 4.4% (8.6 million) in the first quarter of 2015 to 4.7% (9.2 million) in the first quarter of 2016 — was not statistically significant.

* In the first 3 months of 2016, among adults aged 18–64, 24.7% of those who were poor, 23.6% of near poor, and 6.5% of not poor lacked health insurance coverage at the time of interview.

* In the first 3 months of 2016, 24.5% of Hispanic, 13.0% of non-Hispanic black, 8.4% of non-Hispanic white, and 6.7% of non-Hispanic Asian adults aged 18–64 lacked health insurance coverage at the time of interview.

https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201609.pdf

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Comment:

By Don McCanne, M.D.

Six years after the enactment of the Affordable Care Act, we have achieved less than half of the goal of covering all of the uninsured – a decline from 48.6 million in 2010 to 27.3 million earlier this year. Many are celebrating this as a great success, but others do not out of concern for the 27 million who remain uninsured. Besides, there are many other observations in this report that should concern advocates of health care justice for all.

Although 21.3 million uninsured gained coverage since 2010, the further reduction in the uninsured in the past year – 1.3 million – was not statistically significant. This suggests that we are close to the flat of the curve. The feasible patches to ACA are very unlikely to have much more than a negligible impact in further reducing the numbers of uninsured. We need a system that is designed to cover absolutely everyone, such as a single payer national health program.

For adults under 65, 70 percent are privately insured, predominantly through employer sponsored plans. Only 4.7% are insured through the exchanges. Those who dreamed that the nation would swarm to the exchanges because of their superior competitive markets of private plans (HHS even changed the name from exchange to marketplace) had better go back to their drawing boards, and think “improved Medicare for all”.

Perhaps the most alarming trend is the increase in enrollment in high deductible health plans (HDHP). For those under age 65, the percentage has increased from 25.3% in 2010 to 40.0% earlier this year. This has been responsible for much of the financial hardship caused by medical bills for those who are insured. The system is not working well for them, and it is getting worse.

Some say that the answer to high deductible plans is to include health savings accounts (HSA), making them consumer-directed health plans (CDHP). But three-fifths of those with HDHPs do not even have an HSA, and for many of the other two-fifths, the HSAs are inadequately funded. Pretending that deductibles can be paid with empty or nonexistent savings accounts is not sound health policy.

Another concern is that the uninsured rates are higher amongst the poor, Hispanics, and non-Hispanic blacks. Although much still needs to be done to reduce inequities in health care, the task remains much more difficult without adopting an equitable health care financing system (single payer).

So when you see headlines this week stating that the number of uninsured is at an all time low, don’t think, “a job well done.” It wasn’t.

Physicians spend two hours on EHRs and desk work for every hour of direct patient care

Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties

By Christine Sinsky, MD; Lacey Colligan, MD; Ling Li, PhD; Mirela Prgomet, PhD; Sam Reynolds, MBA; Lindsey Goeders, MBA; Johanna Westbrook, PhD; Michael Tutty, PhD; and George Blike, MD
Annals of Internal Medicine, September 6, 2016

Background: Little is known about how physician time is allocated in ambulatory care.

Objective: To describe how physician time is spent in ambulatory practice.

Design: Quantitative direct observational time and motion study (during office hours) and self-reported diary (after hours).

Setting: U.S. ambulatory care in 4 specialties in 4 states (Illinois, New Hampshire, Virginia, and Washington).

Participants: 57 U.S. physicians in family medicine, internal medicine, cardiology, and orthopedics who were observed for 430 hours, 21 of whom also completed after-hours diaries.

Measurements: Proportions of time spent on 4 activities (direct clinical face time, electronic health record [EHR] and desk work, administrative tasks, and other tasks) and self-reported after-hours work.

Results: During the office day, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on EHR and desk work. The 21 physicians who completed after-hours diaries reported 1 to 2 hours of after-hours work each night, devoted mostly to EHR tasks.

Limitations: Data were gathered in self-selected, high-performing practices and may not be generalizable to other settings. The descriptive study design did not support formal statistical comparisons by physician and practice characteristics.

Conclusion: For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.

Primary Funding Source: American Medical Association.

http://annals.org/article.aspx?articleid=2546704

For more on this study:
http://www.medpagetoday.com/PracticeManagement/PracticeManagement/60046

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Comment:

By Don McCanne, M.D.

