PNHP

A final word from David L. Adams, M.D.

A final word from David L. Adams, M.D.

Maine Voices: ‘Medicare for all’ system makes so much sense on so many levels

With lowered costs and universal coverage, single-payer American health care would cure many ills

By David L. Adams, Special to the Press Herald
Portland Press Herald, December 26, 2015

COUSINS ISLAND, Maine — It is open enrollment time for Medicare. Many people are finding themselves totally perplexed by the need to evaluate the competing offerings of the different Medicare supplement plans and Part D drug plans they have to choose from before the Dec. 7 deadline for enrollment.

The problem is the choices are so complicated that comparisons of apples to oranges don’t begin to describe the difficulties.

So why not simplify things by going to a single-payer, Medicare-for-all system, as many industrialized countries around the world have done with striking success? That success can be measured by their administrative costs, which are less than half the costs of our system of private health insurance.

Another measure of success is that there are better outcomes of care in countries with universal coverage, such as those with single-payer health care. There were 15 countries around the world with single-payer systems as of 2009, and all but four had higher-rated health care systems (by the World Health Organization) than the United States.

We pay considerably more for our health care, per person, than do people in any other country. Thanks to Congress, our current system prohibits negotiating about drug pricing, which is another source of cost savings in many countries. But our system does allow inflated salaries to the CEOs and administrators whose main function seems to be to refuse care whenever it will enhance their profit margin.

So, what are the drawbacks to single-payer Medicare for all, which have been cited by conservative Congresses since the 1960s?

• It’s socialized medicine: “Socialized medicine” refers to government-controlled medicine. Medicare for all is certainly not socialized medicine. The people providing your health care would not all work for the government. The decisions you and your health care provider make would continue to be private, without “death panels” or other suggested forms of government interference;

• It would lead to higher taxes: Because of potential savings on administrative costs and on negotiated drug prices, a recent study by economist Gerald Friedman showed that Medicare for all could save $592 billion per year in health care costs. These savings come from $476 billion saved if administrative costs were limited to the percentage spent on administration by Medicare, along with the $116 billion saved by negotiating pharmaceutical prices down to the levels charged in Europe.

This would be enough to offset cost increases for universal coverage. Gerald Friedman’s research shows that 95 percent of U.S. households would save money overall with Medicare for all.

Most importantly, by providing access to care for everyone, our health outcomes such as infant and maternal mortality, life expectancy and care for chronic illnesses, which now lag behind many developed countries, would improve.

Universal coverage and better outcomes at lower cost! So why not Medicare for all?

http://www.pressherald.com/2015/12/26/maine-voices-medicare-for-all-system-makes-so-much-sense-on-so-many-levels/

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Comment:

By Don McCanne, M.D.

As we struggle to bring to America a better health care system for all, it seems appropriate to cap the year with the final words from David L. Adams, M.D. of Cousins Island, Maine.

Following is a note from the editor of the Portland Press Herald:

“EDITOR’S NOTE: David L. Adams, M.D., lived with his wife and family on Cousins Island in Yarmouth for almost 40 years.

“He retired in 1998 after 30 years in active practice with Maine Cardiology in Portland. He was a dedicated volunteer after retirement, winning several awards for his activities.

“A passionate advocate for single-payer health care, Adams was one of the organizers of a celebration of Medicare’s 50th birthday in Monument Square in Portland on July 30.

“As he became cognizant of his approaching death from cancer this fall, he wrote the following column as an act of devotion to his patients and his belief in the importance of affordable health care for all.

“Adams died Dec. 6, the day before the end of open enrollment for Medicare in 2015.”

Michael Marmot: “The Health Gap”

The Health Gap: The Challenge of an Unequal World

By Michael Marmot

From Chapter 1 – The Organisation of Misery

I have used two terms, health inequalities and health inequities. From now on, I am going to use the term health inequities to refer to those systemic inequalities in health between social groups that are judged to be avoidable by reasonable means. Such an approach does not cut off debate. There is ample disagreement as to what are “reasonable means.” But it focuses the argument. Why is this fundamental? Because if people are suffering from ill-health in ways that could be remedied but are not, that is quite simply unjust.

From Chapter 9 – Fair Societies

Proportionate universalism

It was the evidence provided by our Nordic colleagues that led us, at the UCL Institute of Health Equity, to come up with the ugly neologism “proportionate universalism.” Let me explain.

When the British government was planning its Sure Start policy for early child development, I went to a meeting at Her Majesty’s Treasury to discuss the proposed programmme. It turned out that the initial plans for Sure Start were to target it at the most deprived communities. I showed the group the social gradient in literacy of young people according to parents’ education and pointed out that at the top, parents with the highest levels of education, our young people’s literacy levels were on a par with Sweden and Japan. But the gradient was steeper in Britain than in Japan and Sweden; the result was that the lower you go in the social hierarchy the worse our young people score compared with Sweden and Japan. The implication was that Sure Start should be for everyone, not only for the worst off.

The senior Treasury official, the wonderful Norman Glass (deceased sadly), said: “Don’t come to me with that Scandinavian nonsense about universal interventions. We’re Anglo-Saxons. We target and focus on the worst off.”

Anglo-Saxon? Norman was Irish-Jewish, but the point was well made. The default position of British social policy is to target interventions on the worst off. It seems to make sense. The problem with such “common sense” is that it ignores the gradient. All the social and related health problems that we see follow a social gradient. That disadvantage of focusing on the worst off is that you miss those, say, in the middle who have worse health than those at the top, albeit better than those beneath them on the ladder.

It is not just from the Nordic countries that we learned the importance of universalist policies. In Chile they talk of Chile Solidario. The aim is to bring the most socially excluded into the mainstream of society, to emphasize their rights and entitlements, not to see the state as a charitable institution handing out help to a grateful poor. Proportionate universalism is an attempt to marry the obvious need to work hardest on behalf of those in greatest need while preserving the universalist nature of social interventions. Services for the poor are poor services. We should want everyone to gain the benefits of universal policies while putting in effort proportionate to need. A key principle is social cohesion.

