PNHP

Cancer Deaths have Spiked During the Great Recession

Cancer Deaths have Spiked During the Great Recession

An analysis of disease trends in more than 70 nations shows that cancer mortality rose by more than 263,000 deaths

By Michelle Chen
The Nation, June 3, 2016

What happens to people’s health and well-being when whole continents suffer economic decline, and millions of people become exposed to the strains of poverty? For nearly a decade, the Great Recession has presented researchers with a disturbing natural experiment in public health, and emerging data shows that cancer’s death toll rose along with social hardship.

Yet the groundbreaking study, just published in The Lancet, also suggests the health impacts of a financial collapse can be offset by healthcare policies that protect against the economic assault.

The analysis of disease trends in more than 70 nations shows cancer mortality rose by more than 263,000 deaths specifically in the wealthy countries of the Organisation for Economic Co-operation and Development, following the recession from 2008–10. Focusing on “treatable” varieties, like breast and prostate cancer, and less treatable cancers, researchers linked excess cancer deaths to rising, recession-induced unemployment.

But despite elevated cancer mortality, in countries with universal healthcare systems, the trend was much diminished or negligible. Most excess deaths for treatable cancers were concentrated in countries without universal healthcare coverage. In countries with guaranteed coverage, however, “access to health care is less problematic than in non-[universal healthcare] countries, where access is often provided by means of an employment package.” That finding may seem obvious, but it’s a lesson US policymakers keep ignoring.

A more specific, yet-unpublished dataset, co-author Mahiben Maruthappu tells The Nation, reveals that the United States “saw about 18,000 [excess cancer] deaths during that time, whereas the United Kingdom saw zero [excess] deaths…which we believe is likely or possibly due to the fact that in the US, there isn’t universal health coverage.” Similarly, higher public healthcare investment helped mitigate the negative effect of the recession on cancer death rates, regardless of unemployment trends.

The study did not explicitly compare different healthcare policies across countries, and so did not weigh relative benefits of a single-payer system, such as the United Kingdom’s National Health Service, or universal insurance, like Switzerland’s nationwide private-insurance system. Universality of services was the key. The findings demonstrate the obvious: Even amid economic disaster, even for deadly diseases like cancer, your medical fate improves significantly when access to care does not hinge on whether you happen to be gainfully employed at a business that provides a health plan. (The two-year research period also does not capture the more recent implementation of the Affordable Care Act, so coverage was significantly lower then in the United States.)

In the absence of universal coverage, joblessness affects treatment access in many ways. Loss of coverage could lead to a delay in cancer diagnosis. Or, amid intensified socioeconomic instability, the economic disadvantage associated with unemployment can lead to “less health-seeking behaviors,” along with “mental health and behavioral problems” that might limit one’s access to cancer treatment (for example, when chronic depression impedes a patient from maintaining a medication regimen).

The benefits of comprehensive healthcare investments go beyond cancer. In a study on rising suicide rates linked to the recession in North America and Europe, researchers found that suicide rates lowered significantly with every additional $100 spent on suicide prevention programs.

Nonetheless, spending alone doesn’t always improve health outcomes: The United States outspends every other comparable country on healthcare as a portion of GDP. But under the chaotic private insurance system, we spend a shocking amount shockingly badly. The US government generally provides public healthcare only to the aging (through Medicare) and the extremely poor (through Medicaid), and overall per capita healthcare spending is roughly double the amount spent for each resident in the UK’s single-payer system, where everyone is covered by a single public program. But in addition to higher cancer death rates during the recession, Americans generally have shorter life expectancy and higher rates of chronic disease.

According to Maruthappu, any truly universal healthcare infrastructure must be “sufficiently well financed and sufficiently well delivered…in terms of how it’s implemented across a system, how people are made aware to actually…use a universal healthcare system,” and above all, it must be accessible to all regardless of their health or social status. Otherwise, researchers warned, “amid a background of rising health-care costs, if spending restrictions are not accompanied by proportionate improvements in efficiency, worse quality of care and, in turn, higher mortality levels might follow.”

Even within the EU, where many countries offer universal coverage, the study showed that the recession was linked to a net rise in cancer mortality, which suggests that resource gaps might still persist even in regions where healthcare access is purportedly widespread.

That the complexities of a universal system might not fully protect everyone is also a precautionary note for Obamacare. Although the ACA has significantly expanded insurance coverage nationwide, in practice, major deficits in the care infrastructure persist, alongside racial and economic disparities in access. Meanwhile the insurance industry continues to destabilize people’s finances, as the government mandates enrollment in private health plans costing thousands of dollars a year.

Seeking an alternative to corporate-controlled medicine, some progressive segments of the medical community are offering a second opinion on healthcare reform. A recent petition signed by 2,000 doctors calls for a universal single-payer plan. According to an essay on the plan published in The American Journal of Public Health, the program would eliminate private insurance, along with copayments or deductibles. Completely publicly sponsored, the plan would basically expand the Medicare framework, which provides universal coverage for seniors, to the rest of the country. The question of cost efficiency would be resolved immediately as the overhaul of the system saved up to $500 billion annually through cutting administrative costs by some 15 percent.

The Lancet study complements advocates’ demands for universal healthcare as a social entitlement. Physician and activist Adam Gaffney, who co-authored the essay, says via e-mail that, with about 28 million people still uninsured, and many more burdened by devastating costs and inadequate services, “universal health care can attenuate the negative impact of economic shocks on our health…. A single payer system is the best—and most affordable—way to achieve universal health care, with first-dollar coverage, in the United States.”

So the remedies for our ailing healthcare system may be simpler than expected. What we call the healthcare gap is misdiagnosed: It’s actually a blind spot in our political imagination.

Michelle Chen is a contributing writer for The Nation.

http://www.thenation.com/article/cancer-deaths-have-spiked-during-the-great-recession/

‘Value Creation’ And ‘Value Shifting’ In Health Care

By Uwe E. Reinhardt
Health Affairs Blog, June 1, 2016

Corporate executives, the management consultants who advise them, and the financial industry executives who help corporations finance their capital investments tend to believe that whenever their joint work enhances the wealth of a firm’s shareholders, they ipso facto enhance also the nation’s wealth. It is a soothing narrative, one routinely trotted out to college students in their textbooks of economics, which often slouch vaguely toward propaganda.

Very often this narrative is, of course, valid. It is especially so for venture capitalism, which acts as the midwife, so to speak, of newly-born companies creating valuable products hitherto unknown. It is valid also when established companies introduce new products or even when they merely expand existing product lines. Hereafter in this post, this version of capitalism will be labeled “value creation.”

But, as the pharmaceutical industry has been busily teaching us in recent times, alongside this value-creating facet, modern capitalism can also play a more dubious role by merely redistributing wealth from some members of society (for example, sick people) to the shareholders of particular enterprises, without making any net contribution to overall social value. Hereafter we refer to this process as “value shifting,” meaning that value is taken away from some members of society and channeled to the owners of capital.

It is widely thought that the proper fraction of total social value to be garnered by health care product manufacturers as sales revenue is one that just covers research and development (R&D) and production costs, with a profit margin designed to encourage further innovation — hence the demand that drug manufacturers make their costs transparent to the public. Health care product manufacturers, on the other hand, argue that the proper base for their pricing policies is not the cost of developing and producing their products, but the total social value they create for society. This pricing policy is called “value pricing.” At its extreme, it can extract enormous prices from seriously stricken patients or their insurers, because better health and longer life are so precious.

