PNHP

RAND and BR on "savings" through "bundled payments"

RAND and BR on "savings" through "bundled payments"

Health Care Reform: Creating a Sustainable Health Care Marketplace

By Hewitt Associates
Business Roundtable
November 2009

Payment Bundling

Establishing bundled payments would create more incentives for efficient treatments and could be adjusted based on outcomes. Health care reform proposals are moving toward bundled payments. Both the House and the Senate include provisions that focus on improved quality of care and patient outcomes.

The pilot program may cover the following services: acute-care inpatient hospitalizations; physician services delivered inside and outside of the acute-care hospital setting; outpatient hospital services, including emergency department visits; services associated with acute-care hospital readmissions; home health; skilled nursing; inpatient rehabilitation; and long-term care. The episode of care established in the pilot program would start three days prior to a qualifying admission to the hospital and span the length of the hospital stay and 30 days following the patient discharge.

The pilot program’s bundled payment would be made to a Medicare provider or another entity composed of multiple providers to cover the costs of acute-care inpatient and outpatient hospital services, physician services, and post-acute care. The bundled payment for each of the eight selected conditions would be based on the average hospital, physician, and post-acute-care payments made over the hospitalization period for the patient.

CBO does not score savings for this provision, mainly because the language above suggests that Medicare will pay the same as it would otherwise have paid, instead of some lower amount per episode. Over time, however, we believe substantial savings can be achieved by both removing the financial incentive to provide marginally effective services, as well as through the active management of the rate of increase in the bundled reimbursement rate.

http://www.businessroundtable.org/system/assets/drupal/Hewitt_BRT_Sustainable%20Health%20Care%20Marketplace_Final.pdf

And…

Controlling U.S. Health Care Spending — Separating Promising from Unpromising Approaches

By Peter S. Hussey, Ph.D., Christine Eibner, Ph.D., M. Susan Ridgely, J.D., and Elizabeth A. McGlynn, Ph.D.
The New England Journal of Medicine
November 11, 2009

We identified 8 options that evidence suggests have the potential to reduce spending and are broadly applicable to the United States. For these options, we developed high and low estimates of cumulative cost savings over 10 years. The graph (clink on link below) lists the options, ranked according to their savings potential, and shows the percentage change in spending that we estimate could be achieved if that policy alone were implemented.

Among the most promising options are those related to changing the payment methods for health care services. (In the graph, bundled payment stands out as the option that would have by far the greatest impact in reducing spending.)

A “bundled-payment” approach would provide a single payment for all services related to a given treatment or condition, causing providers to assume risk for preventable costs; this approach has proved effective in limited demonstration projects. Bundled payment provides a mechanism for reducing both the volume of services and the prices charged for them. We estimate that under optimistic scenarios and with broad use of the Prometheus model of bundled payment for six chronic conditions and four acute conditions or procedures requiring hospitalization, national health care spending could be reduced by 5.4% between 2010 and 2019. This estimate assumes that providers can achieve a reduction of 25 to 50% in the costs associated with avoidable complications by providing higher-quality, more collaborative care.

http://healthcarereform.nejm.org/?p=2301&query=home

And…

Building a Bridge from Fragmentation to Accountability — The Prometheus Payment Model

By François de Brantes, M.S., M.B.A., Meredith B. Rosenthal, Ph.D., and Michael Painter, J.D., M.D.
The New England Journal of Medicine
September 10, 2009

Most experts agree that some sort of bundled, episode-based payment would help to move the system in the right direction. Our own approach, the Prometheus Payment model, for instance, bundles services and provides a budget with three components: evidence-informed base payment with patient-specific severity adjustments and an allowance for potentially avoidable complications.

The model encourages two behaviors that fee for service discourages: collaboration of physicians, hospitals, and other providers involved in a patient’s care; and active efforts to reduce avoidable complications of care (and the costs associated with them). It accomplishes these goals by paying for all the care a patient needs over the course of a defined clinical episode or a set period of management of a chronic condition, rather than paying for discrete visits, discharges, or procedures.

When incentives are used to drive changes in behavior, it is important that people and organizations are held accountable only for the variables that are actually under their control. That’s why, in designing the Prometheus model, we decided to focus on the potentially avoidable costs of patient care. We separated the costs attributable to patient-related factors from those attributable to providers’ actions. These latter costs are critically important in terms of accountability. In Prometheus, these potentially avoidable costs are called PACs and are recognized as the result of “care defects” — problems necessitating technical care that are under the professionals’ control and that, with the best professional standards, could have been avoided. PACs might include the cost of hospitalization of a patient with uncontrolled diabetes or the readmission for a wound infection of a patient who had recently been discharged after cardiac bypass surgery.

Unlike the current payment system, Prometheus provides larger profit margins for providers who can eliminate these complications, since they keep any unused PAC allowance — they profit by delivering optimal care, not a greater volume of care.

One lesson from our pilots is that hospital-centric provider organizations can expect increased internal tension when they implement an episode-of-care payment system. Prometheus does provide a sort of bonus to the hospital and physicians for working together to avoid readmission. However, physician groups that are paid under the model for managing chronic conditions have substantial opportunities to increase the profits that come from avoiding expensive hospitalizations. This incentive can highlight potential conflicts between the financial interests of physicians and those of hospitals and cause us to question the proposition that hospital-centric provider organizations will deliver the best results for the country.

The Prometheus model, by contrast, can be implemented in a fragmented, largely fee-for-service delivery system if the payer retains the role of financial integrator. Over time, as providers collaborate to improve patient care and optimize their margins, they could more formally integrate into accountable organizations. However, it will and should be their choice to do so.

http://content.nejm.org/cgi/content/full/361/11/1033

Comment:

By Don McCanne, MD

Peter Hussey and his colleagues at RAND, in their NEJM article, try to make the case that a “bundled payment” approach would be one of the
most promising options for controlling health care spending. The Prometheus model of bundled payment, described the other NEJM article cited above, would shift the risk for preventable costs from the payer to the providers of health care services.

Here’s how it would work. The payer (e.g., Medicare) would determine what the costs of all services would be for a given clinical problem under the current system (fee-for-service plus DRGs). All services would be bundled under a single fee that would be discounted by about five percent. That discount represents current preventable costs such as “excessive” days of hospitalization, “unnecessary” imaging studies, “preventable” complications such as wound infections, and “unnecessary” re-hospitalizations for “inadequate” post-discharge followup. If the medical team of professionals and institutions failed to prevent these or other “additional” costs, the team would bear the loss.

Well fine. But how many of these costs are truly preventable? At the time that services are rendered, almost all decisions are clinically appropriate. It is only in retrospect that an occasional decision might have been changed, but most would not have been. Then there is the fallibility of the human mind. Just as no person could be expected to have a perfect score on every exam taken throughout life, no health care professional can be expected to have a perfect score on all clinical decisions, especially when the perfect response is often still an unknown.

Another problem is that bundling requires organizing individuals and institutions together based on a single clinical entity. The composition of the team would vary depending on the nature of the clinical problem. The team would accept the one bundled payment but then internal disputes over the distribution of the funds certainly would be inevitable. Although the payer is relieved of the administrative services of allocating these funds, the process does not bode well for creating a harmonious, collaborative environment for high quality patient care. Those who believe that these arrangements could evolve into “accountable care organizations” are delusional.

In spite of RAND’s optimism, “bundling payments” will not reduce costs. It will only reduce prices, while actually increasing costs by introducing yet greater administrative complexity.

Purists in written composition might contend that I’ve overused “quotation marks” in my comments. My defense is that health care reform should not be based on “quotation marks” and a “wink.” It should be based on sound health policy science (no quotation marks).

RAND and BR on “savings” through “bundled payments”

Health Care Reform: Creating a Sustainable Health Care Marketplace

By Hewitt Associates
Business Roundtable
November 2009

Payment Bundling

Establishing bundled payments would create more incentives for efficient treatments and could be adjusted based on outcomes. Health care reform proposals are moving toward bundled payments. Both the House and the Senate include provisions that focus on improved quality of care and patient outcomes.

The pilot program may cover the following services: acute-care inpatient hospitalizations; physician services delivered inside and outside of the acute-care hospital setting; outpatient hospital services, including emergency department visits; services associated with acute-care hospital readmissions; home health; skilled nursing; inpatient rehabilitation; and long-term care. The episode of care established in the pilot program would start three days prior to a qualifying admission to the hospital and span the length of the hospital stay and 30 days following the patient discharge.

The pilot program’s bundled payment would be made to a Medicare provider or another entity composed of multiple providers to cover the costs of acute-care inpatient and outpatient hospital services, physician services, and post-acute care. The bundled payment for each of the eight selected conditions would be based on the average hospital, physician, and post-acute-care payments made over the hospitalization period for the patient.

