Member Resource – Page 697

Health food for thought

By Evan Tuchinsky
Paradise (Calif.) Post, Oct. 19, 2010

Last week I took an assignment from another newspaper to cover the Mad As Hell Doctors’ appearance in Chico. The advocates for a single-payer system were completing a tour of California, and the capacity crowd at Harlan Adams Theater was the biggest they drew. They found a very receptive audience.

The panel – four physicians from the Pacific Northwest, joined by a local doctor and two local nurses – raised some thought-provoking points about healthcare reform. If you’re unhappy about the Patient Protection and Affordable Care Act, you’re in good company, and you have something in common with these crusading physicians who find reasons for displeasure on both sides of the debate.

They’re mad about disinformation like “death panels” and “socialized medicine,” which clouds the discussion. They’re also mad that the single-payer option wasn’t even considered by the White House and Congress, leaving us with a compromise bill with fundamental flaws.

They see single-payer insurance as critical.

“Single payer” tends to get lumped in with “nationalized medicine” even though there is a key distinction: Insurance would come from the public sector, but care would come from the private sector. Despite the oft-heard crises of “keep your government out of my healthcare,” MAHD speakers argue that the majority of healthcare money flows from the government right now. Three of the five groups covered by insurance are seniors (Medicare), children from low-income families (Medicaid/Medi-Cal) and military veterans (VA).

The imbalance in economics comes when private, for-profit insurers can cherry-pick plum customers. If all insured Americans – young and old, healthy and sick – were part of the same “risk pool,” instead of segregated, premiums from the former would cover expenses of the latter.

The so-called “government option” would have been a disaster, one Mad As Hell Doctor explained, because “the private insurers would game the system and throw all the sick people to the public option, and when the public option failed, the private insurers would say, ‘See, the government can’t do healthcare!'”

The idea of a government-run insurance monopoly raises understandable fears, even among those who see benefits in a single system – benefits such as less paperwork, fewer sets of rules and, correspondingly, a greater share of each healthcare dollar going to actual healthcare.

Before getting alarmed, though, it’s important to look at the status quo and assess fears accordingly. Take the notions of lines and rationing, for instance. There already are lines. Emergency rooms are backed up. It’s hard to get a doctor’s appointment if you don’t already see a primary-care physician. And, as one MAHD speaker asked, how long have you waited on the phone line when calling an insurer?

As for rationing, insurers do this now when they deny treatment or require lengthy authorization processes for procedures, medicines and equipment they cover. The Mad As Hell Doctors gave me a lot to think about, and I know I’m not alone.

http://www.paradisepost.com/opinion/ci_16371041

Expert: Single-Payer Health System Could Save Maine $1 Billion a Year

With health care costs high and rising, state lawmakers are trying to come up with new alternatives incorporating recent federal reform laws. Today in Augusta, a committee heard from a health care expert who says a single-payer system could save a billion dollars in Maine each year.

» Click here to listen to the story

Maine Public Broadcasting Network
Oct 19, 2010

In the early 1990s, when Taiwan wanted to tackle rising health care costs, it hired economist William Hsiao to come up with a solution. And it was a tall order, Hsiao told the Legislature’s Joint Select Committee on Health Care Reform Opportunites and Implementation.

“Taiwan decided that everyone should have access to basic health care. However, health care costs money, and regardless of how you pay for it — either out of your own pocket or though premiums paid partly by your employer or out of your own pocket — it’s going to be paid by somebody, through some avenue.”

With the goal of affordable universal coverage that is sustainable over time, Taiwan developed a single-payer system, adminstered by the government. Hsiao, a professor at Harvard, says the cost is much lower than in the United States health care system, and it is paid for by employers, employees and the federal government.

And, he says, nearly everybody is covered. “They even sent people under the bridges to find the homeless to enroll them. And the Taiwanese that live overseas fly back to Taiwan for their health care, because it is literally free, and high quality.”

Hsiao spoke to a committee room crowded with health care lobbyists. The committee was formed following the passage of the federal Affordable Care Act last spring, to prepare Maine for the law’s implementation.

One committee member wondered if there is another way to develop mandatory, standardized health care coverage while still using private insurers, in a system more like that seen in Holland and Germany.

“I wouldn’t call it single-payer, but then I’m a Republican,” says Rep. Les Fossel, a Republican from Alna. He points out that the state requires car insurance, and it is provided through private insurers. Though he is not sold on single-payer, he says something needs to change.

“The thing is, we simply can’t sustain the system as it is going forward now,” Fossel says. “The Affordable Health Care Act did a whole lot to define coverage, but Truman had it wrong when he said ‘the buck stops here.’ The buck keeps being shoved down to the guy at the lowest level. And we have to figure out a way to pay for it. And this is going to be an extraordinarily difficult thing, and yet if we don’t, we are going to kill people.”

And kill jobs, he might have added. Jim Miller, general manager of Wooden Boat Publications, which employs 33 people in Brooklin, says small businesses are struggling with fast-rising health care costs.

“We had a renewal in May and we experienced a 17 percent increase in premiums, which is an increase of $48,000. That’s a one-year increase,” Miller says. “Unfortunately, there is nothing we can do to offset this cost, nor is there any way to understand why this happened.”?

Miller spoke at a press conference held by Maine AllCare, which used Hsiao’s visit to beat the drum for health care reform. He says Wooden Boat is self-insuring part of its employees’ deductibles this year, basically gambling on the health of its employees. And Miller says the lack of affordable health care puts the business at a competitive disadvantage.

“We are also faced with competition from international magazines located in countries that offer national health insurance,” he says. “They are at a cost advantage, as are the U.S. magazines we compete against who have chosen to drop coverage for their staff.”

William Hsiao is now working as a consultant to the state of Vermont, as it tries to develop an affordable health care plan. And he says that if Taiwan is any example, the United States could save a lot of money by moving toward a single-payer system.

“Taiwan right now, 2009, is spending 6.1 percent of its GDP for health care. The United States last year was spending 16.7 percent of its GDP for health care,” he says.?

In Taiwan, Hsiao says, the system saw 10 percent cost savings just by rooting out the health care providers who were fraudulently or excessively billing for services. Similar savings in Maine, he says, would equal a billion dollars a year.

http://www.mpbn.net/Home/tabid/36/ctl/ViewItem/mid/3478/ItemId/13906/Default.aspx

Poor healthcare may shorten American lives – study

By Maggie Fox, Health and Science Editor
Reuters, Oct. 7, 2010

WASHINGTON — Americans die sooner than citizens of a dozen other developed nations and the usual suspects — obesity, traffic accidents and a high murder rate — are not to blame, researchers reported on Thursday.

Instead, poor healthcare may be to blame, the team at Columbia University in New York reported.

They found that 15-year survival rates for men and women aged 45 to 65 have fallen in the United States relative to the other 12 countries over the past 30 years.

Such figures are frequently cited by supporters of healthcare reform, and critics often point out that the United States also has higher rates of obesity, more traffic fatalities and more murders than these countries.

Columbia’s Peter Muennig, who led the study published in the journal Health Affairs, said his team accounted for these factors this time.

