PNHP

Keep Medicare as a family

Keep Medicare as a family

By RICHARD PROPP
Albany Times Union
First published: Sunday, August 3, 2008

Dear Medicare:

Happy birthday!

Since I first met you on July 31, 1965, I have been smitten with your looks, your fairness, your support of the elderly without regard to social or economic status, skin color, ethnicity, intellectual IQ, emotional IQ, address, clubs, choice of transportation, hobbies, reading list, or favorite restaurant. You took care of our grandparents, our parents, and now you are taking care of us!

Your birth was not without pain. Some of the Southern congressmen could not stand the idea of people with differing skin colors being in the same hospital room. Eventually President Lyndon Johnson, his staff, and senior citizen groups, wore down Congress, the insurance industry, the unions, and the American Medical Association, and Medicare, health care for all Americans aged 65 and over, became law. It was implemented in July of 1966. Health care was not just a necessity, it was now a right for these folks.

In July of 1965, I was moonlighting as a substitute physician in Ravena in southern Albany County with Dr. John Mosher and Dr. Ira Lefevre while I was chief resident at Albany Hospital, now known, of course, as Albany Medical Center Hospital. (Dr. Richard T. Beebe was chief of medicine at Albany Hospital and allowed us to make ends meet in this way.) More than half of our patients in Ravena who were over 65 couldn’t pay for their needed medical care and instead left vegetables and chickens at Mrs. Mosher’s back door. When Medicare came in, it allowed older folks to be treated as paying patients, restoring their dignity and their ability to be diagnosed and treated at an early stage of their illness. Countless lives were saved and diseases prevented. Practitioners and hospitals flourished.

Through the years, dear Medicare, you have been declared broke and broken, and somehow in response to pressure by physicians and patients, wise and compassionate politicians have patched you up and you carry on.

In 2003 you were “modernized” by radical conservatives and the drug and insurance companies, and, frankly, you were exploited. We are just now waking up to the fact that the real goal of this “modernization” was privatization. We are now paying private insurance companies 13 percent more to deliver benefits to those 65 and older through these private Medicare Advantage plans than through traditional Medicare. This wasteful and unnecessary payment scheme was highlighted in the recent struggle over Medicare physician reimbursement rates and hopefully will be addressed through the political process over the next year.

Those of us who believe health care is not just a necessity, but should become a right for all, hope that sometime soon you will have a baby and expand your family!

That baby is already in gestation stage as HR676, Expanded and Improved Medicare for All.

More than 90 members of Congress have signed on in support of this legislation, and there is a strong and growing wave of grass-roots support, as well as in the medical community, local governmental entities, and the labor movement. Your overhead of 4 percent, dear Medicare, is one-sixth that of private insurance plans, and one third that of not-for-profit plans. Among its many benefits, socially and economically, single payer improved and expanded Medicare for all would eliminate the huge administrative expense in time and staff to deal with myriad insurance company plan requirements and reduce overhead. Hospitals would have a guaranteed budget, and rural and urban physicians and other practitioners will have patients for whom they will get full reimbursement. At least 22,000 lives will be saved and over 500,000 medical bankruptcies will be avoided each year. Job mobility and the economy will improve as health insurance becomes separated from employment.

New opposition groups are arising, however, who are very clever about espousing “universal health care”, but, upon scrutiny, what they are really supporting are private insurance-based plans and the status quo.

This is really like putting lipstick on a pig. Even with lipstick, pigs are still pigs.

Forcing everyone into private insurance plans is not the solution to our health care crisis for anyone except the insurance industry. We, your family, dear Medicare, seek to expose these efforts as the cynical delay and denial tactics they represent. We will not let your estimable reputation and outstanding 43 years of success be besmirched, or curtailed by your undermining and privatizing adversaries.

Medicare, we still love you.

Happy birthday, and many more!

Dr. Richard Propp is chair of the Capital District Alliance for Universal Healthcare, Inc.

Millions With Chronic Disease Get Little to No Treatment

By REED ABELSON
New York Times
Published: August 5, 2008

Millions of Americans with chronic disease like diabetes or high blood pressure are not getting adequate treatment because they are among the nation’s growing ranks of uninsured.

That is the central finding of a new study to be published Tuesday in the medical journal Annals of Internal Medicine.

The study, the first detailed look at the health of the uninsured, estimates that about one of every three working-age adults without insurance in the United States has received a diagnosis of a chronic illness. Many of these people are forgoing doctors’ visits or relying on emergency rooms for their medical care, the study said.

The report, based on an analysis of government health surveys of adults ages 18 to 64 years old, estimated that about 11 million of the 36 million people without insurance in 2004 — the latest year of the study — had received a chronic-condition diagnosis.