CBO does not score savings for this provision, mainly because the language above suggests that Medicare will pay the same as it would otherwise have paid, instead of some lower amount per episode. Over time, however, we believe substantial savings can be achieved by both removing the financial incentive to provide marginally effective services, as well as through the active management of the rate of increase in the bundled reimbursement rate.

http://www.businessroundtable.org/sites/default/files/Hewitt_BRT_Sustainable%20Health%20Care%20Marketplace_Final.pdf

And…

Controlling U.S. Health Care Spending — Separating Promising from Unpromising Approaches

By Peter S. Hussey, Ph.D., Christine Eibner, Ph.D., M. Susan Ridgely, J.D., and Elizabeth A. McGlynn, Ph.D.
The New England Journal of Medicine
November 11, 2009

We identified 8 options that evidence suggests have the potential to reduce spending and are broadly applicable to the United States. For these options, we developed high and low estimates of cumulative cost savings over 10 years. The graph (clink on link below) lists the options, ranked according to their savings potential, and shows the percentage change in spending that we estimate could be achieved if that policy alone were implemented.

Among the most promising options are those related to changing the payment methods for health care services. (In the graph, bundled payment stands out as the option that would have by far the greatest impact in reducing spending.)

A “bundled-payment” approach would provide a single payment for all services related to a given treatment or condition, causing providers to assume risk for preventable costs; this approach has proved effective in limited demonstration projects. Bundled payment provides a mechanism for reducing both the volume of services and the prices charged for them. We estimate that under optimistic scenarios and with broad use of the Prometheus model of bundled payment for six chronic conditions and four acute conditions or procedures requiring hospitalization, national health care spending could be reduced by 5.4% between 2010 and 2019. This estimate assumes that providers can achieve a reduction of 25 to 50% in the costs associated with avoidable complications by providing higher-quality, more collaborative care.

http://healthcarereform.nejm.org/?p=2301&query=home

And…

Building a Bridge from Fragmentation to Accountability — The Prometheus Payment Model

By François de Brantes, M.S., M.B.A., Meredith B. Rosenthal, Ph.D., and Michael Painter, J.D., M.D.
The New England Journal of Medicine
September 10, 2009

Most experts agree that some sort of bundled, episode-based payment would help to move the system in the right direction. Our own approach, the Prometheus Payment model, for instance, bundles services and provides a budget with three components: evidence-informed base payment with patient-specific severity adjustments and an allowance for potentially avoidable complications.

The model encourages two behaviors that fee for service discourages: collaboration of physicians, hospitals, and other providers involved in a patient’s care; and active efforts to reduce avoidable complications of care (and the costs associated with them). It accomplishes these goals by paying for all the care a patient needs over the course of a defined clinical episode or a set period of management of a chronic condition, rather than paying for discrete visits, discharges, or procedures.

When incentives are used to drive changes in behavior, it is important that people and organizations are held accountable only for the variables that are actually under their control. That’s why, in designing the Prometheus model, we decided to focus on the potentially avoidable costs of patient care. We separated the costs attributable to patient-related factors from those attributable to providers’ actions. These latter costs are critically important in terms of accountability. In Prometheus, these potentially avoidable costs are called PACs and are recognized as the result of “care defects” — problems necessitating technical care that are under the professionals’ control and that, with the best professional standards, could have been avoided. PACs might include the cost of hospitalization of a patient with uncontrolled diabetes or the readmission for a wound infection of a patient who had recently been discharged after cardiac bypass surgery.

Unlike the current payment system, Prometheus provides larger profit margins for providers who can eliminate these complications, since they keep any unused PAC allowance — they profit by delivering optimal care, not a greater volume of care.

One lesson from our pilots is that hospital-centric provider organizations can expect increased internal tension when they implement an episode-of-care payment system. Prometheus does provide a sort of bonus to the hospital and physicians for working together to avoid readmission. However, physician groups that are paid under the model for managing chronic conditions have substantial opportunities to increase the profits that come from avoiding expensive hospitalizations. This incentive can highlight potential conflicts between the financial interests of physicians and those of hospitals and cause us to question the proposition that hospital-centric provider organizations will deliver the best results for the country.

The Prometheus model, by contrast, can be implemented in a fragmented, largely fee-for-service delivery system if the payer retains the role of financial integrator. Over time, as providers collaborate to improve patient care and optimize their margins, they could more formally integrate into accountable organizations. However, it will and should be their choice to do so.

http://content.nejm.org/cgi/content/full/361/11/1033

Comment:

By Don McCanne, MD

Peter Hussey and his colleagues at RAND, in their NEJM article, try to make the case that a “bundled payment” approach would be one of the most promising options for controlling health care spending. The Prometheus model of bundled payment, described the other NEJM article cited above, would shift the risk for preventable costs from the payer to the providers of health care services.

Here’s how it would work. The payer (e.g., Medicare) would determine what the costs of all services would be for a given clinical problem under the current system (fee-for-service plus DRGs). All services would be bundled under a single fee that would be discounted by about five percent. That discount represents current preventable costs such as “excessive” days of hospitalization, “unnecessary” imaging studies, “preventable” complications such as wound infections, and “unnecessary” re-hospitalizations for “inadequate” post-discharge followup. If the medical team of professionals and institutions failed to prevent these or other “additional” costs, the team would bear the loss.

Well fine. But how many of these costs are truly preventable? At the time that services are rendered, almost all decisions are clinically appropriate. It is only in retrospect that an occasional decision might have been changed, but most would not have been. Then there is the fallibility of the human mind. Just as no person could be expected to have a perfect score on every exam taken throughout life, no health care professional can be expected to have a perfect score on all clinical decisions, especially when the perfect response is often still an unknown.

Another problem is that bundling requires organizing individuals and institutions together based on a single clinical entity. The composition of the team would vary depending on the nature of the clinical problem. The team would accept the one bundled payment but then internal disputes over the distribution of the funds certainly would be inevitable. Although the payer is relieved of the administrative services of allocating these funds, the process does not bode well for creating a harmonious, collaborative environment for high quality patient care. Those who believe that these arrangements could evolve into “accountable care organizations” are delusional.

In spite of RAND’s optimism, “bundling payments” will not reduce costs. It will only reduce prices, while actually increasing costs by introducing yet greater administrative complexity.

Purists in written composition might contend that I’ve overused “quotation marks” in my comments. My defense is that health care reform should not be based on “quotation marks” and a “wink.” It should be based on sound health policy science (no quotation marks).

U.S. Needs Health Care, Not Insurance

By Carol Miller
Albuquerque Journal
Sunday, November 15, 2009

A very complex, mandatory private insurance scheme recently passed the U.S. House. The public is being overwhelmed by sound bites on one hand about how great it is, on the other, how terrible. We are hearing few of the details that are actually in the bill. Having read the bill, it is clear now that what started as health reform has emerged from the political process as health “deform,” building on the worst, not the best of the current system.

It is still a toss-up as to whether the Senate will pass any bill this year. However, due to intense political pressure, the Senate is likely to pass a bill that will make some House provisions better and others worse. What actually comes out in the final conference-committee bill is anyone’s guess at this point — so little time, so many deals still to be made, so many political funders to be appeased.

A careful analysis of the bill shows that it is designed more for political goals than to eliminate financial barriers to health care. For example, the actual coverage doesn’t even begin until 2013, opportunistically after the next presidential election, in 2012. Run on having accomplished “historic reform” but before anyone actually experiences how bad it is? How cynical is that?

Yes, there are some good provisions. The best relate to improving existing programs like the Indian Health Service, community health centers, and health professionals education and training; all are important for New Mexico.

But there bad provisions, which comprise most of the 1,990 pages of the bill. Five key reasons this legislation must be stopped:

• If passed, this law will move the U.S. farther from universal health care, making it harder than ever to accomplish health care justice in the future. If Congress does not have the courage to stand up to the private insurance industry now, it will be even more difficult in the future, especially after giving the industry trillions of new dollars through this terrible legislation. Let’s call this what it is: another corporate bailout on the backs of working people.

Pay attention to your federal representatives as they carefully talk about “health insurance reform.” They aren’t talking about health reform any more. Congress could have defended and built up a system based on popular, high-quality government-run health programs like the military and veterans fully socialized health systems or Medicare, a single-payer program. Instead, the president and Congress let the corporations and government-haters take control of the agenda.

• The legislation institutionalizes permanent inequality in health care. Unlike Medicare where all beneficiaries have a single plan, this bill further divides the U.S. system into tiers based on ability to pay. It creates basic, enhanced, premium and premium-plus plans. A basic plan will provide only 70 percent of the coverage of a “reference benefit package,” one that includes even fewer services than most insured people have today. The bill doesn’t even mention coverage for essential services like vision and adult dental care except in the most costly premium-plus plan.

• Out-of-pocket costs remain sky high. Everyone will be required to pay monthly insurance premiums. Some low-wage workers will receive taxpayer subsidies on a sliding scale. The lowest income people will have full subsidies. But remember, this is not money for care, it is support only to buy insurance.