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Key to living in society is empathy and connectedness – genuine feeling for our fellow members of society. The separate, compartmented lives of people at the top, middle and bottom damage this vital ingredient of society. The previous chapters spell out, in detail, how this lack can damage health through the life course and in communities.

From Chapter 11 – The Organisation of Hope

What the figures on income and wealth show is that there are oceans of money sloshing about. It is not easy to maintain the fiction that we do not have enough money to do good things. The problem is that, within countries, the concentration of wealth is becoming more extreme. That was the message of Piketty’s “Capital in the Twenty-First Century.” At the same time as wealth concentration is increasing, all across Europe and the US we are being lectured to on the dire importance of austerity. Public services have to be cut back because… because… we cannot afford them?

John Maynard Keynes, immediately after the Second World War, wrote: “The day is not far off when the economic problem will take the back seat where it belongs, and the arena of the heart and the head will be occupied or reoccupied, by our real problems – the problems of life and human relations, of creation and behavior and religion.” In country after country, too much of our public conversation is about how we can grow national income, too little about how we can improve society.

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One senior Conservative politician in Britain put it to me that my agenda is closer to social democratic than to Conservative thinking. I have tried studiously in public, and in this book, to make my case on the evidence, not on prior political beliefs. My response to this politician was that avoidable health inequality, health inequity, was the deepest injustice in our society. Was he saying that only social democratic politicians cared? I hoped not. Further, showing that politicians distort the evidence to suit their political ends was not a party-political act; it should be aimed at all our political leaders whatever their makeup. No political party has a monopoly on purveying misleading information.

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If you are in a country with poorly developed social systems, do something. It will make a difference. If your country is on the way, do more. And if you are in the Nordic countries, do it better.

Do something. Do more. Do it better.

(Sir Michael Marmot is professor of epidemiology and public health at University College London, and current president of the World Medical Association.)

http://bloomsbury.com/us/the-health-gap-9781632860798/

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Comment:

By Don McCanne, M.D.

As Michael Marmot explains so well in “The Health Gap,” our health inequities stem from our failure to implement “proportionate universalism,” which he describes in the excerpts above – a must read. In fact, after reading the excerpts, you may agree that his entire book is a must read.

A single payer system standing alone would not be enough to ensure health equity, as Marmot explains in “The Health Gap,” but it would mesh perfectly with proportionate universalism. We just have to do more and do it better.

Value-based pricing: another medical-industrial con job

Value in Medical Care

The New York Times, Letter, December 22, 2015

To the Editor:

We applaud expanding reimbursement analysis beyond Medicare data to include commercial insurance.

It is essential to differentiate locally provided care from complex specialty care best provided by destination medical centers. Future payment models should recognize making an accurate diagnosis, providing appropriate treatment and achieving the best results.

It will be through a commitment to work collaboratively that payers, providers and policy makers build a sustainable, value-based health care delivery system in our country.

John H. Noseworthy
President and Chief Executive
Mayo Clinic, Rochester, Minn.

http://www.nytimes.com/2015/12/22/opinion/value-in-medical-care.html?partner=rssnyt&emc=rss

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Payment for Medical Care

The New York Times, Letter, December 29, 2015

To the Editor:

I take issue with the “value-based payment models” for medical care promoted by John H. Noseworthy, the president of the Mayo Clinic, in his letter to the editor (“Value in Medical Care,” Dec. 22).

When he says, “It is essential to differentiate locally provided care from complex specialty care best provided by destination medical centers,” is he suggesting that his destination medical center should be paid more than local care providers for the same work?

It is my understanding that all doctors are being evaluated equally on the accuracy of their diagnoses, the appropriateness of their treatments and the quality of their results. They should be paid accordingly.

Value-based payment models are used by the pharmaceutical industry to justify a drug price many times greater than the cost to bring it to market and manufacture it. The drug company decides how much “value” its drug provides to the patient who takes it.

Let’s not allow major destination medical centers to follow the same model. Better yet, let’s reverse the trend entirely.

Robert D. Schrock Jr.
Chapel Hill, N.C.

The writer is a retired orthopedic surgeon.

http://www.nytimes.com/2015/12/29/opinion/payment-for-medical-care.html

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Comment:

By Don McCanne, M.D.

It seems that the current policy fixation in health care reform is on paying for value instead of volume. This really plays into the hands of the medical-industrial complex.

Currently the pharmaceutical industry is leading the way. A prime example is the new, outrageously priced drugs for hepatitis C. In explaining why the prices are so high, representatives of the industry indicated that the new standard for drug pricing should not be simply the usual costs such as research and marketing, but rather they should be priced on the value provided – the value of preserving quality of life that would be lost with progression of disease, and the value in preventing expensive care in the future, such as liver transplants. These executives have to gall to claim that the monetary value of the preservation of quality of life and the aborted potential future health care costs should accrue to them and their shareholders.

By that same reasoning, many of the high priced cancer therapy drugs should be repriced at pennies on the dollar since they have an almost negligible benefit on the quality of life, and they actually increase the cost of cancer care simply because of the very high prices of the drugs themselves along with the costs of administering and monitoring them. Of course, then instead of pricing based on value, they resort to their fallback position of the high cost of drug research and other corporate expenses, like executive compensation (plus an extra bonus because this is CANCER, after all).

Of great concern, the pharmaceutical industry was successful in including in the Trans-Pacific Partnership Agreement (TPP) this concept that “value” be included as a legitimate basis for determining the price of drugs – pocketing greater profits for this nebulous add-on to the drug itself.  This is one more reason that TPP should not be approved in its current form.

