PNHP

WellPoint and UCLA privacy breaches

WellPoint and UCLA privacy breaches

WellPoint probing data breach for 130,000 members

Reuters
April 9, 2008

Health insurer WellPoint Inc is investigating the cause of a breach involving protected health information for about 130,000 members, the company said on Wednesday.

The largest U.S. health insurer by membership said it recently discovered data became publicly available over the Internet in the past 12 months.

WellPoint, which offers an array of insurance through public and employer-sponsored plans, declined to identify which type of members were involved, or which states they were in, beyond saying they were in several.

http://www.reuters.com/article/domesticNews/idUSN0921842120080409

And…

Snooping in records has a history at UCLA

By Charles Ornstein
Los Angeles Times
April 11, 2008

Though UCLA Medical Center has portrayed recent privacy breaches as the rare actions of rogue employees, the hospital has known since at least 1995 that staffers were peeking into the medical records of such prominent patients as Tom Cruise and Mariah Carey — and even spying on one another’s medical care, according to records and interviews.

The stakes for hospitals grew in 2003 when a federal law, the Health Insurance Portability and Accountability Act, put in place criminal and civil sanctions for breaches of patient confidentiality.

It appears that UCLA has not gone as far as a major competitor — Cedars-Sinai Medical Center — in providing extra security for the files of high-profile patients.

UCLA officials said this week that every day they audit the medical records of 72 high-profile people who have been patients to monitor which employees view them. Cedars-Sinai reviews 10 times as many.

Only certain employees can access the records at Cedars-Sinai, and if an unauthorized user so much as attempts to get in, he or she can be fired.

Cedars-Sinai spokesman Richard Elbaum said the hospital also uses real-time alerts to signal inappropriate access of certain medical records. And the records of high-profile patients have a special on-screen warning that reads, “This patient record is restricted. All accesses are logged and audited. Inappropriate accesses are grounds for disciplinary action and/or dismissal.”

http://www.latimes.com/news/printedition/california/la-me-ucla11apr11,1,878793,full.story

Comment:

By Don McCanne, MD

Electronic medical records (EMRs) and integrated information technology systems (IT systems) will reduce health care costs in the future. At least that is what the politicians would have you believe, though the systems are expensive and will increase net costs since the expense and maintenance would more than offset any efficiency improvements.

Although EMRs and IT systems are helpful tools, they introduce exposure to privacy breaches that have implications far beyond those of paper records. Looking through a patient’s paper chart is one thing, but obtaining digital information that can be unleashed over the Internet for all the world to see, without any possibility of retracting the release of that information, is quite another.

Representatives of the IT industry claim that information is made secure through encryption. Even if the encryption involves a gazillion steps to access information, individuals such as physicians, nurses, pharmacists, billing administrators, and the patients themselves, who need that information, must be able to access it. It is impossible to create a security system that ensures appropriate access only to those with a need to know, while excluding access to every single other individual who has no right to that information.

Contrasting themselves with UCLA, the officials at Cedars-Sinai gloat that they have adopted extra measures to protect the information of high-profile patients. The implication is that the medical information about most of us does not warrant the same security level, and thus is more vulnerable to breaches. But even for the high-profile patients, many individuals would have legitimate access to those records. How can any administrator ever be certain that each individual with access would never abuse the responsibility that goes along with knowledge of patient’s most intimate medical history and findings? And there is no way to prevent others with nefarious intents (hackers) to access records if they really want the information.

The next politician who claims that we will control costs through EMRs and IT systems needs to be immediately confronted with this request. “Please explain precisely the technology that will be used to ensure that our private medical information can NEVER be unleashed on the Internet.” They will not have an answer, because it doesn’t exist.

Medical students rally for health care

By Jesse Muhammad
Staff Writer
HOUSTON (FinalCall.com)
Apr 10, 2008

Rallying for affordable health care for all, hundreds of medical students from around the country recently gathered at Houston City Hall in conjunction with the American Medical Student Association’s (AMSA) 58th Annual Convention. The group met at the Hyatt Regency Houston and marched to City Hall.

According to statistics, Texas has the largest uninsured population in the nation. Houston alone has 1.1 million uninsured people. Almost 40,000 are children.

“A person is a person; a child is a child; and there are no good moral, ethical, rational or medical reasons to ever exclude human beings from getting the health care they deserve,” said Flavio Casoy, AMSA’s Jack Rutledge Fellow and leader of the rally. “As future physicians, we declare that healthcare is a human right for all people, regardless of race, gender, sexual orientation or country of origin. We invite all Houston residents to join us in asking the 2008 presidential candidates to support a single, public, national health insurance program.”