Almost everyone will have to meet a deductible, capped in the bill at $1,500 a year, higher than most insurance-plan deductibles today. On top of this, insurance companies can charge even more under various “cost sharing” schemes for items like co-pays and co-insurance.

The bill puts a cap on cost sharing, but the total amount is obscene. The cap for an individual is $5,000 a year and for a family it is $10,000 before the plan must cover everything. Well, not exactly everything. Even after paying this huge amount of money, the legislation still allows the corporations to make us pay, billing for non-network providers and, since it is not a comprehensive benefit package, we are still on our own to pay for health care that the plans refuse to cover.

The legislation creates a law to let these corporations increase what they charge people as they get older. In fact, they can be charged up to twice as much as younger people for identical coverage.

• The legislation makes it illegal to not buy health insurance. The penalties are described in a section of the legislation called “Shared Responsibility.” This will let the IRS impose a tax of up to 2.5 percent of modified adjusted gross income for not having health insurance. People on the financial edge, people fighting foreclosure to stay in their homes or people who are unemployed all or part of a year will not be able to afford the insurance premiums or the penalties for not having insurance.

• We will all be drowning in paperwork, which will continue to drive up administrative costs. Right now, insurance administrative waste is about 30 percent of every health care dollar— or about $1 billion a day. Adding more people to an insurance-based system will result in even more money going into this bottomless pit.

As if this isn’t bad enough, the government will be setting up many new agencies to oversee the whole process including, at the top, the Orwellian Health Choices Administration, headed by the Health Choices Commissioner. This is not an agency to help us make health care choices, but to choose a health insurance company. The IRS will play a very large role in everything from certifying our income for subsidies to monitoring and taxing people who don’t buy insurance.

Health Insurance Exchanges will be created across the country with at least one in every state offering both Web sites and telephone assistance. This is where we will go every year to pick our insurance plan in an open enrollment period of at least 30 days between September and November. We can add this unpleasant task to all of our other fall chores.

It is hard to imagine the chaos and wasted resources with the entire country picking insurance plans at the same time, attended by marketing, billboards, advertising and misinformation. We will gamble as we choose a plan, decide which corporation will be the best for us, hoping we pick one that is not dominated by corporate bureaucrats focused on rationing care to maximize their profits. It is not an easy task and if a wrong plan is selected, we are stuck for a year, until the next national open enrollment cycle.

The United States can do better. We can build on a strengthened and well-funded Medicare program. In Medicare, when a person reached the age of eligibility or is determined to qualify because they have a permanent disability, they are in, and there is no re-enrollment.

Imagine real reform, as simple as adding people ages 55 to 65 years old to Medicare in 2010, 35-55 in 2011, and so on until everyone is included by 2013. The bills that promote this kind of reform are under 200 pages, they are simple to implement, cost effective and equitable. Choose a doctor, choose a hospital when needed and let the government pay the bills. Everyone in one system.

That is what real health reform would look like.

Miller is a long-time public health professional and health care advocate. She lives in Ojo Sarco.

Originally published under the title “N.M. Needs Health Care, Not Insurance”

http://www.abqjournal.com/north/opinion/1523131northopinion11-15-09.htm

In House, Many Spoke With One Voice: Lobbyists’

By ROBERT PEAR
New York Times
November 15, 2009

WASHINGTON — In the official record of the historic House debate on overhauling health care, the speeches of many lawmakers echo with similarities. Often, that was no accident.

Statements by more than a dozen lawmakers were ghostwritten, in whole or in part, by Washington lobbyists working for Genentech, one of the world’s largest biotechnology companies.

E-mail messages obtained by The New York Times show that the lobbyists drafted one statement for Democrats and another for Republicans.

The lobbyists, employed by Genentech and by two Washington law firms, were remarkably successful in getting the statements printed in the Congressional Record under the names of different members of Congress.

Genentech, a subsidiary of the Swiss drug giant Roche, estimates that 42 House members picked up some of its talking points — 22 Republicans and 20 Democrats, an unusual bipartisan coup for lobbyists.

In an interview, Representative Bill Pascrell Jr., Democrat of New Jersey, said: “I regret that the language was the same. I did not know it was.” He said he got his statement from his staff and “did not know where they got the information from.”

Members of Congress submit statements for publication in the Congressional Record all the time, often with a decorous request to “revise and extend my remarks.” It is unusual for so many revisions and extensions to match up word for word. It is even more unusual to find clear evidence that the statements originated with lobbyists.

The e-mail messages and their attached documents indicate that the statements were based on information supplied by Genentech employees to one of its lobbyists, Matthew L. Berzok, a lawyer at Ryan, MacKinnon, Vasapoli & Berzok who is identified as the “author” of the documents. The statements were disseminated by lobbyists at a big law firm, Sonnenschein Nath & Rosenthal.

In an e-mail message to fellow lobbyists on Nov. 5, two days before the House vote, Todd M. Weiss, senior managing director of Sonnenschein, said, “We are trying to secure as many House R’s and D’s to offer this/these statements for the record as humanly possible.”

He told the lobbyists to “conduct aggressive outreach to your contacts on the Hill to see if their bosses would offer the attached statements (or an edited version) for the record.”

In recent years, Genentech’s political action committee and lobbyists for Roche and Genentech have made campaign contributions to many House members, including some who filed statements in the Congressional Record. And company employees have been among the hosts at fund-raisers for some of those lawmakers. But Evan L. Morris, head of Genentech’s Washington office, said, “There was no connection between the contributions and the statements.”

Mr. Morris said Republicans and Democrats, concerned about the unemployment rate, were receptive to the company’s arguments about the need to keep research jobs in the United States.

The statements were not intended to change the bill, which was not open for much amendment during the debate. They were meant to show bipartisan support for certain provisions, even though the vote on passage generally followed party lines.

Democrats emphasized the bill’s potential to create jobs in health care, health information technology and clinical research on new drugs.

Republicans opposed the bill, but praised a provision that would give the Food and Drug Administration the authority to approve generic versions of expensive biotechnology drugs, along the lines favored by brand-name companies like Genentech.

Lawmakers from both parties said it was important to conduct research on such “biosimilar” products in the United States. Several took a swipe at aggressive Indian competitors.

Asked about the Congressional statements, a lobbyist close to Genentech said: “This happens all the time. There was nothing nefarious about it.”

In separate statements using language suggested by the lobbyists, Representatives Blaine Luetkemeyer of Missouri and Joe Wilson of South Carolina, both Republicans, said: “One of the reasons I have long supported the U.S. biotechnology industry is that it is a homegrown success story that has been an engine of job creation in this country. Unfortunately, many of the largest companies that would seek to enter the biosimilar market have made their money by outsourcing their research to foreign countries like India.”

In remarks on the House floor, Representative Phil Hare, Democrat of Illinois, recalled that his family had faced eviction when his father was sick and could not make payments on their home. He said the House bill would save others from such hardship.

In a written addendum in the Congressional Record, Mr. Hare said the bill would also create high-paying jobs. Timothy Schlittner, a spokesman for Mr. Hare, said: “That part of his statement was drafted for us by Roche pharmaceutical company. It is something he agrees with.”

The boilerplate in the Congressional Record included some conversational touches, as if actually delivered on the House floor.

In the standard Democratic statement, Representative Robert A. Brady of Pennsylvania said: “Let me repeat that for some of my friends on the other side of the aisle. This bill will create high-paying, high-quality jobs in health care delivery, technology and research in the United States.”

Mr. Brady’s chief of staff, Stanley V. White, said he had received the draft statement from a lobbyist for Genentech’s parent company, Roche.

“We were approached by the lobbyist, who asked if we would be willing to enter a statement in the Congressional Record,” Mr. White said. “I asked him for a draft. I tweaked a couple of words. There’s not much reason to reinvent the wheel on a Congressional Record entry.”

Some differences were just a matter of style. Representative Yvette D. Clarke, Democrat of New York, said, “I see this bill as an exciting opportunity to create the kind of jobs we so desperately need in this country, while at the same time improving the lives of all Americans.”

Representative Donald M. Payne, Democrat of New Jersey, used the same words, but said the bill would improve the lives of “ALL Americans.”

Mr. Payne and Mr. Brady said the bill would “create new opportunities and markets for our brightest technology minds.” Mr. Pascrell said the bill would “create new opportunities and markets for our brightest minds in technology.”

In nearly identical words, three Republicans — Representatives K. Michael Conaway of Texas, Lynn Jenkins of Kansas and Lee Terry of Nebraska — said they had criticized many provisions of the bill, and “rightfully so.”

But, each said, “I do believe the sections relating to the creation of a market for biosimilar products is one area of the bill that strikes the appropriate balance in providing lower cost options.”

http://www.nytimes.com/2009/11/15/us/politics/15health.html

Health insurers could be allowed to bypass some key reforms

Senate bills would include loopholes for proposed 'exchange'

By David S. Hilzenrath
Washington Post
Sunday, November 15, 2009

Nobody wants to spend a lot of time and energy — and taxpayer money — and end up where they started. But that’s what could happen with one of the principal elements of health reform, the “exchange” or “gateway.”