There is growing evidence that, save perhaps for some economists, American society is not comfortable with the idea of value pricing in health care, as can be inferred from the uproar over the pricing policy adopted by Turing Pharmaceuticals, which raised the price of one long-established product by 5,000 percent, and of Valeant Pharmaceuticals International. Valeant’s business model has been to acquire already existing pharmaceutical companies with long-established products, substantially increase the prices of these products and further enhance short-run cash flow to shareholders, reducing outlays on R&D by the acquired firms. These strategies are purely value shifting. In fact, it can be argued that by reducing R&D spending, Valeant destroyed social value.

Although Turing Pharmaceuticals’ and Valeant Pharmaceuticals’ business models are extreme versions of value shifting, the entire drug industry has for some time now leaned more and more toward that model by repeated price increases for long-existing products. Substantial price hikes have been observed even for off-patent generic products.

Spokespeople for the industry argue that the cash from these price increases flows directly to higher spending on R&D. Some of it probably does. But these firms spend considerably more on SG&A, which stands for “sales [marketing] and general and administrative expenses.” Spending on R&D by these companies tend to be well below 20 percent of revenue, while spending on SG&A is well above 20 percent. From the endless series of advertisements for prescription drugs on cable and network news and entertainment, patients (sick people) can infer that with the prices they pay for drugs, directly out of pocket or through health-insurance premiums, they now have become the main source of financing for the television industry — a truly bizarre circumstance.

Another part of the added cash flow generated by price hikes on existing pharmaceutical products often flows to shareholders through buy-backs of these firms’ stocks in the open market, to boost the earnings per share of the remaining stock outstanding. As Obi Ezekoye, Tim Koller, and Ankit Mittal of McKinsey and Co. argued in a recent article, these stock buy-backs usually do not create value even for the remaining shareholders, let alone add social value.

In short, it is far from clear to what end the industry’s repeated price increases under value shifting are used by the industry. There is no reason to believe that they will all, or even predominantly, flow into R&D.

Consolidation in both the R&D-based and the generics industry through mergers appear to have contributed to value shifting. When large pharmaceutical firms acquire smaller entrepreneurial companies, the objective usually is to expand the R&D pipeline of the large companies whose own R&D shops may have failed to produce enough new breakthroughs. But when large pharmaceutical companies or other health care companies merge, the objective is likely to be mainly to reduce price competition.

There is ample empirical research in health economics showing that consolidation on the supply side of the health care sector has served to drive up prices. It is another way of saying that it supports value shifting, rather than value creation.

My gratuitous advice to the drug industry, and to the health care industry in general, is to be very mindful of the distinction between value creation and value shifting in their pricing policies, lest they eventually invoke the wrath of the losers in that game, with dire consequences.

A healthy addition to corporate board meetings at these companies, for example, might be a presentation on the distribution of family income in the United States, whose median now is around $52,000 (meaning 50 percent of American families have a lower family income). Similarly, the boards should know more about the health insurance status of the American people, including the ever-increasing deductibles and coinsurance families are made to bear. These data might give boards some feel for how much money can reasonably and humanely be extracted from their fellow Americans, especially those in the bottom half of the income distribution, with whom the boards and business executives have lost touch.

http://healthaffairs.org/blog/2016/06/01/value-creation-and-value-shifting-in-health-care/

Uwe Reinhardt once again helps us to understand another aspect of the inequitable economics in our health care system by explaining the difference between value creation and value shifting.

Bringing us new beneficial health care services and products creates value, whereas extracting more revenues from the ill without providing any further health benefit shifts value, creating more wealth for the owners of capital (rent-seekers). Value shifting is pervasive throughout our health care system and has been detrimental to the health and finances of middle- and low-income individuals and families.

Reinhardt concludes, “My gratuitous advice to the drug industry, and to the health care industry in general, is to be very mindful of the distinction between value creation and value shifting in their pricing policies, lest they eventually invoke the wrath of the losers in that game, with dire consequences.”

Dire consequences for the health care rent-seekers, anyone? It’s about time.

Universal Health Care Bill Passes N.Y. Assembly

By Andrea Sears
Public News Service (Boulder, Colo.), June 3, 2016

ALBANY, N.Y. – A bill to provide health care coverage to every New Yorker has passed in the state Assembly by an overwhelming majority.

Health care costs continue to rise despite the federal Affordable Care Act, and almost 2 million New Yorkers still lack health insurance. The New York Health Act would provide complete health care without deductibles, co-pays or provider networks.

Dr. Oliver Fein, who chairs the New York Metro Chapter of Physicians for a National Health Program, said it would make the state a leader in providing health care coverage, “offering a pathway to universal coverage without costing more and guaranteeing access to health care for everyone.”

Assembly Health Committee chair Dick Gottfried, D-Manhattan, lead sponsor of the bill, said the publicly funded system could save New Yorkers $45 billion a year.

According to Fein, the profits and administrative costs of the private insurance industry now consume from 20 percent to 30 percent of every health care dollar.

“What you’re measuring in administrative costs is not merely the insurance company costs,” he said, “but also the costs within hospitals, which have to maintain billing departments.”

Last year, 40 percent of New Yorkers reported having to cut down on other expenses to be able to afford medical care. New York’s health-insurance plans are asking the state for a 17 percent rate increase for next year.

Fein said eliminating the costs of private insurance would make it possible to extend coverage to those who now have no insurance.

“We could do it without actually increasing the overall costs to the system,” he said, “so there would be no necessity to raise premium rates.”

The bill has the support of more than 20 state senators, but Fein said he believes the current leadership is unlikely to bring the bill to the floor of the Senate for a vote.

Details of the bill are online at assembly.state.ny.us.

http://www.publicnewsservice.org/2016-06-03/health-issues/universal-health-care-bill-passes-assembly/a52238-1#sthash.Igb1GjTB.dpuf

PNHP note: Additional coverage of the N.Y. Assembly’s action is available at the links below.

Legislative Gazette (Albany, N.Y.)
http://legislativegazette.com/archives/3373

Times Union (Albany, N.Y.)
http://blog.timesunion.com/capitol/archives/249523/advocates-push-for-state-level-single-payer-health-care-system/

North Country Now (Potsdam, N.Y.)
http://northcountrynow.com/news/single-payer-health-care-bill-sponsored-russell-clears-assembly-would-provide-insurance-all-new

Uwe Reinhardt: Support for traditional Medicare is based on trust

Why Many Medicare Beneficiaries Cling to an Allegedly Worse Deal

By Uwe Reinhardt, PhD
JAMA Forum, June 1, 2016

Under the Medicare Prescription Drug, Improvement and Modernization Act of 2003, Congress granted private Medicare Advantage health plans more money per Medicare beneficiary than it granted traditional, government-run Medicare. In other words, the per beneficiary cost paid by the US taxpayers was higher for those enrolled in the private plans than for those enrolled under the traditional, government-run Medicare program.

In addition to these extra payments from government, the private Medicare Advantage plans are able to cut costs through tactics forbidden to traditional Medicare, such as conducting cost-effectiveness analysis for coverage decisions and offering limited networks of health care providers. As a result, the Medicare Advantage plans have been able to offer Medicare beneficiaries more benefits at lower premiums than what is available to them under traditional Medicare–evidently a better deal.

So it’s not surprising, as a recent JAMA Forum post noted, that the Medicare Advantage program has grown in popularity. Currently, about 30% of approximately 55 million beneficiaries are enrolled in a Medicare Advantage plan compared with only 6% a decade ago.

But even so, about 70% of the approximate 55 million Medicare beneficiaries still prefer the “worse” deal, traditional, government-run Medicare. What can explain this revealed preference?