Now the president and CEO of Mayo tells us that the complex specialty care provided by “destination medical centers” implicitly is of higher value and thus presumably should be rewarded more highly through value-based payment models. If they offer unique specialty care that is not offered at other centers, then payment based on costs plus a fair margin would be appropriate. But care that duplicates quality care available in the community should not command higher prices.

We cannot underestimate the uncanny ability of the medical-industrial complex to innovate with policy concepts to further their own pecuniary interests.

This concept of rewarding value instead of volume has led to the implementation of numerous payment models that are backed by not much more than “wish-it-would-work” concepts from the policy community; the initial evidence of benefit is extremely limited. We know single payer works. That’s what we should be implementing instead.

If you wish more information, yesterday’s message, “No more SGR, but… here you go!,” discusses some of these wish-it-would-work concepts such as Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) supposedly rewarding value instead of volume:

https://www.pnhp.org/news/2015/december/no-more-sgr-but…-here-you-go

No more SGR, but… here you go!

CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) (DRAFT)

CMS, December 18, 2015

Building on the principles and foundation of the Affordable Care Act, the Administration announced a clear timeline for targeting 30 percent of Medicare payments tied to quality or value through alternative payment models by the end of 2016 and 50 percent by the end of 2018. These are measurable goals to move the Medicare program and our healthcare system at large toward paying providers based on quality, rather than quantity, of care.

The passage of the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA) supports the ongoing transformation of healthcare delivery by furthering the development of new Medicare payment and delivery models for physicians and other clinicians. Section 102 of MACRA requires that the Secretary of Health and Human Services develop and post on the CMS.gov website “a draft plan for the development of quality measures” by January 1, 2016, for application under certain applicable provisions related to the new Medicare Merit-based Incentive Payment System (MIPS) and to certain Medicare alternative payment models (APMs).

Merit-Based Incentive Payment System

Measures for use in the quality performance category are a specific focus of the MDP. MIPS will build upon existing quality measure sets from the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VM), and Medicare EHR Incentive Program for Eligible Professionals (EPs), commonly referred to as Meaningful Use.

To fill identified measure and performance gap areas, CMS will expand and enhance existing measures to promote alignment and harmonization in the selection of measures and specifications, while concurrently developing new (de novo) measures according to priorities described in Section IV.

To accelerate the alignment of quality measurement and program policies, MACRA sunsets payment adjustments for PQRS, VM, and the EHR Incentive Program and establishes MIPS.

Alternative Payment Models

MACRA establishes incentive payments for EPs participating in certain types of APMs. MACRA requires quality measures used in APMs to be comparable to the quality measures used in MIPS; therefore applicability of candidate measures to support a variety of future APMs is an important element of this MDP.

From the Conclusion

CMS is committed to reducing provider burden through the use of measures aligned across federal and private-payer quality reporting programs. We stress harmonization of data elements and specifications among measure developers, whose cooperation and sharing are essential to creating aligned measures. Toward that end, we also intend to leverage the optional pre-rulemaking process and MAP review for MIPS and to participate with other stakeholders in efforts that promote measure alignment. This draft MDP acknowledges the associated challenges and identifies opportunities for measure developers to share information to reduce duplication of efforts.

CMS Quality Measure Development Plan (MDP) – 61 pages:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Draft-CMS-Quality-Measure-Development-Plan-MDP.pdf

MACRA, MIPS, APMs, MDP, and request for public comment:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html

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Comment:

By Don McCanne, M.D.

Physicians celebrated the passage of the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA) since it brought an end to the much despised SGR (Sustainable Growth Rate) method of adjusting Medicare payment rates. Though SGR was rarely implemented, it carried forward a massive deficit that would have required major reductions in Medicare payment rates. Besides, MACRA included the reauthorization of the Children’s Health Insurance Program. The trade-off, which was largely ignored, was the requirement to establish the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). CMS has now released a draft of the Quality Measure Development Plan for transitioning to MIPS and APMs.

Perhaps the main reason that physicians, who happened to be aware of MIPS and APMs, were not concerned is that they replaced the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VM), and Medicare EHR Incentive Program for Eligible Professionals (EPs), commonly referred to as Meaningful Use. Many thought that this would bring efficiency to existing programs by coordinating them under MIPS.

There are three reasons that physicians should be concerned. The first is that these programs are not simply now coordinated, they are expanded and enhanced with the development of new de novo measures. Think of what that means for new administrative burdens added to existing ones.

Second, some physicians no doubt thought that they could escape the MIPS burdens since MACRA would allow physicians to move into Alternative Payment Models (APMs) – accountable care organizations, patient centered medical homes, or whatever. Don’t celebrate yet. MACRA requires that the quality measures used in APMs to be comparable to the quality measures used in MIPS. MIPS is now an obligation no matter where you turn.

Third, and most important of all, is that the PQRS, VM, and the EHR Incentive Program were highly flawed programs adding significantly to the excessive administrative burden that characterizes the U.S. health care system, while having a relatively negligible impact on improving health care quality. The proper policy step should have been to send these programs back to the drawing boards, and then when it became obvious that there was no there there, locking them in storage forever. The worst policy decision would be to expand these programs and force them on everyone, but that is precisely what they did.

