PNHP

Fixing the ACA Is Not Good Enough

Fixing the ACA Is Not Good Enough

We need to institute ‘Medicare for all’

By Caroline Poplin, M.D., J.D.
MedPage Today, March 1, 2016

National health insurance has become a defining issue in the contest for the Democratic nomination. Bernie has put “Medicare for all” squarely back on the table. Hillary calls that pie-in-the-sky: instead, she would build on the Affordable Care Act (ACA). (As she says, market-based private insurance was originally her idea.)

We can all agree that the ACA has benefited many, particularly the poor and the sick.

But Medicare for all has picked up some interesting supporters: for example, Fareed Zakaria, a high-profile TV commentator whose beat is foreign affairs, and Donald Berwick, MD, who, as administrator of the Centers for Medicare and Medicaid Services, supervised the roll-out of the ACA.

Moreover, the Kaiser Family Foundation December 2015 Tracking Poll demonstrates majority support among ordinary Americans (58%); a 2014 survey of physicians and medical students in Maine showed that many doctors also (in Maine at least) would prefer single-payer, especially those practicing primary care.

So it is disappointing that liberal economists whom I respect, such as New York Times columnist and Nobel laureate Paul Krugman, conclude that single-payer would be too expensive and too disruptive — that we should improve the ACA instead.

Krugman, of course, is trained to crunch numbers — I can’t. But from the exam room where I sit, his conclusion doesn’t make sense. The principal advantage of single-payer, after all, is that it is less expensive than our market-based system.

That is not just idle speculation: every other developed nation has either some form of single-payer or highly regulated private insurance with price controls — and they all achieve better health outcomes, with genuinely universal coverage, for at least 30% less (as a fraction of the Gross Domestic Product) than we do, even though we still cover something less than the entire population.

Perhaps the economists simply substituted Treasury payments for employers’ contributions to their employees’ health insurance (something the ACA was specifically designed to preserve), and left everything else in place: that would indeed be a huge hit to the federal budget, particularly since employers, representing a large group of mostly healthy employee families, can negotiate better deals with insurers than individuals can.

But that is not how Medicare for all would work. Instead, it would be like Medicare today, improved to make it even less expensive for the Treasury and individual beneficiaries. Since everyone would receive the same, comprehensive benefits, administrative costs would be much lower. The huge transaction costs engendered by the ACA — hundreds of thousands of annual negotiations between insurers, doctors, hospitals, pharmaceutical benefit managers, and manufacturers — would decline significantly.

There would be no need for the development of hundreds of different plans at different prices, underwriting, or the careful regulation now required to be sure insurers comply with ACA requirements; there would be no need for exchanges.

And ordinary Americans would not need to spend hours each year figuring out which policy they can afford, or “need.” (In fact, most people estimate health risks poorly; women worry about breast cancer more than heart disease, although heart disease kills five times more women than breast cancer.)

There would be no need for poor people whose incomes vary day-to-day to deal with the incredibly complicated business of subsidies, where mistakes can trigger major tax penalties.

Finally — and most controversially — Medicare, which currently sets prices for doctors and hospitals, would extend price controls to other health services, such as prescription drugs and devices, through open procedures with due process and opportunity for comment as mandated by the Constitution. Or Medicare could negotiate prices, as the Department of Veterans Affairs currently does.

Private health service providers would remain private, although market competition simply hasn’t, doesn’t, and won’t, keep prices down in many healthcare markets in a way that benefits consumers. Every other developed nation has recognized this: they all control prices without compromising care.

For those who believe corporations can do no wrong, and government, nothing right, we can continue Medicare Advantage. Employers who wish could opt out, provided they show that their plans are equal to or better than Medicare. To prevent unnecessary disruption, Medicare for all could be phased in over time.

