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Drug firms gouge taxpayers by gaming Part D catastrophic coverage

Drug firms gouge taxpayers by gaming Part D catastrophic coverage

Pricey Drugs Overwhelm Medicare Safeguard

By Ricardo Alonso-Zaldivar
Associated Press, July 25, 2016

A safeguard for Medicare beneficiaries has become a way for drugmakers to get paid billions of dollars for pricey medications at taxpayer expense, government numbers show.

The cost of Medicare’s “catastrophic” prescription coverage jumped by 85 percent in three years, from $27.7 billion in 2013 to $51.3 billion in 2015, according to the program’s number-crunching Office of the Actuary.

Medicare’s catastrophic coverage was originally designed to protect seniors with multiple chronic conditions from the cumulatively high costs of taking many different pills. Beneficiaries pay 5 percent after they have spent $4,850 of their own money. With some drugs now costing more than $1,000 per pill, that threshold can be crossed quickly.

Lawmakers who created Part D in 2003 also hoped added protection would entice insurers to participate in the program. Medicare pays 80 percent of the cost of drugs above a catastrophic threshold that combines spending by the beneficiary and the insurer. That means taxpayers, not insurers, bear the exposure for the most expensive patients.

Concerns about catastrophic costs undercut the image of Medicare’s prescription program as a competitive marketplace in which private insurers bargain with drugmakers to drive down prices.

“The incentive is to price it as high as they can,” said Jim Yocum, senior vice president of Connecture, Inc., a company that tracks drug prices. Medicare is barred from negotiating prices, “so you max out your pricing and most of that risk is covered by the federal government.”

http://finance.yahoo.com/news/ap-exclusive-medicare-safeguard-overwhelmed-115221318.html

When the Medicare Part D program covering drugs was designed, conservatives were in control of the government. As a result it was decided that the ideology of competition in the marketplace should be used to improve value rather than using government administered pricing. Today’s message demonstrates once again that markets do not work in health care.

Congress knew that they would have to protect the private insurers from adverse selection – that patients with multiple chronic conditions could place an extra burden on the insurers with whom they enrolled. Thus they established catastrophic coverage with the government (taxpayers) paying 80 percent of the costs over a given threshold. This was not to protect the patients, but rather it was to protect the insurers. That is, it was not to protect the taxpayers who finance much of the program, but rather it was to protect the participants in the marketplace – the drug manufacturers, insurers, and pharmacy benefit managers – using our taxpayer funds.

Under the catastrophic coverage, insurers pay 15 percent, patients pay 5 percent, and the taxpayers pay 80 percent. This allows the drug companies to drive their prices sky high. The 15 percent paid by the insurers is closer to the reasonable price of drugs and so they have less incentive to negotiate better prices, since most of it is being paid by the government anyway. The 5 percent paid by the patient is accepted as a necessary “skin in the game” contribution so patients will not fill prescriptions that they allegedly “do not really need” (a flawed policy concept). The 80 percent paid by taxpayers perpetuates the highly dysfunctional, fragmented financing system in the U.S. – using government money for private solutions – that has driven our health care spending up to levels much higher than all other nations.

The magic of the marketplace in health care is a fraud. Taxpayers pay far less for drugs purchased by the government for Medicaid and the VA system. Other nations with greater government oversight of their health care systems also pay much less.

With a well designed single payer national health program, our nation’s pharmacy bill would be fair, and everyone would get the drugs they need. With the price of many drugs now exceeding median household income, you would think there would be a demand to fix our health care financing system. You would think so, but where’s the action?

Medicare for all is the way to go

By Bob Balhiser
Helena (Mont.) Independent Record, Letters, July 24, 2016

This letter is in response to Matt Rosendale’s opinion piece whose title asks the question: “Is your health care better now?”

Mine is still good, Matt – I have Medicare! And, I think all Americans should have Medicare. Done right, Medicare for all would provide a net savings of nearly $1 trillion annually by eliminating private health insurance parasites that cause all sorts of added time, effort and expense for doctors, hospitals, clinics and pharmacies, not to mention the HUGE overheads these companies carry.

Below are daily compensation figures for health insurance CEOs in 2013: overhead costs that Medicare is not burdened with.

Aetna – $90,029
WellPoint (now Anthem) – $49,853
Centene – $42,560
Cigna – $39,589
United Health – $35,484

Remember, Matt, these are daily compensation figures. Can you justify what they could possibly do to actually earn that money? Their job is to minimize losses. Do you know what insurance companies call losses? Losses are “claims” that insurers often try to avoid paying because claims cut into their profit margins. Think private health insurers are doing us a favor, Matt? Think again!

Bob Balhiser resides in Helena.

http://helenair.com/news/opinion/readers_alley/medicare-for-all-is-the-way-to-go/article_8a305a26-9c47-5efa-b15b-8bd589fddaee.html

Medical Economics: Obamacare receives a big, fat ‘F’ from physicians

By Joanna Haugen, Jordan Rosenfeld
Medical Economics, July 25, 2016

The Affordable Care Act (ACA) has been a lightning rod for criticism from various healthcare stakeholders, including physicians, since the law’s passage six years ago.

With the upcoming presidential election likely to alter the landscape of “Obamacare”—from simple tweaks by Democrats to outright attempted repeal by Republicans—Medical Economics asked healthcare policy experts and our readers to debate the law’s effect on U.S. physicians.

Our editorial staff, with the assistance of our physician advisers, selected eight provisions and consequences (both intentional and unintentional) stemming from the law.  Policy analysts provided their thoughts on how Obamacare has shaped the last six years. Then we  asked physicians from our editorial advisory board, our 200-member Reader Reactor Panel (comprised of physician readers nationwide who help direct our content), and our e-newsletter subscribers to grade the various elements based on their own experiences.  Each physician ranked each element in terms of how it assisted their day-to-day work as physicians on a score from 0 (not at all) to 10 (extremely helpful). The average of all respondents was used to derive the letter grade. Physicians also offered short justifications for their ranking.

Medicare bonus for primary care physicians
Grade: 33 = F

Medicaid-Medicare parity
Grade: 34 = F

Increased coverage through healthcare insurance exchanges
Grade: 35 = F

Narrow networks
Grade: 29 = F

Accountable care organizations
Grade: 29 = F

Outcomes-based reimbursement
Grade: 28 = F

Physician ratings via the Physician Compare website
Grade: 26 = F

Expansion of health IT
Grade: 31 = F

http://medicaleconomics.modernmedicine.com/medical-economics/news/obamacare-receives-big-fat-f-physicians

***

Comment:

By Don McCanne, M.D.

