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Berenson: MIPS could be death knell for small practices

Berenson: MIPS could be death knell for small practices

MIPS: The ‘death knell’ for small practices?

By Joseph Burns
Medical Economics, February 25, 2016

Beginning in 2019, the new Merit-based Incentive Payment System (MIPS), which is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), will raise the focus on physician performance measurement to a new level.

MIPS will replace the Physician Quality Reporting System (PQRS) and CMS will adjust Medicare payments to most physicians either up or down by as much as 9% depending on how well they score in four performance categories: quality, resource use, clinical practice improvement activities, and meaningful use of electronic health records systems. Also, physicians who score extremely high will be eligible for a 27% payment bonus.

Robert A. Berenson, MD, a fellow at the Urban Institute in Washington, DC… is one of the nation’s best-known health policy experts. In the interview below, Berenson elaborates on his views regarding MIPS.

Medical Economics:  You’ve been critical of the measurement approach that CMS and other payers have adopted, and you focus in particular on MIPS. Are you concerned that MIPS will have some unintended consequences, and, if so, what concerns you most?

Robert Berenson:  We lack measures that are core to what is central to the performance we expect from particular specialists. I also have concerns that the approach may compromise physicians’ intrinsic motivation to practice high-quality care for their patients as they respond to specific incentives for particular aspects of performance.

With MIPS, Congress is combining PQRS, Meaningful Use and the value-based modifier. Those were three separate programs that were going to add up to a little more than 2% of a physician’s Medicare payment. But the penalties under MIPS now add up to 9%, with potential gains of 27% for some lucky physicians. They’ve created a whole new formula for how you get either rewards or penalties.

Only about 50% of physicians in private practice today are submitting data for PQRS because of the administrative burden and the lack of respect practicing physicians have for what they are being measured on. But now, the total they stand to lose is only 2% or so. No one can afford to lose 9%, which means MIPS has the potential to hasten the demise of small practices.

ME:  Are you saying that physicians in small practices will get a bonus of 9% and have the potential to get a 27% bonus, but that’s not enough of a financial gain to keep physicians in private practice?

RB:  The problem is that you as a physician would have to either spend money to bring in a consultant to produce the data from your medical records or you would have to use one of the registry options that CMS is offering. Both are resource intensive. Some doctors will say, ‘I’m going to have to be part of somebody’s system because I can’t produce this data.’ That happened to my former practice. Shortly after I left they said, ‘We can’t administer this practice. It’s getting too complicated. We’re just going to sell to a hospital system.’

ME:  By ‘too complicated,’ do you mean physicians don’t have the sophisticated IT systems that they would need to collect and report the MIPS data? They don’t have the staff to do it, and there are too many other demands on their time to do MIPS and still see 20 to 40 patients a day?

RB:  That’s right. The obligations required to submit the data mean they will have to pay someone to do it for them. And we already know that small practices are just getting by and accept much lower payment levels from insurers than large practices do. To get back the 2% lost under PQRS, physicians could see a few more patients each week. But when [the loss is] 9% and the requirements are more complex, that’s a whole different situation.

Included in the same MACRA legislation was a replacement for [Medicare] sustainable growth rate payments but that amounted to only nominal fee increases for the next decade. It’s virtually nothing, meaning physician payment is not keeping pace with inflation and then you have the potential of losing 9% on top of that.

So, we’re talking about the potential loss of payment above 9% and perhaps well into double digits. Look at it this way: because the fee increases aren’t keeping up with inflation, practices will need some bonus income to stay even.

ME:  So if it’s no longer financially viable to operate a small physician practice, then is the only alternative to be acquired by a hospital, health system, or some larger entity, in particular because so many payers are moving to value-based care?

RB:  Yes. That’s how it looks, and there are a lot of people in the insurer and provider worlds who say that the Affordable Care Act and now MACRA are all about bigness, meaning consolidation. I don’t believe that myself. But I believe the MACRA legislation indicates that physicians unwilling to accept the yet unproved value-based payment approaches will take a real hit, and when you combine that hit with all the other trends in the market, then you see all these factors pressuring small practices.

ME:  To play devil’s advocate, is it necessarily bad that many physicians will join larger organizations?

RB:  Well, in essence, we are under-valuing small practices and we now have MIPS which could be the death knell of many small practices. And for what? There’s good evidence from a Health Affairs paper by Lawrence P. Casalino, MD, MPH, PhD, and others that, in fact, the smallest practices had the best performance on avoiding unnecessary hospital admissions. The researchers were surprised because they assumed that you needed systemic processes in place to keep ambulatory care-sensitive admissions down.

But what Casalino and others found is not surprising to me. Those doctors know their patients, and when something’s wrong, they see them or they’re on the phone with them. Then they solve the problem without admitting the patient or sending the patient to the ER, which often guarantees an admission. Conversely, many practices in large health systems don’t know their patients as well. I am not saying small practices do as well on all aspects of care, just that what they do well is often underappreciated.

ME:  You question whether we should even be using the performance measures we currently use.

RB:  At the individual doctor level, I believe — and behavioral economists have said so as well — that pay for performance (P4P) actually often is counter-productive. I’d like to know what impact P4P has before enacting a program like the MIPS. So far the evidence hasn’t shown that the approach improves care. We need to evaluate not only what happens to the measures we incentivize, but what happens to overall care when health professionals are financially incentivized to improve particular aspects of care — the only ones we can measure. It may be that ‘testing to the test‘ is the result.

ME:  So, there’s much work to be done. Is there any hope that Congress or CMS will even be willing to improve the MIPS program and perhaps take up some of these issues?

RB:  Well, MACRA, including MIPS, is the law now. Congress tells CMS to do it and CMS has to implement it. My prediction is we will see an annual review not unlike the SGR ‘doc fix,’ except this one will be easier to pass because there will be little budgetary impact. If there is enough pushback or unintended consequences, we may see a willingness to revisit the program.

http://medicaleconomics.modernmedicine.com/medical-economics/news/mips-death-knell-small-practices

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URGENT: Explaining MIPS; Action required

By Don McCanne, M.D.
Quote of the Day, March 21, 2015

Yesterday’s Quote of the Day message sounded the alarm on legislation that would replace the flawed Sustainable Growth Rate formula (SGR) for updating Medicare payments with a new Merit-based Incentive Payment System (MIPS) – legislation with strong bipartisan support that will be taken up in Congress this week and is expected to pass.