Although this study was somewhat selective and its generalizability may be limited, nevertheless, it does show that physicians spend a tremendous amount of time on work that does not involve direct clinical face time with patients. This study and other observations suggest that much of this work is related to record documentation.

What should be the purpose of the medical record? Its primary function should be to assist the health care professionals in caring for the patients. It reinforces memory of the clinical status to date, and it provides a source for newly consulted professionals to quickly assess the status of the patient.

What else does the record do? It provides documentation for those who determine what services should be billed for in fee-for-service models of payment (FFS). In capitation models, it provides evidence that contractual requirements were met. It provides data for various quality assessment programs, including P4P (pay for performance). It provides data for evaluation of payment models, including not only Medicare, Medicaid, CHIP, private insurance plans such as PPOs, EPOs, point of service, and health maintenance organizations, but also models such as patient centered medical homes, accountable care organizations, the Medicare shared savings program, merit-based incentive payment systems (MIPS), alternative payment models (APM), and endless others. The record serves as an information source for accreditation surveys. It also requires extra efforts to include information designed to provide defense in medical liability actions. Records also provide a rich research resource for the policy community as the wonks devise ever more ways of trying to convert the traditional patient service model of health care into a business model concerned more about flow of funds rather than optimal patient care. Those in the trenches can add innumerable other extraneous purposes of the medical record that burden them as they attempt to fulfill the requirements of the record, thereby reducing the face time needed for essential patient interactions.

Other studies have confirmed that much of this work is contributing to physician burnout, which has now reached epidemic proportions.

How about returning the record to the exclusive role of being a virtual clinical document that assists the health care team with care of the patient? That information alone would also be adequate to provide a basis for billing, whether FFS or capitation. So much of the other burdensome record keeping contributes to the extraordinary administrative excesses that characterize the U.S. health care system, wasting both money and time. Let’s get back to what our health care system is all about – taking care of the patient.

Studies Show Veterans Health Care Improving

By Suzanne Gordon
The American Prospect, Tapped Blog, Aug. 16, 2016

When the House Veterans Affairs Committee holds a hearing on September 7 to assess the future of the Veterans Health Administration, federal lawmakers would do well to consider recent reports that challenge the continual drumbeat of negative and often unfair coverage and congressional criticism of the VHA.

One report, from the RAND Corporation, said that while there were differences in care and leadership culture across the system, researchers “did not find evidence of a system-wide crisis in access to VA care.” In fact, the report identified congressional policies as one of the main barriers to VHA improvements (despite the Veteran Affairs Committee Chairman Jeff Miller’s apparent belief that firing VHA leaders is the solution to any access problems). The report noted that “inflexibility in budgeting stem[med] from the congressional appropriation processes,” and concluded that the hastily designed and implemented Veterans Choice Program, “further complicated the situation and resulted in confusion among veterans, VA employees, and non-VA providers.”

Though it received no media attention, another positive report on the VHA came this month from the Joint Commission, the independent nonprofit that accredits U.S. hospitals and health-care organizations. After surveying the VHA between 2014 and 2015, the commission found improvements in access, timeliness, and coordination of care, as well as in leadership, safety, staffing, and competency.

Finally, the Association of VA Psychology Leaders, the Association of VA Social Workers, and unions representing VA employees issued a policy brief opposing the Commission on Care’s proposal to create a new VHA Care System, which would ultimately channel up to 60 percent of eligible veterans into private-sector health care. Two independent national groups, the American Psychological Association (APA) and the National Association of Social Workers, also signed the policy paper.

In an email, Heather O’Beirne Kelly, the APA’s lead psychologist on military and veterans policy, told The American Prospect that the APA “is opposed to the primary recommendation of the Commission on Care’s report, which we feel would in effect disassemble one of the most successful, innovative features of current VA care: the primary care/mental health integrated approach.”

Every report on the VHA over the past two years has documented that the system provides care equal to or superior to private-sector care, and have spotlighted significant improvements in problematic practices that led to two years of scandal-mongering on Capital Hill and in the national media. But instead of lauding the VHA for its progress and working to sustain the system, federal lawmakers and critics are quick to jump on any hint of a glitch and lambast the VHA for not changing more rapidly, steadfastly ignoring the fact that changing the culture of any institution, particularly that of America’s largest health-care system, must take years.