In fact, it may turn out that it is the ACA that is too expensive to be sustained. It is not just a matter of ineffective cost control, but of who pays. ACA supporters believe costs are high because Americans “demand” unnecessary medical services, because they are insured. Therefore, the ACA shifts significant expense to patients, to ensure enough “skin in the game”: the ACA’s so-called “silver plans,” favored by the law, require patients to pay 30% of their annual health care costs in addition to premiums. (Employer-sponsored insurance is moving the same way.)

This means someone who falls ill must pay thousands of dollars of deductible before his expensive insurance kicks in. Sick Americans can still face huge medical debts and bankruptcy, reduced only somewhat since passage of the ACA.

Yes, it is important to get things done in Washington, as long as they are the right things. There will be fierce opposition to Medicare for all, especially from for-profit insurers and providers; it is important to negotiate skillfully, to take a robust initial position, to withhold concessions until the bargaining starts, and to take the long view. The ultimate goal is not “coverage,” but universal, affordable healthcare.

Finally, remember: Medicare is not some exotic Scandinavian import. Medicare is as American as the flag, has served us well for 50 years, and is a solid foundation on which to build.

Caroline Poplin, M.D., J.D., is an attorney and internist in Bethesda, Md. She is a former staff internist for the National Naval Medical Center, and currently practices medicine part-time at the Arlington Free Clinic in Virginia. She also consults for law firms on Medicare and Medicaid fraud.

http://www.medpagetoday.com/Washington-Watch/ElectionCoverage/56479

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

Misleading Medicare-for-All number bashing continues

Cherry-picking Statistics to Bash Sanders’ Medicare-for-All Plan

Contrary to Claims by the Washington Post and Fortune, the Vast Majority of the Poor Would Gain

By Steffie Woolhandler and David Himmelstein
The Huffington Post, March 4, 2016

In the heat of battling Sen. Bernie Sanders, Hillary Clinton’s camp (and the camp followers at the Washington Post and Fortune magazine) has made a remarkable discovery: National health insurance (aka Medicare-for-All) hurts poor people.

How is that possible? It’s not. But a widely-quoted analysis by Ken Thorpe, a former Clinton administration official, used statistical sleight of hand to zoom in on the tiny slice of the poor who might pay more (while getting better care), and hide the vast majority who would gain.

Here are the real numbers we came up with by analyzing data from the Census Bureau’s 2015 Current Population Survey, the standard source for estimates of income and health insurance coverage.

At present 9.2 million people living in poverty — and 8.8 million just above the poverty line — are uninsured. They often can’t get vital care, and when they do, they face ruinous medical bills. For these 18 million, Medicare-for-All would be a godsend.

Another 10.7 million poor Americans and 21.5 million near-poor have private insurance. For virtually all of them, the new Medicare-for-All taxes would cost less than their current premiums.

Some of this windfall would go directly to families that now pay all or part of their own premiums. The rest would go to employers who now chip in to premiums for the poor and near-poor workers, but most economists believe these gains would be passed on to workers since benefit costs are, in fact, deducted from wages.

About 9.7 million poor and near-poor people have Medicare, without wrap-around private or Medicaid supplements. The vast majority of them would be better off under Medicare-for-All, which would relieve them of Medicare premiums, as well as onerous co-payments and deductibles.

What about the 42 million poor and near-poor Medicaid recipients? This is the group that Thorpe (and recent articles and editorials in the Washington Post and Fortune) claims would be hit hard by the new Medicare-for-All payroll taxes, which their employers would pass on to them by lowering their wages.

Yet, 34.6 million (82 percent) of these 42 million are children, retirees or others who have no earnings. Hence, they wouldn’t pay any new payroll tax.

Two million others earn no more than $7.25 an hour, the minimum wage, so employers couldn’t lower their wages to make up for the new taxes.

Only 3 percent (1.2 million) of poor and near-poor Medicaid recipients earn more than $15 an hour — the minimum wage that Sanders has proposed. That’s the number of poor households at risk of financial losses. But even that overstates how many might be harmed, since some pay out-of-pocket costs that Medicare-for-All would eliminate.