Celebrations of the success of the Affordable Care Act have to be tempered by the knowledge that it leaves too many uninsured, that health care is still not affordable for far too many, and that the benefits of tighter insurance regulation were largely offset by the insurance design changes of excessive cost sharing and restrictive narrow networks. One other goal was to improve payment systems so that patients would receive greater quality at lower costs. So what do physicians think about the implementation and effectiveness of the design changes in the payment system?

In this survey, physicians gave a grade of F to all eight of the design features evaluated. In trying to improve payment systems, the legislators and bureaucrats have certainly botched things up. Not only have they failed to achieve any improvement, they have made things worse. Not only that, they have compounded physician burnout, now affecting over half of all physicians. Having an unhappy physician negatively impacts patient care.

Much blame can be attributed to the focus of the policy community and the MBAs that guide them. Medicine is about taking care of patients, but the policy community approaches it as a business that can be improved by incentives.

Would a single payer system fix this? It would provide a more equitable, efficient and effective financing system, but it would still be subject the whims of legislators and bureaucrats who do not seem to appreciate the sanctity of the physician-patient relationship. Once we have in place a national single payer system, our work is not done.

Why Black Lives Matter Ought to Matter to Medical Students: A Familiar Message Revisited

By Suhas Gondi
in-Training, July 18, 2016

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

– attributed to Martin Luther King, Jr.

[PNHP note: The “Letter to our Patients on Racism” cited in the last paragraph of this article has been signed by more than 3,000 physicians and medical students as of July 19.]

In December of 2014, one week after the non-indictment in the case of Michael Brown, in-Training published an article entitled “A Lack of Care: Why Medical Students Should Focus on Ferguson.” In it, Jennifer Tsai argued that the systemic racism rampant in our law enforcement and criminal justice systems also permeates our health care system, affecting both access to care for black patients and the quality of care black patients receive. Lamenting that the medical community was largely absent from the Ferguson controversy, she cited startling statistics of disparities in health and health care as part of her call to action. In light of the events last week in Louisiana, Minnesota, and Texas, it’s time to revisit this message.

The deaths of Alton Sterling and Philando Castile re-galvanized the Black Lives Matter movement, which began in Ferguson and has since spread to every corner of this country. Besides spurring impassioned advocacy, they serve as a reminder to us all of the systemic racism is still ingrained in our society. The seemingly innate biases so many of us carry have not eroded — they still abound in our daily lives and the world around us.

These events should also serve as a reminder to every physician, medical student and premedical student of the ways in which our health care system is subject to those biases. While the white coat has come to represent the profession’s humanity and morality, the evidence decisively shows it is not impermeable to prejudice.

The published literature supporting the existence of racial disparities in health care is vast. The seminal report on the subject was published in 2002 by the Institute of Medicine (IOM), which found that a large body of research highlighted the presence of real disparities. It concluded that even after controlling for insurance status, income, age and severity of conditions, minorities receive a different level of care than white patients. They were less likely to be prescribed appropriate cardiac medications, undergo bypass surgery or receive kidney dialysis and more likely to undergo “less-desirable procedures” such as a lower limb amputation due to complications from diabetes.

Since 2002, when the IOM report brought widespread attention to such disparities, researchers have published hundreds of studies that shed more light on the differences in the way black and white patients are cared for by their doctors. One analysis published two months ago examined nationwide trends for racial disparities in cardiac interventions after a heart attack before and after the 2002 IOM report, finding that disparities persisted well after the report. Some of these disparities have been well-studied and widely cited. Black patients face a two-thirds higher risk than white patients of not receiving an analgesic (a pain medication) when in the ER for a long-bone fracture, even after controlling for confounding variables. Minorities are also less likely than white patients to be prescribed opioid medications for a comparable set of symptoms. This disparity is most significant with conditions that have less objective findings, like a migraine. When patient assessment and test results do not point to a conclusive diagnosis, the effect of inherent biases on clinical decision-making is greater.

The federal government has also published its own studies on the topic. The 2015 National Healthcare Quality and Disparities Report reported that black patients received worse care than whites for about 40 percent of quality measures, a statistic almost identical to the 2011 report, the first annual publication. Even in special populations, such as senior citizens over the age of 65, with similar health problems and the same insurer, racial disparities persist. Black Medicare beneficiaries are, on aggregate, less likely to receive recommended care than white ones.

These differences, along with variation in the social determinants of health across race, contribute to the serious health inequities observed between blacks and whites. While the gap in life expectancy has narrowed over the past several decades, a white baby born today can still expect to live, on average, four years longer than her black counterpart. Although disparities in health outcomes such as longevity are largely the product of structural factors, it is difficult to believe that the lower quality of care delivered to blacks versus whites does not play any role in explaining these gaps.

Clearly, the medical community has a stake in the national conversation around systemic racism and police brutality re-launched by the deaths of Sterling and Castile. The evidence overwhelmingly suggests that physicians are just as vulnerable to the inherent biases that affect police officers. The biases that are blamed for higher arrest rates among blacks for crimes that whites commit more often are the same biases that lead to black patients receiving timely and aggressive intervention far less often than white patients in a cardiovascular emergency. These are distinct symptoms of a single underlying cause. The assumptions that cause well-intended police officers to stop-and-frisk blacks five times as frequently as whites are also harbored by physicians. These ingrained stereotypes are not profession-specific. They are universal.

The tragic deaths of five police officers in Dallas last week points to another parallel with the medical establishment. The tension between police officers and the communities they protect is mirrored by a tension between physicians and the patient populations they care for. The skepticism of black patients toward the medical community, especially in the area of clinical research, is well-documented. A Johns Hopkins study reported that a full quarter of black patients, 10 percent more than whites, believe that their physician would ask them to participate in a study even though the study might harm them. 6 percent more blacks than whites felt their physician would willingly expose them to unnecessary risk. Most striking, almost 60 percent of black participants, well over twice the proportion of whites, thought that physicians use medications to experiment on people without the patient’s consent. Evidently, doctors and police officers share the challenge of serving populations that sometimes put little faith in them and their professional authority.

Just as the distrust that many black men have for police is rooted in America’s history of racial profiling, the lack of trust towards physicians has been shaped by a long history of exploitation and experimentation on black bodies. The Tuskegee syphilis trial, which began in the early 1930s and lasted forty years, is perhaps the most infamous example. Government researchers deceived black patients suffering from syphilis into believing they were receiving treatment when, in fact, they were being observed to gain insight into the natural course of the disease. The legacy of Tuskegee is still reflected in the widespread mistrust that undermines doctor-patient relationships across the country.