Legislators are designing this new insurance marketplace to protect consumers from many of the pitfalls and inequities in the current system. But even as they focus on the details of how the marketplace will work, senators have indicated that they would allow insurers to continue operating outside it, much as the health-insurance lobby has sought.

One Senate bill would preserve the possibility that insurers could tailor policies to draw healthy individuals out of the new markets, leaving coverage less affordable for those who stay behind.

“It’s a leak in the system,” said Karen L. Pollitz, a professor at Georgetown’s Health Policy Institute. “It returns you to problems that we have today.”

Senate bills guarantee that certain basic reforms — such as requiring insurers to accept people regardless of preexisting medical conditions and banning annual and lifetime limits on coverage — would apply both inside and outside the new markets for individuals and small businesses. But that would not be true for a host of other requirements intended to help consumers compare health plans on an apples-to-apples basis and force insurers to compete more directly on price.

For example, the bill written by the Senate health committee would not require insurers operating outside the marketplace to provide standardized disclosures about what they cover.

It would not prohibit health plans outside the exchanges from using marketing practices that discourage the seriously ill from enrolling, nor would it demand that they offer “a wide choice” of medical providers — including “essential community providers . . . that serve predominantly low income, medically-underserved individuals,” as the bill prescribes for insurers inside the exchanges.

Perhaps the sharpest dichotomy is that, under the health committee’s proposal, certain standards governing the nature and extent of covered benefits would apply only to policies sold inside the exchanges.

All of those factors contribute to the possibility that insurers might offer cheaper, less comprehensive policies outside the exchanges and entice healthier people to leave the new markets. That would leave the exchanges responsible for sicker people who are more expensive to insure.

Similarly, outside the exchange, the bill drafted by the Senate Finance Committee would not regulate the marketing of individual coverage, nor would it require that health plans be rated based on quality and price.

The legislation is now in the hands of Senate Majority Leader Harry M. Reid (D-Nev.), who is merging the work of the finance and health committees into a single proposal that could be unveiled as early as next week.

Unlike the Senate bills, the one approved last weekend by the House says that all new policies for individuals would have to be sold within an exchange.

The Senate health committee would give plans operating outside the exchanges another break: Only those inside an exchange would have to pay a surcharge — as much as 4 percent of premiums — to defray the exchange’s overhead costs. That could allow outside plans to undersell inside plans. In a written response to questions, the committee’s Democratic staff said it would not work out that way because plans inside the exchanges would have to spend less on marketing.

Why would the health committee create an elaborate system of consumer protections and then allow insurers to operate outside it?

“Some people may not want to purchase insurance through a gateway. The bill is about creating and enhancing choice,” the committee’s Democratic staff said.

The main lobbying group for the health-insurance industry struck a similar theme in a July letter. Karen Ignagni, president of America’s Health Insurance Plans, wrote that offering plans to individuals outside the exchange would “improve choices for individuals and employers.”

In seeking to create a more standardized marketplace, lawmakers were taking aim at a fundamental problem: It is hard for individuals to comparison shop for health insurance, because policies contain myriad, complex variables. Many people fail to spot gaps in their policies until they become severely ill, Nancy Metcalf, an editor at Consumer Reports, said in June testimony to a Senate panel. Insurance companies “know exactly how to design and market plans whose gaping holes don’t become apparent until it’s much, much too late,” Metcalf said.

The health committee bill would cut through some of the confusion by offering three tiers of coverage within exchanges. Plans competing within each tier would be required to have the same actuarial value, meaning that overall they cover the same percentage of anticipated expenses.

But under the health committee bill, insurance policies offered outside the exchanges would not have to conform to the three tiers, leaving consumers with the challenge of having to make apples-to-oranges comparisons.

The secretary of Health and Human Services would be required to establish an “essential health benefits” package, but it would not be essential that policies outside the exchange include those benefits.

Outside the exchanges, people could buy policies that do not provide the basic coverage required to satisfy the terms of the individual mandate (the requirement that everyone have insurance coverage), thus exposing themselves to penalties.

Even within the exchanges, there could be limits to consumer protections. The health committee bill would not explicitly guarantee consumers the right to an external appeal when a health plan refuses to pay for medical services. The right to an external appeal is a hallmark of the health-benefits program for federal employees, which has served as a model for the proposed exchanges.

Sitting in for Healthcare

A new group takes the fight for a single-payer system directly to insurers—and politicians.

By Diana Novak
Nov. 16, 2009
In These Times

Since September 29, when Mobilization for Health Care for All organized its first sit-in at health insurer Aetna’s New York City offices, more than 147 activists with the group have been arrested in 24 actions around the country. Protesters, opposed to any healthcare reform short of a national single-payer system, have also occupied both Speaker of the House Nancy Pelosi’s office in San Francisco and Senator Joe Lieberman’s office on Capitol Hill.

Mobilization, a two-month-old conglomeration of healthcare action groups, organized the protests as part of a campaign for what it calls “Medicare for All.” Groups in each city work with the new umbrella organization to set up national days for civil disobedience. Since the Aetna sit-in in New York, thousands of protesters have joined the movement, refusing to allow insurance companies to continue to profit by denying care. Chanting “Patients, not profits,” they have entered insurance headquarters and blocked the doors, leaving only when either the company grants coverage of treatments for those with life-threatening conditions, or when they are arrested.

Kai Newkirk, National Coordinator for Mobilization, says that the campaign wants to spotlight the real cause of the heathcare crisis. “We are never going to get real reform until we are able to stand up to the insurance companies and dramatize how much incredible suffering they have caused because they deny care to maximize profit,” Newkirk says. “By spending money that should be going towards care on huge ad campaigns, lobbyists, and campaign contributions, they are trying to keep us from exercising our will on Congress. Until we get them out of our politics and separate them from our democracy, we won’t see reform.”

One man’s experience with coverage denial has motivated him to take his protest a step further. Sam Pullen, 31, was arrested during a sit-in at Blue Cross’s Los Angeles headquarters as he paid tribute to his mother’s quest for cancer treatment at the same office. When Pullen was a teenager, his mother Leanna Bell was diagnosed with multiple-myeloma. Blue Cross wouldn’t cover a recommended bone-marrow transplant, so she staged a one-woman sit-in at the office until the company agreed to pay. Receiving the transplant allowed her to live for five more years.

After being arrested, Pullen refused to post bail, electing to remain in jail until Blue Cross met with him to discuss his demands for universal coverage. Five days later, Pullen’s bail was waived and he was removed from jail against his will. Pullen says his discharge was the result of “mounting pressure from the public.”

According to Newkirk, “When people are willing to do more than just show up and chant, when they are willing to risk arrest…it shows the urgency. It moves people to believe, as we do, that healthcare is a right.”

The group hopes its actions will be the largest nonviolent protests since the civil rights movement. Within three weeks of its late September launch, the campaign received more than 850 pledges from Americans “willing to put their bodies on the line,” Newkirk says.

The first sit-in in New York earned insurance coverage for a man with both cancer and AIDS. “We are already winning small victories in terms of individual cases,” says Pullen, “and once enough of these happen the industry as a whole…will say, ‘We need to stop trying to save money when people are dying because that is really going to get us bad publicity.’ “

Pullen recognizes the collective effort that healthcare reform will need in order to achieve the campaign’s goals. “This issue is so fundamental, and has affected so many people—this goes beyond race, class, gender—everyone has been affected by the profit-hungry, greedy insurance industry,” he says. “I’ve gotta tell you, it feels redemptive, it feels good, to stand up for what’s right.”

Editor’s note: The print version of this article has been edited slightly here to emphasize that Mobilization for Health Care for All exclusively advocates a single-payer system.

http://inthesetimes.com/article/5179/sitting_in_for_healthcare

What next for the single payer movement?

By National Nurses Movement
Thu Nov 12, 2009
Daily Kos

Does passage of a bill that funnels millions of additional Americans into the private insurance system, and the decision of House leaders to shut down debate on one single payer amendment and scuttle another, mean the end of the years of efforts by single payer activists to win the most comprehensive reform of all?

For the nation’s nurses and the many grassroots activists, the answer is clearly no.

In discussions and organizing, now occurring coast to coast, including a strategy conference this weekend in St. Louis hosted by Healthcare-NOW, many are charting a new course that turns next to the U.S. Senate, to the Senate-House Conference Committee, and then to state capitols from Sacramento to Harrisburg where vibrant single payer movements and campaigns continue to grow.

Most single payer advocates acknowledge some important reforms in the House bill, especially the expansion of Medicaid to millions of low income adults, increased regulation of the insurance industry, expanded public health funding for community programs for low income families, and a more progressive tax plan than the onerous tax on middle income health benefits proposed in the Senate.