Quality is not achieved by playing the alphabet games, with nominal penalties and rewards. It is achieved by instilling efficiency and equity into our health care delivery system. A well-designed single payer system does that. A paper written by a team led by Gordon Schiff, and published in JAMA two decades ago, defines quality and describes how it can be achieved by implementing a single payer national health program:

A Better-Quality Alternative: Single-Payer National Health System Reform
JAMA, September 14, 1994, Volume 272 Copyright 1994, American Medical Association

https://www.pnhp.org/publications/a_better_quality_alternative.php

‘Medicare for all’ system makes so much sense on so many levels

With lowered costs and universal coverage, single-payer American health care would cure many ills

By David L. Adams, M.D.
Portland (Maine) Press Herald, Dec. 26, 2015

EDITOR’S NOTE: David L. Adams, M.D., lived with his wife and family on Cousins Island in Yarmouth for almost 40 years. He retired in 1998 after 30 years in active practice with Maine Cardiology in Portland. He was a dedicated volunteer after retirement, winning several awards for his activities. A passionate advocate for single-payer health care, Adams was one of the organizers of a celebration of Medicare’s 50th birthday in Monument Square in Portland on July 30. As he became cognizant of his approaching death from cancer this fall, he wrote the following column as an act of devotion to his patients and his belief in the importance of affordable health care for all. Adams died Dec. 6, the day before the end of open enrollment for Medicare in 2015.

COUSINS ISLAND, Maine — It is open enrollment time for Medicare. Many people are finding themselves totally perplexed by the need to evaluate the competing offerings of the different Medicare supplement plans and Part D drug plans they have to choose from before the Dec. 7 deadline for enrollment.

The problem is the choices are so complicated that comparisons of apples to oranges don’t begin to describe the difficulties.

So why not simplify things by going to a single-payer, Medicare-for-all system, as many industrialized countries around the world have done with striking success? That success can be measured by their administrative costs, which are less than half the costs of our system of private health insurance.

Another measure of success is that there are better outcomes of care in countries with universal coverage, such as those with single-payer health care. There were 15 countries around the world with single-payer systems as of 2009, and all but four had higher-rated health care systems (by the World Health Organization) than the United States.

We pay considerably more for our health care, per person, than do people in any other country. Thanks to Congress, our current system prohibits negotiating about drug pricing, which is another source of cost savings in many countries. But our system does allow inflated salaries to the CEOs and administrators whose main function seems to be to refuse care whenever it will enhance their profit margin.

So, what are the drawbacks to single-payer Medicare for all, which have been cited by conservative Congresses since the 1960s?

• It’s socialized medicine: “Socialized medicine” refers to government-controlled medicine. Medicare for all is certainly not socialized medicine. The people providing your health care would not all work for the government. The decisions you and your health care provider make would continue to be private, without “death panels” or other suggested forms of government interference;

• It would lead to higher taxes: Because of potential savings on administrative costs and on negotiated drug prices, a recent study by economist Gerald Friedman showed that Medicare for all could save $592 billion per year in health care costs. These savings come from $476 billion saved if administrative costs were limited to the percentage spent on administration by Medicare, along with the $116 billion saved by negotiating pharmaceutical prices down to the levels charged in Europe.

This would be enough to offset cost increases for universal coverage. Gerald Friedman’s research shows that 95 percent of U.S. households would save money overall with Medicare for all.

Most importantly, by providing access to care for everyone, our health outcomes such as infant and maternal mortality, life expectancy and care for chronic illnesses, which now lag behind many developed countries, would improve.

Universal coverage and better outcomes at lower cost! So why not Medicare for all?

http://www.pressherald.com/2015/12/26/maine-voices-medicare-for-all-system-makes-so-much-sense-on-so-many-levels/

ACA-compliant plans not providing adequate financial protection

How Much Do Marketplace and Other Nongroup Enrollees Spend on Health Care Relative to Their Incomes?

By Linda J. Blumberg, John Holahan, and Matthew Buettgens
Urban Institute, December 2015

In this paper, we examine premiums and out-of-pocket costs, as well as total financial burdens for individuals with different characteristics enrolled in ACA-compliant nongroup coverage. We show that despite the additional assistance available, individuals across the income distribution who are ineligible for Medicaid can still face very high expenditures. At the median, financial burdens can be reasonably high, particularly for those with incomes between 300 and 400 percent of FPL (Figure 1). As medical care needs increase, however, financial burdens grow appreciably across the income distribution. Even with federal financial assistance, 10 percent of 2016 nongroup marketplace enrollees with incomes below 200 percent of FPL will pay at least 18.5 percent of their income toward premiums and out-of-pocket medical costs. Ten percent of marketplace enrollees with incomes between 200 and 500 percent of FPL will spend more than 21 percent of their income on health care costs. Those in fair or poor health and those over age 45 are most likely to face high median financial burdens.

http://www.urban.org/sites/default/files/alfresco/publication-pdfs/2000559-How-Much-Do-Marketplace-and-Other-Nongroup-Enrollees-Spend-on-Health-Care-Relative-to-Their-Incomes.pdf

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Comment:

By Don McCanne, M.D.

This is just one more study that shows that far too many individuals who need health care still face excessive financial burdens in spite of being insured. Instead of merely trying to tweak our dysfunctional system, we should go ahead and replace it with one that works – a single payer national health program.

Generic drug pricing confirms that markets are not working

Medicare Drug Spending Dashboard

By Andy Slavitt, Acting CMS Administrator and Niall Brennan, CMS Chief Data Officer
The CMS Blog, December 21, 2015

Today, CMS is releasing a new online dashboard to provide information on Medicare spending on prescription drugs, for both Part B (drugs administered in doctors’ offices and other outpatient settings) and Part D (drugs patients administer themselves) to provide additional information and increase transparency.