In a national town hall this week, President Obama spoke on how trust between a community and its police officers is critical for police departments to do their job of serving and protecting. Distrust leads to bad outcomes, often in the form of unwanted violence. The same is true in medicine, except bad outcomes mean poor health. Evidence shows that high levels of distrust of their physicians among black patients contributes to health disparities by causing reduced utilization of preventive services, relative to whites. These services include routine checkups and preventive screening (e.g. mammograms), the most cost-effective and valuable health care services in promoting and preserving health. Distrust also discourages blacks from participating in clinical trials, which hinders the research of therapies targeted at African Americans and intensifies disparities in the quality of health care. Even in the absence of any true discrimination, perceived discrimination, perhaps based on statistics showing differences in how blacks and whites are treated, is associated with poorer health.

Physicians whose priorities are their patients’ health ought to pay attention to disparities in care, the mistrust those disparities breed and the poor health outcomes that are observed as a result. This pernicious cycle begins with subjective biases and often causes objective harm to black patients, perpetuating disparities in care and health.

Black Lives Matter is highlighting and combating the biases that are at the root of unequal policing practices. A medical community that is often impartial to issues outside its purview might find it easy to ignore such a movement. But that would be a grave mistake.

We cannot achieve equity in health care without achieving equity in policing. Both are symptoms that can only be addressed if we treat the underlying cause. We must acknowledge and combat our collective biases in all facets of life to truly cure the disease. Just as the problem is not health care-specific, nor is the solution. We must strive broadly for social justice, not only in the clinic but also in our communities, our neighborhoods and our police departments.

Closing racial disparities is a societal endeavor, and engaging with Black Lives Matter is a step towards that common goal for police officers and physicians alike. If we join the activism all around us and if we stand with this movement for social justice, we can begin to tackle the implicit prejudices that result in a black man getting Tylenol when he needs an analgesic and that result in the fatal shooting of that same man in the absence of any crime. We can begin to heal the underlying problem.

Everyone has a part to play. Physicians can do the challenging work of looking closely at their own patterns of prescribing and treating, searching for biases that are often imperceptible at an individual level but contribute to collective disparities. Medical students and residents can critically reflect on the education they are receiving, if it is imbuing them with stereotypes and ensure they are honing the skills to combat systemic racism. Premedical students, like myself, ought to enter our training understanding the issues at hand and being aware of the unconscious prejudices we, our peers and our mentors hold. It is difficult for us to be critical of the medical guild into which we are working so hard to gain entry, but we are the future of the profession and a necessary part of any solution.

It is natural to feel helpless in the face of the startling statistics of health care disparities and the horrific events of last week. However, there is reason to hope. Over the last few years, the medical community has shown signs of change. Nationwide medical student die-ins in protest of police brutality were a beginning, giving rise to national organizations such as WhiteCoats4BlackLives that consistently advocate for a more equitable future. Doctors for America has taken on racial disparities. Medical leaders, such as New York City’s health commissioner, have joined in the call to action, insisting that the medical community ought “not sit on the sidelines.” Medical education, too, is changing. The American Association of Medical Colleges has spearheaded efforts to incorporate diversity, inclusion and cultural competency as a core value of our nation’s medical schools. Even at the premedical level, the new MCAT encourages studying sociology and explicitly tests knowledge of the disparities in health and health care in an effort to reduce these disparities in the long run.

Perhaps most promising is the recent “Letter to Our Patients on Racism” which has been signed by over 2,600 physicians and medical students. Its authors acknowledge that “historically, physicians as a group have not yet taken adequate responsibility for confronting racism, in our work or outside of it.” They make five commitments: 1) to support Black Lives Matter, 2) to dismantling the structural racism embedded in our healthcare system, 3) to learn how to provide trauma-informed care, and to teach this approach to our students, trainees, and fellow providers, 4) to healing communities ravaged by discriminatory criminal justice practices through engaging public health systems and 5) to using our power as constituents and leaders to insist that every major medical society and association develop a policy on racial justice. These are difficult promises to fulfill, and they require that every one of us do our part.

Suhas Gondi is a pre-medical student at Washington University in St. Louis (Class of 2017). He is pursuing a Bachelor’s degree in Biology with a Neuroscience focus alongside minors in Economics and Healthcare Management. In addition to becoming a physician, he is interested in the systemic problems in American health care (e.g. cost, access, quality) and how we can use innovation and policy initiatives to solve them. A local of the Washington, D.C. metropolitan area, he hopes to pursue leadership in public service at the intersection of government and health care.

http://in-training.org/black-lives-matters-matter-medical-students-familiar-message-revisited-11747

Medical Economics: Obamacare receives a big, fat ‘F’ from physicians

By Joanna Haugen, Jordan Rosenfeld
Medical Economics, July 25, 2016

The Affordable Care Act (ACA) has been a lightning rod for criticism from various healthcare stakeholders, including physicians, since the law’s passage six years ago.

With the upcoming presidential election likely to alter the landscape of “Obamacare”—from simple tweaks by Democrats to outright attempted repeal by Republicans—Medical Economics asked healthcare policy experts and our readers to debate the law’s effect on U.S. physicians.

Our editorial staff, with the assistance of our physician advisers, selected eight provisions and consequences (both intentional and unintentional) stemming from the law.  Policy analysts provided their thoughts on how Obamacare has shaped the last six years. Then we  asked physicians from our editorial advisory board, our 200-member Reader Reactor Panel (comprised of physician readers nationwide who help direct our content), and our e-newsletter subscribers to grade the various elements based on their own experiences.  Each physician ranked each element in terms of how it assisted their day-to-day work as physicians on a score from 0 (not at all) to 10 (extremely helpful). The average of all respondents was used to derive the letter grade. Physicians also offered short justifications for their ranking.

Medicare bonus for primary care physicians
Grade: 33 = F

Medicaid-Medicare parity
Grade: 34 = F

Increased coverage through healthcare insurance exchanges
Grade: 35 = F

Narrow networks
Grade: 29 = F

Accountable care organizations
Grade: 29 = F

Outcomes-based reimbursement
Grade: 28 = F

Physician ratings via the Physician Compare website
Grade: 26 = F

Expansion of health IT
Grade: 31 = F

http://medicaleconomics.modernmedicine.com/medical-economics/news/obamacare-receives-big-fat-f-physicians

Celebrations of the success of the Affordable Care Act have to be tempered by the knowledge that it leaves too many uninsured, that health care is still not affordable for far too many, and that the benefits of tighter insurance regulation were largely offset by the insurance design changes of excessive cost sharing and restrictive narrow networks. One other goal was to improve payment systems so that patients would receive greater quality at lower costs. So what do physicians think about the implementation and effectiveness of the design changes in the payment system?