The SGR formula is considered to be flawed primarily because economic factors considered in the formula would result in inappropriate payment reductions in many of the yearly adjustments. Thus there is consensus that the formula should be repealed. However, it did provide an administratively simple process for trying to keep Medicare rates from increasing well beyond the growth in the economy. That is, there was no administrative burden placed on the providers; they merely had to accept adjustments in their payments.

The concern is over its replacement: MIPS. On reading the summary of the “SGR Repeal and Medicare Provider Payment Modernization Act,” you will see that MIPS places a tremendous administrative burden on health care professionals in a health care system that is already overwhelmingly overburdened with administrative excesses. The only way to escape this additional burden is to participate in Alternative Payment Models (APMs) which, in themselves, create further significant administrative burdens (ACOs, PCMHs, etc.). MIPS is an administrative nightmare.

Under the MIPS payment system, eligible professionals with higher scores will receive positive payment adjustments (and may be eligible for an additional incentive payment). We have observed repeatedly how such systems are gamed in order to receive these extra payments. The problem is that those who do not game the system, and especially those with practice situations and patient populations that make it very difficult to score higher points, will almost automatically receive performance scores below the threshold since their performances will be compared with the gamers. This will result in negative payment adjustments – reducing payments by up to nine percent. If you think SGR is unfair, MIPS robs from these hard-working professionals who are just trying to make the system work for their patients, and gives the spoils to those who likely have consultants to show them how to game the system.

https://pnhp.org/news/2015/march/urgent-explaining-mips-action-required

Physicians were so relieved to get rid of the sustainable growth rate (SGR) method of adjusting Medicare payments that they seemed to care less about the replacement: the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs). They should have cared. Robert Berenson explains why.

After a period of grief, financial stress and burnout, physicians who have not yet bailed out may be ready to push back. Berenson gives us some limited reassurance that since there will not be a huge budgetary impact like there was with repeal of SGR, Congress may be more willing to revisit this legislation. But the protesting physicians had better bring along their pitchforks, just to be sure.

Hillary’s newfound disdain for single payer

By David U. Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.
The Hill, Feb. 29, 2016

Back in 1993, when we met with Hillary Clinton at the White House, she acknowledged that single-payer national health insurance was the best solution to America’s health care mess, but dismissed it as politically impossible.

She kept singing much the same tune until Sen. Bernie Sanders’ (I-Vt.) upstart campaign began rallying support for single-payer reform, and threatening Hillary’s glide path to the nomination. Then she started echoing Republican rhetoric, claiming that “Medicare for All” would break the bank and disrupt care.

Hillary’s flip-flop marked a stark departure from 70 years of Democratic Party policies. Single payer was integral to the party’s platforms from 1948 until 1992.

But even as party leaders and their policy advisers adopted more “politically realistic” reform options, they continued to acknowledge the advantages of single payer. 

Sen. Ted Kennedy (D-Mass.), who sponsored a pure single-payer bill in 1971, urged us on several occasions in subsequent years to rally the support that could make single payer viable in the Senate, and in 2000 endorsed a single-payer ballot initiative in Massachusetts. 

Barack Obama, a full-fledged single-payer advocate in 2003, continued to say as a presidential candidate that he’d prefer single payer “if we were starting from scratch.”

Hillary’s newfound belief that Medicare for All would be an economic disaster (and similar claims by economists Paul Krugman, Austan Goolsbee, and others) rests mostly on an analysis by Kenneth Thorpe, an Emory University professor and former Clinton administration official.

Like Clinton, Thorpe has changed his tune on single payer. Back in 2003 and again in 2005, he published detailed analyses concluding that single payer was the most economical route to universal coverage. In fact, he thought single payer was so good that it would actually lower costs while covering all of the uninsured and upgrading coverage for the tens of millions who were under-insured.

What’s changed?

Back in 2003, Thorpe estimated that single payer would achieve huge administrative savings – more than 10 percent of total health spending, equivalent to $350 billion this year alone. Now he’s cut that estimate in half, despite evidence that the costs of health bureaucracy in the U.S. have climbed even higher, while they’ve remained low in single-payer nations such as Canada. 

The most recent data suggests that single-payer savings would amount to at least 14.3 percent of total U.S. health spending.

Before his recent conversion, professor Thorpe estimated that single payer would cause a modest uptick in the utilization of care. Now – despite the fact that fewer Americans are uninsured – he’s decided there would be a huge increase. Moreover, the surge he forecasts would keep doctors working 24 hours a day and require hospital patients to double bunk. It simply can’t happen. 

Instead, as in other nations that have started up single-payer programs, doctors and hospitals would cut down on the unnecessary care they’re currently delivering to well-insured patients (estimated at $210 billion in 2009 by the National Academy of Medicine) and shift more care to those who are currently uninsured or under-insured.

Thorpe thinks Medicare for All could reap only 20 percent savings on drug prices, far less than the 50 percent discounts that Canada, Australia and the UK have gotten. 

Finally, he posits vast federal government costs on the theory that the feds would give state and local governments a huge bonanza – hundreds of billions annually – by allowing them to keep much of the money they’d save on Medicaid and public employees’ health benefit costs. But no one proposing Medicare for All – certainly not Bernie Sanders – has envisioned it as a gravy train for state and local authorities.

The old Kenneth Thorpe – and the old Hillary Clinton – acknowledged the facts about single payer. The new ones ignore them.

Himmelstein and Woolhandler are professors of health policy and management at the City University of New York School of Public Health and lecturers in medicine at Harvard Medical School. The opinions expressed do not necessarily reflect those institutions’.

http://thehill.com/blogs/congress-blog/healthcare/271001-hillarys-newfound-disdain-for-single-payer

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

CMS’s Slavitt calls for ‘retailization’ of health care

Slavitt: Health Care ‘Retailization’ Is Coming

By Dan Diamond
Politico Pulse, March 1, 2016

Speaking at the Federation of American Hospitals annual meeting on Monday, CMS acting administrator Andy Slavitt invited providers to join the agency’s ongoing push for the “retailization” of health care.