Low-income workers affiliated with Service Employees International Union also spoke at the rally about their daily struggle to secure affordable health care for their families from their employers.

In addition to the rally, AMSA’s annual convention attracted more than 1,500 attendees, who attended workshops and seminars on issues such as pharmaceutical industry marketing, minority health, 2008 election issues, immigrant health, healthcare and the aging population, the AIDS epidemic and mental health.

“Students coming together like this sends a message to the next president of the United States, that we as young people can impact change,” said Dan Glickman, a medical student at Rutger Canden in New Jersey.

Bryan Boynton, a junior at the same school, added, “It’s all about the future. The main issues today are the economy and health care. This rally is critical.”

“As the future physicians, we see a broken system, so if there is going to be change then we are going to be apart of it,” said Laura Janneck of Case Western Reserve University.

Jamil Muhammad, a senior at Girls and Boys Preparatory Academy, came out to show his support. “I am here because healthcare for our families is critical. Most low- income families can’t afford it and young people are suffering from lack of medical check-ups. This was a powerful stance by young people today.”

The American Medical Student Association, with more than a half-century history of medical student activism, is the oldest and largest independent association of physicians-in-training in the United States. Founded in 1950, AMSA is a student-governed, non-profit organization committed to representing the concerns of physicians-in-training. With more than 68,000 members, including medical and premedical students, residents and practicing physicians, AMSA is committed to improving medical training as well as advancing the profession of medicine.

Health Policy Placebos

by DAVID U. HIMMELSTEIN & STEFFIE WOOLHANDLER
The Nation
April 14, 2008

We don’t administer useless nostrums for curable cancer–even when effective treatment is arduous. Yet Hillary Clinton and Barack Obama prescribe the health policy equivalent of placebos. (John McCain suggests arsenic, but more about him another time.)

The Democratic contenders proffer a superficially plausible reform model that has a long record of failure. Their proposals trace back to Nixon’s 1971 employer mandate scheme, concocted to woo moderate Republicans away from Ted Kennedy’s single-payer plan. Like mandate reforms subsequently passed (and failed) in Massachusetts (1988), Oregon (1989) and Washington (1993), Clinton’s and Obama’s plans would couple subsidies for the poor with a requirement that large employers foot part of the bill for employee coverage. These earlier reforms also required the self-employed to buy coverage, an individual mandate that Clinton (like the 2006 Massachusetts reform) would expand to virtually all; Obama limits his mandate to children. In both versions, a federal agency would serve as insurance broker, selling a new public plan and a menu of private ones–reprising the format of Medicare’s ongoing privatization, implemented through competition rigged to favor private plans [see Trudy Lieberman, “The Medicare Privatization Scam,” July 16/23, 2007].

The earlier state reforms foundered on the shoals of cost. As health spending soared, employers rebelled and legislators rescinded the mandates and subsidies. Massachusetts looks set to replay this experience; only 7 percent of those required to buy unsubsidized coverage have yet to sign up, while the state wrestles with massive cost overruns for subsidies.

Proposals that rely on private insurers can add coverage only by adding costs. Both Democrats promise savings from computerization, prevention and chronic disease-care management. Yet medical computing hasn’t yielded savings, despite thirty years of rosy promises. As for prevention, a raft of studies show that it saves lives but not money. And the Medicare Health Support program recently abandoned its care management project because it yielded no savings.

Both Democrats’ proposals forgo the administrative savings possible under single-payer national health insurance (NHI) such as that proposed by the Conyers/Kucinich bill (HR 676) and by Ralph Nader. Bureaucracy consumes 31 percent of US health spending, versus 17 percent in Canada. The difference translates into $350 billion frittered away annually here, where a million healthcare workers, as well as hundreds of thousands in the insurance industry, spend their days on useless paperwork.

This waste is a natural byproduct of private insurance. Private plan overhead is eleven times that of Canada’s NHI program. Each dollar spent on private premiums buys only 88 cents of care; the rest pays for insurers’ marketing, underwriting, utilization reviewers and profits–and for the billions paid to their CEOs. Fragmented coverage also means duplication of claims-processing facilities and mountains of paperwork for doctors and hospitals, which must deal with multiple insurance products each with its own eligibility rules, co-payments, referral networks, etc.–tasks that are absent in Canada. Our multiplicity of insurers also precludes the payment to hospitals of a global, lump-sum budget. In Canada global budgets obviate the need for most hospital billing and much of the internal accounting needed to attribute costs to individual patients and payers.