“These are people who, with modern therapies, can be kept out of trouble,” said Dr. Andrew P. Wilper, the study’s lead author. Therapies for someone with diabetes and hypertension “are routine and widely available, if you have insurance,” said Dr. Wilper, a medical instructor at the University of Washington in Seattle.

The most recent government estimate of the number of people in this country without health insurance is 47 million, which means that if the proportions found in the study have remained constant, there might be nearly 16 million people in this country with a chronic condition but no insurance to pay for medical care.

Nearly a quarter of the uninsured with a chronic illness who were surveyed said they had not visited a health professional within the last year. About 7 percent said they typically went to a hospital emergency room for care.

“A lot of people are suffering from a lack of health insurance,” said Dr. Steffie Woolhandler, another of the study’s authors, who is a physician and associate professor of medicine at Harvard.

People with high blood pressure, for example, are at risk for catastrophic medical events like a stroke if they are not getting the drugs they need or having a doctor monitor their disease, said Karen Davis, the president of the Commonwealth Fund. The fund, a foundation in New York that specializes in health care research, has done its own research into the lack of adequate medical care among the uninsured.

The study, being published Tuesday, may have underestimated exactly how many people who are uninsured have a chronic illness, because it includes only those who have already received such a diagnosis, the authors said. Individuals who have not had their conditions diagnosed because they are not seeing a doctor or nurse are not included.

The study’s authors say that their findings cast doubt on the common assumption that many of the uninsured tend to be young and healthy, requiring little in the way of medical care. Because so many actually have chronic conditions that may be expensive to treat, the cost of covering the uninsured is often underestimated, said Dr. Woolhandler, who advocates a nationalized system of health care.

In Massachusetts, she said, the state’s effort to overhaul its health insurance system to cover more residents is costing much more than expected and has not led to universal coverage because policy makers assumed that more people would be healthy. “The state experiments have all failed because of cost,” she said.

The study describes harsh consequences for neglecting easily treatable diseases in so many people. “For some of the 11.4 million uninsured Americans with serious chronic conditions, access to care seems to be unobtainable; many may face early disability and death as a result,” the study’s authors said.

http://www.nytimes.com/2008/08/05/business/05health.html?ref=business

One-Third of Uninsured Are Chronically Ill

And that can mean missed care, fading health, earlier death, experts say

By Amanda Gardner
HealthDay Reporter
August 4, 2008

MONDAY, Aug. 4 (HealthDay News) — One out of every three working-age, uninsured Americans suffers from a chronic illness and isn’t getting the medical care they need, a new report shows.

Although the study didn’t specifically look at the health consequences of lack of insurance and lack of access to medical care, it’s reasonable to assume that these factors would lead to various medical complications, said the authors of a study published in the Aug. 5 issue of the Annals of Internal Medicine.

“This is something that is very true in my clinical experience,” said Dr. Andrew Wilper, instructor in medicine at the University of Washington in Seattle. “The uninsured can’t get in to see the doctor, they miss medications, their blood pressure is out of control and, really, you see devastating consequences.” Wilper was a fellow in general internal medicine at Harvard Medical School while conducting the study.

Another expert agreed that a lack of insurance along with chronic illness can be a potentially lethal combination.

“These people are going to end up with complications of their illnesses prematurely. They will be disabled early. They will probably die younger. It is a major public health disaster,” said Dr. Oliver Fein, president-elect of Physicians for a National Health Program and professor of clinical medicine and public health at Weill Cornell Medical College of Cornell University in New York City. “Longer-term, there will be expensive admissions to hospitals, usually through the emergency department, due to diabetes out of control and congestive heart failure because of hypertension.”

Information on the number of Americans without health insurance (about 47 million in 2006, up from 31 million in 1987) is plentiful. Less clear has been how many of these individuals suffer from chronic medical conditions, although some, including policymakers, have suggested that many are healthy.

Using data from interviews with almost 12,500 people aged 18 to 64 who had participated in the National Health and Nutritional Examination Survey (NHANES), the authors conclude that an estimated 11.4 million working-age Americans with at least one of seven chronic medical conditions do not have health insurance.

This included 16.1 percent of the 7.8 million people with cardiovascular disease, 15.5 percent of the 38.2 million people with hypertension and 16.6 percent of the 8.5 million people with diabetes.

Other conditions examined were asthma, high cholesterol, chronic obstructive pulmonary disease or a previous diagnosis of cancer.

“We found some pretty striking differences when we compared uninsured individuals with one of these seven conditions with insured individuals with one of the conditions,” Wilper said.

About 26 percent of uninsured people reported no standard site of care, versus only 6.2 percent of those who had insurance. More than 22 percent of uninsured individuals reported no visits to a health professional in the past year compared to 6.2 percent of insured people, and 7.1 percent of uninsured people with a chronic condition reported that the emergency room was their standard site of medical care, versus 1.1 percent of those carrying insurance.