“A retail strategy calls on you to imagine you are negotiating directly with a cash paying consumer who used to be a source of bad debt — except one who now has the wherewithal to pay for services and wants to build a relationship where they can also find elective, outpatient and wellness services,” Slavitt said. He went on to elaborate about the need for further price and billing transparency in health care — just like in other consumer markets.

http://www.politico.com/tipsheets/politico-pulse/2016/03/cms-issues-final-marketplace-rule-slavitt-health-care-retailization-is-coming-why-no-medicaid-expansion-in-south-dakota-this-year-212964

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Comment:

By Don McCanne, M.D.

Yesterday, at the annual meeting of the Federation of American Hospitals, Acting CMS Administrator Andy Slavitt asked the for-profit hospitals to join CMS’s ongoing push for the “retailization” of health care.

Retailization? Providers should imagine negotiating with cash paying consumers. They should strive for “further price and billing transparency in health care — just like in other consumer markets.”

Could there be a more explicit advocacy of consumer-driven health care – placing the patient-consumer in charge of health care spending? It fits with CMS’s efforts to privatize Medicare by over-paying the private Medicare Advantage plans, with overtures to convert Medicare to a premium support (voucher) market of private plans.

Politics? This is coming from an administration headed by a Democrat – a neoliberal administration that has been mislabeled as progressive – and supported by a presidential candidate who rejects Medicare for All and wants to build on Obamacare with its high deductible private health plans that place the patient-consumer in charge.

Retailization. Watch out, here it comes!

Why Obamacare should be changed to a single-payer system

By Eric Naumburg, M.D.
The Baltimore Sun, Feb. 29, 2016

Your editorial “Health care non-debate” (Feb. 22) points out some important facts about the American health care system that are often denied or ignored. The American health care system is not doing very well, yet we are paying a lot for the privilege.

America has by far the world’s most expensive health care system, yet our outcomes are relatively poor. The U.S. ranks 53rd in infant mortality, consistently does poorly in studies of preventable deaths (19th of 20th in a recent study of wealthy nations) and American life expectancy is lower than most wealthy countries in Europe, Asia and Canada, where the governments guarantee — and to a great extent finance — universal health care.

In fact, among wealthy countries, we are the only one that does not have universal health care. In spite of the Affordable Care Act, there are still over 30 million Americans without health insurance — a known risk factor for early death — and many more who are underinsured.

High deductible health insurance policies plus the cost of premiums, co-pays and co-insurance often mean that people essentially can’t seek medical care without having to give up other necessities such as food and housing. One proof of this sad fact is that the most common cause of personal bankruptcy in America is a serious medical illness.

There are a million or so medical bankruptcies per year, even though the majority of people who end up in medical bankruptcy had health insurance when they became ill. Most people don’t realize they are underinsured until they get a serious illness. In countries with universal health care, this problem does not exist. People there are horrified by the concept of medical bankruptcy and consider it immoral and inhumane.

The American health system was not always a laggard. In the 1970s our costs and outcomes were very similar to Canada’s. But then the Canadians passed single-payer, universal health care. Today, Canadian costs are two-thirds of ours, their outcomes are better, and everyone in Canada has health coverage with few, if any, out of pocket expenses.

The happened because two countries went in different directions: While Canada embraced a non-profit, publicly financed single-payer system, we in American increasingly chose a for-profit, privatized health system.

Another example of a natural comparison between a private versus a public system would be the privatization of part of Medicare, the Medicare Advantage program, where health insurance is provided by large for-profit corporations. Medicare Advantage’s costs are greater and rising faster than the publicly run part of Medicare but the patients in the private system are healthier and should cost less.

In fact, much of the savings in the Affordable Care Act as originally written were expected to come from slowly ending the Medicare Advantage program. Instead, the opposite has happened; Medicare Advantage has grown dramatically. The American experiment with privatization of the health system needs to end. It has been an abject failure.

Whether the solution for the American health care crisis is single-payer — i.e. a government run and financed health insurance system — or something else, the bottom line is the system needs to be publicly financed, universal and delivered by a health system that is non-profit.

Universal means everybody in, nobody out and no financial barriers to getting necessary health care. We need to create a health care system where people are not one major illness away from personal bankruptcy; where everyone is able to get needed care without worrying about cost; and where decisions about health care are made based on science and the input of patients and physicians, not by private, profit-driven health insurance companies.

Dr. Eric Naumburg is co-chairman of the Maryland chapter of Physicians for a National Health Program. He resides in Columbia.

http://www.baltimoresun.com/news/opinion/readersrespond/bs-ed-health-care-letter-20160229-story.html

Americans would benefit from single payer

By Patrick Meyer, M.D.
The Capital Times (Madison, Wis.), Letters, Feb. 29, 2016

I would like to tell Dave Zweifel that he hit the nail on the head with his recent column about dispensing with myths about Medicare for All.

I am a recently retired pediatrician and can attest to the terrible effects that our current system has on children and families. Obamacare may have been a step in the right direction, but it is too complicated and did not eliminate the insurance companies from the equation.

Our country pays twice as much as other developed countries for health care, yet the end result is poorer health outcomes and millions uninsured or underinsured. Until we remove the profit motive from the health care industry things will not change. The insurance companies are the primary problem, with their massive administrative costs and exorbitant CEO salaries.

Pharmaceutical companies need some regulation, and hospitals and doctors are not without fault. Eliminating these costs would pay for the program and insure everyone. Slightly higher taxes would be more than offset by lower health care costs for everyone.

I will continue to support a single payer health plan (l am a longtime member of Physicians for a National Health Program), but I am also realistic. The insurance/pharmaceutical lobbies spend millions, which unfortunately influence our politicians to do nothing. The American people need to stand up and be heard. Everyone would benefit. A majority of Americans, including physicians, support a single-payer plan, as does Bernie Sanders. Why not Congress?