Clinton’s and Obama’s plans also lack credible means to redirect the hundreds of billions now wasted on overtreatment. Hospitals, doctors and equipment firms profit from investments in expensive high-tech care, encouraging the overuse of interventions that help some patients but harm others–for example, spine surgery, cardiac stents and CAT scans (which often deliver radiation equivalent to 500 chest X-rays). Insurers limit their outlays through intrusive case-by-case reviews or by raising co-payments. But they have little interest in systemwide cost control, so their efforts have mainly shifted costs to patients or other payers–the economic equivalent of squeezing a balloon. In contrast, NHI would allow explicit public decision-making about today’s capital investments that shape tomorrow’s care, and straightforward mechanisms to limit profit.

Without savings, the tax increases Obama and Clinton propose would be eaten up by subsidies for the uninsured, leaving nothing for the majority of Americans already covered but often unable to afford care. As we found in a 2005 study with Elizabeth Warren and Deborah Thorne, three-quarters of the 750,000 families driven to bankruptcy each year by illness or medical bills had coverage, though with unaffordable co-payments, deductibles and uncovered services. NHI would eliminate these gaps.

Private insurers caused the healthcare crisis. Yet both Democratic contenders advocate reforms that would fortify private plans, making government their debt collector. Their proposals, while palatable to the health industry–which supplies the Democrats with huge donations as well as key officials (DNC credentials committee co-chair James Roosevelt moonlights as an insurance company CEO)–cannot cure our healthcare crisis.

Nonetheless, we’re optimistic about the prognosis for healthcare reform. If you turn up the volume on C-SPAN you can hear the audience cheering whenever Clinton or Obama lets the words “single payer” slip out–a reflection of the fact that three-fifths of the general public, as well as the 124,000-member American College of Physicians, support NHI. As in the JFK era, a charismatic, if only tepidly liberal, candidate can help raise hopes and expectations, igniting a mass movement that pushes a progressive agenda further and faster than the candidate intends.

Obama speaks out on issues

KCPNews

KPC (questioners): Health care is an important issue for most voters. More and more physicians are turning to national health insurance as a solution to our health insurance coverage gaps. According to a survey reported last month by Indiana University, of more than 2,000 doctors surveyed, 59 percent said they support legislation to establish a national health insurance program such as “Medicare for all” to insure all Americans. Why do you think your plan which continues our current patchwork of both public and private insurance is better than expanding Medicare into a “Medicare for all” universal health insurance plan?

Obama: I have said in the past if I were designing a system from scratch I would probably prefer a single-payer system. I think the administrative advantages are significant and by having patients in a single system they are much more likely to benefit from preventive care because the person providing the care has an incentive (to keep people in the system well). There are significant advantages.

The problem is we are not starting from scratch. A sizable percentage of the population gets health insurance from their employers and I think we are going to have to see changed attitudes before we would see a single payer system. I also think there is some advantage to the marketplace being involved and increased competition. So I have said if you are in an employer based plan currently, then we will work with your employer to lower premiums. If you don’t have health insurance then you can buy into a plan that is similar to the plan I have as a member of Congress, and there won’t be exclusions for preexisting conditions. If you can’t afford the plan, then we will subsidize you.

There will be tight regulations on insurers to make sure that we are reimbursing for preventive services, that we are emphasizing the management of the care of the chronically ill more effectively and that we are investing in information technology to reduce bureaucracy, reduce error and improve quality. If we do all those things, we can save as much as $100 – $150 billion per year that we can then use to subsidize those currently without care. These principles have to be applied to Medicare and Medicaid, as well…

This is the most effective way to provide the help people need immediately, and I think this is something we can accomplish within my first term as president of the United States of America.

Health Care System Profiles

Author(s): Karsten Vrangbaek, Isabelle Durand-Zaleski, Reinhard Busse, Niek Klazinga, and Anders Anell
Commonwealth Fund
March 2008

Descriptions of Health Care Systems: Denmark, France, Germany, The Netherlands, Sweden, and the United Kingdom

The work of the Commonwealth Fund’s international program highlights the valuable lessons the U.S. can learn from the health care systems in other industrialized countries. These country profiles provide overviews of the health care systems of several countries, including Denmark, France, Germany, the Netherlands, Sweden, and the U.K. Each profile includes descriptions of how each country organizes, finances, and delivers health services and highlights quality, efficiency, and cost-controlling policy initiatives and reforms

Health Care Horror Stories

Paul Krugman
The New York Times
April 11, 2008

Not long ago, a young Ohio woman named Trina Bachtel, who was having health problems while pregnant, tried to get help at a local clinic.