It’s a shame that even this small group might suffer, and we’d recommend that Sen. Sanders tweak his plan to protect them. That shouldn’t be hard.

But his plan would relieve the poor, as well as the middle class, from the daunting co-payments and deductibles that obstruct care and threaten finances. And it would abolish the narrow provider networks that restrict patients’ choice of doctors and hospitals. Instead, Americans could go anywhere for care, a privilege that every Canadian enjoys, but is rapidly vanishing in our country.

In every nation with national health insurance the poor — and middle-class families — fare better than here. They bear less of the health care cost burden, have better access to care, and live longer and healthier lives.

It takes extraordinary mental and rhetorical gymnastics to portray universal health care as bad for the poor. Having mastered that art, perhaps the Clinton team will turn its attention to repealing the law of gravity.

Steffie Woolhandler, M.D., M.P.H, and David U. Himmelstein, M.D., 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 views expressed do not necessarily reflect the views of those institutions.

http://www.huffingtonpost.com/steffie-woolhandler/bernie-sanders-medicare-for-all_b_9385012.html

***

Comment:

By Don McCanne, M.D.

An Improved Medicare for All system would provide for everyone all necessary health care, and it would be funded with progressive taxes that are fair and affordable for each of us. Using one tentative set of tax policies as an example of how the system could be funded does not change this basic truth.

Selected numbers associated with Bernie Sanders’ loosely sketched out Medicare for All proposal have been used to attack the fundamental concept of single payer with no acknowledgement that eventual legislation would ferret out any numbers or assumptions that might be slightly off (though that’s in dispute) and then carefully tune them to get the financing right.

One example, using the widely circulated set of numbers, indicates that some lower income individuals might end up paying more than they do now, though the extent and intensity of the deficits have been exaggerated, as the analysis by Steffie Woolhandler and David Himmelstein shows. The point is that tax policies are quite malleable, with many potential sources and variable rates. They can be adjusted to ensure that taxes would be equitable for all.

Under the tentative Sanders numbers, about 1.2 million lower-income individuals might be slightly worse off financially, but at least they would be insured. Compare that to the 2.9 million adults who are in the ACA coverage gap who remain uninsured – a far worse problem than facing a modest financial imbalance. It would be far easier to adjust the taxes under a single payer system than it would be to fill in the coverage gap resulting from the complex administrative infrastructure created by ACA.

Those who continue to bash the Medicare for All concept based on tentative numbers and then conclude that we should stick with the Affordable Care Act are being disingenuous.

The Medicare for All model only needs fine tuning to meet the goal of health care for all, whereas merely patching the irreparably flawed ACA infrastructure will always leave us short of the goal. We need the right infrastructure, and then we can get them numbers right.

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

Misleading Medicare-for-All number bashing continues

Cherry-picking Statistics to Bash Sanders’ Medicare-for-All Plan

Contrary to Claims by the Washington Post and Fortune, the Vast Majority of the Poor Would Gain

By Steffie Woolhandler and David Himmelstein
The Huffington Post, March 4, 2016

In the heat of battling Sen. Bernie Sanders, Hillary Clinton’s camp (and the camp followers at the Washington Post and Fortune magazine) has made a remarkable discovery: National health insurance (aka Medicare-for-All) hurts poor people.

How is that possible? It’s not. But a widely-quoted analysis by Ken Thorpe, a former Clinton administration official, used statistical sleight of hand to zoom in on the tiny slice of the poor who might pay more (while getting better care), and hide the vast majority who would gain.

Here are the real numbers we came up with by analyzing data from the Census Bureau’s 2015 Current Population Survey, the standard source for estimates of income and health insurance coverage.

At present 9.2 million people living in poverty — and 8.8 million just above the poverty line — are uninsured. They often can’t get vital care, and when they do, they face ruinous medical bills. For these 18 million, Medicare-for-All would be a godsend.

Another 10.7 million poor Americans and 21.5 million near-poor have private insurance. For virtually all of them, the new Medicare-for-All taxes would cost less than their current premiums.