Dr. Patrick Meyer resides in Middleton.

http://host.madison.com/ct/news/opinion/mailbag/dr-patrick-meyer-americans-would-benefit-from-single-payer/article_2f93b16e-6728-59d1-bcf9-f261c34b5e5e.html

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

CMS’s Slavitt calls for ‘retailization’ of health care

Slavitt: Health Care ‘Retailization’ Is Coming

By Dan Diamond
Politico Pulse, March 1, 2016

Speaking at the Federation of American Hospitals annual meeting on Monday, CMS acting administrator Andy Slavitt invited providers to join the agency’s ongoing push for the “retailization” of health care.

“A retail strategy calls on you to imagine you are negotiating directly with a cash paying consumer who used to be a source of bad debt — except one who now has the wherewithal to pay for services and wants to build a relationship where they can also find elective, outpatient and wellness services,” Slavitt said. He went on to elaborate about the need for further price and billing transparency in health care — just like in other consumer markets.

http://www.politico.com/tipsheets/politico-pulse/2016/03/cms-issues-final-marketplace-rule-slavitt-health-care-retailization-is-coming-why-no-medicaid-expansion-in-south-dakota-this-year-212964

Yesterday, at the annual meeting of the Federation of American Hospitals, Acting CMS Administrator Andy Slavitt asked the for-profit hospitals to join CMS’s ongoing push for the “retailization” of health care.Retailization? Providers should imagine negotiating with cash paying consumers. They should strive for “further price and billing transparency in health care — just like in other consumer markets.”

Could there be a more explicit advocacy of consumer-driven health care – placing the patient-consumer in charge of health care spending? It fits with CMS’s efforts to privatize Medicare by over-paying the private Medicare Advantage plans, with overtures to convert Medicare to a premium support (voucher) market of private plans.

Politics? This is coming from an administration headed by a Democrat – a neoliberal administration that has been mislabeled as progressive – and supported by a presidential candidate who rejects Medicare for All and wants to build on Obamacare with its high deductible private health plans that place the patient-consumer in charge.

Retailization. Watch out, here it comes!

Single-payer health system is the way to go

By Nick Estes
Albuquerque Journal, Feb. 27, 2016

Bernie Sanders is right to call for “single-payer” national health insurance; basically, Medicare for all. It makes lots of sense.

This is no slam on Obamacare. The Affordable Care Act was a tremendous moral and political achievement. Under the ACA over 30 million people have obtained health insurance coverage – most for the first time.

Insurance carriers can’t deny people because of pre-existing conditions, annual and lifetime caps on benefits are not allowed and young adults can stay on their parents’ policies until age 26. However, America could do much better for its citizens by joining the rest of the advanced countries in adopting a true national health insurance program.

This is not “socialized medicine.” Doctors and hospitals would not become part of a national system. Sanders only wants to take Medicare, a payment system with 50 years of successful experience, and extend it to everyone.

Overall there is little doubt that this would be cheaper to society than the present system that relies in large part on private health insurance.

Single-payer would save several hundred billion per year in the unnecessary administrative costs and profit that now go to private health insurers. It takes huge costs to administer a system that requires each company and each provider to determine which costs are covered – depending on the patient’s particular plan, on which entity provided the service, what type of service was provided, and under what circumstances.

A single government payer also would be in a better position to bargain for reasonable rates from providers, drug companies and medical equipment manufacturers.

We pay twice as much for medical care as the rest of the advanced countries, so there is a lot of room for savings. We could use the money from both these savings pools to cover the 30 million people who still have no health insurance.

I don’t advocate this out of antipathy to the health insurers. It’s just that the economics of health care are completely different than the economics of most other goods and services.

With most products and services we leave it up to the consumer to decide whether he or she wants the item enough to pay for it. In most cases that allocates goods and services efficiently to those who want them the most and can afford them.

That’s not the way we allocate health care. A humane society believes that everyone should get high-quality care when they need it. For the most expensive treatments, we are usually talking about life or death, or at least a decent future life versus living with a terrible disability.

Health care is thus like police and fire protection: We try to supply good quality service to everyone without charging people at the time of the service or requiring them to sign up and pay for a personal protection plan. We all pay for this protection through our taxes.

Medical care is similar. Individuals usually don’t know whether they are going to need expensive treatments some day. Some people die of a sudden heart attack, others die of a disease that required years of treatment. Regardless, an ethical society provides the necessary care.

Even the other necessities of survival – food, clothing and shelter – are different from health care. Like health care, they are needed for life, but they come in vastly different quality and expense levels.

Government rightly provides a basic survival level to everyone (for example, in food stamps), but the free market provides anything people want and can afford above that level.

That doesn’t work for health care. It is not ethical to deliberately withhold necessary health care from anyone for whom it is appropriate, regardless of how expensive the diagnosis and treatment may be.

That is why we adopted Medicare and Medicaid 50 years ago.

But this logic is not limited to senior citizens and the poor. This is why all other advanced countries combine a system of mostly private providers with a form of universal health insurance ultimately supported by taxes.

This approach makes sense for the United States, too, and Bernie Sanders is correct to insist that the idea be laid before the American people.

Nick Estes is retired University of New Mexico counsel.

http://www.abqjournal.com/731181/opinion/singlepayer-health-system-is-the-way-to-go.html

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

Physicians & Medical Students: Sign the open letter on the truth about Medicare-for-All

Setting the Record Straight on Medicare for All: An Open Letter From 560 Physicians and Medical Students

By Steffie Woolhandler and David Himmelstein
The Huffington Post, February 28, 2016

The following statement has been signed by more than 560 physicians and medical students. It was crafted by Andrea Christopher, M.D., Fellow in General Internal Medicine at Harvard Medical School, Adam Gaffney, M.D., Fellow in Pulmonary and Critical Care Medicine at Massachusetts General Hospital and Harvard Medical School, and the two of us, Drs. Steffie Woolhandler and David U. Himmelstein. Other physicians and medical students are invited to read and sign the statement here: medicare-for-all.us

Setting the Record Straight on Medicare for All: An Open Letter From 560 Physicians and Medical Students

The renewed debate over the merits of single-payer health reform has been marred by misleading claims that such reform is unnecessary and unaffordable. We write to set the record straight.