Freedom of Choice

One answer, as the JAMA Forum post hinted, is that traditional Medicare still offers  beneficiaries complete freedom of choice among physicians, hospitals, and other professionals or facilities providing health care. In contrast, under Medicare Advantage, beneficiaries are confined to the limited network of such health professionals and facilities chosen by their insurer. Concerns have been raised about the adequacy of networks in the plans, and a September 2015 report from the US Government Accounting Office recommended that the Centers for Medicare & Medicaid Services increase its oversight of Medicare Advantage networks.

Does the general US public actually share the idea that freedom of choice among insurers is more important than freedom of choice among physicians, hospitals, and others who offer health care or is that merely the preference of a policy-making elite that forces the public to accept more limited choice for the sake of cost containment? It is an important question in light of the endless debate over restructuring Medicare.

The Issue of Trust

Another factor that may explain the revealed preference among Medicare beneficiaries for traditional Medicare might be the issue of trust.

It is said that in the eyes of US public, government is incompetent and cannot be trusted. But is that really so?

The strong revealed preference for traditional, government-run Medicare suggests quite the opposite. So does the tenacity with which US veterans defend the existence of the Veterans Health Administration health care system, the purest form of socialized medicine in the world; the public’s staunch opposition to privatizing Social Security, their government-run pension system; or even the most conservative state governor’s swift solicitation of assistance from the Federal Emergency Management Agency whenever natural disaster strikes. Would these same governors have the same trust in, say, an emergency management system operated by a consortium of private casualty insurers?

Enrolling in traditional Medicare can be likened to being married to a spouse who, if not generally thrilling, is an always faithful and reliable companion. The social contract under traditional Medicare is not easily changed and can be changed only after much open debate.

By contrast, by their very nature, private enterprises cannot be more than ephemeral companions. They may be acquired by another company with different ideas of management and social obligations, and their contracts with customers are easily changed, at the behest of boards and managers who make those decisions in secret. The limited networks of physicians, hospitals, and other health care professionals and facilities under Medicare Advantage can easily change over time, as can be the benefit packages they offer.

It is good that older adults in the United States have a choice between traditional, government-run Medicare and the private Medicare Advantage plans. Ideally, US veterans would be offered the same choice. But policy makers should think twice before writing off traditional, government-run Medicare, which evidently has served the elderly well enough to remain their most popular choice.

https://newsatjama.jama.com/2016/06/01/jama-forum-why-many-medicare-beneficiaries-cling-to-an-allegedly-worse-deal/

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Comment:

By Don McCanne, M.D.

Congress has elected to overpay private Medicare Advantage plans in a scheme to entice Medicare beneficiaries out of the public plan and eventually privatize the full program through premium support (vouchers). With the extra funds the private plans are able to bribe patients with lower premiums and supplementary benefits. So why have two-thirds of Medicare beneficiaries refused to fall for this scheme since it would appear to be a better deal for them (though worse for the taxpayers)? Uwe Reinhardt gives us an astute answer, having to do with trust in our government.

Reinhardt ends with the conclusion that it is good to have the choice between the government program and the private plans, especially since it allows beneficiaries to specifically select the trusted government option. In Canada that choice is not allowed for the same reasons that it should not be allowed here. The private version costs taxpayers more, especially because of extra administrative costs due to the more complex private bureaucracies. The private sector also shamelessly manipulates the system to the detriment of those in the public program, a prime example being the ability to enable private patients to jump the queue, leaving the public patients behind. The private sector also is adept at subjecting the public sector to adverse selection, passing more health care costs onto the taxpayers. And so on.

As an interim measure, what we need to do is demand that Congress provide the same level of funding for the traditional program as they do for the private plans so that premiums and benefits can be comparable (actually better since private plan spending is less efficient). They also need to inflict greater penalties on the private plans for their transgressions in unfairly manipulating the system to their benefit. That is, Congress should provide us with an improved Medicare so that it can become the benchmark for a single payer national health program.

Uwe Reinhardt: Support for traditional Medicare is based on trust

Why Many Medicare Beneficiaries Cling to an Allegedly Worse Deal

By Uwe Reinhardt, PhD
JAMA Forum, June 1, 2016

Under the Medicare Prescription Drug, Improvement and Modernization Act of 2003, Congress granted private Medicare Advantage health plans more money per Medicare beneficiary than it granted traditional, government-run Medicare. In other words, the per beneficiary cost paid by the US taxpayers was higher for those enrolled in the private plans than for those enrolled under the traditional, government-run Medicare program.

In addition to these extra payments from government, the private Medicare Advantage plans are able to cut costs through tactics forbidden to traditional Medicare, such as conducting cost-effectiveness analysis for coverage decisions and offering limited networks of health care providers. As a result, the Medicare Advantage plans have been able to offer Medicare beneficiaries more benefits at lower premiums than what is available to them under traditional Medicare–evidently a better deal.

So it’s not surprising, as a recent JAMA Forum post noted, that the Medicare Advantage program has grown in popularity. Currently, about 30% of approximately 55 million beneficiaries are enrolled in a Medicare Advantage plan compared with only 6% a decade ago.

But even so, about 70% of the approximate 55 million Medicare beneficiaries still prefer the “worse” deal, traditional, government-run Medicare. What can explain this revealed preference?

Freedom of Choice

One answer, as the JAMA Forum post hinted, is that traditional Medicare still offers  beneficiaries complete freedom of choice among physicians, hospitals, and other professionals or facilities providing health care. In contrast, under Medicare Advantage, beneficiaries are confined to the limited network of such health professionals and facilities chosen by their insurer. Concerns have been raised about the adequacy of networks in the plans, and a September 2015 report from the US Government Accounting Office recommended that the Centers for Medicare & Medicaid Services increase its oversight of Medicare Advantage networks.

Does the general US public actually share the idea that freedom of choice among insurers is more important than freedom of choice among physicians, hospitals, and others who offer health care or is that merely the preference of a policy-making elite that forces the public to accept more limited choice for the sake of cost containment? It is an important question in light of the endless debate over restructuring Medicare.

The Issue of Trust

Another factor that may explain the revealed preference among Medicare beneficiaries for traditional Medicare might be the issue of trust.

It is said that in the eyes of US public, government is incompetent and cannot be trusted. But is that really so?

The strong revealed preference for traditional, government-run Medicare suggests quite the opposite. So does the tenacity with which US veterans defend the existence of the Veterans Health Administration health care system, the purest form of socialized medicine in the world; the public’s staunch opposition to privatizing Social Security, their government-run pension system; or even the most conservative state governor’s swift solicitation of assistance from the Federal Emergency Management Agency whenever natural disaster strikes. Would these same governors have the same trust in, say, an emergency management system operated by a consortium of private casualty insurers?

Enrolling in traditional Medicare can be likened to being married to a spouse who, if not generally thrilling, is an always faithful and reliable companion. The social contract under traditional Medicare is not easily changed and can be changed only after much open debate.

By contrast, by their very nature, private enterprises cannot be more than ephemeral companions. They may be acquired by another company with different ideas of management and social obligations, and their contracts with customers are easily changed, at the behest of boards and managers who make those decisions in secret. The limited networks of physicians, hospitals, and other health care professionals and facilities under Medicare Advantage can easily change over time, as can be the benefit packages they offer.

It is good that older adults in the United States have a choice between traditional, government-run Medicare and the private Medicare Advantage plans. Ideally, US veterans would be offered the same choice. But policy makers should think twice before writing off traditional, government-run Medicare, which evidently has served the elderly well enough to remain their most popular choice.

https://newsatjama.jama.com/2016/06/01/jama-forum-why-many-medicare-beneficiaries-cling-to-an-allegedly-worse-deal/

Congress has elected to overpay private Medicare Advantage plans in a scheme to entice Medicare beneficiaries out of the public plan and eventually privatize the full program through premium support (vouchers). With the extra funds the private plans are able to bribe patients with lower premiums and supplementary benefits. So why have two-thirds of Medicare beneficiaries refused to fall for this scheme since it would appear to be a better deal for them (though worse for the taxpayers)? Uwe Reinhardt gives us an astute answer, having to do with trust in our government.