Some of this windfall would go directly to families that now pay all or part of their own premiums. The rest would go to employers who now chip in to premiums for the poor and near-poor workers, but most economists believe these gains would be passed on to workers since benefit costs are, in fact, deducted from wages.

About 9.7 million poor and near-poor people have Medicare, without wrap-around private or Medicaid supplements. The vast majority of them would be better off under Medicare-for-All, which would relieve them of Medicare premiums, as well as onerous co-payments and deductibles.

What about the 42 million poor and near-poor Medicaid recipients? This is the group that Thorpe (and recent articles and editorials in the Washington Post and Fortune) claims would be hit hard by the new Medicare-for-All payroll taxes, which their employers would pass on to them by lowering their wages.

Yet, 34.6 million (82 percent) of these 42 million are children, retirees or others who have no earnings. Hence, they wouldn’t pay any new payroll tax.

Two million others earn no more than $7.25 an hour, the minimum wage, so employers couldn’t lower their wages to make up for the new taxes.

Only 3 percent (1.2 million) of poor and near-poor Medicaid recipients earn more than $15 an hour — the minimum wage that Sanders has proposed. That’s the number of poor households at risk of financial losses. But even that overstates how many might be harmed, since some pay out-of-pocket costs that Medicare-for-All would eliminate.

It’s a shame that even this small group might suffer, and we’d recommend that Sen. Sanders tweak his plan to protect them. That shouldn’t be hard.

But his plan would relieve the poor, as well as the middle class, from the daunting co-payments and deductibles that obstruct care and threaten finances. And it would abolish the narrow provider networks that restrict patients’ choice of doctors and hospitals. Instead, Americans could go anywhere for care, a privilege that every Canadian enjoys, but is rapidly vanishing in our country.

In every nation with national health insurance the poor — and middle-class families — fare better than here. They bear less of the health care cost burden, have better access to care, and live longer and healthier lives.

It takes extraordinary mental and rhetorical gymnastics to portray universal health care as bad for the poor. Having mastered that art, perhaps the Clinton team will turn its attention to repealing the law of gravity.

Steffie Woolhandler, M.D., M.P.H, and David U. Himmelstein, M.D., 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 views expressed do not necessarily reflect the views of those institutions.

http://www.huffingtonpost.com/steffie-woolhandler/bernie-sanders-medicare-for-all_b_9385012.html

An Improved Medicare for All system would provide for everyone all necessary health care, and it would be funded with progressive taxes that are fair and affordable for each of us. Using one tentative set of tax policies as an example of how the system could be funded does not change this basic truth.Selected numbers associated with Bernie Sanders’ loosely sketched out Medicare for All proposal have been used to attack the fundamental concept of single payer with no acknowledgement that eventual legislation would ferret out any numbers or assumptions that might be slightly off (though that’s in dispute) and then carefully tune them to get the financing right.

One example, using the widely circulated set of numbers, indicates that some lower income individuals might end up paying more than they do now, though the extent and intensity of the deficits have been exaggerated, as the analysis by Steffie Woolhandler and David Himmelstein shows. The point is that tax policies are quite malleable, with many potential sources and variable rates. They can be adjusted to ensure that taxes would be equitable for all.

Under the tentative Sanders numbers, about 1.2 million lower-income individuals might be slightly worse off financially, but at least they would be insured. Compare that to the 2.9 million adults who are in the ACA coverage gap who remain uninsured – a far worse problem than facing a modest financial imbalance. It would be far easier to adjust the taxes under a single payer system than it would be to fill in the coverage gap resulting from the complex administrative infrastructure created by ACA.

Those who continue to bash the Medicare for All concept based on tentative numbers and then conclude that we should stick with the Affordable Care Act are being disingenuous.

The Medicare for All model only needs fine tuning to meet the goal of health care for all, whereas merely patching the irreparably flawed ACA infrastructure will always leave us short of the goal. We need the right infrastructure, and then we can get them numbers right.