Unfortunately, she had previously sought care at the same clinic while uninsured and had a large unpaid balance. The clinic wouldn’t see her again unless she paid $100 per visit — which she didn’t have.

Eventually, she sought care at a hospital 30 miles away. By then, however, it was too late. Both she and the baby died.

You may think that this was an extreme case, but stories like this are common in America.

Back in 2006, The Wall Street Journal told another such story: that of a young woman named Monique White, who failed to get regular care for lupus because she lacked insurance. Then, one night, “as skin lesions spread over her body and her stomach swelled, she couldn’t sleep.”

The Journal’s report goes on: “Mama, please help me! Please take me to the E.R.,” she howled, according to her mother, Gail Deal. “O.K., let’s go,” Mrs. Deal recalls saying. “No, I can’t,” the daughter replied. “I don’t have insurance.”

She was rushed to the hospital the next day after suffering a seizure — and the hospital spared no expense on her treatment. But it all came too late; she was dead a few months later.

How can such things happen? “I mean, people have access to health care in America,” President Bush once declared. “After all, you just go to an emergency room.” Not quite.

First of all, visits to the emergency room are no substitute for regular care, which can identify and treat health problems before they get acute. And more than 40 percent of uninsured adults have no regular source of care.

Second, uninsured Americans often postpone medical care, even when they know they need it, because of expense.

Finally, while it’s true that hospitals will treat anyone who arrives in an emergency room with an acute problem — and it’s wonderful that they will — it’s also true that hospitals bill patients for emergency-room treatment. And fear of those bills often causes uninsured Americans to hesitate before seeking medical help, even in emergencies, as the Monique White story illustrates.

The end result is that the uninsured receive a lot less care than the insured. And sometimes this lack of care kills them. According to a recent estimate by the Urban Institute, the lack of health insurance leads to 27,000 preventable deaths in America each year.

But are they really preventable? Yes. Stories like those of Trina Bachtel and Monique White are common in America, but don’t happen in any other rich country — because every other advanced nation has some form of universal health insurance. We should, too.

All of which makes the media circus of a few days ago truly shameful.

Some readers may already have recognized the story of Trina Bachtel. While campaigning in Ohio, Hillary Clinton was told this story, and she took to repeating it, without naming the victim, on the campaign trail. She used it as an illustration of what’s wrong with American health care and why we need universal coverage.

Then The Washington Post identified Ms. Bachtel, the hospital where she died claimed that the story was false — and the news media went to town, accusing Mrs. Clinton of making stuff up. Instead of being a story about health care, it became a story about the candidate’s supposed problems with the truth.

In fact, Mrs. Clinton was accurately repeating the story as it was told to her — and it turns out that while some of the details were slightly off, the essentials of her story were correct. After all the fuss, The Washington Post eventually conceded that “Bachtel’s medical tragedy began with circumstances very close to the essence” of Mrs. Clinton’s account.

And even more important, Mrs. Clinton was making a valid point about the state of health care in this country.

In other words, this was a disgraceful episode. It was particularly sad to see a number of Obama supporters (though not the Obama campaign itself) join enthusiastically in the catcalls against Mrs. Clinton’s good-faith effort to put a human face on the cruelty and injustice of the American health care system.

Look, I know that many progressives have their hearts set on seeing Barack Obama get the Democratic nomination. But politics is supposed to be about more than cheering your team and jeering the other side. It’s supposed to be about changing the country for the better.

And if being a progressive means anything, it means believing that we need universal health care, so that terrible stories like those of Monique White, Trina Bachtel and the thousands of other Americans who die each year from lack of insurance become a thing of the past.