“But what really surprised us was that all of the usual suspects — smoking, obesity, traffic accidents, and homicides — are not the culprits,” Meunnig said in a statement.

“The U.S. doesn’t stand out as doing any worse in these areas than any of the other countries we studied, leading us to believe that failings in the U.S. health care system, such as costly specialized and fragmented care, are likely playing a large role in this relatively poor performance on improvements in life expectancy.”

In June, the Commonwealth Fund, which advocates on and does research focusing on healthcare reform, reported that Americans spend twice as much on healthcare as residents of other developed countries — $7,290 per person — but get lower quality and less efficiency.

Muennig and Sherry Glied compared the United States to Australia, Austria, Belgium, Britain, Canada, France, Germany, Italy, Japan, the Netherlands, Sweden and Switzerland.

All these countries provide universal health insurance, in contrast to the United States, where 15 percent of the population lacks health insurance, although healthcare reform passed in March is designed to lower that disparity.

Republicans have promised to derail the legislation if they gain power in Congress in next month’s elections.

COSTS GO UP

Between 1975 and 2005, medical costs went up in all the countries, as did life expectancy. But costs went up far more in the United States and life expectancy increased to a far lower degree.

Glied and Meunnig do not believe obesity accounts for the differences. While more Americans are obese, overall the populations in all the nations have been getting fatter, they said.

“For obesity to explain the decline in U.S. life expectancy or the increase in health spending relative to the 12 comparison countries, Americans would have to be becoming obese at a faster rate than people in the comparison nations over time,” they wrote. But this has not been happening.

Americans are less likely to smoke, and while Americans are more likely to die in car crashes or be murdered, again these rates do not explain the lower life expectancy, the Columbia team said.

“The findings undercut critics who might argue that the U.S. health care system is not in need of major changes,” they wrote.

They noted that the United States has been dropping in life expectancy tables for decades.

“In 1950, the United States was fifth among the leading industrialized nations with respect to female life expectancy at birth, surpassed only by Sweden, Norway, Australia, and the Netherlands,” they wrote. At last count, the United States was 46th in female life expectancy; 49th for both sexes. (Editing by Eric Walsh)

http://www.reuters.com/article/idUSN0622294120101007

Low-Cost Lessons from Grand Junction, Colorado

By Thomas Bodenheimer, M.D., M.P.H., and David West, M.D.
The New England Journal of Medicine
October 7, 2010

According to the Dartmouth Atlas of Health Care, average per capita Medicare spending in Grand Junction was $6,599 in 2007 – 24% lower than the national average and 60% below high-cost Miami.

Moreover, Grand Junction scored above the national average on a number of measurements of preventive care, diabetes, asthma, and other quality metrics.

We believe that seven interrelated features of the health care system that may explain the relatively low health care costs could be adopted elsewhere. These are leadership by the primary care community; a payment system involving risk sharing by physicians; equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients; regionalization of services into an orderly system of primary, secondary, and tertiary care; limits on the supply of expensive resources, including specialists, beds, and equipment; payment of primary care physicians for hospital visits; and robust end-of-life care. These features could be replicated in other markets – though generally not without political battles.

http://www.nejm.org/doi/pdf/10.1056/NEJMp1008450

Comment:

By Don McCanne, MD

Although I am taking a break this week and won’t provide a comment here, an excellent commentary on the Bodenheimer and West article has been posted by Joshua Freeman, Professor and Chair of the Department of Family Medicine for the University of Kansas School of Medicine. He states, “Grand Junction, Colorado may not have all the answers to our health care system, any more than Canada or Britain or Switzerland do. But it is doing a lot of things right, it is saving money, and it is improving the health of the community, and that’s a lot more than most areas in the US are doing.”

For Josh Freeman’s full commentary:
http://medicinesocialjustice.blogspot.com/2010/10/lower-costs-in-grand-junction-primary.html

Low-Cost Lessons from Grand Junction, Colorado

Low-Cost Lessons from Grand Junction, Colorado

By Thomas Bodenheimer, M.D., M.P.H., and David West, M.D.
The New England Journal of Medicine
October 7, 2010

According to the Dartmouth Atlas of Health Care, average per capita Medicare spending in Grand Junction was $6,599 in 2007 – 24% lower than the national average and 60% below high-cost Miami.

Moreover, Grand Junction scored above the national average on a number of measurements of preventive care, diabetes, asthma, and other quality metrics.

We believe that seven interrelated features of the health care system that may explain the relatively low health care costs could be adopted elsewhere. These are leadership by the primary care community; a payment system involving risk sharing by physicians; equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients; regionalization of services into an orderly system of primary, secondary, and tertiary care; limits on the supply of expensive resources, including specialists, beds, and equipment; payment of primary care physicians for hospital visits; and robust end-of-life care. These features could be replicated in other markets – though generally not without political battles.

http://www.nejm.org/doi/pdf/10.1056/NEJMp1008450

For Josh Freeman’s full commentary:
http://medicinesocialjustice.blogspot.com/2010/10/lower-costs-in-grand-junction-primary.html

As Nov. 6 PNHP meeting nears, activity steps up

Oct. 20, 2010

Dear PNHP colleagues and friends,

Momentum is building for PNHP’s Annual Meeting, which is only a couple of weeks away – Saturday, Nov. 6 – in Denver, but it’s still not too late to register. We also have a few spots open for our highly acclaimed Leadership Training Institute the day before (Nov. 5). Please register for one or both today.

You won’t want to miss distinguished speakers like Democracy Now host Amy Goodman, PNHP co-founders Drs. David Himmelstein and Steffie Woolhandler, pharmaceutical industry critics Donald Light (editor of the new book “The Risks of Prescription Drugs”) and Joel Lexchin, American pediatric surgeon practicing in Canada Dr. Sherif Emil, labor activist Rose Roach and journalist T.R. Reid (author of “The Healing of America”), among others.

And you won’t want to miss the chance to compare notes with PNHP activists from all over the country who are continuing the drive for single-payer health reform on the state and national levels.

All events will be held at the Sheraton Denver Downtown Hotel at 1550 Court Place, Denver. To book your room, call 800-325-3535. If you have questions, call the PNHP office at (312) 782-6006. If you are unable to attend, please consider making a donation to help pay for scholarships for medical students to participate.

Meanwhile, PNHP leaders and activists have been active on multiple fronts in recent weeks.