“These are conditions that we take care of in the clinic. We know that we can prevent disabling complications or catastrophe if we are able to manage these conditions,” Wilper said.

“None of it is surprising,” said Greg Scandlen, founder and director of Consumers for Health Care Choices, a nonprofit advocacy group for health-care consumers. “It is interesting that chronic conditions are more common among people with insurance than without. But that isn’t surprising either. People with a chronic condition are likely to place a higher value on their coverage and work harder to get and keep it,” he said.

“But having insurance is not likely to prove to be a panacea for these folks,” Scandlen added. “People with chronic conditions who are insured are not doing so well, either. We do not do a very good job of delivering chronic care in this country for anyone.”

The new findings corroborate those from a study published July 22 in Health Affairs, which concluded that access to care among uninsured, nonelderly U.S. adults with chronic conditions actually got worse between 1997 and 2006.

http://health.usnews.com/articles/health/healthday/2008/08/04/one-third-of-uninsured-are-chronically-ill.html

Many U.S. adults with chronic illness are uninsured

By Anne Harding
Reuters
Mon Aug 4, 2008 5:40pm EDT

NEW YORK (Reuters Health) – An estimated 11.4 million Americans with at least one chronic illness have no health insurance, new research published in the Annals of Internal Medicine shows.

These people are much less likely to have a regular place to get medical care, much less likely to have seen a doctor in the past year, and much more likely to use the emergency room than chronically ill people who are insured, Dr. Andrew P. Wilper and colleagues from Cambridge Health Alliance/Harvard Medical School in Cambridge, Massachusetts, found.

“Primary care doctors know that people who don’t have access to health care due to health insurance suffer,” Wilper, who is now with the University of Washington School of Medicine in Seattle, told Reuters Health. “We wanted to study that issue and bring public attention to it.”

He and his colleagues analyzed data from the National Health and Nutritional Examination Survey for 1999-2004, which included 12,486 men and women 18 to 64 years old. Based on this nationally representative sample, they calculated that 16.1 percent of people with heart disease, 15.5 percent of those with high blood pressure, and 16.6 percent of diabetics are uninsured.

Among the uninsured, 22.6 percent had not visited a physician in the previous 12 months, compared to 16.2 percent of insured chronically ill people.

The corresponding percentages for those lacking a regular site receiving health care were 22.6 percent and 6.2 percent, and for those using the emergency room for regular care the numbers were 7.1 percent and 1.1 percent.

After the researchers adjusted for age, gender and race or ethnicity, they found that the chronically ill uninsured patients were four to six times more likely than sick patients with insurance to have these access problems.

People with chronic illnesses who don’t receive regular medical care run the risk of “catastrophic consequences,” Wilper said.
For example, individuals whose diabetes isn’t under control may wind up on dialysis for the rest of their lives, or need to have a limb amputated. Improving access to care could “prolong their life and prevent disabling complications and a lot of needless suffering,” he added.

In an editorial accompanying Wilper’s study, Dr. Marshall H. Chin of the University of Chicago writes, “Health care insurance reform is necessary for good care for chronic disease.” However, he adds, it won’t be enough until efforts are made to tackle disparities in health care.

Wilper noted that while both US presidential candidates are talking about health care reform, neither has a plan that will solve the issue of inadequate access to health care among chronically ill Americans. “Regardless of who wins the presidential election, for example, we won’t see the problem that we defined here go away.”

SOURCE: Annals of Internal Medicine, August 5, 2008.

http://www.reuters.com/article/healthNews/idUSKRA47698620080804?pageNumber=1&virtualBrandChannel=0

Stephanie Woolhandler shares her views on universal healthcare

Harvard Medical Labcast

Click here to listen to the podcast (mp3)

Stephanie Woolhandler, an associate professor of medicine at the HMS-affiliated Cambridge Health Alliance, investigates disparities and inequalities in healthcare and medicine. In recent years, she has published studies on the relative cost and effectiveness of the Canadian healthcare system. In published editorials and on Capitol Hill, Dr. Woolhandler has argued for full-scale reform of the current system here in the U.S. Last year, she uncovered insurance shortfalls for American military veterans, and her most recent research found unexpected disparities in the way free prescription drug samples are distributed.

As part of her ongoing efforts to increase care for the underserved, Dr. Woolhandler helped found Physicians for a National Health Program in 1986. The group is a single-issue organization that advocates single-payer national health insurance for all Americans.