But those who dismiss the weaknesses, coupled with the overhyped rhetoric comparing the bill to the civil rights legislation of the 1960s or passage of Social Security and Medicare, should be wary of the backlash when millions of Americans continue to face health insecurity and potential bankruptcy as their healthcare costs rise largely unabated and continue to experience denials of medical treatment insurance companies don’t want to pay for.  

As California Nurses Association/National Nurses Organizing Committee Executive Director Rose Ann DeMoro has written

Social Security and Medicare were both federal programs guaranteeing respectively pensions and health care for our nation’s seniors, paid for and administered by the federal government with public oversight and public accountability

By contrast, the main provision of the House bill, and its Senate counterpart, is to expand health care coverage by requiring everyone to “have insurance” — mostly buying private insurance (since the public option is open to so few). Ultimately whether some want to admit it or not, a massive bailout worth tens of billions of dollars to the insurance industry.

Further, while Social Security and Medicare were both significant expansions of public protection, the House bill actually reduces public protection for a substantial segment of the population, women, with its unconscionable rollback of reproductive rights in the anti-abortion amendment.

To that end, tempering some of the triumphalism would be advisable. Equally unfathomable is the threat by some liberal groups to target single payer proponents Dennis Kucinich and Eric Massa who voted against the anti-choice amendment as well as the full bill. (Massa, in particular, was elected with active support from the single payer community and took a principled stand in a swing district.)

Those who start down this road would do well to remember the nurses, physicians, and thousands of single payer grassroots activists who have carried the flame of genuine healthcare reform for years, and will certainly continue to make their voices heard, especially as employers continue to shift skyrocketing healthcare costs to workers and out-of-pocket costs eat up, by some accounts, 15 percent to 19 percent of family incomes.  

One of those suggesting that work must continue, even prior to the vote, was House Whip James Clyburn who told the Associated Press November 5:  

“I didn’t want anyone to think that if you don’t get everything you want in this health care bill right now, that’s the end of the game. What we need to do is lay a foundation. Get passed what we can pass that will have a meaningful impact on people’s lives — not put too many of our people in jeopardy — and then build upon it later. It’s a long road.”

For single payer proponents, the construction on that long road begins in the Senate now where Sen. Bernie Sanders plans to introduce single payer language. As he said on Vermont Public Radio this week:

“I believe that a single payer system is the most effective way to provide comprehensive, universal, cost-effective health care. … (Without single payer) that ain’t going to happen. The health insurance industry and the drug companies are too powerful.”

Sanders is also proposing a federal exemption of legal barriers for states that opt to establish single payer systems, similar to the Kucinich amendment that was stripped out of the House bill by House leaders in the hours leading up to its final vote.

The reason for the amendment, Sanders notes:

“So that if states like Vermont or California or Pennsylvania – states that are strong in a single payer movement – want to move in that direction that they will be able to do so. And I think … what you will probably end up seeing is we will move toward a Medicare for all program when one state does it and does it well. And other states say, ‘You know what? That looks like the most cost effective, fairest way to provide quality care to all people.'”

You can help. Contact your Senator, (202) 224-312, and urge them to join Sanders in supporting this important amendment. That’s what a lot of us will be working on next.

http://www.dailykos.com/story/2009/11/12/175652/94

Another Doctor Mad As Hell

By Dr. Susie Baldwin
Nov 12 2009
Published on RHRealityCheck.org

Congress has done it. They’ve thrown women’s reproductive rights under the bus. They’ve catered to religious extremists rather than protect the health of our mothers, daughters, and sisters. They’ve sacrificed the health of the American people on the altar of health insurance industry profits. They took an historic opportunity to improve the conditions in which Americans live and die, and squandered it to protect the status quo.
 
This is not the change we believed in. President Obama’s tiptoeing around our human rights is not the leadership we voted for.

The House health care reform bill, the “Affordable Health Care for America Act,” won’t actually create affordable health care for America. It will perpetuate our existing inefficient, often inhumane health care system, one that spends twice as much as any other nation on earth yet fails to meet the basic needs of many individuals and communities.  The convoluted logic of our existing health insurance-based system is echoed in the cumbersome pages of HR 3962.

Already, over 30% of each dollar of our insurance premiums goes not to cover actual health care costs, but instead to pay for the overhead and profits of the private health insurance industry. With the House version of health care reform passed last night, we’ll throw more of our tax money into this inefficient, for-profit system. (Medicare, a single payer, not-for-profit, government-run health plan for seniors and some disabled people, spends 2-3% on overhead.)

The health insurance industry, which exists not to care for sick people or keep us healthy, but to reap profits, is the big winner so far in health care reform. As of today, women are the biggest losers. With the addition of the Stupak amendment, health care reform further chips away at women’s fundamental right to abortion by eliminating coverage through health insurance plans associated with Health Insurance Exchanges (what’s left of the ‘public option’). Ironically, the agency overseeing the Exchanges is called the Health Choices Administration.  In fact, there will be no choice in the new health reform plans—the bill restricts any system funds from going to abortion care, even the premium monies women pay out of their own pockets.

The amended bill allows for “non federal entities” including local and state governments and individuals to “purchase supplemental coverage for abortion.” This provision would be hilarious in its absurdity if it were not so tragic. The point of health insurance—indeed, the point of all insurance—is to provide a safety net when life throws unexpected, difficult events our way. Of course, no one plans ahead for their abortion. When women and families are applying for insurance, they don’t think to themselves, “Well, are we going to need an abortion this year?”  Plus, most companies and government entities will surely be unwilling to pay for supplemental coverage of any kind, much less for supplemental coverage for one particular highly marginalized and stigmatized (yet common) reproductive health service.

The House legislation is not all bad. It’s good that the law would prohibit insurance companies from discriminating against people with pre-existing conditions, like me with my cystic fibrosis and breast cancer. It’s good, and about time, that preventive health services will be fully covered under Medicare and Medicaid. It’s a relief that our government will finally be able to negotiate drug prices directly with pharmaceutical companies for Medicare Part D plans.

But HR 3962 is not good enough. It does not provide universal coverage and it will not control health care costs. It does not eliminate or even rein in the private insurance companies, who waste $400 billion each year—enough to cover health care for all 46 million of the uninsured. The law, if passed, will blindside a lot of women, from all walks of life, who won’t care much about the abortion restrictions until life throws them a curveball. When they find themselves in a situation they did not and could not have planned for, they will learn, as do poor women in most states, Native American women, and our soldiers and veterans, that their choices have already been made, by bishops, by corporations, and by their Congress.

RAND and BR on "savings" through "bundled payments"

Health Care Reform: Creating a Sustainable Health Care Marketplace

By Hewitt Associates
Business Roundtable
November 2009
Payment Bundling
Establishing bundled payments would create more incentives for efficient treatments and could be adjusted based on outcomes. Health care reform proposals are moving toward bundled payments. Both the House and the Senate include provisions that focus on improved quality of care and patient outcomes.
The pilot program may cover the following services: acute-care inpatient hospitalizations; physician services delivered inside and outside of the acute-care hospital setting; outpatient hospital services, including emergency department visits; services associated with acute-care hospital readmissions; home health; skilled nursing; inpatient rehabilitation; and long-term care. The episode of care established in the pilot program would start three days prior to a qualifying admission to the hospital and span the length of the hospital stay and 30 days following the patient discharge.
The pilot program’s bundled payment would be made to a Medicare provider or another entity composed of multiple providers to cover the costs of acute-care inpatient and outpatient hospital services, physician services, and post-acute care. The bundled payment for each of the eight selected conditions would be based on the average hospital, physician, and post-acute-care payments made over the hospitalization period for the patient.
CBO does not score savings for this provision, mainly because the language above suggests that Medicare will pay the same as it would otherwise have paid, instead of some lower amount per episode. Over time, however, we believe substantial savings can be achieved by both removing the financial incentive to provide marginally effective services, as well as through the active management of the rate of increase in the bundled reimbursement rate.
http://www.businessroundtable.org/system/assets/drupal/Hewitt_BRT_Sustainable%20Health%20Care%20Marketplace_Final.pdf

And…

Controlling U.S. Health Care Spending — Separating Promising from Unpromising Approaches

By Peter S. Hussey, Ph.D., Christine Eibner, Ph.D., M. Susan Ridgely, J.D., and Elizabeth A. McGlynn, Ph.D.
The New England Journal of Medicine
November 11, 2009
We identified 8 options that evidence suggests have the potential to reduce spending and are broadly applicable to the United States. For these options, we developed high and low estimates of cumulative cost savings over 10 years. The graph (clink on link below) lists the options, ranked according to their savings potential, and shows the percentage change in spending that we estimate could be achieved if that policy alone were implemented.
Among the most promising options are those related to changing the payment methods for health care services. (In the graph, bundled payment stands out as the option that would have by far the greatest impact in reducing spending.)
A “bundled-payment” approach would provide a single payment for all services related to a given treatment or condition, causing providers to assume risk for preventable costs; this approach has proved effective in limited demonstration projects. Bundled payment provides a mechanism for reducing both the volume of services and the prices charged for them. We estimate that under optimistic scenarios and with broad use of the Prometheus model of bundled payment for six chronic conditions and four acute conditions or procedures requiring hospitalization, national health care spending could be reduced by 5.4% between 2010 and 2019. This estimate assumes that providers can achieve a reduction of 25 to 50% in the costs associated with avoidable complications by providing higher-quality, more collaborative care.
http://healthcarereform.nejm.org/?p=2301&query=home