Thirty-nine physicians joined or renewed their membership in PNHP at the recent meetings of the American Academy of Family Physicians and the American Academy of Pediatrics, where we had exhibit booths. Our membership continues to grow – we’re now over 18,000!
Dr. Margaret Flowers and PNHP staffer Ali Thebert just completed a successful chapter visit to North Carolina, where area members arranged for Dr. Flowers give grand rounds, radio interviews and presentations in churches and community halls in Charlotte, Greensboro and Durham-Chapel Hill. In the weeks ahead, similar visits are planned for New Jersey, Wisconsin and Colorado. To arrange a chapter visit, contact Ali Thebert at ali@pnhp.org.
PNHP’s banner at the Oct. 2 “One Nation Working Together” march in Washington calling for “Single payer – improved Medicare for all” was very well received. An estimated 175,000 people attended the event, which is described by Drs. Flowers and Andy Coates here. You can see a picture of our banner here.
Our Washington staff, notably PNHP congressional fellow Dr. Flowers and Ron Hikel, have been meeting with the health legislative assistants of several U.S. senators, aiming to line up more support for single-payer legislation in that chamber. On the House side, the main points of our successful congressional briefing on Sept. 23 are summarized here. The briefing, which focused on the Deficit Commission’s threats to Medicare, drew several dozen health LAs and the participation of Rep. Lynn Woolsey, honorary co-host of the event, and Rep. John Conyers. Rep. Raul Grijalva also co-hosted.
The Nov. 2 midterm elections are just around the corner, and single payer is an issue in many campaigns. You can read the comments of PNHP’s national coordinator, Dr. Quentin Young, on this fall’s political scene at The Huffington Post.
Our physicians continue to engage in a lively debate about health reform on the opinion pages of their regional newspapers. See, for example, the recent op-eds of Dr. Wally Retan in the Birmingham News and Dr. James Mitchiner in the Ann Arbor News. A great resource for evaluating the new health law and making a compelling case for single payer is Dr. John Geyman’s new book, “Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Reform.” You can order it easily through PNHP’s store.

Thanks for your continued support and especially your priceless efforts for reform!

Cordially,

Quentin Young, M.D.
National Coordinator

Mark Almberg
Communications Director

P.S. If you’re a member of CREDO’s phone services or CREDO Action, you can help PNHP by voting on how CREDO distributes its 2010 donations funding. This year PNHP is on the ballot and we need your votes! The more votes we get, the more funding we’ll receive from CREDO. Two years ago we received nearly $65,000 in this way. Voting is easy. Go to http://www.credomobile.com/ballot and vote for us. It’s a quick and effective way to support PNHP — at no extra cost to you. Of course, you can always make a direct, tax-deductible contribution to PNHP online or by mail, too!

State needs single-payer health system

By WALLY RETAN
Birmingham News, Oct. 10, 2010

The cost of health care is out of control. We have to do something about it. Now.

As a nation, we spent about $8,000 per person on health care last year. Tha
t includes premiums, co-payments, deductibles and out-of-pocket payments for what insurance didn’t cover. That’s also the money employers didn’t put into paychecks because they sent it to an insurance company.

It’s also taxes. Medicaid is bankrupting many state governments, including ours, but health care costs also include taxes for the veterans medical system, military medicine and Medicare.

In 1970, health care costs were only $350 per person. Government experts expect the spending to rise to $13,000 per person by 2018, the year the major cost-controlling measures of the new health care law finally become fully effective. That would be more than $30,000 a year for an average family.

We can’t afford to wait for the law to do whatever it’s going to do to control costs.

Medical expenditures in Great Britain, Sweden and Spain are about $3,000 per person each year. The quality of health care in those countries scores very high in international comparisons; in some cases, higher than ours. People who live there are generally well-satisfied with the care they have.

America can follow their example and provide high-quality health care for everyone for about half of what we’re spending now. What it would take is a publicly financed, national health insurance program like those in European countries — a single-payer health care system.

Today, of every U.S. dollar spent for health care, 30 cents or more go to administration, most of it wasted on the paperwork and bureaucracy imposed by private health insurance companies. By comparison, the administrative overhead in the Medicare system is less than 4 cents per dollar.

We need the efficiency of a single, publicly financed health care system, like an improved form of Medicare, providing affordable, high-quality care for everyone. Medicare preserves the right to choose and change one’s physician, fundamental to patient autonomy. Patients would be free to seek care from any licensed health care professional.

Our health facilities should be geared toward optimal patient care, not for optimal return to shareholders. Hospitals should operate as public service organizations, with regional planning agencies setting their global budgets, including their capital expenditures. This would eliminate most of today’s irrational waste.

So, is this the way our country should go?

Doctors would like it. Physicians in single-payer countries live comfortably, much like physicians here. They have much less medical school debt, much lower malpractice insurance and wonderful freedom from hassles with insurance companies.

Patients would like it. We’d all pay a little more Medicare tax, but we’d be free of those sky-high premiums, co-payments and deductibles, and free of wrongful claim denials. We’d know that every one of us could get all of the care we really need, without favoritism and with no one left out.

Businesses would like it. No more double-digit premium increases each year to struggle with. No more worrying about the cost of health care for employees. Employers could get out of the health insurance business and back to doing what they know best.

A single-payer program would also give us powerful tools like the ability to negotiate fees and pharmaceutical prices, thus giving us long-term cost control.

States all across the country are looking hard at what the new health care reform law requires of them. Many states are also looking hard to see if a state single-payer option would make sense for them.

Alabama should be looking at a state single-payer option, too.

Wally Retan, M.D., of Mountain Brook is state coordinator for the Alabama chapter of Physicians for a National Health Program (www.PNHP.org) and Health Care for Everyone — Alabama (www.HealthCareFor-Everyone-Alabama.org). E-mail: info@healthcareforeveryone-Alabama.org.

http://blog.al.com/birmingham-news-commentary/2010/10/my_view_state_needs_single-pay.html

Model exists to provide health insurance for all – it’s called Medicare

By Dr. James C. Mitchiner
Ann Arbor News, Oct. 3, 2010

The announcement last month by the Census Bureau that the number of uninsured increased last year to a record 50.7 million individuals should come as no surprise to those who understand the uniquely American tradition of linking health insurance to employment.

Combined with the corresponding finding that the rate of employer-based insurance has decreased, the conclusion is obvious: in a declining economy, as unemployment rates increase and employer payrolls tighten, the number of people lacking health insurance goes up.

Why is this? I have never understood why health insurance must be associated with employment. Historically, I recognize how businesses’ response to FDR’s wartime wage and price controls lead to the situation we have now. But I fail to see how a model first applied in the 1940s should continue to operate in the 21st century. Other forms of insurance – car, home, boat, flood, and universal life insurance – are not linked to a job, so why should health insurance have this unique relationship?

Imagine a world where your health care coverage would not be predicated on what you did or where you worked, where you lived under a system that provided continual access to care as you moved from job to job or state to state, and guaranteed your health security even if you were laid off or terminated. Picture yourself in such a world where “choice” refers not to your choice of health insurer, but instead to the freedom to choose your own doctor and hospital, based on whatever criteria you and you alone deem to be personally relevant. And imagine a world where more than 95 percent of your contribution to health insurance was actually spent on health care, with no substantial contributions to a bloated and mindless bureaucracy.

The good news is that such a model exists. It is called a single-payer, Medicare-for-All program. It is a plan modeled on Medicare, a popular program that is universal, portable, affordable, non-profit, non-discriminatory, and administratively efficient. An expanded Medicare program would sever the link between employment and health insurance for all Americans, and use as its sole entry criteria nothing more than U.S. citizenship. Such a program would drastically reduce the number of uninsured, at a total cost much less than what we are paying now. And, under a single-payer system, private insurance firms would be used for simple administrative functions only, and not for decisions that place greedy corporate profits over an individual’s right to medical care.