Reinhardt ends with the conclusion that it is good to have the choice between the government program and the private plans, especially since it allows beneficiaries to specifically select the trusted government option. In Canada that choice is not allowed for the same reasons that it should not be allowed here. The private version costs taxpayers more, especially because of extra administrative costs due to the more complex private bureaucracies. The private sector also shamelessly manipulates the system to the detriment of those in the public program, a prime example being the ability to enable private patients to jump the queue, leaving the public patients behind. The private sector also is adept at subjecting the public sector to adverse selection, passing more health care costs onto the taxpayers. And so on.

As an interim measure, what we need to do is demand that Congress provide the same level of funding for the traditional program as they do for the private plans so that premiums and benefits can be comparable (actually better since private plan spending is less efficient). They also need to inflict greater penalties on the private plans for their transgressions in unfairly manipulating the system to their benefit. That is, Congress should provide us with an improved Medicare so that it can become the benchmark for a single payer national health program.

PCORI: What works best?

Patient-Centered Outcomes Research Institute (PCORI)

The Patient-Centered Outcomes Research Institute (PCORI), an independent nonprofit, nongovernmental organization located in Washington, DC, was authorized by Congress in 2010.

Our mandate is to improve the quality and relevance of evidence available to help patients, caregivers, clinicians, employers, insurers, and policy makers make informed health decisions. Specifically, we fund comparative clinical effectiveness research, or CER, as well as support work that will improve the methods used to conduct such studies.

The goal of our work is to determine which of the many healthcare options available to patients and those who care for them work best in particular circumstances. We do this by taking a particular approach to CER called Patient-Centered Outcomes Research, or PCOR, research that addresses the questions and concerns most relevant to patients, and we involve patients, caregivers, clinicians, and other healthcare stakeholders, along with researchers, throughout the process.

From the 2015 Financial Report

The Patient-Centered Outcomes Research Institute was authorized in 2010 by the Patient Protection and Affordable Care Act (42 U.S.C. 1301 et seq.) (Act) to “assist patients, clinicians, purchasers, and policy- makers in making informed health decisions by advancing the quality and relevance of evidence concerning the manner in which diseases, disorders, and other health conditions can effectively and appropriately be prevented, diagnosed, treated, monitored, and managed through research and evidence synthesis.” It does this by supporting comparative clinical effectiveness research (CER) projects designed to answer questions most important to patients. PCORI is also charged with disseminating the results of that research, focusing on “health outcomes, clinical effectiveness, and appropriateness of the medical treatments, services, and items” studied.

PCORI is a 501(c)(1) tax-exempt, nonprofit corporation, governed by a 21-member multi-stakeholder Board of Governors, including 19 members appointed by the Comptroller General of the United States. By law, the Comptroller General must appoint three members representing patients and healthcare consumers; seven members representing physicians and providers; three members representing private payers; three members representing pharmaceutical, device and diagnostic manufacturers or developers; one member representing quality improvement or independent health services researchers; and two members representing the federal government or the states (including at least one member representing a federal health program or agency). The Act also provides that the Directors of the Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health (NIH), or their designees, be members of the Board.

How We’re Funded

PCORI is funded through the Patient-Centered Outcomes Research Trust Fund (PCOR Trust Fund), which was established by Congress through the Patient Protection and Affordable Care Act of 2010. The PCOR Trust Fund receives income from three funding streams:  appropriations from the general fund of the Treasury, transfers from the Centers for Medicare and Medicaid trust funds, and a fee assessed on private insurance and self-insured health plans (the PCOR fee).

PCORI receives 80 percent of the monies collected by the PCOR Trust Fund to support its research funding and operations. The Department of Health and Human Services (HHS) receives the other 20 percent of trust fund monies to support dissemination and research capacity-building efforts (the majority of HHS’s share goes to the Agency for Healthcare Research and Quality).

For government fiscal years (FYs) 2010 through 2012, the PCOR Trust Fund received a total of $210 million total in appropriations from general fund revenues. For FYs 2013 through 2019, the PCOR Trust Fund will receive $150 million from the general fund annually.

http://www.pcori.org

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Re-evaluating the Patient-Centered Outcomes Research Institute

By Zeke Emanuel, Topher Spiro, Thomas Huelskoetter
Center for American Progress, May 31, 2016

The ACA established PCORI with a clear mandate to carry out the “funding of comparative clinical effectiveness research” over 10 years. PCORI was to focus distinctly on CER and not duplicate the types of research funded by the Agency for Healthcare Research and Quality, the National Institutes of Health, or other entities. However, a Center for American Progress analysis in 2014 found that only one-third of PCORI’s funding was going toward CER.

PCORI studies should have the potential to change clinical treatment decisions or insurers’ coverage determinations. Yet to date, this potential impact on the nation’s health care system has not been fully realized. With PCORI only authorized through 2019, the institute is running out of time to make a significant impact on CER.

Cumulatively since its inception, PCORI has invested 51 percent of its almost $1.4 billion in grant funding in CER, totaling $716 million.

To evaluate whether PCORI’s funding was directed toward high-impact research areas, CAP examined how many of its awards addressed research questions that the Institute of Medicine identified as the top 25 highest-priority CER topics. In fairness, this is not the only relevant ranking of CER needs, and priorities may have evolved since the IOM list was published in 2009. However, the IOM list serves as an authoritative, independent rubric by which to judge whether PCORI is focusing on the most critical evidence gaps in medicine.

In its previous analysis, CAP found that only 12 percent of PCORI’s grants and 14 percent of its grant funding went toward research topics in the IOM’s top quartile. In the new CAP analysis, this first figure declined to 4 percent of grants. However, the percentage of funding allocated to the IOM topics increased to 18.5 percent. IOM top-quartile priority topics cumulatively represent 16 percent of PCORI’s funding to date, representing relatively little change from CAP’s previous analysis.

In response to this analysis, PCORI asserts that 72 percent of the IOM’s top 25 topics have been addressed by a PCORI-funded study, along with 62 percent of the IOM’s top 100 topics. Yet this alternate framing of the issue still leaves almost 30 percent of the top quartile and almost 40 percent of the top 100 unaddressed after several years. Furthermore, this metric explains nothing about whether these studies involved significant or merely minimal funding. Many of these research topics concern broad areas of medicine where many studies are needed; as a result, CAP feels it is important not only that high-impact research topics be addressed but that a significant percentage of PCORI’s funding be connected to such topics.

Thus far, PCORI has not made the impact on the health care system that the drafters of the Affordable Care Act envisioned. The need for CER remains urgent, and PCORI still has the potential to help reduce health care costs and improve the quality of care.

https://www.americanprogress.org/issues/healthcare/report/2016/05/31/138242/re-evaluating-the-patient-centered-outcomes-research-institute/

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Report: Federally funded institute avoids comparing drugs, other treatments

By Jane O’Donnell
USA Today, May 31, 2016

An institute that pays researchers to compare medical treatments has spent only half of its more than $1.4 billion in available federal money on what is called comparative effectiveness research and has largely ignored prescription drugs, despite their role in driving up health care costs, according to a study released Tuesday by a Washington-based policy group.

PCORI has been criticized since it first appeared in the legislation that became the ACA. Although CER had bipartisan support, the institute got caught in the politics surrounding what Republican former vice presidential candidate Sarah Palin called “death panels” that could decide who received medical treatment.