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

Donald Trump releases his health reform proposals

Healthcare Reform to Make America Great Again

Donald J. Trump for President

As it appears Obamacare is certain to collapse of its own weight, the damage done by the Democrats and President Obama, and abetted by the Supreme Court, will be difficult to repair unless the next President and a Republican congress lead the effort to bring much-needed free market reforms to the healthcare industry.

By following free market principles and working together to create sound public policy that will broaden healthcare access, make healthcare more affordable and improve the quality of the care available to all Americans.

Congress must act. Our elected representatives in the House and Senate must:

1.  Completely repeal Obamacare.

2.  Modify existing law that inhibits the sale of health insurance across state lines.

3.  Allow individuals to fully deduct health insurance premium payments from their tax returns under the current tax system.

4.  Allow individuals to use Health Savings Accounts (HSAs).

5.  Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals.

6.  Block-grant Medicaid to the states.

7.  Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products.

The reforms outlined above will lower healthcare costs for all Americans. They are simply a place to start. There are other reforms that might be considered if they serve to lower costs, remove uncertainty and provide financial security for all Americans.

https://www.donaldjtrump.com/positions/healthcare-reform

***

Comment:

By Don McCanne, M.D.

As the leading candidate for the Republican nomination for president, we should be aware of Donald Trump’s health policy proposals. His descriptions to date have been vague — replace Obamacare with something terrific, remove the lines around states, and can’t let people die in the streets. Responding to demands for specifics, Trump plays it safe and now releases a brief list of standard recommendations long held by mainstream Republican politicians.

Most of these proposals have been extensively analyzed and would have very little impact on resolving the problems with our health care financing. But repealing Obamacare and using block-grants to reduce Medicaid funding would further impair access to care for millions of Americans. Doesn’t really sound like something terrific.

Trump has said that single payer systems work well in other nations, but his political base is not supportive of such a system here, and so it does not appear on his list of proposed reforms. Once again, politics trumps policy.

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

Donald Trump releases his health reform proposals

Healthcare Reform to Make America Great Again

Donald J. Trump for President

As it appears Obamacare is certain to collapse of its own weight, the damage done by the Democrats and President Obama, and abetted by the Supreme Court, will be difficult to repair unless the next President and a Republican congress lead the effort to bring much-needed free market reforms to the healthcare industry.

By following free market principles and working together to create sound public policy that will broaden healthcare access, make healthcare more affordable and improve the quality of the care available to all Americans.

Congress must act. Our elected representatives in the House and Senate must:

1.  Completely repeal Obamacare.

2.  Modify existing law that inhibits the sale of health insurance across state lines.

3.  Allow individuals to fully deduct health insurance premium payments from their tax returns under the current tax system.

4.  Allow individuals to use Health Savings Accounts (HSAs).

5.  Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals.

6.  Block-grant Medicaid to the states.

7.  Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products.

The reforms outlined above will lower healthcare costs for all Americans. They are simply a place to start. There are other reforms that might be considered if they serve to lower costs, remove uncertainty and provide financial security for all Americans.

https://www.donaldjtrump.com/positions/healthcare-reform

As the leading candidate for the Republican nomination for president, we should be aware of Donald Trump’s health policy proposals. His descriptions to date have been vague — replace Obamacare with something terrific, remove the lines around states, and can’t let people die in the streets. Responding to demands for specifics, Trump plays it safe and now releases a brief list of standard recommendations long held by mainstream Republican politicians.

Most of these proposals have been extensively analyzed and would have very little impact on resolving the problems with our health care financing. But repealing Obamacare and using block-grants to reduce Medicaid funding would further impair access to care for millions of Americans. Doesn’t really sound like something terrific.

Trump has said that single payer systems work well in other nations, but his political base is not supportive of such a system here, and so it does not appear on his list of proposed reforms. Once again, politics trumps policy.

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

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

***

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

***

Comment:

By Don McCanne, M.D.

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.

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.