And the bad news? The United States remains the only western democracy that does not have universal single-payer health insurance. For illogical reasons, we as a country continue to have blind faith in the ability of the private insurance industry to solve the dual problems of access to care and cost containment. If for-profit insurance has not fixed the problems with health care after over 60 years of existence, why would anyone believe it would happen now under the recently passed health care reform act, where private insurance continues to play a dominant role? Clearly, the only logical solution is to insure everyone, and the most efficient way to do that is through single-payer national health insurance.

Dr. James Mitchiner, an Ann Arbor physician, is the fo
rmer president of the Washtenaw County Medical Society and a member of Physicians for a National Health Program.

http://www.annarbor.com/news/opinion/model-exists-to-provide-health-insurance-for-all—its-called-medicare/

Socialized, single payer health care in the U.S. – that works!

By Richard Cranium
Daily Kos, Oct. 15, 2010

Yesterday, I was introduced to a socialized, government-run, single payer health care system that works. And it is working beautifully, right here in America.

It would be almost schadenfreude-ish to see every Republican and blue dog Dem try to take a swipe at this highly efficient model of medical care provision. But they won’t, because it wouldn’t be politically expedient to do so, as it is with “Obamacare”.

If you’re interested in taking a look at what a comprehensive, national health care system might look like – one that is actually operating in the U.S. right now – hop down below the fold.

Toward the end of the health care reform debate, there was a big outcry (championed most publicly by Howard Dean) that the end result should be “Medicare for all”. That’s not a half bad idea, as far as it goes. And it would have been an improvement on what the final HCR bill looked like. I’m wondering, though, if we missed an opportunity. The end result of a comprehensive overhaul of the provision of health care in the United States might actually be closer to the Veterans Administration health care system.

Allow me to explain my own first encounter with the VA model. Now, granted, my experience yesterday was only my first visit, but the coordination of the care I received from the moment I checked in was extremely – and I mean, extremely – efficient.

Here are the bullet points of my day:

12:55 – Arrived at VA medical center, checked in
1:05 – Called by a team nurse, vitals checked, basic information collected, received flu shot
1:15 – Taken to waiting room to see my primary
1:20 – Primary comes to waiting room, introduces herself, we go to her office
2:00 – Leave primary’s office, go to nurse station. Receive Tdap booster.
2:05 – Sign up at lab station
2:10 – Called for lab work
2:15 – Lab samples drawn; head for specialty clinic to make appointment
2:20 – Go to pharmacy to pick up prescriptions; prescriptions are ready
2:25 – Go to radiology clinic
2:45 – Chest Xray and EKG complete
2:55 – Make appointment at another specialty lab
3:00 – Take care of some administrative details at Eligibility station
3:15 – Leave VA medical center

The Details

My primary was very thorough, and took a good amount of time with me to get all of my background, discuss my overall health issues, and conduct a brief physical exam. She was able to write up all of my current meds right from her computer. I can’t emphasize enough how absolutely thorough she was in her data collection and evaluation, and all of this was entered into my profile right on her computer as we talked. More on this in a minute.

During the course of my day, I received a lab workup, a flu shot, Tdap booster, EKG, chest xray, and two specialty referrals (including audiology). By the time I finished the lab, and went to the pharmacy, my prescriptions were ready and waiting – no more than 20 minutes after I had left the primary’s office. I did not wait more than 5 minutes at any one station, from the time I checked in, until the time I checked out. In my 56 years on the planet, that alone made this a unique experience.

I went to Eligibility after everything was complete, and got a form for a hardship request (because I’m out of work) to lower my copays, and to have my picture taken for an ID. And finally, per my primary’s request, I walked the EKG results down to her, knocked on her door, she looked at them and said, “looks great! See you in a month.” I asked her if she wanted the graph. “Not necessary,” she said. “It’s already in the computer and I’ll get a reading sent down by the cardiologist.”

Damn.

The entire process took 2 hours and 15 minutes, from the time I walked in until the time I walked out. I was truly amazed that any health care system that was this efficient, and thorough, was available to me. As I was leaving, I complimented the process to the last woman I spoke with in Eligibility. And I told her: “Every person in America should experience that efficiency and level of caring one time. One time.”

In a two and one quarter hour period, I accomplished more for my medical care than I would have in days with my prior physician, and the outside labs and radiology clinics and specialists. The longest wait time that I had all afternoon was waiting for the elevator after I left the radiology lab.

Here’s the real kicker. Remember that computer stuff the primary was doing? Actually, from the time I first contacted VA about health care, a computer record of me was established. What we did yesterday was to fill in the holes in that record. And now, I can walk into any VA medical clinic or hospital anywhere in the United States, and the medical personnel in that facility will have access to my complete medical history. Talk about records portability.

The cost for all of this? $18 co-pay for each of my 3 prescriptions, and $15 co-pay to see my primary. The efficiency, cost effectiveness, and care that I felt along the way? Priceless.

I have absolutely no doubt that if everyone had the opportunity to experience what I experienced yesterday just once, that there would be a nationalized, single payer health care system in the U.S. in a relatively short period of time.

*************

This diary would be incomplete without acknowledging the assistance of several Kossaks who are also VA customers and military vets. The advice and direction that they generously provided in my previous diary (and off-list email) on the VA medical system helped me to understand the process and navigate the bureaucracy a bit more cleanly before I walked in the door for the first time.

http://www.dailykos.com/story/2010/10/15/102527/19

The midterm elections and Medicare for all

By Dr. Quentin Young
The Huffington Post, October 15, 2010

As we approach Nov. 2, it’s fair to say that in many ways the distortion of political discourse in our country has never been worse.

Extreme right-wing personalities – reincarnated Know-Nothings – are elbowing their way into the nightly airwaves via paid advertisements and Fox News. Billionaires are lavishly funding the Tea Party movement and an assortment of anti-government themes.

As our serious economic destabilization continues, and in the absence of vigorous progressive voices offering convincing, evidence-based solutions to our problems, our population is increasingly being abandoned to the clutches of ultra-right yahoos like Sharron Angle in Nevada, Pat Toomey in Pennsylvania, Ed Martin in Missouri and Christine O’Donnell in Delaware, to name just a few.

Pernicious ballot initiatives aiming to turn the clock back on health care and other social issues have been put on several state ballots, often the result of ultra-conservative stealth organizations deploying deliberately misleading language. Arizona’s Proposition 106, which would proscribe a single-payer system (and prohibit various other federal health programs), is a case in point.

These developments are creating a perilous situation for the republic.

It must be said that the quality of political discourse in the run-up to the midterm elections has not been facilitated by the flawed health reform legislation that the administration squeaked through Congress this spring.

While there are some desirable parts of the Obama administration’s new health law – the funding of community health centers, the expansion of Medicaid, the modest but not unimportant efforts to curb insurance company abuses – it is still widely viewed with unease by the public.

In fact, a recent AP/Stanford/Robert Wood Johnson Foundation poll showed twice as many Americans – 40 percent – believe that the law doesn’t go far enough as believe the government should not have a role in health care, and four-fifths of the public favor “making sure that more Americans get the health care they need.”