In today’s announcement, the topline findings include:

* The diversity, growth, and impact of drug spending in the Medicare program – while the high-cost drugs include brand name Hepatitis C and cancer therapies, some generic drugs are seeing large price increases.

http://blog.cms.gov/2015/12/21/medicare-drug-spending-dashboard/

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Competition Not Stopping Drug Price Hikes, Medicare Data Shows

By Brianna Ehley
Politico Pulse, December 23, 2015

If you think a marketplace monopoly is behind all massive drug price hikes you might want to take a look at the new CMS drug spending dashboard. Eight of the 10 drugs that had big cost increases between 2013 and 2014 were made by multiple manufactures. Among them were five drugs that more than doubled in price during that time. If you expand to taking a look at the 15 drugs with the largest increases, nearly two-thirds or 9 of the 15, were made by multiple manufacturers. This data may throw a wrench in a popular solution proposed by Congress to deal with exponential drug price hikes — have FDA review faster the generic applications for drugs with a market monopoly but no patent or exclusivity protection. Furthermore, only one drug in the top 15 for the biggest price hikes was listed on the FDA’s drug shortage list during 2013-2014, which means we can’t blame companies taking advantage of a limited supply either. Take another look at the drug spending dashboard released this week and play around with the information yourself: http://go.cms.gov/1PkbJEk

http://www.politico.com/tipsheets/politico-pulse/2015/12/obamacare-enrollment-climbs-to-93-million-in-septcompetition-not-curbing-drug-price-hikesutah-can-block-federal-grants-to-planned-parenthood-211914

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Comment:

By Don McCanne, M.D.

Only Rip Van Winkle would not know that drug prices are totally out of control, yet the pharmaceutical industry tells us that there is no problem since the market will price drugs appropriately. But instead of competition bringing down prices, their concept of market dynamics is to push up the prices to the maximum that will be tolerated by patients who are partially insulated by various public and private payers.

If there is an area in pharmaceutical pricing in which competition should work, that would be the competition between generic products that are no longer under patent. But looking at the Medicare drug spending dashboard, it is obvious that the pharmaceutical firms have been able to push pricing of several generic drugs well above the levels that would be expected in a well functioning free market.

When the Republicans passed the Part D Medicare drug program, they prohibited Medicare from negotiating drug prices, instead insisting that the markets would be more effective in bringing drugs prices down. But instead the insurance and pharmaceutical industries have been allowed the freedom to essentially establish their own rules on how markets work. Their rules allow them to maximize their revenues while patients are being gouged, either directly or through taxes and higher insurance premiums. Adam Smith would agree that this corrupted version of markets is no market at all. They are using their control of essential medications to extort us. Extortion is not a tool of normal markets – quite the opposite.

We do not need to recite again the work by Nobel laureate Kenneth Arrow on why health care markets do not work. We have already proven that our reliance on markets is not effective by the mere fact that we spend, per capita, over two and one-half times as much on health care as the average of other wealthy nations.

We simply need to push the ideologues aside and put into place public policies that other nations have used to obtain value in their health care purchasing. The model most suitable for us would be a single payer national health program – an improved Medicare for all.

Republicans and Democrats concerned about health care costs

Healthcare costs a top concern for Republican and Democratic voters

By Jilian Mincer and Erin McPike
Reuters, December 21, 2015

Americans want to know what the next U.S. president will do to lower their rising healthcare costs, a priority shared by Republican and Democratic voters and second only to keeping the country safe, according to a recent Reuters/Ipsos poll.

In all, 62 percent of people surveyed said they would want to know about a presidential candidate’s plan for reducing healthcare costs, according to the online poll conducted Dec. 14-18.

While Republican and Democratic candidates are worlds apart on how to address healthcare, poll results show roughly the same proportion of Republican voters, or 62 percent, view it as a priority compared with 67 percent of Democrats, highlighting their frustration with rising drug prices, insurance premiums and deductibles ahead of the 2016 vote.

The only topic that attracted more interest was national security, as 67 percent wanted to know more about how presidential candidates planned to keep the country safe.

U.S. employers have been shifting more health coverage costs onto workers, particularly through high deductible health insurance plans, which can reach $6,600 in out of pocket costs for an individual and $13,200 for a family before insurance kicks in. Many of these changes have been ushered in with President Barack Obama’s signature healthcare law, as well as recent sharp increases in some prescription drug costs.

Republican strategists said party candidates are more focused on national security and the economy as dominant issues, noting they have little to gain by offering a detailed plan to tackle healthcare costs that could run up against major business interests, including the pharmaceutical industry.

“I’m on Obamacare, and it’s a horrible situation,” said Fred Voeltner, 64, who was laid off in 2009 and now pays for his own insurance. He is frustrated by how far he has to travel for care and how much more he has to pay each visit. “I’m open-minded,” he said. “But I expect to vote for a Republican.”

http://www.reuters.com/article/us-usa-election-healthcare-idUSKBN0U42GU20151221

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Comment:

By Don McCanne, M.D.

Unhappiness over the high costs of health care is not a partisan issue. Both Republicans and Democrats want to know the presidential candidates’ proposals to lower health care costs – a priority almost as great as their concern about national security.

Lest Democrats be smug over the introduction of the Affordable Care Act, it is ACA’s higher deductibles and narrower networks actually brought to us by the Democrats that have further infuriated voters over runaway health care costs.

Republicans keep promising us their replacement plan – the latest promise being by House Speaker Paul Ryan – but they fail to deliver. They actually prefer a “trust us” approach instead of providing specifics, since their telegraphed preferences would worsen patient affordability and access.

In the Reuters article, Fred Voeltner says that he is “frustrated by how far he has to travel for care and how much more he has to pay each visit” – consequences of narrow networks and high deductibles. But he is “open-minded” and expects “to vote for a Republican.” People are having trouble giving the Democrats credit for reform when they can’t see their own doctor and can’t pay their deductibles.

Democrats are now gathering around a candidate that would perpetuate our highly flawed financing system. On the other hand, another candidate – a democratic socialist running for the Democratic nomination – advocates for an affordable model that is supported by a majority of Americans – a single payer Medicare for all.

Unfortunately, presidential politics are complex. When you ask people why they are supporting a given candidate, you will only rarely hear single payer mentioned. Even though they want our next president to fix the health care cost problem, the answers you will hear are meaningless sound bites such as, he will “Make America Great Again.” When final ballots are cast, they will be based more on political personalities rather than public policy.