Now despite widespread concerns about rising drug costs, CER is being attacked by patient groups supported by the pharmaceutical industry that claim the research could limit access to some life-saving drugs.

Congress limited the ability of PCORI to consider costs when comparing health care, drugs or prioritizing research studies.

Patient groups, which are nearly always backed by pharmaceutical companies, are major players in what PCORI decides to research. That can limit the focus on finding lower-cost options, which could hurt the profitability of the companies that pay for the patient groups.

http://www.usatoday.com/story/news/politics/2016/05/31/report-federally-funded-institute-avoids-comparing-drugs-other-treatments/84676320/

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Comment:

By Don McCanne, M.D.

The Patient-Centered Outcomes Research Institute (PCORI) is an independent, nonprofit, nongovernmental organization authorized by the Affordable Care Act and funded predominantly by the federal government. They in turn fund comparative clinical effectiveness research (CER), especially through Patient-Centered Outcomes Research (PCOR). The purpose is to determine the relative effectiveness of various clinical approaches, including the comparison of drug therapies. But Congress specifically prohibited a comparison of costs.

Some readers of yesterday’s report on the ICER (Institute for Clinical and Economic Review) were concerned about the potential conflict of interest that could result from the involvement of various stakeholders. The same concern could be expressed about PCORI. Although we have no reason to doubt the integrity of the individuals involved in these organizations, it would be preferred that their organizations have an infrastructure that did not include the influence of vested interests.

An additional concern regarding PCORI is the interference by Congress in preventing crucial determinations about cost effectiveness. Transparency in pricing is essential if we are to ensure value in our health care purchasing.

Another unique feature of PCORI is that it is only a ten year program, scheduled to end in 2019. It is astonishing that members of the policy community, working with Congress, could ever think that we could complete all important comparative effectiveness research by 2019, and that future drugs and technology would not require such reviews.

Just as with ICER, PCORI is under attack by conservatives and by stakeholders, motivated by ideology and by greed. Once again, it appears that, with their influence, the patient is not always being kept foremost in our policy decisions.

We want health care that is the most effective and with the fairest prices. We don’t want health care that gives the most powerful stakeholders a greater advantage in the health care marketplace while also ensuring them a maximum return on their investments. ICER and PCORI seem to be above that, but 100 percent public funding without stakeholder involvement in governance could give us further assurance that their work product is strictly in the patients’ best interests.

PCORI: What works best?

Patient-Centered Outcomes Research Institute (PCORI)

The Patient-Centered Outcomes Research Institute (PCORI), an independent nonprofit, nongovernmental organization located in Washington, DC, was authorized by Congress in 2010.

Our mandate is to improve the quality and relevance of evidence available to help patients, caregivers, clinicians, employers, insurers, and policy makers make informed health decisions. Specifically, we fund comparative clinical effectiveness research, or CER, as well as support work that will improve the methods used to conduct such studies.

The goal of our work is to determine which of the many healthcare options available to patients and those who care for them work best in particular circumstances. We do this by taking a particular approach to CER called Patient-Centered Outcomes Research, or PCOR, research that addresses the questions and concerns most relevant to patients, and we involve patients, caregivers, clinicians, and other healthcare stakeholders, along with researchers, throughout the process.

From the 2015 Financial Report

The Patient-Centered Outcomes Research Institute was authorized in 2010 by the Patient Protection and Affordable Care Act (42 U.S.C. 1301 et seq.) (Act) to “assist patients, clinicians, purchasers, and policy- makers in making informed health decisions by advancing the quality and relevance of evidence concerning the manner in which diseases, disorders, and other health conditions can effectively and appropriately be prevented, diagnosed, treated, monitored, and managed through research and evidence synthesis.” It does this by supporting comparative clinical effectiveness research (CER) projects designed to answer questions most important to patients. PCORI is also charged with disseminating the results of that research, focusing on “health outcomes, clinical effectiveness, and appropriateness of the medical treatments, services, and items” studied.

PCORI is a 501(c)(1) tax-exempt, nonprofit corporation, governed by a 21-member multi-stakeholder Board of Governors, including 19 members appointed by the Comptroller General of the United States. By law, the Comptroller General must appoint three members representing patients and healthcare consumers; seven members representing physicians and providers; three members representing private payers; three members representing pharmaceutical, device and diagnostic manufacturers or developers; one member representing quality improvement or independent health services researchers; and two members representing the federal government or the states (including at least one member representing a federal health program or agency). The Act also provides that the Directors of the Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health (NIH), or their designees, be members of the Board.

How We’re Funded

PCORI is funded through the Patient-Centered Outcomes Research Trust Fund (PCOR Trust Fund), which was established by Congress through the Patient Protection and Affordable Care Act of 2010. The PCOR Trust Fund receives income from three funding streams:  appropriations from the general fund of the Treasury, transfers from the Centers for Medicare and Medicaid trust funds, and a fee assessed on private insurance and self-insured health plans (the PCOR fee).

PCORI receives 80 percent of the monies collected by the PCOR Trust Fund to support its research funding and operations. The Department of Health and Human Services (HHS) receives the other 20 percent of trust fund monies to support dissemination and research capacity-building efforts (the majority of HHS’s share goes to the Agency for Healthcare Research and Quality).

For government fiscal years (FYs) 2010 through 2012, the PCOR Trust Fund received a total of $210 million total in appropriations from general fund revenues. For FYs 2013 through 2019, the PCOR Trust Fund will receive $150 million from the general fund annually.

http://www.pcori.org

***

Re-evaluating the Patient-Centered Outcomes Research Institute

By Zeke Emanuel, Topher Spiro, Thomas Huelskoetter
Center for American Progress, May 31, 2016

The ACA established PCORI with a clear mandate to carry out the “funding of comparative clinical effectiveness research” over 10 years. PCORI was to focus distinctly on CER and not duplicate the types of research funded by the Agency for Healthcare Research and Quality, the National Institutes of Health, or other entities. However, a Center for American Progress analysis in 2014 found that only one-third of PCORI’s funding was going toward CER.

PCORI studies should have the potential to change clinical treatment decisions or insurers’ coverage determinations. Yet to date, this potential impact on the nation’s health care system has not been fully realized. With PCORI only authorized through 2019, the institute is running out of time to make a significant impact on CER.

Cumulatively since its inception, PCORI has invested 51 percent of its almost $1.4 billion in grant funding in CER, totaling $716 million.

To evaluate whether PCORI’s funding was directed toward high-impact research areas, CAP examined how many of its awards addressed research questions that the Institute of Medicine identified as the top 25 highest-priority CER topics. In fairness, this is not the only relevant ranking of CER needs, and priorities may have evolved since the IOM list was published in 2009. However, the IOM list serves as an authoritative, independent rubric by which to judge whether PCORI is focusing on the most critical evidence gaps in medicine.

In its previous analysis, CAP found that only 12 percent of PCORI’s grants and 14 percent of its grant funding went toward research topics in the IOM’s top quartile. In the new CAP analysis, this first figure declined to 4 percent of grants. However, the percentage of funding allocated to the IOM topics increased to 18.5 percent. IOM top-quartile priority topics cumulatively represent 16 percent of PCORI’s funding to date, representing relatively little change from CAP’s previous analysis.

In response to this analysis, PCORI asserts that 72 percent of the IOM’s top 25 topics have been addressed by a PCORI-funded study, along with 62 percent of the IOM’s top 100 topics. Yet this alternate framing of the issue still leaves almost 30 percent of the top quartile and almost 40 percent of the top 100 unaddressed after several years. Furthermore, this metric explains nothing about whether these studies involved significant or merely minimal funding. Many of these research topics concern broad areas of medicine where many studies are needed; as a result, CAP feels it is important not only that high-impact research topics be addressed but that a significant percentage of PCORI’s funding be connected to such topics.