Despite the advances of the Affordable Care Act (ACA), the health care financing system continues to inflict needless suffering on our patients. Nearly 30 million Americans remain uninsured, and co-payments, deductibles and insurers’ narrow networks obstruct care for many more. Insurers skim billions from premiums, and impose expensive and time-consuming paperwork on doctors, nurses and hospitals.

Studies in the most trusted journals have quantified the bureaucratic savings achievable through single payer reform. We devote 31 percent of medical spending to administration, vs. 16.7 percent in Canada – a difference of $350 billion annually. And single-payer systems in Canada, the UK and Australia all use their bargaining clout to get discounts of 50 percent from the prices drug companies charge our patients. The potential savings on bureaucracy and drugs are enough to cover the uninsured, and to upgrade coverage for all Americans – a conclusion affirmed over decades by multiple analysts, including the Congressional Budget Office and the Government Accountability Office.

Recent critics of Medicare for All warn of large increases in government spending, but fail to note that these would be fully offset by savings on private insurance premiums and out-of-pocket costs. Their forecasts of massive surges in doctor visits and hospital care conflicts with past experience of coverage expansions. When 15 million Americans gained insurance under the ACA in 2014, hospital admissions didn’t budge. No surge in hospital use or doctor visits occurred when Medicare and Medicaid were rolled out, or when Canada’s single-payer system started up; doctors saw sick and poor patients more often, but their healthy, wealthy patients a bit less often.

Experience in many nations over many decades provides convincing evidence that single-payer reform is both medically necessary and economically advisable.

In addition to Drs. Gaffney, Himmelstein, Christopher and Woolhandler, this statement has been signed by more than 560 other physicians and medical students.

http://www.huffingtonpost.com/steffie-woolhandler/setting-the-record-straig_24_b_9341782.html

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Comment:

By Don McCanne, M.D.

With the recent often inaccurate and ill-advised debate taking place in the media over the financing of single payer it is imperative that the record be set straight on the basic, irrefutable facts of single payer. Physicians and medical students who are well informed on the true facts should sign this open letter so that the nation understands clearly that we can ensure that absolutely everyone has free choice of health care in a system that is affordable for everyone, through an improved Medicare-for-All.

Go to medicare-for-all.us to sign the letter.

Colleagues should be encouraged to sign as well. Non-physicians are also encouraged to endorse this letter by signing on to a companion list at this same website.

In a separate release, Steffie Woolhandler explains the background that makes this action an imperative:

“The recent attacks on single payer reform by some liberal economists and politicians are mystifying.  When I met with Hillary Clinton some years ago she acknowledged that single payer would be the cheapest and most efficient way to cover all Americans.  Her only objection then was that single payer wasn’t politically feasible.  Now she’s charging that the numbers don’t add up.  And economists who once projected large savings from single payer, are now saying the opposite, without citing any new data.  They’re playing political games at the expense of the truth.”

Again, please go immediately to medicare-for-all.us to sign the open letter.

Physicians & Medical Students: Sign the open letter on the truth about Medicare-for-All

Setting the Record Straight on Medicare for All: An Open Letter From 560 Physicians and Medical Students

By Steffie Woolhandler and David Himmelstein
The Huffington Post, February 28, 2016

The following statement has been signed by more than 560 physicians and medical students. It was crafted by Andrea Christopher, M.D., Fellow in General Internal Medicine at Harvard Medical School, Adam Gaffney, M.D., Fellow in Pulmonary and Critical Care Medicine at Massachusetts General Hospital and Harvard Medical School, and the two of us, Drs. Steffie Woolhandler and David U. Himmelstein. Other physicians and medical students are invited to read and sign the statement here: medicare-for-all.us

Setting the Record Straight on Medicare for All: An Open Letter From 560 Physicians and Medical Students

The renewed debate over the merits of single-payer health reform has been marred by misleading claims that such reform is unnecessary and unaffordable. We write to set the record straight.

Despite the advances of the Affordable Care Act (ACA), the health care financing system continues to inflict needless suffering on our patients. Nearly 30 million Americans remain uninsured, and co-payments, deductibles and insurers’ narrow networks obstruct care for many more. Insurers skim billions from premiums, and impose expensive and time-consuming paperwork on doctors, nurses and hospitals.

Studies in the most trusted journals have quantified the bureaucratic savings achievable through single payer reform. We devote 31 percent of medical spending to administration, vs. 16.7 percent in Canada – a difference of $350 billion annually. And single-payer systems in Canada, the UK and Australia all use their bargaining clout to get discounts of 50 percent from the prices drug companies charge our patients. The potential savings on bureaucracy and drugs are enough to cover the uninsured, and to upgrade coverage for all Americans – a conclusion affirmed over decades by multiple analysts, including the Congressional Budget Office and the Government Accountability Office.

Recent critics of Medicare for All warn of large increases in government spending, but fail to note that these would be fully offset by savings on private insurance premiums and out-of-pocket costs. Their forecasts of massive surges in doctor visits and hospital care conflicts with past experience of coverage expansions. When 15 million Americans gained insurance under the ACA in 2014, hospital admissions didn’t budge. No surge in hospital use or doctor visits occurred when Medicare and Medicaid were rolled out, or when Canada’s single-payer system started up; doctors saw sick and poor patients more often, but their healthy, wealthy patients a bit less often.

Experience in many nations over many decades provides convincing evidence that single-payer reform is both medically necessary and economically advisable.

In addition to Drs. Gaffney, Himmelstein, Christopher and Woolhandler, this statement has been signed by more than 560 other physicians and medical students.

http://www.huffingtonpost.com/steffie-woolhandler/setting-the-record-straig_24_b_9341782.html

With the recent often inaccurate and ill-advised debate taking place in the media over the financing of single payer it is imperative that the record be set straight on the basic, irrefutable facts of single payer. Physicians and medical students who are well informed on the true facts should sign this open letter so that the nation understands clearly that we can ensure that absolutely everyone has free choice of health care in a system that is affordable for everyone, through an improved Medicare-for-All.