This brings to mind a quote of Winston Churchill, “It has been said that democracy is the worst form of Government except for all those other forms that have been tried from time to time.” (House of Commons, November 11, 1947).

Churchill also said, “At the bot­tom of all the trib­utes paid to democ­racy is the lit­tle man, walk­ing into the lit­tle booth, with a lit­tle pen­cil, mak­ing a lit­tle cross on a lit­tle bit of paper — no amount of rhetoric or volu­mi­nous dis­cus­sion can pos­si­bly dimin­ish the over­whelm­ing impor­tance of that point.” (House of Com­mons, Octo­ber 31, 1944)

A Single-Payer System: Best for Doctors and Patients Alike?

By Neil Chesanow
Medscape, Dec. 21, 2015

Recently, Medscape published two provocative articles on the viability of a single-payer healthcare system in which experts took opposing views on the issue. In one article, one group argued why it would save US healthcare; in the other, another group made the case that adopting a single-payer system would be the ruin of US healthcare.

In the article on why a single-payer system would be our salvation, Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and an architect of the Affordable Care Act (ACA), contended that although the ACA has been “a step forward for the country,” it “does not deal with the problem of waste and complexity in the system,” as he feels a single-payer system would.

And James Burdick, MD, a transplant surgeon at Johns Hopkins University School of Medicine and author of the forthcoming book “Talking About SINGLE PAYER,” argued that a single-payer system is “a more economical way to use healthcare resources. You could reduce expenses and still improve quality. That’s a tremendous opportunity that you don’t have in many other fields.”

Of course, as the article pointed out, this would virtually eliminate the entire commercial insurance industry—with $730 billion in revenues and a workforce of 470,000. But Dr Burdick believes it would likely restore doctors’ authority. And those who favor single-payer say that for all practices, administrative costs would plummet because there would be only one set of payment rules. Prior authorizations, narrow networks, and out-of-pocket payments would be eliminated, proponents of a single-payer system maintain.

The article also pointed to evidence of growing physician support for a single-payer system. For example, a 2014 survey of Maine physicians conducted found that nearly 65% of respondents preferred the single-payer option over trying to fix the current system—up from 52% in a 2008 survey. Physicians in general seem more open to a single-payer system.

Americans are warming up to the idea too. A tiny majority (51%) support Medicare for all, according to a national poll released in January. Many experts believe that the movement for a single-payer system may start at the state level, although the public’s abiding mistrust of government must still be overcome.

The article ignited impassioned arguments about the pros and cons of a single-payer system among the well over 100 physicians who responded with comments. Several doctors proposed thoughtful alternatives to “Medicare-for-all.”

“Commercial insurance is a failure and a joke,” one doctor opined. “Families pay more than $15,000 per year for health insurance and still have $2500 in deductibles, plus high copays. Patients are reluctant to get healthcare in outpatient settings, since private insurance does not cover anything unless a catastrophic event occurs. Many doctors no longer accept private insurance owing to their numerous administrative burdens. We easily forget that the primary goal of private insurance in capitalism to make a profit for the CEOs of insurance companies and the shareholders who own stock in them. Personally, I would prefer a 100% Medicare practice.”

“Medical insurance is supposed to be only for catastrophic events, like car insurance,” another physician shot back. “Can you imagine if Americans wanted insurance to pay for routine maintenance and fuel for their cars? The healthcare system is broken. You solution is to break it some more. My solution for my family is to live within our means, never go into debt for more than 30 days at a stretch, and never purchase health insurance—except very high-deductible, catastrophic-event insurance. Emergency rooms are for broken bones, gushing wounds, anaphylaxis, and other genuine emergencies, not sniffles and sprains. A full medicine chest and a bit of common sense is our family’s strategy.”

“A government-run single-payer system is without a doubt the only way to provide effective medical health therapeutic and management, a doctor contended. “For those who desire a higher level of care—and can afford it—there will be a concierge and private-pay system. As medicine advances technologically, this will become a necessity. The loss of jobs in the insurance industry will be partially offset by an increase in the added positions in the government medical system.”

“Obamacare barely passed through Congress with Democrat-only votes, and only with the assistance of bribes, threats, and lies,” an anesthesiologist fumed. “It has never garnered more than 30% public approval; and it has been changed over 40 times by the Obama regime illegally, without benefit of legislation by the legislative branch. The clowns who thought it was such a terrific idea back then are the same clowns braying for single-payer now. Why we are supposed to trust them this time? Why is it that the only answer to failed socialist government programs is more socialist government programs?”

“Single-payer reform would be an audacious step,” a radiologist observed. “It would virtually eliminate the entire commercial insurance industry—with $730 billion in revenues and a workforce of 470,000—and replace it with one unified payer. EXCEPT that when the government takes over, it will cost $1.4 trillion and require a 900,000-person workforce.”

“A one-payer system will not be like ‘Medicare-for-all’; it will be end up becoming more like ‘Medicaid-for-all,'” a pulmonologist warned. “How many of you in private practice could make a living if 100% of your patients were on Medicaid?”

“Yes, turn it over to the government,” a doctor acerbically wrote. “They will make our lives easier and reduce our paperwork and the onerous documentation requirements during patient encounters. Oh wait! They are the ones doing now that with Medicare. Never mind.”

“I don’t see one valid point against single-payer in these comments, just the usual ‘anticommunist’ stuff,” another doctor reasoned. “A number of comments trashed the Veterans Administration (VA). The VA system has a lot going for it, considering the level of acuity of the population it serves—starting with a functional electronic health record. Do the detractors think that a random assortment of for-profit HMOs would do a better job serving the high-utilization health needs of veterans? Basic healthcare is like a utility—something everyone needs, and in the best interest of our society to make sure everybody gets.”