Sustained improvement will also require transformations in the congressional budgeting process and dramatic shifts in health-care policy. As The New York Times reported in 2014, shortages in the physician workforce have made lengthy waits to get an appointment “the norm in many parts of American medicine.” If Congress is serious about protecting veterans, it must immediately appropriate more money so that VHA can offer salaries competitive with those in the private sector, as even the Commission on Care recommends, and allocate more medical residency training slots to primary, geriatric, and palliative care.

The narrative of a VHA that is broken beyond repair that the news media and some federal lawmakers insist on does not acknowledge that the VHA is a national or global leader in fields like telemedicine, mental health, primary and geriatric care, and reducing opioid use. Why would anyone want to work in a system depicted as broken beyond repair, doomed to disappear, and filled with demoralized staff? That overwrought story discourages nurse practitioners, social workers, psychologists, and other professionals from working at the VHA.

http://prospect.org…

Labor Day message

Letter: Clovis’ teachers benefit from union gains

By Sandra McCanne, San Juan Capistrano
The Orange County Register, August 21, 2016

Re: “On teacher freedom, Clovis sets an example for California” [Opinion, Aug. 18]:

Kudos to the school teachers and administrators in Clovis. However, I disagree that the unions have played no role in their success.

People need to be compensated financially for their work and level of expertise. The teachers union has been key in obtaining adequate pay for its members. If Clovis paid salaries less than surrounding unionized communities, they would not be able to recruit qualified teachers.

Thus, the Clovis teachers reap the benefits without contributing their fair share financially to the process.

http://www.ocregister.com/articles/large-726455-california-scale.html

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Union decline lowers wages of nonunion workers: The overlooked reason why wages are stuck and inequality is growing

By Jake Rosenfeld, Patrick Denice, and Jennifer Laird
Economic Policy Institute, August 30, 2016

Pay for private-sector workers has barely budged over the past three and a half decades. In fact, for men in the private sector who lack a college degree and do not belong to a labor union, real wages today are substantially lower than they were in the late 1970s.

Unions, especially in industries and regions where they are strong, help boost the wages of all workers by establishing pay and benefit standards that many nonunion firms adopt. But this union boost to nonunion pay has weakened as the share of private-sector workers in a union has fallen from 1 in 3 in the 1950s to about 1 in 20 today.

The impact of the erosion of unions on the wages of both union and nonunion workers is likely the largest single factor underlying wage stagnation and wage inequality.

http://www.epi.org/publication/union-decline-lowers-wages-of-nonunion-workers-the-overlooked-reason-why-wages-are-stuck-and-inequality-is-growing/

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Donald Trump is the Anti–Labor Day Candidate: Running Against Fair Wages, Worker Rights, and Unions

By John Nichols
The Nation, September 4, 2016

Donald Trump, the billionaire candidate who has argued that “having a low minimum wage is not a bad thing for this country” and complained in a 2015 GOP debate that wages are “too high,” is running for president this fall on the most virulently anti-worker and anti-union platform in the history of his Republican Party.

Trump’s decision to make fiercely anti-union Indiana Governor Mike Pence his running mate should be read as another signal that the Republican presidential nominee is prepared to steer federal policy making toward the disastrous approaches of dogmatic governors such as Pence and Wisconsin’s Walker.

Trump and the anti-labor partisans who nominated him for the presidency have rejected the legacy of a Grand Old Party that once cheered when Abraham Lincoln declared: “Labor is prior to and independent of capital. Capital is only the fruit of labor, and could never have existed if labor had not first existed. Labor is the superior of capital, and deserves much the higher consideration.”

Dwight Eisenhower warned, as a Republican president, about politicians “who hold some foolish dream of spinning the clock back to days when unorganized labor was a huddled, almost helpless mass.”

“Only a handful of unreconstructed reactionaries harbor the ugly thought of breaking unions,” Eisenhower argued in the prosperous 1950s.

https://www.thenation.com/article/donald-trump-is-the-anti-labor-day-candidate-running-against-fair-wages-worker-rights-and-unions/

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Comment:

By Don McCanne, M.D.

Labor Day seems to be an opportune time to step back and take a look at how today’s labor force is faring.

Wages are stagnant. The income and wealth inequality gap has increased in recent decades. Financial hardship is rampant. This has coincided with the suppression of unions and their bargaining power.