In this survey, physicians gave a grade of F to all eight of the design features evaluated. In trying to improve payment systems, the legislators and bureaucrats have certainly botched things up. Not only have they failed to achieve any improvement, they have made things worse. Not only that, they have compounded physician burnout, now affecting over half of all physicians. Having an unhappy physician negatively impacts patient care.

Much blame can be attributed to the focus of the policy community and the MBAs that guide them. Medicine is about taking care of patients, but the policy community approaches it as a business that can be improved by incentives.

Would a single payer system fix this? It would provide a more equitable, efficient and effective financing system, but it would still be subject the whims of legislators and bureaucrats who do not seem to appreciate the sanctity of the physician-patient relationship. Once we have in place a national single payer system, our work is not done.

The adequacy of insurance coverage is under threat

Obamacare’s Other Success, Under Threat

By Editorial Board
Bloomberg View, July 20, 2016

Obamacare has made great strides toward its signature goal: to reduce the number of Americans without health insurance. Unfortunately, another important goal — ensuring that everyone’s insurance policy provides adequate coverage — remains under siege in the courts and Congress.

Before the Affordable Care Act, private health insurers were free to exclude coverage for all sorts of care.

Moreover, if anyone’s medical expenses grew too high, insurers could cut them off. A serious or complicated illness or injury could leave people essentially uninsured.

Obamacare changed things by establishing 10 categories of benefits that most insurance plans must cover — including hospitalization, prescription drugs, laboratory services and mental health care — and prohibiting annual or lifetime limits on those benefits.

This month, however, a federal appeals court ruled that people can buy plans with far more limited coverage. Yet those who buy such plans risk being surprised twice — first when they’re saddled with the tax penalty for not carrying adequate insurance, and then when they need care and find their coverage doesn’t go as far as they thought.

Republicans in Congress have likewise targeted Obamacare’s minimum coverage requirements, arguing that consumers, not the government, should determine what services they want insurers to provide.

http://www.bloomberg.com/view/articles/2016-07-20/obamacare-s-other-success-under-threat

***

Comment:

By Don McCanne, M.D.

The majority of Americans believe that everyone should have the health care that they need when they need it, and that we need a financing system that will pay for it. Others believe that they should take care of their own health care needs and not be required to pay into a risk pool that covers the health care of others. So should the health insurance system provide comprehensive coverage for all, or should it allow individuals to purchase coverage for only those benefits they perceive they might need?

“As a man, why should I have to pay for maternity benefits I’ll never use?” “As a woman, why should I have to pay for treatment of prostate cancer – a disease that I’ll never have?” “I take good care of myself; why should I have to pay for care of disorders of others due to their smoking, illicit drug use, reckless driving, sexual promiscuity or whatever?” “I’m healthy so why can’t I wait until I will likely need health care instead of wasting money on insurance now?”

“I want to take care of myself by buying only the insurance I need now, and everyone else can buy whatever they feel they need.” But what about that unexpected disorder that racks up medical bills of $350,000? “Well, I didn’t mean that. Nobody can pay those bills, so the government should pay it instead.”

So we’re divided between “we’re all in this together” and “I’ll take care of myself, and you’re on your own.” But medical care doesn’t work that way. The twenty percent of people who use eighty percent of health care are reliant on pooled funds to pay for their health care. Most of the eighty percent who are relatively healthy will someday shift into the high health care needs group and likewise also be dependent on pooled funds.

Although the Affordable Care Act was a step forward in pooling health care risk, there is a campaign to move us in the other direction. An effort to shut down inadequate plans was reversed by the Supreme Court, even though those plans will unfairly shift costs to others when they do not adequately cover expensive diseases and injuries. Also many politicians want to ensure that people will be able to “buy only the insurance they need” through gimmicks such as private insurance exchanges offering the choice of low benefit plans, purchases out of state to avoid regulatory oversight of insurers, reliance on health savings accounts — usually underfunded, etc.

As a group, those individuals who want to take care of themselves include many individuals who will have high medical expenses. Whatever way they set funds aside – spartan insurance plans, health savings accounts, personal savings – collectively they will not have enough funds set aside to pay for the expensive care some members of their group will need. Besides, they have fragmented much of their funds such that only a limited amount would be available for others, largely through catastrophic plans that have intolerably high deductibles. Whereas those of us who support universal pooling of risk would cover our costs equitably, those who are on their own will dump costs onto the rest of us through taxes we pay for public programs or through higher medical bills due to shifting to us the costs of care provided to those who do not pay their bills.

When people sign up for Medicare, they do not ask for only the Medicare that they need. They expect that they will get essentially the same Medicare that everyone else has (though some may receive similar benefits through the private Medicare Advantage plans). It should be that way not for just Medicare beneficiaries, but for everyone. We should improve Medicare and then make it universal. That will satisfy the majority of us who believe that we are all in this together, and for those who want to be on their own, they will accept the benefits of a Medicare for all program just as they now accept Medicare in their retirement years. Also, they will have paid in their equitable share, based on ability, just like the rest of us.

What does the 13% average Covered California premium increase mean for the rest of us?

Covered California Health Plan Rates To Jump 13.2 Percent In 2017

By Chad Terhune and Pauline Bartolone
Kaiser Health News, July 19, 2016

California’s Obamacare premiums will jump 13.2 percent on average next year, a sharp increase that is likely to reverberate nationwide in an election year.

The Covered California exchange had won plaudits by negotiating 4 percent average rate increases in its first two years. But that feat couldn’t be repeated for 2017, as overall medical costs continue to climb and two federal programs that help insurers with expensive claims are set to expire this year.

Some health-policy experts were surprised by the magnitude of the increase in California. Others said it was inevitable the rates would catch up to the rest of the country after insurers determined their coverage had been priced too low.

Blue Shield of California said its premiums were going up 19.9 percent, the highest statewide increase. Anthem Inc., the nation’s second largest health insurer, said it had an average increase of 17.2 percent in its Covered California plans. HMO giant Kaiser Permanente, in contrast, posted an average increase of 6 percent.

“While these rates hikes aren’t as bad as the annual double-digit increases before the Affordable Care Act, that’s not much comfort to consumers who don’t see their paychecks increase by the same percentage,” said Anthony Wright, executive director of Health Access, a consumer advocacy group.

These rate increases apply to people who purchase their own coverage in the individual market, not the majority of Americans who get their health insurance through work or government programs such as Medicare and Medicaid.

http://khn.org/news/covered-california-health-plan-rates-to-jump-13-2-percent-in-2017/

***

Comment:

By Don McCanne, M.D.