“Why does it have to be a single-payer?” one doctor wanted to know. “Why not a government payer for essential care and let private payers compete for the rest?”

“Why not allow anyone to buy Medicare as their insurance, rather than just those over 65?” another doctor counter-proposed. “Young, healthy people could get Medicare, and the premium would be much less than commercial insurance. Their utilization of medical services is generally lower, so the money generated would be a net to Medicare. If commercial insurance wants to compete, it would have to lower its rates. This would generate competition among Medicare and commercial insurers and drive premiums down. If you want Medicare, then get it. If you want commercial insurance, then get it. Let the individual decide, but give the option of Medicare.”

http://www.medscape.com/viewarticle/855269

PolitiFact rates Sanders TRUE on U.S. health spending

Fact-checking Sanders’ claim that U.S. spends 3 times per capita what the U.K. spends on health care

By Jon Greenberg
PolitiFact, December 20, 2015

Sen. Bernie Sanders, I-Vt., says the best solution to address problems in the United States’ health care system is to guarantee every American access to health care as a right.

Speaking at the New Hampshire Democratic presidential debate, Sanders continued to express support for a single-payer health care system that is popular throughout much of the rest of the world.

To make his point, Sanders compared health care costs between the United States and two other Western nations — the United Kingdom and France.

“Why is it that we spend almost three times per capita as to what they spend in the U.K. —  50 percent more than what they pay in France?” Sanders asked. “The insurance companies, the drug companies are bribing the United States Congress. We need to pass a Medicare-for-all single-payer system.”

Sanders’ numbers are arresting and largely correct.

The Organization for Economic Cooperation and Development has the data for all three nations.

Total per capita spending:

$8,713 – United States
$3,234 – United Kingdom
$4,123 – France

Do the math, and total U.S. spending is about 2.7 times what they spend in the United Kingdom per person, and a bit over twice what they spend per person in France. Everything is measured in dollars, and the data are from 2013.

Sanders’ claim in this case is more accurate than more sweeping versions he has made in the past. In 2009 and again in 2015, he claimed that the United States spends twice as much per capita on health care as any other country. Those claims are overly broad.

Our ruling

Sanders said that the United States spends almost three times on health care per capita what is spent in the United Kingdom and about double what they spend in France. The numbers from an independent, reliable source back that up.

We rate this statement True.

http://www.politifact.com/truth-o-meter/statements/2015/dec/20/bernie-s/fact-checking-bernie-sanders-claim-us-spends-three/

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Health at a Glance 2015

OECD

In 2013, the United States continued to outspend all other OECD countries by a wide margin, with the equivalent of USD 8,713 for each US resident. This level of health spending is two-and-a-half times the average of all OECD countries (USD 3,453).

http://www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/health-at-a-glance-2015_health_glance-2015-en#page165

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Comment:

By Don McCanne, M.D.

In the Democratic debate this past weekend, Bernie Sanders said, “Why is it that we spend almost three times per capita as to what they spend in the U.K., 50 percent more than what they pay in France… The insurance companies, the drug companies are bribing the United States Congress. We need to pass a Medicare-for-all single-payer system.” In response, PolitiFact wrote, “Sanders’ numbers are arresting and largely correct.”

Although single payer supporters are very familiar with these numbers, it is a welcome change that a source such as PolitiFact finds these numbers to be “arresting” and largely correct, and thus they rate this statement as True.

Another line that Sanders frequently uses is that we spend twice as much on health care as any other country. PolitiFact has twice rated this as False. Technically they are correct. In 2013, we spent over two-and-a-half times the average of OECD countries, but there are some that spent more than half of what we do. Sen. Sanders trips on his words by saying “any other country” instead of “average of other countries.”

Nevertheless, in the two previous articles, PolitiFact trumpeted the fact that his statement was False (though in the second version they buried in the text the fact that fine tuning his talking point would have made it accurate).

Spending on health care that is more than two-and-a-half times the average OECD nation is a very impressive number, and yet PolitiFact buried this behind their stamp of False.

On today’s PolitiFact we can give them a True. On the two previous articles we can give them a rating of “Technically True but Highly Misleading” simply because they swamped the important and accurate fact about how much more we spend on health care that Sen. Sanders was attempting to convey.

Private insurers are data mining our personal information

Insurers want to nudge you to better health. So they’re data mining your shopping lists

By Rebecca Robbins
STAT, December 15, 2015

Health insurers are scooping up huge quantities of personal information in a bid to figure out when you’re likely to get sick — and to design interventions to keep you healthy.

Insurance companies have always had access to your medical records, and in some cases your genetic data, too. Now, they’re paying data miners to sift through information on everything from what model car you drive to how many hours you sleep, from which magazines you read to where you shop and what you buy.

The goal: To decipher patterns that will allow them to steer you away from health emergencies. And to save themselves a whole lot of money in the process.

Shopping at home-improvement stores, for instance, turns out to be a great predictor of mental health. If you suddenly stop shopping at Lowe’s, your insurance company may suspect that you’re depressed, (Deloitte’s Dr. Harry) Greenspun said.

And if you drive a foreign-made car, you’re more likely to lose your eligibility for Medicaid in the coming year, according to Chris Coloian, president of Predilytics, a Massachusetts health-care data analytics company recently acquired by the firm Welltok.

Not all of this information is useful in crafting interventions to keep patients healthy. But with the help of data miners, insurers are finding that some patterns can make for powerful tools.

The intervention can be as simple as determining patients’ ethnicities to make sure they’re receiving information in the right language. Or it can be as aggressive as sending a patient a free digital scale — unprompted — if, say, she has congestive heart failure; unexpected weight gain from pooling fluids can be a sign the condition is worsening.

Privacy advocates worry that insurers are using all this highly personal, often sensitive information without informed consent and with little transparency or accountability.