In the past, workers who were not members of unions have benefited from the higher standards for all workers that union negotiation had achieved. The study by the Economic Policy Institute demonstrates that the decline in unions coincides with a negative impact on the wages of all workers, union or not.

Unions have also fought for health benefits for their members, and that led to employer sponsored plans covering more Americans, union or not, than any other public or private health program. But that still left many out. With the decline in union power, the nation has turned to the Affordable Care Act to try to fill the void, but that has fallen short as well.

Unfortunately, the problem is political, but it need not be so. The Republican party has traditionally supported America’s workers, and they can do so again, although they seem to be missing the opportunity in this election year.

Just as union support for living wages improves incomes for all workers, their support for health care would do the same. But they do need to redirect their support away from the current fragmented system that leaves so many uninsured and underinsured, and move towards a system that would work for everyone: a single payer national health program – an improved Medicare for all.

(A personal note:  I’m especially proud of Sandy, my bride of 56 years who, without my prompting, wrote the above letter to the libertarian Orange County Register, letting them know that celebrating free riders stains the concept of freedom.)

Physicians for a National Health Program is a nonpartisan educational organization. It neither supports nor opposes any political party or candidate for public office.

Socialize the EpiPen

The EpiPen mess shows that we need drugs that function as real social goods, not rent-producing commodities

By Adam Gaffney, M.D.
Jacobin, Sept. 2, 2016

The ongoing EpiPen debacle has served one useful purpose: it has plainly revealed the uninhibited avarice — and general dysfunction — at the core of the American pharmaceutical system.

The saga of the EpiPen — and the chicanery of Mylan Pharmaceuticals, its merchant but not its maker — exemplifies a slew of troubling developments that have been unfolding throughout the pharmaceutical universe in recent years. Most prominently, of course, there is the appalling price-gouging: Mylan bought the EpiPen in 2007, at which point a pair of them went for about $100; then, as the New York Times reported, it proceeded to jack the price up, at an accelerating pace, to over $600 currently.

This massive and entirely arbitrary sixfold price increase produced a windfall for the company, and made its CEO Heather Bresch colossally rich in the process. Her annual salary skyrocketed from around $2.5 million in 2007, as NBC News reported, to an absurd $18.9 million by 2015.

What did Mylan do to rake in such kingly sums? It’s not quite clear. Mylan didn’t invent the drug or the autoinjector technology that is the EpiPen’s raison d’etre (this device essentially allows individuals to rapidly and easily inject a precise, preloaded dose of epinephrine into the muscle of themselves, or others, when in the throes of a suspected anaphylactic reaction).

Epinephrine, as many have noted, is today cheap as dirt and has been around for more than a century, while the essentials of the autoinjector date back to the 1970s. Indeed, as an article at Timeline describes, the EpiPen actually “owes its existence to public initiative.”

The Pentagon sponsored the development of an autoinjector that could rapidly deliver a nerve gas antidote in case of a chemical weapons attack. This is no aberration: the EpiPen is one of many medical advances whose early development was publicly funded, only to later serve as a source of enormous private profit.

But furthermore, Mylan doesn’t even make the EpiPen: it outsources that to Pfizer’s Meridian Medical Technologies, which manufactures a whole lineup of autoinjector products (including, incidentally, injectors for antidotes for nerve gas among other nasty poisons).

In short: Mylan and its CEO have gotten filthy rich off of a drug that they not only didn’t invent, but don’t so much as glue together.

full:
https://www.jacobinmag.com/2016/09/epipen-mylan-bresch-generics-pharmaceuticals/

AJPH editors define the two sides of the health care reform debate

Editors on the Campaign Trail: Why Bernie Sanders Is Wrong on Health Care (and Hillary Clinton Is Right)

By Roy Grant, MA, Associate Editor, AJPH
American Journal of Public Health, August 2016

The two candidates to the 2016 Democratic Presidential primary, former Secretary of State Hillary Clinton and Senator Bernie Sanders (I-VT), both attempt to implement the principle that health care is a basic right, but Sen. Sanders’ advocacy for single-payer health care has dominated the discussion.

On the Republican side, health care has not received much attention, besides attempts to repeal the Affordable Care Act of 2010 (ACA). Donald Trump, the presumptive 2016 Republican nominee, proposes increasing competition, block granting Medicaid, and expanding health savings accounts, all Republican boilerplate proposals. In the absence of greater specificity, there is no health care plan to discuss.