Thus far, PCORI has not made the impact on the health care system that the drafters of the Affordable Care Act envisioned. The need for CER remains urgent, and PCORI still has the potential to help reduce health care costs and improve the quality of care.

https://www.americanprogress.org/issues/healthcare/report/2016/05/31/138242/re-evaluating-the-patient-centered-outcomes-research-institute/

***

Report: Federally funded institute avoids comparing drugs, other treatments

By Jane O’Donnell
USA Today, May 31, 2016

An institute that pays researchers to compare medical treatments has spent only half of its more than $1.4 billion in available federal money on what is called comparative effectiveness research and has largely ignored prescription drugs, despite their role in driving up health care costs, according to a study released Tuesday by a Washington-based policy group.

PCORI has been criticized since it first appeared in the legislation that became the ACA. Although CER had bipartisan support, the institute got caught in the politics surrounding what Republican former vice presidential candidate Sarah Palin called “death panels” that could decide who received medical treatment.

Now despite widespread concerns about rising drug costs, CER is being attacked by patient groups supported by the pharmaceutical industry that claim the research could limit access to some life-saving drugs.

Congress limited the ability of PCORI to consider costs when comparing health care, drugs or prioritizing research studies.

Patient groups, which are nearly always backed by pharmaceutical companies, are major players in what PCORI decides to research. That can limit the focus on finding lower-cost options, which could hurt the profitability of the companies that pay for the patient groups.

http://www.usatoday.com/story/news/politics/2016/05/31/report-federally-funded-institute-avoids-comparing-drugs-other-treatments/84676320/

The Patient-Centered Outcomes Research Institute (PCORI) is an independent, nonprofit, nongovernmental organization authorized by the Affordable Care Act and funded predominantly by the federal government. They in turn fund comparative clinical effectiveness research (CER), especially through Patient-Centered Outcomes Research (PCOR). The purpose is to determine the relative effectiveness of various clinical approaches, including the comparison of drug therapies. But Congress specifically prohibited a comparison of costs.

Some readers of yesterday’s report on the ICER (Institute for Clinical and Economic Review) were concerned about the potential conflict of interest that could result from the involvement of various stakeholders. The same concern could be expressed about PCORI. Although we have no reason to doubt the integrity of the individuals involved in these organizations, it would be preferred that their organizations have an infrastructure that did not include the influence of vested interests.

An additional concern regarding PCORI is the interference by Congress in preventing crucial determinations about cost effectiveness. Transparency in pricing is essential if we are to ensure value in our health care purchasing.

Another unique feature of PCORI is that it is only a ten year program, scheduled to end in 2019. It is astonishing that members of the policy community, working with Congress, could ever think that we could complete all important comparative effectiveness research by 2019, and that future drugs and technology would not require such reviews.

Just as with ICER, PCORI is under attack by conservatives and by stakeholders, motivated by ideology and by greed. Once again, it appears that, with their influence, the patient is not always being kept foremost in our policy decisions.

We want health care that is the most effective and with the fairest prices. We don’t want health care that gives the most powerful stakeholders a greater advantage in the health care marketplace while also ensuring them a maximum return on their investments. ICER and PCORI seem to be above that, but 100 percent public funding without stakeholder involvement in governance could give us further assurance that their work product is strictly in the patients’ best interests.

Troubled Kids’ Psychiatric Care Often Delayed by Insurance Rules

Dealing with red tape consumes clinicians’ time, poses danger to patients, researchers say

Medline Plus, March 25, 2016

(HealthDay News) — Children with severe psychiatric problems often have lengthy waits before they’re transferred from a hospital emergency department to a psychiatric hospital due to insurance companies’ “prior authorization” requirements, a small study suggests.

Mental health workers at one Rhode Island hospital spent an average of an hour on the telephone seeking insurance companies’ approval, the study authors reported. In one case, the researchers said approval took up to 4.5 hours.

“The majority of these kids are suicidal; a minority of them are homicidal. That’s as dangerous as having a burst appendix,” said study senior author Dr. J. Wesley Boyd, a psychiatrist at Cambridge Health Alliance in Cambridge, Mass.

All of the admissions were ultimately approved. This suggests that prior authorization appears to serve “more as an administrative hurdle,” the study authors wrote.

“This is rationing care by hassle factor,” said study lead author Dr. Amy Funkenstein, an assistant professor of medicine at Tufts University in Boston.

The study was scheduled to be published in a letter March 30 in the American Journal of Emergency Medicine.

Rhode Island allows prior authorization for any inpatient admission but prohibits its use for any type of emergency service, said Linda Johnson. She’s the operations director for the Office of the Health Insurance Commissioner in Cranston, R.I.

Currently, state regulators are combing hundreds of insurance company records to assess compliance with the state’s mental health parity law, she said. The question is whether a patient needing psychiatric hospitalization meets the definition of emergency, she explained.

Prior authorization assures that a patient is covered under a health plan, the requested service is a covered benefit and the most appropriate level of care is provided, explained Pamela Greenberg, president and CEO of the Association for Behavioral Health and Wellness in Washington, D.C.

Patients may be better served in partial hospitalization or intensive outpatient programs, for example, said Greenberg, whose association members are mostly large insurance companies.

“You have to look at costs, too; let’s be honest,” she added.

Dr. Joseph Mawhinney, a San Diego-based child and adolescent psychiatrist, called the prior authorization process “a bureaucratic maze” wrought with wrong phone numbers, dropped calls and people at the other end of the line not having authority to make a decision, requiring a referral to someone else.

“It can go on and on and on. Meanwhile, you don’t have a decision or a placement,” said Mawhinney. He’s also a member of the American Psychiatric Association’s (APA) Council on Healthcare Systems and Financing, and chairs the APA’s Access to Care Workgroup.

Between May and October 2014, psychiatric clinicians at Hasbro Children’s Hospital in Rhode Island kept track of the time spent on the phone with insurance companies on behalf of kids in need of psychiatric admission.

Researchers collected paperwork on 203 patients aged 4 to 19. In more than half of the cases, hospital psychiatrists recommended admission due to suicidal thoughts or a suicide attempt. Other common reasons for admission included aggression (22 percent) and homicidal thoughts (10 percent), the study reported.

From initial contact with the insurer to authorization, phone times ranged from 3 minutes to 270 minutes, and the average amount of time spent on the phone was 60 minutes, the study found.

Based on total psychiatric admissions nationwide, that translates into more than 1.5 million hours of “wasted clinician time,” the researchers said in a Cambridge Health Alliance news release. Those hours translate into a staggering amount of wasted health care dollars — about $31 billion a year, the researchers estimated.

The average time cited in the study is actually shorter than the median 79-minute “boarding time” from emergency department to hospital bed, said Clare Krusing. She’s a spokeswoman for America’s Health Insurance Plans, in Washington, D.C.

While not addressed directly in the study, the authors questioned whether prior authorization for psychiatric admissions violates federal mental health parity legislation. Under federal rules, managed care protocols, such as prior authorization, must be applied equally to mental health and medical/surgical care.

“They [health insurers] use the same process for medical necessity review across all services,” Krusing said.

She also noted that the study “completely ignores any details about what information the clinician provided to the insurance company as they were reviewing the request.”

Boyd believes health insurers continue to unfairly single out psychiatric cases for prior authorization.

“Somehow or other, the insurance companies continue to flout the intent behind parity, and I’m not quite sure how they continue to get away with it,” he said.