Millions of chronically ill, lacking insurance, can't get needed care

Copies of the study are available at http://www.annals.org/cgi/content/abstract/149/3/170

Embargoed until:
August 4, 2008
5:01 p.m. EST

Contacts:
Andrew P. Wilper, M.D., (503) 260-4948, wilp9522@u.washington.edu
Mark Almberg, (312) 782-6006, mark@pnhp.org

Over 11 million Americans with chronic physical illnesses like heart disease, diabetes and asthma are not getting the medical care they need because they don’t have health insurance, a new study shows. The study provides the first national estimate of the number of uninsured adults with these potentially serious but treatable conditions.

According to an article published in the Aug. 5 edition of Annals of Internal Medicine, a leading medical journal, working-age adults with one or more chronic illnesses who reported they were uninsured were nearly four times more likely than their insured counterparts to have not seen a health professional within the past year (22.6 percent versus 6.2 percent). They were also six times more likely to identify a hospital emergency room as their standard site for care when sick (7.1 percent versus 1.1 percent).

“We have made dramatic advances in treatment of chronic illnesses like heart disease and high blood pressure,” said Dr. Andrew Wilper, the study’s lead author. “But many Americans are locked out of the system because they are uninsured and cannot afford this life-saving care.

“Many of these individuals end up with preventable emergency room visits, hospitalizations, amputations, kidney failure or worse because their chronic condition has gotten out of control,” he said.

Wilper’s team analyzed data from surveys conducted by the National Center for Health Statistics. The team found that there are 11.4 million nonelderly adults with one or more chronic conditions who lack health insurance, including 1.3 million who survived a heart attack or stroke, 5.9 million with high blood pressure, 1.4 million with diabetes and 3.5 million with asthma or emphysema. Individuals with at least one of these conditions, or with high cholesterol or prior cancer (excluding minor skin cancers), were considered to have a chronic illness.

The 11.4 million figure represents about one-third of the total number of uninsured people in the United States between the ages of 18 and 64. Altogether, about 47 million Americans lacked health insurance in 2006, according to the U.S. Census Bureau.

The authors say they may have underestimated the number of chronically ill persons who lack insurance because the survey did not query participants about depression or other chronic mental illnesses, and because undiagnosed physical diseases among the uninsured may be common.

Uninsured people with chronic illnesses face serious obstacles to getting needed care, Wilper said. But he also observed that people who are enrolled in high-deductible health plans often face similar barriers to getting regular medical attention.

“Some plans, for example, require people to pay medical bills of $5,000 out-of-pocket before their insurance kicks in,” he said. “These plans put people in the precarious state of being underinsured, which is not that much better than lacking health insurance altogether.”

Wilper, who currently teaches at the University of Washington School of Medicine in Seattle, was a fellow at Harvard University and the Cambridge Health Alliance when the study was carried out.

Dr. Steffie Woolhandler, a co-author of the study, is an associate professor of medicine at Harvard and a primary care physician in Cambridge, Mass. Woolhandler noted: “Some claim that uninsured Americans can get the care they need in emergency rooms. But emergency rooms may provide too little, too late for the millions of uninsured with chronic conditions. They need regular medical monitoring, and a steady supply of medications to control their illnesses, and a whole array of services that are out of reach for the uninsured.

“Only national health insurance can fix this broken system and save thousands of lives each year,” she said.

********

Copies of the study are available at http://www.annals.org/cgi/content/abstract/149/3/170

“Chronically Ill and Uninsured: A National Study of Disease Prevalence and Access to Care in U.S. Adults,” Andrew P. Wilper, MD; Steffie Woolhandler, MD, MPH; Karen E. Lasser, MD, MPH; Danny McCormick, MD; David H. Bor, MD; and David U. Himmelstein, MD. Annals of Internal Medicine, August 2008. Annals of Internal Medicine is published by the American College of Physicians.

Physicians for a National Health Program, a membership organization of over 15,000 physicians, supports a single-payer national health insurance program. To contact a physician-spokesperson in your area, visit www.pnhp.org/stateactions or call (312) 782-6006.

Winners and losers in balance billing

DMHC Builds on Efforts to Protect Patients from Unfair and Unexpected Bills

State of California
Department of Managed Health Care
August 1, 2008
The California Department of Managed Health Care (DMHC) today announced that it has finalized new regulations to restrict the practice of “balance billing” in emergency care settings ā€“ a practice that makes patients, not providers or health plans, responsible for paying the disputed difference between their provider’s bill and the health plan’s coverage. The regulations restrict balance billing by making it an unfair billing practice, thus allowing DMHC enforcement actions against those providers who engage in activities that unfairly burden consumers.
“Consumers, employers and taxpayers pay millions of dollars each year in health care premiums in exchange for a promise to protect them from unexpected bills when a health emergency strikes,” said Cindy Ehnes, Director of the DMHC. “The practice of balance billing breaks this promise to consumers and is unacceptable.”
Balance billing happens most often when an HMO patient receives emergency care from a physician or hospital that is not contracted with their health plan.
The DMHC has a strong record of aggressively protecting consumers from unfair balance billing. It recently filed a lawsuit in the Orange County Superior Court to stop Prime Healthcare Services, a Southern California-based hospital chain, from balance billing more than 3,500 HMO patients for services received at its hospitals.
http://www.hmohelp.ca.gov/library/reports/news/prbbregs.pdf