The recent spate of insurance company premium hikes and their pre-emptive dropping of whole classes of potentially unprofitable policies, such as those that cover individual children, by insurers like WellPoint, UnitedHealth Group, Aetna, Cigna and Humana, haven’t helped build public confidence in the new law’s ability to rein in these corporate profiteers.

Nor have reports that insurance companies and employers are successfully negotiating waivers to evade some of the modest requirements contained in the law.

As a result, skepticism in the law abounds. Polls suggest Republican calls to repeal or defund the new law have gotten some traction, even though their crude scare tactics – e.g. their charge that the administration’s health law is “socialist” – are patently ridiculous.

Big insurers are giving large donations to the GOP again (after having given so generously to Democrats in the run-up to the new law), hoping to dictate the terms of the law’s implementation in a way most favorable to their mercenary interests.

Meanwhile the health care situation in the U.S. is deteriorating at a more rapid pace. The Census Bureau data reported a few weeks ago indicated a startling 4.3 million increase in the number of uninsured since 2008, to 50.7 million people last year. This number would have been much larger if public insurance programs, in the first place Medicaid, hadn’t enrolled an additional 6 million people. The new uninsured numbers represent enormous human suffering.

It’s worth noting that the much vaunted public option, had it been incorporated into the new law, would have had a negligible affect on this number, according to a letter from the Congressional Budget Office. Besides inviting an insurer’s field day of cherry picking, such a provision would have been anything but a step toward single payer, as some of its advocates claimed.

So what to do?

First, it’s important to recognize there are a number of candidates running for office this November who support single-payer legislation, both incumbents and challengers. The candidacy of Dr. David Gill in Illinois’ 15th congressional district is but one example. Building up a single-payer caucus in Congress is an important goal, as is the continuing enlistment of support for single-payer legislation like Rep. John Conyers’ H.R. 676 and Sen. Bernie Sanders’ S. 703.

Second, several state-based movements for single payer are pressing their agenda for local reform. These states include Vermont, where an important Legislature-funded study on state models for reform – including single payer – is well under way, where several candidates have been vying with each other as to who’s more supportive of single payer, including gubernatorial candidate Peter Shumlin. Sen. Sanders has pledged to seek whatever federal waivers are needed should the people of his state declare their preference for a single-payer system.

Third, Medicare, Medicaid and Social Security are under a serious threat from the National Commission for Fiscal Responsibility and Reform. The commission is presumably going to make recommendations for changing these vital social insurance programs in its report to a lame-duck Congress by Dec. 1. Any cuts should be emphatically rejected. Medicare should be strengthened by improving it and expanding it to everyone. That’s also one of the surest ways to control skyrocketing health costs, as a recent congressional briefing by PNHP leaders and others recently pointed out.

Finally, our educational work in support of an improved Medicare for all remains indispensable. There are good reasons to believe that the new health law will be subject to destabilizing pressures from several quarters, including from actions by incorrigible offenders like the insurance industry (which is already complaining about the law’s minimal restraints), and the law may unravel sooner than
many suspect. Single-payer Medicare for all needs to be ready to fill the gap when that happens, and a powerful people’s movement needs to be ready to push it forward in a new, dramatic way.

http://www.huffingtonpost.com/dr-quentin-young/the-midterm-elections-and_b_764305.html

Don’t weaken Medicare – strengthen it and expand it to all

Don’t weaken Medicare – strengthen it and expand it to all

By Margaret Flowers, M.D.

The following article summarizes a Congressional Briefing held on Sept. 23, 2010, titled “An analysis of proposed changes to Medicare before the Deficit Commission and a better alternative: Improved Medicare for all.”

Presenters and honorary hosts:

Tsung-Mei Cheng, distinguished health economist and expert on comparative health systems at Princeton University. Professor Cheng writes and lectures internationally on such topics as single-payer systems, health care quality, financing, pay-for-performance and technology assessment. She also hosts Princeton’s television program, “International Forum.”

Olveen Carrasquillo, M.D., nationally recognized authority on health disparities, minority health, health services research, health policy, access to care and national health insurance. He is presently chief of the Division of General Internal Medicine in the Department of Medicine at the Miller School of the University of Miami and a member of Physicians for a National Health Program.

Michele Evermore, a legislative advocate for National Nurses United. Formerly served as senior legislative officer in the Office of Congressional and Intergovernmental Affairs at the Department of Labor and for 10 years as a congressional staffer for Sen. Tom Harkin in his personal office and on the Health, Education, Labor and Pensions Committee and for then-Ranking-Member George Miller on the House Education and Labor Committee.

The Honorable Raúl M. Grijalva (Honorary Host), Co-chair Congressional Progressive Caucus

The Honorable Lynn Woolsey (Honorary Host), Co-chair Congressional Progressive Caucus

*****

The Deficit Commission has marked Medicare and Medicaid as potential targets for lowering the federal deficit. They are reportedly considering at least three possibilities:

Shifting more seniors into Medicare Advantage
Shifting more of the cost onto the individual through higher co-pays and deductibles
Switching to a voucher program for the purchase of private insurance.

These approaches would be misguided, ineffective and harmful.

Attributing the deficit to Medicare and Medicaid is misguided because these necessary social insurance programs are not the causes of our soaring health care costs, but are rather the result of the lack of a rational health care system.

Medicare, which currently covers 43.4 million people, accounts for 13 percent of total federal outlays (FY 2010) and Medicaid accounts for 8 percent.
Medicare and Medicaid together account for a much smaller proportion of our GDP (< 5 percent) than do our other health care costs and they are rising at a slower rate.

The most effective way to control rising health care costs would be to address the underlying causes which are the large administrative costs of a multi-payer health care financing model and the lack of monopsonistic bargaining power to negotiate fair prices for goods and services.

The changes proposed by the deficit commission will not have a positive effect.

Shifting more seniors into Medicare Advantage will increase federal spending because these are for-profit plans with higher administrative costs, currently 14 percent more expensive than traditional Medicare.
Shifting more of the cost of health care onto individual Medicare beneficiaries through increased co-pays and deductibles or by changing to a voucher system will reduce federal spending. However, the deleterious economic effect on seniors and total health care spending is likely to be significant.
Increasing co-pays and deductibles will place increased financial strain on seniors already burdened with high out-of-pocket costs. According to the Kaiser Family Foundation’s analysis of the CMS Medicare Beneficiary Survey Cost and Use File for 2005, seniors earning less than 200 percent of Federal Poverty Level (FPL) spend 22 percent of their income on health care. Those with incomes between 200 and 400 percent of FPL spend an average of 15 percent of their income on health care.
A recent article published in the New England Journal of Medicine documents that raising Medicare HMO co-pays and deductibles results in fewer outpatient visits and more hospital admissions and days in the hospital. It is reasonable to expect that the savings may be offset by greater hospital costs and will certainly lead to poorer health outcomes for seniors.
Converting Medicare from a defined benefit program to a defined contribution program in which seniors are given vouchers to purchase insurance also seeks to shift more of federal health care spending onto the individual. This will likely increase total health care spending as it further dilutes market power on the demand side by further fragmenting the Medicare population.