***

“Prior authorization for child and adolescent psychiatric patients deemed to be in need of inpatient admission,” Amy Funkenstein, MD, Stephanie Hartselle, MD, J. Wesley Boyd, MD, PhD. The American Journal of Emergency Medicine, May 2016, Vol. 34, Issue 5, pp. 915–916. DOI: http://dx.doi.org/10.1016/j.ajem.2016.02.027

***

SOURCES: J. Wesley Boyd, M.D., Ph.D., psychiatrist, Cambridge Health Alliance, Cambridge, Mass., and professor of psychiatry, Harvard Medical School, Boston; Amy Funkenstein, M.D., assistant professor of medicine, Tufts University, Boston; Linda Johnson, operations director, Office of the Health Insurance Commissioner, Cranston, R.I.; Pamela Greenberg, president and CEO, Association for Behavioral Health and Wellness, Washington, D.C.; Joseph Mawhinney, M.D., child and adolescent psychiatrist, San Diego, member, Council on Healthcare Systems and Financing, and chair, Access to Care Workgroup, American Psychiatric Association, Arlington, Va.; Clare Krusing, spokeswoman, America’s Health Insurance Plans, Washington, D.C.; March 3, 2016, news release, Cambridge Health Alliance; March 30, 2016, American Journal of Emergency Medicine.

https://www.nlm.nih.gov/medlineplus/news/fullstory_157978.html

Support Medicare for All plan

By William Reed, M.D.
Lake Geneva (Wis.) Regional News, Letters, May 26, 2016

I am writing in response to the letter of Joanne Williams on May 5, and the difficult health care situation in the United States.

Indeed, prices for pharmaceuticals, medical equipment and hospital care are much higher than in other wealthy industrialized countries. Yet in the U.S. we have the Veterans Administration system that buys all medicines at a 40 percent discount. Why is that?

The reality is that in our country private, investor-owned insurance plans have proven over 25 years that they have no power to control costs or prices. Yet, they are one of the most profitable sectors of the economy. Other counters spend one-half to one-third less on total national health care, cover all citizens and have better outcomes that we do.

They do this by having a single national health program that directs the spending of public money. For-profit financing by insurance companies add only expenses. Yet, these countries maintain the private, competing provision of health care by doctors and hospitals.

Paul Ryan has an idea of ending traditional Medicare with an unproven “voucher” system and having patients put “more skin in the game” and supporting commercial Medicare HMOs, the Advantage Plans. These are all failed ideas that have been tried.

Medicare works. It has a 3 percent administrative cost, and can be improved to eliminate deductibles and copayments. I believe that our political representatives are obligated to answer: why would Enhanced Medicare for All, as in House Bill HR 676, not work for the U.S.?

Dr. William Reed resides in Walworth.

http://www.lakegenevanews.net/

An important step for Oregon health care reform

By Samuel Metz, M.D.
The Oregonian, May 30, 2016

This month, the Oregon Health Authority made a wise decision: It approved the RAND Corporation to perform its legislatively mandated study of financing high-value health care in our state.

This is no small effort. Health care in Oregon consumes about $38 billion annually (the completed study will provide a better figure) — 18 percent of all spending in the state. This is twice what Europeans and other English-speaking countries spend on health care. Yet most measures of public health place Oregon at the bottom of the industrialized world. The rest of our country looks no better.

The RAND Corporation’s first challenge is to analyze four methods of financing universal care in Oregon, in which each option must provide all Oregonians with care when they need it. Then comes the hard part: It must select the best option for our Legislature.

Why study universal care? To remedy our low-value health care spending, the Oregon Legislature recognized that every other industrialized nation provides universal care. And all these nations provide better care to more people for less money. That’s “high-value.”

Oregon’s study focuses specifically on one aspect of high-value care: how to best collect the money (e.g., premiums, single payer, state-purchased private insurance). The study leaves for another time the question of how to best pay providers (e.g., fee for service, capitated funds, managed care).

This focus is appropriate. Oregon should not speculate on how to spend health care funds until it finds a sustainable way to collect money in the first place. Hence, the RAND Corporation’s study will start Oregon’s health care reform discussion, but not end it.

Why was this organization a good choice? The RAND Corporation is one of America’s oldest policy-analysis think tanks, created in 1948 in the heat of the Cold War. One of its first researchers was Herman Kahn, author of “On Thermonuclear War.” (Kahn was reputedly a model for Dr. Strangelove in the movie of that name.)

But the RAND Corporation expanded from national defense into health care with a dramatic series of experiments in the 1970s examining the relationship between insurance deductibles and outcomes. These publications remain a mainstay of insurance analysis to this day.

The Oregon Health Authority picked a credible, competent and experienced organization to investigate health care financing in Oregon.

One challenge, however: Organizations performing similar studies for other states estimated our study needs 12 to 18 months for completion. Had the OHA made its selection immediately after the bill was signed in August 2015, the chosen organization may have completed its work by the November 2016 deadline. Now, 10 months later, the RAND Corporation has only five months.

But the RAND Corporation knows its business. Regardless of when it presents its results, our legislators will finally possess the information they need to make intelligent decisions about the future of health care in Oregon.

The OHA did its job: It selected the right organization. The RAND Corporation will now do its job: perform a competent analysis. Ultimately, we Oregonians must then do our job: ensure our legislators read and act on the results.

This study is the next critical step toward achieving better care to more people for less in Oregon.

Samuel Metz, of Southwest Portland, is an anesthesiologist.

http://www.oregonlive.com/opinion/index.ssf/2016/05/an_improtant_step_for_oregon_h.html

How to fix health care costs

By Cris M. Currie, R.N.
The Spokesman-Review (Spokane, Wash.), May 28, 2016

I am a registered nurse. Virtually everyone I talk to about American health care has a horror story about paying their medical bills. Yet why is it that most of these same people are resigned to the idea that quality care requires insurance companies who supposedly are looking out for our best interests?

Why are we so accepting of underinsurance with the ever-increasing high deductibles, copays, coinsurance and premiums, of the ever-present worry of physical and financial catastrophe, of limited provider networks, of having to fill out the same paperwork over and over again, of having to seek and wait for pre-authorization, of having to appeal denied claims, of incomprehensible insurance jargon, of having to renew coverage annually, and of multimillion-dollar executive management salaries?

No other country in the developed world has to deal with this kind of deception and abuse and neither should we. While the Affordable Care Act has made a few improvements, cost control was definitely not one of them, and it prompted a merger mania that now has health care conglomerates approaching monopoly status. Managed corporate care has been a colossal failure despite numerous reform efforts. Fortunately there is an alternative.

That alternative is explained in detail in the June 2016 issue of the American Journal of Public Health (available online at www.pnhp.org/nhi). This call for single-payer health reform was prepared by a working group of 39 physicians and endorsed by more than 2,200 physicians from across the country, with more endorsements arriving every day. It is an updated version of a similar physicians’ proposal written in 2003 from which Bernie Sanders has based his health care reform plan.

The key feature is the removal of all financial barriers to medical care primarily by eliminating the nearly 1,300 health insurance companies with their $500 billion in administrative overhead. Instead, the much more successful Medicare program would be expanded to cover everyone as was originally intended (instead of just those over age 65), and its weaknesses would be corrected.

Private insurers’ overhead currently averages 12 percent, compared with only 2.1 percent for fee-for-service Medicare. Numerous studies conducted since 1991 have shown that Americans are already paying way more than is necessary for a universal single-payer system without getting it.