Hillary Clinton Is Right on Health Care

Sec. Clinton maintains that attempting to implement single-payer would disrupt our current health care system, repeal the ACA, and plunge the nation back into contentious debate. The ACA expands insurance coverage as it currently exists in the United States, with 66% privately insured (mostly employer-provided) and 34% government insured. A single-payer system would cover the 11% uninsured but replace coverage and potentially disrupt health care for the nearly 90% of insured Americans and effectively repeal much of the ACA.

Sec. Clinton correctly recognizes the success of the ACA. Between October 2013 and early 2016, 20 million previously uninsured adults gained coverage, reducing the uninsured rate from 20.3% to 11.5%. African-Americans, Hispanics, and women made the greatest gains. The first group to benefit from expanded coverage — young adults — now has fewer emergency room visits, which contributes to lower overall health care costs.

Conclusions

The Sanders single-payer program would fulfill the progressive goal of universal health care as a right, if passed by Congress and successfully implemented. The evidence shows insufficient political support to pass single-payer and implementation barriers including tax policy and devolution of health policy to the states. Evidence supports Sec. Clinton’s position that building on the ACA would move us toward universal coverage but maintain progress made by the law. This approach is consistent with the politics of divided government and more likely to succeed.

The difference between the two positions may be viewed as ideology versus realism. Ideology may be more inspirational but is less likely to produce change.

http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2016.303285

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Brown Responds: Why Hillary Clinton Is Wrong and Bernie Sanders Is Right

By Theodore M. Brown, PhD, Associate Editor, AJPH
American Journal of Public Health, August 2016

Refuting “Clinton Is Right: ACA Represents True Progress”

I agree that the ACA has had certain positive results: 20 million previously uninsured adults have achieved coverage; African-Americans, Hispanics, and women have made considerable gains; and young adults now have expanded coverage on their parents’ policies. Several other positive improvements could be added to this list. However, the ACA fails to establish a right to uniformly high-quality health care, crystallizes unequal levels of access for those who get care, leaves out 30 million people altogether, and adds to the excessively complex and costly administrative features of our health system. The ACA also strengthens the role of the commercial insurance industry by sanctioning its inefficient multiplicity of profit-maximizing companies and their high overhead costs, by allowing exorbitant premium charges, deductibles, and out-of-pocket expenditures (especially in policies bought through the health exchanges), and by condoning tough restrictions in the choice of providers (also especially in policies bought through the exchanges). The ACA, in fact, guarantees the commercial insurance industry substantial new business facilitated by government subsidies and exercises very limited control over the rapidly escalating cost of insurance. Moreover, the ACA fails to limit the huge, often unconscionable prices and profits of the pharmaceutical industry.

Refuting “Single-Payer Would Disrupt Health Care Delivery”

Grant doesn’t say so directly, but he seems to endorse Hillary Clinton’s scare tactic scenario. However, I see no plausibility to the projected cascade of negative events. In fact, it was the ACA that had a disastrous rollout, whereas the implementation of “radical” single-payer Medicare in the 60s was remarkably smooth and efficient.5 Moreover, the supposed fear and opposition of the “protected public” (the 90% of Americans who are currently insured) may be minimal or nonexistent. After all, that public has been frustrated and angered by regular increases in premium costs, deepening deductibles, copayments and out-of-pocket costs generally, runaway and often obscene drug prices, the general threat of medical bankruptcy, and a widespread sense of powerlessness. The American public, in fact, does not feel “protected,” and according to a recent tracking poll has clearly indicated strong willingness to opt for single-payer over yet another attempt at the status quo or its incremental extension.6 We can also add to the widespread sense of dissatisfaction with our current system the realization by employees that they would be freed by a universal single-payer system from job lock and by employers that they would have less obligation to underwrite the health care costs of their workers. Who exactly would feel frightening disruption, other than the profit-maximizers of our current system?

Refuting “Building on ACA Is the Only Pragmatic Way”

Here I strongly disagree because attempting to build incrementally on the ACA will simply consolidate and concretize its fundamental flaws and even deepen some. The essential mistake is to believe that incrementalism is the only true path of American political progress. But this belief is belied by the facts of our political history. That’s not how we got Social Security or civil rights legislation.

Health care is a right, and single-payer is the fairest and most cost-effective way to achieve it in practice.

http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2016.303277

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Comment:

By Don McCanne, M.D.