The issue of balance billing stems from a conflict between contracts (health plans) that patients have with their managed care organizations and contracts that physicians and hospitals do not have with the managed care organizations covering patients that they are required to provide services for in emergency situations.
This action by the California Department of Managed Care requires that hospitals and physicians comply with contracts between patients and their managed care organizations, even though a contract to provide services has never been negotiated with these private managed care entities. Thus the providers are required to accept fees that may be lower than their costs – fees that are dictated by the private health plan.
The example of Prime Healthcare Services demonstrates why it was necessary to adopt regulations to prevent patients from being gouged at unfair rack prices. But this action, in protecting patients, also protected the private managed care organizations, often at the cost of ripping off the health care providers.
In contrast, our public insurance program, Medicare, does set rates with which providers must comply (with slight variations depending on accepting assignment or contracting as a provider). Recently, in many regions, Medicare rates have been declining in relation to provider costs. A greater effort must be made by the administrators of Medicare to establish rates that cover legitimate costs and provide fair profits. Only then is it fair to demand compliance with government regulated rates.
If we had a universal single payer national health program, a unified effort would be made to demand fair compensation at a level that would ensure that our health care delivery system would be there when we need it. What we don’t need is private intermediaries that manipulate patients and providers to accomplish their business goals. We’ve had enough of that.

Winners and losers in balance billing

DMHC Builds on Efforts to Protect Patients from Unfair and Unexpected Bills

State of California
Department of Managed Health Care
August 1, 2008

The California Department of Managed Health Care (DMHC) today announced that it has finalized new regulations to restrict the practice of “balance billing” in emergency care settings — a practice that makes patients, not providers or health plans, responsible for paying the disputed difference between their provider’s bill and the health plan’s coverage. The regulations restrict balance billing by making it an unfair billing practice, thus allowing DMHC enforcement actions against those providers who engage in activities that unfairly burden consumers.

“Consumers, employers and taxpayers pay millions of dollars each year in health care premiums in exchange for a promise to protect them from unexpected bills when a health emergency strikes,” said Cindy Ehnes, Director of the DMHC. “The practice of balance billing breaks this promise to consumers and is unacceptable.”

Balance billing happens most often when an HMO patient receives emergency care from a physician or hospital that is not contracted with their health plan.

The DMHC has a strong record of aggressively protecting consumers from unfair balance billing. It recently filed a lawsuit in the Orange County Superior Court to stop Prime Healthcare Services, a Southern California-based hospital chain, from balance billing more than 3,500 HMO patients for services received at its hospitals.

http://www.hmohelp.ca.gov/library/reports/news/prbbregs.pdf

Comment:

By Don McCanne, MD

The issue of balance billing stems from a conflict between contracts (health plans) that patients have with their managed care organizations and contracts that physicians and hospitals do not have with the managed care organizations covering patients that they are required to provide services for in emergency situations.

This action by the California Department of Managed Care requires that hospitals and physicians comply with contracts between patients and their managed care organizations, even though a contract to provide services has never been negotiated with these private managed care entities. Thus the providers are required to accept fees that may be lower than their costs – fees that are dictated by the private health plan.

The example of Prime Healthcare Services demonstrates why it was necessary to adopt regulations to prevent patients from being gouged at unfair rack prices. But this action, in protecting patients, also protected the private managed care organizations, often at the cost of ripping off the health care providers.

In contrast, our public insurance program, Medicare, does set rates with which providers must comply (with slight variations depending on accepting assignment or contracting as a provider). Recently, in many regions, Medicare rates have been declining in relation to provider costs. A greater effort must be made by the administrators of Medicare to establish rates that cover legitimate costs and provide fair profits. Only then is it fair to demand compliance with government regulated rates.

If we had a universal single payer national health program, a unified effort would be made to demand fair compensation at a level that would ensure that our health care delivery system would be there when we need it. What we don’t need is private intermediaries that manipulate patients and providers to accomplish their business goals. We’ve had enough of that.

Seniors have a special interest in single-payer health care

By William Klepack
Guest Column
The Ithaca Journal
July 31, 2008

In early July, Congress passed a bill to prevent a scheduled cut in Medicare payments to doctors. Although I am pleased with the outcome of this vote, there are several reasons that senior citizens should be concerned about the political maneuvering affecting their care that surrounded this bill and be very interested in single-payer health care.