And…

Building a Bridge from Fragmentation to Accountability — The Prometheus Payment Model

By François de Brantes, M.S., M.B.A., Meredith B. Rosenthal, Ph.D., and Michael Painter, J.D., M.D.
The New England Journal of Medicine
September 10, 2009
Most experts agree that some sort of bundled, episode-based payment would help to move the system in the right direction. Our own approach, the Prometheus Payment model, for instance, bundles services and provides a budget with three components: evidence-informed base payment with patient-specific severity adjustments and an allowance for potentially avoidable complications.
The model encourages two behaviors that fee for service discourages: collaboration of physicians, hospitals, and other providers involved in a patient’s care; and active efforts to reduce avoidable complications of care (and the costs associated with them). It accomplishes these goals by paying for all the care a patient needs over the course of a defined clinical episode or a set period of management of a chronic condition, rather than paying for discrete visits, discharges, or procedures.
When incentives are used to drive changes in behavior, it is important that people and organizations are held accountable only for the variables that are actually under their control. That’s why, in designing the Prometheus model, we decided to focus on the potentially avoidable costs of patient care. We separated the costs attributable to patient-related factors from those attributable to providers’ actions. These latter costs are critically important in terms of accountability. In Prometheus, these potentially avoidable costs are called PACs and are recognized as the result of “care defects” — problems necessitating technical care that are under the professionals’ control and that, with the best professional standards, could have been avoided. PACs might include the cost of hospitalization of a patient with uncontrolled diabetes or the readmission for a wound infection of a patient who had recently been discharged after cardiac bypass surgery.
Unlike the current payment system, Prometheus provides larger profit margins for providers who can eliminate these complications, since they keep any unused PAC allowance — they profit by delivering optimal care, not a greater volume of care.
One lesson from our pilots is that hospital-centric provider organizations can expect increased internal tension when they implement an episode-of-care payment system. Prometheus does provide a sort of bonus to the hospital and physicians for working together to avoid readmission. However, physician groups that are paid under the model for managing chronic conditions have substantial opportunities to increase the profits that come from avoiding expensive hospitalizations. This incentive can highlight potential conflicts between the financial interests of physicians and those of hospitals and cause us to question the proposition that hospital-centric provider organizations will deliver the best results for the country.
The Prometheus model, by contrast, can be implemented in a fragmented, largely fee-for-service delivery system if the payer retains the role of financial integrator. Over time, as providers collaborate to improve patient care and optimize their margins, they could more formally integrate into accountable organizations. However, it will and should be their choice to do so.
http://content.nejm.org/cgi/content/full/361/11/1033

Peter Hussey and his colleagues at RAND, in their NEJM article, try to make the case that a “bundled payment” approach would be one of the most promising options for controlling health care spending. The Prometheus model of bundled payment, described the other NEJM article cited above, would shift the risk for preventable costs from the payer to the providers of health care services.
Here’s how it would work. The payer (e.g., Medicare) would determine what the costs of all services would be for a given clinical problem under the current system (fee-for-service plus DRGs). All services would be bundled under a single fee that would be discounted by about five percent. That discount represents current preventable costs such as “excessive” days of hospitalization, “unnecessary” imaging studies, “preventable” complications such as wound infections, and “unnecessary” re-hospitalizations for “inadequate” post-discharge followup. If the medical team of professionals and institutions failed to prevent these or other “additional” costs, the team would bear the loss.
Well fine. But how many of these costs are truly preventable? At the time that services are rendered, almost all decisions are clinically appropriate. It is only in retrospect that an occasional decision might have been changed, but most would not have been. Then there is the fallibility of the human mind. Just as no person could be expected to have a perfect score on every exam taken throughout life, no health care professional can be expected to have a perfect score on all clinical decisions, especially when the perfect response is often still an unknown.
Another problem is that bundling requires organizing individuals and institutions together based on a single clinical entity. The composition of the team would vary depending on the nature of the clinical problem. The team would accept the one bundled payment but then internal disputes over the distribution of the funds certainly would be inevitable. Although the payer is relieved of the administrative services of allocating these funds, the process does not bode well for creating a harmonious, collaborative environment for high quality patient care. Those who believe that these arrangements could evolve into “accountable care organizations” are delusional.
In spite of RAND’s optimism, “bundling payments” will not reduce costs. It will only reduce prices, while actually increasing costs by introducing yet greater administrative complexity.
Purists in written composition might contend that I’ve overused “quotation marks” in my comments. My defense is that health care reform should not be based on “quotation marks” and a “wink.” It should be based on sound health policy science (no quotation marks).

PNHP co-founder Dr. Steffie Woolhandler on the passage of House Bill 3962

(Excerpted from an interview with Amy Goodman, Democracy Now, November 11, 2009)

AMY GOODMAN: When the House voted on the bill, 220-to-215, what was your reaction? And can you analyze it for us?

DR. STEFFIE WOOLHANDLER: Well, we think that the Congress needs to start from scratch on this bill. The reform process in Washington has been hijacked by the private health insurance industry. If you look at the Baucus framework, which was the basis of the Senate bill—it’s on the Senate Finance Committee website. Just right-click on that document, and it turns out the author of the document was Elizabeth Fowler, who’s a former vice president of Wellpoint, the nation’s largest private insurance company, covering 35 million people. So the private insurance industry has hijacked the process. What’s come out of the House, what’s likely to come out of the Senate, is a completely inadequate bill that takes about $500 billion in taxpayer money and hands it over to the private health insurance industry.

AMY GOODMAN: I mean, explain exactly that, as people are suffering in the midst of this, you know, tremendous economic downturn, this global economic meltdown. You’re talking once again, not only with the bankers, but with the insurance company, of forcing people to buy health insurance, but to buy it from private insurers. So this is an incredible deal for the private insurers.

DR. STEFFIE WOOLHANDLER: Right. Well, the private insurers are getting millions of mandatory new customers. The taxpayers are going to give subsidies. It’s not going to make healthcare affordable, but it’s going to cost the taxpayers a lot of money to give these subsidies.

Private health insurance is a defective product. We know from our studies of bankruptcy that the majority of Americans who face medical bankruptcy start their illness with private health insurance but are bankrupted anyway by gaps in coverage, like co-payments, deductibles and uncovered services.

And under the House and Senate bills, they’ve done nothing to fix private health insurance. They’ve merely made private health insurance mandatory for middle-income working people and forcing those folks to take lots of money out of their pocket to buy this defective product.

AMY GOODMAN: And, of course, most bankruptcies in this country are caused by medical problems; they are medical bankruptcies.

DR. STEFFIE WOOLHANDLER: Right. In our studies, we found that 62 percent of all bankruptcies in the United States are due at least in part to medical illness or medical bills and that the majority of folks in medical bankruptcy started that illness with private health insurance.

AMY GOODMAN: But what about those who perhaps do even support Medicare for all or single payer who are saying, “Well, at least now you’re talking about tens of millions of people who will be insured, who weren’t otherwise”?

DR. STEFFIE WOOLHANDLER: What’s happened in the past when bills like this have passed in the states is that they run out of money very quickly, healthcare is simply unaffordable, and then you start to see the coverage expansions cut back. The subsidies shrink, the Medicaid shrinks, and then you’re back at square one, where you’ve spent a lot of money and not made any progress. And we’ve seen this over and over in the United States—in Massachusetts in 1988, in Oregon in 1992, in Washington 1993—passed bills virtually identical to what’s being passed in the House right now, and there was no durable improvement in the number of uninsured in those states. Healthcare was not affordable ten years after those bills were passed.

The problem with the House bill is it simply won’t work. And, you know, if we want to expand Medicaid, fine, we should expand Medicaid. If we want more primary care, good, let’s expand primary care. But doing it through $500 billion in subsidies to the private health insurance industry will have the effect of making the health insurance industry more powerful, making the health insurance lobby more powerful. And just as they’ve hijacked this process in Washington, it makes them more able to hijack political processes in the future.

AMY GOODMAN: And the cost of drugs? So it’s not only the mandatory—mandating that people buy health insurance from private companies, but the deal that was worked with the pharmaceutical industry in this country. Explain that.

DR. STEFFIE WOOLHANDLER: OK. Well, the deal with the pharmaceutical industry was minimal. The pharmaceutical industry gave up very little. They said for Medicare recipients who are in the doughnut hole, they would make low[er]-priced [brand-name drugs] available. That’s a very small share of the population. For the rest of us, who may be unable to afford expensive medications, we got nothing out of the pharmaceutical industry.