AHIP's definition of equity

The Principles of Pricing Health Insurance

America’s Health Insurance Plans (AHIP)

Equity

Some insureds make more claims than others, and consequently the cost of providing coverage is different for different insureds. The premium amount each insured pays must reflect the expected cost of providing coverage to that insured. Why? Suppose an insurer charged some insureds less than the expected cost of providing coverage to them. That insurer would have to charge other insureds an extra amount to make up for those paying less than cost. Those insureds paying extra would go to other insurers that would not charge them extra. The original insurer would be left only with insureds paying less than costs and could go out of business.

http://www.ahiphiwire.org/HealthInsurance/LearningCenter/Feature.aspx?doc_id=159743

Comment:

By Don McCanne, MD

What is “equity,” as the term would apply to our health care system?

The American Heritage Dictionary defines equity as “something that is just, impartial, and fair.” Merriam-Webster defines it as “something that is equitable,” and equitable as “dealing fairly and equally with all concerned.”

In an article from the Journal of Epidemiology and Community Health (2003;57:254-258), P. Braveman and S. Gruskin define equity in health as “the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage — that is, wealth, power, or prestige.”

And how does the private insurance industry define equity in the pricing of health insurance premiums? The premium that “EACH insured pays must reflect the expected cost of providing coverage to THAT insured,” but not “an extra amount to make up for those paying less than cost.”

So let’s see how that would work in a system that finances health care for everyone. The 80 percent of individuals (243 million people) who use 20 percent of our national health expenditures ($479 billion) would each be responsible for $1970 in an equitable system, according to the insurance industry’s version. The other 20 percent of individuals (61 million people) who use 80 percent of our national health expenditures ($1,915 billion) would each be responsible for $31,400 in AHIP’s version of equity.

So the private insurance industry, in order to establish equity, would set their premiums based on health care costs of $1970 each (plus administrative costs and profits, less cost-sharing) for four-fifths of us. But what about the one-fifth with health care costs averaging $31,400 each? They simply avoid that market.

Thus the insurance industry’s definition of equity is making premiums fair by excluding the costs of those needing health care, which equates with excluding them from coverage under their plans. Those with high costs can use their wealth, power, or prestige to obtain care. But what about those without? Doesn’t that stretch the definition of equity to well past the breaking point?

AHIP’s definition of equity

The Principles of Pricing Health Insurance

America’s Health Insurance Plans (AHIP)

Equity

Some insureds make more claims than others, and consequently the cost of providing coverage is different for different insureds. The premium amount each insured pays must reflect the expected cost of providing coverage to that insured. Why? Suppose an insurer charged some insureds less than the expected cost of providing coverage to them. That insurer would have to charge other insureds an extra amount to make up for those paying less than cost. Those insureds paying extra would go to other insurers that would not charge them extra. The original insurer would be left only with insureds paying less than costs and could go out of business.

http://www.ahiphiwire.org/HealthInsurance/LearningCenter/Feature.aspx?doc_id=159743

Comment:

By Don McCanne, MD

What is “equity,” as the term would apply to our health care system?

The American Heritage Dictionary defines equity as “something that is just, impartial, and fair.” Merriam-Webster defines it as “something that is equitable,” and equitable as “dealing fairly and equally with all concerned.”

In an article from the Journal of Epidemiology and Community Health (2003;57:254-258), P. Braveman and S. Gruskin define equity in health as “the absence of systematic disparities in health (or in the major social determinants of health) between groups with different levels of underlying social advantage/disadvantage — that is, wealth, power, or prestige.”

And how does the private insurance industry define equity in the pricing of health insurance premiums? The premium that “EACH insured pays must reflect the expected cost of providing coverage to THAT insured,” but not “an extra amount to make up for those paying less than cost.”

So let’s see how that would work in a system that finances health care for everyone. The 80 percent of individuals (243 million people) who use 20 percent of our national health expenditures ($479 billion) would each be responsible for $1970 in an equitable system, according to the insurance industry’s version. The other 20 percent of individuals (61 million people) who use 80 percent of our national health expenditures ($1,915 billion) would each be responsible for $31,400 in AHIP’s version of equity.

So the private insurance industry, in order to establish equity, would set their premiums based on health care costs of $1970 each (plus administrative costs and profits, less cost-sharing) for four-fifths of us. But what about the one-fifth with health care costs averaging $31,400 each? They simply avoid that market.

Thus the insurance industry’s definition of equity is making premiums fair by excluding the costs of those needing health care, which equates with excluding them from coverage under their plans. Those with high costs can use their wealth, power, or prestige to obtain care. But what about those without? Doesn’t that stretch the definition of equity to well past the breaking point?