First, Senators voting against the bill were protecting insurance industry profits at the expense of seniors. The bill reduced insurance company profits by an amount necessary to balance the Medicare budget. Senators voting against this bill were, effectively, manipulating seniors’ health care to benefit the insurance companies’ bottom line.

Second, seniors should be upset because this was just the most recent threat in a long pattern of erosion of payments to their personal physicians, and this trend is starting to have an impact on seniors’ access to care. Primary care doctors (family physicians and internists) have worked tirelessly on behalf of Medicare patients, even as Medicare compensation for their services has stagnated since 2001. Physicians have experienced large increases in overhead costs during that period, and primary care doctors simply cannot continue to sustain their businesses when costs rise and payments do not keep pace with both those costs and inflation.

The result of this ongoing trend is that seniors are having more difficulty finding a physician. In March, the Medical Group Management Association reported that nearly 24 percent of all physicians had begun limiting or not accepting new Medicare patients. In December, the Medicare Payment Advisory Commission reported that, nationally, three out of 10 Medicare patients had trouble finding a primary care physician.

Since having access to health care is the single most important factor influencing health, these adverse trends point out serious problems with our current system.

Seniors should support single-payer health care because, under such a system, patients’ access to health care would not be subject to manipulation for insurance company profits. Private insurance companies would not be raking in exorbitant profits — profits that deliver no health care.

Another reason seniors should support single-payer health care is because a health-ministry-type system would no longer be the political football that the current system has been in recent years. If a nonpolitical health ministry were making health care funding decisions, then the power of the insurance industry to influence legislation ensuring their profits would cease.

Seniors should also support single-payer health care because it would establish payment levels that enable their doctors to keep their doors open and simultaneously make the health care dollar deliver more health care. A national board charged with negotiating with physicians would come to an agreement on rates.

The current Medicare insurance card has no value unless there is a doctor in the house. We not only need a doctor in the house; we need every dollar to go farther in delivering care.

Dr. William Klepack is a family physician practicing in Dryden and is medical director of the Tompkins County Health Department. The opinions expressed above are his personal ones and do not reflect Health Department or Tompkins County policy.

http://www.theithacajournal.com/apps/pbcs.dll/article?AID=/20080731/OPINION02/807310306

Medicare national coverage determinations

New list offers sneak peek into agenda of device, pharmaceutical industries

By Jeffrey Young
The Hill
July 31, 2008
The Centers for Medicare and Medicaid Services (CMS) has published its first-ever quarterly list of drugs, medical devices and procedures that Medicare patients may no longer be able to access.
The list, posted on CMS’s website this week, provides an unprecedented glimpse into what companies or sectors might be celebrating or mourning in the months ahead. It’s the Medicare national coverage determinations, or NCDs, that can be the difference between whether a drug- or device maker sees a huge return on research and development or a crushing bust.
And in an effort to improve transparency and public input, all members of the public ā€” whether business interests, healthcare providers or patients ā€” will able to provide CMS with comments.
CMS lists 19 potential topics for national coverage determinations in the next quarter-year. These topics include drugs to treat anemia, “proton beam therapy” to treat prostate cancer, and tiny, implantable devices that keep coronary arteries open while dispensing medication, called drug-eluting stents.
Not only does Medicare command a large portion of the healthcare marketplace, private insurance companies regularly adopt the same or similar coverage policies based on Medicare’s decisions.
CMS’s regional contractors make the vast majority of coverage determinations. In most cases when the agency’s headquarters steps in, it is in response to a request by manufacturers or medical providers seeking greater clarity on Medicare’s coverage policies based on variations in the locally made decisions. Other times, CMS will initiate a national coverage determination based on agency staff recommendations when they see, for example, new clinical evidence that they believe merits a reconsideration of an old decision.
Based on the statutory standard of whether the new technology or procedure is “reasonable and necessary,” the resultant policy then applies to Medicare providers and patients across the country.
(CMS Chief Medical Officer Barry) Straube stressed that the actual NCD process will not change and that CMS does not intend to centralize coverage determinations. “We have no plans right now to change the national coverage-versus-local coverage decision process,” he said, noting that CMS lacks the financial resources to take over for the regional contractors.
http://thehill.com/the-executive/new-list-offers-sneak-peek-into-agenda-of-device-pharmaceutical-industries-2008-07-31.html