California has been a leader in establishing and implementing the health insurance exchanges authorized by the Affordable Care Act. Although they did hold down premium rate increases in the first two years to 4 percent (still above the rate of inflation), the higher costs of health care have caught up with them. That requires an average of a 13.2 percent premium increase for the next year (though other regulatory and market factors cause greater year to year fluctuation in the premiums). What does this mean for those enrolled in those plans and for the rest of us who obtain our health care coverage elsewhere?

Some of those enrolled in the Covered California plans will find the premium increases to be beyond their means. Many of them will be able to shop for plans with lower premiums, but they will likely have to pay higher deductibles, though those who are eligible for government subsidies may find that the burden is not too great. In changing plans, many will have to disrupt their current care since their new plans will have different provider networks. The effort to make the insurance premiums more affordable clearly has detrimental effects in physician choice and affordability of actual access to health care.

In California those people purchasing plans in the individual market will have very similar experiences except that they are not eligible for government subsidies that could reduce the impact of the premium increases.

The employee contribution to employer-sponsored plans has been more stable, although that is beginning to change. Starbucks is the latest of employers who are using private insurance exchanges in which the employees use a voucher or equivalent to purchase their plans. The impact will be very similar to the ACA exchanges – less choice in health care providers and greater out-of-pocket costs merely because eventually the voucher will not be enough to cover plans with wider networks and less cost sharing.

Even Medicare may eventually be impacted. The push to private Medicare Advantage plans is succeeding because of government overpayment to these plans. The conservative and neoliberal coalition is advocating for the establishment of a voucher program for private Medicare plans (premium support), crowding out the traditional Medicare program.

Politicians will likely respond to inevitable protests of intolerable increases in the beneficiaries’ portion of the Medicare premium by allowing insurer innovations in coverage that will reduce the premiums. We already know what some of these will be: larger deductibles and other cost sharing, narrower provider networks, or intrusive prior authorization designed to limit access to expensive drug products and procedures. But this will be nothing compared to what the insurance industry will likely do once it is granted a free rein to innovate. It’s in the DNA of this industry.

ACA supporters are assuring us that we don’t have to worry about these high premium increases in the exchange plans because patients are free to shop for cheaper plans. But they have left out the rest of the story.

Single-payer group turns 25

By Bennett Hall
Corvallis (Ore.) Gazette Times, July 21, 2016

Don’t let the name fool you.

Mid-Valley Health Care Advocates may sound like just another local nonprofit, but the Corvallis-based group’s impact and influence extend far beyond its regional roots.

As the group prepares to mark its 25th anniversary this week (see accompanying story for details), the organization is being celebrated for playing a strong leadership role in pushing for universal health care at the state and national level.

Formed by a committee of parishioners at St. Mary’s Catholic Church in 1991, it’s still going strong, with a mailing list of 1,400 names and a core group of about 200 active volunteers.

Then as now, rising health care costs were a major concern for many people in Oregon and around the country. In the early 1990s, however, the idea of single-payer health care — a government-sponsored health care program similar to Medicare that would cover all citizens in a single risk pool — was a foreign concept to most Americans.

“We were way ahead of our time,” said Betty Johnson, MVHCA’s first leader and still one of its most active volunteers. “It was a struggle to get people to sit down and have a conversation about health care reform.”

Today, with health care costs higher than ever before, the idea of a single-payer system is a much more familiar notion – in part because of the efforts of Johnson and other members.

Other original organizers still with the group say they stay involved because the issue is more important than ever.

“It’s clear that simplifying the system is not going to cost more, it’s going to cost less,” said Louise Ferrell. “The thing I’ve been interested in right from the beginning is one risk pool.”

Edie Orner cited the recent example of her granddaughter, who thought she had solid insurance as a student at Oregon State University but was forced into bankruptcy due to an expensive illness.

“That got me all fired up again,” Orner said. “I just want to get this passed before I leave this planet.”

And Maxine Eckes sees it as a question of economic justice.

“It’s really not a political issue,” she said. “It’s an economic issue.”

Still on the radar

Ellen Pinney, the former director of the Oregon Health Action Campaign and now the ombudsman with the Oregon Health Authority, gives Johnson and her mid-valley cohorts much of the credit for keeping the issue of single-payer health care on the state’s political radar all these years.

“They took that over and became the spearhead of health care reform in Oregon,” Pinney said.

She calls Johnson a “brilliant strategist” and a “master of process” who understands the importance of getting all the right people to the table to move the discussion of reform forward.

“You can’t say no to Betty,” Pinney added. “You can’t say no to a person who has that vision and shows you how much energy she has.”

As early as 1995, group members were testifying before the Oregon Legislature in support of a single-payer bill. The group helped launch Health Care for All-Oregon in 1999 and remains the largest single-issue member of the statewide coalition of more than 100 organizations supporting single payer.

In 2002, MVHCA — and Johnson in particular — led the charge for Ballot Measure 23, an initiative campaign to establish a statewide single-payer plan. The measure tanked at the ballot box, but that didn’t stop the mid-valley believers, who shifted their focus to working with state lawmakers to revive the idea of achieving universal health care through legislative action.

Members of the group established the Interfaith Health Care Network as well as a local chapter of Physicians for a National Health Program and acted as a support team for the Mad As Hell Doctors, a group of Oregon physicians who took their message of health care for all on the road around the state and across the country to Washington, D.C.

MVHCA has repeatedly traveled to Salem to rally with other single-payer supporters on the Capitol steps and has sponsored a steady stream of local forums, panel discussions, movie screenings and other events to educate area residents about health care reform.

And Johnson and Mike Huntington, a longtime MVHCA member and one of the Mad As Hell Docs, regularly participate in conference calls to strategize with single-payer advocates in other states.

“They’re extremely well-respected because they combine strong values with a strong work ethic and a lot of real-world expertise,” said state Sen. Michael Dembrow, a Portland Democrat who has emerged as the leading champion of single payer in Salem.

“Betty Johnson, Mike Huntington and other members have contacts all over the country, which is extremely helpful,” Dembrow added. “They’ve had a strong hand in every version of universal health care legislation I’ve submitted, and that partnership will continue until the job is done.”

In recent years, the group has played a role in getting the Legislature to approve and fund an economic study of single-payer versus other methods of financing health care (a report is due in November) and is helping to draft a bill that would create a task force to study how to implement a statewide single-payer system.

Future actions

Looking to the future, an advisory measure backed by the group will be on the November ballot in Corvallis. If approved by voters, it will direct the City Council to urge the Legislature to move ahead with universal health care.

Bobbi Hall, the current board chair of MVHCA, said the group is also working with its counterparts in the 20 or so other states with active single-payer movements. Vermont has already passed a version of universal health care, Hall noted, and the hope is that additional states will follow suit, building momentum for a national single-payer system.