The pharmaceutical industry, frankly, is thrilled with this bill. And despite all their squawking, the health insurance industry is pretty happy, too. You know, Wall Street has rewarded them by driving up the value of their stocks. And I think any fair and honest reading of this bill would say that it’s a tremendous victory for the health insurance industry. And what we need to do to get to universal healthcare is start from scratch, go for that Medicare-for-all, single-payer approach.

AMY GOODMAN: And the issue of women, reproductive healthcare and abortion?

DR. STEFFIE WOOLHANDLER: Well, that is a horrendous provision in the House bill, which would essentially extend a ban on abortion to private health insurance. In the past, the Hyde Amendment applied only to people who were getting publicly funded care. But in the new bill, any insurance product that’s offered through the exchange has to—

AMY GOODMAN: And explain the exchange.

DR. STEFFIE WOOLHANDLER: Yes. The exchange would be this marketplace where you would go to buy your insurance. If you had subsidized coverage, you would have to buy your insurance through the exchange.

And any insurance plan purchased through the exchange would have to exclude coverage of abortion. So, for the first time, Congress has stepped in and said that even with your own money, with private money, it’s illegal for insurance to cover abortion. It’s a tremendous step backwards for women’s rights.

AMY GOODMAN: And do you think it will make its way through to the final bill?

DR. STEFFIE WOOLHANDLER: Well, I’m not sure about that. Certainly President Obama has weighed in to say, “Well, let’s try to return to what was there before, with just a ban on public funding of abortion,” which is bad enough. It remains unclear what’s going to happen in the Senate, whether the right-to-life folks will step in and get an anti-choice plank in the Senate bill, as well. They certainly were successful in the House. And, of course, that’s one of the many reasons that we think we need to start from scratch on a new health reform bill.

AMY GOODMAN: Steffie Woolhandler, you come from Massachusetts. That’s often held up as the model. I recently saw on CNN your former Governor Weld interviewed about his p
lan that has been adopted by all of Massachusetts. Explain the Massachusetts plan and then how we, as Americans, fit into the rest of the world when it comes to our healthcare system.

DR. STEFFIE WOOLHANDLER: OK. Well, the Massachusetts plan is considered the model for the national legislation. There’s a mandate that makes it illegal to refuse to purchase private health insurance. The fine is up to $1,068. The good thing with the Massachusetts plan was there was a big Medicaid expansion, but you didn’t need to do the mandates in order to do the Medicaid expansion.

Much of the Massachusetts plan has been wildly expensive. According to the state’s report to its bondholders, it’s cost $1.3 billion this year. The state has opted to pay for that by stealing money from safety net clinics and hospitals, so that safety net providers that care for immigrants, the mentally ill, people with substance abuse, that provide primary care, they’ve seen their funds shrunken, so that money could be handed over to purchase insurance policies. Massachusetts now has the highest healthcare costs in the history of the world.

You have to compare that to what goes on internationally. With the average per capita cost of healthcare about half those in the United States, yet people in Canada and western Europe live about two years longer. They have complete free choice of doctor and hospital. They have lower infant mortality. People in other developed nations use some form of nonprofit national health insurance to get better care for less money. And that’s why our group supports the Medicare-for-all approach.

AMY GOODMAN: So the question is where that fits in today. Finally, former President Clinton met with Senate Democrats yesterday and basically said nothing—said something is better than nothing, pass this now. What do you feel about that?

DR. STEFFIE WOOLHANDLER: Well, I think we know—we now know the outlines of what they’re going to pass. It’s not an abstract something; it’s something real. And it’s quite bad. It’s $500 billion in new subsidies to the private health insurance, millions of mandatory new customers for private health insurance.

The public plan option is incredibly puny. According to the Congressional Budget Office, fewer than 2 percent of Americans will enroll. And the premiums will actually be higher—higher—than premiums in the private sector. So the public plan option will be an expensive, tax-funded subsidy to private health insurance, because the public plan option will take the sickest patients off their hands. It’s not going to be something that’s going to generate coverage or decrease costs.

So, we know what the outlines are of the plan, and there are so many bad and harmful planks to the plan that we do need to start from scratch on health reform.

AMY GOODMAN: Since it doesn’t look like they will, will you not support what is coming out right now? Would you have voted no if you were a congressman—Congress member? Would you vote no in the Senate?

DR. STEFFIE WOOLHANDLER: Well, I’m a, you know, doctor; I’m not a politician. I feel a little bit like we’re debating whether to give aspirin or Tylenol to a patient with breast cancer. The patient needs surgery. And what’s being debated in Washington is really Tylenol or aspirin. And I had said for awhile we’d have to see the final shape of the bill, because, of course, we’d—I’d love to see more Medicaid money. Medicaid is very helpful for very poor people. It’s not perfect, but it’s much better than nothing. But I think there’s so many bad planks in the bill that this bill needs to be scratched, and we need to start over.

AMY GOODMAN: Do think this is a better deal for the health insurance industry, for the private health insurance industry in this country, than we have right now?

DR. STEFFIE WOOLHANDLER: I actually do. Their number one demand was the so-called individual mandate that would make it illegal to not have health insurance. It will become a federal crime to be uninsured. If you have private health insurance through your work, and you hate your private health insurance, tough luck, you have to keep that insurance. The mandate means you have to keep it. You can’t buy the public option. You probably won’t be able to go through the exchange. So they’ve made private health insurance mandatory, giving them hundreds of billions in new—mandatory new customers.

There’s some minimal insurance regulation, and I think more regulation is better than less regulation of insurance, but that’s going to be counterbalanced by the tremendous economic boost that will be given to the private health insurance industry through this bill. And as we know, if you have a lot of money, you can buy a lot of political influence. I think down the line we’re actually likely to be worse off in handing over so much taxpayer money to what is essentially a private health insurance industry bailout.

AMY GOODMAN: Dr. Steffie Woolhandler, I want to thank you very much for being with us, professor of medicine at Harvard University, primary care physician in Cambridge, co-founder of Physicians for a National Health Program. We’ll have a link to their study on our website at democracynow.org.

Statement of Dr. Marcia Angell introducing the U.S. National Health Insurance Act

Concurrent with the publication of the Physicians’ Proposal for National Health Insurance in the JAMA, the proposal was adapted into legislative form by Congressmen John Conyers (D-MI), Dennis Kucinich (D-OH) and Jim McDermott (D-WA).

The U.S. National Health Insurance Act (also known as the Expanded and Improved Medicare for All Act), HR 676, was introduced on February 4, 2003. The following is the statement made at the introduction ceremony by Physicians’ Working Group member and former NEJM editor Dr. Marcia Angell.

(A printable handout of this document is available by clicking here)

February 4, 2003
Washington D.C.

We are here today to introduce a national health insurance program. Such a program is no longer optional; it’s necessary.

Americans have the most expensive health care system in the world. We spend about twice as much per person as other developed nations, and that gap is growing. That’s not because we are sicker or more demanding (Canadians, for example, see their doctors more often and spend more time in the hospital). And it’s not because we get better results. By the usual measures of health (life expectancy, infant mortality, immunization rates), we do worse than most other developed countries. Furthermore, we are the only developed nation that does not provide comprehensive health care to all its citizens. Some 42 million Americans are uninsured — disproportionately the sick, the poor, and minorities — and most of the rest of us are underinsured. In sum, our health care system is outrageously expensive, yet inadequate. Why? The only plausible explanation is that there’s something about our system — about the way we finance and deliver health care — that’s enormously inefficient. The failures of the system were partly masked during the economic boom of the 1990’s, but now they stand starkly exposed. There is no question that with the deepening recession and rising unemployment, in the words of John Breaux, “The system is collapsing around us.”

The underlying problem is that we treat health care like a market commodity instead of a social service. Health care is targeted not to medical need, but to the ability to pay. Markets are good for many things, but they are not a good way to distribute health care. To understand what’s happening, let’s look at how the health care market works.
Most Americans receive tax-free health benefits from their employers, who pay insurers a portion of the premiums for health coverage. But not all employers offer benefits, and when they do, the benefits may not be comprehensive. It’s; entirely voluntary. When employers are competing for workers, they offer good benefits; when unemployment rises, they drop them.

The insurers with whom employers do business are mostly investor-owned, for-profit managed care businesses. They try to keep premiums down and profits up by stinting on medical services. In fact, the best way for insurers to compete is by not insuring high-risk patients at all; limiting the coverage of those they do insure (for example, by excluding expensive services, such as heart transplantation); and by passing costs back to patients by denying claims or as deductibles and co-payments. We are the only nation in the world with a health care system based on dodging sick people. These practices add greatly to overhead costs because they require a mountain of paperwork. They also require creative marketing to attract the affluent and healthy and avoid the poor and sick. Not surprisingly, the U. S. has by far the highest overhead costs in the world.