Medicare national coverage determinations (NCDs) are inevitably controversial. Decisions on what procedures, devices and drugs are to be covered must balance the wishes of patients to have unlimited access to all possible care, regardless of demonstrated benefit or lack thereof, with the responsibility of the stewards of our tax funds to not waste them on care that is of no benefit and often is detrimental.
The ethics are fairly straightforward. Medicare, being a publicly-financed program, has an obligation to fund appropriate care, but also has an obligation to prevent misuse of our public funds. Inappropriate care should never be considered to be a right of an individual when the taxpayer would have to pick up the tab.
Generally, a national health program would macro-manage the health care funds, whereas micromanagement of the patient’s care would be provided by the patient’s personal health care professionals. But high-tech care has been the largest contributor to the continuing escalation in health care costs. We are at a point where we should no longer permit the unquestioned use of public funds for unlimited, expensive high-tech care that has not been demonstrated to be of benefit, and sometimes causes harm.
Opponents of government health programs frequently charge that such coverage decisions deny patients life-saving care. Care that might be reasonably expected to reduce suffering or even save a life is not the care that is denied. A cancer drug that has a reasonable probability of providing a significant remission or even a cure is never withheld. Rather, an expensive cancer drug that has not been demonstrated to provide improved outcomes might well be denied. Spending $100,000 of taxpayer funds to provide a false sense of hope where there is no hope is not only wasteful, but it is also cruel because of the adverse effects of such therapies, and the dashed hopes that follow. “Well, we don’t know whether this $100,000 drug will do any good, but let’s try it anyway” should no longer be adequate justification for using public funds for therapeutic whims, even in tragic cases.
It is often said that a national health insurance program should be administered on a regional basis rather than nationally. But this does not necessarily mean that national coverage determinations must rest with regional contractors as they now often do in the Medicare system. Some of the complaints about Medicare stem from the inconsistencies in coverage decisions.
Claiming that CMS lacks the financial resources to centralize national coverage determinations is certainly a feeble excuse for not providing taxpayers with oversight of spending on expensive, unproven, high-tech services. Hopefully 2009 will bring us more enlightened national leaders.

Medicare national coverage determinations

New list offers sneak peek into agenda of device, pharmaceutical industries

By Jeffrey Young
The Hill
July 31, 2008

The Centers for Medicare and Medicaid Services (CMS) has published its first-ever quarterly list of drugs, medical devices and procedures that Medicare patients may no longer be able to access.

The list, posted on CMS’s website this week, provides an unprecedented glimpse into what companies or sectors might be celebrating or mourning in the months ahead. It’s the Medicare national coverage determinations, or NCDs, that can be the difference between whether a drug- or device maker sees a huge return on research and development or a crushing bust.

And in an effort to improve transparency and public input, all members of the public — whether business interests, healthcare providers or patients — will able to provide CMS with comments.

CMS lists 19 potential topics for national coverage determinations in the next quarter-year. These topics include drugs to treat anemia, “proton beam therapy” to treat prostate cancer, and tiny, implantable devices that keep coronary arteries open while dispensing medication, called drug-eluting stents.

Not only does Medicare command a large portion of the healthcare marketplace, private insurance companies regularly adopt the same or similar coverage policies based on Medicare’s decisions.

CMS’s regional contractors make the vast majority of coverage determinations. In most cases when the agency’s headquarters steps in, it is in response to a request by manufacturers or medical providers seeking greater clarity on Medicare’s coverage policies based on variations in the locally made decisions. Other times, CMS will initiate a national coverage determination based on agency staff recommendations when they see, for example, new clinical evidence that they believe merits a reconsideration of an old decision.

Based on the statutory standard of whether the new technology or procedure is “reasonable and necessary,” the resultant policy then applies to Medicare providers and patients across the country.

(CMS Chief Medical Officer Barry) Straube stressed that the actual NCD process will not change and that CMS does not intend to centralize coverage determinations. “We have no plans right now to change the national coverage-versus-local coverage decision process,” he said, noting that CMS lacks the financial resources to take over for the regional contractors.

http://thehill.com/the-executive/new-list-offers-sneak-peek-into-agenda-of-device-pharmaceutical-industries-2008-07-31.html

Comment:

By Don McCanne, MD

Medicare national coverage determinations (NCDs) are inevitably controversial. Decisions on what procedures, devices and drugs are to be covered must balance the wishes of patients to have unlimited access to all possible care, regardless of demonstrated benefit or lack thereof, with the responsibility of the stewards of our tax funds to not waste them on care that is of no benefit and often is detrimental.

The ethics are fairly straightforward. Medicare, being a publicly-financed program, has an obligation to fund appropriate care, but also has an obligation to prevent misuse of our public funds. Inappropriate care should never be considered to be a right of an individual when the taxpayer would have to pick up the tab.

Generally, a national health program would macro-manage the health care funds, whereas micromanagement of the patient’s care would be provided by the patient’s personal health care professionals. But high-tech care has been the largest contributor to the continuing escalation in health care costs. We are at a point where we should no longer permit the unquestioned use of public funds for unlimited, expensive high-tech care that has not been demonstrated to be of benefit, and sometimes causes harm.