Go to medicare-for-all.us to sign the letter.

Colleagues should be encouraged to sign as well. Non-physicians are also encouraged to endorse this letter by signing on to a companion list at this same website.

In a separate release, Steffie Woolhandler explains the background that makes this action an imperative:

“The recent attacks on single payer reform by some liberal economists and politicians are mystifying.  When I met with Hillary Clinton some years ago she acknowledged that single payer would be the cheapest and most efficient way to cover all Americans.  Her only objection then was that single payer wasn’t politically feasible.  Now she’s charging that the numbers don’t add up.  And economists who once projected large savings from single payer, are now saying the opposite, without citing any new data.  They’re playing political games at the expense of the truth.”

Again, please go immediately to medicare-for-all.us to sign the open letter.

AP-GfK poll on single payer spreads falsehoods

AP-GfK Poll: Support shaky for Sanders ‘Medicare for all’

By Ricardo Alonso-Zaldivar and Emily Swanson
AP GfK, February 25, 2016

At first blush, many Americans like the idea of “Medicare for all,” the government-run health system that’s a rallying cry for Democratic presidential candidate Bernie Sanders.

But mention some of the trade-offs — from higher taxes to giving up employer coverage — and support starts to shrivel.

That’s the key insight from an Associated Press-GfK poll released Thursday. The survey also found that people’s initial impressions of Sanders’ single-payer plan are more favorable than their views of President Barack Obama’s health care overhaul.

A slim plurality of 39 percent supports replacing the private health insurance system with a single government-run, taxpayer-funded plan that would cover medical, dental, vision and long-term care, with 33 percent opposed. Only 26 percent say they support Obama’s hard-won health care law.

Asked whether they would continue to support Sanders’ plan if their own taxes went up, under a third of initial supporters of the plan would keep backing it. About 4 out of 10 flipped to opposition.

About the same share of initial backers would ditch single-payer if it meant that people had to give up employer coverage. Twenty-eight percent would continue to support it.

Higher taxes and an end to employer coverage are both a given under the Sanders plan, which would replace private coverage with a taxpayer-funded program, while also offering more generous benefits such as no deductibles and no copayments, as well as coverage for long-term care.

“That’s pie in the sky,” said Patricia Combs, a retired junior-high math teacher from Springboro, Ohio. “It sounds really good, but I don’t think it’s attainable … people would complain about their taxes being raised.”

Elizabeth Medina of Chicago, an office manager not currently working, said she worries that quality would slip.

“Overall it sounds terrific,” she said. “Yeah! Let’s go for it! But Europe and Canada have their problems with the single-payer system … it’s subpar.”

The poll found that 51 percent of initial single-payer backers would switch to opposition if it took longer for new drugs and treatments to become available. Only 14 percent would continue to support the plan. Such an outcome could happen if drugmakers were required to prove that new medications are therapeutically superior to existing ones. The current standard is that new drugs be safe and effective.

Additionally, 47 percent of initial supporters would reconsider if “Medicare for all” meant longer wait times for non-emergency medical services. That could happen if budget-conscious administrators encouraged doctors and hospitals to be parsimonious in using high-tech imaging. Only 18 percent of poll respondents would continue to support the plan in that case.

Overall, the poll found that health care remains a top issue for Americans, with three-fourths calling it extremely crucial or very important.

Topline

HC15. Would you favor or oppose replacing the current private health insurance system in the United States with a single government-run and taxpayer-funded plan like Medicare for all Americans that would cover medical, dental, vision, and long-term care services?

  39%  Total support
       18%  Strongly support
       21%  Somewhat support

  26%  Neither support nor oppose

  33%  Total oppose
       12%  Somewhat oppose
       22%  Strongly oppose

   2%  Refused/Not answered

HC15a. Would you support or oppose replacing the health insurance system in the United States with a single government-run plan if it meant:

  Your own taxes would increase
    28%  Support
    32%  Neither support nor oppose
    29%  Oppose

  Some people needed to switch doctors
    33%  Support
    37%  Neither support nor oppose
    29%  Oppose

  It took longer for new drugs and treatments to become available
    14%  Support
    34%  Neither support nor oppose
    51%  Oppose

  Longer wait times for nonemergency medical services
    18%  Support
    35%  Neither support nor oppose
    47%  Oppose

  People needed to give up other coverage like employer coverage
    28%  Support
    32%  Neither support nor oppose
    39%  Oppose

  The new system would replace Medicare for seniors
    37%  Support
    35%  Neither support nor oppose
    26%  Oppose

http://ap-gfkpoll.com/featured/findings-from-our-latest-poll-32

Topline
http://ap-gfkpoll.com/main/wp-content/uploads/2016/02/AP-GfK_Poll_February-2016-topline_health.pdf

***

Comment:

By Don McCanne, M.D.

Most polls place support for a single payer Medicare-for-all national health program at about 60%, with some variation based on labels, framing, and polling technique. Yesterday’s Kaiser poll placed it at 50%. This new Associated Press GfK poll places it at about 40%, but it is unusual in that over one-fourth of those polled expressed no preference.  Of those expressing a preference, 54% were supportive and 46% opposed. But there was something else that was also very unusual about this poll.

Yesterday’s Kaiser poll demonstrated that the views on single payer were malleable. When asked about negative features that allegedly are associated with single payer, support declined, whereas support increased when asked about positive features. In this AP-GfK poll they were asked only about allegedly negative features, and support declined. But what were these negative features?

*  Your own taxes would increase – But no mention was made of the savings in premiums, out-of-pocket expenses and other taxes that would more than offset the new taxes, resulting in a net savings.

*  Some people needed to switch doctors – But that is a characteristic of private plans with their narrow networks whereas single payer provides free choice of health care professionals.

*  It took longer for new drugs and treatments to become available – There is no way that the pharmaceutical industry is going to walk away from a $3 trillion market.

*  Longer wait times for nonemergency medical services – Responsible stewards would use capacity adjustment and queue management to prevent excessive queues, as has been done successfully in several other nations.