Health reform lessons from Chile

Chile's Neoliberal Health Reform: An Assessment and a Critique

By Jean-Pierre Unger, Pierre De Paepe, Giorgio Solimano Cantuarias, Oscar Arteaga Herrera
PLoS Medicine
April 1, 2008

Summary Points

* The Chilean health system underwent a drastic neoliberal reform in the 1980s, with the creation of a dual system: public and private health insurance and public and private provision of health services.

* This reform served as a model for later World Bank–inspired reforms in countries like Colombia.

* The private part of the Chilean health system, including private insurers and private providers, is highly inefficient and has decreased solidarity between rich and poor, sick and healthy, and young and old.

* In spite of serious underfinancing during the Pinochet years, the public health component remains the backbone of the system and is responsible for the good health status of the Chilean population.

* The Chilean health reform has lessons for other countries in Latin America and elsewhere: privatisation of health insurance services may not have the expected results according to neoliberal doctrine. On the contrary, it may increase unfairness in financing and inequitable access to quality care.

The Impact of the Reform: Efficiency

Here the evidence is clearer. ISAPRES (the private system) has hardly contained costs, and the ISAPRES companies never intended to do so: they have few incentives to be efficient buyers of health services for their clients. Instead, they work hard to be efficient in the selection of their clients (they are allowed to refuse clients). Their focus is on low-risk, high-income patients, with the goal of making a profit. They spend ten times as much on administration per member and about two times as much on health care per member than FONASA (National Health Fund, a public agency), even though ISAPRES members are in better health and need less care. To deliver care, ISAPRES companies rely on a burgeoning private sector, reimbursed on a fee-for-service basis, which induces an increased supply of unnecessary but profitable services.

http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0050079

Comment:

By Don McCanne, MD

This article is worth reading in its entirety because of the important lessons that would apply to reform in the United States.

But do we really need Chile to provide us with these lessons? Just look around. With our $2.4 trillion/year experiment, we’ve already demonstrated the same results here. And yet we keep doing the same thing?

Medicare's failed experiment with disease management

Medicare Finds How Hard It Is to Save Money

By Reed Abelson
The New York Times
April 7, 2008

An ambitious three-year experiment to see whether the Medicare system could prevent expensive hospital visits for people with chronic conditions like congestive heart failure and diabetes has suggested that such an approach may cost more than it saves.

The test borrowed a practice long available through private health plans. Nurses periodically place phone calls to patients to check whether they are taking their drugs and seeing the right doctors. The idea is that keeping people healthier can help patients avoid costly complications.

After paying eight outside companies about $360 million since mid-2005 to try to improve such patients’ health, Medicare is still trying to figure out whether the companies were able to keep people healthier. But the preliminary data indicate that the government is unlikely to save money.

Several of the companies, including two that specialize in disease management, Healthways and Health Dialog, are pressing Medicare to continue the project in some fashion beyond the end of this year, saying the government mishandled the experiment.

“We haven’t proven anything,” said Dr. Jeffrey L. Kang, a former Medicare official who is now the chief medical officer for the insurer Cigna. The companies say Medicare signed up patients who were much sicker than they had expected. Instead of giving companies a chance to intervene before someone went to the hospital, Dr. Kang said, most of the patients were already so ill that it was “no longer a preventive program.”

George B. Bennett, the chief executive of Health Dialog, which is overseeing about 15,000 Medicare patients in western Pennsylvania, favors continuing the experiment, but with adjustments. He wants Medicare to give the companies more flexibility to manage patients in ways they say have already been proven to work among the employees they cover in commercial plans. Such measures, he said, include giving the insurer a bigger role in selecting the patients, with an eye toward identifying the ones most likely to be helped.

Medicare is already exploring other ideas, like the development of so-called “medical homes,” where a doctor with a team of other professionals oversees a patient’s care. A few doctors’ groups involved in a separate Medicare experiment have reported some success in saving the government money by more actively managing their patients’ care.

http://www.nytimes.com/2008/04/07/business/07medicare.html?hp

Comment:

By Don McCanne, MD

The presidential candidates claim that they will pay for expanding coverage to everyone by using the savings made possible though chronic disease management. But what is disease management, and will it save money?

The Medicare experiment with disease management has demonstrated what it should not be. The comments of the executives in the industry contracted by Medicare provide us with an understanding of the flaws of this model. They imply that Medicare was unfair because they selected patients with chronic disease to be managed by these private chronic disease managers. What?