Long before Big Data, of course, health insurers made decisions about which patients to prioritize. But using an algorithm to determine how and when to intervene raises troubling risks, said Kirsten Martin, an assistant professor at George Washington University who studies business ethics and Big Data.

Health insurers say they don’t deny care to anyone based on algorithms; they just use the data to customize the approach to each patient.

In one popular intervention, for instance, three health insurers in the Northeast designed outreach around neighborhood demographics. They staged outdoor health fairs for customers in walkable neighborhoods. Those more likely to drive everywhere were targeted instead with messages about healthy behaviors on social media, Coloian said.

Fifteen years ago, as a young Cornell physics graduate student, (Colin) Hill got swept up in the excitement around the Human Genome Project. He and a fellow physics graduate student started a company that aimed to harness the promise of all that new data.

For nearly a decade, GNS Healthcare worked mostly with pharmaceutical companies, mining genomic and lab test data to help discover drugs and evaluate them. But the firm, based in Cambridge, Mass., has since expanded its focus.

GNS helped the insurance giant Aetna predict which of about 37,000 policyholders were most at risk of developing metabolic syndrome or seeing their condition worsen within a year, using an analysis that took into account demographic variables including ethnicity, cigarette usage, and nightly hours of sleep.

GNS will also rank patients by how much return on investment the insurer can expect if it targets them with particular interventions, such as sending a text message reminding them to refill a prescription or sending a nurse to their home for a checkup. For example, the firm helped a group that manages pharmacy benefits for Regence Blue Cross Blue Shield’s policyholders in the Northwest make decisions about how to target patients who skip their pills.

All patients, of course, should take the medication prescribed to them, “but as a health plan with precious finite resources, where do you focus your energy?” asked Hill, the chief executive of GNS. The algorithm, he said, can tell the insurer not to waste time and money trying to get certain patients to take their pills — but to spend resources on other patients instead.

http://www.statnews.com/2015/12/15/insurance-big-data/

***

Comment:

By Don McCanne, M.D.

The private insurers are masters at innovation. Now they are paying data miners to sift through extensive personal information on each of their clients. Is this really to keep patients healthy, as the insurers claim, or is it to simply to introduce an opaque process to create a new pathway to medical underwriting to benefit their own bottom line?

Big Data now impacts all of us. The attack on our privacy has placed all of us in the Emperor’s new clothes (nobody told you?). Although the Affordable Care Act greatly limited medical underwriting (smoking, age, etc.), insurers can introduce new innovations based on personal data that could have the same impact (e.g., telling the insurer not to waste time or money on certain patients, etc.).

We should ask, who should be partnering with the patient to provide the best health outcomes? Should it be the health care team with a mission to protect and improve the patient’s health, or should it be a private insurance company with a mission to compete for greater business success in the marketplace?

This blatant invasion of our privacy is one more reason that we should get rid of the private insurers and replace them with a well designed single payer national health program – an institution that would be expected to protect our privacy (think of HIPPA).

Why the profit-driven market model doesn’t work in health care

By Jessica Schorr Saxe, M.D.
The Charlotte (N.C.) Observer, Dec. 17, 2015

“Is medicine a business or is that an oxymoron?” asked the moderator of panel members convened by Leadership Charlotte recently.

When I started my medical career, we reflected on the nature of medicine – namely, whether it was an art or a science. No one talked about the business of medicine.

Healing medicine has been practiced for over 2000 years, and scientific medicine for more than 100. The perception of medicine as a business is relatively new.

We now view medical care as a commodity, much as we view buying shoes. Though the market model is pervasive, it does not apply to everything. Some services remain public goods such as police protection, fire protection, and education. I posed this question to our audience: Why do we view health care as different from education, to which most of us believe all children are entitled?

Applying the market model to medical care is a poor fit. Many factors interfere with choice, on which market models rely, in health care. When patients have decisions to make about medical care, they are often scared, vulnerable – and sick. If your doctor tells you you need an MRI because you might have a brain tumor, you are unlikely to do extensive research to see which is the cheapest or most accurate – or if an MRI is actually indicated. And, if you research a medical intervention, you are likely to find cost information opaque – and reliable quality measures even more elusive.

A for-profit system creates perverse incentives. Insurance companies make money for investors when they provide less care. For-profit medical institutions have troubling outcomes. Investor-owned hospitals are more expensive. Death rates are higher in for-profit hospitals and dialysis units.

Drug companies make more profits when they sell newer drugs, still patent-protected. This leads to promotion of new drugs as safe, such as rofecoxib (Vioxx), an anti-inflammatory. After being widely prescribed, it was linked to thousands of deaths.

This incentive to promote new drugs obscures the fact that it is generally better to take an old drug rather than the glittery new drug being promoted.

Also obscured is the fact that often non-drug treatments are superior. For instance, exercise is often as effective a treatment for depression as antidepressant medications.

Your neighbor’s health care has different implications for you than most things that we view as commodities. While we are unaffected by which shoes our neighbors buy, their health and health care affect us. For example, we are better off if the sick server at our local restaurant can see a doctor and have the flu or tuberculosis diagnosed and treated.

One of the biggest casualties of the marketization of medicine has been the doctor-patient relationship. When I started my practice, the patient and I were the only ones in the exam room. Now, the room also contains an insurance company, an administrator and a coding specialist. Though invisible, they all have something to say about what the doctor does.

Is the “business of medicine” its future or a blip in a distinguished history that spans centuries?

Do the words of our exemplars still inspire us? If so, let Sir William Osler, father of modern medicine, have the last word: “We are in the profession as a calling, not as a business. … Once you get down to a purely business level, your influence is gone and the true light of your life is dimmed.”

Jessica Schorr Saxe is a Charlotte family physician and the chair of Health Care Justice – NC. Contact her at: HCJusticeNC@gmail.com.

http://www.charlotteobserver.com/opinion/op-ed/article50323570.html