It’s instructive to follow the health care dollar as it wends its way from employers toward the doctors and nurses and hospitals that actually provide medical services. First, private insurers regularly skim off the top a substantial fraction of the premiums — anywhere from 10 to 25 percent — for their administrative costs, marketing, and profits. The remainder is then passed along a veritable gauntlet of satellite businesses that feed on the health care industry, including brokers to cut deals, disease-management and utilization review companies, drug-management companies, legal services, marketing consultants, billing agencies, information management firms, and so on and so on. Their function is often to limit services in one way or another. They, too, take a cut, including enough for their own administrative costs, marketing, and profits. I would estimate that no more than 50 cents of the health care dollar actually reaches the providers — who themselves face high overhead costs in dealing with multiple insurers.

What are the signs of the imminent collapse of this system? Private health insurance premiums are now rising at an unsustainable rate of about 13 percent per year, and as much as 25 percent in some areas of the country. Coverage is shrinking, as more employers decide to cap their contributions to health insurance and workers find they cannot pay their rapidly growing share. And finally, with the rise in unemployment, more people are losing what limited coverage they had. This is not a system that can be tinkered with. It needs to change.

The program we are introducing today is the very soul of simplicity and efficiency, compared with our private health care system. It is a single-payer system, that is, health care funds would be distributed by a single, public entity, so that health care could be coordinated to eliminate both gaps and overlap. In many ways, our program would be tantamount to extending Medicare to the entire population. Medicare is, after all, a government-financed single-payer system embedded within our private, market-based system. It’s by far the most efficient part of our health-care system, with overhead costs of less than 3 percent, and it covers virtually everyone over the age of 65, not just some of them. Medicare is not perfect, but it is by far the most popular part of the U. S. health care system, and in my opinion its problems would be relatively easy to remedy — but that is another subject.

What are the usual objections to the sort of national program we are calling for today? They are mostly based on a number of myths.

Myth #1 is that we can’t afford a national health care system, and if we try it, we will have to ration care. My answer is that we can’t afford not to have a national health care system. A single-payer system would be far more efficient, since it would eliminate excess administrative costs, profits, cost-shifting and unnecessary duplication. Furthermore, it would permit the establishment of an overall budget and the fair and rational distribution of resources. We should remember that we now pay for health care in multiple ways — through our paychecks, the prices of goods and services, taxes at all levels of government, and out-of-pocket. It makes more sense to pay just once.

According to Myth #2, innovative technologies would be scarce under a single-payer system, we would have long waiting lists for operations and procedures, and in general, medical care would be threadbare and less available. This misconception is based on the fact that there are indeed waits for elective procedures in some countries with national health systems, such as the U. K. and Canada. But that’s because they spend far less on health care than we do. (The U. K. spends about a third of what we do per person.) If they were to put the same amount of money as we do into their systems, there would be no waits and all their citizens would have immediate access to all the care they need. For them, the problem is not the system; it’s the money. For us, it’s not the money; it’s the system.

Myth #3 is that a single-payer system amounts to socialized medicine, which would subject doctors and other providers to onerous, bureaucratic regulations. But in fact, although a national program would be publicly funded, providers would not work for the government. That’s currently the case with Medicare, which is publicly funded, but privately delivered.

As for onerous regulations, nothing could be more onerous both to patients and providers than the multiple, intrusive regulations imposed on them by the private insurance industry. Indeed, many doctors who once opposed a single-payer system are now coming to see it as a far preferable option.

Myth #4 says that the government can’t do anything right. Some Americans like to say that, without thinking of all the ways in which government functions very well indeed, and without considering the alternatives. I would not want to see, for example, the NIH, the National Park Service, or the IRS privatized. We should remember that the government is elected by the public and we are responsible for it. An investor-owned insurance company reports to its owners, not to the public.

Some people say that a single-payer system is a good idea, but politically unrealistic. That is a self-fulfilling prophecy. In my opinion, the medical profession and the public would be enthusiastic about a single-payer system if the facts were known and the myths dispelled. Yes, there would be powerful special interests opposing it and I don’t underestimate them, but with courageous leadership, such as Representative Conyers is providing, and the support of the medical profession and public, I believe there is nothing unrealistic about a National Health Insurance Program.

I want to mention one final and very important reason for enacting a national health program. We live in a country that tolerates enormous disparities in income, material possessions, and social privilege. That may be an inevitable consequence of a free market economy. But those disparities should not extend to denying some of our citizens certain essential services because of their income or social status. One of those services is health care. Others are education, clean water and air, equal justice, and protection from crime, all of which we already acknowledge are public responsibilities. We need to acknowledge the same thing for health care. Providing these essential services to all Americans, regardless of who they are, helps ensure that we remain a cohesive and optimistic country. It says that when it comes to vital needs, we are one community, not 280 million individuals competing with one another. In seeking to ensure adequate health care for all our citizens, we have an opportunity today to reassert that we are indeed a single nation.

Marcia Angell, M. D.
Senior Lecturer, Department of Social Medicine, Harvard Medical School
Former Editor-in-Chief, New England Journal of Medicine

A conservative Republican sees the light

Republicans: Get out of the way of progress

Letters
North County Times
November 13, 2009

I am a retired lifelong conservative Republican, planning to change my registration to Independent. Why? Because of obstructionist practices of the Republicans, such as Saturday night’s vote in the House. Only one Republican voted for the House Bill 3962. All the rest played strict partisan politics.

We need change in our broken health insurance system in America. The best change would be a switch to single-payer — but in the interest of making progress, I implore my Representative, Darrell Issa, to stop playing partisan politics.

I also implore my senators, Dianne Feinstein and Barbara Boxer, to vote in favor of health care reform in the upcoming Senate votes. Again, single-payer is the best way to go, but any change from the present system will be welcome.

We have the most expensive health care system in the world, but our health outcomes are well down among developed nations. Why do our politicians not respond to their constituents? Are some in the pockets of the insurance and pharmaceutical companies? Do the wishes of majorities not count with them?

Edgar Grube
Oceanside

http://www.nctimes.com/news/opinion/letters/article_a335d2e8-dfa1-54bb-8b48-612690807f79.html

And…

Estonia: health care reforms

European Federation of Public Service Unions

In Estonia public health insurance is a social insurance and relies on the principle of solidarity. The purposes of health insurance are to: cover the costs of health services provided to insured people, prevent and cure diseases, finance the purchase of medicinal products and medicinal technical aids and provide benefits for temporary incapacity for work and other benefits. The health insurance is organised by the Health Insurance Fund (EHIF), which covers the costs of health services required by people in the event of illness, regardless of the amount of social tax paid in respect of the person concerned. The Fund uses the social tax paid for the working population also to cover the cost of health services provided to people who have no income from work activities. Employers are required to pay social tax for all people employed, at a rate of 33% of the taxable amount, of which 20% is allocated for pension insurance and 13% for health insurance.

http://www.epsu.org/a/2242

Comment:

By Don McCanne, MD

How about that! A conservative Republican who has decided that single payer is the best way to go. Wow!

So how did he arrive at his conclusions on single payer?

I must confess that Ed Grube is a close personal friend of mine. When we met many years ago, he described himself as being to the right of Genghis Khan, whereas I was to the left of Norman Thomas. We had no pretenses that we could change each others ideology, so we dispensed with the useless rhetoric.

We frequently escaped with our mates on camping trips in spectacular locations, free of the cares of our very busy lives back home. During our hikes the ladies would enjoy the things that really count – the flowers, the vistas, the fauna, etc. – whereas Ed and I would discuss government, free markets, regulation, and other topics that were inappropriate when you are in paradise. But men… you know.

I think that both of us were surprised on how much we agreed, particularly on regulation. We could see the terrible injustices resulting from the move to deregulation, especially since 1980. Recent events have only further solidified our views.

Being the compulsive that I am, I couldn’t leave out the topic of health care reform. Since we had dispensed with silly ideology disputes, we could discuss reform quite rationally. He agreed that the status quo was totally unacceptable, and that there are some very legitimate arguments that support public financing of a private health care delivery system. I agreed that we could have health care justice without the requirement of a government owned health care delivery system.

With the downturn in the economy, Ed decided to shut down his business and retire – a wise decision, except that he was too young to qualify for Medicare. I don’t need to go into this part of the story except to say that he certainly recognized the injustices of overzealous medical underwriting and age discrimination. More than ever he could see the advantages of a single payer system.

But there is more to this story. I am not going to pretend that my smooth talking converted a conservative Republican into a single payer supporter, although I may have given him some of the substrate to frame his thoughts. No, it was much more than that.

Ed, who is Estonian by heritage, met the love of his life – Juta – while visiting the land of his roots. After marriage, they lived together in Estonia long enough to be able to recognize the sharp contrasts on moving back to California. Amongst the most notable differences are our health care systems.

“In Estonia public health insurance is a social insurance and relies on the principle of solidarity.” Juta simply takes that as a given. And now, so does Ed – or at least he passionately believes that it should be a given.