Of course, single-payer supporters already know that the best way to preserve and protect our American legacy, Medicare, is to improve it and expand it to everyone: Everybody in, nobody out.

And now let us examine why expanding and improving Medicare to everyone will control total health care costs while protecting individual patients from financial ruin, improving the health of our population and stimulating the economy.

First it is important to understand that health care costs per capita in the United States are the highest in the world. These high costs are due in large part to the use of a fragmented multi-payer (multiple insurance plans) model with associated high administrative costs.

One third of our health care dollars are used for administration rather than direct patient care.
Administrative costs include developing and marketing plans, determining eligibility for the various plans and then processing the claims for the various plans which each have different rules.
Contrast this with the relatively streamlined administrative cost of Medicare which is less than 3 percent.
There are significant costs to providers (both clinicians and health facilities) in terms of both time and money to interact with the various plans. According to Jim Kahn of the University of California San Francisco Philip R. Lee Institute for Health Policy Studies, every full-time physician spends over $85,000 on billing and insurance functions.

Mr. Kahn states that “Overall, for health care funded through the private insurance system, fully 38 cents of each dollar goes to administration and profits, leaving only 62 cents for clinical care. 20 cents is avoidable administration – which would mainly disappear with single payer.”

Simplifying administration by switching to a national single public fund to collect and pay out our health care dollars will save about 15 percent of total health care spending (over $400 billion per year).

Health care costs in the United States are also very high because the prices we pay for medical goods and services are among the highest in the world. This is a result of a profit-driven model and the lack of a single system with which to negotiate for fair prices.

There has been a temptation to blame over-utilization of health care services and goods for soaring health care costs.

Americans have fewer physician visits and fewer days in the hospital than people in other industrialized nations.
Except for some very expensive, highly technical procedures, people in the U.S. use less health care services per capita than people in other nations.

The growth of health care costs has occurred more slowly for Medicare than it has for the private i
nsurance sector. According to the Kaiser Family Foundation, per capita health care costs rose 6.8 percent for Medicare and 7.1 percent for private insurance during the period from 1998 to 2008. This is impressive considering that Medicare is responsible for a population with greater health care needs: those 65 years of age and older and members of the disability community.

We can preserve and protect our American legacy, Medicare, with its lower administrative costs and slower growth in total costs, by

expanding it to the entire population
placing everyone in a single risk pool
using a streamlined payment mechanism
financing the program with progressive taxation that will typically amount to less than what people are paying now for premiums and out-of-pocket medical expenses.

There will be adequate funds to pay for health care for each person when he or she needs it without fear of losing coverage or going bankrupt.

In addition, improving and expanding Medicare to the entire population will create a health system with proven cost controls:

global budgeting for medical institutions
negotiation of fair prices for goods and services.

It is true that Medicare has weaknesses. We can improve Medicare by making it more comprehensive, removing financial barriers to care such as co-pays and deductibles and improving reimbursement rates.

The most recent nation to adopt a single-payer health system is Taiwan in 1995. We look to their experience to see the impact of changing from multiple private payers and a high number of uninsured to a universal single-payer system.

Prior to having a national health insurance system, only 59 percent of people in Taiwan had health care coverage and health care costs were rising by nearly 14 percent each year.

When the new system in Taiwan began, after a planning period, the remaining 41 percent of people had access to coverage overnight. By the end of the first year, 90 percent of people were enrolled. Within nine years, more than 99 percent of people were enrolled and this percentage has remained steady. The current satisfaction rate with the system is 83 percent (similar to the satisfaction rate for Medicare in the U.S.).

The single-payer system in Taiwan has effectively controlled the rise of health care costs.

There was an expected bump the first year of implementation as total health care costs rose 18 percent (compared to almost 14 percent per year prior to the new system).
Within 10 years, the rise of health care costs had fallen to a more manageable 3.5 percent to 4.5 percent per year, despite the fact that there is high use of the system (average of 15 visits/patient/year).
Administrative costs for the system are a low 1.4 percent.

The proven strengths of the Taiwanese system are

the ability to control national health expenditures
the simplicity of uniform rates and fees
a uniform information technology system
a single standard of care for all people
increased choice: patients are able to choose their health provider freely and the system covers some alternative therapies such as Chinese medicine
as it is in the US under traditional Medicare, physicians are able to use their best clinical judgment without interference from either insurance or government administrators
the important physician-patient relationship is not compromised as it is under the current multiple-insurance based model used in the US.

There are important advantages of creating a national single-payer health system in the U.S. A big plus is that it will virtually eliminate bankruptcies due to medical debt.

A study published in June, 2009 found that 62 percent of personal bankruptcies in the U.S. were due to medical costs.
Nearly 80 percent of those who became bankrupt due to medical costs had health insurance.
In a single-payer system, all medically necessary care is covered throughout the life of the patient.
People pay into the system based on their ability to pay.
There is an end to the loss of coverage with the loss of employment.
There is an end to higher charges based on age, gender or medical condition.

A national single-payer health system will create conditions that will stimulate our economy. In some ways, single payer is a jobs bill.

For small businesses, single payer means relief from the increasing burden of providing health benefits to employees.
Single payer ends job-lock, providing greater security for those who may choose to open their own business.
Single payer enables those who are staying in jobs until they are eligible for Medicare to retire early, which opens jobs for those who are younger.
By controlling rising health care costs, single payer will allow large businesses to be more competitive in the global market.

The changes to Medicare that are being considered by the Deficit Commission are misguided and harmful. Rather than cutting our important social insurance programs, Congress could address both our health care crisis and our federal deficit woes by improving and expanding Medicare to all people in our nation.

Reimbursing based on process and outcomes?

Basing Pay-for-Performance on Outcomes

By Uwe E. Reinhardt
The New York Times
October 15, 2010

In last week’s post I presented the flow chart (at link below), exhibiting the path from the production of health care proper to human well-being, and I asked where in this process one should monitor the performance that we might seek to encourage through financial incentives.

I noted that adherence to what is thought to be best clinical practice for given medical conditions is the most widely used approach to measuring performance, even though it is generally agreed that a better way is to measure performance by clinical outcomes — that is, changes in the health status of patients (Box B in the chart). Much work is now under way to move in that direction.

Unfortunately, measuring performance by clinical outcome is easier said than done.

All of these experiments (mentioned in the article) with pay-for-performance are fledgling efforts, because the science of outcome measurement has yet to scale many methodological hurdles. Furthermore, in practice the approach will work only if the providers of health care find them sufficiently accurate and fair to sign on. And economic theory tells us that to make the approach effective, it must be backed with significant financial incentives. So far, in many instances, the sums of money at stake have been rather small.

Several readers of last week’s post saw in my enumeration of the difficulties of measuring performance a rejection of the idea. Not at all. The task is indeed daunting, but that does not mean we should back away from it. Rather, we must be patient and not expect too much too soon.