In fact, the group’s 25th anniversary celebration this Friday will double as a fundraiser for ColoradoCare, a proposed universal health care plan that will go before that state’s voters in November.

“We feel an obligation to help them,” Hall said. “We kind of feel that helping Colorado will be helping us.”

Mark Lindgren, a longtime MVHCA member who also serves on the board of Health Care for All-Oregon, likens the push for single-payer health care to earlier political struggles such as the fight for abolition and women’s suffrage. Like those earlier movements, he said, there will be many setbacks, but he’s convinced the cause will triumph in the end.

“I believe it,” he said. “It will be impossible till it’s not.”

Reporter Bennett Hall can be reached at 541-758-9529 or bennett.hall@lee.net. Follow him on Twitter at @bennetthallgt.

Anniversary party Friday

Mid-Valley Health Care Advocates will celebrate its 25th anniversary this week with music, dancing and a healthy dose of good, old-fashioned activism.

The party will take place from 7 to 9:30 p.m. Friday in Gatton Hall at the First Congregational United Church of Christ, 4515 S.W. West Hills Road. There is no charge to attend, and everyone is welcome.

The Hilltop Big Band with vocalist Audrey Perkins will perform a variety of arrangements, and Mark Weiss will sing “The Health Care Blues.”

Washington Post correspondent T.R. Reid, creator of the documentary “Sick Around the World,” will appear via video and make an appeal for donations to support ColoradoCare, a universal health care proposal that will be on the ballot this November in his home state. All proceeds collected at the event will go to help fund the Colorado ballot measure campaign.

The event will conclude with the cutting of a birthday cake and more dance music from the Hilltop Big Band.

The group meets at 7 p.m. on the fourth Monday of every month at the Unitarian Universalist Fellowship of Corvallis, 2945 N.W. Circle Blvd. More information is available online at www.mvhca.org.

http://www.gazettetimes.com/news/local/single-payer-group-turns/article_285dbbab-8871-5d2d-bd70-9eb427ac94a3.html

What does the 13% average Covered California premium increase mean for the rest of us?

Covered California Health Plan Rates To Jump 13.2 Percent In 2017

By Chad Terhune and Pauline Bartolone
Kaiser Health News, July 19, 2016

California’s Obamacare premiums will jump 13.2 percent on average next year, a sharp increase that is likely to reverberate nationwide in an election year.

The Covered California exchange had won plaudits by negotiating 4 percent average rate increases in its first two years. But that feat couldn’t be repeated for 2017, as overall medical costs continue to climb and two federal programs that help insurers with expensive claims are set to expire this year.

Some health-policy experts were surprised by the magnitude of the increase in California. Others said it was inevitable the rates would catch up to the rest of the country after insurers determined their coverage had been priced too low.

Blue Shield of California said its premiums were going up 19.9 percent, the highest statewide increase. Anthem Inc., the nation’s second largest health insurer, said it had an average increase of 17.2 percent in its Covered California plans. HMO giant Kaiser Permanente, in contrast, posted an average increase of 6 percent.

“While these rates hikes aren’t as bad as the annual double-digit increases before the Affordable Care Act, that’s not much comfort to consumers who don’t see their paychecks increase by the same percentage,” said Anthony Wright, executive director of Health Access, a consumer advocacy group.

These rate increases apply to people who purchase their own coverage in the individual market, not the majority of Americans who get their health insurance through work or government programs such as Medicare and Medicaid.

http://khn.org/news/covered-california-health-plan-rates-to-jump-13-2-percent-in-2017/

California has been a leader in establishing and implementing the health insurance exchanges authorized by the Affordable Care Act. Although they did hold down premium rate increases in the first two years to 4 percent (still above the rate of inflation), the higher costs of health care have caught up with them. That requires an average of a 13.2 percent premium increase for the next year (though other regulatory and market factors cause greater year to year fluctuation in the premiums). What does this mean for those enrolled in those plans and for the rest of us who obtain our health care coverage elsewhere?

Some of those enrolled in the Covered California plans will find the premium increases to be beyond their means. Many of them will be able to shop for plans with lower premiums, but they will likely have to pay higher deductibles, though those who are eligible for government subsidies may find that the burden is not too great. In changing plans, many will have to disrupt their current care since their new plans will have different provider networks. The effort to make the insurance premiums more affordable clearly has detrimental effects in physician choice and affordability of actual access to health care.

In California those people purchasing plans in the individual market will have very similar experiences except that they are not eligible for government subsidies that could reduce the impact of the premium increases.

The employee contribution to employer-sponsored plans has been more stable, although that is beginning to change. Starbucks is the latest of employers who are using private insurance exchanges in which the employees use a voucher or equivalent to purchase their plans. The impact will be very similar to the ACA exchanges – less choice in health care providers and greater out-of-pocket costs merely because eventually the voucher will not be enough to cover plans with wider networks and less cost sharing.

Even Medicare may eventually be impacted. The push to private Medicare Advantage plans is succeeding because of government overpayment to these plans. The conservative and neoliberal coalition is advocating for the establishment of a voucher program for private Medicare plans (premium support), crowding out the traditional Medicare program.

Politicians will likely respond to inevitable protests of intolerable increases in the beneficiaries’ portion of the Medicare premium by allowing insurer innovations in coverage that will reduce the premiums. We already know what some of these will be: larger deductibles and other cost sharing, narrower provider networks, or intrusive prior authorization designed to limit access to expensive drug products and procedures. But this will be nothing compared to what the insurance industry will likely do once it is granted a free rein to innovate. It’s in the DNA of this industry.

ACA supporters are assuring us that we don’t have to worry about these high premium increases in the exchange plans because patients are free to shop for cheaper plans. But they have left out the rest of the story.

Report: VHA Care Commission Recommends Private-Sector Options

As conservatives and congressional Republicans seek to dismantle the Veterans Health Administration, members of the commission called for giving veterans more private-sector options.

By Suzanne Gordon
The American Prospect, July 12, 2016

After almost a year of meetings and hearings, the Commission on Care has finally issued its report on the future of the Veterans Health Administration. “Care delivered by the VA,” the congressionally mandated report states, “is in many ways comparable or better in clinical quality to that generally available in the private sector.”

But with problems in accessing services, in variations in care, and in the managerial culture at various facilities, the commission believes that the major remedy lies not in outright privatization but in giving veterans more private-sector options, a finding that veterans groups fear may also weaken the decades-old system.