To make the experiment work, the disease managers want to be able to select the patients themselves. We already have ample experience with this industry to know what that means. They want to select the healthy, low-cost patients and turn the expensive, high-needs patients over to the taxpayers. Cream skimming is already rampant in the private insurance industry. We certainly don’t need any more of it.

So what should disease management look like? The establishment of medical homes within a well-functioning primary care infrastructure would be the ideal model for chronic disease management. Although we are approaching a crisis in the shortage of primary care physicians, well trained nurse practitioners, as part of the primary care team, would be well positioned to use standard protocols plus clinical judgement to assist patients in the management of their chronic conditions.

Of course, that would be much simpler through a single payer national health program in which our abundant resources could be realigned to achieve this crucial goal. Imagine… using our resources more efficiently while achieving the goals of a high-performance system. Pipe dream? Don’t think so.

Most Doctors Support National Health Insurance Updated

by DrSteveB
DailyKos
Mon Mar 31, 2008 at 01:54:14 PM PDT

I have always wanted to do a “Breaking” headline. Well this is from a press release embargoed until just now on an article in the professional peer reviewed journal Annals of Internal Medicine (aka: the green journal; it’s generally considered the 3rd most prestigious American medical journal). It reports on a methodologically valid survey of American doctors.

The survey, conducted last year of 2,193 physicians across the United States, showed 59% “support government legislation to establish national health insurance,” while 32% oppose & 9% are neutral. That’s a solid majority of American doctors, and up 10% from 49% in 2002 when a similar study was last done. We have all gotten pretty sick of the insurance companies!

So, yeah for us docs, for getting it! Now if only the Dems running for president were as progressive! Fortunately there is HR-676 in Congress.

UPDATE: For those who want the full original journal article, methods, etc. the full text of the article just went online here: https://pnhp.org/docsurvey/annals_physician_support.pdf

More on the study:

As you know, such plans typically involve a single, federally administered social insurance fund that that guarantees health care coverage for everyone, much like Medicare currently does for seniors. The plans typically eliminate or substantially reduce the role of private insurance companies in the health care financing system, but still allow patients to go the doctors of their choice.

From the Physicians for a National Health Program (PNHP) press release:

The findings reflect a leap of 10 percentage points in physician support for national health insurance (NHI) since 2002, when a similar survey was conducted. At that time, 49 percent of all physician respondents said they supported NHI and 40 percent opposed it.

Support among doctors for NHI has increased across almost all medical specialties, said Dr. Ronald T. Ackermann, associate director of the Center for Health Policy and Professionalism Research at Indiana University’s School of Medicine and co-author of the study.

“Across the board, more physicians feel that our fragmented and for-profit insurance system is obstructing good patient care, and a majority now support national insurance as the remedy,” he said.

Support for NHI is particularly strong among psychiatrists (83 percent), pediatric sub-specialists (71 percent), emergency medicine physicians (69 percent), general pediatricians (65 percent), general internists (64 percent) and family physicians (60 percent). Fifty-five percent of general surgeons support NHI, roughly doubling their level of support since 2002.

Doctors have often expressed concern about lack of patient access to care due to rising costs and patients’ insufficient levels of insurance. An estimated 47 million Americans currently lack health insurance coverage and another 50 million are believed to be underinsured. At the same time, health care costs in the United States are rising at the rate of about 7 percent a year, twice the rate of inflation.

The health care issue continues to rank high among voter concerns in the 2008 elections, placing third in a recent poll after the economy and Iraq.

The current study by the Indiana University researchers is the largest survey ever conducted among doctors on the issue of health care financing reform. It is based on a random sampling of names obtained from the American Medical Association’s master list of physicians throughout the country.

In addition to measuring attitudes toward NHI, the survey also asked doctors about their views about “more incremental reform,” often interpreted as state- or federal-based programs requiring or “mandating” that consumers buy health insurance from private insurance companies, legislative measures providing tax incentives to businesses to provide coverage for their employees, or similar steps.

Fewer physicians (55%) were in support of “incremental” reform. Moreover, virtually all those opposed to national health insurance also opposed incremental reform to improve access to care. In fact, only 14% of physicians overall oppose national health insurance but support more incremental reforms. Ironically, many medical organizations and most politicians have endorsed only incremental changes.

Dr. Aaron E. Carroll, Director of Indiana University’s Center for Health Policy and Professionalism Research and lead author of the study, commented: “Many claim to speak for physicians and reflect their views. We asked doctors directly and found that, contrary to conventional wisdom, most doctors support the government creating national health insurance.”