Basing Pay-for-Performance on Outcomes (Oct. 15):
http://economix.blogs.nytimes.com/2010/10/15/basing-pay-for-performance-on-outcomes/

The Uncertainties of Pay-for-Performance (Oct. 8):
http://economix.blogs.nytimes.com/2010/10/08/the-uncertainties-of-pay-for-performance/

Two published responses to Professor Reinhardt:

2. Don McCanne
San Juan Capistrano, CA
October 15th, 2010

Where are the science and art of medicine headed? Is the health care professional’s role to asses the needs of the patient and try to meet those needs? That alone is a daunting task when you consider studies that show that patients are receiving only about half of the care that they should be receiving.

Will the guidelines for medical care become a complex algorithm of process and outcomes, with the health care professional understanding that the goal and rewards will be found in mastering and optimally executing the measurement junctures within that massive maze? Will these measurements be samplings, or will almost everything be measured (a not so far-fetched concept in this day of computerization)? What burden in time and effort will this entail?

How about the real world? When the child with diabetes who you have been caring for comes in because of being depressed over the fact that her parents just split up, are you going to ignore her immediate overwhelming concern because you are too busy checking to see that you are complying with the glycohemoglobin and whatever other process and outcome junctures on which you will be rewarded?

When the goal is to do our best to see that everyone has the highest quality care that we can manage to pay for, it would be sad to see us caught up in the science of measurements when the greater need is in the art of medicine.

http://community.nytimes.com/comments/economix.blogs.nytimes.com/2010/10/15/basing-pay-for-performance-on-outcomes/?permid=2#comment2

9. Dr. Robert Centor
Birmingham
October 15th, 2010

We must thank Dr. Reinhardt for 2 stimulating posts on P4P. He has pointed out the problems of P4P. But I fear he still believes that P4P could work, despite growing evidence to the contrary. Physicians have multidimensional tasks with each patient. We must make accurate diagnoses; we must treat diagnoses and symptoms; we must communicate with patients and help them make diagnostic and treatment decisions. We must balance the treatment of multiple diseases and weigh the risks and benefits each potential treatment decision.

Implementing a P4P scheme focuses attention on the measurables and decreases attention to those things that are not measured. The NHS P4P project demonstrates that very well. Focusing on prompt visits led to a decrease in physician-patient continuity. Focusing on some parameters led to a degradation in other parameters.

P4P sounds like it should work, but many physicians believe that it cannot work, because no metric can evaluate the extent of our professional responsibilities.

We could look at preventable errors (such as central line infections) and penalize hospitals for unacceptable rates. But we should only do that when we can establish that we have a proven method to achieve the goal. I picked this example because of Dr. Peter Provonost’s excellent work on this particular issue.

Dr. Reinhardt suggests that we use outcomes, but what outcomes should we measure. How do we place a metric on accurate diagnosis? We can study the reasons for diagnostic error, but measuring diagnostic errors represents a most complex and perhaps unsolvable problem?

How do we measure the physician patient interaction? This interaction includes history taking, patient education and patient motivation. Some suggest we use patient satisfaction scores, but those have major flaws and suffer from intense grade inflation.

How do we measure an appropriate balancing for the management of 5 (or more) diseases? How do we assess the appropriate prioritization of medications? How do we value decreasing polypharmacy by not treating every performance indicator to its fullest?

How do we value appropriate referrals to palliative care? How do we put a number on excellent comfort care?

I thank Dr. Reinhardt for shining a light on this problem. While I disagree with his belief that P4P is a solvable problem, I agree that we have not yet solved the problem.

http://community.nytimes.com/comments/economix.blogs.nytimes.com/2010/10/15/basing-pay-for-performance-on-outcomes/?permid=9#comment9

Comment:

By Don McCanne, MD

As part of the current fervor over implementing reform, considerable attention has been directed to controlling spending and improving quality by changing reimbursement methods from those based on volume and complexity of services to models based on measurements of clinical practices and health care outcomes.

Professor Reinhardt suggests that we must not expect too much out of these efforts in the immediate future; I indicate that the science and art of medicine provide far greater benefits than those measurements of process and outcomes could ever adequately assess; and Dr. Centor provides a precise explanation of why current concepts of P4P (pay for performance) miss the target.

The magic of the highly touted accountable care organizations seems to be based on these same principles. It is likely that the magic will turn out to be only sleight-of-hand, at best.

Our policymakers would be much more productive if they would shift their attention from dinking around with P4P to crafting
a financing system that would ensure that everyone would have affordable access to an efficient health care delivery system with a robust primary care infrastructure. PNHP can help our policymakers define that system, if only they will finally listen.

Reimbursing based on process and outcomes?

Basing Pay-for-Performance on Outcomes

By Uwe E. Reinhardt
The New York Times
October 15, 2010

In last week’s post I presented the flow chart (at link below), exhibiting the path from the production of health care proper to human well-being, and I asked where in this process one should monitor the performance that we might seek to encourage through financial incentives.

I noted that adherence to what is thought to be best clinical practice for given medical conditions is the most widely used approach to measuring performance, even though it is generally agreed that a better way is to measure performance by clinical outcomes — that is, changes in the health status of patients (Box B in the chart). Much work is now under way to move in that direction.

Unfortunately, measuring performance by clinical outcome is easier said than done.

All of these experiments (mentioned in the article) with pay-for-performance are fledgling efforts, because the science of outcome measurement has yet to scale many methodological hurdles. Furthermore, in practice the approach will work only if the providers of health care find them sufficiently accurate and fair to sign on. And economic theory tells us that to make the approach effective, it must be backed with significant financial incentives. So far, in many instances, the sums of money at stake have been rather small.

Several readers of last week’s post saw in my enumeration of the difficulties of measuring performance a rejection of the idea. Not at all. The task is indeed daunting, but that does not mean we should back away from it. Rather, we must be patient and not expect too much too soon.

Basing Pay-for-Performance on Outcomes (Oct. 15):
http://economix.blogs.nytimes.com/2010/10/15/basing-pay-for-performance-on-outcomes/

The Uncertainties of Pay-for-Performance (Oct. 8):
http://economix.blogs.nytimes.com/2010/10/08/the-uncertainties-of-pay-for-performance/

Two published responses to Professor Reinhardt:

2. Don McCanne
San Juan Capistrano, CA
October 15th, 2010

Where are the science and art of medicine headed? Is the health care professional’s role to asses the needs of the patient and try to meet those needs? That alone is a daunting task when you consider studies that show that patients are receiving only about half of the care that they should be receiving.

Will the guidelines for medical care become a complex algorithm of process and outcomes, with the health care professional understanding that the goal and rewards will be found in mastering and optimally executing the measurement junctures within that massive maze? Will these measurements be samplings, or will almost everything be measured (a not so far-fetched concept in this day of computerization)? What burden in time and effort will this entail?

How about the real world? When the child with diabetes who you have been caring for comes in because of being depressed over the fact that her parents just split up, are you going to ignore her immediate overwhelming concern because you are too busy checking to see that you are complying with the glycohemoglobin and whatever other process and outcome junctures on which you will be rewarded?