One of the commission’s most complex and potentially problematic recommendations involves the creation of a “VHA Care System,” that would integrate private-sector providers into a VHA-supervised network. The network would service only those veterans eligible for VHA services. Currently, about nine million veterans have been able to establish VHA eligibility; that is, they have health problems connected to their military service or a low-enough income to qualify for enrollment.

The commission recommended that veterans who are VHA-eligible would choose a primary care provider who, in turn, would refer them to specialists. These primary care doctors or specialists could work within the VHA or go outside the VHA to be providers who contract with the agency.

The VHA would be required to create a network that includes all providers who take care of veterans. The agency would have to screen and then contract with community or private-sector providers and ensure that those providers use information-technology systems that are compatible with the VHA’s networks. The VHA would also have to make sure that those providers understand military culture, and would be responsible for coordinating the care veterans receive and helping them navigate the system.

Coordinating care will not be easy. The commission found that veterans who are treated in the VHA do receive coordinated care while those with private plans, Medicare, or TRICARE receive care that is of “lower quality, threatens patient safety, and shifts costs among payers.”

The commission also suggests revising the byzantine VA eligibility requirements that deny benefits to veterans who were “dismissed from military service with an other-than-honorable discharge because of actions that resulted from health conditions (such as traumatic brain injury, posttraumatic stress disorder, or substance use) caused by, or exacerbated by, their service.”

The VHA needs more funding for competitive salaries, which will help recruitment and retention of professional staff. Since there are nationwide shortages of certain health-care professionals, recruiting will not be easy.

The commission estimates that over the next few decades, about 40 percent to 60 percent of veterans will receive some, if not all, private-sector, health-care services. Treating fewer patients could significantly compromise VHA care if health-care providers cannot maintain their clinical skills.

Those developments could also discourage health-care professionals from working in or staying with the VHA, which could lead to closing some facilities. “Reductions in volume of care within VA facilities, and potentially adverse effects on quality” are not addressed, the report notes.

The commission’s recommendations are a product of a fractured political divide within the commission itself. Members who supported the VHA constantly fought with hospital-industry executives as well as representatives of the conservative Koch brothers–funded Concerned Veterans for America (CVA), the so-called Strawman group, which advocated dismantling VHA. Darin Selnick and Stewart Hickey, commissioners who were both connected to CVA, refused to sign the final report. They viewed it as weak on privatization.

Two other commissioners had differing views. Michael Blecker, a Vietnam veteran and executive director of Swords to Plowshares, a San Francisco–based veterans organization, refused to sign the document because of serious concerns that the proposed health-care system “would threaten the viability of VA care for millions of veterans who rely on it.” However, Philip Longman, author of Best Care Anywhere: Why VA Health Care Would Work Better For Everyone, one of the few studies of the veterans health-care system, supports the plan with some reservations. He believes it could bring more veterans into the VHA system and improve the quality of care.

To provide a stronger system, Congress would have to allocate more funds to allow the VHA to hire the necessary staff to provide direct care and handle all the demands of integrating private-sector contractors into the veterans health-care system. Without these resources, the integrity of the VHA will be compromised and the agency would face blame for poor care that veterans receive.

The pending VHA privatization bills proposed by Senator John McCain, an Arizona Republican, and Representative Cathy McMorris Rodgers, a Washington Republican (supported by Representative Jeff Miller, a Florida Republican and chair of the House Veterans Affairs Committee), obviously would not give the agency that leeway. Neither would Donald Trump’s plan to give all veterans vouchers for use in the private sector, which would effectively eliminate the VHA. Announced Tuesday, the plan has already sparked outrage from veterans groups and unions.

The news media will also influence future perceptions of the agency. Mainstream media outlets like CNN that use headlines like “Billions spent to fix VA didn’t solve problems, made some issues worse” to describe the commission report help create a VHA-is-broken-beyond-repair narrative. Although The New York Times has been extremely critical of the VHA, its recent editorial opposing VHA privatization could turn what many veterans groups see as an anti-VHA bent in the national news media.

Finally, the commission report stresses that the VHA currently delivers some of the best care anywhere. Rather than just talking about teamwork, most VHA providers actually work in teams, communicate with one another on electronic medical records, and help patients avoid unnecessary and dangerous overtreatment. The VHA also provides some of the best services for mental health, rehabilitation, and homelessness in the country.

A plan that contributes to strengthening the VHA and improving the private-sector health-care system would be a positive development for veterans and all the rest of us. But if the deficiencies in the civilian health-care system begin to infect the VHA, millions of Americans will lose out.

http://prospect.org/article/report-vha-care-commission-recommends-privatizing-some-services

‘Choice,’ privatization will dismantle VA’s system of care

By Michael Blecker
San Francisco Chronicle, July 15, 2016

Now that we are in the final stretches of the presidential campaign, it is important to examine both Donald Trump’s and Hillary Clinton’s views on the Veterans Health Administration — particularly the hot-button issue of “expanding choice” — that is, privatizing veterans’ health care.

I served as one of 15 commissioners on the congressional Commission on Care, which last month adopted the dangerous idea of moving toward privatization. That will degrade the Veterans Health Administration’s veteran-centered health care system. I made it clear when I joined the commission that if I thought the results of our work would hurt veterans, then I would not sign the final report.

I didn’t sign.

The commission was appointed by the president and Congress to improve the veterans health care system, not dismantle it. I was one of the very few commissioners who represented veterans who use and depend on the health administration.

The commission’s final report includes 18 recommendations aimed at strengthening the administration, and 17 of them outline solid and bold plans for improvement. The most significant recommendation, however, redesigns the care-delivery system to include private health care providers.

The commission’s recommendation for “choice” was not based on data that show cost savings, improved quality of care, shorter wait times or a belief that veterans’ health care and access will be improved. In fact, independent assessments found that VA care is comparable or even better in clinical quality than private health care. Seventy-five recent studies confirmed this, and yet the commission report does not explain why expanding reliance on lower-quality private health care options will improve veteran care. Ultimately, the decision came down to the fact that the majority of the commissioners were determined to establish a path to privatization.

Privatization would:

Increase costs, because VA doctors are salaried, not incentivized.

Reduce access, because resources will be diverted.

Not improve the quality of care, because it does not ensure that health care providers are well equipped to address veterans’ specific health and cultural needs. For example, fewer than 50 percent of private health care providers regularly screen for PTSD, and fewer than 20 percent are trained to document a veteran’s military history, which can be critical in identifying service-connected health issues.

Not shorten wait times to see a doctor. No data found that wait times in the private sector are any shorter than at the VA. Unlike the VA, the private sector isn’t required to measure wait times.