According to more than 40 studies by the Government Accountability Office, the Congressional Budget Office and several prestigious actuarial firms, think tanks and economists, the administrative savings possible with a single-payer system are enough to cover all of the 27 million uninsured people and to upgrade coverage and eliminate all out-of-pocket costs for the underinsured without any increase in total health spending and without restricting the patient’s choice of providers.

The program would be federally financed and administered by federal, state and regional boards, which would determine global budgets for hospitals, set equitable reimbursement rates for providers, negotiate drug prices and improve health planning.

Additionally, modest new progressive taxes would be needed, but these would also reduce income inequality, another cause of poor health. While a payroll tax might be appropriate in the short term, ultimately employers would be freed from the burdens of providing health insurance for their employees. This would greatly facilitate entrepreneurship and increase the global competitiveness of American business.

Importantly, however, any new taxes would be fully offset by the elimination of premiums and other out-of-pocket costs such that the vast majority of Americans would have a substantial increase in their disposable income while being free from the worry of a financial catastrophe related to an unexpected health crisis.

All unrealistic pie-in-the-sky, you say? It’s not, when you talk to the people from other countries who have enjoyed this type of system for decades. Admittedly these other countries did not have an entrenched private insurance system to deconstruct; nor did they face a fanatical capitalism with its oversold faith in free market competition that claims health care as a commodity instead of a right; nor did they have to deal with segregationists who steadfastly refused to provide universal care that would include “Negroes.”

However, the Expanded and Improved Medicare for All Act (HR 676) was recently reintroduced in Congress and now has 62 co-sponsors. Fourteen states, including Colorado (with Amendment 69 on the ballot for this fall) and Washington (HB 1025, 1321 and SB 5132) have pending legislation to develop statewide single-payer health care systems.

And thanks to the Physicians’ Working Group and to Bernie Sanders, the tide is finally starting to turn toward pairing health care with justice.

Cris M. Currie, of Mead, is a registered nurse and member of Health Care for All – Washington.

http://www.spokesman.com/stories/2016/may/28/guest-opinion-how-to-fix-health-care-costs/

Bernie Sanders easily wins the policy debate

By Jeffrey D. Sachs
The Washington Post, May 25, 2016

Mainstream U.S. economists have criticized Democratic presidential candidate Bernie Sanders’s proposals as unworkable, but these economists betray the status quo bias of their economic models and professional experience. It’s been decades since the United States had a progressive economic strategy, and mainstream economists have forgotten what one can deliver. In fact, Sanders’s recipes are supported by overwhelming evidence — notably from countries that already follow the policies he advocates. On health care, growth and income inequality, Sanders wins the policy debate hands down.

On health care, Sanders’s proposal for a single-payer system has been roundly attacked as too expensive. His campaign (for which I briefly served as a foreign policy adviser) is told that his plan will raise taxes and burst the budget. But this attack misses the whole point of his health proposals. While health spending by the government would go up in the Sanders health plan, private insurance payments would disappear, generating huge net savings for the American people.

Countries such as Canada, Germany, Sweden and Britain all follow something like a single-payer approach and pay much less for health care than the United States does. While the United States spent 16.4 percent of gross domestic product on health care in 2013, Canada paid only 10.2 percent; Germany, 11 percent; Sweden, 11 percent; and Britain, 8.5 percent. U.S. overspending is about 5 percent of GDP, or nearly $1 trillion as of 2016, mainly because of the excessive market power of private health insurers and big drug companies. An authoritative study by the U.S. Institute of Medicine confirms this extent of excess costs, finding losses of about 5 percent of GDP in 2009. Critics of Sanders’s health plan have failed to recognize or acknowledge the huge savings and cost reductions that would accompany a single-payer system.

On economic growth, Sanders also easily wins the debate. While President Obama opted for a short-term stimulus that peaked after two years and disappeared by the end of his first term, and Hillary Clinton has proposed a modest infrastructure program over five years, Sanders calls for a much bolder public investment program directed at the skills of young people (through free college tuition) and at modernizing and upgrading America’s infrastructure, with a focus on renewable energy, high-speed rail, safe drinking water and urban public transport. Sanders’s growth strategy would get back to fundamentals: a long-overdue increase in productive investments to underpin good jobs and rising worker productivity.

Sanders’s mainstream critics are mostly Keynesians. Their focus is on total spending, whether it’s consumption or investment. Sanders, instead, focuses on investment because long-term growth depends on more rapid capital accumulation (including in skills and technology). America’s slow growth is no mystery. The U.S. net investment rate has declined to about 5 percent of GDP, down from about 10 percent of GDP during the 1960s and 1970s. Sanders’s plan would restore a high-investment economy and, with it, a higher growth rate.

On income distribution, Sanders accurately argues that U.S. income inequality is uniquely high among the rich countries. Only the United States has deep poverty alongside soaring wealth. Only the United States tolerates a hedge-fund industry in which poorly performing money managers (not to mention quite a few crooks) take home billions of dollars in pay, backed by unconscionable tax breaks pushed by Democratic and Republican senators who live off of the largesse of Wall Street.

Consider the most basic measure of income inequality, the Gini coefficient. This measures the inequality of income among households, with zero signifying complete equality and 1 complete inequality. For high-income countries, a Gini coefficient below 0.3 reflects a low degree of income inequality; between 0.3 and 0.4, a moderate degree; and at 0.4 or above, a high degree. According to the most recent data from the Organization for Economic Cooperation and Development, the U.S. Gini coefficient stood at 0.40, with Canada at 0.32; Germany, 0.29; Sweden, 0.27; and Britain, 0.35.

What accounts for this striking difference? Most important, U.S. inequality has soared in the past 35 years, since the start of the Reagan era. The U.S. Gini coefficient stood at 0.31 in 1980. All countries have faced market pressures pushing toward more inequality — especially increased trade with low-wage countries such as China and automation that has claimed the jobs and wages of workers with only high school educations. Yet only in the United States have these pressures turned into massive inequality of income.

The reasons are clear. The United States unleashed the power of CEOs to enrich themselves with mega-salaries, weakened trade unions and gave massive tax breaks to the super-rich. Sanders’s policies would go after all of these unconscionable moves, bringing the United States back into line with the rest of the high-income world. He would, in short, end the age of impunity in which the rich and the powerful get their way, while the rest suffer. Sanders’s policies include higher taxes on the rich, strengthening unions, raising the minimum wage, supporting families, providing free tuition at public universities and cracking down on financial crimes.

There is nothing magical or utopian about Sanders’s recommendations. He is advocating policies of decency long ago adopted by other prosperous high-income countries. Our own neighbor, Canada, is a case in point. Canada has lower-cost health care, a life expectancy two years higher than in the United States, much lower college tuition, far lower poverty rates and, not surprisingly, more happiness (ranking sixth in the world in life satisfaction, behind Scandinavia and well ahead of the United States, which is 12th).

Mainstream economists long ago lost the melody line. Their models are oriented to the status quo and underemphasize the benefits of public investment. They take America’s bloated health-care costs as a given, not as the result of the influence of the U.S. private health lobby. They treat low growth as natural (“secular stagnation”) rather than as the result of chronic underinvestment. They have come to accept cruelly rising income inequality and rampant impunity for financial crimes. Sanders knows better, based on worldwide experience, an abiding sense of decency and a strong and accurate vision for a brighter economic future.

Jeffrey D. Sachs is director of the Earth Institute and a professor at Columbia University.

https://www.washingtonpost.com/opinions/jeffrey-sachs-bernie-sanders-easily-wins-the-policy-debate/2016/05/25/224209a0-21ac-11e6-8690-f14ca9de2972_story.html?hpid=hp_no-name_opinion-card-b%3Ahomepage%2Fstory

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