Other signs indicate that attitudes among doctors are changing. The nation’s largest medical specialty group, the 124,000-member American College of Physicians, endorsed a single-payer national health insurance program for the first time in December.

By the way, earlier state-level surveys have found that 64% of physicians in Minnesota support single payer. In New Hampshire the figure is 67% supporting single payer!

Admittedly, PNHP’s membership is only around 15,000 nationwide. But did you know that the AMA memberhsip is down to 25% of American physicians and dropping.

Journal Reference for the article in the press release:
“Support for National Health Insurance among American Physicians: Five Years Later,” Aaron E. Carroll and Ronald T. Ackermann, Annals of Internal Medicine, April 2008. Dr. Aaron Carroll is a member of the Board of Directors of PNHP.

Physicians for a National Health Program, a membership organization of over 15,000 physicians (and also many other non-physicians), supports a single-payer national health insurance program. PNHP physician experts are available for interviews and can speak about the health care crisis in your state and options for reform at both the state and national level (e.g. on the leading Presidential candidates health plans).

To contact groups supporting single payer and/or a physician-spokesperson in your state, click here: PNHP-State Actions or call 312-782-6006.

Medicare’s failed experiment with disease management

Medicare Finds How Hard It Is to Save Money

By Reed Abelson
The New York Times
April 7, 2008

An ambitious three-year experiment to see whether the Medicare system could prevent expensive hospital visits for people with chronic conditions like congestive heart failure and diabetes has suggested that such an approach may cost more than it saves.

The test borrowed a practice long available through private health plans. Nurses periodically place phone calls to patients to check whether they are taking their drugs and seeing the right doctors. The idea is that keeping people healthier can help patients avoid costly complications.

After paying eight outside companies about $360 million since mid-2005 to try to improve such patients’ health, Medicare is still trying to figure out whether the companies were able to keep people healthier. But the preliminary data indicate that the government is unlikely to save money.

Several of the companies, including two that specialize in disease management, Healthways and Health Dialog, are pressing Medicare to continue the project in some fashion beyond the end of this year, saying the government mishandled the experiment.

“We haven’t proven anything,” said Dr. Jeffrey L. Kang, a former Medicare official who is now the chief medical officer for the insurer Cigna. The companies say Medicare signed up patients who were much sicker than they had expected. Instead of giving companies a chance to intervene before someone went to the hospital, Dr. Kang said, most of the patients were already so ill that it was “no longer a preventive program.”

George B. Bennett, the chief executive of Health Dialog, which is overseeing about 15,000 Medicare patients in western Pennsylvania, favors continuing the experiment, but with adjustments. He wants Medicare to give the companies more flexibility to manage patients in ways they say have already been proven to work among the employees they cover in commercial plans. Such measures, he said, include giving the insurer a bigger role in selecting the patients, with an eye toward identifying the ones most likely to be helped.

Medicare is already exploring other ideas, like the development of so-called “medical homes,” where a doctor with a team of other professionals oversees a patient’s care. A few doctors’ groups involved in a separate Medicare experiment have reported some success in saving the government money by more actively managing their patients’ care.

http://www.nytimes.com/2008/04/07/business/07medicare.html?hp

Comment:

By Don McCanne, MD

The presidential candidates claim that they will pay for expanding coverage to everyone by using the savings made possible though chronic disease management. But what is disease management, and will it save money?

The Medicare experiment with disease management has demonstrated what it should not be. The comments of the executives in the industry contracted by Medicare provide us with an understanding of the flaws of this model. They imply that Medicare was unfair because they selected patients with chronic disease to be managed by these private chronic disease managers. What?

To make the experiment work, the disease managers want to be able to select the patients themselves. We already have ample experience with this industry to know what that means. They want to select the healthy, low-cost patients and turn the expensive, high-needs patients over to the taxpayers. Cream skimming is already rampant in the private insurance industry. We certainly don’t need any more of it.

So what should disease management look like? The establishment of medical homes within a well-functioning primary care infrastructure would be the ideal model for chronic disease management. Although we are approaching a crisis in the shortage of primary care physicians, well trained nurse practitioners, as part of the primary care team, would be well positioned to use standard protocols plus clinical judgement to assist patients in the management of their chronic conditions.

Of course, that would be much simpler through a single payer national health program in which our abundant resources could be realigned to achieve this crucial goal. Imagine… using our resources more efficiently while achieving the goals of a high-performance system. Pipe dream? Don’t think so.