*  People needed to give up other coverage like employer coverage – But they would be trading that for a superior program with more comprehensive coverage, reduced out-of-pocket costs and greater choices in health care.

*  The new system would replace Medicare for seniors – Who would want to continue with the current Medicare program that pays for only about half of health care when you could have an improved Medicare with more generous benefits?

Why would the Associated Press conduct such a deceptive poll at a risk of impairing its credibility? When you read the AP release, you can’t help but come to the conclusion that it was designed to slam presidential candidate Sen. Bernie Sanders and his support of Medicare for all. They even included a gratuitous comment from an unemployed office manager to the effect that the single payer system is “subpar” like in “Europe and Canada” – an absolute falsehood.

Whatever the intentions of the Associated Press, we must make every effort to dispel the deceptions and disseminate the true facts about single payer Improved Medicare for All. The health of America is at stake.

AP-GfK poll on single payer spreads falsehoods

AP-GfK Poll: Support shaky for Sanders ‘Medicare for all’

By Ricardo Alonso-Zaldivar and Emily Swanson
AP GfK, February 25, 2016

At first blush, many Americans like the idea of “Medicare for all,” the government-run health system that’s a rallying cry for Democratic presidential candidate Bernie Sanders.

But mention some of the trade-offs — from higher taxes to giving up employer coverage — and support starts to shrivel.

That’s the key insight from an Associated Press-GfK poll released Thursday. The survey also found that people’s initial impressions of Sanders’ single-payer plan are more favorable than their views of President Barack Obama’s health care overhaul.

A slim plurality of 39 percent supports replacing the private health insurance system with a single government-run, taxpayer-funded plan that would cover medical, dental, vision and long-term care, with 33 percent opposed. Only 26 percent say they support Obama’s hard-won health care law.

Asked whether they would continue to support Sanders’ plan if their own taxes went up, under a third of initial supporters of the plan would keep backing it. About 4 out of 10 flipped to opposition.

About the same share of initial backers would ditch single-payer if it meant that people had to give up employer coverage. Twenty-eight percent would continue to support it.

Higher taxes and an end to employer coverage are both a given under the Sanders plan, which would replace private coverage with a taxpayer-funded program, while also offering more generous benefits such as no deductibles and no copayments, as well as coverage for long-term care.

“That’s pie in the sky,” said Patricia Combs, a retired junior-high math teacher from Springboro, Ohio. “It sounds really good, but I don’t think it’s attainable … people would complain about their taxes being raised.”

Elizabeth Medina of Chicago, an office manager not currently working, said she worries that quality would slip.

“Overall it sounds terrific,” she said. “Yeah! Let’s go for it! But Europe and Canada have their problems with the single-payer system … it’s subpar.”

The poll found that 51 percent of initial single-payer backers would switch to opposition if it took longer for new drugs and treatments to become available. Only 14 percent would continue to support the plan. Such an outcome could happen if drugmakers were required to prove that new medications are therapeutically superior to existing ones. The current standard is that new drugs be safe and effective.

Additionally, 47 percent of initial supporters would reconsider if “Medicare for all” meant longer wait times for non-emergency medical services. That could happen if budget-conscious administrators encouraged doctors and hospitals to be parsimonious in using high-tech imaging. Only 18 percent of poll respondents would continue to support the plan in that case.

Overall, the poll found that health care remains a top issue for Americans, with three-fourths calling it extremely crucial or very important.

Topline

HC15. Would you favor or oppose replacing the current private health insurance system in the United States with a single government-run and taxpayer-funded plan like Medicare for all Americans that would cover medical, dental, vision, and long-term care services?

39%  Total support
18%  Strongly support
21%  Somewhat support

26%  Neither support nor oppose

33%  Total oppose
12%  Somewhat oppose
22%  Strongly oppose

2%  Refused/Not answered

HC15a. Would you support or oppose replacing the health insurance system in the United States with a single government-run plan if it meant:

Your own taxes would increase
28%  Support
32%  Neither support nor oppose
29%  Oppose

Some people needed to switch doctors
33%  Support
37%  Neither support nor oppose
29%  Oppose

It took longer for new drugs and treatments to become available
14%  Support
34%  Neither support nor oppose
51%  Oppose

Longer wait times for nonemergency medical services
18%  Support
35%  Neither support nor oppose
47%  Oppose

People needed to give up other coverage like employer coverage
28%  Support
32%  Neither support nor oppose
39%  Oppose

The new system would replace Medicare for seniors
37%  Support
35%  Neither support nor oppose
26%  Oppose

http://ap-gfkpoll.com/featured/findings-from-our-latest-poll-32

Topline
http://ap-gfkpoll.com/main/wp-content/uploads/2016/02/AP-GfK_Poll_February-2016-topline_health.pdf

Most polls place support for a single payer Medicare-for-all national health program at about 60%, with some variation based on labels, framing, and polling technique. Yesterday’s Kaiser poll placed it at 50%. This new Associated Press GfK poll places it at about 40%, but it is unusual in that over one-fourth of those polled expressed no preference.  Of those expressing a preference, 54% were supportive and 46% opposed. But there was something else that was also very unusual about this poll.

Yesterday’s Kaiser poll demonstrated that the views on single payer were malleable. When asked about negative features that allegedly are associated with single payer, support declined, whereas support increased when asked about positive features. In this AP-GfK poll they were asked only about allegedly negative features, and support declined. But what were these negative features?

*  Your own taxes would increase – But no mention was made of the savings in premiums, out-of-pocket expenses and other taxes that would more than offset the new taxes, resulting in a net savings.

*  Some people needed to switch doctors – But that is a characteristic of private plans with their narrow networks whereas single payer provides free choice of health care professionals.

*  It took longer for new drugs and treatments to become available – There is no way that the pharmaceutical industry is going to walk away from a $3 trillion market.

*  Longer wait times for nonemergency medical services – Responsible stewards would use capacity adjustment and queue management to prevent excessive queues, as has been done successfully in several other nations.

*  People needed to give up other coverage like employer coverage – But they would be trading that for a superior program with more comprehensive coverage, reduced out-of-pocket costs and greater choices in health care.