Dismantle the Veterans Health Care system because, unlike the VHA, the private health care sector has considerable funds dedicated to marketing its services. Economists estimate that “choice” could reduce the patient base by as much as 40 percent. The Veterans Health Administration would have to pay private health care providers to care for veterans, but would not be able to control how providers deliver that care.

When it comes to providing choice to veterans who live more than 40 miles from a VA facility, the VA has been more than willing to enable veterans to use private health care in their communities. Expanding choice in areas like San Francisco, where veterans have access to excellent care at the Fort Miley and Palo Alto veterans hospitals, is not necessary.

Clinton and Trump disagree on private health care options for vets.

Trump said he wants to ensure that “every veteran has the choice to seek care at VA or private care, paid for by our government.” In his 10-point plan for fixing the VA, he states, “The power to choose will stop the wait-time backlogs and force the VA to improve and compete if the department wants to keep receiving veterans’ health care dollars.”

Clinton has said that she wants to restructure the VA but opposes privatization. In her VA platform plan, she states, “From the top leadership to mid-level managers to entry-level employees, everyone at the VA must embody the highest workplace standards. Supervisors must be empowered to suspend or remove underperforming employees in accordance with due process not only for the good of the organization, but in service of our nation’s veterans.”

When I enlisted, I was promised that the nation would take responsibility for the medical and health consequences of military service. We must design our veterans’ health care system for those who need it most, not for those who want it least.

True, operations failures have overshadowed successes in recent years, yet the system is worth saving. The commission’s recommendations related to improving clinical operations, facility and capital assets, governance, health care equity, information technology, supply chain, and workforce management should be implemented promptly. If we adopt the “choice” model, however, we will eviscerate any chance of improving the systems that provide care for more than 9 million veterans.

As a commissioner, a veteran and a lifelong advocate for community-based veteran support services, I have seen the VHA transform into the comprehensive, integrated, wraparound provider of veteran-centered health care that it is now. I do not want to see us move backward.

Michael Blecker is the executive director of Swords to Plowshares, a community-based nonprofit that provides services to 3,000 veterans in the San Francisco Bay Area. To comment, submit your letter to the editor at http://bit.ly/SFChronicleletters.

Weigh in

Tell your congressional representative know that we cannot degrade our nation’s health care system for our veterans.

Tell your political party leaders it is important to improve the operations, not dismantle, the Veterans Health Administration.

http://www.sfchronicle.com/opinion/article/Choice-privatization-will-dismantle-VA-s-8381277.php

Doctor Urges Physician Control of Healthcare System

James Burdick, MD, proposes a doctor-run single-payer system

By Joyce Frieden
Medpage Today, July 15, 2016

A single-payer healthcare system could work in the U.S., but only if doctors are involved with running it, according to James Burdick, MD.

“When the Clinton health plan failed in late 90s, it started to bother me,” said Burdick, a retired transplant surgeon. “Then I started thinking about how we could make it work. The idea of single-payer wasn’t what I was thinking about — I was thinking about how to make it work, and that meant doctors.”

Burdick, a Harvard Medical School graduate and currently professor of surgery at Johns Hopkins University in Baltimore, has written a book, “Talking About Single Payer: Health Care Equality for America,” to explain his idea. One purpose of the book is to counter peoples’ objections to a single-payer system, in which healthcare costs are paid for by the government and financed through income taxes.

“A little over 50% of the healthcare in this country is provided by government programs now — when you add up Medicare, Medicaid, the VA [Department of Veterans Affairs] and a few others — so it’s not such a wild idea to have the government pay for healthcare,” he told MedPage Today in a phone interview.

Critics say that a single-payer system restricts peoples’ choices in healthcare, but Burdick said that under the current system in which many workers get healthcare through their employers, “the employee is actually getting whatever healthcare package is negotiated by the employer and the insurance company the employer is using, so immediately the choices they might have are interfered with by the negotiation between the employer and the insurance company.”

Under Burdick’s proposal, a quasi-governmental organization called a Health Security Board would be established; it would be overseen by the Department of Health and Human Services but would not be an official government agency. The board would include a variety of providers including physicians, nurses, paramedical personnel, hospital administrator, and laypeople, and its job would be “to oversee the healthcare choices that doctors and their patients make.” Among other duties, the board would decide what would constitute “essential health benefits” to be paid for by the government, as well as help oversee healthcare quality and specify what items need to be incorporated into an electronic health record.

“One of the biggest things from the doctor’s point of view is the remarkably complicated system in place now,” Burdick said. “You may have as many as 1,000 different payers for a group of doctors or for a hospital, and the federal government has another set of rules that are increasingly interfering with ‘best’ clinical practice’ and taking time from helping take care of patients, so those things could vanish if we have the system the way I envision it — the patient goes in, everybody has access, they see their doctor, and all these things [like] billing can be dealt with, without interfering with the doctor-patient relationship.”

The Health Security Board “is a pure issue of government control,” Burdick said. “If the rules are handed down by the government, that’s government control. I’m saying the rules need to be handed down to doctors by doctors themselves.”

One thing the Health Security Board would not do is set prices. “This system is not going to be responsible for telling the country how much to pay a doctor,” Burdick said. “The country’s going to have to [figure that out] separately.” The board would discuss how healthcare would be funded and how many of what type of physician would be needed.

One of the most important cost issues is the price of drugs, Burdick said. “I think there is a general understanding that if we had a national system and a single wall for negotiation with drug companies, that their prices would have to come down. The converse question is, [does that] limit innovation, do we make it harder to get the drugs we need for patients, and I make the argument that the answer is No if we do it right.”

“The country could put together a process for negotiating a drug price that could be a lot lower while still recognizing the extraordinary value of all the pharmaceuticals to cure patients,” he added.

The system Burdick envisions would also have a role for state governments. “The process of arranging for payment but not for actual care decisions — logistics and certificates of need — the states would have a role as well.” That includes financing. “So the states would pay some and the federal government would pay some, and that income comes as a single ‘bolus’ payment to the physician and the hospital.”

The Canadian single-payer system is a good example of federal-state cooperation, he noted. “If you talk to Canadians they love their system, and they have a provincial system — the federal government pays [a certain amount] and the province pays the rest.”

Within the U.S., the way the organ transplantation system is structured is a great example of how things can work under a quasi-governmental organization — in this case, the United Network for Organ Sharing, an organization Burdick, as a retired transplant surgeon, is very familiar with. “It’s really a wonderful model for how the medical profession can make care decisions in this quasi-governmental, quasi-private structure I propose for the whole country. Nothing’s perfect…but it’s so much better than what we’ve got now.”

Joyce Frieden is news editor at Medpage Today.

http://www.medpagetoday.com/Washington-Watch/Reform/59127