Opponents of government health programs frequently charge that such coverage decisions deny patients life-saving care. Care that might be reasonably expected to reduce suffering or even save a life is not the care that is denied. A cancer drug that has a reasonable probability of providing a significant remission or even a cure is never withheld. Rather, an expensive cancer drug that has not been demonstrated to provide improved outcomes might well be denied. Spending $100,000 of taxpayer funds to provide a false sense of hope where there is no hope is not only wasteful, but it is also cruel because of the adverse effects of such therapies, and the dashed hopes that follow. “Well, we don’t know whether this $100,000 drug will do any good, but let’s try it anyway” should no longer be adequate justification for using public funds for therapeutic whims, even in tragic cases.

It is often said that a national health insurance program should be administered on a regional basis rather than nationally. But this does not necessarily mean that national coverage determinations must rest with regional contractors as they now often do in the Medicare system. Some of the complaints about Medicare stem from the inconsistencies in coverage decisions.

Claiming that CMS lacks the financial resources to centralize national coverage determinations is certainly a feeble excuse for not providing taxpayers with oversight of spending on expensive, unproven, high-tech services. Hopefully 2009 will bring us more enlightened national leaders.

Make original Medicare the foundation for health care reform

By JOHN GEYMAN and MALINDA MARKOWITZ
Guest Columnist
Seattle Post Intelligencer
Thursday, July 31, 2008

As Medicare celebrates its 43rd birthday this week, it’s time to take stock of one of the most popular government programs of all time that guarantees all Americans 65 years of age and older universal coverage of comprehensive health care benefits.

At the time of its passage, American seniors were having great difficulty affording health care, especially the costs of hospitalization. They were paying 15 percent of their annual income on health care. Many millions were unable to afford either insurance or their medical bills. Enactment of Medicare gave them access to a set of benefits defined by law, as an earned right for which they contributed, without regard to their health status or income.

Medicare today covers about 43 million American seniors and the disabled, paying about one-half of their health care expenses. Amidst an increasingly unaffordable health care market, Medicare recipients have a solid rock of coverage. The program is administered with an overhead of about 3 percent, less than one-fifth the overhead of competing private programs, while offering defined benefits with free choice of physician and hospital.

A survey by the Commonwealth Fund in 2002 found that Medicare beneficiaries rate the program much higher than private health insurance in terms of quality, help with access to care and payment of their medical bills. A binding social contract has been established and kept with eligible beneficiaries that they can trust and depend on. Even at that, seniors are paying much more out of pocket now than they were in 1965 for health care — 22 percent of their annual income.

Despite its many successes, Medicare has been under relentless attack by conservatives, market stakeholders and their lobbyists pushing to “save” Medicare by killing it. Their agenda is to siphon off more affluent seniors to private plans and shrink Medicare to a much smaller program. There is no ambiguity in this goal. As then Speaker of the House Newt Gingrich said at the time, this kind of “reform” could “solve the Medicare problem” and cause the program to “wither on the vine.”

Private Medicare plans have proven themselves to be more expensive and less reliable. Despite their claims of more choice, better benefits and value, their track record is one of exploitation, made possible only by generous subsidies by the government. The original premise was that these plans would save the government money, but that soon fell by the wayside. Private insurers lobbied early and successfully for generous overpayments. Today’s overpayments average about 12 percent, with the fastest growing private fee-for-service plans at 19 percent.

What do we get for this privatization boondoggle? In the late 1990s, 2.4 million seniors were forced to find new coverage, and often to change doctors, when many Medicare plus Choice plans left the market due to insufficient profits. The 2003 Medicare Prescription Drug Improvement and Modernization Act continued generous government subsidies while also prohibiting the government from negotiating bulk discounts from drug manufacturers as the VA does so effectively with discounts of about 45 percent.

The Government Accounting Office has concluded that private Medicare plans are more expensive, offer fewer benefits than claimed and are of questionable value as public policy.

All incremental efforts to control health care costs have failed over the last 30 years. There are now 75 million uninsured and underinsured, both categories which are growing rapidly with no end in sight. Access to health care for middle-class Americans is seriously threatened, and medical bills have become a leading cause of bankruptcy.

Amidst this deteriorating landscape, original Medicare stands as a shining example of a needs-based program that has consistently served the public interest. Despite being weakened by privatizing, it gives us a solid foundation for real health care reform, when access to necessary health care is even more difficult than in the 1960s.

It is time to expand Medicare as a social insurance program for all Americans through a single risk pool of all 300 million of us. This is the most efficient, fair and sustainable way to insure us all against the costs of illness and injury, coupled with the strengths of our private delivery system. Expansion and improvement is the best way to “save” Medicare.

John Geyman is professor emeritus of family medicine, University of Washington, and past president, Physicians for a National Health Program. Malinda Markowitz is co-president of the California Nurses Association/National Nurses Organizing Committee.