*  The new system would replace Medicare for seniors – Who would want to continue with the current Medicare program that pays for only about half of health care when you could have an improved Medicare with more generous benefits?

Why would the Associated Press conduct such a deceptive poll at a risk of impairing its credibility? When you read the AP release, you can’t help but come to the conclusion that it was designed to slam presidential candidate Sen. Bernie Sanders and his support of Medicare for all. They even included a gratuitous comment from an unemployed office manager to the effect that the single payer system is “subpar” like in “Europe and Canada” – an absolute falsehood.

Whatever the intentions of the Associated Press, we must make every effort to dispel the deceptions and disseminate the true facts about single payer Improved Medicare for All. The health of America is at stake.

Clinton’s ‘Public Option’ is a Diversion: We Need Single Payer, Medicare for All

By Don McCanne, M.D.
Common Dreams, Feb. 24, 2016

You remember the public option. During the drafting of the Affordable Care Act (ACA), efforts were made to include a public option – a government-run plan that would compete with the private health plans in the insurance marketplace.

If the private plans proved that they could provide greater value, then they would prevail. If the government could do a better job, then the public option could expand by demand and eventually become the single payer for the nation, so supporters believed.

The original concept for the public option was to allow individuals to buy into the Medicare program instead of purchasing private insurance. There were some obvious problems. Medicare lacked some important features required of the private plans such as catastrophic coverage – establishing a maximum out-of-pocket responsibility of paying for health care. Also, the existing Medicare pool was composed of the elderly and those with long-term disabilities – expensive groups to insure. The exorbitant premium that would have to be charged could not be competitive with the private plans.

It was then decided to establish a new public insurance program that was designed like the private plans and that would have to follow the same rules. The insurance industry immediately opposed this since it would be “unfair” competition considering the government resources backing up the public plan, and the inherently higher administrative costs that the private insurers face, not to mention the need to profit from their operations – profit not being a feature of a publicly owned insurer. Several (anti-competitive) features were proposed for the public option which would give the private insurers a “fair” playing field.

The insurers were still concerned that they could not compete against even a restricted government plan, and thus they continued to oppose it. There is a basis for that concern since the private Medicare Advantage plans are able to “compete” with the traditional Medicare program only because of the overpayments that are being made to the private plans. If they were in the same playing field, the private plans would perish.

Nevertheless, the issue of the public option became moot when Sen. Joseph Lieberman, with no votes to spare, threatened to kill the entire Affordable Care Act if the public option were included.

We were left with the co-ops as a substitute for the public option. The co-ops are nonprofit organizations in which the insured members are the owners. Congress, under the Republicans, has refused to provide promised funds, and half of them have collapsed. They are now being used by opponents of single payer to “prove” that the government would be incapable of running a single-payer system – an obvious non sequitur.

Since the enactment of ACA there have been endless calls to add a public option. Single payer failed to gain traction because of the pervasive meme that single payer was not politically feasible. But if we could just get a public option, that would automatically evolve into a single-payer system, they said.

Then along came Bernie Sanders. He carried the message that not only was single payer politically feasible, it was a moral imperative to achieve health care justice for all.

To the surprise of Hillary Clinton and her campaign staff, Bernie Sanders came out of nowhere and gained traction carrying the single-payer banner, and, as a result, has become a genuine challenge to her candidacy.

Hillary Clinton has always been an opponent of single payer and instead has supported the private insurance industry. Some have misinterpreted a statement of hers many years ago as supporting the fact that we would have single payer in the United States. But that statement was not in support of single payer but rather was her threat to us that if we did not accept her managed-competition model of reform, we would have single payer.

So what was her campaign to do? They decided to bring back the concept of a public option to appease those who were turning to Sanders because of his advocacy of single payer. They are relying on the meme that the public option is our door to single payer (even though it is not true). But what is her version of the public option?

She says we should build on ACA. She has proposed no new federal public option legislation but she is merely suggesting that the states look at Section 1332 of ACA which authorizes waivers for limited innovations on a state level.

Imagine the difficulties that states would have, within the confines of Section 1332, in building their own intra-state public plan. Unless they used private insurance innovations such as high deductibles, narrow provider networks, and tiered services, the premiums would be unaffordable to most. A single-payer system would be funded equitably through progressive taxes, but you could not do that with a public option since that is only one plan in a multi-payer system.

In 2009, David Himmelstein and Steffie Woolhandler explained in very brief terms why the public option is a flawed concept:

“The ‘public plan option’ won’t work to fix the health care system for two reasons.

“1. It forgoes at least 84 percent of the administrative savings available through single payer. The public plan option would do nothing to streamline the administrative tasks (and costs) of hospitals, physicians offices, and nursing homes, which would still contend with multiple payers, and hence still need the complex cost-tracking and billing apparatus that drives administrative costs. These unnecessary provider administrative costs account for the vast majority of bureaucratic waste. Hence, even if 95 percent of Americans who are currently privately insured were to join the public plan (and it had overhead costs at current Medicare levels), the savings on insurance overhead would amount to only 16 percent of the roughly $400 billion annually achievable through single payer – not enough to make reform affordable.

“2. A quarter century of experience with public/private competition in the Medicare program demonstrates that the private plans will not allow a level playing field. Despite strict regulation, private insurers have successfully cherry-picked healthier seniors, and have exploited regional health spending differences to their advantage. They have progressively undermined the public plan – which started as the single payer for seniors and has now become a funding mechanism for HMOs – and a place to dump the unprofitably ill. A public plan option does not lead toward single payer, but toward the segregation of patients, with profitable ones in private plans and unprofitable ones in the public plan.”

Hillary Clinton is now showing us how the public option is a diversion from the reform we really need – single payer. It is up to us, the people, to convince our politicians that single payer is what we want. It will not happen without us.

Dr. Don McCanne is senior health policy fellow at Physicians for a National Healthcare Program (PNHP), a nonprofit, nonpartisan organization of 20,000 physicians who support single-payer national health insurance. He resides in San Juan Capistrano, California.

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

http://commondreams.org/views/2016/02/24/clintons-public-option-diversion-we-need-single-payer-medicare-all

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