Although more people than ever now have health insurance, there remain intolerable deficiencies in our health care financing system that clearly demand remedy. Two associate editors of the American Journal of Public Health debate the two approaches to reforming health care: Hillary Clinton’s expansion of ACA, and Bernie Sanders” single payer reform.

The thrust of today’s message is that these are the two legitimate approaches. Some in the media still seem to think that the only two approaches are Clinton’s expansion of ACA and Trump’s repeal and replacement of Obamacare. But as stated above, in the absence of greater specificity, the Republicans have “no health care plan to discuss.” Most of their boilerplate proposals would move us backwards – diminishing access and affordability.

So the real choice is, do we live with the dysfunctional system we have, merely tweaking it with measures such as adding yet one more (public) option to our fragmented system, or do we actually fix it by making health care affordable and accessible for all through single payer?

In arguing for ACA expansion Roy Grant indicates that single payer is inspirational but not pragmatic, whereas Theodore Brown points out that pragmatic incrementalism is not how we got Social Security or civil rights legislation. How can we let the nebulous notion of pragmatic inertia obstruct the inspirational, dynamic reform that we need?

California’s answer to surprise, out-of-network medical bills

AB-72, Health care coverage: out-of-network coverage

California State Assembly
California Legislative Information, Sept. 1, 2016

Summary (as amended):

Establishes a payment rate, which is the greater of the average of a health care service plan (health plan) or health insurer’s contracted rate, as specified, or 125% of the amount Medicare reimburses for the same or similar services; and an independent dispute resolution process (IDRP) for claims and claim disputes related to covered services provided at a contracted health facility by a noncontracting individual health care professional for health plan contracts and health policies issued, amended, or renewed on or after July 1, 2017. Limits enrollee and insured cost sharing for these covered services to no more than the cost sharing required had the services been provided by a contracting health professional.

Votes:

8/29/16 – Senate: Passed 35 to 1

8/31/16 – Assembly: Passed 79 to 0

To Gov. Jerry Brown

https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520160AB72

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Comment:

By Don McCanne, M.D.

Under private insurance, a person who is admitted to an in-network hospital may unavoidably or inadvertently receive care from a professional, such as an anesthetist, who is not in the insurer’s network, and thus the patient may be responsible for the entire bill rather than the insurer’s normal contracted amount. This legislation corrects that injustice by making the patient responsible only for cost sharing that is no greater than it would have been had the provider been in the network.

So what are the other implications of this legislation?

The out-of-network provider is no longer able to demand payment for the full fee but has to accept either the same payment that in-network providers receive or 125% of the Medicare rate, whichever is higher. If the out-of-network provider demands more, a dispute resolution process with the insurer is established, but in no circumstances does the patient pay more than the contracted in-network cost sharing.

Think about that. One of the ways that insurers are attempting to control spending is through the use of provider networks, the narrower, the better. If the insurer has a contract with the hospital, then why bother with contracting with the specialists who might be called in since they will have to accept the contracted rate even though no contract has been established with these providers, just as Medicare can establish rates for those who have not signed Medicare contracts. Also, since the insurers do not need as many physicians in their ultra-narrow networks, they can hold out for even lower contracted rates with those who do agree to sign contracts – rates which will also apply to the physicians who remain out-of-network.

Think some more about that. This places the private insurer in the position of being able to dictate price controls within the private health care delivery system. It has long been acknowledged that the government can establish rates through programs such as Medicare and Medicaid. Even though Medicare rates do tend to be fairly low, most physicians continue to see Medicare patients, even if they prefer the higher rates often paid by private insurers. However, the private Medicare Advantage plans are now paying less than traditional Medicare rates. It does not take much to imagine that the private insurers will now try to push the rates for their commercial plans below the traditional Medicare rates as well.

This legislation is important because it recognizes that we must take care of patients first. Also this legislation recognizes that the providers must be paid, but not at extravagant fees that they might set themselves. But what about the private insurers? Why do we need them at all?

Under a single payer Medicare-for-all system, the fees would be set, but at a level that would ensure adequacy of the health care delivery system. The waste of the private insurers and the burden they place on the delivery system would be recovered so that it could be spent on patient care instead. The patients would certainly benefit, and the hospitals, physicians and other professionals would do just fine as well under a public financing system.