When the goal is to do our best to see that everyone has the highest quality care that we can manage to pay for, it would be sad to see us caught up in the science of measurements when the greater need is in the art of medicine.

http://community.nytimes.com/comments/economix.blogs.nytimes.com/2010/10/15/basing-pay-for-performance-on-outcomes/?permid=2#comment2

9. Dr. Robert Centor
Birmingham
October 15th, 2010

We must thank Dr. Reinhardt for 2 stimulating posts on P4P. He has pointed out the problems of P4P. But I fear he still believes that P4P could work, despite growing evidence to the contrary. Physicians have multidimensional tasks with each patient. We must make accurate diagnoses; we must treat diagnoses and symptoms; we must communicate with patients and help them make diagnostic and treatment decisions. We must balance the treatment of multiple diseases and weigh the risks and benefits each potential treatment decision.

Implementing a P4P scheme focuses attention on the measurables and decreases attention to those things that are not measured. The NHS P4P project demonstrates that very well. Focusing on prompt visits led to a decrease in physician-patient continuity. Focusing on some parameters led to a degradation in other parameters.

P4P sounds like it should work, but many physicians believe that it cannot work, because no metric can evaluate the extent of our professional responsibilities.

We could look at preventable errors (such as central line infections) and penalize hospitals for unacceptable rates. But we should only do that when we can establish that we have a proven method to achieve the goal. I picked this example because of Dr. Peter Provonost’s excellent work on this particular issue.

Dr. Reinhardt suggests that we use outcomes, but what outcomes should we measure. How do we place a metric on accurate diagnosis? We can study the reasons for diagnostic error, but measuring diagnostic errors represents a most complex and perhaps unsolvable problem?

How do we measure the physician patient interaction? This interaction includes history taking, patient education and patient motivation. Some suggest we use patient satisfaction scores, but those have major flaws and suffer from intense grade inflation.

How do we measure an appropriate balancing for the management of 5 (or more) diseases? How do we assess the appropriate prioritization of medications? How do we value decreasing polypharmacy by not treating every performance indicator to its fullest?

How do we value appropriate referrals to palliative care? How do we put a number on excellent comfort care?

I thank Dr. Reinhardt for shining a light on this problem. While I disagree with his belief that P4P is a solvable problem, I agree that we have not yet solved the problem.

http://community.nytimes.com/comments/economix.blogs.nytimes.com/2010/10/15/basing-pay-for-performance-on-outcomes/?permid=9#comment9

The magic of the highly touted accountable care organizations seems to be based on these same principles. It is likely that the magic will turn out to be only sleight-of-hand, at best.

Our policymakers would be much more productive if they would shift their attention from dinking around with P4P to crafting a financing system that would ensure that everyone would have affordable access to an efficient health care delivery system with a robust primary care infrastructure. PNHP can help our policymakers define that system, if only they will finally listen.

These physicians are ticked

The Mad as Hell Doctors make a stop in Chico

By Evan Tuchinsky
Chico News and Review, Oct. 14, 2010

“I’m mad as hell, and I’m not going to take it anymore!”

That cry echoed through Harlen Adams Theatre Tuesday night (Oct. 12) as a capacity crowd, exhorted by a physician from the Pacific Northwest, channeled the movie Network in expressing their frustration with health-care economics in America.

Again and again that phrase came up, which only makes sense considering the occasion was a visit from the Mad as Hell Doctors, who capped their three-week tour of California by rolling their medicine show into Chico State.

They shared video clips and stories of gaps in the health-care system—actually, as one described it, “a sick-care non-system.” Joining their call for single-payer insurance, a Chico physician and two local nurses also had inspirations for change.

“I’m mad as hell,” cardiac-care nurse David Welch said, “because of the memory of the 42-year-old man who endured two days of crushing pain before he came into the E.R. and had a heart attack.”

“I’m mad as hell,” Dr. Faraj Walid said, “because not a day goes by that I don’t see patients suffer from a lack of insurance or are underinsured.”

Same for nurse practitioner Paul O’Rourke-Babb, who has had nine patients die “because they didn’t have access to care and insurance.”

The Chico crowd was the largest on the MAHD tour, but the complaints aren’t unique. They’re all too common across the country, where—as signs in the theater starkly noted—50 million Americans lack health insurance, 14,000 lose their coverage each day, and 120 die daily for lack of care.

Moreover, with an emphasis on treating diseases as opposed to preventing them, the majority of health-care funds go to technology and specialties rather than primary care.

Dr. Paul Hochfeld, one of the four visiting MAHD physicians, joked that coffins have nails “so the oncologists can’t get in to give one more round of chemo.” A morbid joke, for sure, but not too detached from a reality in which treatments and tests get lucratively reimbursed while consultations with doctors don’t.

Another MAHD visitor, Dr. Mike Huntington, asked the audience, “How many of you think we have a broken health-care system?” After hands went up and a voice called out, “Trick question,” Huntington pointed to that person and concurred: “We don’t have a system.”

As Hochfeld later put it, “We have a $2.5 trillion health-care factory and there’s nobody in charge.”

Single-payer health insurance is not a new concept, though it’s one that’s not always understood. It gets lumped into the term “government health care” and branded as “socialized medicine” like the national systems in, for example, Canada and Great Britain. However, as Hochfeld noted, the proposals for the U.S. call for publicly funded, privately delivered care.

The major issue, he explained, is the segregation of “risk pools.” Government plans cover many of the neediest Americans: seniors, veterans, individuals with disabilities and those from destitute families.

Private insurance companies, already insulated from these risk pools, further protect their profit margins. “They’re gamblers,” Hochfeld explained. “They gamble that what they collect is more than what they pay out. And they try to fix the odds.” They do so through selective enrollment, contributing to the totals of 50 million uninsured and 75 million underinsured.

Single-payer coverage would put all patients in one risk pool, administered by a public entity instead of myriad private businesses. That insurer would pay the private doctors, hospitals, clinics, pharmacies and others delivering care. One system, one set of policies—no more mazes of administration for providers and patients.

If everyone went into the same pool, Dr. Marc Sapir said, Americans collectively would “save $400 billion the first year after the single-payer system” was established.

“I want one system,” Dr. Katherine Ottaway declared. “Health care for all, one set of rules—that’s why I’m a Mad as Hell Doctor.”

MAHD has 11,500 fans on Facebook (www.facebook.com/MadDrs) and countless followers of its blog (at http://madashelldoctors.com). The group came to California heartened by how far a single-payer bill got in the Legislature, yet aware it didn’t get far enough to become law.

The effort continues. Locally, for instance, the Butte County Health Care Coalition lobbies for a single-payer system.

Sapir, noting that the organization Physicians for a National Health Program came out of the civil-rights movement of the 1960s, called for just that sort of mobilization. “Health care is a human right—don’t believe for a minute anything in the media that says most Americans don’t believe this,” Sapir stated.

“Our plea to you,” Huntington said, “is get mad and stay mad. Call your legislators and talk to your neighbors…. We need to turn this from a welfare system into a health-care system.”

http://www.newsreview.com/chico/content?oid=1858352

Comment:

Low-Cost Lessons from Grand Junction, Colorado

Comment:

Basing Pay-for-Performance on Outcomes

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